Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model

"I Felt Like I Mattered": Caring is a key ingredient of collaborative care for chronic illness

OBJECTIVES

To identify perceptions and experiences related to caring science and collaborative care in intervention participants of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) study, a randomized, multi-site clinical trial for patients with chronic heart failure and reduced health status.

METHODS

Forty-five participants completed semi-structured, telephone interviews with a focus on intervention components, impact of the intervention on participants' lives, and recommendations for intervention change. Data were analyzed using an inductive content analysis approach focusing on the presence and frequency of text to identify patterns, categories, and themes across participants without an a priori code book. The validity of the identified categories was enhanced through triangulation.

RESULTS

Three themes were identified: (1) intervention providers' caring/helping attitude and caring/helping communication; (2) care team availability to respond to concerns or questions; and (3) help with understanding and navigating the healthcare system.

DISCUSSION

Patients highly value caring attitudes and communication, availability, and empowerment to understand and navigate healthcare systems. These attitudes and behaviors may be important mediators of the success of collaborative care programs. These are consistent with the theory of caring science, a framework that is relevant more broadly to patient-centered and team-based care models.

A primary care psychoeducational group intervention for patients with depression and physical comorbidity: A qualitative study with a gender perspective

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.

Needs of multimorbid heart failure patients and their carers: a qualitative interview study and the creation of personas as a basis for a blended collaborative care intervention

Introduction

Involving patients and carers in the development of blended collaborative care (BCC) interventions for multimorbid heart failure (HF) patients is recommended but rarely practised, and research on the patient perspective is scarce. The aim of this study is to investigate patients' and carers' care-related needs and preferences to better customize a novel international BCC intervention.

Methods

A qualitative study design using framework analysis was employed. The study was performed in accordance with the EQUATOR standards for reporting qualitative research (SRQR). Patients aged at least 65 years with HF and at least two other physical diseases as well as their carers completed semistructured interviews in Germany, Italy, and Denmark. Based on these interviews, personas (prototype profiles of patients and carers) were created.

Results

Data from interviews with 25 patients and 17 carers were analysed. Initially, seven country-specific personas were identified, which were iteratively narrowed down to a final set of 3 personas: (a) the one who needs and wants support, (b) the one who has accepted their situation with HF and reaches out when necessary, and (c) the one who feels neglected by the health care system. Carers identifying with the last persona showed high levels of psychological stress and a high need for support.

Discussion

This is the first international qualitative study on patients' and carers' needs regarding a BCC intervention using the creation of personas. Across three European countries, data from interviews were used to develop three contrasting personas. Instead of providing "one size fits all" interventions, the results indicate that BCC interventions should offer different approaches based on the needs of individual patients and carers. The personas will serve as a basis for the development of a novel BCC intervention as part of the EU project ESCAPE (Evaluation of a patient-centred biopSychosocial blended collaborative CAre Pathway for the treatment of multimorbid Elderly patients).

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting

BACKGROUND

Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland.

METHODS

We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding.

RESULTS

Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment.

CONCLUSIONS

Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.

Experiences of Non-Pharmaceutical Primary Care Interventions for Common Mental Health Disorders in Socioeconomically Disadvantaged Groups: A Systematic Review of Qualitative Studies

Common mental health disorders (CMDs) disproportionately affect people experiencing socioeconomic disadvantage. Non-pharmaceutical interventions, such as 'social prescribing' and new models of care and clinical practice, are becoming increasingly prevalent in primary care. However, little is known about how these interventions work and their impact on socioeconomic inequalities in health. Focusing on people experiencing socioeconomic disadvantage, this systematic review aims to: (1) explore the mechanisms by which non-pharmaceutical primary care interventions impact CMD-related health outcomes and inequalities; (2) identify the barriers to, and facilitators of, their implementation in primary care. This study is a systematic review of qualitative studies. Six bibliographic databases were searched (Medline, ASSIA, CINAHL, Embase, PsycInfo and Scopus) and additional grey literature sources were screened. The included studies were thematically analysed. Twenty-two studies were included, and three themes were identified: (1) agency; (2) social connections; (3) socioeconomic environment. The interventions were experienced as being positive for mental health when people felt a sense of agency and social connection. The barriers to effectiveness and engagement included socioeconomic deprivation and underfunding of community sector organisations. If non-pharmaceutical primary care interventions for CMDs are to avoid widening health inequalities, key socioeconomic barriers to their accessibility and implementation must be addressed.

A critical review of research into mental health consumers' perspectives on their physical health: Is there an absence of consumers in the design, conduct, analysis and reporting of this research?

