The comparison of effectiveness of two modalities of mental health
nurse follow-up programmes for female outpatients with depression in
Taipei, Taiwan
Fei-Hsiu Hsiao
RN, PhDCollege of Nursing, Taipei Medical University, No. 250 Wu-Hsing Street, Taipei
Tsung-Tsair Yang
MD, PhDDirector of Department of Psychiatry, Cardinal Tien Hospital, Assistant Professor, Fu-Jen University, School of Medicine
Chiao-Chicy Chen
MD, PhDDirector & Associate Professor, Department of Psychiatry, Songde Branch, Taipei City Hospital, Taipei Medical University
Shang-Ying Tsai
MDChief & Associate Professor, Department of Psychiatry, Taipei Medical University and Hospital
Kuo-chang Wang
PhDProfessor, Department of Health Education, National Taiwan Normal University
Yu-Ming Lai
RN, MSNInstructor, School of Nursing, Chang-Gung University
Chang-Jer Tsai
MDEMBA Chief, Section of Community Psychiatry, Department of Psychiatry, Songde Branch, Taipei City Hospital
Wen-Yin Chang
RN, PhDAssociate Professor, Graduate Institute of Nursing, Taipei Medical University
Submitted for publication: 26 October 2005 Accepted for publication: 6 March 2006
Correspondence: Fei-Hsiu Hsiao College of Nursing Taipei Medical University No. 250 Wu-Hsing Street Taipei 110 Taiwan Telephone: 886 227 361661 Ext. 6317 E-mail: hsiaofei@tmu.edu.tw H S I A O F - H , Y A N G T - T , C H E N C - C , T S A I S - Y , W A N G K - C , L A I Y - M , T S A I C - J & H S I A O F - H , Y A N G T - T , C H E N C - C , T S A I S - Y , W A N G K - C , L A I Y - M , T S A I C - J & C H A N G W - Y ( 2 0 0 7 )
C H A N G W - Y ( 2 0 0 7 ) Journal of Clinical Nursing 16, 1141–1150
The comparison of effectiveness of two modalities of mental health nurse follow-up programmes for female outpatients with depression in Taipei, Taiwan
Aims and objectives. This study compares the effectiveness of two modalities of mental health nurse three-month follow-up programmes: telephone counsel-ling programme and group therapy programme for female outpatients with depression.
Background. The lifetime prevalence of major depression is 15% and is about twice as common in women as in men. Outpatients with depression often dis-continue their treatment after the initial visits to their physicians.
Methods. This study used a quasi-experimental, pre–post-test comparison group design. Twenty-six female outpatients with depression were assigned to one of fol-low-up programmes: telephone counselling programme or group therapy pro-gramme. To qualify for group therapy programme, potential participants were required to come to group sessions weekly. To be accepted into telephone counselling programme, potential participants had to be able to be contacted by phone regularly. Mental health nurse three-month follow-up programmes included care management and structured psychotherapy. Patients in telephone counselling programme received 10 regular telephone calls of 30–60 minutes each. Patients in group therapy pro-gramme received 12 sessions of weekly group meetings of 90–120 minutes each. Results. Wilcoxon signed ranks tests provided evidence that the group therapy programme (S ¼ 52Æ5, p < 0Æ001; S ¼ 31Æ5, p ¼ 0Æ046) and telephone counselling programme (S ¼ 36, p ¼ 0Æ002; S ¼ 25, p ¼ 0Æ050) follow-up programmes were effective in terms of relieving depressed symptoms and improving quality of life. According to Quade’s analysis of covariance, telephone counselling programme and group therapy programme appeared to have similar effects of relieving depressed symptoms (F(1,24)¼ 0Æ06, p ¼ 0Æ813) and increasing quality of life (F(1,24)¼ 0Æ07,
p ¼ 0Æ792). While there was no significant difference in using emergency services (v2
ð1Þ ¼ 0Æ89, p ¼ 0Æ539) between telephone counselling programme and group
therapy programme, the rate of adherence to scheduled outpatient appointments with psychiatrists was higher among patients in group therapy programme than patients in telephone counselling programme (v2
ð3Þ ¼ 8Æ67, p ¼ 0Æ034).
Conclusions. Establishing two modalities of mental health nurse follow-up pro-grammes in Taiwan could benefit patients with different needs.
