Introduction
ChatGPT (Chat Generative Pretrained Transformer), an advanced conversational artificial intelligence (AI) technology, is the product of the research and development endeavours of OpenAI, and is powered by this company’s transformative GPT linguistic model.1 Only a few months after being made publicly available, ChatGPT had already gathered an astounding constituency of 100 million users, marking it as the most rapidly expanding AI consumer application to date.2 ChatGPT has broad competencies for dealing with text-based inquiries ranging from basic requests to intricate demands. It is able to discern and decipher user input and formulate responses that mirror human conversation.1 2 This remarkable capacity to produce human-like dialogue and perform complex functions marks ChatGPT as a pivotal advancement in the domains of natural language processing and AI.1 2 ChatGPT can be used in the fields of education,3 programming4 and psychology.4 5 However, its potential implications in applied psychological settings remain relatively unexplored.6 7 Despite the theoretical potential of ChatGPT,8 its potency in addressing critical clinical mental health challenges has yet to be definitively determined.7 Most studies to date examining the role of ChatGPT in public health focus predominantly on assessing the merits and drawbacks, with very little empirical examination of this topic.7 8 Furthermore, to the best of our knowledge, no studies have investigated the issue of depression in the context of ChatGPT, despite the high prevalence of this condition in the field of mental health.
Depression is a prevalent disorder9 10 for which people often first seek help from primary care physicians. Accurate diagnosis and treatment are crucial for continuity of care.11 The disorder is characterised by a multitude of symptoms, among them persistent melancholy, anhedonia, guilt-related sentiments or low self-esteem, irregularities in sleep patterns or appetite, perpetual fatigue and impaired concentration.10 12 In its most severe state, depression can precipitate suicidal tendencies and augment mortality risk. Depression often follows a chronic trajectory, considerably diminishing the capacity for vocational productivity and degrading quality of life.13 Mild depression is defined by the presence of symptoms that exceed the diagnostic minimum. Although such symptoms are distressing, they remain manageable for the individual, causing only minor hindrances to social or occupational functionality.14
For individuals with depression, primary care providers are often their initial point of interaction with the medical system, and are therefore instrumental in initiating appropriate therapeutic strategies.14 15 Primary care physicians are often the first to identify depressive symptoms in patients, either initiating treatment or referring them to specialists as per guidelines. Accurate diagnosis and treatment are essential for continuous care.15 The longstanding relationship between family physicians and patients enhances therapeutic recovery through mutual trust, and facilitates easier access to patients.16 The course of treatment selected by primary care providers is largely guided by clinical recommendations. These recommendations are crafted by authoritative organisations and offer evidence-informed guidelines for the diagnosis and management of major depressive disorder.17–19 The guidelines conventionally suggest a tiered-care approach, commencing with minimally invasive interventions such as psychoeducation and vigilant observation for less severe cases, and escalating to psychological therapies and pharmacological interventions for moderate to severe manifestations of depression.17 By adhering to these guidelines, primary care providers are able to provide standardised and superior care, thereby mitigating inconsistency in treatment outcomes.14 Various patient attributes, among them depression severity, concurrent medical conditions, antecedent treatment records and individual inclinations, significantly sway the therapeutic decisions of primary care providers.20 For instance, individuals who manifest symptoms of severe depression or are refractory to preliminary interventions may require more aggressive therapeutic approaches, including a combination of antidepressants and psychotherapy.21 Additionally, individual preferences can steer primary care providers toward specific therapies.
