Six types of belief appear important to explore in the detection and subsequent management of depression in people with chronic illness; recognizing a problem, complex causality, the role of primary care, responsibility, resilience, and the importance of the patients’ life story in feeling understood.
Patients do not necessarily understand their undiagnosed distress as 'depression' which makes recognition difficult and explains why they may not present to primary care.
Patients identify a strong link between chronic physical illness and depression that was common throughout all the interviews although there were differences in perceived strength of the link. Discussing depression in a chronic disease review may lead patients who perceive a weak link between the two to not disclose in this situation. Patients’ complex reasons for feeling low may need to be identified so that social factors can be explored, rather than just concentrating on the link between ill health and depression.
Fears about stigma and taking medication for a situational problem may also stop patients disclosing distress.
The sense of responsibility for depression, either in not succumbing to the causes or changing the circumstances to resolve the problem, is an important finding that requires personal action rather than seeking medical treatment.
Depression is perceived to alter a person’s self-identity and not wanting to accept this change may lead to patients avoiding an identity-changing diagnosis. Resilience to depression is seen as an individual trait rather than being derived from social networks.
Patients value time to tell their life story in order to justify why they have depression.
Strengths and limitations
We believe this is the first study to specifically explore beliefs and experiences of depression in a population with chronic illness targeted by depression screening.
The first author’s role as a GP was disclosed at the interviews and may have influenced participants’ interactions. The reflective journal suggested that participants used the interview as an opportunity to get a medical professional to understand their point of view, something that was difficult in a time-limited consultation.
The interview schedule was informed by our preceding systematic review;  however, by asking the participant to describe their personal experience of depression using open-ended questions we ensured participants had opportunity to describe their beliefs in detail before prompts were used.
Participants were not sampled based upon diagnosis of depression as this study aimed to explore beliefs about depression in those targeted by an initiative to detect depression. Both patients with and without experience of depression contributed to the majority of themes, although their views differed greatly concerning the role of primary care.
Despite efforts to recruit a diverse sample, particularly more females and ethnic minorities, the participants were mostly white British males. This is likely to be due to the higher prevalence of CHD and diabetes in males. It is possible that patients of different ethnicity might hold different views, however, previous studies suggest that this may be a difference in emphasis rather than absolute differences in views .
We selected diabetes and coronary heart disease as chronic diseases as they are targeted by initiatives to detect depression. However, many of the issues we identified are likely to be relevant to other chronic diseases such as chronic obstructive pulmonary disease or arthritis.
With this qualitative approach, patients’ beliefs about depression were explored. Conclusions cannot be drawn regarding actual behaviour and engagement with detection; however, assessment of behaviour fell outside the scope of this study.
Comparison with existing literature
This study provides new insights into why patients with CHD or diabetes may not present or engage with detection for depression within primary care. Several studies relating to beliefs about depression associated with chronic physical illness exist; [16, 17]; however, none has explored depression in this targeted population or beliefs about depression beyond those only associated with chronic physical disease [4, 16, 18]. One of the important findings in this study is that beliefs about depression in general cannot be separated from beliefs about depression related to chronic physical illness, the two are interlinked in an individual and both need to be taken into account. Previous studies on illness beliefs in patients with multi-morbidities also found that beliefs about individual illnesses were affected by multi-morbidity .
This study found that patients share similar beliefs to clinicians, viewing depression as an understandable reaction to chronic disease and a social cause to depression. Patients also found it difficult to recognise the symptoms in themselves, often normalising the problem .
The idea of a disease changing the self-identity of a person has been researched in other illnesses [19–24]. These studies identified a loss of self and a shift in identity to a person with a disease or a survivor or victim which can affect coping and the impact of diagnosis. Our findings suggest that depression is also associated with a change in individuals’ perceptions of themselves and their roles. We cannot be sure that this strong sense of altered self is attributable to depression or is displaced from the sense of altered self that comes from chronic disease.
