Contents of General Practitioner-Patient Consultations
in the Treatment of Depression
Michael Linden, MD, PhD, Tatjana Christof, Dipl-Psych, and Christiane Rentzsch, Dipl-Psych
Research Group Psychosomatic Rehabilitation at the Charité University Medicine Berlin, Teltow/Berlin, Germany.
BACKGROUND: Counseling of patients is an indispens-
able part of any drug treatment and even more so in the
treatment of depression.
OBJECTIVE: To describe the content of counseling
additional to prescribing an antidepressant drug.
SETTING: Sixty-three general practices from all over
PATIENTS: Three hundred two patients with the diag-
nosis of either a depressive episode or a recurrent
MEASUREMENTS: Assessment of the content of the
physician-patient encounter by content analysis follow-
ing the pivotal topic method.
DESIGN: Qualitative study embedded in a drug utiliza-
tion study on mirtazapine.
RESULTS: In the initial sessions general practitioners
focused on building a good therapeutic alliance, asses-
sing the symptoms of illness, explaining the course of
treatment, assuring medication compliance, and dis-
cussing problems of life. In the middle phase of
treatment, physicians also dealt with building a thera-
peutic alliance, medication compliance, and the prog-
ress and course of illness. In the last phase relapse
prevention was an important topic. Psychological topics
were more important than medication topics. Almost no
importance was given to management of side effects,
change of cognitions, or suicidal tendencies.
LIMITATIONS: No information is available on how
content was actually discussed. Only encounters were
observed where an antidepressant was prescribed.
CONCLUSIONS: Counseling plays an important part in
day-to-day encounters of general practitioners. Phar-
macotherapy is embedded in comprehensive psycho-
logical care. Training programs for general practitioners
should be specific in respect to different tasks and parts
of the physician-patient encounter (e.g., building a
therapeutic alliance, support for life problems or
change of cognitions).
KEY WORDS: depression; pivotal topic method; antidepressant;
J Gen Intern Med 23(10):1567–70
© Society of General Internal Medicine 2008
It is generally accepted that counseling and psychological
interventions are part of any encounter between physicians
and their patients.1It is of special importance in the treatment
of patients with mental illnesses such as depression, which are
frequent problems in primary care.2–5Physicians have to
inform patients about treatment options and needs. They have
to clarify the state of illness, assess the effects of treatment,
and/or control for unwanted drug effects. In addition to
prescribing medication, general practitioners are also patient
counselors. They give reassurance and support, discuss
problems of life, and help to overcome negative thinking in
depression. Counseling is also an important part of any drug
treatment. There is evidence that the patient-physician en-
counter has an influence on patient cooperation, medication
compliance, the rate of unwanted drug effects, tolerance of
their reactions to unwanted effects, and even the efficacy of
medications. Drug manufacturers must also take into account
how their drug is handled by physicians and patients and what
physicians do to support drug treatment.6–8It is known from
the literature that patients feel more comfortable with physi-
cians who use a patient-centered approach.9
There are theoretically derived concepts and guidelines on
what physicians should talk about with their patients that can
be found in the WHO guidelines for the treatment of depression
in primary health care.10They should guide the use of drugs by
their patients and also help them to cope with and overcome
depression. Still, it is unknown which topics practicing physi-
cians see as important and what they deal with and talk about
in routine care. We wanted to study the type, content, and
frequency of topics that general practitioners discuss with their
patients while prescribing an antidepressant.
This study is part of a drug utilization study on the antide-
pressant mirtazapine (Remergil® SolTab™). Sixty-three gener-
al practitioners participated in the study and reported on 95
male and 207 female patients (mean age=56.1, SD=15.7,
range=19–92 years). Participating physicians were recruited
The study has been done in collaboration with Organon Germany,
Oberschleissheim, Germany. We thank all general practitioners who
participated in the trial.
Received June 10, 2007
Revised December 12, 2007
Accepted March 10, 2008
Published online July 10, 2008
on a nationwide basis by representatives of Organon, the
manufacturer of mirtazapine, and were distributed all over
Germany. The study goal was to observe routine care of
patients who had been prescribed mirtazapine for individual
clinical reasons. Physicians were free to treat patients accord-
ing to individual considerations, including mode of prescrib-
ing, frequency of contact, or duration of treatment. The drug
was prescribed and disturbed by pharmacies according to
routine practice that included patient package inserts.
