Table 5 Sample quotations for analysis of factors that influence the referral to a therapist for assessment with the MINI, with COM-B as framework

FPs’ competence in terms of knowledge and skills

Knowledge about mental disorders

Q1. One has to consider whether there is a need for the MINI (and referral) or if my own assessment is sufficient (FP 8, PHCC 1)

Q2. The doctor knows about injuries and the therapist about the soul (Patient 1).

Communication skills

Q3. I was not really prepared for the visit to the therapist. My FP had only told me that I […] needed to talk to a therapist, which I felt was a good idea. This meant that I did not know that I was about to have an interview and the MINI test. […] So, the therapist was a bit unprepared as well and had to explain what it all was about. However, then we talked about what I needed to discuss with her – before the interview. I felt that this was doing it backwards, we should have made the interview first and talked afterwards (Patient 16).

Consultation skills

Q4. Doctors are doctors after all, they kind of, how shall I express it, take over, I am not in charge anymore. (Patient 9).

The priorities of the management

Lack of supportive routines

Q5. …and there are no fora (for discussions). If you need to contact someone, you have to go and knock on the door when that person is not occupied and you yourself is not occupied. This is very tricky. The alternative is the lunch room… which is well, so-so, you don’t want to do that for all your patients (therapist, PHCC2).

Q6. The administrative extra tasks have to be taken into consideration e.g. to have

a specific time for discussions with the therapist instead of the therapist coming to me in the staff room or in the corridor (FP, PHCC1).

Limited time for FPs’ assessment

Q7. I have had many new patients with short time slots. They present pain and symptoms in different places and you get the impression that depression, anxiety or something similar is behind it all. Then it is important to have this resource (the therapist) since you cannot do that assessment in 15 min (FP 3, PHCC1).

Q8. Stressed doctors have difficulties to sense who you are and to give the adequate questions about your health (Patient 3).

Easy access to a therapist

Q9. I have reasoned that as the waiting time to the therapist is so short, I have referred them (the patients) before initiation of treatment… and then I have perceived that my depression diagnosis is more robust (FP 9 PHCC1).

Patient characteristics

Q10. You and the patient have to agree on what to do. Especially depressive and psychiatric diagnoses, they are extra sensitive. Had this been a project concerning diabetes, it goes without saying, you would refer the patient (FP 6, PHCC 1).

Process facilitator or change agent available

Q11. The therapist chased us in order to catch us for the feedback. I guess it has been heavy for her (FP 9, PHCC1).

Q12. Initially, it took time to fill the time slot (assigned for assessment by the MINI) so I sent out reminders in the patient record system in order to get it moving (therapist, PHCC1).

Beliefs that referral facilitates the work of the FP

Saving time and effort

Q13. So, with the therapist assessment, the table was set when the patients came back. It is amazing! The patient was nearly fully examined. So, it saved time for me (FP 4, PHCC1).

Q14. It is harder for the doctor to arrive at a diagnosis without cooperation with a therapist (patient 1).

Gives additional information

Q15. …a different climate is needed, kind of, in order for those questions to surface. If you have an hour at your disposal, in an undisturbed context and normal clothing (as is the case for the therapist), the conditions for the therapist are so much better than ours (FP 4, PHCC1).

Beliefs that collaboration on diagnosis can improve patient management

Q16. It is a big advantage that there is someone with whom you can discuss the patient (FP 7, PHCC1).

Q17. Patients often refer to conversations with the FP and want me to do something. This could be prevented if the FP and I talk and agree on a treatment plan (therapist, PHCC2).

Q18. I think that you need to meet with a therapist as well as a doctor if you don’t feel well. That the diagnosis and examination are made from both a doctor- and a therapist perspective in order to capture all parts. That the doctor does not label you as being sick “OK take some vitamin-D because you seem to be a bit moody” without the input from someone who is more competent concerning such matters (Patient 18).

Beliefs about professional roles

Q19. But it is something that you feel when you ask the questions (of the MINI) so it becomes an integrated assessment (FP 2, PHCC2).

Q20. What I do NOT want to see, is that patients are sent to us for an assessment only. An assessment means to create an alliance (between the therapist and the patient) and start planning how patient and therapist can work together, during a treatment. (therapist, PHCC2).

Positive experiences facilitate a new habit

Q21. I began to refer patients that did not fulfil the criteria of the MINI-study as well (FP 3, PHCC1).

Q22. … and when I have done it once, the doctors understand that they can use me again. So, then they have referred more patients and I have done many more assessments than those included in the study (therapist, PHCC1).

Easier to continue working as usual

Q23. …many that comes to us for help already have a diagnosis from somewhere else. Then it is easy to accept their diagnosis and continue with treatment. Then there is not much of a diagnostic process, although that does not mean that the original diagnosis is the correct one (FP 2, PHCC2).

Q24. I don’t think that it is self-evident when you see the patient that this person should be referred (for the MINI in a diagnostic process) – it just keeps rolling (FP 8, PHCC1).

Most patients accept meeting FPs first

Q25. If I had the opportunity to choose I had visited the doctor first, after all. Because it feels as if the can place you right […], as I said before, I came for stomach problems and did not think at all that I suffered from depression and anxiety (Patient 11).

Q26. But I can think that it would be good if the doctor could perform the test (MINI) as fast as possible. And if the doctor considers that you suffer from something like --- or if the test suggests that you suffer from something …then the doctor refers you to a therapist (Patient 19).

Importance of personality and knowledge

Q27. It is hard to say who should conduct the test because it depends on background and experience. Maybe the title does not matter much. But the one conducting the test must feel comfortable and understand it. It is not enough to just present the questions and then just fill in “yes” or “no”. Patients might get upset when certain questions are presented, and difficult emotions might come up. So, you have to know how to handle such reactions (Patient 23)