Treatment of common mental disorders in general practice: Are current guidelines useless?

The paper by Croudace et al (2003) confirms the pattern set by previous studies (Upton et al, 1999; King et al, 2002) in showing little or no effect of educational and treatment initiatives on primary care physicians’ practice of psychiatry. The authors provide various explanations for the negative outcome; one of these – ‘failures in the content of the guidelines themselves in terms of their evidence base or relevance’ – deserves greater prominence. Although psychiatry can claim some credit for advances in the diagnoses and treatment of more-severe disorders seen in secondary care, our interventions for the common mental disorders in primary care are much less securely founded.

The guidelines do not take proper account of the well-established fact that approximately two out of five patients presenting with common mental illnesses in general practice (even when considered ill enough to merit psychiatric input) improve rapidly within a few weeks. These probably merit the often forgotten diagnosis of adjustment disorder (Casey et al, 2001). Thirty per cent pursue a slower course of recovery and a further 30%, mostly with mixed anxiety and depressive disorder, have a worse outcome with frequent relapses (Tyrer et al, 2003), although in the short term a variety of interventions can be effective.

The methodology of Croudace et al's study is to be commended and the results show that even when guidelines lead to greater specificity in identifying illness, this is not accompanied by better outcomes. Pressured general practitioners in the past used to take the approach that if a patient with mental health symptoms presented for treatment, the doctor could listen sympathetically and, unless there was significant risk, would ask them to come back in 4 weeks’ time. If the patient returned, he or she might have a more serious problem necessitating formal treatment. Such an approach may have a greater evidence base than any of our guidelines. It nicely separates those with adjustment disorders from the rest, prevents inappropriate therapies that might lead to iatrogenic problems like dependence, and is an excellent predictor of improvement many years later (Seivewright et al, 1998). If we were able to help general practitioners at the time of presentation to diagnose which patients needed intervention and which did not, we might be doing a better service than any of the current guidelines that litter general practice surgeries in this and many other countries.