Disclosure of Depression in Primary Care: A Qualitative Study of Women's Perceptions

District Nurses' Experiences of Practice in Caring for People with Mental Ill-Health in Swedish Primary Care

Mental ill-health is one of the greatest public health challenges in Sweden, and it is estimated that every third person seeking primary care in the country suffers from mental ill-health. Without proper treatment at an early stage, mental ill-health may lead to long-term illness and have a significant impact on functional ability. As district nurses are specialists in public health nursing, they have been pointed out as having a key role in the prevention and management of mental ill-health. The aim was to explore district nurses' practice in caring for people with mental ill-health within primary health care. Individual semi-structured interviews were conducted with district nurses (n = 18) and the transcribed text was subjected to qualitative content analysis. The result was formulated as several subthemes, eventually developed into three themes: Practicing within an organisation where traditional attitudes are impediments, Perceiving mental healthcare as not being an obvious part of district nursing, Working as fellow human beings rather than "professionals". The findings indicate that district nurses feel uncertainty in their practice in this area. Working independently with mental ill-health was not always considered socially acceptable among district nurses. Despite these challenges they tried to remain involved without becoming emotionally overwhelmed. They also strived to meet the needs of these patients with 'small things', that could be effective and a part of recovery-oriented practice, even if they might be defined as unprofessional, and their efficacy negated.

Improving screening for major depressive disorder

BACKGROUND

Depression affects up to 20% of primary care patients and negatively affects patients' mental and physical health.

LOCAL PROBLEM

At a primary care clinic, a review of 291 patient records revealed that no patients were being screened for depression using a validated and reliable tool.

METHODS

The problem was addressed through the implementation of a depression screening and management protocol based on the U.S. Preventive Services Task Force guidelines. Processes used were recommended by the American College of Preventive Medicine and Institute for Clinical Systems Improvement.

INTERVENTIONS

This project implemented a protocol to screen, treat, and manage patients with depression at this primary care clinic. Analysis compared preimplementation and postimplementation metrics, including the number of patients screened for depression, newly diagnosed with depression, offered antidepressants, offered referral, and managed with follow-up.

RESULTS

Implementing a depression screening and management protocol in this clinic significantly increased depression screenings, the percent of patients newly diagnosed with depression, and the number of patients offered treatment.

CONCLUSION

This quality improvement (QI) project improved screening, diagnosis, and management of patients with depression in this primary care clinic. A future QI project for this clinic should focus on measures to track improvements in patients with depression at this primary care clinic.

"Doctor, my back hurts and I cannot sleep." Depression in primary care patients: Reasons for consultation and perceived depression stigma

Background

General practitioners (GPs) play a significant role in depression care. Recognition of depression is crucial for adequate treatment but is impeded by a high portion of depressed patients only reporting physical symptoms to their GP. Among the many reasons for this phenomenon is mental health stigma. We investigated how patients with depression differed from patients without depression regarding the types and number of complaints presented to their GP, as well as their depression stigma. For the subgroup of patients with depression, potential associations between perceived depression stigma and number and types of presented complaints were investigated to see if these might reflect the patient’s intention to conceal mental health symptoms due to fear of being stigmatized by others. Further, we investigated if perceived depression stigma is related to depression treatment.

Methods

Data on depressive symptoms (assessed by the Depression Screening Questionnaire; DSQ), depression stigma (assessed by the Depressions Stigma Scale; DSS), type of complaints reported to the GP and treatment-related factors were collected from 3,563 unselected primary care patients of 253 GPs in a cross-sectional epidemiological study (“VERA study”) in six different German regions. Data of a total of 3,069 patients was used for analysis on complaints reported to the GP (subsample of the VERA study), and for 2,682 out of 3,069 patients data on a stigma questionnaire was available.

Results

Nearly half of the primary care patients with depression (42.2%) reported only physical complaints to their GP. Compared to patients without a depression diagnosis, patients with depression reported twice as many complaints to their GP with a mean of 2.02 (1.33) vs. 1.2 (0.69), including a more frequent combination of physical and mental symptoms (28.8% vs. 3.5%). Patients with depression showed higher total stigma compared to patients without depression, Mdn = 48 (IQR 40–54) vs. Mdn = 46.3 (IQR 29–53), due to higher perceived stigma, Mdn = 27 (IQR 21–32) vs. Mdn = 25.9 (IQR 20–29). Perceived stigma was associated with male gender (beta -.14, p = .005) and a lack of pharmacological treatment (beta -.14, p = .021) in patients with a depression diagnosis.

