Factors influencing prescribing decisions in the treatment of depression: a social judgement theory approach

The under‐diagnosis and inappropriate treatment of depression in primary care has become a serious public health problem despite the development of many clinical guidelines to guide recognition and treatment of the disorder. This study aims to investigate decision‐making processes and to identify factors which influence general practitioners' (GPs) prescribing decisions and how these factors differ from those the guidelines recommend. Brunswik's lens model, from Social Judgement Theory (SJT), was employed to explore individual treatment decision policies of 40 GPs in the Grampian region of Scotland for 20 case vignettes. These individual policies were then aggregated and compared with those derived from guideline recommendations; important differences emerged between the two in the utilization of cues and there was considerable variation between GPs' policies. Guidelines placed more importance on the duration of symptoms whereas GPs gave weight also to particular symptoms, such as ‘thoughts of suicide’ and ‘sleep disturbance’ and patient treatment preference. GPs prescribed antidepressants at a greater rate than was recommended by the guidelines. The findings have important implications for implementation strategies, which maybe developed to accompany clinical guidelines. Copyright © 2002 John Wiley & Sons, Ltd.     

Modelling elderly patients’ perception of the community pharmacist image when providing professional services*

Professional pharmaceutical services may impact on patient’s health behaviour as well as influence on patients’ perceptions of the pharmacist image. The Health Belief Model predicts health-related behaviours using patients’ beliefs. However, health beliefs (HBs) could transcend beyond predicting health behaviour and may have an impact on the patients’ perceptions of the pharmacist image. This study objective was to develop and test a model that relates patients’ HBs to patient’s perception of the image of the pharmacist, and to assess if the provision of pharmacy services (Intervention group-IG) influences this perception compared to usual care (Control group). A qualitative study was undertaken and a questionnaire was created for the development of the model. The content, dimensions, validity and reliability of the questionnaire were pre-tested qualitatively and in a pilot mail survey. The reliability and validity of the proposed model were tested using Confirmatory Factor Analysis (CFA). Structural Equation Modelling (SEM) was used to explain relationships between dimensions of the final model and to analyse differences between groups. As a result, a final model was developed. CFA concluded that the model was valid and reliable (Goodness of Fit indices: x²(80) = 125.726, p = .001, RMSEA = .04, SRMR = .04, GFI = .997, NFI = .93, CFI = .974). SEM indicated that ‘Perceived benefits’ were significantly associated with ‘Perceived Pharmacist Image’ in the whole sample. Differences were found in the IG with also ‘Self-efficacy’ significantly influencing ‘Perceived pharmacist image’. A model of patients’ HBs related to their image of the pharmacist was developed and tested. When pharmacists deliver professional services, these services modify some patients’ HBs that in turn influence public perception of the pharmacist.     

Giving Voice to Patients: Developing a Discussion Method to Involve Patients in Translational Research

Biomedical research policy in recent years has often tried to make such research more ‘translational’, aiming to facilitate the transfer of insights from research and development (R&D) to health care for the benefit of future users. Involving patients in deliberations about and design of biomedical research may increase the quality of R&D and of resulting innovations and thus contribute to translation. However, patient involvement in biomedical research is not an easy feat. This paper discusses the development of a method for involving patients in (translational) biomedical research aiming to address its main challenges.After reviewing the potential challenges of patient involvement, we formulate three requirements for any method to meaningfully involve patients in (translational) biomedical research. It should enable patients (1) to put forward their experiential knowledge, (2) to develop a rich view of what an envisioned innovation might look like and do, and (3) to connect their experiential knowledge with the envisioned innovation. We then describe how we developed the card-based discussion method ‘Voice of patients’, and discuss to what extent the method, when used in four focus groups, satisfied these requirements. We conclude that the method is quite successful in mobilising patients’ experiential knowledge, in stimulating their imaginaries of the innovation under discussion and to some extent also in connecting these two. More work is needed to translate patients’ considerations into recommendations relevant to researchers’ activities. It also seems wise to broaden the audience for patients’ considerations to other actors working on a specific innovation.     

