Family Practice Vol. 18, No. 1, 64-70
© Oxford University Press 2001
Psychological Problems |
Conceptions of depressive disorder and its treatment among 17 Swedish GPs. A qualitative interview study
Hermes Primary Health Care Centre, Säffle,
a Malmö University, Malmö and
b The NEPI Foundation, Malmö, Sweden.
Correspondence to Dr Stig J Andersson, Hermes Vårdcentral, Industrigatan 10, SE-661 33 Säffle, Sweden.
Andersson SJ, Troein M and Lindberg G. Conceptions of depressive disorder and its treatment among 17 Swedish GPs. A qualitative interview study. Family Practice 2001; 18: 64–70.
Received 4 January 2000; Revised 13 June 2000; Accepted 5 September 2000.
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Abstract |
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Background. Making clinical decisions for psychiatric patients in general practice is a complicated issue. A marked variation in the prescribing rates for antidepressant drugs in general as well as between geographical regions has been reported. Also, GPs tend to underestimate and undertreat depressive disorders.
Objectives. The aim of this study was to explore GPs' conceptions of depressive disorder and its treatment.
Method. A qualitative semi-structured interview was carried out on 17 GPs, selected to ensure variation of pre-conditions, in the county of Örebro, Sweden. Informants' conceptions about four depression-related issues were determined: the depressive disorder, antidepressant drugs, the treatment decision and psychotherapy.
Results. Conceptions of the four themes varied widely among informants in the interviews. However, the informants shared certain conceptions concerning the selection of drugs and drug treatment of major depression as well as the patient's role in deciding whether or not to treat pharmacologically.
Conclusions. The study adds knowledge of GPs' thoughts about depressive disorder and their diagnostic and treatment preferences. Utilizing the concepts discussed herein, a quantitative study will be conducted to analyse how GPs' conceptions of depression are inter-related.
Keywords. Antidepressant drugs, conceptions, depressive disorder, GP, treatment decision.
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Introduction |
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Making clinical decisions for psychiatric patients in general practice is a complicated issue. There are grey zones where evidence about the risk–benefit ratios of competing treatments is incomplete. In many situations, a clinician's work may be described as educated guesswork.1 Studies also report that GPs frequently do not detect depressive states, tend to under-treat depression and fail to take up evidence guidelines in the area of depression.2–8 Moreover, prescribing rates for antidepressant drugs differ markedly among individual GPs and between geographical regions according to reports.9,10
For these reasons, the present study aimed to explore GPs' individual conceptions of depression and its treatment.
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Methods |
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In order to capture a broader scope of ideas, the authors of this study created a semi-structured interview schedule based on a set of open questions (Appendix). The questions encompass four sections of the research area: the depressive disorder, antidepressive drugs, the treatment decision and psychotherapeutic treatment. Every informant was able to interpret the questions in his/her own way. Thus, different aspects of the query arose out of the informants' answers. The interview questions themselves were principally the result of the interviewer's understanding of the research field. The interviewer has long experience as a GP and a special interest in psychiatric issues within the practice of family medicine.
During the interview, the interviewer did not attempt to govern the informant but to encourage the informant to clarify his/her own thoughts using follow-up questions. The interviews were tape-recorded and transcribed verbatim. All interviews were conducted and transcribed by one of the authors (SJA). The study was first approved by the regional research ethics committee before being conducted.
Data analysis
The dialogue texts constitute the database. They were scrutinized by one of the authors (SJA). All statements pertaining to GPs' conceptions of depressive disorder and its treatment were selected as examples of conceptions in the form of dialogue excerpts. A conception is presumed to be a fundamental notion with components of personal experience, actual ideas and cultural descent.11
Conceptions of a similar kind held by different informants were grouped together into categories, referred to as ‘categories of conceptions'. They were formulated in accordance with the common essence in the conceptions they represent. Most of them are categories of attitudes or intentions, while others are descriptions of performances. These categories of conceptions constitute the result of the study. Lastly, the categories were grouped according to different aspects of the main issues in each section of the interview. Conceptions of a specific phenomenon appearing in different parts of the interview are grouped together in the Results section.
