Background
Methods
Subjects
Diagnostic categories1
| Number of patients (N) | (%) |
---|---|---|
No current disorder | 4 | 20 |
Subthreshold Depression2
| 14 | 70 |
Major Depression | 2 | 10 |
Dysthymia | 2 | 10 |
Depressive Personality Disorder | 2 | 10 |
Panic Disorder | 3 | 15 |
Social Phobia | 1 | 5 |
Bulimia nervosa | 1 | 5 |
Hypochondria | 1 | 5 |
Instruments
Analysis
Results
General Practitioners | Patients |
---|---|
Proceedings (19)
a: |
Presenting behaviour (20):
|
Making somatic examination (11) | Presentation of somatic symptoms (11): |
Questions on possible psychological causes for symptoms (8) | - Heart complaints/stabbing chest pain (4) |
Using depression criteria (6) | - Thyroid dysfunction (3) |
Making an indirect anamnesis by asking family members or including information about the patients' biography (5) | - Pain (head, limbs) (2) |
Watchful waiting (5) | - Diabetes (1) |
Referring patients to specialists (2) | - Hypertension (1) |
Observation of nonverbal behavior (e.g. body language) (2) | - Overweight (1) |
Using a depression questionnaire (1) | - Fatigue (1) |
- Sleeping problems (1) | |
- Vertigo (1) | |
Diagnostic problems (17)
| Presentation of psychological complaints (9): |
Yes (6): | |
- Time consuming psychological diagnosis (1) | - Overstrain by family or work problems (4) |
- Financial losses because of time consuming psychological diagnosis (1) | - Depression/depressiveness (3) |
- Differential diagnosis of Depression, Parkinsons' and Alzheimers' disease in older patients (1) | - Sleeping problems (3) |
- Fear of overlooking Depression (1) | - Agitation (2) |
- Decision if somatic symptoms are actually caused by Depression (1) | - Feeling low (2) |
- Being sure if the patient really suffers from Depression, detection of Depression (1) | - Anxieties (2) |
No (11) | - Nervousness (1) |
- Loss of zest for life (1) | |
- Loss of drive and energy (1) | |
- Fatigue (1) | |
Satisfaction (16):
| |
Satisfied with diagnostic proceedings (11) | |
Not satisfied with diagnostic proceedings (5) for following reasons: | |
- Missing information about diagnosis and its causes (3) | |
- Feeling of not being taken seriously (1) | |
- No application of concrete measures, such as questionnaire (1) |
General Practitioners | Patients |
---|---|
Applied treatments (18)
a: |
Expectations (17):
|
Therapeutic talk and psychopharmacological medication (14) | Be listened to, conversation about the problems, be taken seriously, sympathy (10) |
Mainly supporting therapeutic talk (7) | Suggestion of concrete treatments (5) |
Mainly psychopharmacological medication (3) | - Medication (3) |
- Referral to psychologist (1) | |
- Symptom relief (1) | |
Advice how to deal with symptoms (2) | |
Topics of conversation (13):
|
Treatment Preferences (20):
|
Possible individual causes for depression (6) | Psychotherapy (6) |
Relaxation techniques (1) | No Psychotherapy (4) |
Psychoeducation (1) | Psychopharmacological treatment (4) |
Activation (1) | No pharmacological treatment (6) |
Reduction of excessive demands (1) | |
Resource orientation (1) | |
Self-worth enhancement (1) | |
Concrete behavioural advises (1) | |
Treatment problems (18):
|
Satisfaction (20):
|
Yes (10) | Satisfied with treatment (14) |
- Patients' refusal of pharmacological therapy or non-compliance (5) | Not satisfied with treatment (6) for following reasons: |
- GPs' insecurity with pharmacological treatment (3) | - Not enough time (2) |
- Motivating the patient to use offers for counselling or psychotherapy (3) | - Insufficient communication between GP and practice nurse (1) |
- Insufficient efficiency of treatment (3) | - Not taking somatic complaints seriously and not offering special treatments such as physical therapy (1) |
- Patients' acceptance of the diagnosis (2) | - Not taking presented complaint (fatigue) seriously and not offering concrete treatment besides exercising (1) |
- Problems with appointments for referral (2) | - Not addressing depression in more detail, e.g. by applying a questionnaire (1) |
- Heightened utilization of primary care (2) | |
- Personal strain due to insufficient efficiency of treatment and perceived lack of competence (2) | |
- Lack of time (1) | |
- Financial losses because of time consuming psychological diagnosis (1) | |
No (8) |
Clinical significance of subthreshold depression in primary care
"I think that the clinical significance is high because patients do suffer from the symptoms. They have a relatively high psychological strain, which they may not be aware of, that it is caused by depression or depressive mood." A15"It's significant because it leads to secondary diseases. I mean, everyone is depressive every now and again, often it's a natural mood swing, but when this isn't recognized as depressive, symptoms often tend to worsen and lead to psychosomatic complaints" A14
"Let's put it this way, I don't think that mild forms of depression are extremely serious...I can't always tell if it is depression, often it's stress, overwork, problems in the workplace and so on." A6
