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Mixed Methods Review: Depression, Communication and Primary Health Care
Summaries
*** indicates a study that was not part of the original literature sample but was
added in following analysis of these papers e.g. their literature reviews used key
papers that had hitherto been missed by the first literature scoping.
Mixed methods (mainly qual, using quant for sampling)
Umesh T Kadam et al ‘A qualitative study of patients’ views on anxiety and
depression’2001
Aim of study, to examine what patients think about depression, as research has tended
to focus on non-detection. Semi structured individual and focus group interviews with
27 individuals, taken from primary care (sampled using quant scale). Current
evidence based emphasis is on improving detection and drug usage. But this study
found that patients describe personal and professional barriers to seeking help and
have particular views about treatment options. Scepticism about drug therapy in
particular, preference for counselling/talking therapies. Some of the barriers: shame/
people thinking they should ‘pull themselves together’ which led to concealment of
symptoms. Many had used their own initiatives in seeking self-help. Many had
reservations about consulting a GP as they thought that GPs were ‘too busy’ to deal
with something so ‘trivial’. Also thought that GPs would only prescribe drugs. Also
there were problems with getting an appointment within a suitable time frame i.e. they
wanted to talk to someone in that moment, not in days or weeks time. Further research
on the degree to which patients perceive the GP environment as encouraging them to
discuss mental health needs. Gps find it difficult to address these problems in routine
consultations due to time restraints- patients reported symptoms on self report
questionnaire that they were not willing to discuss with GP.
Switzer et al. ‘Pull yourself up by the bootstraps’: A Response to depression In older
Adults’ 2006
Addressing the problem of why older adults typically do not seek treatment for
depression or stick to it when they do. Uses cultural model of depression to
understand the problem. Patient behaviour is often a logical extension of the beliefs
they hold about the illness and what to do about it. A cultural model= largely
unspoken attitudes, stances and beliefs about illness and the way it should be treated
that are shared among a group of people. The perception about the appropriate
management of depression has important implications for whether older adults discuss
depression with their doctors . Based on 71 open ended interviews with people aged
65 and older following their participation in a year long spectrum study- collected
structured survey data related to participants’ psychological, cognitive and physical
status. Common themes- pulling yourself out of the depths of depression is the
individual’s responsibility; rejection of self-indulgence or self-pity. Not denying
depression, but underemphasising the need to outside medical help. Health Care
Providers only do an ancillary role GPs should incorporate an understanding of the
role for personal responsibility in their discussions with patients.
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Burroughs et al. ‘Justifiable Depression: How Primary Care Professionals and
Patients View Late-Life Depression? A Qualitative Study’2006
Participants were taken from a feasibility study of an intervention in primary carePrimary Care intervention for Depression in the Elderly (PRIDE) 20 patients over the
age of 60 took part as well as 15 primary care practitioners- 9 GPs, 3 practice nurses,
2 district nurses and 1 community nurse. Problems with communication- older
patients may view depression not as something they should consult for- trivial. They
may complain less about psychological symptoms and instead present with somatic
ones. Physical co-morbidity may make identification harder, they may misattribute
symptoms of major depression as being to do with old age, ill health or grief. Think
anti depressants are addictive. GPs- may be wary of broaching the subject for fear of
opening a ‘pandora’s box’. In deprived areas, GPs may treat depression as a rational
response to difficult circumstances. The patient-practitioner relationship is important
in influencing the diagnosis and management of depression. Older adults may have
difficulties attending different sites for psychiatric treatments. HCPs took part in semi
structured interviews whereas patients were asked open ended questions. Geriatric
Depression Scale used to measure depression. HCPs often saw depression as
justifiable/understandable in later life. GPs perceived a reluctance on part of elderly to
accept the diagnosis of depression as they saw it as a sign of weakness- were not
accustomed to taking that sort of problem to the doctor. Drs don’t want to diagnose it
because they have nothing to treat it with. GPs are generalists, i.e. they don’t
specialise in one area and therefore might not be the most appropriate people to report
depression to.
Mixed Methods (Mainly Quant)
**** Cegala, D. and D.Post. 2009. ‘The Impact of Patients’ Participation on
Physicians’ Patient-Centred Communication’ in Patient Education and Counseling.
2009 [In Press]
Study to determine how patient participation in consultation affects physician
participation. Not specifically on depression. The same 25 physicians were observed
interacting with high and low participating patients. Demographic info taken from
patients beforehand, and both physician and patient completed questionnaire after the
consultation. Used PACE coding system to conduct thematic analysis (translated
themes into units based on who said it, the order in which it was said, what the
function of the utterance was). The transcripts were also coded for evidence of patient
centred communication, they were slotted into pre-determined codes and used as a
dependent variables in the quantitative analysis. When interacting with high
participating patients, physicians engaged more in patient centred communication.
