CanJPsychiatry 2013;58(8):449-455

in Review
Educating Family Physicians to Recognize and Manage
Depression: Where Are We Now?
Linda Gask, MB ChB, MSc, PhD, FRCPsych, FRCGP'
' Honorary Professor of Psychiatry, University of Manchester, Centre for Primary Care, Manchester Academic Health Sciences Centre, Manchester, England.
Correspondence: university of Manchester, Centre for Primary Care, Manchester Academic Health Sciences Centre, Williamson Building, Oxford Road, '
Manchester M13 9PL, United Kingdom; Ig55@niie.com.
Key Words: family practice,
depression, attitudes, primary
care, education, training
Received October 2012,
revised, and accepted January
2013.
Objectives: To consider v^^haf the barriers are fo effecfive depression education; fo
understand whaf affitudes, knowledge, and skills doctors need fo acquire, and finally to
examine whaf we currently know about effecfive ways of training family physicians (FPs)
abouf depression.
Methods: A narrative review of the published literature compiled from searching reviews :
and original articles was conducted using the following key words: education, training,
attitudes, depression, and primary care. Furfher relevant articles were identified from
reference lists.
Results: The identified barriers are FPs' atfifudes and confidence toward recognizing and
managing depression, the way in which they conceptualize depression, and fhe difficulfies
fhey face in implemenfing change in the systems in which they work. We, as educators,
can identify whaf FPs need to know, and this should Include novel ways of organizing care.
However, of key importance is the need to address how more effective Interventions may
be provided, recognizing that FPs may be starting from many different points on 3 differing
continua of attitude, skills, and knowledge in relation fo depression.
Conclusions: We have fo not only ensure that fhe confenf of whaf we teach is perceived
as relevant to primary care but also review exacfly how we go abouf providing it, using
methods that will engage and sfimulafe doctors at differing stages of readiness to acquire
new atfifudes, skills, and knowledge abouf depression. However, we sfill need to find
better ways of helping FPs fo recognize and acknowledge fheir educafional needs. Further
research is also required to thoroughly evaluafe fhese novel approaches fo tailoring
educational interventions.
duquer les mdecins de famille reconnatre et prendre en
charge la dpression : o en sommes-nous?
Objectifs : Examiner quels sont les obstacles une ducation efficace en matire de
dpression; savoir quelles aftitudes, connaissances et comptences doivent acqurir les
mdecins; et enfin, examiner ce que nous savons prsentement des faons efficaces de
former les mdecins de famille (MF) sur la dpression.
Mthodes : Une revue narrative de la littrature publie, tire d'une recherche de revues
et d'articles originaux a t mene l'aide des mots cls suivants : ducation, formation,
attitudes, dpression, et soins de premire ligne. D'autres articles pertinents ont t relevs
dans des bibliographies.
Rsultats : Les obstacles identifis sont les attitudes et la confiance des MF en ce qui
concerne reconnatre et prendre en charge la dpression, la faon dont ils conceptualisent
la dpression, et les difficuifs qu'ils prouvent mettre en uvre le changement au sein
des systmes o ils travaillent. Nous, comme ducateurs, pouvons reconnatre ce que
les MF ont besoin de savoir, ce qui devrait inclure de nouvelles faons d'organiser les
soins. Pourfanf, il est de toute premire importance de rpondre au besoin d'interventions
combien plus efficaces qui peuvent tre offerfes, en reconnaissant que les MF parfenf peut-
tre de nombreux points divers sur 3 continuums diffrents d'attitudes, de comptences, et
de connaissances relativement la dpression.
www.r/eCJP.ca The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 449
In Review
Conclusions : II nous faut faire en sorte non seulement que le contenu de ce
que nous enseignons soit peru comme tant utile aux soins de premire ligne,
mais galement, d'examiner exactement la manire dont nous l'offrons, l'aide de
mthodes qui intresseront et stimuleront les mdecins diffrents stades d'ouverture
acqurir de nouvelles attitudes, comptences, et connaissances relativement la
dpression. Toutefois, nous devons encore trouver de meilleurs moyens d'aider les
MF reconnatre et accepter leurs besoins en matire d'ducation. Il faut aussi
plus de recherche pour valuer avec soin ces nouvelles approches d'interventions
pdagogiques sur mesure.
