Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Clinical Intelligence

An evidence-based first consultation for depression: nine key messages

Bruce Arroll, Weng Yee Chin, Fiona Moir and Christopher Dowrick
British Journal of General Practice 2018; 68 (669): 200-201. DOI: https://doi.org/10.3399/bjgp18X695681
Bruce Arroll
Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
Roles: Professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Weng Yee Chin
Department of Family Medicine and Primary Care, Bau Institute of Medical and Health Sciences Education, University of Hong Kong, Hong Kong.
Roles: Assistant professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Fiona Moir
Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
Roles: Senior lecturer
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christopher Dowrick
University of Liverpool, Liverpool, UK.
Roles: Professor of primary medical care
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading

Published eLetters

eLetter submission guidelines

Submit a Response to This Article
Compose eLetter

More information about text formats

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com. PLEASE NOTE: your email address will be published.
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

  • Antidepressants can benefit patients with major depression, and a 10th key issue is which drugs should be used first-line
    Tony Kendrick, Beth Stuart, Colin Newell, Andrew DeSilva and Sian Stephens
    Published on: 14 August 2018
  • Published on: (14 August 2018)
    Page navigation anchor for Antidepressants can benefit patients with major depression, and a 10th key issue is which drugs should be used first-line
    Antidepressants can benefit patients with major depression, and a 10th key issue is which drugs should be used first-line
    • Tony Kendrick, Professor of Primary Care, University of Southampton
    • Other Contributors:
      • Beth Stuart, Associate Professor of Medical Statistics, University of Southampton
      • Colin Newell, Clinical Informatics Data Manager, University of Southampton
      • Andrew DeSilva, Foundation Doctor, University of Southampton
      • Sian Stephens, Foundation Doctor, University of Southampton

    We agree with Arroll and colleagues1 that GPs should think carefully before prescribing antidepressants, but they suggested even patients with severe depression are unlikely to benefit, citing a 2010 study2 and ignoring the recent Lancet meta-analysis comparing 21 antidepressants and showing that all were more efficacious than placebo for major depression.3

    We understand concerns about increasing GP antidepressant prescribing, and worry the widely reported meta-analysis might increase overall prescribing, rather than influence the relative use of different antidepressants, which was its aim.3 However, we have data to suggest its impact will not be to increase prescribing for new episodes.

    We explored the effects of a 2009 meta-analysis by the same group, comparing 12 antidepressants,4 on GP prescribing using Clinical Practice Research Datalink data.  The previous study stated that sertraline, having the most favourable balance between benefits, acceptability, and cost, might be the best initial choice.4 To explore the effects of this, we conducted time trend analyses of percentages of GP prescriptions for different antidepressants, modelled as an interrupted time series.

    The figure shows percentages of antidepressants prescribed first-choice, for first-ever and recurrent episodes of depression, for citalopram, fluoxetine, sertraline, mirtazapine, and escitalopram. Time trend anal...

    Show More

    We agree with Arroll and colleagues1 that GPs should think carefully before prescribing antidepressants, but they suggested even patients with severe depression are unlikely to benefit, citing a 2010 study2 and ignoring the recent Lancet meta-analysis comparing 21 antidepressants and showing that all were more efficacious than placebo for major depression.3

    We understand concerns about increasing GP antidepressant prescribing, and worry the widely reported meta-analysis might increase overall prescribing, rather than influence the relative use of different antidepressants, which was its aim.3 However, we have data to suggest its impact will not be to increase prescribing for new episodes.

    We explored the effects of a 2009 meta-analysis by the same group, comparing 12 antidepressants,4 on GP prescribing using Clinical Practice Research Datalink data.  The previous study stated that sertraline, having the most favourable balance between benefits, acceptability, and cost, might be the best initial choice.4 To explore the effects of this, we conducted time trend analyses of percentages of GP prescriptions for different antidepressants, modelled as an interrupted time series.

    The figure shows percentages of antidepressants prescribed first-choice, for first-ever and recurrent episodes of depression, for citalopram, fluoxetine, sertraline, mirtazapine, and escitalopram. Time trend analysis showed that, following the 2009 meta-analysis, sertraline rose significantly as a proportion of prescriptions by 0.9% per quarter-year (95% CI 0.7-1.1%) for first-ever episodes and 1.1% (0.8-1.4%) for recurrent episodes. Use of citalopram levelled off significantly, falling by 1.4% per quarter (0.4-2.4%) for first episodes, and 3.3% (0.9-5.7%) for recurrent, and use of fluoxetine continued to fall by 1.0% (0.5-1.4%) and 1.8% (0.8-2.7%) respectively.

