What works to improve depression outcomes?
Brief, low-intensity methods can improve depression management in primary care Dr Simon Gilbody reviews the evidence
Dr Simon Gilbody reviews the evidence
There is clear evidence that pharmacological and psychological treatments are effective for depression in primary care.
However, patients often consult with non-specific symptoms or with a worsening of pre-existing chronic medical conditions, and for this reason depression is often missed. Even when spotted, patients fail to take their medications or default from follow-up.
High-quality research evidence is now available regarding what interventions are effective in improving primary care depression management.
A series of systematic reviews of more than 50 evaluations of these strategies were collated for an Effective Health Care Bulletin, commissioned and published by the NHS Centre for Reviews and Dissemination1,2. This represents the most rigorous and up-to-date information for GPs who want to know how to improve the quality of care for depression.
What doesn't work?
Simple-to-complete paper and pencil questionnaires, such as the General Health Questionnaire or Hospital Anxiety and Depression scale, can be administered in the waiting room.
A large number of trials of screening have been conducted in primary care, however, and meta-analyses of more than 3,000 patients show screening questionnaires do not seem to change GPs' practice.
The routine administration of questionnaires in the waiting room and feedback of the results to GPs does not increase the rate of diagnosis of depression or improve the outcome of patients with depression.
Qualitative work has shown that simple questionnaires, which on the face of it seem a cheap and low-tech intervention, can substantially add to the workload and reduce the efficiency of routine clinics.
Most trials have used a specialist worker to administer and score these questionnaires, which would also be needed if they were used in routine practice.
Guidelines and GP education
Guidelines are commonly used to influence practice and to improve quality and a new series of guidelines is expected from NICE in the near future. GP education is sometimes used to help implement guidelines.
More than 20 trials have looked at the impact of guidelines and GP educational strategies to improve the quality of care and patient outcome. Guidelines by themselves don't appear to help and are largely ignored by practitioners. Similarly, educational strategies to support guidelines targeted at primary care have little impact on depression recognition rates or on the effective management of depression.
An important study in this respect is the UK Hampshire Depression Project3 which used a well-designed and well-received educational package but failed to show any change in management or patient outcome.
But guidelines were effective when combined with some form of organisational support, such as case management or better arrangements between primary and secondary care (see below).
Typically involves the use of telephone follow-up, medication counselling and structured problem solving.
Case management forms an ingredient of more than a dozen studies of effective strategies where improvements in compliance with medication and patient outcomes have been demonstrated. In many studies, patients were referred for case management at the same time as a GP diagnosed the patient as suffering depression or initiated an antidepressant medication.
The case manager's role was to make contact with the patient, discuss current difficulties and monitor compliance and patient response to treatment. Case managers helped to dispel concerns about medication in the crucial first two weeks of treatment, where many patients stop their medication.
This intervention was often low-intensity and fairly brief and in many cases could be delivered over the phone. When patients missed their follow-up appointments or were not showing improvement, a follow-up appointment could be made.
Case management has been delivered by a non-specialist graduate psychologist or practice nurse4,5. This simple intervention was successful in ensuring management was in accordance with accepted evidence-based guidelines.
Integrated primary-secondary care working
Reconfiguration of the roles of primary and secondary care involved GPs gaining more ready access to specialist 'one-off' advice, joint primary care/specialist clinics and specialists providing GP educational sessions.
Several high-quality trials from the US show an enhanced working arrangement between primary care and specialist services was effective in improving the uptake of evidence-based guidelines and in improving patient outcomes. This approach has much in common with other chronic disease management programmes, such as shared care and stepped care for diabetes and rheumatological problems.
This model of care has not yet been widely adopted in the UK but there is robust research evidence to support its clinical and cost effectiveness.
What can be done in UK primary care?
GPs who want to improve the quality of care for their patients with depression would do well to ensure practice nurses or primary care mental health workers are aware of this research evidence.
