There appears to be a theme emerging out here in the Woodland in relation to the direction of healthcare developments; in that we may have become rather isolated in therapeutic copses and actually if we worked together across these boundaries then patients may benefit more!
A year ago, I reported on the collaborative care project for depression and cancer, which showed very positive results. From a wider strategic perspective the 5 year forward view’s new models of care are strongly focused on collaboration.
In this blog I will discuss a recent RCT published in the BMJ by Coventry et al, which looks at collaborative care in the primary care setting for patients with depression and diabetes or cardiovascular disease.
This is a cluster randomised controlled trial within 36 general practices across Merseyside, Greater Manchester and East Lancashire. The aim of the trial was to test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions. Patients were selected if they had a record of diabetes or heart disease, or both, who had depressive symptoms (≥ 10 on patient health questionnaire-9) for at least two weeks.
The collaborative care intervention included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and relapse prevention. This included up to eight sessions of psychological treatment (delivered by an IAPT practitioner) and two treatment sessions delivered jointly with the practice nurse.
Usual care was standard clinical practice provided by general practitioners and practice nurses.
- Collaborative care: 17 practices, 191 patients
- Usual care: 19 practices, 196 patients
- Mean age was 58.5 (SD 11.7)
- 240 (62%) were men
- Mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease
- Primary outcome date for 350 participants
Collaborative care: Mean depressive scores were 0.23 points lower at 4 months on the self reported symptom checklist-13 depression scale (SCL-D13) (95% confidence interval −0.41 to −0.05), equal to an adjusted standardised effect size of 0.30.
Patients in the intervention arm reported significantly lower symptoms of anxiety, being better self managers, rated their care as more patient-centred, and were more satisfied with their care.
There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support.
Collaborative care that incorporates brief low intensity psychological therapy, delivered in partnership with practice nurses in primary care, can reduce depression and improve self management of chronic disease in people with mental and physical multi-morbidity.
Strengths and limitations
The size of the treatment effects were modest and were less than had been hoped for. However, this trial was completed with a deprived population with high levels of mental and physical multi-morbidity. The process of the trial itself may have led to some bias; such as the challenge of blinding participants during a trial of psychological interventions, face-to-face collection of results can in itself lead to some bias also.
This trial does feel refreshing though, in that it appears to be a real life, practically applicable trial which could be translated into wider primary care; helping understand how to integrate mental healthcare in general healthcare through developing innovative care models and strengthening close links to specialist services.
The way forward needs to be collaborative with interdisciplinary thinking. Let’s work together people!
Coventry P, Lovell K, Dickens C, Bower P, Chew-Graham C, McElvenny D, Gask L (2015). Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ, 350 (feb16 3), h638–h638. doi:10.1136/bmj.h638
NHS Five Year Forward View (PDF). NHS England, October 2014.
The NHS 5 year forward view. The King’s Fund website, last accessed 12 Nov 2015.