Maintaining face in the presentation of depression: constraining the therapeutic potential of the consultation

Epistemic justice is the basis of shared decision making

BACKGROUND

There is little evidence that share decision-making (SDM) is being successfully implemented, with a significant gap between theory and clinical practice. In this article we look at SDM explicitly acknowledging its social and cultural situatedness and examine it as a set of practices (e.g. actions, such as communicating, referring, or prescribing, and decisions relating to them). We study clinicians' communicative performance as anchored in the context of professional and institutional practice and within the expected behavioural norms of actors situated in clinical encounters.

DISCUSSION

We propose to see conditions for shared decision-making in terms of epistemic justice, an explicit acknowledgment and acceptance of the legitimacy of healthcare users and their accounts and knowledges. We propose that shared decision-making is primarily a communicative encounter which requires both participants to have equal communicative rights. It is a process that is started by the clinician's decision and requires the suspension of their inherent interactional advantage.

CONCLUSION

The epistemic-justice perspective we adopt leads to at least three implications for clinical practices. First, clinical training must go beyond the development of communication skills and focus more on an understanding of healthcare as a set of social practices. Second, we suggest medicine develop a stronger relationship with humanities and the social sciences. Third, we advocate that shared decision-making has issues of justice, equity, and agency at its core.

Barriers and facilitators to GP-patient communication about emotional concerns in UK primary care: a systematic review

BACKGROUND

In the UK, general practitioners (GPs) are the most commonly used providers of care for emotional concerns.

OBJECTIVE

To update and synthesize literature on barriers and facilitators to GP-patient communication about emotional concerns in UK primary care.

DESIGN

Systematic review and qualitative synthesis.

METHOD

We conducted a systematic search on MEDLINE (OvidSP), PsycInfo and EMBASE, supplemented by citation chasing. Eligible papers focused on how GPs and adult patients in the UK communicated about emotional concerns. Results were synthesized using thematic analysis.

RESULTS

Across 30 studies involving 342 GPs and 720 patients, four themes relating to barriers were: (i) emotional concerns are difficult to disclose; (ii) tension between understanding emotional concerns as a medical condition or arising from social stressors; (iii) unspoken assumptions about agency resulting in too little or too much involvement in decisions and (iv) providing limited care driven by little time. Three facilitative themes were: (v) a human connection improves identification of emotional concerns and is therapeutic; (vi) exploring, explaining and negotiating a shared understanding or guiding patients towards new understandings and (vii) upfront information provision and involvement manages expectations about recovery and improves engagement in treatment.

CONCLUSION

The findings suggest that treatment guidelines should acknowledge: the therapeutic value of a positive GP-patient relationship; that diagnosis is a two-way negotiated process rather than an activity strictly in the doctor's domain of expertise; and the value of exploring and shaping new understandings about patients' emotional concerns and their management.

General practitioners' perspectives on chronic care consultations for patients with a history of cancer: a qualitative interview study

Background

General practitioners (GPs) are responsible for managing chronic care in the growing population of patients with comorbid chronic conditions and cancer. Studies have shown, however, that cancer patients are less likely to receive appropriate chronic care compared to patients without cancer. Patients say that how GPs engage in the care of comorbidities influences their own priority of these conditions. No studies have explored GPs’ attitudes to and prioritization of chronic care in patients who have completed primary cancer treatment. This study aims to explore GPs’ experiences, prioritization of, and perspectives on treatment and follow-up of patients with cancer and comorbidity.

Methods

Semi-structured interviews were conducted during 2016 with 13 GPs in Region Zealand in Denmark. We used Systematic Text Condensation in the analysis.

Results

All participating GPs said that chronic care in patients with a history of cancer was a high priority, and due to a clear structure in their practice, they experienced that few patients were lost to follow-up. Two different approaches to chronic care consultations were identified: one group of GPs described them as imitating outpatient clinics, where the GP sets the agenda and focuses on the chronic condition. The other group described an approach that was more attuned to the patient’s agenda, which could mean that chronic care consultations served as an “alibi” for the patients to disclose other matters of concern.

Both groups of GPs said that chronic care consultations for these patients supported normalcy, but in different ways. Some GPs said that offering future appointments in the chronic care process gave patients hope and a sense of normalcy. Other GPs strove for normalcy by focusing exclusively on the chronic condition and dealing with cancer as cured.