Ensuring that someone in the practice can supplement the GP's care is a low-tech and cost-effective way of improving patient care and outcome. Having some method of flagging up patients with newly diagnosed depression would be helpful in making sure case management can happen.
Not all patients need antidepressant medication and a computerised prescribing system would be helpful but would miss these patients. The national service framework has promised that more than 1,000 new 'graduate primary care mental health workers' will be in place by 2004/5.
There is clear evidence from these reviews regarding what interventions they can use in order to improve the quality of care for depression.
GPs might want to ensure they are using clinically and cost-effective approaches, such as case management, rather than intensive and inefficient interventions that will limit the numbers of patients they can help at any one time. NICE guidelines are expected in coming months and there is clear evidence from these reviews about how these guidelines might best be implemented.
Lastly, depression is one of the conditions where 'enhanced care' will attract enhanced reimbursement under the enhanced services scheme of the new GMS contract.
The evidence presented here provides a template for what this might involve.
Simon Gilbody is senior lecturer in mental health services research at the University of Leeds
Information and help for patients and professionals: www.depressionalliance.org
Information for patients and carers about all mental health problems: www.nelmh.org
1 Gilbody S et al. Improving the recognition and management of depression in primary care. Effective Health Care Bulletin 2002;7 available at www.york.ac.uk/inst/crd/ehcb.htm
2 Gilbody S et al. Educational and organisational interventions to improve the management of depression in primary care:
a systematic review.
3 Thompson C et al. Effects of clinical practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression project randomised controlled trial. Lancet 2000;355:185-91
4 Peveler R et al. Effect of antidepressant drug counselling and information leaflets on adherence to drug treatment in primary care: randomised controlled trial.
5 Hunkeler EM et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-8
A raw deal for patients
The new contract should measure depression care, says Dr Phillip Bland
One of the many disastrous failings of the new contract is its relegation of the fourth most significant cause of suffering and disability worldwide to 'enhanced service' status. Surely the provision of high-quality care for depressed patients should be an essential service, provided by every practice and appropriately recognised and rewarded through the quality and outcomes framework? The fact it is not is a glaring illustration of the fact that the list of 'quality' targets has been assembled on the basis of what is easy to measure, not what is most important.
In my experience it is possible to set quality indicators for some aspects of depression management, namely:
· DSM IV criteria should be applied (unless the criteria for major depression are met, antidepressants are no more effective than placebo)
· Appropriate antidepressant medication should be prescribed at therapeutic doses (bearing in mind the side-effects and safety in overdose: my own first choice is citalopram; lofepramine can be a useful alternative, for example in the very elderly)
· 80 per cent of patients should comply with medication and return for follow-up
· 60 per cent of patients should complete six months' treatment.
To this end we offer our patients shared care with our practice nurse. The electronic referral form incorporates the DSM IV criteria. We aim to provide a first appointment with the nurse within seven days; subsequent follow-up is shared between the GP and nurse. The intention is to improve outcome through education (many patients wrongly believe that antidepressants are addictive), encouragement of re-attendance and follow-up of non-attenders. At my previous practice we were able to increase the number of patients attending for follow-up from 45 to 80 per cent.
Of course, this does not cover all aspects of depression care.
· It is an uncomfortable fact that patients are better judges than we are of therapeutic empathy. Both via the new contract and the revalidation process we are being encouraged to seek feedback from our patients through the use of questionnaires this is a nettle we should grasp.
l Antidepressants alone are not enough. There is increasing evidence that depression is a chronic recurring disorder and that cognitive therapy is more effective in preventing relapse. The challenge is to find a brief CBT approach that complements antidepressant therapy and fits within the severe time constraints of general practice.
· Many patients with depression are not diagnosed and treated; this is a particular problem in the elderly. We are trying to improve our diagnosis rates through targeted screening of patients with chronic conditions, such as CHD patients.
The new contract distorts clinical priorities and gives depressed patients a raw deal. They deserve better.
Phillip Bland is a GP in Dalton-in-Furness, Cumbria