The first consultation for low mood in general practice: what do patients find helpful?

BACKGROUND: Recent evidence suggests that the first consultation with a general practitioner (GP) for symptoms of depression may be more than just a vehicle for assessment and management planning (as current guidelines imply). OBJECTIVES: To identify what patients find helpful, or otherwise, in their first consultation for low mood with a GP. METHODS: A cross-sectional questionnaire and interview study of patients with low mood who had recently consulted their GP, in the North of England. Patients were asked to complete a questionnaire regarding the consultation, and a Patient Health Questionnaire-9 (PHQ-9), within 2 weeks. They were also invited to take part in a face-face interview with a researcher. Both sources of data were subjected to qualitative thematic analysis. RESULTS: Thirty-seven questionnaires were returned; 5 interviews took place. The majority of participants felt better after consulting a GP for the first time for low mood. The factors most commonly cited as helpful were "being listened to" and "understanding or empathy from the GP." Others included "admitting the problem," "being reassured of normality," and "being provided with optimism or hope for change." The most commonly reported difficulty was the patients' struggle to express themselves. Patients often felt that GP follow-up was inadequate. CONCLUSIONS: These results suggest that the therapeutic benefit of the GP consultation is under-recognized in current guidelines. The results of our study will provide crucial information as to how such consultations can be tailored to improve patient satisfaction.

Although patients often tell their general practitioner (GP) that they feel better after a first consultation with symptoms of depression, the degree of patient satisfaction after such consultations seems to vary greatly. In this questionnaire and interview study, patients were asked to state which aspects of the consultation they had found helpful, or otherwise. The results showed that well-recognized factors of patient-centredness (where patients are involved in all decisions about their healthcare) such as "having time to talk" and "being listened to" were highly valued in the current setting. In addition, several aspects of the GP consultation that are more specific to depression were also highly rated, namely: "Admitting the problem," "being reassured of normality," and "being provided with optimism or hope for change." Overall, most patients felt better after the first consultation for low mood­a therapeutic effect that is not well recognized in current guidelines for depression. However, patients consistently reported that they felt GP follow-up after their first consultation for low mood was insufficient. These results should help us to optimize GP consultations for patients presenting for the first symptoms of depression.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time.

OBJECTIVE: This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross-cultural communication in primary care. BACKGROUND: Sustaining the implementation of change using complex interventions is challenging. The EU-funded "RESTORE" study implemented guidelines and training on cross-cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action-PLA). There were positive impacts on knowledge, skills and clinical routines. DESIGN, SETTING AND PARTICIPANTS: Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow-up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE. INTERVENTION; MAIN OUTCOME MEASURES: PLA-style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis. RESULTS: Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare. CONCLUSION: There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed.

Material practices for meaningful engagement: An analysis of participatory learning and action research techniques for data generation and analysis in a health research partnership.

BACKGROUND: The material practices which researchers use in research partnerships may enable or constrain the nature of engagement with stakeholder groups. Participatory learning and action (PLA) research approaches show promise, but there has been no detailed analysis of stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis. OBJECTIVES: To explore stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis. DESIGN: The EU RESTORE implementation science project employed a participatory approach to investigate and support the implementation of guidelines and training initiatives (GTIs) to enhance communication in cross-cultural primary care consultations. We developed a purposeful sample of 78 stakeholders (migrants, general practice staff, community interpreters, service providers, service planners) from primary care settings in Austria, England, Greece, Ireland and The Netherlands. We used speed evaluations and participatory evaluations to explore their experiences of two PLA techniques-Commentary Charts and Direct Ranking-which were intended to generate data for co-analysis by stakeholders about the GTIs under analysis. We evaluated 16 RESTORE researchers' experiences using interviews. We conducted thematic and content analysis of all evaluation data. RESULTS: PLA Commentary Charts and Direct Ranking techniques, with their visual, verbal and tangible nature and inherent analytical capabilities, were found to be powerful tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders had few negative experiences and numerous multifaceted positive experiences of meaningful engagement, which resonated with researchers' accounts. CONCLUSION: PLA techniques and approaches are valuable as material practices in health research partnerships.

A critical analysis of the implementation of service user involvement in primary care research and health service development using normalization process theory.

