The contribution of depressive 'disorder characteristics' to determinations of prognosis for adults with depression: an individual patient data meta-analysis.

BACKGROUND: This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. METHODS: We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. RESULTS: Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3-4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3-4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. CONCLUSIONS: When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.

'Trying to put a square peg into a round hole': a qualitative study of healthcare professionals' views of integrating complementary medicine into primary care for musculoskeletal and mental health comorbidity.

BACKGROUND: Comorbidity of musculoskeletal (MSK) and mental health (MH) problems is common but challenging to treat using conventional approaches. Integration of conventional with complementary approaches (CAM) might help address this challenge. Integration can aim to transform biomedicine into a new health paradigm or to selectively incorporate CAM in addition to conventional care. This study explored professionals' experiences and views of CAM for comorbid patients and the potential for integration into UK primary care. METHODS: We ran focus groups with GPs and CAM practitioners at three sites across England and focus groups and interviews with healthcare commissioners. Topics included experience of co-morbid MSK-MH and CAM/integration, evidence, knowledge and barriers to integration. Sampling was purposive. A framework analysis used frequency, specificity, intensity of data, and disconfirming evidence. RESULTS: We recruited 36 CAM practitioners (4 focus groups), 20 GPs (3 focus groups) and 8 commissioners (1 focus group, 5 interviews). GPs described challenges treating MSK-MH comorbidity and agreed CAM might have a role. Exercise- or self-care-based CAMs were most acceptable to GPs. CAM practitioners were generally pro-integration. A prominent theme was different understandings of health between CAM and general practitioners, which was likely to impede integration. Another concern was that integration might fundamentally change the care provided by both professional groups. For CAM practitioners, NHS structural barriers were a major issue. For GPs, their lack of CAM knowledge and the pressures on general practice were barriers to integration, and some felt integrating CAM was beyond their capabilities. Facilitators of integration were evidence of effectiveness and cost effectiveness (particularly for CAM practitioners). Governance was the least important barrier for all groups. There was little consensus on the ideal integration model, particularly in terms of financing. Commissioners suggested CAM could be part of social prescribing. CONCLUSIONS: CAM has the potential to help the NHS in treating the burden of MSK-MH comorbidity. Given the challenges of integration, selective incorporation using traditional referral from primary care to CAM may be the most feasible model. However, cost implications would need to be addressed, possibly through models such as social prescribing or an extension of integrated personal commissioning.

Professional Nurse Advancement Programs: The Face of Leadership at the Bedside.

AIMS AND OBJECTIVE: This article reviews a professional nurse advancement program and describes how it benefits patient care, staff engagement, and patient satisfaction. BACKGROUND: Existing literature notes that professional nurse advancement programs can empower nurses to improve nursing care at the bedside and contribute to a safe patient care environment. METHOD: The article reviews the qualitative exploration of the activities of participants in a professional nurse advancement program to determine the impact on patient care and identify benefits of the program. The article summarizes findings from thematic and narrative technique analysis of semistructured interviews with nurses, nurse leaders, and nurse administrators, and reviews of nurses' portfolio information. RESULTS: Implementation of a professional nurse advancement program correlated with decreased patient falls, increased bedside clinician involvement in research, and positive outcomes in nursing quality indicators. CONCLUSION: A professional nurse advancement program fosters continued professional growth and opportunities for advancement; promotes pride, personal responsibility, and respect for self; and prepares and enables nurses to lead change in advancing health in communities.

Maternal depression during pregnancy and offspring depression in adulthood: role of child maltreatment.

BACKGROUND: Studies have shown that maternal depression during pregnancy predicts offspring depression in adolescence. Child maltreatment is also a risk factor for depression. AIMS: To investigate (a) whether there is an association between offspring exposure to maternal depression in pregnancy and depression in early adulthood, and (b) whether offspring child maltreatment mediates this association. METHOD: Prospectively collected data on maternal clinical depression in pregnancy, offspring child maltreatment and offspring adulthood (18-25 years) DSM-IV depression were analysed in 103 mother-offspring dyads of the South London Child Development Study. RESULTS: Adult offspring exposed to maternal depression in pregnancy were 3.4 times more likely to have a DSM-IV depressive disorder, and 2.4 times more likely to have experienced child maltreatment, compared with non-exposed offspring. Path analysis revealed that offspring experience of child maltreatment mediated the association between exposure to maternal depression in pregnancy and depression in adulthood. CONCLUSIONS: Maternal depression in pregnancy is a key vulnerability factor for offspring depression in early adulthood.