Conclusions

The participating GPs gave a high priority to chronic care in patients with a history of cancer. Some GPs, however, followed a rigorous agenda. GPs should be aware that a very focused and biomedical approach to chronic care might increase fragmentation of care and collide with a holistic and patient-centered approach. It could also affect GPs’ self-perception of their role and the core values of general practice.

A qualitative study of nurses' clinical experience in recognising low mood and depression in older patients with multiple long-term conditions

AIMS AND OBJECTIVES

To explore how nurses' recognise depression in older patients with multiple long-term conditions and the strategies they use to support the patient.

BACKGROUND

Depression decreases an older person's quality of life and sense of wellness, and increases functional impairment. The positive role of nurses working with patients with long-term conditions is now being recognised internationally; however, there is a gap in the research about how nurses recognise depression in older patients and how this impacts on their practice.

DESIGN

This is a qualitative study informed by a constructivist grounded theory approach.

METHODS

In-depth telephone interviews were conducted with 40 nurses working in geographically diverse areas in New Zealand.

RESULTS

Having the conversation with older patients about their low moods, or specifically about depression was not something that all the nurses had, or felt they could have. While some nurses knew they could provide specific advice to patients, others believed this was not their responsibility, or within the scope of their role.

CONCLUSION

Faced with an increasing number of older people with long-term conditions, one of which maybe depression itself or as a result of living with other long-term conditions, ongoing monitoring and support pathways are necessary to prevent further decline in the older person's quality of life and well-being.

RELEVANCE TO CLINICAL PRACTICE

Nurses in primary health care can build on current knowledge and skills to increase their capability to promote 'ageing well' with older people who have long-term conditions and depression.

'This wound has spoilt everything': emotional capital and the experience of surgical site infections

In this article we explore the experience of suffering from a surgical site infection, a common complication of surgery affecting around 5 per cent of surgical patients, via an interview study of 17 patients in the Midlands in the UK. Despite their prevalence, the experience of surgical site infections has received little attention so far. In spite of the impairment resulting from these iatrogenic problems, participants expressed considerable stoicism and we interpret this via the notion of emotional capital. This idea derives from the work of Pierre Bourdieu, Helga Nowotny and Diane Reay and helps us conceptualise the emotional resources accumulated and expended in managing illness and in gaining the most from healthcare services. Participants were frequently at pains not to blame healthcare personnel or hospitals, often discounting the infection's severity, and attributing it to chance, to 'germs' or to their own failure to buy and apply wound care products. The participants' stoicism was thus partly afforded by their refusal to blame healthcare institutions or personnel. Where anger was described, this was either defused or expressed on behalf of another person. Emotional capital is associated with deflecting the possibility of complaint and sustaining a deferential and grateful position in relation to the healthcare system.

A qualitative study of primary care professionals' views of case finding for depression in patients with diabetes or coronary heart disease in the UK

BACKGROUND

Routinely conducting case finding (also commonly referred to as screening) in patients with chronic illness for depression in primary care appears to have little impact. We explored the views and experiences of primary care nurses, doctors and managers to understand how the implementation of case finding/screening might impact on its effectiveness.

METHODS

Two complementary qualitative focus group studies of primary care professionals including nurses, doctors and managers, in five primary care practices and five Community Health Partnerships, were conducted in Scotland.

RESULTS

We identified several features of the way case finding/screening was implemented that may lead to systematic under-detection of depression. These included obstacles to incorporating case finding/screening into a clinical review consultation; a perception of replacing individualised care with mechanistic assessment, and a disconnection for nurses between management of physical and mental health. Far from being a standardised process that encouraged detection of depression, participants described case finding/screening as being conducted in a way which biased it towards negative responses, and for nurses, it was an uncomfortable task for which they lacked the necessary skills to provide immediate support to patients at the time of diagnosis.

CONCLUSION

The introduction of case finding/screening for depression into routine chronic illness management is not straightforward. Routinized case finding/screening for depression can be implemented in ways that may be counterproductive to engagement (particularly by nurses), with the mental health needs of patients living with long term conditions. If case finding/screening or engagement with mental health problems is to be promoted, primary care nurses require more training to increase their confidence in raising and dealing with mental health issues and GPs and nurses need to work collectively to develop the relational work required to promote cognitive participation in case finding/screening.

