The politics of conducting research on depression in a cross-cultural context

Successful community engagement is often a crucial component of effective qualitative research. In this article we reflect on our experience of engaging with ethnic minority communities in a qualitative study of help seeking for depression. Community engagement emerges as a complex process that provides important insights into the way mental illness is constructed in various cultural contexts and from diverse perspectives. Contested notions of ethnicity, culture, community, and depression were the domains in which personal and public politics were played out. We worked with bilingual research assistants who provided an entrée to the community. Despite this, disparate community subgroups and influential individuals vied for input into and control of the research agenda. We conclude that negotiating the politics of these processes requires great reflexivity and is itself a powerful seam of data, adding richness to findings about the experience of mental distress in a community seeking to locate itself within mainstream society.

How could depression guidelines be made more relevant and applicable to primary care? A quantitative and qualitative review of national guidelines

BACKGROUND

Many guidelines have been developed in the area of depression but there has been no systematic assessment of their relevance to general practice.

AIM

To assess national guidelines on general practice management of depression using two complementary approaches to identify specific ways in which guidance could be made more relevant and applicable to the nature of general practice and the patients who seek help in this context.

DESIGN OF STUDY

Review of national guidelines.

SETTING

Seven English speaking countries: UK, US, Australia, New Zealand, Ireland, Canada, and Singapore.

METHOD

Seven guidelines were independently reviewed quantitatively using the Appraisal of Guidelines for Research and Evaluation (AGREE) scores and qualitatively using thematic coding.

RESULTS

The quantitative assessment highlights that most of the guidelines fail to meet the criteria on rigour of development, applicability, and editorial independence. The qualitative assessment shows that the majority of guidelines do not address associated risk factors sufficiently and the dilemma of diagnostic uncertainty flows over into management recommendations. Management strategies for depression (antidepressants and psychological strategies) are supported by all of the guidelines, with several listing drugs before psychological therapies; there is limited attention paid to the different types of psychological therapies. Moreover, the guidelines in the main fail to acknowledge individual patient circumstances, in particular the influence on response to treatment of social issues such as adverse life events or social support.

CONCLUSION

Assessments of current national guidelines on depression management in general practice suggest significant limitations in their relevance to general practice.

Publish or perish? Evaluation of a writing week

BACKGROUND

To improve research publication output, a general practice department in Australia declared a department wide 'writing week'.

METHOD

Components included: pre-registration, an initial presentation followed by scheduled one-on-one sessions with an external facilitator, a progress 'running sheet', voucher incentives, and a concluding session for shared feedback and 'prize giving'.

RESULTS

Ninety percent (18/90) of potential staff participated, from novice to senior. In the subsequent 3 months eight papers were submitted and a further nine were nearing completion. Expressed benefits were having dedicated and structured time, collegial support and an external facilitator.

DISCUSSION

While effectiveness of writing week could not be precisely measured with respect to publication outputs, researchers, regardless of seniority, benefited from the provision of structural knowledge, quarantined time and/or support to write up research.

The prevalence of depression among Maori patients in Auckland general practice

INTRODUCTION

There has been concern over high rates of mental illness in Maori. Previous studies in general practice have had small sample sizes.

AIM

To determine the prevalence of major depression among Maori patients in Auckland general practice using the CIDI and the PHQ as measurement tools.

METHODS

This prevalence study is part of a larger randomised trial. The patients were recruited from 77 general practitioners from around Auckland who could provide a private room for interviewing. The patients were invited to participate in the waiting room and all consecutive patients were approached. For this study all patients received a computerised CIDI examination and one third received a PHQ assessment prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient did the CIDI.

RESULTS

There were 7994 patients approached from whom there were data on 7432. The prevalence of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI was 10.1% 95% CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95% CI (8.8 to 14.2) and for non-Maori 10.1% 95% CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over at least the previous two weeks on the PHQ > or = 9 for all participants was 12.9% 95% CI (11.2 to 14.5).