Catalysts for psychic change: Perspectives from contemporary psychoanalysis

This paper was given as the inaugural ‘Ellen Noonan Counselling Lecture’ on 3 July 2007, at Birkbeck College, University of London, and I have retained some of the spoken style of the original lecture. Since the 1960s, psychoanalytic models of change and growth have in themselves undergone radical changes. The aims of psychoanalytic and psychodynamic work are now less tied to a model of ‘health’ or ‘normality’ and more linked into processes that enable people to keep developing throughout life. The lecture examines some of the new theories of psychic change and growth from the contemporary Independent, Lacanian and post-Kleinian schools of psychoanalysis and, using clinical illustrations, explores the implications of these new theories for psychodynamic practice.     

Clinical Ethicists Awakened: Addressing Two Generations of Clinical Ethics Issues Involving Undocumented Patients

Because the United States has failed to provide a pathway to citizenship for its long-term undocumented population, clinical ethicists have more than 20 years of addressing issues that arise in caring for this population. I illustrate that these challenges fall into two sets of issues. First-generation issues involve finding ethical ways to treat and discharge patients who are uninsured and ineligible for safety-net resources. More recently, ethicists have been invited to help address second-generation issues that involve facilitating the presentation for care of undocumented patients. In the current environment of widespread fear of deportation in the immigrant community, ethicists are working with health care providers to address patient concerns that prevent them from seeking care. I illustrate that in both generations of issues, values implicit within health care, namely, caring, efficiency, and promotion of public health, guide the strategies that are acceptable and recommended.     

Challenges of patient‐led mental health services to psychoanalytic clinicians

This paper considers implications to psychoanalytic psychotherapy of the British Government's decision to implement a patient choice agenda for state‐funded mental health services in England and Wales. It places the patient choice agenda in the context of consumerist society and argues that the complex nature of psychoanalytic psychotherapy leaves it more vulnerable than other psychological therapy modalities to compete in the current reality of ‘consumer’‐led public mental health, which, in turn reflects a profoundly changed social context from that to which psychoanalysis traces its roots. Unless psychoanalytic clinicians recognize and find ways to adjust to this context they will jeopardize the survival of psychoanalytic psychotherapy in an increasingly market‐orientated model of mental healthcare provision in the public sector, eager to promote more ‘consumer friendly’ psychological therapy models.     

The search for evidence: Psychoanalytic practice and the male imaginary

In this paper, I will attempt to discuss the future of psychoanalytic practice in the wake of the National Institute of Health and Clinical Excellence’s (NICE) embrace of ‘evidence’-based practice. In 2005, NICE, whose task is to regulate the provision of health care across the National Health Service, adopted positivistic evidence-based protocols as the sole proof of the effectiveness of psychotherapy. Despite the success over the past 40?years of psychoanalytic and humanistic therapies in primary care and psychotherapy departments of psychiatric hospitals, NICE insists on restricting therapy, to those who can claim effectiveness as a result of using the data from client questionnaires commonly described as ‘outcome measures’ and it has gone on to promoting new modalities many of which have been imported from the States. As a consequence, most of the provision of psychotherapy in the public sector currently, whether as part of the National Health Service or the voluntary sector, has embraced evidence-based practice’ and many training organisations are promoting it, which will, in time, have an effect on private practice. I use some of the threads of the work of the feminist psychoanalyst Irigaray and others to understand this turn to positivistic science and how it can be understood as an instance of the retrenchment of the ‘male imaginary’ and a re-installation of the values of detachment and mastery. I query whether there are some problems within current theory, practice and institutionalisation which interfere with the emergence of a more progressive psychoanalytic practice.     

What's so special about medicine?

Health care has increasingly come to be understood as a commodity. The ethical implications of such an understanding are significant. The author argues that health care is not a commodity because health care (1) is non-proprietary, (2) serves the needs of persons who, as patients, are uniquely vulnerable, (3) essentially involves a special human relationship which ought not be bought or sold, (4) helps to define what is meant by ‘necessity’ and cannot be considered a commodity when subjected to rigorous conceptual analysis. The Oslerian conception that medicine is a calling and not a business ought to be reaffirmed by both the profession and the public. Such a conception would have significant ramifications for patient care and health care policy.     

