Skip to main content
PMC home page
The British Journal of General Practice logoLink to The British Journal of General Practice
. 2002 Nov;52(484):926–933.

Primary care mental health workers: models of working and evidence of effectiveness.

Peter Bower 1
PMCID: PMC1314446  PMID: 12434963

Abstract

The NHS Plan proposed the creation of a new role in primary care to assist with the management of common mental health problems: the primary care mental health worker (PCMHW). However, it is not clear how PCMHWs should be employed to be most effective. Current literature concerning different models of mental health care is reviewed. This suggests that four key dimensions are of relevance: the types of patients that PCMHWs will manage; the degree to which PCMHWs will work autonomously, or as part of a system of care; at what stage in patients' illness trajectory they will intervene; and whether the role of PCMHWs will be related to clinical interventions, or whether they will have a wider, non-clinical role in the organisation and monitoring of care. Finally, published data concerning relevant interventions are presented. Experimental studies reporting the empirical outcomes associated with these models are reviewed in relation to four different outcomes: clinical effectiveness, cost effectiveness, patient satisfaction, and access to care. The data suggest that problem-solving therapy, group psycho-education, self-help, and some models of 'collaborative care' may be highly relevant to PCMHWs. Each model provides different advantages and disadvantages in terms of the four dimensions of outcome.

Full Text

The Full Text of this article is available as a PDF (85.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Andrews G. Should depression be managed as a chronic disease? BMJ. 2001 Feb 17;322(7283):419–421. doi: 10.1136/bmj.322.7283.419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Appleby L., Warner R., Whitton A., Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ. 1997 Mar 29;314(7085):932–936. doi: 10.1136/bmj.314.7085.932. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Barrett J. E., Williams J. W., Jr, Oxman T. E., Katon W., Frank E., Hegel M. T., Sullivan M., Schulberg H. C. The treatment effectiveness project. A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients: background and research plan. Gen Hosp Psychiatry. 1999 Jul-Aug;21(4):260–273. doi: 10.1016/s0163-8343(99)00023-7. [DOI] [PubMed] [Google Scholar]
  4. Bashir K., Blizard B., Bosanquet A., Bosanquet N., Mann A., Jenkins R. The evaluation of a mental health facilitator in general practice: effects on recognition, management, and outcome of mental illness. Br J Gen Pract. 2000 Aug;50(457):626–629. [PMC free article] [PubMed] [Google Scholar]
  5. Bedi N., Chilvers C., Churchill R., Dewey M., Duggan C., Fielding K., Gretton V., Miller P., Harrison G., Lee A. Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial. Br J Psychiatry. 2000 Oct;177:312–318. doi: 10.1192/bjp.177.4.312. [DOI] [PubMed] [Google Scholar]
  6. Bower P., Byford S., Sibbald B., Ward E., King M., Lloyd M., Gabbay M. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness. BMJ. 2000 Dec 2;321(7273):1389–1392. doi: 10.1136/bmj.321.7273.1389. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bower P., Garralda E., Kramer T., Harrington R., Sibbald B. The treatment of child and adolescent mental health problems in primary care: a systematic review. Fam Pract. 2001 Aug;18(4):373–382. doi: 10.1093/fampra/18.4.373. [DOI] [PubMed] [Google Scholar]
  8. Bower P., Richards D., Lovell K. The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review. Br J Gen Pract. 2001 Oct;51(471):838–845. [PMC free article] [PubMed] [Google Scholar]