We conducted a critical review, using systematic methods, of the literature examining mental health consumer perspectives on their physical and mental health in academic research published between 2005 and 2021. This review examined the inclusion, extent, type and centrality of consumer perspectives regarding their mental and physical health. The search produced 1,865 papers from which 116 met the inclusion criteria. Studies predominantly focused on consumers' individual experiences of their physical and mental health, including but not limited to their understandings and experiences of medication and associated risk factors. They also captured some social aspects of mental health consumers' physical health, including factors that impacted individual agency, stigma, and social and interpersonal factors. Structural factors affecting physical and mental health, such as accessibility of services and financial constraints, were also identified. The review revealed that in comparison to clinician perspectives, the direct representation of consumer perspectives was lacking. Similarly, while clinician and carer perspectives on structural factors were investigated, the consumer perspective in this area was missing. The review also found few genuine codesigned or coproduced research studies. To better identify and respond to the health needs as prioritized by consumers, this paper argues it is imperative that future studies prioritize codesigned and coproduced research. It is argued that a focus on "services as provided" rather than "services as received" has contributed to a lack of progress in addressing the life expectancy gap for consumers. It is recommended that journals, ethics committees and research policy organizations develop guidelines and standards to inform best practice in research on consumer perspectives and experience and to support the implementation of codesigned and/or coproduced approaches in future research. Respecting and including consumers as equal partners in the research process will lead to more meaningful insights to inform policy and practice and reduce the life expectancy gap for people living with mental health concerns.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Experiences of treatment-resistant mental health conditions in primary care: a systematic review and thematic synthesis

Background

Most adults fail to achieve remission from common mental health conditions based on pharmacological treatment in primary care alone. There is no data synthesising the reasons. This review addresses this gap through a systematic review and thematic synthesis to understand adults’ experiences using primary care for treatment-resistant mental health conditions (TRMHCs). We use the results to produce patient-driven recommendations for better support in primary care.

Methods

Eight databases were searched from inception to December 2020 for qualitative studies reporting research on people’s experience with TRMHCs in primary care. We included the following common mental health conditions defined by NICE: anxiety, depression, panic disorder, post-traumatic stress, and obsessive-compulsive disorder. Two reviewers independently screened studies. Eligible studies were analysed using an aggregative thematic synthesis.

Results

Eleven studies of 4456 were eligible. From these eleven studies, 4 descriptive themes were developed to describe a cycle of care that people with TRMHCs experienced in primary care. In the first stage, people preferred to self-manage their mental health and reported barriers that prevented them from seeing a GP (e.g., stigma). People felt it necessary to see their GP only when reaching a crisis point. In the second stage, people were usually prescribed antidepressants, but were sceptical about any benefits they had to their mental health. In the third stage, people self-managed their mental health (e.g., by adjusting antidepressant dosage). The fourth stage described the reoccurrence of mental health and need to see a GP again. The high-order theme, ‘breaking the cycle,’ described how this cycle could be broken (e.g., continuity of care).

Conclusions

People with TRMHCs and GPs could break the cycle of care by having a conversation about what to do when antidepressants fail to work. This conversation could include replacing antidepressants with psychological interventions like talking therapy or mindfulness.

Experience of depression in older adults with and without a physical long-term condition: findings from a qualitative interview study

OBJECTIVE

To understand how the lived experience of depression differs among patients with a long-term condition (LTC) compared with those without an LTC, and how the experience differs across different types of LTC.

DESIGN

Face-to-face, semistructured interviews.

SETTING

Primary care; General Practitioner (GP) surgeries in and around North London.

PARTICIPANTS

41 primary care patients with depression were recruited. Our sample comprised participants aged 55-75 years with depression only (n=12), depression and coronary heart disease (n=5), depression and type 2 diabetes (n=10) and depression and arthritis (n=14).

RESULTS

Interviews were conducted, audio recorded, transcribed and analysed using thematic analysis. The results revealed that the cardinal diagnostic symptoms of depression (anhedonia, sadness) were experienced by all our participants regardless of LTC. However, the LTC did interact with depression by compounding somatic, cognitive and emotional symptoms, increasing disability and reducing independence, and hindering attempts at coping with mental illness. Our findings demonstrate common experiences across patients as well as key differences based on LTC.

CONCLUSIONS

We suggest four key implications for future care practices of these patients: (1) not all participants with depression and LTC view their mental and physical health as interconnected; there should be allowances in care plans for separate treatment pathways; (2) key features of depression that affect LTC management are social withdrawal and lack of motivation to self-manage or access healthcare; (3) key features of LTCs that worsen depression are pain, the unpredictability of future health and progressive disability; (4) positive self-management of LTC could improve self-efficacy and therefore mood, and should be encouraged.

What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: an integrative review

BACKGROUND

Improving the patient experience is one of the quadruple aims of healthcare. Therefore, understanding patient experiences and perceptions of healthcare interactions is paramount to quality improvement. This integrative review aimed to explore how patients with chronic conditions experience Interprofessional Collaborative Practice in primary care.

METHODS

An integrative review was conducted to comprehensively synthesize primary studies that used qualitative, quantitative, and mixed methods. Databases searched were Medline, Embase, CINAHL and Web of Science on June 1st, 2021. Eligible studies were empirical full-text studies in primary care that reported experiences or perceptions of Interprofessional Collaborative Practice by adult patients with a chronic condition, in any language published in any year. Quality appraisal was conducted on included studies using the Mixed Method Appraisal Tool. Data on patients' experiences and perceptions of Interprofessional Collaborative Practice in primary care were extracted, and findings were thematically analyzed through a meta-synthesis.

