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Preference: General Practice and Primary Care

333

An economic case for a cardiovascular polypill? A cost analysis of the Kanyini GAP trial

There is increasing global interest in the use of frequently indicated medications in fixed-dose combination for the prevention of cardiovascular disease (CVD).1,2 Evidence of the effectiveness of such polypills as a strategy in improving adherence to recommended treatment and potentially lowering costs is growing.3,4 Although there are combination blood pressure-lowering and cholesterol-lowering medications, a more comprehensive cardiovascular polypill (containing generic aspirin, a lipid-lowering and two blood pressure-lowering agents) is not currently available in Australia. At a feasible cost of less than $1 per day5 compared with a minimum cost in Australia of $1.70 per day for individual generic therapies (http://pbs.gov.au/info/about-the-pbs), prima facie evidence exists for extensive savings from such a strategy in Australia.

The cost-effectiveness of polypill-based strategies compared with individual medications has yet to be tested in real-life settings, although cost-effectiveness has been shown in different patient groups and health care settings using modelled projections.5,6–8 For instance, based on a modelled analysis of high-risk primary care Dutch participants, polypill use after opportunistic screening was cost-effective among people aged over 40 years.8 Similarly, a polypill strategy was found to be cost-effective and potentially cost-saving in older patients after myocardial infarction.7

This analysis is based on the Kanyini Guidelines Adherence with the Polypill (GAP) pragmatic randomised controlled clinical trial and linked health service and medication administrative claims data from Medicare Australia. Kanyini GAP was pragmatic in that it was conducted within the primary care setting, with the study drug dispensed through community pharmacies, to test the effectiveness of a polypill-based strategy in real-world practice.9 In the trial, the polypill improved patients’ adherence to treatment and there was no difference in mean blood pressure and cholesterol levels.3 The results were consistent with a larger sister trial, the UMPIRE (Use of a Multidrug Pill in Reducing Cardiovascular Events) study. Conducted in Europe and India, UMPIRE found that a polypill strategy yielded improvements in self-reported adherence, along with statistically significant but small additional reductions in blood pressure and cholesterol, compared with non-polypill treatment, in the polypill arm.4 A unique design feature of Kanyini GAP was that all medications, including the polypill, were dispensed at an out-of-pocket charge consistent with prevailing Medicare subsidies (around $35 per medication per month for general patients).

Methods

A within-trial cost analysis of the polypill strategy versus usual care was conducted from the Australian health system perspective (ie, government plus patient costs). Kanyini GAP was carried out within Indigenous and non-Indigenous urban, rural, and remote primary care settings across Australia (randomisation from January 2010 to May 2012; median follow-up, 19 months; maximum follow-up, 36 months).3

Data on health service and medication expenditure throughout Kanyini GAP were obtained via individually linked Australian Medicare records for study participants who consented to linkage. Two separate Medicare datasets were analysed: the Medicare Benefits Schedule (MBS), which records government and patient costs of general practitioner and specialist visits and diagnostic tests; and the Pharmaceutical Benefits Scheme (PBS), which records the total government and patient costs of all medications dispensed outside hospital. The PBS data do not include polypill costs, as it is not marketed in Australia. As no difference was found in safety or clinical outcomes between treatment groups in the Kanyini GAP trial, we assumed no differences in hospital-related expenditure.

The primary outcome was mean MBS and PBS expenditure per patient per year. The base year for the analysis was 2012.10 This study was approved by human research ethics committees in all relevant jurisdictions (Sydney South West Area Health Service; Aboriginal Health and Medical Research Council of New South Wales; Cairns Base Hospital; Princess Alexandra Hospital Centres for Health Research; Central Australia; Northern Territory Department of Health and Menzies School of Health Research; Monash University). Each participant provided written informed consent.

Statistical analysis

Multivariable analysis was conducted to accommodate potential differences between treatment groups, given these analyses were restricted to the subset of trial participants consenting to Medicare linkage.11 Non-significant demographic, socioeconomic, health and treatment-related covariates (P > 0.10) were removed via backwards stepwise elimination. To account for the empirical distribution of MBS and PBS cost data,11–14 generalised linear models were used to estimate the primary outcome, and the marginal difference between treatment groups was compared (Wald test). Deb–Manning–Norton programs for Stata 12.1 (StataCorp) were used.12

Results

Box 1 and Box 2 detail the flow of patients through this analysis. Consent for linkage with MBS and PBS data was obtained from 93.9% (585/623) and 92.0% (573/623) of trial participants, respectively, and data were provided for 94.9% of participants (MBS, 555/585; PBS, 544/573). With regard to PBS data, 10.8% (62/573) of consenting participants were receiving medications under the special rural and remote access provisions of section 100 of the National Health Act 1953 (Cwlth) and were removed from this analysis, as these data were not captured by Medicare at an individual patient level (Box 2). There was no differential availability of linked data between treatment groups.

The MBS and PBS expenditures by the Australian health system (government plus patient costs) per patient per year, excluding the cost of the polypill, are presented in Box 3. The adjusted analysis predicted a mean cost saving for pharmaceutical expenditure of $989 (95% CI, $648–$1331) per patient per year (P < 0.001) to the health system. No significant differences were found in MBS expenditure.

Discussion

Our study showed that participants receiving polypill-based care had significantly lower pharmaceutical expenditure than usual care, with no difference in health service expenditure. The overall potential savings are dependent on the reimbursement price of the polypill. Under current Australian guidelines, fixed-dose combinations such as the polypill are reimbursed at no greater than the sum of the costs of the generic components,15 which was $1.70 per day at the time the trial was conducted. At this maximum price, and based on an average of 264 days per year on polypill treatment as observed in the treatment arm of the Kanyini GAP study,3 the annual savings to the health system would be $540 (ie, $989 − $1.70 × 264 days) per patient.

The Kanyini GAP trial found that the polypill was safe and effective in improving combination preventive treatment use by patients.3,4 Using primary care expenditure data, our within-trial analysis provides evidence of significant cost savings through the introduction of a CVD polypill, showing its economic dominance over conventional individual therapies. The ACE Prevention project, an Australian economic modelling study,5 also indicated dominance, estimating that a polypill at $200 per person per year was cost saving and resulted in a large population health impact, even when provided to patients at lower risk than those in the Kanyini GAP trial. If we had applied this lower cost in our analysis, we would have estimated annual health system savings of $789 per patient.

Challenges remain before large cost savings can be realised in Australia. First, no polypill has had regulatory approval in Australia to date. While several cardiovascular combinations have been approved, these are simple two-component combinations approved on the basis of straight substitution among patients receiving recommended medications (among whom the benefits are smallest),3,4 and have probably increased costs as a result of not being subject to automatic price reductions.16 Another challenge will be appropriate scale-up while maintaining overall cost savings — large investments will be required in order to bring about practice change for this relatively new way of treating patients.

One limitation with using PBS data is that over-the-counter and very low-cost medications priced at below the government copayment level are not captured. However, this potentially leads to an underestimate of the cost savings as it is likely to include some of the individual cardiovascular medicines in usual care, such as aspirin. Additionally, subsequent reductions in the cost of usual care associated with the expiry of patents for atorvastatin and rosuvastatin since conducting the Kanyini GAP trial may have an impact on the translation of such cost savings into contemporary practice.

This is the first study using individual patient-linked administrative data to evaluate the cost offsets associated with a CVD polypill compared with current practice. Given that over 600 000 Australians at high risk of CVD are currently prescribed antiplatelet, blood pressure and lipid-lowering medication, and a similar number are on partial treatment,17,18 this polypill has the potential to not only help to reduce the large gaps that exist in Australia between recommended and actual treatment for patients with CVD,18 but also to free up considerable amounts of pharmaceutical expenditure.

1 Medicare Benefits Schedule expenditure

2 Pharmaceutical Benefits Scheme expenditure

* Patients receiving medications under the special rural and remote access provisions; individual-level data not captured by Medicare.

3 Health system expenditure (government plus patient costs) per patient per year of follow-up*

Scheme

Usual care

Polypill

Marginal difference

Medicare Benefits Schedule

    

No. of participants

270

281

–

Unadjusted expenditure, mean (95% CI)

$1772 ($1581 to $1963)

$1760 ($1602 to $1917)

$13 (− $236 to $261)†

Adjusted‡ expenditure, mean (95% CI)

$1767 ($1583 to $1951)

$1770 ($1615 to $1926)

$40 (− $202 to $281)

Pharmaceutical Benefits Scheme

    

No. of participants

229

229

–

Unadjusted expenditure, mean (95% CI)

$2438 ($2100 to $2775)

$1443 ($1285 to $1601)

$995 ($622 to $1368)†¶

Adjusted§ expenditure, mean (95% CI)

$2448 ($2141 to $2754)

$1446 ($1291 to $1602)

$989 ($648 to $1331)†¶

* 2012 A$, estimated with generalised linear model (gamma family, log link). † In favour of polypill. ‡ Adjusted for sex, Australian rural and remote area index (http://www.aihw.gov.au/rural-health-rrma-classification), adherence at baseline, history of cardiovascular disease and prior medication use. § Adjusted for sex, Australian rural and remote area index, health care concession status–income interaction, adherence at baseline, history of cardiovascular disease and prior medication use. ¶ P < 0.001.

