Use of a structured interview to support diagnosis of depression and anxiety disorders in primary care

Abstract

Aims: The overall aims were to synthesize knowledge about which instruments for depression that are evidence based, and to develop a strategy, based on determinants of practice and theory, to support the use of these instruments in primary care.

Background: A correct diagnosis is essential for appropriate management of depression and anxiety, the two most common mental disorders seen in primary care. However, the diagnosis can be difficult. Structured interviews and rating scales (instruments) have been proposed as a support in the consultation, but the evidence for their accuracy is unclear and their use in primary care limited.

Methods: Determinants of practice were explored in a focus group study with n = 27 family practitioners (FPs) in Västra Götaland. Systematic text condensation was used to analyse the discussions. A systematic review was conducted in accordance to the PRISMA statement to determine which instruments that were evidence-based. Only studies with low or moderate risk for bias were included in the meta-analyses. The evidence for average sensitivity and specificity was rated with GRADE. The acceptability of the evidence-based instrument, the Mini International Neuropsychiatric Interview (MINI), and of a supporting strategy was explored at three primary care centres (PCCs) in Stockholm. Data collection included a structured questionnaire to patients and interviewers (n = 125 patients), semi structured interviews (n = 24 patients and n = 3 therapists) and focus groups (n = 17 FPs). Qualitative content analysis and descriptive statistics were used in the data analysis. Findings across the participant groups were triangulated with the results from the questionnaires. The main component of the intervention strategy was a task shift, where FPs could refer patients to a therapist for the MINI assessment and the results were fed back to the FP. The analyses were based on the interviews and focus groups, where n = 21 patient interviews were relevant. Factors that influenced the referral process was identified with deductive content analysis guided by the COM-B model.

Main Results: Several determinants of practice could influence when, and to what extent Swedish FPs use instruments for depression. These mainly concerned knowledge and attitudes of the individual FP. However, some actors outside primary care could influence the use. The MINI had good diagnostic accuracy for depression. It was appreciated by FP, patients and therapists in primary care. The time for the assessment could be a problem for FPs who want to conduct the MINI. The task shift was appropriate at one of the two PCCs. The inclination to refer was dependent on factors such as FPs’ own knowledge and beliefs that referral gives benefits to the FP and the patient.

Conclusions: The MINI can be a useful part of the consultation in primary care and is appreciated by the patients and interviewers. Referral to a therapist for MINI assessment can be feasible, depending on contextual factors.