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Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced by Family Physicians; a focus group study

Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced... Background: The recognition and treatment of depressive- and anxiety disorders is not always in line with current standards. The results of programs to improve the quality of care, are not encouraging. Perhaps these programs do not match with the problems experienced in family practice. This study aims to systematically explore how FPs perceive recognition, diagnosis and management of depressive and anxiety disorders. Methods: focus group discussions with FPs, qualitative analysis of transcriptions using thematic coding. Results: The FPs considered recognising, diagnosing and managing depressive- and anxiety disorders as an important task. They expressed serious doubts about the validity and usefulness of the DSM IV concept of depressive and anxiety disorders in family practice especially because of the high frequency of swift natural recovery. An important barrier was that many patients have difficulties in accepting the diagnosis and treatment with antidepressant drugs. FPs lacked guidance in the assessment of patients' burden. The FPs experienced they had too little time for patient education and counseling. The under capacity of specialised mental health care and its minimal collaboration with FPs were experienced as problematic. Valuable suggestions for solving the problems encountered were made Conclusion: Next to serious doubts regarding the diagnostic concept of depressive- and anxiety disorders a number of factors were identified which serve as barriers for suitablemental health care by FPs. These doubts and barriers should be taken into account in future research and in the design of interventions to improve mental health care in family practice. Page 1 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 earlier qualitative studies reported problems of FPs in rec- Background Recognition and treatment of depressive disorders and ognition, in differentiating between distress and depres- anxiety disorders in family practice is not always in line sive disorder and addressing depression as a medical/ with current medical standards. Intervention studies to psychiatric disorder. They mainly focussed on depression, improve the standard of care- focussing on education, dis- and did not address problems in management [15-21]. semination and implementation of guidelines and use of screening instruments- are not particularly encouraging The aim of the present study was to systematically explore especially regarding patient outcome. Next to benefits of how FPs perceive recognition, diagnosis and management the programs we assumed that such interventions insuffi- of depressive and anxiety disorders. In addition, we ciently match with the problems experienced by family focussed on problems and barriers as experienced by FPs physicians (FPs). Focus group discussions with FPs were and listed the solutions the FPs proposed to get over these held to explore and analyse the problems FPs encounter barriers. and to get sight the solutions they bring forward. Methods Focus group interviews are loosely structured interviews Depressive and anxiety disorders are the most common mental health problems in the population, with a preva- facilitating participants to offer general and specific infor- lence of 4% respectively 5 – 10%, causing burden to mation. It aims at exploring clinical experiences and patients and society [1,2]. Both disorders are often co beliefs and does not encourage the building of consensus. morbid and form a common reason for consultation in This makes it an appropriate qualitative method to family practice [2,3]. explore complex problems while group interaction can trigger shared experiences [22-25]. For that reason focus When compared to psychiatric interviews and current group interviews were used in this study. guidelines, underrecognition and sub-optimal treatment are reported; in just over half of patients with a major To obtain a wide range of experiences and to allow in- depressive disorder in family practice the diagnosis depth group discussions three groups from three different 'depression' is made, a quarter of them is prescribed an regions in the Netherlands were included in the study. antidepressant subsequently which is, often in a low doses Purposive sampling resulted in: (1) a long existing Con- for a too short period of time [3-5]. For a number of tinuous Medical Education (CME) group of FPs discussing patients better recognition and treatment can probably topics on a monthly basis; (2) a group of FP-trainers of improve their health status [6]. However, there are indica- one of the eight residency training programs in the Neth- tions that the labelling of patients' problems in terms of a erlands and (3) a random group of FPs with their practices disorder is not always important for successful manage- within 100 km of the Nijmegen university. Members of ment or relapse prevention[7]. Although there is a relative group 3 enrolled after 120 invitations had been sent to lack of primary care studies, this may indicate that there is family physicians, 68 responded of whom 10 subscribed still substantial room for improvement of patients' out- and 8 participated. To encourage participation, all FPs come in depression. The same might be true for anxiety were paid (euro 125) for their attendance. disorders [8]. All participating FPs completed the Depression Attitude Recently, the effects of different interventions on the Questionnaire which measures the physician's attitude to detection, management and outcome of depression and depression and is considered as a valid and reliable meas- anxiety in family practice were assessed systematically ure of attitudes of FPs towards depression [25,26]. This is [9,10]. Only interventions that combined strategies of cli- a visual analogue scale consisting of 20 questions with nician and patient education, nurse case management, four components: treatment attitude, professional ease, enhanced support from specialist services and monitoring depression malleability and depression identification of drug compliance showed a positive effect but only of [27]. short duration [9,10]. We suppose that other barriers than knowledge and skills, such as in task perception, attitudes After a brief introduction by the FP chairman a theme was or interview-style, play a role in FPs recognition of depres- introduced and each group member was given the oppor- sive and anxiety disorders as well as patient factors and tunity to give his or her view. This individual round was organisational barriers [11-13]. It is interesting that none followed by a group discussion. The meetings took place of the studies included in the review, though all directed between November 2001 and April 2002, and lasted at the quality of care of depression, actually addressed about 2.5 hours. Meetings were audio taped with consent problems FPs may encounter in recognising, diagnosing of the participants and