Professor Carolyn Chew-Graham explains how the quality standard for depression reinforces the critical role of primary care in the management of adults with this condition
By the year 2020, depression is predicted to be second only to cardiovascular disease in terms of the world's most disabling illnesses.1 The prevalence of depression may be as high as 30% in older people2 and around 20% in people with chronic physical health problems such as diabetes and heart disease.3,4 NICE published a quality standard on depression in adults in March 2011,5 with the aim of improving care and services for people with this condition.
NICE quality standard for depression in adults
The invited Topic Expert Group (TEG) took the 16 key priorities for implementation from NICE Clinical Guidelines (CG) 90 and 91, on the treatment and management of depression of adults with and without a chronic physical health problem,6,7 and developed them into 11 draft quality statements. The remaining recommendations were discussed further and this resulted in five additional draft statements. A total of 16 quality statements, each with an associated quality measure, were presented for consultation and field-testing. Following this, the TEG prioritised 13 statements for inclusion into the final quality standard for depression in adults (see Table 1).5
The quality standard should contribute to improving the effectiveness, safety, and experience of care for people with depression. NICE recognises that there is a wider social context to depression and acknowledges that this is not addressed directly by the quality standard. This article attempts to relate the quality standard for depression in adults to clinical practice and to outline its implications for primary care. It will also discuss how this quality standard reinforces the importance of the GP in supporting and managing people with depression.
|Table 1: NICE quality standard for depression in adults5|
|1||People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment, and the duration of the episode.|
|2||Practitioners delivering pharmacological, psychological, or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.|
|3||Practitioners delivering pharmacological, psychological, or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust delivery of interventions.|
|4||People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.|
|5||People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.|
|6||People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.|
|7||People with moderate depression and a chronic physical health problem receive an appropriate high-intensity psychological intervention.|
|8||People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual cognitive behavioural therapy.|
|9||People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.|
|10||People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for people at risk of relapse.|
|11||People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first 3 months of treatment.|
|12||People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.|
|13||People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.|
|National Institute for Health and Care Excellence website. Quality standard on depression in adults. Reproduced with kind permission. Available at: www.nice.org.uk/guidance/qualitystandards/depressioninadults/home.jsp (accessed 10 February 2012).|
Making the diagnosis and assessment—statement 1
General practitioners have an essential part to play in the identification of depression, particularly in people who are at higher risk. The use of two case-identification questions (see Box 1) is advocated by NICE guidance, either opportunistically in consultations with patients who have chronic health problems, those with a past history of depression, or as part of the holistic clinical assessment of the patient.6,7
There is some evidence that a further question, 'Is this something with which you would like help?' increases the usefulness of the case-identification questions in practice.8 The NICE guideline does not make any recommendations on using this query, but some GPs may believe that this is an important supplementary question, which will help them explore further into the patient's ideas, concerns, and expectations within the consultation. It is hoped that assessment of depression will be facilitated by NICE Clinical Guideline 123 on common mental health disorders, which integrates the identification and assessment of people and care pathways.9
It is recommended that a comprehensive assessment of depression is undertaken, which could include the use of a validated measure (e.g. patient health questionnaire-9 [PHQ-95,8,10]). Clinical assessment should not be based solely on a calculation of the number of symptoms, but should take into account:6,7,11
- the degree of associated functional impairment
- the duration of the episode of depression
- past history of depression
- past history of mood elevation
- response to any previous treatment
- current level of risk
- the patient's social situation.