D
uring fhe last 2 decades of fhe 20fh cenfury, there was
an increased recognition of fhe prevalence of major
depression in fhe general population, and the importance
of ensuring its recognition and treatment in primary care.
Initial efforts focused on the promotion of screening for
depression. However, despite early positive reports, this
has generally not been proven fo be effective in improving
outcomes for pafienfs.''^ My own research, along with
fhat of others, focused on improving the consulting skills
of GPs in the United Kingdom." We knew that some
doctors were more accurate fhan others in recognizing
depression, and fhat fhe beffer recognizers exhibited certain
key behaviours, including making befter eye contact wifh
the patient, beginning with open and moving gradually
fo more closed-ended questions, and asking directive
questions abouf key symptoms and problems later in fhe
consulfafion.^ We developed interactive fraining using
video feedback and role-play methods fo help doctors to
acquire these" and more specific skills relafed fo assessing
and managing depression, with some success.^ However, we
were unable fo show an impact of such fraining on clinical
outcomes for patients.* Indeed, Gilbody et al's systematic
review' concludes rafher pessimistically fhaf "commonly
used guidelines and educational strategies are likely to be
ineffective."'' ^"" However, a recenf sysfemafic review is
marginally more positive, suggesfing that FP training alone
is ineffective in improving outcomes for depression, buf,
if combined with additional guidelines, implementation
results may be more promising for new-onsef depressed
pafient samples.' Bofh reviews'' are clear that additional
changes in the organizational structure of care, such as fhe
implemenfafion of collaborafive care, are much more likely
fo show improved outcomes for depression.
Does this mean if is not worthwhile attempting fo train FPs
in how fo recognize and manage depression? No, if does
nof. The FP plays a key part in depression management,
even within the demonsfrably effecfive organizational
intervention of collaborative care. My paper aims fo
review the literature on fhe barriers to effecfive depression
education; to undersfand what attitudes, knowledge, and
Abbreviations
AD antidepressant
DAQ Depression Attitude Questionnaire
FP family physician
GP general practitioner
Highlight
Educational interventions for FPs have not proved
to be effective in improving outcomes for people
with depression. Potential barriers and facilitators to
educational interventions can be identified.
We need to find ways of tailoring interventions to the
particular needs of FPs, and novel approaches, such
as those based on the stages of change theory, hold
promise.
skills docfors need fo acquire, and finally, fo examine whaf
we currently know about effective ways of fraining FPs
abouf depression.
Understanding the Potential Barriers to
Depression Education
In reviewing fhe published literature, 3 themes emerge. I
will consider each of these in fum.
Attitudes and Confidence
Clinician affifudes and confidence are likely fo be important
in influencing how they assess and respond to patients'
problems and fheir willingness fo adopf new pracfices. In
recenf years, there has been a considerable effort made fo
measure FPs' aftitudes foward depression, and fhe DAQ* has
been widely used in research. A recenf pooled analysis of
DAQ findings from intemafional sfudies during 2 decades'
showed strong disagreement among primary care providers
thaf depression was due fo aging or a characferological
weakness, buf confinenfal European FPs were generally
more posifive abouf depression freafmenfs fhan fhose in
fhe United Kingdom. In this analysis, more recent samples'
considered psychotherapy fo be more beneficial fhan ADs,
indicating perhaps influence from more recent critical
reviews of AD efficacy; and UK doctors were more likely
to consider depression fo improve wifhout AD treatment.'
However, they also were more likely fo resisf the idea
that psychiatrists were beffer placed to manage patients
who require ADs. This suggests some confidence among
FPs, particularly in sfudies in fhe Unifed Kingdom in
comparison to Europe, in understanding when and how to
freaf depression. On whaf mighf have fhis confidence been
based?
Richards ef al' in Australia have reported how participation
in menfal healfh fraining by FPs seems fo be relafed fo fheir
aftifudes foward depressed pafienfs and fo fheir confidence
450 LaRevuecanadiennedepsychiatrie, vol58, no8, aot2013
wmi.LaRCP.ca
Educating Family Physicians to Recognize and Manage Depression; Where Are We Now?
in diagnosing and managing depression. However, it
is unclear whether FPs who profess positive attitudes
are indeed those very doctors who are more likely to
participate in such education in the first place. Andersson
et al," in Sweden, found that in the conception of factors
that influence how they treat depression, FPs tend to
emphasize their own experiences, both from clinical and
personal life, and possibly underestimate the impact of
pharmaceutical companies' marketing on their behaviour.
