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. GPs identified a range of features in their experience of managing depression in gay men and in HIV-positive men. Some were common to the care of other groups with depression, but this paper reports on features unique to this patient group. These include capitalizing on the high frequency of contact with this patient group, taking advantage of the specialist multidisciplinary teams who provide support, building upon the unusual willingness of this patient group to take medication, appreciating the central importance to many gay men of sexual functioning, and recreational drug use, responding to social isolation in this patient group and coping with increasing challenges for the HIV general practice workforce

Kidd, Michael Richard

Kippax, Susan C

Mao, Limin

Newman, Christy E

Saltman, Deborah C

Newman, Christy

Kippax, Susan

Saltman, Deborah

Kidd, Michael

UNSWorks

GPs understanding of how depression affects gay and HIV positive men

Flinders Academic Commons

Archived at the Flinders Academic Commons:  http://dspace.flinders.edu.au/dspace/  This is the publisher’s copyrighted version of this article.  The original can be found at: http://www.racgp.org.au/afp/200808/200808research_newman.pdf © 2008 Australian Family Physician www.afp.org.au Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners. researchLimin MaoBMed, MEdAdmin, PhD, is Research Fellow, National Centre in HIV Social Research, The University of New South Wales.Deborah saltman aMMBBS, MD, FRACGP, FAFPHM, MRCGP, is Head, Institute of Postgraduate Medicine, Brighton and Sussex Medical School Brighton, United Kingdom.susan KippaxBA(Hons), PhD, is Professorial Research Fellow, National Centre in HIV Social Research, The University of New South Wales.christy NewmanBA(Hons), PhD, is Research Fellow, National Centre in HIV Social Research, The University of New South Wales. c.newman@unsw.edu.aualthough there is considerable literature available on how general practitioners approach the diagnosis and management of depression, there is less on their perceptions, attitudes and beliefs about depression, particularly in relation to how depression affects gay men. There is some evidence that gay men experience elevated levels of psychological disorders, including depression1 and suicidality.2 Many studies have also found a high prevalence of depression in people living with HIV/AIDS3–5 and a meta-analysis of aggregated data from 10 studies reported the rate of major depressive disorder as nearly twice as high in HIV positive as HIV negative participants.6 Survey studies have been conducted in the Australian context on rates and factors associated with depression in gay and HIV positive men attending general practices.1,7 However, few qualitative studies have been published in this area,8 and none focuses on GP understandings of how depression affects gay and positive men. Health professionals commonly express beliefs about gender differences in mental health. For example, studies have found: doctors and nurses believe men to be more reluctant to talk about emotional issues than women;9 men are less likely to ‘open up’ about depressive symptoms;10 and men cope with depression differently, more often choosing ‘avoidant, numbing and escape’ behaviours which can lead to ‘aggression, violence and suicide’.11 More generally, primary care physicians have been shown to negotiate between a medicalised understanding of depression and one which understands depression as a response to the social context of patients’ lives.12 One example of this influencing service delivery in the Australian context is the Care and Prevention Program (CPP), which has been providing multidisciplinary care in Adelaide (South Australia) since 1998 for people with HIV and people at risk – with a focus on homosexually GPs understanding of how depression affects gay and  hIV positive men BackgroundThis article explores qualitative descriptions of how a group of Australian general practitioners understand the relationship between depression, gender, and sexuality in their gay male patients, including gay men who are HIV negative and those who are HIV positive.MethodsThematic analysis of 16 semistructured qualitative interviews with GPs who prescribe s100 HIV medications in Sydney, Adelaide and a rural coastal town in New South Wales, Australia. resultsRecurrent themes regarding how depression affects the gay men these GPs see in their practices in comparison with heterosexual men included: differences in seeking help and accepting treatment; and similarities in emotional expression, overuse of alcohol and recreational drugs, and excessive time spent on work. Issues that complicated the management of depression in these populations included aging, sexual dysfunction, social isolation, loss of family and friendship networks, and poverty. DiscussionGeneral practitioners with less experience in treating gay and HIV positive men can benefit from these insights to ensure that depression is accurately detected and effectively treated. 678  reprinted from austraLIaN FaMILy PhysIcIaN Vol. 37, No. 8, August 2008Michael Kidd MBBS, MD, FRACGP, is Professor and Head, Discipline of General Practice, The University of Sydney, New South Wales.active men including a more culturally appropriate approach to the management of depression in gay men.13Methods The Primary Health Care Project on HIV and Depression is a 3 year study employing both qualitative and quantitative methods to answer a range of research questions around HIV and depression. Outcomes will include a module for the self management of depression for HIV positive men on the ClimateGP website.14  Ethics approval was granted by the National Research and Evaluation Ethics Committee of The Royal Australian College of General Practitioners and ratified by the human research ethics committees of participating universities. Stage one of this study comprised semistructured qualitative interviews with GPs who are s100 HIV medication prescribers in Sydney, Adelaide and a rural coastal town in New South Wales. Key practices in each of these locations were engaged by the investigators at the grant application stage. Once the study was funded, presentations were made to each practice about the scope and purpose, and then individual GPs were invited (through practice managers) to take part in interviews. Between August and October 2006, face-to-face interviews of around 1 hour in length were conducted with each GP in an open ended, nonjudgmental and conversational style.15 Questions explored the diagnosis, treatment and management of depression, aspects of depression related to HIV, gender and sexuality, and reflections on practice. Sufficient interviews were conducted to achieve data saturation.  