A collaborative model of care for the management of type 2 diabetes mellitus (T2DM), coronary heart disease (CHD) and co-morbid depression

At baseline, eligible patients in treatment practices (ie those with T2DM &/or CHD and will be screened for depression using the Patient Health Questionnaire (PHQ-9) . A score of 5 or over indicates the patient has mild, moderate, moderately severe or severe depression and is eligible for inclusion in the study. These patients will be recalled for an assessment of lifetyle, biometric (see Key secondary outcome below) and psychological risk factors. Based on this assessment, a Practice Nurse will draft a Care Plan jointly with the patient prioritising risk factors and documenting appropriate behavioural goals to ameliorate these risk factors. The Plan will be reviewed by the patient's General Practitioner (GP) and endorsed or revised as appropriate. The treatment goals may comprise a range of interventions including: Medication (eg selective serotonin reuptake inhibitors, mood stabilisers) Psychological counselling (eg one on one group sessions with a psychologist using cognitive behavioural techniques) over three to six months. Exercise program (this might consist of a range of approaches, depending on patient preferences and resource availability; eg a self led personal exercise program such a regular walking; a referral to a gym or an exercise physiologist, the latter initially for an Medical Benefits Schedule subsidised 8 session group program based on an individualised assessment. Further participation will be subject to user pays ) Patients will then be recalled for regular monitoring by the practice nuse/GP team at 3, 6 9 and 12 months visits. At each visit the patients progress will be reviewed: The patient's goals set at the previous session will be reviewed, outcomes recorded and goals changed or modifed if appropriate. The PHQ-9 questionnaire will be re-administered and the patient's score will be monitored to guide any changes to the treatment care plan. A quality of life measure (Short Form 36 [SF36 version 2] will be administered at baseline and 6 and 12 month visits.