Swiss GPs\u2019 preferences for antidepressant treatment in mild depression: vignette-based quantitative analysis

Stefan Neuner-Jehle,Oliver Senn,Michael P. Hengartner

doi:10.1186/s12875-021-01621-7

Abstract

BackgroundGPs frequently prescribe antidepressants in mild depression. The aim of this study was to examine, how often Swiss GPs recommend antidepressants in various clinical presentations of mild depression and which factors contribute to antidepressant treatment recommendations.MethodsWe conducted an online survey among Swiss GPs with within-subject effect analysis. Alternating case vignettes described a typical female case of mild depression according to International Classification of Diseases, 10th edition criteria, with and without anxiety symptoms and sleep problems. GPs indicated for each vignette their preferred treatments (several recommendations were possible). Additionally, we assessed GP characteristics, attitudes towards depression treatments, and elements of clinical decision-making.ResultsAltogether 178 GPs completed the survey. In the initial description of a case with mild depression, 11% (95%-CI: 7%-17%) of GPs recommended antidepressants. If anxiety symptoms were added to the same case, 29% (23%-36%) recommended antidepressants. If sleep problems were mentioned, 47% (40%-55%) recommended antidepressants, and if both sleep problems and anxiety symptoms were mentioned, 63% (56%-70%) recommended antidepressants. Several factors were independently associated with increased odds of recommending antidepressants, specifically more years of practical experience, an advanced training in psychosomatic and psychosocial medicine, self-dispensation, and a higher perceived effectiveness of antidepressants. By contrast, a higher perceived influence of patient characteristics and the use of clinical practice guidelines were associated with reduced odds of recommending antidepressants.ConclusionsConsistent with depression practice guidelines, Swiss GPs rarely recommended antidepressants in mild depression if no co-indications (i.e., sleep problems and anxiety symptoms) were depicted. However, presence of sleep problems and anxiety symptoms, many years of practical experience, overestimation of antidepressants’ effectiveness, self-dispensation, an advanced training in psychosomatic and psychosocial medicine, and non-use of clinical practice guidelines may independently lead to antidepressant over-prescribing.

Highlights

In Switzerland and most other high-income countries, General practitioners (GPs) treat the majority of patients with depression and prescribe most antidepressants for depression [1, 2]
The recommendation of antidepressant treatment strongly varied based on the specific symptoms depicted: in the initial description of a case with mild depression, antidepressants were rarely recommended (11%), but if sleep problems were added to the vignette, about half of GPs recommended antidepressants (47%)
The rate of 35% for recommending antidepressant treatment across case descriptions of mild depression is consistent with an actual prescription rate of 34% by German GPs when they issued a diagnosis of mild depression according to a large German primary care study [28]

Summary

Introduction

In Switzerland and most other high-income countries, General practitioners (GPs) treat the majority of patients with depression and prescribe most antidepressants for depression [1, 2]. Research has further shown that antidepressants are frequently prescribed to these patients with subthreshold depression [5, 6] It follows that GPs write most of their antidepressant prescriptions for patients with mild depression, including subthreshold cases [1, 6]. According to Martinez et al, British GPs wrote 69% of all antidepressant prescriptions for mild depression, 27% for moderate depression, and only 4% for severe depression [7]. This is a serious issue, for the efficacy of antidepressants has not been firmly established in mild and subthreshold depression [8,9,10]. The aim of this study was to examine, how often Swiss GPs recommend antidepressants in various clinical presentations of mild depression and which fac‐ tors contribute to antidepressant treatment recommendations

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