Ambulatory healthcare for patients with depression: an integration perspective/La atención ambulatoria a los pacientes con depresión: una perspectiva integradora

Numerous studies [1–3] have indicated increasing rates of depression detected in specialised consultations (SC) and primary care (PC). To tackle this problem, the WHO suggests an integrated approach to care [4] and this represents a great challenge. There is currently a debate on new models of healthcare management (such as those focusing on chronic disease and collaborative care) and it seems necessary to investigate various alternatives. Collaborative interventions are effective [5], but little is known about which of their characteristics are essential for them to be successful [6]. Understanding this is important since they are complex and more costly than traditional interventions. In particular, in order to undertake such interventions successfully, we need to assess the attitudes and approaches of all those involved.


Introduction
Numerous studies [1][2][3] have indicated increasing rates of depression detected in specialised consultations (SC) and primary care (PC). To tackle this problem, the WHO suggests an integrated approach to care [4] and this represents a great challenge. There is currently a debate on new models of healthcare management (such as those focusing on chronic disease and collaborative care) and it seems necessary to investigate various alternatives. Collaborative interventions are effective [5], but little is known about which of their characteristics are essential for them to be successful [6]. Understanding this is important since they are complex and more costly than traditional interventions. In particular, in order to undertake such interventions successfully, we need to assess the attitudes and approaches of all those involved.
In relation to this, our team conducted a research study [7] with general practitioners (GPs) and psychiatrists in the public health system, the results of which confirmed the importance of and current deficiencies in links between these professionals, as well as the need for patient-focused models of collaboration and care. After this work, we concluded that it was necessary to widen our vision of the problem by collecting data on the perspective of other stakeholders.
With this objective, we carried out a second project in which we analysed: on the one hand, the perceptions of other professionals involved (psychologists, specialised nurses and social workers), who we had not been

Analysis
The methodology was qualitative, based on discussion groups and interviews recorded, with prior consent, and subsequently transcribed. We then applied a model of sociological discourse analysis using MAXQDA software for text analysis and subsequent validation, by triangulation between researchers and comparison with participants.

Setting and subjects
Bilbao Health Region, Basque Health Service-Osakidetza. Centres and patients were sampled by socioeconomic (SE) level: high vs. low, using open, flexible purposive sampling, with various groups for each modality of care in order to achieve a higher degree of saturation.

Study 1
Six discussion groups were organised, four with GPs (n=29) and two with psychiatrists (n=13). The patient's local health centre was grouped according the SE level (high or low).

Study 2
A further six discussion groups were organised: 1) two with patients seen in PC (one corresponding to high SE level and one to low SE level); 2) another two with patients seen in SC, also grouped according to SE level; 3) a group of psychologists from various different mental health centres (MHC); and 4) a mixed group of nurses and social workers from SC.

Results
The views of GPs and psychiatrists differ as a function of their place of work within the health care system. The type of relationship with patients, the lack of accuracy of diagnoses of depression, professional selfperceptions, and a lack of mutual knowledge between the different levels of care determine the clinical process. Health and social contexts are essential for interpreting the views of professionals with respect to their patients.
Patients follow a variety of different pathways through health services, including PC and SC as well as private care. Expectations and views of the care received also vary widely. Some patients seek support and understanding and appreciate the knowledge and approachability of their GP. Those who value specialised care more are seeking to resolve their symptoms. Such patients tend to have a higher SE level ( Figure 1).
Psychologists, specialised nurses and social workers stress their role in listening and giving support. Professionals believe that there is a high degree of medicalisation of life and/or social problems.

Discussion
Despite advances in recent years, there remains a high degree of uncertainty about which are the most effective practices to adopt for patients with mental health problems and how they should be organised at the various levels of care. This uncertainty leads to excess variability in clinical practice, which is influenced by organisational dynamics closely related to the characteristics and degree of development of each health system [8][9][10].
Despite the importance of the subject, little research has been carried out on the views of the various stakeholders involved in demand, diagnosis and treatment processes in mental illness. In particular, we need to deepen our understanding of patient perceptions and the way that these are expressed [11,12]. Many studies published in recent years endorse the need for qualitative research in this area [13][14][15].

Conclusions
The provision of healthcare to people diagnosed with depression requires patient-centred approaches shared between professionals. Management of these patients is influenced by the cultural and organisational context in which they are seen. Accordingly, we need to improve our understanding of the specific circumstances at each level of care. Further, coordination between services and levels of care must be promoted through active health policies, and programmes for professional training should be tailored to meet the real needs of professionals and patients.
Currently our team is carrying out a systematic review of the scientific literature to identify the best evidence on models for collaborative work and their contexts. Our aim is to produce an interprofessional consensus document with the strategies to follow to provide effective care for patients diagnosed with depression in our area [16]. Once the evidence gathered, we will organise various working sessions, both face-to-face and over the internet, with the participation of psychiatrists, GPs and other professionals involved in this care area.
Once consensus is reached, we will set up an intervention and evaluation pilot project of an integrated care model in our area. This will enable us to put into practice the results of our research work and give continuity to a participatory research approach that encourages the involvement of stakeholders. In this project, we will use participatory action research methods [17] and it is envisaged that two teams of mental health and PC professionals from the provinces of Gipuzkoa and Bizkaia will participate.