For people with significant language or communication difficulties (e.g. those with a sensory impairment or a learning disability), the use of the 'Distress Thermometer' is advocated, and/or asking a family member or carer about the person's symptoms to identify possible depression.6
Effective communication and establishment of a rapport between the GP and patient are vital in enabling patient disclosure of symptoms, assessment, and open discussion of the possibility of depression as a diagnosis. Doctors with poor communication skills and those who do not provide time and empathy are more likely to collude with patients, reinforcing beliefs that depression is a result of life circumstances. Patients may not disclose their symptoms unless the GP explores them sensitively.12
Diagnosis and assessment of depression in people with chronic physical illness can be difficult because of the time-limited nature of primary care consultations, where clinical decision-making is often based on prioritising competing patient demands, which may be centred on medical co-morbidities. This is especially true where the management of people with long-term conditions is driven by guidelines and treatment algorithms that focus on single diseases. Such circumstances often result in physical health problems becoming the main focus for healthcare professionals.13
Additionally, a lack of conformity between patients' and professionals' conceptual language on depression and acceptance of the condition as a normal consequence of ill health can lead to uncertainty about the nature of the problem and reduce opportunities to develop appropriate treatment strategies.
|Box 1: Case-identification questions for depression6,7|
A 'yes' to either question is considered a positive test.
A 'no' response to both questions makes depression highly unlikely.
The NICE guidelines for depression and depression with chronic physical health problems describe a stepped-care model for the assessment and management of depression (see Figure 1).6,7 It provides a framework within which to organise the provision of services supporting patients, carers, and healthcare professionals in identifying and accessing the most effective interventions. The least intrusive, most effective intervention is provided first. If a patient does not benefit from that intervention, or declines an intervention, he/she should be offered an appropriate intervention from the next step.6,7 The GP should support the patient at all steps of the model.
Step 1 of the NICE model focuses on recognition and assessment as described previously. It also covers risk assessment and monitoring. In step 1, NICE suggests that the GP performs 'active monitoring' of patients:6,7
- who may recover with no formal intervention
- with mild depression who prefer not to have an intervention
- with subthreshold depressive symptoms who request an intervention.
Active monitoring should be considered more than simply being prepared to review the patient in 2 weeks. General practitioners require basic skills in counselling, cognitive behavioural techniques, motivational interviewing, and behavioural activation in order to be effective in this role. Clearly, this will have training implications for the profession.
|Figure 1: Stepped-care management of depression6,7|
*Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric co-morbidity or psychosocial factors
† Only for depression where the person also has a chronic physical health problem and associated functional impairment (see 'Depression in adults with a chronic physical health problem: treatment and management' [NICE Clinical Guideline 91]7).
National Institute for Health and Care Excellence (NICE) (2009) CG90. Depression: the treatment and management of depression in adults (update). London: NICE. Reproduced with permission. Available from: www.nice.org.uk/CG90
Quality statement 2 recommends that practitioners receive regular supervision.5 This involves a review and reflection on practice and should be in a format appropriate to the setting, type of practitioner, and type of intervention being delivered. Practitioners delivering psychosocial and psychological interventions in steps 2 to 4 of the NICE model receive regular supervision; GPs, however, do not. It is important that GPs work reflectively, discuss difficult cases at practice team meetings, or attend Balint groups.14
Recording health outcomes at each appointment, as recommended in quality statement 3 and using the findings to modify delivery of interventions, is routine practice in improving access to psychological therapies (IAPT) services.15 Reassessment using a tool (such as PHQ-9) between 4 and 12 weeks after diagnosis is part of the current quality and outcomes framework (QOF) for GPs,16 although it is possible that this may not be incentivised in the revised contract.
Quality statements 4 to 6 focus on the management of depression in people without physical health problems,5 which falls into steps 2-4 of the stepped-care model, depending on the severity of the depressive illness, risk, and patient preference.
Step 2 of the stepped-care model states that patients who have mild to moderate depressive illness should be offered low-intensity psychosocial interventions. The GP should be aware of which services are available in their locality, such as third-sector services, local IAPT service,15 or a primary care mental health team. The GP needs to be able to explain to a patient what the low-intensity intervention might entail and assess whether the patient would find this acceptable. Therefore, GPs require a working knowledge of the low-intensity interventions recommended by the NICE guideline, which include:
- computerised cognitive behavioural therapy (cCBT)
- facilitated self-help based on CBT principles
- structured-group physical activity programmes.
