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Supported self management: Introduction

Defining supported self-management

Supported self-management (SSM) is a low-intensity behavioural intervention in which the patient uses a self-care tool with support from a health care provider. Self-care tools include workbooks, audiofiles, DVDs and web-based material. Programs developed for mental health self-care are typically based on the principles of cognitive-behavioural therapy (CBT).

SSM uses much less clinical time than standard CBT and is suitable for delivery at the primary care level, rather than requiring involvement of scarce mental health specialists. The primary care provider's role in SSM is not to be a psychotherapist, but rather a coach who helps the patient to apply the skills of behavioural change.

As an intervention in clinical practice, SSM falls somewhere between a clinical treatment, targeting mental health symptoms, and a method of knowledge transfer, teaching the patient a set of concepts and strategies helpful in overcoming mental health problems.

Most work in this area has focused on depression, but self-management tools have also been developed for panic disorder, health anxiety, eating disorders and other mental health problems.

Benefits of supported self-management

SSM extends the reach of the primary care clinician

SSM allows a form of CBT that is practical within the time constraints of primary care. There is pressure on primary care providers to offer non-pharmacological interventions and SSM is a behavioural intervention that can be incorporated into standard practice. In a dissemination trial with 85 family physicians, physicians chose to use SSM for depression with 25 per cent of their patients with depression over a six-month period.

Basic SSM can be delivered without extensive training

Acquiring a basic level of competence in SSM does not demand extensive training. A training session as brief as one hour provides sufficient grounding for SSM to be confidently delivered. With more training and experience, clinicians can use this intervention in a more sophisticated way.

SSM is effective for mild depression

Several systematic reviews have shown SSM for mild range depression to be effective compared to control conditions. A 2007 systematic review found that SSM for depression yields an effect similar in magnitude to that of standard depression treatment. However, controlled trials of self-management mostly target individuals with mild symptomatology and are not directly comparable to standard treatment trials.

Care guidelines recommend using SSM

SSM is recommended by a number of care guidelines for common mental health problems, including depression, anxiety and eating disorders. The most notable of these guidelines are those of the U.K. National Institute for Health and Care Excellence (NICE), where SSM is referred to as guided self-help.

SSM may be an alternative to medication in mild cases

SSM for depression provides an effective alternative to antidepressant medication in mild cases.

Overreliance on medication has been highlighted by a leading expert in primary mental health care. According to Katon (2003), "Evidence suggests that patients with minor depression and adjustment disorders are frequently treated with antidepressant medications, which represents ‘overuse' in the IOM [Institute of Medicine] nosology since there is little evidence of effectiveness of medication in these populations."

The NICE guidelines make a similar point: "Antidepressants are not recommended for the initial treatment of mild depression, because the risk–benefit ratio is poor" (National Collaborating Centre for Mental Health, 2004b).

SSM is a low-cost intervention

SSM has low cost to the patient and the health care system. In a dissemination trial of SSM for depression, delivery of SSM cost $15, versus an average cost of $100 for a course of antidepressant medication* (Bilsker et al., 2008; Patten et al., 2008).

The steps of supported self-management

Primary care providers can implement SSM with patients by following three steps

Assess 

Advise

Assist

Each step involves behavioural strategies clinicians can use to encourage and support patients engaging in self-management.


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