    Figure: Proportions of first-line antidepressants, prescribed by GPs for new and recurrent episodes of depression, which were for citalopram, fluoxetine, sertraline, mirtazapine and escitalopram, 2003 to 2013

     

    Includes data for 191,117 patients and 237,178 episodes of depression, across 142 practices in the Clinical Practice Research Datalink database. Of 237,178 episodes, 104,337 were first-ever episodes, 63% of which were treated with an antidepressant within the first 12 months of an episode start date; and 132,841 recurrent episodes, 73% of which were treated.

    Overall antidepressant prescribing did not increase, but remained at around 70% of cases diagnosed5. While prescriptions doubled from 2003-2013, this was not due to more people starting antidepressants, but to longer treatment, with a doubling of mean prescriptions per patient per year.5

    An editorial accompanying the recent meta-analysis suggested three antidepressants with higher efficacy emerged as preferable first choices after factoring in acceptability: agomelatine, escitalopram, and vortioxetine.6 It will be interesting to see whether the use of these increases or not in the next few years, given their higher costs.

    References

    1. Arroll B, Chin WY, Moir F, Dowrick C. An evidence-based first consultation for depression:  nine key messages. Br J Gen Pract 2018; 68:200–201. https://doi.org/10.3399/bjgp18X695681
    2. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010; 303(1):47–53. https://doi.org/10.1001/jama.2009.1943  
    3. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018; 391:1357-66. 2018 https://doi.org/10.1016/S0140-6736(17)32802-7  
    4. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatment meta-analysis. Lancet 2009; 373: 746–58. https://doi.org/10.1016/S0140-6736(09)60046-5
    5. Kendrick T, Stuart B, Newell C, et al. Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003–2013. J Affective Disorders 2015; 186:171–7. https://doi.org/10.1016/j.jad.2015.06.052
    6. Parikh SV, Kennedy SH. More data, more answers: picking the optimal antidepressant. Lancet 2018; 391:1333-1334. http://dx.doi.org/10.1016/S0140-6736(18)30421-5

    Show Less
    Competing Interests: None declared.
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 68 (669)
British Journal of General Practice
Vol. 68, Issue 669
April 2018
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
An evidence-based first consultation for depression: nine key messages
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
An evidence-based first consultation for depression: nine key messages
Bruce Arroll, Weng Yee Chin, Fiona Moir, Christopher Dowrick
British Journal of General Practice 2018; 68 (669): 200-201. DOI: 10.3399/bjgp18X695681

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
An evidence-based first consultation for depression: nine key messages
Bruce Arroll, Weng Yee Chin, Fiona Moir, Christopher Dowrick
British Journal of General Practice 2018; 68 (669): 200-201. DOI: 10.3399/bjgp18X695681
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • 1. DEPRESSION IS COMMON IN PRIMARY CARE BUT MANY PATIENTS MAY NOT RECEIVE A MENTAL HEALTH DIAGNOSIS
    • 2. HOW IMPORTANT IS IT TO HAVE A DIAGNOSIS OF DEPRESSION OR ANXIETY VERSUS ‘BEING HEARD AND UNDERSTOOD’?
    • 3. DIFFERENTIATING PSYCHOLOGICAL DISTRESS FROM DEPRESSION CAN BE VERY CHALLENGING, PARTICULARLY ON THE FIRST VISIT
    • 4. MOST PATIENTS WITH DEPRESSION PRESENT WITH SOMATIC SYMPTOMS, SO OPEN THE CONSULTATION BY INCLUDING MENTAL ALONGSIDE PHYSICAL HEALTH
    • 5. RULE OUT DEPRESSION BY USING TWO QUESTIONS AND EXPLORE FURTHER IF THERE IS A POSITIVE RESPONSE
    • 6. ONE-OFF HIGH DEPRESSION SCORES DO NOT NECESSARILY SIGNIFY MAJOR DEPRESSION AND ARE LIKELY TO BE LOWER AT THE NEXT VISIT
    • 7. CONSIDER NON-DRUG INTERVENTIONS FIRST
    • 8. THINK VERY CAREFULLY BEFORE COMMENCING ANTIDEPRESSANT MEDICATION ON THE FIRST VISIT
    • 9. SEE THE PATIENT AGAIN IN 1 WEEK (IF POSSIBLE) AND CONSIDER PHONING THEM BETWEEN VISITS
    • Acknowledgments
    • Notes
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • How to manage low testosterone level in men: a guide for primary care
  • Hyperparathyroidism (primary) NICE guideline: diagnosis, assessment, and initial management
  • The atypical presentation of COVID-19 as gastrointestinal disease: key points for primary care
Show more Clinical Intelligence

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2022 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242