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Wei J, Li BWX, Han SJ, Zhuang HJ, Cao WH. Effect of continuous nursing on treatment compliance and side effect management of coronary heart disease. World J Clin Cases 2024; 12:3701-3707. [PMID: 38994285 PMCID: PMC11235468 DOI: 10.12998/wjcc.v12.i19.3701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/12/2024] [Accepted: 05/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND There are relatively few studies on continuing care of coronary heart disease (CHD), and its research value needs to be further clarified. AIM To investigate the effect of continuous nursing on treatment compliance and side effect management in patients with CHD. METHODS This is a retrospective study with patients from January 2021 to 2023. The study was divided into two groups with 30 participants in each group. Self-rating anxiety scale (SAS) and Self-rating depression scale (SDS) were used to assess patients' anxiety and depression, and medical coping questionnaire was used to assess patients' coping styles. The pelvic floor dysfunction questionnaire (PFDI-20) was used to assess the status of pelvic floor function, including bladder symptoms, intestinal symptoms, and pelvic symptoms. RESULTS SAS score decreased from 57.33 ± 3.01before treatment to 41.33 ± 3.42 after treatment, SDS score decreased from 50.40 ± 1.45 to 39.47 ± 1.57. The decrease of these two indexes was statistically significant (P < 0.05). PFDI-20 scores decreased from the mean 16.83 ± 1.72 before treatment to 10.47 ± 1.3the mean after treatment, which was statistically significant (P < 0.05). CONCLUSION The results of this study indicate that pioneering research in continuous care of CHD has a positive impact on improving patients' treatment compliance, reducing anxiety and depression levels, and improving coping styles and pelvic floor functional status.
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Affiliation(s)
- Juan Wei
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 750061, Hebei Province, China
| | - Bai-Wen-Xian Li
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 750061, Hebei Province, China
| | - Shao-Jie Han
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 750061, Hebei Province, China
| | - Hong-Jie Zhuang
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 750061, Hebei Province, China
| | - Wen-Hong Cao
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 750061, Hebei Province, China
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Raya-Tena A, Martín-Royo J, Bellido-Pérez M, Sauch Valmaña G, Berenguera Ossó A, Soria-García MD, Ruíz-Serrano S, Lacasta-Tintorer N, Jiménez Herrera MF. A primary care psychoeducational group intervention for patients with depression and physical comorbidity: A qualitative study with a gender perspective. Int J Nurs Pract 2023; 29:e13157. [PMID: 37127403 DOI: 10.1111/ijn.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 03/07/2023] [Accepted: 03/28/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To explore the experiences and emotions of individuals with depression and physical comorbidity within the context of psychoeducational group interventions led by primary care nurses in Catalunya (Spain). METHOD A psychoeducational group intervention was conducted in the first semester of 2019 with 13 primary care teams (rural/urban) and 95 participants with depression and physical comorbidity. The qualitative research and phenomenological perspective were based on 13 field diaries and 7 semi-structured interviews carried out with the observer nurses. The interviews were recorded and transcribed. Codes were identified by segmenting the text into citations/verbatim accounts and emerging categories/subcategories by regrouping the codes. The results were triangulated among the researchers to identify and compare similarities and differences. RESULTS Four major themes were found: (a) gender differences; (b) coping strategies and changes observed during the intervention; (c) functions of the group as a therapeutic element; and (d) the nurses' perceptions of the group experience. Gender differences were identified in relation to experiences and emotions. CONCLUSIONS As some patients acquired skills/behaviours during the intervention that helped them initiate changes and the nurses were satisfied with the intervention, it is important to include this information when planning effective interventions for patients with this profile.