"I don't find this to be a very big problem because I think that quite a lot of patients have mild depressive episodes. I don't think that this is a very relevant clinical symptomatology – feeling a little bit low from time to time. I don't think that this is therapeutically relevant. I don't have the impression that this merits treatment." A9
Diagnosis
GPs
"I also do that to reassure or calm the patient down. The patient is often afraid of having some serious illness and has to be reassured from the outset. They need to hear that "technically" everything is ok and that the instruments show that. And then I just ask. I think that it is not very difficult for the GP because he knows the patients' living conditions." A2
"...You have to try to find something out about the conditions the patient is living in, whether there are problems at work or private problems. You have to develop a sense for that...I ask the patient if there might be something different in the background, problems with the relationship, at work or with the family." A15"Whenever possible I try to take a lot of time for the anamnesis and normally I know the patients living conditions. These patients are primary care patients and I often see the whole family. I may know their friends and I often have background knowledge about things the patient doesn't want to talk about at first. That makes it easier to find out about a psychogenetic factor." A4
"Well, first of all I make a somatic examination, because that's why the patient consults me, he primarily presumes to have a somatic disorder and this needs to be clarified. And depending on how well I know the patient – if I am seeing him for the first time, I wait for about 2 or 3 consultations until we have gotten to know each other – you talk about his career or family and then if I determine there is no evidence of a somatic disorder I will say that I think that there is a connection between the problems the patient talks about and the somatic symptoms. I will say something along the lines that it is really stressful with the kids or being out of work and so on...often the patients are not aware of this and when I directly address this I find that most of them say "well you're actually right". A10
"...There are a few patients who have subthreshold depression on and off. These are momentary disorders which remit relatively quickly and I don't treat them pharmacologically. We talk about it and I tell them to come again in 1, 2, 3 weeks time in order to see how they are and in most cases its fine. If it is a major depressive episode, I will recognize it then. That's why I invite them in again and ask them how they feel." A12
"...I attach great importance to seeing the patient come in and having the opportunity to assess the patient's body language can prove valuable. I think that a large part of the diagnosis is done before the patient sits down. Of course this depends on how long you have known the patient for...With depressive patients, the body language is often muted or reduced." A3
"Well, yes, being certain is a problem. First, I have to arrive at the point where I actually suspect a depression. I don't know in how many patients I detect an existing depression. I often suspect depression but I have to admit that I don't always address this. If a patient comes to me and talks about exhaustion then I wouldn't always immediately say it is depression. I often class it as a kind of burn-out and go on to ask the patient about resources. So, on the one hand, the problem is how many patients with depression I actually detect and on the other, it is 'if I detect it, how can I communicate that to the patient'." A16
"It is definitely a problem that many patients present somatic complaints and other misleading symptoms and it is indeed difficult to find out if there is a covert depressive syndrome in the background." A1
"I don't really have problems with diagnosing these patients. But it can be very difficult to guide them to a place where they can accept that they do actually have a problem with depression when they are experiencing migraine or irritable bladder symptoms or something like that." A2
"Further problems? No. Because, once I speak with the patient, I can go on using the depression criteria." A1
Patients
"I usually don't talk about mental problems, I'm just not that kind of person. I would rather say to him that I'm aching all over and that I can't sleep." P8"Lately, I've been talking to him about mental problems. I told him that I have problems sleeping, that I lost zest for life, that my anxieties worsen and that I sometimes don't want to get up." P17
"I told him that I can't sleep at night, that I suffer from depression and from being lonely." P16"Well, I said to him that I'm always quite nervous, that I couldn't sleep, and that I was upset and depressed – always quite depressed." P6
