that depression is more common among womenâ and ... such as âThe doctor him/herself must be convinced of a treatment .... difficult when the patient is old and.
Family Practice © Oxford University Press 2001
Vol. 18, No. 1 Printed in Great Britain
Conceptions of depressive disorder and its treatment among 17 Swedish GPs. A qualitative interview study Stig J Andersson, Margareta Troeina and Gunnar Lindbergb Andersson SJ, Troein M and Lindberg G. Conceptions of depressive disorder and its treatment among 17 Swedish GPs. A qualitative interview study. Family Practice 2001; 18: 64–70. Background. Making clinical decisions for psychiatric patients in general practice is a complicated issue. A marked variation in the prescribing rates for antidepressant drugs in general as well as between geographical regions has been reported. Also, GPs tend to underestimate and undertreat depressive disorders. Objectives. The aim of this study was to explore GPs’ conceptions of depressive disorder and its treatment. Method. A qualitative semi-structured interview was carried out on 17 GPs, selected to ensure variation of pre-conditions, in the county of Örebro, Sweden. Informants’ conceptions about four depression-related issues were determined: the depressive disorder, antidepressant drugs, the treatment decision and psychotherapy. Results. Conceptions of the four themes varied widely among informants in the interviews. However, the informants shared certain conceptions concerning the selection of drugs and drug treatment of major depression as well as the patient’s role in deciding whether or not to treat pharmacologically. Conclusions. The study adds knowledge of GPs’ thoughts about depressive disorder and their diagnostic and treatment preferences. Utilizing the concepts discussed herein, a quantitative study will be conducted to analyse how GPs’ conceptions of depression are inter-related. Keywords. Antidepressant drugs, conceptions, depressive disorder, GP, treatment decision.
For these reasons, the present study aimed to explore GPs’ individual conceptions of depression and its treatment.
Introduction Making clinical decisions for psychiatric patients in general practice is a complicated issue. There are grey zones where evidence about the risk–benefit ratios of competing treatments is incomplete. In many situations, a clinician’s work may be described as educated guesswork.1 Studies also report that GPs frequently do not detect depressive states, tend to under-treat depression and fail to take up evidence guidelines in the area of depression.2–8 Moreover, prescribing rates for antidepressant drugs differ markedly among individual GPs and between geographical regions according to reports.9,10
Methods In order to capture a broader scope of ideas, the authors of this study created a semi-structured interview schedule based on a set of open questions (Appendix). The questions encompass four sections of the research area: the depressive disorder, antidepressive drugs, the treatment decision and psychotherapeutic treatment. Every informant was able to interpret the questions in his/her own way. Thus, different aspects of the query arose out of the informants’ answers. The interview questions themselves were principally the result of the interviewer’s understanding of the research field. The interviewer has long experience as a GP and a special interest in psychiatric issues within the practice of family medicine.
Received 4 January 2000; Revised 13 June 2000; Accepted 5 September 2000. Hermes Primary Health Care Centre, Säffle, aMalmö University, Malmö and bThe NEPI Foundation, Malmö, Sweden. Correspondence to Dr Stig J Andersson, Hermes Vårdcentral, Industrigatan 10, SE-661 33 Säffle, Sweden.
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Conceptions of depressive disorder and its treatment
During the interview, the interviewer did not attempt to govern the informant but to encourage the informant to clarify his/her own thoughts using follow-up questions. The interviews were tape-recorded and transcribed verbatim. All interviews were conducted and transcribed by one of the authors (SJA). The study was first approved by the regional research ethics committee before being conducted. Data analysis The dialogue texts constitute the database. They were scrutinized by one of the authors (SJA). All statements pertaining to GPs’ conceptions of depressive disorder and its treatment were selected as examples of conceptions in the form of dialogue excerpts. A conception is presumed to be a fundamental notion with components of personal experience, actual ideas and cultural descent.11 Conceptions of a similar kind held by different informants were grouped together into categories, referred to as ‘categories of conceptions’. They were formulated in accordance with the common essence in the conceptions they represent. Most of them are categories of attitudes or intentions, while others are descriptions of performances. These categories of conceptions constitute the result of the study. Lastly, the categories were grouped according to different aspects of the main issues in each section of the interview. Conceptions of a specific phenomenon appearing in different parts of the interview are grouped together in the Results section. Sample selection In order to achieve a breadth of response, we looked for male and female GPs of different ages working both in urban and rural areas as well as in different forms of primary care. Using a list of all the 130 GPs working in the county of Örebro, we selected 17 informants, eight women and nine men aged 40–60 years. Three of the physicians selected had to refuse due to lack of time and were replaced by three others. Fourteen of the GPs chosen were employed by the county council and three were in private practice. About half of the GPs worked in the city of Örebro (population 130 000). The others practised in smaller communities. Two were immigrants. All but one of the informants were unknown to the interviewer. The interviews were performed between August and November, 1997.
Results The informants’ conceptions are grouped into categories and presented in the four tables, one for each section of the research area. To illustrate the character of the categories, a few quotations of the underlying conceptions are given as footnotes to the tables. Table 1 presents conceptions of the depressive disorder. A majority of the informants expressed the conceptual
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categories “The borderline between health and illness is not distinct” and “There are patients who are generally unwell but not depressed in a proper sense”. Several also had conceptions of causes of depression expressed in the three categories “Different causes act together in a complex and obscure way”, “Some depressions have organic causes” and “External overload is the most common cause”. All informants comprised the category “Women consult doctors more often than men”. However, there were also conceptions forming the categories “It is not certain that depression is more common among women” and “Male depression patients are often in a more serious state than female”. Table 2 includes conceptions of antidepressant drugs. All informants expressed the categories “Antidepressants are important requisites in the clinical work” and “Patients with major depression should be given antidepressants”. The same was true for “SSRIs are chosen in the first place because of fewer side effects” and “The introduction of SSRIs has influenced the informant’s readiness to prescribe”. Conceptions of the current increase of prescribing divided the informants into two equal groups, one positive to the increase, the other sceptical against it. A number of informants asserted that antidepressants should be prescribed only in cases where a depressive illness could be diagnosed, while others declared that antidepressant prescribing does not follow the borderline between health and illness. Most informants conceived that introduction of SSRIs had not moved that borderline. Table 3 exposes conceptions of the clinical decision process. A minority of the informants reported sporadic use of a depression rating scale or a checklist of diagnostic criteria. All informants expressed agreement that “The patients must have the opportunity to take his/her part in the treatment decision”. That commitment to patientcentred care seems limited by conceptual categories such as “The doctor him/herself must be convinced of a treatment to propose it” and “The patient may be too ill to be able to make a decision”. The informants held different conceptions of patients’ reluctance towards antidepressant treatment. Frequent conceptions expressed the category “Reluctance towards antidepressant treatment is not uncommon”. Other conceptions were in the category “Most patients who are reluctant about drug treatment will change their minds after some more consultations”. Table 4 comprises conceptions of psychotherapeutic treatment. All informants shared the conceptual category “For patients with major depression, psychotherapy cannot replace drug treatment”. However, the informants had diverging conceptions of the need for psychotherapy and differed in their attitudes to that form of treatment. A number of informants made known their lack of access to psychotherapy. However, GPs’ views of follow-up of their patients as a form of psychotherapeutic treatment were common.
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Family Practice—an international journal TABLE 1
Meaning of depression
Aspects and categories of conceptions of the issue of depressive disorder Causes of depression
Frequency of depression
Depression and gender
Reflections about the meaning of depression appeared in the dialogues without schedule questions.
This aspect was introduced by a schedule question.
This aspect was introduced by informants.
We had a schedule question about gender difference.
The borderline between health and illness is not distinct. (10)
Different causes act together in a complex and obscure way.b (11)
Depression is a common illness. (3)
There are patients who are generally unwell but not depressed in a proper sense.a (9)
Some depressions have organic causes. (11)
Patients with major depression are uncommon in general practice. (2)
Women consult doctors for depression more often than men. (All informants)
Depression is a physiological disturbance of the brain. (3)
External overload is the most common cause. (9)
Patients with major depression are the truly ill patients. (3)
There are several kinds of depression with different causes. (6)
Depression is a sort of flight, a protection of the body. (1)
Early traumata and development crises may cause vulnerability. (5)
It is not certain that depression is more common among women. (12) Male depression patients are often in a more serious state than female.c (6) Depression is more common among women. (5)
Different causes dominate in different ages. (2) Chronic pain may lead to depression. (1) Numbers in parentheses indicate the number of informants with conceptions comprising the category. The following footnotes illustrate some of the conceptions comprising the category: a “A mild state of insufficiency where, in a way, it has been too much for the patient. That is definitely not a mental illness even if antidepressants are prescribed.” b “You come to speculations. I think causes are in the society we live in with its very hard demands on people at many levels (. . .). There is also much of biology behind depressions but . . . it is a combination.” c “I think men are often much more serious. (. . .) They come because someone has told them to consult a doctor. Otherwise they are lying at home or they shoot themselves or hang themselves.”
Discussion Method considerations In order to obtain greater knowledge about the informants’ conceptions of depressive disorder, we chose to adopt a qualitative approach in this study.12–14 However, this approach has its uncertainties and must be conducted with these uncertainties in mind. For example, the credibility of the interviewer increases if the informants feel confidence in him/her.15 In the present study, the interviewer’s position as a colleague of the informants with a shared knowledge and interest in their field may have increased such credibility. The risk in such a relationship, however, is that it may create a case of shared conceptual blindness, allowing the interviewer’s own feelings and opinion about the field to govern the dialogue and interpretation.15,16 The rather detailed interview schedule might add a similar risk. The semistructured approach was employed to achieve a broad range of conceptions, but it could have been too governing and thereby not encourage original thought sufficiently. Another possible weakness of this study lies in the fact that only one of the authors of this study (SJA) examined and analysed the interviews. The results of the interviews might have been more conclusive had all three of the study’s authors been involved in the analysis stage.15
The interview sample ought to represent most of the presumed variation in conceptions of depressive disorder and its treatment. Malterud recommends 15–25 informants in qualitative interview studies.16 Given our sampling procedure, we believe that the 17 interviews conducted reveal a sufficient variation in conceptions. Conceptions shared by all informants The informants’ unanimous belief in the selection of drugs and the necessity for drug treatment is in accordance with their shared professional education. Their common conceptions regarding gender distribution and the treatment of major depression are consistent with results from epidemiological studies and evidence-based recommendations, respectively.17–19 However, their uniform belief in the advantages of selective serotonin re-uptake inhibitors (SSRIs) over triclyclic antidepressants (TCAs) is not supported by scientific documentation. On the other hand, the Swedish authority for drug control, Medical Products Agency, has officially recommended SSRIs for the treatment of depression in primary care cases.19 Depressive disorder Conceptions about the depressive disorder varied widely among the informants. Most of them were reluctant to
The increase is doubtful.c (8)
Patients with major depression should be given antidepressants. (All informants)
SSRIs seem more effective. (1)
Sometimes a TCA is selected because of its lower price. (4)
For patients with chronic pain, TCAs are more effective. (6)
TCAs are more effective. (6)
The effect is partly dependent on the placebo effect. (2)
The drugs replace something lacking or influence an imbalance in a physiological system. (7)
The borderline has been moved because of SSRIs.e (5)
The borderline has not been affected by the introduction of SSRIs. (9)
The drugs affect transmitter substances in the brain.d (12)
SSRIs are chosen in the first place because of fewer side effects. (All informants) The introduction of SSRIs has influenced the informant’s readiness to prescribe. (All informants)
This aspect was introduced by a schedule question.
Conceptions of the mechanism of action were asked for by a schedule question.
The new antidepressants’ influence on the borderline between health and illness
The aspect of drug selection was introduced by two schedule questions.
Drug selection
Mechanisms of action
Numbers in parentheses indicate the number of informants with conceptions comprising the category. The following footnotes illustrate some of the conceptions comprising the category: a “The new antidepressants have revolutionized the treatment of depression, in particular minor depressions.” b “I think it is an adaptation to a better understanding of the problem.” c “ Sometimes I wonder, what is to be the end of this? Because it is often difficult to stop taking drugs.” d “I imagine they have a pure chemical effect. (. . .) This effect makes, in a way, the person easier to activate and more able to solve his/her problems.” e “Before, I saw it self-evident that people have different life conditions and events back in life constituting more of environment influence. Now, I try . . . is this an illness?”
Antidepressants make people more fit to solve their problems. (2)
Antidepressant drugs are not happy pills. (2)
Going through a depression without drug treatment causes unnecessary suffering. (2)
The prescribing of antidepressants does not follow the line between health and illness. (6)
The increase in prescribing is well founded.b (9)
Antidepressants are important requisites in the clinical work.a (All informants) Antidepressants should be prescribed only when a depressive state can be diagnosed as an illness. (4)
Informants introduced this aspect.
Condition for prescribing
A schedule question actualized this aspect.
Current increase in prescribing
Aspects and categories of the issue of antidepressant drugs
This aspect was introduced by a schedule question, but conceptions of this category also appeared in other parts of the interviews.
Importance in clinical praxis
TABLE 2
Conceptions of depressive disorder and its treatment
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Family Practice—an international journal TABLE 3
Aspects and categories of conceptions of the issue of treatment decision
Diagnosis and severity rating
The treatment decision
Patients’ attitudes to drug treatment
A schedule question introduced this aspect of the treatment decision.
This aspect was actualized by a schedule question.
This aspect of the treatment decision appeared spontaneously in the dialogues.
Diagnosis is made by global estimation.a (15)
The patient must get the opportunity to take his/her part in the treatment decision. (All informants)
There are patients who come to the doctor just to get antidepressants. (10)
The decision to prescribe is not always so well founded. (7) A depression rating scale or a checklist of diagnostic criteria is sometimes used.b (3) The diagnosis of depression is difficult when the patient is old and has dementia. (1)
Reluctance towards antidepressant treatment is not uncommon.d (9)
The doctor him/herself must be convinced of a treatment in order to propose it.c (8) It is often difficult to form a judgement at the first consultation. (4)
Most patients who are reluctant about drug treatment will change their minds after some more consultations. (6)
A conception of depression as a biological disorder brings readiness to treat with antidepressants. (1)
Reluctance towards drug treatment is uncommon.e (2)
The patient may be too ill to be able to make a decision. (1)
Reluctance towards drug treatment is most common among depressive patients with somatization and chronic pain syndromes. (1)
Scarcity of time may make the doctor more dominant. (1)
Numbers in parentheses indicate the number of informants with conceptions comprising the category. The following footnotes illustrate some of the conceptions comprising the category: a “Make myself a picture of what sort of person he is. Lay a puzzle.” b “I am very conscious of . . . perhaps, the diagnosis is not right every time. And I should need to use these scales as MADRS, properly speaking.” c “But first, I must myself be quite convinced. Otherwise I cannot motivate the patient.” d “Many patients are negative towards all these psychotropic drugs. To some patients you cannot even suggest it.” e “If it should be needed in my opinion and the patient says, I will not take drugs, then I wait. (. . .) It is uncommon.”
TABLE 4
Aspects and categories of conceptions of the issue of psychotherapeutic treatment: the issue was introduced by two schedule questions
Need for psychotherapy
Attitudes to psychotherapy
For patients with major depression, psychotherapy cannot replace drug treatment. (All informants)
If a depression is moderate, psychotherapy is the better way to achieve health.c (9)
Generally, psychotherapy is needed as a complement to drug treatment.a (10)
There is no difference in quality between drug treatment and psychotherapy. (4)
Only occasionally is psychotherapy needed as a complement to drug treatment. (3)
Psychotherapy can replace drug treatment in only a few patients. (4)
There is a need for but no access to psychotherapy.b (7)
Cognitive therapy is effective and could replace drug therapy. (2) Psychoanalysis is not useful in depression treatment. (2) The patient follow-ups are a form of psychotherapeutic treatment.d (11)
Numbers in parentheses indicate the number of informants with conceptions comprising the category. The following footnotes illustrate some of the conceptions comprising the category: a “I think a person who has gone through some sort of therapy surely comes to a knowledge about himself and his way of working with problems which could be a little preventive.” b “The issue of other therapies than drug treatment, it is a tragic one (. . .) I am a little ashamed sometimes when I make a prescription.” c “If I was allowed to choose, I think I should stake on psychotherapy in first place.” d “It is the meeting I offer. And I offer revisits. I try to talk about the problem but I am not an educated psychotherapist. Nevertheless, I consider also my consultation having its significance.”
view depressive states as illnesses unless such a state was perceived as a major depression. Accordingly, informants perceived the borderline between health and illness as problematic. Most of the informants had multiple conceptions of the causes of depressive disorder. The relatively uniform conceptions held about the use of antidepressants seemed independent of both common and individual conceptions of illness and health.
Drug treatment Although all informants considered antidepressants important and had increased their antidepressant prescribing rates, some of them expressed scepticism about the current increase in antidepressant prescribing. This scepticism appears to mirror a corresponding uncertainty about the correct criteria for diagnosis and treatment. It is also consistent with the reported lack of recognition of depressive states in patients treated by GPs.3–6 Such
Conceptions of depressive disorder and its treatment
uncertainty can be explained by the results of one study showing diverging attitudes between GPs and psychiatrists about the identification and management of depression20 as well as another study reporting that GPs undervalue psychiatrists’ recommendations when determining a course of antidepressant treatment.3 The decision to prescribe The majority of this study’s informants work according to the traditional clinical method without the aid of depression rating scales. This is consistent with other studies of clinical decision making.1,21 Furthermore, most informants viewed the decision to prescribe as the joint responsibility of physician and patient, as expressed in theories on patient-centred consultations.22 A physician’s decision to prescribe and the choice of drug can be considered as a ‘core’ judgement, and is strongly influenced by the importance of the diagnosis.23 The informants’ unanimous conception that major depression should be treated with antidepressants demonstrates their conception of major depression as an important diagnosis. Several informants reported reluctance among their patients to use antidepressants and the need for several consultations before this reluctance was overcome. An investigation of the attitudes of the general public towards depression confirms this scepticism.24 Furthermore, the informants’ difficulties in making a decision to treat with antidepressants are consistent with documentation showing that GPs’ actions are strongly influenced by their patients’ expectations and anxieties about the presenting problem.25,26 GPs have to balance prescribing criteria against their patients’ reluctance and expectations of other measures as well as an often complex clinical situation with multimorbidity.23–27 The informants’ difficulties in deciding in depression cases may illustrate the observation that high task complexity causes doctors to shift from an analytical to a non-analytical decision-making strategy.27,28 GPs’ alleged under-treatment of depressive states may be a consequence partly of the sceptical attitude towards drugs reported among patients in primary care. Moreover, the majority of the studies of antidepressant prescription were made by psychiatrists or psychologists. The profession of the researcher may have significance due to a difference in attitude between GPs and psychiatrists. GPs have been reported as having fewer biological conceptions of the nature of depressive disorder and more confidence in the power of psychotherapy than psychiatrists. This, in turn, may lead to a reluctance to prescribe drug treatment.20 However, there is a wide variation in rates of antidepressant prescription among psychiatrists as well as GPs.20,29,30 Concluding remarks The present study, designed to reveal GPs’ conceptions of depressive disorder and its treatment, showed a wide
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variation of conceptions among participating GPs. It may be assumed that the variation is even greater among GPs in general. The participating GPs (the informants) shared certain conceptions, predominantly dealing with selection of drugs and issues around drug treatment and the role of the patient in a treatment decision. Due to the small sample size, this study is not appropriate for generalizing quantitative statements or analysing the relationships between conceptions. However, knowledge of how the conceptions are inter-related is essential to understand GPs’ diagnostic and treatment preferences and thereby also for planning training and practice. Therefore, utilizing the concepts revealed by the present study, a quantitative study of how GPs’ conceptions of depression are distributed and interrelated will be performed.
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Nayler CD. Grey zones of clinical practice: some limits to evidencebased medicine. Lancet 1995; 345: 840–842. Bodlund O. Anxiety and depression go unrecognised in primary care. (In Swedish with summary in English.) Läkartidningen 1997; 94: 4612–4618. Matthews K, Eagles JM, Matthews CA. The use of antidepressant drugs in general practice. Eur J Pharmacol 1993; 45: 205–210. Orrell M et al. Management of depression in the elderly by general practitioners: use of antidepressants. Fam Pract 1995; 12: 5–11. Rosholm J-U et al. Antidepressant treatment in general practice— an interview study. Scand J Prim Health Care 1995; 13: 281–286. Wells K et al. Use of minor tranquillizers and antidepressant medications by depressed outpatients: results from the medical outcomes study. Am J Psychiatry 1994; 151: 694–700. Kendrick T. Why can’t GPs follow guidelines on depression? We must question the basis of the guidelines themselves (Editorial). Br Med J 2000; 320: 200–201. Thompson C et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000; 355: 185–191. Pharoah P, Melzer D. Variation in prescribing of hypnotics, anxiolytics and antidepressants between 61 general practices. Br J Gen Pract 1995; 45: 595–599. Burman K, Wessling A. Svensk läkemedelsstatistik 1997 (Drug sales in Sweden 1997. In Swedish and English). Stockholm: Apoteket AB, 1998; 184–186. Dahlgren LFM. Phenomenography as a qualitative approach in social pharmacy research. J Soc Admin Pharm 1991; 8: 150–156. Britten N et al. Qualitative research methods in general practice and primary care. Fam Pract 1995; 12: 104–114. Green J, Britten N. Qualitative research and evidence based medicine. Br Med J 1998; 316: 1230–1232. Faltermaier T. Why public health research needs qualitative approaches. Subjects and methods in change. Eur J Publ Health 1997; 7: 357–363. Hamberg K et al. Scientific rigour in qualitative research—examples from a study of women’s health in family practice. Fam Pract 1994; 11: 176–181. Malterud K. Kvalitative metoder i medicinsk forskning en innforing. (Qualitative Methods in Medical Research—An Indroduction. In Norwegian). Oslo: Tano, 1996: 30–63. Cafferata GL, Meyers M. Pathways to psychotropic drugs. Understanding the basis of gender differences. Med Care 1990; 28: 285–300.
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Klerman G, Weissman M. Increasing rates of depression. J Am Med Assoc 1989; 261: 2229–2235. Anonymous. Workshop om depressionsbehandling (Workshop on treatment of depression. In Swedish). Information från läkemedelsverket 1995; 6: 309–322. Kerr M, Blizard R, Mann A. General practitioners and psychiatrists: comparison of attitudes to depression using the depression attitude questionnaire. Br J Gen Pract 1995; 45: 89–92. Dawes R, Faust D, Meehl PE. Clinical versus actuarial judgement. Science 1989; 243: 1668–1674. Pendelton D, Schofield T, Tate P, Havelock P. The Consultation. An Approach to Learning and Teaching. Oxford General Practice Series No. 6. Oxford: 1984. Davis P, Yee RL, Millar J. Accounting for medical variation: the case of prescribing activity in a New Zealand general practice. Soc Sci Med 1994; 39: 367–374. Priest RG et al. Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. Br Med J 1996; 313: 858–859.
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Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations —a questionnaire study. Br Med J 1997; 315: 520–523. Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients’ expectations and doctors’ actions. Br J Gen Pract 1994; 44: 165–169. Bradley C. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners. Br J Gen Pract 1992; 42: 454–458. Chinburapa V, Larson LN, Brucks M, Draugalis JL, Bootman JL, Puto C. Physician prescribing decisions: the effects of situational involvement and task complexity on information acquisition and decision making. Soc Sci Med 1993; 36: 1473–1482. Meridith L, Wells KB, Camp P. Clinician speciality and treatment style for depressed outpatients with and without medical comorbidities. Arch Fam Med 1994; 3: 1065–1072. Olfson M, Pincus HA, Sabshin M. Pharmacotherapy in outpatient psychiatric practice. Am J Psychiatry 1994; 151: 580–585.
Appendix Interview schedule, translated from Swedish 1.
What sort of illness or problem do you treat with antidepressant drugs? (Interviews I–VI only).
2.
What importance have antidepressive drugs for you in your practice? (Interviews VII–XVII only).
3.
The prescription of antidepressant drugs has greatly increased in the 1990s. What do you think about that?
4.
What do you think might be the causes of depression and anxiety disorders?
5.
Do you think there are differences between women and men as regards depression and anxiety disorders? (Interviews I–VI only).
6.
It is reported that women consult doctors more than men do for these problems. What do you think of that?
7.
What criteria do you use when prescribing antidepressant drugs?
8.
How do you decide on a course of treatment?
9.
How involved is the patient in your decision? How involved are family members?
10. There are studies suggesting that GPs do not recognize depression and other mental problems in their patients. What do you think about that? (Interviews VI–XVII only). 11. What do you think of taking over a patient with antidepressant treatment from another doctor? (Interviews VII–XVII only). 12. What is your opinion of different types of antidepressants? 13. Have the new SSRI drugs influenced your way of treating? 14. Have SSRI drugs influenced your view of the borderline between mental health and illness? 15. What do you think about the effects of taking antidepressant drugs? 16. What is your opinion of other treatments besides drug therapy? 17. Do you see a difference between getting well by taking drugs and getting well by undergoing psychotherapy or something similar?
