Treatment resistant depression in primary care: co-constructing difficult encounters

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.

Early Cognitive Decline and its Impact on Spouse's Loneliness

Background

Loneliness is common in dementia caregivers as cognitive impairment (CI) alters marital and social relationships. Unexplored is how an individual's loneliness is affected at earlier, more ambiguous, periods of their spouse's CI.

Methods

Using the Health and Retirement Study, our study participants included 2,206 coupled individuals with normal cognitive function at the 2006/8 baseline. Loneliness outcomes at baseline, 4-year and 8-year follow-up are assessed by the status of transition to cognitive impairment no dementia (TCIND) (2010/12 & 2014/16) using linear mixed models.

Results

Individual's loneliness was stable when their spouse's cognition remained normal, but increased with the spouse's TCIND. The increase in loneliness did not vary by gender.

Conclusions

Loneliness, a key risk factor for reduced life quality and increased depression, increases even at early stages of a partner's CIND. This work suggests the potential impact of early intervention and social support for partners of individuals with CIND.

To support and not to cure: general practitioner management of loneliness

Loneliness is associated with numerous detrimental effects on physical health, mental health, cognition and lifestyle. Older adults are one of the groups at highest risk of loneliness, and indeed about 46% of older adults in England feel lonely. Those experiencing loneliness visit their general practitioner (GP) more frequently than those who are not, which has the capacity to put a strain on GPs and primary care waiting lists and costs. This study's aim was to explore GPs' views and experiences of loneliness within their older adult patients, and to understand GPs' awareness and feelings of agency within this. Nineteen UK GPs were recruited using purposive sampling and snowballing techniques. Individual semi-structured interviews were conducted either in person or over the telephone. Data were analysed using thematic analysis. Four overarching themes were identified from the data: Whose responsibility is it anyway?, Pandora's box of shame; Keeping distance; and Community responsibility. Themes emphasise that GPs tend to hold a medicalised and individualistic view of loneliness. This intensifies stigma which in turn creates barriers to raising the topic. GPs felt powerless in their ability to fix the 'problem' and tended to believe that the solution had to lie in the community, the individual or in social care rather than in primary care. The findings are discussed in the context of literature on GP management of other social problems which give rise to similar issues concerning the restrictions of the medical model and the need for joined-up approaches in which the GP is one part of a wider social support structure. It is suggested that it might be useful for training and support for GPs to address management of social problems jointly rather than training specific to loneliness which GPs tend to see as peripheral to their core remit.

How do healthcare professionals interview patients to assess suicide risk?

BACKGROUND

There is little evidence on how professionals communicate to assess suicide risk. This study analysed how professionals interview patients about suicidal ideation in clinical practice.

METHODS

Three hundred nineteen video-recorded outpatient visits in U.K. secondary mental health care were screened. 83 exchanges about suicidal ideation were identified in 77 visits. A convenience sample of 6 cases in 46 primary care visits was also analysed. Depressive symptoms were assessed. Questions and responses were qualitatively analysed using conversation analysis. χ ² tested whether questions were influenced by severity of depression or influenced patients' responses.

RESULTS

A gateway closed question was always asked inviting a yes/no response. 75% of questions were negatively phrased, communicating an expectation of no suicidal ideation, e.g., "No thoughts of harming yourself?". 25% were positively phrased, communicating an expectation of suicidal ideation, e.g., "Do you feel life is not worth living?". Comparing these two question types, patients were significantly more likely to say they were not suicidal when the question was negatively phrased but were not more likely to say they were suicidal when positively phrased (χ ² = 7.2, df = 1, p = 0.016). 25% patients responded with a narrative rather than a yes/no, conveying ambivalence. Here, psychiatrists tended to pursue a yes/no response. When the patient responded no to the gateway question, the psychiatrist moved on to the next topic. A similar pattern was identified in primary care.

CONCLUSIONS

Psychiatrists tend to ask patients to confirm they are not suicidal using negative questions. Negatively phrased questions bias patients' responses towards reporting no suicidal ideation.

Oral Health in Electroconvulsive Therapy: A Neglected Topic

Psychiatric medications may have serious and untoward adverse effects such as blurred vision, restlessness, agranulocytosis, muscle rigidity, and tremors. When compared to medications, electroconvulsive therapy (ECT) is becoming a more acceptable treatment due to its efficacy, tolerability, and minimal adverse effect profile. Oral trauma can be an ECT-related adverse effect. We reviewed the published literature on oral health and dental protection in patients undergoing ECT, and found that there are deficits in all guidelines on dental protection during ECT. Dental assessment and treatment before and after ECT is warranted. Given the increased risk of poor oral health in psychiatric patients, and the continued evolution of ECT as a mainstay treatment, it is important that studies be conducted to determine the optimal method of oral protection. If adequate care can be ensured, the risks of ECT-induced oral trauma will be minimized.