title: Talking about depression: a qualitative study of barriers to managing depression in people with long term conditions in primary care.
abstract: BACKGROUND
  The risk of depression is increased in people with long term conditions (LTCs) and is associated with poorer patient outcomes for both the depressive illness and the LTC, but often remains undetected and poorly managed. The aim of this study was to identify and explore barriers to detecting and managing depression in primary care in people with two exemplar LTCs: diabetes and coronary heart disease (CHD).
  
  
  METHODS
  Qualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper.
  
  
  RESULTS
  Barriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management.
  
  
  CONCLUSIONS
  Depression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.
authors.affiliation: Greater Manchester Collaboration for Leadership in Applied Health Research and Care, Health Sciences Research Group and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK. peter.a.coventry@manchester.ac.uk
authors.forename: Peter A
authors.initials: PA
authors.lastname: Coventry
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hays
authors.forename: Chris
authors.initials: C
authors.lastname: Dickens
authors.forename: Christine
authors.initials: C
authors.lastname: Bundy
authors.forename: Charlotte
authors.initials: C
authors.lastname: Garrett
authors.forename: Andrea
authors.initials: A
authors.lastname: Cherrington
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
mesh_terms: D000328:Adult; D000368:Aged; D003327:Coronary Disease / Q000150:complications; D003866:Depressive Disorder / Q000175:diagnosis* / Q000628:therapy*; D048909:Diabetes Complications; D005069:Evaluation Studies as Topic; D005260:Female; D017144:Focus Groups; D058005:General Practitioners; D006297:Health Services Accessibility; D006801:Humans; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged