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Table 3 Description of included studies

From: Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a scoping review

Study name Country

Aim of the study

Design

Setting

SMS theoretical foundations

SMS mode of delivery

SMS frequency and duration

Targeted population

SMS strategies

SCAMP study [48,49,50,51] USA

To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression

Protocol [50]

RCT [51]

Qualitative study [48]

longitudinal analysis [49]

11 veteran affairs and university primary care clinics

Stepped-care protocol based on: Stanford SM program, Social Cognitive Theory, SCAMP conceptual model

Face-to-face and by phone

12 weeks antidepressants (step 1), 6 × 30 min Pain SM sessions over 12 weeks, 2 additional contacts occurring at 8–10 months (medication and pain self-management adherence)

Primary care patients with comorbid musculoskeletal pain and depression (n = 250)

Adult patients with musculoskeletal pain in the lower back, hip or knee and comorbid clinical depression

The depression had to be of at least moderate severity, that is, a PHQ-9 score ≥ 10 and endorsement of depressed mood and/or anhedonia. Depression severity was assessed using SCL-20. Anxiety was assessed with GAD-7

• Education on pain SM

• Pain SM manual

• Problem-solving therapy

• Goal setting

• Action-planning

• Condition monitoring

• Feedback

• Behavior monitoring

• Relaxation

• Deep breathing

• Positive thinking

• Evaluating non-traditional treatments

• Practical support to SM

• Health behavior advice

COMPASS study [41,42,43] USA

To disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites

Before-after experimental study [43]

Quantitative descriptive [41]

Intervention development and implementation [42]

Multistates medical groups

(18 care systems, 172 primary care clinics)

Integrated systems

Chronic Care Model (collaborative care) and TEAMcare as base model

Face-to-face and by phone

Duration: 3–12 months

Intensity: at least 1x/month

Active management phase: weekly (1st month) and then frequency gradually extended to monthly to every 3 months

Active depression (PHQ-9 of at least 10) and 1 poorly controlled medical condition (diabetes or high blood pressure)

• Education

• Problem solving

• Goal setting

• Behavioral activation

• Support for treatment adherence

• Motivational interviewing

• Brief intervention for misuse of alcohol or other substances

• Social support

• Systematic case review

• Condition monitoring

UPBEAT-UK study [52,53,54,55,56,57] UK

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

Literature review [53]

Intervention development [52]

Qualitative descriptive [55]

Pilot RCT [56]

Pilot RCT protocol [54]

UPBEAT-UK research program [57]

17 general practices in South London

Practice nurse-delivered personalized care intervention

Own SMS definition: “Enabling patients to take better care of themselves” [56]

Face-to-face and by phone

Weekly, 15 + min sessions

Duration: 6 months. Frequency: depending on needs

Adults with symptomatic CHD (registered on GP CHD QOF register and reporting chest pain), reporting depression symptoms were eligible. HADS-20 (8 or more for depression), modified Rose Angina Questionnaire for CHD

• Education (provide information)

• Problem solving

• Goal setting

• Action planning

• Social support

• Case review

• Self-monitoring

• Motivational interviewing

• Cognitive behavioral therapy

Pathways study [44,45,46,47] USA

1) To investigate prevalence and impact of depression in patients with diabetes enrolled in a health maintenance organization using a population-based investigation; and 2) To test the effectiveness of collaborative care interventions in improving the quality of care and outcomes of depression among patients with diabetes in primary care within a randomized controlled trial

Protocol [46]

RCT [45]

Qualitative descriptive [44]

Secondary analysis [47]

9 primary care clinics in Western Washington

Collaborative Care Model based on the IMPACT study

Face-to-face and by phone

Step 1: 0–12 weeks, follow-up twice a month, 30-60 min

Step 2: 12–24 weeks,

once or twice/month depending on good/bad outcomes, 30 min

Step 3: 24–52 weeks,

once or twice/month, depending on good/bad outcomes, 30 min

Adults with diabetes and depression (PHQ greater than or equal to 10, SCL-20 depression mean item of 1.1 or greater) or dysthymia

• Patient education and support

• Problem-solving

• Goal setting

• Action planning

• Behavioral activation

• Monitoring of adherence and outcomes

• Medication management support

• Motivational approach

• Counselling

• Case review

TEAMcare study [38,39,40] USA

To determine whether a primary care based, care management intervention for multiple conditions would improve medical outcomes and depression scores among patients with major depression and poorly controlled diabetes, coronary heart disease, or both

RCT and results [39]

RCT results [38]

RCT results [40]

14 primary care clinics in Group Health Cooperative in Washington state

Elements from: collaborative care, the Chronic Care Model and treat-to-target strategies (timely pharmacotherapy adjustment to achieve treatment goals)