Depression: the ambivalence of diagnosis

The diagnosis of depression in the clinical context is extremely controversial and is subject to criticism of over-medicalisation and pharmaceuticalisation. Depression can be conceptualised across the entire spectrum of lay and medical belief, from the 'normal' highs and lows of the human condition to its inclusion in the dominant Diagnostic and Statistical Manual of Mental Disorders classificatory system, as a form of serious mental illness. In this context, a better understanding of how people describe, experience, negotiate and participate in the process of diagnosis is needed. This article draws on qualitative interviews to explore lay accounts of being diagnosed with depression. The findings reveal that lay accounts of depression vacillate in and out of the medicalised discourse of depression, highlighting the limitations of the biomedical approach to diagnosis and treatment.

Participants' experiences of being debriefed to placebo allocation in a clinical trial

Participants in placebo-controlled clinical trials give informed consent to be randomized to verum or placebo. However, researchers rarely tell participants which treatment they actually received. We interviewed 4 participants in a trial of acupuncture for irritable bowel syndrome before, during, and after they received a course of placebo treatments over 6 weeks. During the final interview, we informed participants that they had received a course of placebo treatments. We used an idiographic phenomenological approach based on the Sheffield School to describe each participant's experiences of being blinded to and then debriefed to placebo allocation. The participants' experiences of blinding and debriefing were embodied, related to their goals in undertaking the study, and social (e.g., embedded in trusting and valued relationships with acupuncturists). We suggest ways in which debriefing to placebo allocation can be managed sensitively to facilitate positive outcomes for participants.

The interpretation of low mood and worry by high users of secondary care with medically unexplained symptoms

BACKGROUND

Around 1% of adults are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS); many of these patients have depression and anxiety disorders which are unrecognized or inadequately treated. We aimed to investigate the ways patients with MUS and their General Practitioners (GPs) interpret low mood and worry, whether they regard them as depressive or anxiety disorders and how they relate them causally to symptoms.

METHODS

We carried out semi-structured interviews with 27 patients who had been repeatedly referred to specialists for MUS and their GPs and analysed transcripts by qualitative comparison. The analysis examined themes relating to low mood and worry, and their influence on symptoms. It drew on the concept of "otherness", whereby mental phenomena can be located either within the self or as separate entities.

RESULTS

Both patients and GPs acknowledged the presence of low mood and worry. They viewed low mood as either an individual's personal response to circumstances (including their physical symptoms) or as the illness called "depression"; only the latter was amenable to medical intervention. Worry was seen as a trait rather than as a symptom of an anxiety disorder. While low mood and worry were acknowledged to influence physical symptoms, they were considered insufficient to be the main cause by either the patients or their doctors.

CONCLUSIONS

Patients with MUS who are high users of secondary care services interpret low mood and worry in ways which allow them to be discussed with professionals, but not as the cause of their physical symptoms.

Are some more equal than others? Social comparison in self-management skills training for long-term conditions

BACKGROUND

Social comparisons influence self-evaluation and social and psychological adjustment to illness but are under-explored in relation to self-skills training group situations.

METHODS

A longitudinal qualitative study embedded within an RCT of a national programme of lay led self-care support in England (Department of Health, 2001). In-depth interviews were undertaken with a purposeful maximum variation sample of recruits. Data were analysed thematically. Three key themes emerged highlighting (1) the experience of group participation and interaction, (2) the process and (3) function of social comparison.

RESULTS

Data highlight the salience of social comparison as an underlying feature of the group dynamics of self-care skills training. The nature, dimensions and scope of social comparisons extend beyond the cognitive states and dimensions traditionally forming the focus of social-psychological approaches to social comparison to include wider dimensions including entitlement to resources. The results confirm the tendency to make positive comparisons that result in beneficial self-evaluations. However, positive comparisons allow respondents to present themselves as socially and morally worthy, which may act to mask the identification of appropriate need and inequalities.

CONCLUSION

Social comparisons function both as an accurate representation of internal cognitive states but also constitutes identity work involving competing values and moral requirements. We show that even those who report significant needs will sometimes portray themselves in a way that suggests positive social comparisons, which fit with a rationed and morally prescriptive and acceptable view of entitlement to NHS services. Such insights suggest that social comparisons in initiatives such as the EPP may be beneficial for some but exacerbate rather than alleviate health inequalities in long-term condition management for others.

Struck by lightning or slowly suffocating - gendered trajectories into depression

BACKGROUND

In family practice depression is a common mental health problem and one with marked gender differences; women are diagnosed as depressed twice as often as men. A more comprehensive explanatory model of depression that can give an understanding of, and tools for changing, this gender difference is called for. This study explores how primary care patients experience, understand and explain their depression.

