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How patients understand depression associated with chronic physical disease – a systematic review

  • Sarah L Alderson1Email author,
  • Robbie Foy1,
  • Liz Glidewell1,
  • Kate McLintock1 and
  • Allan House1
BMC Family Practice201213:41

https://doi.org/10.1186/1471-2296-13-41

Received: 8 November 2011

Accepted: 12 April 2012

Published: 28 May 2012

Abstract

Background

Clinicians are encouraged to screen people with chronic physical illness for depression. Screening alone may not improve outcomes, especially if the process is incompatible with patient beliefs. The aim of this research is to understand people’s beliefs about depression, particularly in the presence of chronic physical disease.

Methods

A mixed method systematic review involving a thematic analysis of qualitative studies and quantitative studies of beliefs held by people with current depressive symptoms.

MEDLINE, EMBASE, PSYCHINFO, CINAHL, BIOSIS, Web of Science, The Cochrane Library, UKCRN portfolio, National Research Register Archive, Clinicaltrials.gov and OpenSIGLE were searched from database inception to 31st December 2010.

A narrative synthesis of qualitative and quantitative data, based initially upon illness representations and extended to include other themes not compatible with that framework.

Results

A range of clinically relevant beliefs was identified from 65 studies including the difficulty in labeling depression, complex causal factors instead of the biological model, the roles of different treatments and negative views about the consequences of depression. We found other important themes less related to ideas about illness: the existence of a self-sustaining ‘depression spiral’; depression as an existential state; the ambiguous status of suicidal thinking; and the role of stigma and blame in depression.

Conclusions

Approaches to detection of depression in physical illness need to be receptive to the range of beliefs held by patients. Patient beliefs have implications for engagement with depression screening.

Keywords

Depression Comprehension Primary health care Chronic disease Review Systematic

Background

Clinicians are often encouraged to identify emotional problems in patients with physical disorders. For example, guidance from the UK National Institute for Health and Clinical Excellence (NICE) states that “screening should be undertaken in primary care …for depression in high-risk groups” [1]. Up to a quarter of people with diabetes or coronary heart disease have depression [2, 3] which is associated with poorer outcomes [4]. Policy initiatives in the UK have included financial incentives for general practitioners to screen all patients with coronary heart disease or diabetes [5] and expanded access to psychological services for people with long-term physical conditions [6]. Over 92% of eligible patients were screened in 2009–10 [7]. However, it is uncertain whether incentivising screening alone has improved patient outcomes [8].

Three conditions need to be satisfied for screening to improve outcomes: engagement of primary care staff with the screening process [9]; a systematic approach to patient management following detection [1012], and patient engagement with the screening process. This review concentrates on the third condition which is relatively neglected in the previously published literature. Consultation models emphasize the importance of understanding patient perspectives in clinical care [13]. This may be particularly challenging in states such as depression which lack clear cut diagnostic boundaries, and in the context of depression screening in physical illness which usually takes place at chronic disease clinics, or opportunistically during other consultations, where time to explore patient beliefs is often limited. Beliefs will also influence the subsequent management of depression including adherence to anti-depressant medication regimes and referral to specialist mental health services [1416].

We conducted a mixed methods systematic review of studies of people with current depressive symptoms, which investigated their beliefs about those symptoms.

Methods

Search strategy

The review protocol can be requested from the study authors. We sought English-language studies of adults with current depressive symptoms that reported beliefs about depression. We systematically searched for articles and included studies of beliefs associated with chronic physical illness in stage 1 and then systematically searched for studies that included all depression beliefs in stage 2. Searches were limited to primary care where that was possible using the database search terms. We excluded non-English language studies and studies that assessed subjects without current depression or, explored beliefs about other mental health disorders (including anxiety, post-natal depression or bipolar disorder). Figure1 detail our search methods [17]. Appendix 1 details the search terms applied. We (SA) also reviewed reference lists of all included studies.
Figure 1

PRISMA chart of search strategy and identification of publications included in the review.

Initial screening of titles and abstracts, with exclusion of those that were obviously not related to depression beliefs, was undertaken by one reviewer (SA) with 18% (913) of studies reviewed by a second reviewer (KM). Full-text articles were assessed in detail by two reviewers (SA and KM) for all potentially eligible studies. All disagreements between reviewers were resolved by discussion.

Data extraction and quality assessment

Data on study participants, methods and findings were abstracted from included studies using a standardised form specifically developed for this review. The findings of qualitative studies were entered verbatim into NVivo8, a qualitative data analysis software package. We assessed study quality using established criteria [18]. Authors were contacted for further information as required.

Data synthesis

We conducted a narrative synthesis [19]. This approach to the synthesis of evidence relies primarily on the use of words and text to summarise and explain the findings of multiple studies. It is especially suited to a study like ours in which there is wide variation in study type included. Stage one involved a thematic and content analysis of the qualitative data. We initially categorised beliefs about depression using Leventhal’s Illness Representations [20], a framework for characterising patients’ beliefs about illnesses [2123].

The illness representation includes five main categories of belief: identity (beliefs concerning label and associated symptoms), cause (factors and conditions believed to have caused a condition), timeline (acute, cyclical or chronic), consequences (expected effects on physical, social and psychological well-being) and the control and/or cure (to what extent treatment and behaviours will help), along with a parallel emotional representation. We also identified beliefs not adequately captured by the framework and developed new themes which were agreed by consensus. The coding of themes was checked for 10% of studies by a second researcher.

Reviews of the quantitative findings were mapped onto the framework derived from the qualitative literature. For example, the finding that 68% of participants in one study felt that having depression changed the way they viewed themselves [24] supported the theme of existential & self.

In stage two we assessed the robustness of the synthesis by appraising the contribution of weak studies to review findings. Quality was assessed using criteria appropriate to study design [18]. Studies were assigned a score and topics based upon weak studies only were not included in the final analysis.

The final stage involved integrating the findings from the preceding stages into overarching conclusions.

Ethical approval

This project did not require ethical approval.

Results

We identified 7942 abstracts, of which 64 individual studies from 65 reports were included (Figure1). Table1 summarizes all included studies. Studies ranged widely in terms of questions addressed and methods used with 37 studies using qualitative interviews and 27 using self-administered questionnaires. The majority of the studies took place in the UK or the United States. Less than half (45%) applied theoretical frameworks to collect or analyze data, with Leventhal’s Illness Representations being the most commonly used in both qualitative and quantitative studies. Beliefs about depression associated with chronic physical diseases were identified specifically in only two qualitative studies; however participants in other studies referred to physical ill health in their beliefs. We therefore addressed all beliefs about depression within a single synthetic review. No studies were excluded from the review because of poor quality.
Table 1

Table of included Studies

Study & Year of Publication

Country

Gender

Ethnicity

Setting

Research Approach

Theoretical Framework

Depression status

Quality Assessment

Aim

ADDIS 1995 [25]

USA

Female > Male

not given

not given

Cross-sectional Survey

Reasons for Depression

Diagnostic Interview

C

To develop the Reasons For Depression questionnaire and measure its internal consistency and validity

ADDIS 1996 [26]

USA

not given

not given

Primary Care & Community

Cross-sectional Survey

None

Diagnostic Interview

C

To examine the relationships between clients reasons for depression and the outcome of treatment

ALLEN 1998 [27]

UK

Male = Female

not given

Secondary Care

Cross-sectional Survey

None

Screening Test

B

To examine the presence of depressive symptoms as well as attitudes to and knowledge of depression in a group of physically ill inpatients

AL-SAFFAR 2003 [28]

Kuwait

Male > Female

Arabic

Secondary Care

Cross-sectional Survey

Health Belief Model

Diagnostic Interview

B

To determine whether underlying attitudes and health beliefs of patients were affecting their decision to take their medication as prescribed

BACKENSTRASS 2007 [29]

Germany

Female > Male

not given

Primary Care

Semi-structured Interview

none

Diagnostic Interview

B

GP and sub-threshold depression patients views on diagnosis & treatment

BADGER 2007b [30]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Medical Records

B

Attitudes towards and use of self-chosen treatment in patients prescribed antidepressants

BANN 2004 [31]

USA

Female > Male

Mixed

Secondary Care

Cross-sectional Survey

Explanatory Model

Screening Test

C

To evaluate the psychometric properties of the EMD instrument

BOGNER 2008 [32]

USA

Female > Male

Mixed

Primary Care

Semi-structured Interview

none

Screening Test

A

Older patients’ perspectives on the relationship of heart disease to depression

BROWN 2001 [24]

USA

Female > Male

Mixed

Primary Care

Cross-sectional Survey

CS-SRM IR

Screening Test

C

To determine whether primary care patients’ personal illness cognitions for depression are associated with depression coping strategies and treatment related behavior

BROWN 2005 [33]

USA

Female > Male

White

Primary Care

Cross-sectional Survey

CS-SRM IR

Medical Records

B

To describe beliefs about antidepressants, examine the factor structure of the BMQ

BROWN 2007 [34]

USA

Female > Male

White

Primary Care

Cross-sectional Survey

CS-SRM IR

Medical Records

B

to describe personal illness models for depression and the relationship with functional disability

BURROUGHS 2006 [35]

UK

Both

not given

Primary Care

Semi-structured Interview

none

Screening Test

B

Primary care professionals ideas about depression in elderly and elderly views on depression as a problem & help-seeking

CABASSA 2008 [36]

USA

Female > Male

Hispanic

Primary Care

Cross-sectional Survey

CS-SRM IR

Screening Test

C

The aim of the present study is to conduct a confirmatory factor analysis (CFA) of the IPQR adapted for a clinical sample of depressed low-income Latinos served in primary care.

