Background
Introduction
Multi-professional approach to patient | Care provided by a case manager working with the patient’s GP and under supervision from a specialist mental health clinician |
---|---|
Structured management plan | Brief psychological therapy e.g. BA (plus/- medication support) |
Scheduled patient follow-ups | Proactive care |
Enhanced inter-professional communication | Patient-specific written feedback to GPs via letter, email and personal contact |
Methods
Ethical approval
Recruitment and sampling
Interview schedule and selection process
Data collection
Analysis
Results
Gender | Age range | IMDa
| Face to face/telephone | From urban or rural GP practice | |
---|---|---|---|---|---|
PT1 | F | 75–80 | 1 | Face to face | Urban |
PT2 | M | 75–80 | 9 | Face to face | Urban |
PT3 | M | 65–70 | 5 | Face to face | Rural |
PT4 | M | 81–85 | 8 | Face to face | Rural |
PT5 | M | 65–70 | 2 | Face to face | Urban |
PT6 | F | 65–70 | 10 | Face to face | Rural |
PT7 | F | 65–70 | 10 | Face to face | Rural |
PT8 | F | 65–70 | 10 | Face to face | Urban |
PT9 | M | 65–70 | 2 | Face to face | Urban |
PT10 | F | 65–70 | 8 | Telephone | Urban |
PT11 | F | 75–80 | 9 | Face to face | Urban |
PT12 | F | 65–70 | 9 | Telephone | Urban |
PT1W | M | 65–70 | 6 | Face to face | Rural |
ID | Gender | Practice size | IMDa
| Urban or rural GP practice |
---|---|---|---|---|
GP1 | M | 14,886 | 5 | Urban |
GP2 | M | 10,150 | 6 | Urban |
GP3 | M | 19,879 | 10 | Rural |
GP4 | F | 18,083 | 8 | Rural |
GP5 | M | 24,353 | 5 | Urban |
GP6 | M | 15,915 | 4 | Urban |
GP7 | M | 6961 | 6 | Urban |
GP8 | F | 13,000 | 3 | Urban |
GP9 | F | 18,083 | 8 | Rural |
GP10 | F | 11,893 | 6 | Rural |
GP11 | M | 7183 | 10 | Rural |
GP12 | M | 15,432 | 5 | Rural |
ID | Gender | Years of experienceb
| Interview type (face to face & telephone/telephone only) |
---|---|---|---|
CM1 | F | 8 | Face to face |
CM2 | F | 9 | Face to face |
CM3 | F | 4 | Face to face |
CM4 | F | 4 | Face to face |
CM5 | F | 4 | Telephone |
CM6 | F | 3 | Telephone |
CM7 | F | 3 | Telephone |
CM8 | F | 5 | Face to face |
Revealing hidden depression
“It crept up on me really, how I felt. I think it had been coming on for a long time and I didn’t realise how bad I’d got until I filled that form in and I just ticked the boxes and posted it.” PT6
“I think it has probably alerted us to one or two of the… more needy patients who perhaps were not coming to us for help… people have been brought into the system that… had sort of dropped out from seeing the GP.” GP3
“One gentleman that I saw, he said the most useful thing had been the diagnostics, as risk was identified, and so we wrote to the GP about that. And it was… the risk was still there when I saw him for the first time so I put that in a letter as well and he said that had kind of opened the door. He would have never gone and spoken to his GP about it.” CM2“they (the patient) wouldn’t do anything and they wouldn’t commit suicide but they feel ashamed I guess of having some thoughts (that they’d be better off dead)… and those are the sorts of things they don’t always like us to share with the GP because it’s back to that stigma isn’t it?” CM1
“…people don’t talk about it do they, they think it’s a weakness don’t they? But it is something that you can’t help when you are in it, you know as I say you don’t realise you are going in it and as much as you try you know sometimes you can’t get out it, it gets deeper you know.” PT6
“…you know if I broke an arm I’d get a sling wouldn’t I, you know it’s fairly obvious, but I suppose with any mental illness you can’t see it, you don’t know.” PTW1
“It’s sort of an age group where they’re not as open about depression as maybe younger people are, there’s a bit of a stigma attached to it still.” GP8
“You’re sort of aware there are people who have depressive episodes that aren’t possibly addressed, they may themselves not really recognise it, and they just think it’s part of, you know, getting older.” GP3“You’d like to think that primary care is fairly aware of it (depression) anyway. But maybe the temptation is to let sleeping dogs lie, I don’t know. So you know, if you diagnose someone with depression you’ve got to do something about it haven’t you?” GP6
“We often go down a medication route because, well it does help them, and it’s very difficult to get other services. And the psychiatry for the elderly tends to be more focused on dementia.” GP8
