How do older adults understand and manage distress? A qualitative study.

BACKGROUND: Distress is an expected emotional response to a negative life event. Experiences common in later life may trigger distress such as bereavement or loss of physical mobility. Distress is considered to be distinct to anxiety and/or depression and is not diagnostically labelled as a mental health problem. Older adults will often manage their own distress. Previous literature has focused on how younger adults self-manage mental health problems, however little research has explored the self-management strategies used by older people. There is a need to clarify the role of primary care in the context of distressed older adults who may consult healthcare services. This study seeks to address these gaps through qualitative methods. METHODS: Keele University's ethical review panel approved this study. We recruited older adults who self-identified as distressed from community groups in North Staffordshire, England. Data were generated through semi-structured interviews and analysed thematically using constant comparison methods. A patient and public involvement and engagement group contributed to development of the research questions and methods, and offered their perspectives on the findings. RESULTS: After 18 interviews data saturation was achieved. Key themes were: experiences of distress, actions taken, help-seeking from healthcare services and perceptions of treatments offered in primary care. Various forms of loss contributed to participants' distress. Participants initiated their own self-management strategies which included: pursuing independent activities, seeking social support and attending community groups and church. Five participants reported having consulted a GP when distressed but described a lack of acceptable treatments offered. CONCLUSIONS: To support older adults who are distressed, healthcare professionals in primary care should consider exploring how patients currently manage their mood problems, provide a broad range of information about potential management options and consider sign-posting older adults to community resources

How do people with knee osteoarthritis perceive and manage flares? A qualitative study

Background Acute flares in people with osteoarthritis (OA) are poorly understood. There is uncertainty around the nature of flares, their impact, and how these are managed. Aim To explore understandings and experiences of flares in people with knee OA, and to describe self-management and help-seeking strategies. Design & setting Qualitative interview study of people with knee OA in England. Method Semi-structured interviews were undertaken with 15 people with knee OA. Thematic analysis was applied using constant comparison methods. Results The following four main themes were identified: experiencing pain; consequences of acute pain; predicting and avoiding acute pain; and response to acute pain. People with OA described minor episodes that were frequent, fleeting, occurred during everyday activity, had minimal impact, and were generally predictable. This contrasted with severe episodes that were infrequent, had greater impact, and were less likely to be predictable. The latter generally led to feelings of low confidence, vulnerability, and of being a burden. The term ‘flare’ was often used to describe the severe events but this was applied inconsistently and some would describe a flare as any increase in pain. Participants used numerous self-management strategies but tended to seek help when these had been exhausted, their symptoms led to emotional distress, disturbed sleep, or pain experience worse than usual. Previous experiences shaped whether people sought help and who they sought help from. Conclusion Severe episodes of pain are likely to be synonymous with flares. Developing a common language about flares will allow a shared understanding of these events, early identification, and appropriate management

Experiences of general practice care for self-harm: A qualitative study of young people's perspectives

Background Self-harm is a growing concern and rates of self-harm in young people (aged 12–25 years) presenting to general practice are rising. There is, however, little evidence about young people’s experiences of GP care and on accessing general practice. Aim To explore the help-seeking behaviours, experiences of GP care, and access to general practice of young people who self-harm. Design and setting In this qualitative study, semi-structured interviews were conducted with young people aged 16–25 years from England with previous self-harm behaviour. Method Interviews with 13 young people took place between April and November 2019. Young people were recruited from the community, third-sector organisations, and Twitter. Data were analysed using reflexive thematic analysis with principles of constant comparison. A patient and public involvement advisory group informed recruitment strategies and supported interpretation of findings. Results Young people described the avenues of help-seeking they employ and reflected on the mixed experiences of seeing GPs that can influence future help-seeking. Preconceptions and a lack of knowledge about accessing general practice were found to be barriers to help-seeking. GPs who attempt to understand the young person and establish relationship-based care can facilitate young people accessing general practice for self-harm. Conclusion It is important young people are aware of how to access general practice and that GPs listen, understand, and proactively follow-up young people who self-harm. Supporting young people with self-harm behaviour requires continuity of care

Improving recognition of anxiety and depression in rheumatoid arthritis: a qualitative study in a community clinic.

BACKGROUND: Comorbid anxiety and depression are common in patients with rheumatoid arthritis (RA) but are often under-recognised and treated, contributing to worse outcomes. National Institute for Health and Care Excellence (NICE) recommends that patients with RA should be offered a holistic annual review, including an assessment of mood. AIM: To explore patients' perspectives of anxiety and depression in RA and preferences for disclosure and management of mood problems. DESIGN AND SETTING: Qualitative interview study with patients recruited from a nurse-led RA annual review clinic in the Midlands, England. METHOD: Patients attending the clinic who scored ≥3 on the case-finding questions (PHQ-2 and GAD-2) were invited for interview. Data were analysed thematically using principles of constant comparison. RESULTS: Participants recognised a connection between their RA and mood, though this was perceived variably. Some lacked candidacy for care, normalising their mood problems. Fear of stigmatisation, a lack of time, and the perception that clinicians prioritise physical over mental health problems recursively affected help-seeking. Good communication and continuity of care were perceived to be integral to disclosure of mood problems. Participants expressed a preference for psychological therapies, though they reported problems accessing care. Some perceived medication to be offered as a 'quick fix' and feared potential drug interactions. CONCLUSION: Prior experiences can lead patients with RA and comorbid anxiety and depression to feel they lack candidacy for care. Provision of equal priority to mental and physical health problems by GPs and improved continuity of care could help disclosure of mood concerns. Facilitation of access to psychological therapies could improve outcomes for both mental and physical health problems

The potential of general practice to support young people who self-harm: a narrative review

Background Self-harm in young people is a growing public health concern. Young people commonly present to their GP for help with self-harm, and thus general practice may be a key setting to support young people who have self-harmed. Aim To examine the potential of general practice to support young people aged 10–25 years who have harmed themselves. Design & setting A narrative review of published and grey literature. Method The Scale for the Assessment of Narrative Review Articles (SANRA) was used to guide a narrative review to examine the potential of general practice to support young people who have self-harmed. The evidence is presented textually. Results The included evidence showed that GPs have a key role in supporting young people, and they sometimes relied on gut feeling when handling uncertainty on how to help young people who had self-harmed. Young people described the importance of initial clinician responses after disclosing self-harm, and if they were perceived to be negative, the self-harm could become worse. Conclusion In context of the evidence included, this review found that general practice is a key setting for the identification and management of self-harm in young people; but improvements are needed to enhance general practice care for young people to fulfil its potential

Suicide prevention and COVID-19: the role of primary care during the pandemic and beyond

The COVID-19 pandemic has brought with it multiple threats to mental wellbeing — the possibility or reality of serious physical illness; complex COVID-related bereavement; lockdowns that cause isolation and inhibit social contact, or that can increase exposure to abuse in the family; caring for children unable to go to school; and precarious employment and redundancy, failing businesses, and financial insecurity. The pandemic has exacerbated the longstanding pressure on resources and underinvestment in both statutory mental health and wider community services. Against this background we outline the current evidence for impact of COVID-19 on self-harm and suicide rates, and we consider how primary care can contribute to suicide prevention during COVID-19 and after the acute crisis has passed

Risk factors for nonfatal self‐harm and suicide among adolescents: two nested case–control studies conducted in the UK Clinical Practice Research Datalink