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Affiliation(s)
- Antonia Raya-Tena
- Primary Health Care Center Raval Nord, Institut Català de la Salut, Barcelona, Spain
- Nursing Department, Faculty of Nursing, Rovira and Virgili University, Tarragona, Spain
| | - Jaume Martín-Royo
- Unitat Bàsica de Prevenció, Gerència Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain
- Unitat de Suport a la Recerca Barcelona ciutat, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPGol), Barcelona, Spain
| | - Mercedes Bellido-Pérez
- Primary Health Care Center Esparreguera, Institut Català de la Salut, Barcelona, Spain
- Department of Nursing, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Gloria Sauch Valmaña
- Health Promotion in Rural Areas Research Group, Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Sant Fruitós de Bages, Barcelona, Spain
- Unitat de Suport a la Recerca Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPGol), Barcelona, Spain
| | - Anna Berenguera Ossó
- Unitat de Suport a la Recerca Barcelona ciutat, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | | | - Sonia Ruíz-Serrano
- Primary Health Care Center Adrià, Institut Català de la Salut, Barcelona, Spain
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Beaudin J, Chouinard MC, Girard A, Houle J, Ellefsen É, Hudon C. Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a scoping review. BMC Nurs 2022; 21:212. [PMID: 35918723 PMCID: PMC9344621 DOI: 10.1186/s12912-022-01000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
AIM To map integrated and non-integrated self-management support interventions provided by primary care nurses to persons with chronic diseases and common mental disorders and describe their characteristics. DESIGN A scoping review. DATA SOURCES In April 2020, we conducted searches in several databases (Academic Research Complete, AMED, CINAHL, ERIC, MEDLINE, PsycINFO, Scopus, Emcare, HealthSTAR, Proquest Central) using self-management support, nurse, primary care and their related terms. Of the resulting 4241 articles, 30 were included into the analysis. REVIEW METHODS We used the Rainbow Model of Integrated Care to identify integrated self-management interventions and to analyze the data and the PRISMS taxonomy for the description of interventions. Study selection and data synthesis were performed by the team. Self-management support interventions were considered integrated if they were consistent with the Rainbow model's definition of clinical integration and person-focused care. RESULTS The 30 selected articles related to 10 self-management support interventions. Among these, five interventions were considered integrated. The delivery of the interventions showed variability. Strategies used were education, problem-solving therapies, action planning, and goal setting. Integrated self-management support intervention characteristics were nurse-person relationship, engagement, and biopsychosocial approach. A framework for integrated self-management was proposed. The main characteristics of the non-integrated self-management support were disease-specific approach, protocol-driven, and lack of adaptability. CONCLUSION Our review synthesizes integrated and non-integrated self-management support interventions and their characteristics. We propose recommendations to improve its clinical integration. However, further theoretical clarification and qualitative research are needed. IMPLICATION FOR NURSING Self-management support is an important activity for primary care nurses and persons with chronic diseases and common mental disorders, who are increasingly present in primary care, and require an integrated approach. IMPACT This review addresses the paucity of details surrounding integrated self-management support for persons with chronic diseases and common mental disorders and provides a framework to better describe its characteristics. The findings could be used to design future research and improve the clinical integration of this activity by nurses.
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Affiliation(s)
- Jérémie Beaudin
- Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, 3001J1H 5N4, Canada.