Objectively assessed physical activity and lower limb function and prospective associations with mortality and newly diagnosed disease in UK older adults: an OPAL four-year follow-up study.

BACKGROUND: Objective measures of physical activity and function with a diverse cohort of UK adults in their 70s and 80s were used to investigate relative risk of all-cause mortality and diagnoses of new diseases over a 4-year period. PARTICIPANTS: Two hundred and forty older adults were randomly recruited from 12 general practices in urban and suburban areas of a city in the United Kingdom. Follow-up included 213 of the baseline sample. METHODS: Socio-demographic variables, height and weight, and self-reported diagnosed diseases were recorded at baseline. Seven-day accelerometry was used to assess total physical activity, moderate-to-vigorous activity and sedentary time. A log recorded trips from home. Lower limb function was assessed using the Short Physical Performance Battery. Medical records were accessed on average 50 months post baseline, when new diseases and deaths were recorded. ANALYSES: ANOVAs were used to assess socio-demographic, physical activity and lower limb function group differences in diseases at baseline and new diseases during follow-up. Regression models were constructed to assess the prospective associations between physical activity and function with mortality and new disease. RESULTS: For every 1,000 steps walked per day, the risk of mortality was 36% lower (hazard ratios 0.64, 95% confidence interval (CI) 0.44-0.91, P=0.013). Low levels of moderate-to-vigorous physical activity (incident rate ratio (IRR) 1.67, 95% CI 1.04-2.68, P=0.030) and low frequency of trips from home (IRR 1.41, 95% CI 0.98-2.05, P=0.045) were associated with diagnoses of more new diseases. CONCLUSION: Physical activity should be supported for adults in their 70s and 80s, as it is associated with reduced risk of mortality and new disease development.

Why women stop breastfeeding in the early days.

Increasing breastfeeding prevalence rates has been identified as key to improving health and well being outcomes for mothers and babies. (Dyson et al 2008, Unicef 2013; Renfrew et al 2012a; Renfrew et al 2012b). Within one maternity unit in England, in 2014, 80 per cent of women initiated breastfeeding at birth, but by day 10, only 45 per cent were breastfeeding exclusively, identifying a drop off rate of 35 per cent. As part of achieving the Unicef UK Baby Friendly standards, retrospective audit was undertaken to investigate why women were not continuing to exclusively breastfeed. Findings from the study identified that when a baby received a supplement of formula milk before 72 hours of age, the mother was less likely to be exclusively breastfeeding at 10 days. This was statistically significant (Sharp 2014). An innovation was implemented for some mothers to receive additional one-to-one feeding support in hospital and the community, as a result of which supplementation rates decreased.

Generating EQ-5D-3L health utility scores from the Edinburgh Postnatal Depression Scale: a perinatal mapping study.

BACKGROUND: Perinatal depression (PND) describes depression experienced by parents during pregnancy or in the first year after a baby is born. The EQ-5D instrument (a generic measure of health status) is not often collected in perinatal research, however disease-specific measures, such as the Edinburgh Postnatal Depression Scale (EPDS) are widely used. Mapping can be used to estimate generic health utility index values from disease-specific measures like the EPDS. OBJECTIVE: To develop a mapping algorithm to estimate EQ-5D utility index values from the EPDS. METHODS: Patient-level data from the BaBY PaNDA study (English observational cohort study) provided 1068 observations with paired EPDS and EQ-5D (3-level version; EQ-5D-3L) responses. We compared the performance of six alternative regression model types, each with four specifications of covariates (EPDS score and age: base, squared, and cubed). Model performance (ability to predict utility values) was assessed by ranking mean error, mean absolute error, and root mean square error. Algorithm performance in 3 external datasets was also evaluated. RESULTS: There was moderate correlation between EPDS score and utility values (coefficient: - 0.42). The best performing model type was a two-part model, followed by ordinary least squared. Inclusion of squared and cubed covariates improved model performance. Based on graphs of observed and predicted utility values, the algorithm performed better when utility was above 0.6. CONCLUSIONS: This direct mapping algorithm allows the estimation of health utility values from EPDS scores. The algorithm has good external validity but is likely to perform better in samples with higher health status.

