Proactive care from practice nurses improves social functioning for people with severe and recurrent depression

Interventions delivered by nurses appeared the most effective, although further work is needed to confirm this finding.

The mental health charity Mind have published the findings of a three year study which explores whether regular proactive reviews delivered by nurses in GP practices results in better mental health and social outcomes for people living with depression.  The study was a randomised controlled trial carried out by a research team at University College London.

Proactive care is routinely provided by practice nurses for physical chronic conditions such as asthma or diabetes but is not always offered for depression, with nurses often feeling apprehensive about broaching the subject with patients.

558 patients were recruited from 42 general practices throughout the UK. The main trial evaluated the intervention overall, analysing the data collected from all participants using standard outcome measurement scales, while a separate qualitative study collected in-depth interview data from a sub-set of the individual participants and practice nurses who had been involved in the trial.

This trial compared two interventions for people with a history of recurrent or chronic depression:

  • Control group: ‘GP usual care’ (276 patients) with
  • Intervention group: ‘Structured care’ involving regular follow-up by practice nurses in addition to ‘GP usual care’ (282 patients)

The ‘structured care’ intervention consisted of 10 appointments with the practice nurse over a two year period. Participants were given an educational booklet about depression and its treatment at their initial appointment. The nurses answered any questions about current or past treatments and checked whether participants were taking any treatments currently prescribed and clarifying any problems identified. If there were current symptoms of depression, alternative or additional treatments were discussed. These could be in the form of medication, psychological therapies or social interventions. The rationale and evidence for any of these was made clear, both in the background literature given to participants and in their discussions with the nurses. Social factors, which could be contributing to the ongoing nature of participants’ depression, were explored (for example social isolation, low physical activity, unemployment, finance, housing) and appropriate advice given or referrals to other agencies made. The importance of participant choice and their active participation in this process and in deciding the treatments selected was emphasised. A joint management plan was formulated between the nurses and each of their participants and reviewed during subsequent appointments, together with a review of how the participant was feeling and any progress made against previous goals set.

The key outcome was the severity of the symptoms the participant experienced, measured using the Beck Depression Inventory. A range of other outcome measures were used to collect data on social functioning, quality of life, the costs of medical and informal care for these participants and their health service use.

Key findings of the study included:

  • Nurses had improved confidence and skills when empowered to manage patients with depression.
  • Patients experienced significant improvements in social functioning after receiving regular sessions with practice nurses, reporting increased confidence and self esteem.
  • There were small improvements reported in the severity of depression experienced by patients when compared to a control group.
  • Patients attending all ten sessions were likely to experience significant improvements in both symptoms and social functioning.
  • Many patients felt that ongoing proactive care should be provided by a practice nurse rather than a GP.
  • Proactive care was shown to be potentially cost effective in achieving positive changes in severity of depression and improving the patient’s ability to play a fuller role in society.

A full report of the study is available on the Mind website, along with a new training guide on depression aimed at practice nurses.  The report will be of interest to GPs and practice managers looking for new ways to meet the need for services designed to help those with chronic and recurrent depression.

Mind’s Chief Executive Paul Farmer said:

There is clearly an unmet need in offering people with depression ongoing holistic consultation in primary care. Practice nurses are on the front line so are well placed to provide this kind of advice and support. Nurses are already offering enhanced care packages to patients for physical conditions and with the right training and support could be equipped to do the same for depression. There must be a parity of esteem in how mental and physical health problems are addressed in primary care settings.

Royal College of Nursing Chief Executive & General Secretary Dr Peter Carter said:

General practice nurses play a huge role in managing the care of patients with long term physical conditions. However their potential for improving the quality of life for patients with depression has never been realised across the board. We are delighted to support this new initiative and hope that nurses will be encouraged to use this excellent training pack to enhance their skills, knowledge and confidence in the management of depression.

Research nurse Kate O’Brien who took part in the study said:

Caring for patients with depression is challenging and, consequently, extremely rewarding. I found that I needed to develop new skills to enable me to feel that I could be of benefit to my patients. The most important thing was listening, really listening to pick up what patients were trying to tell you. This often meant identifying what they weren’t saying and finding a way of allowing them to talk comfortably.

Comment from a patient who participated in the study:

I have huge faith in my doctor if I go with a medical problem that’s fine but I think depression isn’t an acute medical problem. I think it’s more something that you need to have time with somebody. And the time to me is more important that the prescription. That time to me (with the nurse) was worth 100 prescriptions.

Links

ProCEED: report of a study of proactive care by practice nurses for people with depression and anxiety (PDF). Mind, 31 Aug 2011.

Supporting people with depression and anxiety: a guide for practice nurses (PDF). Mind, 31 Aug 2011.

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Andre Tomlin

Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol with his wife, dog and three little elflings.

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