Numerous studies have demonstrated the efficacy of both psychotherapy and antidepressant medications in treating depression.21 22 Treatment guidelines for managing depression recommend continuous use of antidepressants for several months to reach and maintain remission.17 18 22 Yet, only around half of those affected receive satisfactory treatment.23 This discrepancy in treatment provision can be ascribed to several factors, among them the failure to diagnose depression in primary care settings, the scarcity of outpatient psychotherapists and therapists’ insufficient adherence to evidence-based interventions.24 As a consequence of the limited availability of outpatient psychotherapists, patients exhibiting mild to moderate depressive symptoms are frequently prescribed antidepressant medication only, a practice that contradicts treatment guideline recommendations.12
The positive predictive value of the depression diagnoses of primary care physicians was only 42%, suggesting that 58% of identified cases were false positives.25 From this we can infer that the majority of antidepressant prescriptions written by primary care physicians are for patients manifesting mild depression, including those with subthreshold symptoms.26 The majority (60–85%) of these prescriptions are for treating depression in adults,27 while a minority are prescribed for other conditions. An estimated 5–16% of adults in Europe and the US are prescribed antidepressants each year.28 29
In making clinical decisions, primary healthcare practitioners are significantly affected by their competence and education.30 Those with extensive professional experience are likely to be more confident in diagnosing depression and commencing treatment, in contrast with less experienced providers, who may often delegate patients to specialists.31 Numerous factors may exert a detrimental influence on compliance with the guidelines governing depression management, among which are factors associated with patients, professionals, physicians and healthcare organisations. Patients often deny experiencing symptoms of depression, opting instead to seek help for physical manifestations of distress in a general practice setting.14 15 20 A psychiatric diagnosis does not necessarily ensure that either the patient or the doctor will perceive that treatment is necessary.26 Primary care physicians may have trouble conforming to these guidelines because they are unable to distinguish between typical distress and bona fide anxiety or depressive disorders. Furthermore, some primary care physicians may have difficulty discussing aspects pertinent to this diagnosis with their patients.27 28 31 Finally, organisations may be marked by insufficient collaboration between primary care physicians and mental health experts, long waiting lists for specialised mental health services and inadequate financial incentives.11 28 29
While patient diversity undeniably plays a crucial role in the variance in treatment outcomes, a growing body of evidence underscores the significance of differences in physician decision-making processes. For instance, Cutler et al32 pointed to substantial disparities in physicians' beliefs regarding the optimal course of treatment. Berndt et al33 referred to survey data indicating that most physicians exhibit a preference for a certain drug, with this favoured drug accounting for an average of 66% of their overall prescriptions.
The perspectives of primary care physicians can potentially affect patients' willingness to disclose their issues, thus playing a pivotal role in their initial identification of issues during the clinical encounter, their subsequent therapeutic decision making and their readiness to embrace novel approaches in their clinical practice.30 Clinicians’ beliefs concerning mental illness may encompass prevalent societal stereotypes and misconceptions, coupled with their own personal experiences and professional training.34 A lack of specificity in screening for depression among primary care physicians can result in misdiagnoses, such that individuals without depression are incorrectly identified as having this mental health disorder.35 Such stereotyping is seen more commonly in misdiagnosed depression among female, elderly and racial minority patients.36 37 Such overdiagnoses often cause an unnecessary treatment burden on the healthcare system, resulting in wasted resources and misuse of health services. Overdiagnosis fosters undue reliance on community services and benefits by healthy individuals erroneously diagnosed with depression, along with potential iatrogenic effects of unneeded treatments.32 33
Ample research has explored the implicit racial/ethnic, sociodemographic and gender biases among primary care physicians.36 37 For instance, a study conducted among primary care physicians in Brazil revealed a disproportionate prevalence of mental problems among female patients, unemployed patients, those with limited education and those earning lower incomes.38 Patients with higher socioeconomic status (SES) were more likely to engage in conversations with their physicians.39 White and Stubblefield-Tave40 showed that women, regardless of their backgrounds, are subjected to unequal treatment. Finally, Ballering et al41 found that men who consulted physicians about common somatic symptoms were more likely to be examined physically and sent for diagnostic imaging and specialist referrals than women with similar complaints. These findings and others point to the necessity to address and counter power imbalances in the clinical relationship.36–41
ChatGPT offers several advantages over primary care physicians and even mental health professionals in detecting depression. From the outset, ChatGPT has the potential to offer objective, data-derived insights that can supplement traditional diagnostic methods.7 Moreover, ChatGPT is capable of analysing extensive data rapidly, facilitating early detection and intervention. Finally, it can offer confidentiality and anonymity, thus potentially encouraging patients to seek assistance without fear of stigma or professional consequences.
Study objectives
This study seeks to compare depressive episode evaluations and suggested treatment protocols generated by ChatGPT-3.5 and ChatGPT-4 with those of primary care physicians. Specifically, the study will investigate:
Adjustment of treatment protocols for both mild and severe depression.
Modification of pharmacological treatments as required in specific cases.
Scrutiny and handling of gender or socioeconomic biases.