155 Antidepressant therapy prescription, do psychologists help? Evidence from Portugal INTRODUCTION Depression is a common mental health disorder and a major cause of disability and economic burden worldwide [1, 2]. Most patients with depressive disorders have mild and moderate cases and are treated in primary health care [3–5]. When deciding how to treat these patients, general practitioners (GPs) can choose between prescribing pharmacotherapy, psychological interventions – usually provided by mental health workers – or a combination of both [6]. Psychotherapy is the first-line recommendation in most treatment guidelines for patients with mild cases, whereas antidepressants, psychotherapy or a combination of both are all first-line recommendations for moderate depression [7–12]. In most health care systems, the integration of mental health workers into primary care has been happening for the past decades. This integration can lead to organizational changes and modification of GPs´ clinical routines [13] and it increases the availability of psychological interventions such as psychotherapy, which GPs would usually not have sufficient training or time to provide [14]. At the same time, increased antidepressant utilization has also been registered in several countries [15–18]. Despite representing an expansion in patient treatment, these trends have raised concerns about the benefitrisk ratio of antidepressants for the treatment of mild and moderate cases, and about increasing drug costs [19–21]. As primary prescribers of antidepressants [15, 20], GPs have been at the core of this debate, and a literature stream studying their opinions and practices emerged, mostly using surveys and qualitative studies [14, 22, 23]. Some of these studies suggest that limited access to non-pharmacological treatment resources is a determinant of choice favoring medicines prescription [14, 24]; others failed to identify such association [23, 25]. In fact, there is not enough empirical evidence to back up the commonly stated hypothesis that increasing psychological therapy resources available to GPs would decrease antidepressant prescriptions [14, 26]. We used nationwide data from Portugal to investigate the relationship between the number of psychologists available in primary care and GP prescription of antidepressants to patients with depression, between 2015 and 2018. In Portugal, psychologists are hired as part of local groups, which are primary care governance structures that bring together several GP practices and manage their shared resources. The number of psychologists in primary care is in all regions considered too low in comparison to other countries, and to the standards set by the Portuguese Assembly recommendation that defines a ratio of one psychologist per 5000 inhabitants [27]. International comparisons do also suggest that Portugal has a high level of antidepressant use, in fact the third highest sale volume of antidepressants amongst OECD-26 countries in 2015 [26]. As in other countries with barriers to access to psychological services [14], the limited availability of psychologists in the Portuguese national health system (NHS) is believed to contribute to the excessive use of psychotropic medications [26]. 5
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