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Addition to Literature Review

In accordance with Mojtabai, Olfson and Han (2016), depression is one of mental illness that

occur the most among adults and a high amount of heath care costs are linked with adult

population. It has been projected that depression will be one of leading mental illness among

adults by year 2020. The author projected the prevalence of depression among patients aged

above 60 years may be high as 45% in community healthcare centers while adults below 60

years may be 8 % - 18% in the community health care settings. The depressive states and its

associated prognosis appear to be poor. There has been a meta analysis performed that resulted at

two years and estimated that there were 35% patients who were depressed while 27% patients

died after suffering from depressive states. Another research studies in relation to this subject

indicated that depression among adults might or might not have depressive disorder to symptoms

but they definitely have poorer functioning. This might get worse with the passage of time and

come up with chronic medical conditions like lung diseases or heart attacks, diabetes,

hypertension and arthritis. Additionally, poor functioning not only disturbs the social life of

patients but there is an increased tendency of poor health and high utilization of healthcare costs

and medical services (Strawbridge, Arnone, Danese et al, 2015).

Depression among adult causes poor self rated heath status and such presence is viewed

generally as a risk factor for people. There are recent research studies that highlighted people

who had high chronic diseases had a depression with a higher risk as compared to those with no

chronic diseases. Meanwhile, people with poor self rated heath issues had depression with higher

risk as compared to those people who had good self rated health. But, there are some research

studies which have been investigated and showed that health status is not the only factor that is
 3

linked directly linked with depression among adults (Hallgren, Kraepelien, Öjehagen et al,

2015).

In accordance with Hodgson, Atherton, Stanton et al (2016), depression is a critical and

significant issue among adults and with medical professionals who work for the healthcare of

depressed patients. With the rise in adult population, the tendency of expectation is rising,

showing a higher number of adults suffering from depression. Hence, it is vital and a definite

need to research the risks associated with depression among adults. Wang, Hua, Fu et al (2017)

stated that the factors that incline the risk of depression are health status, financial position,

social status and leisure life. Although, these factors are not restricted for depression but they are

accumulated as significant factors that might cause depressive syndrome or symptoms among

adults.

Hobbs, Joubert, Mahoney et al (2018) concluded that the practice and theory of positivism is

counted in one of the examples used in the community health care to treat depression among

adults. The healthcare professionals and nurses use positivism as non medication treatments for

promoting depressed adults for practicing positive health behavior like following health lifestyle

(for instance no smoking, healthy diet, limited alcohol consumption and avoiding other

unhealthy habits) and medication compliance. This type of treatment in community healthcare

clearly follows a behavioral model theory for depression that relies on maintenance of positive

interaction with depressed patients and limits negative communication that incline depressed

feelings. In accordance to this theory, if an individual who is unable to communicate with the

healthcare staff positively or in the healthcare environment or cannot give appropriate responses

then it is most probable that the tendency of depression might increase (Richardson and

Barkham, 2017).
 4

In the collaborative care model, Varma, Karadag, Oguzhanoglu et al (2017) and Wells and

Sherbourne (2017) agreed with each other with respect to the key elements of the model that

defined the problem really well. It created an understanding among the medical clinicians and

healthcare staff for taking active part in treating depressed patients. This model allowed in

accepting inputs from patient in making a preferred choice in the concerned treatment.

According to Hodgson, Atherton, Stanton et al (2016), one of the significant roles of healthcare

staff in depression recovery to maintain a good relation with the patient while recording and

monitoring the progress of the patient. The record history can be discussed with the GP (General

Physician) to decide whether the treatment should be continued or to put any variation in the

treatment. In some cases, the health care staff may provide direct medical care to the depressed

patient for lowering the risk of depression.

Chang-Quan, Xue-Mei, Bi-Rong et al, (2016) established a statement upon the collaborative care

model that collaborative care acts as a vital component while treating depression and recovering

patients from depression. In a community health care, the medical staff is responsible to show

minimum amount of assistance and enable patients for self recovery. By using this instinct, it

shows that it is good sign in nursing staff for drawing expertise in these cases. In simpler words,

curses can execute collaborative care model in a manner to ensure that the treatment of

depression is effective.

According to Chisholm, Sweeny, Sheehan et al, (2016), behavioral model theory of depression

states that behavior of people is a combination of action and reaction to their environment.

Moreover, the outcome of depressed patients’ outward expression is a result of external and

internal environment and not merely to their response to external impact. In this manner, the

healthcare staff may start collaborative care perspectives for making a situation so that patient
 5

can combine both their actions and reactions according to the environment for reducing their

depression.

