Professor David Clarke¹,
Professor Leon Piterman²
Professor Graeme Smith¹
Dr Kay Cook³
¹Monash University School of Psychology, Psychiatry and Psychological Medicine
²Monash University School of Primary Health Care
³Deakin University School of Health and Social Development
beyondblue Victorian Centre of Excellence Award
Project completion year
Research demonstrates that general practitioners consistently under-diagnose depression. This conclusion is derived from studies that compare GP diagnosis with the results of psychiatric screening or assessment instruments.
There are many possible reasons for this under-diagnosis; one is that the diagnoses made by psychiatric instruments are invalid in the primary care setting. Diagnostic categories that have validity and reliability in a specialist psychiatric setting do not necessarily have validity and reliability in primary care. GPs and psychiatrists may talk a different language; or perhaps the depression that each sees is not the same.
This study built on the assumption that GPs know what depression is, and have a concept of depression, albeit one that might be different from specialist psychiatry. To inform this discussion we aimed to find out what experienced GPs mean by ‘depression’. Taxonomy in this context refers to the description and classification of depression.
The study used videotaped GP consultation characterised by helplessness ns to understand and record GPs decision-making processes with respect to the diagnosis of depression. Doctor-patient dialogue, including questions and answers, were examined to develop preliminary ideas about what doctors thought were important in diagnosing or assessing severity of depression. This examination of consultations was followed by in-depth interviews with GPs to add further detail to the emerging theory. A consideration of the decision-making rules in this way informs the understanding of what GPs mean by depression, and what they consider to be a depression worth treating.
A total of 139 consultations of 14 GPs were filmed. Of these, depression was a focus in 26% of consultations. These interviews became the subject of the analysis which demonstrated that GPs diagnose depression, and make treatment decisions, based on three determinations.
The first is a recognition of distress or depression based upon:
(b) A cluster of symptoms and signs (depressive facial expression – especially seen in the eyes, crying, loss of interest, sleep disturbance)
(a) The recognition that this is a ‘change from usual’
(c) Evidence of impairment in functioning (at work, home, with kids, recreation).
Following recognition of a syndrome of distress, GPs ask themselves: “Is there an identifiable cause?”.
IF NO: they diagnose “episodic endogenous depression”
This type of depression is characterised by a
general lack of interest or motivation
IF YES: they diagnose “reactive or situational” distress
There is a spectrum of acute reactive states. Patients are placed somewhere on this spectrum according to the most prominent feature; at one end being worry (generally a milder disturbance), at the other end hopelessness and feelings of giving up (more severe).
“Reactive Worry/Anxiety” “Reactive Depression/Demoralisation”
(characterised by helplessness & hopelessness)
Implications for Policy and Practice
This model has been operationalised in the Figure below. The strength of this taxonomy is that it is developed from the ‘ground up’ in the primary care setting and has strong face validity.
Further research will refine it and test whether GPs find it useful and whether the model can guide treatment that is effective in reducing distress. A taxonomy like this will likely prove more useful in the primary care setting than one based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) developed in a specialist psychiatric setting.
The researchers are continuing to research issues surrounding depression in primary care and chronic illness.