Collaborative Interventions for Circulation and Depression (COINCIDE)

Background

Significant gains have been made in primary care over recent years to improve access to and quality of depression care, with one promising intervention being ‘collaborative care’, a complex intervention which involves the use of a non-medical case manager – e.g. a Psychological Wellbeing Practitioner (PWP) or a nurse – working in conjunction with the patient’s doctor, often with the support and supervision of a mental health specialist (normally a psychiatrist or psychologist).

Between 2008-13, NIHR CLAHRC Greater Manchester tested a collaborative care approach known as Collaborative Care for Circulation and Depression(COINCIDE) in the NHS, which involved a clinical trial across the north-west in 36 GP surgeries using trained Psychological Wellbeing Practitioners (PWPs) and practice nurses to deliver the COINCIDE intervention, based on a collaborative care model.

Most collaborative care trials have previously been conducted in the United States; the Clinical Effectiveness of Collaborative Care for Depression in UK Primary Care Trial (CADET) was an important first step to showing collaborative care can work in the NHS, but it did not exclusively look at treatment of people with long term conditions or multi-morbidity. Read this research paper, published in the British Medical Journal (BMJ), to find out more about the first test of collaborative care in the NHS

About the COINCIDE trial

COINCIDE was run as a ‘pragmatic’ trial in that it tested collaborative care in real world settings, using Improved Access to Psychological Therapy (IAPT) services and practice nurses. It aimed to show reductions in depression and also other patient reported outcomes such as quality of life and self-management behaviour.

Key points on the rationale aims and design of COINCIDE

  • CADET trial showed benefits of collaborative care can translate to NHS
  • But uncertainty about the effectiveness of collaborative care for managing depression in LTCs (including multi-morbidity) in settings that resemble routine care
  • COINCIDE aimed to test the (cost) effectiveness of an integrated collaborative care model for People with depression and diabetes/coronary heart disease
  • Interventions were delivered by existing providers (i.e. IAPT and practice nurses)
  • Patients had freedom to choose a variety of psychological treatments and/or medication

Trial design

  • Pragmatic cluster-randomised controlled trial conducted in 36 GP surgeries across North West England
  • Compared integrated collaborative care with usual care
  • Primary outcome – severity of depression at 4/6 months using the SCL-D13
  • Secondary outcomes – disease specific QOL, anxiety (GAD-7), QOL (WHOQOL-BREF), self-efficacy, patient ‘centred-ness’ (PACIC) patient self-management behaviour (heiq), patient satisfaction (CSQ-8), social support (ENRICHD), healthcare utilisation and health utilities (EQ-5D).

For further information about the rationale and design of COINCIDE, please read the Trial papers published in Trial Journal in August 2012 and May 2013

COINCIDE Care Model

Illustration of the collaborative care model adopted in COINCIDE

Key Elements

  • Patients with PHQ depression score of ≥10 referred to IAPT from trial manager
  • Biopsychosocial assessment using ABC model
  • Up to 8 sessions of brief psychological interventions based on CBT
  • Session 2 and 8 to be held jointly with practice nurse and PWP
  • Supervision as usual within IAPT
  • Stepped up or signposted to alternative services if appropriate

Patients in the collaborative care arm received interventions modelled on those already given by IAPT but two sessions were designed to be shared between the patient, the nurse, and the PWP to aid integration. Collaborative care in COINCIDE was patient centred, involved a non-medical case manager and liaison between a GP and / or nurse.

Supporting Resources: Patient and Professional Manuals

Delivery of the treatment sessions in COINCIDE was supported by the use of patient and professional manuals. Instead of including the manuals used in the initial trial here, we are making the adapted versions of these available instead. Following the initial COINCIDE trial, the face-to-face training programme has been rolled out to a number of IAPT services, more information about which is available on the COINCIDE rollout page. As part of this rollout, and relying on the qualitative data from the initial COINCIDE trial, PPI consultation and close work with PWPs, the original manuals have been developed further. These manuals are freely available to download from the links below:

  • COINCIDE PWP Manual

    (who will act as case managers) This manual supports psychological well-being practitioners to work with a collaborative care model framework to and to liaise effectively with primary care to improve depression in people with long term conditions.

