Negotiating ‘depression’ in primary care: A qualitative study

Abstract

Psychiatry has provided primary care physicians with tools for recognising and labelling mild, moderate or severe ‘depression’. General practitioners (GPs) in the UK have been guided to manage depression within primary care and to prescribe anti-depressants as a first-line treatment. The present study aimed to examine how GPs would construct ‘depression’ when asked to talk about those anomalous patients for whom the medical frontline treatment did not appear to be effective. Twenty purposively selected GPs were asked in an interview to talk about their experience and management of patients with depression who did not respond to anti-depressants. GPs initially struggled to identify a group, but then began to construct a category of person with a pre-medicalised status characterised by various deviant features such as unpleasant characters and personalities, manipulative tendencies, people with entrenched social problems unable to fit in with other people and relate to people normally. GPs also responded in non-medical ways including feeling unsympathetic, breaking confidentiality and prescribing social interventions. In effect, in the absence of an effective medical treatment, depression appeared to become demedicalised. The implications of this process are discussed in relation to patients' subsequent access or lack of access to services and the way in which these findings highlight the processes by which medicine frames disease.

Introduction

In the middle of the mid 20th century the close relationship between a diagnostic label and a disease, between the word and the thing, began to dissolve. The essentialist belief that diseases simply lay around in nature waiting to be discovered (and given a label) gave way to a nominalist view in which the relationship between diseases and their labels was more problematic: far from diseases ‘existing’ independently, they were, in a sense, constructed from their label. Disease labels therefore rarely emerged fully formed but evolved gradually through a complex social, cultural and political process in which clusters of symptoms and signs and a unifying descriptor interacted over time (Rosenberg & Golden, 1992). The process of negotiating a label for a disease has thus been understood by sociology as a social one and in many ways the status of medicine has been seen to derive its legitimacy from assigning a diagnostic label to patients' misfortunes (Parsons, 1951).

The increasing disassociation of the label from the disease or ‘pathology’ has given impetus to wider conceptual shifts in medical sociology such as medicalisation (Conrad, 2005, Conrad and Schneider, 1992). Debates in sociology have considered whether medicalisation is preventable or inevitable, desirable or undesirable (e.g. Parsons, Friedson and Armstrong's contrasting positions are summarised by Gerhardt, 1989). More recently, it has been recognised that the range of conditions considered to be medicalised have not remained constant (see Smith, 2002) suggesting that those conditions or states described as ‘medicalised’ at a particular point in time represent the contemporary boundaries of medicine and themselves tell us about the historicity of shifting management of deviance.

Wilson contended that mental illness had been medicalised in the 19th century by the dominance of Kraepelinian descriptive psychiatry (Wilson, 1993). Wilson also described the dominance of the psychosocial model in the ideas of Meyer, Menninger and Freud in post World War II USA representing a demedicalisation of mental illness, followed by a period of re-medicalisation in the 1970s coupled with the increasing numbers and uses of psychotropic drugs. It has been argued that the pharmaceutical industry contributed to the medicalisation of misery or unhappiness through marketing practices which required drug branding and linking to medical diseases and thus while evidence suggests that ‘anti-depressants’ have non-specific effects on psychological states including anxiolytic effects (Goldberg & Huxley, 1992), the pharmaceutical industry has branded ‘depression’ with a medical label to enhance sales (e.g. see Healy, 1999). The idea that the pharmaceutical industry has an ongoing pernicious role in health care through the ‘corporate construction of disease’ has been extended more recently for example by Moynihan, Heath, and Henry (2002) who argued that some forms of medicalisation may in fact be described as ‘disease mongering’. Examining the medicalisation of ‘misery’, Pilgrim and Bentall (1999) set out the way in which medicalisation joined the label ‘depression’ to operational definitions such as the DSM classification which has led to a narrowing of focus and obscuration of any social conditions that may give rise to unhappiness. Chodoff (2002) has also criticised the role of the DSM system in the medicalisation of misery and suggested that psychiatrists may sometimes be motivated to apply the diagnosis of depression in order to justify the prescription of an antidepressant rather than engage in psychotherapy.

Within this broad context, the present study is concerned with the ways in which ‘medicalisation’ and ‘demedicalisation’ may be achieved in vivo through the discourse of individuals working in a clinical context. At the time interviews for this study were carried out, UK national guidelines for the management of depression in primary care indicated anti-depressants as the first-line treatment (Littlejohns, Cluzeau, & Bale, 1999). It was therefore expected that primary care physicians would be able to diagnose and treat clinical ‘depression’ in everyday practice. In the current study, general practitioners (GPs) were specifically asked to consider patients whom they considered to have ‘depression’ but for whom the medical paradigm specified treatment (anti-depressants) did not work. The aim was to explore the implications for labels and disease construction in a context in which a medical label (depression) and a corresponding medical treatment (anti-depressants) became decoupled. This was considered an interesting context to examine professional discourse since a potential threat to the medical paradigm would be present in the juxtaposition of a diagnostic label with an implicit challenge and the medical professionals in the study would find themselves constructing explanations for this discrepancy.