title: Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease.
abstract: OBJECTIVE
  To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions.
  
  
  METHODS
  Cluster randomised controlled trial.
  
  
  METHODS
  36 general practices in the north west of England.
  
  
  METHODS
  387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥ 10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial.
  
  
  METHODS
  Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses.
  
  
  METHODS
  The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF).
  
  
  RESULTS
  19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval -0.41 to -0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support.
  
  
  CONCLUSIONS
  Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity.
  
  
  BACKGROUND
  ISRCTN80309252.
authors: NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK peter.a.coventry@manchester.ac.uk.
authors: Peter
authors: P
authors: Coventry
authors: School of Nursing, Midwifery and Social Work and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Karina
authors: K
authors: Lovell
authors: Institute of Health Service Research, University of Exeter Medical School, Exeter EX1 2LU, UK.
authors: Chris
authors: C
authors: Dickens
authors: NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Peter
authors: P
authors: Bower
authors: Research Institute, Primary Care and Health Sciences, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, University of Keele, Keele ST5 5BG, UK.
authors: Carolyn
authors: C
authors: Chew-Graham
authors: NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Damien
authors: D
authors: McElvenny
authors: Centre for Biostatistics and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Mark
authors: M
authors: Hann
authors: Research Institute, Primary Care and Health Sciences, University of Keele, Keele ST5 5BG, UK.
authors: Andrea
authors: A
authors: Cherrington
authors: Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Charlotte
authors: C
authors: Garrett
authors: Manchester Centre for Health Psychology, University of Manchester, Manchester M13 9PL, UK.
authors: Chris J
authors: CJ
authors: Gibbons
authors: NHS Health Education North West, Manchester M1 3BN, UK.
authors: Clare
authors: C
authors: Baguley
authors: Division of Clinical Psychology, University of Liverpool, Liverpool L69 3GB, UK.
authors: Kate
authors: K
authors: Roughley
authors: NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Isabel
authors: I
authors: Adeyemi
authors: NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: David
authors: D
authors: Reeves
authors: Lancashire Care NHS Foundation Trust, Preston PR5 6AW, UK.
authors: Waquas
authors: W
authors: Waheed
authors: Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors: Linda
authors: L
authors: Gask
mesh_terms: D002318:Cardiovascular Diseases / Q000150:complications* / Q000628:therapy*; D016000:Cluster Analysis; D019033:Delivery of Health Care, Integrated; D003863:Depression / Q000150:complications* / Q000628:therapy*; D048909:Diabetes Complications / Q000150:complications* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D011320:Primary Health Care / Q000379:methods*