What is apparent is that they demonstrate a preference for
knowledge in action, as described by Schn in The Refiective
Practitioner.^'^ According to Schn, "The knowing is in
the action. It is revealed by the skilful execution of the
performancewe are characteristically unable to make it
verbally explicit.'"^'P " FPs may reveal skepticism about
scientific evidence, and place a higher value on the benefits
of their own practical wisdom and clinical judgment or
phronesis.'^ This is also apparent in the views expressed
about the introduction of questionnaires to assess severity
of depression in primary care in the United Kingdom,'"
wherein doctors considered their personal judgment to be
more important than objective assessment of depressive
symptoms. The apparent lack of association between FPs'
self-perceived and observed ability to recognize depression
revealed in the study by Olsson et al,'^ in Norway, also
points to an overestimation of their own recognition
abilities. However, this also raises the question of whether
depression as revealed by questionnaires and by psychiatric
interview is perceived as a valid construct itself by FPs, a
point I shall return to shortly. It is certainly clear that in
managing depression FPs highly value their intuition.'*
However, they also seem to question whether depression
is something on which they can actually have any impact,
partly again because of the way in which they conceptualize
the disorder."'^ Some FPs also express a concem to use
the word depression in case of causing distress owing to
stigma, particular in older people." However, this may also
be construed as to hide a reluctance to explore depression to
avoid feeling powerless in the face of limited management
options, in particular the limited access to specialist support
and psychological therapies.^"
How Do FPs Conceptualize Depression?
The nature of depression, particularly in primary care
and in the broader mental health literature beyond the
reach of the Diagnostic and Statistical Manual of Mental
Disorders, remains highly contested,^' with considerable
weight given to the notion of the medicalization of misery
in recent years." In their metasynthesis of recent research
from the United Kingdom, Barley et aF^ unsurprisingly
identified 2 contrasting ways of understanding depression:
depression as a normal response to negative life events,
and a clearly biomdical model of depression. Problems
of everyday life, such as unemployment, chronic illness,
lack of social support, and isolation, may be justifiably seen
as contributing to depression, but this may mean that FPs
conclude it is "largely beyond medical intervention and
can only be palliated [my underline] by pharmacological
means""' " '""in other words, not really treatedand
"we're just a very small part . . . a lot of it is what is
going on their lives."'*' P ^^* Barley et al" conclude that a
normalizing understanding of depression may mean that
clinicians have difficulty in distinguishing between distress
and depression. Alternatively, depression may be seen
as medical condition distinct from everyday life caused
by neurotransmitter dysfijnction, and some clinicians
encourage patients to understand depression in this way,
even if they do not personally hold this view, to "remove
blame and minimise stigma, and to provide a way forward
in the form of antidepressant treatment."^"' P ^ Certainly it
is clear that the way in which FPs move in and out of a
medicalized discourse regarding depression "signals areas
of disjunction and tension in their attempts to understand
r{-| "25,p285
Given the opportunity to describe how they arrived at
a diagnosis of depression in the consultation, a group of
Australian FPs distinguished categories of endogenous
and reactive, an approach to diagnosis that diverges 'om
practice in modem psychiatry." The management of
reactive depression, where a cause could be identified, was
watchful waiting. ADs were most likely to be offered if the
depression was viewed as endogenous, linked with early
moming wakening, chronicity of course, and a biological
view of depression and its treatment. This contrasts
considerably with the promotion of diagnosis as divorced
fi'om etiological theories and the atheoreticalif not now
widely acknowledged to be overly simplisticcategory
of major depression still widely used in psychiatric
classification. The authors" note this may reflect what the
interviewed doctors had been previously taught as much as
their intuitive sense based on experience and reflection, and
it is not known how widely such views are held. However,
the belief that the presence of triggering life events precludes
active treatment will be familiar to those of us who teach
in primary care settings. However, we are equally aware
that the simple view of treating an episode of depression
often fails to capture the complexity of the often prolonged
biopsychosocial conundrum in which a person presenting
in primary care finds themselves,'^''^* about which their
doctor needs to arrive at some kind of understanding and
explanation.^' It also may provide insufficient guidance
in itself as to the best treatment and the likely prognosis.
