Case finding for depression in patients with long-term physical conditions in primary care

The aim of this thesis was to describe the impact and consequences of case finding for depression in patients with long-term physical conditions in primary care from the perspective of primary healthcare professionals. Study one (chapter two) evaluated the effects of incentivised case finding using an interrupted time series analysis of routinely collected data. It found that incentivised case finding increased new depression-related diagnoses and rates of antidepressant prescribing. Increased prescribing is of concern as it may include treatment of people unlikely to respond to medication. Study two (chapter three) identified and classified what has been written about primary healthcare professionals beliefs on implementing case finding using a systematic review and the ‘best fit’ framework synthesis approach. A range of contradictory beliefs and three new themes were identified; mistrust, trade-offs and dilemmas. These findings demonstrate conflict and tensions which could undermine implementation of case finding. Study three (chapter four) characterised the range of positions held by primary healthcare professionals on the role, implementation and value of case finding using an online Q method study involving primary healthcare professionals. Three recognisable positions were produced; objections to the principle of case finding for depression, case finding for depression is worthwhile and objections to implementation of case finding for depression. These positions may influence how clinicians deliver and respond to case finding. Implementation is challenging if there is a spread of perspectives. These findings, considered alongside the absence of evidence that case finding improves clinical outcomes, indicate that case finding for depression in long-term physical conditions should not be recommended or incentivised until more robust evidence of improved patient outcomes resulting from the changes case finding is likely to drive, especially in prescribing, and acceptability to professionals becomes available.