Richard Churchill

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Abstract Objectives: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference. Design: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes. Setting: 31 general practices in Trent region. Participants: Patients aged 18–70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms. Main outcome measures: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria. Results: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval −2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrists overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse. Conclusions: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment. What is already known on this topic Antidepressants and specific psychological interventions are effective in major depression. Generic counselling has not previously been compared with antidepressants in primary care What this study adds 12 months after starting treatment, generic counselling is as effective as antidepressants Patients treated with antidepressants may recover more quickly Given a choice, more patients opt for counselling Patients who choose counselling may benefit more than those with no strong preference

Counseling versus antidepressant therapy for the treatment of mild to moderate depression in primary care economic analysis

OBJECTIVE To compare the cost-effectiveness of generic psychological therapy (counseling) with routinely prescribed antidepressant drugs in a naturalistic general practice setting for a follow-up period of 12 months. METHODS Economic analysis alongside a randomized clinical trial with patient preference arm. Comparison of depression-related health service costs at 12 months. Cost-effectiveness analysis of bootstrapped trial data using net monetary benefits and acceptability curves. RESULTS No significant difference between the mean observed costs of patients randomized to antidepressants or to counseling (342 pounds sterling vs 302 pounds sterling , p = .56 [t test]). If decision makers are not willing to pay more for additional benefits (value placed on extra patient with good outcome, denoted by K, is zero), then we find little difference between the treatment modalities in terms of cost-effectiveness. If decision makers do place value on additional benefit (K > 0 pounds sterling), then the antidepressant group becomes more likely to be cost-effective. This likelihood is in excess of 90% where decision makers are prepared to pay an additional 2,000 pounds sterling or more per additional patient with a good global outcome. The mean values for incremental net monetary benefits (INMB) from antidepressants are substantial for higher values of K (INMB = 406 pounds sterling when K = 2,500 pounds sterling). CONCLUSION For a small proportion of patients, the counseling intervention (as specified in this trial) is a dominant cost-effective strategy. For a larger proportion of patients, the antidepressant intervention (as specified in this trial) is the dominant cost-effective strategy. For the remaining group of patients, cost-effectiveness depends on the value of K. Since we cannot observe K, acceptability curves are a useful way to inform decision makers.

Young People: Understanding the Links Between Satisfaction With Services and Their Health Outcomes in Primary Care

In many health care systems, primary care doctors such as general practitioners (GPs) and family physicians provide the first point of contact for patients of all ages, including young people. However, because young people are relatively infrequent users of services compared with other age groups [1], they may not only be given less priority in terms of consultation duration [2,3] but may also have less attention paid to their opinions and experience. For example, in a review of surveys of patient experience in the National Health Service in England over a 10year period, Hargreaves and Viner [4] found that only one of 38 included the views of young people under the age of 16 years. Consequently, any surveys that do seek the opinions of adolescents are particularly valuable in providing insights into their attitudes, experience, and use of health services. In this issue of the Journal of Adolescent Health, Yassaee et al. [5] report the findings from a large school-based crosssectional survey of young people aged between 11 and 15 years in England in 2014. This was part of the larger international World Health Organization Health Behaviours of School-Aged Children study but included additional questions relevant to individual national health care services. The results reported in this article are based on four questions about patient experience in relation to the respondent’s last GP visit (feeling respected, feeling at ease, satisfied with explanations, and feeling able to talk about personal things) and five questions about health concerns (headaches, sleep disturbance, low mood, self-harm, and overall health status). The study population was based on a random sample of school attenders in accordance with the overall study protocol and is therefore likely to be relatively representative of the general population. The authors found that approximately 80% of young people had consulted their GP within the previous 12 months and, of those who did, the majority reported a positive experience. However, despite this, nearly half felt unable to discuss personal matters with their GP and, overall, there was an inverse relationship between self-reported health status measures and satisfaction with the consultation. Young people from lower income families were likely to not only express more health