Better Doctor-Patient Relationships Are Associated with Men Choosing More Active Depression Treatment

Discussion

The present study sought to examine the relationship between men's experience of primary care—specifically, the quality of the patient-doctor relationship—and the hypothetical preference for 1 of 3 active treatment choices for depression, as opposed to a wait-and-see/no-treatment option. Overall, the degree to which men were likely to opt for pharmacotherapy or individual psychotherapy (compared with no treatment) was significantly associated with the depth of their relationship with their family physician. While the size of this effect was small, it was significant after controlling for severity of depressive symptoms as well as several potentially confounding sociodemographic variables. This finding underscores the value of the patient-doctor relationship in potentially facilitating men's uptake of active treatment for depression. Thus, while strategies to mitigate stigma and adherence to traditional masculinity norms remain important, attention should be devoted to encouraging and facilitating the continuity of men's engagement in primary care.

One sociodemographic variable emerged as significant: being a student. Attention to mental health among postsecondary students has increasingly come into focus through awareness campaigns, peer support programs, and campus counseling services.¹⁶ Men involved in postsecondary studies may thus feel less stigma about mental health issues, and may have greater access to knowledge about the treatment of depression.

Interestingly, further analysis of our sample revealed that the association between the patient-doctor relationship and treatment preference did not hold for men with current depression in the moderate range. This was in contrast to those without major depression and those with more severe depression. It may be that different mechanisms are involved in this relationship between these groups. Nondepressed men may readily imagine opting for treatment based on trust in their physician, when they are not facing the actual burden of symptoms or concerns related to psychotherapy or medication side effects. For men who are actually depressed, the connection with their doctor may carry less weight among a number of factors in their contemplation of an active versus wait-and-see approach. Those with severe depression, however, may especially rely on a secure and trusting relationship with their physician as they face potentially greater comorbidity and risk, and more complex treatment. Alternatively, the nonsignificant finding regarding the patient-doctor relationship among men in the moderately depressed category could be due to the relatively small number of men in this category. It is possible that a smaller effect size—relative to those with severe depression—of the association between the patient-doctor relationship and treatment uptake may not have been detected due to reduced statistical power. Given the simplicity of our survey and the relatively fewer men in these severity categories, further research is needed to examine these possibilities.

While specialized intervention, such as motivational interviewing, may assist family physicians in promoting treatment adherence,¹⁷ key interpersonal/relational qualities such as empathy, compassion, and genuineness can help men to feel accepted, understood, and encouraged about the prospective value of treatment. As the authors of a review of depression in primary care note: “a caring and attentive FP is likely to be highly therapeutic—hardly a surprise, but worth exploiting in a systematic fashion.”³ The depth of the patient-doctor relationship extends beyond a particular consultation, encompassing treatment of the “whole patient” and the total relationship developed between physician and patient over time.^18,19 While maintaining such a relationship may come naturally to many family physicians, concerted attention to men's experience of the relationship may help to enhance empathy and address potential “alliance ruptures.” Borrowed from the psychotherapy literature, alliance ruptures—tension or deterioration of the working relationship—can often be repaired through sensitive inquiry and responsive negotiation.²⁰ Doing so may contribute to a stronger and deeper patient-doctor relationship in the long run.

Several limitations to the present study must be noted. First, the cross-sectional nature of the data precludes inferences regarding causality and raises the possibility of shared method variance. The number of potential confounding variables was also limited. The scenario of being depressed and contemplating treatment was hypothetical; we did not ask which treatment had been selected by men who were indeed depressed, and the options were presented in a forced choice format that precluded the selection of multiple approaches. Men contemplating actual treatment would likely have more nuanced options, and may choose differently compared with a hypothetical scenario. Finally, the Canadian context of the survey—where universal health care obviates financial concerns about many treatments and services (though psychotherapy is only consistently covered when provided by psychiatrists)—may not generalize to other countries. These limitations point to a need for further research concerning men's connections with their primary-care providers in the context of their mental health needs. While more needs to be learned about the nuances of the patient-doctor relationship among men—particularly among those who are reluctant to seek help for mental health problems—the present study provides support for the quality of this relationship as a vital element in the battle against men's depression.