Elsevier

The Lancet

Volume 355, Issue 9199, 15 January 2000, Pages 185-191
The Lancet

Articles
Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial

https://doi.org/10.1016/S0140-6736(99)03171-2Get rights and content

Summary

Background

Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression.

Methods

We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat.

Findings

The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21 409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1·2 [95% CI 0·88–1·61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve.

Intrepretation

Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.

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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