Implementing mental healthcare in chronic care in general practice: a mixed-methods process evaluation of the Healthy Mind intervention

Abstract

Individuals with chronic diseases, such as ischaemic heart disease (IHD) and type 2 diabetes (T2D), are at increased risk of poor mental well-being, which can lead to worse health outcomes and higher mortality. In the Healthy Mind intervention, patients with IHD and/or T2D and poor mental well-being were offered problem-solving therapy (PST). Healthcare professionals guided patients through the structured five-step PST approach, engaging them in selecting problems and solutions to address. The intervention was evaluated in a stepped-wedge cluster-randomised controlled trial (RCT). This process evaluation aims to investigate the implementation of the Healthy Mind intervention. This study used mixed methods. Data sources included RCT monitoring data (PST consultations ( N = 153, patient registrations ( N = 63)), patient questionnaires (baseline: N = 56; post-intervention: N = 36), healthcare professional questionnaires ( N = 51), and purposively sampled semi-structured patient interviews ( N = 10). Quantitative data were analysed descriptively while qualitative data were analysed using thematic analysis. Data were integrated using the ‘following a thread’ technique. Most PST consultations (82% (124/153)) were delivered within the intended 30-minute timeframe, primarily by nurses but also by general practitioners. Among included patients, 43% (27/63) discontinued after attending one consultation or none, mostly due to no-shows/cancellations, or complex life circumstances. Patients had different motivations for participation; a desire to improve own well-being, or mainly to meet healthcare professional or researcher expectations. The initial consultation was essential in determining treatment continuation. This process involved clarifying the intervention’s purpose and demands and the patient’s motivation and capacity for participation. Patients continuing after the first consultation (57% (36/63)) had more severe anxiety symptoms at baseline, attended a median of four (interquartile range: 3–5) consultations, and the majority completed all five PST steps. These patients participated actively in the consultations and felt supported by healthcare professionals. PST can be implemented in chronic care within the time constraints in general practice. For patients attending two or more PST consultations, the intervention was delivered appropriately. However, implementation may be improved by acknowledging the importance of patient motivation and capacity for participation as key factors to successful implementation and desired effect, e.g. by systematically introducing an initial clarifying consultation. ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.