Rural patients travel for health care

A country doctor comes face to face with the devastating realities of needing specialist care in a distant city

Today, I entered the world of the chronically ill. I am forced to grapple with the shattering diagnosis of a life-threatening autoimmune disease. My medical career and life as I have known it are shelved for the foreseeable future. Hopes and dreams are buried under the rubble of severe illness. Suddenly, my husband is my carer, and his career hangs in the balance too. Roles within the family radically change in a moment, and nothing looks familiar. The devastation does not stop there, though. Being casually or self-employed means income ceases immediately for both of us. We have entered the unchartered waters of financial insecurity.

This is enough to swallow for one day. Tomorrow, I start the arduous task of planning and packing for the more than 1100 km round trip for treatment. Being sick, this is the last thing I feel like doing. The long drives are torture to stiff and painful joints, and severely challenge my ability to shut out the nausea. Why am I sentenced to travel for essential health care? I am guilty, like so many other Australians, of living in a regional area. This is the first of monthly journeys that are potentially a life sentence.

Initially, accommodation is provided by the hospital, charged at the state’s Patient Assisted Travel Scheme (PATS) rebate rate, making it affordable. The shared cooking and dining facilities allow for the building of a support network away from home. We are all in the same boat, and the camaraderie of fellow patients in this setting proves invaluable. Six months later, this accommodation closes and, suddenly, we are out in the cold with our comrades with nowhere to stay. In New South Wales this is the trend: country patient accommodation is slowly being closed down. The state government has said it is not its responsibility. The hospitals say accommodation is not an essential part of treatment, and therefore not their responsibility. One state government official told me the responsibility lies with non-government organisations (NGOs). NGOs built country patient accommodation in the city years ago, but these are being demolished or sold off by state governments and hospitals.

The situation for country patients is dire. The only accommodation that might be covered by the PATS rebate in NSW is a dorm bed in backpackers’ accommodation. Not the place for the severely immunosuppressed, nor the healing and restful environment needed by sick patients. For anyone like myself in a wheelchair, accommodation options are further restricted. Try searching the internet for wheelchair-friendly accommodation for less than $100 per night near major hospitals. This is some of the discrimination that people with a disability face when trying to find affordable and accessible accommodation in Australia.

The severely limited facilities provided for regional patients are frequently unaffordable and unfriendly to the sick, limiting their ability to participate in treatment or recovery. Regional Australians are frequently blamed for their plight because they choose to live in the country. Those treating us demand: “Why don’t you move to the city? It would be much simpler.” Simpler for who? Many regional Australians silently suffer every day, and have no voice on this issue because they are sick. They are the ones going into debt or giving up their homes to pay for travel, sleeping in their cars when there is nowhere affordable to stay, losing their jobs because they are away from home, suffering through family breakdown, foregoing treatment altogether, or even dying because no one will take responsibility for this problem.

Getting the levers right: a way forward for rural medicine

The government needs to develop better policies now to ensure a future for rural health care

Anyone who has spent time in the bush knows that if you have seen one rural town, you have only seen one rural town. Tamworth is not the same as Cooktown or Bendigo . . . or any of the towns in between.

Different locations across rural Australia vary in their level of attractiveness to doctors and what medical skills they may require. Regardless of a location’s attractiveness, without appropriate support services and incentives, the next generation of doctors is more likely to gravitate towards urban general practice or specialist practice than towards the bush. This is worrying, given that the iconic rural doctors who have been the backbone of rural medical care for decades are fast approaching retirement.

Generational changes are influencing the working patterns of younger doctors. They are increasingly mobile and want to work fewer hours generally, and more sociable hours overall. Many are daunted by the responsibility and commitment associated with owning a practice. However, many younger doctors still want to provide holistic care for a community as well as individual patients. This is something that rural practice can deliver in spades.

To seal the deal in getting these doctors into rural practice, these generational changes must be reflected in medical workforce policies and programs. A coordinated effort across governments, service providers and professional groups is required. It may take time to respond to these more complex challenges, but key changes must be made at the federal level now if rural practice is to successfully recruit younger doctors into the future.

It is urgent that the federal government fix the Australian Standard Geographical Classification — Remoteness Area (ASGC-RA) system, which continues to be a dead weight for small rural towns in competing for doctors against larger regional locations. While ever a well resourced regional city like Townsville has the same remoteness classification as a small town like Gundagai — resulting in doctors in both locations receiving the same level of federal recruitment and retention incentives — small country towns will find it virtually impossible to compete. Incorporating the Monash Model — developed by Emeritus Professor John Humphreys and his colleagues at Monash University1 — into a revised ASGC-RA system would mean rural towns are more realistically classified and have some chance of recruiting more doctors.

Larger rural towns need well trained specialists who can work across their disciplines rather than practising only within subspecialist areas. The medical colleges will need to identify strategies to train generalists within their specialties in rural areas to meet the needs of rural local health networks and their populations.

Government also needs urgently to reconsider rural general practitioner training strategies, particularly after the recent federal Budget. With the dismantling of General Practice Education and Training from the end of 2014, rural practices and medical graduates need clarity as to how rurally based GP training will be undertaken going forward.

If they are to help meet growing demand for rural GP training placements, rural practices will need to be better supported. This will be particularly important in ensuring that medical students who have undertaken their undergraduate studies in rural and regional areas can go on to undertake GP training in rural settings.

Similarly, the federal government should immediately reverse its decision to scrap the highly successful Prevocational General Practice Placements Program. This program has encouraged many medical graduates to take up careers as rural doctors.

But these are not the only problems affecting the future of GP training. Should the government’s anticipated GP copayment lead to a significant drop in the number of consultations, many practices will decide against taking on GP registrars, leading to a significant drop in the availability of GP training opportunities.

To be sustainable into the future, our health system must shift its focus from specialist medicine and acute care beds to better supporting generalist and team-based community care that is accessible to all Australians, regardless of where they live. In rural and remote Australia, the focus must also be on making the path to rural practice both compelling and easily navigable for the next generation of doctors.

Achieving these outcomes will significantly improve health outcomes in the bush — and will significantly reduce the overall health budget — by ensuring that treatment can be provided closer to home for rural and remote Australians.

Modern challenges in acute coronary syndrome

Despite a growing evidence base, gaps in knowledge and practice leave room for improvement in the treatment of acute coronary syndrome

A few decades ago, there was still controversy about the importance of interruption of blood flow versus myocardial tissue oxygen demand in causing myocardial infarction.1,2 It is now universally accepted that coronary thrombosis at the site of an unstable atherosclerotic plaque is the usual cause of coronary occlusion3 and the cluster of conditions of unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) comprise the clinical complex now called acute coronary syndrome (ACS).

An important observation from the investigations at the start of the “reperfusion era” was the recognition that STEMI and NSTEMI, while both due to coronary thrombosis, had quite different presentations and natural histories.4 Important differences between the pathophysiology of STEMI and NSTEMI determine the focus of treatment. In STEMI, the complete occlusion of the coronary vessel initiates a cascade of myocardial necrosis, which can be prevented by early reperfusion with percutaneous coronary intervention or fibrinolytic therapy.5 In NSTEMI, the less complete occlusion of the coronary vessel means there is less immediate urgency to salvage myocardium, and the initial focus is on antithrombotic therapy to limit the size and instability of the thrombosis in the coronary artery. In this situation, the size, shape and location of the coronary thrombosis are highly variable. The patient’s clinical course can be unpredictable, and progression to STEMI is a pervading concern. In patients with NSTEMI who are at high risk, an early invasive approach has been shown to be superior to a conservative approach,6 but the optimal timing of this remains controversial.7 These major advances in understanding this symptom complex have driven quantum shifts in management approaches and greatly improved outcomes for patients who have suffered a heart attack. However, it remains a condition which can be unpredictable and, despite the best of modern treatments, can still be lethal. As ACS is a symptom of underlying coronary heart disease, long-term management is often more important than the acute phase. This supplement focuses on the many challenges in managing ACS.

The first two articles in this supplement deal with managing the acute stage of ACS. The many valuable guidelines on this topic,8–12 not reiterated in detail in the supplement, all concur on the basics of modern therapy. The use of potent antithrombotic agents is central to tackling the coronary thrombosis, albeit with an increased risk of bleeding. While controversies continue over the ideal duration of antiplatelet therapy, the evidence to support routine early and post-hospital use of potent antiplatelet agents is overwhelming. Statin therapy is also central to the management of the acute episode and for long-term management, irrespective of the low-density lipoprotein cholesterol level at the time of the episode. The role of β-adrenergic blockers and inhibitors of the renin–angiotensin–aldosterone system remain important, but perhaps better targeted to patients at higher risk. The guidelines, while sometimes exhaustingly complete, do not cover all aspects of management.

In the first article in the supplement, Brieger focuses on the identification of patients with ACS who are at high risk (https://www.mja.com.au/doi/10.5694/mja14.01249). He argues that routine risk stratification as soon as possible after presentation will determine the clinical pathway, and that this practice should be embedded in the hospital system — it is too important to leave to ad-hoc and potentially unreliable clinical judgement. This is a challenging change in approach for the hospital system, but bound to be fruitful in reducing decision time when early revascularisation is needed, and avoiding unnecessary intervention when it is not.

Next, McQuillan and Thompson review the limited evidence to guide management in four important subgroups: female, older, diabetic and Indigenous patients (https://www.mja.com.au/doi/10.5694/mja14.01248). These subgroups have been underrepresented in clinical trials, in contrast with the evidence base that guides the care of most other patients with ACS, which is rich and detailed. There is also evidence that these subgroups are at particular risk, and clinical decisions must often be based on extrapolation from the results of clinical trials without absolute certainty that the evidence is applicable.

