Contents of General Practitioner-Patient Consultations in the Treatment of Depression

Abstract

BACKGROUND

Counseling of patients is an indispensable part of any drug treatment and even more so in the treatment of depression.

OBJECTIVE

To describe the content of counseling additional to prescribing an antidepressant drug.

SETTING

Sixty-three general practices from all over Germany.

PATIENTS

Three hundred two patients with the diagnosis of either a depressive episode or a recurrent depressive disorder.

MEASUREMENTS

Assessment of the content of the physician-patient encounter by content analysis following the pivotal topic method.

DESIGN

Qualitative study embedded in a drug utilization study on mirtazapine.

RESULTS

In the initial sessions general practitioners focused on building a good therapeutic alliance, assessing the symptoms of illness, explaining the course of treatment, assuring medication compliance, and discussing problems of life. In the middle phase of treatment, physicians also dealt with building a therapeutic alliance, medication compliance, and the progress and course of illness. In the last phase relapse prevention was an important topic. Psychological topics were more important than medication topics. Almost no importance was given to management of side effects, change of cognitions, or suicidal tendencies.

LIMITATIONS

No information is available on how content was actually discussed. Only encounters were observed where an antidepressant was prescribed.

CONCLUSIONS

Counseling plays an important part in day-to-day encounters of general practitioners. Pharmacotherapy is embedded in comprehensive psychological care. Training programs for general practitioners should be specific in respect to different tasks and parts of the physician-patient encounter (e.g., building a therapeutic alliance, support for life problems or change of cognitions).

INTRODUCTION

It is generally accepted that counseling and psychological interventions are part of any encounter between physicians and their patients.¹ It is of special importance in the treatment of patients with mental illnesses such as depression, which are frequent problems in primary care.^2–5 Physicians have to inform patients about treatment options and needs. They have to clarify the state of illness, assess the effects of treatment, and/or control for unwanted drug effects. In addition to prescribing medication, general practitioners are also patient counselors. They give reassurance and support, discuss problems of life, and help to overcome negative thinking in depression. Counseling is also an important part of any drug treatment. There is evidence that the patient-physician encounter has an influence on patient cooperation, medication compliance, the rate of unwanted drug effects, tolerance of their reactions to unwanted effects, and even the efficacy of medications. Drug manufacturers must also take into account how their drug is handled by physicians and patients and what physicians do to support drug treatment.^6–8 It is known from the literature that patients feel more comfortable with physicians who use a patient-centered approach.⁹

There are theoretically derived concepts and guidelines on what physicians should talk about with their patients that can be found in the WHO guidelines for the treatment of depression in primary health care.¹⁰ They should guide the use of drugs by their patients and also help them to cope with and overcome depression. Still, it is unknown which topics practicing physicians see as important and what they deal with and talk about in routine care. We wanted to study the type, content, and frequency of topics that general practitioners discuss with their patients while prescribing an antidepressant.

METHOD

This study is part of a drug utilization study on the antidepressant mirtazapine (Remergil® SolTab™). Sixty-three general practitioners participated in the study and reported on 95 male and 207 female patients (mean age = 56.1, SD = 15.7, range = 19–92 years). Participating physicians were recruited on a nationwide basis by representatives of Organon, the manufacturer of mirtazapine, and were distributed all over Germany. The study goal was to observe routine care of patients who had been prescribed mirtazapine for individual clinical reasons. Physicians were free to treat patients according to individual considerations, including mode of prescribing, frequency of contact, or duration of treatment. The drug was prescribed and disturbed by pharmacies according to routine practice that included patient package inserts.

The observation was done using standardized instruments and lasted at maximum 12 weeks. Physicians started to document the case and the course of treatment after they had decided to prescribe mirtazapine. According to the clinical judgment of the treating physicians, all patients were suffering from a depressive episode according to ICD-10 F 32 or F 33¹⁰.

To find out what patients and physicians talked about, we used a strategy from psychotherapy research, the pivotal topic method.¹² After each patient contact, physicians were asked to write down what they thought to be the pivotal topic of this encounter. The question that had to be answered in free text read: “In my view the most important topic of the session was….” Multiple responses were allowed. This method does not assess what has been talked about “objectively.” Instead, it refers to the views, perspectives, and memories of the physicians as to what they see as important, what guides their treatment, and what they wanted to do. Pivotal topics describe what is important in the view and memory of the physicians. From an intentional and cognitive perspective, the statements reflect the “subjectively true” content of the encounter.

