Process evaluation of the CO-WORK-CARE model: Collaboration and a person-centred dialogue meeting for patients with common mental disorder in primary health care.

RATIONALE: To ensure optimal patient care based on evidence, it is crucial to understand how to implement new methods in practice. However, intervention studies often overlook parts of the implementation process. A comprehensive process evaluation is necessary to understand why interventions succeed or fail in specific contexts and to integrate new knowledge into daily practice. This evaluation examines the full implementation of the Co-Work-Care model in Swedish primary healthcare to identify strengths and weaknesses. AIM: This study aimed to evaluate the process of implementing the CO-WORK-CARE model that focuses on close collaboration and the use of a person-centred dialogue meeting in primary healthcare for patients on sick leave due to common mental disorders. METHOD: The CO-WORK-CARE model emphasises collaboration among the GP, rehabilitation coordinator and care manager, along with person-centred dialogue meetings involving employers. Following UK Medical Research Council guidelines, we conducted a process evaluation. Data from previous studies were reanalysed. We also analysed field notes and meeting notes using Malterud's qualitative method. RESULTS: The evaluation identified key facilitators for model implementation, including regular visits by facilitators and guidance from the research physician. Peer support meetings also bolstered implementation. However, challenges emerged due to conflicts with existing structures and limitations in person-centred dialogue meetings. CONCLUSION: Adapting the CO-WORK-CARE model to Swedish primary care is feasible and beneficial, with collaboration among the care manager, rehabilitation coordinator and GP and person-centred dialogue meetings. Thorough preparations, ongoing facilitator and peer support and integrated information enhanced implementation efficiency, despite challenges posed by existing structures.

Rehabilitation cooperation and person-centred dialogue meeting for patients sick-listed for common mental disorders: 12 months follow-up of sick leave days, symptoms of depression, anxiety, stress and work ability - a pragmatic cluster randomised controlled trial from the CO-WORK-CARE project.

OBJECTIVES: To study whether early and enhanced cooperation within the primary care centres (PCC) combined with workplace cooperation via a person-centred employer dialogue meeting can reduce days on sick leave compared with usual care manager contact for patients on sick leave because of common mental disorders (CMD). Secondary aim: to study lapse of CMD symptoms, perceived Work Ability Index (WAI) and quality of life (QoL) during 12 months. DESIGN: Pragmatic cluster randomised controlled trial, randomisation at PCC level. SETTING: 28 PCCs in Region Västra Götaland, Sweden, with care manager organisation. PARTICIPANTS: 30 PCCs were invited, 28 (93%) accepted invitation (14 intervention, 14 control) and recruited 341 patients newly sick-listed because of CMD (n=185 at intervention, n=156 at control PCCs). INTERVENTION: Complex intervention consisting of (1) early cooperation among general practitioner (GP), care manager and a rehabilitation coordinator, plus (2) a person-centred dialogue meeting between patient and employer within 3 months. CONTROL GROUP: regular contact with care manager. MAIN OUTCOME MEASURES: 12 months net and gross number of sick leave days at group level. SECONDARY OUTCOMES: 12 months depression, anxiety, stress symptoms, perceived WAI and QoL (EuroQoL-5 Dimensional, EQ-5D). RESULTS: No significant differences were found between intervention and control groups concerning days of sick leave (intervention net days of sick leave mean 102.48 (SE 13.76) vs control 96.29 (SE 12.38) p=0.73), return to work (HR 0.881, 95% CI 0.688 to 1.128), or CMD symptoms, WAI or EQ-5D after 12 months. CONCLUSIONS: It is not possible to speed up CMD patients' return to work or to reduce sick leave time by early and enhanced coordination among GP, care manager and a rehabilitation coordinator, combined with early workplace contact over and above what 'usual' care manager contact during 3 months provides. TRIAL REGISTRATION NUMBER: NCT03250026.

Clinical effectiveness of care managers in collaborative primary health care for patients with depression: 12- and 24-month follow-up of a pragmatic cluster randomized controlled trial.

BACKGROUND: In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. METHODS: Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Västra Götaland and Dalarna, Sweden. Patients ≥18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient's general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). RESULTS: The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. CONCLUSIONS: Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02378272. Submitted 2/2/2015. Posted 4/3/2015.

GPs' experiences of a collaborative care model for patients with common mental disorders who need sick leave certification: a qualitative study.

BACKGROUND: GPs are an important part of collaboration around patients with common mental disorders (CMD) in primary care. The Co-Work-Care model was implemented to further improve collaboration, and emphasised working more closely with patients through active dialogues among care managers, rehabilitation coordinators, and GPs. This enhanced collaborative model also included a person-centred dialogue meeting with patients' employers. AIM: The aim of this study was to explore GPs' experiences of the Co-Work-Care model, an organisation of collaborative care at the primary care centre (PCC) that includes a person-centred dialogue meeting in the care of patients with CMD who need sick leave certification. DESIGN & SETTING: Qualitative individual and group interviews were conducted with Swedish GPs with experience of the Co-Work-Care trial where the PCC was an intervention PCC with the enhanced collaboration model. METHOD: GPs were sampled purposefully from different Co-Work-Care intervention PCCs in Sweden. Focus group and individual, in-depth semi-structured interviews were conducted. All interviews were analysed by systematic text condensation (STC), according to Malterud. RESULTS: The following three codes describing the GPs' experiences of working in the Co-Work-Care model were identified: (1) a structured work approach; (2) competency of the care manager and the rehabilitation coordinator; and (3) gaining control through close collaboration. CONCLUSION: Overall, GPs' experience was that the enhanced collaboration reduced their workload and enabled them to focus on medical care. Patient care was perceived as safer and more effective. These advantages may result in higher quality in medical and rehabilitation decisions, as well as a more sustainable and less stressful work situation for GPs.

Symptom patterns in patients newly sick listed for common mental disorders and associations with work-related and socioeconomic factors: a cross-sectional study in Swedish primary care.

OBJECTIVE: The aim was to determine symptom patterns of depression, anxiety and stress-related mental disorders in newly sick listed due to common mental disorders in Swedish primary care patients and to examine associations with sick leave diagnosis, also in relation to socioeconomic, work-related and demographic factors. DESIGN: Cross-sectional study. SETTING: Primary care in western Sweden. PARTICIPANTS: From a randomised controlled trial, patients aged 18-67, seeking primary care and on sick leave due to depression, anxiety and/or mental stress, in total 341 individuals, during 2018-2020. PRIMARY OUTCOME MEASURES: Patterns of depressive, anxiety and stress symptoms measured via self-assessment questionnaires (Montgomery Asberg Depression Rating Scale-Self (MADRS-S), General Anxiety Disorder Scale-7 (GAD-7), Karolinska Exhaustion Disorder Scale (KEDS)), sick leave diagnosis, perception of Work Ability Index and job strain via the job strain model. RESULTS: A combination of high levels of depressive and stress-related symptoms was more frequent than single symptom clusters among persons with common mental disorders (CMD) on sick leave: 7% of the patients had scores above cut-off for one of the instruments MADRS-S, GAD-7 and KEDS, 12% above cut-off for two and 80% had above cut-off for all three instruments. There was no significant association between low socioeconomic status, high-job strain or working in healthcare/education and having scores above cut-off level for two or more of the instruments. Only perception of own poor work ability showed association with having scores above cut-off level for all three of the assessment instruments of CMD (OR 9.45, 95% CI 2.41 to 37.04). CONCLUSION: The diagnosis on the sick certificate is not always congruent with the dominating symptom score level. In patients sick-leaved for CMDs, possible negative factors such as low socioeconomic status, low social support, high-work strain or working in healthcare/education sector did not show significant associations with self-assessment instruments of anxiety, depression and stress. Only patient's perception of own poor work ability was associated with high scores on all three domains. TRIAL REGISTRATION NUMBER: NCT03250026.

Experiences of patients with common mental disorders concerning team-based primary care and a person-centered dialogue meeting: An intervention to promote return to work.