Guidelines that do not adequately address the issues faced
by FPs in diagnosing and treating depression will not be
followed. "'3
Perceived Barriers to Implementing
High-Quality Care
A major barrier, however, to demonstrating outcomes
for education seems to be the barriers FPs perceive in
implementing changes within the confines of the health care
systems in which they work. A significant problem identified
in the literature is the lack of time available to give to people
presenting with complex psychosocial problems (which,
if available, may improve accuracy of diagnosis^') or in
wmi.TheCJP.ca The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 * 451
In Review
which to carry out new psychological skills that may have
been acquired in education.'^ Lack of access to specialist
mental health care, for support and help with management
and (or) to obtain psychological therapies as an alternative
to prescribing ADs, continues to be problematic,"-^"-""
even though this is what most patients would prefer."
What is clear is the perception that change is not easy
and what is learned in educational sessions regarding new
skills and practices may not be easy for FPs to implement.
Developments in collaborative care during the last decade,
using the model in which treatment is provided by a case
manager working alongside the FP, have, to some extent,
provided a bypass to the FP. This brings with it the risk of
deskilling FPs. However, case managers do not ultimately
replace the key role of the FP in recognition, diagnosis,
managing multimorbidity, and prescribing medication.
Collaborative care also brings its own particular challenges
regarding implementation; for example, finding appropriate
staff within the workforce to adopt the role of case manager.
Delivering More Effective Education
We need to consider not only what we should be addressing
in the education of FPs about depression but also, and
perhaps more crucially, how this should be approached and
executed.
What Do FPs Need to Know About Depression?
Seelig and Katon," from a specialist expert perspective,
commented that to address the gaps between knowledge
and practice in depression care 3 approaches were required:
1. To improve accuracy of diagnosis.
2. To prevent chronic depression.
3. To prevent relapse and recurrence.
According to Palmer et al,^^ patients with depression
want doctors to listen, understand and empathize; provide
thorough and competent diagnosis and management;
follow-up and monitor them; be accessible and not rush
appointments; provide holistic care; and tailor it according
to individual needs. More than a decade ago, Williams et aF'
systematically reviewed the literature to identify the content
and design of educational programs for practising FPs. Their
conclusions (outlined below) retain validity today, although
we can suggest ways in which they could be extended.
Recognition and Diagnosis
Before diagnosis comes recognition, and Williams et aP^
noted that "educators should prioritize communication skills,
and strategies for the use of depression questionnaires."" ' "
Educational sessions need to explore FPs' barriers to the
use of questionnaires, which will enable discussion about
the reasons for and validity or otherwise of using such tools
in the consultation.'"-" Diagnosis requires acknowledging
the limits of current diagnostic criteria,^^ particularly for
primary care settings, practicing key diagnostic questions,
training in interpreting symptoms in the presence of medical
comorbidities and in different age groups, specific training
in suicide risk assessment, how to discuss diagnosis with
the patient, and the importance of very brief screening for
alcohol and drug problems and bipolar disorder. Useful
tools here will include local and national resources about
depression, which may be given directly to the patient or
they may be signposted to such information.
Recently, Mitchell et al,^* who undertook a meta-analysis
of 118 studies that assessed the accuracy of unassisted
diagnosis of depression by FPs, concluded that GPs could
rule out depression in most people who are not depressed,
but diagnosis could be improved by reassessment of people
who may have depression. Thus teaching FPs to bring
patients back for a second look when they are unsure should
be part of depression education.
Treating Depression
Preventing chronic depression requires early and effective
treatment, with knowledge not only of what treatment is
appropriate at which level of depression severity^' but also
of the differing needs of patients in the acute, continuation,
and maintenance stages of treatment and, as indicated above,
the importance of tailoring according to individual needs.