BACKGROUND: There have been recent important advances in conceptualizing and operationalizing involvement in health research and health-care service development. However, problems persist in the field that impact on the scope for meaningful involvement to become a routine - normalized - way of working in primary care. In this review, we focus on current practice to critically interrogate factors known to be relevant for normalization - definition, enrolment, enactment and appraisal. METHOD: Ours was a multidisciplinary, interagency team, with community representation. We searched EBSCO host for papers from 2007 to 2011 and engaged in an iterative, reflexive approach to sampling, appraising and analysing the literature following the principles of a critical interpretive synthesis approach and using Normalization Process Theory. FINDINGS: Twenty-six papers were chosen from 289 papers, as a purposeful sample of work that is reported as service user involvement in the field. Few papers provided a clear working definition of service user involvement. The dominant identified rationale for enrolling service users in primary care projects was linked with policy imperatives for co-governance and emancipatory ideals. The majority of methodologies employed were standard health services research methods that do not qualify as research with service users. This indicates a lack of congruence between the stated aims and methods. Most studies only reported positive outcomes, raising questions about the balance or completeness of the published appraisals. CONCLUSION: To improve normalization of meaningful involvement in primary care, it is necessary to encourage explicit reporting of definitions, methodological innovation to enhance co-governance and dissemination of research processes and findings.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care.

BACKGROUND: Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective. METHODS: We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial. RESULTS: We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery. CONCLUSIONS: This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs. TRIAL REGISTRATION: Current controlled trials ISRCTN68572159.

Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities.

BACKGROUND: The purpose of the study was to improve the quality of primary mental healthcare in underserved communities through involvement with the wider primary care team members and local community agencies. METHODS: We developed training intended for all GP practice staff which included elements of knowledge transfer, systems review and active linking. Seven GP Practices in four localities (North West England, UK) took part in the training. Qualitative evaluation was conducted using thirteen semi-structured interviews and two focus groups in six of the participating practices; analysis used principles of Framework Analysis. RESULTS: Staff who had engaged with the training programme reported increased awareness, recognition and respect for the needs of patients from under-served communities. We received reports of changes in style and content of interactions, particularly amongst receptionists, and evidence of system change. In addition, the training program increased awareness of - and encouraged signposting to - community agencies within the practice locality. CONCLUSIONS: This study demonstrates how engaging with practices and delivering training in a changing health care system might best be attempted. The importance of engaging with community agencies is clear, as is the use of the AMP model as a template for further research.

Comparing public perceptions of substance addictions and behavioural addictions.

INTRODUCTION: Identifying addictions in peers is vital for early referral and improving outcomes. Substance addictions such as alcoholism and cocaine addiction have been recognised for a long time whereas behavioural addictions such as gambling and especially gaming are relatively new addictions. This study aims to evaluate public perceptions of substance addictions compared to behavioural addictions. METHODS: The six ICD-10 characteristics of dependence were incorporated into a series of vignettes. Participants in an online survey were asked to use a Likert scale to judge the presence and severity of addictions. The responses were analysed using the Wilcoxon Sum Rank test to allow the groups to be compared. RESULTS: Of the 247 participants, participants were more likely to say someone was addicted to gambling in the not addicted questions and lightly addicted question sets than the other addictions studied. Alcohol addiction was the poorest identified addiction amongst participants in the lightly addicted questions and was also poorly identified in the heavily addicted questions. Lightly addicted behaviour was poorly identified by participants in all four addictions studied. CONCLUSIONS: The hypothesis that substance addictions are recognised better than behavioural addictions was unsubstantiated. Gambling was seen as the most addictive behaviour/substance of the four addictions whilst alcohol addiction was not recognised when minor dependent traits were exhibited and poorly recognised with heavily dependent traits. Public interventions may be needed to improve peer identification of alcohol addiction in their peers. This study indicates that the general public does not identify any minor addictions in their peers sufficiently to improve outcomes for patients.

Co-creation and collaboration: A promising approach towards successful implementation. Experience from an integrated communication and mental health skills training programme for Japanese General Practice.

INTRODUCTION: This paper describes the co-creation and delivery of an integrated training programme in communication and depression assessment & management for Japanese GPs. METHODS: Experts in communication and depression from EACH and WONCA developed a framework and filled it with content. Through iterative discussions with the Japanese participants and experts during delivery, the training was further adjusted to match local needs. It included didactic and experiential training methods with an emphasis on practicing and feedback. A "train-the-trainer" component helped participants develop their own trainer skills to enhance dissemination of the training in Japan. RESULTS: Six Japanese GPs participated in two one week training-modules in May and November 2018. To aid implementation participants received online supervision on depression management and on teaching between the two modules and after the second module. Evaluation of the content of the training, the teaching methods and the participatory approach was positive. More than two years after the training, many elements of the training continue to be used in daily practice with the GPs teaching communication as well as depression management skills. CONCLUSION: The method of co-creation is promising. Research is needed to confirm that it is effective in transfer to clinical practice.