CAPE 1999 [37]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Screening Test

C

Patients’ reasons for not discussing emotional problems with GP

CHAKRABORTY 2009 [38]

India

Male = Female

Indian

Secondary Care

Cross-sectional Survey

None

Diagnostic Interview

B

Attitudes and beliefs of patients of first episode depression towards antidepressant treatment and the relationship between beliefs and treatment adherence

COOPER 1998 [39]

USA

Female > Male

Mixed

Primary Care

Cross-sectional Survey

None

Diagnostic Interview

B

To compare the views of African-American and white adult primary care patients regarding the importance of various aspects of depression care

COOPER 2000 [40]

USA

Female > Male

Mixed

Primary Care

Cross-sectional Survey

None

Screening Test

B

To select items for inclusion in an instrument to measure attitudes towards depression care

COOPER 2003 [41]

USA

Female > Male

Mixed

Primary Care

Cross-sectional Survey

Theory of Reasoned Action

Diagnostic Interview

B

The objective of this study was to examine whether racial and ethnic differences exist in patient attitudes toward depression care.

COOPER-PATRICK 1997 [42]

USA

Female > Male

Mixed

Primary Care

Focus Group

none

Medical Records

B

Health professionals and patients’ identifying attitudes that influence help-seeking

CORNFORD 2007 [43]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Screening Test

A

Lay beliefs about depression symptoms and how they manage them

DANIELSSON 2009 [44]

Sweden

Equal

Swedish

Primary Care

Semi-structured Interview

Gender Theory

Medical Records

A

To explore how primary care patients experience & understand depression and the impact of gender in this process

DEJMAN 2008 [45]

Iran

Female

Middle-Eastern

Secondary Care

Semi-structured Interview

Explanatory Model

Medical Records & Screening Test

B

Explanatory models of help-seeking and coping with depression in Iranian women

EDLUND 2008 [46]

USA

Male > Female

Mixed

Primary Care

Randomised Controlled Trial

Health Belief Model

Screening Test

B

To assess the extent to which beliefs changed in the intervention and treatment as usual arms of the study

FORTUNE 2004 [47]

UK

Female

not given

not given

Qualitative Writing & Cross-sectional survey

CS-SRM IR

Screening Test

C

To compare the structure and content of peoples models of depression with those of a physical illness

GARFIELD 2003 [48]

UK

Female > Male

Mixed

Primary Care

Semi-structured Interview

none

Medical Records

A

To identify factors of importance to patients when beginning courses of antidepressant treatment

GASK 2003 [49]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Medical Records

B

To explore depressed patients’ perceptions of the quality of care from GP’s

GIVENS 2006 [50]

USA

Female > Male

not given

Primary Care

Semi-structured Interview

Explanatory Model

Diagnostic Interview

B

To understand why older people are adverse to using antidepressants

GIVENS 2007 [51]

USA

Female > Male

Mixed

Online

Cross-sectional Survey

None

Screening Test

B

To describe ethnic differences in attitudes toward depression

GREEN 2002 [52]

UK

Female

Chinese

Primary & Secondary Care & Community

Semi-structured Interview

none

Screening Test

B

To identify barriers to Chinese women accessing help for depression

GRIME 2003 [53]

UK

Female > Male

not given

Primary Care & Community

Semi-structured Interview

none

Medical Records or Self Diagnosis

B

To understand patients views and experiences of taking antidepressants

HEIFNER 1997 [54]

USA

Male

not given

not given

Semi-structured Interview

none

Medical Records

B

To explore the male experience of depression

KANGAS 2001 [55]

Finland

Female > Male

not given

Community

Semi-structured Interview

Narrative Reconstruction

Self Diagnosis

C

To discover how people explain the cause of their depression

KARASZ 2003 [56]

USA

Female > Male

Mixed

Primary Care

Semi-structured Interview

CS-SRM IR

Screening Test

B

To explore patients’ conceptual labels of depression and build a theoretical model linking these to attitudes to treatment

KARASZ 2006 [57]

USA

Female > Male

Hispanic

Primary Care

Semi-structured Interview

none

Screening Test

C

To investigate Hispanic patients’ perceptions of primary care treatments for depression

KARASZ 2008 [58]

USA

Female > Male

Hispanic

Primary Care

Semi-structured Interview

CS-SRM IR

Screening Test

B

To explore the heterogeneity of depression experience

KARASZ 2009 [59]

USA

Female > Male

not given

Primary Care

Semi-structured Interview

CS-SRM IR

Screening Test

A

To examine conceptual models of depression in different ethnic groups and focusing on the degree to which patients conceptual models matched a bio-psychiatric model

KARP 1994 [60]

UK

Female > Male

White British

Secondary Care

Semi-structured Interview

Illness Career

Medical Records

A

How those suffering from uni-polar depression perceive, interpret, and understand a life condition that often seems incoherent, fragmented and intractable

KELLY 2007 [61]

USA

Female > Male

not given

Primary Care

Cross-sectional Survey

CS-SRM IR

Medical Records

B

To examine the relationships between beliefs about depression and emotion

KIRK 2001 [62]

USA

Female

Mixed

Primary Care

Cross-sectional Survey

None

Diagnostic Interview

C

Assessed pre-existing attitudes to depression and its treatment in a population of economically disadvantaged women

KUYKEN 1992 [63]

UK

Female > Male

not given

Secondary Care

Semi-structured Interview & Cross-sectional Survey

none

Screening Test

C

To investigate beliefs and attitudes towards depression in patients’ and compare them to lay people and psychologists

LEWIS 1995 [64]

UK

not given

not given

Primary & Secondary Care & Community

Semi-structured Interview

none

Medical Records or Self Diagnosis

B

To investigate the experience of depression as a meaningful experience

LEYKIN 2007 [65]

USA

not given

not given

Secondary Care

Randomised Controlled Trial

Reasons for Depression

Diagnostic Interview

C

To look at relation between beliefs and outcomes of therapies

LOWE 2006 [66]

Germany

Female > Male

not given

Secondary Care

Semi-structured Interview

none

Diagnostic Interview

C

To investigate attitudes towards treatment approaches

MANBER 2003 [67]

USA

Female > Male

Mixed

Secondary Care

Cross-sectional Survey

CS-SRM IR

Diagnostic Interview

C

To develop the Perception of Depressive illness questionnaire

MARTIN 2007a [67]

Brazil

Female

Brazilian

Secondary Care

Ethnographic observation & Semi-structured Interview

none

Medical Records

B

To describe the perception of depression for women in Embu, Sao Paulo

MARTIN 2007b [68]

Brazil

Female

Brazilian

Secondary Care

Ethnographic observation & Semi-structured Interview

none

Medical Records

B

To assess the meaning of depression in women diagnosed with the disorder, and the context of care given by the psychiatrists

MAXWELL 2005 [69]

UK

Female

not given

Primary Care

Semi-structured Interview

none

Medical Records

A

To explore GP and patients’ accounts of recognizing and treating depression

NOLAN 2005 [70]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Medical Records

B

To identify how patients treated with medication for their depression perceived the relationship with their prescribing clinician

OKELLO 2007 [71]

Uganda

Female > Male

African

Secondary Care

Semi-structured Interview

Explanatory Model

Medical Records

A

To examine depressed patients’ perception of depression

PANG 1998 [72]

USA

Female > Male

Korean

Community

Semi-structured Interview

none

Diagnostic Interview

C

To explore the ways depression symptoms are expressed by elderly Korean women

ROGERS 2001 [73]

UK

Female > Male

not given

Primary Care

Semi-structured Interview

none

Medical Records

B

to explore experiences of depressed people with their contact with primary care

SARKISIAN 2003 [74]