Sleath and Rubin. Gender, ethnicity and physician-patient communication about
depression and anxiety in primary care, 2002
Study to examine the impact of gender and ethnicity on communication about
depression and anxiety in primary care. Many Physicians fail to recognise depression
and emotional distress. Research has shown that patients only hint at the problem and
rely on physicians to probe for more information. Other studies have revealed that the
more questions a physician asks about feelings and affect, the more likely a diagnosis
of depression. How well a patient knows the physician (familiarity) also facilitates
diagnosis. Female physicians more likely to ask patients about psychosocial issues
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and female patients more likely to be actively involved in the medical encounter,
asking questions etc. Patients from diverse backgrounds often have different ways of
expressing it. Previous research has shown that physicians are better at asking
questions to non-hispanic white patients rather than Hispanic patients. Do patients
communicate better with a physician of the same ethnic background? What about
language barriers? 27 resident physicians audiotaped 6-21 of their consultations in
New Mexico. After each audiotaped interaction, the physician filled in a questionnaire
about the consultation. Patients were also interviewed after the consultation to obtain
data about age, general health, familiarity with physician etc. Depression was more
likely to be brought up by patients who rated their mental health poorly. What was
interesting is that whether patients saw physicians of the same gender and ethnicity as
themselves did not significantly influence any aspect of physician-patient interaction.
Female patients more likely to bring it up than males, as were more highly educated
patients. When anxiety was discussed, physicians asked males significantly more
questions than females. It may also be that physicians do not always pick up on
patient ‘cues’. Physicians need to pick up on cues more and ask more open ended
questions.
Carney et al. How Physician Communication Influences Recognition of Depression in
Primary Care 1999
Used unannounced visits by actors playing standardized patients to evaluate verbal
communication between physicians and a patient presenting with minor depression.
They played a 26 year old with chronic headaches. Physicians knew that they would
be visited but did not know that it would be for depression, and it was over a one year
period. After the consultation, the standardized patient filled in a checklist about how
physicians pursued the complaints. Physicians were debriefed after the consultation
and these telephone conversations were recorded and transcribed. A practice survey
was also completed before the visit to provide information on the surgery. Found that
they type of questions asked influenced whether or not physicians discovered the
depression. Looked at the blend of broad/narrow questioning. Looked at whether
physicians interrupted patients to direct the consultation. 43 out of 59 were successful
in identifying depression. Physicians who recognised depression asked twice as many
questions about feelings and affect than those who did not. Recognition tended to
happen at the beginning of the encounter.
Cape and McCulloch. 1999. ‘Patients’ Reasons for not presenting emotional
problems in general practice consultations’ in British Journal of General Practice
From 9 general practices, a sample of patients with high General Health
Questionnaire scores, who planned to present only somatic symptoms to the GP were
interviewed after their consultation for their reasons of not broaching emotional issues
(semi structured). On the basis of the patients’ answers to the semi structured
questions, the interviewer made ratings of the chronicity since onset of problems,
whether the emotional problems interfered with daily life or if patients were able to
cope with them. The interviewer also judged their answers against an 18 point scale to
categorise their reasons for not mentioning emotional problems to their GP. A patient
satisfaction questionnaire was also administered. Data analysis undertaken with SPSS.
The main reason for not presenting emotional problems was lack of time, followed by
the perception that doctors cannot help them.
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Pure Mixed Methods Research
Barg, F. K.. Huss-Ashmore R., Wittink, M., Murray, G., Bogner, H. and J. Gallo.
2006. A Mixed-Methods Approach to Understanding Loneliness and Depression in
Older Adults The Journals of Gerontology Series B: Psychological Sciences and
Social Sciences 61 329-339.
Mixed Methods (multi phase) approach to understand how older people conceptualise
depression and the reasons why they do not accept treatment. Rationale for using
mixed methods: Quant studies can measure the duration, number and
presence/absence of a number of symptoms according to a standardized definition of
depression, however qual studies capture the contextual factors that affect the
experience of depression or the meaning that depression has for people. They can be
complementary conceptual frameworks. “.. in order to illustrate how research
methods from diverse epistemological traditions yield a more nuanced picture about
the experience of depression in older adults than would be gained from a single
research method”. Lack of understanding/acceptance of depression, especially among
African Americans. Older adults may be inclined to describe depressive symptoms in
terms of loneliness
Purposeful sample of 102 patients aged over 65 years of age recruited with and
without depressive symptoms from primary care. Methods used= consensus analysis,
semi-structured interviews, standardised assessments in order to understand
depression in later life.
Bogner, H., Cahill, E., Frauenhoffer, C. and F. Berg. 2009. Older primary care
patients views regarding antidepressants: a mixed methods approach Journal of
Mental Health 18 (1) 57-64.
A mixed methods design that is both hypothesis testing and hypothesis generating .
Adults ages over 65 were recruited from primary care and interviewed in their homes.
Examined the personal characteristics of older adults according to antidepressant use.
Participants taking antidepressants and those not were asked their views about taking
anti depressants as treatment for depression. Themes relating to the use of anti
depressants were examined.
