Aims

The study aimed to explore (1) primary care patients’ perceptions of links between their physical condition and mental health; (2) their experiences of living with depression and CHD; and (3) their own self-help strategies and attitudes to current personalised care (PC) interventions for depression.

Methods

The sampling frame was the UPBEAT-UK cohort study database of primary care patients with CHD. At the time of recruitment (November 2008–January 2009) this numbered 376. On recruitment to the cohort, study participants were given the option of being interviewed in depth about their experiences of CHD and how this affected them emotionally. From participants who agreed to be contacted, we purposively sampled for positive scores on the PHQ-9,⁸⁰ which indicates symptoms of depression. We also sampled for maximum variation on sociodemographic factors: age, sex, ethnicity and occupational status.

At the time of sampling, 42 patients screened positive for symptoms of depression and of these, five were included in the pilot interview study. Of the remaining 37, one patient declined and three could not be contacted or had died. Of the remaining 33 patients, 30 were interviewed, at which point interviewing was stopped as data saturation had been reached.

We conducted five individual unstructured pilot interviews and 30 semistructured interviews. Topic guides were informed by the aims of the research, review of the literature, discussion with coauthors and findings from the pilot interview study. We audio-recorded all interviews and transcribed them verbatim following written informed consent. Transcribed interviews were entered into NVivo 8 qualitative software for analysis and data management.

All transcripts were analysed using a thematic approach⁸¹ involving a process of constant comparison between cases.⁸² Analysis began alongside data collection, with ideas from early analysis informing later data collection in an iterative process. Analysis of individual transcripts commenced with open coding grounded in the data. This generated an initial coding framework, which was added to and refined, with material regrouped and recoded as new data were gathered. Codes were gradually built into broader categories through comparison across transcripts and higher-level recurring themes were developed. Data were scrutinised for disconfirming and confirming views across the range of participants. Discrepancies were resolved by discussion at regular UPBEAT-UK research meetings to ensure consistency.

Study results

Participants

Participant characteristics are recorded in Table 3.

TABLE 3

Participant characteristics

Participants were given pseudonyms to protect their anonymity.

Seven key themes were identified:

1. taking control and individual coping strategies
2. the significance of having heart problems
3. ambivalent attitudes to accessing PC mental health services
4. services participants would like for heart disease and depression
5. future orientation (having achievable hopes and dreams for the future)
6. the positives
7. contributory or causative factors for distress/depression.

Taking control and individual coping strategies

Analysis of pilot interviews revealed the ways in which patients tried to gain control of their health and emotional well-being and the individual coping strategies they used. These included:

• devising own fitness regime
• going to the gym
• studying health issues and alternative or complementary medicine
• meditating
• praying and being an active member of a religious community
• learning specific relaxation techniques based on yoga and Buddhist philosophy
• fishing and being in the natural environment (described as a yoga-like experience)
• being able to drive
• setting goals for exercise and pacing performance
• getting an allotment and growing vegetables
• volunteering at a hospital.

The following are illustrations of strategies used by participants: devising own fitness regime, going fishing and going to the gym. These examples not only illustrate the most cited strategies used but also individual differences in participant preferences for individual or group approaches to self-help.

Geoff described his fitness regime; he has a mini-gym in his sitting room and also goes fishing. He explained:

I’ve got equipment where I train, I’ve got the balls, I’ve got the weights, I’ve got a track that I run on, and I got legs . . . because of this operation, because I have got arthritis I got to strengthen my legs . . . and I got a thing to do my upper body. Yeah I train at least once per week.

When exercising and out walking, Geoff also wears a heart rate watch and he finds this source of ‘biofeedback’ helps him to pace and monitor his exercise, particularly when climbing hills. Geoff finds that being by the river, fishing and enjoying the natural environment a therapeutic experience in itself, he said:

Yeah, yeah, it’s like a yoga, you can go into your own trance can’t you, you can sit by the river and just imagine you’re doing anything, it’s like yoga.