USA

Male = Female

Mixed

Primary Care

Cross-sectional Survey

None

Screening Test

B

To determine whether older adults who attribute their depression to aging are less likely to believe seeking help is important

SCATTOLON 1999 [75]

Canada

Female

not given

Community

Semi-structured Interview

none

Self Diagnosis

A

Explore experiences of depression and their ways of coping

SHIN 2002 [76]

USA

Female > Male

Korean

Community

Semi-structured Interview & Focus Groups

none

Self Diagnosis

A

To investigate Korean Immigrants’ help-seeking behaviours for depression & under-utilization of mental health services

SRINIVASAN 2003 [77]

Canada

Female > Male

not given

Secondary Care

Cross-sectional Survey

None

Medical Records

B

The implications for patients perspectives for treatment preference, delivery & medication compliance

STECKER 2007 [78]

USA

Female > Male

Mixed

Primary Care

Cross-sectional Survey

None

Medical Records

B

To investigate whether attitudes towards psychotherapy in a population of primary care patients diagnosed with depression influenced the likelihood that they initiated psychotherapy

UGARRIZA 2002 [79]

USA

Female

not given

Secondary Care

Semi-structured Interview

Explanatory Model

Medical Records

B

What is the explanation of depression given by a group of older women with depression

VAN VOORHEES 2005 [80]

USA

Female > Male

Mixed

Online

Cross-sectional Survey

Theory of Reasoned Action

Screening Test

B

To develop a multivariate model of intent not to accept a diagnosis of depression

VAN VOORHEES 2006 [81]

USA

Female > Male

Mixed

Online

Cross-sectional Survey

Theory of Reasoned Action

Screening Test

B

Specifically, we examine the relationship between five types of actors and low self-perceived need for treatment: beliefs and attitudes towards treatment behaviors, subjective social norms, past treatment behaviors, illness factors, and personal characteristics.

WAGNER 1999 [82]

USA

Female > Male

Mixed

Community

Semi-structured Interview

none

Self Diagnosis

B

To examine the reasons people choose to self-medicate with St. John’s wort instead of seeking care from a conventional health care provider.

WAITE 2009 [83]

USA

Female

African American

Primary Care

Focus Group

Explanatory Model

Medical Records

A

To examine the explanatory models for depression among a cohort of low-income African American women

WILLIAMS 2001 [84]

UK

not given

not given

Primary Care

Semi-structured Interview

CS-SRM IR

Medical Records

A

To explore the perceptions of cause of psychological distress

WITTINK 2008 [85]

USA

Female > Male

Mixed

Primary Care

Semi-structured Interview

Cultural Models Theory

Medical Records

A

To identify health beliefs about depression in older adults and how they perceive differ from doctors

WITTKAMPF 2008 [86]

Netherlands

Equal

Mixed

Primary Care

Semi-structured Interview

none

Diagnostic Interview

B

To understand the views of patients’ who screened positive in a depression screening programme

YEUNG 2004 [87]

USA

Female > Male

Chinese

Primary Care

Cross-sectional Survey

Explanatory Model

Diagnostic Interview

C

To use the Explanatory Model Interview Catalogue to examine systematically the illness beliefs of depressed Chinese American patients seeking treatment at a primary care clinic.

Beliefs could be coded to all the main categories of illness representation. We developed five new thematic categories for beliefs that did not fit well into the illness representations framework. We labeled these: understandability; the depression cycle, existential and self, suicidal thinking and stigma, blame and responsibility. Table2 shows the studies that contributed to each theme. Figure2 shows themes with their associated subthemes.
Table 2

Table of themes identified in each included study

Study

Identity

Cause

Cure/Control

Consequences

Timeline

Understandability

Depression Cycle

Existential & Self

Suicide

Stigma, blame & responsibility

ADDIS 1195

 

        

ADDIS 1196

 

       

ALLEN 1998

 

       

AL-SAFFAR 2003

 

      

BACKENSTRASS 2007

 

    

BADGER 2007b

 

     

BANN 2004

 

 

     

BOGNER 2008

 

    

BROWN 2001

   

 

BROWN 2005

  

       

BROWN 2007

  

 

BURROUGHS 2006

 

   

CABASSA 2008

     

CAPE 1999

 

    

CHAKRABORTY 2009

 

       

COOPER 1998

 

      

COOPER 2000

 

      

COOPER 2003

  

      

COOPER-PATRICK 1997

     

CORNFORD 2007

 

 

DANIELSSON 2009

 

 

DEJMAN 2008

 

       

EDLUND 2008

 

      

FORTUNE 2004

     

GARFIELD 2003

     

GASK 2003

 

      

GIVENS 2006

 

    

GIVENS 2007

     

GREEN 2002

      

GRIME 2003

 

     

HEIFNER 1997

    

KANGAS 2001

  

KARASZ 2003

     

KARASZ 2006

     

KARASZ 2008

     

KARASZ 2009

 

  

KARP 1994

  

 

KELLY 2007

     

KIRK 2001

 

    

KUYKEN 1992

       

LEWIS 1995

 

 

    

LEYKIN 2007

 

        

LOWE 2006

       

MANBER 2003

     

MARTIN 2007a

    

MARTIN 2007b

     

MAXWELL 2005

 

    

NOLAN 2005

 

    

OKELLO 2007

    

PANG 1998

    

ROGERS 2001

  

 

SARKISIAN 2003

 

       

SCATOLLON 1999

    

SHIN 2002

    

SRINIVASAN 2003

 

        

STECKER 2007

  

       

UGARRIZA 2002

     

VAN VOORHEES 2005

     

VAN VOORHEES 2006

 

      

WAGNER 1999

 

     

WAITE 2009

   

 

WILLIAMS 2001

 

     

WITTINK 2008

       

WITTKAMPF 2008

 

  

YEUNG 2004

      

Figure 2

Map of illness beliefs and their corresponding subthemes.

Identity

Depression, depressed and depressive were the most commonly used labels by both authors and study participants. Other labels used by participants were stress, blues, nerves, sadness, loneliness and emotional or mental disorder.

Some participants said they would rather not know they had depression, whereas others believed the label meant treatment was possible and they were not ‘mad’. Some felt depression or its symptoms were a normal part of life and not a disease and that the word ‘depression’ is used in everyday language without meaning an illness.

“It never occurred to me that I could be depressed, I just thought that I was a nasty person.” [64]

“Did I know what it was? It was pain, but I don’t think I would have called it depression. I think I would have called it my pain.” [60]

Cause

Most study participants could name at least one cause for their depression and many had complex, multi-factorial causes. Most participants believed the causes were external and took the form of significant negative life events and stress rather than subscribing to a mainly biological model. Co-existing physical illnesses were mentioned by several participants. Where the biological model was mentioned it was either to disagree with it or to mention it alongside other causal beliefs.

“I have diabetes and other people with diabetes have experience with depression because of our treatment, and the things we have to do, and the way we have to live now [which is] different from the way we were used to doing things before.” [59]

“I think it [depression] is due to a lack of hormones, that is, a consequence of being exposed to stress over such a long period of time.” [44]

Cure and/or control

Study participants found it difficult to acknowledge the need for help; however, many believed the GP was the right person to approach. Participants had strong beliefs over whether medication or talking therapies would help them. Some mentioned beliefs about alternative therapies such as St. John’s wort or using prayer, often used alone if the depression was not seen as having a severe impact upon their life. A few participants were unable to identify any cure or control and some felt that depression is incurable.

“When I talk about my problems I think about them and I feel worse. So I don’t know if it really is better to talk about them because you remember all your problems. Sometimes I feel better when I am doing other things and not talking about it to anyone.” [58]

“Well I think it’s a waste of time really, he’ll just give me yet another pill and I shall still be depressed because of all the other things that are wrong with me.” [43]

Timeline

The timescales participants mentioned for onset, duration and response to treatment were reported as varying markedly with acute, cyclical and chronic timescales being mentioned. The onset was described as “a bolt out of the blue” or “slow and insidious”. Treatment response was seen as a short or long process.

“I am so afraid that I am going to remain depressed. That is the only thing I fear.” [79]

“Well, if it’s only something that’s going to be short term, then obviously it’s worth getting the help and then sort your problems out and see how things go after that, more or less.” [69]

Consequences

Depression was seen as having mostly negative consequences, affecting all present and future aspects of life, including work, social and home life and physical health, especially where there was a co-existing illness. Some held particular fears of losing control and embarrassing themselves.

