Background
Methods
Step-dep study
Participants and recruitment
Data collection
Data analysis
Results
Participants
Patients | ||
Gender (n) | Female | 8 |
Male | 7 | |
Age | Range | 48–84 |
Mean | 62 | |
Chronic disease (n) | DM2 | 9 |
CHD | 10 | |
DM2 and CHD | 4 | |
Number of long-term conditions | Range | 1–9 |
Mean | 3 | |
Level of education (n) | Low | 4 |
Average | 5 | |
High | 6 | |
History of depression (n) | Yes | 11 |
No | 4 | |
Self-reported depression (n) | Yes | 5 |
No | 10 | |
Depression severity PHQ-9 at inclusion | Range | 7–16 |
Mean | 10,9 | |
Anxiety HADS-A | Range | 2–15 |
Mean | 8 | |
Quality of life EQ5D | Range | 0,39-0,92 |
Mean | 0,72 | |
Social support | Range | 34–55 |
Mean | 45 | |
Locus of control | Range | 5–21 |
Mean | 14 | |
Practice nurses | ||
Gender (n) | female | 7 |
Type (n) | Psychological practice nurse | 6 |
Somatic practice nurse | 3 | |
Number of patients treated during Step-Dep | Range | 3–24 |
Mean | 11 | |
Years of relevant professional experience as health-care provider | Range | 3–30 |
Mean | 16,3 |
Main themes
Themes | Questions | Results |
---|---|---|
Illness perception (identity) | Patient • How would you describe your mental state before starting Step-Dep? • If not depressed: please tell more about it? • If depressed: please tell more about it? Did it influence your life? PN • How did you view their mental state/ depressive symptoms? • Did patients recognize themselves in the depressed profile? | • Patients’ and PNs’ perceptions of depressive symptom severity varied from not to severely depressed and were not always congruent with PHQ-9 scores at inclusion • Almost all patients considered themselves at least mildly to moderately depressed • PNs frequently perceived their patients as ‘not depressed’ • Patients sometimes needed time to talk about and reflect on their mood • Work experience perhaps influenced PNs’ perceptions of patients’ depressive symptoms • Many patients did not initially realize that the mental state they were in was a level of depression • Patients preferred using their own words to describe their mental state, some terms were not connected to mood. • Sleeping was frequently pointed out as the most burdensome symptom |
Need for care (cure/control) | Patient • Were you in need of care/ a preventive program to improve depressive symptoms? • How would it have been, if you had not received an invitation for Step-Dep? • What were your expectations/ hopes from the program? • What would your care of choice have been like? And to improve depressive symptoms? PN • Were the patients in need for care for depression? Other need for care? Why? Why not? | • Most interviewed patients experienced a need for care and preferred psycho-educational advice and talking therapy • PNs frequently said that patients had minimal need for specific care and mostly needed attention • In patients, perceived symptom severity corresponded with perceived need for care, but did not necessarily match help-seeking behaviour • Barriers to seek care: ○ Not realizing that mental state is a level of depression ○ Experienced stigma of depression ○ Unfamiliarity with mental health care ○ Experienced barriers discussing mental problems with GP |
Depression causes (cause) | Patient • Is there a relationship with your chronic disease? How? • What do you think caused your depressive symptoms? • How is your mental state now? If improved: what are the reasons for that? PN • How do you view the relationship with the chronic disease? What coping strategies do patients have with a chronic disease? • What are causes of depressive symptoms? • If the depressive symptoms improved in your patients; what was the reason? | • Most patients and PNs appointed a mix of causes of depression • Most were related to negative life events and circumstances • Many PNs and patients perceived indirect links with long-term conditions via: ○ physical limitation ○ changed future perspectives ○ difficulties with acceptance of diagnosis of a long-term condition |
Illness perception
“ It was not as if I was in a sombre mood when I decided to participate. […] Well yes, that was when I was not feeling too happy…” (P2, female, CHD)
“I was feeling really miserable. Too often feeling sombre and too tired. A complete lack of energy, just a wreck. I had trouble sleeping and concentrating. I was just not happy. Not a fun person anymore, in my opinion. (laughs). There was no room for anything else. I think I was actually barely hanging on. Yes, I was certainly depressed.” (P5, female, DM2)
“But I did not consider them depressed. That is something you can sense, or taste almost. No.” (N7, psychological PN)
“Looking back, I wouldn’t have thought that I was that… how should I phrase that…sombre. That actually shocked me at times. To realize that I seemed quite negative. And I actually was negative back then.” (P9, male, DM2 & CHD)
“Due to that questionnaire, they would say: ‘My gosh, all this time, I have been depressed without knowing.’ The best example was this one patient who had a massive score and was like: ‘My goodness, what is the matter with me?’ Well, she had been feeling miserable, but had not connected the dots.” (N3, psychological PN)
“Sombre would be exaggerating, but I sure wasn’t cheerful. Not a happy lad and at the same time seeing a psychologist.” (P11, male, DM2)
