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General practitioners' and practice nurses' views and experience of managing depression in coronary heart disease: a qualitative interview study

General practitioners' and practice nurses' views and experience of managing depression in... Background: Depression is common in coronary heart disease (CHD). Affected patients have an increased incidence of coronary symptoms and death. Little is known about how best to manage primary care patients with both CHD and depression. This study is part of the UPBEAT-UK programme of research and was designed to understand general practitioners’ (GPs) and practice nurses’ (PNs) views and experience of managing depression in CHD. Methods: Individual in-depth interviews with 10 GPs and 12 PNs in South East London. Data were analysed using constant comparison. Results: GPs and PNs had similar views. Distress following diagnosis or a cardiac event was considered to resolve spontaneously; if it endured or became severe it was treated as depression. GPs and PNs felt that psychosocial problems contributed to depression in patients with CHD. However, uncertainty was expressed as to their perceived role and responsibility in addressing these. In this respect, depression in patients with CHD was considered similar to depression in other patients and no coherent management approach specific for depression in CHD was identified. An individualised approach was favoured, but clinicians were unsure how to achieve this in the face of conflicting patient preferences and the treatment options they considered available. Conclusions: GPs and PNs view depression in CHD similarly to depression uncomplicated by physical illness. However, uncertainty exists as to how best to manage depression associated psychosocial issues. Personalised interventions are needed which account for individual need and which enable and encourage clinicians and patients to make use of existing resources to address the psychosocial factors which contribute to depression. Background improve mood in CHD, although physical health out- Coronary Heart Disease (CHD) can cause distressing comes have not improved [5,6]. A recent trial of colla- symptoms and functional limitation. The prevalence of borative care, an enhanced depression care intervention depression in CHD patients has been estimated at 20% which provides depression severity related treatment gui- [1]. Depression increases the incidence of coronary dance, found improvement in both depression and con- symptoms and death in CHD patients independent of trol of medical disease at 1 year post intervention in other factors [1]. It may also exacerbate the perceived patients with heart disease and/or diabetes [7]. Patients with depression and or CHD are managed severity of symptoms and increase service use [2]. Concurrent physical illness reduces the recognition of mostly in primary care. However, although there has been depression by GPs [3]; accordingly, in the UK, GPs are much work concerning general practitioners’ (GPs) and now remunerated for screening CHD patients for depres- practice nurses’ (PNs) management of depression in pri- sion [4]. Antidepressants and CBT have been found to mary care [8]; little is known concerning how they manage patients with both conditions. A recent qualitative study * Correspondence: elizabeth.barley@iop.kcl.ac.uk aimed to determine barriers to managing depression in Section of Primary Care Mental Health, Health Services and Population people with CHD or diabetes [9]. Interviews and a focus Research Department, PO Box 28, Institute of Psychiatry, King’s College group with healthcare professionals, service users and London, De Crespigny Park, London, SE5 8AF, UK © 2012 Barley et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Barley et al. BMC Family Practice 2012, 13:1 Page 2 of 10 http://www.biomedcentral.com/1471-2296/13/1 carers indicated that depression was often normalised in A purposive, maximum variation approach was used the presence of long term conditions (LTCs) and that per- based on ethnicity, age, practice setting (inner city versus formance managed environments in primary care mili- suburban) and type (single handed versus group). Male tated against shared understandings of depression. and female GPs were recruited; no male PNs were identi- However, the views of PNs were underrepresented in this fied. After several interviews, it was noted that participants study given that, as a group, they have the most regular often mentioned their involvement in the UPBEAT-UK contact with such patients. cohort study and we became concerned that this involve- Similar tensions between delivering care to meet quality ment might have increased awareness of depression in targets and fulfilling the patients’ agenda were found in an CHD. From then on, only clinicians whose practices were interview study of GPs’ and PNs’ perceptions of the man- enrolled in UPBEAT-UK but who were not personally agement of patients with multimorbidity in general [10]. involved were interviewed. Snowballing was also used to Issues specific to CHD were not considered in this study. identify participants independent of UPBEAT-UK. Level The current study was conducted as part of a NIHR of participant involvement in UPBEAT is indicated in funded research programme: UPBEAT-UK [11]. It explores Table 1. Recruitment stopped when saturation of themes GPs’ and PNs’ views and experience of managing depres- was reached; that is, no new themes or information relat- sion in patients with CHD and its findings will inform the ing to the identified themes emerged. development and implementation of strategies within the programme to help primary care staff manage such Data Collection patients effectively. EB conducted all the interviews using a guide based on lit- erature review [8]. Broad topics were: understandings of Methods depression and detecting and managing CHD depression. Sampling Prompts were used to elicit opinions on topics identified The sampling frame was 31 GP practices participating in in the literature search, such as the use of screening tools the UPBEAT-UK cohort study of patients with depression and differences between ‘distress’ and ‘depression’. and CHD. They were from 4 ethnically and socially diverse Prompts were revised iteratively, for instance, early partici- boroughs in South East London (Lambeth, Lewisham, pants introduced the problems of ‘erectile dysfunction’ Southwark and Croydon). and ‘housebound patients’; these were explored with later Table 1 Participant characteristics GPs PNs Age (years) Range 24 - 63 yrs 33 - 59 years Mean 47.6 years 43.3 years Median 48 years 42 years Gender Female 312 Male 70 Ethnicity White British 410 African/Afro-Caribbean 30 Asian 32 Practice setting Mainly deprived 43 Mixed 59 Mainly affluent 10 Practice type Single handed 11 Group 911 UPBEAT-UK involvement Involved 85 Practice recently recruited/participant not yet aware 24 None 03 Barley et al. BMC Family Practice 2012, 13:1 Page 3 of 10 http://www.biomedcentral.com/1471-2296/13/1 participants. In order to ground opinions in practice, parti- Theme: Recognising depression cipants were asked to recall specific patients with CHD Distress versus Depression and depression. Interviews were recorded and transcribed The participants reported difficulty distinguishing in verbatim by EB. Participants gave written informed general between ‘distress’ and depression needing treat- consent. ment. They were aware that many patients with or with- out CHD experienced difficult social circumstances. It was therefore ‘understandable’ that they felt low. Analysis Interviews and analyses were performed concurrently “When they come to the clinics there is some level using principles of constant comparison [12] and the- matic analysis [13]. Three researchers (EB, JM and PW) of depression. Whether it’s due to their disease, it’s coded independently the first interview and agreed difficult to say. I think there is a lot of other things descriptive codes. EB and JM independently applied in this area that cause that.” (P1) these and, where appropriate, new codes to the follow- ing 4 transcripts when consistency in coding was Similarly, in CHD most participants felt that distress achieved. Descriptive codes were collated into themes following diagnosis or a cardiac event was ‘natural’. and a preliminary explanatory framework devised. This was used as the basis for coding and for informing “I guess if someone was to come in with recently future interviews. Data for each theme were gathered being diagnosed with CHD and came in a particu- and coded by EB using computer software (NVIVO 8 larly low mood. Initially, again, you might just put it [14]). The robustness of themes was tested by examining down to the fact that they’ve been diagnosed with differences and similarities between coded data. A sam- quite significant illness, so you may not call it ple of coding was agreed between two researchers (EB depression as such.” (GP7) and JM). Theoretical memos [15] containing ideas and impressions from interviews and transcripts were pro- The potential for sudden death and the feeling of vul- duced and used to inform coding discussions. nerability this produces were highlighted as particularly distressing. Results “....something with your heart, everyone knows that Participants the heart is such an important organ, don’t they? We interviewed 10 GPs, 11 PNs and one clinical pharma- And they, and everyone thinks ‘well, if it stops, that’s cist from 12 practices. The pharmacist’srolewas similar it’.” (GP8) to the PNs’, but she was more involved in medication management. Since during the analysis her views were not found to differ from that of PNs, we treated her data as For mostpeoplewithCHD, it was thoughtthatdis- PN data. We would have recruited more clinical pharma- tress resolves spontaneously, although no time period cists, but we are not aware of any others working within was specified. For many, the level of impact of CHD on practices enrolled in UPBEAT-UK. This pharmacist had life was also important. an important role in managing CHD patients within her practice so we felt that her views were important and that “Part of it is their disability due to their disease, erm, our data would not be complete without them. Participant but not their disease per se. ‘Cause if they’re func- characteristics are shown in Table 1. All contacted agreed tioning OK, I don’t seem to find that there’san to participate. issue. Whereas, if they are actually, you know, ‘I Diverse views were expressed, but, on the whole, can’t walk far, I’mbreathless’ all of that, then yes divergence was not found to be related to participant there is.” (P1) group i.e. the GPs, the PNs, the community pharmacist, those involved in UPBEAT or those less or not involved. Distress and depression in CHD therefore appeared to For most themes a majority view independent of partici- be conceptualised similarly to that in other illnesses and pant profession was identified, that is GPs and PNs had on a continuum of chronicity and/or severity. Only dis- similar views. GP and PN data are therefore combined tress that becomes chronic and /or severe was consid- ered to require management. except where differences were found; these are reported. The themes identified are described, with quotations “You know, if it’ssomeone who’s just feeling crap identified by profession (GP = general practitioner, for a day, you know, that doesn’twarrantit [man- PN = practice nurse) and the interview order (GP1-10; agement], but feeling crap for a long time does........ PN1-11; P1 clinical pharmacist). Barley et al. BMC Family Practice 2012, 13:1 Page 4 of 10 http://www.biomedcentral.com/1471-2296/13/1 something about the, you know, severity and the detected somatic symptoms which could be confused chronicity is important.” (GP2) with depression. “Some hospitals put patients on antidepressant, I’ve noticed, quite quickly, sometimes even before they’ve “Some of them [patients] misinterpret it [PHQ-9], been discharged, which I sometimes worry about because, I mean some of them might/when they’re because obviously the event is all a bit new then older, they find they don’t sleep quite so much and and, and if they are tearful or really distressed it’s they expect to still sleep 12 hours a night. And you do find that a lot of them, do sort of say they have sort of erm understandable that they are in a way.” problems sleeping and there could be other factors (GP8) that are influencing that more than because they are Depression Screening depressed.” (PN3) Most participants regularly used the two screening ques- tions stipulated in the quality and outcomes framework Clinical judgement (QOF) of the UK general practice contract [4]. Several Most participants also valued their clinical judgement. used the Patient Health Questionnaire 9 (PHQ9) [16] or They used this to decide when to ask just the QOF the Hospital Anxiety and Depression Scale (HADS) [17] questions or to give a more detailed questionnaire, or to following a positive response to screening. In some supplement the information obtained by such measures. practices these were not available to PNs. Most agreed that if they felt the QOF questions were Most felt that depression in CHD is under-diagnosed. not providing a ‘true picture’ they would use their clini- This may be because some patients consider it inap- cal judgement. A range of depression indicators was propriate to mention mood during a consultation about described including crying, frequent attending, sleep dis- CHD, or because they fear mental health-related stigma turbance, reduced activity, tiredness, loss of appetite or or causing discomfort. However, screening instruments non-attendance at appointments. Several participants helped some clinicians initiate a conversation about felt they could recognise depression from the patient’s mood in a non-threatening manner. demeanour. For some, this involved intuition; others noted signs such as a head down stance, lethargic man- “we’re saying ‘it’s not actually our fault - we’ve been ner, fixed gaze or lack of eye contact. Several, however, told to do this by big brother. So actually, it’sOKto noted that a ‘jolly demeanour’ may mask depression, talk about it’.Soit’s been very helpful from that which was an argument for active screening. point of view. It’s kind of taken the stigma off asking and responding.” (GP3) “Some of them surprise me - you think ‘oh yes, they’re fine.......and you get them to fill in this form For several participants, these instruments raised and you think ‘oh!’” (PN3) awareness of depression in CHD. No strategies for assessing depression specifically in “Now that I’ve actually been asking the questions, patients with CHD were identified. I’ve picked up people that, actually, looking back, I’ve known it for years and I haven’tdoneanything Theme: GP and PN perceptions of why some CHD about it.” (GP3) patients become depressed Possible physiological links between depression and Reservations were also voiced; these tended to relate CHD were raised by only one GP. to depression screening in general not just in CHD. Sev- eral participants, especially PNs, said that they avoided “if one’s stressed and one’sstresshormonesgoup, using them due to a fear of uncovering unmanageable one’s platelets get more sticky and the endothelium problems. gets more sticky and all that sort of happens. And also if one’s got cardiovascular disease that may “I’m bad at asking, in some ways I think, like lots of influence peoples’ neurotransmitters.” (GP3) nurses, you don’t want to open up something that you then, then can’t deal with afterwards” (PN11) A number of factors commonly associated with CHD such as loss of a valued role (e.g. loss of employment), OneAsian participant(P1)feltthatSouth Asian inability to fulfil responsibilities due to disability and patients conceptualise depression in somatic terms and erectile dysfunction were considered to lead to depres- that these instruments would not detect this. In con- sion. Erectile dysfunction was considered especially trast, another participant felt that the instruments important with most participants agreeing that men are Barley et al. BMC Family Practice 2012, 13:1 Page 5 of 10 http://www.biomedcentral.com/1471-2296/13/1 reluctant to report this. Despite this observation and the depressive phase. Presumably, that’sinherited,it’s availability of specialist clinics, most GPs and PNs did constitution, it’s related to our chemical make up.” not ask about this routinely. (GP9) “No I don’t, no.Again, I wish,Imean,Ishould do Lack of education was thought problematic, although (ask about erectile dysfunction) because that’ssome- one PN felt the educated were more at risk due to the thing that we can offer them as well for that.” stress arising from a greater awareness of potential com- plications. Some patients were thought to hold negative (PN11) attitudes to their CHD which could be disabling inde- Nurses may also be embarrassed to introduce this pendent of disease severity. topic; one PN suggested that being older helped. “It’s their perception that they’re an invalid and quite “it’s probably easier for me because I’malotolder often they’re not an invalid, maybe they could go and maybe they’re not so embarrassed. So if I can back to work.” (PN2) bring it up, then it can be a lot more sort of open.” (PN9) Alcohol or drug use and a past history of depression were also mentioned, Other CHD related factors thought to contribute to depression were feeling responsible for their illness and Theme: depression management having to make unwanted lifestyle changes to prevent All participants felt that treating depression would lead CHD progression. to improvements in self management of CHD, which suggests that they are motivated to address this issue. “I think many people, as perhaps part of their CHD depression, feel guilty about it: ‘yes I did inflict it.” “Cause sooner or later, someone with depression is (GP1) going to say ‘why bother about my statins, my cho- “You know the sort of modification in their lifestyle lesterol, my diet - who cares? Why do the exercise? and things can be really, really difficult. If it’ssome- Smoking - well actually I find it quite comfortable? body that’s been smoking for example and is trying I’m not interested in will I get a lung cancer in 10 to give up smoking and life feels like it’snot worth years time or not, I can’t see ahead for 10 years’. living cause they can’t smoke .....” (P1) Whereas if somebody feels really optimistic, positive then you’re gonna be thinking ‘yes, I’m doing all this Several participants considered that depression may to ensure my own better future.” (GP1) lead to heart disease as depressed individuals are more “if you’ve treated their depression, their outlook on likely to lead an unhealthy life. life might be better as a whole, so therefore they Social problems such as financial and housing difficul- want to remain well, so they’re taking their medica- ties were thought to be related to depression and were tion, not just their medication, their exercise their considered common among CHD patients. Isolation was food, whatever, smoking..... so it ..... all goes hand in mentioned by almost all participants. hand.” (PN10) “Social, loneliness - very important, loneliness, loss Several GPs and PNs stressed the importance of of employment, isolation, the home environment. patient choice in increasing adherence to management Sometime they need their home to be adapted to programmes. their, to their physical and medical needs at the time and they will not have it. But most importantly is “Of course they’ve got tocometoitthemselves, loneliness.” (GP5) because if you’re going to offer any sort of therapy or treatment, it’s a complete waste of time if they Other predisposing factors for depression cited were haven’t got to actually saying ‘well, yes I want it’. not necessarily considered related to CHD. For instance (GP9) some participants mentioned lack of resilience, poor coping skills and ‘premorbid personality’ (GP1). Individual GPs and PNs raised and discussed a variety of management options for depression; sometimes these “I think that while most of us maybe will cope with were related to depression comorbid with CHD but stress and anxiety, there is a core population that if more often participants did not differentiate between they are tipped to a very severe extent will dip into a this and depression in general. Barley et al. BMC Family Practice 2012, 13:1 Page 6 of 10 http://www.biomedcentral.com/1471-2296/13/1 Antidepressants ii) Talking therapy Several GPs and PNs felt that antidepressants were use- Mostly the generic term ‘counselling’ was used, although ful in ‘lifting’ apatient’s mood to the point that they a few participants referred to ‘CBT’ or ‘psychotherapy’. would be able to return to normal functioning. How- Counselling was widely favoured by both GPs and PNs ever, GPs had treated only a few CHD patients in this to help patients come to terms with their condition, to way. The majority only prescribed antidepressants in increase confidence in self management or to aid in CHD when other options had been exhausted, in severe venting feelings. depression, suicidal intent, if mood was deteriorating or if a patient had responded well previously. “I think counselling would definitely be number one on the list. I mean a lot of the time, you just ask the “It isn’t always drug treatment, it’sabout going question ‘would you like someone to talk to?’ And through the rehab programme, getting the confi- then alot of thetimethey willsay ‘yes’.Sorather dencetogoout anddothings,starting driving than ....medicalising it too much, you could maybe again, having sex - all thse sorts of things sometimes try simple steps like counselling services, support are therapeutic.......so very often medication is not groups, helplines. And that might just be enough ...... always needed”. (GP9) to improve their mood.” (GP7) “sometimes just seeing a counsellor and getting Hesitation in prescribing was related to a perceived things off their chest for a few sessions will help.” reluctance in patients to accept antidepressant treatment (PN9) due to fear of stigma or a general dislike of medication. Three GPs said they, or another GP within the prac- “We discuss with the patients. You know, depends tice, provided counselling such as ‘mini’ CBT, problem where the patients stand, yes and then minority of solving therapy or ‘10 minute CBT’. Otherwise, a coun- the cases go on antidepressant tablet/treatments, you sellor or psychologist (or both) was available in most of know, not everyone wants treatment.” (GP10) the practices. Despite this, a lack of availability of coun- selling was commonly raised; all but two PNs said that This was not necessarily associated with the patient’s waiting lists were too long. They complained that this CHD, although patient dislike of medication was consid- meant they were unable to follow treatment guidelines ered increased when they were taking multiple drugs as which promote the use of talking therapy. most CHD patients are. “Because our waiting lists are so long, so although all “she has so many tablets anyway and she’s always the guidelines....say counselling treatment ect, we wanting to stop this and stop that and ‘can I just cut haven’t got primary care counselling really”. (P1) this down?’ and ‘can I just miss out my asprin for a couple of days?’.....To add another tablet, an antide- Only one GP mentioned the Improving Access to pressant, into the mix would just probably be the Psychological Therapies (IAPT) programme: they felt thing that tipped her over the edge."(PN5) that primary care practitioners were not yet fully awareofit. This maybeexpectedas, at thetimeof Only one GP was concerned about drug interactions. the study, this was a relatively new service in the area. Several of the PNs were not prescribers, but, among Computerised CBT was considered by a few partici- those who were, there was reluctance to prescribe anti- pants to be unsuitable for elderly CHD patients who depressants due to a lack of confidence in managing may not be computer literate. Reluctance to undertake depression. therapy was also observed due to perceived stigma or denial. “I have been prescribing a few years now, but I do Some PNs reported that they were not authorised to find I tend to stick to things I’mhappy with and make counselling referrals; they did not complain about that I deal with a lot, which is CHD, diabetes, this. This may further reflect uncertainty among nurses women’s health, travel health family planning........but in managing depression which was summed up by one because it [mental health] is something that I don’t PN: deal with a lot, I’m not happytoprescribe. SoIdo tend to ask advice before I would prescribe.” (PN3) “Icould do [make a referral to a counsellor].On the “I am a nurse prescriber, but I wouldn’t feel comfor- whole, I prefer to do it through the GP, just in case table or sort of competent enough to do that” (PN9) the GP doesn’t agree that they need it.” (PN9) Barley et al. BMC Family Practice 2012, 13:1 Page 7 of 10 http://www.biomedcentral.com/1471-2296/13/1 iii) Informal counselling “Rehab is some mythical thing in primary care I This involved providing education about CHD and think! It just takes place in the hospital and that’s assurancethatdistressisnormal. GPstendedtorefer that.” (PN5) patients to a counsellor if this took too long. Most PNs agreed that this is part of their role; several had CHD Lack of communication was also reported between patients who would come in for ‘achat’.Somewould primary care staff and district/community nurses (DNs) schedule extra consultations for this, despite being who manage housebound CHD patients. Some PNs did unsure how useful it was. They did not know what else not know what DNs did, although they suspected that to do however. they do not address psychological needs due a heavy workload which prioritises physical health. “At the moment, I dunno what to do with this group of people, so I see them more regularly because I “It’s quite sad really, but we don’t have a lot to do feel that they need contact with somebody, but I with our district nurses in this practice. I think if dunno if that’s the best thing to do...."(PN5) they’ve got concerns they speak to the duty doctor. But we as a whole, we don’t sort of link in with each iv) Exercise other. I don’tknowthemand they don’tknowus..” Some participants recommended exercise to improve (PN10) mood. “Ijustdon’t know whether the district nurses go into it [mood] very much, ‘cause they are usually so “I explain to them about serotonin levels - how if busy. They, they sometimes just tick the boxes like, you do exercise you can produce more and it you know, the blood pressure’sbeendoneand what makes/it’s a happy hormone and all the rest of it.” it is and and ‘yes, they are on asprin’.” (PN9) (PN6) OnePN madehomevisitstohouseboundCHD The social aspect of ‘exercise on referral’ schemes and patients in order to gain QOF points. However, a PN at ‘seated exercise classes’ was considered beneficial. a different practice believed these patients were v) involvement of other agencies excluded from QOF registers and so they did not One GP reported having made a psychiatry referral receive any depression screening or management. when she did not know how to progress, but was not helped. “those patients probably get exempt from their regis- ters because they are housebound.........’cause I think “I actually referred him up to psychiatry, because I that if you prove that you’ve written or invited them felt, he was actually very vulnerable and very at risk three times and they haven’tcomeinthenyoucan of suicide. I felt, ‘cause he was very isolated, he lost exempt them.” (PN8) his job, he’s relatively young. But the psychiatrists wouldn’t see him, they just bounced it back and said One GP also noted that talking therapy is not avail- ‘you know, oh you’re doing a good job with your able for housebound patients. medication, nothing more we can do’.” (GP9) “one of the, the quite striking things is that there’s Generally, it was felt that the Community Mental almost no access to talking therapies for people who Health Team (CMHT) was for complex cases and so are housebound. There are, you know, people who they would not deal with depression in CHD patients or are frail, elderly or with things like heart disease depression generally. who may be rather more likely to be housebound, but, you know, counsellors and psychologists are “then we have CMHT and other services - erm not pretty much, you know, practice or clinic based and hugely accessible for this kind of this level of mental don’t go and visit people at home.” (GP2) health problems.” (GP2) A perception of a relationship between depression and Cardiac rehabilitation was considered helpful but social problems, irrespective of the presence of CHD, poorly attended by some patients, such as working peo- led a few clinicians to direct their patients to commu- ple and Asian women reluctant to attend a mixed class. nity facilities, such as church coffee mornings and local Only one GP had liaised with cardiac rehabilitation in libraries. However, they found it difficult to identify the management of a depressed patient. such resources. Barley et al. BMC Family Practice 2012, 13:1 Page 8 of 10 http://www.biomedcentral.com/1471-2296/13/1 “it’s really, it’s knowing what, what is available CHD or a cardiac event, but only when distress becomes because I am sure there’slotsofthingsoutthere, severe and enduring is it seen as depression requiring but it’s just really knowing.....” (PN11) treatment. This view of depression as a natural reaction to life events has been found in studies of the manage- Furthermore, some participants either did not see ment of depression uncomplicated by physical illness resolution of social problems as their responsibility or [18-20]. felt powerless to help. This seemed to be especially the TheGPs andPNs in this studyfeltthatdepressionis case for PNs, perhaps because they have more time to under-diagnosed in CHD. However, their opinions con- cerning the use of screening instruments varied. A study talk to patients about their problems. [21] of GPs’ use of depression screening questionnaires “’cause there’s nothing I can do for them. ....’cause showed that, although doctors used them, they preferred actually what can I do? I can help your physical to rely on their ‘practical wisdom and clinical judgement’. things, but actually if you’ve got issues with your Some of our participants shared these views and many extended family at home, I can’tdo anythingabout PNs did not even have access to questionnaires such as that.” P1 the PHQ9 [16] or the HADS [17]. Some GPs however “There might be something about the grandchild or reported positive applications, and most used their clini- something or the children and there’s not a lot you cal skills as a supplement to screening data or to help to can do about that” (PN2) decide whether to use a more detailed questionnaire. When managing depression uncomplicated by CHD, In contrast, one practice had a social prescribing ser- GPs have been found to favour ‘watchful waiting’ over vice where a professional directed patients with identi- antidepressants [22]. Similarly, in our study, antidepres- fied social problems to appropriate agencies. Staff at this sants were not the GPs’ first choice. Reluctance in CHD practice reported many patients with complex social patients to accept antidepressants was reported; this was needs; one GP stressed her pleasure in working with felt to be either due to fear of mental health-related such patients. This attitude was promoted and a flexible stigma or to negative attitudes towards medication in attitude to time management was adopted. general which may be amplified in patients who require multiple medications for co-morbidity. Talking therapies “I, personally, I really like our population and find were favoured, but few participants differentiated them interesting......Their problems are quite com- between approaches such as CBT or supportive counsel- plex. It’s rare for them to come in with a single pro- ling which may lead to less appropriate referrals. Some blem..........and if they come in with their 3 problems, patients were observed to reject talking therapy due to and actually one problem’s going to take up the fear of stigma. However, the main barrier was a lack of whole of the consultation, more often than not they availability, as reported previously [18]. In the UK, the will get more than what they would have got if the/ Government’s Improving Access to Psychological Thera- it’s unusual for someone to say ‘no, that’sit, you’ve, pies programme [23] is addressing this, but at the time