“So you’ll be dying of sadness, you get that sadness because the doctors say that if you stay really sad you begin to get other types of diseases like those that come from anguish, sadness, from depression you go on getting other types of disease and you end up dying too. Besides depression, it sets off other systems within your organism and ends up killing you.” [88]

“I was already on a pedestal, being the first doctor ever in the family, and my mom and dad didn’t want this to take me down from that pedestal in the other family’s eyes.” [54]

Emotions

We could not distinguish an emotional representation for depression from emotional symptoms of depression. Participants associated depression emotionally with fear, anger, sadness, despair, and guilt.

“Anxiety, anger, confusion, frustration for me is associated with the depression. Not sadness so much.” [59]

“I’m afraid…of being an invalid…not doing the things I want to do.” [32]

Understandability

Participants’ beliefs about depression were not always internally consistent. Some understood their depression in terms of their life story and gave coherent beliefs. Thereby, a woman who believed the cause of her depression was her poor eyesight that stopped her from doing things believed the cure for this was to “get her eyes sorted” [35]. For others depression was “unexplained” and “not understood” which led to conflicting and less fixed beliefs. For example, one study reported of people with depression “Their explanations changed within their narratives and they tried out several explanations, not finding one that explained all of their experience” [55], leading to uncertainty about how to resolve problems.

"Sometimes the account of depression contained several narrative episodes based on more than one storyline.[55]

Depression cycle

Depression was sometimes seen as a spiraling process, with episodes being both a consequence of previous depression and a cause of new onset of depression. These data could not be coded to the cause construct or the cyclical timeframe construct as one episode of depression was believed to be the cause of a subsequent episode of depression itself. Being depressed caused individuals to become more isolated and lonely, and made the sufferer further depressed. Having depression left the person with an internal weakness and predisposed to future depression, a cycle from which it was hard to break out. There are few other diseases where the disease itself can be seen in this way, and in this respect, this depression belief is unique.

“Anxieties cause depression and depression causes self-depreciation.” [59]

Existential and self

This theme concerned the individual’s sense of identity and differs from the identity of the disease theme. For some participants, even more than in physical diseases, depression is deeply interwoven in everyday life, in an existential understanding of the self and in a person’s sense of social and individual identity. It defined the person as who they were in their entirety, not as a consequence of depression but more of a statement of their individuality. Having depression changed the way they viewed themselves and their personality. Depression gave them a new identity, and they joined a category of person in which they had not previously seen themselves. For many this was a distressing and unwelcome experience. On questioning, many participants strongly agreed that having depression affected the way they saw themselves as a person [24, 34].

“You know, I was a mental patient. That was my identity…depression is very private…It’s no longer just my own pain. I am a mental patient. I am a depressive. I am a depressive [said slowly and with intensity]. This is my identity. I can’t separate myself from that. When people know me they’ll have to know about my psychiatric history, because that’s who I am.” [60]

“And when I came out I did feel quite odd because she gave me a prescription. I couldn’t. I suddenly felt like I fell into a bracket of a type of people, emotionally in my head. Which is quite a strange feeling really because . . . I’m not like I thought I was and now I’m a bit different” [48]."

Suicidal thinking

Suicide was rarely mentioned but when it was, it had an ambiguous status and did not fit within an obvious theme and was often a gender specific belief. Suicidal thinking was seen as symptom of depression, something people would never suffer with when well. For others, suicide was a consequence; the depression was so severe that suicide was an understandable response to suffering. It could also be seen as a control mechanism – a means of getting relief from their distress, and the most acceptable way of dealing with a problem. Suicide required a lot of self control and counteracted the image of being weak for having depression, particularly amongst males [54].

“In the beginning, you may not know what’s happening to you… if it gets worse and you don’t get help, people eventually hurt themselves with drugs or they can take their own life.” [83]

“Men who kill themselves are doing what maybe a lot of men have been taught to do. Literally they are taking their lives in their own hands because that’s what guys are taught to do. You know, to take care of it, and they take care of it in a way that is absolutely what they believe to be the right thing to do.” [54]

Stigma, blame and responsibility

Participants feared the outcome of others knowing about their condition. Depression was seen as poorly understood by the public, and misrepresented in the media, so that sufferers were to blame or responsible for their depression. This idea of blameworthiness was different from the situation when external factors were clearly contributing. For example, a severe economic depression in Finland was seen as being responsible for the increase in depression and was socially acceptable [55]. Participants were ashamed of being seen as not been able to cope – the stigma beliefs they had attached to people suffering from depression – and were now a part of themselves. Perceived stigma in itself had consequences, such as their judgment would no longer be trusted whilst they suffered from depression, leading to employment problems and the loss of friendships.

“When you have an operation you have friends who you can talk to. Last year, I had an accident and I received 45 get-well cards, but you go down with depression and nobody knocks on your door.” [70]

“The reason why it was hard to get psychiatric help was because of pride. I didn’t want people to think, “How did he end up this bad?” I just don’t want to be one of those crazy people, and it’s basically admitting that I am not in charge of my own emotions.” [76]

Discussion

Summary of main findings

Our most striking finding is the wide range of beliefs held by people experiencing symptoms when they are questioned, and importantly, although we started with a framework based upon how people think about illness, not all the beliefs we identified could be fitted into this structure. These themes have not been actively looked for in previous literature and therefore the number of studies contributing to each theme is small. They could not be fitted into the illness representations framework without losing some of the most interesting and potentially clinically significant beliefs about depression.

Our new themes support ideas from the health psychology literature. Sense of Coherence is said to assist individual coping with illness by facilitating understanding of the challenge of illness and by allowing the individual to integrate the illness experience with a sense of personal meaningfulness [89]. It is therefore closely related to our themes of understandability and existential and self. Sense of Coherence has been associated with good health and especially with good mental health [90].

There was no evidence that the selection criteria and depression status of the participants influenced beliefs. For example beliefs about whether depression symptoms are a normal part of life were endorsed in studies including participants who were recruited following self-diagnosis of depression, a diagnosis in the medical records and those identified by screening or diagnostic interview. This suggests that beliefs about depression can be similar, regardless of whether a person is formally diagnosed.

Comparison with existing literature

We identified a greater diversity of beliefs than in previous review of the beliefs of people with current depression [16], perhaps because we actively looked for beliefs outside the framework of illness representations. That study also had a wider focus, including beliefs of the general public and those suffering from other problems such as anxiety [16].

Strengths and limitations of the study

Our review strengths include the comprehensive search strategy, the development of themes from methodologically robust studies, the systematic approach to synthesis and the integration of both qualitative and quantitative data. We used one increasingly common approach to integrating mixed data although others exist [19]. The sensitive search strategy employed meant that many non-relevant articles were found in the searches; however this has hopefully ensured that no relevant articles were missed.

Stage 1 identified only two studies with beliefs associated with a chronic physical illness [32, 79]. So in stage 2 we included all depression beliefs. Beliefs associated with a physical illness may differ from those which are not, but the difference is likely to be on emphasis rather than in specific content. For example, symptoms of illness or its treatment may be seen as a cause of depression; or physical symptoms and depression may interact so that the consequences of their co-existence are felt more severely. Cause and consequence are existing themes in our framework, here given new content but not displaced by a new theme. Limiting the scope of this review to primary care may have meant that potentially relevant studies were missed but increased the relevance of this review to the current management of depression in primary care, such as case-finding for at-risk people. In the absence of established methodological consensus on whether or not to include quotations from original studies in a review of this type, we opted for inclusion to enhance illustration of the themes [91].

Implications for further research and clinical practice

As evidence accumulates [92] to show that chronic physical disease is a risk factor for depression, and that depression has a detrimental effect on morbidity and mortality, health professionals are likely to be encouraged to actively seek such at risk people. If we are unable to understand how patients think about depression and take into account their beliefs then the uptake and outcomes of depression screening are likely to be compromised, as well as patient concordance with any subsequent depression management. Particularly important are likely to be beliefs about the inappropriateness of having a quasi-diagnostic label, about the origins of depression in life problems and about medication being inappropriate. Equally important but often neglected is the evidence that not everybody thinks of depression as being illness-like, such beliefs being incompatible in a more fundamental way with interventions based upon screen-treat approaches in healthcare. Our findings are relevant to patients with physical illnesses and we are undertaking two further studies to investigate beliefs about depression associated with a physical illness to pursue this. In Table3 we summarize the clinical implications of our findings.
Table 3

Implications derived from themes

Theme

Implications

Identity

How patients think about depression and about being given a label or diagnosis for it may be important in understanding why patients engage or do not engage in detection.

Cause

Mismatches in what patients and GPs believe causes depression may undermine the development of shared treatment plans and undermine subsequent concordance.

Cure &/or Control

Beliefs about the role and relevance of antidepressants or psychotherapy may affect whether patients wish to have depressive symptoms detected.

Timeline

Patient beliefs about the course of their depression will affect detection. Those who expect quick resolution may not think it to be appropriate to seek treatment.

