Implementation Strategies for Improving the Care of Depressed Elderly Persons—Summary of an International Workshop
Affiliation(s)
Centre for Women’s, Family and Child Health, Faculty of Health Sciences, Buskerud & Vestfold University College, Kongsberg, Norway.
Centre for Women’s, Family and Child Health, Faculty of Health Sciences, Buskerud & Vestfold University College, Kongsberg, Norway.
ABSTRACT
The aim of the study was to identify the most important research priorities as well as future strategies for promoting and implementing evidence-based care of depressed elderly persons. An interdisciplinary workshop was organized using a focus group format and the transcript of the discussion was interpreted by means of the qualitative content analysis. The most important research priorities for improving the care of depressed elderly persons, implementation levels, theoretical approaches as well as possible outcomes were analysed on individual consumer, healthcare system, and policy level. A wide range of theories and methods are necessary to identify and explain implementation processes and results. Qualitative and quantitative methodologies in combination with knowledge synthesis were discussed. In addition, the need to summarize the literature in terms of specific issues was emphasized. In conclusion, the implementation strategies for improving the care of depressed elderly persons should be addressed on three levels: individual consumer, healthcare system and policy. Although some aspects of the implementation model may need to be enhanced, the fact that it includes conditions on individual level, i.e. self-management support, is of importance. The expansion and maintenance of evidence-based care generate potential for change in mental healthcare, thus improving outcomes for individual elderly patients. Areas that require further research are organization, cost and leadership. The use of mixed methods could strengthen future studies. Implementation researchers need a broad repertoire in order to plan and perform evidence-based research. To improve practice, implementation strategies should be developed in clinical and community guidelines.
The aim of the study was to identify the most important research priorities as well as future strategies for promoting and implementing evidence-based care of depressed elderly persons. An interdisciplinary workshop was organized using a focus group format and the transcript of the discussion was interpreted by means of the qualitative content analysis. The most important research priorities for improving the care of depressed elderly persons, implementation levels, theoretical approaches as well as possible outcomes were analysed on individual consumer, healthcare system, and policy level. A wide range of theories and methods are necessary to identify and explain implementation processes and results. Qualitative and quantitative methodologies in combination with knowledge synthesis were discussed. In addition, the need to summarize the literature in terms of specific issues was emphasized. In conclusion, the implementation strategies for improving the care of depressed elderly persons should be addressed on three levels: individual consumer, healthcare system and policy. Although some aspects of the implementation model may need to be enhanced, the fact that it includes conditions on individual level, i.e. self-management support, is of importance. The expansion and maintenance of evidence-based care generate potential for change in mental healthcare, thus improving outcomes for individual elderly patients. Areas that require further research are organization, cost and leadership. The use of mixed methods could strengthen future studies. Implementation researchers need a broad repertoire in order to plan and perform evidence-based research. To improve practice, implementation strategies should be developed in clinical and community guidelines.
Cite this paper
Severinsson, E. and Holm, A. (2014) Implementation Strategies for Improving the Care of Depressed Elderly Persons—Summary of an International Workshop. Open Journal of Nursing, 4, 715-723. doi: 10.4236/ojn.2014.411076.
Severinsson, E. and Holm, A. (2014) Implementation Strategies for Improving the Care of Depressed Elderly Persons—Summary of an International Workshop. Open Journal of Nursing, 4, 715-723. doi: 10.4236/ojn.2014.411076.
References
[1] World Health Organization (WHO) (2012) Depression Is a Common Illness and People Suffering from Depression Need Support and Treatment.
http://www.who.int/mediacentre/news/notes/2012/mental_health_day_20121009/en/ [2] Batterham, P.J., Christensen, H. and Alison, L.C. (2013) Anxiety Symptoms as Precursors of Major Depression and Suicidal Ideation. Depression and Anxiety, 30, 908-916. [3] Chou, K.L. and Cheung, K. (2013) Major Depressive Disorder in Vulnerable Groups of Older Adults, Their Course and Treatment, and Psychiatric Comorbidity. Depression and Anxiety, 30, 528-537.
http://dx.doi.org/10.1002/da.22073 [4] Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R. and Hensley, M. (2011) Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Administration and Policy in Mental Health, 38, 65-76.