“I suppose in a busy clinic we probably don’t have time to sort of delve into depression along with the sort of twelve and a half minutes of consulting on chronic diseases that’s squeezed into ten minutes, so depression would take another five or six, so… we’ll probably skip over that unless they bring it to us.” PT12
Reducing the ‘blind spots’
“so you’ve got the benefit of somebody who’s looking at a person, never having met them before who can see certain things, versus somebody who has known somebody for some time and can see certain things but, those two people, will have, probably have, blind spots… because one person doesn’t know that person very well and the other has maybe, over the years, has just sort of formed a fixed idea about somebody. Collaborative working, not only will it progress the patient forward but it will also… reduce blind spots, I think, in their care.” GP1
“I think a lot of the difficulty… is their support networks have become a bit more fragmented…. especially those that are bereaved, or have families spread around the country or spread around the world… so I can see that maybe we can patch that fragmentation up a little bit… it’s not the same as having your relatives but having some kind of support, I can see that as a benefit.” GP3
“Sometimes, if people can’t talk to their GP or don’t understand that maybe they had a problem like depression, and don’t know how to approach a GP because of stigma and things like that then I’ve been that facilitator, I’ve helped them with that process.” CM1
“…she was using cannabis to manage the pain and she felt there was nothing else the doctors could do, so I spoke to her GP and they said she could get a referral to the pain clinic… She [the patient] had given up all hope, but she was happy for me to pester them a little bit.” CM3
Opportunity to talk outside the primary care consultation
“The most startling thing about the experience was all my life I’ve never had anybody to talk to, there’re things I wouldn’t even discuss with my wife and to have an outsider person that didn’t really know me who was impartial… that helped me a great deal, just by having someone to discuss things with.” PT5“…having someone to talk to… about things in my life that I would talk to say the family about or friends unless they were extremely close friends, it gave me someone objective to talk to you know, that was removed from my situation.” PT2
“You know and the GPs, well they don’t, they don’t seem to be interested I don’t think. Oh, it’s depression, take a pill, go away.” PT12“I just have a bit of a problem with doctors because I just don’t think they do the job that they maybe should be doing, it’s a two minute interview or whatever, they don’t really know your records, they don’t know the history, they don’t tie things up.” PTW1
“…she did everything she possibly could… I mean she went the extra mile. She spoke to the people at Parkinson’s – Parkinson’s UK – to see if there was a network somewhere, an advice centre, and things I didn’t know she found out for me.” PT7
“I thought it was very good. And I think the fact that people were bothered, to see how the older people felt…. I think that was good. You didn’t feel like you just got a script thrown at you and you were waiting for God sort of thing…it was the fact that someone was interested in how you felt.” PT1
‘Moving on’ from depression
“The telephone conversations for me were helpful. She got me to think about doing things. I’m doing a computer course now and there’s a chance I might be able to help them at [voluntary organisation].” PT9“It has helped me thinking about things I can do… I go in the pool, only in the baby pool but it’s good for my legs and my shoulder… and you know it makes you feel better once you’ve done it, not just my legs, but in yourself, you know…” PT6
“I’ve kept a diary all my working life and by going - a daily diary that is - and by going through it we could highlight various things that tip the balance if you like of the scales of happiness and depression and it was highlighted (depression) and between us we figured out a way of coming through it basically.” PT5“When we moved onto the technical part of it where they are asking specific questions and giving specific ideas, I find these very useful and in fact I’ve continued to do those. The ones I am talking about are where you identify things to do… and make a list.” PT4