Psychological treatment centres

Editor—Layard makes a strong economic case for treating depression and anxiety in primary care settings.¹ However, the potential pitfalls in outsourcing psychological treatment (for that is what it would be) are many.

Depression has many characteristics of a chronic disorder: studies show that 72% of patients have more than one episode and patients move between levels of severity and are ill for 59% of weeks.²,³ These more disabled patients contribute disproportionately to overall morbidity and tend to have needs other than psychological treatment—for example, help with social problems, occupational rehabilitation, and physical comorbidities.

These patients are best managed using collaborative care and stepped care models.⁴ A key factor is integrating care for depression (psychological and pharmacological) with other aspects of care, both physical and social. Therefore effective management of these patients requires coordinating multiple inputs.

Two models are relevant. The outsourcing of business processes is now commonplace but works best with comparatively uncomplicated tasks. In health care the chronic illness care model shows that such conditions are best managed in multidisciplinary teams with clarity of role, high quality information and communication, and effective team leadership and management.⁵ The outsourcing of one aspect of care is likely to lead to preferential referral of less complex cases, and consequent dilution of the impact of investment.

New investment should instead create and strengthen multidisciplinary primary care mental health teams integrated with general practice and specialist mental health services. The challenge is to establish the effective team structures required. This needs not only more trained cognitive therapists but also effective clinical leaders and managers.