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