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Research Article Open Access
Mental Health in Family Medicine (2017) 13: 381-388
Research Arcle
2017 Mental Health and Family Medicine Ltd
Regaining Some Good in the World: What
Matters to Persons Diagnosed as Depressed in
Primary Care
Miraj U. Desai
Frederick J. Wertz
Larry Davidson
Introducon
“You feel condent [when] they are there to be your friend…
instead of ‘open your mouth and say ahh,’…[if only] they would
actually take time to understand what’s going on. A simple ‘what
brings you here’ instead of ‘what hurts’.” ~Participant
The identication and effective treatment of depression
in primary care settings is at the forefront of current health
care reform efforts in the United States. Historically, primary
care services have accounted for the highest percentage of
the prescription of psychiatric medications, especially anti-
depressants [1]. Yet primary care has typically lacked the
appropriate mental health expertise to provide psychiatric care
in an effective fashion. Through the combination of federal
parity legislation passed in 2008 and the comprehensive health
care reform efforts outlined in the 2010 Patient Protection
and Affordable Care Act (ACA), this situation may change
dramatically. As a result, primary care settings may begin to
experience a signicant inux of behavioral health professionals
with appropriate training and expertise so that care for mental
health and substance use disorders can be provided, in terms
of both accessibility and effectiveness, on par with all other
medical care [2,3].
Research suggests numerous challenges await the task
of providing effective behavioral health treatment in primary
care for depression, including low help-seeking rates, lack of
adequate care, and mental health treatment drop out [4-6]; c.f.,
[7]. Studies indicate, for example, that roughly only a third to
half of individuals with depression actually seek treatment [5,6],
with members of ethnic minority groups doing so less than their
majority group counterparts [6]. Epidemiological studies have
found that roughly half of individuals with a 12-month episode
of major depressive disorder received treatment, but only about
40% of these individuals actually received adequate care [8].
Finally, Edlund and colleagues found that a fth of patients
in the United States leave mental health treatment early [4],
with another study showing these rates to be highest—around
a third—in general medical settings [9]. Treatment dropout is
of course a longstanding and pervasive problem overall in the
mental health eld, with some studies on psychotherapy attrition
suggesting rates close to 50% [10]. Overall, research suggests
that merely offering the care on-site within primary care settings
may not be enough to ensure that persons with mental health
problems accept, engage, and complete treatment.
There is evidence that a central reason for this apparent
disconnect between the presence of behavioral health issues
and the reception of effective care may be the disparate ways
in which patients and professionals construe distress and
depression [11-21]. For instance, Yeung et al. found signicant
gaps between patients and the health care system in their study
of depression in a primary care clinic in a predominately Chinese
American community [15]. Of the original 40 patients screened
for depression, 19 had records documenting primary care
Research suggests that low rates of mental health service
utilization are partly due to incongruence between patients’
viewpoints and the professional treatment models intended to
help them. In order to shed light on this gap, this article presents
the second in a series examining patients’ own perspectives
on experiences that would be seen as indicators of clinical
depression and treatment need. For those who screened positive
for depression, possibilities for practical action varied and did
not necessarily include seeking clinical help. Some participants
no longer screened positive for depression one month later, in
large part due to their own efforts in revising their central life
aims and commitments. We discuss the implications of these
ndings for policy, practice, and community engagement,
such as the importance of harmonizing professional care with
patients’ main commitments in life—their unattained goals and
efforts to regain a sense of direction in their lives—as situated
in complex community contexts. This, in effect, would reverse
the direction of “adherence.”
MeSh Headings/Keywords: Depression; Primary care;
Phenomenology
Miraj U. Desai, Frederick J. Wertz, Larry Davidson, Alison Karasz
382
physician involvement at the three month follow-up, but only
six of these patients accepted mental health treatment. Reasons
offered by the 13 patients who declined mental health referrals
included: “‘trying to handle the illness by myself,’ ‘do not think
that it is an illness,’ and ‘concerns that condentiality could be
breeched’” [15]. Other research suggests that when patients
were placed in a treatment that was “congruent” with their own
understanding of their predicament, they were more likely to
engage in care than patients whose treatment did not match their
own understanding [22]. Evidently it is crucial that the physician
and patient connect interpersonally and share an understanding
of the situation that will guide helpful collaboration.