Consequences

Negative views about the consequences of having depression may lead to hopelessness or defensiveness in the face of attempts at standardised depression detection.

Coherence

Identifying how the patient thinks can be difficult in consultations, but it will be important to identify and if possible moderate beliefs if they are not helpful to recovery.

Depression Cycle

The cyclical beliefs leave patients feeling a sense of futility about long term approaches to intervention.

Existential & Self

Discussing what depression means to how patients perceive themselves may increase acceptance by a patient that depression can be a concern of clinicians.

Role of suicide

While suicidal acts are relatively rare, suicidal thoughts are relatively common. Exploring the latter is best with an open mind towards their meaning for the patient.

Stigma, blame & responsibility

Presenting screening as a normal and routine part of care may help reduce feelings of shame and “give permission” to discuss depression.

These considerations are important when there is a financial reward for administering a screening test without clear evidence of benefit, and when patients do not undergo an informed consent process which includes the risks and benefits of testing prior to the test being administered.

Conclusions

We need approaches to detection of depression in physical illness that are sensitive to the range of beliefs held by patients. Further research is needed to understand fully how people comprehend depression associated with a physical illness and how this influences help-seeking and engagement with health care services.

Appendix 1 – search terms

A.1. Ovid MEDLINE (1950-present day)

  1. 1)

    exp *Attitude to Health/

     
  2. 2)

    exp *Health Knowledge, Attitudes, Practice/

     
  3. 3)

    (illness adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behav* or reason*)).tw.

     
  4. 4)

    (depress* adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behav* or reason*)).tw.

     
  5. 5)

    exp *“Patient Acceptance of Health Care”/

     
  6. 6)

    exp *Models, Psychological/

     
  7. 7)

    (health belie* adj2 model*).tw.

     
  8. 8)

    (theor* adj2 plan* adj2 behav*).tw.

     
  9. 9)

    (health* adj2 action* adj2 process*).tw.

     
  10. 10)

    (social* adj2 cognit* adj2 model*).tw.

     
  11. 11)

    (protect* adj2 motiv* adj2 theor*).tw.

     
  12. 12)

    (theor* adj2 reason* adj2 action*).tw.

     
  13. 13)

    (common* adj2 sense*).tw. 1676

     
  14. 14)

    (self* adj2 regulat*).tw.

     
  15. 15)

    1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14

     
  16. 16)

    exp *Depression/

     
  17. 17)

    exp *Depressive Disorder/

     
  18. 18)

    depress*.tw.

     
  19. 19)

    16 or 17 or 18

     
  20. 20)

    exp Family Practice/

     
  21. 21)

    exp Primary Health Care/

     
  22. 22)

    exp Physicians, Family/

     
  23. 23)

    ((general or family) adj practi$).tw.

     
  24. 24)

    family physic$.tw.

     
  25. 25)

    (primary adj2 care).tw.

     
  26. 26)

    (gp or gps).tw.

     
  27. 27)

    20 or 21 or 22 or 23 or 24 or 25

     
  28. 28)

    15 and 19 and 27

     
  29. 29)

    limit 28 to “all adult (19 plus years)”

     

A.2. Ovid Embase (1980-present day)

  1. 1)

    exp *attitude to health/

     
  2. 2)

    exp *health belief/

     
  3. 3)

    exp *Health Belief Model/

     
  4. 4)

    exp *patient attitude/

     
  5. 5)

    (illness adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behave* or reason*)).tw.

     
  6. 6)

    (depress* adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behave* or reason*)).tw.

     
  7. 7)

    exp psychological model/

     
  8. 8)

    (health belie* adj2 model*).tw.

     
  9. 9)

    (theor* adj2 plan* adj2 behav*).tw.

     
  10. 10)

    (health* adj2 action* adj2 process*).tw.

     
  11. 11)

    (social* adj2 cognit* adj2 model*).tw.

     
  12. 12)

    (protect* adj2 motivat* adj2 theor*).tw.

     
  13. 13)

    (theor* adj2 reason* adj2 action*).tw.

     
  14. 14)

    (common* adj2 sense*).tw.

     
  15. 15)

    (self* adj2 regulat*).tw.

     
  16. 16)

    1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

     
  17. 17)

    exp *depression/

     
  18. 18)

    depress*.tw.

     
  19. 19)

    17 or 18

     
  20. 20)

    exp general practice/

     
  21. 21)

    exp primary health care/

     
  22. 22)

    exp general practitioner/

     
  23. 23)

    ((general or family) adj pract*).tw.

     
  24. 24)

    family physic*.tw.

     
  25. 25)

    (primary adj2 care).tw.

     
  26. 26)

    (gp or gps).tw.

     
  27. 27)

    20 or 21 or 22 or 23 or 24 or 25 or 26

     
  28. 28)

    16 and 19 and 27

     

A.3. Ovid PsychINFO (1806-present day)

  1. 1)

    exp *Client Attitudes/

     
  2. 2)

    exp *Consumer Attitudes/

     
  3. 3)

    exp *Health Attitudes/

     
  4. 4)

    exp *Health Knowledge/

     
  5. 5)

    exp *“Mental Illness (Attitudes Toward)”/

     
  6. 6)

    (illness adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behave* or reason*)).tw.

     
  7. 7)

    (depress* adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behave* or reason*)).tw.

     
  8. 8)

    (health belie* adj2 model*).tw.

     
  9. 9)

    (theor* adj2 plan* adj2 behav*).tw.

     
  10. 10)

    (health* adj2 action* adj2 process*).tw.

     
  11. 11)

    (social* adj2 cognit* adj2 model*).tw.

     
  12. 12)

    (protect* adj2 motiv* adj2 theor*).tw.

     
  13. 13)

    (theor* adj2 reason* adj2 action*).tw.

     
  14. 14)

    (common* adj2 sense*).tw.

     
  15. 15)

    (self* adj2 regulat*).tw.

     
  16. 16)

    1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

     
  17. 17)

    exp *major depression/

     
  18. 18)

    exp *“Depression (Emotion)”/

     
  19. 19)

    depress*.tw.

     
  20. 20)

    17 or 18 or 19

     
  21. 21)

    exp Primary Health Care/

     
  22. 22)

    exp General Practitioners/

     
  23. 23)

    exp Family Medicine/

     
  24. 24)

    exp Family Physicians/

     
  25. 25)

    ((general or family) adj practi*).tw.

     
  26. 26)

    family physic*.tw.

     
  27. 27)

    (primary adj2 care).tw.

     
  28. 28)

    (gp or gps).tw.

     
  29. 29)

    21 or 22 or 23 or 24 or 25 or 26 or 27

     
  30. 30)

    16 and 20 and 29

     
  31. 31)

    limit 30 to adulthood <18+ years>

     

A.4. EBSCO CINAHL (1982-present day)

  1. 1)

    (MM “Attitude to Mental Illness”)

     
  2. 2)

    MM “Patient Attitudes”

     
  3. 3)

    MM Attitude to health

     
  4. 4)

    TX (health belie* N2 model*) or TX (theor* N2 plan* N2 behav*) or TX (health* N2 action* N2 process*) or TX (social* N2 cognit* N2 model*) or TX (protect* N2 motiv* N2 theor*) or TX (theor* N2 reason* N2 action*) or TX (common* N2 sense*) OR TX (self* N2 regulat*)

     
  5. 5)

    TX illness N2 cognit* or schemat* or percept* or represent* or belie* of attitud* or behav* or reason*

     
  6. 6)

    TX depress* N2 cognit* or schemat* or percept* or represent* or belie* or attitud* or behav* or reason*

     
  7. 7)

    1 or 2 or 3 or 4 or 5 or 6

     
  8. 8)

    (MM “Depression+”)

     
  9. 9)

    TX depress*

     
  10. 10)

    8 or 9

     
  11. 11)

    (MH “Family Practice”)

     
  12. 12)

    (MH “Primary Health Care”)

     
  13. 13)

    (MH “Physicians, Family”)

     
  14. 14)

    TX (general or family N2 practi*) or TX family physic* or TX primary N2 care or TX (gp or gps)

     
  15. 15)

    11 or 12 or 13 or 14

     
  16. 16)

    7 and 10 and 15

     

A.5. ISI web of science (including science citation index expanded, and conference proceedings citation index, 1898–present day)

  1. 1)

    Topic = (attitude to mental illness)

     
  2. 2)

    Topic = (patient attitudes)

     
  3. 3)

    Topic = (attitude to health)

     
  4. 4)

    Topic = (health knowledge)

     
  5. 5)

    Topic = (patient acceptance of healthcare)

     
  6. 6)

