Family Practice Vol. 19, No. 1, 45-52
© Oxford University Press 2002
Original Paper |
Obstacles to effective treatment of depression: a general practice perspective
School of Health and Related Research, Public Health, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 5DA and
a Royal College of Psychiatrists Research Unit, London, UK.
Telford R, Hutchinson A, Jones R, Rix S and Howe A. Obstacles to effective treatment of depression: a general practice perspective. Family Practice 2002; 19: 45–52.
Received 5 March 2001; Accepted 3 September 2001.
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Abstract |
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Background. The Clinical Standards Advisory Group (CSAG) was asked by UK health ministers to advise on the standards of clinical care attainable for people with depression. The GP survey reported here is one part of a multicomponent UK-wide study of services for depression that also included visits to a sample of services and structured patient telephone interviews.
Objectives. The aim of this study was to survey GPs' perceptions of the availability and quality of primary and community-based services for people with depression, and to seek their views on barriers to the provision of good clinical services.
Methods. A structured postal questionnaire was sent to all GPs (3530) in the 11 geographical areas visited during the CSAG study.
Results. A total of 1703 (48%) GPs returned the questionnaire. The main obstacles to providing a good service for people with depression included not having enough time, a lack of services to refer to and difficulty in accessing services. More than half of the respondents (58%) were aware of guidelines for the management of depression, and 62% had attended a teaching session on depression within the last 3 years. Factors that influenced GPs to refer people with depression to other services were risk to the patient, a clear need for specialist treatment and the need for assessment. Overall, GPs appeared to be satisfied with the quality of specialist services.
Conclusions. GPs appeared to view obstacles to providing effective treatment of depression as being more allied to external issues, in particular service provision, rather than internal factors such as their own knowledge and skills. The study revealed continuing concerns over excessive workload, and longstanding difficulties with the interface between primary and secondary mental health services.
Keywords. Depression, general practice, GP, survey.
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Introduction |
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Depression is found commonly in the UK population, with up to 50% of attenders in general practice presenting symptoms of depression,1 of whom ~5% will experience major depression.2 The clinical picture is usually complex, with the co-existence of other mental health problems, psychosocial difficulties and physical health problems. There is growing evidence of high levels of associated social disability and limitations on daily functioning,3,4 with depression estimated to be the leading cause of years lived with a disability in the 1990s.5 Long-term outcome studies show that depressive disorders often recur, with chronicity reported in 25% of patients.6 Approximately 15% of people with major depression die by their own hand.7
It has been estimated that 80% of people with depression are treated entirely in primary care.8 Secondary care services are now clearly focused on people with severe and enduring mental health problems, and it is possible that there is reduced access to specialist mental health services for people with depression. Recent government policies to shift care from hospital services into primary care have given GPs greater commissioning power, but there is no agreement on the most cost-effective model of working at the interface. A recent Cochrane Review9 presented evidence of the short-term benefits of on-site mental health workers in primary care, either replacing primary care providers (‘replacement’ models) or providing collaborative care/support to primary care providers (‘consultation–liaison’ models). However, the results were inconsistent, and longer term studies were recommended to assess whether the effects endured.
The management of depression within general practice has changed recently, with a rapid increase in the provision of practice-based mental health workers, particularly counsellors. Concerns have been voiced about the variations in qualifications and professional accountability.10 Patients and GPs appear to value counselling approaches, but evidence of their effectiveness is sparse, as most studies are not generalizable due to methodological shortcomings. Nevertheless, findings from a randomized controlled trial of non-directive counselling, cognitive–behaviour therapy and usual GP care recently have endorsed the value of counselling in reducing symptoms of depression under standardized conditions.11 Both non-directive counselling and cognitive–behaviour therapy were significantly more effective clinically than usual GP care in the short term, though this was not sustained at follow-up 12 months later. Psychological treatments can be as effective as drugs in treating mild and moderate depression,12 but difficulties in accessing services and poor practitioner knowledge about when to employ psychological interventions may be a barrier to appropriate referral.13 Guidance in the treatment of depression is now more accessible.
In recognition of the importance and prevalence of mental health problems, the National Service Framework for Mental Health14 was one of the first National Service Frameworks to be published. It set out standards and models of treatment and care, and also performance assessment. Assistance in implementing the standards is developing.15 Clinical practice guidelines for deciding what factors to take into account when choosing a psychological therapy, and what therapy is most likely to help which patients, have been issued recently,16 and clinical guidelines for the management of depression have been commissioned by the NHS Executive.14
GPs spend a significant part of their time treating and supporting people with all types of depression. It has been reported that approximately half of those with clinically significant depression may not be recognized by GPs at the first interview.17 Furthermore, antidepressant prescribing is often not in line with consensus guidelines.18,19 It is therefore important to explore the perceived obstacles that GPs face in implementing best practice.
