Multi-morbidity – having more than one long-term health condition, often affecting mental health – is a worsening problem. In the first of two blogs considering the issue, Dr Peter Coventry explains there are ways to improve care.
Of the 53 million people living in England, more than 15 million live with a long-term health condition such as diabetes. By 2018, nearly three million people will be living with three or more long-term conditions.
People living in areas of social and economic deprivation are affected by multi-morbidity 10 to 15 years earlier than those in more affluent districts. Mental disorders are common in people with physical long-term conditions, especially in the most deprived areas. Combined with a long-term condition, depression leads to the greatest reductions in quality of life.
Depression and anxiety are known to drive unscheduled care in the health service. The health economic impact of mental and physical multi-morbidity is significant. The King’s Fund has shown that depression increases the cost of care for patients with long-term conditions by at least 45%, from £3910 to £5670 a year.
Managing mental and physical multi-morbidity is difficult, posing challenges for all health services. The NHS deals with single conditions and is challenged by multi-morbidity. As Professor Chris Salisbury wrote in The Lancet, clinical guidelines and incentives can drive quality across the health service, but do little to meet the needs of patients with multi-morbidity whose lives are poorly served by fragmented and disjointed healthcare.
Despite effective pharmacological and psychological therapies for depression, people with long-term conditions get poorer mental healthcare. Psychological or talking therapies are often preferred by patients, but – as Professor Linda Gask’s ‘Patching the Soul’ blog explains – anti-depressant medication can also help to manage mood. Yet in general practice patients with a long-term condition, including diabetes and heart disease, are less likely to be prescribed anti-depressant medication.
An investigation by our CLAHRC GM team showed that depression was very rarely even talked about in general practice consultations for long-term conditions. Patients and doctors alike preferred to focus on physical health, which they knew more about and felt comfortable discussing. Checklists reinforced this strategy.
One promising approach is collaborative care. This shares many of the tenets of the Chronic Care Model, shifting healthcare away from a reactive approach to a proactive one to keep patients well. This requires system-level change, including enhanced ways for professionals to share information and make decisions. Meanwhile, patients need to become better self-managers.
Collaborative care originated in the United States under Professor Wayne Katon’s team based in Seattle. The evidence is impressive, not least from the TEAMCare trial for people with diabetes and depression, which showed that people managed with collaborative care reported remarkable improvements in both their mental and physical health.
However, the trials in the States were relatively small and recruited selected populations who were relatively affluent and educated – not typical patients in general practice. Furthermore, the US trials were reliant on the input from elite clinical academics to provide the clinical supervision of the case managers. And no collaborative care trial to date had included people with multi-morbidity.
Members of CLAHRC GM reviewed collaborative care and found it achieves better outcomes than usual care for adults with depression and anxiety over the short, medium and long-term. In the first test of collaborative care in UK primary care – the CADET trial, led by Professor David Richards – it was demonstrated that the benefits of collaborative care translate to the NHS. Patients had better mental health outcomes 12 months after treatment and they preferred collaborative care.
CLAHRC GM ran a pragmatic clinical trial to find out how collaborative care would work for multi-morbidity patients. We worked with partners in primary care and from Improving Access to Psychological Therapies (IAPT) to draw up a collaborative approach that became known as Collaborative Interventions for Circulation and Depression (COINCIDE). CLAHRC GM trained psychological well-being practitioners (PWPs) and practice nurses in the COINCIDE care model .
The trial ran from January 2012 until November 2013, conducted across the North West in 36 GP surgeries and in partnership with 13 IAPT teams. We recruited 387 patients from diabetes and heart disease registers who were randomly allocated to GP surgeries for either collaborative care or usual care. This involved patients from deprived areas with high levels of mental and physical multi-morbidity.
The mean age of the sample was 58.5 years – adults of working age, but only a quarter of whom were in work. In addition to diabetes or heart disease, the population had a mean of 6.2 other long-term conditions and severe forms of depression and anxiety. This was representative of people with multi-morbidity who ordinarily do not make it into clinical trials and whose mental health is often overlooked.
Ninety per cent of patients were followed up at four months when the research team evaluated their health, including depression and anxiety, along with their physical quality of life and ratings about disability. The results were positive.
Both depression and anxiety were significantly reduced in patients benefiting from collaborative care, compared with usual care. Given the profile of the people in the trial, the mental health gains achieved were significant – though less strong than we hoped. Perhaps of greater significance, patients with collaborative care reported being better self-managers and deemed their care to be more patient-centred.
The National Institute for Health and Care Excellence (NICE) recommends collaborative care is offered to patients with depression and long-term conditions only after intensive psychological and/or anti-depressant treatment has been unsuccessful. The COINCIDE trial data suggests that people with moderate to severe depression and multiple long-term conditions can benefit from collaborative care much sooner along the care pathway than NICE suggests.
At CLAHRC GM, we are now engaged in supporting a phased roll-out of the COINCIDE training and care model across IAPT. We will evaluate the impact of these training and clinical resources on the quality of mental healthcare for people with long-term conditions.
- A longer version of this blog is published by the National Institute for Health Research.