    Please fill out the form below to view the COINCIDE PWP Manual

    Name *Work Email *

    Fields marked width * are mandatory

  • COINCIDE Patient Manual

    A self-help booklet to help patients with long term conditions and depression and or anxiety. This booklet supports patients during each treatment session with their practitioners.

    Please fill out the form below to view the COINCIDE Patient Manual

    Name *Work Email *

    Fields marked width * are mandatory

  • COINCIDE Workbook

    this is a separate booklet that patients can use to support their progress through the treatment sessions.

    Please fill out the form below to view the COINCIDE-Workbook

    Name *Work Email *

    Fields marked width * are mandatory

Trial Process and Participent Characteristics
find out more here

Once GP surgeries agreed to be in the trial they were randomised to ‘collaborative care’ or ‘usual care’; the CONSORT flow diagram below shows the flow of participants through the trial after randomisation

CONSORT flow diagram showing the number of patients recruited and followed-up at each stage of the trial

Participant characteristics

The participants in the trial were from deprived areas, had relatively high levels of depression – and many LTCs, but only half were treated for their depression or anxiety.

  • 76% of participants were recruited from practices from moderately and heavily deprived areas
  • Only 25% of participants were in paid employment
  • 63% of participants met criteria for moderately severe (or severe depression)
  • 75% of participants met criteria for case-ness for anxiety
  • Participants had a mean of 6.2 long term conditions in addition to either diabetes or coronary heart disease
  • 62% of participants were male, with a mean age of 58.5 years (11.7)
  • Half of participants were prescribed anti-depressant or anti-anxiety medication at baseline.

Therefore, participants in the COINCIDE trial had high levels of psychological and physical ill health and were mainly from deprived areas.

Key Findings from the Trial

There were a range of key findings in the COINCIDE trail from clinical findings and process outcomes to process of care and identification of strengths and weaknesses. Click on each of the links below to find out more

Clinical findings

  • Mean scores were 0.23 SCL-D13 points lower (95% CI -0.41 to -0.05) in the collaborative care arm – equal to an adjusted standardised effect size of 0.30
  • Improved anxiety outcome – equal to a reduction of 1.45 points on the GAD-7

Process outcomes

  • Better self-managers on 5 of 8 domains of the Health Education Impact Questionnaire (heiq)
  • Rated care as more patient centred – congruent with goals of chronic care model
  • More satisfied with their care
  • No significant differences for Quality of Life (QOL), disease specific QOL, self-efficacy, disability, and social support.

Patients who received collaborative care were less depressed and anxious than those who received usual care; they were also more satisfied with their care, were better self-managers, and thought their care was more patient-centred.

Further information: Read the open access version of the trial report in the BMJ to learn more about the findings from COINCIDE

Process of care

While patients only received on average of four rather than eight sessions, at least half of patients had at least one joint treatment session with their nurse and PWP.

  • Patients with PHQ depression score of ≥10 referred to IAPT from trial manager
  • Patients received a mean of 4.4 sessions (3.3, 0-14)
  • 50 (26%) participants attended one joint integrated care session, and 46 (24%) patients attended two joint integrated care sessions
  • Mean length of mental health treatment sessions was 27 mins
  • Mean length of integrated care sessions was 19.7 mins
  • Small but non-significant increase in antidepressant use during the trial (6% increase in collaborative care, 7% in usual care).

Strengths and weaknesses

As with all trials, COINCIDE has strengths and weaknesses; some of these relate to the design of the trial and others relate to the implementation and impact of the intervention.

  • Strengths
    • Pragmatic design in routine settings
    • Population had mental-physical multi-morbidity and from deprived areas
    • Trained existing care providers to adopt collaborative care
  • Weaknesses
    • Effect size less than the pre-specified effect
    • Short term follow-up
    • Only half of patient engaged with integrated care sessions

COINCIDE included many patients that ordinarily would be excluded from trials but the overall effects were fairly modest and less than anticipated.

