A quick guide to
The new QOF offers points for measuring severity of depression at the outset of treatment Professor Tony Kendrick and Professor Helen Lester outline the pros and cons of the different tools GPs can use
It is very important to emphasise that the new QOF does not require practices to screen all patients for depression. The incidence of new cases is relatively low in unselected practice attenders and detecting them by routine screening has not been shown to be cost-effective without the necessary management systems for dealing with those identified. So, there's no need to distribute questionnaires in the waiting room or send them out to all your patients by post!
There are up to 25 points available for the assessment of severity at the outset of treatment for patients with diagnosed depression (payment stages 40 to 90 per cent).
The rationale for measuring severity is that NICE recommends that active treatment, whether with antidepressants or psychological therapy, should be offered routinely only to people with moderate to severe depression, while those with mild depression should be observed for longer ('watchful waiting').
Although we may consider ourselves expert in assessing depression, there is evidence that our global assessment of severity does not accord closely with a more structured assessment of symptoms using valid questionnaires1.
A measure of severity at the outset of treatment enables a discussion with the patient about relevant treatment interventions and options, guided by the stepped care model described in the NICE guidance2.
The British Association of Psychopharmacology Guidelines state that antidepressants are a first-line treatment for major depression irrespective of environmental factors (grade A evidence) and that antidepressants are not indicated for acute milder depressions (grade B evidence)3.
Three measures are approved for assessing severity: the Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale (HADS), and the Beck Depression Inventory second edition (BDI-II) (see box below). Currently, you have to pay for a licence to use the HADS and BDI-II but ongoing negotiations with the copyright holders may change this situation, so watch this space.
Patients you diagnose as depressed might be asked to complete the questionnaire in the consultation (while you enter their history on the computer), or step out into the waiting room to complete it while you see your next patient. Alternatively, they could complete it in the treatment room, or take it away and complete it before their next appointment with you.
Although it would seem sensible for GPs in a practice to become familiar with one of the three questionnaires, there is no one 'right' way to use the severity tools. Each GP needs to use them in a way that makes sense for the individual patient and in a way that reflects good clinical practice.
Professor Kendrick has been using the HAD-D questionnaire because it's quick and easy to score but his practice has decided to switch to PHQ-9 because of cost and its user-friendly website.
The three questionnaires are not systematically different in assessing severity. They are all subject to variation according to current mood, and a borderline result would be made more reliable by repeating the questionnaire a week or two later before deciding about treatment if the GP can make time to do this extra work.
The need for clinical judgment
The underlying principle is that a higher score indicates greater severity requiring different types of treatment. The approximate thresholds for considering active treatment are shown in the box below.
However, the questionnaire score is clearly not a substitute for clinical judgment. So it is important to consider the patient's family and previous history as well as the degree of interference with daily activities, and patient preference in assessing the need for treatment, rather than relying completely on the symptom count.
So it might be preferable to offer antidepressants to a patient with a previous history of severe depression, so that they do not get worse, even if their current score equates to only mild depression. On the other hand, it might be better to avoid active treatment in someone whose social situation is likely to improve given time, particularly if they feel strongly that they do not want to take medication.
Any prior knowledge you have of the patient allows you to take into account the general likelihood of their saying Yes in response to symptom inquiries.
Also, the measures have not been validated in terms of their cultural sensitivity and it is important to bear this in mind if using them with patients of ethnic minority groups.
Screening or case-finding
A maximum of eight points are available for case finding for depression among people on the diabetes register and the coronary heart disease register (payment stages 40-90 per cent). Screening is likely to be more
cost-effective in these groups who have a risk of major depression of over 30 per cent.
There is evidence that treating depression in diabetes can improve glycaemic contro · 5 although very recent research has not confirmed this6.
Up to a third of patients develop depression after a myocardial infarction, and several meta-analyses have shown that depression is associated with a doubling of mortality in coronary heart disease.
Treatment with SSRIs of depressed
subjects in trials of treatment for coronary heart disease has been found to be associated with a 40 per cent lower mortality7.
Questions to ask patients on diabetes/CHD registers
Two standard questions are recommended by NICE:
· During the last month, have you often been bothered by feeling down, depressed, and hopeless?
· During the last month, have you often been bothered by having little interest or pleasure in doing things?
A positive answer to one or both questions is 96 per cent sensitive for depression (so they miss very few cases) but only 67 per cent specific, which means that they will throw up a lot of false positives4.
Patients screening positive therefore need following up with more questions to determine whether they really are depressed, so they should then complete one of the
The initial screen and measurement of severity should be built into patients' annual reviews by practice diabetes and CHD nurses.
Very recent research has shown that it is useful to add a third question:
· Is this something with which you would like help?
This increases the specificity and so reduces the number of false positives requiring further assessment8. A patient with a negative response to the 'help' question would have only a very small chance of being depressed. So asking this question is likely to significantly reduce the extra workload for your team, and yourself!
Competing interests both authors are lead applicants on a study of changes in the GP treatment of depression, following the recent changes to the QOF, funded by Lundbeck, Servier and Lilly.
Dr Kendrick has received fees for speaking at educational events from Wyeth, Lundbeck and Pfizer pharmaceuticals.
Three tools to measure depression severity
· The Patient Health Questionnaire (PHQ-9) includes nine questions and takes around two minutes to complete and score in most cases.
It can be downloaded (www.depressionprimarycare.org).
Pros: the PHQ-9 gives a categorical diagnosis of major depression,
as well as an overall score for assessing severity. It is free of charge.
Cons: It has yet to be validated in a UK primary care sample (although
it is widely used in the US), and is not available in a range of languages.
· The Hospital Anxiety and Depression Scale (HADS) has seven questions on anxiety and seven on depression, and the overall score gives one of four severity categories.
Pros: The full HADS assesses anxiety as well as depression. It has been shown to be valid and reliable in UK primary care.
Cons: It will take longer than the PHQ-9 to complete and score, unless only the seven depression questions are used (the HAD-D). A licence has to be bought for the use of the HADS (see website
www.nfer-nelson.co.uk ) current costs £60 for 100 copies.
· The Beck Depression Inventory second edition (BDI-II) has 21 questions and the overall score puts the patient into one of four severity categories.
Pros: It has been shown to be valid and reliable in the UK and is available in a wider range of languages.
Cons: It takes longer to complete than the PHQ-9 or HAD-D. A licence
is needed (website www:harcourtassessment.com) currently costing £50 for 100 copies.
Measure PHQ-9 score HAD-D score BDI-II score Minimal or no depression, no need for action 1-4 0-7 0-13 Mild depression, monitor for any deterioration 5-9 8-10 14-19 Moderate to severe depression, consider 10 or greater 11 or greater 20 or greater active treatment (maximum 27) (maximum 21) (maximum 63)
Minimal or no depression,
no need for action 1-4 0-7 0-13
Mild depression, monitor
for any deterioration 5-9 8-10 14-19
Moderate to severe
depression, consider 10 or greater 11 or greater 20 or greater
active treatment (maximum 27) (maximum 21) (maximum 63)