Item Details

Depression, sense and sensitivity: On pre-diagnostic questioning about self-harm and suicidal inclination in the primary care consultation

Issue: Vol 10 No. 1 (2013)

Journal: Communication & Medicine

Subject Areas: Healthcare Communication Linguistics

DOI: 10.1558/cam.v10i1.37

Abstract:

National Health Service directives in the UK specify that, in any primary care consultation where a patient either demonstrably has – or is suspected to have –depression, a ‘direct question’ should be asked regarding their thoughts or activities relating to selfharm or suicide. The evidence collected for this study, which takes the form of recorded interactions between doctors and patients in primary care settings, indicates that this is most commonly done post-diagnosis as an exercise in ‘risk assessment’. Suicidal ideation, however, is not only classified as a possible outcome of depression but also a core symptom of the condition and, consequently, such a question is sometimes asked prior to the diagnostic phase of the consultation, as a key step in reaching a depression diagnosis. This specific activity presents a general practitioner with an inferably difficult communicative task: how to raise the matter of suicide/self-harm when the patient does not already have a depression diagnosis as an interactional resource with which to make sense of its local relevance. Herein, using a conversation analytic method, techniques employed by general practitioners and patients in negotiating three of these potentially sensitive moments are examined. Analytic observations are then used to highlight a range of issues pertinent to the formulation of normative frames of ‘good practice’ in handling difficult clinical topics in situ.

Author: Paul Kenneth Miller

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References :