This push towards more synergy and mutual understanding
aligns with the growing international person-centered medicine
movement. This movement places priority on the whole person,
the unique circumstances of each case, and a broader focus on
health rather than only a focus on disease [23]. Mezzich and
colleagues identify important constituents of the totality of
health that have previously not factored centrally into health
care, including a person’s social context, life projects, and
values. In general, this approach demonstrates concern for the
wellness of the person, the provider, and the surrounding world
in which they both live.
Given the anticipated increase in the identication and
treatment of behavioural health conditions in primary care
settings, the challenge of engaging those who need services, and
the growing evidence of divergent perspectives between patients
and professionals, more research is needed about patients’ views
of those experiences that health care professionals identify as
indicators of depression and treatment need during a routine
medical visit. We could nd no study that investigated this issue
based directly on the experiences of individuals who have been
identied in a primary care setting as having a clinical depression
for which treatment is judged relevant. A main limitation with
past literature that examines patients’ points of view is that it
presupposes the singular validity of a Western biomedical
construct of depression. But presupposing the existence of such
a condition as “depression” prohibits researchers from exploring
patients’ own perspectives in their own terms, particularly
among culturally diverse individuals. c.f., [24]. Although
patients’ views of their own experiences may not be relevant to
traditional diagnosis, etiology, and intervention research, they
are of considerable practical importance in helping providers
to understand whether and why such people will seek or follow
through with clinical care.
The present study involved seven participants who were
seeking help with medical concerns in a primary care clinic
and who also screened positive for depression during their
visit. This population allowed for a glimpse into the world of
the non-engaged, affording the opportunity to explore persons’
experiences at the point of contact with services or referrals
for mental health. The current article focusing on practice-
oriented considerations is the second in a two-part series of
articles whose aim is to explore the experiences that give rise to
a positive depression screen and to understand what they mean
to the patients themselves. The main ndings of the rst article
[25] were that: the experiences to which the screen referred
were characterized by a life situation in which participants
were falling away from their most cherished life commitments
and goals. Their experiential focus was not on ‘symptoms’ of
a biomedical condition but rather on questions involving the
world, particularly what was to become of them in the future with
regard to the fullment or failure to full specic life-purposes.
Examples included a recently failed intimate relationship and
a two-year period of unemployment accompanied by a loss of
esteem in the eyes of family. What ensued for participants was
a downward spiral in the realms of the emotions, body, time,
space, self-worth, and interpersonal relations--and edgling
attempts to overcome the experience of failure and collapse, to
restore positive goals and a valued place in the world. The present
article now delves into the latter possibilities for overcoming the
devalued situation and downward fall that generated a positive
depression screen. This may shed more light on the experiences
of people being screened for depression in primary care who
are not yet engaged with mental health care, as well as pointing
to possible points of collaboration and enhanced connection
between patient and provider as both seek ways of ameliorating
the person’s distress.
Methods
This study utilized a qualitative method to elicit and analyze
participants’ narratives regarding the matters that led to a
diagnosis of depression, described in detail elsewhere [25]; (see
also the larger study in which the present one was conducted
[18]). Briey, participants consisted of seven persons entering a
primary care clinic for medical concerns, and meeting positive
criteria for depression according to the PHQ-9 (minimum of
“other depression”) [26]. Participants were asked to describe the
experiences and life contexts that underpinned each response
on the depression screen. We utilized data from two points in
time, which was useful in examining how persons who did not
engage or complete treatment were attempting to come to terms
with the matters they reported in connection with the positive
depression screen. The comprehensive narratives were analyzed
via the procedures of phenomenological psychological analysis
to determine the meaning, context, and general structure of these
experiences from the participants’ own perspective [27,28]. The
study received IRB approval from both Fordham University and
the Albert Einstein College of Medicine, and all participants
were ensured of the condentiality of their responses and signed
informed consent forms.
