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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

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Coventry, P., Lovell, K., Dickens, C., Bower, P., Chew-Graham, C., McElvenny, D., Hann, M., Cherrington, A. +8 more·2015·BMJ
DOI 10.1136/bmj.h638PMC PMC4353275
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Abstract

OBJECTIVE: To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions. DESIGN: Cluster randomised controlled trial. SETTING: 36 general practices in the north west of England. PARTICIPANTS: 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. INTERVENTIONS: 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. MAIN OUTCOME MEASURES: 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. TRIAL REGISTRATION: ISRCTN80309252.

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  • Studies of treatment interventions using standard CBT protocols for depression and/or anxiety in LTCs report low levels of engagement.

    “Studies of treatment interventions using standard CBT protocols for depression and/ or anxiety in LTCs report low levels of engagement with these interventions (Ciechanowski et al . 2010; Coventry et al . 2015).”

    From Improving Distress in Dialysis (iDiD): A tailored CBT self-management treatment for patients undergoing dialysis. (2016) · cites this paper as Coventry et al . 2015

    The Results (‘Delivery of the intervention’; page unavailable) document engagement difficulties: 11% disengaged before any treatment session, and 22% missed at least one scheduled session. The Methods (‘Intervention and comparators’; page unavailable) describe a brief, integrated collaborative-care intervention with CBT-related techniques, not a study of standard CBT protocols. The paper therefore supports the engagement point in this trial but not its characterization as evidence about standard CBT protocols generally. (LLM, conf=0.84)

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  • These problems are diminishing, thanks to concerted efforts across a number of countries to regulate trial registration and reporting.

    “These problems are diminishing, thanks to concerted efforts across a number of countries to regulate trial registration and reporting. 582”

    From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [582]

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3 of the 69 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. [23]NICE. Depression. The treatment and management of depression in adults (updated edition). NICE Clinical Guidelines, No 90. British Psychological Society, 2010. 22132433
  2. [26]Derogatis LR, Cleary PA. Confirmation of the dimensional structure of the scl-90: a study in construct validation. J Clin Psychol 1977; 33: 981-89.

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Authors
Coventry, P., Lovell, K., Dickens, C., Bower, P., Chew-Graham, C., McElvenny, D., Hann, M., Cherrington, A., Garrett, C., Gibbons, C. J., Baguley, C., Roughley, K., Adeyemi, I., Reeves, D., Waheed, W., & Gask, L.
Affiliations
  • Manchester Academic Health Science Centre (GB)
  • University of Exeter (GB)
  • National Institute for Health and Care Research (GB)
  • Keele University (GB)
  • Health Education North West (GB)
  • University of Liverpool (GB)
  • Lancashire Care NHS Foundation Trust (GB)
Corresponding author
Coventry, P.
ORCID
Venue
BMJ
Publisher
BMJ
Published
2015-02-16
Volume
350
Issue
feb16 3
Pages
h638-h638
ISSN
1756-1833 (ISSN-L)
DOI
10.1136/bmj.h638
PMC
PMC4353275
OpenAlex
W2112219174
Cited by
325
References
69
Citations by year
2026: 19 · 2025: 22 · 2024: 30 · 2023: 13 · 2022: 27 · 2021: 28 · 2020: 39 · 2019: 31 · 2018: 35 · 2017: 25 · 2016: 37 · 2015: 19
FWCI
63.27
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • BMJ (publishedVersion, cc-by-nc)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Research Explorer (The University of Manchester) (publishedVersion, cc-by-nc)
  • Figshare (submittedVersion)
  • Open Research Exeter (University of Exeter) (submittedVersion, cc-by-nc)
Funders
National Institute for Health and Care Research
Topics
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
collaborative care, depression, multimorbidity, diabetes mellitus, cardiovascular disease, integrated primary care, behavioral activation, cognitive restructuring, graded exposure, practice nurses, self-management, quality of life, disability, relapse prevention, patient satisfaction, patient-centered care, general practice, anxiety symptoms, self-efficacy, social support
MeSH terms
Cardiovascular Diseases, Depression, Female, Humans, Male, Middle Aged, Patient Care Team, Primary Health Care, Cluster Analysis, Delivery of Health Care, Integrated, Diabetes Complications

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