176 Chapter 5 Additionally, due to data limitations, the interpretation of the results is constrained, resulting in several recommendation for further research. The number of psychologists is only a proxy of actual psychological therapy supply, as psychologists may also be involved in other tasks such as palliative care or long-term care, or they might decide to prioritize some tasks such as patient assessment and counseling vs. psychotherapy, due to the number of patients in the waiting list. To validate our findings and better test the hypotheses of substitution and combined therapy, data on psychologists’ consultations and GPs referrals are required. Additionally, we were unable to capture the numbers or activity of psychologists operating on a private basis outside of NHS. Portugal has many self-employed clinical psychologists, and GPs may recommend these to patients who can afford the out-of-pocket costs. The limited availability of psychologists in the public NHS is therefore likely to contribute to inequalities in access to appropriate mental health treatment and resulting treatment outcomes, which also deserves further investigation. Last, additional research is needed to understand the role of patient beliefs and preferences in the relationship between psychologists and antidepressant use. While some literature shows that patients prefer psychotherapy to antidepressants [33], other studies suggest that GPs failure to recommend non-pharmacological options is not an explanation for high antidepressant prescription rate [54], and that simply removing barriers in access to these approaches would lead to small changes in the actual use of psychotherapy [55]. CONCLUSION Treating depressive disorders is considered a pressing issue in primary care, with pandemic-related lockdowns and economic downturns increasing the demand for mental health care and ongoing public debate about the appropriateness of antidepressants use. Our study provides an important contribution to understanding and quantifying the relationship between pharmacological and psychological treatment approaches of depression. Our results for the Portuguese primary care setting do not support the theoretical prediction that increased numbers of psychologists reduces antidepressants prescription, at least in such a context of short supply. Instead, findings suggest that the extent to which increasing the number of psychologists will impact antidepressants prescription depends on the supply levels of psychological treatment approaches, but also on physician and organizational characteristics that bring together GPs with lower prescription rates and the local groups with higher levels of mental health integration.
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