Educational content will inevitably include knowledge of
ADs and how to use them, in different settings (for example,
people who are medically ill, pregnant, or breast-feeding)
and age groups and how to manage comorbid anxiety, which
will more often than not also be present. It should also
seek to challenge attitudes toward use of ADs that result in
inadequate dosage and shorter prescription in primary care
than is suggested by guidelines, which result in incomplete
therapeutic response."" Williams et aP* again highlight
the crucial need for attention to communication skills in
delivering educational messages that improve adherence
to treatment, and the skills required to communicate
empathically and provide supportive counselling, a message
reinforced by van Os et al."' A simple framework for
therapeutic interviewing skills for FPs has been proposed
by Stuart and Lieberman,"^ who described the BATHE
technique (Background, Affect, Trouble, Handle, and
Empathy). There has been only limited evaluation of this
model, but there is some evidence that it can lead to greater
patient satisfaction with the clinician."^ FPs also need to
know how to obtain and make the best use of self-help
materials in conversation with patients. Many doctors keep
such materials on their computer system in a shared drive,
but resources are also available from websites, such as the
Royal College of Psychiatrists, which has a large collection
of easily downloadable materials. It is possible to teach FPs
a range of cognitive-behavioural skills, such as problem
solving and behavioural activation, adapted for use in the
consultation.^ However, the question remains as to whether
they perceive themselves as having the time available to
use these skills.'* The lack of available supervision and
financial rewards for doing so are further disincentives to
all but a small minority of FPs training in more advanced
psychological therapies."" Guidelines and protocols to
inform treatment need to be specifically designed to address
depression as it is seen in primary care settings, otherwise
they will not be well received."-"' In particular, they should
452 La Revue canadienne de psychiatrie, vol 58, no 8, aot 2013 www.LaRCP.ca
Educating Family Physicians to Recognize and Manage Depression: Where Are We Now?
address the influence of social problems on response to
treatment and how to manage these situations."
Organizing Care
However, improving the quality of depression care means
addressing more than just the transaction between patient
and physician. FPs need to know a great deal about the
particular health care system in which they work and
how, when, and why to step a person up to more intensive
therapy. They also need to consider how best to involve the
wider health care team and to understand the ftiU range of
community resources available to them in supporting the
patient. Wagner's chronic care model (see Wagner et al"*^)
irom which collaborative care developed, highlights the
key areas required in reorganizing care for chronic disease
management of depression, a concept that is gradually
becoming more accepted, and for which there is a growing
evidence base.""-"^ FPs can recognize the parallels between
depression and other health problems requiring continuing
and (or) chronic care, such as diabetes. A greater challenge
lies in making real changes to the organization of care.'^
Providing More Effective Educational Interventions
In their review of the published literature on techniques for
improving the psychiatric knowledge, skills, and attitudes
of primary care physicians, Hodges et al'" made numerous
key recommendations. These include the importance of
conducting a needs assessment of participants; involving
leaders in primary care who can help to define competencies;
ensuring that psychiatrists engaged in education in primary
care familiarize themselves with the context of primary
carenotably by working in a shared care setting; linking
leaming objectives to real clinical practice; and interactive
educational methods, including practice of new skills under
observation and the provision of ongoing programs rather
than single sessions. They note the shortcomings in the
evaluation of such interventions, which often reports only
self-perceived educational benefits and change in behaviour
rather than actual changes in clinical practice. However,
the problem remains that FPs may be starting from many
different points on 3 differing continua of attitude, skills,
and knowledge in relation to depression, and it is unlikely
that 1 size will fit all. In my own experience in Manchester,
I have generally found that around 10% of FPs can be
persuaded to attend training and it is often those who least
need further education who will attend.
In light of this, in recent years, some educators have begun
to use Prochaska and DiClemente's stages of change theory
(see Prochaska et al^") to assess physicians readiness to
change in relation to education about depression. Shirazi
et al" divided participants into small and large groups
depending on their initial stage of change, assessed using
a modified tool developed by Buckley et al." FPs in the
attitude stage were considered to have awareness of the
problem but no commitment to take action. They were
allocated to a large group where methods relevant for
this setting were used (programmed lectures followed by
videos and discussion), with an emphasis on diagnosis.