Relevance to clinical practice. Mental health nurses specialized in management of depression could provide not only care management but also structured psycho-therapy.
Key words: group therapy programme, mental health nurse follow-up programme, pretest–post-test comparison group design, quality of life, telephone counselling programme, women with depression
Introduction
The lifetime prevalence of major depression is 15% and is about twice as common in women as in men (Weissman et al. 1996). Women’s vulnerability to depression is related to psychological and social factors (Ruble et al. 1993, Kornstein & Wojcik 2002). Internalized traditional social prescriptions of female behaviours influence women to rely on the opinion of others, to be dependent on others for their approval and to blame themselves for failure. Accordingly, these factors promote a self-perception of powerlessness, contributing to states of dependency, repression and vulnerability to depres-sion. More than two-thirds of women experience a severe life event preceding the onset of depression (Brown & Harris 1989, Karp & Frank 1995, Nazroo et al. 1997, Kornstein & Clayton 2002). Specific female stressors include women’s roles as wives and mothers, childcare responsibilities, poverty
and employment, violence against women, housing and reproductive problems. Suffering from depression reduces women’s capacity to fulfil their roles in everyday lives. The Global Burden of Disease study (Murray & Lopez 1996) states that depression is a leading cause of disability and will account for 15% of the disease burden worldwide by the year of 2020. Because of the high prevalence rate of depression and associated disability, the World Health Organization strategy for mental health emphasizes the management of depression in community (World Health Organization 2001). In Western societies, primary care physicians and nurses are trained to manage the majority of depression patients in the community. However, in Taipei, the biggest city of Taiwan, primary care physicians and nurses have just begun to receive training to care for outpatients with depression. Therefore, 62% of outpatients with depression are treated by psychiatrists in the outpatient department of hospitals
(National Health Insurance 2004). Almost 30% of patients with depression only received outpatient treatment once in two years. The time constraints of psychiatrists reduce their ability to provide comprehensive follow-up care. An insuffi-cient follow-up programme may lead patients to discontinue treatment, after receiving an initial antidepressant medica-tion. Few studies specifically examine a nurse follow-up intervention programme focused on improving the disconti-nuity problem in Taiwan. Therefore, there is a need to develop a follow-up intervention that is acceptable for depression patients in Taiwan.
In Western societies, the regular follow-up has been developed to enhance the adherence of patients with treat-ment. There are two different care models in follow-up. For one care model, the element of follow-up is care management. For the other care model, the main component of follow-up is care management supplemented by structured psychotherapy. Care management includes patient education, monitoring patients’ conditions and their adherence to medication regi-men, providing support for patients’ distress and feedback on the patient’s condition to the physician. Primary care nurses have been trained to take the main role in the care manage-ment. The randomized controlled studies (Hunkeler et al. 2000, Symons et al. 2004) indicated that primary care nurse follow-up through telephone contact with patients could effectively improve clinical outcomes and could enhance the adherence of patients to doctors’ treatments. The other care model included multifaceted intervention. In addition to care management, structured psychotherapy integrated into the follow-up addresses the problem of the increasing numbers of outpatients with depression receiving antidepressant medica-tions without subsequent follow-up psychotherapy (Young et al. 2001, Olfson et al. 2002, Gilbody et al. 2003). The clinical guideline of depression management (National Colla-borating Centre for Mental Health 2004) indicates that the effect of short-term psychotherapy on treating mild and moderate depression is as effective as antidepressants. More-over, the combination of medication treatments and psycho-therapy is a cost-effective way to deal with severe depression (Young et al. 2001, Olfson et al. 2002). In a multifaceted care model, care management was primarily assigned to primary care nurses and structured psychotherapy was mainly provi-ded by psychologists. The randomized controlled trial studies (Wells et al. 2000, Schoenbaum et al. 2001, Unutzer et al. 2002, Araya et al. 2003, Miranda et al. 2003, Simon et al. 2004) indicated that integrating psychotherapy into care management was more effective in reducing symptoms of depression than usual care and one intervention only (care management or psychotherapy). In addition to the element of care models in follow-up, the ways of contacting patients were
discussed. In these studies, the follow-up was provided via telephone or in-person. The results suggested that telephone-based follow-up programmes could reach the patients who had difficulties with receiving office-based follow-up because of transportation problems, age disabilities or stigma issues. Office-based follow-up programmes could provide the rich-ness of in-person individual psychotherapy. The relative merits of telephone consultations or group-format psycho-therapy is unclear.
