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Table 5 Participant views informing the conceptual framework

From: Embedding effective depression care: using theory for primary care organisational and systems change

Domain Participant Views
COHERENCE The meaning of depression
Developing a shared understanding of what constitutes depression and depression work ...In the end a lot of the so-called 'depression' that we see is related to practical issues like, they haven't got a job or they're caring for five children and a sick grandma, all of those sorts of things...they're not sitting there with existential angst wondering about the meaning of life. It's because of practical issues they're so-called 'depressed' in many cases (GP Coopers Road Practice Meeting 2: 12).
...I think so often they're so deeply meshed, the physical, the emotional and the psychological, that as soon as you start impact on one, you end up impacting on the other...[psychologists] are not sitting there thinking, 'gosh is this the manifestation of heart disease'? So, GPs have got a step before then. I don't see that these are two separate things that are warring with each other -- the psychological versus the physical. It's just part of the melting pot, the mess really (GP Coopers Road Practice Meeting 3: 5).
...If someone who came to seem me as initially a first port of call, I would probably try to work that through. The next level you've got in my mind is, that, I'm starting to realise that the next level of patients are in that 'grey zone,' they've got mood disorders, they have all sorts of issues with work, family, illness and what have you. They're not quite classically, fully depressed by a DSM-IV criteria, but they are in what some people now seem to be calling a disregulated zone. They are not quite fully depressed, but they're not quite right (GP Eastvale Practice Meeting 3: 13).
Diffuse boundaries
...Diagnosis Management is so hard. Do you have to define it and say this is depression, this is anxiety. I don't think that you can (GP West Sanders Practice Meeting 5: 13).
The meaning of depression work
...What I will often do, is, if I'm seeing somebody and I think, 'well, is this masked depression presenting'? I'll just put 'query depression, investigate next attendance.' So the next time that they come in I take the opportunity to then take it further and look at it....I think that happens with depression as there's so many different gradients (GP Franklin Street Practice Meeting 4: 13).
...I think sometimes though, if you're focusing on a psychological problem you have to be careful that you don't actually miss the very obviously physical problem, that there is some pathology going on that you need to try and treat with medication. Sometimes, it's finding that balance (GP Coopers Road Practice Meeting 2: 5).
...I think what would probably be the biggest concern, from our perspective...is because you know you're going to miss -- at the end of the day, you're going to miss things -- and you're going to miss things in depression, or going to miss it in heart disease or stroke or all of those things. Consequently you're constantly aware that the next patient who comes in could have a problem that, if you miss, could have a profound effect on the rest of their lives. That happens every 15 minutes (GP Franklin Street Practice Meeting 2: 21).
COGNITIVE PARTICIPATION Agreement on techniques
Agreement and engagement with a shared set of techniques that deal with depression as a health problem. ...Look, I think with depression it is a bit of give and take. I think when you are seeing a patient who is depressed you often ask, 'well, what are your expectations? You've come to see me regarding depression, what are your thoughts and how can I offer assistance'? It's not just a matter of saying you're depressed, this is what you're going to take and, you know, it will go away. I mean obviously it's an interaction and the whole idea of the doctor patient interaction is to actually work out what the expectations are with the patient and how best to manage that. If it means further referrals and psychological interventions, if it means just listening, if it means regular reviews, finding more time, I mean you work that out with the patient (GP Southville Practice Meeting 1: 19).
...You know, you tell [patients] what to do [for hypertension] and they go, 'good.' For depression, they go, 'no I'm not taking antidepressants.' You know, they have much more fixed ideas, and for various reasons. So, there's a lot more finding out where they're at, and then negotiating your way through than for a lot of straightforward medical illness (GP West Sanders Practice Meeting 1: 23).
Engagement with shared techniques (patients included)
...Look, someone was in yesterday who I think has been depressed for ages and was talking about this and I said to her, 'look, you are really depressed. We need to talk about this.' She knew that something was not right, but she really didn't want to go there...that sort of stuff happens quite often (GP Gibson Practice Meeting 3: 2).
...What do you do if you make a diagnosis but the patient refuses to accept it? I had two patients...one, she just had this terrible half a dozen years, the business went bankrupt and her marriage broke up and she's changed jobs about four times. Her dad died, her mother died when she was young and she's no longer speaking to her brother because of the fights about the will and because there was the new wife who had the fights about the will and [the patient] felt that she was left to do the fighting. Yet, she's says that she's not depressed because people in her family are not depressed...So what do you write in her notes? If I say to this patient, 'I think that you're depressed,' and they say, 'no, I'm not,' then do you put it in their notes? (GP Franklin Street Practice Meeting 4: 7-8).
