Specialist mental health services do work—but they come at a price, study finds

A specialist service offering a tailored approach to treating patients with severe depression is more effective than usual mental health care but comes at a higher cost, research led by academics at The University of Nottingham has revealed.

The study, published in The Lancet Psychiatry and funded through NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) in Nottinghamshire, Derbyshire and Lincolnshire, East Midlands, Cambridgeshire and Peterborough, and the Medical Research Council (MRC), is the first ever trial of its kind into a specialist service for the most severely depressed patients in mental health services.

It found that after 18 months of using the service patients reported a significant improvement in their symptoms compared to those using usual mental health services.

However, the research, led by Professor Richard Morriss in the Department of Psychiatry and Applied Psychology in Nottingham's Institute of Mental Health, also found that the specialist service cost was higher than the services that patients would normally access.

Professor Morriss said: "Despite previous recommendations by NICE in the 2009 Depression Guideline, this is the first multicentre randomised controlled trial ever of a specialist service for the most severely depressed patients, which is quite surprising given that depression is second only to back pain in years lived with a disability of all health conditions worldwide.

"This intervention proved effective but more expensive than that usually recommended by NICE. However, compared to physical health conditions of similar severity and duration, the cost per patient of just over £2,200 is not particularly high.

"Therefore, this will prompt a serious debate about how far we are willing to invest in helping to improve the function and reduce the distress of patients with a severe, chronic mental disorder.

"Also, this does not consider the whole cost to society and the potential economic benefits of patients returning to employment and maintaining parental responsibility in families and we will be following these patients for three years to study this issue."

Depression is an expensive condition that costs the NHS £1.7 billion per year and in 2008 alone cost £7.5 billion to wider society, mainly through lost employment.

Despite these high societal and economic costs, research into treatment for chronic depression has been largely limited to single interventions such as the use of antidepressants or psychotherapy. However, for many people this is not effective.

The Nottingham study followed 94 patients with persistent moderate or severe depression receiving treatment as usual over a 18 month period, compared with 93 who were given access to specialist depression services. Most patients had been ill with depression for many years and had not responded to treatment for depression for six months or longer.

For patients receiving treatment as usual, the treatment was directed by a consultant psychiatrist usually from a community mental health team. It usually consisted of individual work by the psychiatrist in secondary care and treatment with mental health medication, sometimes shared review with primary care and sometimes using psychosocial interventions such as cognitive behavioural therapy (CBT), counselling or community psychiatric nurse support.

The patients who received the specialist depression service were offered a collaborative care approach, receiving specialist pharmacotherapy for depression and specialist CBT for depression.

Medication was specifically tailored for them – patients were carefully monitored to assess the effectiveness of the drugs and if they showed no response were switched to alternatives. The drug treatment was underpinned by shared decision making by the clinicians and collaborative discussions took place about the effect of medication change on psychotherapy.

When a clinical need was identified, psychological interventions were supplemented with mindfulness-based cognitive therapy to prevent relapse. In addition, when clinicians identified high levels of shame and self-criticism, compassion focussed therapy was offered, as well as social-inclusion initiatives including vocational and occupational-based therapies. The services also encouraged patients to access self-help groups.

After 18 months, the results showed that the specialist service group improved from moderate symptoms of depression to mild symptoms compared to patients who received treatment as usual who reported no significant improvement in their symptoms.

The study found that after 18 months the specialist service was not as cost effective as the usual mental health treatment, although most of the incremental costs of the specialist care was spent in the first 12 months, so the intervention may become more cost effective after two to three years.