OBJECTIVES: Common mental disorders in combination with work-related stress are widespread in the western world, not least in Sweden. Various interactive factors, primarily work-related, have impact on the return to work process, for example; a supportive communicative function between the person on sick leave and the employer may facilitate this process. The aim was to investigate experiences of being part of a collaborative care model including a person-centered dialogue meeting with the employer and with a rehabilitation coordinator as the moderator. METHODS: A qualitative design based on individual interviews with 13 persons diagnosed with common mental disorders who participated in an extensive collaborative care model, called the Co-Work-Care model. Persons were recruited as a heterogeneous sample with respect to age, gender, work background, and time since the intervention. All interviews were analyzed with Systematic Text Condensation. RESULTS: Five codes synthesized the results: 1) A feeling of being taken care of, 2) Collaboration within the team was perceived as supportive, 3) An active and sensitive listener, 4) Structure and planning in the dialogue meeting, 5) The person-centered dialogue meeting was supportive and provided increased understanding. CONCLUSIONS: Participants experienced the close collaborative contact with the care manager and the rehabilitation coordinator as highly valuable for their rehabilitation process. Participants valued a well-structured dialogue meeting that included initial planning and a thorough communication involving the patient, the employer, and coordinator. Further, participants appreciated having an active role during the meeting, also empowering the return to work process.

Long-term effect of a care manager on work ability for patients with depression - the PRIM-CARE RCT.

BACKGROUND: Collaborative care with a care manager in primary care improves care. OBJECTIVE: To study whether care manager support leads to improved work ability, decreased job strain and reduced time of sick leave among primary care patients with depression. METHODS: A clinical effectiveness study of care managers for depression patients seeking care in primary care was conducted in a RCT 2014 -2016. Patients in the intervention group were assigned a care manager. In the 12-month follow-up, patients with employment (n = 269; intervention n = 142, control n = 127) were studied concerning work ability, job strain and sick leave. RESULTS: An association was shown between reduction of depressive symptoms and improved work ability for the entire group. At 12-month follow-up a statistically significant difference of reduction of depressive symptoms was seen between the groups (MADRS-S: intervention 10.8 vs control 13.1, p = 0.05) as well as increased quality of life (EQ-5D: intervention 0.77 vs control 0.70, p = 0.04). In the intervention group, a concordance was found between the patient's prediction of return to work and the actual return to work (91%for intervention and 68 %for control group, p = 0.047). CONCLUSIONS: Compared to usual care, the care manager does not seem to further improve perception of work ability, job strain or perception of social support per se among the patients despite a long-term effect on depression symptoms. The lack of a long-term effect regarding these aspects may be due to the fact that care manager support was only provided during the first three months.

The care manager meeting the patients' unique needs using the care manager model-A qualitative study of experienced care managers.

BACKGROUND: Implementation of a care manager in a collaborative care team in Swedish primary care via a randomized controlled trial showed successful outcome. As four years have elapsed since the implementation of care managers, it is important to gain knowledge about the care managers' long-term skills and experiences. The purpose was to examine how long-term experienced care managers perceived and experienced their role and how they related to and applied the care manager model. METHOD: Qualitative study with a focus group and interviews with nine nurses who had worked for more than two years as care managers for common mental disorders. The analysis used Systematic Text Condensation. RESULTS: Four codes arose from the analysis: Person-centred; Acting outside the comfort zone; Successful, albeit some difficulties; Pride and satisfaction. The care manager model served as a handrail for the care manager, providing a trustful and safe environment. Difficulties sometimes arose in the collaboration with other professionals. CONCLUSION: This study shows that long-term experience of working as a care manager contributed to an in-depth insight and understanding of the care manager model and enabled care managers to be flexible and act outside the comfort zone when providing care and support to the patient. A new concept emerged during the analytical process, i.e. the Anchored Care Manager, which described the special competencies gained through experience. TRIAL REGISTRATION: NCT02378272  Care Manager-Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM-CARE).

Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: 12-month economic evaluation of a pragmatic randomised controlled trial.

OBJECTIVES: To study the cost-effectiveness of a care manager organization for patients with mild to moderate depression in Swedish primary care in a 12-month perspective. METHODS: Cost-effectiveness analysis of the care manager organization compared to care as usual (CAU) in a pragmatic cluster randomised controlled trial including 192 individuals in the care manager group and 184 in the CAU group. Cost-effectiveness was assessed from a health care and societal perspectives. Costs were assessed in relation to two different health outcome measures: depression free days (DFDs) and quality adjusted life years (QALYs). RESULTS: At the 12-month follow-up, patients treated at the intervention Primary Care Centres (PCCs) with a care manager organization had larger health benefits than the group receiving usual care only at control PCCs. Mean QALY per patient was 0.73 (95% CI 0.7; 0.75) in the care manager group compared to 0.70 (95% CI 0.66; 0.73) in the CAU group. Mean DFDs was 203 (95% CI 178; 229) in the care manager group and 155 (95% CI 131; 179) in the CAU group. Further, from a societal perspective, care manager care was associated with a lower cost than care as usual, resulting in a dominant incremental cost-effectiveness ratio (ICER) for both QALYs and DFDs. From a health care perspective care manager care was related to a low cost per QALY (36,500 SEK / €3,379) and DFD (31 SEK/€3). LIMITATIONS: A limitation is the fact that QALY data was impaired by insufficient EQ-5D data for some patients. CONCLUSIONS: A care manager organization at the PCC to increase quality of care for patients with mild-moderate depression shows high health benefits, with no decay over time, and high cost-effectiveness both from a health care and a societal perspective. Trial registration details: The trial was registered in ClinicalTrials.com ( https://clinicaltrials.gov/ct2/show/NCT02378272 ) in 02/02/2015 with the registration number NCT02378272. The first patient was enrolled in 11/20/2014.