Severity of depression and response to antidepressants: GENPOD randomised controlled trial.

BACKGROUND: Antidepressant prescribing is widespread. Nonetheless, response to antidepressants is variable. If it was possible to predict response to medication and thus tailor treatment accordingly, this would not only improve patient outcomes but may also have economic benefits. AIMS: To test the hypothesis that individuals with more severe depression would benefit more from noradrenaline reuptake inhibitors (NARIs) than selective serotonin reuptake inhibitors (SSRIs) compared with individuals with less severe depression. METHOD: Individuals recruited from UK primary care who met ICD-10 criteria for a depressive episode and scored 15 or more on the Beck Depression Inventory (BDI) were randomised to either an SSRI (citalopram 20 mg daily) or a NARI (reboxetine 4 mg twice daily). Randomisation was by means of a remote automated telephone system. The main outcome was depressive symptoms measured by the BDI total score 6 weeks after randomisation. ( TRIAL REGISTRATION: ISRCTN31345163.) RESULTS: In total, 601 participants were randomised (citalopram: n = 298, reboxetine: n = 303). Ninety-one per cent were followed up at 6 weeks (citalopram: n = 274, reboxetine: n = 272). There was little evidence to support an interaction between treatment and severity of depression (interaction term: 0.02, 95% CI -0.59 to 0.62, P = 0.96). Adjustment for potential confounders (age, gender, employment status, history of depression, number of life events and social support) did not affect the findings (interaction term: 0.06, 95% CI -0.54 to 0.66, P = 0.85). CONCLUSIONS: Treatment with NARIs does not confer any advantage over SSRI treatment for outcome in those with more severe depressive illness presenting in primary care.

Cross-sectional survey of child weight management service provision by acute NHS trusts across England in 2020/2021.

OBJECTIVE: With one in five children in England living with obesity, we mapped the geographical distribution and format of child weight management services provided by acute National Health Service (NHS) trusts across England, to identify breadth of service provision. DESIGN: A cross-sectional survey. SETTING: The survey was sent to acute NHS trusts (n=148) in England in 2020, via a freedom of information request. PARTICIPANTS: Responses were received from 139 of 148 (94%) acute NHS trusts, between March 2020 to March 2021. OUTCOME MEASURES: The survey asked each acute NHS trust whether they provide a weight management service for children living with obesity. For those trusts providing a service, data were collected on eligibility criteria, funding source, personnel involved, number of new patients seen per year, intervention duration, follow-up length and outcome measures. Service characteristics were reported using descriptive statistics. Service provision was analysed in the context of ethnicity and Index of Multiple Deprivation score of the trust catchment area. RESULTS: From the 139 survey respondents, 23% stated that they provided a weight management service for children living with obesity. There were inequalities in the proportion of acute NHS trusts providing a service across the different regions of England, ranging from 4% (Midlands) to 36% (London). For trusts providing a service, there was variability in the number of new cases seen per year, eligibility criteria, funding source, intervention format and outcome measures collected. A multidisciplinary approach was not routinely provided, with only 41% of services reporting ≥3 different staff disciplines. CONCLUSION: In 2020/2021, there were geographical inequalities in weight management service provision by acute NHS trusts for children living with obesity. Services provided lacked standardisation, did not routinely offer children multidisciplinary care and were insufficient in size to meet need.

Antenatal depression and offspring psychopathology: the influence of childhood maltreatment.