The observation was done using standardized instruments
and lasted at maximum 12 weeks. Physicians started to
document the case and the course of treatment after they
had decided to prescribe mirtazapine. According to the clinical
judgment of the treating physicians, all patients were suffering
from a depressive episode according to ICD-10 F 32 or F 3310.
To find out what patients and physicians talked about, we
used a strategy from psychotherapy research, the pivotal topic
method.12After each patient contact, physicians were asked to
write down what they thought to be the pivotal topic of this
encounter. The question that had to be answered in free text
read: “In my view the most important topic of the session
was….” Multiple responses were allowed. This method does not
assess what has been talked about “objectively.” Instead, it
refers to the views, perspectives, and memories of the physi-
cians as to what they see as important, what guides their
treatment, and what they wanted to do. Pivotal topics describe
what is important in the view and memory of the physicians.
From an intentional and cognitive perspective, the statements
reflect the “subjectively true” content of the encounter.
Two raters independently rated all statements by using a
content analytic method. The content analytic scheme had
been developed on the basis of examples of such reports and in
reference to the WHO guidelines for the treatment of depres-
sion in primary health care.10Interrater reliability13was
87.7%. Content categories refer first to diagnosis and case
management (CM): (1) establishing a therapeutic alliance, (2)
assessment of symptoms, (3) patient education, (4) discussion
of treatment options, (5) explanation of treatment course, (6)
discussion of course and progress, and (7) discussion of
referral to specialist. Second, they refer to medication topics
(MT): (1) indication for drug treatment, (2) dosage, (3) medica-
tion compliance, (4) management of side effects, and (5)
maintenance medication. Third, they refer to psychological
topics (PT): (1) giving the opportunity to talk, (2) reassurance
and support, (3) increase of activities, (4) discussion of
problems in life, (5) problem solving skills, (6) modification of
negative cognitions, (7) stimulation of positive thinking, (8)
stimulation of goal orientation, (9) feedback on positive
development, and (10) suicidal tendency.
The study has been approved by the ethical committee and
internal review board of the Charité University Medicine
Berlin. The part of the study on physician-patient communi-
cation was under the responsibility of the authors of this
paper, who had control over the data, data analysis, and
writing of the manuscript. The company representatives did
not approve or disapprove what has been written.
Sessions lasted on average 19.5 min (SD=9.6 min). Table 1
shows the percentage of sessions in which a topic was
mentioned and gives in parentheses a rank order in relation
to other topics.
Table 1. Frequency of General Practitioner Pivotal Topics
CategoriesT0 (vsa=273) T1 (vsa=270) T2 (vsa=245) T3 (vsa=231)T0–3
% (Rb)% (Rb)% (Rb) % (Rb) Ø % (Rb)
1. Diagnosis and case management (CM)
1.1. Therapeutic alliance
1.2. Assessment of symptoms
1.3. Patient education
1.4. Treatment options
1.5. Explanation of treatment
1.6. Discussion of progress
1.7. Referral to specialists
2. Medication topics (MT)
2.1. Indication for medication
2.3. Medication compliance
2.4. Management of side effects
2.5. Relapse prevention
3. Psychological topics (PT)
3.1. Opportunity to talk
3.2. Reassurance and support
3.3. Increase of activities
3.4. Problems in life
3.5. Problem-solving skills
3.6. Negative cognitions
3.7. Positive cognitions
3.8. Goal orientation
3.9. Feedback on positive change
3.10. Suicidal tendency
aValid sessions: numbers reflect how many general practitioner statements were given at a data collection point
bRank from most often (1) to least often named category
Linden et al.: Content of Gp Consultations
When taking all sessions into account, the most frequent
topics were: the course and progress (35.8%), therapeutic
alliance (11.5%), and medication compliance (7.4%), while the
least often reported topics were management of side effects
(0.1%), stimulation of positive cognitions (0.3%), and modifi-
cation of negative cognitions (0.4%).
When one tries to describe the trajectory of therapeutic
interaction over the course of treatment, general practitioners
start by talking about therapeutic alliance (19%), explanation
of treatment course (18%), problems of life (16%), assessment
of symptoms (13%), and medication compliance (12%). In the
middle of the treatment process, they still talk about thera-
peutic alliance and medication compliance, but also course
and progress. Course and progress (49%) is the primary topic
throughout the further course of treatment. Finally, relapse
prevention (15%) is the topic of interest at the end of treatment.