Associations between antidepressant therapy, work ability, and sick leave for patients with common mental disorders within a two-year perspective - A longitudinal observational cohort study in Swedish primary care.

BACKGROUND: An increasing number of patients are on sick leave because of common mental disorders (CMD), with or without antidepressant therapy. There is a lack of long-term follow-up studies in the primary care context, where most of the patients are treated. The importance of identifying potential factors associated with work ability for CMD patients is increasingly in focus. OBJECTIVE: To investigate the associations between using antidepressants, sick leave duration, reported work ability and psychological symptoms among patients with CMD during a two-year observation period in the primary care context. METHODS: Longitudinal observational cohort study at 28 Primary Care Centers in Region Västra Götaland, Sweden, including 182 patients with an employment and on sick leave for CMD. The following outcomes were assessed: work ability measured with WAI, depressive symptoms with MADRS-S, anxiety symptoms with BAI, fatigue symptoms with KEDS, quality of life with EQ-5D, and days of sick leave. The data were compared between the groups that used and did not use antidepressants, during the 24-months observation period. RESULTS: Work ability and health-related quality of life increased over time in both groups. A steeper decrease of depressive symptoms, anxiety symptoms as well as an increased health-related quality of life at 3, 6 and 12 months was found in the group without antidepressants, although both groups levelled off at 24 months. In both groups, a higher work ability at baseline was associated with less two-year sick leave. CONCLUSION: Our study indicates that a high work ability at baseline has a strong association with a lower total net and gross sick leave duration during the entire two-year follow-up period for patients with CMD in primary health care, irrespective of use of antidepressants. Using WAI in primary health care could therefore be helpful in predicting return to work. Use of antidepressants during the CMD episode could indicate initially a more pronounced overall symptom pattern, motivating introduction of antidepressants, rather than prolonging the sick leave period.

The experiences of care managers and rehabilitation coordinators of a primary care intervention to promote return to work for patients with common mental disorders: a qualitative study.

BACKGROUND: In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers' and rehabilitation coordinators' perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting. METHODS: From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud. RESULTS: Seven codes describing the participants' experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process. CONCLUSION: The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient's situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient. TRIAL REGISTRATION: NCT03250026 (registered August 15, 2017).

Correspondence Between the Neuropsychiatric Interview M.I.N.I. and the BDI-II and MADRS-S Self-Rating Instruments as Diagnostic Tools in Primary Care Patients with Depression.

OBJECTIVE: To investigate the correspondence between the diagnoses received by patients with symptoms of common mental disorder attending primary care, based on the diagnostic instrument International Neuropsychiatric Interview (M.I.N.I.) and the self-assessment instruments such as Beck Depression Inventory (BDI-II) and Montgomery-Asberg Depression Rating Scale - self-rating version (MADRS-S), respectively. DESIGN: Data were collected from a prospective observational study, ADAS, between 2014 and 2015. SETTING: Twenty-eight primary care centers in Region Västra Gotaland, Sweden. PATIENTS: A total of 192 patients, 18-60 years of age, on sick leave ≥14 days, with mild/moderate depression, anxiety syndrome, and stress-related mental illness were included. MAIN OUTCOME MEASURES: Scores of the assessment instruments (BDI-II and MADRS-S) on inclusion, sensitivity, specificity, positive (PPV) and negative predictive value (NPV) for BDI-II and MADRS-S, respectively, with M.I.N.I used as diagnostic instrument. RESULTS: Using M.I.N.I. as gold standard, the BDI-II and MADRS-S showed almost the same sensitivity (86.9% and 87.4%, respectively), but specificity for MADRS-S was doubled compared to BDI-II (36% and 18%, respectively). There was a significant association between MADRS-S and M.I.N.I. (p=0.027). However, the same analysis between BDI and M.I.N.I. was not statistically significant (p= 0.635). NPV and PPV were calculated from assumed prevalences (10% and 75%) and were higher for MADRS-S compared to BDI-II. The PPV differences were between 2% and 7% and NPV differences were between 3% and 19%. CONCLUSION: With M.I.N.I. as gold standard, MADRS-S performs better than BDI-II as a self-assessment tool in the primary care context for depression diagnostics.