The other articles in the supplement deal with the challenges in caring for post-ACS patients at the time of discharge from hospital and handover to the general practitioner. This transition can lead to confusion for the patient and frustration for the GP in dealing with patients returning to their practice with major changes in their management incompletely documented and uncertainty about how best to access the services available to their patients.

Redfern and Briffa use data from three registries to describe common shortfalls in the transition from hospital to primary care (https://www.mja.com.au/doi/10.5694/mja14.01156). The challenges in improving access to effective secondary prevention are concisely summarised, with positive guidance on how to improve secondary prevention in primary care, raising awareness of the need for lifelong secondary prevention, better integration and use of existing services, consideration of the use of registry data in data monitoring and quality assurance, and the potential in embracing new technologies such as automated texting reminders to patients, already outlined in a summit on this topic last year.13

Thompson and colleagues summarise the extensive evidence base for ideal post-hospital therapy (https://www.mja.com.au/doi/10.5694/mja14.01155), focusing on the 50% of patients who do not receive coronary intervention or revascularisation at the time of their acute episode.14 The extensive collaboration on clinical trials and registries that has gone into developing the rich evidence base is a source of pride in modern cardiology, but many gaps in evidence remain.

Thakkar and Chow reassert the truism that drugs do not work in patients who do not take them (https://www.mja.com.au/doi/10.5694/mja14.01157); there is evidence that non-adherence among post-ACS patients is common and associated with adverse outcomes.15 Their review summarises strategies to improve adherence to prescribed medications, and touches on the future possibility of a polypill to include a combination of evidence-based therapies to improve adherence.

Finally, Vickery and Thompson take the GP’s perspective in managing the post-ACS patient and describe eight common challenges that GPs face in this setting (https://www.mja.com.au/doi/10.5694/mja14.01250). The need for courteous, detailed communication between the hospital and primary care is highlighted.

The common theme of each article in this supplement is that progress has been impressive, but much has to be done to continue the improvements in understanding and in translating the knowledge we already have into further improvements in outcomes. The disturbing evidence from recent Australian nationwide surveys that the application of proven evidence-based therapies remains less than optimal16 is a concern and presents a major challenge in the modern management of ACS.

Eight challenges faced by general practitioners caring for patients after an acute coronary syndrome

General practitioners have an essential role in the management of patients who have recently been discharged from hospital after an acute coronary syndrome (ACS). As the duration of hospital stay has shortened over recent decades, this role has become even more important. There are many challenges facing the GP in fulfilling this demanding role. This article deals with eight common challenges faced by the GP caring for patients after an ACS.

Not enough information from the hospital

Insufficient documentation ranks as one of the major gripes of GPs dealing with hospitals. It is a worldwide problem, and not limited to ACS, although arguably of greater consequence in this potentially unpredictable and life-threatening condition. The discharge summary is the most important and often the only form of communication from hospitals to primary care. An Australian study in 2001 showed that only 37% of hospital discharge summaries reached the GP.1 Audits of discharge summaries in Victorian hospitals found high completion rates within hospital records (88%–100%) but significant delays in sending them to GPs (only 4%–32% within 14 days), with fewer than a third available to GPs at the first post-discharge visit.2 Quality improvement initiatives can improve these rates — a recent national audit as part of quality improvement showed that 77% of GPs reported receiving a discharge summary for patients with ACS at a median time of 3 days (range, 0–41 days) after discharge.3 The addition of electronic discharge summaries from hospitals in Australia has improved timeliness, with 83% of GPs receiving them within 2 weeks from hospitals with such a service.4

It is essential that the discharge summary from the hospital conveys the information necessary for the GP to manage the patient’s condition after hospital. The list of medications with proof of benefit is quite large, and the ACS patient may be taking an additional four or five new medications at discharge from hospital. The antithrombotic regimen varies according to whether the patient received conservative management, insertion of a bare-metal stent, or insertion of a drug-eluting stent in hospital.

The patient may be confused about the purpose of their medications or be unconvinced of their benefit, a setting ripe for non-adherence. There is clear evidence that non-adherence to evidence-based medications can have highly adverse effects on outcome after an ACS.5 A clear-cut management plan has been shown to improve adherence and to improve outcomes.6 This is recommended by the National Heart Foundation of Australia7 and should be considered as part of an overall effort to improve risk factor reduction, adherence to medications and improvement of outcomes.8 A timely hospital summary that includes this basic information avoids the patient and the GP wasting valuable time obtaining the information.

The patient is taking dual antiplatelet therapy and needs surgery

The patient who needs surgery during the 12 months after an ACS or insertion of a drug-eluting stent presents a particular challenge. In the stented patient, there is concern about the risk of stent thrombosis, and this is reduced with dual antiplatelet therapy (DAPT; ie, aspirin with a P2Y12 inhibitor such as clopidogrel, ticagrelor or prasugrel).9 Drug-eluting stents significantly reduce the risk of restenosis at the site of the stent, but require a longer period of DAPT than bare-metal stents to allow for re-endothelialisation of the coronary artery lesion.10 As a result, international guidelines recommend 1–3 months of DAPT for patients who have received a bare-metal stent and 12 months of DAPT for patients who have received a drug-eluting stent, with strict adherence to these guidelines recommended.11 Some cardiologists prefer a longer course of DAPT if there has been a complex percutaneous coronary intervention or if there is evidence of previous stent thrombosis. There are recent challenges to the recommendations, which have now been in place for more than 5 years and were based on data from older stents.12 A recent meta-analysis of more modern drug-eluting stent technology shows that 6 months of treatment compared with 12 months reduces the risk of bleeding without any adverse effect on stent thrombosis.13

For the patient requiring surgery while taking DAPT, close communication between the surgeon, cardiologist and GP is essential. The risk of thrombosis versus the risk of bleeding needs to be carefully assessed for each case.14 Some types of minor surgery (eg, removal of superficial skin lesions) can be undertaken while maintaining DAPT. Most surgical procedures can be conducted safely with the patient maintained on aspirin alone. For higher risk procedures, such as neurosurgical or neurovascular procedures, bridging with an alternative rapidly acting antiplatelet regimen using a glycoprotein IIb/IIIa inhibitor may be recommended.15

For those who have been managed conservatively, the relatively high risk of recurrence and the proven efficacy of DAPT16 has led to the current recommendation that DAPT remain for 12 months.17As these patients have not received a coronary stent, their risk of coronary thrombosis may be lower, particularly after the first few months. The patient needs to be apprised of the risks and engaged in the decision-making process.

The post-ACS patient with atrial fibrillation

Atrial fibrillation (AF) commonly coexists with coronary heart disease, or may occur after ACS.18 The antithrombotic regimen for the post-ACS patient targets atherothrombosis, and DAPT is mandated for 12 months after ACS for most patients (see above). The risk of stroke is a concern in patients with AF, with an annual risk of 5%, two to seven times that of people without AF.19 Aspirin, clopidogrel or DAPT have not been shown to be protective against the risk of stroke in AF,20 and anticoagulation with warfarin or a novel oral anticoagulant is recommended in all AF guidelines for patients at risk of stroke, as determined by their CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke, vascular disease, age 65 to 74 years, sex) score.21,22Therefore, most post-ACS patients with AF require triple antithrombotic therapy with a combination of an oral anticoagulant and DAPT. This nearly doubles the risk of bleeding compared with warfarin monotherapy, so the patient requires careful monitoring.23

Recent studies have looked at shortening the duration of DAPT with newer stents,13 or withdrawing one of the antiplatelet agents. A trial in post-stented patients with AF that compared the effect of triple antithrombotic therapy (aspirin, clopidogrel and warfarin) with that of double antithrombotic therapy (clopidogrel and warfarin) showed no adverse effects with stroke or coronary thrombosis and a substantial reduction in bleeding.24 Similar results were seen in the “real world” of a large Danish registry study.25 While this is not definitive evidence, it suggests that it may be possible to withdraw aspirin after a few weeks of triple antithrombotic therapy and continue with warfarin and clopidogrel. There are no clinical trials or observational studies to guide therapy in patients taking the new oral anticoagulants or with newer antiplatelet agents such as ticagrelor, and such studies are urgently needed.

The patient wants to consider smoking cessation medication

Smoking cessation is essential after an ACS. Although it is true that there have not been controlled clinical trials to confirm the benefits of cessation of smoking after an ACS, there are ample observational studies to show that continuation of smoking leads to greatly increased risk of death and recurrence of myocardial infarction,26 and cessation can reduce the risk by about a third.27 While unassisted cessation is the most effective method,28 the reality of clinical practice is that many patients feel they need assistance. A Cochrane review of nicotine replacement therapies (NRTs) in trials involving more than 50 000 patients has shown that all the methods of delivery (chewing gum, transdermal patches, oral and nasal sprays, inhalers and tablets/lozenges) are effective, at least in the short term, in assisting quitting, with 50%–70% of patients achieving abstinence.29

The Cochrane review confirmed that NRTs did not increase the risk of coronary events. Despite this, there are widespread apprehensions among patients30 and stop-smoking practitioners31 about the safety of NRTs, and this limits their use, effectiveness and adherence. GPs have an important role in reassuring post-ACS patients that these safety concerns are misplaced.32

Bupropion is an antidepressant with partial nicotine antagonist properties, and has been extensively evaluated as adjunctive therapy for smoking cessation. It is effective in the short term, and a Cochrane review showed no adverse cardiovascular effects.33 Varenicline has similarly been extensively evaluated in clinical trials, and formal analysis shows no adverse cardiovascular or serious psychiatric adverse effects.34 A summary of the evidence for NRTs, bupropion and varenicline concluded that combination NRTs and varenicline had the highest rate of cessation and the lowest risk of long-term relapse.35 Both varenicline and bupropion have United States Food and Drug Administration (FDA) warnings about the risk of unusual changes in behaviour, with thoughts of suicide or dying in some patients,36 but the warning does not refer specifically to cardiovascular risks for either drug. The GP can discuss the use of these smoking cessation drugs with their patients, and can reassure in general terms about the cardiovascular risks, but may conclude that counselling and support may be more appropriate.