The roles of mental health nurses in involving people with depression in follow-up programme have not often been examined for their contribution to management of depression in the community. In recent years, the collaboration between primary care professionals and mental health nurses in follow-up began to be discussed. For example, White (2004) proposed a consultation liaison model, which empha-sized the collaborative care between community mental health nurses and primary care physicians. Mental health nurses provided a six-week short-term structured psycho-therapy in addition to care management. This programme successfully improved patients’ drop out from treatments and reduced physicians’ workload. The clinical trial study (Swindle et al. 2003) examined the effects of follow-up programme provided by clinical nurse specialists (CNS) for outpatients with depression. This programme was developed because the time constraints reduced physician ability to provide follow-ups and referring to psychiatrists increased the financial load on the institution. In this follow-up programme the CNS recommended the antidepressant, pro-vided cognitive-behavioural therapy and monitored effects of treatments. The results indicated that patients who received follow-up care by CNS were more likely to appear an improvement in symptoms of depression than were patients who received usual care. These two studies (Swindle et al. 2003, White 2004) demonstrated that mental health nurses could be involved in multifaceted intervention, effectively providing both care management and structured psychother-apy for depression patients.
To develop an effective and acceptable follow-up for outpatients with depression in Taiwan, the current study re-examined the effects of multifaceted intervention including care management and structured psychotherapy that were previously conducted based on populations in North America and Europe. The additional issues were also examined: comparing different ways to contact patients during follow-up and effects of involvement of mental health nurses in follow-up. Therefore, in this pilot study, we conducted a phase one clinical trial to examine new interventions of two formats of mental health nurse follow-up programmes: telephone counselling programme (TCP) and group therapy programme
(GTP) to compile effective and safe follow-up protocol for managing depression among outpatients in Taipei.
Method
This is a quasi-experimental, pretest–post-test comparison group design with one group involved in a TCP and another group involved in GTP. This design was chosen to conduct a phase one clinical trial, which aimed to test two new interventions for the first time in a small group of patients and to evaluate the safety and effectiveness of the two intervention models (National Institutes of Health 2004).
Subjects
Female outpatients, who were diagnosed as having depressive disorders by psychiatrists, were recruited to participate in a three-month clinical trial. Those who reported current prob-lems with substance abuse were excluded. To qualify for the GTP, potential participants were required to attend group sessions weekly. To be accepted into TCP, potential partici-pants need to be contactable by phone regularly. During the
initial seven months of recruitment, patients were first assigned to GTP. Those who could not participate in GTP because of personal factors, such as time management problems, were assigned to TCP. During the remaining five months of recruitment, patients were assigned to TCP.
Thirty-five patients were willing to participate in this study. The participants were assigned to two groups: 18 were in GTP and 17 were in TCP. Nevertheless, four participants did not complete the GTP and five did not complete the TCP. Those who did not complete the study were not included in the data analysis. The baseline characteristics of 26 subjects in GTP and TCP were presented in Tables 1 and 2. There was no significant difference in baseline characteristics between these two groups. Nevertheless, the assignment method depending on patients’ needs to different formats of follow-up programmes may affect the comparison between the two groups. The potential impact of assignment method on demonstrating effects of and adherence to follow-up pro-grammes will be discussed later.
