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Background: Multimorbidity is increasingly the norm; however, primary care remains focused on single diseases. Osteoarthritis, anxiety, and depression are frequently comorbid with other long-term conditions (LTCs), but rarely prioritized by clinicians., Objectives: To test the feasibility of a randomized controlled trial (RCT) of an intervention integrating case-finding and management for osteoarthritis, anxiety, and depression within LTC reviews., Methods: A pilot stepped-wedge RCT across 4 general practices recruited patients aged ≥45 years attending routine LTC reviews. General practice nurses provided usual LTC reviews (control period), then, following training, delivered the ENHANCE LTC review (intervention period). Questionnaires, an ENHANCE EMIS-embedded template and consultation audio-recordings, were used in the evaluation., Results: General practice recruitment and training attendance reached prespecified success criteria. Three hundred and eighteen of 466 (68%) of patients invited responded; however, more patients were recruited during the control period (206 control, 112 intervention). Eighty-two percent and 78% returned their 6-week and 6-month questionnaires, respectively. Integration of the ENHANCE LTC review into routine LTC reviews varied. Case-finding questions were generally used as intended for joint pain, but to a lesser extent for anxiety and depression. Initial management through referrals and signposting were lacking, and advice was more frequently provided for joint pain. The stepped-wedge design meant timing of the training was challenging and yielded differential recruitment., Conclusion: This pilot trial suggests that it is feasible to deliver a fully powered trial in primary care. Areas to optimize include improving the training and reconsidering the stepped-wedge design and the approach to recruitment by targeting those with greatest need., Trial Registration: ISRCTN registry (ISRCTN: 12154418). Date registered: 6 August 15. Date first participant was enrolled: 13 July 2015. https://www.isrctn.com/ISRCTN12154418?q=depression%20schizophrenia&filters=conditionCategory:Not%20Applicable&sort=&offset=5&totalResults=9&page=1&pageSize=20&searchType=basic-search., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Depression is a common problem, often being recurrent or becoming chronic. The National Service Framework for Mental Health (published by the Department of Health, 1999) states that people with depression should continue to be predominantly managed in primary care. There is much evidence that the detection and management of depression by GPs could be improved, but little work has focused on GPs' views of their work with depressed patients., Objectives: This was a qualitative study exploring GP attitudes to the management of patients with depression. Views of GPs in socio-economically deprived areas are compared with those serving more affluent populations., Methods: Semi-structured interviews were conducted with two groups of GPs in north-west England. One group of GPs (22) were practising in inner-city areas, and a second group (13) in suburban and semi-rural practices. All were Principals in practices that participated in undergraduate teaching. The interviews were audio-taped and subsequently transcribed verbatim. Analysis was by constant comparison until category saturation of each theme was achieved., Results: Subjects conceptualized depression as an everyday problem of practice, rather than as an objective diagnostic category. Thematic coding of their accounts suggests a tension between three kinds of views of depressed people: (i) That depression is a common and normal response to life events or change and that it reflects the medicalization of these conditions; (ii) That the label or diagnosis of depression offers a degree of secondary gain to both patients and doctors, particularly to those GPs practising in inner-city areas and (iii) That inner-city GPs experienced on-going management of depressed people as an interactional problem, in contrast to those GPs serving a less deprived population who saw depression as a treatable illness and as rewarding work for the GP., Conclusion: Depression is commonly presented to GPs who feel that the diagnosis often involves the separation of a normal reaction to environment and true illness. For those patients living in socio-economically deprived environments, the problems, and therefore the depression, are seen to be insoluble. This has an important implication for the construction of educational interventions around improving the recognition and treatment of depression in primary care: some doctors may be reluctant to recognize and respond to such patients in depth because of the much wider structural and social factors that we have suggested in this paper. That it is the doctors working with deprived populations who express these views, means that the 'Inverse care law' [Tudor Hart J. The inverse care Law. Lancet 1971; 1(7696): 405-412] operates in the management of depression.

Background: Qualitative research methods are recognized increasingly as valuable tools for primary care research, and add an extra dimension to quantitative work., Objective: The aim of this study was to illustrate the benefits and problems attending the dual role of clinician/qualitative researcher., Methods: As part of two studies employing semi-structured interviews of GPs in a North-West conurbation, about the topics of consultations on chronic low back pain and drug misuse in primary care, respondents' views on their interaction with a GP researcher were explored., Results: Access to the GP by the interviewing GP was easier when the GP researcher was known to the respondent. Such prior knowledge, however, may then influence the content of the data and the manner in which the GP researcher is perceived. During the interview itself, where respondents recognized the researcher as a clinician, interviews were broader in scope and provided richer and more personal accounts of attitudes and behaviour in clinical practice. The GP was also identified as an expert and judge, not just of clinical decision making but also about moral judgements made by GPs in their work. This will impact on the data obtained at interview and must be taken into consideration when the data are interpreted and analysed., Conclusion: Qualitative research techniques increasingly are advocated as appropriate for research on and in general practice. The professional identity of the researcher plays an important part in constructing the kind of data obtained in such studies, and this must be made apparent in reporting and discussions of such qualitative work.

Background: Patients presenting in primary care frequently exhibit physical symptoms that may be unrelated to organic pathology. Such symptoms are commonly regarded as products of psychological or emotional problems, and their legitimacy as 'medical' matters is often called into question., Objectives: Our aim was to explore GPs' attitudes to the management of patients that present with medically unexplained symptoms in primary care., Methods: Semi-structured interviews were conducted with 15 GPs in North-West England. Interviews were audio-taped and subsequently transcribed and analysed using a constant comparison technique., Results: Subjects conceptualized patients presenting with medically unexplained symptoms as the presentation of psychological distress. They presented problems of control and authority in the consultation, and difficulties in managing this had a negative impact on the doctor-patient relationship. Such consultations were frustrating for the GP and potentially harmful to the patient., Conclusion: Patients with medically unexplained symptoms were seen to be presenting with inappropriate symptoms that were a manifestation of emotional or social distress. GPs felt ill-equipped to deal with the presentations and the frustrations they felt and may need help in actively and productively managing these patients.