Conclusion

The number of complaints presented to the GP might function as a marker to actively explore depression in primary care patients, in particular when both physical and mental symptoms are reported. Perceived depression stigma should also be addressed especially in male patients. Further research should clarify the role of perceived stigma as a potential inhibitor of pharmacological treatment of depression in primary care.

Selective serotonin reuptake inhibitor use patterns among commercially insured US pregnancies (2005-2014)

The goal of this study was to describe patterns of selective serotonin reuptake inhibitor (SSRI) use during pregnancy in a US cohort (2005-2014) of > 1 million commercially insured women using administrative claims. We used international classification of disease (ICD-9) diagnosis and procedure and current procedural terminology codes in the OptumLabs® Data Warehouse to identify deliveries (including losses) among US women aged 15-45 (n = 1,061,023). SSRI dispensings that overlapped with the timing of pregnancy were identified using national drug codes in linked pharmacy claims. Demographic characteristics were imputed based on residential location, census data, and consumer information. We investigated patterns by trimester, agent, and demographic subgroups. A total of 46,087 of women (4.34%) were dispensed SSRIs during the estimated pregnancy period. Sertraline was the most common overall and had the highest initial use after trimester 1, including women who switched from another SSRI, although dispensing for > 1 SSRI during pregnancy was uncommon. Use of vilazodone was rare and had the highest discontinuation after trimester 1, followed by paroxetine. SSRI use was more common among women who were older, White, college-educated, higher income (≥ $100,000), or resided in the Midwest. Paroxetine and dispensings for > 1 SSRI were more common in lower education subgroups. White women had the highest proportion of use in all trimesters of pregnancy, whereas Hispanic women had the lowest. Among commercially insured US women, SSRI use during pregnancy differed by agent and demographics. More research is needed to understand whether these differences are due to symptom reporting, cultural beliefs, and/or physician preferences.

Le dévoilement de soi dans la recherche d’aide et le suivi dans les services de santé mentale et psychiatrie

Le dévoilement de soi des patients est essentiel au travail des professionnels de la santé, et ceci est encore plus critique en santé mentale où la parole du patient est le reflet du contenu de la psyché. Le dévoilement de soi concerne alors des symptômes invisibles qui sont associés à des problèmes de santé où la discrimination et la stigmatisation sont encore très présentes. Cet article explore les enjeux éthiques de ce phénomène encore très peu étudié. Le dévoilement en tant que processus décisionnel, interpersonnel, dynamique et complexe sera défini et approfondi à l’aide d’exemples tirés de la recherche. Par la suite, la vulnérabilité de la personne qui se dévoile sera abordée, suivie des enjeux liés aux normes de pratique professionnelle associées au dévoilement des patients et à leur responsabilité avers celui-ci. Ces éléments mettent en lumière de nombreuses questions éthiques et nous amènent, en dernier lieu, à une amorce de proposition pour positionner les professionnels impliqués.

Reducing the Impacts of Mental Health Stigma Through Integrated Primary Care: An Examination of the Evidence

The reduction of mental health stigma (MHS) was an expected benefit of integrating behavioral health in primary care (IPC). However, unlike other barriers discussed in agency reports on IPC, discussions of MHS lack research support. To fill this gap, the authors conducted a literature review identifying seven studies. Given the dearth of research, we also examine general IPC research on probable indicators of MHS reduction in IPC, as well as, facets of IPC potentially influencing MHS related factors negatively associated with help-seeking. Using the data from these three types of research, the evidence suggests the potential of IPC to reduce MHS impact on care utilization, but indicates it is premature to draw firm conclusions. Given the possible benefits of primary care and the known benefits of decreased MHS, this review highlights the importance of further research examining this question and provides specific research and program development recommendations.

Perinatal mental distress in a rural Ethiopian community: a critical examination of psychiatric labels

BACKGROUND

Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress.

METHODS

We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data.

RESULTS

Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used.

CONCLUSIONS

This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.