Sample selection
In order to achieve a breadth of response, we looked for male and female GPs of different ages working both in urban and rural areas as well as in different forms of primary care. Using a list of all the 130 GPs working in the county of Örebro, we selected 17 informants, eight women and nine men aged 40–60 years. Three of the physicians selected had to refuse due to lack of time and were replaced by three others. Fourteen of the GPs chosen were employed by the county council and three were in private practice. About half of the GPs worked in the city of Örebro (population 130 000). The others practised in smaller communities. Two were immigrants. All but one of the informants were unknown to the interviewer. The interviews were performed between August and November, 1997.
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Results |
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The informants' conceptions are grouped into categories and presented in the four tables, one for each section of the research area. To illustrate the character of the categories, a few quotations of the underlying conceptions are given as footnotes to the tables.
Table 1
presents conceptions of the depressive disorder. A majority of the informants expressed the conceptual categories "The borderline between health and illness is not distinct" and "There are patients who are generally unwell but not depressed in a proper sense". Several also had conceptions of causes of depression expressed in the three categories "Different causes act together in a complex and obscure way", "Some depressions have organic causes" and "External overload is the most common cause".
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All informants comprised the category "Women consult doctors more often than men". However, there were also conceptions forming the categories "It is not certain that depression is more common among women" and "Male depression patients are often in a more serious state than female".
Table 2 includes conceptions of antidepressant drugs. All informants expressed the categories "Antidepressants are important requisites in the clinical work" and "Patients with major depression should be given antidepressants". The same was true for "SSRIs are chosen in the first place because of fewer side effects" and "The introduction of SSRIs has influenced the informant's readiness to prescribe". Conceptions of the current increase of prescribing divided the informants into two equal groups, one positive to the increase, the other sceptical against it. A number of informants asserted that antidepressants should be prescribed only in cases where a depressive illness could be diagnosed, while others declared that antidepressant prescribing does not follow the borderline between health and illness. Most informants conceived that introduction of SSRIs had not moved that borderline.
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Table 3
exposes conceptions of the clinical decision process. A minority of the informants reported sporadic use of a depression rating scale or a checklist of diagnostic criteria. All informants expressed agreement that "The patients must have the opportunity to take his/her part in the treatment decision". That commitment to patient-centred care seems limited by conceptual categories such as "The doctor him/herself must be convinced of a treatment to propose it" and "The patient may be too ill to be able to make a decision". The informants held different conceptions of patients' reluctance towards antidepressant treatment. Frequent conceptions expressed the category "Reluctance towards antidepressant treatment is not uncommon". Other conceptions were in the category "Most patients who are reluctant about drug treatment will change their minds after some more consultations".
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Table 4
comprises conceptions of psychotherapeutic treatment. All informants shared the conceptual category "For patients with major depression, psychotherapy cannot replace drug treatment". However, the informants had diverging conceptions of the need for psychotherapy and differed in their attitudes to that form of treatment. A number of informants made known their lack of access to psychotherapy. However, GPs' views of follow-up of their patients as a form of psychotherapeutic treatment were common.
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Discussion |
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Method considerations
In order to obtain greater knowledge about the informants' conceptions of depressive disorder, we chose to adopt a qualitative approach in this study.12–14 However, this approach has its uncertainties and must be conducted with these uncertainties in mind. For ex-ample, the credibility of the interviewer increases if the informants feel confidence in him/her.15 In the present study, the interviewer's position as a colleague of the informants with a shared knowledge and interest in their field may have increased such credibility. The risk in such a relationship, however, is that it may create a case of shared conceptual blindness, allowing the interviewer's own feelings and opinion about the field to govern the dialogue and interpretation.15,16 The rather detailed interview schedule might add a similar risk. The semi-structured approach was employed to achieve a broad range of conceptions, but it could have been too governing and thereby not encourage original thought sufficiently.
Another possible weakness of this study lies in the fact that only one of the authors of this study (SJA) examined and analysed the interviews. The results of the interviews might have been more conclusive had all three of the study's authors been involved in the analysis stage.15
The interview sample ought to represent most of the presumed variation in conceptions of depressive disorder and its treatment. Malterud recommends 15–25 informants in qualitative interview studies.16 Given our sampling procedure, we believe that the 17 interviews conducted reveal a sufficient variation in conceptions.