The role of community healthcare staff is to establish a social support infrastructure as it is the

most critical need of adults suffering from depression as indicated by Chisholm, Sweeny,

Sheehan et al, (2016). The researcher emphasized upon the duties of nurses that they must be

forefront to bridge the gap among the factors that have caught people with depression. The

nurses need to make new relationships among adult patients in order to fulfill their social need by

educating and counseling the patient regarding their depression. Hence, these steps would assist

nurses in preventing depression and chronic diseases and also speed up the recovery of patient if

care is taken well through social support (Strawbridge, Arnone, Danese et al, 2015).
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Chapter 4: Findings and Analysis

Introduction

After analyzing the literature for this research study, it can be argued that the knowledge given

on depression is conceptualized. The statement will be further critically analyzed in the light of

scientific objectivism and clinical contexts by taking depression and its recovery by considering

community health care. This chapter will apply and formulate a critical perspective that will help

in enabling a deep understanding for a complicated epistemological situation in regard of

occurrence of depression and its recovery as a function of normative principles. It will further

assist in governing the knowledge production on the research topic.

Discussion

Depression can be taken as an object of an individualized and natural occurrence. In

contradiction, there are many actions and terms where similar amount of knowledge discuss

depression as a fundamental historical phenomena that does not behold any meaning without a

normative and political framework which goes beyond the individual experience.

Depression portray not only as a state of depressed mood but it also refers to a syndrome that

comprises of variety of vegetative and somatic disturbances, psychomotor changes and mood

disorders in a clinical context. A thorough narrative analysis on depression explains that all of

the mentioned changes might be present within a mind of an individual but it shows not more

than a depressed or low mood and the occurrence is essential. Also depression emerges out as a

syndrome or symptom, mood or particular group of mental illnesses. According to Joyce,

Modini, Christensen et al (2016), depression can occur as an extent to these present symptoms
 7

and with a combination that might be variable infinitely while other symptoms are common as it

might dominate sometimes in a clinical situation.

With respect to the interpretivist view, Taylor (2016) and Johnson, Schonbrun, Peabody et al

(2015) have contributed a posthumanist and feminist oriented approach in their researches. A

detailed analysis shows that digital entanglements in regard of non-human and human objects

and elements influence the mental health of an individual. The feminist researcher have argued

on this point by stating that emotions, bodies, leisure lives and work of women are entangled in

global issues, patriarchal practices and bio political formations. These kinds of entanglements are

inclusive of different assortment of state and corporate agencies, individuals, human and non-

human elements.

Within the clinical psychology and psychiatric literature, it is observed that there are different

types of positions acquired on objects that bring depression within an individual’s mind. There

are some texts preserved from McCauley, Gudmundsen, Schloredt et al (2016), Jacobs, (2016)

and Fortinash and Worret (2014) who claimed, there is no current working definition offered

upon depression but there is a wide range of symptoms that have been explored. This approach

shows evidence in the researches of some biologists and psychologists due to their psychological

orientation. This is a clear indication that depression is a concept and has a self evident validity.

But, after performing a close inspection, the literature reveals that, there are many researchers

who have assigned primacy to various psychological phenomena while researching on

depression. For example, Corrigan, Druss and Perlick, (2014) and Bateman, Gunderson and

Mulder (2015) have presented texts who insisted that depression is caused primarily due to mood

disturbance and all linked phenomena are secondary objects to this affective depression state.

Meanwhile, there are other authors who focused primarily upon cognitive features of depression.
 8

In this respect, the most there is no current working definition offered upon depression but there

is a wide range of symptoms that have been explored. This approach shows evidence in the

researches of some biologists and psychologists due to their psychological orientation. This is a

clear indication that depression is a concept and has a self evident validity. But, after performing

a close inspection, the literature reveals that, there are many researchers who have assigned

primacy to various psychological phenomena while researching on depression. Influential views

were backed up by Deegan and his colleagues where they argued that a depressive behavior is

characterized by one’s negative self view, world and future (Deegan, Carpenter-Song, Drake et

al, 2017).

It can concluded from such observations that social constructionism is right to lay emphasis upon

the historical and cultural relativism of first individual’s emotional states but it is wrong during

problematizing every empirical claim regarding invariance in reality and causality of depression.

Medical naturalism is equally correct in this sense to put an emphasis on empirical investigation

of depression but it is wrong in natively confusing with historical and cultural specific

professional ideas with invariant reality templates (in relevance with depression). In other words,

the map is never place in the territory but if a certain case of depression is taken, the map

remains extremely unclear.