BackgroundThe characteristics of adolescents who die by suicide have hitherto been examined in uncontrolled study designs, thereby precluding examination of risk factors. The degree to which antecedents of nonfatal self‐harm and suicide at young age differ remains unknown.MethodWe delineated two nested case–control studies of patients aged 10–19 years using the Clinical Practice Research Datalink with interlinked hospital and national mortality records. Cases were adolescents who between 1st January 2003 and 31st December 2018 had died from suicide (N = 324) – study 1; experienced their first self‐harm episode (N = 56,008) – study 2. In both studies, cases were matched on sex, age and practice‐level deprivation quintile to 25 controls. By fitting conditional logistic regression, we examined how risks varied according to psychiatric diagnoses, prescribed psychotropic medication, patterns of clinical contact and area‐level deprivation.ResultsSuicides occurred more often among boys (66%), but self‐harm was more common in girls (68%). Most individuals who self‐harmed or died from suicide presented to their GP at least once in the preceding year (85% and 75% respectively). Only a third of cases had one of the examined diagnostic categories recorded. Depression was most strongly associated with elevated risks for both outcomes (self‐harm: OR 7.9; 95% CI 7.8–8.2; suicide: OR 7.4; 95% CI 5.5–9.9). Except for autism spectrum disorder, all other diagnostic categories were linked with similar risk elevations for self‐harm as for suicide. Whilst self‐harm risk rose incrementally with increasing levels of area‐level deprivation, suicide risks did not.ConclusionsWe observed few marked differences in risk factor profiles for nonfatal self‐harm versus suicide. As most adolescents who had harmed themselves or died by suicide were known to services in the preceding year, their underlying pathology may not be adequately identified and treated. Our findings highlight the need for a multiagency approach to treatment and prevention

Implementing resources to support the diagnosis and management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) in primary care: A qualitative study.

BACKGROUND: Previous research has highlighted that many GPs lack the confidence and knowledge to diagnose and manage people with CFS/ME. Following the development of an online training module for GPs, and an information pack and DVD for patients, this study explored the extent to which these resources can be implemented in routine primary care. METHODS: Semi structured qualitative interviews were completed with patients and GPs across North West England. All interviews were transcribed and analysed using open exploratory thematic coding. Following this thematic analysis, the authors conducted a further theory-driven analysis of the data guided by Normalisation Process Theory. RESULTS: When used in line with advice from the research team, the information resource and training were perceived as beneficial to both patients and GPs in the diagnosis and management of CFS/ME. However, 47 % of patients in this study did not receive the information pack from their GP. When the information pack was used, it was often incomplete, sent in the post, and GPs did not work with patients to discuss the materials. Only13 out of 21 practices completed the training module due to time pressures and the low priority placed on low prevalence, contentious, hard to manage conditions. When the module was completed, many GPs stated that it was not feasible to retain the key messages as they saw so few patients with the condition. Due to the complexity of the condition, GPs also believed that the diagnosis and management of CFS/ME should take place in a specialist care setting. CONCLUSION: While barriers to the implementation of training and resources for CFS/ME remain, there is a need to support CFS/ME patients to access reliable, evidence based information outside primary care. Our findings suggest that future research should develop an online resource for patients to support self-management

Pre-eclampsia is associated with a twofold increase in diabetes : a systematic review and meta-analysis

CSK and RH are funded by National Institute for Health Research Academic Clinical Fellowships. This study was supported by a grant from the North Staffs Heart Committee.Peer reviewedPublisher PD

"I'm Managing My Diabetes between Two Worlds": Beliefs and Experiences of Diabetes Management in British South Asians on Holiday in the East-A Qualitative Study.

Background. Diabetes is disproportionately high among British South Asians compared to the general UK population. Whilst the migrant British South Asians group has received most attention on research related to diabetes management, little consideration has been given to impact of travel back to the East. This study aimed to explore the role of social networks and beliefs about diabetes in British South Asians, to better understand their management behaviours whilst holidaying in the East. Methods. Semistructured interviews were conducted in Greater Manchester. Forty-four participants were recruited using random and purposive sampling techniques. Interviews were analysed thematically using a constant comparison approach. Results. Migrant British South Asians expressed a strong preference to be in a hot climate; they felt they had a healthier lifestyle in the East and often altered or abandoned their diabetes medication. Information acquisition on diabetes and availability of social networks in the East was valued. Conclusion. Social networks in the East are a valued source of information and support for diabetes. The lack of adherence to medication whilst abroad suggests that some migrant British South Asians have a poor understanding of diabetes. Future research needs to explore whether patients are seeking professional advice on diabetes management prior to their extended holiday