Implementing Collaborative Care for anxiety and depression: a qualitative study from the Capital Region of Denmark

Introduction: Mental health problems constitute a substantial burden for patients and health systems. In order to improve the treatment of patients suffering from anxiety and depression, collaborative care models have been developed. Collaborative care is a complex intervention that involves a systematic cross-sectorial and inter-professional collaboration between primary and secondary care. While positive effects of collaborative care have been found in several trials, fewer studies have focused on implementation issues and most of these have been conducted in the US or the UK. It is important to supplement this knowledge base with implementation research from other health systems. The aim of this study was to identify the various facilitators and challenges to implementing a collaborative care intervention in the Capital Region of Denmark from 2014 to 2017.

Methods and theory: In the intervention, eight care managers (CMs) are employed to treat patients (with anxiety or depression) referred by their general practitioner (GP). The CMs – mostly trained psychiatric nurses – provide psychoeducation and cognitive behavioral therapy, and the overall treatment approach is based on principles of stepped-care. Other important components of the intervention include regular conferences between the GP and the CM about the patients, and regular supervision of the CMs and the GPs by mental health specialists. CMs and GPs participated in introductory training courses in summer 2014, and the first patients were included in December 2014. Between December 2015 and December 2016 we carried out qualitative interviews with all CMs, two psychiatrists, and five GPs. A focus group with all care managers was held in February 2017. We also observed information events, training courses, supervision sessions, and meetings between care managers and general practitioners. The analysis is based on Normalization Process Theory.

Results: GPs appreciated that collaborative care offered their patients free and easy access to mental health care, and had confidence in the skills of the care managers. However, several GPs did not see the point in receiving regular supervision from a psychiatrist for this particular group of patients, leading to low turn-out at the supervision sessions. The case-based meetings between the GPs and the care managers were generally described as being meaningful and constructive. The care managers were highly motivated, and performed a significant amount of implementation work in order to deal with challenges related to limited opportunities for co-location, logistics, and varying degrees of engagement among the GPs.

Discussion and conclusion: Preparing the ground for implementation requires detailed negotiations with representatives from general practice over issues of reimbursement, the location of care managers, and the regular interaction with care managers and psychiatric supervisors. Furthermore, questions of overall leadership and responsibility have to be clarified. Future research could focus on developing and testing extended models of collaborative care which include patients with mental health problems that are more difficult for general practice to handle.