Prevalence and risk factors of suicide and suicidal ideation in veterans who served in the British Armed Forces: a systematic review

INTRODUCTION

Research into the factors resulting in suicide in the military veteran population has yet to reach a consensus. Available research is concentrated on a small number of countries, and there is a lack of consistency with contradictory conclusions. The USA has produced a significant amount of research in a country where suicide is identified as a national health crisis, but in the UK, there is little research regarding veterans from the British Armed Forces.

METHODS

This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Corresponding literature searches were conducted in PsychINFO, MEDLINE and CINAHL. Articles that discussed suicide, suicidal ideation, prevalence or risk factors among British Armed Forces veterans were eligible for review. A total of 10 articles met the inclusion criteria and were analysed.

RESULTS

Veterans' suicide rates were found to be comparable to those of the general UK population. The method of suicide used was most commonly found to be hanging and strangulation. Firearms was recorded in 2% of suicide cases. Demographic risk factors were often contradictory with some research stating that there was risk in older veterans and some in younger. However, female veterans were found to be at higher risk than female civilians. Those who had deployed on combat operations were at lower risk of suicide, with research finding that veterans who took longer to seek help for mental health (MH) difficulties reported more suicidal ideation.

CONCLUSIONS

Peer-reviewed research publications have revealed that UK veteran suicide prevalence is broadly comparable to the general population while highlighting differences across international armed forces. Veteran demographics, service history, transition and MH have all been identified as potential risk factors of suicide and suicidal ideation. Research has also indicated that female veterans are at higher risk than that of their civilian counterparts due to veterans being predominantly male; this could skew results and requires investigation. Current research is limited and further exploration of suicide prevalence and risk factors in the UK veteran population is required.

Non-traditional support workers delivering a brief psychosocial intervention for older people with anxiety and depression: the NOTEPAD feasibility study

Background

Anxiety and depression often coexist in older people. These disorders are often underdiagnosed and undertreated, and are associated with increased use of health and social care services, and raised mortality. Barriers to diagnosis include the reluctance of older people to present to their general practitioner (GP) with mood symptoms because of the stigma they perceive about mental health problems, and because the treatments offered are not acceptable to them.

Objectives

To refine a community-based psychosocial intervention for older people with anxiety and/or depression so that it can be delivered by non-traditional providers such, as support workers (SWs), in the third sector. To determine whether or not SWs can be trained to deliver this intervention to older people with anxiety and/or depression. To test procedures and determine if it is feasible to recruit and randomise patients, and to conduct a process evaluation to provide essential information to inform a randomised trial.

Design

Three phases, all informed by a patient and public involvement and engagement group. Qualitative work with older people and third-sector providers, plus a consensus group to refine the intervention, training, SW manuals and patient participant materials (phase 1). Recruitment and training of SWs (phase 2). Feasibility study to test recruitment procedures and assess fidelity of delivery of the intervention; and interviews with study participants, SWs and GPs to assess acceptability of the intervention and impact on routine care (phase 3).

Setting

North Staffordshire, in collaboration with Age UK North Staffordshire.

Intervention

A psychosocial intervention, comprising one-to-one contact between older people with anxiety and/or depression and a SW employed by Age UK North Staffordshire, based on the principles of behavioural activation (BA), with encouragement to participate in a group activity.

Results

Initial qualitative work contributed to refinement of the psychosocial intervention. Recruitment (and retention) of the SWs was possible; the training, support materials and manual were acceptable to them, and they delivered the intervention as intended. Recruitment of practices from which to recruit patients was possible, but the recruitment target (100 patients) was not achieved, with 38 older adults randomised. Retention at 4 months was 86%. The study was not powered to demonstrate differences in outcomes. Older people in the intervention arm found the sessions with SWs acceptable, although signposting to, and attending, groups was not valued by all participants. GPs recognised the need for additional care for older people with anxiety and depression, which they could not provide. Participation in the study did not have an impact on routine care, other than responding to the calls from the study team about risk of self-harm. GPs were not aware of the work done by SWs with patients.

Limitations

Target recruitment was not achieved.

Conclusions

Support workers recruited from Age UK employees can be recruited and trained to deliver an intervention, based on the principles of BA, to older people with anxiety and/or depression. The training and supervision model used in the study was acceptable to SWs, and the intervention was acceptable to older people.

Future work

Further development of recruitment strategies is needed before this intervention can be tested in a fully powered randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN16318986.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 25. See the NIHR Journals Library website for further project information.

