Clinical guidelines on depression: A qualitative study of GPs’ views

Potential participants were sampled to reflect the range of compliance in response to the previous study’s vignettes (5 exhibited high levels of compliance, 3 medium, and 3 low), and to ensure the sample included GPs from different-sized practices (5 GPs worked in small practices, 5 in medium, and 1 in a large practice) and different locations (7 from the Scottish Grampian region, 4 from the Northeast of England). Eight GPs were male, 3 were female. GPs were interviewed during April 2002 at their practice premises by LS. Previous questionnaires did not reveal that analyses took guideline compliance into account; thus it was deemed that participants would not be affected by social desirability characteristics.

Interview procedure

A topic guide was designed to guide interviews and included the research design showing who was to be interviewed and key questions to be addressed. Questions were open-ended, semi-structured, and followed research questions. GPs’ permission was sought to record interviews, and confidentiality was assured. GPs were encouraged to talk freely. Interviews lasted between 45 and 75 minutes; they were tape-recorded and transcribed with all identifying text removed.

Data analysis

Two researchers (LS & AW) analyzed transcripts using the Framework Technique,²⁴ chosen because it is grounded in and driven by participating GPs’ original accounts and observations. Abstraction began after the full data set was reviewed. Emergent themes and issues were noted and given a code, and an index was constructed. This was revised several times as new issues emerged and was systematically reapplied to all the interview transcripts. Interviews were analyzed independently and any differences of interpretation were resolved through discussion.

Results

Of the 7 GPs who knew which was their latest depression guideline, 2 had no problems with recommendations. However, several GPs disagreed with some recommendations, possibly explaining variable compliance.¹²

Disagreements

One area of disagreement was the recommendation to refer patients, as specialists were not always available or waiting times were too long. Criteria for referring patients to secondary care include diagnostic uncertainty, treatment failure, suicidal tendencies, and psychotic or disturbed behavior. (This recurring issue of referral is discussed below.)

Another area of disagreement was the dura-tion-of-symptoms criterion, as heard in the follow-ing observation:

It stipulates they have to have these features and for at least 2 weeks … and if they only have them for a week why should I wait … why should they be miserable for a week, when I am pretty certain they are depressed? (GP3)

Guidelines’ flexibility

Evidence-based recommendations are usually expressed in terms of typical clinical situations. Perhaps such recommendations are particularly difficult to apply to individuals who can present with varying combinations of pre-existing illness, beliefs about depression, treatment preferences, concerns about confidentiality and stigma, as well as varying degrees of access to care. We therefore asked GPs whether they believed the available depression guidelines are sufficiently flexible to use with all their patients in managing depression.

Many of the GPs thought the guidelines were not flexible. For instance, GP4 said he worried about lawyers becoming involved in guideline compliance, which could result in defensive practice rather than the best treatment for patients. Similarly GP2 said that guidelines should not be used in all situations because they vary so much. GP7 reported that depression guidelines made invalid assumptions about patients presenting with only one illness (and GPs having plenty of time), resulting in the guidelines not being useful for some patients with certain illness combinations.

Barriers to following guidelines

Number of guidelines. The most common perceived barrier preventing these GPs from follow-ing guidelines was the volume of guidelines they receive. They thought they received too many guidelines and had too little time to read them all. The GPs sometimes felt confused about which one to follow. Although they could not quantify how many new guidelines they received in a month, or from how many sources, GPs appeared to feel overwhelmed and despondent.

…There’s a bit of numbing as well: oh no, not another guideline. (GP11)

We get flooded with stuff.… With a lot of stuff I bin it or file it. (GP5)

Time constraints. Lack of time was consistently viewed by participating GPs as a major barrier to guideline use. This is not surprising considering patients are booked in every 5–10 minutes,²⁵ with GPs seeing around 140 patients a week.²⁶ Furthermore, GPs viewed guideline accessibility, style, and presentation as barriers.

SIGN guidelines are always very good because they come on clear to follow laminated cards which are kind of summary versions of them. Many other guidelines are not so good … much longer and difficult to follow.… (GP6)