Health Focused Psychotherapy In Treating a Dual Diagnosed Patient

Health-focused psychotherapy offers a contemporary model used in assessment, treatment planning and evaluation in addressing patients with both medical and psychiatric diagnoses. Clinicians in the health and mental health disciplines must know and understand the importance of standards of care and models of intervention and evaluation in clinical practice for this type of patient. Examined is the use of a specific model providing a tailored orientation to patient education, along with the development and use of a clinical algorithm and care pathway for clinical practice. Provided is a case study for applying the development and use of a clinical algorithm and care pathway for a dual diagnosed patient receiving health-focused psychotherapy.     

Of pharisees and snark‐hunters: Afro‐Cuban religion as an object of knowledge

Examining some recent publications on Afro‐Cuban religions in the US, this essay argues that some of the evident shortcomings of the literature on this subject may hold important epistemological and methodological lessons for the anthropology of religion in general. These concern the pervasive lack of critical attention to the criteria by which formations of religious knowledge and practice are constituted as objects of study; a failure to acknowledge the historical interaction between theoretical models and public demand structures for authenticated cultural difference; the tendency to treat the relation between observer‐ and insider‐discourses as unproblematic and transparent; and a similarly widespread trend towards over‐systematising and homogenising internally heterogeneous and unbounded aggregates of knowledge and practice. What is suggested instead is an ethnographically informed and actor‐centred sociology of knowledge focussed on mutually articulated universes of meaning, and capable of transcending artificial conceptual boundaries between ‘the religious’ and the sphere of ‘everyday life’.     

The professional identity of counselling psychologists in health care: a review and call for research

Despite (a) anecdotal evidence which suggests that it is possible to be a counselling psychologist in non-traditional settings, and (b) the potential integration of counselling psychology foci with the medical model, there has been some discussion about whether counselling psychologists who practice in health care settings might experience a change in their professional identity. Professional identity is defined here as a sense of connection to the values and emphases of counselling psychology. The retention of professional identity seems important for counselling psychologists in health care settings. This is considering that the application of counselling psychology principles has the potential to make their contributions unique among mental health professionals in the health care arena. Here, the authors describe the evolution of ‘counselling health psychology’ and address issues of professional identity. Limitations of existing literature are examined. Recommendations for future research are also made.     

Basic human values: The ethos for methodology

This paper draws on the personal experiences of part of a research project where the original methodology was flawed and needed to change to properly encompass the lives and experiences of the people who the research was for, namely users of mental health services living in supported housing. The change in methodology involved a recognition that the research could not be termed ‘value-free’; that researchers are not objective. It is argued that it was important to demonstrate that the information obtained in the research was ‘valid’, and that despite the subjective nature of the research, there are steps that can be taken to convince others that the information received is ‘real’. It is further argued that the traditional approach to research of separating theory (or knowledge) from practice was not only inappropriate in this sort of research, but is a false notion in any sort of action research that aims to promote change. The importance of the influence and power of service providers in action research is recognised, as well as the constraints placed on short-term funded projects. It was important for the methodology to be non-oppressive so that researchers adopted an open and honest approach and for researchers to become involved with the research participants. The implications of this ‘involvement’ are discussed. There is a concluding discussion about whether non-users of mental health services can be considered as allies in research. It is argued that all oppressed groups need their allies and if the research is led by basic human values, then working alongside people who depend on services can lead to emancipatory outcomes.     

A brief episode of psychosis: Elli's story

This paper explores the notion of a GP practice as a ‘secure base’, suggesting that greater attention could usefully be paid to the importance of attachment relationships in primary care. If professionals feel secure and respected within ‘the practice’ then ‘the practice’ itself is more likely to be able to function as a ‘secure base’ for its patients. It is suggested that this concept could be developed further to provide a conceptual framework for practices to examine their function as therapeutic organizations. A short resumé of John Bowlby's attachment theory is outlined. Illustrations are given of how different attachment styles – secure, avoidant, ambivalent or disorganized – might affect patient care. A case of a mother (with postnatal depression) and her infant is considered in detail to illustrate the value of early intervention in a mother-infant relationship. Professionals are also attached to the practices where they work and the author reflects on his own retirement from being a GP (after 35 years). Finally, the paper describes another case – of a patient who was able to relive, and possibly repair, some of her earlier traumatic childhood separations through her relationship and parting from her GP as retirement approached.     

