GPs are well placed to manage depression and could provide a high standard of care by setting up an enhanced service under the new contract, says Dr Jill Murie


   

Statistics on depression make gloomy reading. Unipolar major depression ranks fourth in the worldwide causes of disability (or second if high income countries are considered alone).1 For both sexes, depression and affective disorders are among the five most common reasons for consulting a GP; for women it ranks second.2 Paradoxically, up to 50% of people with depression may be undiagnosed.3

The retrospective examination of information about people who have killed themselves links 70% of recorded suicides with depression.4 Depression might be viewed as the ‘final common pathway’ to suicide.5 Scotland’s suicide rate is much higher than the rate for the UK as a whole, and the rate of increase over recent decades is among the highest in Europe.6

Meanwhile, antidepressant prescribing increases in the UK;7 and Scotland spends 40% more per head of population on antidepressant drugs than England.6 Evidence of the risks and benefits of these drugs on population health is lacking,8 and in spite of unprecedented demands for psychological therapies, doubts are now being cast on the scientific validity of such interventions.9

Funding enhanced services for patients with depression

The new GMS contract national enhanced service (NES) for depression offers the promise of a "guaranteed floor of money” 10 from PCOs to ensure that the enhanced service can be delivered "where appropriate”.10 In 2003/04, every practice contracted to provide the service was due to receive an annual retainer of £1000 and an annual payment of £80-100 per patient. These figures will be increased by 3.225% in 2004/5 and in 2005/6.

If primary care is to make an impact on the personal, financial and social costs of depression, the condition must be diagnosed accurately and treated appropriately as early as possible. GPs are well placed to understand the nature and complexity of an individual’s experience of life, circumstances, social problems, physical illness and any addictions.

The new contract advocates treating patients at home, with family support and regular monitoring of compliance with therapy by a healthcare professional.

The evidence base is derived from the joint recommendations of the Royal Colleges of Psychiatrists and General Practitioners,11 and the Clinical Standards Advisory Group Report (Box 1, below).12 Key objectives are improved awareness and training of the primary healthcare team and adequate time devoted by GPs to patients with suspected or diagnosed depression.

Box 1: Recommendations for specialised services for depression
Royal College of Psychiatrists and Royal College of General Practitioners "Defeat Depression” campaign11

To educate health professionals, particularly GPs, about the management of depression

To educate the general public about depression and the availability of treatment to encourage people to seek help earlier

To reduce the stigma associated with depression

Clinical Standards Advisory Group Report12
Service delivery Organisation of care

User-centred service with shared decision-making

Respect for religious and cultural beliefs

Assessment of health and social needs

Provision of information

Use of antidepressants, psychological therapies

Carer and family involvement

ECT facilities

Regular monitoring and follow-up

Access to mental health services

Special groups (e.g. ante- and post-natal, ethnic groups)

Indications for psychiatric referral

GP access to community mental health teams

Standards for referral letters, waiting times

Prioritisation of severe conditions

Use of voluntary and self-help organisations

Range of primary care services provided

Intra-agency organisational issues Planning, integration and commissioning

Extended primary healthcare teams

Community-based mental health teams

Team working and representation in PCOs

Training needs analysis and training of GPs and staff

Jointly agreed realistic budgets

Practices have delegated person for mental health

Access to evidence-based information

Access to information on referrals and prescribing

Local supervision registers for patients at risk

Practice protocols and guidelines for management

Health authority conducts health needs assessment

Health authority has written strategy

Local primary care strategy

Health and social care

Health authority has written service specification

Health authority has signed service level agreements

Service agreements include funding, staff, training, protocols, lines of communication, quality standards, risk identification and contingency measures

Resources allowed for primary mental health care

Service outline

Register of patients

The first condition of the service outline is that the practice maintains a register of patients with depression. Although electronic information about individuals may be held without knowledge or consent, patients with mental health problems should understand how the information will be used.13

The prevalence of depression will vary depending on the characteristics of the practice population. Over the years 1994 to 1998, for every 1000 patients, 34 males and 77 females in deprived industrial areas had treatment for depression, compared with rates of 21 and 55 respectively in suburban areas.14

The initial step is a search for repeat prescriptions of antidepressants. Exclusions to be considered are patients with co-morbid mental illness, alcohol and drug abuse who are already under supervision.

