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Grung I, Anderssen N, Haukenes I, Ruths S, Smith-Sivertsen T, Hetlevik Ø, Hjørleifsson S. Patient experiences with depression care in general practice: a qualitative questionnaire study. Scand J Prim Health Care 2022; 40:253-260. [PMID: 35603990 PMCID: PMC9397414 DOI: 10.1080/02813432.2022.2074069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate patient experiences and preferences regarding depression care in general practice. DESIGN AND SETTING A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis. SUBJECTS 250 persons completed the web-based survey, 86% were women. RESULTS The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful. CONCLUSIONS Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment.KEY POINTSDepression is common, and GPs are often patients' first point of contact when they seek help. • Patients who feel depressed appreciate help from their GP. • Patients prefer an empathetic GP who listens attentively and acknowledges their problems. • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.
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Affiliation(s)
- Ina Grung
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- CONTACT Ina Grung Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Norman Anderssen
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Psychosocial Science, University of Bergen, Bergen, Norway
| | - Inger Haukenes
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sabine Ruths
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tone Smith-Sivertsen
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Øystein Hetlevik
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stefan Hjørleifsson
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Wu H, Xu L, Zheng Y, Shi L, Zhai L, Xu F. Application of the Delphi Method in the Study of Depressive Disorder. Front Psychiatry 2022; 13:925610. [PMID: 35873226 PMCID: PMC9301200 DOI: 10.3389/fpsyt.2022.925610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Depressive disorder is a common mental disorder that has a high prevalence and low visiting rate, which caused patients years lived with disability. Due to the complexity of the depressive disorder, the Delphi method is a better choice compared with other commonly used methods, which provides a new perspective for the prevention and treatment of depression. This article will summarize the clinical studies of depressive disorders using the Delphi method from four perspectives, and summarize the advantages and disadvantages of the Delphi method in depressive disorders research, arguing that the Delphi method can cross the gap between clinical research and clinical practice, and is a highly practical part of the research process.
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Affiliation(s)
- Hengjin Wu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Graduate School of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Linjie Xu
- Graduate School of Beijing University of Traditional Chinese Medicine, Beijing, China.,Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Zheng
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lei Shi
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liangfan Zhai
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - FengQuan Xu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Abstract
Person-centred care is at the core of a value-based health system. Its transformative potential is to enable and support key policy, planning and service developments across the system even when these go against the self-interest of individual major players. It offers a potent test for decision makers at all levels. It demands responses that are multi-level, empirically grounded, expert-informed and data-driven that must converge on the singularity of individuals in the places that they live. This requires different approaches that recognise, respect and reconcile two necessary but constitutionally disparate perspectives: the bureaucratic, overtly decontextualised, top-down, policy and planning objectives of central governments and the formally complex, dynamic and contextualised experience of individuals in the system. Conflating the latter with the former can lead unwittingly to a pervasive and reductive form of quasi-Taylorism that nearly always creates waste at the expense of value. This has parallel application in the treatment domain where outcomes are non-randomly clustered and partitioned by socioeconomic status, amplifying unwarranted variation by place that is striking in its magnitude and heterogeneity. In this paper, we propose that a combination of (1) relevant, local and sophisticated data planning, collection and analysis systems, (2) more detailed person-centred service planning and delivery and (3) system accountability through co-design and transparent public reporting of health system performance in a manner that is understandable, relevant, and locally applicable are all essential in ensuring planned and provided care is most appropriate to more than merely the 'average' person for whom the current system is built. We argue that only through a greater appreciation of healthcare as a complex adaptive (eco)system, where context is everything, and then utilising planning, analysis and management methodologies that reflect this reality is the way to achieve genuine person-centred care.
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Parker D, Byng R, Dickens C, McCabe R. Patients' experiences of seeking help for emotional concerns in primary care: doctor as drug, detective and collaborator. BMC FAMILY PRACTICE 2020; 21:35. [PMID: 32059636 PMCID: PMC7020382 DOI: 10.1186/s12875-020-01106-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/05/2020] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Daisy Parker
- College of Medicine and Health, University of Exeter, Exeter, UK.
| | | | - Chris Dickens
- College of Medicine and Health, University of Exeter, Exeter, UK
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Crabtree BF, Miller WL, Gunn JM, Hogg WE, Scott CM, Levesque JF, Harris MF, Chase SM, Advocat JR, Halma LM, Russell GM. Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach. Fam Pract 2018; 35:266-275. [PMID: 29069335 PMCID: PMC5965090 DOI: 10.1093/fampra/cmx091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. OBJECTIVE To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. METHODS We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. RESULTS CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. CONCLUSIONS The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.