Conceptions shared by all informants
The informants' unanimous belief in the selection of drugs and the necessity for drug treatment is in accordance with their shared professional education. Their common conceptions regarding gender distribution and the treatment of major depression are consistent with results from epidemiological studies and evidence-based recommendations, respectively.17–19 However, their uniform belief in the advantages of selective serotonin re-uptake inhibitors (SSRIs) over triclyclic antidepressants (TCAs) is not supported by scientific documentation. On the other hand, the Swedish authority for drug control, Medical Products Agency, has officially recommended SSRIs for the treatment of depression in primary care cases.19
Depressive disorder
Conceptions about the depressive disorder varied widely among the informants. Most of them were reluctant to view depressive states as illnesses unless such a state was perceived as a major depression. Accordingly, informants perceived the borderline between health and illness as problematic.
Most of the informants had multiple conceptions of the causes of depressive disorder. The relatively uniform conceptions held about the use of antidepressants seemed independent of both common and individual conceptions of illness and health.
Drug treatment
Although all informants considered antidepressants important and had increased their antidepressant prescribing rates, some of them expressed scepticism about the current increase in antidepressant prescribing. This scepticism appears to mirror a corresponding uncertainty about the correct criteria for diagnosis and treatment. It is also consistent with the reported lack of recognition of depressive states in patients treated by GPs.3–6 Such uncertainty can be explained by the results of one study showing diverging attitudes between GPs and psychiatrists about the identification and management of depression20 as well as another study reporting that GPs undervalue psychiatrists' recommendations when determining a course of antidepressant treatment.3
The decision to prescribe
The majority of this study's informants work according to the traditional clinical method without the aid of depression rating scales. This is consistent with other studies of clinical decision making.1,21 Furthermore, most informants viewed the decision to prescribe as the joint responsibility of physician and patient, as expressed in theories on patient-centred consultations.22
A physician's decision to prescribe and the choice of drug can be considered as a ‘core' judgement, and is strongly influenced by the importance of the diagnosis.23 The informants' unanimous conception that major depression should be treated with antidepressants demonstrates their conception of major depression as an important diagnosis.
Several informants reported reluctance among their patients to use antidepressants and the need for several consultations before this reluctance was overcome. An investigation of the attitudes of the general public towards depression confirms this scepticism.24 Furthermore, the informants' difficulties in making a decision to treat with antidepressants are consistent with documentation showing that GPs' actions are strongly influenced by their patients' expectations and anxieties about the presenting problem.25,26
GPs have to balance prescribing criteria against their patients' reluctance and expectations of other measures as well as an often complex clinical situation with multi-morbidity.23–27 The informants' difficulties in deciding in depression cases may illustrate the observation that high task complexity causes doctors to shift from an analytical to a non-analytical decision-making strategy.27,28
GPs' alleged under-treatment of depressive states may be a consequence partly of the sceptical attitude towards drugs reported among patients in primary care. Moreover, the majority of the studies of antidepressant prescription were made by psychiatrists or psychologists. The profession of the researcher may have significance due to a difference in attitude between GPs and psychiatrists. GPs have been reported as having fewer biological conceptions of the nature of depressive disorder and more confidence in the power of psychotherapy than psychiatrists. This, in turn, may lead to a reluctance to prescribe drug treatment.20 However, there is a wide variation in rates of antidepressant prescription among psychiatrists as well as GPs.20,29,30
Concluding remarks
The present study, designed to reveal GPs' conceptions of depressive disorder and its treatment, showed a wide variation of conceptions among participating GPs. It may be assumed that the variation is even greater among GPs in general. The participating GPs (the informants) shared certain conceptions, predominantly dealing with selection of drugs and issues around drug treatment and the role of the patient in a treatment decision.
Due to the small sample size, this study is not appropriate for generalizing quantitative statements or analysing the relationships between conceptions. However, knowledge of how the conceptions are inter-related is essential to understand GPs' diagnostic and treatment preferences and thereby also for planning training and practice. Therefore, utilizing the concepts revealed by the present study, a quantitative study of how GPs' conceptions of depression are distributed and interrelated will be performed.
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Appendix |
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References |
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1 Nayler CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet 1995; 345: 840–842.[Web of Science][Medline]
2 Bodlund O. Anxiety and depression go unrecognised in primary care. (In Swedish with summary in English.) Läkartidningen 1997; 94: 4612–4618.[Medline]
3 Matthews K, Eagles JM, Matthews CA. The use of antidepressant drugs in general practice. Eur J Pharmacol 1993; 45: 205–210.
4
Orrell M et al. Management of depression in the elderly by general practitioners: use of antidepressants. Fam Pract 1995; 12: 5–11.
5 Rosholm J-U et al. Antidepressant treatment in general practice—an interview study. Scand J Prim Health Care 1995; 13: 281–286.[Web of Science][Medline]
6
Wells K et al. Use of minor tranquillizers and antidepressant medications by depressed outpatients: results from the medical outcomes study. Am J Psychiatry 1994; 151: 694–700.
7
Kendrick T. Why can't GPs follow guidelines on depression? We must question the basis of the guidelines themselves (Editorial). Br Med J 2000; 320: 200–201.
8 Thompson C et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000; 355: 185–191.[Web of Science][Medline]
9 Pharoah P, Melzer D. Variation in prescribing of hypnotics, anxiolytics and antidepressants between 61 general practices. Br J Gen Pract 1995; 45: 595–599.[Web of Science][Medline]
10 Burman K, Wessling A. Svensk läkemedelsstatistik 1997 (Drug sales in Sweden 1997. In Swedish and English). Stockholm: Apoteket AB, 1998; 184–186.
11 Dahlgren LFM. Phenomenography as a qualitative approach in social pharmacy research. J Soc Admin Pharm 1991; 8: 150–156.
12
Britten N et al. Qualitative research methods in general practice and primary care. Fam Pract 1995; 12: 104–114.
13
Green J, Britten N. Qualitative research and evidence based medicine. Br Med J 1998; 316: 1230–1232.
14
Faltermaier T. Why public health research needs qualitative approaches. Subjects and methods in change. Eur J Publ Health 1997; 7: 357–363.
15
Hamberg K et al. Scientific rigour in qualitative research—examples from a study of women's health in family practice. Fam Pract 1994; 11: 176–181.
16 Malterud K. Kvalitative metoder i medicinsk forskning en innforing. (Qualitative Methods in Medical Research—An Indroduction. In Norwegian). Oslo: Tano, 1996: 30–63.
17 Cafferata GL, Meyers M. Pathways to psychotropic drugs. Understanding the basis of gender differences. Med Care 1990; 28: 285–300.[Web of Science][Medline]
18
Klerman G, Weissman M. Increasing rates of depression. J Am Med Assoc 1989; 261: 2229–2235.
19 Anonymous. Workshop om depressionsbehandling (Workshop on treatment of depression. In Swedish). Information från läkemedelsverket 1995; 6: 309–322.
20 Kerr M, Blizard R, Mann A. General practitioners and psychiatrists: comparison of attitudes to depression using the depression attitude questionnaire. Br J Gen Pract 1995; 45: 89–92.[Web of Science][Medline]
21
Dawes R, Faust D, Meehl PE. Clinical versus actuarial judgement. Science 1989; 243: 1668–1674.
22 Pendelton D, Schofield T, Tate P, Havelock P. The Consultation. An Approach to Learning and Teaching. Oxford General Practice Series No. 6. Oxford: 1984.
23 Davis P, Yee RL, Millar J. Accounting for medical variation: the case of prescribing activity in a New Zealand general practice. Soc Sci Med 1994; 39: 367–374.
24
Priest RG et al. Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. Br Med J 1996; 313: 858–859.
25
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations —a questionnaire study. Br Med J 1997; 315: 520–523.
26 Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients' expectations and doctors' actions. Br J Gen Pract 1994; 44: 165–169.[Web of Science][Medline]
27 Bradley C. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners. Br J Gen Pract 1992; 42: 454–458.[Web of Science][Medline]
28 Chinburapa V, Larson LN, Brucks M, Draugalis JL, Bootman JL, Puto C. Physician prescribing decisions: the effects of situational involvement and task complexity on information acquisition and decision making. Soc Sci Med 1993; 36: 1473–1482.
29
Meridith L, Wells KB, Camp P. Clinician speciality and treatment style for depressed outpatients with and without medical comorbidities. Arch Fam Med 1994; 3: 1065–1072.
30 Olfson M, Pincus HA, Sabshin M. Pharmacotherapy in outpatient psychiatric practice. Am J Psychiatry 1994; 151: 580–585.[Abstract]
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