Managing depression in primary careBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7495.800 (Published 07 April 2005) Cite this as: BMJ 2005;330:800
- Andre Tylee, professor of primary care mental health,
- Roger Jones, Wolfson professor of general practice ()
- Health Services Research Department, Institute of Psychiatry, London SE5 8AF
- Department of General Practice and Primary Care, GKT School of Medicine, London SE11 6SP
Public confidence needs to be restored after concerns over the safety of SSRIs
Depression is a condition of “particular concern, which costs lives and affects the quality of life,” according to UK prime minister Tony Blair.1 Nine out of 10 depressed patients are treated only in primary care,2 3 and up to two thirds of suicide victims contact a general practitioner in the four weeks before the death.4 For years, however, general practitioners have been criticised for failing to deal adequately with depression. Like hypertension, depression is subject to a rule of halves—only half of depressed patients seek help from doctors, half are detected in primary care, half receive treatment with only half completing it: fewer than 10% finish a therapeutic course of treatment.5 A range of initiatives, often erroneously based on educational models for general practitioners, has aimed to improve detection rates and to increase the appropriateness of prescribing in depression with variable success, including a spectacular failure, in Hampshire, to influence general practitioners' behaviour at all.6
There are many reasons why depression goes unrecognised in primary care.7 Patients may attribute symptoms wrongly, may present instead with physical symptoms, may not realise that they need treatment,7 and may attend their doctors' practices too infrequently.8 General practitioners may have negative attitudes to mental health problems and not feel responsible for dealing with them, may lack time, may lack facilities in poorly organised practices, may have inadequate consulting skills, and may be deterred by the workload of long term treatment and monitoring. Before selective serotonin reuptake inhibitors (SSRIs) became available, general practitioners were legitimately concerned about the side effects of treatment, particularly with the older tricyclic antidepressants.7 Although more caution in prescribing has recently been advocated,w1 w2 SSRIs initially offered a new dawn for depression treatment in general practice, with drugs that were relatively free of side effects.
The UK Committee on Safety of Medicines, informed by a report from an expert working group, issued guidance on the safety of SSRIs in December 2004.w3 The committee's advice, which has been incorporated into information for prescribers and patients, concerns withdrawal reactions, dose changes, and suicidal behaviour and recommends that treatment with venlafaxine, a serotonin and noradrenaline reuptake inhibitor, should be initiated only by specialist mental health practitioners, including general practitioners with a special interest in mental health.
The response to these warnings has been extraordinary. The media have caricatured general practitioners as prescribing from the hip, using SSRIs in depression like antibiotics in sore throat. Worse, general practitioners have been portrayed as incapable of judging how to prescribe appropriately. At least one professor of psychiatry has suggested, not for the first time, that all depressed patients requiring drug treatment should be under the care of a psychiatrist. This suggestion would bring the hospital system to its knees within days.
Despite this overreaction, national policy continues to support the strategy that depression should be managed in primary care. On the same day the Committee on Safety of Medicines released its report, the National Institute for Clinical Excellence (NICE) published evidence based guidelines supporting a careful, stepped approach to managing depression in primary care.w4 Depending on the severity of depression, the guidelines recommend watchful waiting, exercise, self help, and psychological therapies, as well as antidepressant treatment. First line treatment for moderate to severe depression, according to NICE, should be with SSRIs, although these are probably of little use in mild depression. The stepped approach will involve the whole primary care team, including the 1000 new graduate mental health workers announced in the NHS Plan for England. A pilot scheme in the Trent region of England has been described.w5
The general public, surveyed a decade ago, preferred to see general practitioners rather than psychiatrists for depression and to receive psychological treatments and counselling rather than drug treatment.9 Many general practices still lack such resources, but could do much more with the help of nurses and graduate health workers. Practice nurses have recently improved access to treatment and increased patients' satisfaction by running an open access depression service in south London.10 Nurses and graduate mental health workers could encourage depressed patients to seek help in primary care and provide advice on nutrition, alcohol, sleep hygiene, and exercise, teach patients to use self help materials, and deliver brief psychological interventions, and to direct patients to voluntary groups such as Depression Alliance. Computerised psychological treatments may solve the problem of low availability of services for some.11
Given that NHS strategy sees primary care as the right place for most depression services, the absence of depression from the list of chronic diseases that general practitioners are specifically paid to manage through the new General Medical Services contract is a glaring omission.w6 However, the Primary Care Programme of the National Institute of Mental Health in England is committed to helping practices to improve depression care, by providing guidance on locally enhanced services for depression and to improving existing training for general practitioners with a special interest in mental health,12 although few of these enhanced services have been established so far.
Public confidence in the ability of general practitioners to manage depression has been knocked by current concerns about SSRIs, exaggerated in the media. Better support for self help, wider provision of effective psychological services, and more appropriate use of antidepressants in primary care, and more urgent attention by NHS planners, should help to restore that confidence.
Additional references w1-w6 are on bmj.com
Competing interests None declared.