title: Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model.
abstract: BACKGROUND
  Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals.
  
  
  METHODS
  Nested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews.
  
  
  RESULTS
  Based on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients' health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems.
  
  
  CONCLUSIONS
  The COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.
authors.affiliation: NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK. sarah.knowles@manchester.ac.uk.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Knowles
authors.affiliation: Primary Care and Health Sciences, University of Keele, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, ST5 5BG, UK. c.a.chew-graham@keele.ac.uk.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.affiliation: 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. isabel.adeyemi@postgrad.manchester.ac.uk.
authors.forename: Isabel
authors.initials: I
authors.lastname: Adeyemi
authors.affiliation: NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK. nia.coupe@postgrad.manchester.ac.uk.
authors.forename: Nia
authors.initials: N
authors.lastname: Coupe
authors.affiliation: 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.forename: Peter A
authors.initials: PA
authors.lastname: Coventry
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000453:epidemiology; D015897:Comorbidity; D003299:Cooperative Behavior; D003863:Depression / Q000453:epidemiology* / Q000628:therapy*; D003920:Diabetes Mellitus / Q000453:epidemiology; D019468:Disease Management; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000458:organization & administration*