DISCUSSION

The prevalence of depression among Maori is high, but not as high as earlier studies. This may be due to the bigger sample size of this study.

Depression recovery from the primary care patient's perspective: 'hear it in my voice and see it in my eyes'

Purpose This paper aims to contribute to the discussion about the concept of recovery from depression from the patient perspective.Methods A structured, computer-assisted telephone interview of 576 participants from the Australian diamond cohort study who were asked, at the one year follow-up, how they would know if someone had recovered from depression. The responses were thematically analysed using a modified grounded-theory approach.Results Participants found the question challenging on a number of levels, relating to the definition of recovery, the subjective nature of getting better from depression, pessimism about the possibility of recovery and concerns that people hide how they really feel. Participants reported observation and human interaction as crucial to deciding if recovery had occurred. This led to three broad groups of indicators for recovery: a person's actions, their appearance and their thoughts and feelings.Conclusions Australian primary care patients with depressive symptoms report using observation and human interaction when trying to decide if someone is getting better from depression, leading to a broad range of indicators of recovery that include, but are not limited to, the traditional symptom-based definitions of depression remission. This data suggests that patients have a rich variety of ways of describing recovery, supporting a call for more patient-centred approaches to setting goals for depression recovery in the primary care setting.

Prevalence of depression among Maori patients in Auckland general practice

INTRODUCTION: There has been concern over high rates of mental illness in Maori. Previous studies in general practice have had small sample sizes. AIM: To determine the prevalence of major depression among Maori patients in Auckland general practice using the CIDI and the PHQ as measurement tools. METHODS: This prevalence study is part of a larger randomised trial. The patients were recruited from 77 general practitioners from around Auckland who could provide a private room for interviewing. The patients were invited to participate in the waiting room and all consecutive patients were approached. For this study all patients received a computerised CIDI examination and one third received a PHQ assessment prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient did the CIDI. RESULTS: There were 7994 patients approached from whom there were data on 7432. The prevalence of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI was 10.1% 95%CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95%CI (8.8 to 14.2) and for non-Maori 10.1% 95%CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over at least the previous two weeks on the PHQ =9 for all participants was 12.9% 95%CI (11.2 to 14.5). DISCUSSION: The prevalence of depression among Maori is high, but not as high as earlier studies. This may be due to the bigger sample size of this study. KEYWORDS: Maori, prevalence, depression, primary care, general practice, New Zealand

Resilience and depression: perspectives from primary care

Resilience refers to the capacity for successful adaptation or change in the face of adversity. This concept has rarely been applied to the study of distress and depression. We propose two key elements of resilience — ordinary magic and personal medicine — which enable people to survive and flourish despite current experience of emotional distress. We investigate the extent to which these elements are considered important by a sample of 100 people, drawn from a longitudinal study of the management of depression in primary care in Victoria, Australia. We also assess how respondents rate personal resilience in comparison with help received from professional sources. Our data are obtained from semi-structured telephone interviews, and analysed inductively through refinement of our theoretical framework. We find substantial evidence of resilience both in terms of ordinary magic — drawing on existing social support and affectional bonds; and in terms of personal medicine — building on personal strengths and expanding positive emotions. There is a strong preference for personal over professional approaches to dealing with mental health problems. We conclude that personal resilience is important in the minds of our respondents, and that these elements should be actively considered in future research involving people with experience of mental health problems.

The application of multiscale modelling to the process of development and prevention of stenosis in a stented coronary artery

The inherent complexity of biomedical systems is well recognized; they are multiscale, multiscience systems, bridging a wide range of temporal and spatial scales. While the importance of multiscale modelling in this context is increasingly recognized, there is little underpinning literature on the methodology and generic description of the process. The COAST (complex autonoma simulation technique) project aims to address this by developing a multiscale, multiscience framework, coined complex autonoma (CxA), based on a hierarchical aggregation of coupled cellular automata (CA) and agent-based models (ABMs). The key tenet of COAST is that a multiscale system can be decomposed into N single-scale CA or ABMs that mutually interact across the scales. Decomposition is facilitated by building a scale separation map on which each single-scale system is represented according to its spatial and temporal characteristics. Processes having well-separated scales are thus easily identified as the components of the multiscale model. This paper focuses on methodology, introduces the concept of the CxA and demonstrates its use in the generation of a multiscale model of the physical and biological processes implicated in a challenging and clinically relevant problem, namely coronary artery in-stent restenosis.