The patient complains of persistent lethargy after ACS

With modern management, the patient who has recovered from an ACS without suffering extensive myocardial damage can usually be expected to return to normal activities a week or two after the event. Unusual lethargy continuing after a coronary event can be a major clinical challenge. Depression is a common comorbidity and an important factor indicating a poor prognosis,37 and should be actively considered in the patient with post-ACS lethargy. The American Heart Association has recently recommended that depression should be elevated to the status of a risk factor for adverse medical outcomes in patients with ACS. However, there is currently no evidence to link causality of depression to ACS, nor that treating depression improves survival from ACS.37

Tricyclic antidepressants have well recognised adverse cardiac effects38 and should be avoided except in low doses. A multicentre study showed that the selective serotonin reuptake inhibitor (SSRI) sertraline was safe and effective among post-ACS patients39 and, subsequently, meta-analysis of the SSRI trials have shown no adverse effect on cardiovascular outcomes.40

Drug-induced causes of lethargy should also be considered. With increasing use of potent antiplatelet regimens after ACS, the risk of gastrointestinal bleeding has increased, and this may lead to lethargy from iron-deficiency anaemia. The negative chronotropic effect of β-blockers may also contribute. There is ongoing debate about the ideal duration of β-blockers after ACS, but in the patient who has recovered well with no left ventricular dysfunction or angina, it may be possible to taper off the β-blocker without adverse effect.41

Hypotension and hypovolaemia are also common in the early post-hospital phase of ACS management. This may be due to unnecessary continuation of diuretics or over-enthusiastic dosing with angiotensin-converting enzyme (ACE) inhibitors. This is easily recognised and its early management can lead to a dramatic improvement in wellbeing. If the patient is free of symptoms of cardiac failure and there is no left ventricular dysfunction on echocardiography, there is no benefit in continuing diuretic therapy. Reduction of the dose of ACE inhibitor may be very helpful for the patient with lethargy from persistent hypotension. Of course, the patient may be lethargic because of cardiac failure, and it is important to check left ventricular function with an echocardiogram or by measuring B-type natriuretic peptide to rule out this possibility.

The patient wants to stop statin therapy

Statins have been extensively studied, and a detailed meta-analysis of 170 000 participants in 26 statin trials has shown them to be very effective and safe in most patients, with a 21%–22% relative risk reduction in cardiovascular disease events per 1 mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) levels over 5 years.42 The evidence is so persuasive that most authoritative bodies now recommend that statins of moderate to high intensity be prescribed after ACS irrespective of the cholesterol level.43

However, there has been a lot of publicity in Australia about the side effects of statins. Some of the reporting has been alarmist and irresponsible,44 and many patients are confused about this issue. The highlighting in 2012 by the US FDA of possible cognitive dysfunction was a major concern for many patients.45 The FDA’s advice was widely promulgated despite meta-analysis of all studies from 1986 to 2012 showing no evidence of increase in dementia or Alzheimer disease.46,47The meta-analysis cited above showed no sign of an increase in cancer.46

An increase in the risk of rhabdomyolysis is the main serious side effect that has been shown with statins in controlled trials. This is exceedingly rare, occurring in about one patient per million prescriptions.48 It is dependent on the type of statin, with a higher rate from high-dose simvastatin than atorvastatin among post-ACS patients.49,50On the other hand, myalgia, with or without marginal elevation of creatine kinase, is common and may occur in about 10% of patients.51 Recent reports of an increase in diabetes52 are further cause for concern with some patients, but it is important to point out that a statin is one of the most effective treatments for lipid management in established diabetes.53

For the patient who is unconvinced by the overwhelming scientific data, a trial of a lower dose or a change in statin may be helpful. If the patient insists on a trial of alternative “natural” cholesterol-lowering drugs, this should be monitored with cholesterol levels if possible. A dramatic increase in total cholesterol or LDL-C level with alternative therapies may be sufficient to persuade the patient to continue with statin therapy. An agreement with the patient that a period of several weeks off the statin to assess the effect on muscle soreness or mental agility may demonstrate that the “side effects” are related to either normal sensations or other causes, rather than a drug side effect.

Among patients who have proven side effects, the use of an alternative LDL-C-lowering agent, such as ezetimibe, cholestyramine or newer experimental agents, may need to be considered. Ezetimibe can effectively lower LDL-C levels, but the benefit of this on outcomes is yet to be established.54 Nicotinic acid has not been shown to be effective.55

Dietary management has shown reductions in LDL-C levels. About 2 g/day of plant stanols and sterols has been shown to reduce LDL-C levels by about 10%,56 and the addition of fish oils in those who cannot take statins may show statistically significant reductions in adverse outcomes, despite conflicting recent meta-analyses.57 This dietary management for reduction in LDL-C levels can be additive to a low-fat diet and cholesterol-lowering medication.

The patient has not reached the target level with statin therapy

The target LDL-C level for post-ACS patients was set at < 1.8 mmol/L after the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT – TIMI 22) study.49 This demonstrated that a high-intensity statin was more effective than a moderate-intensity statin. The median LDL-C level achieved during treatment in the high-intensity (atorvastatin 80 mg) group was 62 mg/dL (1.60 mmol/L) and in the moderate-intensity (pravastatin 40 mg) group was 95 mg/dL (2.46 mmol/L). The outcome was to set the US target level for post-ACS patients to below 70 mg/dL (1.8 mmol/L),58 and Australia followed suit on this.59

A recent revision of the US guidelines has recognised that the target levels were never tested in clinical trials and are based on an extrapolation of the clinical trial evidence.45 These new revised guidelines recommend high-intensity statin therapy (defined as a daily dose that lowers LDL-C by ≥ 50%) rather than moderate-intensity statin therapy (lowering LDL-C by 30% to < 50%). High-intensity statins available on the Australian Pharmaceutical Benefits Scheme are atorvastatin 40–80 mg and rosuvastatin 20–40 mg.

The GP’s role is to check that the patient is taking one of these drugs at the correct dose. If there is persistent elevation of the LDL-C level, a careful check on adherence may be needed. Statin adherence rates overall in Australia are low, with a community-wide study in 2011 showing 43% of patients discontinued statin within 6 months, 23% failed to collect their first repeat prescription at 1 month, and a median persistence of 11 months.60 If adherence has been confirmed, a higher dose of statin could be considered (eg, an increase of atorvastatin from 40 to 80 mg/day, or rosuvastatin from 20 to 40 mg/day). The addition of ezetimibe or another lipid-lowering agent to a statin has been shown to further lower LDL-C levels, but there is no current evidence of a benefit on cardiovascular outcomes.61

The patient seeks advice on erectile dysfunction and the safety of PDE5 inhibitors

People with coronary heart disease have a risk of erectile dysfunction because of the associated endothelial dysfunction,62 and possibly the effect of some cardiovascular drugs.63 While men are notoriously reluctant to seek advice on erectile dysfunction, it may be an indicator of worsened cardiovascular risk and the GP needs to be alert to subtle clues to indicate evidence of erectile dysfunction and encourage discussion.64 Adjustment of medications (such as reduction of β-blockers and diuretics)65 and reduction of cardiovascular risk factors may be helpful.66

Usually, however, use of phosphodiesterase type 5 (PDE5) inhibitors may need to be considered.67 There are multiple studies to confirm the overall safety of PDE5 inhibitors in patients with cardiovascular disease,68 although the longstanding caution that they must not be used in conjunction with nitrates remains valid.69 The GP must check the post-hospital medications to ensure that nitrates in any form (isosorbide mononitrate, nitrate patches, nicorandil) are not being taken by the patient, and that glyceryl trinitrate spray is not used within 24 hours of sildenafil or vardenafil administration or within 48 hours of tadalafil administration.64 Choice of PDE5 inhibitor is a matter of preference. A recent meta-analysis concluded the safety profile of each of the agents was similar.70 The use of low-dose daily tadalafil has been explored as an alternative to intermittent use, with some success and a good safety profile.71 The patient’s partner may express concern about “strain on the heart” of enhanced sexual activity with successful use of a PDE5 inhibitor, but the information that the absolute risk increase for myocardial infarction associated with 1 hour of sexual activity per week is estimated to be only 2 to 3 per 10 000 person-years may be of some reassurance.72

Conclusion

Of these eight challenges, most can be managed with improved communication between the hospital, the treating cardiologist and the GP. A team approach is essential to deliver effective evidence-based care. When balancing risks (for instance, bleeding versus thrombotic risk), the patient needs to be fully engaged in the decision making.

A real-world, data-driven view of general practice prescribing

In my years of working in the health sector, one of the biggest ongoing challenges we are yet to resolve is how to get access to quality population-level data. In this era of progressive health informatics, and despite our incredible advancements in technology, it continues to be a tricky problem.

In 2012, NPS MedicineWise set out to develop a way to better understand prescribing behaviour in Australian general practice — how medicines are prescribed, for whom and why, and what happens when new medicines become available. This program is called MedicineInsight and over 300 practices nationally are now participating, representing over 1500 general practitioners and 3.5 million patient encounters to date.

