Despite UK general practitioners being responsible for helping people to manage
most emotional distress and the majority of psychiatric problems very little is known
about how they do this in their everyday clinical practice. There has been very little
systematic research on general practitioners' views of their work and little critical
reflection on the issues of 'problem definition'. In addition, whilst the perspectives of
patients have been placed at the core ofthe development of health services, there has
been relatively little research on the patient's perspective of depression and its
management in primary care. This study explored the management of depression from
both general practitioner and patient perspectivesUsing qualitative interviews, 37 women and 20 general practitioners were recruited
from practices in four NHS Board areas of Scotland. Each participant was interviewed
at the start ofthe study, and 30 women and 19 general practitioners were re-visited
approximately 9-12 months later to review the process of care. The interviews
explored how women made sense oftheir experiences, and their evaluations of their
care; and how general practitioners made sense of the women's experiences and how
they subsequently managed these women in the context of everyday practice.In making sense of their depressive experience and its management the women drew
upon a range of experiential, biographical and common-sense knowledge surrounding
health, illness, emotions, depression, antidepressant medications and medication use
in general. However, the generally negative views surrounding depression and
antidepressants created a moral dilemma for the women in accepting the diagnosis
and its treatment. The women did not passively accept their general practitioner's
explanation and advice but evaluated this in relation to their own knowledge. They
continually evaluated 'formal medical knowledge' and care in relation to their own
understandings and as new knowledge (experiential and common-sense knowledge)
emerged. General practitioners recognised that patients brought their own
understandings to the consultation and their management involved eliciting patient
beliefs and addressing the moral dilemmas that some of these beliefs created for the
women. General practitioners had to negotiate care by addressing patients' concerns
and sometimes acted strategically in order to persuade, or coerce, patients to accept
their advice and treatment.These findings are discussed in relation to the 'medicalisation' thesis through
reflecting on patient and professional discourses concerning depression and its
management, the doctor-patient relationship, and the doctor-patient interaction. I draw
upon the later work of Foucault which affords patient agency through the
'technologies of the self and also on the work of Habermas and the relationship
between 'system' and Tifeworld' as a theoretical basis for discussion of these
findings. Finally, I consider the implications of the findings for recent policy
developments which call for depression to be managed as a chronic disease and
comment on the applicability of current guidelines for the management of depression
to general practice. I conclude that the development of any management strategies
should be based on a consideration of the 'patient's perspective' and acknowledge
that 'formal medical knowledge' plays only a part in the management of depression in
primary care