of you’ve had your, your time’. ‘Cause we generally this study this was a relatively new innovation and avail- don’t work like that.” (GP8) ability was not consistent across the boroughs in which the participants worked. Informal counselling, such as reassurance and education, was also discussed; most GPs Discussion were unwilling or unable to give much time to this. Some The GPs and PNs in this study identified factors asso- PNsreportedthattheydid have time, but doubted its ciated with CHD such as feelings of responsibility for usefulness. having caused their illness, unwanted lifestyle changes, The GPs and PNs reported liaising rarely with other loss of employment, inability to fulfil responsibilities due professionals when managing patients with CHD and to disability and erectile dysfunction that they felt may be depression despite guidance [24] promoting this. Greater associated with depression, However, these may not be use by health care professionals of services, such as social CHD specific and may be important in other long term clubs and advice agencies, which promote well being has conditions (LTCs). Other predisposing factors for depres- also been encouraged [24]. Knowledge of such services sion which are unrelated to LTCs were also raised such varied widely between our participants. This may relate as social problems, individual differences and coping to our finding of variation in attitudes to managing social skills. On the whole, the GPs and PNs did not differenti- problems. Nurses were especially concerned about social problems, perhaps because they reported spending more ate between depression in patients with CHD and depres- time providing informal counselling and so had greater sion in other patients; it was thought that individuals may opportunity to probe these issues. Our recent meta- ‘naturally’ become distressed following a diagnosis of Barley et al. BMC Family Practice 2012, 13:1 Page 9 of 10 http://www.biomedcentral.com/1471-2296/13/1 synthesis [8] found also that management of depression of experiences. Also, many of the current findings are uncomplicated by physical illness is perceived by primary supported by previous research conducted in other con- care staff in the UK as particularly complex when texts and so are likely to be broadly representative. patients present with social problems; both GPs and PNs Finally, this study was conducted prior to the introduc- in the included studies were aware of the relationship tion in the UK of guidelines for the management of between social and mood problems but they were unsure depression in adults with a chronic physical health pro- of its exact nature and of their role in managing it. The blem [27]; these may impact on attitudes and practice. participants in the current study are especially likely to encounter social problems among their CHD patients as Conclusions heart disease is more common in people from lower In this study, GPs and PNs identified CHD related fac- social economic backgrounds. Previous research [19] has tors that they felt may be associated with depression, identified ‘therapeutic nihilism’ where clinicians feel help- but also other predisposing factors such as social pro- less in the face of the complex social problems which blems which can occur in any depressed population. impact on health. This was seen in several of our partici- The importance of social factors may be increased in pants. However, one practice actively sought to address people with CHD as they are especially likely to come social difficulties by providing ‘social prescribing’;there from lower socioeconomic backgrounds, but this may may be scope to develop this for depressed CHD patients. also be true for other LTCs. Our participants, in com- No clear management strategy specific for patients with mon with those of studies of depression uncomplicated CHD and co-morbid depression was identified; the treat- with physical comorbidity, expressed uncertainty as to ment issues and management options raised appeared how to address depression associated with psychosocial similar to those in depressed patients without physical problems. In the face of perceived individual differences comorbidity. Collaborative care, where nurses and doctors in the causes of depression in CHD, an individualised work together to deliver evidence based treatment, has treatment approach was favoured but clinicians were been shown to be beneficial for depression [25] and, unsure how to achieve this in the face of conflicting recently, a trial conducted in USA found it to improve patient preferences and the treatment options they con- both depression and disease control in patients with CHD sidered available. This suggests that flexible interven- and/or diabetes [7]. However, in this study some nurses tions are needed which enable and encourage clinicians did not consider managing mental health to be their role. and patients to make use of existing resources, such as These PNs reported a lack of training, interest or time. social clubs and advice agencies, to address the psycho- Negative past experience of mental health training has social and other factors which contribute to depression. been found to be associated with nurses’ current negative attitudes towards managing mental health [26]. Since pri- Acknowledgements and Funding mary care patients with CHD commonly receive most of This report/article presents independent research commissioned by the their care through nurse-led clinics, our findings suggest National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1048). The views expressed in this that the development of interventions for depression in publication are those of the author(s) and not necessarily those of the NHS, these patients should include sensitive consideration of the NIHR or the Department of Health. The UPBEAT-UK Research Team nurses’ views. consists of: Andre Tylee (PI), Mark Ashworth, Elizabeth Barley, June Brown, John Chambers, Anne Farmer, Zoe Fortune, Mark Haddad, Sally Hampshire, Morven Leese, Anthony Mann, Paul McCrone, Anita Mehay, Joanna Murray, Strengths and limitations of the study Diana Rose, Gill Rowlands, Rosemary Simmons, Alison Smith, Paul Walters, Some of our participants may have been sensitised to the John Weinman. André Tylee is partly funded by the NIHR Biomedical Research Centre for link between depression and CHD by having been Mental Health at the South London and Maudsley NHS Foundation Trust recruited into the UPBEAT-UK study [11]. However, and Institute of Psychiatry, Kings College London. given this, findings of uncertainty among clinicians in the Our thanks to the GPs and PNs from South London who agreed to be interviewed for this study. understanding and management of this condition appear particularly important. Diverse views were expressed, but Authors’ contributions reducing complex data into themes may result in decon- EB conducted the interviews and the analysis and wrote the first draft of the manuscript. PW and AT conceived the study, assisted in the analysis and texualisation of speakers’ words. We therefore employed interpretation of data and revised the article. JM conceived the study, a rigorous iterative, multidisciplinary approach to our conducted the analysis and revised the article. All authors read and analysis in order to ensure that our summaries are an approved the final manuscript. accurate representation. Authors’ Information This study was confined to South East London; how- EB is a practitioner health psychologist, registered general nurse, researcher ever we recruited participants from contrasting areas and systematic review module leader for the MSc in mental health service and population research at the Institute of Psychiatry. (inner city, suburban, deprived, affluent) with a range of PW is a research fellow and consultant psychiatrist. experience and characteristics in order to elicit a range Barley et al. BMC Family Practice 2012, 13:1 Page 10 of 10 http://www.biomedcentral.com/1471-2296/13/1 AT is a GP, professor of primary care mental health and Academic Director 17. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta of the Mood, Anxiety and Personality Clinical Academic Group at Kings’ Psychiatr Scand 1983, 67:361-70. Health Partners, King’s College London. 18. Chew-Graham CA, Mullin S, May CR, Hedley S, Cole H: Managing JM is a senior lecturer in social research specialising in qualitative studies in depression in primary care: another example of the inverse care law? mental health. Family Practice 2002, 19:632-37. 19. Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C: Competing interests ’Justifiable depression’: how primary care professionals and patients The authors declare that they have no competing interests. view late-life depression? a qualitative study. Family Practice 2006, 23:369-77. Received: 27 September 2011 Accepted: 5 January 2012 20. Murray J, Banerjee S, Byng R, Tylee A, Bhugra D, Macdonald A, et al: Published: 5 January 2012 Primary care professionals’ perceptions of depression in older people: a qualitative study. Social Science & Medicine 2006, 63(5):1363-73. 21. Dowrick C, Leydon GM, McBride A, Howe A, Burgess H, Clarke P, et al: References Patients’ and doctors’ views on depression severity questionnaires 1. Davidson KW, Kupfer DJ, Bigger JT, Califf RM, Carney RM, Coyne JC, et al: incentivised in UK quality and outcomes framework: qualitative study. Assessment and treatment of depression in patients with cardiovascular BMJ 2009, 338:b663. disease: National Heart, Lung, and Blood Institute Working Group report. 22. Hyde J, Calnan M, Prior L, Lewis G, Kessler D, Sharp D: A qualitative study Psychosom Med 2006, 68:645-650. exploring how GPs decide to prescribe anti-depressants. British Journal of 2. Katon W, Von Korff M, Lin E, Simon G, Ludman E, Bush T, et al: Improving General Practice 2005, 55:755-62. primary care treatment of depression among patients with diabetes 23. Department of Health: Commissioning a Brighter Future: improving access to mellitus: the design of the pathways study. 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Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, Pre-publication history Czajkowski SM, DeBusk R, Hosking J, Jaffe A, Kaufmann PG, Mitchell P, The pre-publication history for this paper can be accessed here: Norman J, Powell LH, Raczynski JM, Schneiderman N: Effects of treating http://www.biomedcentral.com/1471-2296/13/1/prepub depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart doi:10.1186/1471-2296-13-1 Disease Patients (ENRICHD) Randomized Trial. JAMA 2003, 289:3106-16. Cite this article as: Barley et al.: General practitioners’ and practice nurses’ 7. Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, views and experience of managing depression in coronary heart disease: a Peterson D, Rutter CM, McGregor M, McCulloch D: Collaborative care for qualitative interview study. BMC Family Practice 2012 13:1. patients with depression and chronic illnesses. 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Tylee A, Ashworth M, Barley E, Brown J, Chambers J, Farmer A, Fortune Z, Haddad M, Lawton R, Leese M, Mann M, Mehay A, McCrone P, Murray R, Pariante C, Rose D, Rowlands G, Smith A, Walters P, Up-Beat UK: A programme of research in to the relationship between coronary heart disease and depression in primary care patients. BMC Family Practice Submit your next manuscript to BioMed Central 2011, , 12: 38[http://www.biomedcentral.com/1471-2296/12/38]. 12. Glaser BG: Theoretical sensitivity: Advances in the methodology of grounded and take full advantage of: theory Mill Valley CA: Sociology Press; 1978. 13. Braun V, Clarke V: Using thematic analysis in psychology. Qualitative • Convenient online submission Research in Psychology 2006, 3:77-101. • Thorough peer review 14. NVivo qualitative data analysis software. QSR International Pty Ltd; 2008, Version 8. • No space constraints or color figure charges 15. Glaser B: Emergence v Forcing: Basics of Grounded Theory Analysis Sociology • Immediate publication on acceptance Press; 1992. • Inclusion in PubMed, CAS, Scopus and Google Scholar 16. Kroenke K, Spitzer RL, Williams JBW: The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine 2001, • Research which is freely available for redistribution 16(9):606-13. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