How Science Is Applied in Technology

Unlike basic sciences, scientific research in advanced technologies aims to explain, predict, and (mathematically) describe not phenomena in nature, but phenomena in technological artefacts, thereby producing knowledge that is utilized in technological design. This article first explains why the covering‐law view of applying science is inadequate for characterizing this research practice. Instead, the covering‐law approach and causal explanation are integrated in this practice. Ludwig Prandtl’s approach to concrete fluid flows is used as an example of scientific research in the engineering sciences. A methodology of distinguishing between regions in space and/or phases in time that show distinct physical behaviours is specific to this research practice. Accordingly, two types of models specific to the engineering sciences are introduced. The diagrammatic model represents the causal explanation of physical behaviour in distinct spatial regions or time phases; the nomo‐mathematical model represents the phenomenon in terms of a set of mathematically formulated laws.     

A Q-methodological study of smoking identities

In contrast to the psychological literature on adolescent smoking, little research has investigated the social identities of adult smokers. This study aimed to identify shared ‘smoking identities’ amongst a sample of 64 British smokers from different socio-economic groups using Q-methodology. Participants were asked to sort 70 items concerning smoking and smokers according to their agreement/disagreement with them. The 64 Q-sorts were then subjected to a by-person factor analysis yielding six factors, with the first four interpretable factors being presented here. Each factor is understood to represent a distinct ‘identity position’. The first two, the ‘addicted’ smoker, and the ‘in control’ smoker, oriented around a biomedical model of smoking as an addictive health risk. The final two, the ‘no big deal’ smoker and the ‘proud’ smoker reflected alternative understandings and values. The identity positions also differed in the extent to which smoking was considered a core part of self-identity. Unpacking the ‘smoking identities’ of current smokers offers the opportunity to devise targeted health promotion.     

The futures of physicians: Agency and autonomy reconsidered

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and ‘not-for-profit’ sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the traditional autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.     

Evidentiary Symbiosis: On Paraethnography in Human–Microbe Relations

Though microbial infections are central concerns for public health workers in urban Nicaragua, health workers there rarely if ever speak of the existence of a ‘microbiome’ when they address such problems. Among scientists and the public in the United States, on the other hand, the microbiome, seen as the ‘internal ecosystem’ that regulates the workings of human guts, is a regular topic of conversation. This raises questions about how one might go about doing a social study of the microbiome in places where it does not (yet) exist as a category of expert practice or public discourse. Evidence from Nicaragua and the United States highlights two sites at which experts engage people in research and discussion about microbial ecologies. In their work, U.S. microbiome scientists and Nicaraguan public health workers both engage in ‘paraethnography,’ the practice of collecting and analyzing qualitative information that does not fit into statistical or other kinds of scientific models. In the United States, paraethnography has driven both traditional scientific experiments on the microbiome and online, crowd-sourced experimental platforms for collecting and analyzing information about gut microbes. In Nicaragua, hygienists generate paraethnographic evidence through word-of-mouth, radio, and print media. A comparison between the work of U.S. scientists and that of Nicaraguan hygienists suggests three different ways (commensal, parasitic, and mutualistic) in which the cultural/interpretive evidence of paraethnography interfaces symbiotically with the quantitative/statistical evidence of bioscience. Attention to evidentiary symbiosis provides insights into the operations of publicly oriented science under conditions of bodily and planetary uncertainty.     

Children’s mental health: Time to stop using psychiatric diagnosis

Hegemonic mental health service approaches stress the need for ‘accurate’ diagnosis in order to understand what the correct ‘treatment’ should be. I review the evidence on how far diagnosis in psychiatry has helped advance scientific knowledge and clinical practice and conclude that it hasn’t. I then examine how National Institute for Health and Care Excellence (NICE) guidelines in relation to children’s behaviour problems reflects the lack of progress that results from adopting a diagnostic approach. Taking mental health practice beyond reliance on narrow non-evidence-based diagnostic algorithms can be developed by adopting existing projects such as the Partners for Change Outcome Management Systems project.