اثربخشی هدایت شده خودیاری برای اختلالات افسردگی و اضطراب در مراقبت های اولیه: یک کارآزمایی تصادفی کنترل شده عمل گرا

The objective of this study is to evaluate the effectiveness of (guided) self-help in primary care for patients diagnosed with a minor or major mood and/or anxiety disorder. The study population consists of 120 (screened) primary care patients aged 18–65 years with at least one mood and/or anxiety disorder. The primary focus is the reduction of depressive and anxiety symptoms. The self-help courses (Problem Solving Treatment and exposure) took 6 weeks to complete. The self-help group reported slightly better outcomes than the care-as-usual group but these results were not significant: d = − 0.18 (95% CI = − 2.29 to 7.31) for symptoms of depression and d = − 0.20 (95% CI = − 0.74 to 2.29) for symptoms of anxiety. For patients with an anxiety disorder only, the anxiety symptoms decreased significantly compared to the care-as-usual group (d = − 0.68; 95% CI = 0.25 to 4.77). Self-help seems only slightly superior to care-as-usual and therefore might not be an effective tool in general practice. But the lack of results could also be due to our selection of patients or to our selection of GPs (with interest in psychiatric disorders). Nonetheless the promising signals with respect to anxiety disorders warrant further research.

Depressive and anxiety disorders are both highly prevalent (Bijl et al., 1997). Anxiety and depression can cause serious functional impairment and reduced quality of life (Wells et al., 1989 and von Korff et al., 1992). Almost half of those who have ever suffered from a psychiatric disorder have had more than one disorder. Comorbid anxiety is the rule rather than the exception in depression with up to 60% of patients with major depressive disorder also suffering from an anxiety disorder (Kessler et al., 2003). Because of this high comorbidity our study is aimed at individuals with depressive disorder, anxiety disorders as well those with comorbid depression and anxiety. Many patients with depressive or anxiety disorders do not seek any help. It is estimated that this is true for about two thirds of cases (Bijl and Ravelli, 2000 and Andrews et al., 2001). Those that do seek help usually go to their general practice first (Bijl and Ravelli, 2000 and Wang et al., 2007). However, they do not always present their symptoms in psychological terms, and it is well known that general practitioners (GPs) often (up to 50% of instances) fail to recognize mental health problems (Ustun and Von Korff, 1995). And those patients whose mental health problems are recognized do not always receive evidence-based treatments. Andrews et al. (2004) estimate that this might be true for half of the patients in primary care. According to several studies (Schulberg et al., 1995, Schulberg et al., 1997 and Cardol et al., 2004) many patients are prescribed antidepressants immediately after the diagnosis is made; however, few patients manage to have adequate dosage and duration of (antidepressant) medication. Approximately 30% of depressed primary care patients stop using antidepressants within the first month of treatment, while only 40% reach the recommended therapeutic dosage (Simon et al., 1993). It is also important to note that the majority of primary care patients prefer psychotherapy as a treatment (van Schaik et al., 2004). Therefore it is not surprising that the research to date suggests that access to psychological treatment in primary care requires improvement. This might be achieved by a new form of treatment delivery: through self-help. Self-help can be defined as a standardized psychological treatment that a patient can work through on his/her own, possibly with some guidance (Marrs, 1995). Most self-help interventions are based on cognitive–behavioural therapy (CBT) (Cuijpers and Schuurmans, 2007) but nowadays other types of treatment (i.e. problem solving treatment (PST), interpersonal therapy (IPT)) have become available as (guided) self-help interventions as well. Self-help interventions are available via books (bibliotherapy) and via the computer (web-based, CD-ROM, DVD) and they can be pure self-help or guided self-help. In pure self-help patients work on the course alone while in guided self-help patients receive feedback on their assignments, for example from a psychologist or psychiatric nurse. The guidance in guided self-help can differ in format (e.g. via telephone, face-to-face or through the Internet) as well as in the intensity (e.g. once a week or on request). It has been demonstrated convincingly that guided self-help is effective for a number of mental health problems (Hirai and Clum, 2006 and Morgan and Jorm, 2008). One way to offer self-help interventions is to embed them into more comprehensive care models, e.g. disease management or stepped care models. In these models patients receive evidence based treatments and their symptoms are monitored by a care manager. The care manager coordinates care, monitors the treatment response and actively guides the patient through the treatment protocol. These models seem promising for the improvement of mental health care in general practice (Katon et al., 2002, Neumeyer-Gromen et al., 2004 and Bower and Gilbody, 2005) and it is therefore important to combine the self-help with the models. One of these is a stepped care model. This model includes a number of treatments of increasing intensity (Bower and Gilbody, 2005). All patients follow the same sequence of treatments. Accordingly, all patients start with the same evidence based minimal intervention. A self-help intervention seems an appropriate first step in a stepped care model because it is easily accessible and is evidence based. Previous RCTs on the effectiveness of (online) self-help treatment (van Straten et al., 2008 and Warmerdam et al., 2008), with varying types and amount of guidance, were performed on community samples. A review showed that while self-help CBT is effective for depression, there is not sufficient data that specifically refers to self-help CBT for the treatment of depression in primary care (Warrilow and Beech, 2009). However, other RCTs in primary care testing (online) self-care in primary care show varying results. A randomized controlled trial comparing a guided self-help intervention with waiting list control for patients with anxiety and depression shows that guided self-help did not provide additional benefit to patients on a waiting list (Mead et al., 2005). Another study found no differences between three groups: computerized cognitive–behavioural therapy (CCBT) for depression, treatment as usual (TAU) and combined CCBT and TAU in primary care. They found medium improvement effect sizes in depressive severity for all interventions (de Graaf et al., 2009). Another randomized trial found that treating general practice patients suffering from anxiety and/or depression with a computerized cognitive–behavioural therapy program led to significant improvement on all response variables measured. For example, depression and anxiety decreased, and work and social adjustment improved. (Proudfoot et al., 2004). We performed a stepped care randomized controlled trial (RCT) for patients with minor and major mood and/or anxiety disorders in primary care. The stepped care model consisted of the following steps: watchful waiting, self-help treatment, brief individual therapy and longer-term individual therapy and/or medication. In this paper we will report our findings on effectiveness after the self-help step.

This pragmatic randomized trial shows that both the intervention group and the care as usual group improve on symptoms of depression while stepped care patients also improve on anxiety symptoms. When compared to care as usual, there is no significant difference in symptom reduction or quality of life. However, this study shows a decrease in anxiety symptoms for patients with one or more anxiety disorder(s) only. This guided self-help intervention is part of a stepped care model which could mean that this single step shows no clear results as such. Nonetheless, it could influence the general outcome of the full stepped care model and the results of these analyses will follow in the near future.