  9. Bower P., Sibbald B. Do consultation-liaison services change the behavior of primary care providers? A review. Gen Hosp Psychiatry. 2000 Mar-Apr;22(2):84–96. doi: 10.1016/s0163-8343(00)00058-x. [DOI] [PubMed] [Google Scholar]
  10. Campbell S. M., Roland M. O., Buetow S. A. Defining quality of care. Soc Sci Med. 2000 Dec;51(11):1611–1625. doi: 10.1016/s0277-9536(00)00057-5. [DOI] [PubMed] [Google Scholar]
  11. Cape J., Barker C., Buszewicz M., Pistrang N. General practitioner psychological management of common emotional problems (I): Definitions and literature review. Br J Gen Pract. 2000 Apr;50(453):313–318. [PMC free article] [PubMed] [Google Scholar]
  12. Cape J., Barker C., Buszewicz M., Pistrang N. General practitioner psychological management of common emotional problems (II): A research agenda for the development of evidence-based practice. Br J Gen Pract. 2000 May;50(454):396–400. [PMC free article] [PubMed] [Google Scholar]
  13. Chilvers C., Dewey M., Fielding K., Gretton V., Miller P., Palmer B., Weller D., Churchill R., Williams I., Bedi N. Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms. BMJ. 2001 Mar 31;322(7289):772–775. doi: 10.1136/bmj.322.7289.772. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Dowrick C., Casey P., Dalgard O., Hosman C., Lehtinen V., Vázquez-Barquero J. L., Wilkinson G. Outcomes of Depression International Network (ODIN). Background, methods and field trials. ODIN Group. Br J Psychiatry. 1998 Apr;172:359–363. doi: 10.1192/bjp.172.4.359. [DOI] [PubMed] [Google Scholar]
  15. Earll L., Kincey J. Clinical psychology in general practice: a controlled trial evaluation. J R Coll Gen Pract. 1982 Jan;32(234):32–37. [PMC free article] [PubMed] [Google Scholar]
  16. Gask L., Sibbald B., Creed F. Evaluating models of working at the interface between mental health services and primary care. Br J Psychiatry. 1997 Jan;170:6–11. doi: 10.1192/bjp.170.1.6. [DOI] [PubMed] [Google Scholar]
  17. Gater R., Goldberg D., Jackson G., Jennett N., Lowson K., Ratcliffe J., Saraf T., Warner R. The care of patients with chronic schizophrenia: a comparison between two services. Psychol Med. 1997 Nov;27(6):1325–1336. doi: 10.1017/s0033291797005631. [DOI] [PubMed] [Google Scholar]
  18. Gilbody S. M., House A. O., Sheldon T. A. Routinely administered questionnaires for depression and anxiety: systematic review. BMJ. 2001 Feb 17;322(7283):406–409. doi: 10.1136/bmj.322.7283.406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Goldberg D., Jackson G., Gater R., Campbell M., Jennett N. The treatment of common mental disorders by a community team based in primary care: a cost-effectiveness study. Psychol Med. 1996 May;26(3):487–492. doi: 10.1017/s003329170003556x. [DOI] [PubMed] [Google Scholar]
  20. Grant C., Goodenough T., Harvey I., Hine C. A randomised controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector. BMJ. 2000 Feb 12;320(7232):419–423. doi: 10.1136/bmj.320.7232.419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Harris T., Brown G. W., Robinson R. Befriending as an intervention for chronic depression among women in an inner city. 1: Randomised controlled trial. Br J Psychiatry. 1999 Mar;174:219–224. doi: 10.1192/bjp.174.3.219. [DOI] [PubMed] [Google Scholar]
  22. Harris T., Brown G. W., Robinson R. Befriending as an intervention for chronic depression among women in an inner city. 2: Role of fresh-start experiences and baseline psychosocial factors in remission from depression. Br J Psychiatry. 1999 Mar;174:225–232. doi: 10.1192/bjp.174.3.225. [DOI] [PubMed] [Google Scholar]
  23. Hellman C. J., Budd M., Borysenko J., McClelland D. C., Benson H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med. 1990 Winter;16(4):165–173. doi: 10.1080/08964289.1990.9934605. [DOI] [PubMed] [Google Scholar]
  24. Hewitt K. Parent education in preventing behaviour problems. Health Visit. 1991 Dec;64(12):415–417. [PubMed] [Google Scholar]
