2.5 The concept of Distress
2.5.1 Physical health problems, life events and distress
Distress has been linked to a range of physical health problems. Adults experiencing distress were twice as likely to be diagnosed with heart disease, lung disease, arthritis or stroke when compared to adults who are not experiencing distress (Pratt, Dey & Cohen, 2007).
Chittleborough, Winefield, Gill, Koster and Taylor (2011) examined associations between distress and chronic health conditions among different age groups. Chittleborough et al used the Kessler 10 scale (Kessler, 2002) to measure distress, the scale assesses symptoms of depression and anxiety. Arthritis and distress were significantly associated with distress for all age groups, cardiovascular disease was significantly associated with distress for those aged 35 and over, asthma and osteoporosis were associated with distress in adults aged 50 and over.
Both Pratt et al and Chittleborough et al’s studies employed a cross-sectional design, therefore, the direction of the relationship between distress and physical health problems could not be inferred.
Distress has been linked to certain life events such as: having a reduction in income, becoming unemployed, going through a divorce or being isolated from family and friends (Shih & Simon, 2008; Taylor, Taylor, Nguyen & Chatters, 2018). Perissinotto et al (2012) conducted a population-based longitudinal study examining the relationships between health changes as people age. The authors found that loneliness, defined as the ‘subjective feeling of isolation, not belonging, or lacking companionship’ (p1080), was associated with feelings of distress. Data from a population-wide survey in Australia has also found that retirement increased the prevalence of distress in older adults (Phongsavan et al, 2006). Although the results may not be applicable to retired older adults who reside in the UK, Phongsavan et al found that being in employment fostered psychological well-being as working provided financial resources and was a valued social role within society.
In a qualitative study reporting interviews with 19 older adults, Kingstone et al (2017) found that participants viewed various forms of losses as justifiable causes of low mood or stress (which are perhaps characteristics of distress). Forms of loss included: a loss of significant relationships (e.g. spouses or friends), changes in physical health and mobility (e.g. joint replacement or osteoarthritis), changes in capabilities (e.g. driving) and a loss of control of daily life (e.g. burden of providing caregiving). Kingstone et al’s sample consisted of 18 females and only 1 male, therefore, male older people’s perspective on the causes of low mood or stress were absent.
33 2.5.2 Help-seeking when experiencing distress
An Australian study conducted by Clover, Mitchell, Britton and Carter (2015) asked oncology outpatients to complete a questionnaire assessing if they were distressed and if they intended to seek help for their mood problems. Distress was measured using the Distress Thermometer which has been widely validated in oncology settings (Ma et al, 2014). Clover et al reported that only one-third of distressed patients with cancer wished to be referred for help from the healthcare system when distressed. Similarly, an Australian study conducted by Baker-Glenn, Park, Granger, Symonds and Mitchell (2011) found that only 36% of distressed patients with cancer expressed a desire to seek help from healthcare services for their mood problems. Baker-Glenn et al found that patients with cancer preferred to manage their experiences of distress on their own, healthcare services were perceived to treat only the physical health problem. As both Baker-Glenn et al and Clover et al sampled distressed cancer patients, the findings may not be applicable to patients suffering from other physical illnesses, or people who do not suffer from any physical health problems.
Lay perspectives about help-seeking when experiencing distress has been explored by Walters, Buszewicz, Weich and King (2008). A total of 1 357 individuals, who attended seven general practices within inner-city London, completed a waiting room questionnaire which consisted of the 12-item General Health Questionnaire (GHQ 12; Goldberg et al, 1997) and questions on help-seeking preferences. The GHQ 12 measures distress and common mental health problems. The maximum score on the GHQ is 12. A score of three or over indicates that an individual is distressed, a score of 9 or more could suggest that an individual is experiencing a mental health problem (Ozdemir & Rezaki, 2007; Baksheev, Robinson, Cosgrave, Baker & Yung, 2011). Of those participants who scored as distressed in Walters et al’s study, 53% reported that they did not wish to consult a GP and preferred to self-manage their distress. Participants self-managed their mood problems by seeking help from friends
and family, engaging in relaxation activities or exercising. Participants who scored higher on the GHQ 12 questionnaire, and who could have possibly received a diagnosis of a mental health problem, particularly valued self-management strategies which permitted social contact. Walters et al’s findings may not reflect the views of individuals who do not attend their general practices, these individuals might have a higher preference to self-manage their mood.
One Australian qualitative study, reporting interviews with 22 adults who lived in rural areas, suggested that individuals may wish to self-manage their experiences of distress due to a sense of stoicism (Fuller, Edwards, Proctor & Moss, 2000). The concept of stoicism has been defined as ‘a lack of emotional expression and exercising emotional control or endurance’ (Wagstaff & Rowledge, 1995: p181). Fuller et al found that individuals who held stoic attitudes assumed greater responsibility for managing their distress, this created a reluctance to seek help from healthcare services. A limitation of Fuller et al’s study is that they did not define how they categorised a rural area. The authors reported that the study setting was the Northern and Western regions of Southern Australia, which are largely populated by remote communities. Fuller et al also did not solely sample older adults, a sense of stoicism may be increased within this population due to the range of barriers to care described in Section 2.4. The literature I have presented within this section suggests that some individuals experiencing distress do not seek help from healthcare services and may hold stoic attitudes towards
managing their mood problems. However, some studies have focused on the management of distress within primary care, I explore these studies within the next section.
2.5.3 Managing distress in primary care
When studying ‘hard to reach’ groups, which were defined as groups of people who were less likely to seek care for mental health problems (e.g. older adults), Bristow et al (2011) found
that distress was not recognised as a biomedical problem and that a biomedical treatment was deemed inappropriate. Geraghty et al (2017) explored lay perspectives on the solutions offered by GPs when experiencing distress. Interviews were conducted with 20 patients whose GPs had identified them as experiencing distress. Patients reported that GPs primarily offered reassurance, time off work or medication to help them to sleep. Geraghty et al
reported that GPs sometimes labelled patients as ‘depressed’ to access a wider range of treatments such as antidepressants or psychological therapies. Geraghty et al argued that interventions are needed which de-medicalise distress and point towards self-management strategies. The participants within Geraghty et al’s research were predominantly older adults, making the findings important for the current study.