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1 Department of Family Medicine, University of Rochester Medical Center, Rochester, NY
2 Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
3 Rochester Center to Improve Communication in Health Care, Rochester, NY
4 Division of General Medicine, Department of Internal Medicine and Center for Health Services Research in Primary Care, UC Davis School of Medicine, Sacramento, Calif
5 Department of Medicine, University of California, San Francisco, San Francisco, Calif
CORRESPONDING AUTHOR: Ronald M. Epstein, MD, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14610, Ronald_Epstein{at}urmc.rochester.edu
PURPOSE This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing.
METHODS We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians’ exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role.
RESULTS In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69–1,120.87; P 
.005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33–9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67–9.68; P .005) and clinical indications (AOR = 4.70; 95% CI, 2.18–10.16; P .005). More thorough history taking of depression symptoms did not mediate these results.
CONCLUSIONS Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.
Key Words: Physician-patient relations • patient-centered care • advertising • antidepressive agents • physician’s practice patterns • prescriptions, drug • adjustment disorders • depression • family practice • mass media • patients • primary care • quality of health care • standardized patients
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