http://dx.doi.org/10.1007/s10488-010-0319-7 [5] Peters, D.H., Nhan, T.T and Taghreed, A. (2013) Implementation Research in Health: A Practical Guide. Alliance for Health Policy and Systems Research, World Health Organization.
http://apps.who.int/iris/bitstream/10665/91758/1/9789241506212_eng.pdf?ua=1 [6] Peters, D.H., El-Saharty S., Siadat B., Janovsky, K. and Vujicic, M. (2009) Improving Health Services in Developing Countries: From Evidence to Action. World Bank, Washington DC. [7] Wallin, L. (2009) Knowledge Translation and Implementation Research in Nursing. International Journal of Nursing Studies, 4, 576-587.
http://dx.doi.org/10.1016/j.ijnurstu.2008.05.006 [8] Grol, R., Bosch, M., Hulscher, M., Eccles, M. and Wensing, M. (2007) Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives. The Milbank Quarterly, 85, 93-138.
http://dx.doi.org/10.1111/j.1468-0009.2007.00478.x [9] Holm, A.L. and Severinsson, E. (2013) Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons—A Norwegian Qualitative Implementation Study. Nursing Research and Practice, 2013, Article ID: 794743.
http://dx.doi.org/10.1155/2013/794743 [10] Holm, A.L. and Severinsson, E. (2014) Perceptions of the Need for Improvements in Healthcare after Implementation of the Chronic Care Model. Nursing& Health Sciences. (Pub Ahead of Print)
http://dx.doi.org/10.1111/nhs.12136 [11] Severinsson, E. (2014) Capacity Building—Challenges for Nurse Managers. Journal of Nursing Management, 22, 407-409.
http://dx.doi.org/10.1111/jonm.12209 [12] Andvig, E., Syse, J. and Severinsson, E. (2014) Interprofessional Collaboration in the Mental Health Service in Norway. Nursing Research and Practice, 2014, Article ID: 849375.
http://dx.doi.org/10.1155/2014/849375 [13] Grol, R. and Grimshaw, J. (2003) From Best Evidence to Best Practice: Effective Implementation of Change in Patients’ Care. The Lancet, 362, 1225-1230.
http://dx.doi.org/10.1016/S0140-6736(03)14546-1 [14] Holm, A.L. and Severinsson, E. (2013) A Systematic Review of Emotional State and Self-Management among Widows. Nursing and Health Sciences, 14, 109-120.
http://dx.doi.org/10.1111/j.1442-2018.2011.00656.x [15] Holm, A.L. and Severinsson, E. (2014) Surviving Depressive Ill-Health: A Qualitative Systematic Review of Older Persons’ Narratives. Nursing and Health Sciences, 16, 131-140.
http://dx.doi.org/10.1111/nhs.12071 [16] Lyberg, A., Holm, A.L., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Experiences with Depressive Ill-Health and Family Support. Nursing Research and Practice, 2013, Article ID: 837529.
http://dx.doi.org/10.1155/2013/837529 [17] Holm, A.L. and Severinsson, E. (2012) Chronic Care Model for the Management of Depression: Synthesis of Barriers to, and Facilitators of, Success. International Journal of Mental Health Nursing, 21, 513-523.
http://dx.doi.org/10.1111/j.1447-0349.2012.00827.x [18] Morgan, D.L. (1997) Focus Groups as Qualitative Research. Sage Publication, London. [19] Gadamer, H.G. (2004) Truth and Method. Interactive Sciences Ltd., Gloucester. [20] Bowen, G. A. (2009) Document Analysis as a Qualitative Research Method. Qualitative Research Journal, 9, 27-40.
http://dx.doi.org/10.3316/QRJ0902027 [21] WHO (2002) Active Aging: A Policy Framework. Geneva.
http://whqlibdoc.who.int/hq/2002/who_nmh_nph_02.8.pdf [22] The Finnish Public Health Programme (2001) Health 2015-Public Health Programme. Ministry of Social Affairs and Health.
https://www.julkari.fi/bitstream/handle/10024/114637/Es200108eng.pdf?sequence=1 [23] The Norwegian Ministry of Health and Care Services (2008) The Coordination Reform. Proper Treatment—At the Right Place and Right Time. Report No.47, 2008-2009.
