Treatment of depression in primary care

Patients with chronic depression commonly present to general practice,1 and they often have other important (physical) diseases.2 Although effective treatment is available, evidence suggests that patients and practitioners make insufficient use of it.3 These are important reasons to improve general practitioners’ care of depression, as pursued by the World Health Organization action to integrate mental health into primary care.4 In England and Scotland, the quality and outcomes framework (QOF) identifies evidence based interventions and provides financial incentives to practices that implement these interventions. This exciting and innovative approach to improving performance is followed with interest outside the United Kingdom.

Two linked studies look at the QOF system and the management of depression in primary care. Kendrick and colleagues (doi:10.1136/bmj.b750) assess whether rates of prescribing antidepressant drugs and referrals to specialist services vary according to patients’ scores on incentivised depression questionnaires.5 Validated screening instruments to assess the severity of depression include the hospital anxiety and depression score, the Beck depression inventory, and the patients’ health questionnaire. Kendrick and colleagues report that practitioners usually administered these questionnaires, but that some patients whose scores qualified them for treatment did not receive antidepressants or referral to specialised services—notably elderly patients and those with comorbidity. In addition, two of the questionnaires gave very different severity grades—83.5% of patients were classified as moderately to severely depressed and in need of treatment by the patients’ health questionnaire, whereas only 55.6% were classified as such by the hospital anxiety and depression score. This difference casts doubt on the validity of these scales and their usefulness in general practice. At first sight these results suggest that the QOF approach may not be as useful as hoped in this situation, but it is important to understand the other factors that come into play.

The first of these factors is the nature of the intervention. Prescription of antidepressants and referral to specialised services are “procedural” aspects of performance. Evidence based criteria can be applied to prescribing and referral, but successful care of patients with depression is determined by a combination of correct clinical procedures and a trusting doctor-patient relationship.6 This shifts the focus from treating just symptoms to treating the patient as a whole. The general practitioners in this study may therefore have opted to forfeit the incentives and work personally with their patient, rather than refer or prescribe. This is especially likely because many of the practices had a special interest in mental health, and because the number of follow-up appointments increased with the severity of depression. The second linked study by Dowrick and colleagues, which assessed how general practitioners and patients valued questionnaires, confirms the importance of a holistic patient centred approach.7

The surprise finding that older patients and those with comorbidity were less likely to be treated for depression brings us to the second factor. Intuitively, we would expect these patients to receive intervention more often rather than less often. But comorbidity is as common as it is poorly investigated. General practitioners rely to a large extent on their clinical judgment, and they may be reluctant to prescribe antidepressants because of potential interactions with other drugs.8 Generic interventions such as empowerment and lifestyle changes may be more attractive because they may treat more than one condition at the same time.9 Given the limited research, this is an area where general practitioners’ experience is well ahead of scientific evidence. Exploration of this experience could further improve the QOF process.

Validated questionnaires can assess the severity of depression, but Kendrick and colleagues show that they were less robust than expected. In their qualitative interview study (doi:10.1136/bmj.b663), Dowrick and colleagues show that patients appreciated the use of these questionnaires.7 It would be interesting to know if this was the questionnaire as such or the explicit unambiguous questions asked about their condition, which could easily be incorporated into the general practitioner’s history taking. General practitioners were at best ambivalent about the questionnaire, and they often used their professional judgment rather than the results of the questionnaire to guide management. Again, it would be interesting to know if this was related to the nature of the questionnaires or the fact that they were less robust than had been assumed. The hospital anxiety and depression score for instance is designed to identify possible depression but further assessment is needed to confirm the diagnosis. This confirmation could possibly come from the general practitioners’ professional judgment.

General practitioners prescribe treatment that is not always in accordance with guidelines or with the QOF system. These studies provide evidence that patients’ needs are better assessed by general practitioners’ professional judgment than by guided care. The two linked studies did not look at the course of the patients’ depression, however, so we do not know how well the patients fared. Further analysis of general practitioners’ experience is therefore warranted for a more robust analysis of the QOF.