Abstract
Recent Australian statistical data [1], [2] reported a 12-month prevalence of depression of 5.1%% while an Australian textbook suggested that ‘10%% of the population will have depressive illness’ and that 20%% of patients attending general practitioners (GPs) are significantly depressed [3].
Several authors stress the under-diagnosis of depression by GPs [4–6]. As GPs are the first medical doctors to whom depressed patients turn for help, it was decided to improve their knowledge in diagnosis and treatment of this disorder. A program of several ‘Insights’ workshops was developed to be attended by participating GPs. These workshops were developed by an independent advisory committee of GPs and psychiatrists with the aim of refreshing and updating knowledge on depression, its diagnosis and treatment, including nonpharmacological, pharmacology and psychosocial interventions.
A baseline questionnaire was developed to be administered at the beginning of the program.
This paper is based on the analysis of the preworkshop data and provides information on the knowledge of depression reported by GPs prior to entering the ‘Insights’ program.
Methods
General practitioners were asked to complete two questionnaires in a group situation. One questionnaire provided information on the gender and age group of the GPs, year of medical graduation, and type of practice. The other questionnaire asked for information on the level of recognition and management of depression by GPs.
GPs were asked to list symptoms (an open ended question) on the basis of which they would diagnose depression.
Multiple choice questions were used to elucidate the class of antidepressants they would choose initially, the name and the dose of the antidepressant of choice, the length of treatment and the eventual steps taken if the patient did not respond to the initial treatment.
GPs were asked also to indicate on a five point scale from none to very good the level of knowledge of, and skills in, the various types of treatment of depression in general, and for selected classes of patients.
Following these questions, they were presented with four vignettes describing different types of patients, and asked to make a diagnosis and suggest treatment for each of the four individuals.
Results
Doctors
Altogether 3289 individuals were included in the study of whom 2040 completed both questionnaires. Another 460 doctors completed the main questionnaire, but did not provide the demographic data on themselves, whilst 789 GPs completed only the demographic questionnaire. Thus, it was possible to analyse the knowledge in recognition and treatment of depressive illness by 2500 GPs. The comparison of gender, age group and year of graduation of those who completed and did not complete the main questionnaire did not show any differences between the respondents and the nonrespondents to the main questionnaires; a higher proportion of respondents worked with one to two partners, while more nonrespondents worked with three or more partners. In both groups only one in 10 worked fewer than 20 h weekly.
Of the General Practitioners, 25.3%% were females, 73.8%% were males, and the remaining 0.9%% did not state their gender. In terms of age, 31.3%% were under the age of 40, 36.5%% were 40–49-year-old, 18.5%% were in the 50–59 years age group, and 12.5%% were 60 years and over. A higher proportion of respondents worked with one to two partners (32.8 vs. 28.1%%), while more nonrespondents worked with three or more partners. One in four of respondents and nonrespondents were in a solo rather than group practice (26.7 and 24.1%%, respectively).
Proportion of patients with depression
General practitioners were asked to estimate the proportion of their patients with depressive illness. Sixty per cent believed that less than 10%% of their patients suffered from depression. Half of these (30%%) felt that this proportion was even less than 5%%. Less than 10%% of the respondents estimated to have 20%% or more of their patients presenting with depression and less than 3%% believed that this proportion exceeded 40%%.
Recognition of depressive illness
We asked the doctors to list symptoms on which they would base the diagnosis of depression. The number of symptoms listed were from none (87 doctors) to 20 or more. These symptoms are listed in descending order of frequency in Table 1. It is interesting to note that 86.8%% of respondents listed sleep disorders as diagnostic specific symptoms, whilst depressed mood was mentioned by only slightly over half of the doctors.
Symptoms Of Which The General Practitioner Based The Diagnosis Of Depression
To compare their description of depressive symptomatology with the DSM-IV criteria for diagnosing a depressive episode the symptoms reported by the GPs were grouped into the nine listed as criteria for diagnosing a major depressive episode. Five or more of those symptoms were needed, including depressive mood and/or loss of interest or pleasure. 2117 doctors (84%%) mentioned one or both of the two main symptoms, but only 699 of these, or 28%% of the total sample, listed at least five criterion symptoms.