http://www.regjeringen.no/upload/HOD/Samhandling%20engelsk_PDFS.pdf [24] The Swedish National Board of Health and Welfare (2010) Guidelines for Care of Depression and Anxiety Disorder.
http://www.socialstyrelsen.se/nationalguidelines/nationalguidelinesforcareincasesofdepressionandanxiety
disorders [25] Kornstein, S. (2003) Gender, Depression and Antidepressant Treatment. Clinical Focus Primary Psychiatry, 10, 58-61. [26] American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, APA, Washington, DC. [27] Waraich, P., Goldner, E.M., Somers, J.M. and Hsu, L. (2005) Prevalence and Incidence Studies of Mood Disorders: A Systematic Review of the Literature. Canadian Journal of Psychiatry, 49, 124-138. [28] Copeland, J.R., Beekman, A.T., Braam, A.W., Dewey, M.E., Delespaul, P., Fuhrer, R., Hooijer, C., Lawlor, B.A., Kivela, S.-L., Lobo, A., Magnusson, H., Mannm, A.H., Meller, I., Prince, M.J., Reischies, F., Roelands, M., Skoog, I., Turrina, C., de Vries, M.W. and Wilson, K.C. (2004) Depression among Older People in Europe: The EURODEP Studies. World Psychiatry, 3, 45-49. [29] Castro-Costa, E., Dewey, M., Stewartm, R., Baerjee, S., Huppert, F., Mendonca-Lima, C., Bulam, C., Reisches, F., Wancata, J., Ritchie, K., Tsolaki, M., Mateos, R. and Prince, M. (2007) Prevalence of Depressive Symptoms and Syndromes in Later Life in Ten European Countries. The SHARE Study. British Journal of Psychiatry, 191, 393-401.
http://dx.doi.org/10.1192/bjp.bp.107.036772 [30] Luppa, M., Sikorski, C., Luck, T., Ehreke, L., Konnopka, A., Wise, B., Weyerer, H., König, H. and Riedel-Heller, S. (2012) Age- and Gender-Specific Prevalence of Depression in Latest-Life—Systematic Review and Meta-Analysis. Journal of Affective Disorders, 136, 212-221.
http://dx.doi.org/10.1016/j.jad.2010.11.033 [31] Horvath, P., Bissix, G., Sumarah, J., Crouchman, E. and Bowdrey, J. (2008) Motivational Orientation, Expectancies, and Vulnerability for Depression in Women. Journal of Prevention & Intervention in the Community, 2, 19-32.
http://dx.doi.org/10.1300/J005v35n02_03 [32] Holm, A.L., Lyberg, A., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Lived Experiences of Depression and Self-Management. Issues in Mental Health Nursing, 10, 757-764.
http://dx.doi.org/10.3109/01612840.2013.809829 [33] Holm, A.L., Lyberg, A., Berggren, I., Cutcliffe, J and Severinsson, E. (2014) Shadows from the Past—The Situated Meaning of Being Suicidal among Depressed Older People Living in the Community. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35, 253-260.
http://dx.doi.org/10.1027/0227-5910/a000259 [34] Holm, A.L., Lyberg, A. and Severinsson, E. (2014) Living with Stigma: Depressed Elderly Persons’ Experiences of Physical Health Problems. Nursing Research and Practice, 2014, Article ID: 527920.
http://dx.doi.org/10.1155/2014/527920 [35] Wade, T.J. and Cairney, J. (1997) Age and Depression in a Nationally Representative Sample of Canadians: A Preliminary Look at the National Population Health Survey. Canadian Journal of Public Health, 88, 297-302. [36] Fässberg, M.M., Östling, S., Braam, A.W., Bäckman, K., Copeland, J., Fichter, M., Kivelä, S.L., Lawlor, B., Lobo, A., Magnusson, H., Prince, M., Reischies, M., Turrina, C., Wilson, K., Skoog, I. and Waern, M. (2014) Functional Disability and Death Wishes in Older Europeans: Results from the EURODEP Concerted Action. Social Psychiatry and Psychiatric Epidemiology, 49, 1475-1482.
