Patient and Physician Accounts of Antidepressant Requests in Primary Care

Abstract

Depression is a nebulous term that is used in a variety of ways to account for a range of experiences usually characterized by low mood, lethargy, diminished pleasure from activities, among others. One prevalent way of making sense of depression in North America is through a biomedical discourse that constructs depression as resulting from an imbalance of neurotransmitters in the brain. Such an explanatory discourse supports antidepressants as the treatment of choice for depression, despite controversy associated with this discourse and disputes about the effectiveness and appropriateness of antidepressants for the treatment of most presentations of depression. In spite of challenges Western physicians face in diagnosing and treating depression, its management overwhelmingly occurs in primary care. Models of primary care treatment decision-making range from those that frame physicians as the principal decision maker (paternalism) to those that feature patients as more autonomous deciders (patient-directed approaches). Existing in the centre of the treatment continuum is a range of joint approaches that feature a more equal relationship between physician and patient.

Over the last several decades, paternalism as the traditional approach to treatment decision-making has given way to joint approaches that are heralded as the best ways to manage complex disorders that involve multiple treatment approaches with variable risks and benefits, as depression is often framed. Requests for antidepressants can be considered either patient-directed or joint approach actions, depending on how they are presented. Research on this topic typically focuses on statistical analyses of whether or not patient requests for antidepressants are granted, and whether they help or hinder treatment. Little research has focused on qualitative explorations of how patients and physicians construct accounts about requests themselves.

For Study 1, Dr. McMullen and I interviewed 11 family physicians and asked them whether they experienced, and how they managed, patient requests for antidepressants. I used a discursive analytic approach in analyzing the data from the interviews and argue that (a) physicians framed patients as autonomous treatment decision-makers while defining limits on these decisions, and (b) they framed denials of what they characterized as inappropriate requests for antidepressants through patient-centered (and persuasive) approaches to refusal. For Study 2, I interviewed 11 patients about their experiences requesting antidepressants from their physicians. Using a discursive analytic approach, I argue that (a) patients provided accounts of employing what can be considered a soft sell approach in requesting antidepressants, while framing their physician’s contribution to decision-making as necessary and important, and that (b) unexpected outcomes which followed requests for antidepressants (i.e., not having their request endorsed by their physician or having their request fulfilled too readily by their physician) can be understood as discrepancies between the patients’ preferred level of involvement in the process of decision-making and what they encountered.

The results of Studies 1 and 2 suggest that these interviewees enacted a physician+ joint approach to treatment decision-making by constructing accounts of requests for antidepressants in ways that largely favour the physician as the lead role within a broadly joint approach to decision-making. Despite attempts to avoid conceptualizations of being overly directive or uninvolved in the process of decision-making, physician and patient interviewees framed conflict as inevitable and offer hints as to how conflict might be avoided or mitigated. To the extent that both patients and physicians are attempting to get their respective needs met from one another within the primary care consultation, I frame their accounts as evidence of a mutual or reciprocal persuasion that is characteristic of more equal relationships. Finally, I bring together some of the controversies associated with treating depression with antidepressants in a primary care setting and raise broader questions about the role of the general practitioner in the management of depression.