| | - Maud-Christine Chouinard
- Faculté Des Sciences Infirmières, Université de Montréal, Pavillon Marguerite-d'Youville, C.P. 6128 succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada
| | - Ariane Girard
- Faculté de Médecine, Université Laval, VITAM Research Center On Sustainable Health, 2601, Chemin de La Canardière (G-2300), Québec, Québec, G1J 2G3, Canada
| | - Janie Houle
- Département de Psychologie, Université du Québec À Montréal, case postale 8888, succ. Centre-ville, Montréal, Québec, H3C 3P8, Canada
| | - Édith Ellefsen
- École des sciences infirmières, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, 3001J1H 5N4, Canada
| | - Catherine Hudon
- Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, 3001J1H 5N4, Canada
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de Pinho LG, Lopes MJ, Correia T, Sampaio F, do Arco HR, Mendes A, Marques MDC, Fonseca C. Patient-Centered Care for Patients with Depression or Anxiety Disorder: An Integrative Review. J Pers Med 2021; 11:776. [PMID: 34442420 PMCID: PMC8400282 DOI: 10.3390/jpm11080776] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/23/2022] Open
Abstract
People have specific and unique individual and contextual characteristics, so healthcare should increasingly opt for person-centered care models. Thus, this review aimed to identify and synthesize the indicators for the care process of the person with depression and/or anxiety disorders, based on patient-centered care, going through the stages of diagnostic assessment and care planning, including intervention. An integrative literature review with research in seven scientific databases and a narrative analysis were carried out. Twenty articles were included, with indicators for diagnostic evaluation and care/intervention planning being extracted. Care planning focused on people with depression and/or anxiety disorder must be individualized, dynamic, flexible, andparticipatory. It must respond to the specific needs of the person, contemplating the identification of problems, the establishment of individual objectives, shared decision making, information and education, systematic feedback, and case management, and it should meet the patient's preferences and satisfaction with care and involve the family and therapeutic management in care. The existence of comorbidities reinforces the importance of flexible and individualized care planning in order to respond to the specific health conditions of each person.
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Affiliation(s)
- Lara Guedes de Pinho
- Escola Superior de Enfermagem São João de Deus, Universidade de Évora, 7000-811 Évora, Portugal; (M.J.L.); (M.d.C.M.); (C.F.)
- Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal;
| | - Manuel José Lopes
- Escola Superior de Enfermagem São João de Deus, Universidade de Évora, 7000-811 Évora, Portugal; (M.J.L.); (M.d.C.M.); (C.F.)
- Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal;
| | - Tânia Correia
- Abel Salazar Institute of Biomedical Sciences, University of Porto, 4050-313 Porto, Portugal;
- NursID: Innovation & Development in Nursing Research Group, CINTESIS—Center for Health Technology and Services Research, 4200-450 Porto, Portugal;
| | - Francisco Sampaio
- NursID: Innovation & Development in Nursing Research Group, CINTESIS—Center for Health Technology and Services Research, 4200-450 Porto, Portugal;
- Higher School of Health Fernando Pessoa, 4249-004 Porto, Portugal
| | - Helena Reis do Arco
- Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal;
- Superior School of Health, Polytechnic Institute of Portalegre, 7300-555 Portalegre, Portugal
| | - Artur Mendes
- Psychiatry Department, Hospital Espírito Santo, 7000-811 Évora, Portugal;
| | - Maria do Céu Marques
- Escola Superior de Enfermagem São João de Deus, Universidade de Évora, 7000-811 Évora, Portugal; (M.J.L.); (M.d.C.M.); (C.F.)
- Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal;
| | - César Fonseca
- Escola Superior de Enfermagem São João de Deus, Universidade de Évora, 7000-811 Évora, Portugal; (M.J.L.); (M.d.C.M.); (C.F.)
- Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal;
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Booth V, Hood-Moore V, Hancox JE, Logan P, Robinson KR. Systematic scoping review of frameworks used to develop rehabilitation interventions for older adults. BMJ Open 2019; 9:e024185. [PMID: 30798309 PMCID: PMC6398678 DOI: 10.1136/bmjopen-2018-024185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Rehabilitation interventions for older adults are complex as they involve a number of interacting components, have multiple outcomes of interest and are influenced by a number of contextual factors. The importance of rigorous intervention development prior to formal evaluation has been acknowledged and a number of frameworks have been developed. This review explored which frameworks have been used to guide the development of rehabilitation interventions for older adults. DESIGN Systematic scoping review. SETTING Studies were not limited for inclusion based on setting. PARTICIPANTS Studies were included that featured older adults (>65 years of age). INTERVENTIONS Studies were included that reported the development of a rehabilitation intervention. PRIMARY AND SECONDARY OUTCOME MEASURES Data were extracted on study population, setting, type of intervention developed and frameworks used. The primary outcome of interest was the type of intervention development framework. RESULTS Thirty-five studies were included. There was a range of underlying medical conditions including mild cognitive impairment and dementia (n=5), cardiac (n=4), stroke (n=3), falls (n=3), hip fracture (n=2), diabetes (n=2), breast cancer (n=1), Parkinson's disease (n=1), depression (n=1), chronic health problems (n=1), osteoarthritis (n=1), leg ulcer (n=1), neck pain (n=1) and foot problems (n=1). The intervention types being developed included multicomponent, support based, cognitive, physical activities, nursing led, falls prevention and occupational therapy led. Twelve studies (34%) did not report using a framework. Five frameworks were reported with the Medical Research Council (MRC) framework for developing and evaluating complex interventions being the most frequently cited (77%, n=17). CONCLUSION At present, the MRC framework is the most popular for developing rehabilitation interventions for older adults. Many studies do not report using a framework. Further, specific guidance to assist this complex field of rehabilitation research is required.