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Affiliation(s)
- Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - William L Miller
- Department of Family Medicine; Lehigh Valley Health Network, Allentown, USA
| | - Jane M Gunn
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - William E Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Cathie M Scott
- Alberta Centre for Child, Family and Community Research, Edmonton, Canada
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia.,Bureau of Health Information, Chatswood, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia
| | - Sabrina M Chase
- Rutgers Biomedical and Health Sciences (RBHS), Rutgers School of Nursing, Rutgers University, New Brunswick, USA
| | - Jenny R Advocat
- Southern Academic Primary Care Research Unit, School of Primary and Allied Health Care, Monash University, Clayton, Australia
| | - Lisa M Halma
- Zone Analytics and Reporting Services, Alberta Health Services, Edmonton, Canada
| | - Grant M Russell
- Southern Academic Primary Care Research Unity, School of Primary and Allied Health Care, Monash University, Clayton, Australia
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Pineros-Leano M, Tabb KM, Sears H, Meline B, Huang H. Clinic staff attitudes towards the use of mHealth technology to conduct perinatal depression screenings: a qualitative study. Fam Pract 2015; 32:211-5. [PMID: 25535280 PMCID: PMC7340322 DOI: 10.1093/fampra/cmu083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The use of mHealth technology is an innovative approach for screening low-income mothers for depression. Past studies show that the use of technology removes barriers such as literacy issues, language challenges, concerns about privacy and lack of transportation and can also increase reliability. However, little is known about staff attitudes and perceptions towards using mHealth technology for screening low-income women for depression in clinics. METHODS Four focus groups were conducted with staff members in a supplemental nutrition program for women, infants and children located in a public health clinic. A semi-structured focus group interview guide was used to examine staff perceptions related to depression screening with tablet technology. All interviews were audio recorded and transcribed verbatim. Thematic analysis was used to analyse all focus group data. RESULTS Three major benefits and two major barriers were found. The benefits of using technology for perinatal depression screenings were reduction of literacy and language barriers, reduction of redundancy and errors and increased privacy for clients. The barriers were increased network issues and responsibility for technology, which included fear of the devices being lost, stolen or broken. IMPLICATIONS Before implementing mHealth tablet technology for depression screening in a public health clinic, it is important to address the concerns of staff members to make the transition more effective. This study provides timely information on staff-perceived benefits and barriers when implementing mHealth technology in a public health setting.
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Affiliation(s)
- Maria Pineros-Leano
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA, Identifying Depression through Early Assessment (IDEA) Research Team, Urbana, IL, USA,
| | - Karen M Tabb
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA, Identifying Depression through Early Assessment (IDEA) Research Team, Urbana, IL, USA
| | - Heather Sears
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA, Identifying Depression through Early Assessment (IDEA) Research Team, Urbana, IL, USA
| | - Brandon Meline
- Identifying Depression through Early Assessment (IDEA) Research Team, Urbana, IL, USA, Champaign Urbana Public Health District, Champaign, IL, USA
| | - Hsiang Huang
- Identifying Depression through Early Assessment (IDEA) Research Team, Urbana, IL, USA, Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA and Institute of Psychiatry & LIM-23, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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Palmer VJ, Johnson CL, Furler JS, Densley K, Potiriadis M, Gunn JM. Written plans: an overlooked mechanism to develop recovery-oriented primary care for depression? Aust J Prim Health 2014; 20:241-9. [PMID: 23647584 DOI: 10.1071/py12128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 04/02/2013] [Indexed: 11/23/2022]
Abstract
There is a global shift to foster patient-centred and recovery-oriented mental health services. This has resulted from the expansion of how the concept of recovery is understood in mental health literature and practice. Recovery is now more than a return to function or reduction in symptoms; it is a subjective, individualised and multi-faceted experience. To date there has not been investigation of how recovery-oriented services can be translated and implemented into the primary mental health care system. This paper presents the results of a survey from a prospective cohort of primary care patients with probable depression about the importance of written plans to recover. The benefits of having a written plan to recover from depression, as outlined by the participants, were analysed using Leximancer software. The findings provide insights into how written plans may be an important mechanism for implementing a recovery-oriented primary mental health care system. We conclude that the benefits of a written plan provide insight into how patients conceptualise recovery.