transcribed verbatim. The tran- and treating depression. A qualitative approach seems the scriptions were analysed independently by two raters best method to analyse FPs' difficulties in this [14]. Some (EvR, HvH) using thematic coding, with the help of Page 2 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 ATLAS.ti, a qualitative data-analysis program [28,29] The features of these disorders were often, over longer periods results of individual analysis were compared and differ- of time, present in the same patient. Such fluctuation of ences were settled by consensus [30]. Saturation of themes symptoms- for example periods of anxiety or panic, fol- was reached after the third focus group and the data-col- lowed by somatoform symptoms or depressive features- lection was stopped. conflicted with the concept of distinct diagnostic entities. A more generic approach and superimposed symptom Results specific treatment would be helpful in the FPs' manage- Participants ment of patients. Also, substantial differences in severity In total 23 family physicians (17 male, 6 female, age or burden between patients with the same diagnosis are range: 41–59 years, all types of practices, urban, suburban seen by FPs. Nevertheless, some considered the criteria a and rural) participated in the study. For these characteris- useful diagnostic tool for diagnosing mentally distressed tics the participants were comparable to Dutch FPs in gen- patients and they regarded a specific diagnosis helpful for eral [31]. Participants' scores on the DAQ are presented in guiding treatment. Attention to patients' non-verbal signs, table 1. In general, the participants did not experience particularly when observed over a longer period of time identification of depression as particularly problematic, can be helpful in recognising depression and anxiety dis- held an optimistic view of its natural course and treatabil- orders, according to nearly all FPs. ity, and felt relatively at ease in managing it. Citations Conceptual doubts Tasks 'I don not believe in those diagnoses, it are symptoms of other Most participants considered recognition, diagnosis and problems, for instance in youth, phase of life or social circum- management of depression and anxiety disorders an stances. Diagnosing an anxiety disorder is not useful at all....' important part of their task, usually interesting but also (FP 4, group B) rather time-consuming. A few participants doubted whether treatment should be a core-job for FPs. Most felt ' For me it is 'horse, trigger, bullet..., when I see patients with capable of managing most of their depressed or anxious indistinct complaints I hand over a check list. If they score pos- patients. itive on 5 of the 9 items... they are depressed.(FP 7, group C) Conceptual doubts/Validity of diagnosis 'At a CME course I have learned to ask for the two core items A greater part of the participants expressed serious doubts of depression. In combination with my own appraisal I decide of the validity of the diagnostic concept of depressive and about the diagnosis.' (FP 2, group C) anxiety disorders used in the DSM IV and practice guide- lines [32,33]. They questioned whether depression and Dealing with patients' preferences and patients' resistance anxiety were always separate diagnostic entities or a syn- An important theme for the FPs was handling the prefer- drome or an arbitrary set of symptoms. They were reluc- ences and resistances of patients. In the experience of the tant to use these diagnostic labels, because a specific FPs patients with a mental health problem often pre- diagnosis had few consequences for treatment or progno- sented themselves with physical (often vegetative) symp- sis. Particularly the demarcation between depressive dis- toms. This hampered diagnosis and further management orders and anxiety disorders and other mental health of depressive or anxiety disorders. In particular as patients problems was thought to be questionable, as the various often deny the psycho-social nature of their symptoms. Table 1: Mean scores of participants on four components of the depression attitude questionnaire (DAQ) range 0–100 mm Component Mean SD (min-max) Treatment attitude 47.9 8.1 High score = biochemical basis of depression, antidepressants useful, psychotherapy unsuccessful (31.3–65.8) Professional ease 63.8 10.2 High score = uncomfortable managing depression, work is having going and not rewarding, psychotherapy should be left to a specialist (47.0–80.3) Depression malleability 32.2 7.7 High score = pessimism towards depression, not amendable to change, is natural part of being old (15.8–47.5) Depression identification 41.1 14.6 High score = difficulty distinguishing between depression from unhappiness, little help beyond FP (13.3–69.6) Page 3 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 And patients seldom seek help with active reference to patients. Continuity of care was usually seen as a helpful their mental health status. Difficulties in accepting the tool for diagnosis as it enabled them to monitor a diagnosis 'depression' or 'anxiety disorder' as the explana- patient's complaints and functioning over time. On the tion for their problems, anhedony, negative thoughts, other hand some participants mentioned disadvantages feelings of shame a guilt and fear for stigmatisation, were of continuity of the doctor patient relation: getting too in the eyes of the FPs important barriers for treatment acquainted wit a patient may 'normalise' pathological while agreement about defining the problem is requisite. mental distress and so, delay recognition of psychiatric The FPs experienced that patients often had a strong resist- disorders. Although the participants were positive about ance to psychopharmacological treatment, especially their communication skills in general, they experienced when prescribed for a longer period of time. This was limited specific skills to cope and communicate with related to fear for side effects and dependency. Patients patients with mental health problems. often stopped taking their medication when symptoms had disappeared or diminished. The FPs felt also restricted Citations Distressed or disorder? in their treatment options due to patients' resistance 'many patients are distressed.... when I think it is serious I will towards referral to specialised mental health care profes- talk it over....' (FP 4, group A) sionals, because of emotional, social and financial barri- ers. 'sometimes, you see a patient so often.... You become too famil- iar. When the patient visits a colleague, she easily recognises a Citations Dealing with patients' preferences and resistance depressed state of mind....'.(FP 5, group A) 'patients only want to talk about the physical things, not about the mental ones. Often they are afraid to be qualified neurotic 'personally I have less rules of thumb for anxiety disorders... or depressed....' (FP 2, group A) especially with the various types of this disorder.' (FP 8, group C) 'Nearly all patients resist drug treatment; they think they have to overcome their problems all on their own and are afraid of Antidepressants and beyond side effects.... And when at last they are convinced to take anti- The FPs expressed difficulties in deciding on best manage- ment. In their professional opinion there is a lack of depressants, they discontinue as soon as they feel better for a few days.' (FP 3, group A) knowledge of the natural history and long-term prognosis of (un)treated depressive and anxiety disorders. From that Distress or disorder? clinical experience FPs attributed a substantial placebo The participants referred to the fact that, in their practice, effect to antidepressant drugs. Persisting co-existing psy- they encountered often-psychological problems of a tran- chosocial problems or deprivation also limited the sient nature, as part of 'normal' life events. According to response to (antidepressant drug) treatment. some, the distinction between such problems and a true psychiatric disorder was difficult. Therefore, most FPs The FPs said to prescribe often relatively low standard dos- were reluctant to label prematurely in diagnostic terms. ages of serotonin reuptake inhibitors. They considered For example, diagnosing major depressive disorder after their knowledge of the different types within this group of only two weeks after presentation of the symptoms was drugs as rather limited and had concerns about how to perceived as far too quick. In this respect, the FPs discontinue antidepressants. In case of non-response they expressed serious concerns of medicalising conditions hesitated to increase dosage or to use other psychotropics. they see as normal human distress. The assessment of the severity of the symptoms was perceived as crucial in decid- The increased focus on antidepressants during a consulta- ing about the diagnosing a depressive disorder or anxiety tion, limited the application of other approaches such as disorder as described in the DSM IV and as important for psycho-education or counselling. FPs considered cogni- deciding about treatment. Nevertheless, many FPs tive behavioural therapy (CBT) and problem solving ther- reported difficulties in how to assess the severity. FPs iden- apy (PST) as valuable interventions, suitable in family tified a number of patient groups in which recognition practice, but experienced a deficit in skills to apply such and diagnosis of depressive and anxiety disorders was par- techniques. ticularly problematic: the elderly, patients with a different cultural background and patients with limited verbal Citations Antidepressants and beyond skills. In patients with a chronic somatic-medical disease 'I think we overvalue antidepressants, we use them too FPs noticed difficulties in interpreting the cause of physi- soon, much of their effect is natural recovery of the disor- cal symptoms. FPs expressed a deficiency in their knowl- der' (FP 5, group C) edge of the specific anxiety disorders, and saw this deficiency as a potential cause of underdiagnosis in these Page 4 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 'maybe I hesitate to diagnose a depression because of the long systematic follow up of the patients was considered term treatment with antidepressant drugs....' (FP 6, group B) important. 'nowadays I spend so much time with talking about pills that Discussion there is barely time left for explaining the patients himself can The FPs valued recognising, diagnosing and managing do....' (FP 3, group A) depressive and anxiety disorders as important primary care tasks. However, many had strong reservations about Conflicting demands and possibilities the validity and usefulness of the DSM IV concepts of In addition, a number of structural barriers were men- these disorders for family practice. Different diagnostic tioned: a lack of time for detailed anamnesis and elabo- styles of the FPs were identified. With regard to diagnosis rate diagnostic procedures. This is reinforced because of and management FPs expressed a mismatch between the limited reimbursement for additional time investment. recommendations in guidelines of a specific – often phar- The time available for a standard consultation was seen as macological approach and patients' preferences. Resist- too limited for CBT or PST. Time pressure also limited ance against (long term use of) antidepressants and the extensive psycho-education. Patients and FPs are con- fact that other psychosocial co-morbidity may over- fronted with long waiting lists for specialised mental shadow or colour the features of depression and anxiety health care. A major concern of the FPs was the non struc- disorder, were seen as barriers for applying the guidelines. tural co-operation between family practice, primary care The management should focus more on patient empow- psychologists and specialised mental health care. Cooper- erment than antidepressant prescription only. FPs seems ation depended largely on personal relationships and to hesitate to use the diagnostic term depressive disorder experiences, only few mentioned more formal ways of or anxiety disorder while the fullfillment of these criteria cooperation like local or regional protocols or stepped imply a need for specific treatment. The argument of the care approaches need clear distinction between a diagnosis and need for treatment was also given from a theoretical point of view Citations Conflicting demands and possibilities [34]. 'for removing a naevus surgically in 5 minutes I received an extra fee, talking 15 minutes with a anxious patient is not This study started out on the medical paradigm/model rewarded at all' (FP 1, group A) but during the study the usefulness of this model was dis- puted. For FPs 'patient context' or patient background var- 'Finally, at the point the patient is convinced that referral is the iables were important in establishing mental health best option.... we faced a waiting list of 5 months....' (FP 4, problems. One of the barriers in implementing evidence group B) was that family physicians interpret evidence in an indi- vidual patients' context [35]. You need a lot of endurance when trying to communicate with psychiatrist or psychologist. Getting them on the During the group discussions proposals were made to phone takes lots of time. (FP 4, group A) overcome the problems experienced. It was noteworthy that the FPs touched upon a number of unresolved issues Needs and solutions in the medical literature: the effectiveness of antidepres- The group discussions did produce valuable solutions for sants in mild depressive disorders and the management of the problems encountered. It emphasized the importance co-morbid psychiatric disorders [36]. This underlines the of using time as a diagnostic tool. FPs receive more then need to take practical clinical experience from primary one opportunity to recognise a disorder. The approach of care into account in the design of further research on men- 'watchful waiting' when a disorder was suspected should tal health problems. receive more attention in clinical guidelines. Regarding management, patient education should be strengthened, Although this study provided important new informa- aiming