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Talking about depression: a qualitative study of barriers to managing depression in people with long term conditions in primary care
Peter A Coventry, Rebecca Hays, Chris Dickens, Christine Bundy, Charlotte Garrett, Andrea Cherrington, Carolyn Chew-Graham
BMC Family Practice , 2011, DOI: 10.1186/1471-2296-12-10
Abstract: Qualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper.Barriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management.Depression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.People with chronic physical health problems or long term conditions (LTCs) are approximately twice as likely to suffer from depression than the adult general population [1,2]. Furthermore, when present with
Improving long-term outcome of depression in primary care: a review of RCTs with psychological and supportive interventions
Smit,Annet; Tiemens,Bea G.; Ormel,Johan;
The European Journal of Psychiatry , 2007, DOI: 10.4321/S0213-61632007000100005
Abstract: background and objectives: depression is often a recurrent or persistent disorder. since the majority of depressed patients are treated in primary care, it is clear that to improve long-term outcomes more effective treatments in this setting are needed. the goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. methods: we conducted a systematic literature search to identify improvement strategies tested in randomized controlled trials in primary care, reporting at least six months effects on depression course and outcome. results: four strategies were identified: (1) training primary care physicians (pcps) - this appears ineffective (2) supporting pcps by other professionals - this produces better short term outcomes but does not prevent recurrence (3) organisational quality improvement - this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) recurrence - and chronicity prevention strategies - these have not been shown to be effective. conclusion: since effects of the reviewed strategies generally do not seem to persist over time and no clear superiority over usual care has been demonstrated, we conclude that for improving long-term outcome of depression in primary care new directions or even a novel paradigm is needed.
Improving long-term outcome of depression in primary care: a review of RCTs with psychological and supportive interventions  [cached]
Annet Smit,Bea G. Tiemens,Johan Ormel
The European Journal of Psychiatry , 2007,
Abstract: Background and objectives: Depression is often a recurrent or persistent disorder. Since the majority of depressed patients are treated in primary care, it is clear that to improve long-term outcomes more effective treatments in this setting are needed. The goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. Methods: We conducted a systematic literature search to identify improvement strategies tested in randomized controlled trials in primary care, reporting at least six months effects on depression course and outcome. Results: Four strategies were identified: (1) training primary care physicians (PCPs) - this appears ineffective (2) supporting PCPs by other professionals - this produces better short term outcomes but does not prevent recurrence (3) organisational quality improvement - this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) recurrence - and chronicity prevention strategies - these have not been shown to be effective. Conclusion: Since effects of the reviewed strategies generally do not seem to persist over time and no clear superiority over usual care has been demonstrated, we conclude that for improving long-term outcome of depression in primary care new directions or even a novel paradigm is needed.
The many faces of depression in primary care
Hegadoren, Kathy;Norris, Colleen;Lasiuk, Gerri;Silva, Denise Guerreiro Vieira da;Chivers-Wilson, Kaitlin;
Texto & Contexto - Enfermagem , 2009, DOI: 10.1590/S0104-07072009000100019
Abstract: depression is a serious global health problem. it creates a huge economic burden on society and on families and has serious and pervasive health impacts on the individual and their families. specialized psychiatric services are often scarce and thus the bulk of care delivery for depression has fallen to primary care providers, including advanced practice nurses and experienced nurses who work in under-serviced regions. these health professionals require advanced knowledge about the many faces that depression can display. this article reviews some of the faces of depression seen by primary care providers in their practices. considering depression as a heterogeneous spectrum disorder requires attention to both the details of the clinical presentation, as well as contextual factors. recommendations around engagement and potential interventions will also be discussed, in terms of the client population as well as for the practitioner who may be isolated by geography or discipline.
Organizational factors and depression management in community-based primary care settings
Edward P Post, Amy M Kilbourne, Robert W Bremer, Francis X Solano, Harold Pincus, Charles F Reynolds
Implementation Science , 2009, DOI: 10.1186/1748-5908-4-84
Abstract: We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance).The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment.The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.Recent reports from the Institute of Medicine suggest that substantial gaps remain between evidence-based care and actual practice [1-3]. This is especially true for chronic conditions. The reports attribute these gaps to organizational barriers in the delivery of longitudinal care and stress the need for future research to identify and reduce barriers to quality and equitable health care. A central challenge is that primary care practices are arranged largely to provide acute treatment; this creates a barrier to improving long-term management of conditions such as depression [4,
Observational studies of depression in primary care: what do we know?
