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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Who owns the problem and the solution?
Replyh to Aikens' letter
Funding agencies and patient-subjects disagree about the nature of mental health problems and solutions
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Larry B. Mauksch, Seattle, USA Senior Lecturer, Department of Family Medicine, University of Washington
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I would like to add my thanks and convey my respect for the contribution of Zayas et al. Their conclusions provide a useful outline for those of us who desire to improve quality of care in clinical settings. While their study focuses on a specific population, the conclusions probably apply to any provider- patient-family community, particularly where treating mental illness is the target. The stigma that is felt by patients and providers may represent an added barrier to clinician adoption and patient engagement. Elizabeth Lin and colleagues document the difficulty in sustaining change in provider behavior after a successful research trial and educational intervention to improve care for patients suffering from depression in primary care (1, 2). The comments by Aikens and reply by Zayas address the gulf that exists between the scientific community and the clinic-patient/ family community. Unless funding organizations employ mechanisms that stimulate clinician and consumer curiosity in quality improvement and promote shared ownership of systems change, quality improvement may be hard to sustain. I had the privilege and challenge of spending one year in a primary care clinic serving only low income, uninsured adults. One half of the patients had one or more mental disorders (3) and the most common problem that patients wanted to discuss with their providers was “problems with mood (4). My job was to integrate a new way of addressing mental disorders. Any lasting successful change in this clinic came because the surrounding community, board of directors, executive director, clinicians, staff and patients were and continue to be involved in defining the problems, owning mistakes, creating solutions, examining more mistakes and bringing in outside consultation to stimulate new solutions. In 2002 we described the phases of integration (5) of mental health care , including pitfalls, missteps and improvements and are currently evaluating changes in quality of care between 1999 and 2004. The lessons from our experience and from the Zayas et al study replicate the lessons I have learned from 20 years of practice as a psychotherapist. When significant change occurs patients and families own the problem, and own the solution. 1. Lin EH, Katon WJ, Simon GE, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care. 1997;35(8):831-842. 2. Lin EH, Simon GE, Katzelnick DJ, Pearson SD. Does physician education on depression management improve treatment in primary care? J Gen Intern Med. Sep 2001;16(9):614-619. 3. Mauksch, Tucker SM, Katon WJ, et al. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract. Jan 2001;50(1):41-47. 4. Mauksch LB, Katon WJ, Russo J, Tucker SM, Walker E, Cameron J. The content of a low-income, uninsured primary care population: including the patient agenda. J Am Board Fam Pract. Jul-Aug 2003;16(4):278-289. 5. Cameron J, Mauksch L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health. 2002;20(4):343-363. Competing interests: None declared |
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Luis H Zayas, PhD, St. Louis, MO Washington University in St. Louis
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I appreciate Dr. Aikens' supportive comments. He is very right to note that funding agencies and their reviewers seldom realize deliverable protocols must be flexibly driven by patient-centered concerns. That is the problem as I see it, that reviewers look for elements of the efficacy study despite the less-than-stable community contexts in which such studies are implemented. Writing this kind of flexibility into a grant isa real challenge, and reviewers will always ask "what happens if..." questions that can be almost infinite. While I don't think we should simply be funded on a "trust me" basis, reviewers must also acknowledge the challenges in community based intervention research. Ultimately, we must keep trying to write study grants in ways that convey a solid scientific basis while remaining flexible to community vicissitudes. Competing interests: None declared |
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James E. Aikens, Ann Arbor, United States of America Assistant Professor of Family Medicine and Psychiatry, Univ. of Michigan
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Zayas et al. present a bold and useful self-examination of their attempt to adapt a psychosocial intervention to urban primary care settings. Their story is sobering but educational. Despite NIMH funding, the selection of an obviously significant research topic, and the researchers’ experience in the field, there were massive unanticipated barriers to delivering the standardized protocol. Subjects tended to receive only three of eight planned cognitive- behavioral sessions, with none receiving all eight. An average of one of four planned child education sessions was delivered, with no subject receiving all four. Although therapist turnover and administrative issues certainly contributed to the problem, the overriding issue was that patient preferences and priorities rule the day. Subjects saw themselves as upset and stressed rather than depressed, and self-tailored their own protocols accordingly. I agree with the authors that more qualitative preliminary work probably would have led to a leaner, more flexible protocol, and that Participatory Action Research approaches may have reduced the chances of a failed trial. However, all the preliminary work in the world cannot change the fact that patient-subjects and funding agencies have very different models of mental health problems and their solutions. This issue is most heightened in translational research, where the participants view themselves as patients first, and not subjects. Naturally, patients only attend appointments that they view as relevant and potentially helpful. Yet, funding agencies and their reviewers seldom realize that unless a mental health protocol is deliverable, it cannot be clinically relevant. And if not clinically-relevant, then it has reduced scientific significance. And in order to be deliverable, protocols must be flexibly driven by patient-centered concerns. Standardization helps rule out alternative explanations, and this is obviously a vital concern in any scientific experiment. However, standardization can only be applied to aspects under full experimenter control. Zayas at al.’s findings shows us that in the real world, number of psychosocial sessions is not under experimenter control. Perhaps instead of testing “8 cognitive- behavioral sessions,” future trials could be designed to test “access to 8 cognitive-behavioral sessions.” Session agendas could accordingly be designed flexibly enough to reflect the philosophy that any given session might be the subject’s final session. James E. Aikens, Ph.D. Competing interests: None declared |
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