Abstract
BackgroundPatients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals.MethodsNested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews.ResultsBased on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients’ health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems.ConclusionThe COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.
Highlights
Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression
Findings suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. Such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC
The framework offered by collaborative care was valued by professionals, especially by Psychological wellbeing practitioner (PWP), because it increased opportunities for care co-ordination and information sharing with Practice nurse (PN), and enhanced their confidence to manage mood problems in the context of complex physical symptoms: PWP10: Working collaboratively...in terms of your practice it’s very helpful to get that reassurance that what you’re doing in the sessions is the right thing, is useful, and will be helpful for the person
Summary
Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Within the context of primary care, short consultation times and a tendency on the part of patients and practitioners to normalise depression in the presence of LTCs [5] has typically led to prioritisation of physical over mental health problems, thereby limiting opportunities for integrated healthcare. The cost and health burden associated with poor management of depression and LTCs has prompted widespread recognition among clinicians [6], policy makers [7], and governments [8] that there are significant gains to be made by developing more integrated ways of working that foster partnership working between mental health and other health professionals [3,9]
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