Improving the lives of people with long term conditions and depression: lessons from Australia.
Many people with long term conditions (LTCs) (such as diabetes and coronary obstructive pulmonary disease) experience problems with depression. However, poor recognition and management in primary care is common. The impact on people’s lives is significant and can affect work, relationships and engagement in the local community.
Typically patients with LTCs and depression have to access and navigate multiple healthcare services which creates barriers and additional demands on them. Collaborative Care, based on the Chronic Care Model which is a framework often used to treat chronic physical conditions (Wagner et al., 1996), has proven efficacy in treating depression (Archer et al., 2012). It involves a number of health professionals working with a patient to help them overcome their problems. Collaborative care often involves a medical doctor, a case manager (with training in depression and anxiety), and a specialist such as a mental or physical healthcare Consultant. The case manager has regular contact with the patient and organises care, together with the medical doctor and specialist. The case manager may offer help with medication, or access to a ‘talking therapy’ to help the patient get better. Collaborative care being recommended in the NICE (2009) guideline Depression with a Chronic Physical health Problem. However, in the UK there is no consensus as to who the case manager should be; Practice Nurse or Psychological Wellbeing Practitioners (Improving Access to Psychological Therapies [IAPT] initiative) and issues such as this act as a barrier to implementation yet in order to improve patient outcomes there is a need to embed this evidence based, NICE recommended, intervention into clinical practice.
The IAPT programme aims to improve access to evidence based psychological interventions for people with common mental health problems (CMHPs), such as depression and anxiety, but the training programmes do not train these clinicians to work effectively with people with LTCs and CMHPs. There is a need to equip clinicians with the necessary skills to recognise and manage these comorbid conditions effectively if patient outcomes including quality of life are to be improved.
The first aim of this study was to learn from and develop close collaborations with researchers and areas of clinical excellence in the recognition and management of LTCs and depression. The second aim was to use the findings to develop a brief training programme for mental health clinicians working with people with long term conditions and depression. This would be conducted in collaboration with a local IAPT service (Six Degrees Social Enterprise) to ensure the training meets the needs of the local community.
The objectives were to:
- Engage with nurse practitioners, educationalists and researchers at these centres in order to understand their experiences (barriers and catalysts) of improving care for people with LTCs and depression.
- Consult with patients with LTCs currently accessing local services
- Develop a training programme for mental health clinicians on the recognition and management of LTCs and depression.
In Australia an evidence based training package has been developed and evaluated by clinicians and researchers at Flinders University which equips healthcare professionals with the skills to assess and manage a wide variety of long term conditions and depression; The Flinders Program. In addition a large Australian multi-site randomised controlled trial (RCT) (TrueBlue) has found that practice nurse-led collaborative care is effective in the management of depression for patients with heart disease or diabetes. After making contact with key people involved in the above projects it was decided that a visit to Australia would be extremely valuable in informing the proposed project.
A four week travel timetable was developed which included visits to meet with the directors of The Flinders Program and a variety of meetings across a large geographical area with key stakeholders (GPs, practice nurses, specialists and researchers) involved in designing, implementing and evaluating the TrueBlue study. Other visits were also arranged to visit: COTA ‘Beyond Maturity Blues’ to understand how the service engage with and develop interventions specifically targeted at older people (who often suffer with multiple LTCs); attendance and presentation of work at the 14th International Mental Health Conference of the Australian and New Zealand Mental Health Association; attendance at a seminar at Melbourne University on Long Term Conditions and multipharmacology issues; meeting with Professor Lorna Moxham at The University of Wollongong, and meeting with Professor Nick Titov at MindSpot an on-line therapy program which has also explored on-line therapy for older people many of whom suffer from LTCs.
From the experiences of the study trip a draft outline of the training program is being developed and in 2014 meetings have been organised with the local IAPT service and two service user Consultants have been recruited to help engage with patients to establish what the training should consist of from their perspective. A meeting has also been organised with a senior researcher from CHOICE (Choosing Health Options in Chronic Care Emergencies) a local research program which is focussed on long term conditions and seeking appropriate and effective structures of care instead of having to use emergency or out-of-hours health services.
The trip was extremely useful in helping to develop and refine ideas for the training program proposed. In addition discussions took place regarding developing future collaborations and joint research proposals linked to the area of LTCs and CMHPs.
The training program will be developed during the first half of 2014 and is expected to be piloted in 2014 before being embedded within the MSc Advanced Practice Interventions in Mental Health programme. A publication based on the experiences gained from the study tour is planned for 2014.