Exploring general practitioners' experience of informing women about prenatal screening tests for foetal abnormalities: a qualitative focus group study

Background

Recent developments have made screening tests for foetal abnormalities available earlier in pregnancy and women have a range of testing options accessible to them. It is now recommended that all women, regardless of their age, are provided with information on prenatal screening tests. General Practitioners (GPs) are often the first health professionals a woman consults in pregnancy. As such, GPs are well positioned to inform women of the increasing range of prenatal screening tests available. The aim of this study was to explore GPs experience of informing women of prenatal genetic screening tests for foetal abnormality.

Methods

A qualitative study consisting of four focus groups was conducted in metropolitan and rural Victoria, Australia. A discussion guide was used and the audio-taped transcripts were independently coded by two researchers using thematic analysis. Multiple coders and analysts and informant feedback were employed to reduce the potential for researcher bias and increase the validity of the findings.

Results

Six themes were identified and classified as 'intrinsic' if they occurred within the context of the consultation or 'extrinsic' if they consisted of elements that impacted on the GP beyond the scope of the consultation. The three intrinsic themes were the way GPs explained the limitations of screening, the extent to which GPs provided information selectively and the time pressures at play. The three extrinsic factors were GPs' attitudes and values towards screening, the conflict they experienced in offering screening information and the sense of powerlessness within the screening test process and the health care system generally. Extrinsic themes reveal GPs' attitudes and values to screening and to disability, as well as raising questions about the fundamental premise of testing.

Conclusion

The increasing availability and utilisation of screening tests, in particular first trimester tests, has expanded GPs' role in facilitating women's informed decision-making. Recognition of the importance of providing this complex information warrants longer consultations to respond to the time pressures that GPs experience. Understanding the intrinsic and extrinsic factors that impact on GPs may serve to shape educational resources to be more appropriate, relevant and supportive.

What do GPs get out of participating in research? - experience of the LEAP trial

BACKGROUND

Maximising the health of our communities requires a strong foundation of clinical research. Undertaking community based clinical research requires an understanding of what motivates practitioners to participate in research and how they experience the process. It has been suggested that a primary care sector with a strong research culture and evidence base is crucial to getting evidence into practice, yet general practice research has been criticised for ignoring clinical research. This article examines why a group of general practitioners took part in clinical research.

METHODS

Participants completed surveys before and after involvement in the Live, Eat and Play (LEAP) study, a randomised controlled trial to reduce childhood overweight.

RESULTS

Thirty-four GPs enrolled in LEAP and completed the baseline survey; 30 delivered the intervention and 29 completed all surveys. Sixtyone percent (17) of the GPs agreed that their expectations of their participation in the project had been met. Twenty-eight of 29 GPs stated they would participate in similar research if asked again. Responses to open ended questions indicated that the most highly valued reason for participating in research was to learn new clinical skills, update knowledge and reflect on practice.

DISCUSSION

General practitioners were driven to participate in research by altruism, the desire to update their knowledge and clinical skills, and the opportunity to reflect on their practice rather than the promise of 'rewards' such as quality assurance and continuing medical education points.

Routine use of gastrograffin enema prior to the reversal of a loop ileostomy

BACKGROUND/AIMS

Anastomotic failure occurs in up to 10% of patients following anterior resection. Selective use of a loop ileostomy may reduce the septic consequences of anastomotic leak. The use of gastrograffin enema to confirm the anastomotic integrity prior to ileostomy closure is still controversial. Our aim was to determine the impact of the routine use of gastrograffin enema on patients' management prior to ileostomy reversal.

METHODS

A review of 81 patients who underwent low anterior resection with loop ileostomy for rectal cancer over 3 years.

RESULTS

Gastrograffin enema was performed in 69 patients (85.2%). The mean time from operation to gastrograffin enema was 22 weeks. Four patients (5.8%) had a positive radiological leak without clinical suspicion of anastomotic problems, 2 patients (2.9%) of these subsequently had the ileostomy closed despite the positive result, 2 patients (2.9%) had a gastrograffin enema repeated which showed no leak and the patients are awaiting reversal.

CONCLUSION

The incidence of positive radiological leak in uncomplicated patients is low; such patients had their loop ileostomies closed with or without serial gastrograffin enema. Routine gastrograffin enema in the absence of a clinical suspicion of anastomotic failure would appear to be of little value.

Women's views and outcomes of an educational intervention designed to enhance psychosocial support for women during pregnancy

BACKGROUND

Identification of psychosocial issues in pregnant women by screening is difficult because of the lack of accuracy of screening tools, women's reluctance to disclose sensitive issues, and health care practitioner's reluctance to ask. This paper evaluates if a health professional education program, a new (ANEW) approach, improves pregnant women's ratings of care and practitioner's listening skills and comfort to disclose psychosocial issues.

METHODS

Midwives and doctors from Mercy Hospital for Women, Melbourne, Australia, were trained from August to December 2002. English-speaking women (<20 wks' gestation) were recruited at their first visit and mailed a survey at 30 weeks (early 2002) before and after (2003) the ANEW educational intervention. Follow-up was by postal reminder at 2 weeks and telephone reminder 2 weeks later.

RESULTS

Twenty-one midwives and 5 doctors were trained. Of the eligible women, 78.2 percent (584/747) participated in a pre-ANEW survey and 73.3 percent (481/657) in a post-ANEW survey. After ANEW, women were more likely to report that midwives asked questions that helped them to talk about psychosocial problems (OR 1.45, CI 1.09-1.98) and that they would feel comfortable to discuss a range of psychosocial issues if they were experiencing them (coping after birth for midwives [OR 1.51, CI 1.10-2.08] and feeling depressed [OR 1.49, 1.16-1.93]; and concerns relating to sex [OR 1.35, CI 1.03-1.77] or their relationships [OR 1.36, CI 1.00-1.85] for doctors).

CONCLUSIONS

The ANEW program evaluation suggests trends of better communication by health professionals for pregnant women and should be evaluated using rigorous methods in other settings.

General practitioners and St. John's Wort: A question of regulation or knowledge?

BACKGROUND

St. John's Wort (SJW), also known as Hypericum perforatum, is a herbal remedy available over-the-counter. There is evidence that it can treat mild to moderate depression but has potential side effects and important drug interactions.

OBJECTIVE

To determine general practitioners' (GPs') knowledge and recommendation of SJW for mild to moderate depression within a climate of widespread community use of complementary therapies and debate about regulation.

DESIGN AND SETTING

Postal survey of a random sample of 350 Australian GPs.

RESULTS

Forty-eight percent responded. One-third (31%) reported recommending SJW to patients with mild to moderate depression. Of these, only one-third (32%) reported specific dosage instructions. Respondents' knowledge of side effects and interactions was much less than for selective serotonin reuptake inhibitor antidepressants.

CONCLUSIONS

Australian GPs know less about safety of SJW than antidepressants and do not widely recommend it to patients. Despite this, many patients use SJW, probably in combination with other pharmaceuticals. Effective dissemination of further research into effectiveness and risk profiles of complementary therapies is needed to inform health professionals, regulatory bodies and consumers.

Do longer consultations improve the management of psychological problems in general practice? A systematic literature review

BACKGROUND

Psychological problems present a huge burden of illness in our community and GPs are the main providers of care. There is evidence that longer consultations in general practice are associated with improved quality of care; but this needs to be balanced against the fact that doctor time is a limited resource and longer consultations may lead to reduced access to health care. The aim of this research was to conduct a systematic literature review to determine whether management of psychological problems in general practice is associated with an increased consultation length and to explore whether longer consultations are associated with better health outcomes for patients with psychological problems.

