A qualitative study exploring how GPs decide to prescribe antidepressants

Institute of Psychiatry, King's College London.
British Journal of General Practice (Impact Factor: 2.36). 11/2005; 55(519):755-62.
Source: PubMed

ABSTRACT To influence GPs' prescribing policies and practices it is necessary to have an understanding of how they make decisions. The limited evidence available suggests that not only do GPs find making decisions about diagnosing and prescribing for depression problematic, but that decisions are severely constrained by lack of resources. As a result, it might be thought that GPs, in line with current guidelines, will inevitably prescribe antidepressants for patients presenting with symptoms of anxiety and depression. This study examines the accuracy of this view.
To explore how GPs decide to prescribe antidepressants.
Focus groups with self-selected GPs.
Bristol and the surrounding district.
Qualitative study of five focus groups with 27 GPs.
GPs' decisions about whether an antidepressant would be an appropriate form of management are shaped by a set of rules based on 'clinical' and 'social' criteria. The preferred strategy is to 'wait and see', but antidepressants are prescribed earlier when symptoms are perceived to be persistent, unresolving, severe and 'classic'. Decisions to prescribe are also shaped by organisational constraints of time, lack of accessible alternative management options, cost of prescribing and perceived patient attitude.
The evidence from this study provides little support for the view that GPs take the easy option of prescribing antidepressants in the face of uncertainty. Evidence suggests that the GPs' prescribing was cautious, which indicates that GPs would support the initiative of recent draft guidelines regarding watchful waiting. This guidance, however, needs to be clear about what constitutes mild depression and address the question of prescribing to patients who are experiencing social adversity. Furthermore, alternatives to antidepressants such as counselling would need to be readily and equitably accessible. In addition, GPs need to be convinced that alternatives to antidepressants are at least as effective for patients with so-called 'mild depression'.

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Available from: David Kessler, Jan 15, 2014
    • "These opposing positions add to the complexity GPs face when patients consult with psychological symptoms. Determining when patients present with symptoms reflecting 'normal' distress, and when they show signs suggesting underlying disorder is a difficult process (Hyde et al., 2005). Nonetheless, it is important in providing appropriate care, improving the targeting of interventions and reducing the provision of treatments that may inadvertently lead to harm (Fergusson et al., 2005). "
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    ABSTRACT: Detection of psychiatric disorder in primary care is a complex issue. Distinctions between 'normal' emotional distress and psychiatric disorder depend on how disorder is conceptualized. Our aim was to explore two different conceptualizations by examining patients' scores on one-dimensional depression measures and scores on the Four Dimensional Symptom Questionnaire (4DSQ), a measure that uniquely has separate dimensions for general distress and depressive disorder. This was a cross sectional study of 487 primary care patients attending general clinics in Hampshire, UK. Patients completed the 4DSQ, Patient Health Questionnaire-9 (PHQ-9), General Health Questionnaire-12 (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS) whilst in the waiting room. The 4DSQ classified 26% (126/485) of patients as having heightened distress levels and 8% (38/468) as possible cases of depressive disorder. Casesness was consistently higher across the one-dimensional measures (PHQ-9: 16%, GHQ-12: 28%, HADS-D: 13%). Of those patients deemed possible cases by the PHQ-9 (≥10), the 4DSQ classified 91% (71/78) as having heightened distress and 44% (32/72) as possible cases of depressive disorder. The sample was predominately older and white, which may limit generalizability of the findings to more diverse patient groups. There are limits to self-report measures in the assessment of complex diagnostic issues. Inclusion of a distinct general distress dimension alongside a dimension focusing on specific depression symptomatology lowered the number of primary care patients classified as possible cases of disorder. This view of symptoms may have implications for the targeting of existing treatments, and may be useful in guiding the development of novel self-management interventions. Copyright © 2015. Published by Elsevier B.V.
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    • "A common theme in these studies is that the push for primary care guidelines for depression does not capture the complexity of the diagnostic process. Physicians' accounts of diagnosing depression reveal that they experience a tension between the biomedical discourse of depression in which they are trained and which accords them clinical authority, and the recognition that the social context of patients' lives contributes to their experience of emotional distress (Thomas-MacLean and Stoppard 2004), with many prescribing antidepressants reluctantly (Hyde et al. 2005). Some physicians report feeling powerless when dealing with patients they have diagnosed as depressed because they see the causes of patients' distress as social, and therefore beyond the medical domain (Kokanovic et al. 2010). "
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    ABSTRACT: The diagnosis of depression in the clinical context is extremely controversial and is subject to criticism of over-medicalisation and pharmaceuticalisation. Depression can be conceptualised across the entire spectrum of lay and medical belief, from the 'normal' highs and lows of the human condition to its inclusion in the dominant Diagnostic and Statistical Manual of Mental Disorders classificatory system, as a form of serious mental illness. In this context, a better understanding of how people describe, experience, negotiate and participate in the process of diagnosis is needed. This article draws on qualitative interviews to explore lay accounts of being diagnosed with depression. The findings reveal that lay accounts of depression vacillate in and out of the medicalised discourse of depression, highlighting the limitations of the biomedical approach to diagnosis and treatment.
    Sociology of Health & Illness 08/2012; 35(3). DOI:10.1111/j.1467-9566.2012.01486.x · 1.88 Impact Factor
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    • "However, there is also evidence that GPs may not accurately identify which patients are likely to benefit from antidepressant medication, and if antidepressants are prescribed, adherence is often problematic (Van Geffen et al, 2009). Furthermore, it has been shown that GPs are tentative with regard to prescribing antidepressant medication, particularly for what is perceived as self-limiting conditions of emotional distress brought on by social circumstances (Chew-Graham, Mullin, May, Hedley, & Cole, 2002; Hyde et al., 2005). A recent meta-synthesis of quantitative and qualitative research has identified that GPs prescribe medication due to a lack of psychological therapy or other specialist services. "
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