journal club 30/09/05 v dory gp treatment decisions for patients with depression: an observational...

Journal Club 30/09/05 V Dory

GP treatment decisions for patients with depression: an observational study

Kendrick T, King F, Albertella L, Smith P

Br J Gen Pract 2005;55:280-6


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


Research question :Understanding GP behaviour

What influences GP treatment decisions for depression:Severity of depressionPatient demographic factorsAdverse life eventsPast historyPatient attitudes towards antidepressants (as

seen by GPs/ as reported by patients)


Methods

Observational studyPatients:

– HADS (HAD-D severity)

– Socio-demographic factors

– Perceived financial difficulties

– Brief schedule of threatening life events

– Health status

– Attitudes to antidepressants


GPs: Is patient depressed : 0-4

If >= 2:Action takenAdverse life event or difficultiesPatient’s attitude towards antidepressantsPrevious mental health problemsChronic physical health pbsPrevious antidepressant treatmentHow well do you know patientAcknowledgement of diagnosis of depression


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


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


Methods: recruitment

Patients

Inclusion criteria: >18 years old Able to complete screening questionnaire

Exclusion criteria: Currently taking AD/psychiatric treatment Terminal illness


Consent

Ph I : directly approached by researcher

Ph II: approached by receptionist then researcher

Consent slip given to GP before consultation


Patients437 + 257 patients = 694 patients59%- 43% of appts100 depressed

67 HAD-D 8-1033 HAD-D >10


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)


Results: diagnosis of depression

GPs are not very accurate:

Ph I HAD +

HAD -

total

GP + 19 42 61

GP - 38 326 364

total 57 368 425

Prév 13,4%

Se 33%

Sp 89%

PPV 31%

NPV 89%

LR+ 3

LR- 0.75


Results: treatment decisions

Acknowledgement: 49%/35%

AD: 8%/22%

Follow-up/referral: 16%/7%


Results: association between AD offers and GP perceptions

Severity of depressionModerate>mildP = 0.019/0.001

Attitude of patient twds ADP= 0.045/0.004

Absence of adverse life events or difficultiesP=0.03/0.847


Results: GP perceptions of patient’s attitudes

GP ‘pos attitude’ // patient ‘addictiveness’

GP ‘neg attitude’ # patient ‘effectiveness’


Results : changes between ph I and II

More offers of ADNo link between offer of AD and adverse

life events

BUT:

Different population

Insufficient numbers of GPs


Discussion : Main findings

Poor diagnostic accuracy

Management :– Lack of acknowledgement with patients– AD offers linked to severity and perceived

patient attitude to AD


Limitations

Selection of practices???

Relatively small sample size re R/ decisions (101)

2 phases : different practices so no comparison feasable

journal club 30/09/05 v dory gp treatment decisions for patients with depression: an observational...

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