METHODS

A search was conducted on Medline (Ovid) databases up to 7 June 2006. The following search terms, were used:general practice or primary health care (free text) or family practice (MeSH)AND consultation length or duration (free text) or time factors (MeSH)AND depression or psychological problems or depressed (free text).A similar search was done in Web of Science, Pubmed, Google Scholar, and Cochrane Library and no other papers were found. Studies were included if they contained data comparing consultation length and management or detection of psychological problems in a general practice or primary health care setting. The studies were read and categories developed to enable systematic data extraction and synthesis.

RESULTS

29 papers met the inclusion criteria. Consultations with a recorded diagnosis of a psychological problem were reported to be longer than those with no recorded psychological diagnosis. It is not clear if this is related to the extra time or the consultation style. GPs reported that time pressure is a major barrier to treating depression. There was some evidence that increased consultation length is associated with more accurate diagnosis of psychological problems.

CONCLUSION

Further research is needed to elucidate the factors in longer consultations that are associated with greater detection of psychological problems, and to determine the association between the detection of psychological problems and the attitude, gender, age or training of the GP and the age, gender and socioeconomic status of the patient. These are important considerations if general practice is to deal more effectively with people with psychological problems.

Observational studies of depression in primary care: what do we know?

BACKGROUND

We undertook a systematic review of observational studies of depression in primary care to determine 1) the nature and scope of the published studies 2) the methodological quality of the studies; 3) the identified recovery and risk factors for persistent depression and 3) the treatment and health service use patterns among patients.

METHODS

Searches were conducted in MEDLINE, CINAHL and PsycINFO using combinations of topic and keywords, and Medical Subject Headings in MEDLINE, Headings in CINAHL and descriptors in PsycINFO. Searches were limited to adult populations and articles published in English during 1985-2006.

RESULTS

40 articles from 17 observational cohort studies were identified, most were undertaken in the US or Europe. Studies varied widely in aims and methods making it difficult to meaningfully compare the results. Methodological limitations were common including: selection bias of patients and physicians; small sample sizes (range 35-108 patients at baseline and 20-59 patients at follow-up); and short follow-up times limiting the extent to which these studies can be used to inform our understanding of recovery and relapse among primary care patients with depression. Risk factors for the persistence of depression identified in this review were: severity and chronicity of the depressive episode, the presence of suicidal thoughts, antidepressant use, poorer self-reported quality of life, lower self-reported social support, experiencing key life events, lower education level and unemployment.

CONCLUSION

Despite the growing interest in depression being managed as a chronic illness, this review identified only 17 observational studies of depression in primary care, most of which have included small sample sizes and been relatively short-term. Future research should be large enough to investigate risk factors for chronicity and relapse, and should be conducted over a longer time frame.

GPs' use of problem solving therapy for depression: a qualitative study of barriers to and enablers of evidence based care

Background

Depression is a major health concern, predominantly treated by general practitioners (GPs). Problem solving therapy (PST) is recognised as an effective treatment for depression that is not widely used by GPs. This research aims to explore barriers and enablers that may influence GPs use of this treatment.

Method

Qualitative methodology was used including individual and focus group interviews of GPs, PST experts and consumers. Analysis was undertaken using the Theory of Planned Behaviour (TPB) as a framework.

Results

A spectrum of potential influences, on GPs' use of PST emerged. Both barriers and enablers were identified. PST was perceived as being close to current practice approaches and potentially beneficial to both doctor and patient. In addition to a broadly positive attitude to PST, expressed by those with previous experience of its use, potential solutions to perceived barriers emerged. By contrast some GPs expressed fear that the use of PST would result in loss of doctor control of consultations and associated potential adverse patient outcomes. Patient expectations, which emerged as not always coinciding with GPs' perception of those expectations, were identified as a potential influence on GPs' decision concerning adoption of PST. In addition specific factors, including GP skill and confidence, consultation time constraints and technical issues related to PST were noted as potential concerns.

