Research projects

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

Principal Researchers

Mr Michael McGartland, Dr Rob Selzer, Dr Steve Ellen, Dr Grant Blashki, Dr Paul Fitzgerald, Ms Ingrid Ozols, Ms Jill Day, Ms Fiona Foley


The Alfred Hospital



Award Type

beyondblue Victorian Centre of Excellence

Project completion year


Project brief

The Inner South East Primary Mental Health Team (PMHT) provides one-off psychiatric assessments to patients referred by GPs for diagnostic clarification and treatment recommendation.  The outcomes of the assessment are communicated to the GP by means of an assessment letter.  The project investigated the effects of letter copying, that is, sending the letter (which outlines the patient’s diagnosis and treatment recommendations) to GPs and patients simultaneously, and whether this intervention improved patients’ adherence to treatment recommendations and overall outcomes.

The practice of letter copying was implemented in the UK in 2004 based on research suggesting that patients wanted to receive health-related correspondence.  As well as making patients feel more involved in their own healthcare, holding copies of health records allows patients greater continuity when changing  practitioners. 

This has been the first study investigating whether letter copying influences patient outcomes.  The study sample consisted of 21 in the experimental “get letter” group and 18 in the control “no letter” group.  All participants were followed up by telephone interview one month and three months after the letter was sent.

Key findings

The study showed that the letter intervention significantly improved the patients’ adherence to treatment recommendations and their stress symptoms and also showed a trend toward improving their depression and anxiety symptoms compared with patients not receiving the letter. 

Although both groups showed significant improvement over time in all areas of the Depression Anxiety and Stress Symptoms (DASS) scale after their interaction with the PMHT, the “get letter” group reported significantly less stress than the “no letter” group.

Larger numbers of experimental group participants showed improvement (a change in DASS score > 0) over the control group at one month, indicating that the patients receiving the letter see an improvement in their symptoms earlier than those without the letter.  The magnitude of the improvement was also greater in the experimental group participants.


Providing a copy of a psychiatric assessment letter to the patient does not appear to cause any negative outcomes.  At follow-up, patients who received a copy of their assessment letter were significantly more adherent to the treatment suggestions than those who did not receive a letter.  The letter intervention improved the level of communication between patients and GPs.  The GPs discussed more treatment suggestions more often with patients who had received their assessment letters.

Having their own copy of the assessment report, that they can read in their own time, in a less stressful setting than a medical consultation and that they can discuss with family members, may overcome issues of trying to recall verbal recommendations as well as giving patients an understanding of the importance of the recommendation within the context of their illness.

Implications for policy, practice and further research

The practice of letter copying is a simple and inexpensive interaction which encourages self-management by giving patients an opportunity to be active agents in their treatment program.

Another benefit is an improvement in service relationships between patients, primary care physicians and specialists, as all work from the same information.  The practice is of benefit to people from marginalised groups who are more likely to have a number of professionals involved in their care and more likely to have changes in practitioners.

Further investigation in an extended medical setting (including patients experiencing psychotic illness) is required and/or the practice of letter copying should be raised for consideration in Australian policy.  It is simple, practical and easily applicable to many areas of primary care.

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