‘Doing the right thing’: factors influencing GP prescribing of antidepressants and prescribed doses

Abstract

BackgroundAntidepressant prescribing continues to increase, with 5-16% of adults receiving antidepressants annually. Total prescribing growth is due in part to increased long-term use, greater selective serotonin re-uptake inhibitor (SSRI) use and the use of higher SSRI doses. Evidence does not support routine use of higher SSRI doses for depression treatment, and factors influencing the use of such doses are not well known. The aim of this study was to explore factors influencing GPs’ use of antidepressants and their doses to treat depression.MethodsSemi-structured interviews with a purposive sample of 28 practising GPs; sampled by antidepressant prescribing volume, practice size and deprivation level. A topic guide drawing on past literature was used with enough flexibility to allow additional themes to emerge. Interviews were audio-recorded and transcribed verbatim. Framework analysis was employed. Constant comparison and disconfirmation were carried out across transcripts, with data collection being interspersed with analysis by three researchers. The thematic framework was then systematically applied to the data and conceptualised into an overarching explanatory model.ResultsDepression treatment involved ethical and professional imperatives of ‘doing the right thing’ for individuals by striving to achieve the ‘right care fit’. This involved medicalised and non-medicalised patient-centred approaches. Factors influencing antidepressant prescribing and doses varied over time from first presentation, to antidepressant initiation and longer-term treatment. When faced with distressed patients showing symptoms of moderate to severe depression GPs were confident prescribing SSRIs which they considered as safe and effective medicines, and ethically and professionally appropriate.Many GPs were unaware that higher doses lacked greater efficacy and onset of action occurred within 1-2 weeks, preferring to wait 8-12 weeks before increasing or switching. Ongoing pressures to maintain prescribing (e.g. fear of depression recurrence), few perceived continuation problems (e.g. lack of safety concerns) and lack of proactive medication review (e.g. patients only present in crisis), all combine to further drive antidepressant prescribing growth over time.ConclusionsGPs strive to ‘do the right thing’ to help people. Antidepressants are only a single facet of depression treatment. However, increased awareness of drug limitations and regular proactive reviews may help optimise care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0643-z) contains supplementary material, which is available to authorized users.

“Every structure we're taught goes out the window”: General practitioners' experiences of providing help for patients with emotional concerns'

“…Firstly, many GPs in this study reported understanding patients’ emotional concerns as due to life stress. This is reflected in the literature, where GPs report tensions between being trained to approach emotional concerns as a biomedical issue, and their own beliefs that emotional concerns result from life stressors (Dew et al, ; Johnson et al, ; Thomas‐MacLean et al, ). As a result, some GPs preferred to utilise a multifaceted treatment approach including social prescribing (Johnson et al, ).…”

“…GPs report tensions between being trained to approach emotional concerns as a biomedical issue, and their own beliefs that emotional concerns result from life stressors (Dew et al, 2005;Johnson et al, 2017;Thomas-MacLean et al, 2005). As a result, some GPs preferred to utilise a multifaceted treatment approach including social prescribing (Johnson et al, 2017).…”

Barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis

“…Of the three full papers assessed, two were excluded (no data on attitudes, beliefs, feelings, perceptions on continuing or discontinuing antidepressant use n=1, did not use qualitative data collection and analysis n=1). A total of 22 papers reporting 22 studies were therefore included in our review (Karp, 1993;Knudsen et al, 2002;Pollack and Grime, 2002;Hoogen, 2006;Verbeek-Heida and Mathot, 2006;Holt, 2007;Johnston et al, 2007;Leydon et al, 2007;Wilson, 2007;McMullen and Herman, 2009;Aselton, 2010;Dickinson et al, 2010;McKinney and Greenfield, 2010;Iden et al, 2011;Schofield et al, 2011;Buus et al, 2012;Bayliss and Holttum 2015;Eveleigh, 2015;Nygaard et al, 2015;Weaver, 2015;Bosman et al, 2016;Johnson et al, 2017). Of note, no potentially relevant titles and abstracts were excluded solely on the basis of being non-English language publications.…”

Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population

“…The reasons for potential antidepressant overprescribing in our study remain unclear, but may include the availability of agents that are safer for use in the elderly, the improved detection of emotional distress in geriatric patients, and the increasing use of antidepressants in general practice . The challenges associated with managing a large number of co‐occurring chronic health conditions during brief office visits may also be an important factor–one that we were unable to assess directly in this research. However, potential antidepressant overprescribing in our study was associated with factors representing higher clinical complexity or severity.…”