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Affiliation(s)
- Vicky Booth
- Division of Rehabilitation and Ageing, University of Nottingham School of Medicine, Nottingham, UK
| | - Victoria Hood-Moore
- Division of Rehabilitation and Ageing, University of Nottingham School of Medicine, Nottingham, UK
| | - Jennie E Hancox
- Division of Rehabilitation and Ageing, University of Nottingham School of Medicine, Nottingham, UK
| | - Phillipa Logan
- Division of Rehabilitation and Ageing, University of Nottingham School of Medicine, Nottingham, UK
| | - Katie R Robinson
- Division of Rehabilitation and Ageing, University of Nottingham School of Medicine, Nottingham, UK
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Møller MCR, Mygind A, Bro F. Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers. BMC FAMILY PRACTICE 2018; 19:78. [PMID: 29848295 PMCID: PMC5977752 DOI: 10.1186/s12875-018-0764-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/18/2018] [Indexed: 01/13/2023]
Abstract
Background Collaborative care treatment is widely recognized as an effective approach to improve the quality of mental healthcare through enhanced and structured collaboration between general practice and specialized psychiatry. However, studies indicate that the complexity of collaborative care treatment interventions challenge the implementation in real-life general practice settings. Four Danish Collaborative Care Models were launched in 2014 for patients with mild/moderate anxiety and depression. These involved collaboration between general practitioners, care managers and consultant psychiatrists. Taking a multi-practice bottom-up approach, this paper aims to explore the perceived barriers and enablers related to collaborative care for patients with mental health problems and to investigate the actual experiences with a Danish collaborative care model in a single-case study in order to identify enablers and barriers for successful implementation. Methods Combining interviews and observations of usual treatment practices, we conducted a multi-practice study among general practitioners who were not involved in the Danish collaborative care models to explore their perspectives on existing mental health treatment and to investigate (from a bottom-up approach) their perceptions of and need for collaborative care in mental health treatment. Additionally, by combining observations and qualitative interviews, we followed the implementation of a Danish collaborative care model in a single-case study to convey identified barriers and enablers of the collaborative care model. Results Experienced and perceived enablers of the Danish collaborative care model mainly consisted of a need for new treatment options to deal with mild/moderate anxiety and depression. The model was considered to meet the need for a free fast track to high-quality treatment. Experienced barriers included: poor adaptation of the model to the working conditions and needs in daily general practice, time consumption, unsustainable logistical set-up and unclear care manager role. General practitioners in the multi-practice study considered access to treatment and not collaboration with specialised psychiatry to be essential for this group of patients. Conclusions The study calls for increased attention to implementation processes and better adaptation of collaborative care models to the clinical reality of general practice. Future interventions should address the treatment needs of specific patient populations and should involve relevant stakeholders in the design and implementation processes. Electronic supplementary material The online version of this article (10.1186/s12875-018-0764-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marlene Christina Rosengaard Møller
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Flemming Bro
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
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Pinto S, Caldeira S, Martins J. The use of the Medical Research Council framework in the study of complex interventions in nursing: a literature review. Nurse Res 2018:e1530. [PMID: 29762981 DOI: 10.7748/nr.2018.e1530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Nursing care addresses several complex interventions and international research into complex interventions is growing. The Medical Research Council framework (MRC-f) is the most cited framework describing the development and evaluation of interventions, but little is known about its use in nursing sciences. AIM To review the literature for uses of MRC-f in developing complex interventions. DISCUSSION Of 287 studies initially identified; the final sample comprised 13 papers. Most studies referred to the development or feasibility phase and were performed in the community. They were mainly focused on the physical dimension and few had a holistic approach. The lack of time and financial support, the subjective nature of these interventions, and difficulties in the recruitment of participants were reported as barriers. CONCLUSION The use of MRC-f in the study of complex interventions is recent in nursing research, but it enhances the design of more feasible and effective nursing interventions. The lack of time, difficulties in the recruitment of adequate sample sizes and lack of financial support were identified as important barriers in the development of complex nursing interventions. IMPLICATIONS FOR PRACTICE Nurse researchers need to develop skills in planning and conducting research into complex interventions. Academic courses may also be helpful in improving such skills.
