Patients’ perspectives on depression case management in general practice – A qualitative study

https://doi.org/10.1016/j.pec.2011.02.020Get rights and content

Abstract

Objective

General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients’ perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management.

Methods

This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis.

Results

Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy.

Conclusion

Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner.

Practice implications

General practices should ensure that depression case management is patient-centered and non-mechanical.

Introduction

Depression is a common mental disorder in primary care, with a prevalence of about 10% [1]. It is associated with morbidity AND mortality and causes a substantial disease burden [2].

The majority of patients living with depression are treated in primary care, and general practitioners (GPs) are more often the first point of contact [3], [4] than psychiatrists [5]. An adequate diagnosis and treatment of depression is complicated by the fact that patients more often complain about somatic than depressive symptoms, and general practitioners tend to focus on somatic diseases [6]. Nowadays, more and more concepts for depression management in primary care are being established, e.g. case management.

Collaborative care improves depression outcomes by providing decision support and clinical information for physicians, as well as self-management support and follow-up for patients [7]. Most of the evidence on collaborative depression care stems from managed care settings in the Unites States [7], [8], [9], [10]. In small, isolated primary care settings, resources are often limited [11]. In the United States, 26% of primary care practices are solo or two-person partnerships, where extensive collaborative models would be difficult to implement, and 22% are located in rural areas with limited access to mental health specialists [12]. Case management is an essential, patient-centered element of collaborative care that is effective in improving symptoms and adherence to medication in primary care patients [7], [8], [13]. It has been defined as “taking responsibility for following up patients, determining whether patients were continuing the prescribed treatment as intended, assessing whether depressive symptoms were improving, and taking action when patients were not adhering to guideline-based treatment or when they were not showing expected improvement” [14]. It may also support patients’ self-management-activities, facilitate behavioral changes and empower patients to undertake pleasant activities [15].

Case management involves the whole practice team in a collaborative approach and emphasizes proactive support for the patient [16]. Various health professionals are able to provide depression case management [4], such as practice nurses [17], [18] or less well qualified staff such as health care assistants [19]. In Europe, health care assistants are well established in various primary care systems. In the United Kingdom, for instance, about 50% of family practices employ health care assistants [20], who increasingly deliver basic medical tasks traditionally performed by practice nurses [21]. In Germany, health care assistants are also well established in family practices, and mainly responsible for administrative tasks and simple medical procedures, such as measuring blood pressure [22]. They receive less training (they are not college graduates) than U.S. physician assistants or nurse practitioners, who provide first-contact-care [21]. Health care assistants are a potentially important resource for enhancing patient care in primary care settings [21].

In general, patients living with depression miss the feeling of being listened to by their GPs [23]. Qualitative research has shown that regular monitoring of patients’ symptoms is regarded as helpful by patients living with depression as it provides feedback on their current situation [24]. However, listening alone is not perceived as being sufficient [25]. Being monitored by telephone has been shown to be appreciated by patients as it provides some control over the situation. Patients living with depression value adequate information and counselling by their GPs, while receiving a prescription of anti-depressive-medication is viewed as less important [26]. Patients are able to trust and rely on case managers, who are seen as people they can speak to, who assist them in understanding the meaning of mental illness, who motivate and encourage them and who help them to believe in themselves [27]. However, comprehensive knowledge of what exactly patients living with depression experience in a case management program is still lacking.

The aim was to explore the patients’ perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management.

Section snippets

The trial

This qualitative study was nested in a large cluster-randomized controlled trial conducted between 2005 and 2007 on the effectiveness of case management provided by practice-based health care assistants for patients living with major depression in primary care [28]. We used written consent procedures. The institutional review board of Goethe University Frankfurt/Main approved the study protocol on 25 April, 2005 [29].

The intervention in the main trial

The intervention consisted of 1-year of case management designed in accordance

Participants

The basic socio-demographic characteristics of the 41 patients enrolled in this study (Table 2) did not differ from the sample in the main trial [28]. The high percentage of women (78%) is consistent with epidemiological findings, which indicate that about twice as many women as men are diagnosed with depression [36].

Emergent themes

The main themes that arose from the interview analyses are presented in the following sections. When exploring experiences with case management it became clear that these were not

Discussion

This qualitative study sheds light on the perception of practice-based depression case management of patients living with depression in Germany. While most of the evidence on collaborative depression care stems from managed care settings in the Unites States [7], [8], [9], [10], this study adds value by exploring the benefits of case management in settings outside of America.