Involving migrants in the adaptation of primary care services in a 'newly' diverse urban area in Ireland: The tension between agency and structure.

In line with World Health Organization policy (WHO, 2016; 2019), primary care services need to be adapted to effectively meet the needs of diverse patient populations. Drawing from a European participatory implementation study, we present an Irish case study. In a hybrid participatory space, migrants, general practice staff and service planners (n = 11) engaged in a project to implement the use of trained interpreters in primary care over 17 months. We used Normalisation Process Theory to analyse data from 15 Participatory Learning and Action research focus groups and related sources. While stakeholders' agency and expertise produced relevant positive results for the introduction of changes in a general practice setting, structural factors limited the range and scope for sustained changes in day-to-day practice.

Developing evidence for how to tailor medical interventions for the individual patient.

We aim to answer the question: How can we develop an evidence base that will assist tailoring health interventions to individual patients? Using social theory and interview data from people living with chronic illness, we developed a new approach to analysis. Individuals were considered as emergent complex systems, adjusting and adapting within their environment and sometimes transforming. The notion of illness trajectory brought our attention to data in the interviews about the "emergent present," the current period of time when all domains of life, from across time, have expression. We summarized patterns of adjustment and adaptation within the emergent present for people living with chronic back pain, depression, and diabetes. We considered the potential of this analysis approach to inform medical decision making. Our analysis approach is the first step in developing a categorization of individuals that might be useful in tailoring health care interventions to the individual.

A care-full diagnosis: three Vietnamese Australian women and their accounts of becoming "mentally ill".

It is often argued that Western medical responses to illness take illness out of the intimate social contexts within which illness becomes meaningful for people and that, as a result, Western medicine can often constitute an ineffective or, at worst, a disempowering response to illness. While not wishing to challenge such arguments, we seek in this article to present material that might serve as a useful caveat to them. Drawn from interviews conducted as part of an Australian study exploring cross-cultural understandings and experiences of mental illness, we present the accounts of three Vietnamese Australian women. In these accounts, the diagnoses of mental illness that these women had received from their Australian doctors were not presented as being meaningless or disempowering. Rather, as the women presented it, being seen and treated as mentally ill had precipitated and continued to precipitate a sense of belonging and self-worth.

Effectiveness of mental health community training on depression and anxiety to the health care profession working in rural centers of eastern Nepal.

BACKGROUND: Depression and anxiety is the leading cause of disease burden in low- and middle-income countries. It is associated with a worse clinical course over the lifespan. This study aims the post-effect on the approach of managing depression and anxiety after the training on diagnosis and management of depression and anxiety. METHODS: This is a prospective observational study done in the health care professionals who had done training on diagnosis and management of depression and anxiety from me. The participants were evaluated with the questionnaire. RESULTS: The training was given in three parts in three different places of eastern Nepal with the health care professionals working near to those centers. There were total of 49 participants from 17 different primary health care centers. The referral rate of patients with depression and anxiety was decreased by 27% as stated by the participants as they can give psychoeducation and counseling in a very well manner after training which was lacking before training. CONCLUSIONS: Overall, the findings from the current data suggest that there is merit in continuing to evaluate and deliver community health training programs for depression and anxiety. While prevention type and personnel delivering the intervention account for aspects of the heterogeneity observed, more research is needed to identify how program completion and fidelity impact outcomes.

The APEC Digital Hub-WONCA Collaborative Framework on Integration of Mental Health into Primary Care in the Asia Pacific.

Mental ill health affects individual well-being and national economic prosperity and makes up a substantial portion of the burden of disease globally, especially in the Asia-Pacific region. Integrating mental health into primary care is widely considered a key strategy to improve access to mental health care. Integration, however, is a complex process that needs to be addressed at multiple levels. A collaboration between the Asia-Pacific Economic Cooperation (APEC) Digital Hub for Mental Health and the World Organization of Family Doctors (WONCA) is described in this paper, which outlines a framework and next steps to improve the mental health of communities in APEC economies. This paper notes gaps related to the integration of mental health into primary care across the region and identifies enablers and current best practices from several APEC economies. The potential of digital technology to benefit primary mental health care for populations in the APEC region, including delivery of training programs for healthcare staff and access to resources for patients, is described. Finally, key next steps are proposed to promote enhanced integration into primary care and improve mental health care throughout the APEC region.