General practitioners' and practice nurses' views and experience of managing depression in coronary heart disease: a qualitative interview study

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Springer Journals
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Copyright © 2012 by Barley et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1471-2296
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10.1186/1471-2296-13-1
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22221509
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Abstract

Background: Depression is common in coronary heart disease (CHD). Affected patients have an increased incidence of coronary symptoms and death. Little is known about how best to manage primary care patients with both CHD and depression. This study is part of the UPBEAT-UK programme of research and was designed to understand general practitioners’ (GPs) and practice nurses’ (PNs) views and experience of managing depression in CHD. Methods: Individual in-depth interviews with 10 GPs and 12 PNs in South East London. Data were analysed using constant comparison. Results: GPs and PNs had similar views. Distress following diagnosis or a cardiac event was considered to resolve spontaneously; if it endured or became severe it was treated as depression. GPs and PNs felt that psychosocial problems contributed to depression in patients with CHD. However, uncertainty was expressed as to their perceived role and responsibility in addressing these. In this respect, depression in patients with CHD was considered similar to depression in other patients and no coherent management approach specific for depression in CHD was identified. An individualised approach was favoured, but clinicians were unsure how to achieve this in the face of conflicting patient preferences and the treatment options they considered available. Conclusions: GPs and PNs view depression in CHD similarly to depression uncomplicated by physical illness. However, uncertainty exists as to how best to manage depression associated psychosocial issues. Personalised interventions are needed which account for individual need and which enable and encourage clinicians and patients to make use of existing resources to address the psychosocial factors which contribute to depression. Background improve mood in CHD, although physical health out- Coronary Heart Disease (CHD) can cause distressing comes have not improved [5,6]. A recent trial of colla- symptoms and functional limitation. The prevalence of borative care, an enhanced depression care intervention depression in CHD patients has been estimated at 20% which provides depression severity related treatment gui- [1]. Depression increases the incidence of coronary dance, found improvement in both depression and con- symptoms and death in CHD patients independent of trol of medical disease at 1 year post intervention in other factors [1]. It may also exacerbate the perceived patients with heart disease and/or diabetes [7]. Patients with depression and or CHD are managed severity of symptoms and increase service use [2]. Concurrent physical illness reduces the recognition of mostly in primary care. However, although there has been depression by GPs [3]; accordingly, in the UK, GPs are much work concerning general practitioners’ (GPs) and now remunerated for screening CHD patients for depres- practice nurses’ (PNs) management of depression in pri- sion [4]. Antidepressants and CBT have been found to mary care [8]; little is known concerning how they manage patients with both conditions. A recent qualitative study * Correspondence: elizabeth.barley@iop.kcl.ac.uk aimed to determine barriers to managing depression in Section of Primary Care Mental Health, Health Services and Population people with CHD or diabetes [9]. Interviews and a focus Research Department, PO Box 28, Institute of Psychiatry, King’s College group with healthcare professionals, service users and London, De Crespigny Park, London, SE5 8AF, UK © 2012 Barley et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Barley et al. BMC Family Practice 2012, 13:1 Page 2 of 10 http://www.biomedcentral.com/1471-2296/13/1 carers indicated that depression was often normalised in A purposive, maximum variation approach was used the presence of long term conditions (LTCs) and that per- based on ethnicity, age, practice setting (inner city versus formance managed environments in primary care mili- suburban) and type (single handed versus group). Male tated against shared understandings of depression. and female GPs were recruited; no male PNs were identi- However, the views of PNs were underrepresented in this fied. After several interviews, it was noted that participants study given that, as a group, they have the most regular often mentioned their involvement in the UPBEAT-UK contact with such patients. cohort study and we became concerned that this involve- Similar tensions between delivering care to meet quality ment might have increased awareness of depression in targets and fulfilling the patients’ agenda were found in an CHD. From then on, only clinicians whose practices were interview study of GPs’ and PNs’ perceptions of the man- enrolled in UPBEAT-UK but who were not personally agement of patients with multimorbidity in general [10]. involved were interviewed. Snowballing was also used to Issues specific to CHD were not considered in this study. identify participants independent of UPBEAT-UK. Level The current study was conducted as part of a NIHR of participant involvement in UPBEAT is indicated in funded research programme: UPBEAT-UK [11]. It explores Table 1. Recruitment stopped when saturation of themes GPs’ and PNs’ views and experience of managing depres- was reached; that is, no new themes or information relat- sion in patients with CHD and its findings will inform the ing to the identified themes emerged. development and implementation of strategies within the programme to help primary care staff manage such Data Collection patients effectively. EB conducted all the interviews using a guide based on lit- erature review [8]. Broad topics were: understandings of Methods depression and detecting and managing CHD depression. Sampling Prompts were used to elicit opinions on topics identified The sampling frame was 31 GP practices participating in in the literature search, such as the use of screening tools the UPBEAT-UK cohort study of patients with depression and differences between ‘distress’ and ‘depression’. and CHD. They were from 4 ethnically and socially diverse Prompts were revised iteratively, for instance, early partici- boroughs in South East London (Lambeth, Lewisham, pants introduced the problems of ‘erectile dysfunction’ Southwark and Croydon). and ‘housebound patients’; these were explored with later Table 1 Participant characteristics GPs PNs Age (years) Range 24 - 63 yrs 33 - 59 years Mean 47.6 years 43.3 years Median 48 years 42 years Gender Female 312 Male 70 Ethnicity White British 410 African/Afro-Caribbean 30 Asian 32 Practice setting Mainly deprived 43 Mixed 59 Mainly affluent 10 Practice type Single handed 11 Group 911 UPBEAT-UK involvement Involved 85 Practice recently recruited/participant not yet aware 24 None 03 Barley et al. BMC Family Practice 2012, 13:1 Page 3 of 10 http://www.biomedcentral.com/1471-2296/13/1 participants. In order to ground opinions in practice, parti- Theme: Recognising depression cipants were asked to recall specific patients with CHD Distress versus Depression and depression. Interviews were recorded and transcribed The participants reported difficulty distinguishing in verbatim by EB. Participants gave written informed general between ‘distress’ and depression needing treat- consent. ment. They were aware that many patients with or with- out CHD experienced difficult social circumstances. It was therefore ‘understandable’ that they felt low. Analysis Interviews and analyses were performed concurrently “When they come to the clinics there is some level using principles of constant comparison [12] and the- matic analysis [13]. Three researchers (EB, JM and PW) of depression. Whether it’s due to their disease, it’s coded independently the first interview and agreed difficult to say. I think there is a lot of other things descriptive codes. EB and JM independently applied in this area that cause that.” (P1) these and, where appropriate, new codes to the follow- ing 4 transcripts when consistency in coding was Similarly, in CHD most participants felt that distress achieved. Descriptive codes were collated into themes following diagnosis or a cardiac event was ‘natural’. and a preliminary explanatory framework devised. This was used as the basis for coding and for informing “I guess if someone was to come in with recently future interviews. Data for each theme were gathered being diagnosed with CHD and came in a particu- and coded by EB using computer software (NVIVO 8 larly low mood. Initially, again, you might just put it [14]). The robustness of themes was tested by examining down to the fact that they’ve been diagnosed with differences and similarities between coded data. A sam- quite significant illness, so you may not call it ple of coding was agreed between two researchers (EB depression as such.” (GP7) and JM). Theoretical memos [15] containing ideas and impressions from interviews and transcripts were pro- The potential for sudden death and the feeling of vul- duced and used to inform coding discussions. nerability this produces were highlighted as particularly distressing. Results “....something with your heart, everyone knows that Participants the heart is such an important organ, don’t they? We interviewed 10 GPs, 11 PNs and one clinical pharma- And they, and everyone thinks ‘well, if it stops, that’s cist from 12 practices. The pharmacist’srolewas similar it’.” (GP8) to the PNs’, but she was more involved in medication management. Since during the analysis her views were not found to differ from that of PNs, we treated her data as For mostpeoplewithCHD, it was thoughtthatdis- PN data. We would have recruited more clinical pharma- tress resolves spontaneously, although no time period cists, but we are not aware of any others working within was specified. For many, the level of impact of CHD on practices enrolled in UPBEAT-UK. This pharmacist had life was also important. an important role in managing CHD patients within her practice so we felt that her views were important and that “Part of it is their disability due to their disease, erm, our data would not be complete without them. Participant but not their disease per se. ‘Cause if they’re func- characteristics are shown in Table 1. All contacted agreed tioning OK, I don’t seem to find that there’san to participate. issue. Whereas, if they are actually, you know, ‘I Diverse views were expressed, but, on the whole, can’t walk far, I’mbreathless’ all of that, then yes divergence was not found to be related to participant there is.” (P1) group i.e. the GPs, the PNs, the community pharmacist, those involved in UPBEAT or those less or not involved. Distress and depression in CHD therefore appeared to For most themes a majority view independent of partici- be conceptualised similarly to that in other illnesses and pant profession was identified, that is GPs and PNs had on a continuum of chronicity and/or severity. Only dis- similar views. GP and PN data are therefore combined tress that becomes chronic and /or severe was consid- ered to require management. except where differences were found; these are reported. The themes identified are described, with quotations “You know, if it’ssomeone who’s just feeling crap identified by profession (GP = general practitioner, for a day, you know, that doesn’twarrantit [man- PN = practice nurse) and the interview order (GP1-10; agement], but feeling crap for a long time does........ PN1-11; P1 clinical pharmacist). Barley et al. BMC Family Practice 2012, 13:1 Page 4 of 10 http://www.biomedcentral.com/1471-2296/13/1 something about the, you know, severity and the detected somatic symptoms which could be confused chronicity is important.” (GP2) with depression. “Some hospitals put patients on antidepressant, I’ve noticed, quite quickly, sometimes even before they’ve “Some of them [patients] misinterpret it [PHQ-9], been discharged, which I sometimes worry about because, I mean some of them might/when they’re because obviously the event is all a bit new then older, they find they don’t sleep quite so much and and, and if they are tearful or really distressed it’s they expect to still sleep 12 hours a night. And you do find that a lot of them, do sort of say they have sort of erm understandable that they are in a way.” problems sleeping and there could be other factors (GP8) that are influencing that more than because they are Depression Screening depressed.” (PN3) Most participants regularly used the two screening ques- tions stipulated in the quality and outcomes framework Clinical judgement (QOF) of the UK general practice contract [4]. Several Most participants also valued their clinical judgement. used the Patient Health Questionnaire 9 (PHQ9) [16] or They used this to decide when to ask just the QOF the Hospital Anxiety and Depression Scale (HADS) [17] questions or to give a more detailed questionnaire, or to following a positive response to screening. In some supplement the information obtained by such measures. practices these were not available to PNs. Most agreed that if they felt the QOF questions were Most felt that depression in CHD is under-diagnosed. not providing a ‘true picture’ they would use their clini- This may be because some patients consider it inap- cal judgement. A range of depression indicators was propriate to mention mood during a consultation about described including crying, frequent attending, sleep dis- CHD, or because they fear mental health-related stigma turbance, reduced activity, tiredness, loss of appetite or or causing discomfort. However, screening instruments non-attendance at appointments. Several participants helped some clinicians initiate a conversation about felt they could recognise depression from the patient’s mood in a non-threatening manner. demeanour. For some, this involved intuition; others noted signs such as a head down stance, lethargic man- “we’re saying ‘it’s not actually our fault - we’ve been ner, fixed gaze or lack of eye contact. Several, however, told to do this by big brother. So actually, it’sOKto noted that a ‘jolly demeanour’ may mask depression, talk about it’.Soit’s been very helpful from that which was an argument for active screening. point of view. It’s kind of taken the stigma off asking and responding.” (GP3) “Some of them surprise me - you think ‘oh yes, they’re fine.......and you get them to fill in this form For several participants, these instruments raised and you think ‘oh!’” (PN3) awareness of depression in CHD. No strategies for assessing depression specifically in “Now that I’ve actually been asking the questions, patients with CHD were identified. I’ve picked up people that, actually, looking back, I’ve known it for years and I haven’tdoneanything Theme: GP and PN perceptions of why some CHD about it.” (GP3) patients become depressed Possible physiological links between depression and Reservations were also voiced; these tended to relate CHD were raised by only one GP. to depression screening in general not just in CHD. Sev- eral participants, especially PNs, said that they avoided “if one’s stressed and one’sstresshormonesgoup, using them due to a fear of uncovering unmanageable one’s platelets get more sticky and the endothelium problems. gets more sticky and all that sort of happens. And also if one’s got cardiovascular disease that may “I’m bad at asking, in some ways I think, like lots of influence peoples’ neurotransmitters.” (GP3) nurses, you don’t want to open up something that you then, then can’t deal with afterwards” (PN11) A number of factors commonly associated with CHD such as loss of a valued role (e.g. loss of employment), OneAsian participant(P1)feltthatSouth Asian inability to fulfil responsibilities due to disability and patients conceptualise depression in somatic terms and erectile dysfunction were considered to lead to depres- that these instruments would not detect this. In con- sion. Erectile dysfunction was considered especially trast, another participant felt that the instruments important with most participants agreeing that men are Barley et al. BMC Family Practice 2012, 13:1 Page 5 of 10 http://www.biomedcentral.com/1471-2296/13/1 reluctant to report this. Despite this observation and the depressive phase. Presumably, that’sinherited,it’s availability of specialist clinics, most GPs and PNs did constitution, it’s related to our chemical make up.” not ask about this routinely. (GP9) “No I don’t, no.Again, I wish,Imean,Ishould do Lack of education was thought problematic, although (ask about erectile dysfunction) because that’ssome- one PN felt the educated were more at risk due to the thing that we can offer them as well for that.” stress arising from a greater awareness of potential com- plications. Some patients were thought to hold negative (PN11) attitudes to their CHD which could be disabling inde- Nurses may also be embarrassed to introduce this pendent of disease severity. topic; one PN suggested that being older helped. “It’s their perception that they’re an invalid and quite “it’s probably easier for me because I’malotolder often they’re not an invalid, maybe they could go and maybe they’re not so embarrassed. So if I can back to work.” (PN2) bring it up, then it can be a lot more sort of open.” (PN9) Alcohol or drug use and a past history of depression were also mentioned, Other CHD related factors thought to contribute to depression were feeling responsible for their illness and Theme: depression management having to make unwanted lifestyle changes to prevent All participants felt that treating depression would lead CHD progression. to improvements in self management of CHD, which suggests that they are motivated to address this issue. “I think many people, as perhaps part of their CHD depression, feel guilty about it: ‘yes I did inflict it.” “Cause sooner or later, someone with depression is (GP1) going to say ‘why bother about my statins, my cho- “You know the sort of modification in their lifestyle lesterol, my diet - who cares? Why do the exercise? and things can be really, really difficult. If it’ssome- Smoking - well actually I find it quite comfortable? body that’s been smoking for example and is trying I’m not interested in will I get a lung cancer in 10 to give up smoking and life feels like it’snot worth years time or not, I can’t see ahead for 10 years’. living cause they can’t smoke .....” (P1) Whereas if somebody feels really optimistic, positive then you’re gonna be thinking ‘yes, I’m doing all this Several participants considered that depression may to ensure my own better future.” (GP1) lead to heart disease as depressed individuals are more “if you’ve treated their depression, their outlook on likely to lead an unhealthy life. life might be better as a whole, so therefore they Social problems such as financial and housing difficul- want to remain well, so they’re taking their medica- ties were thought to be related to depression and were tion, not just their medication, their exercise their considered common among CHD patients. Isolation was food, whatever, smoking..... so it ..... all goes hand in mentioned by almost all participants. hand.” (PN10) “Social, loneliness - very important, loneliness, loss Several GPs and PNs stressed the importance of of employment, isolation, the home environment. patient choice in increasing adherence to management Sometime they need their home to be adapted to programmes. their, to their physical and medical needs at the time and they will not have it. But most importantly is “Of course they’ve got tocometoitthemselves, loneliness.” (GP5) because if you’re going to offer any sort of therapy or treatment, it’s a complete waste of time if they Other predisposing factors for depression cited were haven’t got to actually saying ‘well, yes I want it’. not necessarily considered related to CHD. For instance (GP9) some participants mentioned lack of resilience, poor coping skills and ‘premorbid personality’ (GP1). Individual GPs and PNs raised and discussed a variety of management options for depression; sometimes these “I think that while most of us maybe will cope with were related to depression comorbid with CHD but stress and anxiety, there is a core population that if more often participants did not differentiate between they are tipped to a very severe extent will dip into a this and depression in general. Barley et al. BMC Family Practice 2012, 13:1 Page 6 of 10 http://www.biomedcentral.com/1471-2296/13/1 Antidepressants ii) Talking therapy Several GPs and PNs felt that antidepressants were use- Mostly the generic term ‘counselling’ was used, although ful in ‘lifting’ apatient’s mood to the point that they a few participants referred to ‘CBT’ or ‘psychotherapy’. would be able to return to normal functioning. How- Counselling was widely favoured by both GPs and PNs ever, GPs had treated only a few CHD patients in this to help patients come to terms with their condition, to way. The majority only prescribed antidepressants in increase confidence in self management or to aid in CHD when other options had been exhausted, in severe venting feelings. depression, suicidal intent, if mood was deteriorating or if a patient had responded well previously. “I think counselling would definitely be number one on the list. I mean a lot of the time, you just ask the “It isn’t always drug treatment, it’sabout going question ‘would you like someone to talk to?’ And through the rehab programme, getting the confi- then alot of thetimethey willsay ‘yes’.Sorather dencetogoout anddothings,starting driving than ....medicalising it too much, you could maybe again, having sex - all thse sorts of things sometimes try simple steps like counselling services, support are therapeutic.......so very often medication is not groups, helplines. And that might just be enough ...... always needed”. (GP9) to improve their mood.” (GP7) “sometimes just seeing a counsellor and getting Hesitation in prescribing was related to a perceived things off their chest for a few sessions will help.” reluctance in patients to accept antidepressant treatment (PN9) due to fear of stigma or a general dislike of medication. Three GPs said they, or another GP within the prac- “We discuss with the patients. You know, depends tice, provided counselling such as ‘mini’ CBT, problem where the patients stand, yes and then minority of solving therapy or ‘10 minute CBT’. Otherwise, a coun- the cases go on antidepressant tablet/treatments, you sellor or psychologist (or both) was available in most of know, not everyone wants treatment.” (GP10) the practices. Despite this, a lack of availability of coun- selling was commonly raised; all but two PNs said that This was not necessarily associated with the patient’s waiting lists were too long. They complained that this CHD, although patient dislike of medication was consid- meant they were unable to follow treatment guidelines ered increased when they were taking multiple drugs as which promote the use of talking therapy. most CHD patients are. “Because our waiting lists are so long, so although all “she has so many tablets anyway and she’s always the guidelines....say counselling treatment ect, we wanting to stop this and stop that and ‘can I just cut haven’t got primary care counselling really”. (P1) this down?’ and ‘can I just miss out my asprin for a couple of days?’.....To add another tablet, an antide- Only one GP mentioned the Improving Access to pressant, into the mix would just probably be the Psychological Therapies (IAPT) programme: they felt thing that tipped her over the edge."(PN5) that primary care practitioners were not yet fully awareofit. This maybeexpectedas, at thetimeof Only one GP was concerned about drug interactions. the study, this was a relatively new service in the area. Several of the PNs were not prescribers, but, among Computerised CBT was considered by a few partici- those who were, there was reluctance to prescribe anti- pants to be unsuitable for elderly CHD patients who depressants due to a lack of confidence in managing may not be computer literate. Reluctance to undertake depression. therapy was also observed due to perceived stigma or denial. “I have been prescribing a few years now, but I do Some PNs reported that they were not authorised to find I tend to stick to things I’mhappy with and make counselling referrals; they did not complain about that I deal with a lot, which is CHD, diabetes, this. This may further reflect uncertainty among nurses women’s health, travel health family planning........but in managing depression which was summed up by one because it [mental health] is something that I don’t PN: deal with a lot, I’m not happytoprescribe. SoIdo tend to ask advice before I would prescribe.” (PN3) “Icould do [make a referral to a counsellor].On the “I am a nurse prescriber, but I wouldn’t feel comfor- whole, I prefer to do it through the GP, just in case table or sort of competent enough to do that” (PN9) the GP doesn’t agree that they need it.” (PN9) Barley et al. BMC Family Practice 2012, 13:1 Page 7 of 10 http://www.biomedcentral.com/1471-2296/13/1 iii) Informal counselling “Rehab is some mythical thing in primary care I This involved providing education about CHD and think! It just takes place in the hospital and that’s assurancethatdistressisnormal. GPstendedtorefer that.” (PN5) patients to a counsellor if this took too long. Most PNs agreed that this is part of their role; several had CHD Lack of communication was also reported between patients who would come in for ‘achat’.Somewould primary care staff and district/community nurses (DNs) schedule extra consultations for this, despite being who manage housebound CHD patients. Some PNs did unsure how useful it was. They did not know what else not know what DNs did, although they suspected that to do however. they do not address psychological needs due a heavy workload which prioritises physical health. “At the moment, I dunno what to do with this group of people, so I see them more regularly because I “It’s quite sad really, but we don’t have a lot to do feel that they need contact with somebody, but I with our district nurses in this practice. I think if dunno if that’s the best thing to do...."(PN5) they’ve got concerns they speak to the duty doctor. But we as a whole, we don’t sort of link in with each iv) Exercise other. I don’tknowthemand they don’tknowus..” Some participants recommended exercise to improve (PN10) mood. “Ijustdon’t know whether the district nurses go into it [mood] very much, ‘cause they are usually so “I explain to them about serotonin levels - how if busy. They, they sometimes just tick the boxes like, you do exercise you can produce more and it you know, the blood pressure’sbeendoneand what makes/it’s a happy hormone and all the rest of it.” it is and and ‘yes, they are on asprin’.” (PN9) (PN6) OnePN madehomevisitstohouseboundCHD The social aspect of ‘exercise on referral’ schemes and patients in order to gain QOF points. However, a PN at ‘seated exercise classes’ was considered beneficial. a different practice believed these patients were v) involvement of other agencies excluded from QOF registers and so they did not One GP reported having made a psychiatry referral receive any depression screening or management. when she did not know how to progress, but was not helped. “those patients probably get exempt from their regis- ters because they are housebound.........’cause I think “I actually referred him up to psychiatry, because I that if you prove that you’ve written or invited them felt, he was actually very vulnerable and very at risk three times and they haven’tcomeinthenyoucan of suicide. I felt, ‘cause he was very isolated, he lost exempt them.” (PN8) his job, he’s relatively young. But the psychiatrists wouldn’t see him, they just bounced it back and said One GP also noted that talking therapy is not avail- ‘you know, oh you’re doing a good job with your able for housebound patients. medication, nothing more we can do’.” (GP9) “one of the, the quite striking things is that there’s Generally, it was felt that the Community Mental almost no access to talking therapies for people who Health Team (CMHT) was for complex cases and so are housebound. There are, you know, people who they would not deal with depression in CHD patients or are frail, elderly or with things like heart disease depression generally. who may be rather more likely to be housebound, but, you know, counsellors and psychologists are “then we have CMHT and other services - erm not pretty much, you know, practice or clinic based and hugely accessible for this kind of this level of mental don’t go and visit people at home.” (GP2) health problems.” (GP2) A perception of a relationship between depression and Cardiac rehabilitation was considered helpful but social problems, irrespective of the presence of CHD, poorly attended by some patients, such as working peo- led a few clinicians to direct their patients to commu- ple and Asian women reluctant to attend a mixed class. nity facilities, such as church coffee mornings and local Only one GP had liaised with cardiac rehabilitation in libraries. However, they found it difficult to identify the management of a depressed patient. such resources. Barley et al. BMC Family Practice 2012, 13:1 Page 8 of 10 http://www.biomedcentral.com/1471-2296/13/1 “it’s really, it’s knowing what, what is available CHD or a cardiac event, but only when distress becomes because I am sure there’slotsofthingsoutthere, severe and enduring is it seen as depression requiring but it’s just really knowing.....” (PN11) treatment. This view of depression as a natural reaction to life events has been found in studies of the manage- Furthermore, some participants either did not see ment of depression uncomplicated by physical illness resolution of social problems as their responsibility or [18-20]. felt powerless to help. This seemed to be especially the TheGPs andPNs in this studyfeltthatdepressionis case for PNs, perhaps because they have more time to under-diagnosed in CHD. However, their opinions con- cerning the use of screening instruments varied. A study talk to patients about their problems. [21] of GPs’ use of depression screening questionnaires “’cause there’s nothing I can do for them. ....’cause showed that, although doctors used them, they preferred actually what can I do? I can help your physical to rely on their ‘practical wisdom and clinical judgement’. things, but actually if you’ve got issues with your Some of our participants shared these views and many extended family at home, I can’tdo anythingabout PNs did not even have access to questionnaires such as that.” P1 the PHQ9 [16] or the HADS [17]. Some GPs however “There might be something about the grandchild or reported positive applications, and most used their clini- something or the children and there’s not a lot you cal skills as a supplement to screening data or to help to can do about that” (PN2) decide whether to use a more detailed questionnaire. When managing depression uncomplicated by CHD, In