Contributions

J. Gensichen, C. Guethlin, C. Jäger, D. Sivakumaran, N. Sarmand, and F.M. Gerlach contributed to the conception and design. J. Gensichen, C. Jäger, D. Sivakumaran, and K. Mergenthal contributed to the data collection. J. Gensichen, J.J. Petersen, N. Sarmand, C. Guethlin, C. Jäger, F.M. Gerlach analysis and interpretation. J. Gensichen, C. Guethlin, J.J. Petersen, N. Sarmand provided drafting of the article. All authors contributed to the critical revision of the article for important

Conflict of interest

We declare that we have no conflict of interest.

Acknowledgements

The Primary Care Monitoring for depressive Patients Trial (PRoMPT) has been awarded by the “German Research Award for Primary Care - Dr. Lothar-Beyer-Award 2008”. Grant support for the Primary Care Monitoring for depressive Patients Trial (PRoMPT) came from the German Ministry of Education and Research [grant number 01GK0302].

References (49)

  • U.T. Kadam et al.

    A qualitative study of patients’ views on anxiety and depression

    Brit J Gen Pract

    (2001)
  • W.J. Katon et al.

    Population-based care of depression: team care approaches to improving outcomes

    J Occup Environ Med

    (2008)
  • M. Olfson et al.

    National trends in the outpatient treatment of depression

    J Am Med Assoc

    (2002)
  • S. Gilbody et al.

    Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes

    Arch Intern Med

    (2006)
  • G. Gilchrist et al.

    Observational studies of depression in primary care: what do we know?

    BMC Fam Pract

    (2007)
  • N. Kates et al.

    Chronic disease management for depression in primary care: a summary of the current literature and implications for practice

    Can J Psychiat

    (2007)
  • T. Bodenheimer et al.

    The primary care-specialty income gap: why it matters

    Ann Intern Med

    (2007)
  • American Academy of Family Physicians. Practice profile of family physicians by family medicine residency completion;...
  • J. Gensichen et al.

    Case management to improve major depression in primary health care: a systematic review

    Psychol Med

    (2006)
  • M. Von Korff et al.

    Improving outcomes in depression

    Brit Med J

    (2001)
  • F. Kanfer et al.

    Einführung in die Thematik

  • E.H. Wagner et al.

    Improving outcomes in chronic illness

    Manag Care Q

    (1996)
  • H. Christensen et al.

    Models in the delivery of depression care: a systematic review of randomised and controlled intervention trials

    BMC Fam Pract

    (2008)
  • P. Bower et al.

    The clinical effectiveness of counselling in primary care: a systematic review and meta-analysis

    Psychol Med

    (2003)
  • Cited by (33)

    • Depressed patients’ experiences with and perspectives on treatment provided by homeopaths. A qualitative interview study embedded in a trial

      2017, European Journal of Integrative Medicine
      Citation Excerpt :

      Descriptions of homeopaths’ behaviour as being warm and friendly, non-judgmental, accepting good listeners, have strong similarities with “empathic understanding” and “unconditional positive regard”, key concepts considered in the Rogerian tradition to be among the necessary and sufficient conditions to facilitate change in patients’ mental health state [37,38]. The theme of trust has also been described as a significant factor in general practice [39], which together with caring support contributed to a positive patient-practitioner relationship. This relationship, which may be described as a therapeutic alliance between patient and practitioner, plays an important role in improvement of patient outcomes in psychotherapy [40], as well as in homeopathy [41,42].

    • What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review

      2017, Journal of Affective Disorders
      Citation Excerpt :

      Five studies interviewed patients (Bennett et al., 2013; Chew-Graham et al., 2007; Gensichen et al., 2012; Knowles et al., 2015; Simpson et al., 2008) The 18 included qualitative papers investigated the barriers and facilitators of implementing and evaluating Collaborative Care for depression with (Kathol et al., 2010; Knowles et al., 2015, 2013; Wozniak et al., 2015) or without (Bennett et al., 2013; Bentham et al., 2011; Blasinsky et al., 2006; Chew-Graham et al., 2007; Coupe et al., 2014; Eghaneyan et al., 2014; Gensichen et al., 2012, 2011; Landis et al., 2007; Murphy et al., 2014; Nutting et al., 2007; Oishi et al., 2003; Simpson et al., 2008; Whitebird et al., 2014) an associated physical health condition (see table 4 for details). Seven studies were from the UK (Bennett et al., 2013; Chew-Graham et al., 2007; Coupe et al., 2014; Knowles et al., 2015, 2013; Murphy et al., 2014; Simpson et al., 2008) eight were from the USA (Bentham et al., 2011; Blasinsky et al., 2006; Eghaneyan et al., 2014; Kathol et al., 2010; Landis et al., 2007; Nutting et al., 2007; Oishi et al., 2003; Whitebird et al., 2014), one studies was conducted in Canada (Wozniak et al., 2015) and a further two in Germany (Gensichen et al., 2012, 2011).

    View all citing articles on Scopus
    View full text