Where depression is suspected, DSM-IV diagnostic criteria for major depressive illness (Box 2, below) 15 should be applied and confirmed by the appropriate validated screening test,16-21 and specialist opinion. Scales that measure depressed mood at symptomatic level can be problematic and miss atypical presentation of depression with more somatic features, depression with cognitive impairment, and depression in older people, who tend to deny such feelings.

Box 2: DSM-IV diagnostic criteria for a major depressive episode15

A At least one of the following three abnormal moods which significantly interfered with the person’s life:

  1. Abnormal depressed mood most of the day, nearly every day, for at least two weeks
  2. Abnormal loss of all interest and pleasure most of the day, nearly every day, for at least two weeks
  3. If 18 or younger, abnormal irritable moods most of the day, nearly every day, for at least two weeks

B At least five of the following symptoms have been present during the same 2-week depressed period: Note: Do not include symptoms that are clearly due to a general medical condition, or mood incongruent delusions or hallucinations

  1. Abnormal depressed mood (or irritable mood if a child or adolescent) as defined in criterion A1
  2. Markedly diminished interest or pleasure in all or almost all activities as defined in criterion A2
  3. Abnormal weight loss when not dieting or decrease in appetite
  4. Abnormal weight gain or increase in appetite
  5. Insomnia or abnormal hypersomnia
  6. Abnormal agitation or slowing (observable by others)
  7. Abnormal fatigue or loss of energy
  8. Abnormal self-reproach or inappropriate guilt
  9. Abnormal poor concentration or indecisiveness
  10. Abnormal morbid thoughts of death (not just fear of dying) or suicide

C The symptoms are not due to a mood-incongruous psychosis

D There has never been a manic episode, a mixed episode or a hypomanic episode

E The symptoms are not due to physical illness, alcohol, medication or drug misuse

F The symptoms are not due to bereavement

GPs generally do not use screening tools, because of time constraints – instruments can take up to 30 minutes to administer. However, scales can be self-administered or administered by trained or non-trained staff to patients at high risk, such as women during the perinatal period and those with dementia.22,23 New patient medicals also present potentially useful opportunities to assess mental health, using GHQ 12.

A multidisciplinary approach

The new contract promotes a multidisciplinary approach, involving psychiatrists, psychologists and community psychiatric nurses. Comprehensive community service objectives defined within national frameworks for mental health services in Scotland and England, however, go further.24,25

These frameworks advocate integrating NHS, local authority and voluntary sector mental health services for children, adults and older people and their carers. These combined approaches to mental health services incorporate healthcare and health promotion, social care and housing support, education and training, employment and leisure.

Personal health plans

Personal health plans should contain details of diagnosis, investigations, reassessment dates, referrals and rating scale results. The records may be patient-held, to promote involvement, and also used as audit tools. The plan should be explicit about the roles and responsibilities of all the agencies involved in the patient’s care. An example of a care plan is shown in Figure 1 (below).

Figure 1: Personal health plan

Antidepressant medication

When prescribing an antidepressant drug it is important to take into consideration co-morbidities, such as cardiac disease, prostatism and glaucoma, the drug’s side-effect profile and potential drug interactions, for example with lithium.26 Special care should be taken when switching or withdrawing drugs. While the unit costs of selective serotonin and norepinephrine reuptake inhibitors are higher than the older, tricyclic, antidepressants, evidence suggests that they are more cost effective because of better compliance.27

Review

Regular structured assessments carried out in collaboration with specialist mental health services, for example the community psychiatric nurse, key worker and carer improve the efficiency of the review. The frequency of the review varies from 2-weekly, when side-effects are assessed and the dose adjusted according to response, to 8-weekly, to provide ongoing support and encourage compliance.