Interventions
The mental health nurse three-month follow-up programmes included care management and structured psychotherapy. Care management included monitoring symptoms and responses to medication, crisis assessment and management, links with crisis services, providing psychiatrists with feed-back on the patients’ conditions and patient education. Structured psychotherapy emphasized stress management and body-mind-spirit empowerment strategies. The content was developed based on ‘the Depression Workbook’ (Cop-eland 1992) and ‘body-mind-spirit group therapy’ (Chan 2001). The body-mind-spirit empowerment group integrated
Table 2 Baseline characteristics of 26 sub-jects assigned to group therapy programme (GTP) and telephone counselling pro-gramme (TCP) Characteristics GTP n (%) TCP n (%) Fisher exact p n ¼ 14 n ¼ 12 Educational levels Primary school 0 (0Æ00) 1 (100Æ00) 0Æ092
Junior high school 1 (100Æ00) 0 (0Æ00)
Senior high school 2 (25Æ00) 6 (75Æ00)
Bachelor degree 10 (66Æ67) 5 (33Æ33)
Master degree 1 (100Æ00) 0 (0Æ00)
Different types of depressive disorders
Major depressive disorder 9 (56Æ25) 7 (43Æ75) 0Æ920
Major depressive disorder/recurrent 2 (50Æ00) 2 (50Æ00)
Neurotic depression 3 (60Æ00) 2 (40Æ00)
Dysthymia disorder 0 (0Æ00) 1 (100Æ00)
The first or not first onset
The first onset 7 (41Æ18) 10 (58Æ82) 0Æ110
Not first onset 7 (77Æ78) 2 (22Æ22)
Table 1 Baseline characteristics of 26 subjects assigned to group therapy programme (GTP) and telephone counselling programme (TCP) based on the results of Wilcoxon–Mann–Whitney rank sum test Characteristics GTP (n ¼ 14) TCP (n ¼ 12) S p Mean Mean Age 35Æ79 37Æ17 160 0Æ930 BDI 29Æ86 27Æ75 154 0Æ695 WHO-QOL 2Æ92 2Æ82 149 0Æ518
concepts and practices from Western medicine (e.g. positive psychology and forgiveness therapy), traditional Chinese medicine and the Eastern philosophes of Buddhism, Taoism and Confucianism. This type of the group emphasized that the physical, emotional, social and spiritual holistic well-being of individual was inseparable. Personal growth and transformation from negative experiences were the focus in the group. The main topics include ‘experiences of depres-sion’, ‘a medical overview of depressive disorders’, ‘the way out of depression’, ‘taking a look at your lifestyle’, ‘prevent-ing suicide’, ‘growth through pain’, ‘lett‘prevent-ing go and forgive-ness’, ‘love yourself’ and ‘transformation of self’. A patient education booklet, which included information about depres-sive disorders, antidepressant medication, coping with stress and suicide preventions, was provided to patients. Both interventions were conducted by the researcher (the first author) who is a psychiatric nurse and an assistant professor who has working experience with depressive disorder inpa-tients and outpainpa-tients.
Mental health nurse follow-up programmes included two formats: TCP and GTP. Both programmes consisted of care management and structured psychotherapy but they were provided differently, by phone or through group. The telephone counselling programme consisted of 10 telephone calls including one call per week during the first eight weeks of the programme and one call every two weeks during the remaining four weeks. Calls lasted 30–60 minutes duration. Extra calls were provided as required by patients, for crisis situations or by the researcher’s assessments of patients’ severe conditions. Group therapy programme was provided for 90– 120 minutes every week for 12 weeks. The group therapy was conducted in the consultation room of the medical school where the primary researcher (the first author) worked. Extra calls were provided as required by patients for crisis situa-tions or by the researcher’s assessments of patients’ severe conditions.
Measures
Symptoms of depression
The Beck Depression Inventory (BDI) (Beck et al. 1961, 1988) is a self-administered 21-item measure. It is designed to assess the severity of the symptoms of depression, to monitor the beneficial or adverse effects of treatment and to assess symptom changes over time. Statements denote symptom severity along with an ordinal continuum from absent (scored as 0) or mild (scored as 1) to severe (scored as 3). The responses are summed to determine possible scores ranging from 0 to 63, with higher scores indicating a greater level of
symptoms. Based on the study of psychiatric patients, BDI indicates a high internal consistency. Cronbach’s alphas ranged from 0Æ76 to 0Æ95.
Quality of life
The Taiwanese version of the World Health Organization Quality Of Life-abbreviated version (Yau 2000) is a 28-item self-administered instrument for the assessment of health status and response to therapy. Participants are asked to judge their quality of life subjectively based on their experience of the last two weeks as a time reference. Statements denote five degrees of satisfaction with quality of life and range from ‘not satisfied at all’ (scored as 1), ‘somewhat satisfied’ (scored as 2), ‘moderately satisfied’ (scored as 3), ‘very satisfied’ (scored as 4) and ‘extremely satisfied’ (scored as 5). The total score is derived from summing the responses of 28 items. A high score indicates a higher quality of life than a low score. Cronbach’s alpha for the internal consistency of this instrument is 0Æ90 (Yau 2000).