Two raters independently rated all statements by using a content analytic method. The content analytic scheme had been developed on the basis of examples of such reports and in reference to the WHO guidelines for the treatment of depression in primary health care.¹⁰ Interrater reliability¹³ was 87.7%. Content categories refer first to diagnosis and case management (CM): (1) establishing a therapeutic alliance, (2) assessment of symptoms, (3) patient education, (4) discussion of treatment options, (5) explanation of treatment course, (6) discussion of course and progress, and (7) discussion of referral to specialist. Second, they refer to medication topics (MT): (1) indication for drug treatment, (2) dosage, (3) medication compliance, (4) management of side effects, and (5) maintenance medication. Third, they refer to psychological topics (PT): (1) giving the opportunity to talk, (2) reassurance and support, (3) increase of activities, (4) discussion of problems in life, (5) problem solving skills, (6) modification of negative cognitions, (7) stimulation of positive thinking, (8) stimulation of goal orientation, (9) feedback on positive development, and (10) suicidal tendency.

The study has been approved by the ethical committee and internal review board of the Charité University Medicine Berlin. The part of the study on physician-patient communication was under the responsibility of the authors of this paper, who had control over the data, data analysis, and writing of the manuscript. The company representatives did not approve or disapprove what has been written.

RESULTS

Sessions lasted on average 19.5 min (SD = 9.6 min). Table 1 shows the percentage of sessions in which a topic was mentioned and gives in parentheses a rank order in relation to other topics.

Table 1.

Frequency of General Practitioner Pivotal Topics

Categories	T0 (vsa = 273)	T1 (vsa = 270)	T2 (vsa = 245)	T3 (vsa = 231)	T0–3
	% (Rb)	% (Rb)	% (Rb)	% (Rb)	Ø % (Rb)
1. Diagnosis and case management (CM)
1.1. Therapeutic alliance	19.1 (1)	17.0 (2)	13.1 (2)	9.1 (3)	11.5 (2)
1.2. Assessment of symptoms	12.8 (4)	2.2 (9)	4.5 (8)	3.5 (8)	4.2 (6)
1.3. Patient education	8.8 (6)	1.5 (14)	1.6 (12)	0.4 (18)	1.7 (14)
1.4. Treatment options	2.9 (11)	0.4 (18)	0 (21)	0.9 (14)	0.5 (19)
1.5. Explanation of treatment	18.3 (2)	8.5 (4)	5.7 (4)	4.3 (5)	5.1 (4)
1.6. Discussion of progress	4.4 (9)	41.9 (1)	49.8 (1)	48.9 (1)	35.8 (1)
1.7. Referral to specialists	2.6 (12)	0.7 (16)	0.4 (19)	0.9 (14)	0.5 (19)
2. Medication topics (MT)
2.1. Indication for medication	6.2 (7)	0.4 (18)	0 (21)	0 (22)	0.8 (17)
2.2. Dosage	2.6 (12)	2.2 (9)	1.2 (16)	4.3 (5)	2.3 (13)
2.3. Medication compliance	12.1 (5)	12.6 (3)	6.9 (3)	3.5 (8)	7.4 (3)
2.4. Management of side effects	1.1 (17)	0.4 (18)	0 (21)	0 (22)	0.1 (23)
2.5. Relapse prevention	0 (20)	0 (22)	2.0 (11)	14.7 (2)	4.2 (6)
3. Psychological topics (PT)
3.1. Opportunity to talk	1.5 (16)	1.1 (15)	1.6 (12)	0.9 (14)	0.9 (16)
3.2. Reassurance and support	4.8 (8)	5.9 (6)	1.6 (12)	2.6 (11)	3.2 (9)
3.3. Increase of activities	1.1 (17)	1.9 (11)	3.7 (9)	3.5 (8)	2.6 (11)
3.4. Problems in life	15.8 (3)	7.4 (5)	5.3 (6)	2.2 (13)	5 (5)
3.5. Problem-solving skills	1.8 (14)	3.7 (7)	5.3 (6)	2.6 (11)	3.2 (9)
3.6. Negative cognitions	1.8 (14)	0.4 (18)	0.4 (19)	0.9 (14)	0.4 (21)
3.7. Positive cognitions	0 (20)	0 (22)	0.8 (18)	0.4 (18)	0.3 (22)
3.8. Goal orientation	3.7 (10)	3.3 (8)	5.7 (4)	5.6 (4)	3.9 (8)
3.9. Feedback on positive change	0 (20)	1.9 (11)	3.7 (9)	3.9 (7)	2.5 (12)
3.10. Suicidal tendency	0.4 (19)	0.7 (16)	1.2 (16)	0.4 (18)	0.6 (18)
4. Others	0 (20)	1.9 (11)	1.6 (12)	0.4 (18)	1 (15)

^aValid sessions: numbers reflect how many general practitioner statements were given at a data collection point

^bRank from most often (1) to least often named category

When taking all sessions into account, the most frequent topics were: the course and progress (35.8%), therapeutic alliance (11.5%), and medication compliance (7.4%), while the least often reported topics were management of side effects (0.1%), stimulation of positive cognitions (0.3%), and modification of negative cognitions (0.4%).