Cognitive behavioural therapy

Cognitive behavioural therapy can improve impaired mood and behaviour. However, most studies find that, with the exception of those with panic disorders, patients are left with residual symptoms and a tendency to relapse or seek further treatment within 2 years of therapy.28

Other non-pharmacological or complementary therapies, such as family therapy, anxiety management, bereavement and adult survivor (child sexual abuse) support groups and counselling, may be of benefit.

Referral

Only 10% of people with depression are referred to psychiatric services. Reasons for referral to secondary care are summarised in Box 3 (below).

Box 3: Indications for referral to secondary care
  • Diagnostic uncertainty
  • Failure to respond to two classes of antidepressant at effective doses (treatmentresistant depression)
  • Primary care resources not available, e.g. community nursing, psychological services
  • Dual diagnoses (drug misuse, alcoholism, eating disorders, learning disabilities, organic brain disease)
  • Risk of self-harm, suicide, serious self-neglect
  • Violent behaviour and risk to others
  • Psychotic or bipolar phenomena
  • Pregnancy
  • Postnatal depression where symptoms severe (EPDS 20+), resistant to treatment, psychotic or any risk to the wellbeing of the child
  • Depression in children or adolescents

Audit

Opportunities for audit include adherence to criteria for inclusion on the register, response to medication using MADRS, screening of all pregnant women for postnatal depression, lithium monitoring and benzodiazepine prescribing.

Templates with the capacity to show outcomes individually and in cohorts and produce data analyses for providers and PCOs will facilitate the process.

Patient feedback

Patient empowerment is a key aim of the National Service Framework for Mental Health. In addition to patient information and self-assessment of symptom scores, there are patient and carer feedback questionnaires including one that assesses patients’ ability to understand their illness and cope with life.29

Training and professional accreditation

The new contract states that doctors who have equivalent experience in providing services for depression will be accredited as long as they can demonstrate the relevant evidence for appraisal and revalidation.

In addition to clinical and communication skills, training may be required in organisational areas such as team working, facilitation and negotiating skills.

Conclusion

Organisational factors and resource implications may be powerful disincentives to participation in this national enhanced service.The publication of a guideline on effective care for depression using economic analysis by NICE may inform future developments.30

The costs of delivering specialised care for people with depression must be weighed up against the significant proportion of GPs’ budgets spent on inappropriate antidepressant prescribing, improved quality of life through resolution of residual symptoms, fewer hospital admissions and potentially enormous gains to families and communities.

The issue is not just of resources but also of the way we work, communicate and share information. PCOs will need to build capacity and redesign services in order to provide a fully integrated national enhanced service of specialised intermediate care for depression.

Acknowledgements

I would like to thank Dr Libby Morris, SCIMP, Dr Alistair Noble, Nairn and Ardersier LHCC and Alistair Philp, Improving Mental Health Information Programme, Information and Statistics Division, NHS Scotland, for information and advice.

