Elsevier

General Hospital Psychiatry

Volume 26, Issue 3, May–June 2004, Pages 184-189
General Hospital Psychiatry

Psychiatry and primary care
Patients' preferences in the treatment of depressive disorder in primary care

https://doi.org/10.1016/j.genhosppsych.2003.12.001Get rights and content

Abstract

Patients' preferences in the treatment of depression are important in clinical practice and in research. Antidepressant medication is often prescribed, but adherence is low. This may be caused by patients preferring psychotherapy, which is often not available in primary care. In randomized clinical trials, patients' preferences may affect the external validity. The aim of this article is to study patients' preferences regarding psychotherapy and antidepressant medication and the impact of these preferences on treatment outcome. A systematic review of the literature was performed. The majority of patients preferred psychotherapy in all available studies. Antidepressants were often regarded as addictive and psychotherapy was assumed to solve the cause of depression. Discussing and supporting preferences as part of a quality improvement program of depression care, resulted in more patients receiving the treatment that was most suitable to them. In two patient-preference trials, preferences did not influence treatment outcome. It can be concluded that a substantial percentage of well-informed patients prefer psychotherapy. Patients with strong preferences, mostly for psychotherapy, are likely not to enter antidepressant treatment or randomized clinical trials if their preferences are not supported.

Introduction

In recent years, patients' treatment preferences and their impact on depression care have received growing interest, not only because “patient-centered” medicine has influenced health care in general [1], but also because it is thought that taking account of patients' preferences may improve compliance [2]. In addition, from a research perspective, it has been argued that patients' treatment preferences influence patient selection, treatment compliance and attrition in randomized clinical trials. Therefore, the external validity of clinical trials is affected by these preferences and alternative study designs have been used that incorporated patients' preferences into the study design [3].

For treating major depressive disorder in primary care, two main treatment options have proven to be equally effective: antidepressant medication and short-term psychotherapies, such as Interpersonal Psychotherapy, Cognitive Behavioural Therapy and Problem Solving Therapy [4], [5], [6], [7]. In addition, counseling is often provided. However, counseling is not a manual-based psychotherapy and is therefore heterogeneous in its process. Its effectiveness has not been sufficiently demonstrated [8].

Patients with major depressive disorder in primary care are generally offered treatment with antidepressant medication because psychotherapy is mostly not available. Moreover, prescribing medication fits more easily into the routine practice of the physician. It has been found that general practitioners prescribed antidepressant medication during the first visit in which depression was diagnosed in 73% of cases [9]. Yet, in another study it was observed that 50% of patients ceased taking the antidepressants within 6 weeks [10]. Although several factors contribute to compliance problems, divergent views between patient and physician with regard to type of treatment may be a crucial component. The beliefs held by the general public about mental disorders differ substantially from those of health practitioners [11], and patients often prefer psychotherapy to antidepressants [2], [12]. Patient choice and autonomy should be valued, but more knowledge about patients' preferences and their influence on the treatment process is necessary to learn to what extent the preferences should be supported by changes in the organization of primary care practice.

In this article, we review the literature about preferences regarding the treatment of depressive disorder in primary care. As these preferences are affected by attitudes and beliefs of the general public, it is not only findings from surveys carried out in depressed primary care populations that are of interest but also surveys conducted in nondepressed populations. Furthermore, we summarize findings from clinical trials in which attention has been paid to patients' preferences.

The aim of this article is to answer the following questions:

  • 1.

    Which treatment do people with and without depression prefer for depressive disorder in primary care?

  • 2.

    What are the underlying assumptions and associated factors of patients' preferences?

  • 3.

    Do patients' preferences affect treatment compliance and outcome in clinical trials?

Section snippets

Identification of relevant publications

Two systematic searches of Medline, PsychInfo and the Cochrane Library were performed separately for depressed primary care populations and for primarily nondepressed general populations during the period 1990–January 2003. To retrieve studies in depressed primary care populations we used the following medical subject headings and key words: depressive disorder/therapy, depression/therapy, depression, psychotherapy, counseling, antidepressants, patient satisfaction, preference, family practice,

Preferences among depressed primary care patients and among nondepressed primary care or general populations

Nine articles, concerning six studies, were identified as presenting preference data of depressed primary care patients [2], [5], [12], [13], [14], [15], [16], [17], [18]. Relevant characteristics of the studies are presented in Table 1. Articles presenting data of the same studies are presented in one row. From Table 1 it can be seen that in studies comparing counseling with antidepressants 23–38% more patients preferred counseling. In the two studies comparing psychotherapy with

Conclusions

  • Which treatment do depressed and nondepressed people prefer? In all studies, psychotherapy and counseling were preferred to antidepressants.

  • What are the underlying assumptions and the associated factors? Psychotherapy was preferred because it was assumed to provide an opportunity for personal exchange and to solve the problem underlying the depression. Antidepressants were often seen as addictive. Using psychotropic drugs was accompanied by more fear of losing control than using drugs for

Discussion

The finding that psychotherapy and counseling were preferred to antidepressant medication was strikingly unequivocal. However, considerable differences were found in the degree to which the preferences for psychotherapy over antidepressants were expressed. Interpretation of this variation is difficult because of methodological variation among studies. For example, the amount of information provided about the treatment options, the way questions were formulated and the timing of the questions

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