People in the intention stage, who were assessed as being
prepared for behavioural change, were allocated to a small
group workshop setting, using case illustrations and role
play, emphasizing novel treatments of depression and
differential diagnosis. This approach was tested out with
positive findings on knowledge and attitudes (but no formal
assessment of skills) in a randomized controlled trial.^'
Tailoring education to fit with the audience also means
developing and delivering it locally, based on identified
needs and making it relevant to the needs of the local
community." This may mean scheduling on-site education
at their place of work, to reach FPs who may not be
prepared to travel or see the relevance of educational
sessions provided beyond their local context. This also
allows the inclusion of the mental health professionals with
whom they work, with the aim of building more effective
relationships across the interface.^"*
What we have come to realize is how providing continuing
medical education that is effective is not a simple process,
but there are some key principles that, if applied, may help
us to achieve more success." First, we have to consider
where participants are in terms of their stage of leaming
and help them to recognize what they need to know. This
is not always easy, as they may not know what they do not
know, thus planning an educational session for FPs may
require some discussion and negotiation as well as local
data collection, audit, and feedback. If even this level of
engagement is not possible, we have to find ways to simply
increase awareness of a need to change, as described
earlier. Second, teaching must be practical and focused on
real clinical problems. Third, this must be contextually and
professionally relevant. Sherman et al" talk about "building
education into tasks that will occur anyway such as a referral
form or follow up fi-om a consultation."'' "" Finally, it must
provide multiple opportunities for active leaming, practice,
and feedback.
Conclusion
We have moved a long way from a simplistic view that
education of FPs is the answer to the underrecognition and
undertreatmeht of depression. Education is clearly necessary
but not sufficient. We need to understand, acknowledge, and
challenge the perceived barriers to depression education.
Further, we have to not only ensure that the content of
what we teach is perceived as relevant to primary care but
also review exactly how we go about providing it, using
methods that will engage and stimulate doctors at differing
stages of readiness to acquire new attitudes, skills, and
knowledge about depression. However, we still need to find
better ways of helping FPs to recognize and acknowledge
their educational needs, and fiarther research is also required
to thoroughly evaluate these novel approaches to tailoring
educational interventions.
Acknowledgements
Dr Gask has received speaking fees from Eli Lilly.
www.7heCJP.ca
The Canadian Joumal of Psychiatry, Vol 58, No 8, August 2013 ' 453
In Review
The Canadian Psychiatric Association proudly supports the
In Review series by providing an honorarium to the authors.
References
1. Gilbody S, Whitty P, Grimshaw J, et al. Educational and
organizational interventions to improve the management
of depression in primary care: a systematic review. JAMA.
2003;289:3145-3151.
2. Thompson C, Kinmonth A-L, Stevens L, et al. A randomised
controlled trial of the effects of a clinical practice guideline and
practice based education on the detection and outcome of depression
in primary care: the Hampshire Depression Project. Lancet.
2000;355:185-191.
3. Goldberg DP, Huxley P. Mental illness in the community: the
pathway to psychiatric care. London (GB): Tavistock; 1980.
4. Gask L, McGrath G, Goldberg D, et al. Improving the psychiatric
skills of established general practitioners: evaluation of group
teaching. Med Educ. 1987;21:362-368.
5. Gask L, Usherwood T, Thompson H, et al. Evaluation of a training
package in the assessment and management of depression in primary
care. Med Educ. 1998;32:190-198.
6. Gask L, Dowrick C, Dixon C, et al. A pragmatic cluster
randomized controlled trial of an educational intervention for GPs
in the assessment and management of depression. Psychol Med.
2004;34:63-72.
7. Sikorski CM, Luppa HH, Knig H, et al. Does GP training in
depression care affect patient outcome? A systematic review and
meta-analysis. BMC Health Serv Res. 2OI2;12:IO.
8. Botega N, Mann A, Blizard R, et al. General practitioners and
depressionfirst use of the Depression Attitude Questionnaire. Int J
Methods Psychiatr Res. 1992;2:169-180.
9. Haddad M, Menchetti M, Walters P, et al. Clinicians attitudes to
depression in Europe: a pooled analysis of Depression Attitude
Questionnaire findings. Fam Pract. 2012;29:121-l30.
10. Richards JC, Ryan P, McCabe MP, et al. Barriers to the effective
management of depression in general practice. Aust N Z J
Psychiatry. 2004;38:795-803.
11. Andersson SJ, Troein M, Lindberg G. General practitioners'
conceptions about treatment of depression and factors that may
influence their practice in this area. A postal survey. BMC Fam
Pract. 2005;6:2l.
12. Schn, D. The reflective practitioner: how professionals think in
action. New York (NY): Basic Books; 1983.
