Counselling for depression in primary care.
BACKGROUND
There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting.


OBJECTIVE
To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling.


METHODS
The search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned. Contact was made with subject experts and CCDAN members.


METHODS
Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review.


METHODS
Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality.


RESULTS
Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care.


CONCLUSIONS
Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.
Rowland
N
N
York Health Services Research Unit, York NHS Trust, Bootham Park Hospital, Bootham, York, North Yorkshire, UK, Y030 7BY. Nancy.Rowland@excha.yhs-tr.northy.nhs.uk
Bower
P
P
Mellor
C
C
Heywood
P
P
Godfrey
C
C
D018849:Controlled Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D003863:Depression / Q000628:therapy*; D006801:Humans; D001523:Mental Disorders / Q000628:therapy; D011613:Psychotherapy; D016032:Randomized Controlled Trials as Topic