at empowering patients. FP -friendly psychometric tion, a number of limitations of its design should be taken tools for diagnosis and severity or mental burden are wel- into account. The explorative design with a limited comed. Additional training on specific anxiety disorders, number of FPs may hamper the extrapolation of the for communication skills to cope better with patients with results to all FPs. The method of the focus group discus- mental health problems and for comprehensive psycho- sions worked quite well and yielded problems the partici- therapeutic techniques is needed. The FPs emphasized the pants experienced in all domains of their clinical practice need of a better co-operation with a limited number of of depressive- and anxiety disorders. Rigour was enhanced specialised mental health care providers. Better financial using the DAQ as an instrument for triangulation. The rewards for the time-intensive treatment of depressive- scores on the DAQ are in line with previously reported and anxiety disorders and appointing practice nurse for studies, also indicating that the participants of this study Page 5 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 represented the variation in FPs attitudes towards mental reported earlier. These factors refer to insufficient under- health problems [25,26]. Unfortunately specific Dutch standing of the natural history, and course over time, of reference data concerning the DAQ are lacking. In the mental health problems. It stresses the importance of a Netherlands most health problems are treated in primary primary care research agenda of mental health problems care and FPs are serving as a 'gate keeper' for secondary focussing on those factors. It should form an integral part care. As many other countries have comparable health of the further improvement of mental health care. We rec- care systems and also a mix of private and public funding ommend to pay more attention to patient education/psy- the results of this study generalise to other countries as cho education, patient activation, self-management well. programs in family practice, the need for user-friendly psychometric tools for assessment and monitoring. For The serious conceptual doubts have not been presented instance the use of the PHQ-9 or the Beck Depression earlier, but some barriers had been reported earlier in a Inventory. The instruments can also be used for monitor- review, which was based on epidemiological data and the- ing the course of the disorder when using a watchfull wait- oretical considerations rather then on the experience of ing strategy or to evaluate treatment effects. Some of the FPs[11,37,38]. The FPs' opinions about the extremely approaches mentioned above can be provided by FPs, short 2 week period of the presence symptoms to diag- other by (community) mental health nurses working in nose a depressive disorder is supported by epidemiologi- family practice. cal data [39]. As well as a high recovery rate of depressive disorders within three months without a formal interven- Development of an effective generic approach for the tion [40]. Most qualitative studies published recently, did management of various mental health problems in family examine the FPs experience in recognizing depression practice and additional training for comprehensive psy- [15-21]. Recently the patient perspective on talking with chotherapeutic techniques is a priority. The FPs empha- doctors about depression was published [41]. Recogni- sized the need of a better co-operation with specialised tion and management of anxiety disorders were not stud- mental health care providers. Various collaborative care ied earlier [15-21]. Only a Swedish study reported on the models are developed, seem effective and can be used in management of depressive disorders, mainly on pharma- different health care models. cological treatment [21]. The GPs in our study reported considerable reservations regarding antidepressant drugs, In addition, the barriers and solutions should be taken felt unskilled to offer other specific treatment modalities into account in the design of primary care based interven- (like problem solving treatment) and experienced diffi- tions on recognition and management depressive- and culties in cooperation with specialized mental health care. anxiety disorders. This may result in better patient out- These difficulties are reflected in the relatively high score come and provision of cost effective care. on the DAQ subscale professional ease. Competing interests A study on British FPs did not report time pressure which The authors declare that they have no competing interests. was emphasized in this study as well as by British patients [18]. The difficulties in discriminating between psycho- Authors' contributions logical distress and a psychiatric disorder were reported EvR and HvH: have made substantial contributions to conception and design, or acquisition of data, or analysis earlier by Swedish FPs. They also modified the concept of depression with different causes and expressed reserva- and interpretation of data; tions of the increase in antidepressant prescribing [21]. It also emphasised the relevance of non-verbal signs and EvR, HvH, EvdL, FZ and CvW have been involved in draft- pre-existing knowledge of FPs. In accordance with our ing the manuscript or revising it critically for important results the collaboration with psychiatry consultants was intellectual content and have given final approval of the perceived as unsatisfactory [17]. The difficulties in man- version to be published. agement depressive disorders in patients with persisting psychosocial problems as reported by the FPs was Acknowledgements This study was co-funded by the International Health Foundation, Utrecht, described earlier in a study with FP working in socio-eco- the Netherlands. nomically deprived areas [16]. References Conclusion 1. Konig-Zahn C, Furer J, Tax B, Berg Jvd, Rijnders C, Zandstra S, Rijsw- This study confirmed the FPs' substantial professional role ijk Ev: Regioproject Nijmegen 2: Psychiatrische morbiditeit in in the diagnosis and management of depression and anx- de regio. Nijmegen 1999:1-141. 2. Bijl RV, Ravelli A, van Zessen G: Prevalence of psychiatric disor- iety. 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Your research papers will be: 25. Botega NJ, Silveira GM: General practitioners attitudes towards available free of charge to the entire biomedical community depression: a study in primary care setting in Brazil. Int J Soc Psychiatry 1996, 42(3):230-237. peer reviewed and published immediately upon acceptance 26. Dowrick C, Gask L, Perry R, Dixon C, Usherwood T: Do general cited in PubMed and archived on PubMed Central practitioners' attitudes towards depression predict their clinical behaviour? Psychol Med 2000, 30(2):413-419. yours — you keep the copyright 27. Kerr M, Blizard R, Mann A: General practitioners and psychia- BioMedcentral trists: comparison of attitudes to depression using the Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced by Family Physicians; a focus group study