Categories that tend to increase over time are course and
progress, increase of activities, stimulation of positive cogni-
tions and relapse prevention. Decreasing are therapeutic
alliance, medication compliance, assessment of symptoms,
problems of life, management of side effects, patient education,
indication for drug treatment, and explanation of treatment
Comparing CM, MT, and PT over the course of treatment for
depression (Table 2), general practitioners predominantly dealt
with diagnosis and case management in all sessions (68%
versus 75%). Medication topics (10% versus 23%) were
preferably a topic in the initial and final phase of treatment.
Psychological topics (23% versus 31%) had a consistent role
throughout the treatment with some reduction at the end.
DISCUSSION AND CONCLUSION
In an earlier publication we asked: “Is the pharmacotherapist
mute?”14The answer from this study is definitely no. Physi-
cians put great emphasis on establishing a therapeutic
alliance, i.e., to convey to the patient that the therapist
understands how the patient feels and what he/she wants.
Most important in the encounter between physician and
patient is the assessment of the state of illness and course of
improvement. This is closely related to issues of compliance
and justification of medication.
Side effects of drug treatment are a topic in only about 1% of
encounters at the start of treatment, and in the further course
of treatment are not discussed at all. The question is whether
physicians avoid this topic as they do not want to stir up a
problem or whether they think that mostly minor side effects
are not a topic that needs long discussion and therefore is not
mentioned as a “pivotal” topic.
Similarly, suicidal tendencies are discussed in less than 1%
of encounters. This is in contrast with the fact that according
to the symptom measures 1% of patients were suffering from
severe, 11% from moderate, and 22% from mild suicidal
ideations. The literature reports that a majority of general
practitioners feel uncomfortable in talking about suicidal
tendencies in their patients,15while all respective textbooks
recommend that it is better to talk about suicidal ideas than to
Guidelines recommend10that modification of negative
thinking should play an important role even in the primary
care management of depression. This is also seen in less than
1% of encounters. Less than half of all physician statements
referred to psychological topics.
The results of this study show that counseling is an
important part of the day-to-day medical routine. It also shows
that a large variety of topics are addressed. Verbal encounters
fulfill many tasks, e.g., building a relationship, patient educa-
tion, reassurance, support in life problems, or change of
attitudes and cognitions. Our data also show that counseling
is not a single event, but a process over time with different
topics at the beginning or the end of an encounter. They also
point to topics like side effects, suicidal ideation, or cognitive
modifications, which are rare. Further research should clarify
whether this is sufficient or needs improvement.
The data from this study can help in preparing or revising
guidelines and implementing educational programs. As
mentioned, we found some differences in reported emphases
from recommended guidelines, e.g., WHO guideline for the
management of depression.10This could stimulate and guide
educational programs10,15,18–22and possibly also help to
develop guidelines that have a better fit with clinical reality.
There are several limitations to this study. Only physicians
who prescribed an antidepressant were included in the study.
As the study is part of a drug utilization observation and as
physicians have been recruited and compensated for the
documentation work by the drug manufacturer, there may be
a bias toward sampling physicians who are more disposed
toward prescribing. Results could be very different in physi-
cians who prefer psychological means to treat depressive
episodes. We also did not tape record and assess what
physicians talked about “in reality,” but only can say what
they thought was important.16,17Finally it must be remem-
bered that content also needs skillful communication23and
that we do not know how the physicians conveyed their
messages to the patient.
Acknowledgment: We want to thank all physicians who partici-
pated in this study and who reported on the content of their
communication with the patients.
The study has been organized and financed by Organon,
Potential conflict of interest: The data for this study were taken
fom a drug surveillance study on mirtazapine that was done by
Organon, Germany. Neither the company representatives nor any
other party participated in data analysis and writing of the
manuscript, nor did they approve or disapprove what has been
There is no other conflict of interest.
Corresponding Author: Michael Linden, MD, PhD; Research Group
Psychosomatic Rehabilitation, Rehabilitation Centre Seehof, Lichter-
felder Allee 55 14513, Teltow/Berlin, Germany
Table 2. Frequency of General Practitioner Pivotal Topics
Sum variables T0T1T2 T3
Diagnosis and case management
Linden et al.: Content of Gp Consultations
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