Quest to unravel depression crisis
A consultation on depression is one of the most intimate I have as a GP.
It is detective work with compassion, working out a patient's deepest feelings from just a few starting facts.
Successfully lifting someone's gloom and helping them get on with their life is one of the most satisfying things about being a GP.
But like many GPs, I am frustrated I still have to write so many prescriptions for SSRIs. I know these patients would be better off with talking therapies, either alone or as an adjunct, but am unable to offer them because the services are simply not available.
And this frustration comes after NICE published guidelines a year ago which said we should offer therapy alongside drugs or even before we start them (see box, below).
A study published in the BMJ last year found expenditure on antidepressants rose £310 million between 1991 and 2002, enough, according to the researchers, to pay for 1.54 million courses of therapy.
So why is drug expenditure spiralling when waiting times for therapy seem to be getting worse? I set out on a one-woman mission to find out.
I decided to start with my local PCT in Lambeth. I wanted to know how much it was spending on therapies and on drugs.
My trust gave a figure of £2.5 million a year for antidepressants. For therapy the picture was less clear. Enhanced services totalled £738,000, GP funding £75,000 and service level agreements with counselling centres £123,000. The PCT did not know the cost of therapy provided in primary care by the local mental health trust.
This piecemeal picture reflects the way therapy has developed in Lambeth ad-hoc and reactive.
Counselling became fashionable a few years ago and the PCT responded to our requests for counsellors quite generously but irrationally. I doubt if there is an audit of their effectiveness.
My PCT did try to audit funding on therapy, but found the data difficult to collect.
I explained my findings to Professor Andre Tylee, director of the National Institute for Mental Health in England.
Professor Tylee said: 'My direct experience which is only with one or two PCTs is that it's very difficult to find out exact costs. It starts to get messy when someone works in a surgery but is employed by a mental health trust.'
Dr Chris Manning, chief executive of Primary Care Mental Health and Education, said there was a need for a common portal to collate therapy expenditure as was the case for prescribing.
He warned: 'The result of not having clear budgets is poor decision-making when it comes to deciding what services to provide next.'
The pressure to prescribe antidepressants has intensified with the Government's 48-hour access target.
I know practices are supposed to offer advance appointments but, like many, ours doesn't for most patients. We have to keep two-thirds of slots back for same-day availability as this is the only way we can keep the PCT happy.
But the NICE guidelines recommend 'watch and wait' before prescribing SSRIs and this is only possible if patients can book appointments in advance.
There is a danger patients with mild depression will be lost to the system and so it makes sense to prescribe SSRIs while the patient is there in front of you.
Another fallout of 48-hour access is that patients often see a different GP every time and the prospect of retelling their entire story can put them off coming back.
Professor Tylee agreed. 'I am particularly concerned the new access arrangements work best for those who can assert themselves and get GP appointments by phone. Many depressives find this very difficult,' he said.
Despite the obvious difficulties with access, the NICE depression guidance was widely welcomed when it came out in December 2004.
Under the NICE stepped approach, patients with mild depression should have 'watchful waiting' or exercise referral rather than SSRIs.
But in reality the NICE approach is unrealistic because of the lack of resources available to GPs.
I put these points to Dr Stephen Pilling, consultant clinical psychologist and co-director of the National Collaborating Centre for Mental Health, which developed the NICE guideline on depression. He told me NICE did not want the recommendations to be constrained by the resources currently available.
Dr Pilling said: 'The guideline is ambitious and it will take some time to implement even where resources are available. But I think it is right to have such ambitions for the treatment of depression and I believe the guideline provides a framework in which these ambitions can be realised.'
I take his point that you should set goals high but it's hardly been made explicit that these are future objectives and not obtainable with current resources. It leaves me feeling greatly frustrated.
I put these points to my two experts.
Professor Tylee said: 'The NICE guidelines are there to summarise the evidence and tell people what interventions will help their patients. Hopefully it empowers people to obtain the resources they need.
'Some PCTs are working to implement the guidelines and others aren't. The question is, how are some PCTs managing it when others say they can't?'
Dr Manning had a different take on the guidelines. He said: 'I'm not interested in aspiration, I'm interested in quality.
'There's no point in saying GPs should refer a patient to a psychologist or CBT if they don't exist.'
Dr Pilling claimed NICE was seeking to 'enhance the capacity' of the whole primary care team to manage mental health, with interventions such as guided self-help and computerised CBT that can be used by a wide range of staff.
It's an interesting idea but the reality is that virtually all these interventions end up being provided by the GP.
Patients would have to give their story all over again if I referred them to another member of the team. And while our nurses can give emotional support they are not trained in mental health. Invariably they would end conversations by telling the patient 'Come and see the doctor!'.
So what have I learnt from my investigation?
- We're spending more on antidepressants not less and this drugs spiral needs to be addressed.
- To reduce use of drugs we need more access to therapies, but we won't get good commissioning until we know what is already out there.
- We need to abandon the 48-hour access system when it comes to patients with depression and consider ways we can allocate longer consultations to these patients.
- It needs to be made clear to GPs that the NICE guidelines are an aspiration only and action needs to be taken to ensure PCTs implement them.
- GPs need help in the short-term to deal with patients so they don't have to turn to the quick-fix of an SSRI.
Sally Whittet is a GP in Clapham, south-west London