RESULTS

Forty-eight (n = 48) studies met the inclusion criteria with a total of n = 3803 participants. Study quality of individual studies was limited by study design, incomplete reporting, and the potential for positive publication bias. Three themes and their sub-themes were developed inductively: (1) Interacting with Healthcare Teams, subthemes: widening the network, connecting with professionals, looking beyond the condition, and overcoming chronic condition collectively; (2) Valuing Convenient Healthcare, subthemes: sharing space and time, care planning creates structure, coordinating care, valuing the general practitioner role, and affording healthcare; (3) Engaging Self-care, subthemes: engaging passively is circumstantial, and, engaging actively and leading care.

CONCLUSIONS

Patients overwhelmingly had positive experiences of Interprofessional Collaborative Practice, signaling it is appropriate for chronic condition management in primary care. The patient role in managing their chronic condition was closely linked to their experience. Future studies should investigate how the patient role impacts the experience of patients, carers, and health professionals in this context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020156536.

Integrated primary care and social services for older adults with multimorbidity in England: a scoping review

BACKGROUND

As the prevalence of older adults with multimorbidity increases, greater integration of services is necessary to manage the physical and psycho-social needs of this cohort. This study describes and summarises current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England.

METHODS

A scoping review was conducted involving systematic searches of a range of electronic academic and policy databases. Articles were screened and extracted in duplicate by two independent reviewers. Data were extracted onto a charting sheet and thematic synthesis was used to summarise findings. Articles were included if published in English and related to primary care, social care and multimorbidity in older adults in England. Conceptually, the review was framed using the Rainbow Model of Integrated Care.

RESULTS

The search yielded 7656 articles of which 84 were included. Three themes were identified: (1) a focus on individual level services rather than multi-level or multi-sector integration, with an increasing emphasis on the need to consider broader determinants of population health as critical to integrated care for older adults with multimorbidity; (2) the need for policymakers to allow time for integration to embed, to enable new structures and relationships to develop and mature; and (3) the inherent tension between top-down and bottom-up driven approaches to integrated care requires a whole-systems structure, while allowing for local flexibilities.

CONCLUSIONS

There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in England. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organisation or design across services as one single system of provision. This may take time to establish and will require local input.

Clinician perceptions of common mental disorders before and after implementation of a consultation-liaison psychiatry service: a longitudinal qualitative study in government-operated primary care settings in Penang, Malaysia

OBJECTIVES

To explore primary care clinician perceptions of barriers and facilitators in delivering care for common mental disorders (CMD) before and after implementation of a consultation-liaison psychiatry service (Psychiatry in Primary Care (PIPC)) in government-operated primary care clinics and to explore the clinicians' experience of the PIPC service itself.

DESIGN

This longitudinal qualitative study was informed by the Normalisation Process Model and involved audiotaped semi-structured individual interviews with front-line clinicians before (Time 1) and after (Time 2) the PIPC intervention. The Framework Method was used in the thematic analysis of pre/post interview transcripts.

SETTING

Two government-operated primary care clinics in Penang, Malaysia.

PARTICIPANTS

17 primary care medical, nursing and allied health staff recruited purposely to achieve a range of disciplines and a balanced representation from both clinics.

INTERVENTION

Psychiatrists, accompanied by medical students in small numbers, provided one half-day consultation visit per week, to front-line clinicians in each clinic over an 8-month period. The service involved psychiatric assessment of patients with suspected CMDs, with face-to-face discussion with the referring clinician before and after the patient assessment.

RESULTS

At Time 1 interviewees tended to equate CMDs with stress and embraced a holistic model of care while also reporting considerable autonomy in mental healthcare and positively appraising their current practices. At Time 2, post-intervention, participants demonstrated a shift towards greater understanding of CMDs as treatable conditions. They reported time pressures and the demands of key performance indicators in other areas as barriers to participation in PIPC. Yet they showed increased awareness of current service deficits and of their potential in delivering improved mental healthcare.

CONCLUSIONS

Despite resource-related and structural barriers to implementation of national mental health policy in Malaysian primary care settings, our findings suggest that front-line clinicians are receptive to future interventions designed to improve the mental healthcare capacity.

Perceptions of mental health nurses about psychosocial management of depression in adolescents, North West province, South Africa

Background

Depression in adolescents is a multifactorial global public health concern, with devastating consequences on the sufferer. The prevalence of depression amongst this age group is on the rise, and thus there is the need for greater attention.

Aim

To explore and describe the perceptions of mental health nurses regarding the psychosocial management of depression in adolescents in North West province, South Africa.

Setting

The study was conducted in two mental healthcare institutions and two mental healthcare units within two general hospitals in North West province, South Africa.

Method

A qualitative, explorative, descriptive and contextual research design was used in conducting this study. Data were collected through focus group discussions from four groups of mental health nurses from each of the mental healthcare institutions and mental healthcare units with 18 mental health nurses. Data were analysed using Tesch’s open coding method.

Results

Two themes emerged from the study: comprehensive psychosocial management and involvement of different stakeholders.

Conclusion

The findings revealed clear psychosocial management for depression in adolescents. Adopting the findings of this study could improve depressive symptoms and curtail the prevalence of depression amongst adolescents in the North West province, South Africa.

Therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions

OBJECTIVE

Improving Access to Psychological Therapies (IAPT) services in England have established a long-term condition (LTC) pathway in recent years, meaning that LTC therapies are now delivered via varied modes and by professionals with varied experiences. To gain insight into how this new pathway is functioning in practice, this study aimed to explore therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in LTCs.

