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Mixed Methods Review depression, communication primary health care

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Mixed Methods Review depression, communication primary health care

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    Mixed Methods Review: Depression, Communication and Primary Health Care

Summaries

    *** indicates a study that was not part of the original literature sample but was added in following analysis of these papers e.g. their literature reviews used key papers that had hitherto been missed by the first literature scoping.

Mixed methods (mainly qual, using quant for sampling)

    Umesh T Kadam et al ‘A qualitative study of patients’ views on anxiety and depression’2001

    Aim of study, to examine what patients think about depression, as research has tended to focus on non-detection. Semi structured individual and focus group interviews with 27 individuals, taken from primary care (sampled using quant scale). Current evidence based emphasis is on improving detection and drug usage. But this study found that patients describe personal and professional barriers to seeking help and have particular views about treatment options. Scepticism about drug therapy in particular, preference for counselling/talking therapies. Some of the barriers: shame/ people thinking they should „pull themselves together‟ which led to concealment of symptoms. Many had used their own initiatives in seeking self-help. Many had reservations about consulting a GP as they thought that GPs were „too busy‟ to deal with something so „trivial‟. Also thought that GPs would only prescribe drugs. Also there were problems with getting an appointment within a suitable time frame i.e. they wanted to talk to someone in that moment, not in days or weeks time. Further research on the degree to which patients perceive the GP environment as encouraging them to discuss mental health needs. Gps find it difficult to address these problems in routine consultations due to time restraints- patients reported symptoms on self report questionnaire that they were not willing to discuss with GP.

    Switzer et al. ‘Pull yourself up by the bootstraps’: A Response to depression In older Adults’ 2006

    Addressing the problem of why older adults typically do not seek treatment for depression or stick to it when they do. Uses cultural model of depression to understand the problem. Patient behaviour is often a logical extension of the beliefs they hold about the illness and what to do about it. A cultural model= largely unspoken attitudes, stances and beliefs about illness and the way it should be treated that are shared among a group of people. The perception about the appropriate management of depression has important implications for whether older adults discuss depression with their doctors . Based on 71 open ended interviews with people aged 65 and older following their participation in a year long spectrum study- collected structured survey data related to participants‟ psychological, cognitive and physical

    status. Common themes- pulling yourself out of the depths of depression is the individual‟s responsibility; rejection of self-indulgence or self-pity. Not denying

    depression, but underemphasising the need to outside medical help. Health Care Providers only do an ancillary role GPs should incorporate an understanding of the role for personal responsibility in their discussions with patients.

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    Burroughs et al. ‘Justifiable Depression: How Primary Care Professionals and Patients View Late-Life Depression? A Qualitative Study’2006

    Participants were taken from a feasibility study of an intervention in primary care- Primary Care intervention for Depression in the Elderly (PRIDE) 20 patients over the age of 60 took part as well as 15 primary care practitioners- 9 GPs, 3 practice nurses, 2 district nurses and 1 community nurse. Problems with communication- older patients may view depression not as something they should consult for- trivial. They may complain less about psychological symptoms and instead present with somatic ones. Physical co-morbidity may make identification harder, they may misattribute symptoms of major depression as being to do with old age, ill health or grief. Think anti depressants are addictive. GPs- may be wary of broaching the subject for fear of opening a „pandora‟s box‟. In deprived areas, GPs may treat depression as a rational response to difficult circumstances. The patient-practitioner relationship is important in influencing the diagnosis and management of depression. Older adults may have difficulties attending different sites for psychiatric treatments. HCPs took part in semi structured interviews whereas patients were asked open ended questions. Geriatric Depression Scale used to measure depression. HCPs often saw depression as justifiable/understandable in later life. GPs perceived a reluctance on part of elderly to accept the diagnosis of depression as they saw it as a sign of weakness- were not accustomed to taking that sort of problem to the doctor. Drs don‟t want to diagnose it because they have nothing to treat it with. GPs are generalists, i.e. they don‟t

    specialise in one area and therefore might not be the most appropriate people to report depression to.

Mixed Methods (Mainly Quant)

**** Cegala, D. and D.Post. 2009. ‘The Impact of Patients’ Participation on

    Physicians’ Patient-Centred Communication’ in Patient Education and Counseling.

