• Alison Karasz, Christopher Dowrick, Richard Byng, Marta Buszewicz, Lucia Ferri, Tim C Olde Hartman, Sandra van Dulmen, Evelyn van Weel-Baumgarten, and Joanne Reeve.
• World Trade Center Environmental Health Center, Bellevue Hospital, New York, NY, USA. alison.karasz@einstein.yu.edu
• Br J Gen Pract. 2012 Jan 1;62(594):e55-63.

BackgroundEfforts 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.AimThe study sought to understand conversational influences on physician decision making about treatment for depression.DesignA 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.MethodThe 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.ResultsPatients 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.ConclusionResults 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.

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