Results
Struggling to Transcend: Praccal Opons and Acons in
Response to the Devalued Situaon
Participants’ main concerns stemmed from their challenges
in meeting the most central goals and commitments of their
lives, as embedded in worldly contexts. This was the stuff
of life in the real, changing world: unemployment, ongoing
relationship and custody struggles, physical health issues,
and profound discouragement in a public service career. One
person struggled with the constriction of her life, freedom, and
work in the aftermath of sudden panic attacks (and fears about
their return). As goals faded for these individuals, their action,
energy, and lived world, now without meaningful direction or
purpose, began to constrict as well. A characteristic sense of
Regaining Some Good in the World: What Maers to Persons Diagnosed as Depressed in Primary Care 383
hopelessness, sadness, immobility, passivity, self-devaluation,
and alienation arose in the face of these problematic situations
and thwarted goals, which remained their primary concern. It
is important to emphasize here that it was their situations that
concerned them primarily, and if they were concerned about
their internal experience or mental life as such, these were
of secondary concern. As one participant stated, “This will
continue until I get a job. [With a job,] I’ll be focused and clear
my head.”
There was, as alluded to in the quote above, a possibility
for positive transformation of their devalued situation. That is,
these troubling situations in life, work, and the community were
not nished or resolved but contained within them possibilities
for agency and action that engaged the person in an effort to
overturn them. Successful efforts, as evidenced by the person no
longer screening positive for depression during the one-month
follow-up interview, included one participant changing her
original goals after her self-perceived failures at work and social
change (“I’m very small in this picture and there’s not much I
can do. Do the best I can and get a tiny bit out of it”) and another
re-establishing reciprocal relationship with afrming others
after a failed relationship (“I speak to my friends and they listen
to me and give me advice, and it helps me in a way [because] I
let out everything I have inside”). These instances revealed the
possibility of re-awakening their own agency through practical
action directed at their life situations, as well as renewing their
sense of belonging with others. Here, changing the situation
or their perspective on the situation was the primary source of
change, rather than traditional behavioural health treatment.
Other attempts at practical action are detailed next, including
the role of the screening items and other persons, followed by an
outline of the ingredients of successful professional interactions.
Screening Items as Referring to Fledgling Aempts to
Overcome the Devalued Situaon
Some of the screening items themselves referred to edgling
attempts to regain a sense of gratication in the world, to focus
on a new “good.” One major example of this constituent was
the experience of eating. For instance, four participants reported
overeating to give themselves a new gratifying aim and
overcome feelings of sadness. In each of these cases, although
the initial meaning of eating was pleasure and restoration of
satisfaction in life, its eventual signicance, given the bodily
shame that accompanied overeating, was negative and led to
their devaluing themselves rather than regaining a positive
value in life. After being abandoned by a signicant other, one
participant found herself craving sweetness: “Since I have this
relationship ended, I noticed I eat a lot. I wasn’t the type of
person who eat a lot and crave for sweetness. Well I let myself
down because I never got this big.” Another participant dealing
with a challenging work situation stated, “I would normally eat
right after work to feel better. It [was] like my only form of
happiness in a way.”
Several also described constantly thinking and ruminating
about their issues, to the point of insomnia, whether it be a
betrayal in a relationship, the loss of companionship, or chronic
unemployment. This process, while not necessarily leading to
productive solutions, indeed reected how engrossed people
were in dealing with or addressing their life situation. The
participant above who was facing relational abandonment stated
she had sensed her signicant other’s initial betrayals and lies
in her dreams, but that these dreams—however helpful—and
additional ruminations disrupted her sleep:
Whatever he [was] hiding, I nd it. In my dream, I nd out.
The drugs, the phone calls, when he go out on certain days.
When I dreamed it, it came true? That’s how I knew. It would
wake me up, on top of getting overheated. I feel tired because I
don’t get any sleep. I have hot ashes too so it makes it worse…
And just thinking about everything that’s happening.
Seeking Belonging with Non-Alienang Others and
Insisng on Respect and Understanding
Persons’ primary goals were deeply social in nature: to be
with a genuine life-partner, be in the company of good friends,
secure a valued role in the social world, and work towards
social change. In the context of the failure to realize these goals,
participants felt incapable, worthless, and devalued. Others
exacerbated this sense of devaluation when not attuned to the
challenges the persons faced in their situations. Individuals
could attempt to transcend devaluation in the context of others by
insisting on being treated with more respect and understanding
in relation to their situation. One participant rejected her sister’s
insensitivity by insisting on her own dignity and worthiness:
My sister thinks [my unemployment is] funny. I don’t think
so. Treat me like a human being… She should treat me like a
real person and not a kid; like a mature person, not a stranger, if
you care about me like a sister.