DESIGN

A qualitative design was employed using semi-structured interviews.

METHODS

Fifteen therapists were recruited from IAPT and physical health care settings. Interviews were first analysed using inductive thematic analysis. A deductive approach was then taken to map themes onto Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflective monitoring) to guide steps towards improving implementation.

RESULTS

Four key themes highlighted patient, therapist, and service-level factors related to uptake and engagement: Working flexibly with barriers within the National Health Service context; Acceptability of 'embedded' versus 'separate' psychological care; Confidence in working with people with LTCs; and Navigating implementation of online therapies. Therapists recognized the need for tailored LTC therapies, though opinions about online therapies varied. Therapists expressed commitment to flexibly adapting their practice to suit patient needs, but felt their flexibility was limited by system and service constraints.

CONCLUSION

Barriers to uptake and engagement need to be addressed to optimize LTC pathways. Findings demonstrated the importance of offering flexible, tailored therapy to people with LTCs, and equipping staff and services with adequate training and resources to improve functioning of LTC pathways in practice.

Physical health among patients with common mental health disorders in primary care in Europe: a scoping review

Introduction:

Mental disorders are increasingly common among adults in both the developed and developing world and are predicted by the WHO to be the leading cause of disease burden by 2030. Many common physical conditions are more common among people who also have a common mental disorder. This scoping review aims to examine the current literature about the prevention, identification and treatment of physical problems among people with pre-existing mental health disorders in primary care in Europe.

Methods:

The scoping review framework comprised a five-stage process developed by Arksey & O’Malley (2005). The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Both quantitative and qualitative studies were included, with no restriction on study design.

Results:

The initial search identified 299 studies, with a further 28 added from the hand-search (total n = 327) of which 19 were considered relevant to the review research question and included for full analysis. Depression was the mental health condition most commonly studied (nine studies), followed by depression and anxiety (seven studies), with three studies examining any mental disorder. Eleven studies examined the effects of various interventions to address physical and mental comorbidity, with the most commonly studied intervention being collaborative care.

Conclusions:

With just 19 studies meeting our criteria for inclusion, there is clearly a paucity of research in this area. Further research is essential in order to understand the pathophysiological mechanisms underlying the association between mental disorders and chronic conditions.

Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study

BACKGROUND

The growing number of patients with complex chronic conditions presents an urgent challenge across the Canadian health care system. Current care delivery models are overburdened, struggling to monitor and stabilize the complex needs of this growing patient population.

OBJECTIVE

This qualitative study aimed to explore the needs and perspectives of patients and members of the care team to inform the development of an innovative integrated model of care and the needs of telemonitoring (TM) for patients with complex chronic conditions. Furthermore, we explored how these needs could be successfully embedded to support this novel model of complex chronic care.

METHODS

A qualitative description design was utilized to conduct and analyze 29 semistructured interviews with patients (n=16) and care team members (CTM) (n=13) involved in developing the model of care in an ambulatory care facility in Southern Ontario. Participants were identified through purposive sampling. Two researchers performed an iterative thematic analysis using NVivo 12 (QSR International; Melbourne, Australia) to gain insights from examining multiple perspectives of different participants on complex chronic care needs.

RESULTS

The analysis revealed 3 themes and 13 subthemes, including the following: (1) adequate health care delivery remains challenging for patients with complex care needs, (2) insights into how to structure an integrated care model, and (3) opportunities for TM in an integrated model of care. Participants not only identified continued challenges in accessing and navigating care in a fragmented and disconnected delivery system but also identified the need for more self-management support. Patients and CTM described the structure of an integrated model of care, including the need for a clear referral and triage processes and composing a tight-knit circle of collaborating interdisciplinary providers led by a nurse practitioner (NP). Finally, opportunities for TM in an integrated model of care were identified, including increasing access and communication, the ability to monitor specific signs and symptoms, and building a clinical workflow around TM-enabled care.

CONCLUSIONS

Despite entrenched health care service delivery models, a new model of care is acutely needed to care for patients with complex chronic needs (CCN). NPs are in a unique position to lead TM-enabled integrated models of care. TM can facilitate frequent and necessary monitoring of patients with CCN with more than one condition in integrated models of care.

Collaborative Care to Improve Access and Quality in School-Based Behavioral Health

BACKGROUND

Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations.

METHODS

To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents.

RESULTS

We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health.

CONCLUSIONS

Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.

Mapping Evidence of Patients' Experiences in Integrated Care: A Scoping Review

OBJECTIVES

Despite the established clinical and cost-effectiveness of integrated care (IC) models for patients with comorbid mental and physical illness, little is known about whether these models facilitate a better care experience from the patient's perspective. The authors conducted a scoping review of the literature to explore how IC influences patients' care experiences.

METHODS

MEDLINE, EMBASE, PSYC INFO CINAHL, AMED, the Cochrane Library, and grey literature were searched to identify relevant articles. Eligible studies were systematically reviewed and analyzed, using thematic analysis approach, to identify patterns, trends, and variation in patient experience within IC settings.