Legitimacy of depression as a health problem
...I wouldn't have thought we had that many patients with depression presenting previous to the government funding coming in [for structured mental health plans]...because sometimes I think that maybe they are not really depressed but because it is rebated they are coming in? (Receptionist Gibson Practice Meeting 2: 15).
COLLECTIVE ACTION Skill set workability
Agreement about how care is organised. Who is required to deliver care, and their structural and human interactions. ...A couple of patients come to mind because there has been a combination of assessing the depression, then there was housing, then there was visa, then there was parenting and, you know, there were services just flying everywhere and I was trying to figure out how to combine them...It was Monday you go to her, Tuesday you go there and Wednesday you go there. So I found that a bit overwhelming in terms of how to pull that together and even to get them to see the people they needed (GP Coopers Road Practice Meeting 4: 21).
...I mean, I find it very hard to get your patients booked in with private psychiatrists, especially as a lot of psychiatrists have got closed books (GP Southville Practice Meeting 4: 18).
...I saw in this general practice, this mental health nurse was actually facilitating the care in a way that took a lot of the arduousness out of if for the GP and in doing that she did a bit of low grade kind of counseling at the same time as doing the process (GP West Sanders Practice Meeting 5: 6).
...I don't think it's appropriate for practice nurses to do depression care, it's a three year course (Practice Nurse Southville Practice Meeting 3: 13).
Contextual integration
...I don't want to leave the consulting room to go out and get one of those [depression] brochures and then walk back in and give it to the patient (GP Southville Practice Meeting 4: 3).
...The trouble is that importing portable document files (PDFs) into our electronic medical record system is an exercise in intermittent frustrations because sometimes they stay and sometimes they don't. We've tried to do it before (GP Southville Practice Meeting 4: 5).
...The other thing that would help toward a model of depression care is having a more thorough database for referrals. I think it's quite difficult sometimes to assess or to know which psychologists have experience or expertise in particular areas. The same even with psychiatrists. Sometimes it feels like you're just sort of sending patients off a bit blindly and hoping it works out (GP West Sanders Practice Meeting 5: 9).
Interactional workability
...With the resources, I don't think that I'd be giving anything out unless really Meredith (GP) said you could give them such and such because I wouldn't know what to give out for the type of condition the patient has got (Practice Nurse Gibson Street Practice Meeting 4: 19).
Relational integration
...I guess just in terms of the mental health care nurse, I am not clear which part of it I'd be happy for someone else to do (GP West Sanders Practice Meeting 5:7).
...I think, from my point of view it is recognition. I certainly don't know of patients that have depression. How am I to know? How is that going to be flagged to me, that this particular person is somebody that I have to spend that extra three to four minutes with....so that is my concern (Receptionist Eastvale Practice Meeting 3: 14).
...The thing that I find is that I don't think that I'm skilled enough to do the counseling that psychologists can do. I mean they really are doing this day in and day out - we're actually doing a lot of other things. I mean we're diagnosing a lot of other different illnesses, treating a lot of different illnesses...Even if we did have more time, I don't think GPs, the majority of us are trained enough to be able to input the strategies that psychologists can (GP Southville Practice Meeting 2: 14).
REFLEXIVE MONITORING Monitoring for effective depression care
Depression work requires the ongoing assessment of how depression care is done. ...A lot of psychologists don't have any time or really much to do with doctors because the ones that, even the ones that we've had long term close liaison with, it's been a battle for them to get their acts together and prepare letters...it's something professionally that they've never done - they've seen themselves as quite separate (GP Eastvale Practice Meeting 3: 10).
...For monitoring quantitative auditing could help and Balint groups and some sort of organised support mechanisms for GPs (GP Coopers Road Evaluation Meeting 1: 1).
...What are the measures? Is the care - what the patient wants or what the evidence would suggest would help them? (GP Franklin Street Evaluation Meeting 1:1).
...Always a follow-up visit. It is amazing that follow up visit. I reckon almost 50% feel - they've had the blood tests, they've been understood, and they're actually able to move on from there, with very little extra support (GP West Sanders Practice Meeting 2: 13).