Her assertion of self-worth was an effort to re-establish
a “good” kind of relationship, in which she felt valued and
supported (unlike how she felt in relation to employers), and
indeed one that would better serve her efforts to land a job.
Another participant longed for greater concern from others
regarding the importance of tackling social justice issues, which
formed the basis of her life goals and her own public interest
work:
Why can’t they see that I really care about this? They
perceive my intensity and passion as going off the deep end.
And I want to say, you need to stop chilling out! You need to be
less nonchalant about things and that’s why there are so many
problems out there.
When faced with unsupportive relationships, some opted
to go it alone in the hopes of enhancing their situation and
value. The individual dealing with chronic unemployment and
unsupportive family and friends went the solo route in her quest
for enjoyment and meaningful activity, which even made her
appreciate aspects of her current situation: “She works all the
time. I at least have fun. Playing slot machines! Life is too short
and you need to have fun.” Another participant wanted a life
surrounded by others she loved and valued but had given up
due to the loss of a relationship decades ago. Now, coupled with
numerous physical issues and the loss of her mother, she often
remained alone (with important exceptions being when she was
able to visit her mother in the cemetery and, as will be discussed
below, attend a senior center). However, aside from the company
Miraj U. Desai, Frederick J. Wertz, Larry Davidson, Alison Karasz
384
of television, solitude left her further isolated from others and
without the moments of revitalization they might provide.
Spirituality was central for some in reconnecting with others.
The participant above reconnected spiritually with loved ones
she had lost: “That’s why I put those pictures up. I have lots of
others’ pictures there too, ex-boyfriends, nephew. I talk to my
mother. Spiritually. It really does [help].” One participant who
struggled with a gradual life collapse (less socializing, leaving
an enjoyable job and being stuck in a boring one), pervasive
fears of panic attacks, and stigma regarding both, found she was
able to reframe her situation and efforts to overcome it with
the help of spirituality. Specically, she hoped to serve as an
inspiration for others one day: “I think I have fallen back on my
spiritual side. And thinking about humanity and making it better
for the next generation. To make it a little bit more acceptable
for them.” Both of these participants beneted from professional
guidance—one before and another after the rst screen (which
she sought independently and not as a suggestion during her
visit). We will now delve into the nature of such collaborations
with health care professionals.
Successful, Unsuccessful, and Paral Collaboraons in
Primary Care: The Role of the Other in Overcoming the
Devalued Situaon
As stated above, participants desired supportive relationships
with people with whom they could travel through life and rely
upon in tough times. These types of supportive others respected
and understood their goals and values, and could be helpful in
moving through their current obstacles. A helpful rather than
alienating relation emerged when others’ contributions and
advice were trustworthy, relevant to the patients’ meaningful
pursuits, and aligned with their efforts to transcend their
current situation. Sometimes, these trusted others could even
perceive needs and reveal possibilities that the person had
not realized or considered. Social institutions could serve this
advisory function within the patients’ practical eld of action.
In general, the operative principle of successful collaborations
in primary care specically was a t with patients’ desires
and goals. Unsuccessful collaborations, on the other hand,
were characterized by the lack of such a t. Finally, a partial
collaboration was characterized by attendance to only isolated
aspects of the overall quest to restore the good and reverse the
collapse. Examples of unsuccessful, successful, and partial
collaborations in primary care are described next.
Unsuccessful collaborations: The following illustrates the
meaning of unsuccessful collaboration, in which individuals
experienced the doctor’s advice and treatment recommendations
as disconnected from their valued commitments. One participant
experienced her physician’s advice as incongruent with her
goals of producing social change, having a leadership role in
public service, and garnering the appreciation of her family
through her independent efforts. She felt that the advice did not
really take her goals—and their importance to her—seriously,
and instead offered what she viewed as impersonal suggestions
and care:
Researcher: Did your doctor counsel you or give you advice
during the visit? If so, what did he say?