http://dx.doi.org/10.1007/s00127-014-0840-1 [37] Hepple, J. and Quinton, C. (1997) One Hundred Cases of Attempted Suicide in the Elderly. British Journal of Psychiatry, 171, 42-46.
http://dx.doi.org/10.1192/bjp.171.1.42 [38] Lebret, S., Perret-Vaille, E., Mulliez, A., Gerbaud, L. and Jalenzues, I. (2006) Elderly Suicide Attempters: Characteristics and Outcome. International Journal of Geriatric Psychiatry, 21, 1052-1059.
http://dx.doi.org/10.1002/gps.1605 [39] Stroebe, M., Stroebe, W. and Abakoumkin, G. (2005) The Broken Heart: Suicidal Ideation in Bereavement. American Journal of Psychiatry, 162, 2178-2180.
http://dx.doi.org/10.1176/appi.ajp.162.11.2178 [40] Kjöseth, I., Ekeberg, O. and Steihaug, S. (2010) Why Suicide? Elderly People Who Committed Suicide and Their Experience of Life in the Period before Their Death. International Psychogeriatrics, 22, 209-218.
http://dx.doi.org/10.1017/S1041610209990949 [41] Severinsson, E. and Holm, A.L. (2014) Chronic Disease Management-Implementation and Coordination of Healthcare Systems for Depressed Elderly Persons. Issues in Mental Health Nursing. (Pub Ahead of Print)
http://dx.doi.org/10.3109/016/2840.2014.930215 [42] Holm, A.L. and Severinsson, E. (2013) Reflection on the Ethical Dilemmas Involved in Promoting Self-Management. Nursing Ethics, 21, 402-413.
http://dx.doi.org/10.1177/0969733013500806
[1] World Health Organization (WHO) (2012) Depression Is a Common Illness and People Suffering from Depression Need Support and Treatment.
http://www.who.int/mediacentre/news/notes/2012/mental_health_day_20121009/en/ [2] Batterham, P.J., Christensen, H. and Alison, L.C. (2013) Anxiety Symptoms as Precursors of Major Depression and Suicidal Ideation. Depression and Anxiety, 30, 908-916. [3] Chou, K.L. and Cheung, K. (2013) Major Depressive Disorder in Vulnerable Groups of Older Adults, Their Course and Treatment, and Psychiatric Comorbidity. Depression and Anxiety, 30, 528-537.
http://dx.doi.org/10.1002/da.22073 [4] Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R. and Hensley, M. (2011) Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Administration and Policy in Mental Health, 38, 65-76.
http://dx.doi.org/10.1007/s10488-010-0319-7 [5] Peters, D.H., Nhan, T.T and Taghreed, A. (2013) Implementation Research in Health: A Practical Guide. Alliance for Health Policy and Systems Research, World Health Organization.
http://apps.who.int/iris/bitstream/10665/91758/1/9789241506212_eng.pdf?ua=1 [6] Peters, D.H., El-Saharty S., Siadat B., Janovsky, K. and Vujicic, M. (2009) Improving Health Services in Developing Countries: From Evidence to Action. World Bank, Washington DC. [7] Wallin, L. (2009) Knowledge Translation and Implementation Research in Nursing. International Journal of Nursing Studies, 4, 576-587.
http://dx.doi.org/10.1016/j.ijnurstu.2008.05.006 [8] Grol, R., Bosch, M., Hulscher, M., Eccles, M. and Wensing, M. (2007) Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives. The Milbank Quarterly, 85, 93-138.
http://dx.doi.org/10.1111/j.1468-0009.2007.00478.x [9] Holm, A.L. and Severinsson, E. (2013) Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons—A Norwegian Qualitative Implementation Study. Nursing Research and Practice, 2013, Article ID: 794743.
http://dx.doi.org/10.1155/2013/794743 [10] Holm, A.L. and Severinsson, E. (2014) Perceptions of the Need for Improvements in Healthcare after Implementation of the Chronic Care Model. Nursing& Health Sciences. (Pub Ahead of Print)
http://dx.doi.org/10.1111/nhs.12136 [11] Severinsson, E. (2014) Capacity Building—Challenges for Nurse Managers. Journal of Nursing Management, 22, 407-409.
