Renata Kokanovic

Embedding effective depression care: using theory for primary care organisational and systems change

BackgroundDepression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.MethodsWe used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.ResultsFive privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.ConclusionsIdeas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

Resilience and depression: perspectives from primary care

Resilience refers to the capacity for successful adaptation or change in the face of adversity. This concept has rarely been applied to the study of distress and depression. We propose two key elements of resilience — ordinary magic and personal medicine — which enable people to survive and flourish despite current experience of emotional distress. We investigate the extent to which these elements are considered important by a sample of 100 people, drawn from a longitudinal study of the management of depression in primary care in Victoria, Australia. We also assess how respondents rate personal resilience in comparison with help received from professional sources. Our data are obtained from semi-structured telephone interviews, and analysed inductively through refinement of our theoretical framework. We find substantial evidence of resilience both in terms of ordinary magic — drawing on existing social support and affectional bonds; and in terms of personal medicine — building on personal strengths and expanding positive emotions. There is a strong preference for personal over professional approaches to dealing with mental health problems. We conclude that personal resilience is important in the minds of our respondents, and that these elements should be actively considered in future research involving people with experience of mental health problems.

Exploring Doctor–Patient Communication in Immigrant Australians with Type 2 Diabetes: A Qualitative Study

OBJECTIVEThe study explored the perceptions of Australian immigrants about their interactions with doctors regarding the diagnosis, treatment, and management of type 2 diabetes mellitus.RESEARCH DESIGN AND METHODSIn-depth interviews were conducted with 30 men and women from Greek, Indian, Chinese, and Pacific Island backgrounds living in Melbourne, Australia, to elicit their perceptions of the management of diabetes and its impact. Participants were recruited through a convenience sample of general practitioners and community organizations providing support to people living with diabetes. Topics discussed included initial reaction to diagnosis, patient—health care provider communication, and the influence of message framing on the perception of the quality of the doctor–patient relationship. Transcripts were coded and analyzed by both authors.RESULTSNumerous issues facilitate or inhibit constructive and positive relationships between doctors and patients with type 2 diabetes. Patients reported difficulty in absorbing all the information provided to them at early consultations, and experienced difficulty comprehending the practical aspects of management. Styles of communication and discourses of normalization and catastrophe influenced participants’ responses.CONCLUSIONDoctors face a complex task in encouraging behavioral change and adherence and establishing and maintaining a supportive relationship with patients. The timing and technical complexity of communication about diabetes, its management, and the prevention of complications require further attention.

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.

``Worried all the time'': distress and the circumstances of everyday life among immigrant Australians with type 2 Diabetes

People with diabetes commonly experience emotional distress and are often diagnosed with depression. To explore lay accounts of the conditions and social aspects of their co-occurrence, we draw on qualitative research conducted in metropolitan Melbourne, Australia. Data derive from in-depth interviews with men and women from Greek, Chinese, Indian and Pacific Island communities, all of which have a higher than average incidence of type 2 diabetes mellitus. Participants generally saw stress as a precursor to diabetes, influencing their ability to control symptoms. Yet they also emphasized that life adversities, trauma, disruption, and multiple losses caused distress and depression. Participants regarded diabetes as an illness that interrupted their ability to carry out everyday living tasks. This contributed to their social isolation and unsettled self-identity, resulting in feelings of personal inadequacy, loss and further distress. These themes were common across immigrant groups.

Resilience as a response to the stigma of depression: A mixed methods analysis

BACKGROUND Stigma has been shown to have a significant influence on help-seeking, adherence to treatment and social opportunities for those experiencing depression. There is a need for studies which examine how the stigma of depression intersects with responses to depression. METHODS 161 telephone interviews with people experiencing depressive symptoms, derived from a longitudinal cohort study, were sampled on the basis of their perceptions of stigma around depression. Interview transcripts were searched for references to stigma and analysed thematically. The frequency of the themes was calculated and cross-referenced, producing a meta-theme matrix. RESULTS Stigma was closely linked to ideas about responsibility for causation and/or continuation of depressive symptoms. Stigmatized individuals felt compelled to take steps to develop their resilience including drawing on existing support networks and expanding on positive emotions and personal strengths in order to counteract this stigma. However, such strategies were burdensome for some. These participants gained relief from relinquishing their personal responsibility. LIMITATIONS The data were briefer than many interview studies. This narrowed its interpretation, but allowed a large sample of participants. CONCLUSIONS When considering how to tailor therapies for those experiencing depressive symptoms, health professionals should consider the interaction of stigma with coping strategies. Many individuals can build on existing relationships and personal strengths to develop resilience, some however need to first relinquish the expectation of having sufficient pre-existing resilience within themselves.

