Charles S. Cornford

BACKGROUND: Depressive symptoms are common in primary care, yet considerable professional controversy exists about appropriate management including the effectiveness of treatments. In addition, avoiding prescribing antidepressants at least initially is recommended. Views of patients themselves should therefore be particularly important in agreeing management strategies. OBJECTIVE: To examine lay beliefs about depressive symptoms in primary care. METHOD: A total of 23 semi-structured interviews were conducted with patients scoring positively for depression on the Hospital Anxiety and Depression Score in a primary care setting. RESULTS: Differentiating 'depression' from understandable reactions to adversity was difficult for patients. The wide range of consequences discussed included adverse effects on others, difficulties coping with feeling out of control and loss of self-identity. Negative images of depression, such as depression being a 20th century phenomenon, were pervasive. Views about medication varied. Various management strategies described included strategies of detachment, engagement in activities and 'blotting out' symptoms. CONCLUSIONS: Patients' views about depressive symptoms are significantly different from conventional medical views. A 'disease management approach' fits uncomfortably with patients' experiences. Acknowledging feelings of loss of control and loss of self-identity in consultations may be useful. The wide employment of techniques patients use to control their disorders, such as support from others, engagement in activities and working at relationships, may be useful to encourage in consultations as alternatives to the use of antidepressant medication.

BACKGROUND: Irritable bowel syndrome (IBS) is a common condition associated with no certain organic cause, though diet and stress are widely implicated. The condition is frustrating for both sufferers and doctors, and there are problems in diagnosing and treating the condition. Eliciting explanatory models (EMs) is a useful tool for understanding how individuals relate to their illnesses and their expectations for treatment, particularly for illnesses with uncertain aetiology like IBS. OBJECTIVES: To understand the EMs, experiences and expectations for management of patients with IBS. METHODS: Qualitative, semi-structured interviews were conducted with 51 primary care patients (31 in the UK, 20 in The Netherlands) meeting the Rome II diagnostic criteria for IBS. RESULTS: Although IBS often had a significant dampening effect on daily life, IBS patients made great efforts not to allow the condition to take over their lives. Triggers of symptoms were more important to patients than understanding the underlying aetiology of IBS. Diet and stress were both recognized as important triggers, but views about which foods were problematic and the extent to which stress was modifiable were inconsistent. Diagnosis and treatment were often a confusing and frustrating process, and patients often expected more diagnostic tests than they were offered before receiving a diagnosis of IBS. However, the often poor outcome of medical interventions does not, in general, appear to have a negative impact on the patient-doctor relationship. CONCLUSIONS: Clinicians should be aware of the extensive impact of IBS on sufferers' daily life and the frustration that results from repeatedly trying treatments with little effect. Clearly explaining the guidelines for diagnosing IBS and the range of treatment options may help patients to make sense of the diagnostic and treatment processes. The personal EM should be addressed during the consultation with the IBS patient, ensuring that any successive medical interventions match with the patients' disease perception.

BACKGROUND: Although it is the commonest symptom presented to general practitioners (GPs), little is known about why someone decides to consult with a cough. AIM: To describe the illness behaviour of patients with a cough. METHOD: Patients who had consulted a GP because of a cough, and a group of subjects who had recently had a cough but had not consulted, were interviewed in a qualitative study that investigated how they made sense of their illness. RESULTS: Consulting patients understood their cough to be abnormally severe, whereas non-consulting subjects regarded their cough as 'normal' and mild. Consulting patients thought the cough would interfere with social roles and non-consulting subjects did not. The consulting patients were much more likely to be worried about the cough than the non-consulting subjects. In particular, half of the consulting patients were worried about their hearts, whereas the non-consulting subjects were not. The two groups did not distinguish bacteria from viruses, and did not differ in beliefs about the role of antibiotics that they thought were needed for severe coughs. Both groups had concerns about pollution. CONCLUSIONS: For consulting patients, cough breached the taken for granted property' of health that the non-consulting subjects with a cough were able to maintain. Cough, for the consulting patients, was not a trivial illness.

<h3>Background</h3> Users of illicit opioids are at increased risk of hospital admission for deep vein thromboses (DVTs); however, the community prevalence, risk factors, and complications of DVTs in this group are poorly understood. <h3>Aim</h3> This study aimed to describe the prevalence of previous DVT for users of opioids in primary care; provide age- and sex-adjusted annual incidence rates of DVT; and explore factors associated with DVT, concordance with subsequent treatment, and complications. <h3>Design</h3> A retrospective analysis of DVT prevalence and incidence, and analysis of risk factors for DVT using Poisson regression of incidence rates. <h3>Method</h3> A review of 734 patients in treatment for opioid addiction, who were registered to a single, specialised primary care practice in Middlesbrough, England. <h3>Results</h3> The prevalence of previous DVT in users of opioids was 13.9% (95% confidence interval [CI] = 11.5 to 16.6) with an annual incidence rate of 3.2% (95% CI = 2.6 to 3.7). The incidence rate increased with age and for female users; an exploration of risk factors suggests that rising age, female sex, sex-worker status, and intravenous delivery all independently increase the risk of DVT. Concordance with treatment appeared reasonable and, compared with DVT in groups of people who do not use drugs, there was no evidence of increased risk of pulmonary embolism. Participants with previous DVT reported lower health and wellbeing scores. <h3>Conclusion</h3> Primary care providers should be aware of the considerably increased risk of DVT and its sequelae in users of intravenous drugs. Evidence for effective primary care prevention and the effective management of DVT complications is lacking; until this emerges, vigilance on the part of clinicians may help to minimise harm.