Making sense of the experience of depression : general practitioners' and women's accounts of the management of depression in primary care

Despite UK general practitioners being responsible for helping people to manage most emotional distress and the majority of psychiatric problems very little is known about how they do this in their everyday clinical practice. There has been very little systematic research on general practitioners' views of their work and little critical reflection on the issues of 'problem definition'. In addition, whilst the perspectives of patients have been placed at the core ofthe development of health services, there has been relatively little research on the patient's perspective of depression and its management in primary care. This study explored the management of depression from both general practitioner and patient perspectivesUsing qualitative interviews, 37 women and 20 general practitioners were recruited from practices in four NHS Board areas of Scotland. Each participant was interviewed at the start ofthe study, and 30 women and 19 general practitioners were re-visited approximately 9-12 months later to review the process of care. The interviews explored how women made sense oftheir experiences, and their evaluations of their care; and how general practitioners made sense of the women's experiences and how they subsequently managed these women in the context of everyday practice.In making sense of their depressive experience and its management the women drew upon a range of experiential, biographical and common-sense knowledge surrounding health, illness, emotions, depression, antidepressant medications and medication use in general. However, the generally negative views surrounding depression and antidepressants created a moral dilemma for the women in accepting the diagnosis and its treatment. The women did not passively accept their general practitioner's explanation and advice but evaluated this in relation to their own knowledge. They continually evaluated 'formal medical knowledge' and care in relation to their own understandings and as new knowledge (experiential and common-sense knowledge) emerged. General practitioners recognised that patients brought their own understandings to the consultation and their management involved eliciting patient beliefs and addressing the moral dilemmas that some of these beliefs created for the women. General practitioners had to negotiate care by addressing patients' concerns and sometimes acted strategically in order to persuade, or coerce, patients to accept their advice and treatment.These findings are discussed in relation to the 'medicalisation' thesis through reflecting on patient and professional discourses concerning depression and its management, the doctor-patient relationship, and the doctor-patient interaction. I draw upon the later work of Foucault which affords patient agency through the 'technologies of the self and also on the work of Habermas and the relationship between 'system' and Tifeworld' as a theoretical basis for discussion of these findings. Finally, I consider the implications of the findings for recent policy developments which call for depression to be managed as a chronic disease and comment on the applicability of current guidelines for the management of depression to general practice. I conclude that the development of any management strategies should be based on a consideration of the 'patient's perspective' and acknowledge that 'formal medical knowledge' plays only a part in the management of depression in primary care

Sense of Community in Graduate Online Education: Contribution of Learner to Learner Interaction

Distance learning technologies offer a multitude of ways to build interaction into online courses to support learning. Based on social constructivism theory, this study explored which types of interaction are most predictive of students’ sense of community in online graduate courses at a regional comprehensive university. Surveys were used to measure sense of community and the frequency and importance of nine learner–learner interactions. Interactions that were most predictive of sense of community were introductions, collaborative group projects, sharing personal experiences, entire class discussions, and exchanging resources. The interaction that offered the highest payoff to instructors was exchanging resources. The article discusses implications for online course design

Policy addressing suicidality in children and young people: a scoping review protocol

Introduction Suicide is one of the leading causes of death among children and young people globally and a major public health issue. Government policies determine how much recognised health issues are prioritised and set the context for investment, development and delivery of services. A review of policies concerning children and young people who are suicidal could shed light on the extent that this public health issue is prioritised and highlight examples of best practice in this area. There has never been a review to explore how policy worldwide addresses the specific needs of this vulnerable population. This review will map the key policy documents and identify their relevance to the review question: how does policy address the treatment and care of children and young people who experience suicidality? (international, national (UK) and local (Scotland)). Methodology Employing scoping review methodological guidance a systematic and transparent approach will be taken. Preliminary searches will facilitate the identification of MeSh terms, subject headings, individual database and platform nuances. A full search strategy will be created to search five databases: CINAHL, PsychInfo, Medline, Web of Science and Cochrane. Government and other key agency websites (eg, WHO, Unicef) will be searched to identify policy documents. The reference lists of identified documents will be checked. A second reviewer will independently screen and cross validate eligible studies for final inclusion. A data extraction template will then be used to extract key information. We will report our findings using narrative synthesis and tabulate findings, by agreed key components. Ethics and dissemination Ethical approval is not required to conduct a scoping review. We will disseminate the findings through a peer-reviewed publication and conference presentation

Achieving ‘coherence’ in routine practice : a qualitative case-based study to describe speech and language therapy interventions with implementation in mind

Funding This paper is based on work carried out as part of an ESRC funded PhD studentship awarded to AN at the NMAHP Research Unit, University of Stirling. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript Acknowledgements Thank you to all participants for giving so generously of their time and expertise, and to the services and people who facilitated access. Thanks also to retired speech and language therapists Linda Armstrong and Jen Reid for critical feedback throughout the research; to Marian Brady at NMAHP Research Unit, Glasgow Caledonian University for the many discussions around TIDieR as well as critical feedback on early versions of this paper; and to Sue Roulstone at the University of the West of England for sage advice at the revision stage. Finally, thank you to the two peer reviewers for their constructive suggestions, which helped us improve the paper.Peer reviewedPublisher PD