The use of hospitalization and emergency services and the adherence to scheduled outpatient appointments
Medical charts were reviewed to obtain frequencies of the use of medical resources, including hospitalization and emer-gency services and of the adherence to scheduled outpatient appointments.
Data collection
This study was approved by the institutional review board. The approval of the head of the department of psychiatry and the patients’ primary medical practitioners were required before approaching the patients to enter the study. The potential subjects obtained the information about this study from psychiatrists of outpatient department of psychi-atry. With the permission of patients, psychiatrists provided the researcher with patient contact numbers. The researcher contacted each and arranged an in-person interview in a place determined by the patient’s preference: the patient’s house, a restaurant near the home, or the researcher’s office. During the interview, the subjects gave their written consent to participate in the study after the purposes, the risks and benefits of the study had been explained to them verbally and in writing. Meanwhile, baseline data were also collec-ted. After patients completed the three-month follow-up programme, the outcomes of post-treatment were then collected.
Data analysis
Data were managed by the SAS system. The Wilcoxon signed ranks test was performed to examine the difference in reducing symptoms of depression and in improving quality of life before and after participating in GTP or TCP follow-up programmes. The Spearman rank correlation test, Kruskal– Wallis one-way analysis of variance by rank and the Wilcoxon– Mann–Whitney rank sum test were performed to find the possible individual factors influencing the effects of GTP or TCP follow-up programmes. To compare two modalities of follow-up programmes, Quade’s analysis of covariance was conducted to find out the difference in changing symptoms of depression and quality of life. This rank analysis was performed according to steps indicated by Huitema (1980). Moreover, Pearson chi-square and Fisher exact tests were performed to compare the difference in adhering to scheduled outpatient appointment and using inpatient and emergency services between two modalities of follow-up programmes.
Results
The effects of group format of mental health nurse follow-up programme
Table 3 presents the results of medians and interquartile ranges of the rated depression and quality of life sores for before–after GTP three-month follow-up programme. The Wilcoxon signed ranks test revealed that there were signifi-cant effects of GTP follow-up programme on reduction of symptoms of depression (S ¼ 52Æ5, p ¼ 0Æ000) and improvement of quality of life (S ¼ 31Æ5, p ¼ 0Æ046). Wilc-oxon signed ranks tests provided evidence that the GTP follow-up programme was effective.
The Spearman rank correlation test, the Kruskal–Wallis one-way analysis of variance by rank and Wilcoxon–Mann– Whitney rank sum test were conducted to explore the relationships between factors of individuals and effects of
GTP follow-up programme. The results indicated that factors including educational levels (rs¼ 0Æ276, p ¼ 0Æ339;
rs¼ 0Æ196, p ¼ 0Æ502), different types of depressive
disor-ders (v2
ð2Þ¼ 1Æ798, p ¼ 0Æ407; v2ð2Þ ¼ 0Æ209, p ¼ 0Æ901) and
the first or not first onset (S ¼ 47Æ5, p ¼ 0Æ555; S ¼ 55Æ5, p ¼ 0Æ736) did not influence the effects of reducing depressed symptoms and improving quality of life. However, age (rs¼ 0Æ696, p ¼ 0Æ006; rs¼ 0Æ608, p ¼ 0Æ021) did
influ-ence the effects of reducing depressed symptoms and improving quality of life. The results indicated that the reduction of depression and improvement of quality of life were greater in the subjects who were older. The results may demonstrate that the subjects who were older could obtain more benefit from group supports. The results suggested that the GTP follow-up programme designed for the study appeared to have been equally effective for patients with different conditions and backgrounds, except age.
The effects of telephone format of mental health nurse follow-up programme
Table 4 presents the results of medians and interquartile ranges of the rated depression and quality of life sores for before and after TCP three-month follow-up programme. The Wilcoxon signed ranks test revealed that there were significant effects of TCP follow-up programme on reduction of symptoms of depression (S ¼ 36, p ¼ 0Æ002) and improvement of quality of life (S ¼ 25, p ¼ 0Æ050). The Wilcoxon signed ranks tests provided evidence that the TCP follow-up programme was effective.