Buszewicz, M., Pistrang, N., Barker, C., Cape, J. and J. Martin. 2006. ‘Patients’
Experiences of GP Consultations for Psychological Problems’ in British Journal of
General Practice
12 GPs recorded their consultations. If the consultations had a substantial
psychological component (ascertained by content analysis), the participant was
invited to take part in an interview. The consultation was played back and they were
asked to identify the most and least helpful parts. They then completed the Clinical
Interview Schedule-Revised in order to determine which patients met the formal
psychiatric diagnostic criteria.
Found that GPs play a vital role in managing psychological problems
Benoit, C., Westfall, R., Treloar, A., Phillips, R. and S. Jansson. 2007. Social factors
linked to postpartum depression: a mixed-methods longitudinal study Journal of
Mental Health 16 (6) 719-730.
Put posters up in ante natal classes, physician’s office etc. to recruit women.
Interviewed them three times : during their third trimester, at 4-6 weeks postpartum
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and 4-6 months postpartum. The women were asked both open and closed questions
to concurrently gather qualitative and quantitative data. Used Beck Depression
Inventory as well as self reported measures of overall health, as well as physical,
mental and emotional health. They sometimes began with closed questions e.g. rate
your birth on a scale of 1 to 5, and then were asked to elaborate on this. There was
also a written questionnaire at the end of the interview for sensitive questions on
income and depression. Interviews were tape recorded. The analysis was led by the
survey data- certain characteristics- economic resources, maternity care provider and
birth satisfaction were analysed and the qual data were used to expand on the analysis.
Wittink, M, Barg, F. and J. Gallo. 2006. Unwritten Rules of Talking to Doctors About
Depression: Integrating Qualitative and Quantitative Methods Annals of Family
Medicine 4 (4) 302-309.
48 participants over the age of 65 derived from a larger ‘Spectrum study’ to examine
how older primary care patients report depression. Physician analysis rated
participants depression on scale of 1-4 (non-severe) and how well they knew the
patient. Information was obtained on age, sex, ethnicity, marital status, living
arrangements, level of educational attainment and number of visits made to the
practice for medical care within 6 months. Centre for Epidemiological Studies
Depression (CES-D) Scale was used as well as the Beck Anxiety Inventory and Beck
Hopelessness Scale. Semi structure interviews were also carried out in participants’
homes and analysed with N6. Analytic strategy- compared the group of patients who
identified themselves as being depressed whereas their physician did not, and those
whose views were concordant with their physicians’.
Nutting, P., Rost,K., Dickinson, M., Werner, J., Dickinson, P., Smith, J. and B.
Gallovic. 2002. Barriers to Initiating Depression Treatment in Primary Care Practice
Journal General Internal Medicine 17 103-111.
Aim of study- to better understand why GPs and nurses to not implement guidance
concordant acute-care for patients with current major depression. Qualitative
interviews with 12 physicians and nurses were used to develop a checklist of barriers
to depression treatment. This checklist was then completed by the physicians for the
64 patients who had been identified from a trial of depression treatment had failed to
receive guidance-concordant acute care. The physicians weighted each barrier to
treatment on a scale of 1-100 to prioritise barriers.
Priest, R., Vize, C., Roberts, A., Roberts, M., Tylee, A. 1996. Lay people’s attitudes to
treatment of depression: results of opinion poll for defeat depression campaign just
before its launch in BMJ 313 858-859.
A pilot qualitative study was followed up by a quantitative survey. Qual study- 8
group discussions, with 8 people on each pane. Quant- 2003 people were interviewed.
Results show that general public feel that gps are intolerant of depressed people and
think they are neurotic, which explains why there is some reluctance in consulting a
GP.
****Bell, R., Paterniti, D. Azari, R., Duberstein,P., Epstein, R., Rochlen, A., Dwight
Johnson, M., Orrange, S., Slee, C. and R. Kravitz.2009.’Encouraging Patients with
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Depressive Symptoms to Seek Care: A Mixed Methods Approach to Message
Development’ in Patient Education and Counseling[in press]
Study designed to encourage people with depression to seek help, and also to offer
guidance to health care professionals about how to encourage their patients to talk
about emotional problems, and to make appropriate responses. The different sorts to
barriers to seeking care for depression were discussed with 3 focus groups, each with
5 participants who had personal/familial history of depression. The focus groups were
devised to elicit the sorts of beliefs and ideas that prevent individuals getting
appropriate help/care for depression. These beliefs were then translated into
‘messages’ that could be used in campaigns to encourage people to report depression,
or as responses to patients’ concerns in primary care. The popularity/usefulness of the
messages was then tested through an online survey through a health related internet
commuity. 249 surveys were completed by those with a past diagnosis of unipolar
depression. Each message was rated by importance values.
Multi- Method Quantitative Studies
**** Adelman, R., Greene, M., Friedman, E. and M.A. Cook. 2008. ‘Discussion of
Depression in Follow-Up Visits with Older Patients’ in Journal of the American
Geriatrics Society
Convenience sample of 482 audiotaped consultations. 376 community dwelling older
patients and 43 primary care physicians. Audiotapes analysed using the MultiDimensional Interaction Analysis system to determine the content and process of
medical conversations. Patients then completed the Medical outcomes study 36 item
short form survey questionnaires immediately after the visit.