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Affiliation(s)
- Sara Pinto
- Escola Superior de Saúde de Santa Maria, Oporto, Portugal, nursing researcher, Center for Research in Health Technologies and Services, NursID, Oporto, Portugal
| | - Sílvia Caldeira
- Instituto de Ciencias da Saude, Universidade Catolica Portuguesa, Lisbon, Portugal
| | - José Martins
- Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal
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Tylee A, Barley EA, Walters P, Achilla E, Borschmann R, Leese M, McCrone P, Palacios J, Smith A, Simmonds R, Rose D, Murray J, van Marwijk H, Williams P, Mann A. UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- André Tylee
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Elizabeth A Barley
- Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
| | - Paul Walters
- Weymouth and Portland Community Mental Health Team, Dorset HealthCare University NHS Foundation Trust and Bournemouth University, Dorset, UK
| | - Evanthia Achilla
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rohan Borschmann
- Centre of Adolescent Health, The Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Morven Leese
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jorge Palacios
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Alison Smith
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rosemary Simmonds
- Academic Unit of Primary Health Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Diana Rose
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Joanna Murray
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Harm van Marwijk
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - Paul Williams
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony Mann
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Levati S, Campbell P, Frost R, Dougall N, Wells M, Donaldson C, Hagen S. Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used. Pilot Feasibility Stud 2016; 2:17. [PMID: 27965837 PMCID: PMC5153688 DOI: 10.1186/s40814-016-0058-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 03/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many complex intervention trials fail to show an intervention effect. Although this may be due to genuine ineffectiveness, it may also be the result of sub-optimal intervention design, implementation failure or a combination of these. Given current financial constraints and the pressure to reduce waste and increase value in health services research, pre-trial strategies are needed to reduce the likelihood of design or implementation failure and to maximise the intervention's potential for effectiveness. In this scoping review, we aimed to identify and synthesise the available evidence relating to the strategies and methods used to 'optimise' complex interventions at the pre-trial stage. METHODS We searched MEDLINE, CINAHL, AMED, PsycINFO and ProQuest Nursing & Allied Health Source for papers published between January 2000 and March 2015. We included intervention development and optimisation studies that explored potential intervention weaknesses and limitations before moving to a definitive randomised controlled trial (RCT). Two reviewers independently applied selection criteria and systematically extracted information relating to the following: study characteristics; intervention under development; framework used to guide the development process; areas of focus of the optimisation process, methods used and outcomes of the optimisation process. Data were tabulated and summarised in a narrative format. RESULTS We screened 3968 titles and 231 abstracts for eligibility. Eighty-nine full-text papers were retrieved; 27 studies met our selection criteria. Optimisation strategies were used for a range of reasons: to explore the feasibility and acceptability of the intervention to patients and healthcare professionals; to estimate the effectiveness and cost-effectiveness of different combinations of intervention components; and to identify potential barriers to implementation. Methods varied widely across studies, from interviews and focus groups to economic modelling and probability analysis. CONCLUSIONS The review identifies a range of optimisation strategies currently used. Although a preliminary classification of these strategies can be proposed, a series of questions remain as to which methods to use for different interventions and how to determine when the intervention is ready or 'optimised enough' to be tested in a RCT. Future research should explore potential answers to the questions raised, to guide researchers in the development and evaluation of more effective interventions.
