Dr Alan Cohen and his colleagues at the Care Services Improvement Partnership (CSIP) discuss the implications of the depression clinical indicators in primary care
The 2006 amendment to the quality and outcomes framework (QOF2) of the GMS contract for primary care services introduced several new clinical domains, as well as amending some of the pre-existing clinical domains. With regards to the mental health domains, the mental health clinical indicators were updated, and two new domains – depression and dementia – were added.
The Care Services Improvement Partnership (CSIP) has produced best practice guidance for primary care staff related to the mental health domains, which is being serialized in Guidelines in Practice, continuing this month with the depression clinical domain. The mental health domain was featured in the November issue of the journal, and the dementia domain will complete the series in January 2007.
Although designed for primary care clinicians so that they provide high quality, evidenced based, essential services, this guidance will also be of interest to specialist mental health trust clinicians; a greater understanding of the level of care being provided in primary care should lead to improvements in the primary/secondary care interface.
This is a new domain, which incorporates recommendations from the NICE guideline on depression. There are just two indicators (Table 1); the first – DEP 1 – is to case-find people with diabetes or ischaemic heart disease who also suffer from depression.
People with these conditions are more at risk of suffering from depression, and are more likely to have poorer outcomes if the depression is untreated. It is likely that in most practices the case finding will be done by practice nurses, and nurse practitioners, who routinely manage the care of these two groups of people.
The NICE guideline describes a stepped care approach to the management of people with depression. The type of intervention offered needs to be tailored to the severity of the disorder.
The second depression indicator – DEP 2 – is the structured assessment of the severity of the depressive disorder, using one of the following three validated questionnaires:
- Beck II.
It is likely that in most practices, the assessment of severity will be undertaken by the GP or by an experienced mental health professional such as a practice-attached counsellor or psychologist.
The diagnosis of depression remains the responsibility of an appropriately trained primary care clinician, and is not included in either of the two indicators.
Together, the two indicators represent 33 points.
|Table 1: Clinical indicators for depression|
|Disease indicator||Clinical indicator||
The percentage of patients on the diabetes register and/or the CHD register for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions
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 severity at the outset of treatment using an assessment tool validated for use in primary care
DEP 1 – Background
This indicator is derived from the NICE guidance, which recommends case finding for people at increased risk of depression.
Although other groups are also at increased risk of depression, the evidence is strongest for patients with diabetes and ischaemic heart disease, and these groups also represent the most accessible database/register from which the target population can be identified.
This should not preclude other target populations from being searched to identify those people who are likely to suffer from depression, if practices wish to do this.
The anticipation is that practices will already be reviewing people with diabetes and ischaemic heart disease, as part of the relevant clinical domains. Therefore, there should not be a need to call individuals specifically for this part of the depression domain, but that it should be undertaken as part of the routine healthcare provided to these groups.
The two standard questions referred to in the indicator are together called the PHQ-2 (Box 1), and they are a screening tool for depression. They do not 100% guarantee that an individual scoring positively on the PHQ-2 will definitely have depression, just that it is likely.
As part of the preparation for starting to use this questionnaire, there should be an agreement within the practice on the following issues:
1. Who should administer the questionnaire? – Most practices use their practice nurses, or nurse practitioners, to manage the routine care associated with people with diabetes and ischaemic heart disease. It is, therefore, appropriate that it is these nurses who administer the questionnaire.
2. Those who administer the PHQ-2 should know what to do with people who score positively or negatively.
An appropriate response for a positive screen would be to refer the individual to the GP, for a fuller assessment.
Some practices may choose to refer to the practice counsellor, or in-house mental health professional, if there is one. Whatever process is agreed, the referral should be recorded appropriately, and an explanation provided to the individual.
An appropriate response for a negative/ normal screen would be to record the results from the screening questionnaire (see below), and the outcome.
3. There should be an agreement on which Read Codes are used to record the appropriate data. The code for recording the administration of the PHQ-2 is 6896.
|Box 1: The two questions that make up the PHQ-2 are:|
Over the last two weeks, how often have you been bothered by the following problems?
|Not at all||Several days||More than half the days||Nearly every day|
1. Little interest or pleasure in doing things
2. Feeling low, depressed, or hopeless
A score of 3 or above represents a positive screen, and the individual should be referred for a fuller assessment, as agreed above
DEP 2 – Background
This indicator is derived from the NICE guideline on depression, which recommends a stepped care approach to the management of depression. The stepped care approach is provided in Figure 1.