BACKGROUND: Antenatal depression and childhood maltreatment have each been associated with offspring psychopathology, but have never been examined in the same sample. AIMS: To determine whether childhood maltreatment influences the association between antenatal depression and offspring psychopathology. METHOD: Prospectively collected data on antenatal depression, offspring maltreatment (age 11) and offspring psychopathology (age 11 and 16) were analysed in 120 mother-offspring dyads from the community-based South London Child Development Study. RESULTS: Antenatal depression increased the risk of maltreatment in the offspring by almost four times. Children exposed only to antenatal depression or only to childhood maltreatment were no more at risk of developing psychopathology; however, children exposed to both antenatal depression and childhood maltreatment were at almost 12 times greater risk of developing psychopathology than offspring not so exposed. CONCLUSIONS: Research investigating exposure to adverse events in utero and offspring psychopathology should take account of postnatal adverse events such as maltreatment.

Polymorphism of the 5-HT transporter and response to antidepressants: randomised controlled trial.

BACKGROUND: Antidepressants exhibit a variety of pharmacological actions including inhibition of the serotonin and noradrenaline transporters. We wished to investigate whether genetic variation could be used to target or personalise treatment, in a comparison of selective serotonin reuptake inhibitors (SSRIs) with noradrenaline reuptake inhibitors (NARIs). AIMS: To test the hypothesis that patients homozygous for the long (insertion) polymorphism of the serotonin transporter (5-HTTLPR) have an increased response to SSRI antidepressants but not to NARI antidepressants. METHOD: In an individually randomised, parallel-group controlled trial, people meeting criteria for a depressive episode who were referred by their general practitioner were randomised to receive either citalopram (an SSRI) or reboxetine (an NARI). Randomisation was by means of a remote automated system accessed by telephone. The main outcome was depressive symptoms, measured by Beck Depression Inventory (BDI) total score 6 weeks after randomisation. The trial was registered with the International Standard Randomised Controlled Trials Number registry (ISRCTN31345163). RESULTS: Altogether 298 participants were randomised to receive citalopram and 303 were randomised to reboxetine. At 6 weeks follow-up, complete data were available for 258 participants taking citalopram and 262 taking reboxetine. We found no evidence to support an influence of 5-HTTLPR on outcome following antidepressant treatment. The interaction term for BDI score at 6 weeks was 0.50 (95% CI -2.04 to 3.03, P = 0.70), which indicated that responses to the SSRI and NARI were similar irrespective of 5-HTTLPR genotype. CONCLUSIONS: It is unlikely that the 5-HTTLPR polymorphism alone will be clinically useful in predicting response to antidepressants in people with depression.

Mothers' antenatal depression and their children's antisocial outcomes.

Interviews of 120 British adolescents and their parents (80% of a random sample of antenatal patients drawn from a representative urban population and followed longitudinally) revealed that 40 (33%) had been arrested and/or had a diagnosis of DSM-IV conduct disorder by 16 years of age; of those, 18 (45%) had committed violent acts. Depression in pregnancy significantly predicted violence in adolescence, even after controlling for the family environment, the child's later exposure to maternal depression, the mother's smoking and drinking during pregnancy, and parents' antisocial behavior. Mothers with a history of conduct problems were at elevated risk to become depressed in pregnancy, and the offspring of depressed women had a greater chance of becoming violent by age 16.

Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study.

BACKGROUND: In the UK, 8-15% of women suffer from postnatal depression with long term consequences for maternal mood and child development. Current guidelines state that health visitors and GPs should continue to have a major role in the detection and management of postnatal depression. Previous literature suggests that women are reluctant to disclose symptoms of postnatal depression. This study aimed to explore general practitioners' (GPs), health visitors' and women's views on the disclosure of symptoms which may indicate postnatal depression in primary care. METHODS: In-depth interviews with GPs, health visitors and women who were participating in a randomised controlled trial of anti-depressants versus health visitor delivered non-directive counselling for the treatment of postnatal depression. Interviews were audio-taped and fully transcribed. Thematic analysis with an iterative approach was used, allowing the views of practitioners and patients to be explored and then compared. RESULTS: Nineteen GPs, 14 health visitors and 28 women were interviewed. A number of common themes were identified across all three data sets: understanding and negotiating the diagnosis of postnatal depression, hindering and facilitating disclosure, and the system of care. Both women and health professionals described postnatal depression in psychosocial terms: an adjustment reaction to change in life circumstances and the reality of motherhood not meeting personal expectations. Women described making a conscious decision about whether or not to disclose their feelings to their GP or health visitor. Health professionals described strategies used to hinder disclosure and described a reluctance to make a diagnosis of postnatal depression, as they had few personal resources to manage women with postnatal depression themselves, and no services to which to refer women for further treatment. CONCLUSION: To improve disclosure of symptoms in primary care, there should be a move away from questioning why health professionals do not make the diagnosis of depression and in response suggesting that education and training will improve skills and thus improve detection of depression. Improving the detection and management of postnatal depression in primary care requires recognition of the context in which women consult, and system changes that ensure health professionals work in an environment that can facilitate disclosure and that the necessary resources for management are available. TRIAL REGISTRATION: ISRCTN 16479417.