Geoff had worked as a porter in the various Covent Garden markets for most of his life but since retiring he had built up a sizeable collection of books on alternative and complementary approaches to health. Geoff may have symptoms of depression, as detected by his PHQ score, but he is actively taking control of his health.

Another participant, June, talked about the ‘psychosocial’ benefits she gained from her regular trips to a gym where there was a special programme for heart disease patients:

. . . there is a group there [at the gym] and nine times out of ten we spend most of our time laughing!

This participant clearly enjoyed the fun she had with other people who had similar health problems and were trying to cope with the gym equipment and exercises through laughter.

The significance of having heart problems

For all five participants, having heart problems was not the health condition that concerned them the most. Three out of the five participants suffered from arthritis and this condition appeared to be causing more problems than heart disease owing to chronic pain and impaired mobility. One participant, June, was unable to work because of arthritis in her shoulder, arms, legs and ankles. She had already undergone five operations for arthritis.

Out of the five participants, Gurch seemed the most depressed or unhappy. Gentle probing about his heart problems (bypass surgery and a number of heart attacks) and how this had affected his feelings almost immediately led onto the topic that dominated the interview: his unhappy marriage and home life and his abuse of alcohol. The following exchange illustrates the problems Gurch had experienced:

Researcher:

But how did it [heart bypass surgery] affect you emotionally, what did you think and what did you feel?

Gurch:

At that time there are family problems.

Researcher:

Did you have family problems?

Gurch:

Yes family problems you know then I just take so much whisky you know drank you know.

Researcher:

All right so I understand that you were saying that you had family problems and that was why you were drinking a lot.

Gurch:

It was one of the causes you know, the family problem you know I don’t know (. . .) my wife is but I do not know at that time you know, what are right what are wrong, anyhow it were due to my family quarrelling.

A little later in the interview he reflected that at the time of his heart bypass surgery, nearly 23 years ago, he was ‘totally unhappy, just spending my time you know just passing my time’.

Like Gurch, four out of the five participants had experienced problems in their marital relationships that seemed to have affected them over a long period of time and caused them unhappiness, anxiety and depression. In comparison with their relationship issues, participants seemed almost blasé about their heart problems.

Ambivalence about accessing mental health services

The next theme explored participants’ ambivalence about accessing mental health services through their GP and these included:

• cultural perceptions of depression can act as barrier to accessing help, for example in South Asian and Sikh communities
• not knowing the meaning of ‘depression’
• suffering seen as Karmic – in the hands of God
• cannot talk to anyone in community (stigma?)
• fearing negative perceptions of GPs as always ‘moaning and groaning’ (this idea is reinforced when doctor praises client for not moaning)
• discomfort in talking about emotional issues
• low self-esteem and a sense that their problems are not worthy of attention
• the perception that their health is relatively good and that there are people in far worse situations
• some people do not want to go down that path because it frightens them.

Excerpts from interviews with June and Ivy illustrated how health stoicism and fear of being viewed negatively by their GP acted as an inhibitor to accessing primary care health services. Although June suffered from asthma, arthritis, heart disease and possible depression she seemed reluctant to visit her GP other than for her regular 2-monthly check-ups. June explained ‘. . . there are some times when you are thinking to yourself that there are people a lot worse off than you!’.

Ivy had also adopted this approach – even though she was 79 years old and had heart disease, arthritis, balance problems and symptoms of depression. She explained:

Ivy:

To be honest, I hardly go near them [GP surgeries] . . . I mean they have got enough to do when they have got a whole lot of patients who are worse off than I am.

Researcher:

OK so do you think of yourself as being in quite good health?

Ivy:

Yeah.

Researcher:

You think ‘I’m OK I’m much better off than some people’?

Ivy:

Yeah, yeah.

Researcher:

And does that make you feel better?

Ivy:

Sometimes it does.

Although the strategies of stoicism and ‘counting your blessings’ that Ivy used can have some positive benefits (putting problems into perspective to combat feelings of anxiety about health) it can also act as an inhibiter to accessing health care.

June was concerned that her GP might perceive her negatively by making more frequent visits to the surgery. June explained:

June:

I don’t want to come in too often!