When one tries to describe the trajectory of therapeutic interaction over the course of treatment, general practitioners start by talking about therapeutic alliance (19%), explanation of treatment course (18%), problems of life (16%), assessment of symptoms (13%), and medication compliance (12%). In the middle of the treatment process, they still talk about therapeutic alliance and medication compliance, but also course and progress. Course and progress (49%) is the primary topic throughout the further course of treatment. Finally, relapse prevention (15%) is the topic of interest at the end of treatment. Categories that tend to increase over time are course and progress, increase of activities, stimulation of positive cognitions and relapse prevention. Decreasing are therapeutic alliance, medication compliance, assessment of symptoms, problems of life, management of side effects, patient education, indication for drug treatment, and explanation of treatment course.

Comparing CM, MT, and PT over the course of treatment for depression (Table 2), general practitioners predominantly dealt with diagnosis and case management in all sessions (68% versus 75%). Medication topics (10% versus 23%) were preferably a topic in the initial and final phase of treatment. Psychological topics (23% versus 31%) had a consistent role throughout the treatment with some reduction at the end.

Table 2.

Frequency of General Practitioner Pivotal Topics

Sum variables	T0	T1	T2	T3
	%	%	%	%
Diagnosis and case management	68.9	72.2	75.1	68.0
Medication topics	22.0	15.6	10.1	22.5
Psychological topics	30.9	26.3	29.3	23.0

DISCUSSION and CONCLUSION

In an earlier publication we asked: “Is the pharmacotherapist mute?”¹⁴ The answer from this study is definitely no. Physicians put great emphasis on establishing a therapeutic alliance, i.e., to convey to the patient that the therapist understands how the patient feels and what he/she wants.

Most important in the encounter between physician and patient is the assessment of the state of illness and course of improvement. This is closely related to issues of compliance and justification of medication.

Side effects of drug treatment are a topic in only about 1% of encounters at the start of treatment, and in the further course of treatment are not discussed at all. The question is whether physicians avoid this topic as they do not want to stir up a problem or whether they think that mostly minor side effects are not a topic that needs long discussion and therefore is not mentioned as a “pivotal” topic.

Similarly, suicidal tendencies are discussed in less than 1% of encounters. This is in contrast with the fact that according to the symptom measures 1% of patients were suffering from severe, 11% from moderate, and 22% from mild suicidal ideations. The literature reports that a majority of general practitioners feel uncomfortable in talking about suicidal tendencies in their patients,¹⁵ while all respective textbooks recommend that it is better to talk about suicidal ideas than to ignore them.

Guidelines recommend¹⁰ that modification of negative thinking should play an important role even in the primary care management of depression. This is also seen in less than 1% of encounters. Less than half of all physician statements referred to psychological topics.

The results of this study show that counseling is an important part of the day-to-day medical routine. It also shows that a large variety of topics are addressed. Verbal encounters fulfill many tasks, e.g., building a relationship, patient education, reassurance, support in life problems, or change of attitudes and cognitions. Our data also show that counseling is not a single event, but a process over time with different topics at the beginning or the end of an encounter. They also point to topics like side effects, suicidal ideation, or cognitive modifications, which are rare. Further research should clarify whether this is sufficient or needs improvement.

The data from this study can help in preparing or revising guidelines and implementing educational programs. As mentioned, we found some differences in reported emphases from recommended guidelines, e.g., WHO guideline for the management of depression.¹⁰ This could stimulate and guide educational programs^{10,15,18–22} and possibly also help to develop guidelines that have a better fit with clinical reality.

There are several limitations to this study. Only physicians who prescribed an antidepressant were included in the study. As the study is part of a drug utilization observation and as physicians have been recruited and compensated for the documentation work by the drug manufacturer, there may be a bias toward sampling physicians who are more disposed toward prescribing. Results could be very different in physicians who prefer psychological means to treat depressive episodes. We also did not tape record and assess what physicians talked about “in reality,” but only can say what they thought was important.^16,17 Finally it must be remembered that content also needs skillful communication²³ and that we do not know how the physicians conveyed their messages to the patient.