"Well, if I go to the doctor he of course asks what the problem is, but the thing is that you don't really talk about depression. When I have the flu, I can say that my head aches or my throat hurts or something like that, but with something emotional I can't really say what hurts. There is something deep inside that hurts and I can't really talk about that." P3
"Well, I think that for me everything went as well as it could. I don't have any reason to say that anything should have or could have been better. She arranged the therapy for me, she detected my depression without me having to directly address it..." P4
"I wished he would have taken me more seriously and not have told me to exercise more frequently. I work all day long and still feel beat-up." P10
"Well, actually it was not that important to me that she didn't specify my complaints with a diagnosis. Sometimes I think its better you don't label it that clearly." P2"She said its stress and exhaustion. If she had told me it's something depressive, I would have thought "I'm not nuts", because that's what you first think." P4
"Well, I would have appreciated being told what the doctor diagnosed, what it is. He always said "psychosomatic disorder" or something like that. But I would have really been interested in what is it and why." P6
"He sometimes said that this is depression but I wasn't sure. And I didn't need or find it necessary to be told that – in fact, most of the time I would rather not hear it." P11
Treatment
GPs
"I mainly treat them with supporting talk. I use medication when the patients suffer from sleeping problems or if the symptoms they experience are causing real discomfort of distress. But I always combine that with talking about the problems." A10"The most important is the therapeutic talk. I use pharmacological treatment partly to bring about relief but also to show, by way of the symbolic application of medication, that it is a disorder that should be taken seriously and that can be treated..." A19"Well, talking to the patient a few times, giving him information and sometimes, in cases of subthreshold depression, also treating him herbally with St. Johns' wort. I don't go any further without having a diagnosis from a specialist. If the specialist says, it's a full-blown depression and gives me a treatment recommendation, I follow that." A12"Well, I have an authorization for basic psychosomatic care, so I use therapeutic talk or refer to a psychotherapist, but I also give medication, maybe St. John's wort or a mild antidepressant and before that I examine whether the estrogen situation might be the cause." A2
"Well, regarding medication, there are so many possibilities that, to be honest, I regularly experience the problem of knowing just where to start." A4Despite these problems, some of the GPs have developed a clear strategy for dealing with these patients:"...when patients fulfill criteria for depression it doesn't always mean that they are in need of treatment, in the sense of antidepressant treatment. Often, I'd say in 50% of cases, talking to the patient is enough, making him aware that he is experiencing a depressive mood, and then the patient finds a solution for the situation by himself." A1
Patients
"I didn't have any special expectations. I just wanted to talk to someone I completely trust and who listens to me." P13"Sometimes I think, because one has the notion that a GPs knows how to deal with everything, that sometimes you hope that he just listens and sees the other side of the person, not only the somatic side." P8
"Well, I think you always expect that the doctor will be able to help you almost immediately, that she can give you a 'magic pill' that makes everything disappear. You think you go to the doctor and that settles the matter – I know this isn't the case but she takes a lot of time and always tells me that I can come again and again even if it's just for talking." P17
"Well, I actually wanted to have psychotherapy." P14"Well, yes, he talked to me about giving me tablets or something. But I have to say that I disapprove a little bit of taking pills...I'm more interested in psychotherapy." P11
"I was very satisfied. She was very understanding. She really is very warm-hearted and very nice and maybe it's because we've known each other for many years, I'm one of her first patients and she got to know me during a completely different time when I was in a completely different state. We got along very well and I could always rely on her not least because I had the impression that she didn't try to keep the patient to herself but was happy to refer to specialists as well, that is one of her strengths..." P4
"Well, sometimes I wish she had more time. Sometimes I wanted to tell her something but was unable because she was so pressed for time." P17"The only thing that occurs to me is that when I've been talking to her and she has told me "I will give you this and that to take with you" the practice nurses often don't know what she has said and this breakdown in communication can cause problems... I would sometimes appreciate it if I didn't have to remind them again." P2