Primary care contact with the patient should not end because referral has taken place; indeed, the QOF recommends patient follow up and a further assessment of symptoms, using PHQ-9, to monitor progress.16
Some groups of people, such as the elderly or people from black and minority ethnic groups, should be offered interventions that encourage social engagement (e.g. befriending and enhancement of creative, physical, and social activity).17,18 Commissioners need to be aware of this, so that patient groups are not excluded from CBT-based IAPT services.15
High-intensity psychological interventions for patients with moderate to severe depression are recommended in step 3 of the NICE model and for people with mild to moderate depression who have not responded to initial interventions. Such interventions focus primarily on CBT and must be delivered by competent therapists (appropriately supervised) within a recognised service, such as IAPT.15 The GP should continue to support the patient while they are waiting for treatment and following discharge from high-intensity psychological intervention therapy.
Pharmacological treatments are indicated at steps 2 (depending on presentation and previous treatment), 3, and 4 of the model. Before prescribing medication, the GP needs to obtain agreement from the patient that they have a depressive illness which may benefit from drug treatment. The patient's views on tablets and, in particular, antidepressants and any myths should be explored, discussed, and dispelled. Reassurance is often needed that antidepressants are not addictive. Involvement of the patient in decisions regarding treatment is a fundamental principle. If the patient agrees to try an antidepressant, they can be involved in the choice of medicine. With so many antidepressants to choose from, it is important to match the antidepressant to the patient, depending on tolerability, safety, side-effects, drug interactions, contraindications, and previous patient experience of such drugs.
The NICE guidance makes specific recommendations on monitoring patient response to medication and when to consider switching.6,7
Collaborative care—quality statements 7, 8, 9
Although NICE recommends a stepped-care approach to the management of depression, there is limited evidence for this model, particularly in elderly people, and it has been suggested that systematic models of care dedicated to managing depression proactively as a chronic illness are required.19
The PROSPECT study (PRevention Of Suicide in Primary care Elderly: Collaborative Trial) studied the effect of a depression-care manager offering recommendations to GPs according to a guideline and helping patients with adherence to medication.20 The IMPACT (Improving Mood—Promoting Access to Collaborative care Treatment) study assigned a case manager who coordinated care and delivered a specific psychosocial intervention (behavioural activation or problem-solving treatment) with or without medication management, and liaised with both the GP and the specialist mental health services.19 Both studies suggest the effectiveness of such a collaborative-care approach, which has been shown to be acceptable to family physicians and has a growing evidence base.21,22 Initial evidence from the UK is also promising.23
Collaborative care is recommended at step 3 of the NICE model and in quality statement 9 for people with depression and a long-term physical condition.5,6 The intervention should involve:24
- a multiprofessional approach to patient care delivered by a GP and at least one other healthcare professional (e.g. a nurse, psychologist, psychiatrist, or pharmacist)
- a structured patient-management plan that facilitates delivery of evidence-based interventions (either pharmacological or non-pharmacological)
- scheduled patient follow ups on one or more occasions, either face-to-face or by remote communication (e.g. telephone)
- enhanced interprofessional communication between the multiprofessional team, which shares responsibility for the care of the depressed patient (e.g. team meetings, case conferences, supervision).
A key component of collaborative care is the introduction of a care (or case) manager in primary care. This person acts as the conduit between the patient and professionals in primary and specialist care and works as the patient's support or advocate to determine problems jointly, set goals and action plans, and to offer education and problem-solving skills as ways to promote better patient self-care.