Researcher:

Too often?

June:

Even though they say they don’t get fed up, you don’t want them to get fed up, you know?

In relation to depression, a study by Priest et al.⁸³ found that stigma was still associated with depression, and patients felt ambivalent about consulting a family doctor. Some feared the GP would make negative evaluations of them or would be irritated or annoyed. With this in mind, June might be similarly reluctant to disclose her feelings of depression to her GP.

Services participants would like for heart disease and depression

In relation to the services participants would like for heart disease and depression, participants seemed more interested and comfortable in talking about services they would like for heart disease. The following suggestions were made:

• more frequent (physical) check-ups at the GP surgery with specialist nurse and improved feedback
• being able to request a check-up when needed
• access to a gym with specialist cardiac trainer for attention, guidance and reassurance
• the promotion of wrist heart rate monitors
• some people were interested in having counselling
• one participant had counselling and found it helpful.

Three out of the five participants had used a gym as part of their aftercare but only one participant, June, seemed to have attended sessions that were designed for people with heart problems. The other participants attended general fitness centres where they were assessed by a trainer and then given a set of exercises and left to get on with these on their own. These three participants all felt that a dedicated session would be preferable, particularly in the period immediately after their coronary incident when they needed the most reassurance about symptoms and safety while exercising. June’s experience of going to a dedicated gym session was an enjoyable one because there were a group of people ‘in the same boat’ and they had a good laugh. She also felt safe and reassured by the trainer when she had some cardiac symptoms. Even though this kind of CR might not be considered a psychological intervention, in the strictest sense, it may have some positive outcomes for patients suffering from mild depression and may also help to prevent a ‘cardiac invalid’ mind set.

Only two out of the five participants had received help for depression from their GP. None of the participants had received antidepressant medication, June had received information and Ivy had attended counselling sessions. Geoff had been offered group therapy but did not want to attend. Generally participants seemed cautiously positive about the idea of receiving one-to-one counselling while less positive about group therapy.

Future orientation (having achievable hopes and dreams for the future)

When asked if there was anything the participants enjoyed or were looking forward to doing with their lives, the following topics were discussed:

• planning for a holiday with a friend
• gaining skills needed for a new way of life
• planning to retire and live abroad
• wanting to learn how to use a laptop
• volunteering at a hospital.

In a critical literature review of the relevance of hope in the trajectory of heart failure illness, Davidson et al.⁸⁴ explained:

. . . hope . . .  defend[s] against despair by focusing on the future. Expectations can be directed toward relief from a difficult situation. To achieve this relief, people must have a sense of control over their environment and feel that they are capable of making decisions that alter their life circumstances.

In relation to hope, four out of the five participants gave examples of achievable personal goals. When talking about their personal dreams, participants looked relaxed and animated, and their body language changed. Even the unhappiest participant, Gurch, seemed a different person when talking about his activities as a volunteer with Parkinson disease patients at a London hospital. Besides a lot of other benefits, being a volunteer had given Gurch some future orientation. Gurch explains how this has affected him as follows:

Gurch:

It makes me feel good, when I help a person and I can see that they are suffering like that you know and I help ladies and gentlemen who are suffering from this disease how to do step by step.

Researcher:

You are looking a lot happier while you are talking to me about doing the volunteering you look quite happy.

Gurch:

Yes I am happy.

Another participant, James, talked about his hopes and dreams for the future as follows:

. . . we’ve got friends in Portugal that are living in a very beautiful kind of place and it is very nice to go and visit them and I think ‘this will do me fine’ nothing grand, just something with a bit of land. Errrh, yeah and this is why I am doing the allotment because I need to know that I can do it, if I want to.

James was close to retirement age and was seriously considering starting a new life abroad. He was taking some practical steps in preparation for his goal of having some land of his own to cultivate.

Similarly, June talked about her wish to go travelling as follows:

June:

What I want to do at the moment is to go travelling and I can’t at the moment, I want to go away for a holiday but I will have to wait. That is what I want; I really, really want to go away.