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Copyright © 2009 by van Rijswijk et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: The recognition and treatment of depressive- and anxiety disorders is not always in line with current standards. The results of programs to improve the quality of care, are not encouraging. Perhaps these programs do not match with the problems experienced in family practice. This study aims to systematically explore how FPs perceive recognition, diagnosis and management of depressive and anxiety disorders. Methods: focus group discussions with FPs, qualitative analysis of transcriptions using thematic coding. Results: The FPs considered recognising, diagnosing and managing depressive- and anxiety disorders as an important task. They expressed serious doubts about the validity and usefulness of the DSM IV concept of depressive and anxiety disorders in family practice especially because of the high frequency of swift natural recovery. An important barrier was that many patients have difficulties in accepting the diagnosis and treatment with antidepressant drugs. FPs lacked guidance in the assessment of patients' burden. The FPs experienced they had too little time for patient education and counseling. The under capacity of specialised mental health care and its minimal collaboration with FPs were experienced as problematic. Valuable suggestions for solving the problems encountered were made Conclusion: Next to serious doubts regarding the diagnostic concept of depressive- and anxiety disorders a number of factors were identified which serve as barriers for suitablemental health care by FPs. These doubts and barriers should be taken into account in future research and in the design of interventions to improve mental health care in family practice. Page 1 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 earlier qualitative studies reported problems of FPs in rec- Background Recognition and treatment of depressive disorders and ognition, in differentiating between distress and depres- anxiety disorders in family practice is not always in line sive disorder and addressing depression as a medical/ with current medical standards. Intervention studies to psychiatric disorder. They mainly focussed on depression, improve the standard of care- focussing on education, dis- and did not address problems in management [15-21]. semination and implementation of guidelines and use of screening instruments- are not particularly encouraging The aim of the present study was to systematically explore especially regarding patient outcome. Next to benefits of how FPs perceive recognition, diagnosis and management the programs we assumed that such interventions insuffi- of depressive and anxiety disorders. In addition, we ciently match with the problems experienced by family focussed on problems and barriers as experienced by FPs physicians (FPs). Focus group discussions with FPs were and listed the solutions the FPs proposed to get over these held to explore and analyse the problems FPs encounter barriers. and to get sight the solutions they bring forward. Methods Focus group interviews are loosely structured interviews Depressive and anxiety disorders are the most common mental health problems in the population, with a preva- facilitating participants to offer general and specific infor- lence of 4% respectively 5 – 10%, causing burden to mation. It aims at exploring clinical experiences and patients and society [1,2]. Both disorders are often co beliefs and does not encourage the building of consensus. morbid and form a common reason for consultation in This makes it an appropriate qualitative method to family practice [2,3]. explore complex problems while group interaction can trigger shared experiences [22-25]. For that reason focus When compared to psychiatric interviews and current group interviews were used in this study. guidelines, underrecognition and sub-optimal treatment are reported; in just over half of patients with a major To obtain a wide range of experiences and to allow in- depressive disorder in family practice the diagnosis depth group discussions three groups from three different 'depression' is made, a quarter of them is prescribed an regions in the Netherlands were included in the study. antidepressant subsequently which is, often in a low doses Purposive sampling resulted in: (1) a long existing Con- for a too short period of time [3-5]. For a number of tinuous Medical Education (CME) group of FPs discussing patients better recognition and treatment can probably topics on a monthly basis; (2) a group of FP-trainers of improve their health status [6]. However, there are indica- one of the eight residency training programs in the Neth- tions that the labelling of patients' problems in terms of a erlands and (3) a random group of FPs with their practices disorder is not always important for successful manage- within 100 km of the Nijmegen university. Members of ment or relapse prevention[7]. Although there is a relative group 3 enrolled after 120 invitations had been sent to lack of primary care studies, this may indicate that there is family physicians, 68 responded of whom 10 subscribed still substantial room for improvement of patients' out- and 8 participated. To encourage participation, all FPs come in depression. The same might be true for anxiety were paid (euro 125) for their attendance. disorders [8]. All participating FPs completed the Depression Attitude Recently, the effects of different interventions on the Questionnaire which measures the physician's attitude to detection, management and outcome of depression and depression and is considered as a valid and reliable meas- anxiety in family practice were assessed systematically ure of attitudes of FPs towards depression [25,26]. This is [9,10]. Only interventions that combined strategies of cli- a visual analogue scale consisting of 20 questions with nician and patient education, nurse case management, four components: treatment attitude, professional ease, enhanced support from specialist services and monitoring depression malleability and depression identification of drug compliance showed a positive effect but only of [27]. short duration [9,10]. We suppose that other barriers than knowledge and skills, such as in task perception, attitudes After a brief introduction by the FP chairman a theme was or interview-style, play a role in FPs recognition of depres- introduced and each group member was given the oppor- sive and anxiety disorders as well as patient factors and tunity to give his or her view. This individual round was organisational barriers [11-13]. It is interesting that none followed by a group discussion. The meetings took place of the studies included in the review, though all directed between November 2001 and April 2002, and lasted at the quality of care of depression, actually addressed about 2.5 hours. Meetings were audio taped with consent problems FPs may encounter in recognising, diagnosing of the participants and transcribed verbatim. The tran- and treating depression. A qualitative approach