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Depression in older people is common, under-recognised and often undertreated. This study aimed to explore the reasons why older people with depression may not present to primary care. Secondary analysis was carried out, of qualitative data collected in two previous studies in North-West England. Older people are reluctant to recognise and name 'depression' as a set of symptoms that legitimises attending their general practitioner (GP). They do not consider themselves candidates for help for their distress. This is partly due to perceptions of the role of the GP but also to previous negative experiences of help seeking. In addition, treatments offered, which are predominantly biomedical, may not be acceptable to older people. Interventions offered to older people need to encourage social engagement, such as befriending, and enhancement of creative, physical and social activity.

This paper reports on the qualitative findings of the first phase of the INDEPENDENT Project, an EPSRC funded EQUAL 4 consortium project in the UK that aims to investigate enabling environments for people with dementia. The overall project focus is on wellbeing and quality of life for people in different types of housing, with particular focus on the possible roles technology can play in maintaining the person's independence as long as possible. Connection to nature, access to the outdoors, and participation in nature-based activities were among a wide range of enjoyable activities reported by study participants living in their

BackgroundSince 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients. AimTo gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF. Design of studySemi-structured qualitative interview study, with purposive sampling and constant comparative analysis. SettingThirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk. MethodGPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views. ResultsAnalysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs' identities as professionals with expertise, constructed as integral to the process of diagnosis. ConclusionGP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression. Keywordsdepression; diagnosis; general practice. INTRODUCTIONIn April 2004, the UK government incorporated a payfor-performance scheme in the GP contract, through the Quality and Outcomes Framework (QOF). Since April 2006 the contract has rewarded GPs for carrying out assessments of the severity of symptoms of depression at the outset of treatment in patients with a new diagnosis. 1 The rationale is that national guidelines on depression recommend more active intervention for patients with moderate to severe depression (antidepressant treatment or referral for psychological treatment) than for mild depression (guided self-help and watchful waiting), 2 and therefore accurate assessment of severity is necessary to decide on appropriate responses to new cases.The QOF has not been received without controversy. Some have suggested it is in danger of encouraging a 'medicine by numbers' approach to