In accordance with Fortinash and Worret (2014), a theory of helplessness was proposedby

Abramson that focused on depression. The theory claimed that when depression occurs, there are

individual experiences in response to negative events that are uncontrollable. But, there are also

individual attributes to such causes that are internal to the self, global in their influence and

stable over time in number of areas in a person’s life. Subsequent research study by Gale,

Gilbert, Read et al (2014) has indicated that patients suffering from depression during their
 9

whole lives appeared to possess expected attributes for negative events but it was less clear that

attributes like internality were trait for vulnerability markers for depressed patients just as the

theory proposed.

In the light of such inconsistent findings, the theory by Abramson was revised further and it was

argued that the attributes represented as distal foundation of hopelessness and it was now

considered as the depressed mood’s proximal mediator. It seems clear that the model is valid for

a sub-type of depression which is why it was labeled as negative cognition of depression. For

avoiding the inevitable circularity of such position, Halter, (2017) made a comparison with

depressed patient with a pessimistic cognitive style against depressed patients suffering with

non- pessimistic cognitive style. The finding revealed that a former group of patients with

pessimistic cognitive style were probable to be diagnosed with personality disorder while other

group of patients was likely to be involved with abusive or difficult relations with their parents or

loved ones. This research clearly implies that attributes play a significant role in

psychopathology but it does not provide a certain complicated case for allocation of particular

causal role in sub-type of depression. It further complicates the matter when other researchers

like Johnsen and Friborg (2015) and Rosenbaum, Tiedemann, and Ward (2014) have revealed

that the self-styled `depressogenic’ attributes are observed in people who have been diagnosed to

be suffering from anxiety disorders.

In regard of recovery from depression, a proper execution of healthcare is needed for patients.

Adults suffering from depression in an early stage can overcome depression more easily as

compared to patients who have been suffering from depressive syndrome. This statement is

supported by Moos (2017) where he explained how different patients arrived at the rehabilitation

for treating depression. He researched on people who were suffering from depression and noted
 10

time duration since they were trapped in depressive moods. He found that people whose time

duration of depression was more than people with less time duration of depression appeared to

recover early in most of the cases. The recovery period from depression was dependent upon the

social and emotional need of the person that required intellectual skills of the healthcare workers

to make them relive and re-learn the real values of life. But, the important part while living in the

community was to make use of least professional support and learn from each other experiences.

A critical analysis on the literature tells that there is a significant impact or influence of

community care upon patients and the practices of rehabilitation upon the mental illness of a

person. It basically changes the perception of how one looks at things and perceive it internally

and externally. There are many patients who have cured and learnt to take world with a complete

new perspective and live a normal live. This is because community healthcare enables people to

shift their focus from mental illness model like depression toward a functional disability model.

There are other measures received as results from clinical conditions that portrays to be relevant

enough and matches with the mental illness stage of patients. This is specifically true in the

functioning of social roles that includes quality of life, family burden and social relationships

like work life and leisure life. These social roles are basically the major burdens for depressed

people who live their lives in the community. But, as time passes by it becomes much easier for

them to share their thoughts and get this burden out of their head after listening to other stories of

people living in the same community. Sharing bitter thoughts enable people to compare their

own negative events that have caused depression that eventually helps them to get their burden

off chest with minimal assistance of healthcare professionals or staff in the community.

In accordance with Jacobs (2016), the community health care for treating depression focuses on

disabilities and deficits of people that have caused depression. It also centres upon the
 11

aspirations, capacities and strengths of people in order to access the mind recovery stage. The

support services by the community healthcare aims to enhance the ability of a person in order to

develop an identity that is positive enough to frame their depression experience and self manage

their depression for pursuing personal valued social relationships.

A community health care that treats adults in overcoming their depression is a broadly defined

case. In particular, there are many factors which are considered while curing these people in the

community. For example, it emphasized on the management or reduction of environmental

adversity, strengths of social networks, communities, families and corporations that surround

people who suffer from depressive signs (Oud, Mayo-Wilson, Braidwood et al, 2016). The

individuals directly or indirectly call for a commitment to social justice by communicating the

need of undeserved population like homeless people, mortality in children and youth, ethnic

minorities and basic service provision where those people in need can be located and live in a

manner that is accessible and acceptable to the society.