The significance of this stepped care approach is that different management strategies are appropriate for different severities of depression. For example, it is not usually appropriate to use medication for somebody with mild depression.
The different levels of severity of depression described in the stepped care model relate to the clinical criteria for diagnosis described in the International Classification of Diagnosis v.10 (ICD 10). It recognizes three levels of depression severity – mild, moderate and severe.
Figure 1: The stepped care approach to management of depression
This model can be found at www.nice.org.uk/pdf/CG023NICE guideline.pdf. Any questionnaire that is used to assess severity should categorize it into one of the three levels, so that there is a clear link between severity of depression and the management agreed with the patient.
Three questionnaires have been approved by the negotiators as appropriate to use to assess the severity of the depression. It should be made clear that the DEP 2 indicator is encouraging the use of questionnaires to assess the severity of the depression. The clinical diagnosis of depression lies with the clinical acumen of the clinician.
While the QOF indicator incentivizes the use of the questionnaire at the beginning of treatment, the questionnaires have also been validated for use as a monitoring tool, and they may be repeated to assess the progress of the patient.
The three questionnaires approved by the negotiators for use in this indicator are PHQ-9, Beck II and HAD.
The indicator presupposes that a diagnosis of depression has been made by a GP, a mental health professional working in the practice, or another suitably qualified professional.
The questionnaire to assess severity can be administered either in the waiting room, or during the consultation.
Administration of one of the three questionnaires should be recorded using the following Read codes:
- PHQ-9 –Read code 388f.
- Beck II – Read code 388g.
- HAD – Read code 388P.
The outcome of the questionnaire should be recorded as a measure of the severity of the depression – the following Eu[X] codes map directly to the ICD 10 diagnostic categories:
- Mild depression – Eu[X]32.0
- Moderate depression – Eu[X]32.1
- Severe depression– Eu[X]32.2
The indicator does NOT assess whether or not an appropriate/NICE guideline intervention has been offered. It also does not apply to people with other conditions such as generalized anxiety disorder or panic disorder, but does apply to the less clearly defined condition 'mixed anxiety and depression'.
What does a practice need to do?
For DEP 1:
- Identify who normally manages people with diabetes and CHD
- Ensure that the practice has a plan so that the professional who administers the screening questions knows what to do with people who have either a positive or negative result
- Ensure that at each annual check for people with these conditions, the PHQ-2 is administered
- Ensure that the clinical record is annotated appropriately with the Read code 6896
- Record the outcome of the screening question
- Where appropriate, refer those with a positive screening result to the GP or a mental health professional for further assessment.
- The practice needs to agree which questionnaire to use
- Beck II
For each patient where a diagnosis of depression has been made:
- Administer one of the three questionnaires that assess severity of depression
- Record the administration of that questionnaire with 388f. (PHQ-9), 388g. (Beck II), or 388P. (HAD)
- Record the outcome of that questionnaire in terms of severity of depression
- Mild depression Eu[x]32.0
- Moderate depression Eu[x]32.1
- Severe depression Eu[x]32.2
The treatment pathway for depression is shown in Figure 2.
Figure 2: Treatment pathway for depresssion
The author would like to thank:
Professor Jane Gilliard, Social Care Lead, Older People's Mental Health Programme, CSIP.
Ian McPherson, Director, CSIP West Midlands Development Centre.
Ruth Eley, National Programme Lead – Older People, CSIP.
Nadine Schofield, National Lead – Older People's Mental Health, CSIP.
Kate Hardy, Project Manage – Older People & Disability, Directorate of Care Services, Department of Health.
Debbie Nixon, National Programme Lead – Primary Care and Commissioning, CSIP.
|This article is reproduced and adapted with kind permission of Dr Alan Cohen of the Care Services Improvement Partnership (CSIP) as part of the Improving Primary Care Mental Health Services resource suite.
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