The overarching goal of primary care is to offer all patients individualised and
context-sensitive healthcare with high access and continuity. One of the reasons primary
care struggles with this goal is that a large proportion of patients suffer from mental
and behavioural health problems, alone or in combination with one or several chronic
illnesses. Despite many patients needing psychosocial interventions, there is a lack of
mental health professionals as well as clear pathways for these patients.
Primary Care Behavioural Health (PCBH) is an innovative way of organising primary care,
where mental health professionals have more yet shorter visits, strive for same-day
access, and have an active consulting role in the primary care team. To help patients
achieve relevant behavioural changes, so called brief interventions are used, which are
based on isolated components from psychological treatments such as Cognitive Behavioural
Therapy (CBT) and Acceptance and Commitment Therapy (ACT). Brief interventions usually
stretch over 1-4 treatment sessions. Assessments within the model are generally
contextual and largely avoid psychiatric diagnostics, instead focussing on the patient's
situation and their associated coping strategies - whether they be positive or negative.
However, these interventions have not been systematically evaluated in the same way that
structured CBT has, and there is a risk that patients that would have benefitted from
structured CBT and a diagnostic assessment are undertreated due to lack of diagnostics
and the reduced visit duration and amount.
Data will be collected at primary care centres (PCCs) that already have a high fidelity
to a PCBH framework. Fidelity will be measured by an expert group as well as using four
questionnaires, one for each of mental health professionals, medical doctors, registered
nurses and leadership. These fidelity scales will be validated in a separate study. In
addition to fidelity, work environment and satisfaction with the PCBH implementation will
be measured.
Patients at the centres will be randomised between receiving contextual assessments
followed by brief interventions, or a diagnostic assessment, which can lead to treatment
with either self-help CBT (if a treatable diagnosis is confirmed and the patient is
suitable for self-help CBT) or brief interventions (if self-help CBT is not deemed to be
a suitable intervention). The primary comparison is the outcome for patients who either
received self-help CBT or are deemed suitable for the intervention based on screening
data, while secondary analyses will look at treatment outcomes for all patients,
including those with non-psychiatric problems such as crises, loss or work- or
family-related problems. The study will also look at implementation outcomes for
self-help CBT and diagnostic assessments to see if self-help CBT is a feasible addition
to the PCBH model. Our main research questions are:
Does an extended version of PCBH, including an additional assessment and the option
of guided self-help CBT when indicated by a patient's problem profile, lead to
superior patient outcomes compared to standard PCBH where a brief, contextual
assessment followed by Brief Interventions is the only option? If not, can standard
PCBH be shown to be non-inferior?
Does the addition of guided self-help CBT have a negative effect on availability,
reach, and cost-effectiveness compared to standard PCBH? If not, can guided
self-help CBT be shown to be non-inferior to standard PCBH concerning these
outcomes?
PCBH has the potential to increase the quality and access of care for many patients with
mental and behavioural health problems. This study is the first to step towards answering
whether or not the effects of brief intervention are large enough to merit large-scale
implementation, and if an add-on of other brief and easily implementable treatments can
increase the treatment effects.