FPIN’s Clinical Inquiries
Psychosocial Interventions Delivered by Primary Care Physicians to Patients with Depression
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Am Fam Physician. 2006 Nov 1;74(9):1580-1581.
Are psychosocial interventions by primary care physicians as effective as antidepressants for symptom relief in patients with major depression?
Few high-quality studies have been conducted examining the effectiveness of psychosocial interventions performed by primary care physicians for patients with major depression. Two randomized controlled clinical trials (RCTs) found that a psychosocial intervention, specifically problem-solving therapy, is as effective as pharmacotherapy for symptoms of major depression.1,2 (Strength of recommendation: B) However, these results should be interpreted with some degree of caution because of the limited number of studies and their small sample size.
One RCT compared a psychosocial intervention (problem-solving therapy) delivered by a primary care physician with the antidepressants fluvoxamine (Luvox) and paroxetine (Paxil) in patients with major depression.1 It found no differences between the two groups in scores on depression scales at six-, 12-, or 52-week follow-up (Table 1).1 However, the results should be interpreted with caution because the treatments were provided by three “research general practitioners” and were supervised by the researcher conducting the study. Furthermore, the problem-solving group (39 participants) and the medication group (36 participants) contained fewer participants than are needed to detect a potentially clinically-important difference.
In a second RCT by the same researchers, problem-solving assistance, delivered by two general practitioners and a psychiatrist, was compared with the antidepressant amitriptyline and placebo.2 The study included 91 patients with major depression and did not find any significant differences in depression scores at six- or 12-week follow-up between the two groups (using the Beck Depression Inventory, the Hamilton Rating Scale for Depression, and the Social Adjustment Scale).
For both studies, the specific psychosocial intervention of problem solving consisted of six 30- to 60-minute sessions over a 12-week period; session time was spent clarifying and defining problems, setting realistic goals, developing and deciding upon solutions, implementing a chosen solution, and performing evaluation.1,2 A systematic review of the literature, which included the previously discussed RCTs, combined data from the two studies to improve the sample size and statistical power.3 The authors concluded that there was good evidence that problem solving delivered by general practitioners was as effective as antidepressants for major depression.
The results of these studies may not be generalizable to all primary care physicians given that formal training in problem-solving therapy is not a standard part of all residencies. However, the Accreditation Council for Graduate Medical Education does state in the Program Requirements for Graduate Medical Education in Family Medicine that there must be instruction in “counseling skills.”4
Mean Depression Scores of Patients Receiving Problem-Solving Therapy and Those Receiving Medication
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Recommendations from Others
Of the treatment guidelines for depression reviewed, none commented on the use of psychosocial interventions performed by primary care physicians. The Department of Defense clinical practice guidelines for depression in primary care settings suggests that patient preference should be given consideration given that no difference in outcome has been found between psychotherapy and pharmacotherapy for mild to moderate depression.5 However, these guidelines are referring to more formal therapy, such as cognitive behavior therapy, and not merely psychosocial interventions. In addition, practitioner experience in delivering psychological interventions should be taken into account by the referral source because level of experience has been shown to influence treatment effectiveness.
Most family physicians do not provide formal psychosocial interventions for a variety of reasons, such as lack of formal training, office time constraints, and insurance reimbursement issues. However, family physicians maintain an important and unique role in the delivery of comprehensive, longitudinal care to patients with depression. Family physicians are in an ideal position to manage depression because of the high lifetime prevalence of major depression (18.5 percent) among adults in the United States.6 Furthermore, conditions commonly treated in the primary care setting such as diabetes, hypertension, and coronary artery disease are associated with an increased risk of depression.7–9 Family physicians can provide a much-needed supportive role, which includes empathy, effective listening, and a personal relationship with the rest of the family. Therefore, even without proven effectiveness of psychosocial interventions by primary care providers, family physicians should continue to explore the psychosocial concerns of their patients and offer support, guidance, and proper referral, if indicated.
Copyright Family Physicians Inquiries Network. Used with permission.
Author disclosure: nothing to disclose.
REFERENCESshow all references
1. Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ. 2000;320:26–30....
2. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. BMJ. 1995;310:441–5.
3. Huibers MJ, Beurskens AJ, Bleijenberg G, van Schayck CP. The effectiveness of psychosocial interventions delivered by general practitioners. Cochrane Database Syst Rev. 2003;(2):CD003494.
4. Accreditation council for graduate medical education. Program requirements for graduate medical education in family medicine. September 2005.
5. VHA/DOD clinical practice guideline for the management of major depressive disorder in adults. Washington D.C.: Veterans Health Administration, Department of Defense; August 2000.
6. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States using a clinical significance criterion to reconcile 2 surveys’ estimates. Arch Gen Psychiatry. 2002;59:115–23.
7. Scalco AZ, Scalco MZ, Azul JB, Lotufo Neto F. Hypertension and depression. Clinics. 2005;60:241–50.
8. Carney RM, Freedland KE, Sheline YI, Weiss ES. Depression and coronary heart disease: a review for cardiologists. Clin Cardiol. 1997;20:196–200.
9. Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes Care. 1993;16:1167–78.
Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/levels_of_evidence.asp).
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