seems the scriptions were analysed independently by two raters best method to analyse FPs' difficulties in this [14]. Some (EvR, HvH) using thematic coding, with the help of Page 2 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 ATLAS.ti, a qualitative data-analysis program [28,29] The features of these disorders were often, over longer periods results of individual analysis were compared and differ- of time, present in the same patient. Such fluctuation of ences were settled by consensus [30]. Saturation of themes symptoms- for example periods of anxiety or panic, fol- was reached after the third focus group and the data-col- lowed by somatoform symptoms or depressive features- lection was stopped. conflicted with the concept of distinct diagnostic entities. A more generic approach and superimposed symptom Results specific treatment would be helpful in the FPs' manage- Participants ment of patients. Also, substantial differences in severity In total 23 family physicians (17 male, 6 female, age or burden between patients with the same diagnosis are range: 41–59 years, all types of practices, urban, suburban seen by FPs. Nevertheless, some considered the criteria a and rural) participated in the study. For these characteris- useful diagnostic tool for diagnosing mentally distressed tics the participants were comparable to Dutch FPs in gen- patients and they regarded a specific diagnosis helpful for eral [31]. Participants' scores on the DAQ are presented in guiding treatment. Attention to patients' non-verbal signs, table 1. In general, the participants did not experience particularly when observed over a longer period of time identification of depression as particularly problematic, can be helpful in recognising depression and anxiety dis- held an optimistic view of its natural course and treatabil- orders, according to nearly all FPs. ity, and felt relatively at ease in managing it. Citations Conceptual doubts Tasks 'I don not believe in those diagnoses, it are symptoms of other Most participants considered recognition, diagnosis and problems, for instance in youth, phase of life or social circum- management of depression and anxiety disorders an stances. Diagnosing an anxiety disorder is not useful at all....' important part of their task, usually interesting but also (FP 4, group B) rather time-consuming. A few participants doubted whether treatment should be a core-job for FPs. Most felt ' For me it is 'horse, trigger, bullet..., when I see patients with capable of managing most of their depressed or anxious indistinct complaints I hand over a check list. If they score pos- patients. itive on 5 of the 9 items... they are depressed.(FP 7, group C) Conceptual doubts/Validity of diagnosis 'At a CME course I have learned to ask for the two core items A greater part of the participants expressed serious doubts of depression. In combination with my own appraisal I decide of the validity of the diagnostic concept of depressive and about the diagnosis.' (FP 2, group C) anxiety disorders used in the DSM IV and practice guide- lines [32,33]. They questioned whether depression and Dealing with patients' preferences and patients' resistance anxiety were always separate diagnostic entities or a syn- An important theme for the FPs was handling the prefer- drome or an arbitrary set of symptoms. They were reluc- ences and resistances of patients. In the experience of the tant to use these diagnostic labels, because a specific FPs patients with a mental health problem often pre- diagnosis had few consequences for treatment or progno- sented themselves with physical (often vegetative) symp- sis. Particularly the demarcation between depressive dis- toms. This hampered diagnosis and further management orders and anxiety disorders and other mental health of depressive or anxiety disorders. In particular as patients problems was thought to be questionable, as the various often deny the psycho-social nature of their symptoms. Table 1: Mean scores of participants on four components of the depression attitude questionnaire (DAQ) range 0–100 mm Component Mean SD (min-max) Treatment attitude 47.9 8.1 High score = biochemical basis of depression, antidepressants useful, psychotherapy unsuccessful (31.3–65.8) Professional ease 63.8 10.2 High score = uncomfortable managing depression, work is having going and not rewarding, psychotherapy should be left to a specialist (47.0–80.3) Depression malleability 32.2 7.7 High score = pessimism towards depression, not amendable to change, is natural part of being old (15.8–47.5) Depression identification 41.1 14.6 High score = difficulty distinguishing between depression from unhappiness, little help beyond FP (13.3–69.6) Page 3 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 And patients seldom seek help with active reference to patients. Continuity of care was usually seen as a helpful their mental health status. Difficulties in accepting the tool for diagnosis as it enabled them to monitor a diagnosis 'depression' or 'anxiety disorder' as the explana- patient's complaints and functioning over time. On the tion for their problems, anhedony, negative thoughts, other hand some participants mentioned disadvantages feelings of shame a guilt and fear for stigmatisation, were of continuity of the doctor patient relation: getting too in the eyes of the FPs important barriers for treatment acquainted wit a patient may 'normalise' pathological while agreement about defining the problem is requisite. mental distress and so, delay recognition of psychiatric The FPs experienced that patients often had a strong resist- disorders. Although the participants were positive about ance to psychopharmacological treatment, especially their communication skills in general, they experienced when prescribed for a longer period of time. This was limited specific skills to cope and communicate with related to fear for side effects and dependency. Patients patients with mental health problems. often stopped taking their medication when symptoms had disappeared or diminished. The FPs felt also restricted Citations Distressed or disorder? in their treatment options due to patients' resistance 'many patients are distressed.... when I think it is serious I will towards referral to specialised mental health care profes- talk it over....' (FP 4, group A) sionals, because of emotional, social and financial barri- ers. 'sometimes, you see a patient so often.... You become too famil- iar. When the patient visits a colleague, she easily recognises a Citations Dealing with patients' preferences and resistance depressed state of mind....'.