13. Hilton SR, Slotnik HB. Proto-professionalism: how
professionalization occurs across the continuum of medical
education. Med Educ. 2005;39:58-65.
14. Dowrick C, Leydon GM, McBride A, et al. Patients' and doctors'
views on depression severity questionnaires incentivised in
UK quality and outcomes framework: qualitative study. BMJ.
2009;338:b663.
15. Olsson I, Mykletun A, Dahl AA. General practitioners' self-
perceived ability to recognize severity of common mental disorders:
an underestimation factor in case identification? Clin Pract
Epidemiol Ment Health. 2006;2:l-9.
16. Railton S, Mowatt H, Bain J. Optimizing the care of patients with
depression in primary care: the views of general practitioners.
Health Soc Care Community. 2000;8:119-128.
17. May C, Allison G, Chappie A, et al. Framing the doctor-patient
relationship in chronic illness: a comparative study of general
practitioners' accounts. Sociol Health Illn. 2004;26:135-158.
18. Gask L, Dixon C, May C, et al. Qualitative study of an educational
intervention for GPs in the assessment and management of
depression. Br J Gen Pract. 2005;55:854-859.
19. Burroughs H, Lovell K, Morley M, et al. 'Justifiable depression':
how primary care professionals and patients view late-life
depression? A qualitative study. Fam Pract. 2006;23:369-377.
20. Telford R, Hutchinson A, Jones R, et al. Obstacles to effective
treatment of depression: a general practice perspective. Fam Pract.
2002; 19:45-52.
21. Dowrick C. Beyond depression. Oxford (GB): Oxford University
Press; 2009.
22. Pilgrim D, Bentall R. The mdicalisation of misery: a critical
realist analysis of the concept of depression. J Mental Health.
1999;8:261-274.
23. Barley EA, Murray J, Walters P, et al. Managing depression in
primary care: a meta-synthesis of qualitative and quantitative
research from the UK to identify barriers and facilitators. BMC Fam
Pract. 2011 ;12:47.
24. Johnston O, Kumar S, Kendall K, et al. Qualitative study of
depression management in primary care: GP and patient goals, and
the value of listening. Br J Gen Pract. 2007;57:872-879.
25. Thomas-Maclean R, Stoppard JM. Physicians' constructions of
depression: inside/outside the boundaries of medicalization. Health.
2004;8:275-293.
26. Clarke DM, Cook K, Smith GC, et al. What do general practitioners
think depression is? A taxonomy of distress and depression for
general practice. Med J Aust. 2008; 188( 12 Suppl):S 110-S113.
27. Rogers A, May C, Qliver D. Experiencing depression, experiencing
the depressed: patients and doctors' accounts. J Ment Health.
2001;10:317-334.
28. Gask L, Klinkman M, Fortes S, et al. Capturing complexity: the case
for a new classification system for mental disorders in primary care.
Eur Psychiatry. 2008;23:469-476. .
29. Cape J, Morris E, Burd M, et al. Complexity of GPs' explanations
about mental health problems: development, reliability, and validity
of a measure. Br J Gen Pract. 2008;58:403-410.
30. Kendrick T. Why can't GPs follow guidelines on depression?
We must question the basis of the guidelines themselves. BMJ.
2000;320:200-201.
31. Hutton C, Gunn J. Do longer consultations improve the management
of psychological problems in general practice? A systematic
literature review. BMC Health Serv Res. 2007;7:71.
32. Younes N, Gasquet 1, Gaudebout P, et al. General practitioners'
opinions on their practice in mental health and their collaboration
with mental health professionals. BMC Fam Pract. 2005;6:18.
33. Prins MA, Verhaak PF, Bensing JM, et al. Health beliefs
and perceived need for mental health care of anxiety and
depressionthe patients' perspective explored. Clin Psychol Rev.
2008;28:1038-1058.
34. Seelig MD, Katon W. Gaps in depression care: why primary care
physicians should hone their depression screening, diagnosis, and
management skills. J Occup Environ Med. 2008;50:451-458.
35. Palmer V, Gunn J, Kokonovic R, et al. Diverse voices, simple
desires: a conceptual design for primary care to respond to
depression and related disorders. Fam Pract. 2010;27:447-458.
