Depression in general practice: underrecognition? Overtreatment? Adequate care!

Overall this thesis gives an optimistic picture of current care for depressed patients in primary care compared to previous literature and media reports. We conclude that, in general, the care for depressed patients in primary care is in most cases adequate, i.e. in accordance with ruling guideline recommendations.

The general practitioner recognized over two-thirds of depressed patients. Patients discussing psychological problems with the general practitioner, those with more depressive symptoms and with a concurrent anxiety disorder were better recognized. The atypical symptom increased appetite led to worse recognition.

58% of depressed patients were referred for psychological or psychiatric care. General practitioners took guideline recommendations into account in referring; patients with preference for psychotherapy, chronic depression or suicidal tendency were referred more often.

Treatment with antidepressants was also prescribed according to guideline recommendations. In only 5.4% of antidepressant users it could be called overtreatment. Furthermore, over half of these overtreated patients started with a good reason, but were treated too long according to guideline recommendations.

From review of the literature we conclude that guideline recommendations for antidepressant treatment are thoroughly evidence-based for acute treatment and relapse prevention during several months, but not for maintenance treatment.
Recommendations for maintenance treatment are also less often followed. Maintenance users are not, as the guideline prescribes, patients with chronic or recurrent depression. It does however seem that maintenance antidepressant users are those with a worse prognosis such as patients with comorbid dysthymia or anxiety and patients also receiving sedatives or patients with recent psychiatric contacts.