Twelve GPs, 13 patient participants (of whom 12 had completed the intervention, one withdrew before starting therapy) and 8 case managers were interviewed (see Table 2 , Table 3 and Table 4 ).
Only one patient was interviewed who had withdrawn from the study. Most trial participants who withdrew did so at the outset, either declining to receive the intervention or withdrawing after only one session. It was difficult to recruit such older people to participate in an interview. As an ethical consideration, our protocol stated that after inviting withdrawn participants by letter to take part in an interview, we would not follow up those who did not respond.
Eight case managers consented to be interviewed. The reasons for the four declining are unclear, but all worked in the site which was last to join the study; they saw fewer patients than other case managers and were on short-term, part-time contracts.
We report the main themes identified in the data: Revealing hidden depression, reducing the 'blind spots', opportunity to talk outside the primary care consultation and 'moving on' from depression.
Data is presented to support analysis and labelled by identifier and number: CM = case manager; PT = patient; PTW = withdrawn patient; GP = general practitioner.
Revealing Hidden Depression
For most of the older people we interviewed, being invited to participate in the CASPER Plus study seemed to raise awareness of low mood:
"It crept up on me really, how I felt. I think it had been coming on for a long time and I didn't realise how bad I'd got until I filled that form in and I just ticked the boxes and posted it." PT6
Several GPs described how taking part in the CASPER plus trial helped to raise awareness of depression in their older population. One GP said:
"I think it has probably alerted us to one or two of the… more needy patients who perhaps were not coming to us for help… people have been brought into the system that… had sort of dropped out from seeing the GP." GP3
Some case managers (CMs) described how some patient participants admitted they had not spoken to others, including their GPs, about how low they felt.
"One gentleman that I saw, he said the most useful thing had been the diagnostics, as risk was identified, and so we wrote to the GP about that. And it was… the risk was still there when I saw him for the first time so I put that in a letter as well and he said that had kind of opened the door. He would have never gone and spoken to his GP about it."CM2
"they (the patient) wouldn't do anything and they wouldn't commit suicide but they feel ashamed I guess of having some thoughts (that they'd be better off dead)… and those are the sorts of things they don't always like us to share with the GP because it's back to that stigma isn't it?" CM1
While some patient participants did not use labels such as 'depression' or 'low mood', those who did so suggest that other older people may fail to recognise or admit their feelings because of the perceived stigma of doing so:
"…people don't talk about it do they, they think it's a weakness don't they? But it is something that you can't help when you are in it, you know as I say you don't realise you are going in it and as much as you try you know sometimes you can't get out it, it gets deeper you know." PT6
A few patient participants commented on the 'invisibility of depression':
"…you know if I broke an arm I'd get a sling wouldn't I, you know it's fairly obvious, but I suppose with any mental illness you can't see it, you don't know." PTW1
Several GPs reported an awareness of the stigma associated with depression, especially in this age group, which might impact on whether it is raised within a consultation:
"It's sort of an age group where they're not as open about depression as maybe younger people are, there's a bit of a stigma attached to it still." GP8
A few GPs described how they normalised depression in older people; one admitted possibly colluding with the patient in ignoring cues within the primary care consultation:
"You're sort of aware there are people who have depressive episodes that aren't possibly addressed, they may themselves not really recognise it, and they just think it's part of, you know, getting older."GP3
"You'd like to think that primary care is fairly aware of it (depression) anyway. But maybe the temptation is to let sleeping dogs lie, I don't know. So you know, if you diagnose someone with depression you've got to do something about it haven't you?"GP6
Some GPs described a tension between a desire to consider the 'whole' patient and, due to limited time and treatment options, a tendency to prescribe antidepressants to older people who they did recognise as being depressed.
"We often go down a medication route because, well it does help them, and it's very difficult to get other services. And the psychiatry for the elderly tends to be more focused on dementia." GP8
Several GPs recognised that depression in older people often occurs alongside complex physical conditions or social problems, including loneliness. Some of these GPs disclosed a reluctance to identify the condition, partly due to the absence of a psychological treatment pathway for depression in the over-65 s and a tendency to prioritise physical symptoms over emotional health.
"I suppose in a busy clinic we probably don't have time to sort of delve into depression along with the sort of twelve and a half minutes of consulting on chronic diseases that's squeezed into ten minutes, so depression would take another five or six, so… we'll probably skip over that unless they bring it to us." PT12
Being invited to participate in the CASPER Plus trial provided an opportunity for some people to talk about depression, enabling them to recognise and seek help for low mood.