Participant: Not really. About my job—He said you either
quit, have a meltdown, or take medication. And I was like
“great” (sarcastic tone). It was helpful in that it’s nice to know
that I could take something that might make me feel better. My
friends have said “take it, take it” but I can’t bring myself to do
it. I don’t want to become addicted, it could change the way I act.
Anti-anxiety and anti-depression medications have bad stigmas.
I don’t like that how after 20 minutes in a doctor’s ofce that
you can prescribe something without really knowing me.
While acknowledging they may make her feel better,
medication went against her desire for autonomy, self-efcacy,
and individuation from her mother and sister (who were both
taking anti-depressant medication). This participant was
prescribed anti-anxiety and anti-depressant medications, but
only lled the former because of insurance restrictions. She
took one dose and said it was “working” and “kind of enjoyed
it” but discontinued it precisely for those reasons. She not only
feared addiction, which would push her further away from her
goals, but there was a sense that these feelings brought on by
the medications were illusory and signied giving up on her
commitment to confront the real world. To a question pertaining
to side effects, for example, she responded:
“Dizziness, a serenity that is fake because you’re not in
reality anymore.” During the second time point, she no longer
screened positive for depression, possibly due to shifting her
goals, albeit ambivalently, to what she now perceived was
possible in her public interest job:
I feel relatively better…It’s a mix of things. I let things go. I
came to the realization that I can’t put it all on myself. I’m very
small in this picture and there’s not much I can do. Do the best
I can and get a tiny bit out of it. I lowered my expectations. I’m
hoping I don’t look back on that though and regret it.
Successful collaborations: Turning now to successful
collaborations, one participant’s trusted physician helped
address the social isolation, passivity, and self-devaluation she
had been living with ever since the loss of past relationships,
which were exacerbated by her debilitating physical illness.
The physician specically recommended, even prior to the
positive screen, that she attend a senior center, which her family
encouraged and which she eventually found to be illuminating.
She described:
I initially went to [the senior center] because of my doctor.
I told her that I was depressed so she recommended the senior
centre. She never prescribed or asked about medications or
anything like that. She said I could benet from socializing and
exercising more. See, I never talked about my depression to any
other doctors, ever. But this doctor, I had her for a long time and
felt I could tell her. She was telling me I needed to socialize and
exercise more, instead of sitting at home all the time. Before, I
would sit with the TV on all day and night and do nothing. At
the centre, at rst, I did not want to go but my doctor, my sister,
my brother, and my friend all said I should…I didn’t talk to
nobody at rst but I went and liked it. It was like an opening.
It was like an opening because it helped my depression. I could
be more expressive. Nothing there makes me feel depressed.
The senior centre, when I’m there, it doesn’t make me think of
Regaining Some Good in the World: What Maers to Persons Diagnosed as Depressed in Primary Care 385
things that make me depressed…They have activities, exercises,
bingo, and computer training even.
This participant’s use of the terms “depression” and
“depressed” appeared to signify emotional problems (deep
sadness), extreme loneliness, and living a life of profound
isolation, rather than her focus being on recovering from an
illness. Her trusted primary care physician was indeed deeply
attuned to those social lacks in her life, came up with creative
solutions, and successfully helped her regain some good
company and positive movement in her life.
Partial collaborations: Finally, partial collaborations
involved professional focus on isolated aspects of experience
(e.g., fatigue, sleep, etc.) but did not directly address the core
of persons’ life situations. One participant, who had struggled
with longstanding relationship, divorce, custody, and childcare
issues, had beneted from a prescription for Paxil in the past,
before the time of this study:
Well my doctor told me I looked upset so I started telling
him what was going on—about not sleeping and the problems
in the house, being upset all the time…and he said that has to do
with not sleeping. And he suggested I should go to counselling
and he prescribed the Paxil.
He did not go to individual therapy at the time, but eventually
participated in family therapy (through his then-wife’s
counsellor) that helped “resolve some issues with the family.”
This participant stated that medication only addressed certain
problems: “It just took away that anger. It didn’t change how
I felt…it didn’t make me happy, didn’t make me want to cry.
