Friday, September 18, 2009

Are Antidepressants UNDERprescribed in Primary Care Settings?

Despite everything else you've heard and read (and watched on ABC) recently, the answer is yes. Or maybe. At least in Scotland. Antidepressants might be UNDERprescribed by General Practitioners, according to a new study published in the British Journal of General Practice (Cameron et al., 2009). The authors conducted a chart review of 898 adults screened for anxiety and depression in a general practice setting. They concluded:
Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.
However, another article in the same issue of the journal interviewed 63 GPs to determine their explanations for the dramatically increased rate of prescribing in Scotland (Macdonald et al., 2009). Many thought the present-day level of prescribing was too high and
believed that unhappiness, exacerbated by social deprivation and the breakdown of traditional social structures, was being 'medicalised' inappropriately.
In contrast to Cameron and colleagues, MacDonald et al. concluded that antidepressants are OVERprescribed by GPs in Scotland, and recommended a change in prescribing patterns (as have many others).

So which is it? Who are we to believe? Unfortunately, I don't have access to either paper, so we'll have to make do with the abstracts.


Cameron, I., Lawton, K., & Reid, I. (2009). Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting British Journal of General Practice, 59 (566), 644-649 DOI: 10.3399/bjgp09X454061

Background: Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially. Aim: To assess whether GPs prescribe antidepressants appropriately. Design of study: Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP. Setting: Four practices in Grampian, Scotland. Method: Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed. Results: A total of 237 (26%) participants had HADS scores indicating 'possible' (15%) or 'probable' (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. ... In 101 participants with 'probable' depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression. Conclusion: There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.

Macdonald, S., Morrison, J., Maxwell, M., Munoz-Arroyo, R., Power, A., Smith, M., Sutton, M., & Wilson, P. (2009). ‘A coal face option’: GPs' perspectives on the rise in antidepressant prescribing British Journal of General Practice, 59 (566), 299-307 DOI: 10.3399/bjgp09X454106

Background: Levels of antidepressant prescribing have dramatically increased in Western countries in the last two decades. Aim: To explore GPs' views about, and explanations for, the increase in antidepressant prescribing in Scotland between 1995 and 2004. Design: Qualitative, interview study. Setting: General practices, Scotland. Participants: GPs in 30 practices (n = 63) purposively selected to reflect a range of practice characteristics and levels of antidepressant prescribing. Method: Interviews with GPs were taped and transcribed. Analysis followed a Framework Approach. Results: GPs offered a range of explanations for the rise in antidepressant prescribing in Scotland. Few doctors thought that the incidence of depression had increased, and many questioned the appropriateness of current levels of prescribing. A number of related factors were considered to have contributed to the increase. These included: the success of campaigns to raise awareness of depression; a willingness among patients to seek help; and the perceived safety of selective serotonin reuptake inhibitors, making it easier for GPs to manage depression in primary care. Many GPs believed that unhappiness, exacerbated by social deprivation and the breakdown of traditional social structures, was being 'medicalised' inappropriately. Conclusion: Most antidepressant prescriptions in Scotland are issued by GPs, and current policy aims to reduce levels of prescribing. To meet this aim, GPs' prescribing behaviour needs to change. ...

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At September 18, 2009 3:10 PM, Blogger Neuroskeptic said...

I can't access the papers either, which is annoying.

However going by the abstracts: Cameron et al's data show one of two things: 1) The HADS self-report questionnaire over-diagnoses depression or 2) GPs under-diagnose depression.

The truth is likely to be both, but I suspect that it's more 1) than 2). Just because I tend to trust trained doctors over pieces of paper.

Also, even if there are lots of cases of undiagnosed depression in primary care, it is presumably mild (severe depression is often, although not always, obvious), in which case antidepressants are not likely to be very effective.

At September 18, 2009 4:35 PM, Blogger The Neurocritic said...

I wasn't that familiar with the HADS but I found this (Lisspers et al. 1997):

"It was somewhat surprising that the factor analyses were consistently extracting two factors, 'depression' and 'anxiety', while on the other hand both BDI [Beck Depression Inventory] and STAI [State Trait Anxiety Inventory] tended to correlate more strongly with the total HAD score than with the specific depression and anxiety HAD subscales. Nevertheless, the HAD appeared to be (as was indeed originally intended) a useful clinical indicator of the possibility of depression and clinical anxiety."

So I think you're probably right...


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