    2009 [In Press]

    Study to determine how patient participation in consultation affects physician participation. Not specifically on depression. The same 25 physicians were observed interacting with high and low participating patients. Demographic info taken from patients beforehand, and both physician and patient completed questionnaire after the consultation. Used PACE coding system to conduct thematic analysis (translated themes into units based on who said it, the order in which it was said, what the function of the utterance was). The transcripts were also coded for evidence of patient centred communication, they were slotted into pre-determined codes and used as a dependent variables in the quantitative analysis. When interacting with high participating patients, physicians engaged more in patient centred communication.

    Sleath and Rubin. Gender, ethnicity and physician-patient communication about depression and anxiety in primary care, 2002

    Study to examine the impact of gender and ethnicity on communication about depression and anxiety in primary care. Many Physicians fail to recognise depression and emotional distress. Research has shown that patients only hint at the problem and rely on physicians to probe for more information. Other studies have revealed that the more questions a physician asks about feelings and affect, the more likely a diagnosis of depression. How well a patient knows the physician (familiarity) also facilitates diagnosis. Female physicians more likely to ask patients about psychosocial issues

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    and female patients more likely to be actively involved in the medical encounter, asking questions etc. Patients from diverse backgrounds often have different ways of expressing it. Previous research has shown that physicians are better at asking questions to non-hispanic white patients rather than Hispanic patients. Do patients communicate better with a physician of the same ethnic background? What about language barriers? 27 resident physicians audiotaped 6-21 of their consultations in New Mexico. After each audiotaped interaction, the physician filled in a questionnaire about the consultation. Patients were also interviewed after the consultation to obtain data about age, general health, familiarity with physician etc. Depression was more likely to be brought up by patients who rated their mental health poorly. What was interesting is that whether patients saw physicians of the same gender and ethnicity as themselves did not significantly influence any aspect of physician-patient interaction. Female patients more likely to bring it up than males, as were more highly educated patients. When anxiety was discussed, physicians asked males significantly more questions than females. It may also be that physicians do not always pick up on patient „cues‟. Physicians need to pick up on cues more and ask more open ended questions.

    Carney et al. How Physician Communication Influences Recognition of Depression in Primary Care 1999

    Used unannounced visits by actors playing standardized patients to evaluate verbal communication between physicians and a patient presenting with minor depression. They played a 26 year old with chronic headaches. Physicians knew that they would be visited but did not know that it would be for depression, and it was over a one year period. After the consultation, the standardized patient filled in a checklist about how physicians pursued the complaints. Physicians were debriefed after the consultation and these telephone conversations were recorded and transcribed. A practice survey was also completed before the visit to provide information on the surgery. Found that they type of questions asked influenced whether or not physicians discovered the depression. Looked at the blend of broad/narrow questioning. Looked at whether physicians interrupted patients to direct the consultation. 43 out of 59 were successful in identifying depression. Physicians who recognised depression asked twice as many questions about feelings and affect than those who did not. Recognition tended to happen at the beginning of the encounter.

    Cape and McCulloch. 1999. ‘Patients’ Reasons for not presenting emotional problems in general practice consultations’ in British Journal of General Practice

    From 9 general practices, a sample of patients with high General Health Questionnaire scores, who planned to present only somatic symptoms to the GP were interviewed after their consultation for their reasons of not broaching emotional issues (semi structured). On the basis of the patients‟ answers to the semi structured questions, the interviewer made ratings of the chronicity since onset of problems, whether the emotional problems interfered with daily life or if patients were able to cope with them. The interviewer also judged their answers against an 18 point scale to categorise their reasons for not mentioning emotional problems to their GP. A patient satisfaction questionnaire was also administered. Data analysis undertaken with SPSS. The main reason for not presenting emotional problems was lack of time, followed by the perception that doctors cannot help them.

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    Pure Mixed Methods Research

    Barg, F. K.. Huss-Ashmore R., Wittink, M., Murray, G., Bogner, H. and J. Gallo. 2006. A Mixed-Methods Approach to Understanding Loneliness and Depression in Older Adults The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 61 329-339.

    Mixed Methods (multi phase) approach to understand how older people conceptualise depression and the reasons why they do not accept treatment. Rationale for using mixed methods: Quant studies can measure the duration, number and

    presence/absence of a number of symptoms according to a standardized definition of depression, however qual studies capture the contextual factors that affect the experience of depression or the meaning that depression has for people. They can be complementary conceptual frameworks. “.. in order to illustrate how research methods from diverse epistemological traditions yield a more nuanced picture about the experience of depression in older adults than would be gained from a single research method”. Lack of understanding/acceptance of depression, especially among African Americans. Older adults may be inclined to describe depressive symptoms in terms of loneliness

    Purposeful sample of 102 patients aged over 65 years of age recruited with and without depressive symptoms from primary care. Methods used= consensus analysis, semi-structured interviews, standardised assessments in order to understand depression in later life.

