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Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease

BMJ 2015; 350 doi: (Published 16 February 2015) Cite this as: BMJ 2015;350:h638
  1. Peter Coventry, senior research fellow1,
  2. Karina Lovell, professor of mental health2,
  3. Chris Dickens, professor of psychological medicine3,
  4. Peter Bower, professor of health services research4,
  5. Carolyn Chew-Graham, professor of general practice research5,
  6. Damien McElvenny, research fellow1,
  7. Mark Hann, research fellow6,
  8. Andrea Cherrington, clinical studies coordinator7,
  9. Charlotte Garrett, research associate8,
  10. Chris J Gibbons, NIHR postdoctoral research fellow9,
  11. Clare Baguley, psychological professions network lead10,
  12. Kate Roughley, trainee clinical psychologist11,
  13. Isabel Adeyemi, student1,
  14. David Reeves, reader4,
  15. Waquas Waheed, consultant psychiatrist12,
  16. Linda Gask, emerita professor primary care psychiatry8
  1. 1NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
  2. 2School of Nursing, Midwifery and Social Work and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
  3. 3Institute of Health Service Research, University of Exeter Medical School, Exeter EX1 2LU, UK
  4. 4NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
  5. 5Research Institute, Primary Care and Health Sciences, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, University of Keele, Keele ST5 5BG, UK
  6. 6Centre for Biostatistics and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
  7. 7Research Institute, Primary Care and Health Sciences, University of Keele, Keele ST5 5BG, UK
  8. 8Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
  9. 9Manchester Centre for Health Psychology, University of Manchester, Manchester M13 9PL, UK
  10. 10NHS Health Education North West, Manchester M1 3BN, UK
  11. 11Division of Clinical Psychology, University of Liverpool, Liverpool L69 3GB, UK
  12. 12Lancashire Care NHS Foundation Trust, Preston PR5 6AW, UK
  1. Correspondence to: P Coventry peter.a.coventry{at}
  • Accepted 29 December 2014


Objective To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions.

Design Cluster randomised controlled trial.

Setting 36 general practices in the north west of England.

Participants 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial.

Interventions Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses.

Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF).

Results 19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval −0.41 to −0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support.

Conclusions Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity.

Trial registration ISRCTN80309252.


  • Contributors: PC, KL, CD, PB, CC-G, AC, CG, CJG, CB, KR, IA, WW, MH, and LG were responsible for drafting and revising the original protocol. PC was the chief investigator and had overall responsibility for management of the trial. KL, CC-G, LG, CB, WW, and LG delivered the training to practice nurses, psychological wellbeing practitioners, and clinical supervisors. LG provided additional clinical supervision and risk assessment training. CG, CJG, KA, and IA collected the data. DM wrote the analysis plan and cleaned and analysed the data under supervision from MH and DR. PC wrote the first draft of the report and revised subsequent draft. All authors contributed to and approved the final report. PC is guarantor.

  • Funding: This trial was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester. The views expressed in this article are those of the authors and not necessarily those of the NIHR, NHS, or the Department of Health.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: all authors had financial support from NIHR for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the national research ethics service committee North West-Preston (NRES/11/NW/0742); research governance approvals were granted by participating primary care trusts and informed consent was given by all patients.

  • Data sharing: Patient level data is available from the corresponding author. Consent for data sharing was not obtained but the presented data are anonymised and risk of identification is low.

  • Transparency declaration: PC affirms that the manuscript is an honest, accurate, and transparent account of the research findings and no important aspects of the study have been omitted.

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