ArticlesEffects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial
Introduction
Most patients with depression are managed in primarycare settings, but there is thought to be a lack of knowledge and skills1 in the physicians' diagnosis,2 and in pharmacological3 and psychological management4 of the disorder. There has been professional consensus that educational interventions may not only improve the care of treated patients but may also reduce the public-health burden of depressive symptoms.5, 6, 7, 8, 9 However, the evidence to support this approach is weak, consisting of small non-randomised trials among selected physicians.10 The most influential study7 was done on the Swedish island of Gotland (18 physicians, population 60 000), where didactic seminars seemed to lead to a decrease in sickness absence, hospital referrals, and suicide rates, and an increase in antidepressant prescribing lasting about 4 years. Hannaford and colleagues11 and Howe12 found greater recognition of psychological illnesses after education. None of these uncontrolled studies assessed rates of recovery from depression as an outcome of the intervention.
The educational approach depends on three assumptions: first, that cases can be reliably identified; second, that there are effective treatments that can be generally applied; and third, that it is possible to modify the behaviour of most primary-care professionals through education.
The use of multifaceted, highly structured, clinical-practice guidelines, in collaboration with mental-health workers, is more effective than routine primary care in randomised controlled trials. However, all the patients in these studies had major depressive episodes.5, 13 Such approaches directed at selected groups are high-cost options compared with attempts to improve population-based general-practice care through education.
The Hampshire Depression Project was designed as a randomised controlled trial of an educational programme that could be generalised across primary-care settings. Our main hypotheses were that an educated group of primary-care physicians would show greater sensitivity and specificity for recognition of depressive symptoms than a control group of physicians, and that an educated group of practice teams would achieve greater recovery rates in their patients than a control group of practices.
Section snippets
Clinical-practice guideline
The development of the clinical-practice guideline has been described in detail elsewhere.14 The guideline was written after an extensive review of existing guidelines and consensus statements.9, 15, 16, 17 It included advice on practice organisation, the roles of non-medical professionals, and a resource pack containing useful general and local information. If evidence relating to primary care was available, it was given primacy, but secondary-care evidence and consensus statements were also
Practice and participant characteristics
The study practices were representative of the district from which they were drawn but were slightly larger than the average for the country as a whole (table 1).
Randomisation produced adequate matching between the intervention and control groups (table 2). The numbers of practices, physicians, and patients in each part of the study are shown in figure 1 and table 3.
Discussion
The education did not increase the sensitivity and specificity of physicians' recognition of depression, and there was no improvement in recovery rates of the patients identified through screening. Recognised patients were more likely to have improved at 6 weeks when seen by a recently educated physician, but this difference has to be interpreted in the context of the large number of comparisons tested for significance. Furthermore, any benefit was lost by 6 months, patients recognised as
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