Supporting antidepressant discontinuation: the development and optimisation of a digital intervention for patients in UK primary care using a theory, evidence and person-based approach.

OBJECTIVES: We aimed to develop a digital intervention to support antidepressant discontinuation in UK primary care that is scalable, accessible, safe and feasible. In this paper, we describe the development using a theory, evidence and person-based approach. DESIGN: Intervention development using a theory, evidence and person-based approach. SETTING: Primary Care in the South of England. PARTICIPANTS: Fifteen participants with a range of antidepressant experience took part in 'think aloud' interviews for intervention optimisation. INTERVENTION: Our digital intervention prototype (called 'ADvisor') was developed on the basis of a planning phase consisting of qualitative and quantitative reviews, an in-depth qualitative study, the development of guiding principles and a theory-based behavioural analysis. Our optimisation phase consisted of 'think aloud' interviews where the intervention was iteratively refined. RESULTS: The qualitative systematic review and in-depth qualitative study highlighted the centrality of fear of depression relapse as a key barrier to discontinuation. The quantitative systematic review showed that psychologically informed approaches such as cognitive-behavioural therapy were associated with greater rates of discontinuation than simple advice to reduce. Following a behavioural diagnosis based on the behaviour change wheel, social cognitive theory provided a theoretical basis for the intervention. The intervention was optimised on the basis of think aloud interviews, where participants suggested they like the flexibility of the system and found it reassuring. Changes were made to the tone of the material and the structure was adjusted based on this qualitative feedback. CONCLUSIONS: 'ADvisor' is a theory, evidence and person-based digital intervention designed to support antidepressant discontinuation. The intervention was perceived as helpful and reassuring in optimisation interviews. Trials are now needed to determine the feasibility, clinical and cost-effectiveness of this approach.

What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms.

BACKGROUND: Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor-patient communication, though not necessarily patient health. OBJECTIVE: To examine patient experiences of GPs' attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome. DESIGN: Qualitative study. PARTICIPANTS: Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general. APPROACH: Thematic analysis of in-depth interviews. RESULTS: Potential barriers include the complexity of patients' problems and patients' judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution. CONCLUSIONS: Improving GP explanation of unexplained symptoms is insufficient to reduce patients' concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor-patient relationship in which patients can perceive psychosocial enquiry as appropriate.

The development of the Brief Edinburgh Depression Scale (BEDS) to screen for depression in patients with advanced cancer.

BACKGROUND: The development of a brief valid tool to screen for depression in patients with advanced cancer is important. This paper reports data on the psychometric properties of the Brief Edinburgh Depression Scale. METHOD: Two hundred and forty six patients who fulfilled the inclusion criteria completed the 10-item EDS and Present State Examination. RESULTS: Factor extraction revealed 6 items from the ten item EDS. The most valid cut off for defining a case, using the PSE diagnosis as the "gold-standard", was a score of 6 out of 18 on the Brief Edinburgh Depression Scale which gave a sensitivity of 72% and specificity of 83% with a PPV of 65.1% and NPV of 87.1%. CONCLUSIONS: The six item EDS is a brief and sensitive method of screening for depression in advanced cancer patients--this novel use of the Edinburgh depression scale may have a significant impact on the assessment and thus management of this distressing symptom.

A pilot study of adherence with light treatment for seasonal affective disorder.