  25. Holden J. M., Sagovsky R., Cox J. L. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ. 1989 Jan 28;298(6668):223–226. doi: 10.1136/bmj.298.6668.223. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hunkeler E. M., Meresman J. F., Hargreaves W. A., Fireman B., Berman W. H., Kirsch A. J., Groebe J., Hurt S. W., Braden P., Getzell M. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med. 2000 Aug;9(8):700–708. doi: 10.1001/archfami.9.8.700. [DOI] [PubMed] [Google Scholar]
  27. Jackson G., Gater R., Goldberg D., Tantam D., Loftus L., Taylor H. A new community mental health team based in primary care. A description of the service and its effect on service use in the first year. Br J Psychiatry. 1993 Mar;162:375–384. doi: 10.1192/bjp.162.3.375. [DOI] [PubMed] [Google Scholar]
  28. Katon W., Robinson P., Von Korff M., Lin E., Bush T., Ludman E., Simon G., Walker E. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996 Oct;53(10):924–932. doi: 10.1001/archpsyc.1996.01830100072009. [DOI] [PubMed] [Google Scholar]
  29. Katon W., Rutter C., Ludman E. J., Von Korff M., Lin E., Simon G., Bush T., Walker E., Unützer J. A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry. 2001 Mar;58(3):241–247. doi: 10.1001/archpsyc.58.3.241. [DOI] [PubMed] [Google Scholar]
  30. Katon W., Von Korff M., Lin E., Bush T., Russo J., Lipscomb P., Wagner E. A randomized trial of psychiatric consultation with distressed high utilizers. Gen Hosp Psychiatry. 1992 Mar;14(2):86–98. doi: 10.1016/0163-8343(92)90033-7. [DOI] [PubMed] [Google Scholar]
  31. Katon W., Von Korff M., Lin E., Simon G., Walker E., Unützer J., Bush T., Russo J., Ludman E. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999 Dec;56(12):1109–1115. doi: 10.1001/archpsyc.56.12.1109. [DOI] [PubMed] [Google Scholar]
  32. Katon W., Von Korff M., Lin E., Unützer J., Simon G., Walker E., Ludman E., Bush T. Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry. 1997 May;19(3):169–178. doi: 10.1016/s0163-8343(97)00016-9. [DOI] [PubMed] [Google Scholar]
  33. Katon W., Von Korff M., Lin E., Walker E., Simon G. E., Bush T., Robinson P., Russo J. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5;273(13):1026–1031. [PubMed] [Google Scholar]
  34. Katzelnick D. J., Simon G. E., Pearson S. D., Manning W. G., Helstad C. P., Henk H. J., Cole S. M., Lin E. H., Taylor L. H., Kobak K. A. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000 Apr;9(4):345–351. doi: 10.1001/archfami.9.4.345. [DOI] [PubMed] [Google Scholar]
  35. Klerman G. L., Budman S., Berwick D., Weissman M. M., Damico-White J., Demby A., Feldstein M. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care. 1987 Nov;25(11):1078–1088. doi: 10.1097/00005650-198711000-00006. [DOI] [PubMed] [Google Scholar]
  36. Kupshik G. A., Fisher C. R. Assisted bibliotherapy: effective, efficient treatment for moderate anxiety problems. Br J Gen Pract. 1999 Jan;49(438):47–48. [PMC free article] [PubMed] [Google Scholar]
  37. Lave J. R., Frank R. G., Schulberg H. C., Kamlet M. S. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998 Jul;55(7):645–651. doi: 10.1001/archpsyc.55.7.645. [DOI] [PubMed] [Google Scholar]
  38. Lin E. H., Simon G. E., Katon W. J., Russo J. E., Von Korff M., Bush T. M., Ludman E. J., Walker E. A. Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry. 1999 Apr;156(4):643–645. doi: 10.1176/ajp.156.4.643. [DOI] [PubMed] [Google Scholar]
  39. Lynch D. J., Tamburrino M. B., Nagel R. Telephone counseling for patients with minor depression: preliminary findings in a family practice setting. J Fam Pract. 1997 Mar;44(3):293–298. [PubMed] [Google Scholar]
  40. Mann A. H., Blizard R., Murray J., Smith J. A., Botega N., MacDonald E., Wilkinson G. An evaluation of practice nurses working with general practitioners to treat people with depression. Br J Gen Pract. 1998 Jan;48(426):875–879. [PMC free article] [PubMed] [Google Scholar]
