Review article
Effect of psychiatric consultation models in primary care. A systematic review and meta-analysis of randomized clinical trials,☆☆,

https://doi.org/10.1016/j.jpsychores.2009.10.012Get rights and content

Abstract

Objective

Psychiatric consultation in primary care is meant to enhance and improve treatment for mental disorder in that setting. An estimate of the effect for different conditions as well as identification of particularly effective elements is needed.

Methods

Database search for randomized controlled trials (RCTs) on psychiatric consultation in primary care. Validity assessment and data extraction according to Cochrane criteria were performed by independent assessors in duplicate. Meta-analysis was performed.

Results

Data were collected from 10 RCTs with a total of 3408 included patients with somatoform disorder or depressive disorder, which compared psychiatric consultation to care as usual (CAU). Meta-analysis irrespective of condition showed a weighted mean indicating a combined assessment of illness burden as outcome of psychiatric consultation, compared to CAU, of 0.313 (95% CI 0.190–0.437). The effect was especially large in somatoform disorder (0.614; 95% CI 0.206–1.022). RCTs in which after the consult, consultation advice was given by means of a consultation letter, showed a combined weighted mean effect size of 0.561 (95% CI 0.337–0.786), while studies not using such a letter showed a small effect of 0.210 (95% CI 0.102–0.319). Effects are highest on utilization of health care services with 0.507 (95% CI 0.305–0.708).

Conclusion

Psychiatric consultation in the primary care setting is effective in patients with somatoform and depressive disorder. Largest effects are seen in reduction of utilization of health care services.

Introduction

Primary care is ‘the point of entry into the health care system and the locus of responsibility for organizing care for patients and populations over time’ [1]. Various multidisciplinary collaborative care models as well as guidelines for anxiety disorders [2] and depressive disorders [3], [4] have been developed in the primary care setting. In these models, access to integrated care is much better guaranteed than by referring the patient to a second-line mental health care setting, as was common practice before [5], [6]. Psychiatric consultation has been developed as a way to support family physicians in the implementation of those models and guidelines and in the best and quickest treatment of those patients towards remission [7], [8]. However, in general, the effect size of such consultations, and the effectiveness of different models for consultation, has not yet been studied.

In psychiatric consultation as described by Caplan [9] from the perspective of ‘community mental health,’ the psychiatrist himself sees the patient and provides the family physician with a diagnosis and treatment plan. Afterwards, the family physician continues treatment according to this consultation advice. This psychiatric consultation can take place at the location of the psychiatric practice, as in the studies of Smith et al. [10], [11], or at the family practice, where it is mostly done in the presence of the family physician [4], [12]. Family physicians appreciate this form of support [13]. Psychiatric consultation is often embedded in a larger collaborative relationship in which other disciplines, especially psychiatric nurses, also play a role, so-called collaborative care. Such collaborative models can take a variety of forms, depending on the psychiatric facilities and the target group [12], [14]. In general, such collaboration is considered collaborative care if at least two out of three professionals (family physician, consultant psychiatrist, and care manager) are involved in the treatment of the patient. In such collaboration, the consultant psychiatrist can advise the family physician or the care manager, and perform consultation vis-à-vis the patient during the course of treatment.

As several effect studies have addressed the issue of psychiatric consultation, be it in the context of collaborative care or otherwise, perhaps an estimate can be made of the overall effect, as well as the effect on particular disorders such as somatoform disorder, which is the most difficult problem in primary care, in terms of treatment resistance, and for depressive disorder, the most prevalent. This estimate would be useful in clinical context as well as in the context of health services policies to enhance the treatment of mental disorders in the primary care practice setting. In this article, we review systematically the effects of consultation by a psychiatrist actually seeing the patient, resulting in advice to the family physician in the primary care practice setting, vs. usual care, and perform a meta-analytic synthesis.

Section snippets

Method

From 2006 to 2007, the multidisciplinary workgroup for the guideline ‘consultation psychiatry’ of the Netherlands Psychiatric Association developed a guideline on psychiatric consultation with the scientific support of the Dutch Institute for Healthcare Improvement (CBO), which was published in 2008 [15], [16]. The workgroup consisted of a family physician, a specialist in internal medicine, three consultant psychiatrists working in the hospital setting, and three consultant psychiatrists

Study selection

The search yielded 78 hits, including one feasibility study [8], 17 RCTs, two study protocols, and two meta-analyses on collaborative care, which took the effects of the availability of structural consultation for patients with depressive disorder into account [29], [30]. Those meta-analytic reviews reviewed 35 of the 37 respective RCTs; however, there was significant overlap between the RCTs that were included. As both were published in 2006, only the meta-analysis of Gilbody et al. [29] was

Discussion

In this meta-analysis, a first attempt is made to summarize randomized clinical trials evaluating the effect of any kind of psychiatric consultation in the primary care setting and to estimate the size of the effect. However, there are several limitations that will be discussed first.

Conclusion

This systematic review and meta-analysis evaluated the existing literature and found that a psychiatric consultation model for patients with somatoform disorders and depression in primary care is effective. This type of consultation has the strongest effects on somatoform disorder, in terms of relief of medical symptoms and reduction of health care use. In view of this evidence, it is a remarkable finding that, in the last 5 years, only three RCTs were performed evaluating this consultation

References (48)

  • VerhaakPF et al.

    GPs' referral to mental health care during the past 25 years

    Br J Gen Pract

    (2000)
  • Van der Feltz-CornelisCM et al.

    Treatment of mental disorder in the primary care setting in the Netherlands in the light of the new reimbursement system: a challenge?

    Int J Integr Care

    (2008)
  • Van der Feltz-CornelisCM et al.

    Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice

    Psychother Psychosom

    (2006)
  • Van der Feltz-CornelisCM et al.

    Psychiatric consultation for somatizing patients in the family practice setting: a feasibilty study

    Int J Psychiatry Med

    (1996)
  • CaplanG

    Types of mental health consultation

    Am J Orthopsychiatry

    (1963)
  • SmithGR et al.

    Psychiatric consultation in somatization disorder: a randomized controlled study

    N Engl J Med

    (1986)
  • SmithGR et al.

    A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients

    Arch Gen Psychiatry

    (1995)
  • HerbertCM et al.

    Wat wil de huisarts? Evaluatie van wensen van huisartsen ten aanzien van psychiatrische consulten in de praktijk

    Maandbl Geest Volksgezond

    (2004)
  • LeentjensAFG et al.

    Richtlijnwerkgroep Consultatieve Psychiatrie van de Nederlandse Vereniging voor Psychiatrie. Richtlijn ‘Consultatieve psychiatrie’ van de Nederlandse Vereniging voor Psychiatrie voor consulten in de eerste lijn en in de ziekenhuissetting

    Ned Tijdschr Geneeskd

    (2008)
  • MoherD et al.

    Preferred reporting items for systematic reviews and meta-analysis: the PRISMA Statement

    PLoS Med

    (2009)
  • Van der Feltz-CornelisCM et al.

    Randomization in psychiatric intervention research in general practice setting

    Int J Methods Psychiatr Res

    (2000)
  • McGuireH et al.

    International Cochrane Colloquium (6th: 1998: Baltimore, MD). Quality assessment of trials found within the scope of Cochrane Collaboration Depression, Anxiety & Neurosis (CCDAN)

    Syst Rev Evid Action Int Cochrane Colloq 6th 1998 Baltim Md

    (1998)
  • PhillipsB et al.

    Oxford Centre for Evidence-Based Medicine Levels of Medicine (March 2009)

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    All authors declare that there are no competing interests.

    ☆☆

    Ethics approval was not required for this article.

    This study was not funded.

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