This study resulted in two main key findings. The first was the GPs' prescription in numerous medical conditions not including strictly psychiatric conditions. Although we encountered AD prescription related to well-defined diseases, "combined situations" with variable combinations of physical symptoms and psychological distress were the more standard situations leading to prescription. It is already known that more than 90% of depressed patients suffer from another physical or mental disorder [19
]. Although "standard causes" (e.g. depression and anxiety) were the main reasons to prescribe, the decision whether or not to prescribe was very difficult to make. Our data suggest that the GPs tried to circumvent their difficulties by developing their own tools.
The second main finding, clearly related to the first one, was a consensus on the inadequacy of the guidelines as a tool to help physicians decide whom to treat with antidepressants. The GPs developed specific skills to come up with their own personal "scales", usually based on an implicit combination of "gut feeling", "knowledge of the patient", and "small signs". This way of assessing patients has already been described [20
]. In case of doubt, uncertainty could be diminished using the drug as a "therapeutic test". GPs also made their decision based on information about difficulties in the patients' social, professional and family lives, fatigue and repeated, unexplained requests for medical care. This way of coping with uncertainty is a strategy specific to GPs [20
]. Though our GPs developed a strategy, no clear threshold for making the decision to prescribe an antidepressant was identified. This decision was clearly affected by the GPs' opinions on antidepressants, which were seen as useful drugs with no major adverse effects. The decision to prescribe was also influenced by patient's background and history, as well as by a lack of available psychotherapeutic options. In this context, a GP could view prescription of an antidepressant as "justified", even though the scale-based criteria were not met.
Our results reflected the basics of medical decision-making: combining necessity, effectiveness, safety and economy [22
]. For the GPs in our sample, "necessity" meant focusing mainly on lack of recognition of depressive symptoms and under treatment, rather than useless or ineffective overtreatment. Effectiveness was seen as one of the main characteristics of antidepressants, even though the lack of practical studies in real prescribing situations has already been pointed out. Another main finding was related to the safety of antidepressants. Compared to psychological care, economy was a concern for GPs. The overall combination of these 4 factors could lead to a high antidepressant prescription rate.
Strengths and limitations
Several points support these findings. Firstly, all of the GPs harshly criticized the guideline criteria and agreed they were irrelevant in primary care settings, thus clearly and explicitly assuming responsibility for the nature of their actual practices. From this point of view, the study's phenomenological approach was successful: the GPs recounted their true-life experiences with prescribing ADs, and the analysis was based on these experiences, not on general opinions. This was facilitated by a comprehensive approach: the participating GPs did know that this study was being conducted by GP researchers. This option was chosen in order to ensure the GPs that they would not be judged by psychiatrists: otherwise, the GPs may not have discussed their choices and difficulties so freely. Secondly, a wide variety of diagnoses, in addition to psychiatric conditions, were assessed. This leads us to believe that the GPs talked very freely about their real problems, even though this study was based on related behaviours. Finally, and despite the fact that they were younger and less experienced, the locums mostly shared the same opinions. We clearly made this choice in order to try to discover borderline therapeutic choices among GPs who would have declined the invitation to take part in a focus group on the sensitive topic of AD prescription. None of the locums recounted unexplained prescription of ADs. The choice to use a sample composed of both urban and rural GPs was also made to try to discover behaviours and difficulties related to overbooked practices or a variety of patient situations. No clear differences in their approach or behaviour appeared during the data analysis. This was the case for both younger and older, more experienced male and female GPs. This strengthens the hypothesis that our outcomes are on the whole related to primary care situations, and not only to certain practice characteristics.
Conducting focus groups on this sensitive subject could have proven to be a limitation, hiding relevant material: the GPs could have chosen to conceal odd prescriptions or decisions not covered by validated scale criteria. Nevertheless, the options chosen for the sample could not have selected doctors very interested in this topic, or on the contrary those with a strong aversion to psychiatric conditions. Another limitation is the need for more insight on the exact usefulness of the GP's personal way of assessing a patient: feelings and knowledge are well known in primary care, but we did not collect any relevant material on the way the GPs made them part of their decision-making process. One key finding was that the GPs used a personal scale, but that no data were collected to evaluate the actual performances of these scales. No evidence was gathered concerning a threshold, determined using these skills, after which an antidepressant is prescribed. Our study was not designed to explore these aspects in detail. The outcomes enable us only to make hypothesis on GPs' possibly prescribing more than necessary, and not to focus on a particular explanation. It is already well known that the positive predictive value for routine diagnosis of depression is low [18
]. Could GP assessments using these personal tools increase this rate?
Relevance for practice and future research
Another finding concerned GPs' doubts regarding the usefulness of guideline depression scales in primary care settings. In our study, we saw GPs reinventing criteria. This is consistent with other studies, showing that physicians' familiarity with a patient was an important condition in recognizing and managing depression [23
]. If physicians do not see these tools as useful and do not use them at all, we should perhaps draw some conclusions: instead of making every effort to generalize the use of these tools, shouldn't we assess what is currently used in real practice? Such an assessment would likely result in practices that were more often used in everyday primary care settings. The relevance of antidepressant treatment in non-psychiatric situations in primary care seems to be a key question amongst many researchers. Various studies and trials have tested the usefulness of antidepressant drugs in "non-psychiatric" situations [24
]. As regards primary care, the external validity of these studies is controversial, as primary care rarely involves one clear condition, but rather combines a wide variety of physical symptoms, psychological distresses and social issues. The usefulness of antidepressant treatment in various primary care settings needs to be comprehensively assessed. Prescribing fewer drugs should be considered along with making counselling and psychotherapy more available. The next step is to try and understand decision making in real settings by collecting data on antidepressant prescriptions from patient records.