References

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  2. NHS National Services Scotland. Improving Mental Health. Newsletter 32. June 2004. http://www.isdscotland.org/imhip
  3. National Institute for Clinical Excellence. Technology Appraisal Guidance No 51. Guidance on the use of computerised cognitive behavioural therapy for anxiety and depression. NICE, 2002. https://www.nice.org.uk/pdf/51_CCBT_Full_guidance.pdf
  4. Mental Health Foundation. Suicide and Deliberate Self-harm: a briefing from the Mental Health Foundation. May 1997. http://www.mentalhealth.org.uk/
  5. Williams JMG, Pollock LR. Factors mediating suicidal behaviour: their utility in primary and secondary prevention. J Mental Health 1993; 2: 3-26.
  6. Audit Scotland. An overview of the performance of the NHS in Scotland. Edinburgh: Stationery Office, 2004. http://www.audit-scotland.gov. uk/publications/pdf/2004/04or01ag.pdf
  7. Middleton N, Gunnell D,Whitley E et al. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med 2001; 23: 262-7.
  8. Gunnell D,Ashby D.Antidepressants and suicide: what is the balance of benefit and harm. Br Med J 2004; 329: 34-8.
  9. Goldbeck-Wood S, Fonagy P. The future of psychotherapy in the NHS. Br Med J 2004; 329: 245-6. Editorial.
  10. Investing in General Practice: The New General Medical Services Contract. www.bma.org.uk
  11. Rix S, Paykel ES, Lelliott P et al. Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign, Br J Gen Pract 1999; 49: 99-102.
  12. Royal College of Psychiatrists, Royal College of General Practitioners, Health Advisory Service. CSAG-Depression Study Standards. Clinical Standards Advisory Group http://www.rcpsych.ac.uk/
  13. Murie J. Contract will address needs of patients with severe mental illness. Guidelines in Practice 2004; 7(3): 35-43.
  14. Office of Population Censuses and Surveys (OPCS). Prevalence of treated depressions: by type of area and gender, 1994-1998. Social Trends 31 OPCS 2002 http://www.statistics.gov.uk/
  15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (DSM-IV).Washington DC, 1994 http://www.psychologynet.org/major.html
  16. Goldberg DP, Blackwell B. Psychiatric illness in general practice. A detailed study using a new method of case identification Br Med J 1970; 1: 439-43.
  17. Hamilton M. A rating scale for depression. J Neurol, Neurosurg Psychiatry 1960; 23: 56-62.
  18. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979; 134: 382-9.
  19. Yesavage JA,Brink TL, Rose TL et al.Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982- 83; 17: 37-49.
  20. Beck AT, Ward CH, Mendelson M et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-71.
  21. Cox JL, Holden JM, Sagousky R. Detection of postnatal depression: development of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782.
  22. Scottish Intercollegiate Guidelines Network. SIGN 60. Postnatal depression and puerperal psychosis.Edinburgh:SIGN,2002.www.sign.ac.uk
  23. Scottish Intercollegiate Guidelines Network. SIGN 22. Interventions in the management of behavioural and psychological aspects of dementia.Edinburgh:SIGN,1998.www.sign.ac.uk
  24. Scottish Executive. The Framework for Mental Health Services in Scotland. Edinburgh: Stationery Office, 1997 www.show.scot.nhs.uk/ publications/mental_health_services/mhs/ index.htm
  25. Department of Health. National Service Framework for Mental Health. London: DoH, 1999.www.doh.gov.uk/nsf/mentalhealth.htm
  26. Murie J. Lithium monitoring audit highlights need for regular review. Guidelines in Practice 2002; 5(3): 81-9.
  27. Anderson IM, Tomenson BM. Treatment discontinuation with selective serotonin reuptake inhibitors compared with tricyclic antidepressants: a meta-analysis. Br Med J 1995; 310: 1433-8.
  28. Roth A, Fonagy P. What Works for Whom? A critical review of psychotherapy research. New York: Guilford Press 1996.
  29. Howie JG, Heaney DJ,Maxwell M et al. Quality at general practice consultations: cross sectional survey. Br Med J 1999; 319: 738-43.
  30. National Institute for Clinical Excellence. Depression: core interventions in the management of depression in primary and secondary care. NICE guideline. First consultation, September, 2003. London: NICE, 2003. https://www.nice.org.uk/pdf/Depression_NICEguideline_1stconsultation.pdf

A useful resource, Enhanced services specification for depression under the new GP contract: a commissioning guidebook is now available at: http://www.nimhenorthwest.org.uk/archives/work_primary_care/002097.shtml

Guidelines in Practice, October 2004, Volume 7(10)
© 2004 MGP Ltd
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