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Affiliation(s)
- Victoria J Palmer
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - Caroline L Johnson
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - John S Furler
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - Konstancja Densley
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - Maria Potiriadis
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - Jane M Gunn
- Primary Care Research Unit, The Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
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Keeley RD, West DR, Tutt B, Nutting PA. A qualitative comparison of primary care clinicians' and their patients' perspectives on achieving depression care: implications for improving outcomes. BMC FAMILY PRACTICE 2014; 15:13. [PMID: 24428952 PMCID: PMC3907132 DOI: 10.1186/1471-2296-15-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 01/05/2014] [Indexed: 01/05/2023]
Abstract
Background Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into “Patient-centered Medical Homes” (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient’s perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians’ and their patients’ perceptions of the patients’ experiences, expectations and preferences as they try to achieve care for depression. Methods We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. Results Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients’ observations regarding stigma’s effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open “Pandora’s box” of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients’ ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. Conclusions Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients’ experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians’ and patients’ perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients’ unique ‘therapeutic spaces.’
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Affiliation(s)
- Robert D Keeley
- Department of Family Medicine, University of Colorado, Denver, Mail Stop F-496, Academic Office 1, 12631 E, 17th Ave, Aurora, CO 80045, USA.
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Sung SC, Low CCH, Fung DSS, Chan YH. Screening for major and minor depression in a multiethnic sample of Asian primary care patients: a comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16 ). Asia Pac Psychiatry 2013; 5:249-58. [PMID: 24123813 DOI: 10.1111/appy.12101] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 07/23/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Depression is common, disabling, and the single most important factor leading to suicide, yet it is underdiagnosed in busy primary care settings. A key challenge facing primary care clinicians in Asia is the selection of instruments to facilitate depression screening. Although the nine-item Patient Health Questionnaire (PHQ-9) and 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16 ) are used internationally, they have not been directly compared or widely validated in Asian primary care populations. This study aimed to validate the PHQ-9 and QIDS-SR16 against a structured interview diagnosis of Diagnostic and Statistical Manual, 4th Edition, depression based on the Mini-International Neuropsychiatric Interview in a multiethnic Asian sample. METHODS From April through August 2011, we enrolled 400 English-speaking Singaporean primary care patients. Participants completed a demographic data form, the PHQ-9, and the QIDS-SR16 . They were assessed independently for major and minor depression using the Mini-International Neuropsychiatric Interview. RESULTS Sensitivity and specificity for diagnosing major depression were 91.7% and 72.2%, respectively, for the PHQ-9 (optimal cutoff score of 6), and 83.3% and 84.7%, respectively, for the QIDS-SR16 (optimal cutoff score of 9). The QIDS-SR16 also detected minor depression at an optimal cutoff score of 7, with a sensitivity of 94.4% and specificity of 77.9%. The PHQ-9 and QIDS-SR16 showed good internal consistency (Cronbach's α: 0.87 and 0.79, respectively) and good convergent validity (correlation coefficient: r = 0.73, P < 0.001). The overall prevalence of major and minor depressive disorders was 9%. DISCUSSION The PHQ-9 and QIDS-SR16 appear to be valid and reliable for depression screening in Asian primary care settings.
