The chronic disease management model for depression in primary care

Objective: This paper reviews the development of chronic disease management approaches, and explores the suitability and effectiveness of these ways of organizing care for depression. Method: The relevant literature including systematic reviews, service evaluations, and clinical guidelines have been appraised to provide a review of the development of health care management approaches for long term conditions and their application to depression. Results: The chronic care model originally developed in the USA has been successfully adopted in other countries, and has been applied to the management of depression in primary care. This multicomponent approach involves enhanced collaboration between primary and secondary care clinicians often by means of case managers, support for improved patient self-management, and systematic follow-up. These approaches to health care organization significantly enhance the quality of care for depression: reviews consistently show improvements in depression severity, treatment adherence, and patient satisfaction. Conclusions: There appears value in the continued use of chronic disease management approaches for depression in primary care. For depression alone and depression combined with medical conditions there is consistent evidence for beneficial effects on depression outcomes. However there remain challenges in tailoring these approaches to influence physical outcomes in patients with medical comorbidity

School nurses' involvement, attitudes and training needs for mental health work: a UK-wide cross-sectional study

Aim.  The aim of this study was to identify school nurses’ views concerning the mental health aspects of their role, training requirements and attitudes towards depression in young people. Background.  Mental health problems in children and young people have high prevalence worldwide; in the United Kingdom they affect nearly 12% of secondary school pupils. School nurses have a wide-ranging role, and identifying and managing mental health problems is an important part of their work Methods.  A cross-sectional study was conducted using a postal questionnaire sent to a random sample of 700 school nurses throughout the United Kingdom in 2008. Questions concerned involvement in mental health work and training needs for this work. Attitudes were measured using the Depression Attitude Questionnaire Results.  Questionnaires were returned by 258 (37%) nurses. Nearly half of respondents (46%) had not received any postregistration training in mental health, yet 93% agreed that this was an integral part of their job. Most (55%) noted that involvement with young people’s psychological problems occupied more than a quarter of their work time. Staff attitudes were broadly similar to those of other primary care professionals, and indicated a rejection of stigmatizing views of depression and strong acknowledgement of the role of the school nurse in providing support. Conclusion.  Working with young people who self-harm, and recognizing and being better equipped to assist in managing depression and anxiety are key topics for staff development programmes

Clinicians' attitudes to depression in Europe: a pooled analysis of Depression Attitude Questionnaire findings

Background: Depression in primary care is common but under-recognized and suboptimally managed. Health professionals’ attitudes are likely to play an important part in their recognition and management of depression. Objectives: To pool findings from studies using the Depression Attitude Questionnaire (DAQ) to provide greater detail of clinicians’ attitudes and the measure’s psychometric properties. Methods: Electronic databases and grey literature were searched for relevant studies. Data from eligible studies were requested and pooled analysis conducted. Results: Twenty studies were eligible and data were obtained from 12 of these involving GPs (n = 1543) and nurses (n = 984). Responses showed strong disagreement that depression is due to ageing or weakness. European GPs were more positive about depression treatments than UK GPs; nurses were more favourable about psychotherapy than GPs. UK GPs especially strongly opposed notions that depression is best managed by psychiatrists. Trends over time indicated increasing acknowledgement of psychological therapies and the nurse’s role in depression management. Factor analysis indicated that many DAQ items fitted weakly within an overall model. The most parsimonious solution involved two factors: a positive view of depression and its treatment response and professional confidence in depression management. Conclusions: Individual DAQ items appear to measure key aspects of clinicians’ attitudes to depression, and item responses indicate important differences between professions and geographical settings as well as changes over time. There are problems with the DAQ as a scale: its internal consistency is weak, and several items appear specific to particular professions or service structures, indicating that this questionnaire should be revised

The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study

Background: Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression. Methods: Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables. Result: 1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000. Conclusions: Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU

Up-beat UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients.

Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression

A pilot randomised controlled trial of personalised care for depressed patients with symptomatic coronary heart disease in South London general practices: the UPBEAT-UK RCT protocol and recruitment.

ABSTRACT: Background: Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings. Methods: This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care. 81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire. Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant’s physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant’s mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient’s self efficacy to solve their problems. Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation. Discussion: This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care. Trial registration: ISRCTN21615909

Chest pain, depression and anxiety in coronary heart disease:Consequence or cause? A prospective clinical study in primary care

Objective To examine if chest pain increases the risk of depression and anxiety, or, on the other hand, depression and anxiety increase the risk of chest pain onset in patients with coronary heart disease (CHD). Design Prospective clinical study. Setting 16 general practices in the Greater London Primary Care Research Network. Participants 803 participants with a confirmed diagnosis of CHD at baseline on the Quality and Outcomes Framework (QOF) CHD registers. Main outcome measures Rose Angina Questionnaire, HADS depression and anxiety subscales and PHQ-9 were assessed at seven time points, each 6 months apart. Multi-Level Analysis (MLA) and Structural Equation Modelling (SEM) were applied. Results Chest pain predicts both more severe anxiety and depression symptoms at all time points until 30 months after baseline. However, although anxiety predicted chest pain in the short term with a strong association, this association did not last after 18 months. Depression had only a small, negative association with chest pain. Conclusions In persons with CHD, chest pain increases the risk of both anxiety and depression to a great extent. However, anxiety and depression have only limited effects on the risk for chest pain. This evidence suggests that anxiety and depression tend to be consequences rather than causes of cardiac chest pain. Intervention studies that support persons with CHD by providing this information should be devised and evaluated, thus deconstructing potentially catastrophic cognitions and strengthening emotional coping

Characteristics of people with low health literacy on coronary heart disease GP registers in South London: A cross-sectional study

Objective To explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). Design Cross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. Setting 16 General Practices in South London, UK. Participants Inclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. Primary outcome measure REALM. Results Of the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. Conclusions There is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use