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QUESTION: Does feedback of results of routinely administered patient psychiatric questionnaires to clinicians improve the recognition, management, and outcomes of psychiatric disorders in non-psychiatric settings?
Studies were identified by searching Medline (1966–2000), EMBASE/Excerpta Medica (1981–2000), CINAHL (1982–2000), PsycLIT (to 2000), and the Cochrane Controlled Trials Register (to 2000); handsearching key journals; and reviewing bibliographies of retrieved papers.
Randomised controlled trials were selected if patients were treated in non-psychiatric settings, the intervention involved the use of a standardised measure to screen for psychiatric symptoms in routine care and clinicians received feedback results, and the control condition involved routine care where clinicians did not receive feedback.
Data were extracted on study quality and outcomes. Main outcomes were recognition of, treatment or referral for, and outcomes of psychiatric disorders. Study quality was assessed using the Jadad and Campbell criteria.
9 studies met the selection criteria: 6 were in primary care and 3 were in general medical outpatient settings. Studies randomised either all patients regardless of their score (unselected) or only those with a probable psychiatric disorder (high risk). Pooled results of 2 studies (n=2261) showed that recognition of psychiatric disorder in unselected patients did not improve with questionnaire feedback (table⇓). Pooled results of 2 studies (n=196) showed that recognition of psychiatric disorder in high risk patients improved if clinicians received feedback (table⇓). 5 of 6 studies found no change in initiation of treatment by clinicians who received questionnaire feedback. Long term psychiatric outcome did not differ for patients of clinicians who received feedback and those who did not (4 studies).
In non-psychiatric settings, clinicians who receive feedback from routinely administered, patient psychiatric questionnaires have improved recognition of psychiatricdisorders in high risk patients but not in unselected patients. Feedback has no effect on initiation of treatment or long term psychiatric outcomes.
This systematic review by Gilbody et al documents no effect of providing clinicians with the results of routinely administered questionnaires for depression and anxiety among unselected patients in non-psychiatric settings, such as primary care or hospital outpatient clinics. However, there appears to be a clinical effect of feedback alone in improving the recognition of psychiatric disorders among high risk patients in non-psychiatric settings. As one might expect from a perspective of behaviour change theory,1 information, although necessary, is alone insufficient to substantially change management or outcomes. As Gilbody et al have discussed, more complex strategies in which feedback is accompanied by increased resources (eg, an outside referral agency that administers and scores the questionnaire) and educational interventions can result in improved outcome for depression.
The results are applicable to nurses who practice in non-psychiatric settings in the community or in general hospitals. The findings support the renewed emphasis on mental health practice by generalist nurses. Mental health care in primary healthcare settings is a practice that is unemphasised by nurses and other clinicians, yet is a main contributor to expenditures for resources consumed by those with chronic physical illnesses.2 Evidence shows that investing in additional resources for psychosocial care in outpatient clinics for physical illness,3 and in primary care is both more effective and less expensive.4 Psychosocial care pays for itself with reductions in the use of other insured resources.
Source of funding: no external funding.
For correspondence: Dr S M Gilbody, Academic Unit of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK. Fax +44 (0)113 243 3719..
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