title: What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes.
abstract: 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 decision making about treatment.
  
  
  OBJECTIVE
  The study sought to understand conversational influences on physician decision making about treatment for depression.
  
  
  METHODS
  A secondary analysis  of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription  of medication.
  
  
  METHODS
  The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.
  
  
  RESULTS
  Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising  life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.
  
  
  CONCLUSIONS
  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.
authors.affiliation: World Trade Center Environmental Health Center, Bellevue Hospital, New York, NY, USA. alison.karasz@einstein.yu.edu
authors.forename: Alison
authors.initials: A
authors.lastname: Karasz
authors.forename: Christopher
authors.initials: C
authors.lastname: Dowrick
authors.forename: Richard
authors.initials: R
authors.lastname: Byng
authors.forename: Marta
authors.initials: M
authors.lastname: Buszewicz
authors.forename: Lucia
authors.initials: L
authors.lastname: Ferri
authors.forename: Tim C
authors.initials: TC
authors.lastname: Olde Hartman
authors.forename: Sandra
authors.initials: S
authors.lastname: van Dulmen
authors.forename: Evelyn
authors.initials: E
authors.lastname: van Weel-Baumgarten
authors.forename: Joanne
authors.initials: J
authors.lastname: Reeve
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use; D003142:Communication; D003657:Decision Making; D003695:Delivery of Health Care; D003866:Depressive Disorder / Q000523:psychology / Q000628:therapy*; D006801:Humans; D008487:Medical History Taking; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents