Background
Methods
Aim
Design and setting
Sampling and recruitment
Individual GP Characteristics (n = 28) | |||
Female (%) | 14 (50) | ||
Median age (range) | 43 (33 to 60) | ||
Years since qualified as doctor, median (range) | 19 (10 to 37) | ||
Years as a GP median (range) | 12 (2 to 33) | ||
Number of GPs with psychiatry training as part of GP training rotation (%) | 19 (68) | ||
Number of GPs with extra psychiatric training/experience as locum or psychiatry trainee (%) | 4 (14) | ||
Individual practice characteristics (n = 20) | |||
Antidepressant volumes in DDD/1000 patients, n (GPs) | Low = 9 (10) | Medium = 4 (6) | High = 7 (12) |
Number of GP partners, n (GPs) | Small (single handed) = 1 (1) | Medium (2-3 GPs) = 10 (13) | Large (≥4 GPs) = 9 (14) |
Deprivation, n (GPs) | Low = 6 (6) | Medium = 5 (7) | High = 9 (15) |
Training practice, n (GPs) | Yes = 10 (16) | No = 10 (12) |
Data collection
Analysis
Ethical approval
Results
Depression diagnosis and management
Diagnosing depression
…the bottom line for GPs is that we want to help, we want to offer something that we think will help. D12,8
You also want to look at the person as a whole and find out where they are in their life. You have to assess the actual severity of the situation before determining what kind of treatment would be appropriate for them. Then, we would go down the route of discussing what sort of therapies we could offer them. D25,6
…for a lot of people with a mild to moderate depressive illness, is to say, “you might not need anything here. You might just need, someone to talk to you about it and some support and things might improve on their own.” D12,96
They think they’re coming here [pause] for me to do something for them [empathetically said]. And that, they almost feel as if there needs to be a physical display of that, like the prescription or whatever. D2,14
More than drugs
I explain to them that, “You have to look at this [responding to an antidepressant] in conjunction with other things.” So, it’s always going to be a multifactorial approach. It’s never going to be just one thing [an antidepressant]. D28,28.
Patients’ expectations and characteristics
I think most of my colleagues here wouldn’t prescribe unless they felt somebody was going to get benefit from them [antidepressants]. We all kind of have roughly the same sense of what’s bad and what’s good. D4,24
I think there’s an expectation generally, that if there is a problem perhaps you know there is a pill for it. I think that is an expectation that’s held by a lot of people. Other people are very resistant to the idea of taking antidepressants. D18,6
GP experience and relationships
I think initially absolutely with guidelines and I guess, as I alluded to before, the more experienced I’ve got, the more idiosyncratic I’ve got. It tends to be how a patient’s presenting, so it might be side-effects or likely side-effects or beneficial side-effects that may guide me on where I would go [with treatment]. D24,20
We’ve got our in-house pharmacist, and it’s fantastic, ‘cause we sit down and talk about these things... For example, with venlafaxine slow release people, we’ve changed all of them [to lower cost ordinary release], and we resisted pressure from secondary care and patients as well. So that’s definitely a positive influence. Because we’re not pharmacists, and we don’t know nearly as much about pharmacology as pharmacists do. D26,129
The other issue is prescribing antidepressants in young people. We won’t prescribe antidepressants that are unlicensed in young people. We won’t prescribe them in people under the age of 18 because there is no shared-care protocol. Unfortunately, without the support of shared-care protocol we don’t feel really we have the specialist knowledge to be prescribing it much for [children and adolescents]. D25,29 We’ve been asked to prescribe sertraline and fluoxetine, I think, in people around about age 15. Both of which we’ve refused. We’ve refused all of them. The issue then is that they feel that once they’ve initiated it we should take over the prescription. But because there’s no shared-care protocol it still leaves us fairly vulnerable. So, we have still decided as a partnership that we won’t be involved in that…D25,31
Well... escitalopram really pissed me off, I hate that sort of carry on, it was like loratadine and desloratadine, I just hate that! I mean ‘me-too’ drugs that happen to appear just as patents are running out and are another way of creaming money out of the unsuspecting public,… D21,70…there was the Defeat Depression campaign and that was the Royal College. But the Royal College and GPs really got into tow I think with pharma in a big way, and I think actually that was probably fairly influential but,… pharma were probably being very very clever there, and more subtle than usual. I would say…people get quite well develop antibodies to pharma now. So they actually probably have to work harder to convince me… But they are more subtle, and they have subtle links. D18,23
I think that the media give quite a muddled view on things. They all seem to be reporting the celebrities who are getting treatment or counselling for this, that and the other. And, then, on the other hand, they bash GPs for overprescribing antidepressants like sweeties.D3,20
Antidepressant use: safety, risk management and effectiveness
Drug choice
You aim to certainly do it [prescribe] in partnership with the patient. At the end of the day, if you don’t do it in partnership with them and you prescribed it, then they won’t take it anyway, so you do it in partnership with the patient. …based on advice, guidelines. I think there is an element of doing what you believe is the right thing from your own experience. D8,22
They’re safer. So, no one in their right mind now is going to give an MAOI if you’re a GP. There’s no good reason to start a tricyclic rather than an SSRI unless you’d been through a few of them [antidepressants] already. You know, there’s far less risk from a GP’s point of view in terms of overdosing, in terms of side effects from the medication. D22,33
…well I know that it’s a funny drug [mirtazapine], because it’s supposed to be only sedating at low dose, because it has the antihistamine effect. We use it a lot at 15mg just for the sedating effects, as a non-addictive sleeping pill, really. D26,39
Well that’s one of the places I have been influenced by secondary care. Because a lot of the psychiatrists say, we’re going to add this to augment the effect of this. It’s usually mirtazapine and citalopram together. And I actually do think that works, I’m not quite sure the biochemistry behind that. But... erm, I now do that sometimes myself. It’s often for the poor sleepers. D26,65
SSRI efficacy: time to effect and dose response
Keep them on... probably quite some time, 2 or 3 months, and if they weren’t responding, then change. D17, 50
As we know the response to higher doses doesn’t grow, you know, parallel to the increasing dose. So, if we get a good response to the first dose... doubling the dose to, a higher dose doesn’t always make a big difference. That’s our clinical experience. D6,44
…when you’ve got a patient, a desperate patient in front of you wanting something to be done, it’s the temptation is to crank up the dose. Again, one of my colleagues will go up to much higher doses of fluoxetine than, than perhaps the rest of us would. D3,60
SSRI efficacy: use of higher SSRI doses for depression treatment
I think there’s two of us in the practice seeing more people who have got psychological problems. I would then however suspect that others might prescribe more antidepressants per head if you know what I mean. Whereas I would be more interested in trying alternatives to antidepressants. D18,26
I suppose if you’ve got somebody that goes through crisis and they’re on a drug anyway for a long time, every time they have a crisis the dose might be bumped up and then not reduced. So, I wonder if there’s an element of just not reducing the drug when it’s appropriate... and patients psychologically seem to be quite dependent on these drugs as well. So, they might want that increased dose too. D10,93
…it is probably if you’ve got somebody who’s on long-term benzos it suggests they’re not very well. There’s long-term issues there. …probably most of those issues are not going to be dealt with by a drug. D24,74