Psychotherapists' perspectives on collaboration and stepped care in outpatient psychotherapy-A qualitative study

Kerstin Maehder, Bernd Löwe, Martin Härter, Daniela Heddaeus, Olaf von dem Knesebeck, Angelika Weigel, Kerstin Maehder, Bernd Löwe, Martin Härter, Daniela Heddaeus, Olaf von dem Knesebeck, Angelika Weigel

Abstract

Objective: Stepped and collaborative care with outpatient psychotherapy as one treatment step is guideline-recommended for mental health care. To date, the experiences and evaluation of psychotherapists regarding collaboration and stepped care have been neglected. In order to improve collaborative mental health care, this qualitative study aimed at identifying psychotherapists' perspectives and needs within collaboration and stepped care.

Methods: Semi-structured qualitative interviews with 20 German outpatient psychotherapists were conducted and analyzed applying thematic analysis. The analysis was realized in a recursive process to first identify themes and then relate these themes back to the research questions with regard to collaboration and stepped care.

Results: Collaboration mainly took place in small networks, with general practitioners and psychiatrists as the most important partners and psychotherapists wishing to intensify collaboration. Main barriers for collaboration were seen in deficient resources and remuneration and in a perceived lack of esteem by other medical specialties. Stepped care was appreciated for intensified collaboration and low-threshold access to care. Doubts were cast on its implementation within current health care conditions, worries concerned a primacy of economic principles instead of patient-orientation. Among further needs, psychotherapists demanded increased knowledge about psychotherapy, especially among general practitioners.

Conclusion: Psychotherapists expressed ambivalent attitudes towards stepped and collaborative care, substantially influenced by health care conditions and the perceived own standing among care providers. Psychotherapists' needs within stepped care comprise intensified collaboration, sufficient time, personal and financial resources for collaboration and opportunities for a constructive interprofessional dialogue.

Trial registration: ClinicalTrials.gov NCT03226743.

Conflict of interest statement

The authors have declared that no competing interests exist.

