A qualitative study exploring how GPs decide to prescribe antidepressants

Institute of Psychiatry, King's College London.
British Journal of General Practice (Impact Factor: 2.29). 11/2005; 55(519):755-62.
Source: PubMed


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
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    • "Our paper began by outlining some discontents surrounding the category of depression as a diagnostic term, and the associated mixed fortunes of antidepressants. While many doctors and patients are adamant that antidepressants are a useful treatment when used appropriately (Ridge, 2009; Hyde et al., 2005), doctors frequently have insufficient time to adequately explain their use and value, and questions around their effectiveness, morality and legitimacy continue. Our study examined this moral dilemma, and provides a unique multi-country narrative approach to the lived experience of antidepressant use, spanning the final decades of the 20th Century to 2012. "
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    ABSTRACT: Discontents surrounding depression are many, and include concerns about a creeping appropriation of everyday kinds of misery; divergent opinions on the diagnostic category(ies); and debates about causes and appropriate treatments. The somewhat mixed fortunes of antidepressants - including concerns about their efficacy, overuse and impacts on personhood - have contributed to a moral ambivalence around antidepressant use for people with mental health issues. Given this, we set out to critically examine how antidepressant users engage in the moral underpinnings of their use, especially how they ascribe legitimacy (or otherwise) to this usage. Using a modified constant comparative approach, we analyzed 107 narrative interviews (32 in UKa, 36 in UKb, 39 in Australia) collected in three research studies of experiences of depression in the UK (2003-4 UKa, and 2012 UKb) and in Australia (2010-11). We contend that with the precariousness of the legitimacy of the pharmaceutical treatment of depression, participants embark on their own legitimization work, often alone and while distressed. We posit that here, individuals with depression may be particularly susceptible to moral uncertainty about their illness and pharmaceutical interventions, including concerns about shameful antidepressant use and deviance (e.g. conceiving medication as pseudo-illicit). We conclude that while people's experiences of antidepressants (including successful treatments) involve challenges to illegitimacy narratives, it is difficult for participants to escape the influence of underlying moral concerns, and the legitimacy quandary powerfully shapes antidepressant use.
    Full-text · Article · Oct 2015 · Social Science [?] Medicine
    • "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.
    No preview · Article · Sep 2015 · Journal of Affective Disorders
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    • "Indeed, previous research has shown that little effort is used to form a second opinion on a patient’s problem when psychotropic drug treatment has been initiated by another doctor [15]. The dilemma of pressure from patients has been described previously [9,15-17], as has the difficulty in finding a balance between rational prescribing and consideration of each patient’s problems [16]. Recently, a hypothesis on emotional prescribing was formulated as an attempt to explain inappropriate or irrational prescribing, and the need for further research on this type of prescribing was emphasized [18]. "
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    ABSTRACT: Psychotropic drug prescribing is problematic and knowledge of factors affecting the initiation and maintenance of such prescribing is incomplete. Such knowledge could provide a basis for the design of interventions to change prescribing patterns for psychotropics. The aim of this study was to explore the views of general practitioners (GPs), GP interns, and heads of primary care units on factors affecting the prescribing of psychotropic drugs in primary care. We performed four focus group discussions in Gothenburg, Sweden, with a total of 21 participants (GPs, GP interns, and heads of primary care units). The focus group discussions were transcribed verbatim and analyzed using manifest content analysis. Three different themes emerged from the focus group discussions. The first theme Seeking care for symptoms, reflects the participants' understanding of why patients approach primary care and comprised categories such as knowledge, attitudes, and society and the media. The second theme, Lacking a framework, resources, and treatment alternatives, which reflects the conditions for the physician-patient interaction, comprised categories such as economy and resources, technology, and organizational aspects. The third theme, Restricting or maintaining prescriptions, with the subthemes Individual factors and External influences, reflects the physicians' internal decision making and comprised categories such as emotions, knowledge, and pharmaceutical industry. The results of the present study indicate that a variety of factors may affect the prescribing of psychotropic medications in primary care. Many factors were related to characteristics of the patient, the physician or their interaction, rather than the patients' medical needs per se. The results may be useful for interventions to improve psychotropic prescribing in primary care.
    Full-text · Article · Aug 2013 · BMC Family Practice
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