The impact of NHS based primary care complementary therapy services on health outcomes and NHS costs: a review of service audits and evaluations.

BACKGROUND: The aim of this study was to review evaluations and audits of primary care complementary therapy services to determine the impact of these services on improving health outcomes and reducing NHS costs. Our intention is to help service users, service providers, clinicians and NHS commissioners make informed decisions about the potential of NHS based complementary therapy services. METHODS: We searched for published and unpublished studies of NHS based primary care complementary therapy services located in England and Wales from November 2003 to April 2008. We identified the type of information included in each document and extracted comparable data on health outcomes and NHS costs (e.g. prescriptions and GP consultations). RESULTS: Twenty-one documents for 14 services met our inclusion criteria. Overall, the quality of the studies was poor, so few conclusions can be made. One controlled and eleven uncontrolled studies using SF36 or MYMOP indicated that primary care complementary therapy services had moderate to strong impact on health status scores. Data on the impact of primary care complementary therapy services on NHS costs were scarcer and inconclusive. One controlled study of a medical osteopathy service found that service users did not decrease their use of NHS resources. CONCLUSION: To improve the quality of evaluations, we urge those evaluating complementary therapy services to use standardised health outcome tools, calculate confidence intervals and collect NHS cost data from GP medical records. Further discussion is needed on ways to standardise the collection and reporting of NHS cost data in primary care complementary therapy services evaluations.

Exploring how lifestyle weight management programmes for children are commissioned and evaluated in England: a mixed methodology study.

OBJECTIVE: To assess how lifestyle weight management programmes for children aged 4-16 years in England are commissioned and evaluated at the local level. DESIGN: This was a mixed-methods study comprising an online survey and semistructured telephone interviews. SETTING: An online survey was sent to all local authorities (LAs) in England regarding lifestyle weight management services commissioned for children aged 4-16 years. Online survey data were collected between February and May 2016 and based on services commissioned between April 2014 and March 2015. Semistructured telephone interviews with LA staff across England were conducted between April and June 2016. PARTICIPANTS: Commissioners or service providers working within the public health department of LAs. MAIN OUTCOME MEASURES: The online survey collected information on the evidence base, costs, reach, service usage and evaluation of child lifestyle weight management services. The telephone interviews explored the nature of child weight management contracts commissioned by LAs, the type of outcome data collected and whether these data were shared with other LAs or organisations, the challenges faced by these services, and the perceived 'markers of success' for a programme. RESULTS: The online survey showed that none of the participating LAs was aware of any peer-reviewed evidence supporting the effectiveness of their specific commissioned service. Despite this, the telephone interviews revealed that there was no national formal sharing of data to enable oversight of the effectiveness of commissioned services across LAs in England to help inform future commissioning decisions. Challenges with long-term data collection, service engagement, funding and the pressure to reduce the prevalence of obesity were frequently mentioned. CONCLUSIONS: Robust, independent, cost-effectiveness analyses of obesity strategies are needed to determine the appropriate allocation of funding to lifestyle weight management treatment services, population-level preventative approaches or development of whole system approaches by an LA.

Antepartum and postpartum exposure to maternal depression: different effects on different adolescent outcomes.