SMS is defined self-care support [38]

Face-to-face and by phone

Structured visits every 2–3 weeks until targets reached, every 4 weeks afterward (maintenance)

Adults with diagnoses of diabetes, coronary heart disease, or both, and depression (PHQ-2 3 or greater; PHQ-9 10 or greater)

• Provision of self-care materials (self-help book, booklet, a video compact disk)

• Problem solving treatment for primary care (PST-PC)

• Goal setting

• Behavioral activation

• Medication adherence strategies

• Condition monitoring

• Motivational coaching

• Support for self-care

• Support for self-monitoring

• Moral boosting

• Case review

• SMS materials

TEAMcare-PCN [65,66,67] Canada

To evaluate the comparative effectiveness of a collaborative model of care for patients with type 2 diabetes and depressive symptoms in the Canadian primary care setting while also determining the value of screening for depression itself when compared with usual care delivered outside the trial setting

Protocol [65]

Controlled pragmatic trial [66]

Qualitative implementation evaluation [67]

4 primary care networks in Alberta

Adaption of Collaborative Care Model from TEAMcare approach

Face-to-face and by phone

Follow-up 1-2x/month, over 12-month period

Adults with type 2 diabetes and under the care of a primary care network family physician, Score >  = 10 on the PHQ-9, speak English and have adequate hearing to complete telephone interviews and be willing and able to provide written informed consent to participate

• Patient education

• Problem-solving therapy

• Action planning

• Shared care plan

• Behavioral activation

• Treatment adherence monitoring

• Motivational interviewing

CAREplus study [59, 60] UK

To evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation

Protocol and pilot testing [59]

RCT [60]

8 general practices in Glasgow

The CARE plus approach (holistic patient-centred care approach) and SMS

Face-to-face

30–45 min consultations

Adults with multimorbidity (average of 5 CD) (including CD and CMD) Depression/anxiety were present for nearly 70% of participants

• Education with SMS materials (mindfulness-based stress management CDs, CBT-derived self-help booklet, written material)

• Goal setting

• Action planning

• Motivational interviewing

Trueblue study [61, 62] Australia

To determine the effectiveness of collaborative care in reducing depression in primary care patients with diabetes or heart disease using practice nurses as case managers

RCT protocol [61]

RCT [62]

11 Australian general practices

Adaptation of IMPACT Collaborative Care Model, including stepped-care (psychotherapy or pharmacotherapy)

Face-to-face

45 min session every 3 months for 1 year

Adults with comorbid depression (PHQ-9 5 or greater) and heart diseases/diabetes

• Education and educational SMS materials

• Problem-solving

• Goal setting

• Action planning

• Behavioral techniques

• Health behavior advice

Step-dep study [63, 64] The Netherlands

To investigate whether a pragmatic nurse-led stepped-care program is effective in reducing the incidence of major depressive disorders at 12-months follow-up in comparison to usual care among patients with type 2 diabetes and/or coronary heart disease and subthreshold depression (Step-Dep trial)

Cluster RCT protocol [64]

Pragmatic cluster RCT [63]

27 primary care centers

Stepped-care intervention based on van’t Veer-Tazelaar Model

Face-to-face and by phone

4 steps of 3 months each

Adults with subthreshold depression (PHQ-9 six or greater) and NOT major depression according to DSM-IV measured with MINI and diabetes and/or heart diseases

• Provide information (step 1)

• Guided self-help course (step 2)

• Problem-solving treatment (max. 7 sessions during 12 weeks, step 3)

• Motivational interviewing

• Condition monitoring

Langer study [58] UK

To outline the intervention; to use the accounts of patients who experienced the intervention to characterize its main features; to use the accounts of primary care staff to understand how the intervention was incorporated into primary care; and to reflect on implications for meeting psychosocial needs of patients with COPD in UK general practice

Qualitative study [58]

6 primary care practices

Collaborative care, Whole System Framework and cognitive-behavioural approaches

Liaison health workers (LHW) are nurses added to the primary care clinics

Face-to-face, at-home or by phone

Not specified

Adults with COPD and common mental disorders and psychosocial problems (QOF diagnosis with at least 1 QOF diagnosis of depression, social isolation, and chronic or recent psychosocial stressors)

• Education and information (medication management, SMS materials)

• Problem-solving

• Goal setting

• Psychosocial interventions

• Cognitive behavioral therapy

• Health behaviour advice

• Social support

• Relaxation techniques

• Practical support

  1. CHD Chronic heart disease, COPD Chronic obstructive pulmonary disease, QOF Quality and Outcomes Framework, RCT Randomized controlled trial, SM Self-management, SMS Self-management support