“took a bad turn” (P10, male, DM2) “rough times” (P11, male, DM2) “continuous sorrow” (P13, male, CHD) “down and out” (P12, female, DM2 & CHD) “wrecked” (P12, female, DM2 & CHD)
“loss of self-confidence” “stress” (P11, male, DM2) “ burdensome worries” (P1, female, CHD) “burn-out” (P12, female, DM2 & CHD)
“Trouble sleeping. You fall into a downwards spiral, you get so tired, chronically tired I would say. It makes it so easy to stay underneath the covers in the morning, drifting off to depression.” (P15, female, CHD)
Need for care
“The majority did not have a need for care, no. And those who did, were so depressed that they needed clinical treatment.” (N7, psychological PN)
“Just talking to someone, every other week, for half an hour or an hour. To get some practical advice of (name practice nurse) on how to cope with trouble sleeping for example. For her to say: ‘Why don’t you try this’, that really works.” (P15, female, CHD)
“I did not know much about it, except for the term ‘psychotherapy’.” (P7, male, DM2)
“I often reckoned that maybe they just needed some attention. Not to be negative or anything. Just to have somewhere and someone to talk to without sparing that someone, like they would have to with a partner or family member. The freedom to just talk. A need for attention.” (N2, psychological PN)
“Being a true ‘Twent’ (Dutch word for someone from the eastern province of the Netherlands) I never reveal what I am truly feeling.” (P10, male, DM2)
“I never would have asked for that kind of help myself. Growing up, I was taught not to complain. Especially not about mental problems, because that is just all in your head and therefor something you should resolve on your own. […] To overcome the idea of ‘You used to be normal, yet now you have become a psychiatric patient’ […] The stigma already completely surrounds you.” (P7, male, DM2)
“So many of them were of a certain age, when society used to say ‘Take it like a man, stop complaining.’ And so many would lead their lives according to these social codes, bearing their problems in silence.” (N1, psychological PN)
“I wonder if I would have looked for any help, since I was just so used to feeling like that. I just feel so much better now. It makes me think: ‘Darn, things were definitely not alright back then.’ But, it was normal for me.” (P5, female, DM2)
“But in the end, there were quite a few who did have a need for care. But apparently, they had not acted upon it yet. It had not reached their frontal lobe yet, so to say. Not up to the point where they would say: ‘I need to do something about this, I should make an appointment.’”(N3, psychological PN)
“I guess because I was unfamiliar with that area of health care, I would not have looked for it.” (P9, male, DM2 & CHD)
“In my experience, GP’s are always short on time. That makes it really difficult to discuss that kind of problems. Because GPs, like mine, are so busy already and work part-time too, that you always see a different one, which I find very disturbing.” (P1, female, CHD)
Causes of depressive symptoms
“Those life events obviously had an impact on their quality of life and appealed to their coping mechanisms.” (N1, psychological PN)
“It was caused by job insecurity, financial problems or by thyroid medication that needed adjusting. They would appoint very specific problems and say: ‘The way I felt, was a reaction to those problems.’ Circumstances, yes.” (N2, psychological PN)
“I used to walk 20 to 25 km with a friend every other week. That used to be so easy for me, but I can’t anymore. The fact that we had to turn around, that I couldn’t finish that specific walk and had to take a short-cut back… That had a considerable impact. It did not cheer me up at all, to the contrary.” (P6, male, CHD)
“But even in those people with severe limitations, it would not necessarily have that much of an impact. I am remembering this lady who was severely limited, but was so incredibly active. (laughs) In her case, it did not influence her mood, per se.” (N4, psychological PN)
“I don’t really feel those glucose levels. I know the diabetes is there and I realize its consequences, which is possibly the most frightening aspect for me. People say that it is a secret assassin, and that is true, actually.” (P10, male, DM2)
“It is a kind of ‘mourning’ process that you have to go through, to reach a state of acceptance of your losses, like your energy levels, at work, things you used to be able to do. You have to learn to accept that you won’t be able to do all of that anymore. Well, that was my biggest problem.” (P7, male, DM2)
“That (her and her husband’s chronic diseases) absolutely has it effect on the things you want to do or the way you feel. I do believe that.” (P12, female, DM2 & CHD)
“Well, I have seen how being chronically ill just leads to a depressed mood.” (N8, somatic PN)
“Well, it didn’t even cross my mind, that is how important it is to me. I have a hint of diabetes. (laughs) I just use one pill a day. For me, it is such a none-issue, that it hadn’t even occurred to me.” (P11, male, DM2)
“I did not see that presumed relation, or hardly. It is very well possible that people adjust their lifestyle, and realize the impermanence of life…that it is a wake-up call and acts as an anti-depressant.” (N7, psychological PN)