June and a friend were hoping to go to Jamaica in a year’s time, health permitting.

Maintaining hope and encouraging a future orientation may be important factors to consider in devising interventions for patients with CHD and depression. Patients with CHD may need some help in either finding a future goal or in taking practical steps to achieve something they want to do.

The positives

Although all five participants had positive scores for the PHQ-2⁸⁰ and had suffered from periods of ‘unhappiness’ over the course of their lives, participants spoke about the positive aspects of their lives, their friendships, interests, hopes and dreams or about how they had successfully tackled personal problems, such as alcohol abuse. Of the five participants:

• four had a close friend, group of friends and contact with family members
• four mentioned things that they enjoyed doing
• one participant had used his experience of heart disease as an opportunity for personal growth and improved care of self
• the unhappiest participant was trying to improve his situation by volunteering and by trying to understand his unhappy relationship
• two participants with alcohol problems had managed to either abstain or moderate their drinking behaviour.

One participant, James, thought that his heart disease had given him the opportunity for change and personal growth. James explained as follows:

I started the yoga and the Buddhism and a couple of the meditation techniques. It did change me quite a lot and I was quite happy about that change . . . I used to be somebody I didn’t like very much and now I am somebody who is OK, as far as I’m concerned. I used to treat people very badly and I used to argue about anything and would drink a lot and I have stopped doing a lot of those things really.

In the excerpt above James explained how having a heart attack had been a catalyst for change in his life. He had also changed his diet and lost 5 stone in weight.

Participants’ perceptions of what caused or contributed to feelings of distress and depression

Participants talked about the issues that they felt had contributed to or caused their depression and these included fear of dying, boredom, unhappy relationships, chronic pain and disability, low self-confidence, alcohol abuse, being bullied and being bereaved.

In the interview with Geoff, dying and fear of dying was a topic touched on in different ways. Geoff was understandably scared when he realised he was about to undergo open-heart surgery. Geoff also referred to his sense of frustration with other heart disease sufferers who were becoming ‘cardiac invalids’ because of their fear of dying and he gave examples of friends who had suddenly died from a heart attack, reminding him of his own mortality.

The following extract describes Geoff’s reaction when he first realised he was going to have a heart operation.

Geoff:

So I went up the hospital earlier about me stomach he looked at me diagrams and me sheets and all that and he said ‘do you want us to do this one first’ and I thought ‘what one is that?’ He said sort out yer valves in your artery and so I said Oh . . . !

Researcher:

So that was news to you was it?

Geoff:

Scary and all. So I said ‘OK then’ he said ‘do you want to know what the chances are of dying?’ and he said ‘six to one′ so I said ‘all right then.’ So he said it will be a little while before we get a spare bed so I come home here and then I got a phone call to say could you come in. So that’s when the scary part went in!

Geoff’s interview provided examples of how the reality of dying had affected and distressed him. Indeed, since his operation some years ago he had become very interested in health matters and had devised his own fitness regime that involved monitoring his heart rate, using a wrist monitor. One could speculate that Geoff’s anxieties had been channelled into monitoring his heart rate, as the following extracts might suggest:

Researcher:

You go fishing yeah and what does going fishing do for you? Why do you prefer going fishing to group therapy?

Geoff:

Because I can train. I got a hill like that (tilts hand) and I go up the hill but I don’t do that straight away but that’s a little bit of training that is getting me heart pumping I do it and when I reach the 120 heart murmurs I stop because I have to watch . . . that’s a good idea if you can get them free, a heart watch so if people are training and have just had open heart surgery and the doctor said ‘if you want your heart rate to be 120 you should look at your watch and if it says 120 and then I stop, stop going up the hill work it to about 112 and then I will carry on back up the hill, don’t forget I’ve got all me fishing gear with me and a barra [barrow].

And later in the interview he continued . . .

