1,721,119 research outputs found
The confidential patient: the social construction of therapeutic relationships in general medical practice
No full textThe interpersonal relationship between doctor and patient is fundamental to general medical practice. In this paper we explore the ways in which general practitioners make sense of the changing political economy of this relationship, as it is restructured by ideas about the patient as consumer, and as it increasingly constitutes the consultation as a point of interaction that may be intrinsically therapeutic. In particular, we explore the ways in which the consultation is the site of negotiated power relations between doctor and patient, and is the site of the doctor's negotiation of powerful discourses of professional and institutional identity.<br/
Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from 'hard to reach' groups
No full textKnowledge about depression, access and help-seeking has increasingly been influenced from a range of disciplines including clinical and applied social science. A range of interventions can improve outcomes of depression and anxiety. However, many in need do not seek help, or their interaction with care-givers does not address their needs. We carried out a systematic search for qualitative articles focusing on the experiences of eight exemplar groups with exceptional problems in access (the homeless, long-term unemployed, adolescents with eating disorders, depressed elderly people, advanced cancer sufferers, patients with medically unexplained symptoms, asylum seekers and people from black and minority ethnic groups). Twenty articles representing these groups were selected, findings were then developed using qualitative meta-synthesis, this suggested a range of mechanisms accounting for poor access among these groups. Many regarded their mental health problems as rooted in social problems and employed a variety of self-management strategies to maintain function. These strategies could involve social withdrawal, focusing available resources on close family relationships and work roles. Over-investment in these roles could result in a sense of insecurity as wider networks were neglected. Material disadvantage affected both the resources people could bring to performing social roles and influenced help-seeking. A tacit understanding of the material, psychological and social 'costs' of engagement by patients and health professionals could influence decisions to seek and offer help. These costs were felt to be proportionally higher in deprived, marginalized and minority communities, where individual resources are limited and the stigma attached to mental ill-health is high. © The Author(s) 2011
Painful symptoms in depression: under-recognised and under-treated?
No full textCurrent diagnostic systems maintain an artificial division between ‘physical’and ‘psychological’disorders. This is exemplified by the way in which pain symptoms are dealt with in the context of depressive illness. The consequences of this are discussed, and ways to enhance the clinical care of patients with depression and pain are suggested
Process evaluation for complex interventions in primary care: understanding trials using the normalization process model
Get PDFBackground: the Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.Method: in this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.Results: application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.Conclusion: the model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare setting
The politics of conducting research on depression in a cross-cultural context
No full textSuccessful community engagement is often a crucial component of effective qualitative research. In this article we reflect on our experience of engaging with ethnic minority communities in a qualitative study of help seeking for depression. Community engagement emerges as a complex process that provides important insights into the way mental illness is constructed in various cultural contexts and from diverse perspectives. Contested notions of ethnicity, culture, community, and depression were the domains in which personal and public politics were played out. We worked with bilingual research assistants who provided an entrée to the community. Despite this, disparate community subgroups and influential individuals vied for input into and control of the research agenda. We conclude that negotiating the politics of these processes requires great reflexivity and is itself a powerful seam of data, adding richness to findings about the experience of mental distress in a community seeking to locate itself within mainstream societ
Managing antidepressant discontinuation: a systematic review
Get PDFPurposeTo determine the effectiveness of interventions to manage antidepressant discontinuation, and outcomes for patients.MethodsSystematic review with narrative synthesis and meta-analysis. Sources: MEDLINE, PubMed, Embase, PsycINFO, AMED, Health Management Information Consortium (HMIC), OpenGrey, and WHO International Clinical Trials Registry Platform (ICTRP) to March 2017. Including: randomised controlled trials (RCTs), quasi-experimental, and observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Primary outcomes: antidepressant discontinuation, and discontinuation symptoms. Secondary outcomes: relapse/ recurrence, quality of life, antidepressant reduction, sexual, social, and occupational function.ResultsOf 15 studies included, 12 were in the synthesis (8 RCTs, 2 single-arm trials, 2 retrospective cohort studies). None of the studies was rated high risk for selection or detection bias. Two studies prompting primary care provider (PCP) discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, versus 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of between 40% and 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/ recurrence was lower with cognitive behaviour therapy (CBT) plus taper versus clinicalmanagement plus taper (15%-25% vs 35%-80%: RR 0.34, 95% CI 0.18 to 0.67; 2 studies).Relapse/recurrence rates were similar for mindfulness based cognitive therapy (MBCT) with tapering and maintenance antidepressants (44%-48% vs 47%-60%; 2 studies).ConclusionsCBT or MBCT can help patients discontinue antidepressants without increasing the risks of relapse/recurrence, but are resource intensive. More scalable interventions are needed, incorporating psychological support
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Managing patients with dementia
No full text1. Dementia is a clinical syndrome with several causes whichcreates impairments in mental ability, personality, affect andsocialisation.2. Information from family members can be very useful in theearly identification of cognitive impairment.3. Patients presenting with cognitive impairment should be evaluatedfor potentially reversible causes, with a range of laboratorytests and investigations.4. Sharing the diagnosis is one of the hardest parts of dementiacare. Family physicians/ general practitioners (FPs/GPs) shouldgive information gradually and sensitively.5. Dementia medications have only modest efficacy. It is encouragedto discuss the risks, side effects and benefits with thepatient and family.6. Non-pharmacological management such as regular structuredroutine, good sleep hygiene, reminiscence and cognitive stimulationcan help to improve the wellbeing of patients with dementia.7. During the course of dementia most patients develop behaviouraland psychological symptoms of dementia (BPSD).These result in a lower quality of life, high caregiver burdenand psychotropic drug use.8. When the burden of care exceeds the resources of the caregiver,nursing home placement commonly ensues.9. When patients with dementia lack mental capacity to make decisionsabout areas of their lives, legal processesmay be necessary.10. In dementia care there are considerable differences betweencountries and within countries
Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study
No full textObjective: to gain understanding of general practitioners’ and patients’ opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. Design Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. Participants: 34 general practitioners and 24 patients. Setting: 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. Results: patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment ("phronesis") to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. Conclusions: despite general practitioners’ caution about measures of severity for depression, these may benefit primary care consultations by increasing patients’ confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires
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