So how does it work? Using a custom-built data extraction tool that operates seamlessly and securely in the background with the practice’s clinical software, non-identifiable patient and clinical care information from participating practices is collected and analysed. Regular reports and whole-of-practice facilitated discussions assist GPs to track their patient care over time, and in particular their prescribing of medicines. This provides a better understanding of the effect of those medicines on patients and where health care improvements could occur, either in practice or in policy. The program is government-funded and received ethics approval from the Royal Australian College of General Practitioners. Early evaluation indicates that participants greatly value the tailored reports they receive to inform and improve their clinical practice and patient care.

MedicineInsight has the potential to be the primary source of real-world general practice data on patient care, from diagnosis through to medicines used, tests ordered and clinical impacts of management. These unique longitudinal data will inform health services planning, monitoring and evaluation at all levels — from the individual patient to the whole health system. However, realising this potential relies on more practices becoming involved. More information on the program and how to register is available at http://www.medicineinsight.org.au.

A framework to support team-based models of primary care within the Australian health care system

This is a republished version of an article previously published in MJA Open

Health systems with strong primary care orientations are known to be associated with improved equity, better access for patients to an increased number of appropriate services at lower costs, and improved population health.1,2 However, these health systems also need to be able to respond to the increasing demands created by an ageing population and workforce, and increasing complexity in primary care presentations. This needs to occur in the setting of health systems that are becoming increasingly complicated and fragmented. Problems such as workforce shortages and maldistribution of workforce skill mix and roles within geographical and service settings lead to services not always matching the needs of patients.

Team-based models of care have emerged in response to such demands on health systems.3,4 The prevailing pattern of service delivery is evolving, from the solo general practitioner to team-based care (involving the GP, practice nurse and allied health professional) and to expanded primary care teams (involving health system facilitators, care coordinators, generalist rehabilitation assistants, physician assistants, nurse practitioners, pharmacists and paramedics). These expanded team-based models of primary care involve and support transformation in workforce roles and relationships within primary care. They are designed to:

  • contribute to building the primary care workforce multidisciplinary skill mix;

  • enhance patient access to a broader range of primary care providers; and

  • improve the quality of primary care.

Factors influencing team-based models of primary care

Multiple factors are required for successful team-based models of primary care, including interprofessional education and learning, organisational and management policies, and practice support systems.5–11

Interprofessional education and learning

Interprofessional education and learning (IPEL) is recognised internationally as a building block to help primary care professionals work more effectively in team-based care.7,9,11–15 IPEL initiatives enable acquisition of knowledge and skills and have been well received. Limited evidence exists that IPEL can enhance practice, improve service delivery and make positive impacts on care. IPEL still suffers from lack of definitional clarity; variable content, duration, and professional participation; and variable evaluative studies.11

The recent release of core sets of IPEL competencies16 in the United States and Canada will add rigour and clarity to IPEL.

Nine key ingredients of successful IPEL initiatives include: recognising that one size does not fit all; adequate and dedicated resourcing; curricula development across universities and the community; introduction at the right time; creation of collaborative learning environments; modification of structures to support collaboration; embedding IPEL in the system; making a case for IPEL based on the evidence; and interprofessional participants engaging the community.7

Organisational and management policies and systems

Evidence from experience with primary care groups and primary care trusts in the United Kingdom, primary health organisations in New Zealand and family health teams and family health networks in Canada strongly suggests that regional-level primary care organisational structures, policies and systems can enable and support team-based models of primary care through financial, governance and institutional support mechanisms.17–19 However, it is also known that funding, organisational and regulatory arrangements need to align to support such organisational structures.12

Practice support systems

We have chosen to describe two of the most current and relevant practice support systems within primary care that demonstrate the interrelatedness of health system innovations within care delivery, workforce systems, records management, and payment systems.

Electronic health records

Electronic health records (EHRs) are an example of a practice support system that is firmly on the agenda in many countries, and progress has been made in their introduction and use across primary and secondary care settings.18 EHRs have the capacity to enhance teamwork, but there is insufficient evidence to conclude that they are currently being used to achieve this. E-health systems underpinning EHRs are being poorly implemented and require substantial funding for successful integration and utilisation.18

Practice-level payment systems

Practice-level payment systems also can enhance teamwork but do not guarantee teamwork. The UK Quality and Outcomes Framework (QOF) is an example of a practice-level payment system that has led to an expanded workforce (eg, practice nursing) but has not facilitated teamwork, as payment systems have reinforced traditional hierarchies headed by GPs, and have disempowered nurses.20 The QOF has promoted task delegation rather than collaborative teamwork.20 Team-based performance management and payment systems have potential to enable, support and reward teams for collective performance within primary health care, though rewards to team members need to be viewed as equitable among team members.21,22 Evidence of the effect of specific funding parameters on team-based work is limited. For example, while capitation payment based on an enrolled population of patients has potential to enable teamwork, when it has been adopted there has been little evaluation of the contextual and mitigating factors influencing teamwork outcomes.12,14 Blended-payment systems are being used to reward teamwork, although their effect on teamwork and outcomes is unclear.14 Fee-for-service payment systems are a barrier to teamwork within primary care, as they reinforce professional autonomy and independence, and are not appropriate for patients with chronic and complex conditions, who often require continuous care (not episodic) by multiple primary care professionals working together.14

Other influences on teamwork outcomes

Outcomes of implementing team-based models are also influenced by the type and level of team leadership (particularly collaborative or distributed leadership styles); team composition, including skill mix, knowledge and experience; the extent to which members have shared objectives, communicate, make decisions jointly, support innovation and review working progress; the extent to which funding arrangements reward teamwork; and to what degree regulatory mechanisms support, value or reward teamwork.10

A framework to support team-based models
of primary care

To ensure that practice is influenced by evidence about interprofessional education, organisational and management policies and practice support, we propose a framework to support team-based models of primary care within the Australian health care system.

Current Australian health reforms continue to emphasise the need to provide all Australians with access to cost-effective community-based primary care by supporting and strengthening a well trained, multi-disciplinary, team-based workforce.23 Thus an evidence-informed framework that assists policymakers, educators, researchers, managers and health professionals to support team-based models of primary care within the Australian health care system is essential.

Our proposed framework comprises five key domains: theory, implementation, infrastructure, sustainability and evaluation (Box). The framework was informed by a realist evaluation approach24 and seeks to understand what mechanisms work for whom, and within which contexts.

Context is a particularly complex concept in health care, and even within primary health care, due to the ever-changing and inconsistent nature of the context in which care is delivered. The ultimate goal of a realistic evaluation is that it opens up the “black box” and analyses how and why interventions work or don’t work in particular contexts or settings. This is important because it “closes the loop” on a new intervention, in this case changing the culture of primary health care delivery because we are able to explore the factors supporting this change in the relevant contexts.

Theory

There is wide recognition that interventions fail or succeed depending on the appropriateness or validity of the theory or assumption on which they are based. Multiple theoretical perspectives (eg, sociological, organisational, systems) exist about interprofessional working relationships that can inform support for team-based models of care. We discuss here the potential of an organisational (ie, relational coordination) and a system (ie, complex adaptive system) theoretical framework that may provide a way forward to use the evidence base to develop, implement and evaluate team-based models of primary care.

For over a decade, primary care has been described as a complex adaptive system (CAS).25 “Complex” implies diversity; “adaptive” suggests capacity to change and ability to learn from experience; “system” recognises that primary care is comprised of a set of multiple interconnected or interdependent agents acting with common purpose with dynamic environments. More recently within the public health setting, the term “fifth wave”26 has been used to rebalance and reorient our mindsets, our models and our learning processes in response to challenges facing public health. A CAS requires facilitative leadership, high-quality relationships, and feedback in reciprocal interactions to increase the capacity for collective, creative problem solving. A CAS can provide a framework for sharing common sets of concepts and principles, common language and a common approach that facilitates team-based approaches among primary care professionals.

Based on the argument that coordination is the management of task interdependence, and is therefore fundamentally relational,27 we need to understand the importance of relationships in coordinating team-based work. According to the theory of relational coordination, coordination that occurs through frequent, timely and problem-solving communication supported by shared goals, shared knowledge and mutual respect will better achieve the desired outcomes. The “relational coordination” lens can provide a theoretical framework for team-based models of primary care.

Implementation

There is also wide recognition that interventions may fail or succeed when implementation or the “how to” has not had sufficient attention. This is often a frustration of the change agents involved (who may be health professionals, service managers, or a range of other “key players”). A multitude of factors can influence (enable or constrain) the capacity of the system to support team-based models of primary care. At the individual level these can include role delineation, skill sets, competencies, and personality attributes. At the organisational level these can include culture, structure, leadership, contractual arrangements and time frame. At the systems level these can include, for example, policy context, sector policy know-how, workforce pressures and funding pressures. To build the capacity of the system to support team-based models of primary care, a capacity-building lens focusing on three operational capacity-building dimensions is required: individual-level workforce skills and competencies; organisational-level leadership and interactions; and system-level infrastructure — to provide a transparent and systematic approach to ensuring key ingredients of successful team-based models are implemented as intended.

Infrastructure or resources

Preparing and supporting the primary care workforce to work in team-based models requires adequate and dedicated infrastructure and resourcing. An existing framework that articulates the type and level of infrastructure and resources required is the WHO framework for action on interprofessional education and collaborative practice.28 The WHO framework identifies three mechanisms that can provide a framework to ensure that the multifaceted and multidimensional resources that support team-based models of primary care are implemented as intended:

  • institutional support mechanisms — eg, governance models, structural protocols, shared operating resources, personal policies and supportive management practices;

  • working culture mechanisms — eg, communication strategies, conflict resolution policies and shared decision-making processes; and

  • environmental mechanisms — eg, built environment, facilities and space design.