RESULTS

Search results yielded 5250 unique resources of which 21 primary studies met our eligibility criteria for analysis. Findings from this scoping review revealed variation in patients' experiences in IC settings. IC models enhanced patients' experience by creating theraputic spaces: improving patient access to care, developing collaborative relationships, and personalizing patient care to address individual needs.

CONCLUSION

Productive interactions with care team were key to improve patient engagement and experience of centeredness in IC settings. Successful implementation of IC demanded purposeful alignment of IC structural components and care processes to create therapeutic spaces that address patient care needs and preferences.

Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study

BACKGROUND

Depressive symptoms and/or depression are commonly experienced by older people. Both are underdiagnosed, undertreated and regularly overlooked by healthcare professionals. Healthcare facilities for people aged ≥75 years have been in place in Sweden since 2015. The aim of these care centres, which are managed by registered nurses (RNs), is to offer care adjusted to cater to the complex needs and health problems of older people. Although the mental health of older people is prioritised in these centres, research into the experience of RNs of depressive symptoms and/or depression in older people in this setting is limited. Therefore, this study aimed to illuminate RNs, working at care centres for older people, experience of identifying and intervening in cases of depressive symptoms.

METHODS

The data for this qualitative descriptive study were collected through interviews (n = 10) with RNs working at 10 care centres for older people in southern Sweden. The transcribed texts were analysed using inductive content analysis.

RESULTS

The participants' experiences could be understood from four predominant themes: (1) challenging to identify, (2) described interventions, (3) prerequisites for identification, and (4) contextual influences. Key findings were that it was difficult to identify depression as it often manifested as physical symptoms; evidence-based nursing interventions were generally not the first-line treatment used; trust, continuity and the ability of RNs to think laterally; and the context influenced the ability of RNs to manage older people's depressive symptoms and/or depression.

CONCLUSIONS

The process of identifying depressive symptoms and performing an appropriate intervention was found to be complex, especially as older people were reluctant to present at the centres and provided obscure reasons for doing so. A nurse-patient relationship that was built on trust and was characterised by continuity of care was identified as a necessary prerequisite. Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression. Further research is also needed into efficacious nursing interventions targeting depressive symptoms and/or depression.

Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review

OBJECTIVES

To understand how and why effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.

DESIGN

A realist review.

DATA SOURCES

Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.

ANALYSIS

We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.

RESULTS

106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, disease management programmes and case management; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients' capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.

CONCLUSIONS

To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.

PROSPERO REGISTRATION NUMBER

CRD42014014489.

Link-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care

Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.

Treating Illness Distress in Chronic Illness

Abstract. Cognitive-behavioral therapy (CBT) is an evidence-based treatment for depression and anxiety recommended for those with and without physical long-term conditions (LTCs). However, the cognitive-behavioral mechanisms targeted in CBT protocols are based on empirical cognitive-behavioral models of depression and anxiety. In these models, emotions are conceptualized as primary mental health disorders rather than a reaction to the challenges of living with a LTC commonly referred to as illness distress. This raises important clinical questions with theoretical implications. These include: Is the experience of illness distress conceptually distinct from primary mental health diagnoses of anxiety and mood disorder? Are there unique cognitive-behavioral mechanisms related to illness self-management, which should be incorporated into CBT for illness distress? How can illness self-management interventions be embedded within existing CBT protocols for depression and anxiety? To address these questions, we distinguish between primary mental health disorders and illness distress conceptually and explore the impact of this on tailored treatment planning and engagement. Second, we review how health psychology theoretical models can help to inform modifications of existing cognitive-behavioral treatments for anxiety and depression to better support the needs of individuals experiencing illness distress. Third, we provide examples of how to embed processes important for illness self-management including, illness cognitions and adherence, alongside existing CBT techniques. The mechanisms and intervention techniques discussed may help to inform the development of integrated CBT treatments for illness distress for future hypothesis testing in comparative effectiveness trials.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework

Background

Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC.

Methods

We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives).

Results

Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health.

Conclusions

Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.

Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational ("internal") and contextual ("external") themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational ("internal") and contextual ("external") themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial

Background

Depression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.

Methods

A qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients’ and professionals’ views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory.

Results

Thirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation.

Conclusions

A telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs’ understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.

Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers

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.

Multidisciplinary collaboration in primary care: a systematic review

BACKGROUND

Several studies have discussed the benefits of multidisciplinary collaboration in primary care. However, what remains unclear is how collaboration is undertaken in a multidisciplinary manner in concrete terms.

OBJECTIVE

To identify how multidisciplinary teams in primary care collaborate, in regards to the professionals involved in the teams and the collaborative activities that take place, and determine whether these characteristics and practices are present across disciplines and whether collaboration affects clinical outcomes.

METHODS

A systematic literature review of past research, using the MEDLINE, ScienceDirect and Web of Science databases.

RESULTS

Four types of team composition were identified: specialized teams, highly multidisciplinary teams, doctor-nurse-pharmacist triad and physician-nurse centred teams. Four types of collaboration within teams were identified: co-located collaboration, non-hierarchical collaboration, collaboration through shared consultations and collaboration via referral and counter-referral. Two combinations were commonly repeated: non-hierarchical collaboration in highly multidisciplinary teams and co-located collaboration in specialist teams. Fifty-two per cent of articles reported positive results when comparing collaboration against the non-collaborative alternative, whereas 16% showed no difference and 32% did not present a comparison.

