Key factors

1. High psychological morbidity associated with long term conditions
There is high psychological morbidity associated with each of the three conditions we have chosen to study. For example, rates of depression in patients with COPD are 2.5 times higher than controls (47), and the presence of diabetes doubles the odds of co-morbid depression compared to no diabetes (48). There is similar evidence for high psychological morbidity in rheumatologic disorders (49,50), including Scientific supervisor's previous studies [16,18,31,34,51,53,56,88].

2. Poor Health Outcomes Associated with Psychological Symptoms
The presence of psychological symptoms in long term conditions is associated with poor health outcomes in all three conditions.  Depression has an adverse effect on HRQoL in COPD (51) diabetes (52) and rheumatologic disorders [21,3150,51]. In diabetes, depression has been linked to poorer self care (53), and a self-sacrificing style is associated with poor adherence to treatment [14].

3. Increased Health Expenditure Associated with Psychological Morbidity
The presence of psychological symptoms is associated with increased health care use and expenditure in LTCs and those with depressive disorder are twice as likely to use emergency department services as those without depression (54). In diabetes, total health care expenditure is 4.5 times higher for individuals with depression than for those without depression (55).

4. Treatment of Depression Improves Outcome
In diabetes, treatment of depression produces an improvement in symptoms at no additional overall cost, as savings are made by reductions from in-patient medical costs and other forms of medical care (56). Improved self care of diabetes also reduces healthcare costs (57).

At present, we have limited information about which patients with LTCs develop major depression, and what is the impact of social and financial crises and the specific reasons for that. We know that the mental health needs of people with LTCs are rarely addressed appropriately and in a timely way.

Added Value

We will develop and test a ‘clinical prediction rule’ to identify patients with long term conditions who are at risk for development a Major Depressive Disorder.

We will gain an understanding of factors affecting MDD development and those which are disease specific in the era of the current recession. We will use these findings to identify specific measures which reduce the risk for MDD and enhance resilience to MDD during the crisis.

We will directly address the help needed by many patients with long term conditions who are identified as depressed in routine screening.

We will develop a pilot low-intensity intervention to use in conjunction with the clinical prediction rule which will be user informed and aiming to promote self management in long term conditions.