Background
The volume and heterogeneity of mental health problems that primary care patients
present with is a substantial challenge for health systems, and both undertreatment
and overtreatment are common. We developed Link-me, a patient-completed Decision Support
Tool, to predict severity of depression or anxiety, identify priorities, and recommend
interventions. In this study, we aimed to examine if Link-me reduces psychological
distress among individuals predicted to have minimal/mild or severe symptoms of anxiety
or depression.
Methods
In this pragmatic stratified randomised controlled trial, adults aged 18–75 years
reporting depressive or anxiety symptoms or use of mental health medication were recruited
from 23 general practices in Australia. Participants completed the Decision Support
Tool and were classified into three prognostic groups (minimal/mild, moderate, severe),
and those in the minimal/mild and severe groups were eligible for inclusion. Participants
were individually and randomly assigned (1:1) by a computer-generated allocation sequence
to receive either prognosis-matched care (intervention group) or usual care plus attention
control (control group). Participants were not blinded but intervention providers
were only notified of those allocated to the intervention group. Outcome assessment
was blinded. The primary outcome was the difference in the change in scores between
the intervention and control group, and within prognostic groups, on the 10-item Kessler
Psychological Distress Scale at 6 months post randomisation. The trial was registered
on the Australian and New Zealand Clinical Trials Registry, ACTRN12617001333303.
Outcomes
Between Nov 21, 2017, and Oct 31, 2018, 24 616 patients were invited to complete the
eligibility screening survey. 1671 of these patients were included and randomly assigned
to either the intervention group (n=834) or the control group (n=837). Prognosis-matched
care was associated with greater reductions in psychological distress than usual care
plus attention control at 6 months (p=0·03), with a standardised mean difference (SMD)
of −0·09 (95% CI −0·17 to −0·01). This reduction was also seen in the severe prognostic
group (p=0·003), with a SMD of −0·26 (−0·43 to −0·09), but not in the minimal/mild
group (p=0·73), with a SMD of 0·04 (−0·17 to 0·24). In the complier average causal
effect analysis in the severe prognostic group, differences were larger among those
who received some or all aspects of the intervention (SMD range −0·58 to −1·15). No
serious adverse effects were recorded.
Interpretation
Prognosis-based matching of interventions reduces psychological distress in patients
with anxiety or depressive symptoms, particularly in those with severe symptoms, and
is associated with better outcomes when patients access the recommended treatment.
Optimisation of the Link-me approach and implementation into routine practice could
help reduce the burden of disease associated with common mental health conditions
such as anxiety and depression.
Funding
Australian Government Department of Health.
