Targeted education for general practitioners reduces risk of depression or suicide ideation or attempts in older primary care patients
Question: Can a targeted educational intervention for general practitioners (GPs) reduce the 2-year prevalence of depression and self-harm among older patients?
Population: 373 Australian GPs and 21 762 patients aged 60 years or older (mean age 71.8 years).
Setting: General practices in Australia; June 2005–June 2008.
Intervention: Practice audit with personalised automated audit feedback and educational material (intervention) versus audit with no personalised feedback (control). The audit was of 20 consecutive older patients attending the practice, who filled in a questionnaire including the nine-item Patient Health Questionnaire (PHQ-9) and the Depressive Symptom Index Suicidality Scale. GPs were asked to fill out questionnaires about these patients, including the likelihood of their being depressed and suicide risk. Feedback was given to the intervention group GPs on the number of patients with depression in their practice compared with other practices, the number of patients with depression and self-harm ideation that they correctly identified, and information about the patients with self-reported symptoms of depression. GPs assigned to the intervention also received printed educational material and 6-monthly educational newsletters for 24 months, and were directed to relevant sections of the materials based on the results of the audit. The education materials provided information about screening, diagnosis and management of depression and suicide behaviour in later life. GPs at control practices received feedback only on pooled data and a newsletter detailing progress of the study.
Outcomes: Composite outcome of self-reported clinically significant depression (PHQ-9 score ≥10) or self-harm behaviour (self-reported suicide ideation or attempt during the previous year) at 12 and 24 months after recruitment. Analyses were adjusted for baseline depressive and self-harm behaviour, and potential confounders.
Patient follow-up: 88% of patients and 99.7% of GPs completed the study; 97% of patients in the intervention group were included in intention-to-treat analyses and 91% of those in the control group.
Design: Cluster randomised controlled trial.
Follow-up period: 24 months.
The personalised feedback and educational intervention reduced the proportion of older patients experiencing depression or suicide ideation or attempt during follow-up compared with control (absolute risk 10.4% with intervention vs 11.4% with control; adjusted OR 0.90, 95% CI 0.83 to 0.97). When the outcomes were examined separately, the intervention had no effect on depression (AR 8.1% with intervention vs 8.7% with control; adjusted OR 0.93, 95% CI 0.83 to 1.03), but it did reduce the risk of suicide ideation or attempt compared with control (AR 4.5% with intervention vs 5.1% with control; adjusted OR 0.80, 95% CI 0.68 to 0.94). Secondary analyses suggested that the differences seen were not due to differences in the numbers of patients receiving antidepressants, contact with mental health professionals or other types of support between the groups.
Practice audit and targeted education for GPs reduced the composite 2-year risk of depression or suicide ideation or attempt in older patients.
GPs were randomised in blocks of 24 doctors. GPs working at the same practice were assigned to the same group, to reduce the risk of contamination. Patients who died during the study were excluded from analyses.
Sources of funding The National Health and Medical Research Council of Australia (NHMRC) and beyondblue Australia.
Previous attempts to reduce the prevalence of depression have focused on improving its detection and management in primary care. The evidence supports complex interventions that include case management or collaborative care models which are not achievable or sustainable in many countries. This study reports on a trial of an educational intervention for GPs that aimed to reduce the 2-year prevalence of depression and self-harm behaviour among their older patients via a simple and sustainable intervention using educational materials and a practice audit with individualised feedback.
Like the majority of educational interventions for depression aimed at professionals, this study showed no impact on medium-term to long-term outcomes for patients, no impact on the management of depression by GPs and no decrease in the prevalence of depression or self-harm behaviour. It did show a modest effect on the prevalence of a composite measure of depression and self-harm behaviour.
Older adults in the intervention group were less likely to display self-harm behaviour than controls but this was not associated with better treatment of depression. The authors hypothesise that education about depression may improve the attitudes of physicians toward mental health issues and increase their empathy and willingness to discuss emotional concerns, which may play an important role in reducing self-harm ideation. The association between empathy and therapeutic benefit is well known, therefore improving physician communication and empathy may be a better focus for education than screening and management of depression.
It is also time to think beyond educational interventions that focus on improving physician responses once patients have reached the screening threshold. This calls for health promotion interventions at an earlier stage: knowing and identifying the risk factors and trying to do something about them. Increasing opportunities to discuss emotional concerns and increase social interaction might be a better entry point for reducing depression and self-harm in older adults. Such interventions could be delivered within many existing community-based projects and alongside primary care—perhaps a focus on preventative interventions at this level might yield more positive results.