Primary health care project on HIV and depression

Commencing in April 2006 this three-year-project adopted a comprehensive and multi-method approach to investigate the prevalence, nature, clinical management and self-management of depression among men, particularly homosexually active men, attending HIV-caseload general practice clinics

Does drug and alcohol use undermine concordance between doctors' assessments of major depression and patients' scores on a screening tool for depression among gay men attending general practice?

General practitioners (GPs) identify that depression can be difficult to diagnose in populations with high rates of alcohol and other drug (AOD) use. This is a particular concern with gay men who are a population known to engage in high rates of AOD use and who are vulnerable to depression. This paper uses data from 563 gay men and their GPs to describe concordance between assessments of major depression and, in particular, whether AOD use undermines concordance. Data were collected as part of a larger study of male patients and GPs at high HIV-caseload general practices in Australia. Concordance was measured by comparing patients’ scores on the PHQ-9 screening tool, which is based on DSM-IV criteria, and GPs’ ratings of the likelihood of depression for each participant. We observed high concordance between GPs’ assessments of major depression and patients’ scores on the PHQ-9 (79% agreement), although our analysis also suggests that concordance was better when it related to cases in which there was no depression. The high concordance observed in our study did not appear to be undermined by gay male patients’ AOD use, with the exception of frequent use of crystal methamphetamine. Here, men who reported frequent use of methamphetamine were significantly less likely to have concordant assessments (AOR 0.3, 95% CI 0.1-0.8). Overall, GPs appear to identify depression among many of their gay male patients. While GPs should be aware of the potential complications presented by frequent crystal methamphetamine use, other AOD use may have less impact on the diagnosis of depression

Discourses of depression of Australian general practitioners working with gay men

The data for this article are from a primary health care project on HIV and depression, in which the prevalence, nature, clinical management, and self-management of depression among homosexually active men attending high-HIV-caseload general practice clinics were investigated. One of the qualitative arms consisted of in-depth interviews with general practitioners (GPs) with high caseloads of gay men. The approach to discourse analysis was informed by Halliday’s systemic functional linguistics. GPs constructed three discourses of depression: engaging with psychiatric discourse, engaging with the patient’s world, and engaging with social structures. When GPs drew on the discourse of psychiatry, this discourse was positioned as only one possible construction of depression. This discourse was also contextualized in the social lives of gay men, and it was explicitly challenged and rejected. Engaging with their patients’ social world was considered vital for recognizing depression in gay men. Finally, the GPs’ construction of depression was inextricably linked to social disadvantage and marginalization. Depression is highly heterogeneous and constructed in terms of social relationships rather than as an independent entity that resides in the individual. There is a synergy between GPs’ constructions of depression and men’s experiences of depression, which differs from conventional medical views, and which enables GPs to be highly effective in dealing with the mental health issues of their gay patients

Experiences in managing problematic crystal methamphetamine use and associated depression in gay men and HIV positive men: in-depth interviews with general practitioners in Sydney, Australia

Background: This paper describes the experiences of Australian general practitioners (GPs) in managing problematic crystal methamphetamine (crystal meth) use among two groups of male patients: gay men and HIV positive men. Methods: Semi-structured qualitative interviews with GPs with HIV medication prescribing rights were conducted in Sydney, Adelaide and a rural-coastal town in New South Wales between August and October 2006. Participants were recruited from practices with high caseloads of gay and HIV positive men. Results: Sixteen GPs were recruited from seven practices to take part in interviews. Participants included 14 male GPs and two female GPs, and the number of years each had been working in HIV medicine ranged from two to 24. Eleven of the GPs who were based in Sydney raised the issue of problematic crystal meth use in these two patient populations. Five key themes were identified: an increasing problem; associations with depression; treatment challenges; health services and health care; workforce issues. Conclusion: Despite study limitations, key implications can be identified. Health practitioners may benefit from broadening their understandings of how to anticipate and respond to problematic levels of crystal meth use in their patients. Early intervention can mitigate the impact of crystal meth use on co-morbid mental illness and other health issues. Management of the complex relationships between drug use, depression, sexuality and HIV can be addressed following a `stepped care` approach. General practice guidelines for the management of crystal meth use problems should address specific issues associated with gay men and HIV positive men. GPs and other health practitioners must appreciate drug use as a social practice in order to build trust with gay men to encourage full disclosure of drug use. Education programs should train health practitioners in these issues, and increased resourcing provided to support the often difficult task of caring for peo