Patients' experiences of seeking help for emotional concerns in primary care: doctor as drug, detective and collaborator

Background

NICE guidelines for the management of emotional concerns in primary care emphasise the importance of communication and a trusting relationship, which is difficult to operationalise in practice. Current pressures in the NHS mean that it is important to understand care from a patient perspective. This study aimed to explore patients’ experiences of primary care consultations for emotional concerns and what patients valued when seeking care from their GP.

Methods

Eighteen adults with experience of consulting a GP for emotional concerns participated in 4 focus groups. Data were analysed thematically.

Results

(1) Doctor as Drug: Patients’ relationship with their GP was considered therapeutic with continuity particularly valued. (2) Doctor as Detective and Validator: Patients were often puzzled by their symptoms, not recognising their emotional concerns. GPs needed to play the role of detective by exploring not just symptoms, but the person and their life circumstances. GPs were crucial in helping patients understand and validate their emotional concerns. (3) Doctor as Collaborator: Patients prefer a collaborative partnership, but often need to relinquish involvement because they are too unwell, or take a more active role because they feel GPs are ill-equipped or under too much pressure to help. Patients valued: GPs booking their follow up appointments; acknowledgement of stressful life circumstances; not relying solely on medication.

Conclusions

Seeking help for emotional concerns is challenging due to stigma and unfamiliar symptoms. GPs can support disclosure and understanding of emotional concerns by fully exploring and validating patients’ concerns, taking into account patients’ life contexts. This process of exploration and validation forms the foundation of a curative, trusting GP-patient relationship. A trusting relationship, with an emphasis on empathy and understanding, can make patients more able to share involvement in their care with GPs. This process is cyclical, as patients feel that their GP is caring, interested, and treating them as a person, further strengthening their relationship. NICE guidance should acknowledge the importance of empathy and validation when building an effective GP-patient partnership, and the role this has in supporting patients’ involvement in their care.

Assessment of Patient Nondisclosures to Clinicians of Experiencing Imminent Threats

IMPORTANCE

Patient disclosure to their clinician about experiencing an imminent threat is a critical step toward receiving support or assistance.

OBJECTIVE

To examine the frequency of patients not disclosing their experience of imminent threats to their clinician and their reasons for doing so.

DESIGN, SETTING, AND PARTICIPANTS

Survey study incorporating results from 2 national, nonprobability samples of 2011 US adults recruited from Amazon's Mechanical Turk (MTurk) from March 16 to 30, 2015, and 2499 recruited from Survey Sampling International (SSI) from November 6 to 17, 2015. Data analysis was conducted from December 20 to 28, 2018.

MAIN OUTCOMES AND MEASURES

Self-reported nondisclosure of 4 types of imminent threats (depression, suicidality, abuse, and sexual assault) to their clinician and reasons for nondisclosure.

RESULTS

There were 2011 participants in the MTurk sample (1210 [60.3%] female; 1696 [60.2%] white; mean [SD] age, 35.7 [12.4] years; age range, 18-79 years) and 2499 participants (1273 [51.0%] female; 1968 [78.8%] white; mean [SD] age, 61.0 [7.6] years; age range, 50-91 years) in the SSI sample. Among those who reported experiencing at least 1 of the 4 imminent threats, 613 of 1292 MTurk participants (47.5%) and 581 of 1453 SSI participants (40.0%) withheld information from their clinician. The most commonly endorsed reasons for withholding this information included being embarrassed (MTurk: 72.7%; SSI: 70.9%), not wanting to be judged or lectured (MTurk: 66.4%; SSI: 53.4%), and not wanting to engage in a difficult follow-up behavior (MTurk: 62.4%; SSI: 51.1%). Respondents who experienced at least 1 of the 4 imminent threats had significantly higher odds of nondisclosure in both samples if they were female (MTurk: odds ratio [OR], 1.66 [95% CI, 1.30-2.11]; and SSI: OR, 1.33 [95% CI, 1.07-1.67]) or younger (MTurk: OR, 0.99 [95% CI, 0.98-1.00]; and SSI: OR, 0.98 [95% CI, 0.97-1.00]). Worse self-rated health was also associated with nondisclosure, but only in the SSI sample (OR, 0.85 [95% CI, 0.74-0.96]).

CONCLUSIONS AND RELEVANCE

This study suggests that many people withhold information from their clinicians about imminent health threats that they face. A better understanding of how to increase patients' comfort with reporting this information is critical to allowing clinicians to help patients mitigate these potentially life-threatening risks.