This study was undertaken as part of the Clinical Standards Advisory Group (CSAG) review of primary care services for people with depression.20 Its aim was to survey GPs' perceptions of the availability and quality of NHS depression services, and to elicit their views on barriers to providing good services for people with depression.
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Methods |
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Questionnaire design
A two-page questionnaire was developed to evaluate GP perspectives, based in part on that used in an evaluation of the Defeat Depression Campaign.21 A first draft of the questionnaire was commented on by 16 GPs and mental health professionals, and some poorly worded questions were discarded. Only minor revisions were made after pilot testing with 131 GPs. The questionnaire addressed the following issues:
- Perceived obstacles to GPs providing a good service to people with depression.
- Influences concerning decisions to refer people with depression to other services.
- Issues arising from referral to secondary services for people with depression.
- Methods currently used in general practice to treat depression.
- Awareness of guidelines for the management of depression.
- Information concerning secondary care services provided in general practice.
- Details of training in depression management.
No definitions were offered for ‘depression’ or ‘counselling’. A copy of the questionnaire is available at: http:// www.shef.ac.uk/~scharr/publich/pub/pub2002.html.
Sampling
The study involved 11 health authorities/health boards that included a mix of urban/rural and socially deprived/ privileged areas representing the range found in the UK. One health authority or health board was selected from each of the eight NHS regions in England and one each from Northern Ireland, Wales and Scotland. The areas were co-terminous with putative primary care groups and their equivalents in Northern Ireland, Wales and Scotland.
The survey sample comprised every GP in the 11 selected health authorities/health boards. Of these 3626 GPs (identified from a list provided by the Department of Health), 96 were excluded from the sample because they had retired, were no longer at that address, had emigrated or were deceased. The number of possible returns therefore was 3530. A first mailing of the questionnaire was undertaken in October 1998, with reminder questionnaires sent to non-responders in November 1998.
Data analysis
Analysis of valid responses was conducted using SPSS, version 6.0. Percentages were based on valid responses, and P-values are shown for chi-square tests and t-tests where results were statistically significant. Where possible, results were compared with the findings of an earlier large-scale survey of GPs conducted to evaluate the impact of the Defeat Depression Campaign.21
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Results |
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The number of questionnaires returned was 1703, giving a response rate of 48%.
Characteristics of respondents
Of the responders, 69% were male, and the average number of years since qualification for all responders was 19 [95% confidence interval (CI) 18–19]. Male GPs had a higher mean number of years since qualification (20 years, CI 19–20) than female GPs (16 years, CI 16–17) (t-test, significant value <0.001). The average practice list size was 8064 (CI 7870–8258). These figures are consistent with the GP population recorded by the Department of Health. 22
Over half of the respondents (62%) stated that they had attended a teaching session on the management of depression within the previous 3 years (a moderate increase from the 56% reported in the evaluation of the Defeat Depression Campaign),21 and 58% said they were aware of guidelines for the management of depression. Only 10% of respondents had training in a specific psychological/psychiatric intervention, although 46% had hospital experience in mental health care, with 34% having 6 months or more in the speciality (31% in the evaluation of the Defeat Depression Campaign).21
Obstacles to providing good services and referral decisions
GPs were asked to rate how frequently they encountered a variety of obstacles to providing a good service for people with depression (see Table 1
): not enough time emerged as a substantial obstacle, as did too much work. Other concerns were a lack of provision of services to refer to, and difficulty in accessing services. Risk to the patient and a clear need for specialist treatment were key factors which either very often or always influenced GPs' decisions to refer people with depression to other services (see Table 2). The two most problematic issues for GPs in referring to specialist mental health services were speed of response to referral and access to the preferred professional (see Table 3).
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Treatment approaches currently used in the practice
Not surprisingly, medication was cited as the most frequently used treatment (98%), followed by advice (92%) and counselling (85%). Some respondents reported that the following treatment options were unavailable: formal psychological therapies (14%), self-help groups (13%), self-help literature (11%) and counselling (7%).
Services from other professionals
The most frequently reported services provided in the practice by other professionals were counselling (58%) and mental health nursing services (41%). The least frequently reported were psychology (29%), psychiatry (23%) and social work services (15%). Responders were also asked to comment on the availability and quality of services outside the practice. They reported high levels of satisfaction with the quality of services from mental health professionals outside the practice, with mental health nursing being rated as OK/good by 95%, followed by psychology (92%), psychiatry (91%), counselling (90%) and social work services (81%). However, they reported poor accessibility to services: psychology (76%), counselling (65%), social work (57%), psychiatry (38%) and mental health nursing (33%).
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Discussion |
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This UK-wide survey provides pertinent information concerning the availability and quality of services for people with depression in primary care, which will be of interest to primary care groups/trusts (PCG/Ts) and those commissioning or providing services for people with depression.
