By Dr Liz Smith
Over ten years ago, after finishing my degree in Psychology, I secured funding from the Medical Research Council (MRC) to do a PhD investigating why clinical guidelines (which at the time had become an increasingly familiar component of health care) were not always implemented. I knew that there was a massive gap between evidence and practice and that this was particularly true for depression. At this time antidepressant prescribing had increased for all age and sex groups over the previous 20 years. GPs regularly handed out anti-depressant drugs but very rarely referred patients for therapy even though this may have been the preferred treatment. So my PhD focused on how clinicians used clinical guidelines in depression.
The first couple of quantitative studies I carried out confirmed that (1) a gap existed between clinical guidelines and practice; (2) the GPs in my study tended to overprescribe relative to recommendations and (3) prescribing no drugs at all was extremely rare. This led me to the question of why. The next study I undertook was one of the most enjoyable research studies I have ever carried out. It was a qualitative study using in-depth interviews with a purposive sample of GPs. Here I aimed to elicit GPs’ views about the depression guidelines, how they used them in their practice and any barriers they thought there were that prevented them from implementing them. The GPs who took part in the study were from general practices across the Scottish Grampian region and North East England.
The main findings were that (1) the GPs did not always agree with recommendations of the depression guidelines current at that time; (2) they thought the guidelines were insufficiently flexible to use with the variety of patients they see; and (3) lack of resources, particularly mental health professionals for referrals, were seen as the main barriers to guideline use.
For these GPs lack of resources emerged as a major barrier to following guideline recommendations. They had problems in referring patients to mental health specialists. They reported having no specialist to refer them to, patients being misled about specialists’ qualifications, and problems with patient confidentiality issues. Several GPs reported that they had tried their best to follow the guidelines and refer patients for some form of talking therapy but by the time patients received appointments from mental health specialists, the patients reported that their depression problems had disappeared and they no longer wanted appointments. Waiting times reported were between 2 to 26 weeks for psychiatrists or community psychiatric nurses and 9 to 12 months for psychologists. These delays partially explained GPs’ tendency to over prescribe relative to recommendations. In sum, these GPs saw the lack of mental health professionals as a main barrier to following depression guidelines. When this study was published we recommended that those involved in guideline production should be demonstrating the case for more mental health professionals.
Since this time I have not given the issue much thought as I changed my career track and worked on research within a business school for 8 years. However, last year I returned back to the realms of psychology, here at the University of Salford. On checking out the courses which ran from here I discovered that there is a postgraduate course in Applied Psychology (Therapies). The University advertises these courses as providing great opportunities for students to prepare to undertake a role in therapeutic interventions and Cognitive Behaviour Therapy (CBT) which is high on the government agenda “Improving Access to Psychological Therapies” (IAPT).
The IAPT programme has its own website where it claims to support the frontline NHS in implementing National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety. The website states that the initiative was developed with the aim of offering patients realistic and routine first-line treatment, combined where appropriate with medication which they say was traditionally the only treatment available. It is amazing that something I found out to be true in my early research days has been addressed by the government and the institute where I carry out my current research actually trains people to prepare them for the IAPT programme. In chatting with the leader of the course, Dr Simon Cassidy, he tells me that a substantial number of students graduating from the Applied Psychology (Therapies) course go on to work in this initiative.
It’s really great to see that someone somewhere has recognized the need for psychological therapies in the treatment of depression. It would be marvelous to obtain funding for a follow up study to investigate how clinicians use clinical guidelines in depression today and to see if the gap has closed between evidence and practice.
Contact Details: Dr Liz Smith, Email: firstname.lastname@example.org