Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial

Background: Depression, a common disorder often treated by family physician s, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by fami ly physicians could be improved through an educational strategy. Methods: In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CP Gs] for depression and access to a psychiatrist for consultation) or to a c ontrol group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly d iagnosed depression and to record information on severity of depression, me dications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measu re was the "gain" score (difference between first and last CES-D scores). Results: During the study period physicians in the intervention group diagn osed 91 new cases of depression (mean 4.1 per physician) and those in the c ontrol group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in th e control group received a prescription for an antidepressant on their firs t visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, si gnificantly more patients in the intervention group were taking an antidepr essant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number o f visits per patient was similar in the 2 groups (7.7 in the intervention g roup and 7.6 in the control group). Physicians in the intervention group co nsulted the psychiatrist 9 times. The overall rate of referrals to psychiat rists and other mental health professionals was 10.9%; however, referrals w ere significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05 ). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient' s self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0 .04) and the physicians' ratings of depression severity before treatment an d at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02). Interpretation: The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns rega rding the low rates of drug treatment and referral to mental health profess ionals by family physicians.