References

    1. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology. 2011;21(9):655–79. 10.1016/j.euroneuro.2011.07.018
    1. Lang C, Gottschall M, Sauer M, Köberlein-Neu J, Bergmann A, Voigt K. „Da kann man sich ja totklingeln, geht ja keiner ran“–Schnittstellenprobleme zwischen stationärer, hausärztlicher und ambulant-fachspezialisierter Patientenversorgung aus Sicht Dresdner Hausärzte [Interface problems between inpatient, GP and outpatient specialist care: Viewpoint of general practitioners in Dresden]. Gesundheitswesen. 2019;81:822–830. 10.1055/a-0664-0470
    1. Salize HJ, Rossler W and Becker T. Mental health care in Germany: Current state and trends. European Archives of Psychiatry and Clinical Neuroscience. 2007;257:92–103. 10.1007/s00406-006-0696-9
    1. Gaebel W, Kowitz S, Fritze J and Zielasek J. Use of health care services by people with mental illness: Secondary data from three statutory health insurers and the German Statutory Pension Insurance Scheme. Deutsches Ärzteblatt International. 2013;110:799–808. 10.3238/arztebl.2013.0799
    1. Linden M, Gothe H and Ormel J. Pathways to care and psychological problems of general practice patients in a "gate keeper" and an "open access" health care system: A comparison of Germany and the Netherlands. Social Psychiatry and Psychiatric Epidemiology. 2003;38:690–7. 10.1007/s00127-003-0684-6
    1. National Institute for Health and Clinical Excellence (NICE). Common mental health problems: Identification and pathways to care (CG123). 2011. Available from: .
    1. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). S3-Leitlinie Funktionelle Körperbeschwerden [Clinical practice guideline: Functional somatic symptoms]. AWMF, 2018. Available from: .
    1. American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder—Third edition 2010. APA 2010. Available from: .
    1. Richards DA, Bower P, Pagel C, Weaver A, Utley M, Cape J, et al. Delivering stepped care: An analysis of implementation in routine practice. Implementation Science. 2012;7:3 10.1186/1748-5908-7-3
    1. Grochtdreis T, Brettschneider C, Wegener A, Watzke B, Riedel-Heller S, Härter M, et al. Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: A systematic review. PLOS ONE 2015;10:e0123078 10.1371/journal.pone.0123078
    1. Härter M, Watzke B, Daubmann A, Wegscheider K, König HH, Brettschneider C, et al. Guideline-based stepped and collaborative care for patients with depression in a cluster-randomised trial. Scientific Reports. 2018;8:9389 10.1038/s41598-018-27470-6
    1. Ho FY, Yeung WF, Ng TH and Chan CS. The efficacy and cost-effectiveness of stepped care prevention and treatment for depressive and/or anxiety disorders: A systematic review and meta-analysis. Scientific Reports. 2016;6:29281 10.1038/srep29281
    1. Löwe B, Piontek K, Daubmann A, Härter M, Wegscheider K, König HH, et al. Effectiveness of a stepped, collaborative, and coordinated health care network for somatoform disorders (Sofu-Net): A controlled cluster cohort study. Psychosomatic Medicine. 2017;79:1016–1024. 10.1097/PSY.0000000000000491
    1. Maehder K, Löwe B, Härter M, Heddaeus D, Scherer M and Weigel A. Management of comorbid mental and somatic disorders in stepped care approaches in primary care: A systematic review. Family Practice. 2019;36(1):38–52. 10.1093/fampra/cmy122
    1. van Straten A, Hill J, Richards DA and Cuijpers P. Stepped care treatment delivery for depression: A systematic review and meta-analysis. Psychological Medicine. 2015;45:231–46. 10.1017/S0033291714000701
    1. Haugh JA, Herbert K, Choi S, Petrides J, Vermeulen MW and D’Onofrio J. Acceptability of the stepped care model of depression treatment in primary care patients and providers. Journal of Clinical Psychology in Medical Settings. 2019. 10.1007/s10880-019-09599-2
    1. Hermens ML, Muntingh A, Franx G, van Splunteren PT and Nuyen J. Stepped care for depression is easy to recommend, but harder to implement: Results of an explorative study within primary care in the Netherlands. BMC Family Practice. 2014;15:5 10.1186/1471-2296-15-5
    1. Franx G, Oud M, de Lange J, Wensing M and Grol R. Implementing a stepped-care approach in primary care: Results of a qualitative study. Implementation Science. 2012;7:8 10.1186/1748-5908-7-8
    1. Pols AD, Schipper K, Overkamp D, van Dijk SE, Bosmans JE, van Marwijk HWJ, et al. Process evaluation of a stepped-care program to prevent depression in primary care: Patients' and practice nurses' experiences. BMC Family Practice. 2017;18 10.1186/s12875-017-0583-7
    1. Heddaeus D, Steinmann M, Liebherz S, Härter M, Watzke B. Psychenet—The Hamburg network for mental health: Evaluation of the health network depression from the perspective of participating general practitioners, psychotherapists and psychiatrists. Psychiatrische Praxis. 2015;42 Suppl 1:S54–S9. Epub 07/02. 10.1055/s-0034-1387688
