175 Antidepressant therapy prescription, do psychologists help? Evidence from Portugal contributors behind the increased between term. GPs are civil servants hired by public tender- to state owned primary care practices. The hiring in the Portuguese national health system is highly regulated by a national recruitment program and physicians apply mostly through the national tender to open positions in existing practices. On the patient side, there are limited options to choosing or moving GPs. Patients must enrol in the practices corresponding to their catchment area, and the lack of GPs to cover the Portuguese population is one biggest weakness of NHS, widely discussed in the society. Approximately 7.5% of the Portuguese residents did not have a GP in August 20189), with some regions being characterised by a greater number of patients waiting to be registered with a GP. Therefore, we hypothesize that local group level processes are most likely the confounders behind the magnitude and significance of the between term. Local groups with more psychologists might also be those where mental health services are better integrated; with local protocols and experience supporting the use of psychotherapy alone; or in which clinical leadership and education provided to GPs favours lower prescription of antidepressants. These findings should direct policymakers that aim at reducing antidepressant use to act beyond increasing psychologists’ supply; and effectively understand what are the organizational factors that maximize the likelihood of substitution. In fact, there is only one national guideline on treating depression, which dates from 2012 and focuses on major depression [51]; each local group has their own (internal) referral pathways and guidance on what patients and cases should be referred to psychologists, which can differ considerably according to anecdotal evidence. Identifying and scaling up best practices, developing nationwide evidence-based guidelines on referral to psychotherapy in primary care and promoting awareness and educational interventions for GPs might be as important as increasing the number of psychologists. There are important considerations to be made when interpreting our findings. First, the causal interpretation of our findings is limited, even for the within term. Despite not being affected by time-invariant variables, the within coefficient may still be biased due to time-variant unmeasured variables. It is possible that the local group-level confounders we discussed earlier may change over time, (e.g. maturity of mental health services integration or clinical leadership preferences), although this is unlikely to vary substantially over a short panel of four years. Second, as with most literature, we are unable to determine the appropriateness of either treatment approach. Antidepressant drugs are a crucial therapeutic tool in managing depression, and increases in their use are not necessarily inappropriate, but may be a consequence of increased detection, reduced stigma, improved patient acceptance, among others. The effectiveness of antidepressants, particularly serotonin re-uptake inhibitors (SSRIs), has recently been subjected to extensive public debate [52, 53]. It is important to clarify that this study does not support arguments presented in discussions against the use of antidepressants. 9 Data retrieved from the Transparency Portal from the Portuguese NHS https://transparencia.sns.gov.pt/explore/ dataset/utentes-inscritos-em-cuidados-de-saude-primarios/ (accessed in 1 May 2023). 5
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