September Focus

My Cumbrian GP friend, who has featured in this column before, published a study of obstetric deliveries taking place outside specialist units in 1996.1 The care provided was, of course, the responsibility of midwives. However, there was a finding that never made it into print. Planning and having a successful out-of-hospital delivery depended in some vague way on the support of the GPs. I was reminded of this by the two papers published this month on place of death. The study from Belgium found a link between GPs' knowledge of patients' preference, and such preferences being fulfilled (page 665). The authors concluded that knowing their patients' preference would encourage GPs to make an active contribution. That idea gains support from the study from Denmark, which found a strong association between the GPs making home visits and the likelihood of dying at home (page 671). As with obstetrics, much of the work of terminal care in the UK is done by nurses and other professionals, but this evidence suggests that support by GPs is an important element in achieving the desired outcome. The linked editorial describes the difficulties that may be involved, and cautions that while we should give patients the opportunity to discuss their preference we must also respect their desire not to have such a discussion (page 642). A reminder of Clement Attlee's famous rebuke to Harold Laski: ‘A period of silence would be most welcome.’ One has to hope that, having a discussion about place of death isn't going to appear as a QOF target. By the same token I assume that Helen Lester's suggestion of a QOF target measuring ‘eye contact’ is a joke, only the resulting laughter has a hollow ring (page 706).

Mental health matters dominate the rest of this month's BJGP. There is further evidence, this time from Sweden, that the recommended cut-off points for the PHQ may encourage overdiagnosis of depression (page 650). I hope by now that those GPs who (like me and my own colleagues) are using the PHQ routinely are not trusting its results above their own judgement. The study on page 644 is a suitable corrective: here the GPs' assessment of severity seemed to match the more reliable HADS scores (see particularly the figure on page 646). The authors also concluded that there was little inappropriate antidepressant prescribing. This study originated with the finding that such prescribing had increased substantially in the last 20 years. However, one interpretation would be that it is a rational response to all the exhortation we have had to devote more energy to identifying patients with depression, and treating those identified more vigorously. Such an interpretation would be consistent with the findings from the qualitative study on page 658. Here GPs offered various reasons for the changes, including their response to the ‘Defeat Depression’ campaign, but there was also a strong element in the study that the GPs felt that they were very much at the mercy of external drivers. The contrasting paper on page 656 looked at GPs' decisions to refer patients for psychological therapies. Here the findings suggested GPs were taking a wide range of factors into account and were revealing themselves to be rational decision makers. The accompanying commentary on page 657 bemoans the lack of predictors to tell us who is likely to respond to which kinds of treatment. The study on page 660 looks at reasons for young people choosing whether to disclose psychological problems to their doctors. The likelihood was increased by having consulted with the GP more in the past, and by confiding with other adults. But I am struck by a thought that feels as if it has taken at least 20 years to reach consciousness. We know that only a small proportion of patients with symptoms of anything choose to consult a doctor. So if patients have, for instance, symptoms of moderate osteoarthritis it doesn't bother us if they choose to manage it without our help. So, why do we get so bothered by patients managing moderate degrees of depressive illness on their own? Answers not on a postcard but by email please.

In the headline editorial on page 636, Chris Dowrick thinks there are various ways that we can improve our handling of patients with depression, but concludes that there is plenty to celebrate. Stop feeling so defensive about it!

• © British Journal of General Practice, 2009.