Dr Phillip Bland explains how practice audit highlighted the benefits of sharing the care of patients who were newly diagnosed with depression with the practice nurse
Depression is very common in general practice: it has been estimated1 that 5–10% of patients attending the surgery have major depression.
The National Service Framework for Mental Health standard two states:
'Any service user who contacts their primary healthcare team with a common mental health problem should (a) have their mental health needs identified and assessed and (b) be offered effective treatments.'2
However, the criteria for effective treatment are not specified.
Both antidepressant medication and psychological interventions have been shown to be effective in treating patients with major depression, with some studies3 reporting a 12-month full recovery rate of 64%.
Others, however, report a poor outcome: a multicentre naturalistic study4 found that 60% of depressed patients in general practice remained depressed at 12 months, and another study5 concluded that 'neither diagnosis nor disclosure of depression has an appreciable impact on outcome'.
There are a number of possible reasons for poor outcome, including:
- Patients' antipathy to antidepressants (78% of a door-to-door sample regarded antidepressants as addictive6)
- Inadequate duration of prescribing (treatment for 6 months halves the relapse rate2)
- Persisting social and interpersonal problems.
The aim of this audit was to determine the baseline effectiveness of my care of patients with major depression and to evaluate the impact of a new shared-care arrangement with our practice nurse through completion of the audit cycle.
Aims of care
For the care of patients with major depression to be effective:
- Patients should satisfy the DSM-IV criteria7 for major depression
- Antidepressant medication should be prescribed at an effective dosage
- Patients should comply with antidepressant therapy and return for follow-up
- A 6-month course of treatment should be completed.
The following standards were set:
- 100% should satisfy the criteria.
- 100% should be prescribed effective treatment.
- 80% of patients should return for follow-up (a study of the impact of shared care with practice nurses8 achieved 91% follow-up at 4 months).
- 60% of patients should complete a 6-month course of treatment (given a reported mean duration of antidepressant prescribing in two recent studies3, 4 of 10.7 weeks, this was, perhaps, ambitious).
Results of first audit
Patients seen with a new diagnosis of depression between 1/11/98 and 30/4/99 were identified by means of a drugs search and screening of medical records. Twenty-two patients (16 female and 6 male) were identified in this way.
- Patients were assessed against the DSM-IV criteria by reference to the number of symptoms recorded in the notes: 17 (77%) had at least five features documented and a further two had significant suicidal ideation.
- In all cases, antidepressants, either a selective serotonin reuptake inhibitor (SSRI) or lofepramine, were prescribed at therapeutic doses.
- Only 10 patients (45%) returned for follow-up: 1 male (17%) and 9 female (56%).
- Only 5 patients (23%) completed 6 months' treatment: 1 male (17%) and 4 female (25%).
Funding was obtained from the PCG to increase the hours of one of our practice nurses in order to set up a shared-care depression clinic. It was hoped that involvement of the nurse would improve outcome through:
- Education: drug counselling, including information about depression, has been reported to improve compliance with antidepressant medication significantly at 12 weeks.9
- Encouragement of reattendance and follow-up of non-attenders: systematic follow-up by telephone has been reported to improve outcome.10
- Exploration of social and interpersonal problems: problem-solving therapy has been shown to be an effective treatment for depressive disorders in primary care.11
- The referring GP must complete a referral form incorporating the DSM-IV criteria for major depression; symptoms should have been present for at least 2 weeks. Patients with alcohol consumption exceeding 40 units/week in men and 30 units/week in women, or with substance abuse or recent bereavement (within 2 months), are excluded.
- The nurse will see the patient within 7 days to provide initial education regarding depression and antidepressant therapy.
- Subsequent follow-up alternates between the nurse and GP. Nurse follow-up incorporates both monitoring of antidepressant therapy and the use of problem-solving techniques.
- Non-attenders to be identified and contacted.
To avoid the problem of referral bias, all patients presenting to me between 1/4/00 and 30/9/00 who fulfilled the criteria were referred for shared care (see Figure 1, below).
|Figure 1: Depression referral form|
- 25 patients (7 male and 18 female) were referred.
- 13 were seen by the nurse.
- Of the remaining 12, one declined an appointment, 3 failed to make an appointment, one could not be contacted and 7 failed to attend their appointments (see Figure 2, below).
Nevertheless, 7 of the 12 returned to see the GP, giving an initial follow-up rate of 13 + 7 = 20 (80%).
|Figure 2: Uptake of practice nurse appointments|
Results of re-audit
- 100% fulfilled the DSM-IV criteria.
- 100% were prescribed effective treatment.