Non-adherence with antidepressant medication regimens is now recognised as a substantial problem when evaluating depression outcome. Given the behavioural demands of light treatment (LT), it might be expected that non-adherence would be even more pronounced in LT, a form of intervention for seasonal affective disorder (SAD). However, little research has focused upon the extent to which patients in light treatment protocols adhere to set regimens. Nineteen patients with SAD were allocated to either treatment with bright white light (intervention) or dim red light (control condition) in a four-week protocol. Light exposure was estimated automatically (without participants' knowledge) with elapsed time meters built into the light box. Daily diaries were also used to measure self-reported light box use. Participants were instructed to use the light box for 30 min each day during week 1, 45 during week 2 and one hour during weeks 3 and 4 (total duration of prescribed light exposure 1365 min). The results indicated that mean duration of light box operation for the entire sample was 59.3% of the prescribed 1365 min. Six of nineteen (31.6%) patients dropped out of treatment. Amongst those completing treatment, adherence to the prescribed duration of exposure averaged 83.3% (S.D.=31.4). A trend was found for the intervention condition to generate a lower dropout rate, as well as a trend for the degree of adherence to be greater in the intervention condition. Importantly, there was no association between adherence as measured automatically and the higher rates of self-reported adherence as measured in diaries. In summary, the results of this pilot study suggest that adherence with light treatment is of a similar order of magnitude to antidepressant medication adherence. Patient self-report was found to be unrelated to objectively estimated duration of light box use, a finding with significant research and clinical implications. Future research studies should routinely measure and evaluate adherence with light therapy and evidence-based techniques for maximising treatment adherence should be incorporated into routine clinical practice.

Design of a clustered observational study to predict emergency admissions in the elderly: statistical reasoning in clinical practice.

OBJECTIVE: To describe the statistical design issues and practical considerations that had to be addressed in setting up a clustered observational study of emergency admission to hospital of elderly people. STUDY DESIGN AND SETTING: Clustered observational study (sample survey) of elderly people registered with 18 general practices in Halton Primary Care Trust in the north-west of England. RESULTS: The statistical design features that warranted particular attention were sample size determination, intra-class correlation, sampling and recruitment, bias and confounding. Pragmatic decisions based on derived scenarios of different design effects are discussed. A pilot study was carried out in one practice. From the remaining practices, a total of 4000 people were sampled, stratified by gender. The average cluster size was 200 and the intra-class correlation coefficient for the emergency admission outcome was 0.00034, 95% confidence interval (0-0.008). CONCLUSION: Studies that involve sampling from clusters of people are common in a wide range of healthcare settings. The clustering adds an extra level of complexity to the study design. This study provides an empirical illustration of the importance of statistical as well as clinical reasoning in study design in clinical practice.

Conceptualizing psychosis in Uganda: the perspective of indigenous and religious healers.

A qualitative study, investigating the representations and explanatory models of ;madness' held by indigenous and religious healers, was undertaken in urban Uganda. Case vignettes of individuals with a diagnosis of a psychotic disorder were discussed by the healers in terms of phenomenology, causality, intervention and outcome. Indigenous healers primarily understood ;madness' as spiritual or physiological, whereas religious healers also held psychological models. Healers' understandings of ;madness' are inextricably linked with the historical and sociopolitical context and may be useful to individuals with psychotic experiences, however, it is likely that these models are dynamic and continually changing.

Usefulness of PHQ-9 in primary care to determine meaningful symptoms of low mood: a qualitative study.

BACKGROUND: Self-administered questionnaires, such as the Patient Health Questionnaire (PHQ-9), are regularly used in clinical practice to guide prescribing or to measure recovery and response to treatment. There are concerns that patients are not all interpreting the questionnaire items in the same way. Cognitive interviewing is a research technique that identifies 'interpretative measurement error' (IME). IME is distinct from traditional components of measurement error, such as not reading the question as worded, or recording answers inaccurately. AIM: To use cognitive interviewing techniques to explore patterns in answer mapping and comprehension of the PHQ-9 questionnaire to ascertain whether the measure captures meaningful symptoms of low mood. DESIGN AND SETTING: Qualitative study using cognitive interviewing techniques and card sorting in six GP practices in Bristol. METHOD: The study recruited 18 participants at the point of entry to a longitudinal primary care depression cohort study, PANDA (the indications for Prescribing ANtiDepressants that will leAd to a clinical benefit). Participants were interviewed 2, 4, and 6 weeks after their baseline visit. Cognitive interviews were digitally recorded. Analysis used the digital audio file, rather than verbatim transcripts, as it retained important features needed for analyses. RESULTS: Cognitive interviewing revealed that items on the PHQ-9 are interpreted in a range of ways, that patients often cannot 'fit' their experience into the response options, and therefore often feel the questionnaire is misrepresenting their experience of meaningful symptoms of low mood. CONCLUSION: The PHQ-9 may be missing the presence and/or intensity of certain symptoms that are meaningful to patients. Clinicians should adopt caution when using it.