appraisal Archives | GP Tools Blog

BMJ Medicine has published a systematic review and meta-analysis on primary care and community interventions for people living with multimorbidity involving depression or anxiety. Across 29 randomised controlled trials, the main message is practical but measured: interventions can help, yet most effects are small and some fade with time. Collaborative care stood out as the clearest model with sustained benefit.

Key Takeaway

For patients with long term physical conditions plus depression or anxiety, structured care can improve mental health and quality of life in the short term. The review found the most durable signal for collaborative care, particularly for depression outcomes at 18 to 24 months.

What The Review Found

The BMJ Medicine review included 29 RCTs with 9,487 participants. Studies tested primary care or community based interventions for adults with depression or anxiety and at least one long term physical condition.

The authors grouped interventions into two broad categories:

Organisational interventions, including collaborative care, stepped care, and post-discharge interventions.
Patient oriented interventions, including exercise, psychotherapy, and psychoeducation.

Organisational interventions produced small improvements in depression symptoms and quality of life by the end of the intervention, but no clear effect on anxiety symptoms. Patient oriented interventions also produced small short term improvements in depression symptoms and quality of life, with weaker long term evidence.

Why Collaborative Care Matters

Collaborative care was the intervention type with the clearest sustained benefit. In subgroup analysis, it continued to show small improvements in depression symptoms at 18 to 24 months. The review also found evidence of benefit from organisational interventions, especially collaborative care, on some physiological outcomes such as HbA1c.

For appraisal and revalidation, this is a useful reminder that multimorbidity with mental health needs is not just a collection of separate problems. The evidence points toward proactive, coordinated, team based care rather than isolated advice or short courses of support.

Questions For Reflection

How do we identify patients whose physical health care is being limited by untreated depression or anxiety?
Are our reviews structured enough to connect mental health, long term condition monitoring, medication, function, and quality of life?
Where could collaborative care principles be applied within existing primary care workflows?
How do we avoid assuming that short term improvement means long term benefit?

Bottom Line

This BMJ Medicine review supports the value of integrated care for multimorbidity involving depression or anxiety, while keeping expectations realistic. The gains are generally small, but collaborative care appears to offer the strongest sustained benefit and deserves attention in primary care quality improvement, appraisal, and revalidation discussions.

Source: Primary care and community interventions for multimorbidity involving depression or anxiety: systematic review with meta-analysis, BMJ Medicine. DOI: 10.1136/bmjmed-2025-002400.

Low-value care is one of the quiet drains on primary care: it can expose patients to unnecessary treatment, add avoidable workload, and consume resources that could be used for higher-value clinical work. A BMJ Medicine systematic review and meta-analysis brings useful evidence to a practical question for general practice: what actually helps reduce low-value tests and treatments?

The review, titled Effectiveness of different de-implementation strategies in primary care, analysed 140 randomised trials of interventions designed to reduce care that offers little or no benefit to patients. The trials covered common primary care targets including antibiotic prescribing, other drug treatments, imaging, and laboratory testing.

Key takeaway

The clearest signal was not that one simple educational message solves the problem. The review found moderate-certainty evidence that provider education combined with audit and feedback reduced targeted low-value care. Other strategies, including provider education alone, audit and feedback alone, patient education, decision support, and combinations of these approaches, may also reduce low-value care, but the certainty of evidence was generally lower.

In practical terms, this points towards a familiar lesson in quality improvement: changing clinical behaviour usually needs more than information. Clinicians need clear standards, usable data, feedback loops, and support for conversations with patients.

Why low-value care matters in general practice

Low-value care is not just a policy phrase. In day-to-day primary care, it can mean antibiotics for likely viral infections, repeat investigations that do not change management, imaging where harms outweigh benefits, or prescribing patterns that continue because stopping is harder than starting.

For patients, low-value care can create false reassurance, incidental findings, adverse effects, and anxiety. For practices, it can mean extra appointments, follow-up results, prescribing reviews, and administrative work. For the wider NHS, it diverts capacity from care that is more likely to improve outcomes.

What the BMJ Medicine review found

The authors screened more than 13,000 abstracts and included 140 randomised trials. Median follow-up was 287 days. More than half of the trials aimed to reduce antibiotic use, while others focused on drug treatments, imaging, and laboratory testing.

Across the evidence base, de-implementation strategies reduced targeted low-value care by roughly 10-35% in relative terms. Multi-strategy approaches appeared more promising, particularly where patient education was combined with clinician-focused education and feedback. The review also noted that provider education plus audit and feedback had moderate-certainty evidence, making it one of the more defensible choices for service improvement.

What this means for clinicians

For GPs, appraisers, and practice leaders, the review supports a pragmatic approach: choose a specific low-value activity, measure it, give clinicians feedback, and pair that with concise education that explains both the evidence and the intended alternative.

The patient side matters too. Many low-value interventions persist because they are easier to offer than to explain. Patient-facing information, shared decision making, and consistent practice messaging can help reduce the pressure to prescribe, refer, scan, or test when the likely benefit is small.

Questions for appraisal and revalidation

This paper also offers useful material for reflective practice. Clinicians could use it to consider:

Which low-value interventions are most common in my clinical setting?
Do I have feedback data that shows my own prescribing, testing, or referral patterns?
Where could patient information make it easier to avoid unnecessary care?
What would be a realistic quality improvement project for my practice or PCN?

Bottom line

The BMJ Medicine review suggests that reducing low-value care in primary care is possible, but it needs structured de-implementation rather than vague encouragement. The strongest practical message is to combine clinician education with audit and feedback, then support patients with clear explanations about why more care is not always better care.

Source: BMJ Medicine: Effectiveness of different de-implementation strategies in primary care. DOI: 10.1136/bmjmed-2025-001343

GP Tools Blog

All Posts Tagged: appraisal

Multimorbidity With Depression or Anxiety: BMJ Medicine Review