Implementation of care managers for patients with depression: a cross-sectional study in Swedish primary care.

OBJECTIVES: To perform an analysis of collaborative care with a care manager implementation in a primary healthcare setting. The study has a twofold aim: (1) to examine clinicians' and directors' perceptions of implementing collaborative care with a care manager for patients with depression at the primary care centre (PCC), and (2) to identify barriers and facilitators that influenced this implementation. DESIGN: A cross-sectional study was performed in 2016-2017 in parallel with a cluster-randomised controlled trial. SETTING: 36 PCCs in south-west Sweden. PARTICIPANTS: PCCs' directors and clinicians. OUTCOME: Data regarding the study's aims were collected by two web-based questionnaires (directors, clinicians). Descriptive statistics and qualitative content analysis were used for analysis. RESULTS: Among the 36 PCCs, 461 (59%) clinicians and 36 (100%) directors participated. Fifty-two per cent of clinicians could cooperate with the care manager without problems. Forty per cent regarded to their knowledge of the care manager assignment as insufficient. Around two-thirds perceived that collaborating with the care manager was part of their duty as PCC staff. Almost 90% of the PCCs' directors considered that the assignment of the care manager was clearly designed, around 70% considered the priority of the implementation to be high and around 90% were positive to the implementation. Facilitators consisted of support from colleagues and directors, cooperative skills and positive attitudes. Barriers were high workload, shortage of staff and extensive requirements and demands from healthcare management. CONCLUSIONS: Our study confirms that the care manager puts collaborative care into practice. Facilitators and barriers of the implementation, such as time, information, soft values and attitudes, financial structure need to be considered when implementing care managers at PCCs.

[Effects of a care manager organization for care of people with mild-moderate depression in Swedish primary care]. / Vårdsamordnare för depression ­ effektivt grepp i primärvården - Gav friskare patienter och hälsoekonomiska vinster.

By strengthening accessibility and continuity and support via a care manager for primary care patients with depression corresponding to 20-30% of a nursing service, patients recovered significantly faster and to a greater extent than in primary care-as-usual. Return to work occurred significantly earlier in the first three months, and net sick leave period was significantly shorter during the following 4-6 months. To introduce a collaborative care organizational change where the care manager is the hub and coordinates care for the patient and makes it possible to adapt the care according to the patient's needs throughout the care process, is thus the individual effort shown to have the greatest efficiency in Swedish primary care to increase the quality of care of depression. This approach, where the clinic and academy work closely and continuously in the development and evaluation phases, makes it possible to rapidly develop new ways of working where consideration is given to the complexity of primary care and the complexity of care needs and care efforts.

Newly educated care managers' experiences of providing care for persons with stress-related mental disorders in the clinical primary care context.

OBJECTIVE: Our aim was to explore how the care managers put the complex care manager task into practice and how they perceived their task, which was to facilitate effective, person-centred treatment for stress-related disorder concordant with evidence-based guidelines in primary care. DESIGN: This was a qualitative study using examination reports from the course for care managers. Systematic text condensation according to Malterud was used for the analysis. SETTING: Primary health care centres. SUBJECT: Twenty-eight newly educated care managers in primary health care participated in the study. The median age was 50 (31-68) years. Twenty-seven were women and one was a man. Twenty-one were employed as nurses and seven as counsellors. RESULTS: The informants perceived the role as care manager as meaningful but at times complicated. To participate in teams and to work closely with the general practitioner was experienced as important. The co-ordinating function was emphasised as especially important, as well as the increased continuity in care. The dual role as care manager and counsellor was sometimes experienced as problematic. CONCLUSION: The informants took advantage of the knowledge they had attained during the course. They perceived themselves as being a bridge between patients and other professionals. The result of having dual roles at the primary health care centre unexpectedly revealed difficulties for some professionals. The nurses seemed more familiar with the new way of working.