Can support workers from AgeUK deliver an intervention to support older people with anxiety and depression? A qualitative evaluation

BACKGROUND

Anxiety and depression often co-exist. These disorders are under-diagnosed and under-treated, specifically among older people, and lead to increased use of health and social care services and raised mortality. Older people report a reluctance to present to their GP with depression or anxiety symptoms due to perceived stigma about mental health problems, lack of acceptable treatments and the prioritising of physical health problems. Third sector organisations, who work closely with older people in the community, are well-placed to provide additional support. We developed a brief intervention based on principles of Behavioural Activation, with encouragement to participate in a group activity, for delivery by Support Workers from AgeUK. The aim of the study was to examine whether this brief intervention could be delivered to older people with anxiety and/or depression, with sufficient fidelity, and whether this approach was acceptable to patients, GPs and AgeUK Support Workers.

METHODS

Semi-structured interviews with older people with self-reported anxiety and/or depression (who received the intervention), Support Workers and GPs to assess acceptability of the intervention and impact on routine care. A constant comparative approach was used to analyse the data. Intervention sessions between Support Workers and older people were digitally recorded and reviewed by the research team to assess fidelity.

RESULTS

The Support Workers delivered the intervention with fidelity; access to the training maual and ongoing supervision were important. Older people found the intervention acceptable and valued the one-to-one support they received; group activities suggested by Support Workers were not valued by all. GPs recognised the need for additional support for vulnerable older people, but acknowledged they could not provide this support. Participation in the study did not impact on GP routine care, other than responding to the calls from the study team about risk of self-harm.

CONCLUSIONS

Support Workers within AgeUK, can be recruited and trained to deliver an intervention, based on the principles of Behavioural Activation, to older people with anxiety and/or depression. The training and supervision model used in the study was acceptable to Support Workers, and the intervention was acceptable to older people and GPs. This model has the potential to contribute to improving the support and care of older people in primary care with anxiety and depression. Further testing is required in a full trial.

TRIAL REGISTRATION

Trial registration number ISRCTN16318986 . Registered 10/11/2016.

The value of an embedded qualitative study in a trial of a second antidepressant for people who had not responded to one antidepressant: understanding the perspectives of patients and general practitioners

BACKGROUND

Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease. The number of prescriptions for antidepressants has risen dramatically in recent years yet up to 50% of patients who are treated for depression with antidepressants do not report feeling better as a result of treatment, and do not show the desired improvement on depression measures. We report a qualitative study embedded in a trial of second antidepressant for people who had not responded to one antidepressant, exploring the acceptability of a combination of antidepressants from the perspectives of both patients and practitioners, together with experiences of participating in a clinical trial.

METHODS

A qualitative study embedded in a randomized controlled trial investigating the effectiveness and cost-effectiveness of combining mirtazapine with Serotonin-Noradrenaline Reuptake Inhibitor (SNRI) or Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants versus SNRI or SSRI therapy alone (the MIR trial). 59 interviews were conducted with people who declined to participate in the trial, people who completed the study and people who withdrew from the intervention, and 16 general practitioners.

RESULTS

Across the data-sets, four main themes were identified: the hard work of managing depression, uncertainties over the value of a second antidepressant, help-seeking at a point of crisis, and attainment and maintenance of a hard-won equilibrium.

CONCLUSIONS

Exploring reasons for declining to participate in a trial of a second antidepressant in people who had not responded to one antidepressant suggests that people who are already taking one antidepressant may be reluctant to take a second, being wary of possible side-effects, but also being unconvinced of the logic behind such a combination. In addition, people describe being in a state of equilibrium and reluctant to make a change, reflecting that this equilibrium is 'hard-won' and they are unwilling to risk disturbing this. This makes some people reluctant to enrol in a clinical trial. Understanding a patient's view on medication is important for GPs when discussing antidepressants.

TRIAL REGISTRATION

MIR Trial Registration: ISRCTN 06653773 .

How older adults self-manage distress - does the internet have a role? A qualitative study

BACKGROUND

Anxiety and depression are common in older adults, but often under-recognised by GPs. Rather than perceiving themselves as suffering from anxiety or depression, older adults are more likely to self-identify as experiencing low mood, stress or distress. Older people may also feel responsible for managing their own mood problems. The Internet has the potential to support the self-management of distress through accessing health information or social support.

METHODS

This study was approved by Keele University's ethical review panel. Older adults who self-identified as experiencing distress were recruited from community groups in the West Midlands, England. To generate data, 'think-aloud' methods (including storyboards and an extract from an online forum) were embedded within semi-structured interviews. Thematic analysis, incorporating constant comparison methods, were used for data analysis.