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Affiliation(s)
- Sharon Cohan Sung
- Office of Clinical Sciences, Duke-NUS Graduate Medical School Singapore, Singapore; Department of Child & Adolescent Psychiatry, Institute of Mental Health, Singapore
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Gask L. Educating family physicians to recognize and manage depression: where are we now? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:449-55. [PMID: 23972106 DOI: 10.1177/070674371305800803] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To consider what the barriers are to effective depression education; to understand what attitudes, knowledge, and skills doctors need to acquire, and finally to examine what we currently know about effective ways of training family physicians (FPs) about depression. METHODS A narrative review of the published literature compiled from searching reviews and original articles was conducted using the following key words: education, training, attitudes, depression, and primary care. Further relevant articles were identified from reference lists. RESULTS The identified barriers are FPs' attitudes and confidence toward recognizing and managing depression, the way in which they conceptualize depression, and the difficulties they face in implementing change in the systems in which they work. We, as educators, can identify what FPs need to know, and this should include novel ways of organizing care. However, of key importance is the need to address how more effective interventions may be provided, recognizing that FPs may be starting from many different points on 3 differing continua of attitude, skills, and knowledge in relation to depression. CONCLUSIONS We have to not only ensure that the content of what we teach is perceived as relevant to primary care but also review exactly how we go about providing it, using methods that will engage and stimulate doctors at differing stages of readiness to acquire new attitudes, skills, and knowledge about depression. However, we still need to find better ways of helping FPs to recognize and acknowledge their educational needs. Further research is also required to thoroughly evaluate these novel approaches to tailoring educational interventions.
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Affiliation(s)
- Linda Gask
- Manchester Academic Health Sciences Centre, Manchester, England.
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Gunn J, Elliott P, Densley K, Middleton A, Ambresin G, Dowrick C, Herrman H, Hegarty K, Gilchrist G, Griffiths F. A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care. J Affect Disord 2013; 148:338-46. [PMID: 23375580 DOI: 10.1016/j.jad.2012.12.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/24/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care. METHODS 789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months. RESULTS Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables. LIMITATIONS Adult only cohort, self-report measures. CONCLUSIONS Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.
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Affiliation(s)
- Jane Gunn
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053, Australia.
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Almeida OP, Pirkis J, Kerse N, Sim M, Flicker L, Snowdon J, Draper B, Byrne G, Goldney R, Lautenschlager NT, Stocks N, Alfonso H, Pfaff JJ. A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients. Ann Fam Med 2012; 10:347-56. [PMID: 22778123 PMCID: PMC3392294 DOI: 10.1370/afm.1368] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE We wanted to determine whether an educational intervention targeting general practitioners reduces the 2-year prevalence of depression and self-harm behavior among their older patients. METHODS Our study was a cluster randomized controlled trial conducted between July 2005 and June 2008. We recruited 373 Australian general practitioners and 21,762 of their patients aged 60 years or older. The intervention consisted of a practice audit with personalized automated audit feedback, printed educational material, and 6 monthly educational newsletters delivered over a period of 2 years. Control physicians completed a practice audit but did not receive individualized feedback. They also received 6 monthly newsletters describing the progress of the study, but they were not offered access to the educational material about screening, diagnosis and management of depression, and suicide behavior in later life. The primary outcome was a composite measure of clinically significant depression (Patient Health Questionnaire score ≥10) or self-harm behavior (suicide thoughts or attempt during the previous 12 months). Information about the outcomes of interest was collected at the baseline assessment and again after 12 and 24 months. We used logistic regression models to estimate the effect of the intervention in a complete case analysis and intention-to-treat analysis by imputed chain equations (primary analysis). RESULTS Older adults treated by general practitioners assigned to the intervention experienced a 10% (95% CI, 3%-17%) reduction in the odds of depression or self-harm behavior during follow-up compared with older adults treated by control physicians. Post hoc analyses showed that the relative effect of the intervention on depression was not significant (OR = 0.93; 95% CI, 0.83-1.03), but its impact on self-harm behavior over 24 months was (OR = 0.80; 95% CI, 0.68-0.94). The beneficial effect of the intervention was primarily due to the relative reduction of self-harm behavior among older adults who did not report symptoms at baseline. The intervention had no obvious effect in reducing the 24-month prevalence of depression or self-harm behavior in older adults who had symptoms at baseline. CONCLUSIONS Practice audit and targeted education of general practitioners reduced the 2-year prevalence of depression and self-harm behavior by 10% compared with control physicians. The intervention had no effect on recovery from depression or self-harm behavior, but it prevented the onset of new cases of self-harm behavior during follow-up. Replication of these results is required before we can confidently recommend the roll-out of such a program into normal clinical practice.
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Affiliation(s)
- Osvaldo P Almeida
- School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia.