METHODS

Twenty men and women of varying ages and socioeconomic backgrounds diagnosed with depression according to ICD-10 were interviewed in-depth. Data were assessed and analyzed using Grounded Theory.

RESULTS

The core category that emerged from analysis was "Gendered trajectories into depression". Thereto, four categories were identified - "Struck by lightning", "Nagging darkness", "Blackout" and "Slowly suffocating" - and presented as symbolic illness narratives that showed gendered patterns. Most of the men in our study considered that their bodies were suddenly "struck" by external circumstances beyond their control. The stories of study women were more diverse, reflecting all four illness narratives. However, the dominant pattern was that women thought that their depression emanated from internal factors, from their own personality or ways of handling life. The women were more preoccupied with shame and guilt, and conveyed a greater sense of personal responsibility and concern with relationships.

CONCLUSION

Recognizing gendered narratives of illness in clinical consultation may have a salutary potential, making more visible depression among men while relieving self-blame among women, and thereby encouraging the development of healthier practices of how to be a man or a woman.

"Medication career" or "moral career"? The two sides of managing antidepressants: a meta-ethnography of patients' experience of antidepressants

The UK National Institute for Clinical Excellence (NICE) Clinical Guidelines recommend routine prescription of antidepressants for moderate to severe depression. While many patients accept a prescription, one in three do not complete treatment. We carried out a meta-ethnography of published qualitative papers since 1990 whose focus is patients' experience of antidepressant use for depression, in order to understand barriers and facilitators to concordance and inform a larger qualitative study investigating antidepressant use over time. A systematic search of five databases was carried out, supported by hand searches of key journals, writing to first authors and examining reference lists. After piloting three critical appraisal tools, a modified version of the CASP (Critical Appraisal Skills Programme) checklist was used to appraise potentially relevant and qualitative papers. We carried out a synthesis using techniques of meta-ethnography involving translation and re-interpretation. Sixteen papers were included in the meta-ethnography. The papers fall into two related groups: (1) Papers whose focus is the decision-making relationship and the ways patients manage their use of antidepressants, and (2) Papers whose focus is antidepressants' effect on self-concept, ideas of stigma and its management. We found that patients' experience of antidepressants is characterised by the decision-making process and the meaning-making process, conceptualised here as the 'medication career' and 'moral career'. Our synthesis indicates ways in which general practitioners (GPs) can facilitate concordant relationships with patients regarding antidepressant use. First, GPs can enhance the potential for shared decision-making by reviewing patients' changing preferences for involvement in decision-making regularly throughout the patient's 'medication career'. Second, if GPs familiarise themselves with the competing demands that patients may experience at each decision-making juncture, they will be better placed to explore their patients' preferences and concerns--i.e. their 'moral career' of medication use. This may lead to valuable discussion of what taking antidepressants means for patients' sense of self and how their treatment decisions may be influenced by a felt sense of stigma.

Exploring men's and women's experiences of depression and engagement with health professionals: more similarities than differences? A qualitative interview study

Background

It is argued that the ways in which women express emotional distress mean that they are more likely to be diagnosed with depression, while men's relative lack of articulacy means their depression is hidden. This may have consequences for communicating with health professionals. The purpose of this analysis was to explore how men and women with depression articulate their emotional distress, and examine whether there are gender differences or similarities in the strategies that respondents found useful when engaging with health professionals.

Methods

In-depth qualitative interviews with 22 women and 16 men in the UK who identified themselves as having had depression, recruited through general practitioners, psychiatrists and support groups.

Results

We found gender similarities and gender differences in our sample. Both men and women found it difficult to recognise and articulate mental health problems and this had consequences for their ability to communicate with health professionals. Key gender differences noted were that men tended to value skills which helped them to talk while women valued listening skills in health professionals, and that men emphasised the importance of getting practical results from talking therapies in their narratives, as opposed to other forms of therapy which they conceptualised as 'just talking'. We also found diversity among women and among men; some respondents valued a close personal relationship with health professionals, while others felt that this personal relationship was a barrier to communication and preferred 'talking to a stranger'.

Conclusion

Our findings suggest that there is not a straightforward relationship between gender and engagement with health professionals for people with depression. Health professionals need to be sensitive to patients who have difficulties in expressing emotional distress and critical of gender stereotypes which suggest that women invariably find it easy to express emotional distress and men invariably find it difficult. In addition it is important to recognise that, for a minority of patients, a personal relationship with health professionals can act as a barrier to the disclosure of emotional distress.