RESULTS

Data saturation was achieved after 18 interviews. All participants reported having access to the Internet, but only a few described using the Internet to obtain general information or to conduct online purchases. Most participants described barriers to Internet use which included: a lack of interest, knowledge and confidence, a fear of technology and no trust in social media sites. Facilitators of Internet use included family encouragement and attending community groups which taught computer use. Female participants reported valuing the social contact provided by attending such groups. The Internet was seen as a source of health information once a GP had diagnosed a physical problem, but was not considered a source of information about distress or mood problems. Participants did not use the Internet to access social support and described a preference for face-to-face communication.

CONCLUSIONS

GPs need to understand how an individual patient utilises the Internet. GPs should explore the self-management strategies already employed by older adults experiencing distress and understand that directing these older people to online support might not be acceptable. Encouraging distressed older adults to attend computer group classes might be useful as this permits face-to-face social contact, and may help to facilitate Internet use in the future.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation-as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

A feasibility study for NOn-Traditional providers to support the management of Elderly People with Anxiety and Depression: The NOTEPAD study Protocol

BACKGROUND

Anxiety and depression are common among older people, with up to 20% reporting such symptoms, and the prevalence increases with co-morbid chronic physical health problems. Access to treatment for anxiety and depression in this population is poor due to a combination of factors at the level of patient, practitioner and healthcare system. There is evidence to suggest that older people with anxiety and/or depression may benefit both from one-to-one interventions and group social or educational activities, which reduce loneliness, are participatory and offer some activity. Non-traditional providers (support workers) working within third-sector (voluntary) organisations are a valuable source of expertise within the community but are under-utilised by primary care practitioners. Such a resource could increase access to care, and be less stigmatising and more acceptable for older people.

METHODS

The study is in three phases and this paper describes the protocol for phase III, which will evaluate the feasibility of recruiting general practices and patients into the study, and determine whether support workers can deliver the intervention to older people with sufficient fidelity and whether this approach is acceptable to patients, general practitioners and the third-sector providers. Phase III of the NOTEPAD study is a randomised controlled trial (RCT) that is individually randomised. It recruited participants from approximately six general practices in the UK. In total, 100 participants aged 65 years and over who score 10 or more on PHQ9 or GAD7 for anxiety or depression will be recruited and randomised to the intervention or usual general practice care. A mixed methods approach will be used and follow-up will be conducted 12 weeks post-randomisation.

DISCUSSION

This study will inform the design and methods of a future full-scale RCT.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN16318986 . Registered 10 November 2016. The ISRCTN registration is in line with the World Health Organization Trial Registration Data Set. The present paper represents the original version of the protocol. Any changes to the protocol will be communicated to ISRCTN.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study

BACKGROUND

Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions.

METHODS

We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data.

RESULTS

Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement.

CONCLUSIONS

We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model.

TRIAL REGISTRATION

Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

Community Engagement in a complex intervention to improve access to primary mental health care for hard-to-reach groups

BACKGROUND

Despite the availability of effective evidence-based treatments for depression and anxiety, many 'harder-to-reach' social and patient groups experience difficulties accessing treatment. We developed a complex intervention, the AMP (Improving Access to Mental Health in Primary Care) programme, which combined community engagement (CE), tailored (individual and group) psychosocial interventions and primary care involvement.

OBJECTIVES

To develop and evaluate a model for community engagement component of the complex intervention. This paper focuses on the development of relationships between stakeholders, their engagement with the issue of access to mental health and with the programme through the CE model.

DESIGN

Our evaluation draws on process data, qualitative interviews and focus groups, brought together through framework analysis to evaluate the issues and challenges encountered.

SETTING & PARTICIPANTS

A case study of the South Asian community project carried out in Longsight in Greater Manchester, United Kingdom.

KEY FINDINGS

Complex problems require multiple local stakeholders to work in concert. Assets based approaches implicitly make demands on scarce time and resources. Community development approaches have many benefits, but perceptions of open-ended investment are a barrier. The time-limited nature of a CE intervention provides an impetus to 'do it now', allowing stakeholders to negotiate their investment over time and accommodating their wider commitments. Both tangible outcomes and recognition of process benefits were vital in maintaining involvement.

CONCLUSIONS

CE interventions can play a key role in improving accessibility and acceptability by engaging patients, the public and practitioners in research and in the local service ecology.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care

BACKGROUND

Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.

METHODS

We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.

RESULTS

We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.

CONCLUSIONS

This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.

TRIAL REGISTRATION

Current controlled trials ISRCTN68572159.

Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities

Background

The purpose of the study was to improve the quality of primary mental healthcare in underserved communities through involvement with the wider primary care team members and local community agencies.

Methods

We developed training intended for all GP practice staff which included elements of knowledge transfer, systems review and active linking. Seven GP Practices in four localities (North West England, UK) took part in the training. Qualitative evaluation was conducted using thirteen semi-structured interviews and two focus groups in six of the participating practices; analysis used principles of Framework Analysis.

Results

Staff who had engaged with the training programme reported increased awareness, recognition and respect for the needs of patients from under-served communities. We received reports of changes in style and content of interactions, particularly amongst receptionists, and evidence of system change. In addition, the training program increased awareness of – and encouraged signposting to - community agencies within the practice locality.

Conclusions

This study demonstrates how engaging with practices and delivering training in a changing health care system might best be attempted. The importance of engaging with community agencies is clear, as is the use of the AMP model as a template for further research.

Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study

Background

Evidence-based interventions exist for common mental health problems. However, many people are unable to access effective care because it is not available to them or because interactions with caregivers do not address their needs. Current policy initiatives focus on supply-side factors, with less consideration of demand.

Aim and objectives

Our aim was to increase equity of access to high-quality primary mental health care for underserved groups. Our objectives were to clarify the mental health needs of people from underserved groups; identify relevant evidence-based services and barriers to, and facilitators of, access to such services; develop and evaluate interventions that are acceptable to underserved groups; establish effective dissemination strategies; and begin to integrate effective and acceptable interventions into primary care.

Methods and results

Examination of evidence from seven sources brought forward a better understanding of dimensions of access, including how people from underserved groups formulate (mental) health problems and the factors limiting access to existing psychosocial interventions. This informed a multifaceted model with three elements to improve access: community engagement, primary care quality and tailored psychosocial interventions. Using a quasi-experimental design with a no-intervention comparator for each element, we tested the model in four disadvantaged localities, focusing on older people and minority ethnic populations. Community engagement involved information gathering, community champions and focus groups, and a community working group. There was strong engagement with third-sector organisations and variable engagement with health practitioners and commissioners. Outputs included innovative ways to improve health literacy. With regard to primary care, we offered an interactive training package to 8 of 16 practices, including knowledge transfer, systems review and active linking, and seven agreed to participate. Ethnographic observation identified complexity in the role of receptionists in negotiating access. Engagement was facilitated by prior knowledge, the presence of a practice champion and a sense of coproduction of the training. We developed a culturally sensitive well-being intervention with individual, group and signposting elements and tested its feasibility and acceptability for ethnic minority and older people in an exploratory randomised trial. We recruited 57 patients (57% of target) with high levels of unmet need, mainly through general practitioners (GPs). Although recruitment was problematic, qualitative data suggested that patients found the content and delivery of the intervention acceptable. Quantitative analysis suggested that patients in groups receiving the well-being intervention improved compared with the group receiving usual care. The combined effects of the model included enhanced awareness of the psychosocial intervention among community organisations and increased referral by GPs. Primary care practitioners valued community information gathering and access to the Improving Access to Mental Health in Primary Care (AMP) psychosocial intervention. We consequently initiated educational, policy and service developments, including a dedicated website.

Conclusions

Further research is needed to test the generalisability of our model. Mental health expertise exists in communities but needs to be nurtured. Primary care is one point of access to high-quality mental health care. Psychosocial interventions can be adapted to meet the needs of underserved groups. A multilevel intervention to increase access to high-quality mental health care in primary care can be greater than the sum of its parts.

Study registration

Current Controlled Trials ISRCTN68572159.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Improving access to psychosocial interventions for common mental health problems in the United Kingdom: narrative review and development of a conceptual model for complex interventions

BACKGROUND

In the United Kingdom and worldwide, there is significant policy interest in improving the quality of care for patients with mental health disorders and distress. Improving quality of care means addressing not only the effectiveness of interventions but also the issue of limited access to care. Research to date into improving access to mental health care has not been strongly rooted within a conceptual model, nor has it systematically identified the different elements of the patient journey from identification of illness to receipt of care. This paper set out to review core concepts underlying patient access to mental health care, synthesise these to develop a conceptual model of access, and consider the implications of the model for the development and evaluation of interventions for groups with poor access to mental health care such as older people and ethnic minorities.

METHODS

Narrative review of the literature to identify concepts underlying patient access to mental health care, and synthesis into a conceptual model to support the delivery and evaluation of complex interventions to improve access to mental health care.