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13
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[Views of patients diagnosed with depression and cared for by general practitioners and psychiatrists]. Aten Primaria 2012; 44:595-602. [PMID: 22575484 DOI: 10.1016/j.aprim.2012.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 02/27/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To explore the experiences of patients treated for depression either by general practitioners (GPs) or psychiatrists (Ps) with the aim of identifying improvement strategies. DESIGN Health services research-oriented qualitative methodology. Exploratory design. PARTICIPANTS AND CONTEXTS: A total of 31 patients diagnosed with depression receiving pharmacological treatment for at least one year, belonging to 20 Health Centres and 8 Mental Health Centres of the Basque Health Service-Osakidetza in Bizkaia, and grouped according to the type of professional (GPs/Ps) and socioeconomic level. METHOD Information generation by means of 5 discussion groups and 2 in-depth interviews carried out in 2009 and 2010. Recording and transcription with previous confidentiality agreement and informed consent. Sociological discourse analysis. Technique triangulation and agreement among researchers. RESULTS Patients' experiences of depression are associated with their social contexts and their previous experience outside and inside the health services. These components also appear in perceptions on quality of care, with different expectations related to GPs and Ps. Deficiencies in time and psychotherapy are mentioned in general. Collaboration between both professionals does not spontaneously emerge as a patient priority. CONCLUSIONS Patient assessments provide dimensions of individual and contextual components in the diagnosis and treatment of depression. These dimensions should be taken into account in the identification of needs and the design of strategies shared by GPs and Psychiatrists to improve care.
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Lynch JM, Askew DA, Mitchell GK, Hegarty KL. Beyond symptoms: Defining primary care mental health clinical assessment priorities, content and process. Soc Sci Med 2012; 74:143-9. [DOI: 10.1016/j.socscimed.2011.08.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 05/10/2011] [Accepted: 08/24/2011] [Indexed: 12/18/2022]
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Verdoux H, Gaudron Y, Tournier M. Transition in care in persons with antidepressant prescription in naturalistic conditions. Fam Pract 2011; 28:400-5. [PMID: 21398386 DOI: 10.1093/fampra/cmr009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Few studies have explored transition to psychiatric care in persons treated by antidepressants in primary care. OBJECTIVE To assess the rates of transition in care after a dispensing of antidepressant and the characteristics associated with transition from primary to psychiatric care. METHODS A follow-up study of persons (n = 19 975) starting antidepressant treatment was carried out on a representative sample of the 2005-07 French Social Security Insurance national database. Prescribers were categorized as GPs, hospital practitioners (as a proxy for public psychiatrist), private psychiatrists and other private specialists. Transition in care was defined as a prescription of psychotropic drugs by a prescriber belonging to a category different from that of the index antidepressant prescriber. RESULTS Eighty per cent of incident antidepressant treatments were initiated by a GP and 28% of persons transited in care. The most frequent pattern was transition from a GP to a hospital practitioner (8%) or to a private psychiatrist (5%). Transition to psychiatric care was independently associated with younger age and markers of illness severity (psychiatric chronic illness status, duration of the index antidepressant treatment >6 months and prescription of other classes of psychotropic drugs). Almost all treatments with antipsychotics or mood stabilizers were initiated after the transition to a specialist. CONCLUSIONS Transition to psychiatric care seemed coherent with distribution of tasks between primary and secondary care according to illness severity. Further studies using detailed clinical information are required to assess not only the clinical appropriateness of psychiatric referral but also lack of referral in antidepressant users.
