A programme of research to develop and test stepped care for patients with depression and physical illness in primary care’

The AIMS are; 1) to explore and describe the relationship between symptomatic Coronary Heart Disease (sCHD)), distress and depression in primary care patients2) to develop a treatment programme to optimize management of primary care patients with sCHD and co-morbid depression.BACKGROUND; By 2020 the two most burdensome conditions globally, in terms of disability, will be coronary heart disease and unipolar depression. The presence of depression even at low severity increases the incidence and recurrence of acute coronary syndromes and death from any cause in patients with heart disease.Both conditions have been prioritized in the GP Contract to improve quality of care and are also the subject of recent national guidelines. Both conditions appear to be linked biologically and depression prevalence is twice that expected when CHD is present. Cardiac outcome may be improved by managing concurrent depression. Despite this, currently there is no accepted stepped care management for patients with both conditions and no studies testing this. This Programme is designed to improve our understanding of the relationship between physical symptoms, distress and depression in primary care patients with CHD and to develop and test a stepped care programme for patients with CHD and ICD-10 Depressive Disorders utilizing practice nurse case management. RESEARCH PLANS;This Programme consists of 4 interrelated studies: 1) a 5-year cohort study: The aims of this study are to determine prevalence, incidence and risk factors for depression in primary care patients with sCHD and describe the course, prognosis and management of physical and depressive symptoms in depressed primary care patients with sCHD. This study will also determine the effect of co-morbid depression on mortality, symptom severity, quality of life, disability, pain, service use, service costs and lost employment costs in primary care patients with sCHD; 2) a qualitative study to explore patients’ with sCHD perspectives on the differences between distress and depression, and explore patients’ views on service needs and treatment options. This will inform the stepped-care programme to be developed and evaluated in a randomized controlled trial. This information will also be used to develop a patient informed questionnaire to differentiate between distress and depression. This will be piloted during the cohort study; 3) a qualitative study to explore primary care professionals (GPs and practice nurses) views on the differentiation between distress and depression in this patient group, and explore their views on service needs and treatment options. 4) A randomized controlled trial of a practice nurse case-management programme versus treatment as usual for depressed patients with sCHD.RESEARCH TEAM;The multidisciplinary team consists of academics, clinicians and service-users that are leaders in their particular fields of expertise. Team members have been specifically chosen to reflect the necessary clinical and academic skills for this Programme of research. Team members all have strong track records in delivering high quality research that leads to Health Services re-design for the benefits of patients.RESEARCH ENVIRONMENT;The South London and Maudsley Mental Health Trust (SLaM) and the Institute of Psychiatry have a very close academic and service relationship,to improve care for people with mental health problems.ANTICIPATED OUTPUTS, OUTCOMES AND IMPACT;The impact of this programme of research is that we will have a better understanding of the relationship between heart disease, distress and depression and will have a better form of intervention to be applied throughout primary care. Practice nurses already manage most CHD and are increasingly managing depression since the advent of GMSII, so a blended approach when both conditions co-exist is likely to have an impact on current care and reduce overall costs to the NHS.PUBLIC INVOLVEMENT;The Service User Research Enterprise (SURE)