Conclusion

This research contributes to our knowledge of the factors that may influence GPs' decisions regarding use of PST as a treatment for depression. It recognises both barriers and enablers. It suggests that for many GPs, PST is viewed in a positive light, providing encouragement to those seeking to increase the provision of PST by GPs. In identifying a number of potential barriers, along with associated options to address many of these barriers, it provides insights which may assist in the planning of GP training in PST.

Using problem solving therapy in general practice

BACKGROUND

In Australia, mild and moderate depression is predominantly treated by general practitioners. Many of these patients prefer a nondrug therapeutic approach. Problem solving therapy (PST) is an evidence based psychological treatment that can be provided to such patients by GPs.

OBJECTIVE

This article aims to explain what PST is, how PST skills may be developed, and how specific difficulties using PST may be addressed.

DISCUSSION

Problem solving therapy consists of a series of sequential structured stages. While many GPs use elements of the PST approach, few use its structured format. In this article the specific stages of PST are described in detail. This is followed by a discussion of ways GPs can learn more about developing PST skills from their existing problem solving skills. Finally, difficulties observed using PST are described in combination with potential responses to these difficulties.

A snapshot of the prevalence of physical activity amongst older, community dwelling people in Victoria, Australia: patterns across the 'young-old' and 'old-old'

BACKGROUND

Physical activity has a range of health benefits for older people. The aim of this study was to determine physical activity prevalence and attitudes amongst respondents to a trial screening survey.

METHODS

A cross-sectional survey was conducted. Subjects were community dwelling older people aged > or = 65 years, recruited via general practices in Victoria, Australia. Participants completed a mailed screening tool containing the Geriatric Depression Scale, the Active Australia survey and the Physical Activity Readiness Questionnaire.

RESULTS

Of 330 participants, 20% were > or = 80 years. Activity levels were similar to those reported in population studies. The proportion of participants reporting physical activity was greatest for the walking category, but decreased across categories of physical activity intensity. The oldest-old were represented at all physical activity intensity levels. Over half reported exercising at levels that, according to national criteria are, 'sufficient to attain health benefit'. A greater proportion of participants aged 85 years and older were unaware of key physical activity messages, compared to participants aged less than 85 years.

CONCLUSION

Most population surveys do not provide details of older people across age categories. This survey provided information on the physical activity of people up to 91 years old. Physical activity promotion strategies should be tailored according to the individual's needs. A better understanding of the determinants of physical activity behaviour amongst older sub-groups is needed to tailor and target physical activity promotion strategies and programs to maximise physical activity related health outcomes for older people.

Vascular delivery of c-myc antisense from cationically modified phosphorylcholine coated stents

c-Myc is involved in the formation of neointimal hyperplasia. We investigated in vitro, ex vivo and in vivo release of antisense c-myc from cationically modified phosphorylcholine-coated stents, as well as the effects on c-Myc expression and neointima formation in a porcine coronary stent model. In vitro experiments were performed to determine optimal loading of stents with antisense. Stents loaded with labelled antisense were deployed in porcine arteries ex vivo and in vivo. Antisense was detected in the vessel wall directly surrounding the stent of pig carotid and coronary artery up to 48 h after stent deployment. Nuclear uptake was observed in endothelial and vascular smooth muscle cells. Labelled antisense within peripheral tissues in vivo was <1.0% of that within stented arterial segments. Control and antisense loaded stents implanted into 10 pig coronary arteries and analysed at 28 days post-stenting showed that lumen area within the antisense stents was significantly increased (i.e. 30.5% greater, P<0.01), whilst both neointimal area and neointimal thickness were significantly reduced (17.5% and 19.5%, respectively, P<0.01) compared to control stents. Cationically modified phosphorylcholine coated stent-based delivery of c-myc antisense is feasible with minimal systemic delivery and is associated with a reduction of in-stent neointimal hyperplasia in pig coronary arteries.