Abstract
BACKGROUND: Depression, a common disorder often treated by family physicians, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy. METHODS: In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CPGs] for depression and access to a psychiatrist for consultation) or to a control group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression, medications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measure was the "gain" score (difference between first and last CES-D scores). RESULTS: During the study period physicians in the intervention group diagnosed 91 new cases of depression (mean 4.1 per physician) and those in the control group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in the control group received a prescription for an antidepressant on their first visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number of visits per patient was similar in the 2 groups (7.7 in the intervention group and 7.6 in the control group). Physicians in the intervention group consulted the psychiatrist 9 times. The overall rate of referrals to psychiatrists and other mental health professionals was 10.9%; however, referrals were significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient's self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0.04) and the physicians' ratings of depression severity before treatment and at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02). INTERPRETATION: The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians.
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Selected References
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- Emslie C., Grimshaw J., Templeton A. Do clinical guidelines improve general practice management and referral of infertile couples? BMJ. 1993 Jun 26;306(6894):1728–1731. doi: 10.1136/bmj.306.6894.1728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Haynes R. B., Davis D. A., McKibbon A., Tugwell P. A critical appraisal of the efficacy of continuing medical education. JAMA. 1984 Jan 6;251(1):61–64. [PubMed] [Google Scholar]
- Jackson M. N., Nutting P. A. Clinical guidelines development: opportunities for family physicians. J Fam Pract. 1991 Aug;33(2):129–132. [PubMed] [Google Scholar]
- Johnstone A., Goldberg D. Psychiatric screening in general practice. A controlled trial. Lancet. 1976 Mar 20;1(7960):605–608. doi: 10.1016/s0140-6736(76)90415-3. [DOI] [PubMed] [Google Scholar]
- Katon W., Von Korff M., Lin E., Walker E., Simon G. E., Bush T., Robinson P., Russo J. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5;273(13):1026–1031. [PubMed] [Google Scholar]
- Kendrick T., Burns T., Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long term mentally ill patients. BMJ. 1995 Jul 8;311(6997):93–98. doi: 10.1136/bmj.311.6997.93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mitchell-Heggs N. Aspects of the natural history and clinical presentation of depression. Proc R Soc Med. 1971 Dec;64(12):1171–1174. [PMC free article] [PubMed] [Google Scholar]
- Prestidge B. R., Lake C. R. Prevalence and recognition of depression among primary care outpatients. J Fam Pract. 1987 Jul;25(1):67–72. [PubMed] [Google Scholar]
- Wensing M., van der Weijden T., Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract. 1998 Feb;48(427):991–997. [PMC free article] [PubMed] [Google Scholar]
- Worrall G., Chaulk P., Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ. 1997 Jun 15;156(12):1705–1712. [PMC free article] [PubMed] [Google Scholar]
- Zung W. W., King R. E. Identification and treatment of masked depression in a general medical practice. J Clin Psychiatry. 1983 Oct;44(10):365–368. [PubMed] [Google Scholar]