Sustainability

Policymakers, professionals and communities face challenges in sustaining worthwhile innovations, especially in primary care. Internationally and within Australia, multiple reviews of factors that promote or constrain sustainability of interventions within the system have been conducted. Endeavours to expand knowledge about sustainability have been labelled “sustainability science”,29 which is underpinned by the concept of “ecosystem”. This recognises that the organisation and interaction of the components of the system are as important as the system itself. Gruen and colleagues conducted a systematic review of conceptual frameworks and empirical studies about sustainability29 and developed a unifying model based on the “ecosystem” lens. The model proposes that sustainability of interventions within systems is influenced by the interaction and alignment between three key components: the health concerns of the population, the intervention elements, and the drivers (positive and negative) of the intervention. It can be used to determine the potential sustainability of interventions designed to support team-based models of primary care.

Evaluation

There is clearly a lack of evidence regarding the implementation and impact of team-based models of primary care to inform what works, for whom and in what circumstances. A review of incentives for primary health care team service provision10 recommended, on the basis of limited evaluative evidence, that a key priority was to develop teamwork-focused evaluative tools and indicator sets. The review also suggested that investment was required in reviewing existing (international and Australian) teamwork-related, evidence-based, evaluative inventories, tools and methods for use in the Australian setting, as well as in developing and piloting a set of process and summative teamwork-evaluation indicators (at patient, provider, organisational, and systems levels) for use in the Australian setting. Since then, a systematic review of instruments used to assess teamwork has been conducted28 that further emphasises recommendations supporting team-based service provision.10 Another review of instruments to measure teamwork30 found that very few existing measures demonstrated psychometric properties recommended for use, and that there was inconsistency in conceptualisations of teamwork. A key recommendation was that more research be undertaken to aid in developing and refining measures of teamwork for reliable use by researchers and practitioners or managers. Overall, there is a need for an integrated evaluation strategy focusing on interprofessional, organisational, and practice support strategies for team-based models of primary care.

Conclusion

Current Australian health care policy reforms continue to emphasise team-based primary care, and the proliferation of team-based models and investments designed to sustain their implementation require a robust framework of support. The framework we propose is an evidence-informed way to assist policymakers, educators, researchers, managers and health professionals to support team-based models of primary care within the Australian health care system. The framework is not necessarily for use as a whole, nor is it to be followed as a recipe, without reflection; rather, it is as a set of ingredients to support the implementation and sustainability of team-based models of primary care.

A framework to support team-based models of primary care

Difficult-to-treat-depression: what do general practitioners think?

This is a republished version of an article previously published in MJA Open

The social, economic and personal burdens caused by depression are substantial1 and well documented.2 Nonetheless, shortcomings in treatment of depression have been identified in both primary and specialised care, with respect to diagnosis, management and patient adherence.

Health professionals, including general practitioners, may be confused about diagnosis and management when clear definitions and acceptable taxonomy cannot be found. In the literature, terms including “difficult-to-treat depression”, “treatment-resistant depression”, “treatment-refractory depression”, “treatment-resistant major depressive disorder” and “major depressive disorder” are often used interchangeably,3–5 resulting in considerable confusion. Further problems arise because of a mismatch between current classification systems, such as the Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) or the International Classification of Diseases, and the possible clinical phenotypes of mental disorders, particularly as they present in primary care.6 It has also been suggested that meaningful subtypes of depression might have different treatment outcomes, raising another clinical imperative for accurate diagnosis.

Against this background, we aimed to explore GPs’ understanding of the definitions of and management guidelines for difficult-to-treat depression (DTTD), and their experiences of diagnosing and managing patients with DTTD.

Methods

During 2011, a convenience sample of GPs from inner Melbourne, outer Melbourne and rural Victoria was recruited through Monash University networks using an email invitation, followed by telephone contact.7,8

A semi-structured interview schedule comprising five topics was developed from the literature to address the study aims.7,8 Topics explored were: (1) understanding of DTTD; (2) understanding of other terms used to describe DTTD; (3) experiences of diagnosing DTTD; (4) experiences of managing DTTD; and (5) management options.

A 90-minute face-to-face focus group was conducted with participants from inner Melbourne. Participants from outer Melbourne and rural Victoria each had a telephone interview of 15–30 minutes’ duration. The focus group and interviews were audiotaped and transcribed verbatim. Data were collected in the latter half of 2011 by one of us (K J).

Data were analysed manually and independently by two of us (K J, L P) using the framework method,9 to understand participants’ perspectives. When there was a difference of opinion between the two reviewers, the issues were discussed until consensus was reached.9

Results

Ten GPs were invited and all agreed to participate: five (two women, three men) from inner Melbourne participated in the focus group; three (all men) from outer Melbourne and two (one woman, one man) from rural Victoria had a telephone interview. All participants had been working in general practice for at least 15 years.

Findings are reported based on the interview schedule’s five topics. Quotes are attributed to participants of the focus group (FG) or those interviewed by telephone (GP).

1 Understanding of difficult-to-treat depression

Participants’ understanding of DTTD varied: some had never heard the term before, while others had an understanding that reflected most of the descriptions found in the literature. Most participants expressed confusion about the various terms used.

… in GP land, it [DTTD] is depression that hasn’t responded to the standard treatment with an antidepressant and some counselling with a psychologist (GP2)

Participants indicated they experienced challenges regarding duration of therapy and response, predictability, complexity, patient-centredness and a lack of acceptance of conventional treatment by patients.

… to me it means that it’s either [that] there are a complexity of factors that compound the treatment plan or that … either I or some other doctor already has had experience with various treatment modalities that have failed or been of limited success (GP5)

In spite of their efforts to understand and manage the condition, including consulting with psychiatrists and other health professionals, participants reported that some patients had suicided.

… I think GPs have a very different view of or define depression differently from psychiatrists (FG3)

… I can think of two cases [of patients] who have suicided and in both instances it was so complex … it’s really difficult to manage (FG2)

2 Understanding of other terms used to describe
difficult-to-treat depression

The participants were confused by the various terms used in the literature to describe DTTD. Most had not heard of treatment-resistant depression; one participant suggested that this term was linked to patients’ lack of acceptance of their problem and subsequent non-adherence to medication.

… in fact I even [checked] “Scholared” this afternoon just to make sure it [treatment-resistant depression] was a real entity (FG3)

… treatment-resistant means you’ve gone through a gamut of treatment options and still have major depression symptoms on your hands (GP1)

Most participants had an understanding of treatment-refractory depression. Their concepts of this included insufficient time being allowed for the treatment to improve the patient’s condition. Few participants had heard of treatment-resistant major depressive disorder, and those who had thought it was complex and may be a subtype of major depression. One participant thought the term described patients who had other psychiatric comorbidities.

… [treatment-resistant major depressive disorder] is this [DSM-IV] … is that a category? It’s just a bunch of words that have happened together basically to describe a category of people? (FG5)

3 Experiences of diagnosing difficult-to-treat depression

There was agreement among participants that only a small number of patients present to GPs with DTTD, but that they take up a disproportionate amount of clinician time. Diagnosis was considered difficult, particularly in cases complicated by coexisting conditions.

… I question the initial diagnosis, whether there’s something more going on, or whether there are some other methods of treatment which may be required (GP1)

Some participants used management guidelines, such as the DSM-IV, but felt they were not always helpful, as they were difficult to negotiate and apply to particular patients. Others suggested that diagnostic tests have an important role in ensuring any initial diagnosis is correct. The general consensus was that tight diagnostic labels may not help GPs, but that the term DTTD could be useful because it would flag patients who may require input from a specialist.

… the names, the labels, don’t mean that much, it’s the patient in front of me … that matters (GP2)

However, the value of referral to specialists was questioned by some participants.

… just knowing [patients] are difficult to treat doesn’t actually mean that they should go and see a psychiatrist or that going to see a psychiatrist changes the outcome at all. A lot of them, in that more or less major depressive sort of sphere, don’t actually respond to a psychiatrist or psychologist (FG3)

Participants generally felt that their relationship with the patient was important in managing them, but the option of involving family members was not mentioned.

4 Experiences of managing difficult-to-treat depression

All participants had managed patients with DTTD and often found it difficult.

… ongoing management, even if shared care, is still a difficult proposition (GP1)

… I’m considering a couple of patients with really long-term chronic pain, already on antidepressants; it’s just so hard to sort of tease out their mood and what’s going on (FG1)

Managing these patients was described as a team effort because there can be many exacerbating environmental factors, such as low socioeconomic status, social isolation and relationship conflict, that could be related to poor treatment outcome.

… some of the patients who don’t accept that they have a problem, they are really, really difficult (GP4)

Shared care was valued, particularly for patients who had been hospitalised or who had comorbidities. Participants felt they knew about the patients’ physical and family issues, but their level of concern about patients at risk led them to seek input from experts.

… GPs are much better at individualising treatment based on a bit more [of a] holistic approach, and that’s one reason why it’s difficult to get a treatment algorithm for all very seriously depressed patients (FG3)

Few participants knew about or had used available services, such as the Primary Mental Health Team initiative in Victoria, or government initiatives such as the Mobile Aged Psychiatry Service. Most participants were aware of the Medicare “Better Access” program.

… I didn’t realise you could claim for it [GP psychiatry support] (FG4)

5 Management options

Only one participant had heard of the Wagner chronic illness management model,10 but all acknowledged that a chronic disease management model can be useful in DTTD.