http://dx.doi.org/10.1111/jonm.12209 [12] Andvig, E., Syse, J. and Severinsson, E. (2014) Interprofessional Collaboration in the Mental Health Service in Norway. Nursing Research and Practice, 2014, Article ID: 849375.
http://dx.doi.org/10.1155/2014/849375 [13] Grol, R. and Grimshaw, J. (2003) From Best Evidence to Best Practice: Effective Implementation of Change in Patients’ Care. The Lancet, 362, 1225-1230.
http://dx.doi.org/10.1016/S0140-6736(03)14546-1 [14] Holm, A.L. and Severinsson, E. (2013) A Systematic Review of Emotional State and Self-Management among Widows. Nursing and Health Sciences, 14, 109-120.
http://dx.doi.org/10.1111/j.1442-2018.2011.00656.x [15] Holm, A.L. and Severinsson, E. (2014) Surviving Depressive Ill-Health: A Qualitative Systematic Review of Older Persons’ Narratives. Nursing and Health Sciences, 16, 131-140.
http://dx.doi.org/10.1111/nhs.12071 [16] Lyberg, A., Holm, A.L., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Experiences with Depressive Ill-Health and Family Support. Nursing Research and Practice, 2013, Article ID: 837529.
http://dx.doi.org/10.1155/2013/837529 [17] Holm, A.L. and Severinsson, E. (2012) Chronic Care Model for the Management of Depression: Synthesis of Barriers to, and Facilitators of, Success. International Journal of Mental Health Nursing, 21, 513-523.
http://dx.doi.org/10.1111/j.1447-0349.2012.00827.x [18] Morgan, D.L. (1997) Focus Groups as Qualitative Research. Sage Publication, London. [19] Gadamer, H.G. (2004) Truth and Method. Interactive Sciences Ltd., Gloucester. [20] Bowen, G. A. (2009) Document Analysis as a Qualitative Research Method. Qualitative Research Journal, 9, 27-40.
http://dx.doi.org/10.3316/QRJ0902027 [21] WHO (2002) Active Aging: A Policy Framework. Geneva.
http://whqlibdoc.who.int/hq/2002/who_nmh_nph_02.8.pdf [22] The Finnish Public Health Programme (2001) Health 2015-Public Health Programme. Ministry of Social Affairs and Health.
https://www.julkari.fi/bitstream/handle/10024/114637/Es200108eng.pdf?sequence=1 [23] The Norwegian Ministry of Health and Care Services (2008) The Coordination Reform. Proper Treatment—At the Right Place and Right Time. Report No.47, 2008-2009.
http://www.regjeringen.no/upload/HOD/Samhandling%20engelsk_PDFS.pdf [24] The Swedish National Board of Health and Welfare (2010) Guidelines for Care of Depression and Anxiety Disorder.
http://www.socialstyrelsen.se/nationalguidelines/nationalguidelinesforcareincasesofdepressionandanxiety
disorders [25] Kornstein, S. (2003) Gender, Depression and Antidepressant Treatment. Clinical Focus Primary Psychiatry, 10, 58-61. [26] American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, APA, Washington, DC. [27] Waraich, P., Goldner, E.M., Somers, J.M. and Hsu, L. (2005) Prevalence and Incidence Studies of Mood Disorders: A Systematic Review of the Literature. Canadian Journal of Psychiatry, 49, 124-138. [28] Copeland, J.R., Beekman, A.T., Braam, A.W., Dewey, M.E., Delespaul, P., Fuhrer, R., Hooijer, C., Lawlor, B.A., Kivela, S.-L., Lobo, A., Magnusson, H., Mannm, A.H., Meller, I., Prince, M.J., Reischies, F., Roelands, M., Skoog, I., Turrina, C., de Vries, M.W. and Wilson, K.C. (2004) Depression among Older People in Europe: The EURODEP Studies. World Psychiatry, 3, 45-49. [29] Castro-Costa, E., Dewey, M., Stewartm, R., Baerjee, S., Huppert, F., Mendonca-Lima, C., Bulam, C., Reisches, F., Wancata, J., Ritchie, K., Tsolaki, M., Mateos, R. and Prince, M. (2007) Prevalence of Depressive Symptoms and Syndromes in Later Life in Ten European Countries. The SHARE Study. British Journal of Psychiatry, 191, 393-401.