36. Williams JW Jr, Bhogte M, Flinn JF. Meeting the needs of primary
care physicians: a guide to content for programs on depression. Int J
Psychiatry Med. I998;28:123-I36.
37. Gilbody SM, House AO, Sheldon TA. Screening and case finding for
depression. Cochrane Database Syst Rev. 2005;(4):CD002792.
38. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in
primary care: a meta-analysis. Lancet. 2009;374:609-619.
39. National Institute for Health and Clinical Excellence (NICE).
Depression: the treatment and management of depression in adults.
London (GB): NICE; 2009. NICE clinical guideline 90.
40. Fitch K, Molnar FJ, Power B, et al. Antidepressant use in older
people: family physicians' knowledge, attitudes, and practices. Can
Fam Physician 2005;51:80-81.
41. van Os TW, van den Brink RH, Tiemens BG, et al. Communicative
skills of general practitioners augment the effectiveness of
guideline-based depression treatment. J Aff Disord. 2005;84:4351.
42. Stuart MR, Lieberman JA. The fifteen minute hour: a short-term
approach to psychotherapy in primary care. 3rd ed. Philadelphia
(PA): Saunders; 2002.
43. Leiblum SR, Schnall E, Seehuus M, et al. To BATHE or not to
BATHE: patient satisfaction with visits to their family physician.
FamMed. 2008;40:407-411.
44. Aschim B, Lundevall S, Martinsen EW, et al. General practitioners'
experiences using cognitive behavioural therapy in general practice:
a qualitative study. Scand J Prim Health Care. 2011;29:176-180.
454 < La Revue canadienne de psychiatrie, vol 58, no 8, aot 2013 wmi.LaRCP.ca
Educating Family Physicians to Recognize and Manage Depression: Where Are We Now?
45. Hegarty K., Gunn J, Blashki G, et al. How could depression
guidelines be made more relevant and applicable to primary care?
A quantitative and qualitative review of national guidelines. Br J
Gen Pract. 2009;59:322-328.
46. Wagner EH, Austin BT, Von Korff M. Organizing care for patients
with chronic illness. Milbank Q. 1996;74:511-544.
47. Archer J, Bower P, Gilbody S, et al. Collaborative care for people
with depression and anxiety. Cochrane Database Syst Rev.
20l2;(10):CD006525.doi: I0.1002/14651858.CD006525.
48. Kates N, Mach M. Chronic disease management for depression in
primary care: a summary ofthe current literature and implications
for practice. Can J Psychiatry. 2007;52:77-85.
49. Hodges B, Inch C, Silver I. Improving the psychiatric knowledge,
skills and attitudes of primary care physicians, 1950-2000: a review.
Am J Psychiatry. 2001 ; 158:1579-1586.
50. Prochaska JO, DiClemente CC, Norcross JC. In search of how
people change. Applications to addictive behaviors. Am Psychol.
1992;47:1102-1114.
51. Shirazi M, Parikh SV, Alaeddini F, etai. Effects on knowledge and
attitudes of using stages of change to train general practitioners on
management of depression: a randomized controlled study. Can J
Psychiatry. 2009;54:693-700.
52. Buckley LL, Goering P, Parikh SV, et al. Applying a 'stages of
change' model to enhance a traditional evaluation of a research
transfer course. J Eval Clin Pract. 2003;9:385-390.
53. Sherman SE, Fotiades J, Rubenstein LV, et al. Teaching systems-
based practice to primary care physicians to foster routine
implementation of evidence-based depression care. Acad Med.
2007;82:168-175.
54. Hodgins G, Judd F, Davis J, et al. An integrated approach to general
practice mental health training: the importance of context. Austral
Psychiatry. 2007; 15:52-57.
55. Moore DE Jr, Cervero RM, Fox R. A conceptual model of CME to
address disparities in depression care. J Contin Educ Health Prof
2007;27(Suppl l):S40-S54.
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1. Robinson RG, Spalleffa G. Posfstroke Depression: A Revievi/. Can J Psychiatry. 2010;55(6):341-349. 22
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High-Risk Symptoms for Psychosis. Can J Psychiafry. 2010;55(3):165-171.
s Web of Knowledge. Web of Science. Canadian Journal of Psychiatry. Available from: http://apps.webofknowledge.com/CitationReport.
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