Table 1.

Characteristics of 30 studies published between 1990 and 2018 included in qualitative synthesis

Paper	Sample size	Method	Objective	Key findings
Reviews
Thompson and McCabe (37)	20 papers	Systematic review	To identify whether an association exists between clinician–patient alliance or communication and treatment adherence in mental health care	Clinician–patient alliance is associated with improved adherence.
Ford et al. (19)	323 GPs	Metasynthesis	To synthesize the available information from qualitative studies on GPs’ attitudes, recognition and management of perinatal anxiety and depression	GPs use strategies to mitigate the lack of timely access to psychological therapy. GPs are reluctant to medicalize distress and rely on clinical judgement more than guidelines.
Qualitative interviews/focus groups
Pollock (16)	32 patients	Qualitative interviews	To discuss patient accounts of maintaining face and the effort to conceal depression	Face work used to maintain successful social interaction bleeds into the medical domain and can make it challenging for patients to disclose distress.
Buszewicz et al. (34)	12 GPs, 20 patients	Interviews with tape-assisted recall	To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful	GP consultations can be beneficial for patients with psychological problems, particularly, as GPs providing a safe space where patients feel listened to and understood.
Cape et al. (38)	11 GPs, 14 patients	GP and patient interviews with tape-assisted recall	To explore how patients’ understanding of common mental health problems is developed in GP consultations	GPs can help patients develop an understanding of the problem by focusing and shaping patients’ own understandings.
Tavabie and Tavabie (11)	20 GPs	Analysis of interviews and focus groups	To identify effects of using mental health questionnaires on views of GPs managing depression and how this might influence patient care	Using mental health questionnaires could improve GPs’ confidence; questionnaires were a way to involve patients.
Garfield et al. (31)	51 patients	Qualitative interviews	To identify information needs and the level of involvement in decision-making desired by patients beginning courses of antidepressant medication	Patients want information about adverse drug reactions, process of recovery, dosage and length of treatment but this is often unmet. Patient preferences for involvement in decision-making vary.
Gask et al. (12)	27 patients	Qualitative interviews	To explore depressed patients’ perceptions of the quality of care received from GPs	The depressed person may feel that they do not deserve to take up the doctor’s time or that it is not possible for doctors to listen to them and understand how they feel.
Johnston et al. (24)	61 patients, 32 GPs	Qualitative interviews	To identify issues of importance to GPs, patients and patients’ supporters regarding depression management	GPs and patients find it hard to separate depression from life circumstances, but GPs may encourage a biological approach to relieve stigma. Patient’s goals were varied and influenced by perceptions of cause, controllability and duration. GPs give patients time to talk and emphasize an individual approach and listening.
Malpass et al. (30)	9 GPs and 10 patients	Qualitative interviews	To explore what important issues remain unsaid during a primary care consultation for depression, patients’ reasons for non-disclosure and the nature of the GP–patient relationship in which unvoiced agendas occur	Unvoiced agendas may be patients’ attempts to protect their GP. Patients may withhold treatment preferences if they perceived lack of patient-centred communication. Patients would drop clues about their preferences.
Chew-Graham et al. (22)	19 GPs, 14 health visitors	Qualitative interviews	To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression	Ongoing organizational changes within primary care, such as the implementation of corporate working by health visitors, affect care provided to women after birth, which, in turn, has an impact on the diagnosis and management of postnatal depression.
Chew-Graham et al. (18)	19 GPs, 14 health visitors, 28 women	Qualitative interviews	To explore GPs’, health visitors’ and women’s views on the disclosure of symptoms which may indicate postnatal depression in primary care	Both women and heath care professionals (HCPs) describe depression in psychosocial terms, women make a conscious decision about disclosure and HCPs hinder disclosure and are reluctant to make a diagnosis due to lack of personal resources and services.
Chew-Graham et al. (26)	35 GPs	Qualitative interviews	To explore GP attitudes to the management of patients with depression and compare the attitudes of patients in more and less socio-economically deprived areas	GPs feel the need to separate normal reactions to life stressors and true illness. For patients living in deprived areas, these problems may seem insoluble.
Pollock and Grime (35)	32 patients	Qualitative interviews	To investigate patients’ perceptions of entitlement to time in general practice consultations for depression	Patients feel intense time pressure and use self-rationing, which affects patient’s ability to open up. Patients value time to talk. There is a mismatch between patients’ own sense of time entitlement and the doctors’ capacity to respond flexibly.
Pollock and Grime (32)	19 GPs	Qualitative interviews	To investigate GP perspectives on consultation time and the management of depression in general practice	GPs generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients, which they felt undermined their capacity to benefit from the consultation.
