Communication & Medicine, Vol 11, No 2 (2014)

Disclosure of mental health problems in general practice: The gradual emergence of latent topics and resources for achieving their consideration

Christel Tarber, Lisbeth Frostholm
Issued Date: 17 Aug 2015


Common mental disorders often go undetected in primary care. Sharpening general practitioners’ (GPs’) attention to potential signs thereof is therefore crucial. This conversation-analytic study arises from the observation that the consideration of psychological problems in new-concern visits can be achieved by way of ‘gradual topic emergence’. This entails that the problem is not presented directly, but adjunct to somatic symptoms, and is hinted at by way of generic, ambiguous complaints, and furthermore by expressions of frustration and uncertainty and talk about lifeworld problems. It is argued that these materials are ‘trouble-premonitory’, alerting the GP to the presence of an underlying problem that can then be addressed through further inquiry. The patient logic behind this approach is to assure the GP’s recipiency and thus ratification of the problem’s medical legitimacy. It allows the patient to introduce a potentially delicate problem ‘off the record’, thus guarding the patient against the loss of face that could result from no uptake by the GP. The results of the study point to the importance of GPs being receptive to such interactional clues to psychological problems provided by patients.

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DOI: 10.1558/cam.v11i2.17404


Balint, M. (1957) The Doctor, His Patient and the Illness. Second edition. London: Pitman Medical.

Beckman, H. D. and Frankel, R. M. (1984) The effect of physician behavior on the collection of data. Annals of Internal Medicine 101 (5): 692–696.

Byrne, P. S. and Long, B. E. L. (1984) [1976 ] Doctors Talking to Patients: A Study of the Verbal Behaviour of General Practitioners Consulting in their Surgeries. Exeter, UK: The Royal College of General Practitioners.

Campion, P. and Langdon, M. (2004) Achieving multiple topic shifts in primary care medical consultations: A conversation analysis study in UK general practice. Sociology of Health & Illness 26 (1): 81–101.

Cannizzaro, M., Harel, B., Reilly, N., Chappell, P. and Snyder, P. J. (2004) Voice acoustical measurement of the severity of major depression. Brain and Cognition 56 (1): 30–35.

Heinemann, T., Lindström, A. and Steensig, J. (2011) Addressing epistemic incongruence in question-answer sequences through the use of epistemic adverbs. In T. Stivers, L. Mondada and J. Steensig (eds) The Morality of Knowledge in Conversation, 107–130. Cambridge: Cambridge University Press.

Hepburn, A. (2004) Crying: Notes on description, transcription, and interaction. Research on Language & Social Interaction 37 (3): 251–290.

Heritage, J. (1984) Conversation analysis. In J. Heritage (ed.) Garfinkel and Ethnomethodology, 233–292. Cambridge: Cambridge University Press.

Heritage, J. and Robinson, J. D. (2006a) The structure of patients’ presenting concerns: Physicians’ opening questions. Health Communication 19 (2): 89–

Heritage, J. and Robinson, J. D. (2006b) Accounting for the visit: Giving reasons for seeking medical care. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interaction between Primary Care Physicians and Patients, 48–85. Cambridge: Cambridge University Press.

Heritage, J., Robinson, J. D., Elliot, M. N., Beckett, M. and Wilkes, M. (2006). Reducing patients’ unmet concerns in primary care: The difference one word can make. Journal of General Internal Medicine 22 (10): 1429–1433.

Jefferson, G. (1980) On ‘trouble-premonitory’ response to inquiry. Sociological Inquiry 50 (3/4): 153–185.

Jefferson, G. (1985) On the interactional unpackaging of a ‘gloss’. Language in Society 14 (4): 435–466.

Jefferson, G. (1988). On the sequential organization of troubles talk in ordinary conversation. Social Problems 35 (4): 418–442.

Jefferson, G. (2004) Glossary of transcript symbols with an introduction. In G. H. Lerner (ed.) Conversation Analysis: Studies From the First Generation, 13–23. Philadelphia, PA: John Benjamins.

Lipkin M., Frankel R. M., Beckman H. B., Charon R. and Fein O. (1995) Performing the interview. In M. Lipkin, S. M. Putnam and A. Lazare (eds) The Medical Interview: Clinical Care, Education and Research, 65–82. New York: Springer.

Marvel, M. K., Epstein, R. M., Flowers, K. and Beckman, H. B. (1999) Soliciting the patient’s agenda: Have we improved? Journal of the American Medical Association 281 (3): 283–287.

Mishler, E. G. (1984) The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, NJ: Ablex.

Nilsonne, A. (1988) Speech characteristics as indicators of depressive illness. Acta Psychiatrica Scandinavica 77 (3): 253–263.

Østergaard I., Andersen, J. S., Christensen, B., Damsbo, N., Lauritzen, T. and Witt, K. (2003) Almen Medicin. København: Munksgaard.

Pomerantz, A. (1986) Extreme case formulations: A way of legitimizing claims. Human Studies 9 (2–3): 219–229.

Praktiserende Lægers Organisation (2014). Vigtige afregningsregler i almen praksis [Important rules for the settlement of accounts in general practice]. Retrieved from:!

Robinson, J. D. (2001) Closing medical encounters: Two physician practices and their implications for the expression of patients’ unstated concerns. Social Science & Medicine 53 (5): 639–656.

Robinson, J. (2006) Soliciting patients’ presenting concerns. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interaction between Primary Care Physicians and Patients, 22–
47. Cambridge: Cambridge University Press.

Tarber, C. (in review) ‘Just to be on the safe side’. Medical authority and the management of uncertainty in the issuing of referrals.

Üstün, T. B. and Sartorius, N. (1995) Mental Illness in General Health Care: An International Study. Chichester, UK: John Wiley & Sons.

Weatherall, A. (2011) ‘I don’t know’ as a prepositioned epistemic hedge. Research on Language and Social Interaction 44 (4): 317–337.

Wheat, H. (2012) The Interactional Management of ‘Early’ Mental Health Issues in GP-Patient Consultations. Unpublished doctoral dissertation, Peninsula College of Medicine and Dentistry, Plymouth, UK.

White, J. C., Rosson, C., Christensen, J., Hart, R. and Levinson, W. (1997) Wrapping things up: A qualitative analysis of the closing moments of the medical visit. Patient Education and Counseling 30 (2): 155–165.

Zimmerman, C., Del Piccolo, L., Bensing, J., Bergvik, S., De Haes, H., Eide, H., Fletcher, I., Goss, C., Heaven, C., Humphris, G., Kim, Y-M., Langewitz, W., Meeuwesen, L., Nuebling, M., Rimondini, M., Salmon, P., van Dulmen, S., Wissow, L., Zandbelt, L. and Finset, A. (2011) Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR-CoDES). Patient Education and Counseling 82 (2): 141–148.


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