Depression was discussed in 7.3% of visits and physicians raised it in 41% of visits.
Physicians with geriatric training were more likely to mention it.
****Duberstein, R., Chapman, B., Epstein, R., McKollumm, K. and R. Kravtiz. 2008.
‘Physician Personality Characteristics and Inquiry about Mood Symptoms in Primary
Care’ in Journal of Internal Medicine
Secondary data analysis of data from randomised controlled trial. Forty Six physicians
were visited by standardized patients, one with major depression, and one with an
adjustment disorder. The consultations were audiotaped and the sps completed a form
on doctoring behaviour and symptom inquiry. For assessment of diagnostic
documentation, medical records were reviewed. Physician personality was assessed
with NEO-PI-R. Physicians who were more dutiful and vulnerable were more likely
to document a diagnosis of depression.
**** Novosel, Marie. 2007. ‘Depressive Symptomatology, patient-provider
communication, and patient satisfaction: a multi level analysis’ PhD thesis:
University of South Florida
123 patient-provider encounters tape recorded, encounters analysed with Roter
Interaction Analysis System (8 verbal communication methods) categorized by
speaker, type of utterance and content of utterance. Depression is associated with, but
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does not predict increased provider perceived difficulty in the patient-provider
relationship.
**** Monica Mohaglegh. 2006. ‘Depression and the Quality of Physician-Patient
Communication in Diabetes Patients’ (Thesis: Alliant International University)
408 structured interviews with patients in 2 primary care clinics at San Fransisco
General Hospital (all with Type 2 Diabetes)
Depression was measured using CESD-10 and communication was measured using
the 20 communication items from the Interpersonal Processes of Care in Diverse
Populations Questionnaire (IPC) which contains 7 subscales.
Patients who reported non-optimal communication had higher CESD-10 scores
Weich, S., Morgan, L., King, M. and I. Nazareth. 2007. ‘Attitudes to Depression and
its Treatment in Primary Care’ Psychological Medicine 37 1239-1248.
Cross sectional survey of 866 individuals with confirmed history of depression in the
12 months preceding interview, extracted from 36 GPs surgeries. Attitudes and beliefs
about depression were extracted using a 19 point self-report questionnaire.
People with moderate or severe depression have subtle and divergent views about this
condition, its outcome, and appropriate help. Such beliefs should be considered in
primary care as they may significantly impact on help seeking and adherence to
treatment. The attitudes go beyond attitudes to treatment but are actually about the
nature of depression itself.
Robbins, J., Kirmayer, L., Cathebras, P., Yaffe, M. and M. Dworkind. 1994. Physican
Characteristics and the Recognition of Depression and Anxiety in Primary Care
Medical Care 32 (8) 795-812.
Characteristics associated with the recognition of depression and anxiety in primary
care. 55 physicians treating a total of 600 patients completed a measure of
psychosocial orientation, psychological mindedness, self rating of sensitivity to
hidden emotions and a video test of sensitivity to nonverbal communication.
Callahan, E.J., Betrakis, K.D., Azari, R., Robbins, J., Helms, J. and J. Miller.1996.
The influence of Depression on Physician- Patient Interaction in Primary Care
Family Medicine 26 346-51.
508 individuals with depression assigned to 105 primary care physicians. Interactions
video taped and analysed using Davis Observation code. Discovered that failure to
diagnose depression was associated with increased length of time to take medical
history.
Del Piccolo, L. Saltinni, A. and C. Zimmerman. 1998. Which Patients Talk about
Stressful Life Events and Social Problems to the General Practitioner? In
Psychological Medicine 28 1289-1299
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Whilst there have been studies that have examined the way in which physician
characteristics influence disclosures in primary care, but not so much attention has
been paid to patient characteristics. Six experienced male GPs took part- audiotaped
their consultations with all consecutive patients attending for a new illness. Those
who reported a stressful life event with emotional problems were invited to complete
a questionnaire after their consultation, then the GPs completed a form recording the
patients’ name and relevant clinical data. Found that a belief about appropriateness is
a major barrier to patients confiding in their GP. Educational efforts need to be
directed towards the reduction of disclosure thresholds in the many patients who think
it is appropriate, but nevertheless do not disclose.
Volkers, A., Nuyen, J., Verhaak, P. and F. Schellevis. 2004. ‘The problem of
diagnosing major depression in elderly primary care patients’ in Journal of Affective
Disorders
Under-recognition and under-diagnosing of depression is assumed to be more salient
in elderly primary care patients. Younger age and female sex with comorbidity with
anxiety disorder linked to a higher diagnostic rate. Less is known about the influence
of somatic and psychiatric comorbidity on an accurate diagnosis in this age group.
Neurological disorders like dementia and parkinson’s, cardiovascular diseases like
stroke, cancer and metabolic and endocrine disorders are linked to depression and
may distract attention from depression when consulting GP. Taken from Dutch
National Survey of General Practice. Different measures used- General Health
Questionnaire, CAGE questionnaire for alcoholism, Composite International
Diagnostic Interview (CIDI). Further data was collected from the electronic medical
record made at the time the patient contacted the GP. Also got information about drug
prescriptions from Gps. Found that 13.2% of patients with depression were
misclassified as having non-medical problems.