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Affiliation(s)
- Sara Levati
- NMAHP Research Unit, Glasgow Caledonian University, Level 6, Govan Mbeki Building 70 Cowcaddens Road, Glasgow, G4 0BA Scotland
| | - Pauline Campbell
- NMAHP Research Unit, Glasgow Caledonian University, Level 6, Govan Mbeki Building 70 Cowcaddens Road, Glasgow, G4 0BA Scotland
| | - Rachael Frost
- NMAHP Research Unit, Glasgow Caledonian University, Level 6, Govan Mbeki Building 70 Cowcaddens Road, Glasgow, G4 0BA Scotland
| | - Nadine Dougall
- NMAHP Research Unit, University of Stirling, Unit 13 Scion House, Innovation Park, Stirling, FK9 4NF UK
| | - Mary Wells
- NMAHP Research Unit, University of Stirling, Unit 13 Scion House, Innovation Park, Stirling, FK9 4NF UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, M201, George Moore Building 70 Cowcaddens Road, Glasgow, G4 0BA Scotland
| | - Suzanne Hagen
- NMAHP Research Unit, Glasgow Caledonian University, Level 6, Govan Mbeki Building 70 Cowcaddens Road, Glasgow, G4 0BA Scotland
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10
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Barley EA, Clifton A, Lee G, Norman IJ, O'Callaghan D, Tierney K, Richards D. The Space From Heart Disease Intervention for People With Cardiovascular Disease and Distress: A Mixed-Methods Study. JMIR Res Protoc 2015; 4:e81. [PMID: 26133739 PMCID: PMC4526970 DOI: 10.2196/resprot.4280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/14/2015] [Accepted: 04/28/2015] [Indexed: 11/30/2022] Open
Abstract
Background Poor self-management of symptoms and psychological distress leads to worse outcomes and excess health service use in cardiovascular disease (CVD). Online-delivered therapy is effective, but generic interventions lack relevance for people with specific long-term conditions, such as cardiovascular disease. Objective To develop a comprehensive online CVD-specific intervention to improve both self-management and well-being, and to test acceptability and feasibility. Methods Informed by the Medical Research Council (MRC) guidance for the development of complex interventions, we adapted an existing evidence-based generic intervention for depression and anxiety for people with CVD. Content was informed by a literature review of existing resources and trial evidence, and the findings of a focus group study. Think-aloud usability testing was conducted to identify improvements to design and content. Acceptability and feasibility were tested in a cross-sectional study. Results Focus group participants (n=10) agreed that no existing resource met all their needs. Improvements such as "collapse and expand" features were added based on findings that participants’ information needs varied, and specific information, such as detecting heart attacks and when to seek help, was added. Think-aloud testing (n=2) led to changes in font size and design changes around navigation. All participants of the cross-sectional study (10/10, 100%) were able to access and use the intervention. Reported satisfaction was good, although the intervention was perceived to lack relevance for people without comorbid psychological distress. Conclusions We have developed an evidence-based, theory-informed, user-led online intervention for improving self-management and well-being in CVD. The use of multiple evaluation tests informed improvements to content and usability. Preliminary acceptability and feasibility has been demonstrated. The Space from Heart Disease intervention is now ready to be tested for effectiveness. This work has also identified that people with CVD symptoms and comorbid distress would be the most appropriate sample for a future randomized controlled trial to evaluate its effectiveness.