CONCLUSION

Overall, collaboration was found to be positive or neutral in every study that compared collaboration with a non-collaborative alternative. A collaboration typology based on objective measures was devised, in contrast to typologies that involve interviews, perception-based questionnaires and other subjective instruments.

Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

BACKGROUND

In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity.

METHODS

A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US.

RESULTS

In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2).

CONCLUSION

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

Memory and Learning Complaints in Relation to Depression among Elderly People with Multimorbidity

Although current models of care are generally well-suited to providing treatment for individual medical conditions, the emergence of multimorbidity is becoming a serious concern for practitioners and policy researchers, particularly in developing countries. The challenges of tackling multimorbidity are further compounded when the multimorbidity co-occurs with psychiatric conditions such as cognitive and depressive disorders. Understanding the relationships between multimorbidity and psychiatric illnesses is therefore of considerable clinical importance. In the present study, we cross-sectionally examined whether multimorbidity has an association with perceived cognition-including memory, learning complaints, and depression-among elderly population in South Africa. Study subjects were 422 men and women aged 50 years and older. The prevalence of arthritis, asthma, cancer, diabetes, heart disease, chronic lung disease, hypertension, and stroke was respectively 31.5, 7.3, 1.7, 10.2, 1.2, 1.7, 52.1, and 31.5%, and that of multimorbidity was 30.8%. In the multivariate analysis, women with multimorbidity were 4.33 times (OR = 4.33, 95%CI = 2.96⁻14.633) more likely to report memory complaints. The odds of diagnosed depression were 1.4 times (OR = 1.4, 95%CI = 1.045⁻5.676), and the odds of self-reported depression were 1.7 times (OR = 1.7, 95%CI = 1.41⁻2.192) higher among women who had multimorbidity compared with those who had no morbid conditions. However, the association was not significant among men. Overall, the findings suggest that the occurrence of multimorbidity warrants special attention, especially regarding its compounding effects on psychological health. The findings need to be replicated through longitudinal studies that consider a broader range of chronic conditions.

What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review

BACKGROUND

Collaborative Care is an evidence-based approach to the management of depression within primary care services recommended within NICE Guidance. However, uptake within the UK has been limited. This review aims to investigate the barriers and facilitators to implementing Collaborative Care.

METHODS

A systematic review of the literature was undertaken to uncover what barriers and facilitators have been reported by previous research into Collaborative Care for depression in primary care.

RESULTS

The review identified barriers and facilitators to successful implementation of Collaborative Care for depression in 18 studies across a range of settings. A framework analysis was applied using the Collaborative Care definition. The most commonly reported barriers related to the multi-professional approach, such as staff and organisational attitudes to integration, and poor inter-professional communication. Facilitators to successful implementation particularly focussed on improving inter-professional communication through standardised care pathways and case managers with clear role boundaries and key underpinning personal qualities.

LIMITATIONS

Not all papers were independent title and abstract screened by multiple reviewers thus limiting the reliability of the selected studies. There are many different frameworks for assessing the quality of qualitative research and little consensus as to which is most appropriate in what circumstances. The use of a quality threshold led to the exclusion of six papers that could have included further information on barriers and facilitators.

CONCLUSIONS

Although the evidence base for Collaborative Care is strong, and the population within primary care with depression is large, the preferred way to implement the approach has not been identified.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Process evaluation of a stepped-care program to prevent depression in primary care: patients' and practice nurses' experiences

Background

Depression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable. Recently, a cluster randomized trial of stepped care to prevent depression among patients with DM2 and/or CHD and subthreshold depression in Dutch primary care (Step-Dep) versus usual care showed no effectiveness. This paper presents its process evaluation, exploring in-depth experiences from a patient and practice nurse perspective to further understand the results.

Methods

A qualitative study was conducted. Using a purposive sampling strategy, data were collected through semi-structured interviews with 24 participants (15 patients and nine practice nurses). All interviews were audiotaped and transcribed verbatim. Atlas.ti 5.7.1 software was used for coding and structuring of themes. A thematic analysis of the data was performed.

Results

The process evaluation showed, even through a negative trial, that Step-Dep was perceived as valuable by both patients and practice nurses; perceived effectiveness on improving depressive symptoms varied greatly, but most felt that it had been beneficial for patients’ well-being. Facilitators were: increased awareness of mental health problems in chronic disease management and improved accessibility and decreased experienced stigma of receiving mental health care. The Patient Health Questionnaire 9 (PHQ-9), used to determine depression severity, functioned as a useful starting point for the conversation on mental health and patients gained more insight into their mental health by regularly filling out the PHQ-9. However, patients and practice nurses did not widely support its use for monitoring depressive symptoms or making treatment decisions. Monitoring mental health was deemed important in chronically ill patients by both patients and practice nurses and was suggested to start at the time of diagnosis of a chronic disease. Appointed barriers were that patients were primarily motivated to participate in scientific research rather than their intrinsic need to improve depressive symptoms. Additionally, various practice nurses preferred offering individually based therapy over pre-determined interventions in a protocolled sequence and somatic practice nurses expressed a lack of competence to recognise and treat mental health problems.