  41. Marks I. Controlled trial of psychiatric nurse therapists in primary care. Br Med J (Clin Res Ed) 1985 Apr 20;290(6476):1181–1184. doi: 10.1136/bmj.290.6476.1181. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Marsh L., Dawson T. M. Treatment of early Parkinson's disease. BMJ. 2000 Jul 1;321(7252):1–2. doi: 10.1136/bmj.321.7252.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. McLeod C. C., Budd M. A., McClelland D. C. Treatment of somatization in primary care. Gen Hosp Psychiatry. 1997 Jul;19(4):251–258. doi: 10.1016/s0163-8343(97)00047-9. [DOI] [PubMed] [Google Scholar]
  44. Miranda J., Muñoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994 Mar-Apr;56(2):136–141. doi: 10.1097/00006842-199403000-00009. [DOI] [PubMed] [Google Scholar]
  45. Mitchell A. R. Psychiatrists in primary health care settings. Br J Psychiatry. 1985 Oct;147:371–379. doi: 10.1192/bjp.147.4.371. [DOI] [PubMed] [Google Scholar]
  46. Muñoz R. F., Ying Y. W., Bernal G., Pérez-Stable E. J., Sorensen J. L., Hargreaves W. A., Miranda J., Miller L. S. Prevention of depression with primary care patients: a randomized controlled trial. Am J Community Psychol. 1995 Apr;23(2):199–222. doi: 10.1007/BF02506936. [DOI] [PubMed] [Google Scholar]
  47. Mynors-Wallis L. M., Gath D. H., Day A., Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ. 2000 Jan 1;320(7226):26–30. doi: 10.1136/bmj.320.7226.26. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Mynors-Wallis L. M., Gath D. H., Lloyd-Thomas A. R., Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. BMJ. 1995 Feb 18;310(6977):441–445. doi: 10.1136/bmj.310.6977.441. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Mynors-Wallis L., Davies I., Gray A., Barbour F., Gath D. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. Br J Psychiatry. 1997 Feb;170:113–119. doi: 10.1192/bjp.170.2.113. [DOI] [PubMed] [Google Scholar]
  50. Osgood-Hynes D. J., Greist J. H., Marks I. M., Baer L., Heneman S. W., Wenzel K. W., Manzo P. A., Parkin J. R., Spierings C. J., Dottl S. L. Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets: an open U.S.-U.K. study. J Clin Psychiatry. 1998 Jul;59(7):358–365. doi: 10.4088/jcp.v59n0704. [DOI] [PubMed] [Google Scholar]
  51. Peveler R., George C., Kinmonth A. L., Campbell M., Thompson C. Effect of antidepressant drug counselling and information leaflets on adherence to drug treatment in primary care: randomised controlled trial. BMJ. 1999 Sep 4;319(7210):612–615. doi: 10.1136/bmj.319.7210.612. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Priest R. G., Vize C., Roberts A., Roberts M., Tylee A. Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ. 1996 Oct 5;313(7061):858–859. doi: 10.1136/bmj.313.7061.858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Robson M. H., France R., Bland M. Clinical psychologist in primary care: controlled clinical and economic evaluation. Br Med J (Clin Res Ed) 1984 Jun 16;288(6433):1805–1808. doi: 10.1136/bmj.288.6433.1805. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Ross M., Scott M. An evaluation of the effectiveness of individual and group cognitive therapy in the treatment of depressed patients in an inner city health centre. J R Coll Gen Pract. 1985 May;35(274):239–242. [PMC free article] [PubMed] [Google Scholar]
  55. Schulberg H. C., Block M. R., Madonia M. J., Scott C. P., Rodriguez E., Imber S. D., Perel J., Lave J., Houck P. R., Coulehan J. L. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry. 1996 Oct;53(10):913–919. doi: 10.1001/archpsyc.1996.01830100061008. [DOI] [PubMed] [Google Scholar]