(FP 5, group A) 'patients only want to talk about the physical things, not about the mental ones. Often they are afraid to be qualified neurotic 'personally I have less rules of thumb for anxiety disorders... or depressed....' (FP 2, group A) especially with the various types of this disorder.' (FP 8, group C) 'Nearly all patients resist drug treatment; they think they have to overcome their problems all on their own and are afraid of Antidepressants and beyond side effects.... And when at last they are convinced to take anti- The FPs expressed difficulties in deciding on best manage- ment. In their professional opinion there is a lack of depressants, they discontinue as soon as they feel better for a few days.' (FP 3, group A) knowledge of the natural history and long-term prognosis of (un)treated depressive and anxiety disorders. From that Distress or disorder? clinical experience FPs attributed a substantial placebo The participants referred to the fact that, in their practice, effect to antidepressant drugs. Persisting co-existing psy- they encountered often-psychological problems of a tran- chosocial problems or deprivation also limited the sient nature, as part of 'normal' life events. According to response to (antidepressant drug) treatment. some, the distinction between such problems and a true psychiatric disorder was difficult. Therefore, most FPs The FPs said to prescribe often relatively low standard dos- were reluctant to label prematurely in diagnostic terms. ages of serotonin reuptake inhibitors. They considered For example, diagnosing major depressive disorder after their knowledge of the different types within this group of only two weeks after presentation of the symptoms was drugs as rather limited and had concerns about how to perceived as far too quick. In this respect, the FPs discontinue antidepressants. In case of non-response they expressed serious concerns of medicalising conditions hesitated to increase dosage or to use other psychotropics. they see as normal human distress. The assessment of the severity of the symptoms was perceived as crucial in decid- The increased focus on antidepressants during a consulta- ing about the diagnosing a depressive disorder or anxiety tion, limited the application of other approaches such as disorder as described in the DSM IV and as important for psycho-education or counselling. FPs considered cogni- deciding about treatment. Nevertheless, many FPs tive behavioural therapy (CBT) and problem solving ther- reported difficulties in how to assess the severity. FPs iden- apy (PST) as valuable interventions, suitable in family tified a number of patient groups in which recognition practice, but experienced a deficit in skills to apply such and diagnosis of depressive and anxiety disorders was par- techniques. ticularly problematic: the elderly, patients with a different cultural background and patients with limited verbal Citations Antidepressants and beyond skills. In patients with a chronic somatic-medical disease 'I think we overvalue antidepressants, we use them too FPs noticed difficulties in interpreting the cause of physi- soon, much of their effect is natural recovery of the disor- cal symptoms. FPs expressed a deficiency in their knowl- der' (FP 5, group C) edge of the specific anxiety disorders, and saw this deficiency as a potential cause of underdiagnosis in these Page 4 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 'maybe I hesitate to diagnose a depression because of the long systematic follow up of the patients was considered term treatment with antidepressant drugs....' (FP 6, group B) important. 'nowadays I spend so much time with talking about pills that Discussion there is barely time left for explaining the patients himself can The FPs valued recognising, diagnosing and managing do....' (FP 3, group A) depressive and anxiety disorders as important primary care tasks. However, many had strong reservations about Conflicting demands and possibilities the validity and usefulness of the DSM IV concepts of In addition, a number of structural barriers were men- these disorders for family practice. Different diagnostic tioned: a lack of time for detailed anamnesis and elabo- styles of the FPs were identified. With regard to diagnosis rate diagnostic procedures. This is reinforced because of and management FPs expressed a mismatch between the limited reimbursement for additional time investment. recommendations in guidelines of a specific – often phar- The time available for a standard consultation was seen as macological approach and patients' preferences. Resist- too limited for CBT or PST. Time pressure also limited ance against (long term use of) antidepressants and the extensive psycho-education. Patients and FPs are con- fact that other psychosocial co-morbidity may over- fronted with long waiting lists for specialised mental shadow or colour the features of depression and anxiety health care. A major concern of the FPs was the non struc- disorder, were seen as barriers for applying the guidelines. tural co-operation between family practice, primary care The management should focus more on patient empow- psychologists and specialised mental health care. Cooper- erment than antidepressant prescription only. FPs seems ation depended largely on personal relationships and to hesitate to use the diagnostic term depressive disorder experiences, only few mentioned more formal ways of or anxiety disorder while the fullfillment of these criteria cooperation like local or regional protocols or stepped imply a need for specific treatment. The argument of the care approaches need clear distinction between a diagnosis and need for treatment was also given from a theoretical point of view Citations Conflicting demands and possibilities [34]. 'for removing a naevus surgically in 5 minutes I received an extra fee, talking 15 minutes with a anxious patient is not This study started out on the medical paradigm/model rewarded at all' (FP 1, group A) but during the study the usefulness of this model was dis- puted. For FPs 'patient context' or patient background var- 'Finally, at the point the patient is convinced that referral is the iables were important in establishing mental health best option.... we faced a waiting list of 5 months....' (FP 4, problems. One of the barriers in implementing evidence group B) was that family physicians interpret evidence in an indi- vidual patients' context [35]. You need a lot of endurance when trying to communicate with psychiatrist or psychologist. Getting them on the During the group discussions proposals were made to phone takes lots of time. (FP 4, group A) overcome the problems experienced. It was noteworthy that the FPs touched upon a number of unresolved issues Needs and solutions in the medical literature: the effectiveness of antidepres- The group discussions did produce valuable solutions for sants in mild depressive disorders and the management of the problems encountered. It emphasized the importance co-morbid psychiatric disorders [36]. This underlines the of using time as a diagnostic tool. FPs receive more then need to take practical clinical experience from primary one opportunity to recognise a disorder. The approach of care into account in the design of further research on men- 'watchful waiting' when a disorder was suspected should tal health problems. receive more attention in clinical guidelines. Regarding management, patient education should be strengthened, Although this study provided important new informa- aiming at empowering patients. FP -friendly psychometric tion, a number of