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

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Patient reported outcomes (PROs) refer to any report of the status of a patient's health condition that comes directly from the patient. While PROs are a well-developed technology with robust standards in research their use for informing health care decisions is generally poorly understood. In this paper we review relevant examples of their application in health care provision to date, and examine the challenges associated with routinely implementing PROs in clinical settings. We evaluate evidence for their use, and examine key barriers, such as where there is a lack of alignment between interpretation of scores and clinical decision making on the ground. Based on available evidence we have developed a framework of the key requirements for the successful implementation of PROs in clinical practice. We conclude by exploring potential future developments for the use of PROs in clinical practice, such as individualised measurement and efficient administration through the use of computer adaptive tests (CATs).[Abstract word limit = 120 words, currently 154] Manuscript for J Comparative Effect Res

BackgroundThere is growing body of evidence on the experience of stress in nursing students. Much of this research is quantitative in focus and all draws on their experience of distress with little attempt to understand experiences of eustress. AimThe aim of this study was to identify experiences that led to both distress and eustress and to make recommendations to help students cope with course demands. Method

Aim. This article is a report of a study conducted to explore the relationship between sources of stress and psychological well-being and to consider how different sources of stress and coping resources might function as moderators and mediators on well-being. Background. In most research exploring sources of stress and coping in nursing students, stress has been construed as psychological distress. Sources of stress likely to enhance well-being and, by implication, learning have not been considered. Method. A questionnaire was administered to 171 final year nursing students in 2008. Questions were asked to measure sources of stress when rated as likely to contribute to distress (a hassle) and rated as likely to help one achieve (an uplift). Support, control, self-efficacy and coping style were also measured, along with their potential moderating and mediating effects on well-being, operationalized using the General Health Questionnaire and measures of course and career satisfaction. Findings. Sources of stress likely to lead to distress were more often predictors of well-being than were sources of stress likely to lead to positive, eustress states, with the exception of clinical placement demands. Self-efficacy, dispositional control and support were important predictors, and avoidance coping was the strongest predictor of adverse well-being. Approach coping was not a predictor of well-being. The mere presence of support appeared beneficial as well as the utility of that support to help a student cope. Conclusion. Initiatives to promote support and self-efficacy are likely to have immediate benefits for student well-being. In course reviews, nurse educators need to consider how students' experiences might contribute not just to potential distress, but to eustress as well.