Do general practitioners and psychiatrists agree about defining cure from depression? The DEsCRIBE™ survey

In 2006, the US National Institute of Mental Health published an article regarding the possibility of finding a cure for mental disorders [1]. This paper was a call to health practitioners to set themselves more ambitious goals when treating patients with mental illness. Moreover, this initiative aimed to cause a paradigm shift in perceptions of depression and its cure. While such an effort is admirable the paper failed to take into account the complexity of mental disorders such as depression and the inadequacies in our current ability to monitor and define the disease. Depression is multifactorial, and its aetiology and presentation differ greatly from one patient to the next. Furthermore, decades of research have failed to find consistent biological markers for depression or for its outcomes. To date, clinical and sociodemographic characteristics, such as comorbid anxiety, age or employment status, are the most consistent prognostic factors in depression [2, 3], while evaluation of outcomes in depression has been limited to changes in symptom severity and concepts such as response, remission, recovery, relapse and recurrence [4, 5]. Remission is usually defined as a score of less or equal to 7 on the Hamilton Depression Rating Scale (17 item version) or less or equal to 10 on the Montgomery-Asberg Depression Rating Scale: remission is therefore defined only on the basis of absence of symptoms.

In reality, most patients with depression present with comorbid somatic symptoms [6] or anxiety often reaching a severity akin to that of an anxiety disorder or a somatoform disorder [7]. A recent study of patients with major depressive disorder has illustrated that these symptom clusters (pain, anxiety and depression) are important in patients' assessment of improvement [8]. Patients reportedly value symptom resolution, normalisation of function and quality of life (QoL) when assessing whether their depression has remitted [9, 10].

Additional evidence suggests that current definitions of outcome are inadequate. For example, although many psychiatrists believe anhedonia to be a core symptom of depression, assessment of change during the treatment of depression is usually limited to a decrease in negative affect, while an increase in positive affect is neglected. Furthermore, although the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) definition of major depressive disorder includes a functional criterion (i.e., symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning), functioning is often neglected in the inclusion criteria and the outcome measures of randomised controlled trials (RCTs). In order to address the limitations of existing outcome measures, a number of published papers have begun to address the importance of QoL in quantifying patients' response to antidepressant treatment [11, 12]. QoL potentially represents a generic, global outcome measure that allows comparison of treatment effects across different disorders.

While we assert that the current narrow outcome definitions in the treatment of depression present only the view of the medical field instead of the outcomes that matter most to patients, there is presently a paucity of published data on patients' views of what constitutes a good outcome in depression [13, 10]. Moreover, the views of individual physicians on the different dimensions that are important in defining a good outcome are also poorly documented. Kerr and colleagues [14] have reported that the attitudes of general practitioners [GPs] and psychiatrists towards depression and the treatment of depression differ markedly and also determine their prescribing practice and treatment outcomes. It is therefore expected that the attitudes of GPs and psychiatrists are also likely to differ about how to define satisfactory outcomes in depression treatment.

PROact^® (PRognosis Optimisation by adequate customised therapy) is an initiative that aims to define cure from depression by creating a therapeutic contract between patients and physicians. This paper documents the first part of PROact^® - DEsCRIBE™ (DEfinition of the CRIteria of BEing cured). In DEsCRIBE™ physicians were asked to consider what they thought was important in defining cure in patients with depression. In addition, we analysed the attitudes of GPs and psychiatrists concerning depression and whether their attitudes affect their prescribing practices and/or predict the outcome dimensions that are ranked highest when defining cure from depression.

The primary study finding was that GPs and psychiatrists give very similar responses when asked about which depressive symptoms and broader outcome dimensions are most important in defining cure from depression. Indeed, when the nine depression items of the PHQ-9 were ranked by these physician groups, the three most and least important items were identical. To the best of our knowledge this is the first documented comparison of GPs' and psychiatrists' opinions about defining cure from depression.

The 10 most important items in defining cure comprised the PHQ-9 items of anhedonia, depressed mood and suicidal ideation, the SDS items of occupational functioning and social functioning, the WHO-QOL items of being able to enjoy life, being able to concentrate and feeling life is meaningful and the PANAS-pos items of being interested and being active. The 10 least important items were all items from the somatic symptom scale. This is a remarkable finding as the importance of painful and non-painful symptoms has recently received a great deal of attention in the scientific literature [2, 7, 16, 17].