    Topic = ((illness SAME (cognit* OR schemat* OR percept* OR represent* OR belie* OR attitud* OR behav* or reason*))) OR Topic = ((depress* SAME (cognit* OR schemat* OR percept* OR represent* OR belie* OR attitud* OR behav* or reason*)))

     
  7. 7)

    Topic = (psychological models) OR Topic = ((health belie* SAME model*)) OR Topic = ((theor* SAME plan* SAME behave*)) OR TOPIC = ((health SAME action* SAME process*)) OR Topic = (((social* SAME cognit* SAME model*)) OR Topic = ((protect* SAME motiv* SAME theor*)) OR Topic = ((theor* SAME reason* SAME action*)) OR Topic = ((common* SAME sense*)) OR Topic = ((self* SAME regulat*))

     
  8. 8)

    1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7

     
  9. 9)

    Topic = (depression) OR Topic = (depress*)

     
  10. 10)

    Topic = (primary SAME care) OR Topic = (Family SAME physic*) OR Topic = (gp OR gps) OR Topic = ((general OR family) practice*) OR Topic = (family SAME medic*)

     
  11. 11)

    8 AND 9 AND 10

     

A.6. Cochrane library, Wiley InterScience, 2009 issue 4 (including the Cochrane database of systematic reviews, database of abstracts of reviews of effects, Cochrane central register of controlled trials, health technology assessment database, NHS economic evaluation database, and about the Cochrane collaboration)

  1. 1)

    Title – depress* AND (attitude* OR belie* OR percept* OR cognit* OR schemat* OR represent* OR behave* OR reason*)

     

BIOSIS (previews)

  1. 1)

    exp Behavioral biology - Human behavior/

     
  2. 2)

    (illness adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behav* or reason*)).tw.

     
  3. 3)

    (depress* adj2 (cognit* or schemat* or percept* or represent* or belie* or attitud* or behav* or reason*)).tw.

     
  4. 4)

    (health belie* adj2 model*).tw.

     
  5. 5)

    (theor* adj2 plan* adj2 behav*).tw.

     
  6. 6)

    (health* adj2 action* adj2 process*).tw.

     
  7. 7)

    (social adj2 cognit* adj2 theor*).tw.

     
  8. 8)

    (protect* adj2 motiv* adj2 theor*).tw.

     
  9. 9)

    (theor* adj2 reason* adj2 action*).tw.

     
  10. 10)

    (common* adj2 sense*).tw.

     
  11. 11)

    (self* adj2 regulat*).tw.

     
  12. 12)

    1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11

     
  13. 13)

    exp “Behavioral and Mental Disorders”/

     
  14. 14)

    exp Psychiatry/

     
  15. 15)

    depress*.tw.

     
  16. 16)

    13 or 14 or 15

     
  17. 17)

    ((general or family) adj practi*).tw.

     
  18. 18)

    family physic*.tw.

     
  19. 19)

    (primary adj2 care).tw.

     
  20. 20)

    (gp or gps).tw.

     
  21. 21)

    17 or 18 or 19 or 20

     
  22. 22)

    12 and 16 and 21

     
  23. 23)

    limit 22 to human

     
  24. 24)

    limit 23 to adult

     

A.7. The National Institute for Health Research Clinical Research Network Coordinating Centre (NIHR CRN CC)

  1. 1)

    Topic – All

     
  2. 2)

    Title – depression

     

A.8. The national research register archive

  1. 1)

    Keywords – depressive disorder AND attitude-to-health

     

A.9. Www.ClinicalTrials.Gov

  1. 1)

    Title – depression AND attitudes

     

A.10. OpenSIGLE – grey literature

  1. 1)

    Keyword = depression

     

Funding

This project was not externally funded.