Further information: Read this BMJ editorial paper to learn more about the strengths and limitations of the COINCE care model

Key findings and implications

  • Integrated collaborative care can reduce depression and improve chronic disease self-management in people with mental-physical multi-morbidity
  • Mental health providers and practice nurses can be trained to deliver patient centred integrated health care for people with mental-physical multi-morbidity
  • COINCIDE can be potentially implemented within the context of routine chronic disease management with only minimal changes to the organisation of primary care.

The findings support the use of collaborative care for managing mental-physical multi-morbidity.

Did COINCIDE Deliver Integrated Care?

COINCIDE aimed to integrate mental and physical health care in people with long-term conditions, but was that achieved in line with widely used definitions? Click through the list below to find out

What is integrated care?

  • Integrated care is an organising principle for care delivery that aims to improve patient care and experience through improved coordination.
  • Integration is the combined set of methods, processes and models that seek to bring this about.

Integrated care is about improving patient outcomes and experience by improving coordination. Integration is how we achieve this, for example through combining services under one roof as in COINCIDE

See this King’s Fund overview of. Visit the Nuffield Trust website for more detail about the rationale and origins of integrated care. To learn more about the place of Integrated Care in the new NHS, see the King’s Fund’s Integrated Care Summary.

The experience of patients and health professionals

To learn more about how patients and health professionals experienced COINCIDE we interviewed both groups using in-depth qualitative interviews. Learn more

  • Patient and provider perspectives on integration
  • Interviews with
    • 11 PWPs, 12 PNs, and 7GPs
    • 31 patients (15 completers, 16 disengaged treatment)
  • Integration
    • Enhanced co-ordination of mental and physical health care
    • Provided a sense that patients’ health was being more holistically managed
  • Division
    • Preference for therapeutic separation between mental and physical health.
    • Patients valued separate space outside of LTC clinic to discuss emotional health problems
  • What health professionals and patients told us
    • Health Professionals:

“Working collaboratively…in terms of your practice it’s very helpful to get that reassurance that what you’re doing in the sessions is the right thing, is useful, and will be helpful for the person.” – Psychological Wellbeing Practitioner

“If you mention mental health there is still that ‘yeah’, another word for it is, it’s still a stigma. People don’t like to address it, admit to it, or whatever. So maybe I think it needs to be addressed side-by-side, as part of the whole care. At present it does anyway, until people’s attitudes change.” –
Practice Nurse

Typically health professionals were very positive that the COINCIDE care model gave them more confidence and opportunity to deal with mental and physical health problems in a holistic way.

    • Patients

For some patients, mental and physical health were perceived to be the responsibility of different health professionals, making it difficult to implement the COINCIDE care model:

“[The PWP] is more qualified in that sense [talking about emotions]. She’s… the nurse, basically looks after your body, not your mind. Each one’s got a job to do.” – Patient (Male, Completed)

“We tried to do a gated, ‘boundaried’ piece of work… Some [patients] wanted to receive treatment on their mental health and talk about things that were nothing to do with their health condition” – Psychological Wellbeing Practitioner

Some patients wanted to keep mind and body separate and health professionals struggled sometimes to manage health problems in a holistic way.

Levels of integration in COINCIDE:

Feedback from the health professional and patient interviews showed that COINCIDE did engender collaborative working but that this did not necessarily translate into therapeutic integration.

  • COINCIDE achieved integration through improved:
    • Care coordination between providers
    • Inter-professional communication
  • Partially achieved clinical and therapeutic integration but need for flexible approach to achieve integrated care for patients with multi-morbidity

Collaborative care can support more integrated working between mental and non-mental health professionals but we need to be mindful of patient preferences when delivering depression care in the context of long-term conditions.

More information

For further information about the project, please contact Michael Spence, Programme Manager.

Please also see related project pages: COINCIDE roll-out and COINCIDE 24