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Quality and Outcomes Framework
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Rationale for inclusion of depression in DEP1
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Rationale for inclusion of depression in DEP2
(www.studentdepression.org)
Between 1994 and 1998, the number of consultations for
depression more than doubled, rising from 4 million to 9 million
consultations (MHF, 2005). The following list identifies some of the
factors responsible for this increase:
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Social factors - isolation, loneliness.
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Chronic stress.
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Lack of control over life events and personal environment.
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Societal factors - increased consumerism and materialistic expectations.
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Unrealistic expectations of wealth, appearance etc fuelled by the
various forms of media.
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Broadening of the scope of the diagnosis of depression as
a disease category.
People with depression are most likely to seek help and receive
treatment
from their GP; and indeed, the majority of patients with depression, 80%, are looked
after solely in primary care (NICE, 2004). It is estimated that up to 30% consultations
in general practice relate to a mental health problem, and depression is the
most common mental disorder found in primary care (MHF, 2005). Other organisations do
provide help for people with depression.
(MHF, 2005)
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In the past 12 years the number of prescription for antidepressants in
England has almost tripled from 9.9 million prescriptions in 1992 to 27.7
million prescriptions in 2003.
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The cost of these prescriptions has risen
even more, from £18.1 million to £395.2 million. This represents an increase of
2000% and has coincided with the introduction of a new class of antidepressant
medication, the SSRIs.
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The safety profile of this class of antidepressant, the
SSRIs, is improved on previous types of antidepressant, but the
effectiveness and the safety of the SSRIs is being increasingly challenged.
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Their is evidence to prove the SSRIs are little better
than placebo and there is evidence to support an increased incidence of
self-harm and suicide in some users.
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Concerns also exist about the syndrome of discontinuation
when patients stop their SSRI, although this is argued to be different from
withdrawal.
Quality and Outcomes Framework
(QOF):
(BMA, 2006)
In the amendments to the 2006 QOF,
depression is included as a clinical indicator for the first time:
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DEP2: In
those patients with a new diagnosis of depression, recorded between the
preceding 1 April to 31 March, the percentage of patients who have had an
assessment of the severity at the outset of treatment using an assessment
tool validated for use in primary care.
The rationale for the
inclusion of depression - DEP1- in the indicator set is outlined in the GP
Contract as follows:
(BMA, 2006)
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Depression is common and
disabling.
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Depression and CHD:
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Depression is more common in people with CHD and the
presence of depression is associated with poorer outcomes.
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Up to 33% patients develop depression after an MI.
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Depressive symptoms and clinical depression in people with
CHD increases mortality for all follow-up periods, even after adjustment for
other risk factors.
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Depression and diabetes
mellitus:
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There is a 24% lifetime prevalence of co-morbid depression
in people with diabetes mellitus; a prevalence rate 3 times higher than the
general population.
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Depression is clinically relevant in nearly 1 in 3 patients
with diabetes.
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Treatment for depression may improve glycaemic control.
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Psychological well-being has been identified as an
important goal of diabetes management in its own right by the St Vincent
Declaration.
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NICE guidance recommends that
screening should be undertaken in primary care for depression in high-risk
groups, and that screening should include the use of at least 2 questions
concerning mood and interest:
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During the past month, have you often been bothered by
feeling down, depressed or hopeless?
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During the past month, have you often been bothered by
having little interest or pleasure in doing things?
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The estimated point prevalence
for major depression among 16-65 year olds in the UK is 21/1000 (males 17,
females 25).
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Mixed anxiety and depression is
prevalent in a further 10% of adult patients attending general practices.
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Depression contributes 12% of
the total burden of non-fatal global disease.
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By 2020 depression is set to be
the second most disabling disease after cardiovascular disease.
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Major depressive disease is
increasingly seen as disabling and relapsing, resulting in high levels of
personal disability, lost quality of life for patients, their families and
carers, multiple morbidity, suicide, higher levels of service use and many
associated economic costs.
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In 2000, 109.7 million lost
working days and 2615 deaths were attributable to depression.
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Total annual cost of adult depression in England has been
estimated at over £9 billion, of which £370 million represents direct
treatment costs.
The rationale for the
inclusion of depression - DEP2- in the indicator set is outlined in the GP
Contract as follows:
(BMA, 2006)
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This is a prospective indicator
and applies to adults aged 18 years and over with a new diagnosis of
depression after 1 April 2006, it excludes women with postnatal depression.
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GP global assessment does not
accord closely with more structured assessment of symptoms.
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Assessment of severity is
essential to decide on appropriate interventions and improve the quality of
care.
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A measure of severity at the
outset of treatment enables a discussion with the patients about relevant
treatment interventions and options, guided by the NICE guidance stepped
model of care.
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Antidepressants are not
recommended for the initial treatment of mild depression, but should be
routinely considered for all patients with moderate or severe depression.
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Antidepressants are the
first-line treatment for major depression irrespective of environmental
factors.
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NICE guidance uses the ICD-10
symptoms to define depression as mild, moderate, severe or severe with
psychotic symptoms.
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A higher score indicates greater
severity requiring different type of treatment.
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Clinicians should also consider
family and previous history as well as degree of associated disability and
patient preference in making an assessment of the need for treatment, rather
than relying completely on a single symptom count.
The 3 recommended severity
measures validated for use in a primary care setting are:
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PHQ-9.
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Becks Depression Inventory 2nd
Edition.
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Hospital Anxiety and Depression Scale
(on-line HADS).
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The PHQ-9 and the Becks
Depression Inventory 2nd. Edition have not been validated in terms of their
cultural sensitivity, it is important to bear this in mind if they are used
with black and minority ethnic populations.
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It is advisable for a practice
to choose one of these three measures and become familiar with the questions
and scoring system.
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