All participants had referred some of their patients with depression to a psychiatrist. Some did so because the patients had multiple needs, others when they felt they needed a psychiatrist’s opinion; some felt referring to a psychiatrist was reserved for severely ill or suicidal patients.

… if I’m getting uneasy, that to me is good enough to call for help, because [of] the consequences, I think [management is] better under specialist care (GP5)

However, accessing a psychiatrist was problematic because of lack of availability, especially of bulk-billing psychiatrists.

… there is a gross limitation of availability [of psychiatrists] in this rural region, so availability is a major issue; so is cost (GP1)

… I work in a bulk-billing practice and patients want to be bulk-billed, and we don’t have enough bulk-billing psychiatrists (GP3)

In the absence of an accessible psychiatrist, some participants used mental health care plans to refer patients to psychologists and social workers. Others used the services of the Primary Mental Health Teams.

… [in my area] for some patients, getting an appointment is a problem because all psychiatrists are private, but various patients now have a mental health care plan and they go to a psychologist (GP4)

… I use the Primary Mental Health Team; it’s a useful concept when, with this sort of complicated cases [and] you’re not quite sure, they will feed back information, then assist you in the management (FG2)

Regardless of cost and accessibility, the relationship between the specialist and the patient was felt to be particularly important.

… a significant challenge is to find a psychiatrist who’s compatible with the patient, and a significant proportion of the people who most need it can’t afford it and then they’ll be at the mercy of the public system, which has very limited access (GP5)

Most participants felt that non-pharmacological or complementary treatments and “lifestyle options” have a role in managing DTTD.

… there are patients who seek alternative treatments like hypnotherapy, St John’s wort, acupuncture, and I suggest lifestyle stuff, setting themselves an agenda for the day (FG5)

… I’ve got somebody [who is] connected with a church, and it’s been a real comfort and help for her, and another who I suggested meditation to (FG1)

Discussion

This small qualitative study of experienced GPs from urban and rural settings in Victoria raises a number of important issues regarding how GPs evaluate and respond to patients with DTTD.

Although participants demonstrated limited knowledge of the different classifications of DTTD, they had extensive experience in managing and treating patients whose illness was difficult to treat. They had little interest in the nuances of classification, and instead focused on the patient and what to do in practical terms regarding optimal management.

While all participants were aware in general terms of government initiatives that could provide support for patients with DTTD, there were gaps in their knowledge about the specific programs and resources available. Participants were also aware that specialist resources were limited, regardless of location. Thus, they used other management options, including non-pharmacological or complementary treatments. Few were enamoured of existing guidelines, finding them difficult to access and use.

Limitations of this study include the small number of participating GPs and the fact that all were from Victoria. However, they all had extensive clinical experience, and a number of themes relevant to DTTD were raised.

To improve management and treatment of DTTD in both primary and specialised care, resources need to be more available and accessible, including guidelines that are current and relevant to general practice in Australia. Overcoming barriers to accessing specialist and non-medical care should be seen as a priority in assisting GPs to treat patients with DTTD.

Shared decision making: what do clinicians need to know and why should they bother?

To the Editor: The ideas expressed by Hoffman and colleagues1 are laudable. In an ideal situation, shared care as described can offer benefits to patients and doctors in choosing patient-centred appropriate care.

However, for older patients with multiple morbidities and complex acute health care problems, the evidence to guide investigations and treatments is often lacking or not directly applicable. The basic knowledge of health care that patients need to possess in order to understand the risks and side effects of interventions — and even their knowledge about the natural history and processes of disease — is often absent or inadequate.2 Further, many older people have cognitive impairment that does not allow a sufficiently sophisticated assessment of risk and benefit.

In the clinical scenario provided in Hoffman et al, there was a single-system problem with good evidence. Even in this situation, I suspect that shared decision making would be challenging with a tired, distressed mother and a screaming child.

We should also be mindful that shared decision making should not result in doctors abdicating responsibility for making difficult decisions.3

Psychosocial treatment approaches to difficult-to-treat depression

This is a republished version of an article previously published in MJA Open

Despite adequate first-line treatment for depression, 50%–60% of patients remain symptomatic.1 These people require more outpatient visits and psychotropic medications than do those who respond to initial treatment,2,3 and they continue to have impaired social and occupational functioning and morbidity from other illness.4 This difficult-to-treat depression (DTTD) is therefore a considerable burden in the community, and current management options are only partially effective.5–7

There are several approaches to defining DTTD.5,8,9 A common pragmatic conceptualisation is that of treatment-resistant depression, usually defined as a failure to respond to one or more adequate trials of antidepressants. Emerging themes that may explain the occurrence of DTTD in patients include coexisting psychiatric and medical conditions, environmental and contextual factors, inadequate diagnosis and treatment, medication non-adherence, and issues such as low self-esteem, hopelessness and cognitive reactivity.

Psychosocial interventions are widely used in the treatment of major depressive disorder (MDD)10 but are less routinely applied in DTTD, despite some evidence of their efficacy.11,12 A possible reason for this is the dominance of biological treatments in the research literature for DTTD.5,11,13 A systematic review of randomised trials using psychotherapy for DTTD identified only six unique studies, all but one of which showed efficacy for psychotherapy in DTTD.12 Biological approaches to the management of DTTD are outlined elsewhere in this supplement (see Chan et al, and Fitzgerald).8,14 Here, we consider the role of psychosocial interventions.

We conducted a review of publications examining psychosocial interventions in DTTD using search phrases including: treatment-resistant depression, refractory depression, treatment-refractory depression, psychosocial, psychology, CBT, therapy, and risk factors. Articles identified included review papers, uncontrolled pilot studies, case reports and randomised controlled trials (RCTs).

Links between psychosocial factors and DTTD

Medical and psychiatric comorbidity

Patients with depression, particularly those with chronic depression or DTTD, often have coexisting medical and psychiatric conditions.7,15,16 In patients with comorbid depression and medical conditions (eg, thyroid disorders, infections, neurological conditions), the depression is often untreated or unrecognised because of shared symptoms.7 The United States National Comorbidity Survey found most lifetime cases of depression were secondary to another psychiatric disorder and that 75% of people with depression had another psychiatric disorder.17 Anxiety and depression often coexist, so that patients with a diagnosis of depression commonly experience an anxiety disorder, such as generalised anxiety disorder, obsessive–compulsive disorder or panic disorder (see Tiller).18,19 Alcohol and other substance dependencies and personality disorders also frequently coexist with depression,1,18 and recent studies have begun to identify “hidden” bipolarity features as significant factors for treatment resistance.20 Complexity and comorbidity should be considered the norm.7,15 These comorbidities complicate the clinical picture, worsen the depression, and make it difficult to treat.

Environmental and contextual factors

Patients with a diagnosis of depression, and specifically DTTD, often experience a range of negative environmental or contextual factors, such as family conflict, financial distress, work stress or job loss, poor-quality interpersonal relationships and social support, poor social adjustment, and other serious life events.1,4,5,15,21 Adverse health behaviour such as obesity, sedentary lifestyle and smoking are also identified risks for people with MDD.22 A recent systematic review of 25 primary studies involving 5192 patients with chronic depression identified that negative social interaction and low levels of social integration coexist with chronic depression.16 There is consensus that late onset of depression, family history of DTTD, and severity or chronicity of depression are also risk factors for treatment resistance.15,18

Inadequate diagnosis and treatment

Depression in primary care appears in many guises. Two-thirds of patients with depression initially present with one or more physical symptoms,23 and comorbid anxiety, personality traits, addictive behaviour and bipolarity can all potentially alter the clinical presentation. Furthermore, although there are probably different types of depression, such as melancholic, hopeless or situational depression,24 these heterogeneous presentations are often treated as though they are the one condition.

If a patient has not responded fully to the first-line treatment, it is always necessary to review the diagnosis and the treatment. Antidepressant medication and psychotherapy are both recommended as first-line treatments, either alone or in combination, for patients with mild to moderate MDD.25 However, these treatments are not always equally efficacious. For example, there is evidence that depression characterised by severe hopelessness responds poorly to antidepressants.26 Coexisting psychiatric disorders and medical illnesses require treatment in their own right if the treatment for depression is to be successful.16

Similarly, persisting contextual factors need to be taken into account when making a comprehensive diagnosis of the situation. Continuing stressors, or poor resources and coping skills, have a ceiling effect on the level of improvement that can be expected from pharmacotherapy alone.2,6

Medication non-adherence

Patients with depression often do not take, forget to take, or cannot be bothered to take their medication.18 This non-adherence to antidepressants is explained partly by personality characteristics,27 the strength of the doctor–patient alliance,28 intolerable side effects,18 and health beliefs and stigma.29 Patients’ attitudes and beliefs are at least as important as side effects in predicting adherence to medication.29 Furthermore, the depression, anhedonia and secondary demoralisation (the “giving up”, “can’t be bothered”, “it won’t help” attitude) that so often accompany depressive illness reinforce the likelihood of non-compliance.

