GP treatment decisions for patients with depression: an observational study

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GP treatment decisions for patients with
depression an observational study

• Kendrick T, King F, Albertella L, Smith P
• Br J Gen Pract 200555280-6

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Background

• England Increase in anti-depressant
  prescriptions- may be inappropriate
• Many patients (2/3) with major depression are not
  receiving recommended treatment
• This may be linked to GPs beliefs and patients
  beliefs

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Research question Understanding GP behaviour

• What influences GP treatment decisions for
  depression
• Severity of depression
• Patient demographic factors
• Adverse life events
• Past history
• Patient attitudes towards antidepressants (as
  seen by GPs/ as reported by patients)

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Methods

• Observational study
• Patients
• HADS (HAD-D ? severity)
• Socio-demographic factors
• Perceived financial difficulties
• Brief schedule of threatening life events
• Health status
• Attitudes to antidepressants

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• GPs
• Is patient depressed 0-4
• If gt 2
• Action taken
• Adverse life event or difficulties
• Patients attitude towards antidepressants
• Previous mental health problems
• Chronic physical health pbs
• Previous antidepressant treatment
• How well do you know patient
• Acknowledgement of diagnosis of depression

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• Notes checked after 2 months for subsequent
  diagnosis of / treatment for depression

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Methods Recruitment

• Recruitment of GP practices
• Phase I 2 practices ? 9 GPs (of 9)
• Phase II 6 practices (5 of 7 newly approached
  1 from phase I) ? 11 GPs (of 18)
• No information on selection process

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Methods recruitment

• Patients
• Inclusion criteria
• gt18 years old
• Able to complete screening questionnaire
• Exclusion criteria
• Currently taking AD/psychiatric treatment
• Terminal illness

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• Consent
• Ph I directly approached by researcher
• Ph II approached by receptionist then researcher
• Consent slip given to GP before consultation

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• Patients
• 437 257 patients 694 patients
• 59- 43 of appts
• 100 depressed
• 67 HAD-D 8-10
• 33 HAD-D gt10

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Results

• Missing data
• GPs completed questionnaires for 97-95 of
  patients enrolled
• Patients all filled in HAD on the spot but sent
  other questionnaires by post in 73-72 of cases
  (no difference in HAD-D score)

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Results diagnosis of depression
Prév 13,4 Se 33 Sp 89 PPV 31 NPV 89 LR
3 LR- 0.75

• GPs are not very accurate

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Results treatment decisions

• Acknowledgement 49/35
• AD 8/22
• Follow-up/referral 16/7

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Results association between AD offers and GP
perceptions

• Severity of depression
• Moderategtmild
• P 0.019/0.001
• Attitude of patient twds AD
• P 0.045/0.004
• Absence of adverse life events or difficulties
• P0.03/0.847

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Results GP perceptions of patients attitudes

• GP pos attitude // patient addictiveness
• GP neg attitude patient effectiveness

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Results changes between ph I and II

• More offers of AD
• No link between offer of AD and adverse life
  events
• BUT
• Different population
• Insufficient numbers of GPs

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Discussion Main findings

• Poor diagnostic accuracy
• Management
• Lack of acknowledgement with patients
• AD offers linked to severity and perceived
  patient attitude to AD

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Limitations

• Selection of practices???
• Relatively small sample size re R/ decisions
  (101)
• 2 phases different practices so no comparison
  feasable