    Bogner, H., Cahill, E., Frauenhoffer, C. and F. Berg. 2009. Older primary care patients views regarding antidepressants: a mixed methods approach Journal of Mental Health 18 (1) 57-64.

    A mixed methods design that is both hypothesis testing and hypothesis generating . Adults ages over 65 were recruited from primary care and interviewed in their homes. Examined the personal characteristics of older adults according to antidepressant use. Participants taking antidepressants and those not were asked their views about taking anti depressants as treatment for depression. Themes relating to the use of anti depressants were examined.

Buszewicz, M., Pistrang, N., Barker, C., Cape, J. and J. Martin. 2006. ‘Patients’

    Experiences of GP Consultations for Psychological Problems’ in British Journal of General Practice

    12 GPs recorded their consultations. If the consultations had a substantial psychological component (ascertained by content analysis), the participant was invited to take part in an interview. The consultation was played back and they were asked to identify the most and least helpful parts. They then completed the Clinical Interview Schedule-Revised in order to determine which patients met the formal psychiatric diagnostic criteria.

    Found that GPs play a vital role in managing psychological problems

    Benoit, C., Westfall, R., Treloar, A., Phillips, R. and S. Jansson. 2007. Social factors linked to postpartum depression: a mixed-methods longitudinal study Journal of Mental Health 16 (6) 719-730.

    Put posters up in ante natal classes, physician‟s office etc. to recruit women. Interviewed them three times : during their third trimester, at 4-6 weeks postpartum

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    and 4-6 months postpartum. The women were asked both open and closed questions to concurrently gather qualitative and quantitative data. Used Beck Depression Inventory as well as self reported measures of overall health, as well as physical, mental and emotional health. They sometimes began with closed questions e.g. rate your birth on a scale of 1 to 5, and then were asked to elaborate on this. There was also a written questionnaire at the end of the interview for sensitive questions on income and depression. Interviews were tape recorded. The analysis was led by the survey data- certain characteristics- economic resources, maternity care provider and birth satisfaction were analysed and the qual data were used to expand on the analysis.

    Wittink, M, Barg, F. and J. Gallo. 2006. Unwritten Rules of Talking to Doctors About Depression: Integrating Qualitative and Quantitative Methods Annals of Family Medicine 4 (4) 302-309.

    48 participants over the age of 65 derived from a larger „Spectrum study‟ to examine how older primary care patients report depression. Physician analysis rated participants depression on scale of 1-4 (non-severe) and how well they knew the patient. Information was obtained on age, sex, ethnicity, marital status, living arrangements, level of educational attainment and number of visits made to the practice for medical care within 6 months. Centre for Epidemiological Studies Depression (CES-D) Scale was used as well as the Beck Anxiety Inventory and Beck Hopelessness Scale. Semi structure interviews were also carried out in participants‟

    homes and analysed with N6. Analytic strategy- compared the group of patients who identified themselves as being depressed whereas their physician did not, and those whose views were concordant with their physicians‟.

    Nutting, P., Rost,K., Dickinson, M., Werner, J., Dickinson, P., Smith, J. and B. Gallovic. 2002. Barriers to Initiating Depression Treatment in Primary Care Practice Journal General Internal Medicine 17 103-111.

    Aim of study- to better understand why GPs and nurses to not implement guidance concordant acute-care for patients with current major depression. Qualitative interviews with 12 physicians and nurses were used to develop a checklist of barriers to depression treatment. This checklist was then completed by the physicians for the 64 patients who had been identified from a trial of depression treatment had failed to receive guidance-concordant acute care. The physicians weighted each barrier to treatment on a scale of 1-100 to prioritise barriers.

    Priest, R., Vize, C., Roberts, A., Roberts, M., Tylee, A. 1996. Lay people’s attitudes to treatment of depression: results of opinion poll for defeat depression campaign just before its launch in BMJ 313 858-859.

    A pilot qualitative study was followed up by a quantitative survey. Qual study- 8 group discussions, with 8 people on each pane. Quant- 2003 people were interviewed. Results show that general public feel that gps are intolerant of depressed people and think they are neurotic, which explains why there is some reluctance in consulting a GP.