Policy addressing suicidality in children and young people: An international scoping review

Suicide is a global health policy priority. As many as 800,000 lives are lost to suicide annually, in what is arguably a preventable cause of death. The World Health Organisation’s Mental Health Action Plan 2013-20 sets a target of reducing suicide rates by 10% by 2020, with member states agreeing to work towards this outcome. However, public policies instituted at national level can vary in how they translate this target into practical support. Suicide is a leading cause of death among children and young people (CYP) worldwide, with an estimated 1 in 3 children in some countries having considered suicide in the past year. Despite acknowledgment that children and young people have different needs to adults, most suicide prevention and mental health strategies take a universal approach, in which the specific needs for children and young people risk becoming lost. As the WHO’s target date of 2020 approaches, this briefing paper summarises a global review of national policy documents, considering how they address the treatment and care needs of suicidal children and young people. In doing so, it highlights best practice for how policy can influence the resourcing of services, and identifies gaps in policy provision for this vulnerable population. The paper aims to support both the WHO and individual countries that wish to develop new, or refine existing policies that address suicidality in children and young people

New postnatal urinary incontinence: obstetric and other risk factors in primparae.

Objective To identify obstetric and other risk factors for urinary incontinence which occurs during pregnancy or after childbirth. Design Questionnaire survey of women. Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). Population 3405 primiparous women with singleton births delivered during one year. Methods Questionnaire responses and obstetric casenote data were analysed using multivariate analysis to identify associations with urinary incontinence. Main outcome measures Urinary incontinence at three months after delivery first starting in pregnancy or after birth. Results The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with higher maternal age (oldest versus youngest group, odds ratio, OR 2.02, 95% CI 1.35 to 3.02); and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19 to 0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92 to 1.51) or vacuum delivery (OR 1.16, 95% CI 0.83 to 1.63). Incontinence first occurring during pregnancy and still present at three months was associated with higher maternal body mass index (BMI > 25, OR 1.68, 95% CI 1.16 to 2.43), and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12 to 2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27 to 0.58) but incontinence was not associated with age. Conclusions Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher body mass index and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings

Risk and protective factors for suicide and suicidal behaviour: a literature review

The Scottish Development Centre for Mental Health, in partnership with the University of Edinburgh (Research Unit in Health, Behaviour and Change and General Practice Section) and the University of Stirling (Department of Applied Social Science and Department of Nursing and Midwifery), were commissioned by the then Scottish Executive to undertake a review of the literature on risk and protective factors for suicide and suicidal behaviour. The review had two overarching aims: first, to describe and assess current knowledge regarding the societal and cultural factors associated with increased incidence of suicide (risk factors), and to delineate the population subgroups that are at increased risk of suicidal behaviour; and second, to describe and assess current knowledge regarding factors that promote resilience and healthy survival against suicidal behaviour amongst people who are exposed to known suicidal risk conditions (protective factors)

A realist evaluation of a normal birth programme

Background. Complex programmes are characterised by multiple components, acting independently and interdependently, at multiple levels, within diverse and dynamic systems. High-quality evaluation of such programmes is imperative for optimising their development, implementation and effectiveness, but is often challenging. There is debate about whether the traditional outcome-focused approaches are feasible or appropriate for evaluations of large-scale, complex programmes as they often fall short of explaining how and why they do or do not work. Theory-driven approaches offer a more appropriate alternative as they attempt to uncover the black-box between the programme's inputs and the resulting complex pattern of outcomes. Aim. This paper illustrates drawing upon a realist evaluation to assess a complex programme to support normal birth. Method. Firstly, the programme theories - the ideas about how the programme would bring about change - were elicited from programme developers and key stakeholders. Secondly, these initial hypotheses were tested out by collecting data on how the programme worked in different contexts, using a multiple case study design. Thirdly, the data were analysed and interpreted to refine the programme theories in light of evidence on how the programme unfolded in practice. Findings. Described in detail are the process of conducting a realist evaluation, methods used, steps in data analyses, challenges encountered and the approach adopted to overcome them. The usefulness of this approach and some limitations are discussed

Linking relief and development

This Discussion Paper reports on a workshop on 'Linking Relief and Development', held at IDS, Sussex in March 1994. Development and relief often operate at cross-purposes, with different objectives, cultures and modes of operation. Change which leads to mutual reinforcement of the two is an attractive, even a necessary idea; though problematic in the growing number of cases where emergencies are related to conflict. A simple linear sequence, 'relief-rehabilitation-development' is not appropriate: more dynamic models are required, which recognize the complexity and diversity of livelihood strategies. And in selecting interventions, analysis is needed of cost, sequencing and institutional issues