What we talk about when we talk about depression: Doctor-patient conversations and treatment decision outcomes

Background: Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decisionmaking about treatment. Aim: The study sought to understand conversational influences on physician decisionmaking about treatment for depression. Design: A secondary analysis of consultation data collected in other studies. Using amaximumvariation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected fromdatasets collected in three countries. Transcripts were analysed to discover factors associated with prescription ofmedication. Method: The study employed two qualitative analysis strategies: amicro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problempresentation. Results: Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative formof the problempresentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, andmixed narratives. Physician decisionmaking regarding medication treatment was strongly associated with the formof the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments. Conclusion: Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.