Ranking the outcomes at the dimension level gives a broader definition of what a useful outcome in clinical practice might be. This contrasts with the narrow outcome definitions espoused by RCTs, which tend to focus on depression scale scores, response and remission [18]. It has been documented that patients enrolled in RCTs rarely typify the patients seen in clinical practice [19], and our data illustrate that the concept of cure encompasses more than can be captured by single scale scores and the current notions of response and remission. This idea has been mooted previously in the published literature [4, 20] and has been stated particularly elegantly by Linsey McGoey of the Said Business School, University of Oxford: "Never before have the inadequacies of RCTs been so apparent to so many. Yet equally, never before have those in positions of authority - from regulators, to NICE policy makers, to doctors - relied so extensively on RCT evidence" [21]. Our data are indeed an illustration of the previous statement since endpoints in RCTs and endpoints in physicians' view seem to be very different.

The broader definition of cure from depression championed here seems to agree largely with published data reporting what patients consider to be important in defining cure. Patients give highest priority to positive mental health (optimism, vigour and self-confidence) followed by feeling normal, a return to usual levels of functioning at work or at home, feeling in emotional control, participating in and enjoying relationships with family and friends and, finally, the absence of depressive symptoms [9].

Analysis of these broader outcome dimensions is also instructive when looking at the concepts of relapse and recurrence. Residual deficits after treatment should not refer only to residual symptoms, rather they should encompass impairments in social and occupational functioning (even independently of depressive symptom scores). These broader outcome dimensions have been reported to be significant and independent risk factors for relapse and recurrence [22–24].

A second finding of this study were the important differences in attitudes about depression and its treatment demonstrated by GPs and psychiatrists (as measured using the DAS). Overall, psychiatrists have a more positive attitude towards depression and its treatment - this has also been reported in a study based in Wales [14]. In the current study, a factor analysis gave a different solution for GPs (3 factors) and psychiatrists (5 factors; 3 of them being the same as for the GPs). A 4-factor solution was reported in a study of 72 GPs by Botega and colleagues [15], where 3 of the 4 factors are mainly comparable to 3 of the 5 factors reported here. Factors I (antidepressant/psychotherapy), II (professional unease) and III (inevitable course of depression) in the Botega paper [15] correspond with Factors 2, 3 and 5 in our sample. It is a matter of concern that GPs feel that treating patients with depression is unrewarding (Factor 2) but it is interesting that GPs are pessimistic about what to do if a patient does not respond to their treatment (Factor 3) and that they feel most of their depressed patients should be treated with antidepressants (Factor 5).

The importance of physicians' attitudes to depression and their ability to manage this disorder effectively have been commented upon previously [14, 15, 25]. For example, one study [25] used a modified form of the DAS and found that non-psychiatrist physicians in Taiwan who were positive about the treatment of depression did not display avoidant/helpless attitudes and had the best scores in depression management. These findings support an earlier study of GPs in Scotland that also used the DAS [26]. This study reported that pessimism associated with the treatment of depression was linked to unwillingness to become involved with managing patients with depression, while confidence resulted in earlier recognition of the disorder [26]. Feeling comfortable with treating depression was also linked to more accurate diagnosis in a study of GPs in the north of England [27]. This study concluded that the accurate identification and appropriate management of depression by GPs was not an independent variable; instead it differed with different physicians' attitudes and skills [27].

It is perhaps unsurprising that psychiatrists are more comfortable treating patients with depression and find the experience more rewarding than GPs as they are specialists in this field. It has been reported that mental health expertise among GPs is also helpful in improving their attitudes towards the treatment of depression. An earlier study of GPs using the DAS revealed that physicians who had gained postgraduate mental health qualifications were more optimistic about achieving positive outcomes for their patients with depression and felt more comfortable in assisting these patients [28]. By contrast, a study of primary care physicians' attitudes to depression conducted in Brazil illustrates that a lack of exposure to patients with depression has the opposite effect [29]. The results of such surveys are useful as they suggest that training and experience can influence physicians' comfort in dealing with depression. It should also be considered that attitudes may influence participation in training programmes and influence the patients that physicians treat within their own practice. The finding that psychiatrists' attitudes do not appear to influence how they treat their patients is harder to explain. Perhaps the greater experience of psychiatrists concerning mental illness leads them to be less influenced by personal attitudes.