Declarations

Authors’ Affiliations

(1)
Institute of Health Sciences, University of Leeds

References

  1. National Institute of Clinical Excellence: Depression: Management of depression in primary and secondary care. National Clinical Practice Guidelines. Volume 23. 2004, National Institute for Clinical Excellence, London, 362-Google Scholar
  2. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH: Diabetes, depression, and quality of life. Diabetes Care. 2004, 27 (5): 1066-1070. 10.2337/diacare.27.5.1066.View ArticlePubMedGoogle Scholar
  3. Rudisch B, Nemeroff CB: Epidemiology of comorbid coronary artery disease and depression. Biol Psychiatry. 2003, 54 (3): 227-240. 10.1016/S0006-3223(03)00587-0.View ArticlePubMedGoogle Scholar
  4. Carney RM, Freedland KE, Miller GE, Jaffe AS: Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms. J Psychosom Res. 2002, 53 (4): 897-902. 10.1016/S0022-3999(02)00311-2.View ArticlePubMedGoogle Scholar
  5. Whooley MA, Avins AL, Miranda J, Browner WS: Case-finding instruments for depression. Two questions are as good as many.[see comment]. J Gen Intern Med. 1997, 12 (7): 439-445. 10.1046/j.1525-1497.1997.00076.x.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Department of Health: Talking therapies: a four-year plan of action. 2011Google Scholar
  7. Quality and outcomes framework - online GP practice results database. [http://www.qof.ic.nhs.uk/]
  8. Subramanian DN, Hopayian K: An audit of the first year of screening for depression in patients with diabetes and ischaemic heart disease under the Quality and Outcomes Framework. Qual Prim Care. 2008, 16 (5): 341-344.PubMedGoogle Scholar
  9. Barley E, Murray J, Walters P, Tylee A: Managing depression in primary care: a meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Fam Pract. 2011, 12 (1): 47-10.1186/1471-2296-12-47.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Dowrick C, Buchan I: Twelve month outcome of depression in general practice: does detection or disclosure make a difference?. BMJ. 1995, 311 (7015): 1274-1276. 10.1136/bmj.311.7015.1274.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Gilbody SM, House A, Sheldon T: Screening and case finding instruments for depression [Systematic Review]. Cochrane Database Syst Rev. 2009, 3: 3-Google Scholar
  12. Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN: Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002, 136 (10): 765-776.View ArticlePubMedGoogle Scholar
  13. Kurtz S, Silverman J, Benson J, Draper J: Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Academic Med. 2003, 78 (8): 802-809. 10.1097/00001888-200308000-00011.View ArticleGoogle Scholar
  14. Lynch J, Kendrick T, Moore M, Johnston O, Smith PWF: Patients’ beliefs about depression and how they relate to duration of antidepressant treatment. Use of a US measure in a UK primary care population. Primary Care Mental Health. 2006, 4 (3): 207-217.Google Scholar
  15. Johnston O, Kumar S, Kendall K, Peveler R, Gabbay J, Kendrick T: Qualitative study of depression management in primary care: GP and patient goals, and the value of listening. Br J Gen Pract. 2007, 57 (544): 1E-14E. 10.3399/096016407782318026.View ArticleGoogle Scholar
  16. Prins MA, Verhaak PFM, Bensing JM, van der Meer K: Health beliefs and perceived need for mental health care of anxiety and depression - The patients’ perspective explored. Clin Psychol Rev. 2008, 28 (6): 1038-1058. 10.1016/j.cpr.2008.02.009.View ArticlePubMedGoogle Scholar
  17. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Br Med J. 2009, 339: 37-View ArticleGoogle Scholar
  18. NHS Centre for Reviews and Dissemination: Systematic Reviews: CRD’s guidance for undertaking reviews in health care. 2001, University of York, York, 292-2Google Scholar
  19. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Steven D: Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. 2006, Lancaster, ESRC Methods, 1Google Scholar
  20. Cameron LD, Leventhal H: The Self-Regulation of Health and Illness Behaviour. 2003, Routledge,Google Scholar
  21. Hampson SE: Illness Representations and the Self-Management of Diabetes. Perceptions of Health and Illness. Edited by: Petrie KJ, Weinman J. 1997, Harwood Academic Publishers, Amsterdam, 323-348.Google Scholar
  22. Petrie KJ, Weinman JA: Perceptions of Health and Illness. 1997, Harwood Academic Publishers, Amsterdam, 1Google Scholar
  23. Lobban F, Barrowclough C, Jones S: A review of the role of illness models in severe mental illness. Clin Psychol Rev. 2003, 23 (2): 171-196. 10.1016/S0272-7358(02)00230-1.View ArticlePubMedGoogle Scholar
  24. Brown C, Dunbar-Jacob J, Palenchar DR, Kelleher KJ, Bruehlman RD, Sereika S, Thase ME: Primary care patients’ personal illness models for depression: a preliminary investigation. Fam Pract. 2001, 18 (3): 314-320. 10.1093/fampra/18.3.314.View ArticlePubMedGoogle Scholar
  25. Addis ME, Truax P, Jacobson NS: Why do people think they are depressed? The reasons for depression questionnaire. Psychotherapy. 1995, 32 (3): 476-483.View ArticleGoogle Scholar
  26. Addis ME, JN S: Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. J Consult Clin Psychol. 1996, 64: 1417-1424.View ArticlePubMedGoogle Scholar
  27. Allen RL, Walker Z, Shergill SS, D'Ath P, Katona CLE: Attitudes to depression in hospital inpatients: a comparison between older and younger subjects. Aging Ment Health. 1998, 2 (1): 36-39. 10.1080/13607869856911.View ArticleGoogle Scholar
  28. Al-Saffar N, Deshmukh A, Eid S, Carter P: Health beliefs and drug compliance of depressed patients in Kuwait. J Social Administrative Pharm. 2003, 20 (4): 142-150.Google Scholar
  29. Backenstrass M, Joest K, Rosemann T, Szecsenyi J: The care of patients with subthreshold depression in primary care: is it all that bad? A qualitative study on the views of general practitioners and patients. BMC Health Serv Res. 2007, 7: 190-10.1186/1472-6963-7-190.View ArticlePubMedPubMed CentralGoogle Scholar
  30. Badger F, Nolan P: Use of self-chosen therapies by depressed people in primary care. J Clin Nurs. 2007, 16 (7): 1343-1352. 10.1111/j.1365-2702.2007.01769.x.View ArticlePubMedGoogle Scholar
  31. Bann CM, Parker CB, Bradwejn J, Davidson JR, Vitiello B, Gadde KM: Assessing patient beliefs in a clinical trial of Hypericum perforatum in major depression. Depress Anxiety. 2004, , , 122-144.Google Scholar
  32. Bogner HR, Dahlberg B, de Vries HF, Cahill E, Barg FK: Older patients’ views on the relationship between depression and heart disease. Fam Med. 2008, 40 (9): 652-657.PubMedPubMed CentralGoogle Scholar
  33. Brown C, Battista DR, Bruehlman R, Sereika SS, Thase ME, Dunbar-Jacob J: Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Med Care. 2005, 43 (12): 1203-1207. 10.1097/01.mlr.0000185733.30697.f6.View ArticlePubMedGoogle Scholar
  34. Brown C, Battista DR, Sereika SM, Bruehlman RD, Dunbar-Jacob J, Thase ME: Primary care patients’ personal illness models for depression: relationship to coping behavior and functional disability. Gen Hospital Psychiatry. 2007, 29 (6): 492-500. 10.1016/j.genhosppsych.2007.07.007.View ArticleGoogle Scholar
  35. Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C: ‘Justifiable depression’: how primary care professionals and patients view late-life depression? A qualitative study. Fam Pract. 2006, 23 (3): 369-377. 10.1093/fampra/cmi115.View ArticlePubMedGoogle Scholar
  36. Cabassa LJ, Lagomasino IT, Dwight-Johnson M, Hansen MC, Xie B: Measuring Latinos’ perceptions of depression: a confirmatory factor analysis of the Illness Perception Questionnaire. Cultur Divers Ethni Minor Psychol. 2008, 14 (4): 377-384.View ArticleGoogle Scholar
  37. Cape J, McCulloch Y: Patients’ reasons for not presenting emotional problems in general practice consultations. Br J Gen Pract. 1999, 49 (448): 875-879.PubMedPubMed CentralGoogle Scholar
  38. Chakraborty K, Avasthi A, Kumar S, Grover S: Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment. Social Psychiatry and Psychiatric Epidemiol. 2009, 44 (6): 482-488. 10.1007/s00127-008-0468-0.View ArticleGoogle Scholar
  39. Cooper LA, Brown C, Vu HT, Ford DE, Powe NR: How important is intrinsic spirituality in depression care? A comparison of white and African-American primary care patients. 15th Annual Meeting of the Association-for-Health-Services-Research: Jun 21–23 1998. 1998, Blackwell Science Inc, Washington, D.C, 634-638.Google Scholar
  40. Cooper LA, Brown C, Vu HT, Palenchar DR, Gonzales JJ, Ford DE, Powe NR: Primary care patients’ opinions regarding the importance of various aspects of care for depression. Gen Hosp Psychiatry. 2000, 22 (3): 163-173. 10.1016/S0163-8343(00)00073-6.View ArticlePubMedGoogle Scholar
  41. Cooper LA, Gonzales JJ, Gallo JJ, Rost KM, Meredith LS, Rubenstein LV, Wang N, Ford DE: The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care. 2003, 41 (4): 479-489.PubMedGoogle Scholar
  42. Cooper-Patrick L, Powe NR, Jenckes MW, Gonzales JJ, Levine DM, Ford DE: Identification of patient attitudes and preferences regarding treatment of depression. J Gen Intern Med. 1997, 12 (7): 431-438. 10.1046/j.1525-1497.1997.00075.x.View ArticlePubMedPubMed CentralGoogle Scholar
  43. Cornford CS, Hill A, Reilly J: How patients with depressive symptoms view their condition: a qualitative study. Fam Pract. 2007, 24 (4): 358-364. 10.1093/fampra/cmm032.View ArticlePubMedGoogle Scholar
  44. Danielsson U, Bengs C, Lehti A, Hammarstrom A, Johansson EE: Struck by lightning or slowly suffocating - gendered trajectories into depression. BMC Fam Pract. 2009, 10: 56-10.1186/1471-2296-10-56.View ArticlePubMedPubMed CentralGoogle Scholar
  45. Dejman M, Ekbad S, Forouzan AS, Baradaran-Eftekhari M, Malekafzali H: Explanatory model of help-seeking and coping mechanisms among depressed women in three ethnic groups of Fars, Kurdish, and Turkish in Iran. Arch Iran Med. 2008, 11 (4): 397-406.PubMedGoogle Scholar