Gail Gilchrist, Jane Gunn
BMC Family Practice , 2007, DOI: 10.1186/1471-2296-8-28
Abstract: Searches were conducted in MEDLINE, CINAHL and PsycINFO using combinations of topic and keywords, and Medical Subject Headings in MEDLINE, Headings in CINAHL and descriptors in PsycINFO. Searches were limited to adult populations and articles published in English during 1985–2006.40 articles from 17 observational cohort studies were identified, most were undertaken in the US or Europe. Studies varied widely in aims and methods making it difficult to meaningfully compare the results. Methodological limitations were common including: selection bias of patients and physicians; small sample sizes (range 35–108 patients at baseline and 20–59 patients at follow-up); and short follow-up times limiting the extent to which these studies can be used to inform our understanding of recovery and relapse among primary care patients with depression. Risk factors for the persistence of depression identified in this review were: severity and chronicity of the depressive episode, the presence of suicidal thoughts, antidepressant use, poorer self-reported quality of life, lower self-reported social support, experiencing key life events, lower education level and unemployment.Despite the growing interest in depression being managed as a chronic illness, this review identified only 17 observational studies of depression in primary care, most of which have included small sample sizes and been relatively short-term. Future research should be large enough to investigate risk factors for chronicity and relapse, and should be conducted over a longer time frame.A recent World Health Organization report states that depression is the leading cause of disability worldwide among people aged five and above [1]. People with depression are mainly managed in primary care/general practice [2], yet current management guidelines are mainly based upon data collected in the secondary and tertiary sectors. Studies of relapse rates, risk factors for relapse and efficacy of maintenance therapy have been cond
DEPRESSION IN PRIMARY CARE. PART 1: SCREENING AND DIAGNOSIS
AM Zainab,XV Pereira
Malaysian Family Physician , 2007,
Abstract: One of the commonest psychological problems that a clinician would encounter in primary care is depression. Theprevalence of depression is high in women, the elderly and those with underlying physical problems or during the postpartumperiod. The spectrum of clinical presentations is wide and somatic complaints are more common in primary care clinics.Depression may present as a primary disorder and co-morbidity with other psychological problems or physical illnessesis high. A good clinical interview is an important form of assessment and a quick screening of depression can be donewith the administration of proper rating scales, such as the Patient Health Questionnaire, Hamilton Depression RatingScale or Geriatric Depression Scale. Repeated use of the same scale in a patient would help the clinician to monitor theprogress objectively.
DEPRESSION IN PRIMARY CARE. PART 2: MANAGEMENT
XV Pereira,AM Zainab
Malaysian Family Physician , 2007,
Abstract: The management of depression in the primary care setting should ideally take a biological, psychological, and sociologicalapproach. Antidepressants are the most commonly used biological agents in the treatment of depression. Psychologicaltherapies and psychosocial interventions improve the outcome of treatment when combined with pharmacotherapy.Clinical depression is treatable and thus efforts should be made to alleviate the suffering of patients with depression.
Knowledge, attitudes and practice pertaining to depression among primary health care workers in Tanzania
Joseph Mbatia, Ajit Shah, Rachel Jenkins
International Journal of Mental Health Systems , 2009, DOI: 10.1186/1752-4458-3-5
Abstract: All the primary health care workers (N = 14) in four primary health care centres in Tanzania were asked to complete the Depression Attitude Questionnaire, which assesses the health worker's knowledge and attitude towards the causes, consequences and treatment of depression.The majority of respondents felt that rates of depression had increased in recent years, believed that life events were important in the aetiology of depression, and generally held positive views about pharmacological and psychological treatments of depression, prognosis and their own involvement in the treatment of depressed patients.However, the majority of respondents felt that becoming depressed is a way that people with poor stamina deal with life difficulties.The findings suggest a need to strengthen the training of primary health care workers in Tanzania about the detection of depression, pharmacological and psychological treatments, and psychosocial interventions.Human resources devoted to health systems in sub-Saharan Africa are scarce. In order to bring health care to the population, strategic primary care structures have evolved, although there is widespread concern about their performance and capacity to deliver in resource poor settings. Primary care of mental disorders is crucial in all parts of the world because of the sheer scale of psychiatric morbidity, and specially in sub-Saharan Africa where specialist expertise is very scarce. Tanzania only has 13 psychiatrists for a population of 37 million, and nine of these psychiatrists are in Dar es Salaam. In fact Tanzania has produced a total of 25 psychiatrists, of whom 11 are working in the Tanzanian public service, 2 work in private practice, 9 are aborad and 2 have retired. In addition, 1000 mental health nurses have been trained, but only 460 are currently deployed in the mental health services.Examination of consultation data in primary care settings in Tanzania shows that while psychoses are routinely diagnosed and treated at pr
Structured Pro-Active Care for Chronic Depression by Practice Nurses in Primary Care: A Qualitative Evaluation  [PDF]
Madeleine Bennett, Kate Walters, Vari Drennan, Marta Buszewicz
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0075810
Abstract: Purpose This qualitative study explored the impact and appropriateness of structured pro-active care reviews by practice nurses for patients with chronic or recurrent depression and dysthymia within the ProCEED trial. ProCEED (Pro-active Care and its Evaluation for Enduring Depression) was a United Kingdom wide randomised controlled trial, comparing usual general practitioner care with structured ‘pro-active care’ which involved 3 monthly review appointments with practice nurses over 2 years for patients with chronic or recurrent depression. Method In-depth interviews were completed with 41 participants: 26 patients receiving pro-active care and 15 practice nurses providing this care. Interview transcripts were analysed thematically using a ‘framework’ approach. Results Patients perceived the practice nurses to be appropriate professionals to engage with regarding their depression and most nurses felt confident in a case management role. The development of a therapeutic alliance between the patient and nurse was central to this model and, where it appeared lacking, dissatisfaction was felt by both patients and nurses with a likely negative impact on outcomes. Patient and nurse factors impacting on the therapeutic alliance were identified and nurse typologies explored. Discussion Pro-active care reviews utilising practice nurses as case managers were found acceptable by the majority of patients and practice nurses and may be a suitable way to provide care for patients with long-term depression in primary care. Motivated and interested practice nurses could be an appropriate and valuable resource for this patient group. This has implications for resource decisions by clinicians and commissioners within primary care.
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