The Spearman rank correlation test, the Kruskal–Wallis one-way analysis of variance by rank and the Wilcoxon– Mann–Whitney rank sum test were conducted to explore the relationships between factors of individuals and effects of TCP follow-up programme. The results indicated that factors including age (rs¼ 0Æ435, p ¼ 0Æ158; rs¼ 0Æ069,
p ¼ 0Æ837), educational levels (rs¼ 0Æ191, p ¼ 0Æ552;
rs¼ 0Æ444, p ¼ 0Æ149), different types of depressive disorders
Table 4 The Wilcoxon signed ranks test results for comparison of effects of before and after telephone counselling programme (TCP) follow-up programme
Variables n
Effects of TCP programme
S p
Pretest Post-test
Median IQR Median IQR
BDI 12 24 15 11Æ50 12Æ50 36 0Æ002
WHO-QOL 12 2Æ86 0Æ57 3Æ14 0Æ84 25 0Æ050
BDI, Beck depression inventory; IQR, interquartile ranges. Table 3 Wilcoxon signed ranks test results for comparison of effects
of before and after group therapy programme (GTP) follow-up programme
Variables n
Effects of GTP programme
S p
Pretest Post-test
Median IQR Median IQR
BDI 14 33 19 10 12 52Æ5 0Æ000
WHO-QOL 14 2Æ95 0Æ50 3Æ21 0Æ93 31Æ5 0Æ046
(v2
ð3Þ¼ 1Æ781, p ¼ 0Æ619; v2ð3Þ ¼ 2Æ830, p ¼ 0Æ419) and the
first or not first onset (S ¼ 12, p ¼ 0Æ909; S ¼ 13, p ¼ 1Æ000) did not influence the effects of reducing depressed symptoms and improving quality of life. The results suggested that the TCP follow-up programme designed for the study appeared to have been equally effective for patients with different conditions and backgrounds.
Comparing two formats of mental health nurse follow-up programmes was to understand which programme was more effective. The results could provide suggestion that which format of follow-up programmes was more worth to be developed in Taiwan. The results were indicated as follows: The comparison of reduction of depressed symptoms between GTP and TCP
In Table 5, the results of Quade’s analysis of covariance indicated that there was no significant difference in reducing symptoms of depression between GTP and TCP modalities (F(1,24)¼ 0Æ06, p ¼ 0Æ813). The result suggested that the two
modalities of follow-up programmes had similar effect on relieving patients’ symptoms of depression.
The comparison of improvement of quality of life between GTP and TCP
In Table 6, Quade’s analysis of covariance revealed that there was no significant difference in improving quality of life between GTP and TCP (F(1,24)¼ 0Æ07, p ¼ 0Æ792). The result
suggested that the two follow-up programmes made similar contribution to the improvement of the patients’ quality of life. The comparison of adherence to scheduled outpatient appointments between GTP and TCP
Table 7 summarizes frequencies (and per cent) of adherence to scheduled outpatient appointment between GTP and TCP. As indicated in Table 7, the results revealed that over 70% of the subjects in GTP completed all scheduled outpatient appointments with psychiatrists while only 25% patients in TCP completed all appointments. In addition, subjects in GTP did not drop from outpatient appointments after one to two months. On the other hand, five subjects in TCP did. Fisher exact test was used to confirm these two differences (p ¼ 0Æ022). The results suggested that subjects in GTP appeared to have a better adherence to scheduled outpatient appointments than patients in TCP.
The comparison of uses of inpatient and emergency services between GTP and TCP
None of the patients from either the GTP or TCP were admitted to the hospital during the three-month follow-up. As shown in Table 8, Fisher’s exact test indicated that no significant difference in use of emergency service between GTP and TCP was found (p ¼ 1Æ000).