As has been evidenced in multiple settings, qualitative methods are particularly appropriate for exploring such a range of health and practice issues.16–18 Interviews were transcribed verbatim and de-identified to protect participant confidentiality. Transcripts were coded by the primary qualitative researcher (and interviewer) on the study through an iterative process of theme identification, using the qualitative analysis software NVivo. Thematic analysis allows for empirically grounded findings to emerge from the data rather than being restricted to predetermined hypotheses.19 Reliability was established through a process of independent coding and discussion among the qualitative members of the team. resultsSixteen GPs were recruited from seven practices to take part in interviews. The five practices in Adelaide (1) and Sydney (4) have a high caseload of gay or homosexually active men as well as HIV positive men. The two in the rural/coastal town have a lower caseload of these groups, but see many of the gay and positive men living in that area. Participants included 14 male GPs and two female GPs, and the number of years each had been working in HIV medicine ranged 2–24.  General practitioners perceived gay men as more ‘in tune’ with their emotional selves than heterosexual men. However, they also described them as ‘still men’.‘They’ll talk about sex in a maybe more open and whatever way than straight men sometimes would... But when it comes to actually looking at how they’re feeling and whether they might be depressed, they’re very blokey, they don’t talk about it.’ (SYD-GP4)General practitioners believed male patients often downplayed their symptoms. However, they suggested gay men were more willing to seek help and accept treatment than heterosexual men.‘I think it’s the culture of this group that it’s more sensitive and in tune with their feelings and issues of depression. So they’re much more likely, able to identify this as an issue and come forward, and accept treatment or discuss it.’ (ADE-GP1)Particular characteristics were described by GPs as typical of men, but also of their gay male patients. This included using alcohol and recreational drugs to self medicate depression, and hiding emotional problems behind excessive work.‘Sometimes gay men that are high achievers and... they’ve never had any problems at all in the past, they’ve always sailed through. You know, successful careers, successful relationships and then they hit a brick wall.’ (SYD-GP3)Gay men were described by GPs as often immersed in social environments that placed a high value on being fit, attractive and sexually active. General practitioners believed this had a significant impact on the emotional health of gay men, particularly as they grew older.‘Your whole life’s been around body image, maybe, or being able to get a root whenever you want it, and suddenly you’re not interested in sex and you’ve got to find other things to give your life some value.’ (SYD-GP8)Associated with this was the understanding that gay men were more likely to present with sexual dysfunction as a symptom of depression, and more reluctant to take antidepressants that may affect libido and erectile function. General practitioners believed many of their gay male patients were socially isolated, particularly as major life events such as a relationship breakdown were often undervalued by family and work colleagues. They described what they perceived as ‘unresolved’ issues for many gay men in relation to their sexuality, worsened by family rejection or not being taken seriously by those in positions of authority. Gay men from culturally and linguistically diverse backgrounds were perceived as particularly vulnerable. General practitioners reported that many gay men were ostracised from family and friends, or had lost large parts of their social networks to HIV.‘So whether you’re positive or negative, if you’re the one left hanging around when nearly everyone else has gone... and you reprinted from austraLIaN FaMILy PhysIcIaN Vol. 37, No. 8, August 2008  679research GPs understanding of how depression affects gay and hIV positive men Implications for general practiceGeneral practitioners understanding of how depression is related to gender and sexuality in their male patients inform their approach to the diagnosis and management of depression in men. General practitioners with less experience in treating gay and HIV positive men can benefit from the insights of s100 prescriber GPs to ensure that depression is accurately detected and effectively treated in this population. Conflict of interest: none.acknowledgement This research was funded by the General Practice Clinical Research Program of the National Health and Medical Research Council (351020). references1. Rogers G, Curry M, Oddy J, Pratt N, Beilby J, Wilkinson D. Depressive disorders and unprotected casual anal sex among Australian homosexually active men in primary care. HIV Med 2003;4:271–5.2. Abelson J, Lambevski S, Crawford J, Bartos M, Kippax S. Factors associated with ‘feeling suicidal’: The role of sexual identity. J Homosex 2006;51:59–80.3. Judd FK, Cockram AM, Komiti A, Mijch AM, Hoy J, Bell R. Depressive symptoms reduced in individuals with HIV/AIDS treated with highly active antiretroviral therapy: a longitudinal study. Aust N Z J Psychiatry 2000;34:1015–21.4. Amirkhanian YA, Kelly JA, McAuliffe TL. Psychosocial needs, mental health, and HIV transmission risk behavior among people living with HIV/AIDS in St Petersburg, Russia. AIDS 2003;17:2367–74.5. Tate D, Paul RH, Flanigan TP, et al. The impact of apathy and depression on quality of life in patients infected with HIV. AIDS Patient Care STDs 2003;17:115–20.6. Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry 2001;158:725–30.7. Komiti A, Judd F, Grech P, et al. Depression in people living with HIV/AIDS attend-ing primary care and outpatient clinics. Aust N Z J Psychiatry 2003;37:70–7.8. Dawson MT, Grech P, Hyland B, et al. A qualitative approach to the mental health care needs of people living with HIV/AIDS in Victoria. Australian Journal of Primary Health 2002;8:30–8.9. Seymour-Smith S, Wetherell M, Phoenix A. ‘My wife ordered me to come!’: A discursive analysis of doctors’ and nurses’ accounts of men’s use of general prac-titioners. J Health Psychol 2002;7:253–76.10. Brownhill S, Wilhelm K, Eliovson G, Waterhouse M. ‘For men only’: a mental health prompt list in primary care. Aust Fam Physician 2003;32:443–50.11. Brownhill S, Wilhelm K, Barclay L, Schmied V. ‘Big build’: hidden depression in men. Aust N Z J Psychiatry 2005;39:921–31.12. Thomas-MacLean R, Stoppard JM. Physicians’ constructions of depression: inside/outside the boundaries of medicalization. Health 2004;8:275–93.13. Rogers GD, Barton CA, Pekarsky BA, et al. Caring for a marginalised community: the costs of engaging with culture and complexity. Med J Aust 2005;183(Suppl 10):S59–63.14. Andrews G. ClimateGP – web based patient education. Aust Fam Physician 2007;36:371–2.15. Denzin NK, Lincoln YS, editors. Collecting and interpreting qualitative materials. Thousand Oaks, CA: Sage, 2003.16. Green J, Britten N. Qualitative research and evidence based medicine. BMJ 1998;316:1230–2.17. Pope C, Mays N. Qualitative research: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995;311:42–5.18. Malterud K. Qualitative research: Standards, challenges and guidelines. Lancet 2001;358:483–8.19. Strauss A, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory. 2nd edn. London, Thousand Oaks, New Delhi: Sage Publications, 1998.haven’t got family as well or you haven’t got sympathetic or supportive family, it’s really isolating.’ (SYD-GP8)Other losses experienced by positive gay men that GPs perceived as worsening depression included the loss of relationships and social connectedness, career and earning capacity, a sense of future and longevity, health and treatment options.‘It’s a sense of, ‘I was told I was going to die 15 years ago, and I’m still here. And now I’m living in poverty. And I gave up my career because of this. And I’ve not been able to have a relationship. And I’m quite lonely and isolated.’ (ADE-GP1)DiscussionA number of recurring themes emerged from the analysis of the GPs’ interviews. These included: that gay men often differ from heterosexual men in terms of seeking help and accepting treatment, but like heterosexual men can struggle with emotional expression; overuse of alcohol and recreational drugs; and excessive work. General practitioners believe particular issues worsen depression for gay men including aging, sexual dysfunction, social isolation, and loss of family and friendship networks. For gay men living with HIV, multiple losses are seen to increase the risk of depression, particularly for those living in poverty. This analysis suggests that this group of GPs has quite particular and pronounced understandings about how depression is related to gender and sexuality in their male patients, which inform their approach to the diagnosis and management of depression in men. General practitioners with less experience in treating gay and HIV positive men can benefit from these insights to ensure that depression is accurately detected and effectively treated. However, these understandings about gay men must be approached warily to ensure that they are not used to further stereotype this population. Further research will be analysed from this study to assess the perspective of gay and positive men themselves on their experiences of depression and how depression is diagnosed and managed in the context of Australian general practice. Forthcoming papers will address related issues such as the changing context of depression in HIV positive men and the different experiences of GPs and patients in different geographical settings.summary of important points •	Rates	of	depression	are	higher	in	gay	men	than	heterosexual	men,	and higher again in gay men who are HIV positive.•	There	is	little	literature	available	on	GP	understandings	about	how	depression affects gay men, including those who are HIV positive.•	Australian	GPs	who	prescribe	 s100	HIV	medications	 suggest	 that	gay men are more likely to seek help and accept treatment for depression than heterosexual men, but that both groups of men struggle with emotional expression, alcohol and drug use, and overwork.•	GPs	 believe	 particular	 issues	worsen	 depression	 for	 gay	 and	HIV	positive men, including aging, sexual dysfunction, social isolation, loss of family and friendship networks, and poverty. CORRESPONDENCE afp@racgp.org.au680  reprinted from austraLIaN FaMILy PhysIcIaN Vol. 37, No. 8, August 2008

GPs understanding of how depression affects gay
            and HIV positive men

Newman, CE

Kippax, SC

Mao, L

Saltman, D

Kidd, MR

http://dspace.flinders.edu.au/xmlui/bitstream/handle/2328/11681/2006015491.pdf?sequence=1

GPs understanding of how depression affects gay and HIV positive men

Abstract

Similar works

Full text

Available Versions

UNSWorks

Flinders Academic Commons

UNSWorks