After reviewing the research work by Deegan, Carpenter-Song, Drake et al (2017) in the

literature review, a critical analysis can be extracted from it. Evidence is found from the practical

ethics and clinical studies where a scientific approach to community healthcare service is shown

to prioritize the best available data on the interventions and its effectiveness while treating

depression. At this period of time, there are individuals residing in the community healthcare that

not only undergoes the depression but have no clue what they are currently experiencing. Hence,

for recovery stage, it is utterly significant to let these people know about their depression and the

cause that have led them to that particular depressive stage. But, it should be made to an extent

that healthcare professionals understand people. This approach seems very appropriate for

considering the available options for the interventions and helpful information that can assist in
 12

treating depression rapidly. Hence, the overall effect would reflect upon decision making

process, its effectiveness and minimize side effects while knowing the preferences of suffered

people.

The treatment and recovery of people suffering from depression depends greatly on the

intervention strategies used in the community healthcare. Generally, there are two intervention

strategies that prove helpful in the recovery from depression among adults. The first process in

the individual-centred strategy that develops the skills of patient in communicating the most

painful events that motivates them to get stronger and inspire other patient to get through their

depression. The second intervention strategy is the ecological approach and it directs towards the

development of environmental resources for reducing potential stressors (that made people to

suffer from depression). After reviewing the interventions, it can be said that the first strategy

gives more energy and power to overcome the depression in lesser amount of time as compared

to second strategy.

The structural components of healthcare, like policies and resources (facilities, healthcare

workforce and training) that bear measurement-based care are essential to achieve high-quality

health care. Although, the relevant structural measures provide the essential infrastructure to

report on results, processes and implementation of improvement measures, yet, they do not offer

enough information on the quality of services or the outcomes that are actually being provided as

intended or acceptable by the patient.

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Chapter 5: Conclusion

Introduction

This chapter will conclude the findings that have been obtained and discussed in previous

chapter. A brief literature review will also be highlighted in order to draw necessary and main

conclusions of this research study.

Synthesis of Conclusion

The research study is based upon people suffering from depression and their recovery from

community health care. Depression is considered as one of the most critical issues among adults.

As the number of adult population is increasing, the occurrence of depression is expected to rise

with the passage of time. The research study has investigated the risk of depression and the

factors that cause depressive symptoms. The identified factors that carry the tendency of causing

depression are poor health status, financial position, leisure life and social interaction.

The research has explored some of the gaps that are evident from the literature review. There are

previous research studies that have been conducted on investigating the phenomena of

depression and the chronic diseases that might happen after depression. It has been revealed that

addiction disorder and other mental illnesses are other issues that might trap a depressed patient

and makes their medical condition worse in the coming years.

Depression in adults causes poor health and is generally considered a risk factor for people.

Recent studies have shown that people with high chronic disease were at greater risk for

depression than those who did not have chronic disease. Meanwhile, people with low health had

a higher risk of depression than people with good self-esteem. But, there are some studies that
 14

have been studied that have shown that health is not the only factor directly related to depression

in adults.

The dependency of a depressed patient inclines upon the community health care staff in order to

assist them to cope with their lives. It is the utmost responsibility of health care nurses to

maintain their life balance and build new relationship while living with other patients going

through similar or worsen stages of depression while keeping least amount of their presence. The

least amount of aid is necessary in order to make depressed patients feel that it was their self

interest to recover from depression while they were under medical treatments. There are people

who live in community health care do not realise what they are going through. Therefore, it is

absolutely vital for the recovery phase to inform these people about their depression and the

cause that led them to this particular depressive episode. However, this must be done so that

health professionals understand people. This approach seems to be very suitable to consider the

available options for interventions and useful information that can help in the rapid treatment of

depression. Therefore, the overall effect would be reflected in the decision making process and in

its effectiveness, minimizing the side effects of knowing the preferences of the sufferer.

In response to the medical treatment in community healthcare, there exists a large gap of the

effectiveness of recovery from depression among adults. The investigation in the research study

has revealed that there are certain medical conditions in depression that has to be explored due to

which it lays a significant influence upon the effectiveness of depression treatments. Another

reason for this gap existence is that depression occurs in practical world which most of the time

collide with the theory in response to primary care settings.

The research has identified different roles of community health care staff in regard of treatment

of depression. It has discussed the guidelines that can be used for depression recovery for the
 15

community health care personnel for which the most appropriate goal is to provide medical

attention and care for a person suffering from depression. This is inclusive of establishing a trust

based relation and empathy with the depressed patient and encouraging them to use positivism in

their routine life. This practice enables the depressed patients to overcome the trauma that have

made them to suffer with depression. It also encourages the patient in developing a mechanism to

cope up with negative events and use problem solving skills with other patients. This creates a

positive health behavior like healthy choices, healthy lifestyle and medical compliance. During

the period of residing in a community health care, the medical personnel ensure to promote the

engagement of a patient with their support and social network. They also make sure that an

effective collaboration is established between other relevant medical service providers by means

of effective working communication and relationships. It is vital to promote and support the self

care activities among depressed patients as it revives their relations with their family and loved

ones and motivates them to overcome depression in order to live back to their normal lives.