Conclusion

This study demonstrates both the benefits and unique demands of programs such as Step-Dep. The appointed facilitators and barriers could guide the development of future studies aiming to prevent depression in similar patient groups.

Development and refinement of a complex intervention within cardiac rehabilitation services: experiences from the CADENCE feasibility study

BACKGROUND

Patients who experience a cardiac event are at higher risk of developing depression than the general population. Despite this, cardiac rehabilitation (CR) programmes do not provide a systematic approach to psychological care for depression. The CADENCE study aimed to develop and pilot an enhanced psychological care (EPC) intervention consisting of behavioural activation (BA) and mental health care coordination. Following original research commissioning guidance, the intervention was planned to be embedded in routine care and delivered by CR nurses to patients with depression attending CR. This paper describes how qualitative methods were used to develop, embed and refine the intervention.

METHODS

This feasibility study involved three CR teams. Observations were made of CR nurses delivering usual care, of EPC training given to nurses, and of supervision sessions provided to the CR nurses. Four nurses were interviewed shortly after their EPC training, and three were interviewed again 6-7 months later having delivered EPC to patients. All nine patients recruited to receive EPC were interviewed. Analyses of the observation notes and interview transcripts focused on how the intervention could be improved in terms of its acceptability and implementation.

RESULTS

Variations were found between the CR teams regarding patient waiting list times, how CR was delivered, what facilities were available and how many CR sessions were offered to patients. EPC was acceptable to both nurses and patients. However, nurses struggled to provide this additional care within their existing workload and resources, and patients' disrupted progression through the CR programme affected EPC delivery. Limited time and availability of private space meant nurses also delivered EPC by telephone, which was viewed as a pragmatic solution but less preferable than face-to-face. Nurses indicated that patients struggled with some of the written materials. Findings were used to revise the intervention to become a protocol of care coordination which included guided self-help BA.

CONCLUSIONS

Insights gained through conducting interviews and observations enabled us to identify barriers to the implementation of EPC, and to modify the intervention to facilitate its delivery within existing services whilst remaining acceptable to both nurses and patients. The multiple method, iterative approach used was key to the success of this qualitative study.

TRIAL REGISTRATION

ISRCTN34701576 Registered 29/05/2014.

Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review

Background

Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression.

Methods

We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT).

Results

We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers.

Conclusions

The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0519-y) contains supplementary material, which is available to authorized users.

Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions

Background

Practice nurses (PNs) deliver much of the chronic disease management in primary care and have been highlighted as appropriately placed within the service to manage patients with long-term physical conditions (LTCs) and co-morbid depression.

This nested qualitative evaluation within a service development pilot provided the opportunity to examine the acceptability of a Brief Behavioural Activation (BBA) intervention within a collaborative care framework. Barriers and facilitators to engaging with the intervention from the patient and clinician perspective will be used to guide future service development and research.

Methods

The study was conducted across 8 practices in one Primary Care Trust ¹ in England. Through purposive sampling professionals (n = 10) taking part in the intervention (nurses, GPs and a mental health gateway worker) and patients (n = 4) receiving the intervention participated in semi-structured qualitative interviews. Analysis utilised the four Normalisation Process Theory (NPT) concepts of coherence, cognitive participation, collective action and reflexive monitoring to explore the how this intervention could be implemented in practice.

Results

Awareness of depression and the stigma associated with the label of depression meant that, from a patient perspective a PN being available to ‘listen’ was perceived as valuable. Competing practice priorities, perceived lack of time and resources, and lack of engagement by the whole practice team were considered the greatest barriers to the implementation of this intervention in routine primary care.

Conclusion

Lack of understanding of, participation in, and support from the whole practice team in the collaborative care model exacerbated the pressures perceived by PNs. The need for formal supervision of PNs to enable them to undertake the role of case manager for patients with depression and long-term conditions is emphasised.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-016-0190-2) contains supplementary material, which is available to authorized users.

A qualitative study of perceived needs and factors associated with the quality of care for common mental disorders in patients with chronic diseases: the perspective of primary care clinicians and patients

BACKGROUND

The prevalence of comorbid anxiety and depressive disorders is high among patients with chronic diseases in primary care, and is associated with increased morbidity and mortality rates. The detection and treatment of common mental disorders in patients with chronic diseases can be challenging in the primary care setting. This study aims to explore the perceived needs, barriers and facilitators for the delivery of mental health care for patients with coexisting common mental disorders and chronic diseases in primary care from the clinician and patient perspectives.

METHODS

In this qualitative descriptive study, we conducted semi-structured interviews with clinicians (family physician, nurse, psychologist, social worker; n = 18) and patients (n = 10) from three primary care clinics in Quebec, Canada. The themes explored included clinician factors (e.g., attitudes, perception of roles, collaboration, management of clinical priorities) and patient factors (e.g., needs, preferences, access to care, communication with health professionals) associated with the delivery of care. Qualitative data analysis was conducted based on an interactive cyclical process of data reduction, data display and conclusion drawing and verification.

