Depression explanatory models of primary care patients and doctors: Relationship with self-stigma, communication effectiveness, and recovery

Abstract

This thesis examines the role of patient and doctor perspectives in primary care depression management. The analytical term chosen to explore these perspectives is Kleinman’s explanatory model (EM), defined as “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (1980, p. 105). This research is exploratory and focuses mainly on patients, with input from a small number of general practitioners (GPs).I examine self- stigma in depression patients because there has been an attempt in recent years to reduce stigma by describing depression as a medical condition like diabetes. This may have decreased some public stigma, but the association between biomedical explanations for depression and patient self-stigma has not been studied in-depth. Self- stigma is the internalisation of negative stereotypes and prejudices about having mental illness and it can inhibit help-seeking and outcomes more than public stigma. Another factor that can influence depression outcomes is the therapeutic relationship between patient and their doctor. Studies report empathy and good communication as characteristics of caring patient-doctor relationships. Mutual understanding of patient and doctor perspectives could help foster empathy and effective communication, which is framed in this thesis using communication accommodation theory (CAT: Gallois, Ogay, & Giles, 2005; Giles, 1973).My research questions are:RQ1. What are depression EMs of primary care patients and do these change over time?RQ2. Does high endorsement of biomedical causation for depression correlate with low patient self-stigma?RQ3. Does agreement to certain aspects of patient EMs correlate with patient perception of greater GP-patient communication effectiveness?RQ4. How aware are GPs of their patient’s depression EM, how concordant are GP EMs with patient EMs, and how does awareness and/or concordance correlate to depression outcomes?Two different groups of participants were recruited by convenience sampling – the first consisted individuals aged 18-65 who had sought primary care treatment for depression. I collected longitudinal data using two online surveys spaced six months apart (Time 1 n = 238; Time 2 n = 129). A subset of patients (n = 10) who completed the later survey was interviewed between August 2015 and January 2016. The second group comprised GPs (n = 29) whose details were provided by individuals from the patient survey. The GPs were surveyed once. Ten additional GPs were recruited independently for interviews on EMs between April 2015 and January 2016. The patient survey contained validated instruments on four areas: patient EM, self-stigma levels, GP-patient communication effectiveness, and symptoms. EM beliefs were measured with Haidet et al.’s (2008) CONNECT instrument modified for this study. It consisted 16 items on causation, internal locus of control, sense of agency, efficacy of non-medical therapies, significance of depression, and preference for GP-patient cooperation. The GPs were surveyed with a version of this instrument on their perception of their patient’s EM (to quantify awareness) and the EM they adopt for their patient’s depression (to quantify concordance). Patient self-stigma was measured using the Internalised Stigma of Mental Illness scale modified for this study, with items on alienation, discrimination experience, help-seeking inhibition, and social withdrawal. A CAT-based instrument, consisting items for emotional expression, discourse management, interpretability, and interpersonal control, measured communication effectiveness. Participants indicated agreement to instrument items using a Likert-type scale ranging from 1 (strongly disagree) to 6 (strongly agree).The Clinically Useful Depression Outcomes Scale (CUDOS: Zimmerman, Chelminski, McGlinchey, & Posternal, 2008) was used to track depression symptoms. Patients rated how well the items (e.g., My energy level was low) described them in the past week using a scale of 0 (Not at all true) to 4 (Almost always true). Quantitative analysis methods mainly consisted of non-parametric tests for differences between groups and strength of correlations. Interviews were analysed manually and with textual analysis software Leximancer.RQ1 results showed that most participants had a strong or moderate belief about whether biomedical and/or psychosocial factors caused their depression, and most EM beliefs did not change over time. RQ2 results indicated that biomedical belief was associated with lower helpseeking inhibition but also greater alienation. RQ3 results highlighted that endorsement of GP-patient cooperation was strongly positively correlated with communication effectiveness. Patient interviews yielded exemplars to illustrate these findings. RQ4 results from a paired study (n = 29) suggest that the GPs were aware of and concordant with their patient’s EMs. Awareness appears to be more important in determining recovery than concordance. Incidentally, GP interviews showed that doctors mostly accorded importance to knowing their patient’s EM but concordance was seen as less crucial.This thesis gives new understanding about depression EM beliefs that are associated with lower patient self-stigma and more effective GP-patient communication. Results from this research on awareness-concordance were not generalisable due to the small sample size, but future work with larger samples will undoubtedly yield more insights into the importance of EMs in primary care depression management.