That uptight feeling…it just took that away.” The matter-of-fact
advice from his physician, which he appreciated, spoke more
directly to his situation: “the whole situation with my wife…he
said [If I] can’t x it to leave it alone.” At the time of the present
study, the participant continued to struggle with the care of his
children, post-divorce, and remained open to treatment, but this
option remained an uncertain prospect due to his commitment
to, and the time demands of, parenting.
Another participant’s experience of physicians was that they
were useful for attending to the bodily collapse inherent in her
experience, but they did not provide a pathway toward the larger
life transformation she desired: “She can deal with the physical
aspects of it…headaches, aches. I mentioned to her that I don’t
want to be one of those individuals that is happy to take a pill.”
She later consulted a psychotherapist on her own, independent
of the screen and primary care visit, to resume a life where she
could freely socialize with others and return to creative and
engaging work, both of which were inhibited by her ongoing
fears about another (public) panic episode. Psychotherapy
carried the potential to reconnect her with these important life
goals and also to obtain greater awareness and determinacy of
how she had gotten to this place of social isolation, boring work,
and lack of freedom.
Discussion
Many people with depression do not seek or receive
treatment [5,6,8] suggesting a gap between health services and
the specic populations they are designed to help. In the present
study, experiences that health care professionals identify as
indicators of depression and need for treatment were part of a
larger backdrop of individuals feeling removed from their most
valued goals, which they dened in terms of their life situations.
Participants saw a number of practical options to achieve
important ends and thereby get back within reach of what was
lost or nd a new “good” in order to regain a sense of purpose
and direction in the world. The nature of their difculties, as
well as the specic doctor-patient communication process,
determined whether clinical help appeared as relevant to their
attempts to confront and change their current situation.
Concrete Pracce Suggesons
Overall, we found that at the heart of the encounter between
potential patients and the health care system is a risk of
incongruence: What is pertinent to the patient may not appear
related to what health care can offer; what is pertinent to the
health care provider may not be communicated in terms that
relate to patients’ central values and goals. The ndings suggest
that one way to bridge this incongruence in primary care, as
illustrated through the successful collaborations in this study, is
to genuinely convey how doctors’ offerings relate to the same
goals toward which persons are striving, so that health services
are understood by the patient as serving these personally
meaningful ends. This suggestion reverses the traditional
meaning of “adherence”—rather than patients adhering to
a treatment prescribed by a practitioner, services need to
adhere to, or relate to, patients’ most meaningful pursuits and
commitments as embedded in diverse settings.
The basis of identifying individuals with depression in
the current study was a commonly used depression screening
checklist (PHQ-9) [29,30]. The screening criteria identied
individuals who were struggling through various situations,
and the current descriptive approach offers further suggestions
regarding how physicians might proceed from identication to a
fuller recognition of the struggle in which these individuals are
engaged, as a basis for exploring opportunities for collaboration.
Despite the inherent turbulence and uncertainty of patients’
situations (e.g., unemployment, lack of progress in social action
efforts, a life-long lived in solitude, ongoing custody issues),
there were openings for a caring other to enter into their worlds
and support their attempts to address these unattained goals
and stied desires. Indeed, whether others were experienced
as afrming or alienating depended on their level of sensitivity
to, and understanding of, the matter. Successful collaborations
were determined by the relevance of the pathways offered by
physicians to patients’ aims, whereas unsuccessful ones were
determined by experiences of the lack of relevance. A person
struggling with decades of social isolation in the aftermath of
loss beneted from attending a community centre on the advice
of her trusted doctor and encouragement of family and friends.
A person struggling with social justice goals and confronting
problematic social conditions saw medication as irrelevant to,
if not obstructing, these goals. This latter case demonstrated the
unintended outcome on the part of someone who was trying to
help but whose advice was seen as too narrow and not addressing
the person’s fundamental concerns.
Miraj U. Desai, Frederick J. Wertz, Larry Davidson, Alison Karasz
386
The present article suggests that physicians may be able to
collaborate with their patients more successfully by utilizing
screening information to discuss the patient’s desires, goals,
and situational context from which the positive criteria for
depression emerged. This approach situates the physician in
the person’s world as a caring other who understands what they
are living toward, how important it is to them, and how it has
come to be experienced as failing. There were some instructive
examples of physicians in this study who saw right to the core of
the situation and developed a meaningful connection, sometimes
simply through asking “what was going on.”