RESULTS

Clinician interviews highlighted a number of needs, barriers and enablers in the provision of patient services, which related to inter-professional collaboration, access to psychotherapy, polypharmacy as well as communication and coordination of services within the primary care clinic and the local network. Two specific facilitators associated with optimal mental health care were the broadening of nurses' functions in mental health care and the active integration of consulting psychiatrists. Patients corroborated the issues raised by the clinicians, particularly in the domains of whole-person care, service accessibility and care management.

CONCLUSIONS

The results of this project will contribute to the development of quality improvement interventions to increase the uptake of organizational and clinical evidence-based practices for patients with chronic diseases and concurrent common mental disorders, in priority areas including collaborative care, access to psychotherapy and linkages with specialized mental health care.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study

BACKGROUND

Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low.

OBJECTIVES

Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations.

DESIGN

A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection.

SETTING

Diabetes care in a regional group of family practices in the south of the Netherlands.

PARTICIPANTS

Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire.

METHODS

First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning.

RESULTS

The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients over 65. Patients' openness to discussing psychosocial problems was not significantly (p<0.05) associated with the nurses being trained in the biopsychosocial self-management approach.

CONCLUSION

Patients see primary care nurses primarily as specialists regarding the biomedical management of diabetes. Although patients seemed to support the ideal of integrated care, they did not expect a discussion about psychosocial problems in diabetes consultations. The incorporation of systematic detection of patients with psychosocial problems in diabetes care requires endeavours to make patients acquainted with the new role of the nurse.

Integrating emotional and psychological support into the end-stage renal disease pathway: a protocol for mixed methods research to identify patients' lower-level support needs and how these can most effectively be addressed

BACKGROUND

As a result of difficulties related to their illness, diagnosis and treatment, patients with end-stage renal disease experience significant emotional and psychological problems, which untreated can have considerable negative impact on their health and wellbeing. Despite evidence that patients desire improved support, management of their psychosocial problems, particularly at the lower-level, remains sub-optimal. There is limited understanding of the specific support that patients need and want, from whom, and when, and also a lack of data on what helps and hinders renal staff in identifying and responding to their patients' support needs, and how barriers to doing so might be overcome. Through this research we therefore seek to determine what, when, and how, support for patients with lower-level emotional and psychological problems should be integrated into the end-stage renal disease pathway.

METHODS/DESIGN

The research will involve two linked, multicentre studies, designed to identify and consider the perspectives of patients at five different stages of the end-stage renal disease pathway (Study 1), and renal staff working with them (Study 2). A convergent, parallel mixed methods design will be employed for both studies, with quantitative and qualitative data collected separately. For each study, the data sets will be analysed separately and the results then compared or combined using interpretive analysis. A further stage of synthesis will employ data-driven thematic analysis to identify: triangulation and frequency of themes across pathway stages; patterns and plausible explanations of effects.

DISCUSSION

There is an important need for this research given the high frequency of lower-level distress experienced by end-stage renal disease patients and lack of progress to date in integrating support for their lower-level psychosocial needs into the care pathway. Use of a mixed methods design across the two studies will generate a holistic patient and healthcare professional perspective that is more likely to identify viable solutions to enable implementation of timely and integrated care. Based on the research outputs, appropriate support interventions will be developed, implemented and evaluated in a linked follow-on study.

Behavioural health consultants in integrated primary care teams: a model for future care

BACKGROUND

Significant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes. In this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients' needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting such an approach, especially for staff who must adapt to working more collaboratively with each other and patients. Strong leadership is needed to assist in this, particularly to support organisations to adopt the shift in values and attitudes towards collaborative working.

CONCLUSIONS

Integrated primary care services that embed behavioural health as part of a multi-disciplinary team may be part of the solution to significant modern day health challenges. However, developing this model is unlikely to be straight-forward given current primary care structures and ways of working. The discussion, developed in this article, adds to our understanding of what the BHC role might consist off and how integrated care may be supported by such behavioural health expertise. Further work is needed to develop this model in the UK, and to evaluate its impact on health outcomes and health care utilisation, and test robustly through research trials.

Revealing hidden depression in older people: a qualitative study within a randomised controlled trial

BACKGROUND

The prevalence of depressive symptoms in older people may be as high as 20 %. Depression in older people is associated with loss, loneliness and physical co-morbidities; it is known to be under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.

METHODS

A nested qualitative study in a randomised controlled trial for older people with moderate to severe depression: the CASPER Plus Trial (Collaborative Care for Screen Positive Elders). We interviewed GPs, case managers (CM) and patient participants to explore perspectives and experiences of delivering and receiving a psychosocial intervention, developed specifically for older adults in primary care, within a collaborative care framework. Transcripts were analysed thematically using principles of constant comparison.

RESULTS

Thirty three interviews were conducted and, across the three data-sets, four main themes were identified: revealing hidden depression, reducing the 'blind spots', opportunity to talk outside the primary care consultation and 'moving on' from depression.

CONCLUSIONS

Depression in older people is commonly hidden, and may coexist with physical conditions that are prioritised by both patients and GPs. Being invited to participate in a trial about depression may allow older people to disclose their feelings, name the problem, and seek help. Offering older people an opportunity to talk outside the primary care consultation is valued by patients and GPs. A psychosocial intervention delivered by a case manager in the primary care setting may fill the gap in the care of older people with depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45842879 .

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

METHODS

We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

RESULTS

Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

CONCLUSIONS

The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.