UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Abstract

BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

Screening and referral is not enough: a qualitative exploration of barriers to access and uptake of mental health services in patients with cardiovascular diseases

“…When accessed, mental health interventions appear acceptable [ 21 , 22 ], yet specifically why this population tends not to utilise dedicated mental health services even after a positive depression screen and referral remains unclear. The broader literature highlights a number of barriers to mental health help seeking, such as hegemonic masculinity, fear of disclosure, stigma, and concerns around judgement from others [ 23 , 24 ], as well as financial barriers, and symptom severity [ 25 ].…”

Chest pain, depression and anxiety in coronary heart disease: Consequence or cause? A prospective clinical study in primary care

“…The cohort was described in more detail elsewhere. [16] The sampling focus of the main study, of which data was used for the present study, was on patients with CHD. General practitioners are remunerated for keeping CHD registers under the QOF.…”

“…For the purposes of the UPBEAT-UK cohort, the chest pain categorical variable comprised three groups: 'no pain', 'exertional pain', and 'non-exertional pain'. [16] These three categories were also used for the present study. Participants who did not report having chest pain were classified as having 'no chest pain'.…”

Screening and Referral is Not Enough: A Qualitative Exploration of Barriers to Access and Uptake of Mental Health Services in Patients With Cardiovascular Diseases

“…When accessed, mental health interventions appear acceptable (21,22), yet speci cally why this population tends not to utilise dedicated mental health services even after a positive depression screen and referral remains unclear. The broader literature highlights a number of barriers to mental health help seeking, such as hegemonic masculinity, fear of disclosure, stigma, and concerns around judgement from others (23,24), as well as nancial barriers, and symptom severity (25).…”