So when I go fishing there is a hill and it is a hill, but I want to work me heart so going up this hill is errh when I get to 120 . . . I done 130 actually and then I did stop. I wasn’t out of breath but I just thought ‘well that’s too much for me’ so I went and I looked at me clock and it was 130 and I thought ‘that’s quite good’, it went down to 112 and when it goes down to 112 the heart is (makes pumping sounds) just nicely beating . . .

Although Geoff was doing something positive about his health, his need for reassurance through biofeedback could be a manifestation of the anxiety he was experiencing. Geoff was not interested in attending group therapy sessions because he felt that listening to everyone’s symptoms of heart disease would make him worried for them (or perhaps remind him of his own health issues).

Discussion

The themes explored in this pilot study have revealed more similarities than differences among five participants who were purposively sampled for contrasting demographic backgrounds.

The participants did not want to be perceived as ‘moaning and groaning’ in relation to accessing health care and were mostly uncomfortable in talking about their feelings and ambivalent about accessing mental health services.

Although all of the participants had experienced unhappiness in their lives (mainly owing to relationship problems) they were all still trying to do the best they could and seemed to prefer taking their own courses of action to improve their lives, thereby preserving a sense of agency, control and future orientation.

For all of the participants, having heart disease and the symptoms of heart disease did not seem to be their main health concern. In contrast, chronic pain and impaired mobility caused by conditions such as arthritis seemed to affect participants the most.

Most participants would like to be able to attend dedicated gym sessions for people with heart problems so that they feel safe and supported. As dedicated sessions provide an opportunity for social interaction with other people with heart problems there is also an opportunity to make these fun and enjoyable and thereby emotionally therapeutic.

The main difference between the responses of the participants was evident with one participant, James, who seemed more comfortable about introspecting and talking about his feelings. James occupied the highest occupational status of the five participants and this difference in socioeconomic status/social class might indicate that he has access to and is familiar with psychological discourses, whereas the other four participants appeared to refer to ideas of stoicism in preference to introspection. There may well be issues of social class influencing the importance patients place on their feelings and whether or not these are appropriate and safe topics to discuss, either with a researcher or a health-care professional.

How the pilot study informed the main interview study

For the pilot study, an unfocused interview approach was adopted to allow participants to raise issues that were salient to them around the topic of CHD and depression. Findings from the pilot interviews and UPBEAT-UK literature reviews were used to inform the topic guide for the main interview study. This approach allowed us to balance topics identified in academic literature with patient-centred perspectives.

The researcher commenced the interviews by asking the following question: ‘So, if you wouldn’t mind just starting by telling me about when you first knew that you had some problems with your heart.’ Participants responded to this request by recounting personal accounts of their lives in the context of CHD and depression. This narrative approach worked well in the pilot study; it provided an opportunity to assess how participants perceived the connections between their physical, social and emotional worlds, in the context of illness. For this reason a narrative-based topic guide was developed for use in the main interview study.

Study results

RS interviewed 30 patients with CHD and symptoms of depression. The main findings from this study have been published in an open access journal paper by Simmonds et al.⁸⁵

The interviews were conducted using a narrative approach guided by topics informed by findings from the pilot interview study.

While recounting their stories of CHD and depression the following topics were explored:

1. participants’ perceptions of the relationship between their physical and mental health
2. participants’ experiences of living with depression
3. participants’ own self-help strategies for coping with depression
4. participants’ views and experiences of primary care interventions for depression
5. participants’ ideas for primary care-based interventions for depression that they would like to be made available.

Direct links made between coronary heart disease and depression

Of the 30 participants interviewed, 63% (19 participants) were male. Nearly half of these male participants (30% of the sample) reported feeling depressed, very depressed or suicidal after having a heart attack and explicitly stated a link between feeling depressed and having CHD.

The way men described their feelings was closely connected to the loss of perceived manliness (emasculation) and gender roles, which included loss of ability to work, erectile dysfunction and generally feeling ‘useless’.

Indirect links made between coronary heart disease and depression

Fewer direct links were made between CHD and depression by participants who reported a history of negative life events.