Coyne, J, Schewenk, T. and S. Fechner-Bates. 1995. Nondetection of Depression by
Primary Care Physicians Reconsidered in General Hospital Psychiatry
Research is suggesting that underdetection of depression is a major public health
problem. However, few studies have examined the effects of detection on patient
outcomes, so it is not known whether detection helps them. The relationship of
severity of depression to detection has not been studied extensively. Low detection
rate could be due to physician’s inability to provide effective treatment. Patients
recruited from 50 family physicians in south eastern Michigan. They completed a
screening form which included Center for Epidemiologic Studies Depression Scale
plus demographic info and self ratings on appetite, sleep, energy levels, mood and
stress. Physicians also filled in a form for each attending patient including a direct
question about whether or not they were depressed. Based on the CES-D score, a
subsample of patients were selected for semi structured interview. The physicians
detected little more than a third of the depressed patients. Presence of anxiety, overt
psychological distress made detection more likely.
M. Halter. 2004. The Stigma of Seeking Care and Depression in Archives of
Psychiatric Nursing
Much evidence suggests that depression can be treatable but that help is not sought
because of the stigma of depression- large scale surveys have revealed that people
think that people with depression could just ‘pull themselves together’. It stands to
9
reason that people who hold stigmatising views of depression would also hold
negative attitudes toward seeking care for depression. The study examines the
influence of stigma on care seeking behaviour. Subjects were adults recruited from
waiting areas of two health care facilities. Goal was to obtain a sample that was of
diverse age race and gender. 117 surveys were completed – a demographics data form
(e.g. gender, marital status, race, political affiliation), the second inventory used the
Attribution Questionnaire developed by Corrigan et al (2001), presented a vignettemeasured emotional and behavioural responses to a person with depression. Third
inventory-shortened form of the Attitudes Towards Seeking Professional
Psychological Help Scale. Responses measured on a 4 point Likert scale. Found that
there was a relationship between perceived responsibility between responsibility and
endorsement of health care seeking behaviours, as well as a lesser relationship
between pity and responsibility. Responsibility beliefs were significantly associated
with anger- associated with behavioural response of segregation and coercion. Gender
mediated the connection between stigma and care seeking. Men held Robert
(Vignette) as being more responsible for his condition than women did. Men believe
that depression is caused by genetics, chemical imbalances and stress and yet this
does not translate into help seeking behaviours. Urban respondents more likely to
endorse avoidance and segregation than non-urban respondents.
Van der Pasch, M. and P. Verhaak. 1997. Communication in general practice:
recognition and treatment of mental illness in Patient Education and Counseling
Patients often present their mental health problems as a somatic condition. Some GPs
are more adept at identifying these patients than others. Why? Communication style
may be key to identifying why. Verhaak- the tendency of GPs to interpret complaints
as psychosocial in nature is linked to communication style- bringing up new subjects,
asking many open ended questions, showing empathy and interest, and expressing
various forms of non-verbal behaviour (nodding, agreeing), the length of consultation
time was also linked to a psychosocial diagnosis. Does it matter whether or not it is
recognised because treatment may not affect patient outcomes. The literature presents
conflicting conclusions- early recognition of mental illness has been shown to
beneficial in some cases. Uses secondary data from a study on morbidity of mental
illness carried out in the Netherlands in 1987/1988 (Dutch National Study of
Morbidity and Interventions in General Practice) Gps who took part registered each
contact with every patient over a 3 month period. Each diagnosis made by the GP was
assessed- looked for patients diagnosed with a mental illness. A sample of 15 GPs
consented to taking part in an additional study- observation study (about 25 medical
interviews with random samples of patients recorded onto videotape and
communication style analysed). Secondly, the 15 GPs participated in a longitudinal
follow up study dealing specifically with mental morbidity. To qualify for this study,
patients had to have been assessed by the GP as having complaints that were mainly
‘psychosocial’ in nature, they had to have been diagnosed with a mental illness at
least once. The second group consisted of patients with a somatic diagnosis that had
been assessed by their GP as being mainly ‘psycho social in nature’ = psychosomatic
illnesses. Follow up was over 9 months, GPs recorded details of treatment. In
addition, the patients filled in questionnaires. Gps should be able to recognise
emotional disturbance in otherwise healthy patients as well.
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Tylee, Freeling, Kerry and Burns. 1995. How does the content of consultations affect
the recognition by general practitioners of major depression in women? In British
Journal of General Practice
The recognition of depression is a major issue as it is linked to patient outcomes .
Patient characteristics may be linked to the recognition of depression and what they
say to GPs, as well as in terms of GPs and the kinds of questions they ask patients.