Practice nurses may be well placed to act as case managers for patients with depression and long-term conditions. They are central to routine chronic disease management and patients are accustomed to nurse-led clinics in primary care. Additionally, there is some evidence that patients perceive nurses as being more holistic and approachable, and as able to afford more time to interactional tasks that underscore patient-centred healthcare.25
However, primary care consultations are time limited and clinical activity is highly circumscribed by the need to meet quality improvement targets set by the QOF; this reduces opportunities for nurses to devote time to training and additional tasks associated with the collaborative care of patients with depression and long-term conditions. Additionally, because practice nurse consultations are routine and driven by guidelines and templates, it may be harder to train nurses to take on additional duties and new ways of working.26,27 For example, when promoting self-care for patients with diabetes, primary care nurses are familiar with traditional didactic health education approaches, but might find it problematic to provide lifestyle counselling that draws on motivational and behavioural approaches typically used by mental healthcare professionals.28 Moreover, training primary care professionals to improve recognition of and outcomes for depression has not proven a success in UK settings, highlighting the need to test consultation-liaison models, such as collaborative care, for certain patients.29
Antidepressants—statements 10, 11, and 12
People with depression who benefit from antidepressant therapy should be advised to continue with treatment for at least 6 months after remission,7 extending to at least 2 years for people at risk of relapse. The GP has an important part to play in supporting the patient and offering review during this time and should ensure that patients treated solely with antidepressants are reviewed at least every 2 to 4 weeks for at least the first 3 months of treatment.5,6
Unless there is good reason to reduce the dose, such as unacceptable adverse effects, the level of medication at which acute treatment is effective should be maintained for at least 2 years if the patient has:5,6
- had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
- other risk factors for relapse, such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
- is likely to experience severe consequences of relapse (for example, suicide attempts, loss of functioning, severe life disruption, and inability to work).
The decision to continue maintenance antidepressant therapy beyond 2 years should take into account age, co-morbid conditions, and other risk factors. Patients will require regular monitoring as determined by co-morbid conditions, risk factors for relapse, and severity and frequency of previous episodes of depression.6
It is vital that depression is considered a long-term condition and patients are offered regular review, monitoring, and referral to appropriate psychological and/or third-sector services. This need for regular review has implications for practices in terms of the numbers of consultations required.
'Augmentation' of an antidepressant by combining it with a mood-stabiliser drug such as lithium, should only be considered in liaison with a specialist,6,7 either through referral or when working within a collaborative care model.
Quality statement 12 requires a review of the treatment plan for people who have not responded adequately to initial treatment within 6-8 weeks.5 This involves sequencing of treatments.6
Psychological interventions and relapse—statement 13
Depression is a long-term condition and people who have had one episode of depression are at risk of further episodes. Therefore, patients should be informed of this risk and advised to monitor and reflect on their mood. Antidepressants should be offered to patients to reduce the risk of relapse as described in the previous section.
People with depression who are considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, should be offered psychological interventions.5
If relapse has occurred despite antidepressant medication, or for people who have a significant history of depression and residual symptoms despite treatment, individual CBT should be offered. Mindfulness-based cognitive therapy should be made available to people who are currently well, but have experienced three or more previous episodes of depression.5,6 Commissioners need to be aware of the need for such services, as well as IAPT-mediated interventions for people with single episodes of depression.14 A report from the Mental Health Foundation highlights the role of mindfulness-based therapies and GPs' lack of knowledge on this technique.30
Depression is common and leads to significant morbidity and mortality, but most people with the condition can be managed in primary care. The NICE quality standard for depression in adults combined with the guidelines for depression, depression with chronic physical health problems, and common mental health pathways, offers a framework for front-line practitioners and commissioners to provide flexible and equitable care for people with depression.
|Key areas for audit|
View the Guidelines summary of NICE guidance on treatment and management of depression in adults, including adults with a chronic physical health problem at: egln.co.uk/link/9641
- In the future, commissioners are likely to be judged against the quality standard for depression in the commissioning outcomes framework
- Evidence will be needed to prove achievement of the quality statements
- Wherever possible, commissioners should specify the necessary outcome markers in service contracts, such as those for talking therapies
- The quality standard for depression concentrates on primary care interventions where contracts are often set nationally (such as GMS) so measurement against some of these quality markers will be difficult
- Commissioners will need to ensure that they have commissioned sufficient talking therapies to provide the NICE-specified treatment plan for depression.
- Murray C, Lopez A. Alternative projections of mortality and disability by cause 1990-2020: global burden of disease study. Lancet 1997; 349 (9064): 1498-1504.