Treatment
Over one third of GPs (35.2%%) claimed never to rely on pharmacological treatment alone. The most popular treatment was the combination of pharmacological and nonpharmacological treatment: almost 60%% of doctors used it in more than half of their patients (Figure).
The proportion of doctors reporting the frequency of use of each of three types of treatment. (a) Medication only; (b) Non–pharmacological only;(c) Non-pharmacological and medication. 
, Nil; 
, 1–19%; 
, 20–49%; 
, >50%.
Almost three fifths of respondents (56.3%%) relied on tricyclic antidepressants, dothiepin being the most commonly named drug from this group. Monoamine oxidase inhibitors (MAOI) and tetracyclic drugs were selected as drug of choice by 0.1 and 2.3%% respondents, respectively. Selective serotonin uptake inhibitors (SSRI) and reversible inhibitors of monoamine oxidase (RIMA) were chosen by one fifth of doctors each. Only 77 (3.1%%) did not respond to this question. Very few doctors recommended doses below or above the recommended therapeutic range. Paroxetine and sertraline were recommended more often in the low end of the therapeutic range, whilst the opposite was true for moclobemide. This is consistent with current teaching on the use of these agents.
Almost two thirds of GPs report they would refer fewer than 1 in 5 of their depressed patients to psychiatrists. This is consistent with the current practice of primary community care [3].
Almost all GPs involved other family members in the therapeutic process while slightly fewer reported using other community agencies.
Self assessment of knowledge and skills
Responses to the questions regarding their knowledge and skills in various areas of treatment are presented in Table 2. The doctors claimed moderate and good knowledge and skills in brief and prolonged counselling, but less in other nonpharmacological treatments. Some 30%% of GPs did not answer this question. In contrast, the majority of the doctors assessed their knowledge and skills in the use of antidepressant medication as good or moderate. They had very little confidence in dealing with children. Two thirds of them described their knowledge in this area as minimal or none. On the other hand, over 90%% claimed to have very good, good or moderate knowledge of depression in the elderly. The knowledge and skills to deal with depression with pregnancy, and suicide was reported as moderate.
GPs Self Assessment Of Knowledge And Skills
Vignettes
The GPs were presented with vignettes of four patients, named White, Black, Green and Brown, describing their problems and symptoms. Mrs White is an elderly widow, who recently lost her husband, whilst Ms Black is a single mother with various psychological and social problems. Mr Green is a 38-year-old man with abdominal complaints, who recently lost weight, became anxious and irritable and cannot cope with work, whilst Mrs Brown presented with recurrent depression, from which she has suffered for 15 years. The full description of these patients, as presented to the doctors, are given in the appendix.
Diagnostic Categories – Diagnosis
Whilst the problems of the elderly widow, Mrs White, were diagnosed mainly as adjustment disorder or uncomplicated bereavement, one third of the GPs felt that the single mother Ms Black is suffering from a major depressive episode. No striking differences are noted between the diagnoses given to Mr Green and Mrs Brown.
Only Mrs Brown is felt to be an extreme suicide risk by the majority of doctors, whereas all the others are recorded as at most a possible risk by the majority of doctors. A small proportion of doctors regarded all as extreme risk (0.8%% white, 2.3%% black, 4.5%% green).
Whilst the doctors are confident to treat the elderly widow, and to a lesser extent the single mother, most would refer Mrs Brown to a psychiatrist or to a hospital. This was also true to a lesser extent to Mr Green. Except for Mrs Brown, the majority of doctors would use individual therapy for the other three patients, but would not resort to group or family therapy.
