Depression, sense and sensitivity: on pre-diagnostic questioning about self-harm and suicidal inclination in the primary care consultation

National Health Service directives in the UK specify that, in any primary care consultation where a patient either demonstrably has – or is suspected to have –depression, a “direct question” should be asked regarding their thoughts or activities relating to self-harm or suicide. The evidence collected for this study, which takes the form of recorded interactions between doctors and patients in primary care settings, indicates that this is most commonly done post-diagnosis as an exercise in “risk assessment.” Suicidal ideation is, however, not only classified as a possible outcome of depression but also a core symptom of the condition and, consequently, such a question is sometimes asked prior to the diagnostic phase of the consultation, as a key step in reaching a depression diagnosis. This specific activity presents a general practitioner with an inferably difficult communicative task: how to raise the matter of suicide/self-harm when the patient does not already have a depression diagnosis as an interactional resource with which to make sense of its local relevance. Herein, using a conversation analytic method, techniques employed by general practitioners and patients in negotiating three of these potentially sensitive moments are examined. Analytic observations are then used to highlight a range of issues pertinent to the formulation of normative frames of “good practice” in handling difficult clinical topics in situ