Mental Health special section

Psychs get the goldmine, GPs get the shaft

Why is it that those in family practice who treat depressed patients get stuck with the defiant no-hopers?

By Owen Dyer

Being a general practitioner can be a thankless task. The GP has by far the toughest diagnostic load, being presented with every kind of symptom and having to choose between thousands of possibilities. Once the diagnosis is made, if it's serious, the GP sends the patient off to a specialist, who then takes most of the credit for any resulting improvement.

Many diseases apparently respond better to specialist treatment than to treatment in a primary care setting. That's hardly surprising in a field like radiation oncology, but what about depression? On the one hand, the specialist is an expert on the disease, but on the other the GP is more of an authority on the individual patient. That personal knowledge, and the holistic approach that is key to primary care medicine, should logically give family doctors an advantage to set against their lack of specialized knowledge in treating depression. Yet it's been demonstrated repeatedly that depressed patients do better in the care of mental health specialists.

As soon as patients realize there's something seriously wrong with them, they want to see a specialist. But in the case of depressed patients, there are many who don't acknowledge the existence of their condition and, as a result, are much harder to treat. Could it be that GPs are being left with an unwilling rump of uncooperative, non-compliant depressed patients who refuse to accept their illness?

NO, NO, NO

A recent issue of the Journal of General Internal Medicine carried US research which compared the attitude of depressed patients in a primary care setting to those seen by specialists. They found that, compared with patients who received care from mental health specialists, patients who received mental health services exclusively from primary care providers were 2.7 times as likely to believe that no treatment was a match for their illness. They were also 2.4 times as likely to reject evidence-based treatment options such as antidepressants.

"Patients with depression treated exclusively by primary care providers, " the study authors conclude, "have attitudes and beliefs more averse to care than those seen by mental health specialists. These differences in attitudes and beliefs may contribute to lower quality depression care observed in comparisons of primary care and speciality mental health providers. "

GPs are far from surprised by the conclusions of this study. Dr Daniel Ezekiel, who practises in Vancouver, readily accepts the findings. "This is something that I have been seeing in practice for years, " he says. "I can diagnose depression just as easily, and with my own patients, probably better, than any psychiatrist can, and yet when I tell a patient what I think, I encounter resistance to pharmacological treatment. But if that same patient, if seen by "experts " he or she does'nt know, will gladly take prescribed medications. It baffles me. From my perspective, the study is accurate. I've always felt that it's not the psychiatrists who are seeing the most difficult cases of depression, it's the GPs. "

Dr David Yue, a GP from Edmonton, is of the same mind. "From my personal experience, I would agree with the conclusions of this study. I find patients who decline or refuse to be assessed by psychiatrists tend to have less success with their treatment either because of compliance issues or because of the stigma attached to seeking specialist care, for whatever reason -- personal or cultural. "