A great deal of time and money has been spent on improving the diagnosis and management of depression and self-harm in primary care. The evidence tells us that collaborative care and case management can be effective approaches, which is all well and good, but these complex interventions are not always feasible.
This new cluster randomised controlled trial published in the Annals of Family Medicine, investigates the value of an educational intervention targeting general practitioners (GPs), to help reduce the prevalence of depression and self-harm behaviour in older primary care patients.
373 GPs from Australia and 21,762 patients aged 60 and older (mean age 71.8 years) were involved in the study. The GPs were randomised to one or two interventions:
- A practice audit with personalised feedback and educational materials (focusing on screening, diagnosis and management of depression and suicide in later life)
- An audit with no personalised feedback (control)
The audit was done on 20 consecutive patients attending the practice. The GPs used questionnaires to assess depression and self-harm behaviour:
- Patient Health Questionnaire (PHQ-9)
- Depressive Symptom Index Suicidality Scale
The GPs in the intervention group then received feedback on:
- How many patients with depression they had in their practice compared with other practices
- How many patients with depression and self-harm ideation that they correctly identified
- Which patients had self-reported symptoms of depression
Here’s what they found:
- Compared with control, the personalised feedback and educational intervention reduced the proportion of older patients with depression or suicide ideation/attempt (absolute risk 10.4% with intervention vs 11.4% with control; adjusted OR 0.90, 95% CI 0.83 to 0.97)
- The intervention did not reduce depression (AR 8.1% with intervention vs 8.7% with control; adjusted OR 0.93, 95% CI 0.83 to 1.03)
- The intervention did reduce the risk of suicide ideation or attempt (AR 4.5% with intervention vs 5.1% with control; adjusted OR 0.80, 95% CI 0.68 to 0.94)
- Secondary analysis showed that these differences were not due to patients receiving antidepressants, contact with mental health staff or other group support
The authors concluded:
Practice audit and targeted education of general practitioners reduced the 2-year prevalence of depression and self-harm behaviour by 10% compared with control physicians. The intervention had no effect on recovery from depression or self-harm behaviour, but it prevented the onset of new cases of self-harm behaviour during follow-up.
It has to be said, this is not a wildly positive finding. The educational intervention showed no impact on long term outcomes for the older patients in the trial, no impact on depression management by GPs, and no reduction in depression prevalence or self-harm behaviour.
The study did report that older adults who received the intervention were less likely to exhibit self-harm behaviour, but this was not related to improved depression treatment. The researchers suggest that this positive finding may be explained by the higher levels of empathy and improved understanding that may result when GPs have the opportunity to use high quality educational materials.
It seems sensible to suggest that improving the communication skills and empathy of family doctors is likely to result in depressed older people receiving better care. Perhaps a move away from the (sometimes) rigid screening and assessment of depression towards more preventative interventions makes sense? Clearly, it’s not just GPs that can provide this kind of social and emotional support, but this kind of care does need time and space to work.
Almeida OP, Pirkis J, Kerse N, Sim M, et al. A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients. Ann Fam Med 2012; 10: 347– 56.