  56. Scott A. I., Freeman C. P. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. BMJ. 1992 Apr 4;304(6831):883–887. doi: 10.1136/bmj.304.6831.883. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Scott C., Tacchi M. J., Jones R., Scott J. Acute and one-year outcome of a randomised controlled trial of brief cognitive therapy for major depressive disorder in primary care. Br J Psychiatry. 1997 Aug;171:131–134. doi: 10.1192/bjp.171.2.131. [DOI] [PubMed] [Google Scholar]
  58. Sibbald B., Addington-Hall J., Brenneman D., Freeling P. Counsellors in English and Welsh general practices: their nature and distribution. BMJ. 1993 Jan 2;306(6869):29–33. doi: 10.1136/bmj.306.6869.29. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Simon G. E., Manning W. G., Katzelnick D. J., Pearson S. D., Henk H. J., Helstad C. S. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry. 2001 Feb;58(2):181–187. doi: 10.1001/archpsyc.58.2.181. [DOI] [PubMed] [Google Scholar]
  60. Simon G. E., VonKorff M., Rutter C., Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000 Feb 26;320(7234):550–554. doi: 10.1136/bmj.320.7234.550. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Sobell M. B., Sobell L. C. Stepped care as a heuristic approach to the treatment of alcohol problems. J Consult Clin Psychol. 2000 Aug;68(4):573–579. [PubMed] [Google Scholar]
  62. Stewart M. Towards a global definition of patient centred care. BMJ. 2001 Feb 24;322(7284):444–445. doi: 10.1136/bmj.322.7284.444. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Teasdale J. D., Fennell M. J., Hibbert G. A., Amies P. L. Cognitive therapy for major depressive disorder in primary care. Br J Psychiatry. 1984 Apr;144:400–406. doi: 10.1192/bjp.144.4.400. [DOI] [PubMed] [Google Scholar]
  64. Wagner E. H., Austin B. T., Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511–544. [PubMed] [Google Scholar]
  65. Wagner E. H. More than a case manager. Ann Intern Med. 1998 Oct 15;129(8):654–656. doi: 10.7326/0003-4819-129-8-199810150-00015. [DOI] [PubMed] [Google Scholar]
  66. Wagner E. H., Simon G. E. Managing depression in primary care. BMJ. 2001 Mar 31;322(7289):746–747. doi: 10.1136/bmj.322.7289.746. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Ward E., King M., Lloyd M., Bower P., Sibbald B., Farrelly S., Gabbay M., Tarrier N., Addington-Hall J. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: clinical effectiveness. BMJ. 2000 Dec 2;321(7273):1383–1388. doi: 10.1136/bmj.321.7273.1383. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Warner R. W., Gater R., Jackson M. G., Goldberg D. P. Effects of a community mental health service on the practice and attitudes of general practitioners. Br J Gen Pract. 1993 Dec;43(377):507–511. [PMC free article] [PubMed] [Google Scholar]
  69. Wessely S. The rise of counselling and the return of alienism. BMJ. 1996 Jul 20;313(7050):158–160. doi: 10.1136/bmj.313.7050.158. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Wickberg B., Hwang C. P. Counselling of postnatal depression: a controlled study on a population based Swedish sample. J Affect Disord. 1996 Jul 29;39(3):209–216. doi: 10.1016/0165-0327(96)00034-1. [DOI] [PubMed] [Google Scholar]
  71. Wilkinson G., Allen P., Marshall E., Walker J., Browne W., Mann A. H. The role of the practice nurse in the management of depression in general practice: treatment adherence to antidepressant medication. Psychol Med. 1993 Feb;23(1):229–237. doi: 10.1017/s0033291700039027. [DOI] [PubMed] [Google Scholar]
  72. Williams J. W., Jr, Barrett J., Oxman T., Frank E., Katon W., Sullivan M., Cornell J., Sengupta A. Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. JAMA. 2000 Sep 27;284(12):1519–1526. doi: 10.1001/jama.284.12.1519. [DOI] [PubMed] [Google Scholar]
  73. Williams P., Clare A. Changing patterns of psychiatric care. Br Med J (Clin Res Ed) 1981 Jan 31;282(6261):375–377. doi: 10.1136/bmj.282.6261.375. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners

RESOURCES