Caroline Kappelin

Att förbättra välmående och livskvalitet för personer med depression eller ångest och multisjuklighet i primärvård

The number of patients suffering from more than one chronic disease and depression or anxiety is on the rise in primary care. A structured care model, Collaborative care, will be adapted and implemented in Swedish primary care aiming to improve these patients’ quality of life and wellbeing.

Multimorbidity, defined as having more than one chronic disease, is on the rise in primary care (1). Patients suffering from multimorbidity more often suffer from depression (2) and anxiety (3), with low quality of life (4) and increased mortality (5). In addition, mental illness is often undiagnosed and untreated in this group (6,7), especially anxiety (7–9). Moreover, the care of these patients has been shown insufficient regarding somatic symptoms (10) as well as depressive and anxiety symptoms (11,12). The need to address all of these patients’ diseases in the same time to improve their quality of life and wellbeing has been suggested by the World Health Organisation, WHO (13) as well as the NICE guidelines (14).

The care model that has shown best results, Collaborative Care, was developed in the psychiatry in the 1970s (15). Collaborative Care involves at least two health care personals that cooperate in the care of the patient. A nurse or a psychologist work as a care manager and has regular contact with the patients’ physician. Furthermore, the care manager and the patient set up a care plan involving medication and or psychological treatment as well as scheduled follow-ups(16).

Collaborative Care has shown good results in treating depression and anxiety in primary care internationally (17), as well as in treating depression in primary care in Sweden (18). Moreover, it has shown good results in patients with multimorbidity involving depression in international studies (15) regarding depressive (15) as well

as somatic symptoms (19). However, it has not yet been implemented for the same group of patients in Sweden.  In addition, there is a lack of both international and Swedish studies regarding patients with multimorbidity and anxiety (8).

To improve care for patients with multimorbidity and anxiety, the incidence of undiagnosed anxiety in patients with multimorbidity must be better investigated.  Furthermore, Collaborative care must be developed and pilot for patients with multimorbidity and both anxiety and depression in Swedish primary care to improve their health.

This doctoral project consists of 4 studies.
Study 1 is a literature review and narrative analysis of effective content of Collaborative Care models for patients with multimorbidity involving depression and/or anxiety.

Study 2 is a cohort study to investigate the risk of having a prescription of benzodiazepines without a psychiatric diagnosis in multimorbid patients in the Region of Stockholm as an indication of undiagnosed anxiety in patients with multimorbidity.

Study 3 is a qualitative study. Focus group interviews will be held with primary care physicians regarding their experiences of taking care of patients with multimorbidity and depression or anxiety to identify their needs and possible solutions for development of a Collaborative Care model.

Study 4 is a pilot study where a Collaborative Care model derived from study 1 and 2 will be implemented and evaluated in 4 primary care units in Stockholm.

The objective of this doctoral project is to elaborate the care of the increasing number of patients suffering from more than one chronic disease and co-existing depression or anxiety in primary care. Our aim is to improve the quality of life and wellbeing for these patients.

Department of Neurobiology, Care Sciences and Society. Division of Family Medicine and Primary Care. Karoliska Institutet.

Caroline Wachtler, Family Medicine Resident, MD, PhD