limitations of its design should be taken tools for diagnosis and severity or mental burden are wel- into account. The explorative design with a limited comed. Additional training on specific anxiety disorders, number of FPs may hamper the extrapolation of the for communication skills to cope better with patients with results to all FPs. The method of the focus group discus- mental health problems and for comprehensive psycho- sions worked quite well and yielded problems the partici- therapeutic techniques is needed. The FPs emphasized the pants experienced in all domains of their clinical practice need of a better co-operation with a limited number of of depressive- and anxiety disorders. Rigour was enhanced specialised mental health care providers. Better financial using the DAQ as an instrument for triangulation. The rewards for the time-intensive treatment of depressive- scores on the DAQ are in line with previously reported and anxiety disorders and appointing practice nurse for studies, also indicating that the participants of this study Page 5 of 7 (page number not for citation purposes) BMC Family Practice 2009, 10:52 http://www.biomedcentral.com/1471-2296/10/52 represented the variation in FPs attitudes towards mental reported earlier. These factors refer to insufficient under- health problems [25,26]. Unfortunately specific Dutch standing of the natural history, and course over time, of reference data concerning the DAQ are lacking. In the mental health problems. It stresses the importance of a Netherlands most health problems are treated in primary primary care research agenda of mental health problems care and FPs are serving as a 'gate keeper' for secondary focussing on those factors. It should form an integral part care. As many other countries have comparable health of the further improvement of mental health care. We rec- care systems and also a mix of private and public funding ommend to pay more attention to patient education/psy- the results of this study generalise to other countries as cho education, patient activation, self-management well. programs in family practice, the need for user-friendly psychometric tools for assessment and monitoring. For The serious conceptual doubts have not been presented instance the use of the PHQ-9 or the Beck Depression earlier, but some barriers had been reported earlier in a Inventory. The instruments can also be used for monitor- review, which was based on epidemiological data and the- ing the course of the disorder when using a watchfull wait- oretical considerations rather then on the experience of ing strategy or to evaluate treatment effects. Some of the FPs[11,37,38]. The FPs' opinions about the extremely approaches mentioned above can be provided by FPs, short 2 week period of the presence symptoms to diag- other by (community) mental health nurses working in nose a depressive disorder is supported by epidemiologi- family practice. cal data [39]. As well as a high recovery rate of depressive disorders within three months without a formal interven- Development of an effective generic approach for the tion [40]. Most qualitative studies published recently, did management of various mental health problems in family examine the FPs experience in recognizing depression practice and additional training for comprehensive psy- [15-21]. Recently the patient perspective on talking with chotherapeutic techniques is a priority. The FPs empha- doctors about depression was published [41]. Recogni- sized the need of a better co-operation with specialised tion and management of anxiety disorders were not stud- mental health care providers. Various collaborative care ied earlier [15-21]. Only a Swedish study reported on the models are developed, seem effective and can be used in management of depressive disorders, mainly on pharma- different health care models. cological treatment [21]. The GPs in our study reported considerable reservations regarding antidepressant drugs, In addition, the barriers and solutions should be taken felt unskilled to offer other specific treatment modalities into account in the design of primary care based interven- (like problem solving treatment) and experienced diffi- tions on recognition and management depressive- and culties in cooperation with specialized mental health care. anxiety disorders. This may result in better patient out- These difficulties are reflected in the relatively high score come and provision of cost effective care. on the DAQ subscale professional ease. Competing interests A study on British FPs did not report time pressure which The authors declare that they have no competing interests. was emphasized in this study as well as by British patients [18]. The difficulties in discriminating between psycho- Authors' contributions logical distress and a psychiatric disorder were reported EvR and HvH: have made substantial contributions to conception and design, or acquisition of data, or analysis earlier by Swedish FPs. They also modified the concept of depression with different causes and expressed reserva- and interpretation of data; tions of the increase in antidepressant prescribing [21]. It also emphasised the relevance of non-verbal signs and EvR, HvH, EvdL, FZ and CvW have been involved in draft- pre-existing knowledge of FPs. In accordance with our ing the manuscript or revising it critically for important results the collaboration with psychiatry consultants was intellectual content and have given final approval of the perceived as unsatisfactory [17]. The difficulties in man- version to be published. agement depressive disorders in patients with persisting psychosocial problems as reported by the FPs was Acknowledgements This study was co-funded by the International Health Foundation, Utrecht, described earlier in a study with FP working in socio-eco- the Netherlands. nomically deprived areas [16]. References Conclusion 1. Konig-Zahn C, Furer J, Tax B, Berg Jvd, Rijnders C, Zandstra S, Rijsw- This study confirmed the FPs' substantial professional role ijk Ev: Regioproject Nijmegen 2: Psychiatrische morbiditeit in in the diagnosis and management of depression and anx- de regio. Nijmegen 1999:1-141. 2. Bijl RV, Ravelli A, van Zessen G: Prevalence of psychiatric disor- iety. 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Your research papers will be: 25. Botega NJ, Silveira GM: General practitioners attitudes towards available free of charge to the entire biomedical community depression: a study in primary care setting in Brazil. Int J Soc Psychiatry 1996, 42(3):230-237. peer reviewed and published immediately upon acceptance 26. Dowrick C, Gask L, Perry R, Dixon C, Usherwood T: Do general cited in PubMed and archived on PubMed Central practitioners' attitudes towards depression predict their clinical behaviour? Psychol Med 2000, 30(2):413-419. yours — you keep the copyright 27. Kerr M, Blizard R, Mann A: General practitioners and psychia- BioMedcentral trists: comparison of attitudes to depression using the Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes)

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