Feeling et al- patients who get their depression missed tend to be the ones who don’t
look depressed, did not believe they were depressed, experienced feelings other than
an exaggeration of misery, had low mean scores for depression and had physical
illness contributing to their depression. They were also more likely to have had their
symptoms for more than a year. Patients with physical illness were 5 times as likely to
have their depression missed than those who had no physical illness. 47 practitioners
in 15 practices agreed to participate – 28 to 70 years old. Women attenders were
eligible if they were 16-65 and had not had depression diagnosed in previous three
months. They completed a 30 minute general health questionnaire and gave consent
for their consultation to be videotaped. Participants who scored over 11 were
administered a psychiatric interview within 3 days of the consultation. In some of the
consultations recognised as depression even where symptoms were not directly
mentioned, suggesting that gps were reading non verbal communication. The
recognition of depression appears to be patient led. Gps are dependent on the
sequence of symptom mentioning in the consultation to diagnose depression.
Brody, D., Khaliq, A. and Thompson, T. 2002. Patients’ perspectives on the
management of emotional distress in primary care settings in Jo9urnal of General
Internal Medicine
Used patient surveys to investigate how patients view the treatment of emotional
distress in primary care in general and also to primary care patients with depression,
to evaluate the types of intervention they would like to see. A lot of primary care
physicians cite patient resistance to diagnosis and adherence to treatment as a major
obstacle to providing care. Handed out surveys to 403 patients, in a subset they also
enrolled the Medical Outcome Study Short Form General Health Survey, also got
physicians to rate patients’ health. Majority of all primary care patients thought that it
was important that their physician helped them with emotional distress. Data suggests
that it might be useful for primary care physicians to ask routinely about the impact of
emotional distress on their patients have been feeling and functioning. Most patients
want counselling over medication of a referral.
*** Tylee, A., Freeling, P. and S. Kerry. 1993. ‘Why do General Practitioners
Recognise Major Depression in One Woman Patient yet Miss it in Another?’ in
British Journal of General Practice
Study designed to uncover whether patient characteristics and the presence/absence of
physical illness affects GPs recognition of major depressive illness in women. 30
item general health questionnaire was used as a first stage screening instrument for
psychiatric morbidity and each patient selected was interviewed usually within three
days of consulting their GP (Clinical interview). 72 women were included with a
major depressive disorder from 36 GPs practices. Each GP provided one patient in
whom depression had been recognised, and one whose depression had been
unrecognised. Few differences were found between the groups. Women with serious
physical disease were five times more likely to have their depression go unrecognised.
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Bucholz, K. and L. Robins. 1987. ‘Who Talks to a doctor about existing Depressive
Illness?’ in Journal of Affective Disorders
Longitudinal study of 218 respondents who had at some point experienced a major
depressive episode. Three structure interviews approximately 6 months apart- social
and demographic info, Diagnostic Interview Schedule, contact with doctors. Loss of
weight was the symptom that most often triggered getting medical help. Weight loss
my trigger others to urge medical consultation. Experiencing a recent decline in
health was also a prompt for a discussion with a health care professional about
depressive symptoms- when health declines, a person may no longer be able to bear
depressive symptoms, or the contact with health care professionals could bring the
opportunity up for them to be discussed. Sex, race, and proportion of somatic
symptoms previously discussed with doctors had no effect.
Freeling, P., Rao, B., Paykel, E., Sireling, L. and R. Burton. 1985. ‘Unrecognised
Depression in General Practice’ in British Medical Journal
Patients attending their GPs were screened using General Health Questionnaire and a
group with unrecognised major depression identified. The group was interviewed and
compared with a group who were correctly recognised as depressed by their GPs.
Those who were unrecognised were less obviously depressed and their illness had
lasted longer. Physical illness present in 13% of those whose depression was
unrecognised and the depression seemed related to it. Patients might benefit it GPs
were better trained to recognise depression.
Multi Method Qualitative Studies
****Wisdom, J., Clarke, G. and C. Green. 2006. ‘What Teens Want: Barriers to
Seeking Care for Depression’ in Administration and Policy in Mental Health
15 in depth interviews and 7 focus groups with teenagers being treated for depression
in primary care. Used grounded theory approach to identify themes. Teenagers
reported faring best when providers actively considered and reflected upon the
teenagers’ developmentally appropriate desires to be normal, to feel connected and to
be autonomous. The providers achieved this by establishing rapport, exchanging
information about depression etiology and treatment and helping teens make decisions
about treatment.
McPherson and Armstrong. 2009. Negotiating Depression in Primary Care: A
Qualitative Study in Social Science and Medicine
Begins with literature review considering the status of diagnostic labels. Interested in
how medicalisation and demedicalisation operate in a clinical context. Twenty Gps
were interviewed, sampled through the use of focus groups. Asked to describe a
patient who have had depression for some time but who have not responded to anti
depressants. Gps tended to define depression in terms of social deviance rather than a
medical label when depression did not respond to treatment.
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Prior, L. Wood, F., Lewis, G. and R. Pill. 2003. Stigma revisited, disclosure of
emotional problems in primary care consultations in Wales in Social Science and
Medicine
Stigma has been shown to be linked to disclosure rates of depression in primary care.