- Twenty patients (80%) returned for follow-up: 6 male (86%) and 14 female (78%). Of these, 19 (76%) were given at least two prescriptions for antidepressant medication.
- Nine patients (36%) completed 6 months' antidepressant therapy (this figure includes a patient who left the practice 4 months into his therapy). (The period of therapy was deemed to have ended if there was a gap of more than 1 month in the prescription records, even if further prescriptions were subsequently issued.)
- 13 patients (52%) completed 3 months' antidepressant therapy.
A summary of the results is shown in Figure 3.
|Figure 3: Summary of results of the audit and re-audit|
Just over half the sample took up the offer of an appointment with the nurse. Of those who did not, the three patients who failed to make an appointment may have been too embarrassed to do so: we have subsequently changed the protocol so that the nurse phones the patient to make the initial appointment. Patients who are depressed are more likely to forget to attend their appointments. Non-attenders were contacted by letter, but a phone call might have been more effective.
The improvement in initial patient compliance, from 45 to 80% attending for follow-up, is very encouraging. We feel that this figure can be improved still further by contacting non-attenders by telephone.
There was a change in the prescribing pattern between the two audits, with six of the first group receiving lofepramine and none of the second group receiving it. The possibility that poor tolerance of lofepramine could have adversely affected compliance in the first group is, however, discounted by the fact that four of the six patients prescribed lofepramine returned for follow-up.
The number of patients completing 6 months' treatment, however, remains disappointingly low and well below the target figure. This was perhaps over-optimistic. Peveler et al9 achieved 63% compliance with drug therapy at 12 weeks in patients receiving drug counselling (compared with 39% in the control group). Simon et al10 achieved 90+ days adequate antidepressant dosage in 30% of patients receiving a care management package incorporating telephone follow-up (compared with 18% in the usual care group). Just over half (52%) of our sample completed 3 months' treatment.
8n order to improve the 6-month figure we suggest that:
- Both the GP and the nurse should emphasise at the outset that a 6-month course of antidepressant treatment is recommended.
- Patients not returning for follow-up should be contacted by phone.
Presentation of our shared care approach to the Oldham West PCG NSF (Mental Health)-Learning Set generated a lot of interest and we intend to produce a shared-care pack for practices interested in copying our approach. This will incorporate a shared care protocol, referral forms, information about practice nurse training and suggestions for audit.
As a further development of our project, we intend to look at another factor contributing to poor outcome in depression, namely failure to recognise depression. Over the 6-month period of the second audit, I referred 25 patients to the nurse – considerably fewer than would be expected from prevalence rates.
It is estimated that 30–50% of patients attending the surgery with depression are not detected.2 Of particular concern to us is the fact that only one of the 25 patients was over 65 years of age, since depression is particularly common in the elderly, affecting 12–15% in community studies.12
We have applied for funding for an increase in our practice nurse hours to enable us to evaluate the use of screening questionnaires. By this means we hope to increase our diagnosis rates in the elderly and/or chronically disabled.
Our practice nurse has become skilled in the use of DSM-IV criteria for the diagnosis of depression, and we hope she will be able to screen out false-positive results, enhancing the specificity of the screening programme.
I have just joined a practice in South Cumbria where I hope to set up a similar shared-care arrangement and to share ideas with local practices interested in measuring the quality of care they provide and improving outcomes for their depressed patients.
- Anderson IM, Nutt DJ, Deakin JFW. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol 2000; 14: 3-20.
- Department of Health: National Service Framework for Mental Health. London: HMSO, 1999.
- Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. Br Med J 2000; 320: 26-30.
- Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840-4.
- Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? Br Med J 1995; 311: 1274-6.
- Priest RG, Vize C, Roberts A, Roberts M, Tylee A. Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. Br Med J 1996; 313: 858-9.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edn.Washington DC: APA, 1994.
- Mann AH, Blizzard R, Murray J et al. An evaluation of practice nurses working with general practitioners to treat people with depression. Br J Gen Pract 1998; 48: 875-9.
- Peveler R, George C, Kinmonth A, Campbell M, Thompson C. Effect of antidepressant drug counselling and information leaflets on adherence to drug treatment in primary care: randomised controlled trial. Br Med J 1999; 319: 612-15.
- Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. Br Med J 2000; 320: 550-4.
- Dowrick C, Dunn G, Ayuso-Mateos JL et al. Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. Br Med J 2000; 321: 1450-4.
- Beekman ATF, Copland JRM, Prince MJ. Review of community prevalence of depression in late life. Br J Psychiatry 1999; 174: 307-11.