A third finding of this study is that compared with psychiatrists, GPs prescribe antidepressants to a much smaller proportion of their patients with depression. This could of course be due to lower severity of depression in the patients seen by GPs and/or by the fact that in Belgium most patients first seek help for depression in primary care and are often only treated by a specialist when a first-line modality has failed. However, our data suggest that prescribing patterns are also predicted by physicians' attitudes, although this was only the case for GPs, not psychiatrists. To the best of our knowledge, this is a novel finding that has not been previously reported. Our study also indicates that low prescribing in GPs (but not in psychiatrists) is predicted by the following attitudes: that it is not rewarding to look after patients with depression (Factor 2) and that depression has a poor outcome (Factor 3). Studies regarding the relationship between physicians' attitudes and their prescribing patterns are scarce. Botega and colleagues [15] identified a subgroup (n = 26/72) of high-prescribing GPs. Analysis of low-dose prescribers among GPs in a study in Wales [14] indicated that, compared with standard-dose prescribers, this group were more in favour of psychotherapy as a treatment modality, agreed less strongly that depression has a biological basis, and agreed less strongly that depression could be treated effectively with antidepressants. Dowrick and colleagues [27] found that GPs' attitudes (measured using the DAS) did not predict the frequency with which they prescribed antidepressants; however, more positive attitudes regarding the biological basis of depression did predict the class of antidepressants that they prescribed (selective serotonin reuptake inhibitors). The present data suggest that, for GPs at least, finding it rewarding to look after patients with depression is correlated with more positive attitudes towards psychotherapy and with a less strong belief in a biological basis for depression. One could therefore speculate that these physicians find a good doctor-patient relationship more satisfying than they do prescribing an antidepressant.

A final finding of our study was that the outcome dimensions considered to be important in defining cure from depression were associated with physicians' attitudes towards depression. This result was more pronounced in GPs than in psychiatrists. It is difficult to interpret this finding, especially as overall both physician groups agreed strongly on the outcome dimensions that were important in defining cure. Our perception is that this result is consistent with the earlier finding that GPs are more influenced by their attitudes about depression than are psychiatrists. The data also suggest female GPs attach more importance to QoL issues than their male colleagues.

As with any survey, the findings reported here are only valid for the physicians who participated. The characteristics of physicians who declined to participate were not described and comparison of basic demographic characteristics revealed that the survey population consisted of a smaller percentage of women than the general Belgian physician population. However, refusal to participate is a universal issue in observational studies and on this issue our study was no more or less biased than any other study of similar methodology.

Our study asked physicians to rate whether they prescribe antidepressants to ≤ 50% or > 50% of their patients with depression. Responses to this question could be subject to recall bias and may be influenced by physicians' attitudes. Furthermore, the types of patients that are seen by psychiatrists and GPs differ. In Belgium, patients with depression are initially treated by a GP who then refers patients requiring second-line treatment to a psychiatrist. Consequently, GPs may treat more patients with depressive adjustment disorder while psychiatrists see more patients with major depressive disorder. The attitudes, beliefs and treatment patterns of GPs and psychiatrists are therefore likely to vary in response to the differences in their respective patient populations.

The present study illustrates that (Belgian) GPs and psychiatrists strongly agree on the criteria that are important in defining cure from depression but strongly differ in their attitudes towards depression. Psychiatrists prescribe antidepressants to a larger proportion of their patients with depression compared with GPs. Prescribing patterns are significantly influenced by physicians' attitudes about depression, but only in GPs. The outcome dimensions considered to be most important in defining cure are also influenced by physicians' attitudes - this finding was more pronounced for GPs than for psychiatrists. Future research should address patients' perceptions of what defines cure and whether these attitudes correspond with those of their physician. Such research could even assess whether convergence or divergence between physicians' and patients' expectations about cure influences outcome or treatment satisfaction.