BACKGROUND: Postpartum depression (PPD) is considered a major public health problem that conveys risk to mothers and offspring. Yet PPD typically occurs in the context of a lifelong episodic illness, and its putative effects might derive from the child's exposure to other episodes, in pregnancy or later childhood. The aim of the study is to test two hypotheses: (1) that the effects of PPD on adolescent outcomes are partly explained by antepartum depression (APD) and (2) that the effects of APD and PPD are both explained by later exposure to the mother's depression. METHOD: A random sample of 178 antenatal patients was drawn from two general medical practices in South London; 171 gave birth to live infants, and 150 (88%) were assessed at 3 months post partum, with 121 of their offspring (81%) assessed for emotional disorders (ED), disruptive behaviour disorders (DBD) and IQ, at 11 and 16 years of age. RESULTS: When APD and subsequent episodes of depression were taken into account, PPD had a significant effect on adolescent IQ, especially for boys, but did not predict psychopathology. ED and DBD in adolescence were predicted by the extent of exposure to maternal depression after 3 months post partum; a significant effect of APD on ED in girls was accounted for by later exposure to the mother's illness. Mothers' symptoms of anxiety, smoking and alcohol use in pregnancy did not predict adolescent outcomes, once maternal depression was taken into account. CONCLUSIONS: Some effects attributed to mothers' mental health problems in pregnancy or post partum may be mediated by cumulative exposure to maternal illness, probably reflecting genetic influence and gene-environment correlation. However, PPD has a direct effect on cognition. Clinicians should endeavour to identify women with depression in pregnancy (31% of this sample) and help them to manage their lifelong illness.

Postnatal depression and child outcome at 11 years: the importance of accurate diagnosis.

BACKGROUND: One in ten women suffers from postnatal depression (PND) and their children have elevated rates of psychopathology. We compared caseness of PND using the Edinburgh Postnatal Depression Scale (EPDS), the most commonly used research tool for the detection of PND, and the Clinical Interview Schedule (CIS) in terms of their relative abilities to identify infants at risk of psychopathology in middle childhood. METHOD: In a prospective longitudinal primary care study, 147 randomly selected women were administered both the CIS and the EPDS at three months postpartum. Childhood psychopathology was identified by face-to-face interview at 11 years. RESULTS: The risk for psychiatric disorder at 11 years was four times greater among children whose mothers were cases of PND on the CIS, compared to children whose mothers were not depressed. Using the EPDS to identify PND, there was no significant difference in the risk for children whose mothers scored above and below a conventional cut-off score. LIMITATIONS: This study was retrospectively designed and was not part of the original study plan. CONCLUSIONS: These data support the evidence that accurate detection of PND is better achieved by face-to-face clinical interview than through the use of the EPDS. They provide novel evidence that a simple diagnostic clinical interview for PND, in contrast to the EPDS, can identify mothers whose children will be at an increased risk of developing psychiatric disorder in later childhood.

GPs' and health visitors' views on the diagnosis and management of postnatal depression: a qualitative study.

BACKGROUND: In the UK, 8-15% of women suffer from postnatal depression, with long-term consequences for maternal mood and child development. Previous literature suggests that health visitors struggle with their conflicting roles with respect to mother and infant. Current policy is redirecting the emphasis and organisation of health visitor work, but guidelines state that health visitors and GPs should continue to have a major role in the detection and management of postnatal depression. AIM: To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression. DESIGN OF STUDY: A qualitative study nested within a multicentre randomised controlled trial. SETTING: Nine primary care trusts in Bristol, Manchester, and London. METHOD: In-depth interviews with GPs and health visitors from primary care trusts participating in a randomised controlled trial of antidepressants versus health visitor-delivered non-directive counselling. Interviews were audiotaped and fully transcribed. Thematic analysis with an iterative approach was used to develop conceptual categories from the transcripts. RESULTS: Nineteen GPs and 14 health visitors were interviewed. GPs and health visitors described their work in making and negotiating the diagnosis of postnatal depression, the value of a long-term relationship with the woman, and how labelling affects management of women with postnatal depression. Responders described how they viewed others' roles in the management of postnatal depression, and how national policy and local organisational changes had an impact on patient care, so that no one health professional was assuming overall responsibility for the care of women with postnatal depression. CONCLUSION: Ongoing organisational changes within primary care, such as the implementation of corporate working by health visitors, affect care provided to women after birth, which in turn has an impact on the diagnosis and management of postnatal depression.