An interview study of the care manager function-Opening the door to continuity of care for patients with depression in primary care.

AIM: To explore experiences among patients with depression of contact with a care manager at a primary care centre. DESIGN: A qualitative explorative study. METHODS: During spring and summer 2016, 20 individual face-to-face interviews were conducted with patients with experience of care manager contact. The material was analysed using systematic text condensation. RESULTS: The participants described that having contact with a care manager was a support in their recovery process. Care became more available, and the structured continuous contact and the care manager's availability contributed to a trusting relationship. Having someone to share their burden with was a relief. However, it was described as negative when the care manager was perceived as inflexible and not open to issues that the participants felt a need to discuss. For the care manager contact to be successful, there is a need for flexibility and individually tailored contact.

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences.

Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

Patient experiences of living with chronic leg ulcers and making the decision to seek professional health-care.

OBJECTIVE:: The aim of the study was to elucidate how patients experience living with chronic leg ulcers before consulting a health professional, and to determine the reasons behind the decision to visit a health-care centre. METHOD:: A qualitative interview study was carried out. There were 11 participants, five men and six women (age range: 27-83 years old). All participants in the study were patients visiting the public primary medical centre in western Sweden for the first time for a chronic leg ulcer. The data was obtained by recorded interviews. Systematic text condensation (STC) by Malterud was applied to the analysis. RESULTS:: The analysis identified five main categories of the issues relating to ulcers to their ulcers: convictions, pain, emotions, strategies, and health-care treatment. At first, patients accepted the inconvenience of a leg ulcer. Gradually, they focused more on strategies dealing with the ulcer, and withdrew from their social context, while their fears increased. Many needed support in the decision to seek professional care. CONCLUSION:: Despite pain, anxiety, emotional lability, and disappointment, they had strategies to cope with ulcers on their own. A social network seems crucial for the decision to seek professional health care and greater knowledge of leg ulcers, particularly in the elderly population, is needed.

Influence of antidepressant therapy on sick leave in primary care: ADAS, a comparative observational study.

BACKGROUND: Compared to other European countries, Sweden's yearly sick leave expenditures are moderate. Common mental disorders (CMD) are important causes of sick leave, affecting 10-15% of the adult population. A Swedish register based study indicates that antidepressant therapy for patients on long-term sick leave for CMD leads to longer sick leave and higher frequency of non-time-limited sickness compensation as compared to psychotherapy, work oriented rehabilitation, and other therapies. AIM: To verify if patients on antidepressant therapy and on long-term sick leave for depression, anxiety and stress-related mental disorders have a longer sick leave than patients treated with other therapies. METHOD: Prospective, observational study at 28 primary health care centers in the Region Västra Götaland, Sweden, including 192 patients on sick leave for CMD. Outcome measures were gross and net sick leave days. INTERPRETATION: There were no significant differences in sick leave days (gross or net) due to CMD when comparing the patients treated and not treated with antidepressants during the 12 month observation period. The groups differed at baseline only concerning frequency of exhaustion disorder, with a higher frequency of exhaustion disorder in the group without antidepressants. Analysis of other possible factors associated with shorter or longer sick leave only showed associations with the patient's own perception of possibility of returning to work in near and distant future. An important factor associated with longer sick leave was the patient's own perception of possibility of return to present workplace. As CMD are important causes of sick leave and sick leave costs, this factor should be highlighted in future research on the rehabilitation process.

Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study.

OBJECTIVE: To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective. DESIGN: Cost-effectiveness analysis. SETTING: 23 PCCs in two Swedish regions. PARTICIPANTS: Patients with depression (n=342). MAIN OUTCOME MEASURES: A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-Åsberg Depression Rating Scale-Self and quality-adjusted life years (QALYs). Results were expressed as the incremental cost-effectiveness ratio: ∆Cost/∆QALY and ∆Cost/∆DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping. RESULTS: Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were €368 (healthcare perspective) and €6217 (societal perspective) for the intervention patients and €246 (healthcare perspective) and €7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was €6773 (healthcare perspective) and from a societal perspective the CM programme was dominant. DISCUSSION: The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level. TRIAL REGISTRATION NUMBER: NCT02378272; Results.