- van't Veer-Tazelaar P, van Marwijk H, Jansen A et al. Depression in old age (75+), the PIKO study. J Affect Disord 2008; 106 (3): 295-299.
- Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res 2002; 53 (4): 859-863.
- Evans D, Charney D, Lewis L et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 2005; 58 (3): 175-189.
- National Institute for Health and Care Excellence website. Quality standard on depression in adults. www.nice.org.uk/guidance/qualitystandards/depressioninadults/home.jsp (accessed 19 January 2012).
- National Institute for Health and Care Excellence. Depression: the treatment and management of depression in adults (update). Clinical Guideline 90. London: NICE, 2009.Available at: www.nice.org.uk/guidance/CG90
- National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: treatment and management. Clinical Guideline 91. London:
NICE, 2009. Available at: www.nice.org.uk/guidance/CG91
- Arroll B, Goodyear-Smith F, Kerse N et al. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ 2005; 331 (7521): 884.
- National Institute for Health and Care Excellence. Common mental health disorder: identification and pathways to care. London:
NICE, 2011. Available at: www.nice.org.uk/guidance/CG123
- Kroenke K, Spitzer R, Williams J. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16 (9): 606-613.
- National Collaborating Centre for Mental Health. Depression: the treatment and management of depression in adults. London: British Psychological Society, The Royal College of Psychiatrists, 2009. Available at: www.nice.org.uk/CG90fullguideline
- Goldberg D, Jenkins L, Millar T, Faragher E. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993; 23 (1): 185-193.
- Coventry P, Hays R, Dickens C et al. Talking about depression: a qualitative study of barriers to managing depression in people with long-term conditions in primary care. BMC Fam Pract 2011; 12: 10.
- The Balint Society website. Balint Group. balint.co.uk/index.php/about-us/balint-groups (accessed 17 December 2011).
- Improving Access to Psychological Therapies website. www.iapt.nhs.uk/ (accessed 17 December 2011).
- British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
- Chew-Graham C, Kovandži? M, Gask L et al. Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data. Health Soc Care Comm 2012; 20 (1): 52-60.
- Kovandži? M, Chew-Graham C, Reeve J et al.
Access to primary mental healthcare for hard-to-reach groups: from 'silent suffering' to 'making it work'. Soc Sci Med 2011; 72 (5): 763-772.
- Unützer J, Katon W, Callahan C et al; IMPACT Investigators. Improving mood-promoting access to collaborative treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288 (22): 2836-2845.
- Bogner H, Bruse M, Reynolds C. The effect of memory, attention and executive dysfunction on outcomes of depression in a primary care intervention trial: the PROSPECT study. Int J Geriatr Psychiatry 2007; 22 (9): 922-929.
- Levine, S, Unützer J, Yip J. Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care. Gen Hosp Psychiatry 2005; 27 (6): 383-391.
- Katon W, Lin E, Von Korff M et al. Collaborative care for patients with depression and chronic illness. NEJM 2010; 363 (27): 2611-2620.
- Chew-Graham C, Lovell K, Roberts C et al. A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people. Br J Gen Pract 2007; 57 (538): 364-370.
- Gunn J, Diggens J, Hegarty K, Blashki G. A systematic review of complex system interventions designed to increase recovery from depression in primary care. BMC Health Serv Res 2006; 6: 88.
- Morgan M, Dunbar J, Reddy P et al. The TrueBlue Study: is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes. BMC Family Practice 2009; 10: 46.
- May C, Fleming C. The professional imagination: narrative and the symbolic boundaries between medicine and nursing. J Adv Nurs 1997; 25 (5): 1094-1100.
- Macdonald W, Rogers A, Blakeman T, Bower P. Practice nurses and the facilitation of self-management in primary care. J Adv Nurs 2008; 62 (2): 191-199.
- Jansink R, Braspenning J, van der Weijden T et al. Primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis. BMC Fam Pract. 2010; 11:41.
- Thompson C, Kinmonth A, Stevens L et al. Effects of a 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 (9199): 185-191.
- Mental Health Foundation. Be mindful report. MHF, 2011. G