Discussion
The comparison of effects on improving clinical outcomes between group and telephone formats of mental health nurse follow-up programmes
This data revealed that after patients participated in group or telephone format of mental health nurse follow-up pro-gramme, their symptoms of depression were reduced and
Table 7 Fisher exact test for comparison of adherence to scheduled outpatient appointment between group therapy programme (GTP) and telephone counselling programme (TCP)
Groups
Adherence to scheduled outpatient appointments
p Complete all
appointments n (%)
Miss one to two appointments n (%)
Drop from appointment after one to two months n (%)
Drop from appointment after first appointment n (%)
GTP 10 (71Æ43) 2 (14Æ29) 0 (0Æ00) 2 (14Æ29) 0Æ022
TCP 3 (25Æ00) 2 (16Æ67) 5 (41Æ67) 2 (16Æ67)
Table 5 Quade’s analysis of covariance results for comparison of group therapy programme (GTP) and telephone counselling pro-gramme (TCP) on pre–postchanges in reported symptoms of depression
Source Sum of squares d.f. Mean square F p
Intervention 2Æ30 1 2Æ30 0Æ06 0Æ813
Error 965Æ14 24 40Æ21
Table 6 Quade’s analysis of covariance results for comparison of group therapy programme (GTP) and telephone counselling pro-gramme (TCP) on pre–postchanges in reported quality of life
Source Sum of squares d.f. Mean square F p Intervention 1Æ81 1 1Æ81 0Æ07 0Æ792 Error 607Æ67 24 25Æ3194
quality of life was improved. To explore which was the better way to provide follow-up in Taiwan, group and telephone formats of follow-up programmes were compared. The present study indicated that the effects of group and telephone formats were similar in improving clinical out-comes and quality of life in outpatients with depression. The same elements of interventions: care management and struc-tured psychotherapy might contribute to the outcome of equivalent effectiveness between two formats of follow-up programmes. The results of this pretest–post-test study and the previous randomized clinical trials on follow-up (Wells et al. 2000, Schoenbaum et al. 2001, Unutzer et al. 2002, Araya et al. 2003, Miranda et al. 2003, Swindle et al. 2003, Simon et al. 2004) suggested that care management supple-mented by structured psychotherapy was the more effective intervention for improving clinical outcomes for outpatients with depression. In this and previous studies, care manage-ment commonly included patient education, crisis inter-vention and frequent monitoring of patients’ conditions. Its effects could enhance patient knowledge about nature of depression and treatments for depression and could increase their adherence to treatment. Regarding the provision of structured psychotherapy, while in the previous studies cognitive-behavioural therapy was commonly provided, the psychotherapeutic approach in this study was empowerment therapy. The therapy which included stress management and body-mind-spirit empowerment strategies could help patients to learn coping strategies for current difficulties and to engender a positive self view and the use of their inner power. Through practicing psychotherapeutic activities, symptoms of depression such as sense of hopelessness and helplessness could be minimized. In addition to the same elements of interventions, adequate rates of follow-up treatment could also contribute to positive clinical outcomes, whether provi-ded in telephone or group formats. In this study, the 12-session group programme and 10-session telephone pro-gramme in three-month follow-up both met the standard rates of treatment according to the clinical guideline of depression management (National Collaborating Centre for Mental Health 2004).
The comparison of patients’ adherence to mental health nurse follow-up programmes between group and telephone formats
The present study revealed that patients appeared to have a high attendance rate of follow-up. This may be because in the assignment method patients were assigned into telephone or group format of follow-up based on their needs. Therefore, their motivation toward adherence to follow-up was high. Over 90% (91Æ7%) of the patients in telephone format completed all 10 calls of the follow-up care. This study and the previous study (Simon et al. 2004) demonstrated a high rate of patient completion of telephone-based follow-up programme. The telephone format provided a beneficial flexibility to help patients who were not able to attend office-based follow-up programme because of distance, time problems, or stigma issues. The group-based follow-up programme held regular meetings at specific times, which might have influenced patients to complete all sessions of follow-up programme. All patients in group format attended at least six sessions with 57Æ1% participating in 8–11 sessions and 35Æ7% in all 12 sessions of the follow-up programme. However, compared with the office-based individual psychotherapy format, in this study the majority of patients in office-based group therapy format achieved high attendance rate. Horvitz-Lennon et al. (2003) found that most patients in an office-based follow-up programme with an individual psychotherapy format did not reach more than four sessions. The results suggested that group support might enhance patients’ motivation to attend the group format of follow-up programme. The results of this study suggested that both modalities of follow-up pro-grammes could be established together in outpatient setting for depression patients with different needs. Those patients who require flexible scheduled-treatment would benefit from telephone format and those who want to obtain group support might choose group format.