Features of the management of depression in gay men and men with HIV from the perspective of Australian GPs

In contrast to the broad literature on depression in the general population, little is known about the management of depression affecting gay men and HIV-positive men attending general practice clinics. This paper explores qualitative descriptions of how depression in gay men and HIV-positive men is managed by GPs. Despite the identification of several key strengths in working with this patient group, the ability of GPs to develop their capacity to manage depression in gay men and men with HIV is uncertain in the context of a growing range of challenges for GPs in both mental health and HIV care

Self-reported sexual difficulties and their association with depression and other factors among gay men attending high HIV-caseload general practices in Australia

Introduction. Sexual expression affects physical, mental and social well-being. There is a lack of understanding of male sexual dysfunction in homosexually active men. Aim. We investigated gay men's self-report of a number of sexual problems. Methods. The survey data were from a sample of 542 self-identified gay men, 40% of whom were HIV positive, recruited from six high HIV-caseload general practices in Australia. Main Outcome Measures. The reporting of experiencing three or more sexual problems over a period of at least 1 month in the 12 months prior to a survey was defined here as having "multiple" sexual problems. We explored a number of factors, including HIV status, depression, alcohol and other drug use, and sexual risk-taking with casual male partners, in association with multiple sexual problems

Rates of depression among men attending high-HIV-caseload general practices in Australia

This paper compares rates of current depression among men attending high-HIV-caseload general practices in New South Wales and South Australia. Current depression was assessed by the treating general practitioner (GP), using the nine-item Patient Health Questionnaire (PHQ-9), and by patient self-reporting. The study found that GPs, the PHQ-9 screening tool and patients were equally likely to identify current depression. High rates of depression were observed among the men attending general practices, with the highest rates among men with HIV and men who did not identify as either heterosexual or homosexual

Roles ascribed to general practitioners by gay men with depression

BackgroundThis article identifies the roles that gay men with depression ascribe to their chosen general practitioner and considers how they might influence the dynamics of clinical interactions between gay men and their doctors.MethodsForty gay identified men with depression (recruited from high HIV caseload general practices in New South Wales and South Australia) took part in semistructured interviews that were analysed using the principles of thematic analysis. Seventeen men (aged 20–73 years) were HIV positive. ResultsFive distinct roles were identified: GP as trusted confidant, gentle guide, providerof services, effective conduit, and community peer. DiscussionGay men who have ongoing contact with their GP may expect them to intuitively understand which roles are expected and appropriate to perform in each consultation and over time. General practitioners should consider these changing roles, and take them into account (as appropriate) to achieve open and trusting relationships in the care of their gay male patients

HIV generations? Generational discourse in interviews with Australian general

The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of ‘HIV generations’ was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms e ‘a different time’ and ‘difference today’ - suggesting that concepts of time and inequity are deeply embedded in these men’s understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and ‘lay’ understandings of changes and patterns in the HIV epidemic

The role of the general practitioner in the Australian approach to HIV care: Interviews with ‘key informants’ from government, non-government and professional organisations

Objectives HIV care is provided in a range of settings in Australia, but advances in HIV treatment and demographic and geographic changes in the affected population and general practitioner (GP) workforce are testing the sustainability of the special role for GPs. This paper explores how a group of ‘key informants’ described the role of the GP in the Australian approach to HIV care, and conceptualised the challenges currently inspiring debate around future models of care.Methods A thematic analysis was conducted of semistructured interviews carried out in 2010 with 24 professionals holding senior roles in government, non-government and professional organisations that influence Australian HIV care policy.Results The strengths of the role of the GP were described as their community setting, collaborative partnership with other medical and health professions, and focus on patient needs. A number of associated challenges were also identified including the different needs of GPs with high and low HIV caseloads, the changing expectations of professional roles in general practice, and barriers to service accessibility for people living with HIV.Conclusions While there are many advantages to delivering HIV services in primary care, GPs need flexible models of training and accreditation, support in strengthening relationships with other health and medical professionals, and assistance in achieving service accessibility. Consideration of how to support the GP workforce so that care can be made available in the broadest range of geographical and service settings is also critical if systems of HIV care delivery are to be realistic and cost-effective and meet consumer needs