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Rapid Responses: Rapid Responses published:
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Depression management clinics in general practice
- Danny Allen (28 February 2000)
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Concentrating on similarities of disease management
- Chris Manning (13 March 2000)
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Flawed argument
- Richard Churchill (24 March 2000)
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Danny Allen
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Dear Editor I would like to endorse Tony Kendrick's call for depression management clinics in general practice (BMJ 320, pp 527-528). When I was a GP Trainee I set up an Asthma Clinic (How to set up a Nurse-Run Asthma Clinic.Horizons [1990]. Vol 4, 6, 332-335) and thus have some experience of the concept. I agree with everything which Professor Kendrick says about the management of depression in general practice. As a psychiatrist now, I believe that many GPS lack confidence in treating this extremely common and debilitating condition. Many referrals come at the same time as the first prescription of an antidepressant for example. Similarly guidelines on when and how to stop antidepressants could make a huge impact on the relapse rate and the misery caused to untold numbers of patients, not to mention the re-referral rate to psychiatrists. I believe that patients are well able to play a part in managing their illness and that the psychological difficulties which some patients have in coming to terms with a relapsing illness are exactly the same as those I experienced with patients with asthma. It is increasingly clear that some people need to take medication long term and psychiatrists are unlikely to be able to keep all these people under review even were it appropriate to do so. Danny Allen
MRCGP MRCPsych
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Chris Manning, Co Chair PriMHE (Primary care Mental Health Education) Hampton Wick
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Dear Sir At long last, depression is receiving the attention it deserves and I am delighted that the appropriate use of nurses in its management is stimulating genuine academic interest.I have always felt that we should be concentrating on the similarities of disease management models, rather than be obsessed by differences. The experience with asthma and diabetes should have been enough to convince people long ago. With a few provisos, it would seem to make sense that the cloying power of stigma could be reduced by a "so what" attitude and that there is really nothing special in happening to have a condition that affects your brain, rather than lung or pancreas, and which, in itself,is no cause for shame. The concern which many of us have as regards our medical records also needs to be tackled, especially by insurance companies and employers, who, in addition to the sufferer, also often regard depression as a weakness. The appropriate medicalisation of this condition could go a long way towards validating patients' experiences and getting many of the stigmatising attitudes "off their backs". Nurses also increasingly seem to be able to provide the continuity of care that was once much more the provenance of GPs, and indeed, aside from the institutional and political battles between colleges, end-users have much to gain from seeing a human being who is skilled enough to deal with their condition, no matter what they might happen to be called. Further, I would welcome recognition by the DoH that depression is now statistically and fiscally warranting of clinic status(or whatever we call it, in whatever way we operate it for it to be acceptable) and the appropriate remunerative mechanism that applies to asthma and diabetes.In the past, this has usually provided the national motivation for GPs' flagging interests in a disease area. Expecting this to happen at local level is a cop-out. This is a National and International disease now, requiring a strategic and Government response at this level. Anyway, how do we seriously expect to be able to track this condition, measure its true effects at personal and societal levels and the outcomes of different management options, without naming it for exactly what it is ? For those who are interested, the Depression Care Training Centre(DCTC), under the direction of Liz Armstrong, has been running validated courses for depression and schizophrenia for some two and a half years - so the mechanism exists to match words with action now. Yours faithfully Dr. Chris Manning
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Richard Churchill
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Editor - In his recent editorial, Kendrick proposes the introduction of special clinics for the management of depression in general practice because of its nature as a chronic remitting condition.1 He draws analogies with other chronic conditions such as diabetes and asthma, where care is often provided in clinics purely devoted to the management of the specific condition. We believe that his argument is flawed on a number of counts. Firstly, both diabetes and asthma are relatively homogeneous physical illnesses for which there are acceptable treatments, objective measures of control, defined management targets, and some knowledge of long-term sequelae if poorly managed. In contrast, the psychopathology of depression is less well understood, and the condition, particularly in general practice, is heterogeneous, with less known about long-term outcomes. Thus, the analogy is simplistic and relies on the inappropriate application of a reductionist medical model. Secondly, the diagnosis of depression does not merely involve the recognition of symptoms and clinical signs on mental state examination. As McWhinney points out, the biological diagnosis is but one of three parts to any disease process, namely biomedical, individual, and contextual components all coalescing in the 'triple diagnosis'.2 A clinic- based service may detract from assessment of pertinent situational and psychosocial management components. Thirdly, Kendrick implies that current management of depression by GPs is often inappropriate and uses the fact that they may refer patients to non- directive counsellors to support this assertion. He states that such intervention has been shown to be ineffective. However the study he cites did not investigate depression per se, but included a mixed group of subjects with a range of psychological and emotional problems.3 At present there is inadequate evidence to support the use of non-directive counselling for depression4, but the absence of evidence does not equate to lack of efficacy. The results of studies to evaluate counselling specifically for depression have not yet been published. Finally, Kendrick implies that GPs are potentially paternalistic in their approach to the management of depressed patients. However, special clinics impose their own form of paternalism in which patients are required to conform to medically defined protocols. Good primary care will enable patients to make informed choices, adapt treatments to circumstances and aid them in the complexities of a poorly understood condition with multiple emotional, social and psychological complications. Surely such 'made to measure' intervention will always result in a better fit than 'off the peg' provision. Richard Churchill
Lionel Jacobson
References 1. Kendrick T. Depression management clinics in general practice? BMJ 2000; 320:527-528. 2. McWhinney I. A textbook of family medicine. Oxford: Oxford University Press 1996. 3. Friedli K, King MB, Lloyd M, Horder J. Randomised controlled assessment of non-directive psychotherapy versus routine general practitioner care. Lancet 1997; 350:1662-1665. 4. Churchill R, Dewey M, Gretton V, Duggan C, Chilvers C, Lee A. Should general practitioners refer patients with major depression to counsellors? A review of current published evidence. Brit J Gen Pract 1999; 49:738-743. |
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