Research report
Are effects of depression management training for General Practitioners on patient outcomes mediated by improvements in the process of care?

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Abstract

Background: Depression treatment by General Practitioners (GPs) and patient outcomes improved significantly after a comprehensive 20-h training program of GPs. This study examines whether the effects on patient outcomes are caused by the improvements in the process of care. Methods: Seventeen GPs participated in the training program. A pre-test–post-test design was used. A total of 174 patients (85 pre-test, 89 post-test) aged 18–65 met ICD-10 criteria for recent onset major depression. The main indicator of mediation was a drop in training effect size (η2) on patient outcome after adjustment for individual and combined process of care variables. We evaluated depression-specific (recognition, accurate diagnosis, prescription of antidepressant, adequate antidepressant treatment) and a non-specific process of care variable (communicative skillfulness of the GP) as well as the combination of adequate antidepressant treatment and communicative skillfulness. Patient outcomes were assessed at 3 months and consisted of change in severity of symptomatology, level of daily functioning and activity limitation days from baseline. Results: Depression-specific interventions mediated up to one third of the observed improvement in patient outcome. ‘Adequate dosage and duration of an antidepressant’ explained 36% of the training effect on patient outcome (η2 from 0.044 to 0.028). ‘Communicative skillfulness of the GP’ only was a weak mediator (18% explained; η2 from 0.044 to 0.036). However, the combination of both, that is adequate antidepressant treatment by a communicative skillful GP, proved to be the strongest mediator of the observed training effect on patient outcomes (59% explained; η2 from 0.044 to 0.018). Limitations: The training effects on patient outcomes in this sample were small. Hence, the scope for mediation was limited. Conclusion: GP communication skills are important to enhance depression-specific interventions in bringing about improvements in patient outcomes and should be addressed in GP training programs for the treatment of depression.

Introduction

Recent reviews point out significant shortcomings in the management of depression in primary care settings. A significant proportion of patients with active depression seen by General Practitioners (GPs) remain undiagnosed (Ormel et al., 1991, Eisenberg, 1992, Üstün and Sartorius, 1995, Tiemens et al., 1996) and even when depression is accurately diagnosed, many do not receive adequate dosage and duration of antidepressant treatment (Thompson and Thompson, 1989, Katon et al., 1992, Katon et al., 1995, Maddox et al., 1994, Donoghue and Tylee, 1996, Johnson et al., 1996, Gregor et al., 1998, Lawrenson et al., 2000). This suggests the need for training programs for GPs targeting the process of care for depression.

We developed an active hands-on training program that offered both specific diagnostic and management guidelines for depression and training in general clinical approaches to mental illness, including communication skills (Jenner et al., 1995). Ormel et al. (1998), van Os et al., 1999, van Os et al., 2002 and Tiemens et al. (1999) reported the effects of this training program. GP treatment regimens improved in accordance with treatment guidelines. Antidepressant treatment increased significantly from 24% to 40%. Adequate dosage and duration increased from 47% to 84% of all patients prescribed an antidepressant for depression. Communicative skillfulness of GPs improved from 37% to 72%.

Regarding patient outcomes, Tiemens et al. (1999) found positive but small effects for depressed patients. At the 3-months follow-up, the depressed patients of trained physicians had less symptomatology than depressed patients of the same physicians prior to the training. For a subgroup of depressed patients, however, stronger effects were found. This subgroup consisted of patients with an episode duration less than 12 months at the time of the index visit (‘recent onset’) who were also recognised by their physician as having a mental health problem. At the 3-months follow-up, the post-training patients from this subgroup had less severe symptomatology, better daily functioning and less activity limitation days than the pre-training group had at the 3-months follow-up. In addition, the median duration of the episode was 5 weeks shorter for the post-training group than for the pre-training group.

The present study examines whether the observed training effects on 3-months patient outcomes were caused by the observed improvements in process of care, and if so, which process of care variables were responsible for these better patient outcomes. Both depression-specific aspects (recognition; accuracy of depression diagnosis; prescription of antidepressant; adequate dosage and duration of antidepressant treatment) and a non-specific one (communicative skillfulness of the GP) as well as a combination of adequate antidepressant treatment and communicative skillfulness were examined. Our analysis targets all patients with a recent onset ICD-10 depression, irrespective of whether the depressed patient was recognised by the GP as having a mental health problem, because firstly, recognition by the GP is one of the potential mediators of improvement in patient outcomes, and secondly, as a result of the training, the case mix of the patient groups recognised by the GPs before and after the training may differ. For example, after the training GPs may recognise more patients with mild symptomatology or disability who are known to have a better prognosis (van den Brink et al., 2002). Because we did not find a training effect on episode duration for the current sample of all recent onset depression cases, we restricted our analyses to the changes over the 3-months follow-up period in severity of symptomatology, level of daily functioning and activity limitation days.

Section snippets

Patient and data collection

The present study was carried out in the context of an intervention study designed to evaluate the effects of a post-academic training program (Jenner et al., 1995) on the process of care for depression and patient outcomes in primary care (Ormel et al., 1998, van Os et al., 1999, van Os et al., 2002, Tiemens et al., 1999). Although the study has been described extensively in earlier publications, we present an outline of the recruitment and data collection procedures.

Independent samples of

Patient, illness and process of care characteristics

A total of 174 patients with a recent onset ICD-10 depression were identified in the pre- and post-training samples (N pre=85; N post=89). Of these, 76 patients were missing one of the patient outcome variables. The dropouts did not show significant differences from the study sample on patient characteristics, illness characteristics or process of care variables.

Pre and post differences in process of care

Table 1 shows the pre- and post-training recognition rates and accuracy of diagnosis as well as the treatment of all recent onset

Discussion

The present study aimed to examine whether observed improvements in patient outcomes were caused by improvements in process of care. We examined the patients with a recent onset depression. What did we find? Recognition and accuracy of diagnosis did not mediate the patient outcome, probably because these process of care variables did not improve by the training. The provision of an antidepressant did improve, but this improvement was not responsible for the observed training effect on patient

Acknowledgements

We gratefully acknowledge the participating general practitioners, the research workers who interviewed the patients, and H. Hallie for the data entry.

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