    ****Bell, R., Paterniti, D. Azari, R., Duberstein,P., Epstein, R., Rochlen, A., Dwight Johnson, M., Orrange, S., Slee, C. and R. Kravitz.2009.’Encouraging Patients with

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    Depressive Symptoms to Seek Care: A Mixed Methods Approach to Message Development’ in Patient Education and Counseling[in press]

    Study designed to encourage people with depression to seek help, and also to offer guidance to health care professionals about how to encourage their patients to talk about emotional problems, and to make appropriate responses. The different sorts to barriers to seeking care for depression were discussed with 3 focus groups, each with 5 participants who had personal/familial history of depression. The focus groups were devised to elicit the sorts of beliefs and ideas that prevent individuals getting appropriate help/care for depression. These beliefs were then translated into „messages‟ that could be used in campaigns to encourage people to report depression, or as responses to patients‟ concerns in primary care. The popularity/usefulness of the

    messages was then tested through an online survey through a health related internet commuity. 249 surveys were completed by those with a past diagnosis of unipolar depression. Each message was rated by importance values.

Multi- Method Quantitative Studies

    **** Adelman, R., Greene, M., Friedman, E. and M.A. Cook. 2008. ‘Discussion of Depression in Follow-Up Visits with Older Patients’ in Journal of the American

    Geriatrics Society

    Convenience sample of 482 audiotaped consultations. 376 community dwelling older patients and 43 primary care physicians. Audiotapes analysed using the Multi-Dimensional Interaction Analysis system to determine the content and process of medical conversations. Patients then completed the Medical outcomes study 36 item short form survey questionnaires immediately after the visit.

    Depression was discussed in 7.3% of visits and physicians raised it in 41% of visits. Physicians with geriatric training were more likely to mention it.

    ****Duberstein, R., Chapman, B., Epstein, R., McKollumm, K. and R. Kravtiz. 2008. ‘Physician Personality Characteristics and Inquiry about Mood Symptoms in Primary Care’ in Journal of Internal Medicine

    Secondary data analysis of data from randomised controlled trial. Forty Six physicians were visited by standardized patients, one with major depression, and one with an adjustment disorder. The consultations were audiotaped and the sps completed a form on doctoring behaviour and symptom inquiry. For assessment of diagnostic documentation, medical records were reviewed. Physician personality was assessed with NEO-PI-R. Physicians who were more dutiful and vulnerable were more likely to document a diagnosis of depression.

**** Novosel, Marie. 2007. ‘Depressive Symptomatology, patient-provider

    communication, and patient satisfaction: a multi level analysis’ PhD thesis: University of South Florida

    123 patient-provider encounters tape recorded, encounters analysed with Roter Interaction Analysis System (8 verbal communication methods) categorized by speaker, type of utterance and content of utterance. Depression is associated with, but

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    does not predict increased provider perceived difficulty in the patient-provider relationship.

**** Monica Mohaglegh. 2006. ‘Depression and the Quality of Physician-Patient

    Communication in Diabetes Patients’ (Thesis: Alliant International University)

    408 structured interviews with patients in 2 primary care clinics at San Fransisco General Hospital (all with Type 2 Diabetes)

    Depression was measured using CESD-10 and communication was measured using the 20 communication items from the Interpersonal Processes of Care in Diverse Populations Questionnaire (IPC) which contains 7 subscales.

    Patients who reported non-optimal communication had higher CESD-10 scores

    Weich, S., Morgan, L., King, M. and I. Nazareth. 2007. ‘Attitudes to Depression and its Treatment in Primary Care’ Psychological Medicine 37 1239-1248.

    Cross sectional survey of 866 individuals with confirmed history of depression in the 12 months preceding interview, extracted from 36 GPs surgeries. Attitudes and beliefs about depression were extracted using a 19 point self-report questionnaire. People with moderate or severe depression have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment. The attitudes go beyond attitudes to treatment but are actually about the nature of depression itself.

    Robbins, J., Kirmayer, L., Cathebras, P., Yaffe, M. and M. Dworkind. 1994. Physican Characteristics and the Recognition of Depression and Anxiety in Primary Care Medical Care 32 (8) 795-812.

    Characteristics associated with the recognition of depression and anxiety in primary care. 55 physicians treating a total of 600 patients completed a measure of psychosocial orientation, psychological mindedness, self rating of sensitivity to hidden emotions and a video test of sensitivity to nonverbal communication.

    Callahan, E.J., Betrakis, K.D., Azari, R., Robbins, J., Helms, J. and J. Miller.1996. The influence of Depression on Physician- Patient Interaction in Primary Care Family Medicine 26 346-51.

