Qualitative study of depression management in primary care: GP and patient goals, and the value of listening

Johnston, Olwyn; Kumar, Satinder; Kendall, Kathleen; Peveler, Robert; Gabbay, John; Kendrick, Tony

doi:10.3399/096016407782318026

Cited by 82 publications

(114 citation statements)

References 36 publications

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“…9 GPs and patients may have different goals associated with the long-term treatment of depression. Patients emphasise the value of listening and GPs acknowledge its importance, 10 but we know little about how patients or GPs think about treatment with long-term medicines or about the strategies used to manage patients receiving long-term antidepressant therapy.…”

Section: Introductionmentioning

confidence: 99%

Long-term prescribing of antidepressants in the older population: a qualitative study

Dickinson

Knapp²,

House³

et al. 2010

Br J Gen Pract

124

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MethodThirty-six patients aged ≥75 years and 10 GPs were interviewed. Patients were sampled to ensure diversity in age, sex, antidepressant type, and home circumstances. ResultsParticipants perceived significant benefits and expressed little apprehension about taking long-term antidepressants, despite being aware of the psychological and social factors involved in onset and persistence of depression. Barriers to discontinuation were identified following four themes: pessimism about the course and curability of depression; negative expectations and experiences of ageing; medicine discontinuation perceived by patients as a threat to stability; and passive (therapeutic momentum) and active (therapeutic maintenance) decisions to accept the continuing need for medication. ConclusionThere is concern at a public health level about high rates of long-term antidepressant prescribing, but no evidence was found of a drive for change either from the patients or the doctors interviewed. Any apprehension was more than balanced by attitudes and behaviours supporting continuation. These findings will need to be incorporated into the planning of interventions aimed at reducing long-term antidepressant prescribing in older people. Keywordsantidepressants; prescribing; attitudes. INTRODUCTIONA previous study of antidepressant prescribing in the UK reported high rates of long-term prescribing. For patients aged ≥75 years, 14% were being prescribed an antidepressant, while the rate in those aged <75 years was less than half that (6%). 1Among patients aged ≥75 years prescribed an antidepressant, almost half (48%) had been in receipt of a prescription for more than 2 years. Few patients' records had evidence of medication review or discussion of possible withdrawal.Depression is common in later life, 2,3 but it is not clear why the rates of prescribing, and of long-term prescribing in particular, appear to be so much higher in patients aged ≥75 years. 4 Most older patients with depression are managed in primary care by their GP. Guidance regarding the management of depression in the UK is provided by the National Institute for Health and Clinical

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Section: Introductionmentioning

confidence: 99%

Long-term prescribing of antidepressants in the older population: a qualitative study

Dickinson

Knapp²,

House³

et al. 2010

Br J Gen Pract

124

View full text Add to dashboard Cite

show abstract

“…Seven qualitative [37][38][39][40][41][42][43] and 10 quantitative studies of the management of primary depression were included. [44][45][46][47][48][49][50][51][52][53] Figure 1 shows the flow of studies through the review process.…”

Section: Review Resultsmentioning

confidence: 99%

“…Attitudes to managing depression GP responses to chronic depression 37 Interactional difficulties with depressed people 42 Pessimistic about outcome 43 Positive about outcome 40,41 Lack of confidence in managing depression 39,46,48,53 Ambivalence 49,51 GPs and PNs experience frustration in managing depression. Some are confident about outcomes, but commonly there is ambivalence…”

Section: Relationships Between Professionalsmentioning

confidence: 99%

“…Constructing and resisting boundaries between depression, the self and 'normal' sadness 37 Depression as a normal response to life events 42 Inconsistency between beliefs and practice 43 Concerns surrounding the medicalisation of social problems 40 Depression as 'understandable reaction to distressing circumstances' 38 Aetiology of depression 49 Nature of depression 49,52,53 Depression may be seen as a normal reaction to distressing events or as pathology. Understandings of depression may conflict with management strategies…”

Section: Professionals' Understanding Of Depressionmentioning

confidence: 99%

“…GP goals and management approach 37 GPs' accounts of diagnosing and caring for patients with depression 40 GPs experience of the diagnosis and management of depression 43 Importance of listening 37 Time as a barrier to listening 42 Time and consultation length, disclosure, antidepressants, time management 41 Management of late-life depression in primary care 39 Antidepressant use 44,[47][48][49]52 Role of specialist services 50 Managing depression 46 Clinicians used antidepressants, talking therapies, listening and specialist services. Listening to depressed patients takes time; this may be a barrier to effective treatment, but one in-depth study contested this…”

Section: Management Strategies and Toolsmentioning

confidence: 99%

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UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Tylee

Barley

Walters

et al. 2016

Programme Grants Appl Res

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BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

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Complex Depression in High-Pressure Care Settings: Strategies and Therapeutic Competences

Parra

Zúñiga

Dagnino

et al. 2021

Depression and Personality Dysfunction

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Qualitative study of depression management in primary care: GP and patient goals, and the value of listening

Cited by 82 publications

References 36 publications

Long-term prescribing of antidepressants in the older population: a qualitative study

Long-term prescribing of antidepressants in the older population: a qualitative study

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Complex Depression in High-Pressure Care Settings: Strategies and Therapeutic Competences

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