Research report
Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment

https://doi.org/10.1016/j.jad.2004.09.005Get rights and content

Abstract

Background

Although good physician communication is associated with positive patient outcomes, it does not figure in current depression treatment guidelines. We examined the effect of depression treatment, communicative skills and their interaction on patient outcomes for depression in primary care.

Methods

In a cohort of 348 patients with ICD-10 depression in primary care, patient outcomes were studied over 3- and 12-month follow-ups. The association of these outcomes with both depression-specific process of care variables and a nonspecific variable—communicative skillfulness of GP—was examined. Patient outcomes consisted of change from baseline in symptomatology, disability, activity limitation days, and duration of the depressive episode.

Results

In accordance with treatment guidelines, some main effects of depression treatment were found, in particular on symptomatology, but these remained small (effect size<0.50). A moderate effect was found for treatment with a sedative, which proved to be related to worse patient outcomes at 12 months. An accurate GP diagnosis of depression and adequate antidepressant treatment were associated with better patient outcomes, but only when provided by GPs with good communicative skills. In contrast to the main effects, these interactions were seen on disability and activity limitation days, not on symptomatology.

Limitations

The study is observational and does not permit firm conclusions about causal relationships. Communicative skillfulness of the GP was assessed by patient report only.

Conclusion

Neither depression-specific interventions nor good GP communication skills seem to be sufficient for optimal patient improvement. Only the combination of treatments according to guidelines and good communication skills results in an effective antidepressive treatment.

Introduction

Two approaches to improve the effects of depression management in primary care have been studied. The first targets the depression-specific aspects of care stressed in current clinical guidelines. The second addresses nonspecific aspects of care, in particular the communication skills of the GP. Both approaches have been shown to be effective in improving patient outcomes (Rutz et al., 1990, Schulberg et al., 1996, Katon et al., 1996, Roter et al., 1995). Whether these effects are additive or dependent remains unclear, however. Therefore, we examined the main effects of both specific and nonspecific aspects of depression care on outcome as well as their interaction. The core hypothesis in the study was that the effectiveness of the depression-specific interventions depends on the communicative skillfulness of the GP providing the treatment.

Section snippets

Patients and data collection

The present analyses were carried out using data from an intervention study designed to improve process of care for depression and patient outcomes in primary care (Ormel et al., 1998, van Os et al., 1999, van Os et al., 2002, van Os et al., 2004, Tiemens et al., 1999). Eighteen GPs participated in the study. Consecutive patients, aged 18 to 65 years, attending one of the GPs at randomly selected days, were assessed by screening and standardized psychiatric interview. They were asked to fill in

Results

Three-hundred forty-eight patients with an ICD-10 depression were identified at baseline by screening and subsequent diagnostic interview. At the 3-month outcome assessment 86 patients did not participate, 39 had missing data on an outcome measure and 8 on control variables leaving 215 patients (62%) for the analyses. At the 12-month outcome assessment, 63 patients did not participate, 70 had missing data on an outcome measure and 8 on control variables leaving 207 patients (59%). Episode

Findings

We investigated the association between process of care for depression and patient outcomes over 3 and 12 months in a naturalistic design, and examined main effects as well as interactions with the communicative skillfulness of the GP providing the care. On the composite outcome measure, small independent effects on patient outcome were found for recognition and accuracy of diagnosis. A moderate effect on patient outcome was found for treatment with a sedative, which proved to be related to

Acknowledgments

We gratefully acknowledge the participating general practitioners, the research workers who interviewed the patients and H. Hallie for the data entry.

This study was financially supported by the Dutch Organization for Scientific Research (NWO), Medical Sciences, KWAZO-program, from the National Fund for Public Mental Health (NFGV), and SGO, the Promotion Program Health Research.

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