Objective: To explore rural family physicians' decision-making processes when they encounter depression.
Design: Exploratory qualitative "field study" using individual in-depth interviews and participant observation. Interviews were audiotaped, transcribed, and analyzed by an editing approach.
Setting: Rural Nebraska family physicians' offices.
Participants: A purposeful sample of six rural Nebraska family physicians, including five men and one woman, aged 35 to 65 years; two in solo practice, three in two-person practices, and one in a group practice; in communities with populations ranging from 600 to 6500.
Main outcome measures: Themes common to all interviews.
Results: Themes included the following: depression is easy to recognize but difficult to diagnose; depression is readily treatable but requires negotiation to manage; and depression is important but time and resources are limited. The inadequate diagnosis and treatment of depression appeared to be partly artifactual and must be understood against a background of perceived stigma, high prevalence of depressive symptoms, structural barriers to care, and context of rural practice.
Conclusions: Rural family physicians may have a more deliberate, organized, and rational approach to depressive disorders than previously reported. Depression is commonly recognized by rural family physicians; however, they hesitate to diagnose this condition because of diagnostic uncertainty, perceived stigma, the desire to preserve the physician-patient relationship, time and financial pressures, and a lack of supporting resources.