Understanding the prescription of antidepressants: a Qualitative study among French GPs
Alain Mercier
0
Isabelle Auger-Aubin
2
Jean-Pierre Lebeau
1
Paul Van Royen
4
Lieve Peremans
3
0
Department of General Practice, Rouen University and CIC Inserm 0204, Rouen University
,
Rouen
,
France
1
Department of General Practice, Tours University
,
Tours
,
France
2
Department of General Practice, Denis Diderot Paris 7 University
,
Paris
,
France
3
Department of Public Health, Vrije Universiteit of Brussels
,
Brussels
,
Belgium
4
Department of Primary and Interdisciplinary Care, Faculty of Medicine, University of Antwerp
,
Antwerp
,
Belgium
Background: One-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them. Method: Six focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers. Results: Antidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four non-psychiatric conditions possibly leading to prescription of antidepressants in primary care were found. Conclusions: The GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.
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Background
According to the French health insurance system,
approximately 10% of the countrys population is
reimbursed for at least one antidepressant (AD) [1,2].
Between 1980 and 2008, AD sales increased sevenfold,
from 84 million to 525 million [3]. Reports from the
national insurance system and the European
Commission have confirmed these trends [4,5]. Frances
consumption of ADs ranks amongst the highest in the
European Union [5]. They are mainly prescribed by
General Practitioners (GPs) [6]. The reasons for this
high prescription rate by French GPs remain unclear.
According to the available data, this consumption is
supposed to be related to a higher rate of depressed
patients in France, an increase in the number of patients
treated for depression, and higher demand for medical
care [6,7]. Clinical practice guidelines in France officially
recommend using an AD for major depressive episodes
and for anxiety only when the condition has
consequences on the patients life [8]. Dysthymia, isolated
symptoms not fulfilling the DSM IV criteria, light or
moderate episodes, or those lasting less than 15 days
should not be treated by ADs. One-third of the
prescriptions (30-35%) probably do not comply with these
statements and 20% may not be related to any
psychiatric evidence based on standardized questionnaires
[9,10]. Furthermore, the data are not homogeneous:
other studies have shown that in 85% of cases, the
patients treated with GP-prescribed antidepressants met
DSM-IV depression criteria [11]. The main indications
for ADs are major depressive episodes and anxiety
disorders. Other conditions, such as neuropathic pain, also
result in prescription [12], but some indications remain
controversial [13,14]. Similar trends have been noticed
in other countries [15,16]. The aim of this study was to
explore GPs viewpoints regarding their reasons for
prescribing antidepressants and to determine what
indications they reported using them for in daily practice.
Methods
Participant recruitment procedure
Groups were chosen using a purposeful sampling
method. This study population was drawn from two
different sources. Firstly, four focus groups (FG) were held
with GPs recruited from existing quality circles. These
GPs already knew each other from previous professional
training sessions based on the French peer group
technique. In this technique one of the participants presents
to the group of GPs a structured analysis of patient files
with a specific medical condition (e.g. diabetes,
medications for high blood pressure). The group analyses all of
the issues, decisions or potential improvements to the
care of the patient and provides feedback to the
participant presenting the case. The dynamic interaction
amongst these group members enabled us to collect
reliable data on their actual practices. Secondly, we
organized two focus groups with locum GPs. Locum
physicians could have a different, m (...truncated)