Rogers et al. (14)	27 Patients, 10 GPs	Qualitative interviews	To explore the ways that doctors and patients conceptualize and respond to depression as a problem in the specific organizational context of primary care.	The perceived nature of primary care provision and the legitimacy of their problem influenced patient expectations. Dealing with depression constitutes work that is shaped and constrained by both individual preference and wider medical knowledge, resources and professional interactions.
Kadam et al. (13)	27 Patients	Qualitative interviews and focus groups	To explore patient perspectives in relation to their health care needs in anxiety and depression	Patients describe personal and professional barriers to seeking help and have particular views on the treatment options. This perspective contrasts with the current professional emphasis on detection and medication use.
Maxwell (25)	37 Women, 20 GPs	Qualitative interviews	To explore women’s and GPs’ experiences of recognizing depression and their experiences of the management of depression	The acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes.
McPherson and Armstrong (27)	20 GPs	Qualitative interviews	To examine how GPs would construct ‘depression’ when asked to talk about those anomalous patients for whom the medical frontline treatment did not appear to be effective	GPs responded in non-medical ways, including feeling unsympathetic, breaking confidentiality and prescribing social interventions.
Murray et al. (20)	18 GPs, 7 practice nurses, 5 practice counsellors	Qualitative interviews	To understand the attitudes that underlie interaction between clinicians and older patients with depression	Older people rarely report psychological difficulties, especially men; GPs worried about medicalizing normal ageing; stigma is a barrier to seeking help.
Railton et al. (17)	15 GPs	Qualitative interviews	To explore the experience of GPs about how they approached the care of patients with depression in relation to their skills, knowledge and attitudes	GPs experience a lack of time, valued continuity of care and resisted the categorization imposed by guidelines; some GPs use talking therapy; caring for depressed patients is emotionally draining for GPs; GPs rely on intuition; GPs acknowledge the critical role of stigma.
Qualitative analysis of consultation recordings
McPherson et al. (29)	12 consultations	Analysis of audio-recorded consultations	To investigate ways in which difficult interactions may arise from the medical context, which imposes constraints on the number and nature of problems a patient may present in a single consultation	The context (structure and format) of the GP consultation restricts GPs when supporting these patients. Working with patients to construct biopsychosocial model and circumvent the traditional consultation structure.
Miller (39)	3 GP consultations	Conversation analysis of recorded consultations	To investigate GP’s communication when asking about suicidal ideation pre-diagnosis of depression	It is important to fit questions about suicidality into the interactional sequence. This can be done by prefacing the question with a summary of the patients’ concern.
Karasz et al. (23)	30 transcripts	Secondary analysis of consultation data	To explore how interaction patterns common to most doctor–patient conversations shaped physician decision outcomes in the management of distress	Patients’ preferences and conceptual models affect what treatment GPs recommend.
Millar and Goldberg (21)	19 general practice vocational trainees	Analysis of taped consultations	To investigate possible relationships between the ability to detect emotional disorder and the ability to give information, advice and management to the patient	Able identifiers of mental illness were more likely to offer patients information and advice about their treatment, possibly reflecting greater confidence and superior patient-centred communication style.
McPherson and Armstrong (27)	12 patients, 12 GPs	Analysis of audio-recorded consultations	To explore how patients with treatment-resistant depression and GPs co-construct difficult consultations	Presentation of multiple problems in multiple domains clash with the consultation format. The question and answer format restricts multifaceted discussions of social and emotional problems.
Quantitative
Cape (63)	57 Patients	Statistical analysis of coded interview and questionnaire data	To explore the association between therapeutic relationship and clinical outcome in GP treatment of emotional problems	Results indicate a correlation between patients’ perceived quality of relationship with their GP and reduction in symptom severity 3 months later.
Cape (28)	88 patients, 9 GPs	Statistical analysis of coded consultation, interview and questionnaire data	To investigate the extent to which psychological treatment of emotional problems is undertaken by interested doctors in routine general practice and to explore what aspects of GPs’ psychological treatment might be therapeutic	Less than half the average consultation was found to comprise psychological treatment. Although psychological treatment generally was associated with positive patient experiences, the strongest effects found were for listening interactions and for rated doctor empathy
Cape and McCulloch (15)	64 patients 9 GPs	Statistical analysis of coded interview, consultation, and questionnaire data	To investigate patients’ (with high General Health Questionnaire scores) self-reported reasons for not disclosing psychological problems in consultations with GPs	Most common reason for non-disclosure is the perception that GP doesn’t have enough time and that there is nothing the doctor can do.
Cape and Stiles (36)	88 patients, 9 GPs	Statistical analysis of coded consultation, interview and questionnaire data	To examine the interrelations of speech act, content and evaluative measures	Patient-centred exchanges called Social Exposition and Emotional Exposition, which may serve psychotherapeutic purposes, were relatively prominent in those consultations rated relatively positively by patients and by external raters.