Kangas  and Kokanovic  have found that patients use a life story to talk about their depression, often absorbing it into their story to reinforce that they had always been depressed. In this study patients used the life story to explain why they did not have depression and how their life experience helped them recover, rather than seeing potential recovery as a threat . Our participants described their depression in the context of their life story, apparently mainly as a way of contextualising their current experiences rather than because they always had a life narrative into which depression was woven. Needing time to tell a life story will be difficult to resolve in primary care where consultations are time limited, although continuity of care with one practitioner may help and is often seen as important by those with chronic illness and the elderly for this reason . The emphasis of services for mental health is currently shifting from a focus on explanation in terms of the self-identity of the patient towards coping skills development (e.g. brief interventions offered by Improving Access to Psychological Therapies). Yet our and others’ work suggest patients prefer an opportunity to discuss their lives more widely. This may relate to the finding that those who had experienced brief psychological interventions did not feel it addressed their needs whereas it was viewed positively by those with no personal experience. There may be limited understanding of what psychotherapy entails leading to unmet expectations. Psychological interventions have small effects only on depression symptoms in patients with coronary heart disease and chronic obstructive pulmonary disease [28, 29]. Unmet patient expectations may help explain this finding.
The difficulty individuals have in recognising their distress or a change to an abnormal state has been identified in other studies [18, 30], and the reluctance to visit their GP with what might be considered a minor problem compared to a physical one such as heart disease, or with failing to cope with life, has also been identified previously [18, 31]. Negative beliefs regarding medication and stigmatization have been identified previously as barriers to recognising depression associated with chronic physical disease . We also found an additional barrier in that depression negatively changed the sense of social and individual identity of the patient and prevented admission of depression symptoms.
We found other factors that can facilitate disclosure of depressive symptoms. Those with depression believed that despite the chronicity of their own depression, the positive view of primary care and the help received there by those with depression offered hope for recovery. Depression has a mean duration of 18 months in those over the age of 55 in a recent study  and this hope for recovery may facilitate help-seeking from primary care in this age group.
Literature describes resilience in managing or resisting depression as drawing on personal resources (‘being strong’) and deriving support from the network of people around the depression sufferer . The participants in our study largely interpreted resilience as an individual attribute. This may explain why patients in the study by Dowrick et al. study preferred to manage their mental health with personal approaches such as drawing on personal strength rather than support from others .
Viewing help-seeking as not taking responsibility for addressing the circumstances that cause the depression may prevent disclosure of depression symptoms. Identifying such beliefs in consultations may be important in depression recognition and management in consultations about chronic disease.
Implications for practice and research
Further work is needed to develop tailored detection strategies that better fit with how patients think. When approaching a new diagnosis, the acceptance by the patient often involves a process of assimilation of information and accommodation to existing beliefs. Experience with other conditions, such as dementia and cancer, suggest that the sharing of potentially difficult diagnoses is seldom a ‘one-off’ process [35, 36]. The detection of depression associated with chronic physical illness in primary care in the face of multiple competing demands is therefore a more complex task than previously appreciated . The findings from this study suggest that doctors will need to be flexible in consultations and explore patients’ ideas, concerns and expectations when detecting depression. Questions aimed at uncovering these beliefs may help patients to disclose their concerns. The following list provides examples of issues that could be explored in consultations to elicit these beliefs before approaching screening.
The difficulty and uncertainty in managing a chronic condition on top of other life pressures – is this manageable or the last straw?
The difficulty people have in recognising depression in themselves although others may have noticed a change in mood
Concerns about not being able to function as normal – what can people not do anymore that they used to be able to do?
People with depression often do not feel like themselves anymore
Concerns about being a ‘weak’ person by admitting to depression symptoms
Concerns about the effects of treatment and its ‘masking’ of the problem
Feeling responsible for being depressed and not being able to change the situation
Given the accumulating evidence [1, 2] showing that depression associated with chronic physical illness has a detrimental effect on morbidity and mortality, health professionals will continue to be encouraged to actively seek such at risk people. The list summarizes summarises implications of our findings for mental health care provision.
Care needs to be taken when asking about possible depression in chronic disease reviews so that those who are symptomatic but perceive a weak link between the two feel able to disclose.
The responsibility felt by those with depression for not being able to resist depression could be reduced by explaining the link between depression and chronic disease before case-finding.
Concerns regarding medication ‘masking’ the problem and adding to the tablet burden might be improved by increasing access to services such as brief psychological interventions (such as IAPT) at the time of referral.
Integrating chronic disease and mental health services (such as in collaborative care models) may help reduce the stigma of depression and the burden of extra appointments.
Unmet expectations following psychotherapy may be prevented by discussing the role of brief interventions (such as IAPT) to increase understanding.