A Randomised Controlled Trial of a Letter Intervention in Primary Care Patients to Improve Depression and Anxiety Disorders

In 2004, the UK National Health Service mandated the practice of sending patients copies of all correspondence between clinicians involved in their care. Such a policy is consistent with the principle of autonomy and with the right of the patient to access information about themselves (Somerville, 1994). It is also supportive of a collaborative model of service delivery in which patients are viewed as active agents in their own wellbeing, as opposed to passive recipients of treatment.

Letter interventions have boosted attendance rates for cervical screening (McDowell, Newell & Rosser, 1989a), blood pressure checks (McDowell, Newell & Rosser, 1989b), and mammography follow-up (Saywell et al., 2003). They have also resulted in improved adherence to antihypertensive medications and lipid lowering agents (Atthobari, Monster & de Jong-van den Berg, 2004). However, caution has been urged in relation to the use of letters in some patient subpopulations, such as persons who lack the capacity to consent and patients who have psychiatric diagnoses (Jelley, van Zwanenberg & Walker, 2002).

Despite these cautions, psychiatric patients react positively to the idea of receiving a copy of the letters containing clinical information that are routinely sent to their GP. At least three quarters of patients who had never received such a letter wished to do so (Dale, Tadros, Adams & Deshpande, 2004; Marzanski, Musunuri & Coupe, 2005), and at least 80% of patients who had received a letter supported the practice (Asch, Price & Hawks, 1991; Nandhra, Murray, Hymas & Hunt, 2004). Most psychiatric patients wished to continue to receive such letters, and a number commented that "seeing their problems understood and described objectively helped them to gain perspective" (Nandhra et al., 2004, p. 41).

Some psychiatric patients and practitioners, even those who favour letter interventions in principle, have expressed reservations. One commonly expressed concern is over the preservation of patient confidentiality, especially with regard to psychiatric reports that containing highly personal information (see, for example, Marzanski et al., 2005; Nandhra et al., 2004). To date, however, there have been no reported breaches of confidentiality in Britain. In fact, most patients are happy for letters to be mailed to them, as are the carers of patients with dementia (Harris & Boaden, 2003). Some patients and practitioners are also concerned that the contents of the letter may cause distress (Marzanski et al., 2005; Nandhra et al., 2004). However, the reaction reported by most psychiatric patients themselves was that when they read the letter they did not experience any distress at all. A minority of patients did initially feel distress, but they reported that once they had regained composure they found the letter helpful and were glad they had received it (Nandhra et al.).

An issue that has not yet been clarified is whether receipt of a letter improves adherence to treatment recommendations in cases of psychiatric illness. This is a critical issue; a recent review of adherence to antidepressant medication found drop out rates as high as 33% (Pampallona & Bollini, 2002). The major aim of the current study is to establish whether adherence to treatment is boosted by a letter intervention. If such an effect is found, it should follow that increased adherence leads to improved reduction in the severity of symptoms, and consequently to improved patient outcomes.