Factors contributing to or causing depression in this category were underpinned by feelings of interpersonal loss. The main issues that participants reported as ‘getting them down the most’ were:

• marriage and partnership breakdown/unhappiness, problems with access to children after marital breakdown, loss of home/homelessness
• bereavement issues through the death of a child, partner, parents and friends
• being a full-time carer for wife, not having any support or respite and not being able to visit children in America.

Although partnership breakdown was reported as being a major, long-term, stressful experience by male and female participants alike, more male participants talked about the added stress of either losing touch or being denied access to their children. Destructive family politics were mentioned by a number of participants, both male and female, and these corrosive situations had caused a great deal of stress.

For participants who had talked about marital or relationship breakdown the breakdown had preceded CHD and participants partly attributed their feelings of distress or depression to this experience and partly to their physical condition. Experiencing stressful life events was seen more as a factor that caused participants’ heart disease rather than heart disease causing them to feel depressed.⁸⁶

Participants experienced bereavement as a severe loss and the source of ongoing distress. Some participants believed that there was a causal link between experiencing grief and heart disease. Parkes et al.⁸⁷ argued that the association between heart disease and bereavement is one that cuts across social class difference. Patients with CHD may need particular help in the case of bereavement.

One participant was a full-time carer for his wife, who was incapacitated through rheumatoid arthritis. Although this participant was in his eighties and had suffered a heart attack, he did all the housework, washing, cooking, shopping and personal care for this wife.

This participant reported feeling depressed about being trapped in the daily grind of being a carer and not being able to visit his children in America. His wife refused any respite care and her family were unsupportive. The loss that this participant was experiencing centred round a loss of freedom, which included the freedom to visit his children in America.

Weak links made between coronary heart disease and depression

A number of participants were coping with CHD and comorbid conditions including: asthma, psoriasis, chronic obstructive pulmonary disease (COPD), arthritis, diabetes, thrombosis, sarcoidosis, stroke, hearing loss, poor eyesight, diabetic blindness, memory loss, prostate problems, kidney problems, paroxysmal positional vertigo, morbid obesity, underactive thyroid and restless leg syndrome. Chronic painful conditions limited mobility and interfered with the daily activities of participants.

Conditions that caused pain, such as arthritis, seemed to distress participants the most. As there are no ‘cures’ for some health conditions participants were faced with a seemingly never-ending illness trajectory. These factors, coupled with the realities of ageing, made the future seem bleak for some participants. Links made between depression and CHD were weaker in participants coping with other painful health conditions. Participants with comorbidities seemed more depressed and attributed low mood to physical conditions that were painful and disabling, such as arthritis.

NHS interventions and services participants found helpful or unhelpful

NHS services for depression that participants did not find helpful

Discussion

Most participants in this study had suffered heart attack(s) and other health/personal traumas that had impacted on every area of their lives. The losses experienced by participants were complex and multiple. For this reason the association participants made between CHD and depression varied substantially.

Male participants in the study made the strongest links between their physical state and mental health. Charmaz⁸⁸ (p. 268) observed ‘illness can reduce a man’s status in masculine hierarchies, shift his power relations with women and raise his self-doubt about masculinity’. These observations were reflected in our study of men who felt emasculated by CHD. Men who suffer serious cardiac disease may need specific therapeutic support to help them find new ‘scripts’ through which they can perform positive masculine identities.

Participants who had suffered losses in their personal relationships through divorce and bereavement made weaker causal links between CHD and depression. These participants attributed depression mainly to the unhappiness and upheaval they had experienced in their lives. Together with patients who had multiple health conditions, these participants felt that they needed someone to talk to, who would get to know them, rather than take antidepressant medications. Patients who have lost a partner through death or divorce might find the experience of ageing and ill health a lonely process. These participants do not want to ‘burden’ their children with their concerns and they are reluctant to talk to their GP because they generally do not want to be perceived as ‘moaning and groaning’. Older CHD patients, living alone, may be more susceptible to depression if they lack an intimate confidante and someone they can share age-related anxieties with.