    508 individuals with depression assigned to 105 primary care physicians. Interactions video taped and analysed using Davis Observation code. Discovered that failure to diagnose depression was associated with increased length of time to take medical history.

    Del Piccolo, L. Saltinni, A. and C. Zimmerman. 1998. Which Patients Talk about Stressful Life Events and Social Problems to the General Practitioner? In Psychological Medicine 28 1289-1299

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    Whilst there have been studies that have examined the way in which physician characteristics influence disclosures in primary care, but not so much attention has been paid to patient characteristics. Six experienced male GPs took part- audiotaped their consultations with all consecutive patients attending for a new illness. Those who reported a stressful life event with emotional problems were invited to complete a questionnaire after their consultation, then the GPs completed a form recording the patients‟ name and relevant clinical data. Found that a belief about appropriateness is

    a major barrier to patients confiding in their GP. Educational efforts need to be directed towards the reduction of disclosure thresholds in the many patients who think it is appropriate, but nevertheless do not disclose.

Volkers, A., Nuyen, J., Verhaak, P. and F. Schellevis. 2004. ‘The problem of

    diagnosing major depression in elderly primary care patients’ in Journal of Affective Disorders

    Under-recognition and under-diagnosing of depression is assumed to be more salient in elderly primary care patients. Younger age and female sex with comorbidity with anxiety disorder linked to a higher diagnostic rate. Less is known about the influence of somatic and psychiatric comorbidity on an accurate diagnosis in this age group. Neurological disorders like dementia and parkinson‟s, cardiovascular diseases like

    stroke, cancer and metabolic and endocrine disorders are linked to depression and may distract attention from depression when consulting GP. Taken from Dutch National Survey of General Practice. Different measures used- General Health Questionnaire, CAGE questionnaire for alcoholism, Composite International Diagnostic Interview (CIDI). Further data was collected from the electronic medical record made at the time the patient contacted the GP. Also got information about drug prescriptions from Gps. Found that 13.2% of patients with depression were misclassified as having non-medical problems.

    Coyne, J, Schewenk, T. and S. Fechner-Bates. 1995. Nondetection of Depression by Primary Care Physicians Reconsidered in General Hospital Psychiatry

    Research is suggesting that underdetection of depression is a major public health problem. However, few studies have examined the effects of detection on patient outcomes, so it is not known whether detection helps them. The relationship of severity of depression to detection has not been studied extensively. Low detection rate could be due to physician‟s inability to provide effective treatment. Patients recruited from 50 family physicians in south eastern Michigan. They completed a screening form which included Center for Epidemiologic Studies Depression Scale plus demographic info and self ratings on appetite, sleep, energy levels, mood and stress. Physicians also filled in a form for each attending patient including a direct question about whether or not they were depressed. Based on the CES-D score, a subsample of patients were selected for semi structured interview. The physicians detected little more than a third of the depressed patients. Presence of anxiety, overt psychological distress made detection more likely.

    M. Halter. 2004. The Stigma of Seeking Care and Depression in Archives of Psychiatric Nursing

    Much evidence suggests that depression can be treatable but that help is not sought because of the stigma of depression- large scale surveys have revealed that people think that people with depression could just „pull themselves together‟. It stands to

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    reason that people who hold stigmatising views of depression would also hold negative attitudes toward seeking care for depression. The study examines the influence of stigma on care seeking behaviour. Subjects were adults recruited from waiting areas of two health care facilities. Goal was to obtain a sample that was of diverse age race and gender. 117 surveys were completed a demographics data form

    (e.g. gender, marital status, race, political affiliation), the second inventory used the Attribution Questionnaire developed by Corrigan et al (2001), presented a vignette- measured emotional and behavioural responses to a person with depression. Third inventory-shortened form of the Attitudes Towards Seeking Professional Psychological Help Scale. Responses measured on a 4 point Likert scale. Found that there was a relationship between perceived responsibility between responsibility and endorsement of health care seeking behaviours, as well as a lesser relationship between pity and responsibility. Responsibility beliefs were significantly associated with anger- associated with behavioural response of segregation and coercion. Gender mediated the connection between stigma and care seeking. Men held Robert (Vignette) as being more responsible for his condition than women did. Men believe that depression is caused by genetics, chemical imbalances and stress and yet this does not translate into help seeking behaviours. Urban respondents more likely to endorse avoidance and segregation than non-urban respondents.