Because our ndings suggest that behavioural health
services in particular might not be experienced as an option
by many patients on their own, it is important that physicians
provide recommendations and treatments on the basis of a
shared understanding and a direct connection to patients’ lives.
After all, the notion of behavioural health care may appear
incongruent to many in the community [11,18,21], who, in the
present study, were mostly directed towards future goals and
dealing with challenging worldly circumstances. Given this
focus, natural supports like local community centres, family,
friends, and vocation can also be discussed [11,31], in addition
to existing intervention options and allied interdisciplinary
team help (social work, psychology, etc.). This broad-based and
holistic approach is in line with the spirit of person-centered
medicine [21,23].
Finally, care providers could also acknowledge and align
with the positive and healthy ways individuals are already
attempting to regain purpose and direction in their lives. In the
present article, these practices included establishing relations
with more welcoming and supportive others after failed intimate
relationships and reframing goals to match expectations during
disappointing career developments. These led to what could be
considered by some professionals as “spontaneous recovery
from depression.” Previous studies in primary care have
similarly found the presence of these kinds of agentic efforts
in patients’ own management strategies [11]. Aligning with
these efforts directly relates to recovery-oriented practice in the
context of health care reform, with its emphasis on a person’s
own agency, goals, and strengths, fortied by the resources of
health care and everyday social supports [3,31].
Limitaons and Future Research
Limitations regarding the study’s recruitment and data
collection are outlined in the rst article, (25) and include:
sparse data sections due in part to time and setting limitations
and a lack of interviews with individuals meeting criteria for
severe depression. Findings and limitations of the present study
also suggest future avenues of research. More research may
be needed on how physicians can make a connection, gather
personal information, and frame a productive collaboration.
Further, more studies that follow patients over time, including
those experiencing “spontaneous recovery,” would be useful.
Research differentiating freshly screened individuals from those
with longer histories of engagement with the mental health
system is warranted, e.g., [32] as well as additional research
on doctor-patient conversations to identify precise moments
of connection and incongruence [21]. Quantitative analysis of
the frequency of key ndings in the general population, such
as the number of individuals who successfully transcend the
situations detailed above, are another avenue of investigation.
Future research may also seek to develop complementary
screening measures or items pertaining to situational context,
a suggestion that Galasiński’s study of lay persons’ interactions
with depression assessments also suggests [14].
It should be mentioned here that further exploration of
the role of problematic social conditions mentioned by some
participants (e.g., social injustice, unemployment, nancial
issues, and traumatic histories involving sexual abuse and
gender-based violence) may help broaden the picture of what
we are seeing and suggest the need to ally health care with
more community-based initiatives for social change. Complex,
problematic social realities are themselves worthy targets of
intervention [33-36].
In the context of health care reform and a growing integration
of primary care with behavioural health, the present article
offers knowledge of the kinds of issues that might arise in the
patient-provider encounter. Despite risks of incongruence, we
found that there remains an opening for a supportive other to
delve into the thickets of persons’ suffering, understand its direct
relation to patients’ most valued dreams, and, as their trusted
condant, enter into a fruitful collaboration with them—all in
an effort to help them regain a sense of the good in the world.
To be sure, the situation that frontline health care providers and
primary care physicians themselves face is not an easy one. Not
only are they dealing with increasing time demands, but they
often serve the role of trusted advisor, sometimes the only one,
to individuals who are facing a signicant amount of pressure
from the world. The present study offers a few suggestions and
for fortifying the frontline care provider’s everyday efforts to
directly—and therefore more quickly—start diving into the life
and community issues that their family practice patients face,
and get them connected to social supports, relevant treatments,
others in the interdisciplinary team, or people in the community
who may be able to assist in furthering personal and community
well-being.
Acknowledgments
We thank the participants in the study, members of the
research team, and the Department of Family and Social
Medicine at Monteore Medical Center. Portions of this paper
were presented at the 116th Convention of the American
Psychological Association in Boston, MA. The research was
conducted while the rst author was a graduate student at
Fordham University.
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ADDRESS FOR CORRESPONDENCE:
Submitted 17 February, 2016
Accepted 28 March, 2017
