Title: The Antidepressant Advisor: A decision support system for UK primary care - a feasibility study
Funder: Department of Health and Social Care

Abstract: Background Depression is particularly disabling because most patients do not recover after treatment with one standard antidepressant medication or talking therapy. The National Institute for Health and Care Excellence (NICE) recommends three first-line antidepressants with similar mechanisms of action. Second- and third-line antidepressants are recommended by NICE, but are only prescribed by some GPs, because of uncertainty and lack of clear strategies for how to use them, as well as difficulties getting advice from psychiatrists who focus on high-risk patients. This means that patients access to second- and third-line antidepressants is highly variable. Guidelines are therefore poorly implemented contributing to the overall burden of depression. A computerised tool to help GPs make decisions about antidepressant prescribing has been shown to improve depression in a US study. For UK GPs, however, there is no available antidepressant decision support tool. Aims Here, our aims are to 1) develop the first such tool for people with depression through collaboration with EMIS, the leading provider of GP electronic health records, and 2) to estimate unknown variables needed to plan a subsequent larger trial, such as lost to follow-up rates, GP satisfaction, impact on health service use, and standard deviations on our future primary outcome measure. Plan of investigation We propose a randomised controlled feasibility trial with GPs in different practices being randomised to two interventions: 1) Usual care with no decision support, 2) Using our computerised decision support tool to advise on choice of antidepressants. This prepares for future definitive trials probing the effect on depressive symptoms after 16 weeks of treatment. Potential benefits to patients and the NHS Service users have strongly endorsed the importance of our approach and will continue to be involved in the implementation and dissemination of this research, as well as being steering group members. The results will be presented to GPs and patients locally, at national conferences, and published in high-quality journals. If successful, the proposed study will demonstrate the feasibility of our trial and allow us to apply for further funding by the NIHR Health Technology Agency (HTA) to fund a definitive randomised controlled trial in a larger sample. If successful, this would lead to a positive HTA appraisal and national implementation, thereby improving depression outcomes in the NHS by changing prescribing patterns in primary care.

Lay abstract: Depression is particularly disabling because most patients do not recover after treatment with one standard antidepressant medication or talking therapy. The National Institute for Health and Care Excellence (NICE) recommends using a choice of three antidepressants in the first instance, all of which work in a similar way. NICE also recommends a choice of antidepressants to be used in the second and third instance if the first antidepressants fail to help. There is, however, a lack of clear strategy for how to use these antidepressants, and it is difficult to receive advice from psychiatrists who have experience prescribing these antidepressants. As a result, second- and third-line antidepressants are only prescribed by some GPs, meaning patients access is highly variable, which increases their burden of depression. A computerised tool to help GPs make decisions about antidepressant prescribing has been shown to improve depression in a US study. For UK GPs, however, there is no available antidepressant decision support tool. Here, our aims are to 1) develop the first such tool through collaboration with EMIS, the leading provider of GP electronic health records, and 2) to find out what factors are important to consider for future larger studies, such as how many participants drop out of the study, what impact the tool has on patient care and how satisfied GPs are with the tool. In our proposed study, we will randomly allocate GPs into two groups: one group will provide care as they normally would; the second group will use the decision support tool to advise on choice of antidepressant. The findings of this study are necessary for planning future studies, which will investigate whether this decision support tool improves symptoms of depression. Service users have strongly endorsed the importance of our approach and will act as steering group members.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MENTAL HEALTH