The comparison of patients’ adherence to psychiatrists’ outpatient appointments between group and
telephone formats
The present study indicated that the patients in group format were more likely to complete all scheduled outpa-tient appointments with psychiatrists than the paoutpa-tients in telephone format. The findings suggested that when patients in group therapy shared the information about the import-ance of having their conditions regularly monitored by doctors, their motivation might keep appointments increased. Patients in telephone format requiring flex-ible scheduling might have more difficulty to complete
Table 8 Fisher exact test for comparison of use of emergency service between group therapy programme (GTP) and telephone counselling programme (TCP)
Groups
Frequency of use of emergency services n (%)
p
0 1
GTP 13 (92Æ86) 1 (7Æ14) 1Æ000
psychiatrists’ office outpatient appointments than patients in group format.
The comparison of use of medical resources between group and telephone formats
The present study indicated that there was no significant difference in use of medical resources between two formats of follow-up programmes. The results revealed that no patient in group or telephone format was admitted to the hospital for depression during the three-month follow-up. One patient in group format used emergency services one time. The findings suggested that regular follow-up with extra calls for crisis assessments and interventions might have effectively contri-buted to the potential saving in using inpatient and emer-gency services although intervention costs increased for follow-up care. In the cost-effectiveness study, Schoenbaum et al. (2001) found that the follow-up programmes increased intervention fees, but the patients had fewer days with the burden of depression and had longer period of being employed. Therefore, follow-up care might be considered as a cost-effective strategy in managing depression in commu-nity through its effects on saving the cost of inpatient and emergency treatment, reducing symptoms of depression and enhancing patients’ quality of life.
Conclusion and limitations
The results of this pilot study suggested that two new interventions of mental health nurse follow-up programmes were safe and effective protocol for managing depression among outpatient in Taipei. Moreover, developing both telephone and group formats for follow-up care could meet different needs of outpatients with depression. Nevertheless, there are four limitations of this study, which might influence the general applicability of the results of the follow-up programmes: (i) This phase one clinical trial with exclusively female patients raises questions regarding the applicability of this follow-up protocol to male patients with depression; (ii) Because this phase one clinical trial aims to develop follow-up protocol, the research design does not include a control group at this stage. The results of this study cannot compare the effects of mental health nurse follow-up programme with the usual care of only receiving the psychiatrist’s treatment; (iii) Patients were assigned into telephone or group format according to their needs. This assignment method was chosen to test if the follow-up programmes could benefit patients with different needs. Therefore, this method does not involve random process. Accordingly, there is an unstudied impact of subject characteristics on the comparison of the two groups;
and (iv) The outcomes are evaluated at baseline (pretreat-ment) and post-treatment after three-month interventions. It is unknown whether the effects will be maintained after the follow-up programmes are ended.
Implications for nursing and health care practice
This study and that of Swindle et al. (2003) found that in follow-up programmes mental health nurses working closely with primary care physicians could effectively improve clinical outcomes and adherence to treatment in outpatients with depression. Mental health nurses specialized in man-agement of depression could provide not only care manage-ment but also structured psychotherapy. In the study of Swindle et al. (2003) the follow-up programme offered by clinical nurse specialist focused on management of major depression because they thought that patients with minor depression might recover during watchful-waiting. Neverthe-less, the present study revealed that the mental health nurse follow-up was effective to both major and minor depression. The merit of focusing on management of both major and minor depression might help to prevent more patients’ condition from worsening.The implication of this study for nursing practice in Taiwan relates to the need of developing telephone and group formats of mental health nurse follow-up programmes. In follow-up programmes, nurses play important educator and counselling roles in order to improve continuity of treatment among outpatient with depression. Moreover, improving quality of care in management of depression among outpa-tient could enhance the outcomes of secondary prevention, such as preventing a worsening of patients’ conditions and resulting admission to an inpatient unit. Further studies need to include a phase two clinical trial which examines the limitations of this study and includes female and male patients, control groups, random assignment and measure-ment of maintaining effects in order to test the effectiveness of mental health nurse follow-up programmes in a more general population base.
Acknowledgement
This study was supported by a grant from the National Science Council (NSC92-2314-B-038-027).
Contributions
Study design: FHH; data collection: FHH, TTY, CCC, SYT, YML, CJT, WYC; data analysis: FHH, KCW; manuscript preparation: FHH and literature review: FHH, YML.
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