It has been estimated that half of those showing symptoms of depression and anxiety
are not identified during a consultation with their general practitioner. Linked to the
idea that anti depressants are addictive and ineffective. Twenty focus groups
conducted with people- asked to discuss issues relating to the disclosure of emotional
problems. Participants were selected from registers of primary care practices. They
used vignettes to get people talking about the issues. The second exercise involved the
ranking of physical and emotional issues on a scale to rate their significance and
likelihood to consult GP. The study suggested that rather than focusing on the way in
which people suppress depression, it might be more fruitful to look at the kinds of
symptoms and signs that lay people enrol into their framework of illness and
especially psychiatric illness. The evidence suggests that stigma is not an important
factor in the consultation with gps. More significant is the way in which lay people
construct and recognise psychiatric illness, rather than how they consciously mask the
symptoms and signs. They also hold mistaken views about what Gps can do for
depressed people.
McNair, Highet, Hickie and Davenport. 2002. Exploring the Perspectives of people
whose lives have been affected by depression in MJA
Consultative processes were designed to elicit information from a broad range of
people with depression or anxiety and their families or cares. These included public
meetings, focus groups, website-based mechanisms and consultation with existing
consumer and carer organisations. Key themes derived from these range of datadepression is not acknowledged as an illness, there is discrimination in the workplace.
Single Method Qualitative
**** Nutting, p., Gallagber, K., Riley, K., White, S., Dickinson, W. Korsen, N. ad A
Dietrich. 2008. ‘Care management for depression in primary care practice: Findings
from the RESPECT-depression trial’
Semi structured interviews with 42 primary care clinicians from 30 practice sites, 18
care managers and 7 mental health professionals to explore experience and
perceptions with depression care management for patients. Clinicians and care
managers emphasised the need for effective communication amongst themselves as
well as maintaining a consistent and continuous relationship with patients.
**** Maxwell, M. 2005. ‘Making Sense of the Experience of Depression: General
Practitioners’ and Women’s Accounts of the Management of Depression in Primary
Care [Thesis University of Edinburgh]
Qualitative interviews with 37 women and 20 GPs (30 of the women and 19 of the
GPs were revisited 9-12 months later to review the progress of care) Women did not
passively accept GPs advice and diagnosis but evaluated this in relation to their own
experiential, emotional and biographical knowledge. GPs sometimes acted
13
strategically in order to persuade, or coerce patients to accept their advice and
treatment.
Cooper-Patrick, L., Powe, R., Jenckes, M., Gonzales, J., Levine, D. and D. Ford.
2002. Identification of Patient Attitudes and Preferences Regarding the Treatment of
Depression.
Three focus group discussions – experiences with depression, help seeking
behaviours, treatment preferences and perceived barriers to mental health care. Focus
groups with different people- two patient groups (stratified by race and gender) and
one professional group. Found various factors important in help seeking behaviour:
attributes of the different sorts of treatments, aspects of the patient-provider
relationship, personal coping strategies, psychological receptivity and perceptions of
stigma. The study also revealed that patients placed substantially more importance on
the effective communication between patient and physician than physicians did. Many
patients used spirituality as a means by which to cope with depression before seeking
help for it. Interpersonal trust an important aspect of this especially for ethnic
minorities.
Baik, S., Bowers, B., Oakley, L. and J. Susman. 2005. ‘The Recognition of
Depression: The Primary Care Clinicians’ Perspective’ in Annals of Family Medicine
8 clinicians sampled to get their perspective on why depression is under-recognised in
primary care. Found that the likelihood of diagnosing depression is tied up with the
context in which interactions occur- it goes beyond their ability to recognise
symptoms. “During the past 10 to 15 years, most studies of depression in primary care
have conceptualised influencing factors as separate variables and have left gaps in
understanding the process of how these factors may come into play in clinical
encounters of the everyday practice environment” (p. 34)
Chew-Graham, C., Mullin, S., May, C., Hedley, S. and H. Cole. 2002. ‘Managing
Depression in Primary Care: Another Example of the Inverse Care Law?’ in Family
Practice
Qualitative study exploring GP attitudes to the management of patients with
depression. Semi structured interviews were conducted with two groups of GPs in
north-west England, one group practising in inner city areas, the second group in
surburban and semi-rural practices. Three views of depressed people emerged: 1) that
depression is a normal response to daily life 2) that the label of depression offers
secondary gain to both doctors and patients 3) that inner-city GPs experienced
depression as an interactional problem, whereas GPs in less deprived areas saw
depression as a treatable illness from which much professional satisfaction can be
gained from treating. For those in inner city areas, the problem of depression is seen
as insoluble. Some doctors may be unwilling to diagnose depression because of wider
structural and social factors.
Rogers, A., May, C. and D. Oliver. 2001. ‘Experiencing Depression, Experiencing the
Depressed: The Separate Worlds of Patients and Doctors’ in Journal of Mental
Health
Explored the way in which doctors and patients conceptualise and respond to
depression as a problem in the specific organisational context of primary care. Done
by drawing on the narratives of patients and their doctors. Twenty seven patients and
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ten Gps recruited from ten different practices in the Greater Manchester area. Whilst
the need for help was anxiously sought, it was found to be of little significance in
contrast to the magnitude of their experienced problems. Low expectations of what
the GP can provide was a significant influence on help seeking. From a Gp
perspective, dealing with depression is shaped and constrained not only by the
patient’s preferences but also the political organisation of resources, the wider
formulation of medical practice and professional interactions in primary care.