Discussion
The total number of 2500 GPs who completed the main questionnaire is sufficiently large to draw conclusions from the data. Over another 200 questionnaires arrived after the data were already coded and computerised. However, the 783 doctors who did not complete this questionnaire have to be regarded as those possibly with a low insight into depression or low confidence in its assessment and treatment. This should be taken into consideration when the level of recognition and knowledge of treatment of depression by GPs is assessed. It is worthwhile to stress that the nonrespondents differed from the respondents only in terms of the size of practice. We intentionally left the list of symptoms on which the GPs based the diagnosis of depression as an open-ended question, to avoid any bias from suggesting symptoms listed, for example in the SPHERE depression checklist [4], [5] from the researchers. Only 87 GPs did not answer this question. However, responses did not conform to the rigors of the DSM-IV criteria in diagnosing major depressive disorder. GPs relied often on less important or more nonspecific symptoms such as sleep disturbances or weight changes, or even nonspecific items such as anxiety or psychosomatic complaints. However, the DSM criteria refer to a major depressive disorder whilst the GP had a much broader view of the diagnosis of depression [6].
Despite this broad approach to the diagnosis of depression, the estimated proportion of patients with depressive problems in general practice is significantly lower than that suggested by Judd and Burrows [2]. Many authors claim under-recognition of depression by nonpsychiatric medical staff [7–9]. A more recent study [10] of recognition of depression by doctors referring hospital patients to a psychiatric consultation-liaison service indicates it is under-diagnosing by nonpsychiatrists, although in a proportion of cases the psychiatrist rejected the diagnosis of the referring doctor. It is therefore necessary for the purpose of general practice to widen the criteria to help identify the diagnosis of depression beyond the major depressive episode, and refine both identification and diagnostic skills to ensure that this disorder is neither under-diagnosed nor over-diagnosed.
Tricyclic antidepressants were the drug of choice by over half of the GPs, whilst SSRI and RIMA were selected by one-fifth of the respondents each. MAOI's were not used at all. Only 3%% of doctors did not respond to this question. It is of great satisfaction that only a minute proportion of GPs (0–5%%) suggested a nontherapeutic or potentially toxic dose of prescribed medications.
The self-assessment of their knowledge and skills has been taken at its face value. The doctors felt confident about their knowledge and skills in pharmacological and nonpharmacological treatment of depression and about dealing with elderly patients. They felt uncomfortable only in treating children, the pregnant, and suicidal patients, which has to be taken up in their future training. These were addressed in later workshops.
The GP reports of higher referral rates than normally reported from general practice may be because GPs who attended these workshops were more interested in depression than the average and as a result referred more patients to psychiatrists.
The diagnostic vignettes proved to be a good method to determine whether the GPs distinguish between various types of patients. Whilst the general trend in diagnosing, assessing severity and treatment suggestions were in the right direction, there was a sizeable minority who would over-diagnose and over-treat the bereaved widow or the single mother.
Conclusions
The study has shown that the majority of GPs have a satisfactory insight into recognition and treatment of depression, although a sizeable minority based their diagnosis on somatic symptoms, such as sleep or eating disturbances.
A sizeable minority, however, did not feel confident to complete the questionnaires or based their diagnoses on secondary or nonspecific symptoms. The use of medication is generally satisfactory, although a proportion of doctors would over-treat uncomplicated bereavement. There is a need to improve knowledge in child psychiatry, depression in pregnancy, and in dealing with suicidal patients. A postworkshop analysis will determine the effectiveness of the ‘Insights’ program.
Footnotes
Acknowledgements
We are grateful to all the doctors who took part in these workshops and completed the questionnaires. Mr Alan Mackenzie carried out the computer analysis of the data. The ‘Insights’ depression education program was developed by an independent depression education advisory committee, chaired by Dr JWG Tiller, Dr Robert LIewellyn Jones, Dr Dimity Pond, Dr Geoff Riley, Dr Simon Wilcock, Professor Gordon Johnson, Dr Nick O'Connor, Dr Jonathan Phillips, Dr Mike Theodoros, Dr Anne Sved-Williams, and were assisted by Oxford Clinical Communications. The educator initiative was supported by an educational grant from Roche Products. Roche Products had no input into the design and content of the education program.