Impact of functional and structural social relationships on two year depression outcomes: A multivariate analysis.

Background: High rates of persistent depression highlight the need to identify the risk factors associated with poor depression outcomes and to provide targeted interventions to people at high risk. Although social relationships have been implicated in depression course, interventions targeting social relationships have been disappointing. Possibly, interventions have targeted the wrong elements of relationships.

Mental health interventions and future major depression among primary care patients with subthreshold depression.

Background: Subthreshold depression is prevalent in primary care and is associated with poorer quality of life, higher health care use and increased risk of major depressive disorder (MDD). Currently, it is unclear how subthreshold depression should be managed in primary care and no studies have investigated the relationship between current models of care and the development of MDD. This study aimed to describe usual care over a six month follow-up for primary care patients with subthreshold depression and to investigate the relationship between usual care and the development of MDD.

The effect of strategies of personal resilience on depression recovery in an Australian cohort: a mixed methods study.

Strategies of personal resilience enable successful adaptation in adversity. Among patients experiencing depression symptoms, we explored which personal resilience strategies they find most helpful and tested the hypothesis that use of these strategies improves depression recovery. We used interview and survey data from the Diagnosis, Management and Outcomes of Depression in Primary Care 2005 cohort of patients experiencing depression symptoms in Victoria, Australia.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

Objectives: Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists.

Challenges of nurse delivery of psychological interventions for long-term conditions in primary care: a qualitative exploration of the case of chronic fatigue syndrome/myalgic encephalitis.

Background: The evidence base for a range of psychosocial and behavioural interventions in managing and supporting patients with long-term conditions (LTCs) is now well-established. With increasing numbers of such patients being managed in primary care, and a shortage of specialists in psychology and behavioural management to deliver interventions, therapeutic interventions are increasingly being delivered by general nurses with limited training in psychological interventions. It is unknown what issues this raises for the nurses or their patients.

Questionnaire severity measures for depression: a threat to the doctor-patient relationship?

Background: Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.

Aim: To gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.

Design Of Study: Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.

The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort.

Purpose: To assess the link between multimorbidity, type of chronic physical health problems and depressive symptoms

Method: The study was a cross-sectional postal survey conducted in 30 General Practices in Victoria, Australia as part of the diamond longitudinal study. Participants included 7,620 primary care attendees; 66% were females; age range from 18 to 76 years (mean = 51 years SD = 14); 81% were born in Australia; 64% were married and 67% lived in an urban area. The main outcome measures include the Centre for Epidemiologic Studies Depression Scale (CES-D) and a study-specific self-report check list of 12 common chronic physical health problems.

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

Background: Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred.

Primary care consultations about medically unexplained symptoms: how do patients indicate what they want?

Background: Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs.

Objective: To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention.

Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms.

Objective: We tested the theory that general practitioners (GPs) offer somatic intervention to patients with medically unexplained symptoms (MUS) as a defensive response to patients' dependence. We predicted that GPs most likely to respond somatically after patients indicated symptomatic or psychosocial needs had attachment style characterised by negative models of self and others.

Method: Twenty-five GPs identified 308 patients presenting MUS and indicated their own models of self and others.

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

Objective: Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.

Methods: Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others).

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model.

Background: The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.

Method: In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention.

Objective: In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

Methods: Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded.

Considering the case for an antidepressant drug trial involving temporary deception: a qualitative enquiry of potential participants.

Background: Systematic reviews of randomised placebo controlled trials of antidepressant medication show small and decreasing differences between pharmacological and placebo arms. In part this finding may relate to methodological problems with conventional trial designs, including their assumption of additivity between drug and placebo trial arms. Balanced placebo designs, which include elements of deception, may address the additivity question, but pose substantial ethical and pragmatic problems.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure.

Objective: We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients' attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians.

Methods: Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn.

What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?

Objective: We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this.

Design: Thirty-five doctors participated in a cross-sectional comparison of case-matched groups. Three hundred fifty-seven patients attending consecutively with MUS were matched for doctor and time of attendance with 357 attending with explained symptoms.

The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms.

Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients' belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors' subjective reports.

Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners.

Background: Symptomatic investigation and treatment of unexplained physical symptoms is often attributed to patients' beliefs and demands for physical treatments.

Aim: To test the influential assumption that patients who present symptoms that the general practitioner (GP) considers to be medically unexplained do not generally provide the opportunity for discussion of psychological issues.

Design Of Study: Qualitative analysis of audiotaped consultations between patients and GPs.

Normalisation of unexplained symptoms by general practitioners: a functional typology.

Background: Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood.

Aim: To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

Background: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care.

Aim: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs).

Design Of Study: Group randomised controlled trial, using the health centre as the unit of randomisation.