Low self-esteem, hopelessness, anhedonia and cognitive reactivity

Individuals with chronic depression that is difficult to treat tend to experience significant low self-esteem, anxiety, demoralisation, hopelessness, and lack of joy and drive (anhedonia).21,30 In some people, these may be lifelong traits; in others, they may be activated by the depression.30 Nevertheless, people with treatment-resistant depression have more negative affect and dysfunctional cognitions than those with non-resistant depression,31 and people who experience repetitive and unhelpful thinking about depression tend to have prolonged depressive symptoms.30,32 Severe and persistent depression occurs when there is a recurring reinforcing relationship between depressed mood and negative cognitive processing. This phenomenon, in which the symptoms of depression and secondary beliefs maintain each other, producing a continuous cycle of reinforcement, is described as cognitive reactivity or cognitive vulnerability.30,32

Usefulness of psychological interventions

Patients’ thinking and behaviour play a large role in determining outcomes of treatment for depression32 and are thus prime candidates for intervention through a psychosocial treatment regimen. Evidence-based psychological therapies can be used to explore and overcome interpersonal difficulties, health beliefs and stigma, medication non-adherence, anhedonia and ruminative thinking, and can assist with the behavioural changes necessary to encourage patient activation and full recovery.

Psychological therapies with Level I evidence for use in depression are cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT), family-based therapy (FBT) and brief psychodynamic psychotherapy (BPP). Mindfulness-based cognitive therapy (MBCT) has Level III evidence for depression.10 All these therapies are brief and manualised, which allows them to be applied in a reliable way, such that their efficacy can be examined in research trials.

While considerable research has demonstrated the effectiveness of psychotherapeutic interventions in MDD, there has been substantially less investigation of these in DTTD.5,12 A recent critique of current novel antidepressant and brain stimulation therapies for treatment-resistant depression contended that psychotherapy substantially increases response rates in non-psychotic depression, and that the restrictive definition of treatment-resistant depression should be expanded to include failure to respond to psychotherapy.33 Several other case studies, reviews, uncontrolled pilot studies, open studies and RCTs provide evidence for the use of psychotherapy in DTTD.6,31,32,34–36 The range of potential psychosocial treatments for DTTD is shown in the Box.

A patient-centred approach involving adequate education, assessing a patient’s motivation and readiness for treatment, preparing the patient to accept treatment, and communicating realistic treatment expectations is an important clinical skill that has been shown to facilitate medication adherence.37 CBT and regular contact with the treating clinician may encourage medication adherence during treatment of depression.13

Cognitive behaviour therapy

A recent systematic review of 13 articles, representing seven RCTs with a total of 592 patients, concluded that psychotherapy had utility in managing treatment-resistant depression.12 Six of the trials used cognitive therapy. CBT was mostly used to augment antidepressants, but in two trials it was a standalone treatment, delivered in 16 sessions. The review concluded that primary care providers should consider psychotherapy as a reasonable treatment option for treatment-resistant depression.12 In another study, improvements in social functioning and reductions in depressive symptoms were observed after group CBT, and were maintained at 12-month follow-up.11 A combination of CBT and medication was found to be effective in patients with chronic depression and those with residual symptoms.38

CBT techniques are useful in dealing with some of the specific risk factors associated with DTTD.12,16,21,35 For example, the maladaptive cognitions and behaviour that perpetuate chronic depressive symptoms can be modified by CBT techniques such as cognitive restructuring.12,21,35 Activity scheduling, social skills training and other behavioural interventions can help overcome anhedonia, interpersonal or social problems, and coexisting anxiety.12,21,36

Interpersonal psychotherapy

There is considerable evidence that IPT is effective in treating depression, particularly around improving the quality of social relationships and interpersonal skills.10 There is little research about the effectiveness of IPT in DTTD, but it has been recommended for the treatment of chronic depression.39 IPT, as an additional or standalone treatment, has been found to be beneficial in people with recurrent MDD.40 Features of IPT that make it potentially beneficial in treating people with DTTD or chronic depression include: attention to the therapeutic alliance and the patient’s readiness to change; the case formulation that considers issues of attachment, culture, self-definition and interpersonal relatedness; and its addressing of effects of trauma, abuse or insecure attachment on patterns of relating and interpersonal sensitivity.41 IPT can also help deal with aspects of grief, relational conflict and role transition that may be intrinsic parts of the depression or consequences of it.

Family-based therapy

FBT is designed to improve communication and resolve conflicts between family members. There is considerable evidence that family therapy is effective in treating depression, particularly as individuals with depression report significant problems in multiple areas of family functioning.10 However, there is little research evidence regarding its efficacy in DTTD. Family members of patients with depression experience change in their own lives because of the depression.2 The way in which family members respond to the depression can have a significant effect on whether the patient will engage in treatment, as well as the duration of the depressive episode.2 There is a need for research to identify the precise mechanisms of change activated through FBT. A meta-analysis of research conducted in a related area — family therapy as an adjunct treatment for chronic disease interventions — showed it was efficacious, but which components of the therapy led to the change are still not understood.2 Nevertheless, outcome benefits of FBT have been found after five sessions.2

Brief psychodynamic psychotherapy

There is considerable evidence that BPP is effective in treating depression, particularly in helping patients overcome problems in regulating complex feelings,10 but there is little research about its effectiveness in DTTD. In a small sample of 10 patients with treatment-resistant depression who were provided with about 12 sessions of BPP, substantial functional and symptomatic gains were associated with the therapy.35

Mindfulness-based cognitive therapy

Studies have shown that MBCT, which combines CBT with mindfulness techniques, is effective in reducing relapse rates in people with multiple episodes of depression.42 MBCT has also been shown in pilot studies to be useful in people with DTTD.31,32,36 A single RCT showed MBCT to be effective in chronic depression.43 MBCT is useful in decreasing ruminative thinking, as well as in changing the relationship the patient has with his or her unhelpful depressive thoughts and feelings, anhedonia, low self-esteem and feelings of hopelessness.31

Conclusions

The goal of treatment for patients with depression is remission of symptoms, coupled with a return to a state of functioning and wellbeing. In clinical practice, antidepressant medications are frequently used, as they seem at face value to be more cost-effective than a course of psychotherapy. However, there is strong evidence to support the use of psychological treatments in depression in general, and a smaller amount of evidence to support its use in DTTD and chronic depression.

It is clear that DTTD is often accompanied or complicated by a range of primary or secondary psychological and interpersonal issues that may benefit from attention through non-pharmacological techniques. Before deeming a patient’s DTTD to be “treatment-resistant”, a thorough assessment should be made to determine whether the depressive symptoms are being complicated by coexisting medical, psychiatric, personality, environmental or social factors. It is also crucial that patients are educated about their depressive illness and the potential contributing factors. The importance of medication adherence needs to be emphasised, and the patient should be supported through regular contact with the treating clinician. Specific psychological therapies should be offered to assist with dysfunctional thinking (depressive thoughts and ruminations) and behaviour (non-compliance, addictions), comorbid anxiety, social integration (to increase social support), and rehabilitation (to engage in productive work). If the patient is ambivalent about accepting treatment, an exploration of health beliefs and motivation through therapy would be useful.

The effective treatment of a person with depression is a multidisciplinary concern involving a doctor and a psychologist, and sometimes a psychiatrist. Communication among health professionals is important, as is engagement with the patient’s family, to ensure there is a comprehensive and integrated plan of recovery. Combining pharmacotherapy with a range of cognitive, behavioural and interpersonal strategies is seemingly beneficial. However, there remains a need for more well conducted quality trials investigating effectiveness of psychosocial interventions in DTTD.

Factors associated with difficult-to-treat depression and psychological interventions that can help

Medical and psychiatric comorbidity (cancer; endocrine, heart or inflammatory disease; substance dependency; anxiety disorders; personality disorders; bipolarity):

  • Clarification and differentiation of comorbid psychiatric conditions, including contribution of personality

  • Specific treatment of anxiety disorders and addictive behaviour

Environmental and contextual factors (family and relational conflict; social and interpersonal problems; financial distress; work stress or job loss; weak social supports; serious illness; other serious life event):

  • CBT: behavioural interventions and problem-solving techniques can be useful in developing social skills and resolving interpersonal difficulties

  • IPT: can address social and interpersonal issues, work stress, job loss and adjustment to life events or change. Helps patient understand how these problems lead to becoming distressed and depressed and facilitates making appropriate changes or adjustments

  • FBT: to address the manner in which family members interact, so as to improve family relationships and communication, reduce stress and increase support

  • BPP: to explore and work through conflicts within oneself and with others that affect relating and coping styles (eg, avoidance or denial, need for approval). Draws on the patient’s accounts of current and past relationships, and the relationship with the therapist (transference)

Inadequate diagnosis and treatment (comorbidities; types of depression [melancholic or anhedonic, demoralisation or hopelessness, situational reaction]; unresolved environmental influences):

  • Review of psychiatric, social and psychological aspects of diagnosis

  • Specific treatments for comorbidities (eg, CBT for anxiety disorders)

  • Cognitive therapy for hopeless depression; remoralisation therapy for demoralisation

  • Problem solving for unresolved social stressors

Medication non-adherence:

  • Psychoeducation

  • Review of health beliefs, stigma and attitudes to depression and medication

  • Support of motivation for recovery

Low self-esteem, hopelessness, anhedonia and cognitive reactivity:

  • CBT: to help combat hopelessness, other negative thoughts and unhelpful core beliefs associated with low self-esteem. Scheduling of pleasant events can (paradoxically) be effective in anhedonia. Exposure and relaxation (eg, deep breathing exercises) reduce anxiety. Motivational interviewing helps motivation and patient activation. Activity scheduling can help increase activity level, which increases physical exercise and hedonic activity

  • MBCT: to facilitate relaxation and, through encouraging acceptance, help reduce avoidance behaviour, give patient a different attitude and “relationship” to depressive thoughts, and decrease rumination

CBT = cognitive behaviour therapy. IPT = interpersonal psychotherapy. FBT = family-based therapy. BPP = brief psychodynamic psychotherapy. MBCT = mindfulness-based cognitive therapy.