Severity alone should no longer determine therapeutic choice in the management of depression in primary care: findings from a survey of general practitioners.

Background: The treatment of depression in primary care remains suboptimal for reasons that are complex and multifactorial. Typically GPs have to make difficult decisions in limited time and therefore, the aim of this study was to examine the management of depression of varying severity and the factors associated with treatment choices.

Method: Nested within a primary care educational initiative we conducted a survey of 1760 GPs. The GPs each identified four patients with clinical depression whom they had treated recently and then answered questions regarding their diagnosis and management of each patient.

Results: Comorbid anxiety, sadness and decreased concentration appeared to direct the management of depression toward psychological therapy, whereas comorbid pain and a patient's overall functioning, such as the ability to do simple everyday activities, directed the initiation of pharmacological treatment. The use of antidepressants with a broader spectrum of actions (acting on multiple neurotransmitters) increased from mild to severe depression, whereas this did not occur with the more selective agents. SSRIs were prescribed more frequently compared with all other antidepressants, irrespective of depression severity.

Limitations: GPs chose the RADAR programme and therefore they were potentially more likely to have an interest in mental health compared to GPs who did not participate.

Conclusions: GPs do not appear to be determining pharmacological treatment based on depression subtype and specificity, but rather on the basis of the total number of symptoms and overall severity. While acknowledging important differences between primary care and specialist practice, it is suggested that guidelines to assist GPs in matching treatment to depression subtype may be of practical assistance in decision-making, and the delivery of more effective treatments.