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Difficult-to-treat-depression: what do general practitioners think?

Kay M Jones, David J Castle, Eleanor M Curran and Leon Piterman
Med J Aust 2013; 199 (6): S6-S8. || doi: 10.5694/mja12.10566
Published online: 29 October 2013

This is a republished version of an article previously published in MJA Open

The social, economic and personal burdens caused by depression are substantial1 and well documented.2 Nonetheless, shortcomings in treatment of depression have been identified in both primary and specialised care, with respect to diagnosis, management and patient adherence.

Health professionals, including general practitioners, may be confused about diagnosis and management when clear definitions and acceptable taxonomy cannot be found. In the literature, terms including “difficult-to-treat depression”, “treatment-resistant depression”, “treatment-refractory depression”, “treatment-resistant major depressive disorder” and “major depressive disorder” are often used interchangeably,3-5 resulting in considerable confusion. Further problems arise because of a mismatch between current classification systems, such as the Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) or the International Classification of Diseases, and the possible clinical phenotypes of mental disorders, particularly as they present in primary care.6 It has also been suggested that meaningful subtypes of depression might have different treatment outcomes, raising another clinical imperative for accurate diagnosis.

Against this background, we aimed to explore GPs’ understanding of the definitions of and management guidelines for difficult-to-treat depression (DTTD), and their experiences of diagnosing and managing patients with DTTD.

Results

Ten GPs were invited and all agreed to participate: five (two women, three men) from inner Melbourne participated in the focus group; three (all men) from outer Melbourne and two (one woman, one man) from rural Victoria had a telephone interview. All participants had been working in general practice for at least 15 years.

Findings are reported based on the interview schedule’s five topics. Quotes are attributed to participants of the focus group (FG) or those interviewed by telephone (GP).

3 Experiences of diagnosing difficult-to-treat depression

There was agreement among participants that only a small number of patients present to GPs with DTTD, but that they take up a disproportionate amount of clinician time. Diagnosis was considered difficult, particularly in cases complicated by coexisting conditions.

Some participants used management guidelines, such as the DSM-IV, but felt they were not always helpful, as they were difficult to negotiate and apply to particular patients. Others suggested that diagnostic tests have an important role in ensuring any initial diagnosis is correct. The general consensus was that tight diagnostic labels may not help GPs, but that the term DTTD could be useful because it would flag patients who may require input from a specialist.

However, the value of referral to specialists was questioned by some participants.

Participants generally felt that their relationship with the patient was important in managing them, but the option of involving family members was not mentioned.

4 Experiences of managing difficult-to-treat depression

All participants had managed patients with DTTD and often found it difficult.

Managing these patients was described as a team effort because there can be many exacerbating environmental factors, such as low socioeconomic status, social isolation and relationship conflict, that could be related to poor treatment outcome.

Shared care was valued, particularly for patients who had been hospitalised or who had comorbidities. Participants felt they knew about the patients’ physical and family issues, but their level of concern about patients at risk led them to seek input from experts.

Few participants knew about or had used available services, such as the Primary Mental Health Team initiative in Victoria, or government initiatives such as the Mobile Aged Psychiatry Service. Most participants were aware of the Medicare “Better Access” program.

5 Management options

Only one participant had heard of the Wagner chronic illness management model,10 but all acknowledged that a chronic disease management model can be useful in DTTD.

All participants had referred some of their patients with depression to a psychiatrist. Some did so because the patients had multiple needs, others when they felt they needed a psychiatrist’s opinion; some felt referring to a psychiatrist was reserved for severely ill or suicidal patients.

However, accessing a psychiatrist was problematic because of lack of availability, especially of bulk-billing psychiatrists.

In the absence of an accessible psychiatrist, some participants used mental health care plans to refer patients to psychologists and social workers. Others used the services of the Primary Mental Health Teams.

Regardless of cost and accessibility, the relationship between the specialist and the patient was felt to be particularly important.

Most participants felt that non-pharmacological or complementary treatments and “lifestyle options” have a role in managing DTTD.

Discussion

This small qualitative study of experienced GPs from urban and rural settings in Victoria raises a number of important issues regarding how GPs evaluate and respond to patients with DTTD.

Although participants demonstrated limited knowledge of the different classifications of DTTD, they had extensive experience in managing and treating patients whose illness was difficult to treat. They had little interest in the nuances of classification, and instead focused on the patient and what to do in practical terms regarding optimal management.

While all participants were aware in general terms of government initiatives that could provide support for patients with DTTD, there were gaps in their knowledge about the specific programs and resources available. Participants were also aware that specialist resources were limited, regardless of location. Thus, they used other management options, including non-pharmacological or complementary treatments. Few were enamoured of existing guidelines, finding them difficult to access and use.

Limitations of this study include the small number of participating GPs and the fact that all were from Victoria. However, they all had extensive clinical experience, and a number of themes relevant to DTTD were raised.

To improve management and treatment of DTTD in both primary and specialised care, resources need to be more available and accessible, including guidelines that are current and relevant to general practice in Australia. Overcoming barriers to accessing specialist and non-medical care should be seen as a priority in assisting GPs to treat patients with DTTD.


Provenance: Commissioned by supplement editors; externally peer reviewed.

Received 29 March 2012, accepted 6 September 2012

  • Kay M Jones1
  • David J Castle2,3
  • Eleanor M Curran2
  • Leon Piterman1

  • 1 Monash University, Melbourne, VIC.
  • 2 St Vincent’s Hospital, Melbourne, VIC.
  • 3 University of Melbourne, Melbourne, VIC.


Correspondence: kay.jones@monash.edu

Acknowledgements: 

We extend our sincere thanks to the GPs who participated, Dr Ian Chenoweth for assisting with the focus group and reading a draft of this manuscript, and AstraZeneca for funding this project.

Competing interests:

David Castle has received travel support, honoraria and payment for advisory board membership from AstraZeneca. Leon Piterman has received payment for advisory board membership from AstraZeneca and Pfizer.

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