Peter Coventry

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

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.

Talking about depression: A qualitative study of barriers to managing depression in people with long term conditions in primary care

BackgroundThe risk of depression is increased in people with long term conditions (LTCs) and is associated with poorer patient outcomes for both the depressive illness and the LTC, but often remains undetected and poorly managed. The aim of this study was to identify and explore barriers to detecting and managing depression in primary care in people with two exemplar LTCs: diabetes and coronary heart disease (CHD).MethodsQualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper.ResultsBarriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management.ConclusionDepression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.

Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: A systematic review and meta-analysis

OBJECTIVE Patients with diabetes suffer high rates of mental health problems, and this combination is associated with poor outcomes. Although effective treatments exist for both diabetes and mental health problems, delivering services for physical and mental health problems separately ignores their interaction and may be inefficient. This systematic review sought to identify psychosocial interventions that could improve both the physical and mental health of patients with diabetes. RESEARCH DESIGN AND METHODS Studies were identified from the following databases: CENTRAL, MEDLINE, Excerpta Medica (EMBASE), Psychinfo, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The review included randomized controlled trials in patients with type 1 and type 2 diabetes who received psychosocial interventions and where both mental health and physical health outcomes were reported. Data were extracted on study quality, the content and process of interventions, and outcomes. RESULTS Eighty-five eligible comparisons were identified, of which 49 reported sufficient data for analysis. Psychosocial interventions modestly improved A1C (standardized mean difference −0.29 [95% CI −0.37 to −0.21]) and mental health outcomes (−0.16 [−0.25 to −0.07]). However, there was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes. CONCLUSIONS Managing physical and mental health in long-term conditions are increasingly important. The review did not identify types of interventions that consistently provide benefits for both physical and mental health. Developing such interventions remains an important challenge. The findings have implications for understanding the interaction between physical and mental health problems and for the coordination of care.

Characteristics of Psychological Interventions That Improve Depression in People With Coronary Heart Disease: A Systematic Review and Meta-Regression

Objective Despite previous intervention trials, it is unclear which psychological treatments are most effective for people with coronary heart disease (CHD). We have conducted a systematic review with meta-regression to identify the characteristics of psychological interventions that improve depression and depressive symptoms among people with CHD. Methods Searches of multiple electronic databases up to March 2012 were conducted, supplemented by hand-searching of identified reviews and citation tracing of eligible studies. Studies were included if they reported a randomized controlled trial of a psychological intervention for people with CHD and included depression as an outcome. Data on main effects and characteristics of interventions were extracted from eligible studies. Standardized mean differences (SMDs) were calculated for each study and pooled using random-effects models. Random-effects multivariate meta-regression was performed to identify treatment characteristics associated with improvements in depression. Results Sixty-four independent treatment comparisons were identified. Psychological interventions improved depression, although the effect was small (SMD = 0.18, p < .001). Problem solving (SMD = 0.34), general education (SMD = 0.19), skills training (SMD = 0.25), cognitive-behavioral therapy (CBT; SMD = 0.23), and relaxation (SMD = 0.15) had small effects on CHD patients who were recruited irrespective of their depression status. Among high-quality trials of depressed CHD patients, only CBT showed significant but small effects (SMD = 0.31). When entered into multivariable analysis, no individual treatment component significantly improved depression. Conclusions CBT and problem solving should be considered for inclusion in future treatment developments and randomized controlled trials. However, the effects are small in magnitude, and there is room to develop new interventions that may be more effective.

The Effect of Complex Interventions on Depression and Anxiety in Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

Background Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective. Methods and Findings Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference −0.28, 95% confidence interval −0.41 to −0.14) and anxiety (standardised mean difference −0.23, 95% confidence interval −0.38 to −0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference −0.47, 95% confidence interval −0.66 to −0.28), and for anxiety (standardised mean difference −0.45, 95% confidence interval −0.71 to −0.18). Conclusions Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

Psychosocial risk factors for hospital readmission in COPD patients on early discharge services: a cohort study

BackgroundHospital readmission for acute exacerbation of COPD (AECOPD) occurs in up to 30% of patients, leading to excess morbidity and poor survival. Physiological risk factors predict readmission, but the impact of modifiable psychosocial risk factors remains uncertain. We aimed to evaluate whether psychosocial risk factors independently predict readmission for AECOPD in patients referred to early discharge services (EDS).MethodsThis prospective cohort study included 79 patients with AECOPD cared for by nurse led EDS in the UK, and followed up for 12 months. Data on lung function, medical comorbidities, previous hospital admissions, medications, and sociodemographics were collected at baseline; St Georges Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS), and social support were measured at baseline, 3 and 12-months. Exploratory multivariate models were fitted to identify psychosocial factors associated with readmission adjusted for known confounders.Results26 patients were readmitted within 90 days and 60 patients were readmitted at least once during follow-up. Depression at baseline predicted readmission adjusted for sociodemographics and forced expiratory volume in 1 second (odds ratio 1.30, 95% CI 1.06 to 1.60, p = 0.013). Perceived social support was not significantly associated with risk of readmission. Home ownership was associated with the total number of readmissions (B = 0.46, 95% CI -0.86 to -0.06, p = 0.024). Compared with those not readmitted, readmitted patients had worse SGRQ and HADS scores at 12 months.ConclusionDepressive symptoms and socioeconomic status, but not perceived social support, predict risk of readmission and readmission frequency for AECOPD in patients cared for by nurse-led EDS. Future work on reducing demand for unscheduled hospital admissions could include the design and evaluation of interventions aimed at optimising the psychosocial care of AECOPD patients managed at home.

Does pulmonary rehabilitation reduce anxiety and depression in chronic obstructive pulmonary disease

Purpose of review Symptoms of anxiety and depression are prevalent in at least 20–40% of patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) and are known to affect prognosis and worsen quality of life. This review examines whether pulmonary rehabilitation can effectively improve psychological status in COPD patients. Recent findings Over the last decade, evidence has accumulated to show that comprehensive pulmonary rehabilitation, which includes exercise training and disease education or psychosocial support or both, can effectively improve anxiety and depression in COPD. The quality of supporting data varies but indicates a consistent and homogeneous effect in favour of pulmonary rehabilitation for anxiety and depression when compared with conventional community care. Pulmonary rehabilitation also appears to improve anxiety and depression in rehabilitating COPD patients with less favourable psychosocial health, but its efficacy for treating more severe and enduring anxiety and depression is largely unproven. Additionally, it is not certain which components of pulmonary rehabilitation lead to improved anxiety and depression, and further research is needed to ensure that psychological benefits accrued during rehabilitation are sustained. Summary Anxiety and depression afflict a significant proportion of COPD patients and lead to worse patient-centred outcomes. Evidence supports the use of pulmonary rehabilitation to effectively manage psychological morbidity in COPD.

Improving outcomes for COPD patients with mild-to-moderate anxiety and depression: A systematic review of cognitive behavioural therapy

PURPOSE Anxiety and depression are highly prevalent in patients with chronic obstructive pulmonary disease (COPD) and are associated with lower levels of self-efficacy, impaired health status, poorer treatment outcomes and reduced survival following emergency admission. Cognitive behavioural therapy (CBT) may be effective for treating anxiety and depression in COPD patients but evidence for this is uncertain. METHODS A systematic review of controlled trials that evaluated the effectiveness of CBT for treating mild-to-moderate anxiety or depression in adults with clinically stable COPD. Ovid electronic bibliographic databases were searched from inception to May 2006; all content held by the Cochrane Library Issue 3, 2006 was also searched. RESULTS One small randomized controlled trial (RCT) of moderate quality showed that CBT, when given with exercise training and education, was associated with large and significant treatment effects for both anxiety (-1.39 (95% CIs -2.19, -0.59)) and depression (-0.86 (95% CIs -1.61, -0.11)). Additionally, a larger RCT of higher quality demonstrated that CBT, when given with exercise and education, was associated with large and significant treatment effects for depression (-0.76 (95% CIs -1.34, -0.17)), but not for anxiety. No other included study reported significant reductions in either anxiety or depression in COPD patients given CBT. CONCLUSION There is only limited evidence that CBT, when used with exercise and education, can contribute to significant reductions in anxiety and depression in COPD patients. There is scope for a well-powered RCT to evaluate the effectiveness and acceptability of CBT among this patient population.

Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials

Background Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication). Methods and Findings Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient −0.11, 95% CI −0.20 to −0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. Conclusion Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.

Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease

More than one third of individuals with chronic obstructive pulmonary disease (COPD) experience comorbid symptoms of depression and anxiety. This review aims to provide an overview of the burden of depression and anxiety in those with COPD and to outline the contemporary advances and challenges in the management of depression and anxiety in COPD. Symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired health-related quality of life and increased mortality risk. Depression and anxiety also increase health care utilization rates and costs. Although the quality of the data varies considerably, the cumulative evidence shows that complex interventions consisting of pulmonary rehabilitation interventions with or without psychological components improve symptoms of depression and anxiety in COPD. Cognitive behavioral therapy is also an effective intervention for managing depression in COPD, but treatment effects are small. Cognitive behavioral therapy could potentially lead to greater benefits in depression and anxiety in people with COPD if embedded in multidisciplinary collaborative care frameworks, but this hypothesis has not yet been empirically assessed. Mindfulness-based treatments are an alternative option for the management of depression and anxiety in people with long-term conditions, but their efficacy is unproven in COPD. Beyond pulmonary rehabilitation, the evidence about optimal approaches for managing depression and anxiety in COPD remains unclear and largely speculative. Future research to evaluate the effectiveness of novel and integrated care approaches for the management of depression and anxiety in COPD is warranted.