Clinical guidelines on depression: A qualitative study of GPs’ views

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Original Research

Clinical guidelines on depression: A qualitative study of GPs’ views

J Fam Pract. 2004 July;53(7):556-561

By

Liz Smith, MA, PhD

Anne Walker, BSc, PhD

Ken Gilhooly, MA, MSc, PhD

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References

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8. Littlejohns P, Cluzeau F, , Bale R, Grimshaw J, Feder G, Moran S. The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK. Br J Gen Pract 1999;49:205-210.

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Practice recommendation

Health planners may help enhance guideline use if resources are available for implementation, recommendations are consistent across multiple guidelines, and audit and feedback mechanisms are developed (C).

ABSTRACT

Background: Clinical guidelines have become an increasingly familiar component of health care, although their passive dissemination does not ensure implementation. This study is concerned with general practitioners’ (GPs) views of guideline implementation in general practice. It focuses specifically on their views about guidelines for the management of patients with depression.

Objective: To elicit and explore GPs’ views about clinical guidelines for the management of depression, their use in practice, barriers to their use, and how best to implement guidelines.

Design: Qualitative study using in-depth interviews with a purposive sample of GPs.

Setting: General Practices across the Scottish Grampian region, and Northeast England.

Methods: Eleven GPs who had participated in a previous questionnaire based depression study were interviewed. Interviews were transcribed and analyzed using the “framework technique.”

Results: Several participating GPs did not agree with recommendations of the current depression guidelines; some thought they were insufficiently flexible to use with the variety of patients they see. The volume of guidelines received, lack of time and resources (particularly mental health professionals for referrals) were seen as the main barriers to guideline use.

Conclusions: A range of factors contributes to variability in compliance with guidelines for the management of depression. For guideline use to increase, GPs in this study said they would like to see more resources put in place; a reduction in the number of guidelines they receive; incorporation of guideline recommendations onto computer decision support systems; and regular audit and feedback to allow them to monitor their practice.

Clinical practice guidelines have become a common aspect of clinical care.¹ Guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care.”² Clinical practice guidelines have been seen as the remedy to at least 3 problems facing healthcare systems³: wide variation in the health care people receive⁴; rising health care costs⁵; and health professionals’ difficulty in keeping abreast of research evidence.⁶ Despite increasing numbers of clinical practice guidelines, clinicians often do not change their practice accordingly.⁷ The reasons for this have not been fully explained.¹

At least 45 different depression guidelines have been published for use in primary care since 1991. However, a review concluded that they all make essentially the same recommendations.⁸ Thus, whichever guidelines GPs used, the recommendations were similar and were based on the 1992 joint consensus statement,⁹ which advises that that 4 depressive symptoms must have been present for at least 2 weeks before prescribing antidepressants. In this study, in-depth interviews explored GPs’ views on guidelines for the management of depression, how they used these in practice, barriers to using the guidelines, and how best to implement guidelines.

Barriers to effective treatment

Successful implementation of a depression guideline (by the US Agency for Healthcare Research and Quality) increases the quality of care and improves clinical outcomes.¹⁰ However, a widely acknowledged gap exists between research findings and their clinical implementation.¹¹ In the UK, GPs tend to overprescribe relative to recommendations¹²—antidepressant prescribing has increased for all age and sex groups over the last 20 years¹³; prescribing no drugs is rare.¹⁴ Nevertheless, depressed persons are often under-diagnosed and undertreated^13,15; only about 10% receive appropriate treatment.¹⁶

Barriers preventing effective treatment for depression include service provision¹⁷; patients’ attitudes and beliefs about depression and its care¹⁸; lack of access to care; treatment preference; and concerns about confidentiality and stigma.^19-21 Physicians have sometimes overruled guidelines when patients have complex illness patterns.¹⁸ Physician factors, including lack of time²² and poor awareness of guidelines,^22,23 may also contribute.

Asking questions about guidelines in practice

This study sought GPs’ views about the gap between depression guideline recommendations and practice, and examined how best to implement clinical guidelines from the GPs’ perspective. Specifically, the following research questions were addressed:

Do GPs agree with the recommendations made by depression guidelines?
Do GPs feel that guidelines are flexible enough to manage depression in all patients?
What barriers do GPs perceive to following the recommendations?
What do GPs perceive to be the most fruitful method to promote guideline use?

Methods

Participants’ characteristics

GPs eligible for this study (n=102) participated in 1 of 2 postal questionnaires, wherein they were asked to make treatment decisions in 20 systematically varied case vignettes of patients with symptoms that might indicate depression. Fifteen GPs were invited to participate, of whom 11 (73%) agreed to be interviewed.