Participants in both studies reported that most screening was conducted by practice or specialist (DM or CHD) nurses, therefore much of the data is focused on nurses’ experiences and concerns. We present findings in relation to three key topics: barriers to incorporating depression screening into a routine consultation; replacing a naturalistic and individualised approach to distress with mechanistic questioning; and disconnection for nurses (in terms of process, knowledge and skills) between physical and mental health.
Barriers to incorporating screening into the routine review consultation
The method of screening that participants reported that they aimed to use was the two screening questions, then, if there was cause for concern, following this up with a further assessment tool such as the Patient Health Questionnaire (PHQ-9) [26
], Hospital Anxiety and Depression Scale (HADS) [27
] or Beck Depression Inventory (BDI) II [28
], either during the consultation or later in accordance with guidelines. However they reported concerns about the way screening was incorporated into the consultation which suggested that not only was it difficult, but that it may bias the results. Time constraints were a particular problem:
I think the screening questions are seen as a sort of tick box exercise. Also there’s not time, you know, we have twenty minutes/half an hour, we’ve to do their feet, BP, cholesterol and right at the end it’s ‘are you depressed?’ ‘no?’, (phew!) that’s fine, next!…(Study 2, Group 1b, Specialist Diabetes Nurse)
For most nurses, the inclusion of questions on emotional health at the end of a long list of physical health priorities minimised its importance. The resultant manner in which the questions were administered discouraged patients from disclosing any problems.
You know, the evidence of mental health problems in people with chronic disease is very high, but we don’t seem to pick up as many perhaps as we should be. And I think that’s because the screening questions are just perhaps fired at people and they go, “Well fine, thanks very much … well, that’s okay then”. (Study 1, Group 1, GP).
The problem of time for the consultation and screening extended to the problem of dealing with a positive result; with concerns that the clinician might be overwhelmed by opening a ‘Pandora's box’ or ‘can of worms’. As a result, questions may be asked in a way which discouraged the patient to respond:
GP1: And when this QOF stuff came out, you know, I think we all thought ‘well it’s great identifying it, but what are we going to do with the extra 300/400 patients who identify with mild anxiety and depression?’. [....] So one way of dealing with it of course is not to deal with it…
GP2: Just ignore it.
GP1: And let’s ignore, well we ask the question, but not in a way…[participant interrupted by another] (Study 1, Group 1, GPs)
Nurses also reported concerns about a lack of services or options available if people were identified as depressed. This suggests a lack of knowledge or confidence for both GPs and Nurses concerning the availability of resources to help manage depressed patients.
Nevertheless, despite similar reservations, one GP commented that having the two questions built into annual reviews ensured that screening for depression was not forgotten: “there’s something there about you working with a template that prompts you to do it…” (Study 1, Group 4, GP).
Replacing an individualised naturalistic approach with mechanistic screening
The introduction of recommended tools was reported by both nurses and GPs as replacing a more holistic discussion with patients. They described this more mechanistic process as ‘less professional’, and disrupting the normal patient/professional interaction. Nurses felt that the scripted questions required more surrounding dialogue.
‘The QOF questions are progress in tackling this issue but a lot of us don’t like using PHQ9 because we’re sitting speaking to the patient, you then print off this sheet, give it to them to fill in rather than engaging verbally … it’s really much less professional I think most of us feel, but we have to do it, so…’(Study 2, Group 3a, Specialist Nurse)
This mechanical reliance on formal measures was portrayed as superfluous to some nurse’s professional skills and instincts:
“So I think in the half hour you get a good idea of whether someone is… this is just a bad day, or whether there’s been a lot of bad days… And I think your instinct kicks in, you know?” (Study 1, Group 3, Practice Nurse).
Disconnection between physical and mental health
Most nurses reported that their professional role, until recently, had not included mental health and while they valued the recognition of its role in wider health, they required a better understanding of mental health to more effectively introduce screening to patients.
Because if you (nurse) don’t really know why you're doing it then you're not going to be able to gauge that question properly in order to get the most accurate answer. Because you want to say to people ‘this (diabetes/CHD) can affect your mental health and your mental wellbeing’ and you want to kind of give them an explanation of why you're asking them about this, not just ‘oh I have to ask this question’… (Study 2, Group 1b, Specialist nurse)
The lack of training preceding the implementation of screening may account for some of the failure of nurses to adopt mental health awareness and promotion as part of their role and to develop appropriate skills to engage effectively with patients. Indeed one nurse reported: ‘We’ve been floundering for a couple of years’ (Study 2, Group 3a, Specialist Nurse).
In other instances, the nurses’ own lack of confidence prevented them from challenging patients’ reluctance to seek help, thereby missing potential opportunities to intervene.
This lack of confidence in dealing with the consequences of disclosure of mental health problems by patients made nurses feel vulnerable: emphasised their lack of skills, and was considered unsatisfactory for patients who had made disclosures to then have their discussion curtailed.
It’s not like taking somebody’s blood pressure or measuring somebody’s weight. It’s like how to approach the subject and how to appropriately respond because […] let’s suppose if a person comes up with something which you are not expecting at all, then you just sit there and think ‘oops, what am I supposed to say?’ […] You do feel vulnerable and in order to approach a question for mental health determining whether your patients are mild or moderate or severely depressed, you need to have that much confidence to remove your vulnerability. (Study 1, Group 2, Practice Nurse).
However, when nurses felt confident in dealing with mental health, normally through some previous experience or training in mental health, they viewed themselves as being able to take an holistic approach, which included encouraging discussion of mood. They were also more able to see a role for themselves (alongside the GP) in responding to patients.
I’ve got him coming back in six months time; he didn’t want to see anybody, but I thought it was planting the seeds to… you know, if he went home and thought about it and thought ‘well, actually maybe I do need to speak to somebody’ then he could come back and do that either at the [nurse led] clinic or with the GP. (Study 1, Group 3, Practice Nurse)