Better together? a naturalistic qualitative study of inter-professional working in collaborative care for co-morbid depression and physical health problems

Abstract

BackgroundMental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. Collaborative care models encourage inter-professional working to deliver better care for patients with multiple chronic conditions, such as depression and long-term physical health problems. Successive trials from the United States have shown that collaborative care effectively improves depression outcomes, even in people with long-term conditions (LTCs), but little is known about how to implement collaborative care in the United Kingdom. The aim of the study was to explore the extent to which collaborative care was implemented in a naturalistic National Health Service setting.MethodsA naturalistic pilot study of collaborative care was undertaken in North West England. Primary care mental health professionals from IAPT (Increasing Access to Psychological Therapies) services and general practice nurses were trained to collaboratively identify and manage patients with co-morbid depression and long-term conditions. Qualitative interviews were performed with health professionals at the beginning and end of the pilot phase. Normalization Process Theory guided analysis.ResultsHealth professionals adopted limited elements of the collaborative care model in practice. Although benefits of co-location in primary care practices were reported, including reduced stigma of accessing mental health treatment and greater ease of disposal for identified patients, existing norms around the division of mental and physical health work in primary care were maintained, limiting integration of the mental health practitioners into the practice setting. Neither the mental health practitioners nor the practice nurses perceived benefits to joint management of patients.ConclusionsEstablished divisions between mental and physical health may pose particular challenges for multi-morbidity service delivery models such as collaborative care. Future work should explore patient perspectives about whether greater inter-professional working enhances experiences of care. The study demonstrates that research into implementation of novel treatments must consider how the introduction of innovation can be balanced with the need for integration into existing practice.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

“…The findings support the literature, which suggests that participation in a trial and active case management can help to reduce stigma and may improve the care for mental health problems, such as depression, 10,66 and that being invited to participate in a trial acted as a catalyst for older people to reflect on their feelings and depression, which may not have been identified outside the trial setting.…”

Anxious and depressed women's experiences of emotional suffering and help seeking in a Rio de Janeiro favela

“…The care of people with anxiety and depression involves aspects ranging from stigma 1 , acceptance of the illness 2 and clinical management 3 . Disregarding these circumstances might affect patients´ quality of life 4 and worsen the prognosis of chronic physical diseases 5 .…”

CHOICE: Choosing Health Options In Chronic Care Emergencies

“…Nevertheless, the practice staff perspective is consistent with previous findings that the compartmentalisation of UK primary care has prevented integration of interventions designed to address psychosocial needs. 299,332 The duration of the study was only 12 months, which meant there had to be a run-in period at the beginning, when the LHWs were being embedded in the practice, and a run-down period at the end, when no further patients could be recruited. This created a somewhat artificial dimension to the treatment and may have been an additional barrier to the integration of the LHWs within the practices.…”

“…In addition, there is evidence that patients may not be accepting of the management of approaches which encourage the holistic management of physical and mental health problems in primary care. 332 Even if depression is acknowledged, it is often normalised and conceptualised by staff as a common and understandable response to the losses and stresses associated with LTCs, mitigating against diagnosis and treatment. 308 Other issues linked to depression in long-term illness, such as a sense of loss, loneliness and other interpersonal problems, together with complex social issues, also need to be recognised and addressed.…”