Reducing the 'Blind Spots'
Several case managers and three GPs described how two practitioners working with a patient helped to reduce the 'blind spots', as each professional offered a different perspective.
"so you've got the benefit of somebody who's looking at a person, never having met them before who can see certain things, versus somebody who has known somebody for some time and can see certain things but, those two people, will have, probably have, blind spots… because one person doesn't know that person very well and the other has maybe, over the years, has just sort of formed a fixed idea about somebody. Collaborative working, not only will it progress the patient forward but it will also… reduce blind spots, I think, in their care." GP1
One GP saw the CM as helping to 'patch up' the gaps in the patient's support network.
"I think a lot of the difficulty… is their support networks have become a bit more fragmented…. especially those that are bereaved, or have families spread around the country or spread around the world… so I can see that maybe we can patch that fragmentation up a little bit… it's not the same as having your relatives but having some kind of support, I can see that as a benefit." GP3
The CMs viewed their role as a facilitator, or 'go-between', able to convey information to the GP which the patient may be reluctant to disclose directly.
"Sometimes, if people can't talk to their GP or don't understand that maybe they had a problem like depression, and don't know how to approach a GP because of stigma and things like that then I've been that facilitator, I've helped them with that process." CM1
For example, one CM reported advocating on behalf of a patient who was having problems with pain:
"…she was using cannabis to manage the pain and she felt there was nothing else the doctors could do, so I spoke to her GP and they said she could get a referral to the pain clinic… She [the patient] had given up all hope, but she was happy for me to pester them a little bit." CM3
GPs and CMs offered different perspectives on patients' health needs which was seen to reduce 'blind spots' in depression care.
Opportunity to Talk Outside the Primary Care Consultation
Offering an opportunity to talk outside the GP consulting room was valued by the majority of patients:
"The most startling thing about the experience was all my life I've never had anybody to talk to, there're things I wouldn't even discuss with my wife and to have an outsider person that didn't really know me who was impartial… that helped me a great deal, just by having someone to discuss things with." PT5
"…having someone to talk to… about things in my life that I would talk to say the family about or friends unless they were extremely close friends, it gave me someone objective to talk to you know, that was removed from my situation." PT2
Some patients suggested that GPs were not always receptive to discussing problems with mood:
"You know and the GPs, well they don't, they don't seem to be interested I don't think. Oh, it's depression, take a pill, go away." PT12
"I just have a bit of a problem with doctors because I just don't think they do the job that they maybe should be doing, it's a two minute interview or whatever, they don't really know your records, they don't know the history, they don't tie things up."PTW1
In contrast, most patients described the CM as providing empathic support, being able to offer more time than the GP and knowing where to signpost patients to voluntary organisations:
"…she did everything she possibly could… I mean she went the extra mile. She spoke to the people at Parkinson's – Parkinson's UK – to see if there was a network somewhere, an advice centre, and things I didn't know she found out for me." PT7
Patient participants spoke about the benefit of having someone to talk to in confidence, outside the primary care consultation; someone who was said to listen without judging, allowing them to talk openly about feelings and personal issues:
"I thought it was very good. And I think the fact that people were bothered, to see how the older people felt…. I think that was good. You didn't feel like you just got a script thrown at you and you were waiting for God sort of thing…it was the fact that someone was interested in how you felt." PT1
Giving patients an opportunity to talk outside of the clinical setting of the primary care consultation room appears to be valued by most of the older people we interviewed, and by their GPs.
'Moving on' From Depression
Some patients reported how the CM encouraged them to increase activity and social contact which the patients felt had improved both their physical health and mood. For example:
"The telephone conversations for me were helpful. She got me to think about doing things. I'm doing a computer course now and there's a chance I might be able to help them at [voluntary organisation]."PT9
"It has helped me thinking about things I can do… I go in the pool, only in the baby pool but it's good for my legs and my shoulder… and you know it makes you feel better once you've done it, not just my legs, but in yourself, you know…" PT6
A few patients valued the practical aspects and the techniques learned from the CM:
"I've kept a diary all my working life and by going - a daily diary that is - and by going through it we could highlight various things that tip the balance if you like of the scales of happiness and depression and it was highlighted (depression) and between us we figured out a way of coming through it basically." PT5
"When we moved onto the technical part of it where they are asking specific questions and giving specific ideas, I find these very useful and in fact I've continued to do those. The ones I am talking about are where you identify things to do… and make a list." PT4
Case management with BA provides older people with tools to help manage their depressive symptoms and to understand that behaviour and mood are closely linked. BA promotes participation in social and physical activity which may enable older people to 'move on' from depression and to experience improved wellbeing.