Shaw and colleagues stated no changes in depression management were seen in studies they reviewed of using patient health questionnaire (PHQ-9) scores to guide primary care treatment.1 This statement is an inaccurate reflection of the literature they reviewed and cannot go unchallenged.
The observational study conducted in Southampton practices, in the year following the introduction of the DEP3 QOF indicator rewarding the use of symptom questionnaires at follow-up of depressed patients between 5 and 12 weeks, showed that follow-up scores appeared to influence decisions to change treatment significantly.2 After controlling for confounders, patients who showed an inadequate response in questionnaire-score change at follow-up were nearly five times more likely to experience a subsequent change in treatment, compared to those with an adequate response (odds ratio 4.72, 95% CI = 2.83 to 7.86).2
Shaw and colleagues downplayed the evidence of the quasi-randomised trial from the US which found that feeding back PHQ-9 scores to primary care physicians at diagnosis and follow-up led to significantly increased rates of remission and response, clearly showing benefit to patients.3 They failed to point out that changes in management in the intervention arm of the trial were actually more numerous too. More patients received antidepressant treatment at baseline, and antidepressant regimen changes over the following 6 months among partial or non-responders were all more numerous in the intervention arm.4 Although these differences in treatment changes were not statistically significant, they were all in the direction expected if feedback of PHQ-9 scores was influencing treatment,4 suggesting the trial was under-powered to detect small but clinically significant differences in care in those cases where treatment changes were indicated.
Research in specialist practice, specifically excluded from Shaw and colleagues’ review, has even more convincingly demonstrated the benefits of monitoring depression treatment with symptom questionnaires. Systematic reviews and meta-analyses in specialist psychological and psychiatric care have shown that outcomes can be improved with an effect size of between 0.1–0.3 standard deviations, being most beneficial when patients are involved in rating their own problems and receive feedback on progress, in addition to feedback to the practitioner.5
Now that the use of symptom questionnaires is an optional component of the QOF incentivised initial and follow-up assessments in depression, it will be interesting to see whether practices continue to use them, given the evidence that patients like them,6 and that they can help improve patient outcomes in depression.3
- © British Journal of General Practice 2013