RESULTS

The narrative review adopted a process model of access to care, incorporating interventions at three levels. The levels comprise (a) community engagement (b) addressing the quality of interactions in primary care and (c) the development and delivery of tailored psychosocial interventions.

CONCLUSIONS

The model we propose can form the basis for the development and evaluation of complex interventions in access to mental health care. We highlight the key methodological challenges in evaluating the overall impact of access interventions, and assessing the relative contribution of the different elements of the model.

Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data

Depression in older people is common, under-recognised and often undertreated. This study aimed to explore the reasons why older people with depression may not present to primary care. Secondary analysis was carried out, of qualitative data collected in two previous studies in North-West England. Older people are reluctant to recognise and name 'depression' as a set of symptoms that legitimises attending their general practitioner (GP). They do not consider themselves candidates for help for their distress. This is partly due to perceptions of the role of the GP but also to previous negative experiences of help seeking. In addition, treatments offered, which are predominantly biomedical, may not be acceptable to older people. Interventions offered to older people need to encourage social engagement, such as befriending, and enhancement of creative, physical and social activity.

Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence

Background

Common mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care.

Methods

We began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.

We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users.

Conclusions

Our methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people

BACKGROUND

Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability.

AIM

To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting.

DESIGN OF STUDY

Randomised controlled trial with 16-weeks follow up.

SETTING

A primary care trust in Manchester.

METHOD

Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention.

RESULTS

The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients.

CONCLUSION

A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.

'Justifiable depression': how primary care professionals and patients view late-life depression? A qualitative study

BACKGROUND

Depression is the commonest mental health problem in elderly people and continues to be underdiagnosed and undertreated.

AIM

To explore the ways that primary care professionals and patients view the causes and management of late-life depression.

DESIGN

A qualitative study using semistructured interviews.

SETTING

One Primary Care Trust in North West England.

PARTICIPANTS

Fifteen primary care practitioners comprising nine GPs, three practice nurses, two district nurses and one community nurse; twenty patients who were over the age of 60 and who were participating in a feasibility study of a new model of care for late-life depression [PRIDE Trial: PRimary care Intervention for Depression in the Elderly (a feasibility study in Central Manchester funded by the Department of Health)].

RESULTS

Primary care practitioners conceptualized late-life depression as a problem of their everyday work, rather than as an objective diagnostic category. They described depression as part of a spectrum including loneliness, lack of social network, reduction in function and viewed depression as 'understandable' and 'justifiable'. This view was shared by patients. Therapeutic nihilism, the feeling that nothing could be done for this group of patients, was a feature of all primary care professionals' interviews. Patients' views were characterized by passivity and limited expectations of treatment. Depression was not viewed as a legitimate illness to be taken to the GP. Primary care professionals recognized that managing late-life depression did fall within their remit, but identified limitations in their own skills and capabilities in this area, as well as a lack of other resources to which they could refer patients.

CONCLUSION

This study highlights the complicated nature of the diagnosis and management of late-life depression. Protocols for the diagnosis and treatment of depression emphasis the biomedical model which does not fit with the everyday experience of GPs or elderly patients who share the views of primary care professionals that depression is a consequence of social and contextual issues. There is a need for the development of evidence-based provision for older people with depression within primary care, but also a need for elderly patients to be made aware of the legitimacy of presenting low mood and misery to their primary care professional.

Early adult outcomes of adolescents who deliberately poisoned themselves

OBJECTIVE

To describe the early adult psychopathological and social outcomes of adolescents who deliberately poisoned themselves.

METHOD

Prospective cohort study with a 6-year follow-up of 132 of 158 (84%) adolescents who, between ages 11 and 16 years, had taken part in a randomized trial of a brief family intervention after deliberate self-poisoning. Comparisons were made with a sample of participants matched for age, gender, and childhood social class. Both groups were assessed using standardized measures of psychopathology and social functioning.

RESULTS

In most cases (93/132 or 70%) self-harm stopped within 3 years. Psychiatric disorders, particularly depression (74/132 or 56%), were prevalent, and self-harm in adulthood was restricted to this subgroup. There was a strong association between childhood adversity, in particular childhood sexual abuse, and self-harming risk in adulthood. Adulthood adversity also added to the risk, especially for those who had experienced index episode major depression. These associations were not mediated by childhood problem solving and hopelessness.

CONCLUSIONS

For some young people, deliberate self-poisoning in adolescence seems to be part of a complex and continuing network of problems, marked by high rates of psychopathology, comorbidity, with other disorders and high psychosocial adversity.