The theme of resistance underpinning reasons participants gave for not wanting to take antidepressants may be reflecting one way in which patients can reclaim some control. These patients may have been demonstrating resistance to the medicalisation of their lives and perhaps the resulting feelings of disempowerment this engendered. As a number of participants felt that their lives were already dominated by ‘taking pills’ perhaps they felt they could say ‘no’ to antidepressants, in contrast to the rest of their medication, which was probably essential to the functioning of their hearts. A diagnosis for depression as a ‘mental illness’ is a culturally powerful label that can have serious implications for how a person is perceived. Resisting antidepressants could be a way of resisting the meaning given to ‘depression’ via medical records and biomedical discourse.^89–92

Barriers to accessing care provided by GPs, such as an overly bureaucratic GP appointment system, a lack of patient privacy when upset and a lack of continuity of care can affect the quality of care for patients with mild to moderate depression.⁹³ Continuity of care, that allows the patient to develop a relationship over time with one GP, might also have the benefit of improving facilitation of conversations about emotions and feelings for patients who are distressed or depressed. Privacy and continuity of care may be important elements to consider when designing a primary care intervention for CHD and depression.

From care currently provided by the NHS for patients with CHD, CR courses and appropriately supervised exercise were rated highly by participants. However, the fact that participants enjoyed CR may not equate with a significant improvement in their depressive symptoms. A longitudinal study on the effect of CR on depressive symptomatology⁹⁴ concluded that exercise itself is not effective in alleviating depression and that CR programmes should provide specific screening and treatment for depression. Doing something enjoyable or useful is important to most people and perhaps this should be seen as just one important ingredient in a holistic approach to improving mental health rather than a treatment for depression per se.

Although a theme of ‘loss’ underpins participants’ accounts of CHD and depression, this does not mean that participants’ lives were totally devoid of happiness and pleasure. Participants talked about enjoying rewarding relationships with grandchildren, going on holidays and day trips, doing voluntary work and in self-development. Despite having symptoms of distress/depression, most participants had hopes and dreams for the future, some of which could be achieved through support in goal-setting and realistic pacing. A primary care intervention that includes a mentoring approach, as part of a stepped care model for treating depression, could help patients identify and achieve some of their goals while enhancing a sense of self-determination and control over their lives. Table 4 summarises participants’ ideas and preferences for interventions that could be delivered in primary care.

TABLE 4

Summary table of participant ideas/preferences for primary care interventions for CHD and depression

How findings from the interview studies informed the pilot intervention

A clear finding from the patient interview studies was that (1) participants were experiencing a range of social, physical and gender identity (erectile dysfunction) losses; (2) some participants preferred to do things on their own, whereas others preferred group activities; (3) most participants had hopes and dreams for the future or enjoyed some aspect of their lives; (4) participants felt disempowered by ill health and the medicalisation of their lives; (5) participants preferred therapeutic treatment approaches for depression; (6) participants were not enthusiastic about antidepressant medication; and (7) loneliness was a problem for a number of participants.

Given the diverse needs of the sample (older people with chronic health conditions who feel lonely, men who felt emasculated and/or want to work again and participants who had experienced a number of adverse life events) an intervention for patients with CHD and depression may need to adopt an individual approach that can accommodate the specific sociocultural and personal needs of patients. A holistic, case management/mentoring approach to depression in CHD could help patients to feel more empowered and in control of their lives, especially if they are supported to achieve personal and health goals.

While conducting the patient interview study, interim findings, participant suggestions and final conclusions were discussed iteratively with the UPBEAT-UK team. The final design of a primary care, nurse-led complex intervention was informed by both the GP and PN (see Chapter 2), and patient qualitative studies together with the UPBEAT-UK literature reviews.

Plans for the content and structure of a nurse-led complex intervention were discussed in-depth with patients (suffering from sCHD and depression) during a series of two focus groups. Adjustments to the design and content of the intervention were made according to recommendations from the focus groups.

Ethical approval

Bexley and Greenwich Ethics Committee gave ethical permission for the study (reference 07/H0809/38), and approval was obtained from NHS trust research governance offices in south-east and south-west London. The researcher (RS) consented the participants.