    1. Braun V and Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77–101.
    1. Braun V, Clarke V. Successful Qualitative Research: A practical guide for beginners. London: SAGE Publications; 2013.
    1. Heddaeus D, Dirmaier J, Brettschneider C, Daubmann A, Grochtdreis T, von dem Knesebeck O, et al. Study protocol for the COMET study: A cluster-randomised, prospective, parallel-group, superiority trial to compare the effectiveness of a collaborative and stepped care model versus treatment as usual in patients with mental disorders in primary care. BMJ Open. 2019;9(11):e032408 10.1136/bmjopen-2019-032408
    1. Bundespsychotherapeutenkammer (BPtK). Wege zur Psychotherapie [Ways to psychotherapy]. BPtK, 2018. Available from: .
    1. Tong A, Sainsbury P and Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19:349–57. 10.1093/intqhc/mzm042
    1. World Medical Association. Declaration of Helsinki: Ethical principles for medical research involving human subjects. Journal of the American Medical Association. 2013;310(20):2191–4. 10.1001/jama.2013.281053
    1. European Union. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation). EUR-Lex, 2016. Available from: .
    1. Bramesfeld A, Ungewitter C, Bottger D, El JJ, Losert C and Kilian R. What promotes and inhibits cooperation in mental health care across disciplines, services and service sectors? A qualitative study. Epidemiology and Psychiatric Sciences. 2012;21:63–72. 10.1017/s2045796011000539
    1. Overbeck G, Davidsen AS and Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: A systematic qualitative review. Implementation Science. 2016;11:165 10.1186/s13012-016-0519-y
    1. Osborn R, Moulds D, Schneider EC, Doty MM, Squires D and Sarnak DO. Primary care physicians in ten countries report challenges caring for patients with complex health needs. Health Affairs. 2015;34:2104–12. 10.1377/hlthaff.2015.1018
    1. Wood E, Ohlsen S and Ricketts T. What are the barriers and facilitators to implementing collaborative care for depression? A systematic review. Journal of Affective Disorders. 2017;214:26–43. 10.1016/j.jad.2017.02.028
    1. Jacob V, Chattopadhyay SK, Sipe TA, Thota AB, Byard GJ and Chapman DP. Economics of collaborative care for management of depressive disorders: A community guide systematic review. American Journal of Preventive Medicine. 2012;42:539–49. 10.1016/j.amepre.2012.01.011
    1. Katon W, Schoenbaum M, Fan M, Callahan C, Williams J, Hunkeler E, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Archives of General Psychiatry. 2005;62:1313–1320. 10.1001/archpsyc.62.12.1313
    1. Meeuwissen JAC, Feenstra TL, Smit F, Blankers M, Spijker J, Bockting CLH, et al. The cost-utility of stepped-care algorithms according to depression guideline recommendations—Results of a state-transition model analysis. Journal of Affective Disorders. 2019;242:244–254. 10.1016/j.jad.2018.08.024
    1. Fredheim T, Danbolt LJ, Haavet OR, Kjonsberg K and Lien L. Collaboration between general practitioners and mental health care professionals: A qualitative study. International Journal of Mental Health Systems. 2011;5:13 10.1186/1752-4458-5-13
    1. Kassenärztliche Bundesvereinigung (KBV). BIX 2018—Der Bürokratieindex für die vertragsärztliche Versorgung [BIX 2018—The index of bureaucracy in the statutory health insurance health care]. KBV, 2018. Available from: .
    1. Woolhandler S and Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction. International Journal of Health Services. 2014;44:635–42. 10.2190/HS.44.4.a
    1. National Institute for Health and Clinical Excellence (NICE). Guidance on co-locating mental health therapists in primary care. NICE, 2018. Available from: .
    1. Dezetter A, Briffault X, Bruffaerts R, De Graaf R, Alonso J, König HH, et al. Use of general practitioners versus mental health professionals in six European countries: The decisive role of the organization of mental health-care systems. Social Psychiatry and Psychiatric Epidemiology. 2013;48:137–49. 10.1007/s00127-012-0522-9
    1. Levine DM, Linder JA and Landon BE. Characteristics and disparities among primary care practices in the United States. Journal of General Internal Medicine. 2018;33:481–486. 10.1007/s11606-017-4239-z
    1. Falconer E, Kho D and Docherty JP. Use of technology for care coordination initiatives for patients with mental health issues: A systematic literature review. Neuropsychiatric Disease and Treatment. 2018;14:2337–2349. 10.2147/NDT.S172810
    1. Tönnies J, Hartmann M, Wensing M, Szecsenyi J, Icks A, Friederich HC, et al. Mental health specialist video consultations for patients with depression or anxiety disorders in primary care: Protocol for a randomised controlled feasibility trial. BMJ Open. 2019;9(9):e030003 Epub 2019/09/07. 10.1136/bmjopen-2019-030003

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