A Qualitative Exploration of General Practitioners' Treatment Decision-Making for Depressive Symptoms

General practitioners (GPs) provide the most antidepressant prescriptions and psychologist referrals in Australia, yet little is known about how they decide between treatments for depressive symptoms.

This study examined the decision cues that GPs use when deciding how to treat depressive symptoms and the meaning they attribute to these associations.

Structured interviews were conducted with 16 Australian GPs in a "think-aloud" verbal protocol analysis format. The transcripts were analyzed using content coding and thematic analysis, informed by the dual processes model of decision making.

Participants associated prescribing antidepressants with severe depressive symptoms, and psychologist referrals were the preferred initial treatment provided patients were willing to engage. Four main themes emerged from the thematic analysis: 1) psychologist as default, 2) the risk is just too high, 3) medication as supplement, and 4) drivers of antidepressants. Contrary to previous findings, participants identified a strong heuristic association between depressive symptoms and psychologist referral. Antidepressant prescription was associated with severe symptoms, higher risk, and a cluster of cues that lead them away from psychologist referral.

Participants demonstrated an oversensitivity to depressive symptom severity, associating psychologist referrals with subclinical depressive symptoms, and starting antidepressants for suicidal ideation and significant functional decline.

Psychologist referrals were the default preference for GPs when treating depressive symptoms, whereas antidepressants were reserved for patients with elevated risk from severe depressive symptoms and suicidal ideation.Participants' conceptualization of depression severity was oversensitive compared with treatment guidelines.Contrary to treatment guidelines, GPs in this study demonstrated their discomfort for referring patients with suicidal ideation to a psychologist without initiating antidepressants.GPs should consider whether patients within their mild to moderate assessment range can be treated exclusively with more cost-effective means than psychological therapy such as e-mental health programs, guided self-help, and lifestyle changes alone.