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Affiliation(s)
- Elizabeth Alexandra Barley
- Post Graduate Research Department, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, United Kingdom.
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11
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Knowles SE, Chew-Graham C, Adeyemi I, Coupe N, Coventry PA. Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model. BMC FAMILY PRACTICE 2015; 16:32. [PMID: 25886864 PMCID: PMC4355419 DOI: 10.1186/s12875-015-0246-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND 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. 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. METHODS Nested 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. RESULTS Based 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. CONCLUSION The 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.
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Affiliation(s)
- Sarah E Knowles
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Carolyn Chew-Graham
- Primary Care and Health Sciences, University of Keele, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, ST5 5BG, UK.
| | - Isabel Adeyemi
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Nia Coupe
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Peter A Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
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12
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Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev 2015; 2015:CD010523. [PMID: 25733495 PMCID: PMC6486144 DOI: 10.1002/14651858.cd010523.pub2] [Citation(s) in RCA: 275] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition. OBJECTIVES To assess the effects of personalised care planning for adults with long-term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013. SELECTION CRITERIA We included randomised controlled trials and cluster-randomised trials involving adults with long-term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both. DATA COLLECTION AND ANALYSIS Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health-related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long-term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings. MAIN RESULTS We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end-stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face-to-face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods. Physical healthNine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of -0.24% (95% confidence interval (CI) -0.35 to -0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).Six studies measured systolic blood pressure, a combined mean difference of -2.64 mm/Hg (95% CI -4.47 to -0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD -0.71 mm/Hg (95% CI -2.26 to 0.84).We found no evidence of an effect on cholesterol (LDL-C), standardised mean difference (SMD) 0.01 (95% CI -0.09 to 0.11) (five studies) or body mass index, MD -0.11 (95% CI -0.35 to 0.13) (four studies).A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control. Psychological healthSix studies measured depression. We were able to pool results from five of these, giving an SMD of -0.36 (95% CI -0.52 to -0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes. Subjective health statusTen studies used various patient-reported measures of health status (or health-related quality of life), including both generic health status measures and condition-specific ones. We were able to pool data from three studies that used the SF-36 or SF-12, but found no effect on the physical component summary score SMD 0.16 (95% CI -0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI -0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.Four studies measured condition-specific health status. The combined results showed no difference between the intervention and control groups, SMD -0.01 (95% CI -0.11 to 0.10) (moderate quality evidence). Self-management capabilitiesNine studies looked at the effect of personalised care on self-management capabilities using a variety of outcome measures, but they focused primarily on self efficacy. We were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43) (moderate quality evidence).A further five studies measured other attributes that contribute to self-management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support. Other outcomesPooled data from five studies on exercise levels showed no effect due to personalised care planning, but there was a positive effect on people's self-reported ability to carry out self-care activities: SMD 0.35 (95% CI 0.17 to 0.52).We found no evidence of adverse effects due to personalised care planning.The effects of personalised care planning were greater when more stages of the care planning cycle were completed, when contacts between patients and health professionals were more frequent, and when the patient's usual clinician was involved in the process. AUTHORS' CONCLUSIONS Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people's capability to self-manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.
