Exploring how patients respond to GP recommendations for mental health treatment: an analysis of communication in primary care consultations

Abstract

BackgroundPatient take-up and adherence to antidepressants and talking therapy is low. However, little is known about how GPs recommend these treatments and whether patients accept them.AimTo examine how GPs recommend antidepressants and talking therapy, and how patients respond.Design & settingA total of 52 recorded primary care consultations for depression, anxiety, and stress were analysed.MethodUsing a standardised coding scheme, five ways doctors recommend treatment were coded, conveying varying authority and endorsement. The treatment recommendation types were as follows: more directive pronouncements (I’ll start you on X); proposals (How about we start X?); less directive suggestions (Would you like to try X?); offers (Do you want me to give you X?); and assertions (There are medications that might help). It was also coded whether patients accepted, passively resisted (for example, withholding response), or actively resisted (for example, I’ve tried that before).ResultsA total of 33 recommendations occurred in 23 consultations. In two-thirds of cases, GPs treated the patient as primary decision-maker by using suggestions, offers, or assertions. In one-third of cases, they used more directive pronouncements or proposals. GPs endorsed treatment moderately (67%), weakly (18%), or strongly (15%). Only one-quarter of recommendations were accepted immediately. Patients cited fears about medication side effects and/or dependency, group therapy, and doubts about treatment efficacy. Despite three-quarters of patients resisting, 76% got prescriptions or self-referral information for talking therapy.ConclusionInitially, GPs treat patients as the decision-maker. However, although patients resist, most end up with treatment. This may impact negatively on treatment uptake and success. Social prescribing may fill a treatment gap for some patients.

General practitioners’ and psychiatrists’ attitudes towards antidepressant withdrawal

“…In an analysis of 52 recorded primary care consultations for depression, anxiety and stress, patients resisted treatment because of doubts about its efficacy based on previous experiences, fears about dependency and/or side-effects, and concerns about attending group therapy. 14 Historically, it was known than many patients on longer-term courses of antidepressants were not being appropriately reviewed. 15 A study of Scottish GPs during 2014–2015 noted that the lack of proactive medication reviews (e.g.…”

Use of the Patient Health Questionnaire (PHQ-9) in Practice: Interactions between patients and physicians

“…The doctor’s first suggestion in this extract is that the patient try “fluoxetine” (Line 4) or, as he clarifies at Line 6, “Prozac.” The patient responds very negatively to this suggestion at Line 8 (“.hhhhha:h No: hhh !” 6 ), and after further discussion, they agree at Lines 21–22 that the patient will try a different antidepressant that will help her to sleep. Although there is still negotiation about what antidepressant will be prescribed, the patient has gone from strongly resisting an antidepressant, to negotiating about an antidepressant, to ultimately agreeing to take an antidepressant that is sedative—a common form of turnaround in this context ( Ford et al, 2019 ). A key to the turnaround in this case has been the doctor using the PHQ-9 to provide an “evidential basis” ( Peräkylä, 1998 ) to support his treatment recommendation.…”

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

“…Conversation analytic studies of healthcare settings often focus on specific sequences of talk (e.g., question and answer) or specific communicative actions (e.g., giving a diagnosis) (Barnes 2019) and how these impact on visit outcomes such as treatment acceptance Ford et al 2019;Bergen 2020). Less attention has been paid to the complex relationships between communicative actions (e.g., how earlier talk may lay the groundwork for later communicative actions) and how these may impact on visit outcomes (see Voutilainen et al 2010;Barnes 2018).…”

“…There are many ways to give medical advice. Treatment recommendations can be delivered as pronouncements, suggestions, proposals, offers or assertions, with each having a different impact on the trajectory of the conversation Ford et al 2019).…”