'I didn't want her to panic': unvoiced patient agendas in primary care consultations when consulting about antidepressants

Background Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants. Aim To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP-patient relationship in which unvoiced agendas occur. Design of study Qualitative interview study. Setting Primary health care. Method Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 'pairs' of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs' consent), using a patient-held tape recorder. Results Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were 'letting the GP down' by not being able to report feeling better. Conclusion Unvoiced agendas are not necessarily an indication that 'shared decision making' is absent but may in some cases represent patients' attempts to 'protect' their GPs.