  46. Edlund MJ, Fortney JC, Reaves CM, Pyne JM, Mittal D: Beliefs about depression and depression treatment among depressed veterans. Med Care. 2008, 46 (6): 581-589. 10.1097/MLR.0b013e3181648e46.View ArticlePubMedGoogle Scholar
  47. Fortune G, Barrowclough C, Lobban F: Illness representations in depression. Br J Clin Psychol. 2004, 43: 347-364. 10.1348/0144665042388955.View ArticlePubMedGoogle Scholar
  48. Garfield SF, Smith FJ, Francis S: The paradoxical role of antidepressant medication – returning to normal functioning while losing the sense of being normal. J Ment Heal. 2003, 12 (5): 521-535. 10.1080/09638230310001603582.View ArticleGoogle Scholar
  49. Gask L, Rogers A, Oliver D, May C, Roland M: Qualitative study of patients’ perceptions of the quality of care for depression in general practice. Br J Gen Pract. 2003, 53 (489): 278-283.PubMedPubMed CentralGoogle Scholar
  50. Givens JL, Datto CJ, Ruckdeschel K, Knott K, Zubritsky C, Oslin DW, Nyshadham S, Vanguri P, Barg FK: Older patients’ aversion to antidepressants. A qualitative study. J Gen Intern Med. 2006, 21 (2): 146-151.PubMedPubMed CentralGoogle Scholar
  51. Givens JL, Houston TK, Van Voorhees BW, Ford DE, Cooper LA: Ethnicity and preferences for depression treatment. Gen Hosp Psychiatry. 2007, 29 (3): 182-191. 10.1016/j.genhosppsych.2006.11.002.View ArticlePubMedGoogle Scholar
  52. Green G, Bradby H, Chan A, Lee M, Eldridge K: Is the English National Health Service meeting the needs of mentally distressed Chinese women?. J Health Serv Res Policy. 2002, 7 (4): 216-221. 10.1258/135581902320432741.View ArticlePubMedGoogle Scholar
  53. Grime J, Pollock K: Patients’ ambivalence about taking antidepressants: a qualitative study. Pharma J. 2003, 271 (7270): 516-519.Google Scholar
  54. Heifner C: The male experience of depression. Perspect Psychiatric Care. 1997, 33 (2): 10-18.View ArticleGoogle Scholar
  55. Kangas I: Making sense of depression: perceptions of melancholia in lay narratives. Health. 2001, 5 (1): 76-92.Google Scholar
  56. Karasz A, Sacajiu G, Garcia N: Conceptual models of psychological distress among low-income patients in an inner-city primary care clinic. J Gen Intern Med. 2003, 18 (6): 475-477. 10.1046/j.1525-1497.2003.20636.x.View ArticlePubMedPubMed CentralGoogle Scholar
  57. Karasz A, Watkins L: Conceptual models of treatment in depressed hispanic patients. Ann Fam Med. 2006, 4 (6): 527-533. 10.1370/afm.579.View ArticlePubMedPubMed CentralGoogle Scholar
  58. Karasz A: The development of valid subtypes for depression in primary care settings: a preliminary study using an explanatory model approach. J Nerv Ment Dis. 2008, 196 (4): 289-296. 10.1097/NMD.0b013e31816a496e.View ArticlePubMedPubMed CentralGoogle Scholar
  59. Karasz A, Garcia N, Ferri L: Conceptual models of depression in primary care patients a comparative study. J Cross-Cultural Psychology. 2009, 40 (6): 1041-1059. 10.1177/0022022109348782.View ArticleGoogle Scholar
  60. Karp DA: Living with depression: illness and identity turning points. Qual Health Res. 1994, 4 (1): 6-30. 10.1177/104973239400400102.View ArticleGoogle Scholar
  61. Kelly MA, Sereika SM, Battista DR, Brown C: The relationship between beliefs about depression and coping strategies: Gender differences. Br J Clin Psychol. 2007, 46 (3): 315-332. 10.1348/014466506X173070.View ArticlePubMedGoogle Scholar
  62. Kirk LB: Attitudes toward depression and its treatment in disadvantaged, depressed women. Dissertation Abstracts International. 2001, 4409-Google Scholar
  63. Kuyken W, Brewin CR, Power MJ, Furnham A: Causal beliefs about depression in depressed-patients, clinical psychologists and lay persons. Br J Med Psychol. 1992, 65: 257-268. 10.1111/j.2044-8341.1992.tb01706.x.View ArticlePubMedGoogle Scholar
  64. Lewis SE: A search for meaning: making sense of depression. J Ment Heal. 1995, 4 (4): 369-382. 10.1080/09638239550037424.View ArticleGoogle Scholar
  65. Leykin Y, DeRubeis RJ, Shelton RC, Amsterdam JD: Changes in patients’ beliefs about the causes of their depression following successful treatment. Cognitive Therapy and Research. 2007, , , 437-449.Google Scholar
  66. Lowe B, Schulz U, Grafe K, Wilke S: Medical patients’ attitudes toward emotional problems and their treatment. What do they really want?. J Gen Intern Med. 2006, 21 (1): 39-45. 10.1111/j.1525-1497.2005.0266.x.View ArticlePubMedPubMed CentralGoogle Scholar
  67. Manber R, Chambers AS, Hitt SK, McGahuey C, Delgado P, Allen JJB: Patients’ perception of their depressive illness. J Psychiatr Res. 2003, 37 (4): 335-343. 10.1016/S0022-3956(03)00019-0.View ArticlePubMedGoogle Scholar
  68. Martin D, Quirino J, Mari J: Depression among women living in the outskirts of Sao Paulo, Southeastern Brasil. Rev Saude Publica. 2007, 41 (4): 591-597.View ArticlePubMedGoogle Scholar
  69. Maxwell M: Women’s and doctors’ accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients’ and doctors’ decisions. Chronic Illness. 2005, 1 (1): 61-71.View ArticlePubMedGoogle Scholar
  70. Nolan P, Badger F: Aspects of the relationship between doctors and depressed patients that enhance satisfaction with primary care. J Psychiatr Ment Health Nurs. 2005, 12 (2): 146-153. 10.1111/j.1365-2850.2004.00806.x.View ArticlePubMedGoogle Scholar
  71. Okello ES, Neema S: Explanatory models and help-seeking behavior: Pathways to psychiatric care among patients admitted for depression in Mulago hospital, Kampala, Uganda. Qual Health Res. 2007, 17 (1): 14-25. 10.1177/1049732306296433.View ArticlePubMedGoogle Scholar
  72. Pang KYC: Symptoms of depression in elderly Korean immigrants: Narration and the healing process. Cult Med Psychiatr. 1998, 22 (1): 93-122. 10.1023/A:1005389321714.View ArticleGoogle Scholar
  73. Rogers A, May C, Oliver D: Experiencing depression, experiencing the depressed: the separate worlds of patients and doctors. J Ment Heal. 2001, 10 (3): 317-333.View ArticleGoogle Scholar
  74. Sarkisian CA, Lee-Henderson MH, Mangione CM: Do depressed older adults who attribute depression to “old age” believe it is important to seek care?. J Gen Intern Med. 2003, 18 (12): 1001-1005. 10.1111/j.1525-1497.2003.30215.x.View ArticlePubMedPubMed CentralGoogle Scholar
  75. Scattolon Y, Stoppard JM: “Getting on with life”: Women’s experiences and ways of coping with depression. Can Psychol-Psychol Can. 1999, 40 (2): 205-219.View ArticleGoogle Scholar
  76. Shin JK: Help-seeking behaviors by Korean immigrants for depression. Issues Ment Health Nurs. 2002, 23 (5): 461-476. 10.1080/01612840290052640.View ArticlePubMedGoogle Scholar
  77. Srinivasan J, Cohen NL, Parikh SV: Patient attitudes regarding causes of depression: implications for psychoeducation. Can J Psychiatry. 2003, 48 (7): 493-495.PubMedGoogle Scholar
  78. Stecker T, Alvidrez J: Patient decision-making regarding entry into psychotherapy to treat depression. Issues Ment Health Nurs. 2007, 28 (7): 811-820. 10.1080/01612840701415967.View ArticlePubMedGoogle Scholar
  79. Ugarriza DN: Elderly women’s explanation of depression. J Gerontol Nurs. 2002, 28 (5): 22-29. quiz 54–25View ArticlePubMedGoogle Scholar
  80. Van Voorhees BW, Fogel J, Houston TK, Cooper LA, Wang NY, Ford DE: Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults. Ann Fam Med. 2005, 3 (1): 38-46. 10.1370/afm.273.View ArticlePubMedPubMed CentralGoogle Scholar
  81. Van Voorhees BW, Fogel J, Houston TK, Cooper LA, Wang NY, Ford DE: Attitudes and illness factors associated with low perceived need for depression treatment among young adults. Social Psychiatry and Psychiatric Epidemiol. 2006, 41 (9): 746-754. 10.1007/s00127-006-0091-x.View ArticleGoogle Scholar
  82. Wagner PJ, Jester D, LeClair B, Taylor AT, Woodward L, Lambert J: Taking the edge off - Why patients choose St. John’s Wort. J Fam Pract. 1999, 48 (8): 615-619.PubMedGoogle Scholar
  83. Waite R, Killian P: Perspectives about depression: explanatory models among African-American women. Arch Psychiatr Nurs. 2009, 23 (4): 323-333. 10.1016/j.apnu.2008.05.009.View ArticlePubMedGoogle Scholar
  84. Williams B, Healy D: Perceptions of illness causation among new referrals to a community mental health team: “explanatory model” or “exploratory map”?. Soc Sci Med. 2001, 53 (4): 465-476. 10.1016/S0277-9536(00)00349-X.View ArticleGoogle Scholar
  85. Wittink MN, Dahlberg B, Biruk C, Barg FK: How older adults combine medical and experiential notions of depression. Qual Health Res. 2008, 18 (9): 1174-1183. 10.1177/1049732308321737.View ArticlePubMedPubMed CentralGoogle Scholar
  86. Wittkampf K, van Zwieten M, Smits F, Schene A, Huyser J, van Weert H: Patients’ view on screening for depression in general practice. Fam Pract. 2008, 25 (6): 438-444. 10.1093/fampra/cmn057.View ArticlePubMedGoogle Scholar
  87. Yeung A, Chang D, Gresham RL, Nierenberg AA, Fava M: Illness beliefs of depressed Chinese American Patients in primary care. J Nerv Ment Dis. 2004, 192 (4): 324-327. 10.1097/01.nmd.0000120892.96624.00.View ArticlePubMedGoogle Scholar
  88. Martin D, de Jesus Mari J, Quirino J: Views on depression among patients diagnosed as depressed in a poor town on the outskirts of Sao Paulo, Brazil. Transcult Psychiatry. 2007, 44 (4): 637-658. 10.1177/1363461507083902.View ArticlePubMedGoogle Scholar
  89. Antonovsky A: Health, Stress, and Coping. 1979, Jossey-Bass,Google Scholar
  90. Lindstrom B, Eriksson M: Contextualizing salutogenesis and Antonovsky in public health development. Heal Promot Int. 2006, 21 (3): 238-244. 10.1093/heapro/dal016.View ArticleGoogle Scholar
  91. Integrative approaches to qualitative and quantitative evidence. [http://www.nice.org.uk/page.aspx?o=508055]
  92. National Institute of Clinical Excellence: Depression in adults with a chronic physical health problem: treatment and management. NICE. Volume CG 91. 2009, NICE,Google Scholar
  93. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/13/41/prepub

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