Results of a focus group study36 we conducted during the development phase suggested that physicians use 3 different approaches for recognizing depression, depending on patient cues. Physicians may take a biomedical approach first, where they consider depression only after possible medical conditions are ruled out. Another approach involved considering depression first, where antidepressants were used to help rule depression in. The last approach involved simultaneously addressing possible depression and pursuing any suspected medical problems. In this study, all 3 approaches were familiar to the focus group physicians. The various patterns of questioning we found associated with recognition of depression may be related to the approach physicians took in considering how to pursue the possibility of depression as part of their differential diagnoses in responding to the standardized patient scenario.
In our study, we found no instances of physicians interrupting the patient to redirect the encounter. This finding differs from those of Marvel and colleagues,40 who found in a linguistic analysis of 264 physician-patient encounters that 75.4% of physicians interrupted patients and redirected the dialogue. In that study, physicians began interrupting patients approximately 23 seconds into the encounter. Our study was restricted to encounters with a new patient, where interrupting may be less common than for established patients, where certain problems or diagnoses have already been defined.
Limitations
Our study has some limitations. Obtaining complete interview data for ISIE coding was challenging. Sound quality diminished when audiotapes were copied, which affected the amount of data we could include in our final analysis. When mechanical failures occurred during the encounters, we dropped those encounters from the analysis, since we could not determine what occurred during the missing interview segment. In addition, while unannounced standardized patients allow control for patient factors, interactions with actual patients who have depressive symptoms and established relationships with their providers may have yielded different findings.
A final issue concerns interview timing and the interpretation of findings. If the interest is in determining the type of behavior that occurs during an office visit that assists the physician in recognizing depression, it is important to distinguish the behaviors that occurred before diagnosis from the behaviors that occurred afterward. We had only physician self-report data to indicate when depression was recognized, which may have questionable validity. In any case, although it is difficult to argue that differences in communication occurring after recognition are responsible for successful recognition, it is possible that physicians’ thoughts and feelings are also responsible for successful recognition. Unfortunately, evaluating this possibility was beyond the scope of this investigation, but this is an important area for future research on this topic.
Conclusions
We found that physicians who recognized depression differed significantly in the percentage of questions they asked about feeling and affect and that an increase in questions about feelings may precede a diagnosis of depression. We found that physicians who recognized depression did not differ in their use of open-ended or close-ended questions compared with physicians who did not; the groups also did not differ in the use of medical versus psychosocial questions. Overall, these physicians spent the majority of their time asking about broad medical issues. More research is needed to verify these important findings.
Acknowledgment
This study was supported by the John D. and Catherine T. MacArthur Foundation.