Murray, J., Banerjee, S., Byng, R., Tylee, A., Bhugra, D. and A. Macdonald. 2006.
Primary Care Professionals’ perceptions of depression in older people: a qualitative
study in Social Science and Medicine
Gps, nurses and counsellors working in 18 south London primary care practices were
interviewed about their conceptualisations of depression in older people. All
professional groups shared a psychosocial model for understanding it. They saw coexisting illnesses as complicating the diagnosis, GPs reported that older people rarely
mentioned psychological symptoms, but practice nurses felt that they were less
inhibited about talking to them about such issues. Older men were particularly less
likely to discuss these issues and were more vulnerable to severe depression and
suicide. GPs had mixed feelings about offering medication when they saw some of the
depression as being linked to social isolation and loneliness. Older people tended to
view depression as a sign ‘of weakness’ and the perceived stigma of mental illness
was a significant barrier to seeking help. Cultural variations in illness beliefs,
especially the attribution of symptoms were thought to profoundly influence the help
seeking behaviour of elders from minority ethnic groups. Families were the main
source of support but also of distress, and so their influence may be crucial in the
recognition of depression.
Pollock, K. and J. Grime. 2002. Patients’ perceptions of entitlement to time in general
practice consultations for depression: qualitative study in BMJ
Qualitative study based on interviews with patients with mild to moderate depression
from eight general practices in the west midlands. 32 patients were taken from general
practice and 30 were taken from the depression alliance. An intense sense of time
pressure and a self imposed rationing of time in consultations were key concerns
among the interviewees. These constraints prevented them from talking about certain
key issues. Patients took it upon themselves to manage Gps time spent on their
consultation. Patients valued time to talk and would have liked more, but they did not
necessarily associate length of consultation with quality. Doctors need to have greater
awareness of patients anxieties about time and should allay such fears by pre-emptive
reassurance and reinforcing entitlement to time. Patients see health service as a
collective rather than personal resource and thus ration their own time which has
serious implications for the recognition of depression in primary care.
**** Heneghan, A., Morton, S. and N. DeLone. 2007. ‘Paediatricianss’ attitudes
about discussing maternal depression during a paediatric primary care visit’ in
Child: Care, Health and Development
In depth telephone conversations with 23 primary care paediatricians from a practicebased research network. Asked about: * maternal symptoms *Strategies to identify
mothers at risk * barriers encountered * potential strategies to improve recognition
and treatment of maternal depression. Results showed few paediatricians used a check
15
list or direct questions, relied on observational cues. All felt that lack of time was a
barrier. Fear of judgement and stigma were thought to barriers preventing mothers
disclosing.
Single Method Quantitative
Schwenk, T., Evans, D., Laden, S. and L. Lewis. 2004. Treatment Outcome and
Physician-Patient Communication in Primary Care Patients with Chronic, Recurrent
Depression
Structured telephone interviews with participants samples from larger patient survey.
Over five thousand households identified where one member of the household has
depression, this was then filtered down to exclude those with concurrent diagnoses,
those who were taking more than a single anti depressant or where their prescription
had been made outside of primary care. The remaining 1,001 took part in structured
telephone interview (20 mins). Despite the fact these patients had recurrent
depression, most reported satisfaction with the care received. Patients may be more
accepting of incomplete recovery for depression than for other conditions. A team
building approach to communication between physician and patient has been shown
to be useful in increasing adherence to treatment
UMDS Msc in General Practice Teaching Group, 1999. ‘You’re depressed’; ‘no I’m
not’: Gps’ and Patients’ different models of depression in British Journal of General
Practice
Nine GPs distributed questionnaires to 900 consecutive patients aged over 16 and to
135 GPs. Found that GPs and patient models differed considerably in that GPs had
more medical models- they placed more emphasis on somatic symptoms than
emotional ones. Patients who have personal experience of depression are more likely
to share GPs’ perspectives. Having depression may change an individual’s model of
depression, or does acceptance of the diagnosis mean buying in to a medicalised
perspective?
**** Epstein, S., Hooper, L., Weinfurt, K., Depuy, V., Cooper, L, Harless, W. and T.
Cynthia. 2008. ‘Primary Care Physicians’ Evaluation and Treatment of Depression
Results of an Experimental Study using Video Vignettes’ in Medical Care and
Research Review
404 randomly selected primary care physicians, structured interviews after CD Rom
interaction vignetters of actors portraying depressed patients Vignettes varied along
the dimensions of medical comorbidity attributions regarding the cause of depression ,
style, race/ethnicity and gender. Results showed that GPs show a wide range of
variation in treatment decisions. Physician characteristics appear more important in
determining treatment decisions than patient characteristics.