The response rate appears to be similar to that of a recently reported large-scale UK GP survey: separate groups of researchers conducted postal surveys of random national samples of GPs in 1987, 1990 and 1998. The samples consisted of 1817, 917 and 1828 GPs, with response rates of 45, 61 and 49%, respectively.23 However, the findings should be interpreted with some caution as the response rate was low (48%). Although the study population represents one in 18 GPs in the UK, factors influencing response rate cannot be determined.
Too much work and lack of time to provide high quality care emerged as important factors in the survey. These issues are not new,23 and have also been reported for primary care practitioners in the USA.24 The need for treatment and assessment, and risk to the patient were powerful influences on referral. Tensions relating to competing demands were apparent, and the majority of GPs identified a lack of provision of services to refer to. There is widespread belief that the prevalence of mental health problems in the community is increasing, with consequent additional demands on the GP's time.25,26 These factors are compounded by mental health policy, which requires secondary care mental health services to focus their priorities on people with severe and enduring mental health problems. Lack of available services has been identified similarly as a barrier to referral to mental health providers in the USA.27
Over half the respondents (58.2%) provided practice-based counselling services, a higher figure than that previously reported.25,28 The continuing growth of counselling services has been attributed partly to a response by GPs to problems in securing prompt services for people in distress. No definition of counselling was offered in the survey, and it is possible that it was interpreted in different ways, or there could have been a response bias in the respondent sample.
There is now good evidence of the effectiveness of psychological therapies such as interpersonal therapy and cognitive–behavioural therapy, both as sole therapeutic interventions and as an adjunct to pharmacological treatment.16,29,30 Despite their therapeutic potential and recent guidance that psychological therapies should routinely be considered as a treatment option,16 they are seldom used by GPs, and limited availability appeared to be an issue in this study. Self-help literature and self-help groups were also employed infrequently. This finding is of interest in the light of a survey by Depression Alliance, which reported their members' preference for greater provision of counselling and psychotherapy, together with an increase in the availability of local self-help groups.31
The survey revealed considerable numbers of mental health professionals working in general practice. It was not an aim of the research to explore the models of assessment and intervention they brought to primary care, or the resulting benefits. Given this large investment of expertise, it is pertinent to clarify which working arrangements maximize the impact on services for people with depression. While guidance on implementing the National Service Framework for Mental Health is now becoming available,15 it is suggested that longer term studies are needed to evaluate the complex issue of clinical outcomes.9
Difficulties were reported in obtaining assistance from specialist mental health services outside the practice for people with depression, for both urgent and routine referrals. Speed of response, access to the preferred professional and timely information back to the primary health care team were all noted to be problematic. Access was particularly poor for psychology services, and counselling services were also hard to obtain outside the practice. The problems outlined above cannot easily be dismissed, particularly in relation to urgent referrals. Two of the seven standards in the National Service Framework for Mental Health14 relate to primary care and access to services, and there are specific directives to establish local protocols for depression. Many practices represented in the survey would clearly benefit from joint discussions with local specialist mental health services to develop shared protocols.
Despite the problems encountered with accessing services outside the practice, there was a high level of satisfaction with the quality of services provided by individual professionals. This contrasts with the finding that over half of GPs saw poor quality of services as an obstacle to providing a good service for people with depression. It appears that GPs differentiate between the quality of the service provision and the quality of the professionals within it.
Two years after the end of the Defeat Depression Campaign in 1996, most GPs were aware of guidelines for the management of depression, and the majority had attended a teaching session on this topic. There was recognition of the importance of training, as a high proportion identified lack of training as sometimes an obstacle in providing a good service. Implementation of evidence-based practice needs to take into account the realities of practice life, as well as individual practitioner styles and patient wishes.
Respondents appeared to view the challenge to provide good services to people with depression as more service dependent than related to their personal knowledge and skills. Clearly it is not possible, from the results of this survey, to know if this is an accurate interpretation. However, the findings provide valid evidence of the beliefs of a large number of GPs and their attitudes to barriers, which is of interest in itself.
In the face of high prevalence rate of depression, chronicity and recurrence, it is essential that available effective treatments, both pharmacological and psychological, are utilized discerningly and effectively. This is more likely to occur when GPs have good access to a wide range of adequately resourced health and social care services, which can be deployed flexibly according to the needs of individualized patient care.32 Clinical practice guidelines and local protocols can also assist in providing appraised research evidence and recommendations of best practice as an aid to decision making.14,16,20
The difficulties identified in this survey reflect longstanding problems with the interface between primary and specialist mental health services. The development of PCG/Ts, in the context of clearer evidence and guidance on effective treatments, offers a new opportunity to facilitate a collaborative approach to developing and implementing policies and protocols that should lead to better and more integrated services for people with depression.
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Acknowledgments |
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We thank all the GPs who took part in the survey. This work was undertaken by members of the CSAG Depression Research Team, which received funding from the Department of Health; the views expressed in this publication are those of the authors and not necessarily those of the Department of Health.
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