PURPOSE The purpose of this study was to explore the responses of primary care clinicians to patients who complain of symptoms that might indicate depression, to examine the clinical strategies used by clinicians to recognize depression, and to identify the conditions that infl uence their ability to do so. METHODSThe grounded theory method was used for data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed.RESULTS This study identifi ed 3 processes clinicians engage in to recognize depression-ruling out, opening the door, and recognizing the person-and 3 conditions-familiarity with the patient, general clinical experience, and time availability-that infl uence how each of the processes is used. CONCLUSIONSThe likelihood of accurately diagnosing depression and the timeliness of the diagnosis are highly infl uenced by the conditions within which clinicians practice. Productivity expectations in primary care will continue to undermine the identifi cation and treatment of depression if they fail to take into consideration the factors that infl uence such care.

The objective of this study was to identify conditions that influence primary care clinicians’ referral decisions related to depression care. Forty primary care clinicians (15 general internists, 10 nurse practitioners, and 15 family practice physicians) were included in this study. The clinicians participated in semistructured interviews and completed two quantitative instruments (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis revealed that several conditions influence a clinician’s decision to refer a depressed patient to a mental health specialist: the patient’s resources, the clinician’s comfort in prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment. The decision to refer a patient with depression to a mental health specialist is a complex process involving the clinician, patient, and practice-related issues. Understanding these relationships may provide strategies to improve depression care management and lead to the design of depression care quality-improvement interventions that accommodate primary care practice context. The findings from this study suggest a need to increase mental health training opportunities for primary care clinicians to strengthen their skills and comfort level in managing depressed patients and encourage the development of relationships between primary care clinicians and mental health specialists to facilitate timely and accessible mental health care for patients.

PURPOSE Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that infl uence their use.METHODS Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offi ces. Investigators' fi eld notes on offi ce practice environments complemented individual interviews. RESULTSThe clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions. CONCLUSIONS Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context infl uences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression. Ann Fam Med 2010;8:224-230. doi:10.1370/afm.1113. INTRODUCTIOND epression is a highly prevalent, disabling, and costly public health condition in the United States, 1-3 and more than one-half of people with mental health issues receive care from primary care clinicians. 4 Despite decades of research, there remains a gap between ideal care for depression and actual outcomes in primary care settings. 5,6 One strategy for enhancing depression management has been the development of depression instruments to help diagnose, stratify the severity of, and evaluate the treatment of depression. Since the development of the Hamilton Rating Scale for Depression, 7 the Beck Depression Inventory, 8 and the Zung Self-Rating Depression Scale 9 in the early 1960s, continued work in the development of depression instruments has led to the availability of numerous depression instruments today.It is nearly impossible to identify all the depression instruments available today or to describe each instrument's purposes and performance. Salient dimensions of development efforts, however, have been the testingretesting of performance and comparing the instruments' psychometrics R EINV EN T ION O F DEPR ES SION ...

Purpose: Depression is a highly prevalent condition in primary care settings. In our previously reported work, we investigated the processes and conditions that influence primary care clinicians' recognition of depression. Three conditions influence the recognition of depression: familiarity with the patient, time available, and clinical experience. This article further describes the role of clinical experience in depression care.Methods: The grounded theory method was used to guide data collection and analysis. In-depth, inperson interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed.Results :

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