Table 3 Description of the Cadence EPC intervention during the feasibility study and changes made for the pilot study (agreed changes in italics)

Nurse-led behavioural activation (BA) sessions supported by patient handbook. Care coordination on exiting BA sessions

Nurse provision of care coordination with embedded nurse-supported self-help behavioural activation sessions using patient handbook as core material

• Two days, delivered by the intervention developers:

• Two days, delivered by the intervention developers (or for nurses unable to attend these session, or one day + web-based/DVD training):

• Assessing and managing risk

• No change

• Explaining BA to patients

• Explaining BA to patients– more detail

• Care coordination

• Care coordination – more detail/practice

• Behavioural activation, role play and skills practice

• Behavioural activation role play and skills practice

• Ending the Cadence Programme

• Ending the Cadence Programme – more detailed information

• Support available

• Support available (more information on optimising supervision provision)

• Short guide to delivering BA and separate care coordination manual

• Longer guide, incorporating care coordination and BA, with more structured session guides for BA and guidance throughout

• Written memory aids for nurses to use in discussion with patients to cover: introducing EPC concepts, explaining treatment options, regular review and BA.

o Plain cover, very similar to the nurse manual.

o Shorter BA handbook for participants to take home, read and follow: Colour coded to be distinct from nurse manual

o Patient case studies with a cardiac event and depression

o Patient case studies with a cardiac event and how their depression resolved

o Five-step guide to self-guided BA

o No change

o Appendices with examples of the other materials

o No change

• Screen for depressive symptoms using PHQ-9 and GAD-7

• No change

• Discuss nurse-led BA programme

• No change

• Provide mental health care coordination (MHCC) if patient not interested in receiving BA

• Nurse/participant agree a treatment plan (i.e. BA or referral to specialist services or GP)

• Weekly individual supervision with experienced clinicians

• Fortnightly individual or group nurse supervision with an experienced clinician

• No aids for nurse preparation of supervision sessions

• Standardised record sheets for nurse preparation of supervision sessions

• Providing the patient with the Cadence BA handbook to use and asking the patient to read through it

• Providing the patient with the Cadence EPC handbook to use; emphasising the importance of working through and being guided by the handbook

• Introducing mood/behaviour activity diary for patient to complete/review each week

• No change

• Introducing other materials where appropriate (e.g. valued activities sheet, TRAP/TRAC) over time

• Introducing other materials where over time. TRAP/TRAC not included in these materials but other materials added

• Nurse will guide participant through the programme and patient is given tasks or ‘homework’

• Nurse will check participants’ understanding and progress through the programme.

• Nurse and patient follow a structured BA session guide

• Provision of mental health care coordination if patient prefers not to receive BA or at end of CR programme

• Regular review of patient’s mental health status (whether or not receiving BA) and care coordination to include onward referral to other services at any point during or at completion of BA as appropriate.

• Consider referral to existing community/primary care mental health services (e.g. GP, Improving Access to Psychological Therapies (IAPT), CR team psychologist)

• More formal review of PHQ-9 and overall progress at Session 4. Make decision whether to continue with the current care coordination plan or move to a different approach.

Nurse-led delivery of BA by CR nurses during their usual CR sessions:

Nurse-supported delivery of self-help BA during their usual CR sessions (symptom assessment, risk assessment, review of progress and forward planning):

• Opportunistic accommodation for BA session e.g. gym changing room

• No change but nurses are asked to consider optimal choices for delivering EPC in terms of space and privacy during their training

• Monitor patient’s mental health using PHQ-9/GAD-7

• No change

• No standardised paperwork for recording number and contents of BA sessions with patients

• Standardised paperwork for recording number and contents of sessions with patients, to store with patient’s other nursing notes

• Review PHQ-9/GAD-7 each week if nurse has concerns. BA discontinued if PHQ-9 score drops to < 10 (i.e. depression symptoms improved)

• Review PHQ-9/GAD-7 regularly, especially if nurse records deterioration or no improvement in mental health. BA discontinued if PHQ-9 score drops to < 10 (i.e. depression symptoms improved)

• BA can continue until patient is discharged from their CR

• Maximum number of EPC sessions with the nurse = 8

• Discharge from EPC and provide care coordination at the end of contact with rehabilitation nurse

• Discharge from EPC and provide care coordination when PHQ-9 score < 10 and/or when up to 8 sessions completed

• Nurse writes to GP at end of CR programme. At this point, also consider referral to existing community/primary care mental health services (e.g. GP, IAPT, CR team psychologist)

• Standardised discharge letter back to GP at CR programme end. Consider referral to community/primary care mental health services (e.g. GP, IAPT, CR team psychologist) at any point during the sessions, but especially if no improvement or there is deterioration