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'.

Download full-text


Available from: David Kessler, Jan 15, 2014
  • Source
    [Show abstract] [Hide abstract]
    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
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Antidepressants have shown to be effective in the treatment of depression and anxiety by reducing symptoms, as well as the risk of relapse and recurrence. Yet, several obstacles have been acknowledged in the process of adequate diagnosis and treatment of patients with these diseases: underrecognition of the health problem by the patient, underconsultation among patients who need treatment, failure to recognise and diagnose the problem by the physician, failure to prescribe drug treatment for those who need so, and eventually, on the part of the patient, not taking the drug as instructed. This thesis aims to understand why patients deviate from the prescribed and advised treatment with antidepressant drugs. The studies presented are build upon the framework of the course of drug taking consisting of three phases, namely initiation, execution and discontinuation of therapy. In this thesis, we explore patients’ considerations and decisions, based on the three phases within the course of taking antidepressants. Initiation of antidepressant drug treatment has hardly been addressed in research. This thesis showed that over one in four patients who receive a first-time antidepressant prescription appeared to decline treatment; they either do not initiate drug taking or do not persist antidepressant use for longer than two weeks. Declining a first-time antidepressant prescription was more common in patients who consult their physician for a non-specific indication, in elderly and non-western immigrants. Illness perceptions and severity, treatment needs and concerns, and patients’ views on information revealed to be important factors in the initiation of antidepressant drug taking. Fundamental in exploring the execution phase of antidepressant therapy are changes in patients’ attitude towards antidepressant treatment in response to the experiences while taking them. Health beliefs and illness severity at start showed to influence patients’ decisions about antidepressant drug taking. Patients who discontinued treatment some months after start perceived the physician’s role as limited, both during initiation and execution of treatment. They seemed to be less involved in decision making, and often appeared to have little confidence in their physician. Discontinuers were often unconvinced about the necessity of using an antidepressant, and appeared to have a strong desire to discontinue treatment. Finally, assessing whether patients taper treatment as opposed to abrupt discontinuation is important to understand patients’ behaviour during discontinuation of antidepressant therapy. We showed that one in five patients abruptly discontinue their therapy. Abrupt discontinuation caused a larger increase in the number of discontinuation symptoms than tapering. Of all patients, only one-third used a physician-made tapering schedule. We recommend healthcare professionals to inform patients of the pros and cons of taking or not taking antidepressant medication, involve patients in the treatment decision, reflect progress with treatment over time, and elicit considerations as to whether continue or discontinue drug taking. In addition, we suggest that research could systematically incorporate patients’ perspectives on medicines. Evaluation of patients’ experienced advantages and disadvantages of drug taking may contribute to the understanding of why patients take certain decisions regarding their medication use.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In the Netherlands, antidepressants are indicated for treating depression, generalized anxiety disorders, obsessive-compulsive disorders, social phobia, panic disorders, eating disorders, neuropathic pain and nocturnal enuresis. In addition, antidepressants are sometimes used for treating off-label indications such as sleeping disorders, urinary incontinence and headache. The diversity in the nature of these conditions results in a variety of antidepressant treatment patterns. The common use of antidepressants in the general population, in addition to the fact that their treatment pattern does not always represent the traditional episodic nature of depression, makes this particular drug class a suitable model for methodological research on drug exposure. In pharmacoepidemiology the effects of drug use in large populations are studied. Currently, pharmacoepidemiological research often uses prescribing and dispensing moments to construct drug treatment episodes in order to classify drug exposure. Construction of drug treatment episodes involve many methodological aspects, such as defining the start and the end of a treatment episode, which need to be accounted for. The objective of this thesis was to investigate methodological topics in observational research relevant to the construction of antidepressant treatment episode(s). When designing observational studies and deciding which definitions should be used to compose a study cohort and construct treatment episodes, there are some basic considerations that will influence the choice of definitions. Firstly, does the study question require knowledge on disease status of the patient or only drug use as such? Secondly, does the study aim to investigate patients who receive a prescription, regardless of whether they start therapy or not? Are there possible differences in risk profiles between patients who are experiencing their first treatment episode and those who re-initiate treatment? And finally, is the drug intended for short, episodic or long term use and what is its daily dosing scheme? When the aim is to investigate drug exposure in relation to particular outcomes, it is essential that drug treatment episodes are well defined. The methodological choices for study definitions depend on the exposure-outcome relationships under investigation. If definitions are not selected properly, it could influence study outcomes and lead to biased estimates. Nowadays, the majority of pharmacoepidemiologic research uses administrative databases to define drug treatment patterns which are subsequently associated with specific (disease) outcomes. The observed treatment patterns which are used to divide patients into different groups are often based on assumptions of the patients’ specific treatment patterns. Future research should investigate patient behavior in relation to specific treatment patterns seen in administrative databases. Thereby, we would not only describe the treatment patterns and drug taking behavior of the patient but investigate the reasons and understand why the patient exerts a specific treatment pattern. Many factors can influence patient decision making on whether and how they use their medicines and if they comply with therapy or not. These factors can differ between patients and also within a single patient over the course of time. Understanding what kind of patient behavior results in a specific treatment pattern observed in administrative databases may lead to new definitions when investigating adherence in administrative data.