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders 4th-TR Edition. Washington DC: American Psychiatric Association.
Antaki, C. (2002) Personalised revision of ‘failed’ questions. Discourse Studies 4 (4): 411–428.
Antaki, C., Barnes, R. and Leudar, I. (2005) Diagnostic formulations in psychotherapy. Discourse Studies 7 (6): 627–647. http://dx.doi.org/10.1177/1461445605055420
Bergmann, J. R. (1992) Veiled morality: Notes on discretion in psychiatry. In P. Drew and J. Heritage (eds) Talk at Work: Interaction in Institutional Settings, 137–162. Cambridge: Cambridge University Press.
Edwards, D. (2000) Extreme case formulations: Softeners, investment, and doing nonliteral. Research on Language and Social Interaction 33 (4): 347–373. http://dx.doi.org/10.1207/S15327973RLSI3304_01
Frankel, R. M. (1984) From sentence to sequence: Understanding the medical encounter through micro-interactional analysis. Discourse Processes 7: 135–170. http://dx.doi.org/10.1080/01638538409544587
Garfinkel, H. (1967) Studies in ethnomethodology. Englewood Cliffs, NJ: Prentice Hall.
Harris, S. (2001) Being politically impolite: Extending politeness theory to adversarial political discourse. Discourse and Society 12 (4): 451–472. http://dx.doi.org/10.1177/0957926501012004003
Heath, C. (1992) The delivery and reception of diagnosis in the general practice consultation. In P. Drew and J. Heritage (eds) Talk at Work: Interaction in Institutional Settings, 235–267. Cambridge: Cambridge University Press.
Heritage, J. and Sefi, S. (1992) Dilemmas of advice: Aspects of the delivery and reception of advice in interactions between health visitors and first-time mothers. In P. Drew and J. Heritage (eds) Talk at Work: Interaction in Institutional Settings, 359–417. Cambridge: Cambridge University Press.
Horne, J. and Wiggins, S. (2009) Doing being ‘on the edge’: Managing the dilemma of being authentically suicidal in an online forum. Sociology of Health & Illness 31 (2): 170–184. http://dx.doi.org/10.1111/j.1467-9566.2008.01130.x
Hutchby, I. and Wooffitt, R. (2002) Conversation Analysis: Principles, Practices and Applications. Cambridge: Polity Press.
Jefferson, G. (1978) Sequential aspects of storytelling in conversation. In J. Schenkein (ed.) Studies in the Organization of Conversational Interaction, 219–248. New York: Academic Press.
Jefferson, G. (1979) A technique for inviting laughter and its subsequent acceptance/declination. In G. Psathas (ed.) Everyday Language: Studies in Ethnomethodology, 79–96. New York: Irvington.
Jefferson, G. (1984a) On stepwise transition from talk about a trouble to inappropriately next-positioned matters. In J. M. Atkinson and J. Heritage (eds) Structures of Social Action: Studies in Conversation Analysis, 191–222. Cambridge: Cambridge University Press.
Jefferson, G. (1984b) Notes on a systematic deployment of the acknowledgement tokens ‘yeah’ and ‘mm hm’. Papers in Linguistics 17 (2): 197–206. http://dx.doi.org/10.1080/08351818409389201
Jefferson, G. and Lee, J. R. E. (1981) The rejection of advice: Managing the problematic convergence of a ‘troubles-telling’ and a ‘service encounter’. Journal of Pragmatics 5 (5): 399–422. http://dx.doi.org/10.1016/0378-2166(81)90026-6
McLeod, J. (1994) Doing Counselling Research. London: Sage.
Maynard, D. W. (1991) The perspective-display series and the delivery and receipt of diagnostic news. In D. Boden and D. H. Zimmerman (eds) Talk and Social Structure: Studies in Ethnomethodology and Conversation Analysis, 162–192. Oxford: Polity Press.
National Institute for Clinical Excellence (2009) Depression: The NICE Guideline on the Treatment and Management of Depression in Adults (updated edition). Clinical Guideline 90. Leicester: The British Psychological Society/The Royal College of Psychiatrists.
Owen, G., Belam, J., Lambert, H., Donovan, J., Rapport, F. and Owens, C. (2012) Suicide communication events: Lay interpretation of the communication of suicidal ideation and intent. Social Science & Medicine 75 (2): 419–428. http://dx.doi.org/10.1016/j.socscimed.2012.02.058
Owens, C., Owen, G., Lambert, H., Donovan, J., Belam, J., Rapport, F. and Lloyd, K. (2009) Public involvement in suicide prevention: Understanding and strengthening lay responses to distress. BMC Public Health 9: 308–316. http://dx.doi.org/10.1186/1471-2458-9-308
Owens, C., Owen, G., Belam, J., Lloyd, K., Rapport, F., Donovan, J. and Lambert, H. (2011) Recognising and responding to suicidal crisis within family and social networks: Qualitative study. BMJ (Clinical Research Ed.) 343: d5801. http://dx.doi.org/10.1136/bmj.d5801
Palmer, D. (2000) Identifying delusional discourse: Issues of rationality, reality and power. Sociology of Health and Illness 22 (5): 661–678. http://dx.doi.org/10.1111/1467-9566.00225
Paykel, E. S. and Priest, R. G. (1992) Recognition and management of depression in general practice: Consensus statement. British Medical Journal 305 (6863): 1198–1202. http://dx.doi.org/10.1136/bmj.305.6863.1198
Peräkylä, A. (2006) Communicating and responding to diagnosis. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care. Interaction between Primary Care Physicians and Patients, 214–247. Cambridge: Cambridge University Press.
Pomerantz, A. M. (1986) Extreme case formulations: A way of legitimizing claims. Human Studies 9 (2): 219–30. http://dx.doi.org/10.1007/BF00148128
Sacks, H. (1963) On sociological description. Berkeley Journal of Sociology 8: 1–16.
Sacks, H. (1972) An initial investigation of the usability of conversational data for doing sociology. In D. Sudnow (ed.) Studies in Social Interaction, 31–74. New York: Free Press.
Sacks, H. (1984) On doing ‘being ordinary’. In J. M. Atkinson and J. Heritage (eds) Structures of Social Action: Studies in Conversation Analysis, 413–429. Cambridge: Cambridge University Press.
Sacks, H. (1987) On the preferences for agreement and contiguity in sequences in conversation. In G. Button and J. R. E. Lee (eds) Talk and Social Organisation, 54–69. Clevedon: Multilingual Matters.
Sacks, H., Schegloff, E. A. and Jefferson, G. (1974) A simplest systematics for the organization of turn-taking in conversation. Language 50 (4): 696–735. http://dx.doi.org/10.2307/412243
Schegloff, E. A. (2000) Overlapping talk and the organization of turn-taking for conversation. Language in Society 29 (1): 1–63. http://dx.doi.org/10.1017/S0047404500001019
Schegloff, E. A. and Lerner, G. H. (2009) Beginning to respond: Well-prefaced responses to wh-questions. Research on Language and Social Interaction 42 (2): 91–115. http://dx.doi.org/10.1080/08351810902864511
Silverman, D. (1994) Analyzing naturally-occurring data on AIDS counselling: Some methodological and practical issues. In M. Boulton (ed.) Challenge and Innovation: Methodological Advances in Social Research on HIV/AIDS, 69–93. London: Falmer Press.
Silverman, D. (1997) Discourses of Counselling: HIV Counselling as Social Interaction. London: Sage.
Stivers, T. (2006) Treatment decisions: Negotiations between doctors and patients in acute care encounters. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interaction between Primary Care Physicians and Patients, 279–312. Cambridge: Cambridge University Press.
Suchman, L. and Jordan, B. (1990) Interactional troubles in face-to-face survey interviews. Journal of the American Statistical Association 85 (409): 232–241. http://dx.doi.org/10.1080/01621459.1990.10475331
Ten Have, P. (1991) Talk and institution: A reconsideration of the ‘asymmetry’ of doctor–patient interaction. In D. Boden and D. H. Zimmerman (eds) Talk and Social Structure: Studies in Ethnomethodology and Conversation Analysis, 138–163. Cambridge: Polity Press.
Terasaki, A. K. (2004) Pre-announcement sequences in conversation. In G. H. Lerner (ed.) Conversation Analysis: Studies from the First Generation, 171–223. Amsterdam: John Benjamins.
Tylee, A., Priest, R. and Roberts, A. (1996) Depression in General Practice. London: Martin Dunitz.
Vannoy, S. D., Fancher, T., Meltvedt, C., Unützer, J., Duberstein, P. and Kravitz, R. L. (2010) Suicide inquiry in primary care: Creating context, inquiring, and following up. Annals of Family Medicine 8 (1): 33–39. http://dx.doi.org/10.1370/afm.1036
World Health Organization (2010) The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: WHO.
Zimmerman, D. H. (1992) The interactional organization of calls for emergency assistance. In J. Heritage and P. Drew (eds) Talk at Work: Interaction in Institutional Settings, 418–469. Cambridge: Cambridge University Press.