There are researches that states the psychologists are more prone for assuming the psychological

functioning and continuous distribution of personality features with an inclusive sepressive

behavior while it is quite probable that psychiatrists argue that depression is a discontinuous state

or a category. This biasness in views is most likely to reflect the professional socialization of

each psychologists group that operates in the statistical assumptions regarding depressive

behavior and experience of negative events. On the other hand, the medical practitioners are

taught to differentiate between normal and abnormal behavior by emphasizing on the diagnostic

criteria of depression.

Authors who have focused on the cognitive characteristics of depressive behavior, there is no

current definition of the work that is offered on depression, but there is a wide range of
 16

symptoms that have been explored. This approach shows evidence in the surveys of some

biologists and psychologists because of their psychological orientation. This is a clear indication

that depression is a concept and has obvious validity

A critical analysis of the literature shows that there is a significant impact or influence of

community care on patients and rehabilitation practices in a person's mental illness. Basically, it

changes the perception of how one looks at things and perceives them inwardly and outwardly.

Many patients are healed and have learned to look at the world from a completely new

perspective and lead a normal life. In fact, community-based health care enables people to move

from a model for mental illness, such as depression, to a functional disability model. There are

other measures that are obtained due to clinical conditions that describe that they are sufficiently

relevant and consistent with the stage of the patient's mental illness.

There are mainly two interventions used for the treatment of depression. The first intervention is

individual-centred strategy while the second intervention is ecological strategy. Through proper

investigation, it can be said that the first intervention appears to be more effective in the

community healthcare. The reason for its effectiveness is that it requires less amount of health

care personnel engagement and it can be used at any stage of depression of patient.

Implications

The first implication occurs during the suggestion of middle or third position of critical realism.

This is because it will prove more helpful approach for investigating the factors that cause

depression among adults. This approach ensures that a proper caution is carried about cultural

and historical relativism with no degeneration into never ending nihilism and relativism that

meet social constructionism. This position is also aligned with the empirical findings about the

multiple determinants of depression and does not collapse into the medical naturalism and its
 17

nave realism. This implication is concerned with research, given that the depression concept is

extremely narrow for allowing the specification of biological and cognitive mediators of distress.

It might be necessary to imply the research focus on more narrowed defined experience and

behaviors like anhedonia, fatigue and low self esteem as experienced in particular social setting.

The second implication is based on a critical realist view for misery that is concerned with

depression formulation and associated interventions. The treatment followed for depression for

recovery in community health care setting suggest that many psychological approaches might act

helpful but using a combination of cognitive behavior therapy and antidepressant medication is

the most effective option as treatment.

Meanwhile, it is not surprising that a cognitive and biological pincer approach appears to be

effective in contrast to no treatment for helping depressive patients. There still exists a risk of

using such reductionist approaches to treating depression or distress as experienced by the

patient. The technical treatment might obscure the approach but there is a possibility to help the

patient to recover at a rapid pace. For instance, poor task control or insecurity in job roles might

increase the risk of depression among people. Also issues like unemployment often raise a

probability of suicide and demoralization. These points are helpful in diagnosis or identification

of depressive states in a person who is never willing to reveal their relationships and their

internal feelings that require social interaction rather than following the inquiry methods of

psychiatry.

Both implications are provided to focus upon the idiosyncratic formulations of patients’ current

and antecedent conditions. It is inclusive of the patient’s self attributed meaning that has shaped

the expression and experience of patient’s depression or distress. The approach and its relative

signs are evident already with the feminist therapy and community psychology with its
 18

therapeutically orientated forms. But, there is a latter for the psychodynamic roots and it has

been criticized several times for being prone to the psychological reductionism.

There is a holistic understanding that still persists and would meet the social determinants of

depression and would invite the exploration of individual attribute meanings of a depressed

patient. This understanding would be same to the current practices used in CBT (Cognitive

Behavior Therapy) but it will also include applying the lessons learnt from the model by

Abramson. This is because there is a strong evidence that has explored different antecedent

stressors in the context of sociological research on quality of life and healthy lifestyles. In the

most traditional form of CBT, it is still prone to the psychological reductionism as it relies upon

the cognitive processes of a person and implies that reality is not an issue, it is the direction that

is construed.
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