Social support and self-management of type 2 diabetes among immigrant Australian women

Objective: To elucidate the social meanings and interpretations that immigrant women attach to the diagnosis of type 2 diabetes, and the social support and professional advice that they receive following this diagnosis. Methods: In-depth interviews were conducted with 16 immigrant women living in Melbourne, Australia, from communities with a higher than average incidence of type 2 diabetes. Women were recruited purposively through general practitioners and community organizations. The womens initial reaction to the diagnosis of diabetes, understandings of the behavioural changes required to control symptoms and prevent complications and the nature of the social and professional supports were discussed. Interviews were audio-taped, transcribed, coded and analysed thematically by both authors. Results: Some women were critical of their doctors but also manipulated their encounters to avoid receiving unwelcome information about the progress of the disease and consequent required changes in management. Social interactions influenced womens adjustments to diagnosis and informed their communication and adaptation of their lives. Choice of support varied by cultural background, but many respondents reflected on the thin line between support and interference. All women found most understanding from others living with diabetes. Discussion: The social context of people with type 2 diabetes is important in facilitating or inhibiting the management of the condition. Variations in attitudes to family and professionals influenced adherence to advice and emphasized the need for appropriate support to women to sustain behavioural change.

The Politics of Conducting Research on Depression in a Cross-Cultural Context

Successful community engagement is often a crucial component of effective qualitative research. In this article we reflect on our experience of engaging with ethnic minority communities in a qualitative study of help seeking for depression. Community engagement emerges as a complex process that provides important insights into the way mental illness is constructed in various cultural contexts and from diverse perspectives. Contested notions of ethnicity, culture, community, and depression were the domains in which personal and public politics were played out. We worked with bilingual research assistants who provided an entrée to the community. Despite this, disparate community subgroups and influential individuals vied for input into and control of the research agenda. We conclude that negotiating the politics of these processes requires great reflexivity and is itself a powerful seam of data, adding richness to findings about the experience of mental distress in a community seeking to locate itself within mainstream society.

Diverse voices, simple desires: a conceptual design for primary care to respond to depression and related disorders

Background. The World Health Organization and the World Organization of Family Doctors have called for ‘doable’ and ‘limited’ tasks to integrate mental health into primary care. Little information is provided about tasks GPs can undertake outside of guidelines that suggest to prescribe medication and refer to specialists. Objectives. The reorder study aimed to gather diverse patient and community perspectives to inform the development of an effective system of depression care. Method. Five hundred and seventy-six patients completed computer-assisted telephone interviews. Two hundred and seventy-six community stakeholders completed a modified two round Delphi. Responses were analysed to identify tasks and these were synthesised into a conceptual design. Results. Fifteen core tasks were identified, 5 were agreed upon and a further 10 identified by each group but not agreed upon. Listen, understand and empathize, provide thorough and competent diagnosis and management, follow-up and monitor patients, be accessible and do not rush appointments and provide holistic approach and tailor care to individual needs were agreed on. Other tasks included: develop plans with patients, assess for severity and suicide risk, account for social factors, be well trained in depression care and offer a range of treatment options, appropriate and timely referral, support and reassurance, educate patients about depression, prescribe appropriately and manage medication and be positive and encouraging. Conclusions. The tasks form the basis of a conceptual design for developing a primary care response to depression. They fit within three domains of care: the relational, competency and systems domains. This illustrates tasks for GPs beyond prescription and referral.

‘Nobody Can Help Me...I am Living Through it Alone’: Experiences of Caring for People Diagnosed with Mental Illness in Ethno-Cultural and Linguistic Minority Communities

Caregivers of people diagnosed with mental illness in ethno-cultural and linguistic minority communities (ECLMCs) face considerable demands and difficulties in their day-to-day caring role. Data from interviews with 20 caregivers from Polish, Croatian, Bosnian, and Chinese communities, undertaken in Perth, Western Australia, explore the roles caregivers play in the lives of their relatives and illustrate their use and non-use of support services. A diverse array of challenges confronts caregivers across the different ECLMCs. Although not an unequivocally negative experience, caring for a relative diagnosed with mental illness was found to frequently disrupt family relationships and to lead to physical and mental exhaustion as well as social isolation. The stigma associated with mental illness in ECLMCs is a significant factor dissuading people from seeking assistance from external agencies. Many mainstream services are seen as inappropriate, which appears to be a factor in their under-utilization. If mental health policies and community services are to seriously address the issue of appropriate support for caregivers from ECLMCs, it is important that they are aware of the nature of the considerable demands placed on such caregivers as they endeavor to support their dependent relatives.