Prioritising physical and psychological symptoms: what are the barriers and facilitators to the discussion of anxiety in the primary care consultation?

Background

Anxiety is under-recorded and under-treated in the UK and is under-represented in research compared with depression. Detecting anxiety can be difficult because of co-existing conditions. GPs can be reluctant to medicalise anxiety symptoms and patients can be reluctant to disclose them, for a variety of reasons. This research addresses the gap in evidence of real-life consultations of patients with anxiety and explores how physical and psychological symptoms are discussed and prioritised by patients and GPs in primary care consultations.

Methods

A mixed methods study using a baseline questionnaire, video-recorded primary care consultations and interview data with patients and GPs.

Results

Seventeen patients with anxiety symptoms (GAD-7 score ≥ 10) completed a questionnaire, had their consultation video-recorded and took part in a semi-structured interview. Four GPs were interviewed. The main themes that emerged from GP and patients accounts as barriers and facilitators to discussing anxiety mostly mirrored each other. The GP/patient relationship and continuity of care was the main facilitator for the discussion of anxiety in the consultation. The main barriers were: attribution of or unacknowledged symptoms; co-morbidities; and time constraints. GPs overcame these barriers by making repeat appointments and employing prioritising techniques; patients by choosing an empathetic GP.

Conclusions

The findings add to the evidence base concerning the management of anxiety in primary care. The findings suggest that the discussion around anxiety is a process negotiated between the patient and the GP influenced by a range of barriers and facilitators. Co-existing depression and health anxieties can mask anxiety symptoms in patients. Good practice techniques such as bringing back patients for appointments to foster continuity of care and understanding can help disclosure and detection of anxiety symptoms. Future research could investigate this longitudinally and should include a wider range of GPs practices and GPs.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0996-6) contains supplementary material, which is available to authorized users.

Correlation Between Personal Health History and Depression Self-Care Practices and Depression Screening Among African Americans With Chronic Conditions

Little is known about the influence of personal health history and depression self-care practices on screening for depression by health care providers among African Americans with chronic conditions. African Americans (N = 203) aged 18 years or older and living with at least one chronic health condition in a metropolitan city completed a 45-item community perceptions survey. The number of depression symptoms experienced per month was positively associated with screening for depression by a health care provider; perceived ability to identify depression symptoms was inversely associated with screening by a health care provider. Understanding patients’ health history and self-care practices can initiate provision of information or support services to improve patient–provider communication about depression.

An Exploration of Residents' Implicit Biases Towards Depression-a Pilot Study

BACKGROUND

Implicit attitudes are outside of conscious awareness and are thought to affect automatic responses outside of one's deliberate control, with the potential to impact physician-patient relationships.

OBJECTIVE

To measure the nature and extent of implicit biases towards depression in internal medicine and psychiatry residents.

DESIGN

Descriptive and comparative study.

PARTICIPANTS

Fifty-one residents from three internal medicine programs and 35 residents from three psychiatry programs located in two states.

INTERVENTIONS

Participants were sent a link to voluntarily participate in four online implicit association tests. Residents' identities were anonymous.

MAIN MEASURES

Four implicit association tests to measure the association of (1) attitude (good/bad), (2) permanence, (3) controllability, and (4) etiology with depression/physical illness.

KEY RESULTS

Internal medicine residents demonstrated a significant association between depression and negative attitudes (t(38) = 6.01, p < .001, Cohen's d = .95), uncontrollability (t(35) = 4.80, p < .001, Cohen's d = .79), temporariness (t(37) = 2.94, p = .006, Cohen's d = .48), and a psychologic etiology (t(1) = 6.91, p < .001, Cohen's d = 1.24). Psychiatry residents only demonstrated an association between depression and a psychologic etiology (t(2) = 4.79, p < .001, Cohen's d = 4.5). When comparing the two specialties, internal medicine and psychiatry differed on two of the IATs. Internal medicine residents were more likely to associate negative attitudes with depression than psychiatry residents (t(63) = 4.66, p < .001, Cohen's d = 1.18) and to associate depression with being uncontrollable (t(57) = 3.17, p = .002, Cohen's d = .81).

CONCLUSIONS

Internal medicine residents demonstrated biases in their attitudes towards depression and significantly differed in some areas from psychiatry residents. This pilot study needs to be replicated to confirm our findings and further work needs to be done to determine the effect of these attitudes on the provision of clinical care.