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Affiliation(s)
- Angela Coulter
- University of OxfordHealth Services Research Unit, Nuffield Department of Population HealthOld Road Campus, HeadingtonOxfordUKOX3 7LF
| | - Vikki A Entwistle
- University of AberdeenHealth Services Research UnitHealth Services Building Level 3ForesterhillAberdeenUKAB25 2ZD
| | - Abi Eccles
- University of OxfordDepartment of Primary Care Health Sciences23‐28 Hythe Bridge StreetOxfordUKOX1 2ET
| | - Sara Ryan
- University of OxfordQuality and Outcomes Research Unit and Health Experiences Research Group23‐28 Hythe Bridge StreetOxfordUKOX1 2ET
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordUKOX3 7LF
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
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Furler J, Blackberry I, Manski-Nankervis JA, O'Neal D, Best J, Young D. Optimizing care and outcomes for people with type 2 diabetes - lessons from a translational research program on insulin initiation in general practice. Front Med (Lausanne) 2015; 1:60. [PMID: 25688345 PMCID: PMC4310321 DOI: 10.3389/fmed.2014.00060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/19/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical inertia, failure to intensify treatment according to evidence-based guidelines, leads to prolonged, avoidable hyperglycemia in people with type 2 diabetes (T2D). This is a challenge for General Practice and Primary Care, where most people with T2D receive most of their care. Sustained, integrated translational research programs are needed to embed effective treatments in routine practice, yet many challenges exist for developing such programs. OBJECTIVES To explore challenges and facilitators to implementing a translational research program focused on insulin initiation and titration among people with T2D in general practice and to identify key factors important to support and sustain such translation research in primary care. Operationalizing a program of translational work in primary care: We describe a series of studies on insulin initiation and titration in general practice including theory and qualitative work (Phase 1), a small feasibility and acceptability pilot (Phase 2), a large scale pilot (Phase 3), and a pragmatic cluster randomized trial currently under way (Phase 4). We used mixed methods to explore practice level implementation issues, and reflective investigator discussions to explore broader research program sustainability. Challenges for translational research in primary care: Key facilitators and barriers at practice and research program levels, include: Appropriate funding structures to secure long-term capacity building and people support; Building and maintaining linkages between communities of practice, primary and secondary/tertiary care researchers, institutions, and industry partners; Strategies for engagement and support for practitioners and participants. CONCLUSION Building effective and sustainable translational research programs are critical for developing evidence-based policy that drives improved outcomes at a population level. Diverse sources of funding that support extensive and sustained trans-mural collaboration as well as engagement with practitioners, patients, and policymakers in the field are crucial.
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Affiliation(s)
- John Furler
- General Practice and Primary Health Care Academic Centre, The University of Melbourne , Carlton, VIC , Australia
| | - Irene Blackberry
- General Practice and Primary Health Care Academic Centre, The University of Melbourne , Carlton, VIC , Australia ; John Richards Initiative, School of Nursing and Midwifery, La Trobe University , Wodonga, VIC , Australia
| | - Jo-Anne Manski-Nankervis
- General Practice and Primary Health Care Academic Centre, The University of Melbourne , Carlton, VIC , Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital, The University of Melbourne , Fitzroy, VIC , Australia
| | - James Best
- Melbourne Medical School, The University of Melbourne , Parkville, VIC , Australia
| | - Doris Young
- General Practice and Primary Health Care Academic Centre, The University of Melbourne , Carlton, VIC , Australia
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Barley EA, Walters P, Haddad M, Phillips R, Achilla E, McCrone P, Van Marwijk H, Mann A, Tylee A. The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study. PLoS One 2014; 9:e98704. [PMID: 24901956 PMCID: PMC4047012 DOI: 10.1371/journal.pone.0098704] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/01/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression. METHODS Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables. RESULT 1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000. CONCLUSIONS Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU. TRIAL REGISTRATION Controlled-Trials.com ISRCTN21615909.
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Affiliation(s)
- Elizabeth A. Barley
- Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, King's College London, London, United Kingdom
| | - Paul Walters
- Dorset HealthCare University NHS Foundation Trust, Weymouth and Portland Community Mental Health Team, Mental Health Centre, Weymouth, Dorset, United Kingdom
| | - Mark Haddad
- School of Health Sciences, City University London, London, United Kingdom
| | - Rachel Phillips
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Evanthia Achilla
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Paul McCrone
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Harm Van Marwijk
- Department of General Practice & Elderly Care Medicine and the EMGO Institute for Health and Care Research of VU University Medical Centre, Amsterdam, The Netherlands
| | - Anthony Mann
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Andre Tylee
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
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