The burden of depression in primary care: a qualitative investigation of general practitioners' constructs of depressed people in the inner city

Depression is a common problem, often being recurrent or becoming chronic, it has been stated that people with depression should continue to be predominantly managed in primary care. There is much evidence to suggest that the detection and management of depression by general practitioners (GPs) could be improved, but little work has focused on GPs' views on their work with depressed patients. This was a qualitative study exploring GPs' attitudes to the management of patients with depression. Semi-structured interviews were conducted with 22 GPs in north-west England. These GPs were practising in urban or inner-city areas and were all based in practices that participated in undergraduate teaching. The interviews were audiotaped and subsequently transcribed. Analysis was by constant comparison until category saturation was achieved. The subjects conceptualized depression as an everyday problem of practice rather than as an objective diagnostic category. Thematic coding of their accounts suggested a tension between three kinds of views of depressed people, namely (1) that depression is a common and normal response to socioeconomic disadvantage and that it reflects the medicalization of these conditions, (2) that the diagnosis of depression offers a degree of secondary gain to both patients and doctors and (3) that GPs experienced depressed people as an intractable interactional problem. It was concluded that depression is commonly presented to GPs who feel that its diagnosis often involves the separation of a normal reaction to a harsh environment and true illness. In addition, they felt ill-equipped to deal with the long-term management of such patients. They doubted that anything therapeutic occurs in review consultations with such patients. This has an important implication for the construction of educational interventions around improving the recognition and treatment of depression in primary care: doctors may be reluctant to recognize and respond to such patients in depth because of the much wider structural and social factors chat we have suggested in this paper. Primary Care Psychiatry 2000; 6:137-141. Copyright (C) 2000 by LibraPharm Limited.