http://dx.doi.org/10.1192/bjp.bp.107.036772 [30] Luppa, M., Sikorski, C., Luck, T., Ehreke, L., Konnopka, A., Wise, B., Weyerer, H., König, H. and Riedel-Heller, S. (2012) Age- and Gender-Specific Prevalence of Depression in Latest-Life—Systematic Review and Meta-Analysis. Journal of Affective Disorders, 136, 212-221.
http://dx.doi.org/10.1016/j.jad.2010.11.033 [31] Horvath, P., Bissix, G., Sumarah, J., Crouchman, E. and Bowdrey, J. (2008) Motivational Orientation, Expectancies, and Vulnerability for Depression in Women. Journal of Prevention & Intervention in the Community, 2, 19-32.
http://dx.doi.org/10.1300/J005v35n02_03 [32] Holm, A.L., Lyberg, A., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Lived Experiences of Depression and Self-Management. Issues in Mental Health Nursing, 10, 757-764.
http://dx.doi.org/10.3109/01612840.2013.809829 [33] Holm, A.L., Lyberg, A., Berggren, I., Cutcliffe, J and Severinsson, E. (2014) Shadows from the Past—The Situated Meaning of Being Suicidal among Depressed Older People Living in the Community. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35, 253-260.
http://dx.doi.org/10.1027/0227-5910/a000259 [34] Holm, A.L., Lyberg, A. and Severinsson, E. (2014) Living with Stigma: Depressed Elderly Persons’ Experiences of Physical Health Problems. Nursing Research and Practice, 2014, Article ID: 527920.
http://dx.doi.org/10.1155/2014/527920 [35] Wade, T.J. and Cairney, J. (1997) Age and Depression in a Nationally Representative Sample of Canadians: A Preliminary Look at the National Population Health Survey. Canadian Journal of Public Health, 88, 297-302. [36] Fässberg, M.M., Östling, S., Braam, A.W., Bäckman, K., Copeland, J., Fichter, M., Kivelä, S.L., Lawlor, B., Lobo, A., Magnusson, H., Prince, M., Reischies, M., Turrina, C., Wilson, K., Skoog, I. and Waern, M. (2014) Functional Disability and Death Wishes in Older Europeans: Results from the EURODEP Concerted Action. Social Psychiatry and Psychiatric Epidemiology, 49, 1475-1482.
http://dx.doi.org/10.1007/s00127-014-0840-1 [37] Hepple, J. and Quinton, C. (1997) One Hundred Cases of Attempted Suicide in the Elderly. British Journal of Psychiatry, 171, 42-46.
http://dx.doi.org/10.1192/bjp.171.1.42 [38] Lebret, S., Perret-Vaille, E., Mulliez, A., Gerbaud, L. and Jalenzues, I. (2006) Elderly Suicide Attempters: Characteristics and Outcome. International Journal of Geriatric Psychiatry, 21, 1052-1059.
http://dx.doi.org/10.1002/gps.1605 [39] Stroebe, M., Stroebe, W. and Abakoumkin, G. (2005) The Broken Heart: Suicidal Ideation in Bereavement. American Journal of Psychiatry, 162, 2178-2180.
http://dx.doi.org/10.1176/appi.ajp.162.11.2178 [40] Kjöseth, I., Ekeberg, O. and Steihaug, S. (2010) Why Suicide? Elderly People Who Committed Suicide and Their Experience of Life in the Period before Their Death. International Psychogeriatrics, 22, 209-218.
http://dx.doi.org/10.1017/S1041610209990949 [41] Severinsson, E. and Holm, A.L. (2014) Chronic Disease Management-Implementation and Coordination of Healthcare Systems for Depressed Elderly Persons. Issues in Mental Health Nursing. (Pub Ahead of Print)
http://dx.doi.org/10.3109/016/2840.2014.930215 [42] Holm, A.L. and Severinsson, E. (2013) Reflection on the Ethical Dilemmas Involved in Promoting Self-Management. Nursing Ethics, 21, 402-413.
http://dx.doi.org/10.1177/0969733013500806