The new contract’s aspirations for enhanced care for depressed patients are laudable but underfunded, says Dr Phillip Bland
The prognosis for depression is poor. A multicentre study found that 60% of patients in general practice remained depressed at 12 months.1 Strategies for improving outcomes include screening for depression in high-risk populations and improving compliance through practice nurse shared care.2
Even when patients have responded to antidepressant treatment, approximately 30% will relapse within 12 months.3 There is evidence that cognitive behavioural therapy (CBT) is more effective than antidepressants in preventing relapse.4
Under the enhanced service for depression in the new GMS contract, practices will be funded to "use cognitive behavioural therapy and other non-drug treatments where appropriate.”5 This is laudable, but begs some questions: Who should receive CBT, all patients or a privileged few? Who should provide it, therapists or GPs? Is an annual retainer of £1000 and a payment of £80 per patient realistic for a service incorporating CBT?
Depression is common: an estimated 5-10% of patients attending surgery have major depression.6 CBT is time-consuming, a course usually consisting of between 12 and 20 hour-long sessions.3 To provide CBT for all our newly diagnosed depressed patients would need around 3570 hours of therapist time each year, requiring one therapist for every two GPs.
An alternative is for GPs to acquire skills in brief CBT interventions.7 I recently attended an 8-day course, ‘The Rough Guide to CBT’. I found it rewarding but believe that incorporating CBT into the GP consultation will present formidable problems.
Much of the course focused on the key skill of teaching patients to identify and evaluate their automatic thoughts. I find three questions useful in eliciting these thoughts during a 10-minute consultation: How do you see your life? How do you see yourself? How do you see the future?8
The model of general practice patient management that I was taught can be considered under the headings of reassurance, advice, prescription, referral, investigation, observation and prevention 9 – all things that the GP does. In contrast, in CBT, therapist and patient work as a team.10
My approach to cognitive therapy in the consultation is to identify dysfunctional cognitions myself and challenge them, even though this violates the basic principle of CBT that "guided discovery is the engine that drives client learning in cognitive therapy.”10
Is it feasible to adopt CBT in the GP consultation? Doctors and patients feel an intense sense of time pressure.11
Nevertheless, I believe that all depressed patients can potentially benefit from CBT; we must cease to regard it as a specialised treatment for a very few patients referred to secondary care. As for who should provide CBT, there are so few therapists that patients are unlikely to receive it if their GP does not provide it.
I note with irony the new contract’s statement that "GPs need to be able to devote more time to patients with suspected and diagnosed depression”. The funding suggested for enhanced care of depression will enable us to continue to provide practice nurse shared care but is inadequate to provide CBT, whether through therapists or appropriately trained and motivated GPs.
- Goldberg D, Privett M, Ustun B, Simon G, Linden M.The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840-4.
- Bland PM. Practice nurse input improves care of depressed patients. Guidelines in Practice 2001; 4: 75-81.
- Moore RG. Improving the treatment of depression in primary care: problems and prospects. Br J Gen Pract 1997; 47: 587-90.
- Gloaguen V, Cottraux J,Cucherat M, Blackburn IM. A metaanalysis of the effects of cognitive therapy in depressed patients. J Affect Disord 1998; 49: 59-72.
- Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk
- Anderson IM,Nutt DJ, Deakin JFW. Evidence-based guidelines for treating depressive disorders with antidepressants:a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol 2000; 14: 3-20.
- King M, Davidson O, Taylor F, Haines A, Sharp D, Turner R. Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial. Br Med J 2002; 324: 947-50.
- Beck AT. Cognitive therapy and the emotional disorders. New York: International Universities Press, 1976.
- McAvoy BR. Patient management. In: Fraser RC (ed). Clinical method: a general practice approach. Oxford: Butterworth-Heinemann, 1992.
- Padesky CA. Developing cognitive therapist competency: teaching and supervision models. In Salkovskis PM (ed). Frontiers of cognitive therapy.New York: Guildford Press,1996.
- Pollock K,Grime J. Patients’perceptions of entitlement to time in general practice consultations for depression: qualitative study. Br Med J 2002; 325: 687-90.