    Van der Pasch, M. and P. Verhaak. 1997. Communication in general practice: recognition and treatment of mental illness in Patient Education and Counseling Patients often present their mental health problems as a somatic condition. Some GPs are more adept at identifying these patients than others. Why? Communication style may be key to identifying why. Verhaak- the tendency of GPs to interpret complaints as psychosocial in nature is linked to communication style- bringing up new subjects, asking many open ended questions, showing empathy and interest, and expressing various forms of non-verbal behaviour (nodding, agreeing), the length of consultation time was also linked to a psychosocial diagnosis. Does it matter whether or not it is recognised because treatment may not affect patient outcomes. The literature presents conflicting conclusions- early recognition of mental illness has been shown to beneficial in some cases. Uses secondary data from a study on morbidity of mental illness carried out in the Netherlands in 1987/1988 (Dutch National Study of Morbidity and Interventions in General Practice) Gps who took part registered each contact with every patient over a 3 month period. Each diagnosis made by the GP was assessed- looked for patients diagnosed with a mental illness. A sample of 15 GPs consented to taking part in an additional study- observation study (about 25 medical interviews with random samples of patients recorded onto videotape and communication style analysed). Secondly, the 15 GPs participated in a longitudinal follow up study dealing specifically with mental morbidity. To qualify for this study, patients had to have been assessed by the GP as having complaints that were mainly „psychosocial‟ in nature, they had to have been diagnosed with a mental illness at least once. The second group consisted of patients with a somatic diagnosis that had been assessed by their GP as being mainly „psycho social in nature‟ = psychosomatic

    illnesses. Follow up was over 9 months, GPs recorded details of treatment. In addition, the patients filled in questionnaires. Gps should be able to recognise emotional disturbance in otherwise healthy patients as well.

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    Tylee, Freeling, Kerry and Burns. 1995. How does the content of consultations affect the recognition by general practitioners of major depression in women? In British Journal of General Practice

    The recognition of depression is a major issue as it is linked to patient outcomes . Patient characteristics may be linked to the recognition of depression and what they say to GPs, as well as in terms of GPs and the kinds of questions they ask patients. Feeling et al- patients who get their depression missed tend to be the ones who don‟t

    look depressed, did not believe they were depressed, experienced feelings other than an exaggeration of misery, had low mean scores for depression and had physical illness contributing to their depression. They were also more likely to have had their symptoms for more than a year. Patients with physical illness were 5 times as likely to have their depression missed than those who had no physical illness. 47 practitioners in 15 practices agreed to participate 28 to 70 years old. Women attenders were

    eligible if they were 16-65 and had not had depression diagnosed in previous three months. They completed a 30 minute general health questionnaire and gave consent for their consultation to be videotaped. Participants who scored over 11 were administered a psychiatric interview within 3 days of the consultation. In some of the consultations recognised as depression even where symptoms were not directly mentioned, suggesting that gps were reading non verbal communication. The recognition of depression appears to be patient led. Gps are dependent on the sequence of symptom mentioning in the consultation to diagnose depression.

    Brody, D., Khaliq, A. and Thompson, T. 2002. Patients’ perspectives on the management of emotional distress in primary care settings in Jo9urnal of General Internal Medicine

    Used patient surveys to investigate how patients view the treatment of emotional distress in primary care in general and also to primary care patients with depression, to evaluate the types of intervention they would like to see. A lot of primary care physicians cite patient resistance to diagnosis and adherence to treatment as a major obstacle to providing care. Handed out surveys to 403 patients, in a subset they also enrolled the Medical Outcome Study Short Form General Health Survey, also got physicians to rate patients‟ health. Majority of all primary care patients thought that it was important that their physician helped them with emotional distress. Data suggests that it might be useful for primary care physicians to ask routinely about the impact of emotional distress on their patients have been feeling and functioning. Most patients want counselling over medication of a referral.

*** Tylee, A., Freeling, P. and S. Kerry. 1993. ‘Why do General Practitioners

    Recognise Major Depression in One Woman Patient yet Miss it in Another?’ in British Journal of General Practice

    Study designed to uncover whether patient characteristics and the presence/absence of physical illness affects GPs recognition of major depressive illness in women. 30 item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity and each patient selected was interviewed usually within three days of consulting their GP (Clinical interview). 72 women were included with a major depressive disorder from 36 GPs practices. Each GP provided one patient in whom depression had been recognised, and one whose depression had been unrecognised. Few differences were found between the groups. Women with serious physical disease were five times more likely to have their depression go unrecognised.

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