Title: Lessons from the Hampshire Depression Project
Abstract: In the Hampshire Depression Project Thompson and colleagues1Thompson C Kinmonth AL Stevens L et al.Effects of clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial.Lancet. 2000; 355: 185-191Summary Full Text Full Text PDF PubMed Scopus (456) Google Scholar have given us food for thought in how best are we to manage depression in primary care. Here is a large, well-designed, randomised, controlled trial testing the assumption that educating GPs in the recognition and management of depression among their patients will lead to an increase in numbers being diagnosed and treated successfully. So why did the findings prove negative? There would appear to be few flaws in the study design. Limitations are discussed by the investigators. However, recruitment of practices was based upon self-selection (60 recruited from 224 eligible practices). We learn nothing of those practices choosing to decline. Does acceptance of participation in a research process signify greater motivation and interest among its participants thereby reducing the power of the intervention? One of the two study end-points was improvement in depression. This was assessed by serial hospital anxiety and depression (HAD) scales. While accepting this to be an appropriate rating scale, there are difficulties in using a threshold score of 8–10 as a measure of depression. Dowell and Biran2Dowell AC Biran LA Problems in using the hospital anxiety and depression scale for screening patients in general practice.Br J Gen Pract. 1990; 40: 27-28PubMed Google Scholar used the HAD as a screening tool in a primary care population. The prevalence of probable caseness for anxiety and depression rose from 28% when an HAD threshold of 11 was used to 51% at a threshold of 8. Within the admittedly different context of an intervention study, this could still have implications. Inclusion of study participants scoring 8–10 may have weakened the power of the intervention. The study's educational intervention was based on existing guidelines on depression management. But Kendrick questions the place of such guidelines.3Kendrick T Why can't GPs follow guidelines on depression?.BMJ. 2000; 320: 200-201Crossref PubMed Scopus (107) Google Scholar And are GPs who appear not to follow these guidelines really “failing” their patients? Numerous studies have confirmed that GPs miss psychological illness when it first presents. Naturalistic studies of detection and its effect on the course of depressive illness have produced mixed findings. In one study, unrecognised cases of depression in primary care were shown to have less severe depression and do better than recognised (more severely depressed) cases at 1 year.4Goldberg D Privett M Ustun B et al.The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities.Br J Gen Pract. 1998; 48: 1840-1844PubMed Google Scholar Is under-recognition therefore a serious problem? Once recognised, this heterogeneous illness often fails to conform to the pattern seen in secondary care (and that which informs guidelines). In practice, GPs are frequently faced with a distressed patient, fearful of the label of depression, wary of the assurances that antidepressant medication is not addictive, and concerned about job security in the face of an inability to work (through the illness or side effects of medication). We are told we are overprescribing serotonin-reuptake inhibitors in minor depression and using subtherapeutic doses of tricyclic antidepressants in major depression. Our patients fail to comply with our prescriptions. Some who do stay the course experience a return of symptoms. The GP refers to a practice counsellor, because this seems to be what the patient wants, but this referral will not alter the intractable social disturbances which, for many, hinder recovery.5Goldberg D Bridges K Cook D et al.The influence of social factors on common mental disorders: destabilisation and restitution.Br J Psychiatry. 1990; 156: 704-713Crossref PubMed Scopus (45) Google Scholar How much of this behaviour is evidence-based? The management of depression in the context of a continuum of psychological distress is complex and the processes by which we, as GPs, negotiate compliance with follow-up and medication with our patients require much more research. These issues do not sit easily within the framework of clinical guidelines. Guidelines will continue to fail to have an impact until we look further at the natural history of depression in the community, address the wider social issues, and seek the perspective of the patients we are endeavouring to treat. Then, perhaps, we will have a more valuable tool to evaluate. Lessons from the Hampshire Depression ProjectAuthor's reply Full-Text PDF