Research projects

Improving Community Coordination, Access and Networks (I-CCaN): primary care for depression, anxiety and related disorders with co-morbid chronic physical illness

Principal researchers

Dr Victoria Palmer
Professor Jane Gunn
Dr John Furler
Kirsty Forsdike


Primary Care Research Unit, Department of General Practice, The University of Melbourne



Award type

Beyond Blue Victorian Centre of Excellence

Project completion year


Project brief

The I-CCAaN project (Improving Community Coordination, Access and Networks) involved developing and trialling an innovative intervention in General Practice for the identification and care of previously undiagnosed depression and anxiety in patients with chronic physical illness.

This intervention had two elements: a rapid identification and assessment method (RAM) and a brief innovative ‘social prescription’ aimed at increasing a patient’s social engagement activity in the community. 

The RAM consisted of an in-practice system for a) screening eligible patients (chronic physical condition without an existing diagnosis of depression) and b) recalling them for an assessment to confirm a diagnosis of depression. For screening, we used a simple validated self-administered screening tool (Two Questions with Help, TQWH). For assessment, we developed a modified Mental Health Plan with a structured assessment approach that also prompted GPs to implement the novel social engagement activity.

Key findings

Two general practices, one regional and one metropolitan, participated in the pilot. Patients were recruited over a three-month period in each practice. In total, 210 patients were screened, of whom 26 (12.4 per cent) screened positive. Of these, 19 (73.1 per cent) consented to participate and 12 (63.2 per cent) eventually completed all measures and participated in the social engagement intervention. Of these, eight (66.7 per cent) patients achieved a significant reduction in depression and/or anxiety scores. 

In pre- and post-intervention there was an increase in the numbers of participants who rated their health as excellent, very good or good, and a decline in those who said that they were dissatisfied.  All depression and anxiety measures, PHQ-9, GAD-7 and DASS showed improvements to patients’ depression, anxiety and stress. It appears likely that this was as a result of their participation in the RAM and the social engagement activity; although to be certain will require testing the approach using a comparison group in a randomised trial design.

Implications for policy and practice

  1. Identifying target groups for screening requires suitable information systems and skilled staff with the time to undertake the task.
  2. Although low levels of the target group met criteria for depression (approx. 3 per cent) because chronic physical illness is so common, detecting and intervening in this group could potentially have a significant impact at the population health level.
  3. Patients value general practitioners asking about their mental health and social participation and GPs find the approach useful.
  4. Implementing social assessment and ‘social prescriptions’ within mental health planning processes requires further development and testing to see if it is effective and sustainable in practice.

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