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Positive impact of a family practice-based depression case management on patient's self-management. Gen Hosp Psychiatry 2011; 33:23-8. [PMID: 21353124 DOI: 10.1016/j.genhosppsych.2010.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/08/2010] [Accepted: 11/10/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Family practice-based depression case management improves depression symptoms and adherence to medication. The aim of this study was to explore the long-term effects of practice-based depression case management on patient depression-related self-management knowledge and activities. METHODS This long-term follow-up of a randomized controlled trial study took place 12 months after the end of the 1-year case management intervention. We used a modified version of the depression-specific self-management questionnaire described in Ludman et al. [Psychol Med, 33 (2003) 1061-1070]. Analyses of self-management knowledge and activities used a linear mixed model accounting for practice cluster effects and treatment group. RESULTS Of the 626 patients included at baseline, 439 (70.1%) participated 24 months later in this follow-up study, i.e., 12 months after the end of the intervention. Compared to control recipients, intervention recipients presented statistically significant increased knowledge of medication side-effects and felt more able to avoid situations that may trigger depression. They also tried more often to undertake enjoyable activities and set more time aside for these activities. CONCLUSION This study suggests that case management improves depression-related self-management knowledge and activities in depressed primary care patients 12 months after the end of the intervention. PRACTICE IMPLICATIONS Clinicians may consider introducing practice-based case management for improving patients' self-management activities and knowledge.
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Roth T, Bogan RK, Culpepper L, Doghramji K, Doghramji P, Drake C, Grauke JH, Knoepflmacher P, Sateia M, Silvershein D, Thorpy MJ. Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management. Curr Med Res Opin 2010; 26 Suppl 2:S3-24; quiz S25-7. [PMID: 21077746 DOI: 10.1185/03007995.2010.532544] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders. OBJECTIVE To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders. METHODS Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES. RESULTS After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements – five each for assessment/diagnosis and treatment/ongoing care – were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy. CONCLUSION ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.
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Affiliation(s)
- T Roth
- Henry Ford Hospital, Sleep Disorders Center, Detroit, MI 48202, USA.
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Gunn JM, Palmer VJ, Dowrick CF, Herrman HE, Griffiths FE, Kokanovic R, Blashki GA, Hegarty KL, Johnson CL, Potiriadis M, May CR. Embedding effective depression care: using theory for primary care organisational and systems change. Implement Sci 2010; 5:62. [PMID: 20687962 PMCID: PMC2925331 DOI: 10.1186/1748-5908-5-62] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 08/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. METHODS We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. RESULTS Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences. CONCLUSIONS Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.
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Affiliation(s)
- Jane M Gunn
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Victoria J Palmer
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Christopher F Dowrick
- Department of Primary Care, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool, UK
| | - Helen E Herrman
- Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Frances E Griffiths
- Centre for Primary Health Care Studies, Warwick Medical School, University of Warwick, UK
| | - Renata Kokanovic
- Department of Sociology, School of Political and Social Enquiry, Monash University, Australia
| | - Grant A Blashki
- Nossal Institute for Global Health, The University of Melbourne, Australia
| | - Kelsey L Hegarty
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Caroline L Johnson
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Maria Potiriadis
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Carl R May
- Institute of Health and Society, Newcastle University, UK
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Furler J, Kokanovic R, Dowrick C, Newton D, Gunn J, May C. Managing depression among ethnic communities: a qualitative study. Ann Fam Med 2010; 8:231-6. [PMID: 20458106 PMCID: PMC2866720 DOI: 10.1370/afm.1091] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Clinical care for depression in primary care negotiates a path between contrasting views of depression as a universal natural phenomenon and as a socially constructed category. This study explores the complexities of this work through a study of how family physicians experience working with different ethnic minority communities in recognizing, understanding, and caring for patients with depression. METHODS We undertook an analysis of in-depth interviews with 8 family physicians who had extensive experience in depression care in 3 refugee patient groups in metropolitan Victoria and Tasmania, Australia. RESULTS Although different cultural beliefs about depression were acknowledged, the physicians saw these beliefs as deeply rooted in the recent historical and social context of patients from these communities. Traumatic refugee experiences, dislocation, and isolation affected the whole of communities, as well as individuals. Physicians nevertheless often offered medication simply because of the impossibility of addressing structural issues. Interpreters were critical to the work of depression care, but their involvement highlighted that much of this clinical work lies beyond words. CONCLUSIONS The family physicians perceived working across cultural differences, working with biomedical and social models of depression, and working at both community and individual levels, not as a barrier to providing high-quality depression care, but rather as a central element of that care. Negotiating the phenomenon rather than diagnosing depression may be an important way that family physicians continue to work with multiple, contested views of emotional distress. Future observational research could more clearly characterize and measure the process of negotiation and explore its effect on outcomes.
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Affiliation(s)
- John Furler
- Primary Care Research Unit, Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Victoria 3053.
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