ORIGINAL ARTICLE Do Patient Requests for Antidepressants Enhance or Hinder Physicians’ Evaluation of Depression? A Randomized Controlled Trial Mitchell D. Feldman, MD, MPhil,* Peter Franks, MD,† Ronald M. Epstein, MD,‡ Carol E. Franz, PhD,§ and Richard L. Kravitz, MD, MSPH¶ Objective: We sought to ascertain whether patients’ requests for antidepressants affect visit duration or history taking by primary care physicians (PCPs) for patients with depressive symptoms and a coexisting musculoskeletal disorder and to determine whether more thorough history taking is associated with diagnostic accuracy or with provision of minimally acceptable initial care for major depression. Design: This was a randomized trial using standardized patients (SPs). Six roles involved 2 conditions (major depression and adjust- ment disorder, both with coexisting musculoskeletal conditions) and 3 patient request types (brand-specific, general, or none). We con- ducted the study in 152 PCP offices in Northern California and Rochester, New York. Physicians were assigned randomly to see 2 SPs with depression/wrist pain or adjustment disorder/back pain. Main Outcome Measures: Physician history-taking for depression and the musculoskeletal condition; depression diagnosis in the medical record; antidepressant prescriptions/samples; referral/fol- low-up recommendations; visit duration; and provision of minimally acceptable initial depression care. Results: General antidepressant requests were associated with more depression history-taking (Adjusted Parameter Estimate = 0.80 more questions of 10 (95% confidence interval = 0.31–1.29, P  0.001); brand-specific requests were marginally associated with more depression history-taking (Adjusted Parameter Estimate = 0.45, 95% confidence interval =-0.04 – 0.93, P = 0.07). Antide- pressant medication requests were not related to musculo-skeletal question asking (P  0.3) or visit length (P  0.8). Depression history taking was directly associated with the likelihood of a chart diagnosis of depression and the provision of minimally acceptable initial depression care. Conclusion: General antidepressant requests increase depression history taking, including screening for suicide. Patients’ requests for medication do not appear to short-circuit history taking for depres- sion or distract the physician’s attention from coexisting musculo- skeletal conditions. Key Words: depression, patient requests, doctor-patient communication (Med Care 2006;44: 1107–1113) D epression is common in primary care patients and results in disability and increased health care costs. 1–3 Although there have been significant advances in the treatment of depression in primary care in recent years, primarily in the context of collaborative care models, 4,5 patients with depres- sion frequently are overlooked and inadequately treated. 6–8 To date, research has focused primarily on the role of im- proved screening and detection by practitioners and on sys- tem innovations; little attention has been paid to the role patient requests for treatment may play in improving detec- tion and treatment of depression in primary care. Previous research has demonstrated, however, that patient requests for treatment can be a powerful influence on the type and quality of care. 9 –11 As a result, the pharmaceutical industry spends billions of dollars on direct to consumer advertising (DTCA) in the United States each year. 12 One recurring allegation is that patient requests for treatment may steer the physician into discussing the indications, risks, and benefits of brand- name medicines that may not be indicated, leading to neglect of other visit priorities. 13–17 In particular, time spent discuss- ing a specific drug may detract from conscientious history- taking, arguably the bedrock of the diagnostic process. 18,19 This view is not universally endorsed; some insist that re- quests may promote a broader differential diagnosis and more thorough medical evaluation. 20 From the *Division of General Internal Medicine, Department of Medicine, University of California, San Francisco; †Center for Health Services Research in Primary Care and Family and Community Medicine, Uni- versity of California, Davis, Sacramento; ‡Departments of Family Med- icine and Psychiatry and Center to Improve Communication in Health Care, University of Rochester School of Medicine and Dentistry, Roch- ester, New York; §Center for Health Services Research in Primary Care, University of California, Davis; and ¶Center for Health Services Re- search in Primary Care and Department of Internal Medicine, University of California, Davis. Supported by a grant (5 R01 MH064683) from the National Institute of Mental Health. The design, conduct, data collection, analysis, and inter- pretation of the results of this study were performed independently of the funders. The funding agencies also played no role in review or approval of the manuscript. Reprints: Mitchell D. Feldman, MD, MPhil, Division of General Internal Medicine, Department of Medicine, University of California San Francisco, 400 Parnassus Ave, San Francisco, CA. E-mail: mfeldman@medicine. ucsf.edu. Copyright © 2006 by Lippincott Williams & Wilkins ISSN: 0025-7079/06/4412-1107 Medical Care • Volume 44, Number 12, December 2006 1107