contrast, one practice had a social prescribing ser- GPs have been found to favour ‘watchful waiting’ over vice where a professional directed patients with identi- antidepressants [22]. Similarly, in our study, antidepres- fied social problems to appropriate agencies. Staff at this sants were not the GPs’ first choice. Reluctance in CHD practice reported many patients with complex social patients to accept antidepressants was reported; this was needs; one GP stressed her pleasure in working with felt to be either due to fear of mental health-related such patients. This attitude was promoted and a flexible stigma or to negative attitudes towards medication in attitude to time management was adopted. general which may be amplified in patients who require multiple medications for co-morbidity. Talking therapies “I, personally, I really like our population and find were favoured, but few participants differentiated them interesting......Their problems are quite com- between approaches such as CBT or supportive counsel- plex. It’s rare for them to come in with a single pro- ling which may lead to less appropriate referrals. Some blem..........and if they come in with their 3 problems, patients were observed to reject talking therapy due to and actually one problem’s going to take up the fear of stigma. However, the main barrier was a lack of whole of the consultation, more often than not they availability, as reported previously [18]. In the UK, the will get more than what they would have got if the/ Government’s Improving Access to Psychological Thera- it’s unusual for someone to say ‘no, that’sit, you’ve, pies programme [23] is addressing this, but at the time of you’ve had your, your time’. ‘Cause we generally this study this was a relatively new innovation and avail- don’t work like that.” (GP8) ability was not consistent across the boroughs in which the participants worked. Informal counselling, such as reassurance and education, was also discussed; most GPs Discussion were unwilling or unable to give much time to this. Some The GPs and PNs in this study identified factors asso- PNsreportedthattheydid have time, but doubted its ciated with CHD such as feelings of responsibility for usefulness. having caused their illness, unwanted lifestyle changes, The GPs and PNs reported liaising rarely with other loss of employment, inability to fulfil responsibilities due professionals when managing patients with CHD and to disability and erectile dysfunction that they felt may be depression despite guidance [24] promoting this. Greater associated with depression, However, these may not be use by health care professionals of services, such as social CHD specific and may be important in other long term clubs and advice agencies, which promote well being has conditions (LTCs). Other predisposing factors for depres- also been encouraged [24]. Knowledge of such services sion which are unrelated to LTCs were also raised such varied widely between our participants. This may relate as social problems, individual differences and coping to our finding of variation in attitudes to managing social skills. On the whole, the GPs and PNs did not differenti- problems. Nurses were especially concerned about social problems, perhaps because they reported spending more ate between depression in patients with CHD and depres- time providing informal counselling and so had greater sion in other patients; it was thought that individuals may opportunity to probe these issues. Our recent meta- ‘naturally’ become distressed following a diagnosis of Barley et al. BMC Family Practice 2012, 13:1 Page 9 of 10 http://www.biomedcentral.com/1471-2296/13/1 synthesis [8] found also that management of depression of experiences. Also, many of the current findings are uncomplicated by physical illness is perceived by primary supported by previous research conducted in other con- care staff in the UK as particularly complex when texts and so are likely to be broadly representative. patients present with social problems; both GPs and PNs Finally, this study was conducted prior to the introduc- in the included studies were aware of the relationship tion in the UK of guidelines for the management of between social and mood problems but they were unsure depression in adults with a chronic physical health pro- of its exact nature and of their role in managing it. The blem [27]; these may impact on attitudes and practice. participants in the current study are especially likely to encounter social problems among their CHD patients as Conclusions heart disease is more common in people from lower In this study, GPs and PNs identified CHD related fac- social economic backgrounds. Previous research [19] has tors that they felt may be associated with depression, identified ‘therapeutic nihilism’ where clinicians feel help- but also other predisposing factors such as social pro- less in the face of the complex social problems which blems which can occur in any depressed population. impact on health. This was seen in several of our partici- The importance of social factors may be increased in pants. However, one practice actively sought to address people with CHD as they are especially likely to come social difficulties by providing ‘social prescribing’;there from lower socioeconomic backgrounds, but this may may be scope to develop this for depressed CHD patients. also be true for other LTCs. Our participants, in com- No clear management strategy specific for patients with mon with those of studies of depression uncomplicated CHD and co-morbid depression was identified; the treat- with physical comorbidity, expressed uncertainty as to ment issues and management options raised appeared how to address depression associated with psychosocial similar to those in depressed patients without physical problems. In the face of perceived individual differences comorbidity. Collaborative care, where nurses and doctors in the causes of depression in CHD, an individualised work together to deliver evidence based treatment, has treatment approach was favoured but clinicians were been shown to be beneficial for depression [25] and, unsure how to achieve this in the face of conflicting recently, a trial conducted in USA found it to improve patient preferences and the treatment options they con- both depression and disease control in patients with CHD sidered available. This suggests that flexible interven- and/or diabetes [7]. However, in this study some nurses tions are needed which enable and encourage clinicians did not consider managing mental health to be their role. and patients to make use of existing resources, such as These PNs reported a lack of training, interest or time. social clubs and advice agencies, to address the psycho- Negative past experience of mental health training has social and other factors which contribute to depression. been found to be associated with nurses’ current negative attitudes towards managing mental health [26]. Since pri- Acknowledgements and Funding mary care patients with CHD commonly receive most of This report/article presents independent research commissioned by the their care through nurse-led clinics, our findings suggest National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1048). The views expressed in this that the development of interventions for depression in publication are those of the author(s) and not necessarily those of the NHS, these patients should include sensitive consideration of the NIHR or the Department of Health. The UPBEAT-UK Research Team nurses’ views. consists of: Andre Tylee (PI), Mark Ashworth, Elizabeth Barley, June Brown, John Chambers, Anne Farmer, Zoe Fortune, Mark Haddad, Sally Hampshire, Morven Leese, Anthony Mann, Paul McCrone, Anita Mehay, Joanna Murray, Strengths and limitations of the study Diana Rose, Gill Rowlands, Rosemary Simmons, Alison Smith, Paul Walters, Some of our participants may have been sensitised to the John Weinman. André Tylee is partly funded by the NIHR Biomedical Research Centre for link between depression and CHD by having been Mental Health at the South London and Maudsley NHS Foundation Trust recruited into the UPBEAT-UK study [11]. However, and Institute of Psychiatry, Kings College London. given this, findings of uncertainty among clinicians in the Our thanks to the GPs and PNs from South London who agreed to be interviewed for this study. understanding and management of this condition appear particularly important. Diverse views were expressed, but Authors’ contributions reducing complex data into themes may result in decon- EB conducted the interviews and the analysis and wrote the first draft of the manuscript. PW and AT conceived the study, assisted in the analysis and texualisation of speakers’ words. We therefore employed interpretation of data and revised the article. JM conceived the study, a rigorous iterative, multidisciplinary approach to our conducted the analysis and revised the article. All authors read and analysis in order to ensure that our summaries are an approved the final manuscript. accurate representation. Authors’ Information This study was confined to South East London; how- EB is a practitioner health psychologist, registered general nurse, researcher ever we recruited participants from contrasting areas and systematic review module leader for the MSc in mental health service and population research at the Institute of Psychiatry. (inner city, suburban, deprived, affluent) with a range of PW is a research fellow and consultant psychiatrist. experience and characteristics in order to elicit a range Barley et al. BMC Family Practice 2012, 13:1 Page 10 of 10 http://www.biomedcentral.com/1471-2296/13/1 AT is a GP, professor of primary care mental health and Academic Director 17. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta of the Mood, Anxiety and Personality Clinical Academic Group at Kings’ Psychiatr Scand 1983, 67:361-70. Health Partners, King’s College London. 18. Chew-Graham CA, Mullin S, May CR, Hedley S, Cole H: Managing JM is a senior lecturer in social research specialising in qualitative studies in depression in primary care: another example of the inverse care law? mental health. Family Practice 2002, 19:632-37. 19. Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C: Competing interests ’Justifiable depression’: how primary care professionals and patients The authors declare that they have no competing interests. view late-life depression? a qualitative study. Family Practice 2006, 23:369-77. Received: 27 September 2011 Accepted: 5 January 2012 20. Murray J, Banerjee S, Byng R, Tylee A, Bhugra D, Macdonald A, et al: Published: 5 January 2012 Primary care professionals’ perceptions of depression in older people: a qualitative study. Social Science & Medicine 2006, 63(5):1363-73. 21. 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BMC Family Practice – Springer Journals

Published: Jan 5, 2012

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