Dr Peter Young's team, joint runner up in the Guidelines in Practice Award 2006, shows how implementing the NICE guideline for depression can reduce antidepressant prescribing
The Oxford Terrace Medical Group is an urban general practice in Gateshead with a list of 10,000 patients. In April 2005, with the aim of implementing the NICE guideline on the management of depression in primary and secondary care,1 we employed a mental health worker to increase access to psychological therapy; developed a care pathway to guide management of patients with depression in accordance with the NICE guideline; and held a series of educational sessions for the primary care team on the care of patients with depression and the NICE guideline.1
Motivation for this project stemmed from an awareness that our practice population has a higher number of patients with mental illness than average, owing to the fact that the Oxford Terrace Medical Group serves a patient population with a high level of deprivation,2 higher than average antidepressant prescribing,3 and long waiting times for patients who require psychological therapy. Living in a deprived area is associated with higher levels of treatment for depression.4 We were also aware that we had well-established pathways of care for patients with other chronic diseases, such as diabetes and hypertension, but not for depression. Implementing the NICE guideline would help us to address this imbalance.1
Setting up the project
We successfully applied for Health Action Zones5 funding from our PCT, and employed a mental health worker who had training and experience in counselling and cognitive behavioural therapy (CBT). Our mental health worker helped to develop and monitor the project, and provided brief psychological interventions based on a CBT approach for patients with depression.
A care pathway for patients with depression was developed (Figure 1) and was based on the stepped-care approach in the NICE guideline.1 We also held a series of educational sessions during our primary healthcare team meetings on areas such as:
- use of screening tools (the Two Questions test) as recommended by the NICE depression guideline,1 and rating scales (PHQ9)6
- assessment of patients with depression, including risk of harm or neglect to self, and risk of harm to others
- diagnosis using ICD-10 criteria7
- management of patients following a stepped-care approach.
We developed a template on our practice computer system to facilitate collection and recording of assessment information. A system for active case management, involving proactive telephone follow-up of patients with moderate to severe depression or significant risk, was also introduced. Telephone call active case management involves reassessing risk, checking for and discussing adverse effects of medication, encouraging concordance with medication, reminding about follow-up appointments, and offering support.
Figure 1: Oxford Terrace Medical Group depression pathway
Success of the care pathway
During the first year of the scheme, 55 patients received psychological therapy from the project mental health worker (in addition to patients seen by the practice-based, PCT-funded, community psychiatric nurse, and the practice counsellor). Assessment of patients with depression and documentation of this information in their electronic patient record became more systematic and thorough.
Surveys of patients who had received psychological therapy showed high levels of satisfaction with their care. Patients are sent an evaluation form after their last appointment with the therapist. Analysis of the questionnaires sent out during the first year of the project showed a response rate of 79%. When asked if they found the psychological therapy helpful, 91% of responders found it excellent or very good, and 82% felt that they had developed better coping strategies as a result of the counselling.
Effects of prescribing
Initial evaluation of effects on prescribing was done by comparing management of patients who presented with a new episode of depression between April and December 2004 (before the project) with those who presented between April and December 2005 (during the first 9 months of the project):
- cases of watchful waiting went up from 1% to 12%
- incidence of an antidepressant being prescribed during the depressive episode decreased from 99% to 64%
- numbers of patients who received psychological therapy but did not use medication during the episode of depression increased from 0% to 23%
- the practice's overall antidepressant prescribing reduced, in terms of items, by 0.3% compared with a Gateshead-wide increase of 0.8%; and the cost of prescribing these medications reduced by 19% compared with a Gateshead-wide reduction of 12%. During this time there was a nationwide reduction in the cost of antidepressant prescribing as a result of the increased availability of cheaper generic selective serotonin reuptake inhibitors following the expiry of the patents for fluoxetine and citalopram.
By implementing the NICE guideline1 we have applied chronic disease management principles to the management of depression and have increased the capacity of provision of psychological therapy to make this a realistic choice for patients suffering from depression. Psychological therapy was popular with patients and appears to have reduced the need for antidepressant medication. The measured overall reduction in units of antidepressants prescribed by the practice may not be statistically significant, but the larger drop in the cost of these antidepressants may reflect the reduced frequency of switching patients to more expensive second-line agents now that the option of starting them on psychological therapy is available to us.
We feel that patient care has been significantly improved by implementing the NICE guideline on depression.1 Many of the improvements in the management of patients with depression have been achieved by the development of our care pathway, and from improved knowledge and skills of members of our primary healthcare team.
The practice has continued to fund the project mental health worker after the 1-year Health Action Zones funding finished. Therefore, patients with depression continue to have timely access to psychological therapy. Local funding of an enhanced service for depression would secure the long-term continuation of this.
To date, Gateshead PCT has not provided this funding; however, a number of practices and PCTs around the country have prepared similar projects as part of the Primary Care Mental Health Collaborative organised by the National Primary Care Development Team in 2006.
Other possible benefits from implementing the NICE depression guideline include improved patient safety through risk assessment, faster recovery time, and improved patient social function, but these are difficult to assess.
- Currently, mental health services are not covered by the standard national tariff for payment by results
- A tariff for mental health services may appear in 2008–2009, but PCTs should be sharing data of their practice´s spend on mental health for this year
- The excess costs involved in commissioning CBT as recommended by NICE guidance can be offset by a lower spend on the prescribing element of the indicative budget
- National Institute for Clinical Excellence. Clinical Guideline 23. Depression. Management of depression in primary and secondary care. London: NICE, 2004.
- Department for the Environment, Transport and the Regions. Indices of Deprivation, 2000. DETR, 2000.
- Prescription Pricing Authority. PACT Standard Report, June 2004. Newcastle: PPA, 2004.
- National Statistics. Prevalence of treated depression: by type of area and gender, 1994–1998: Social Trends 31. www.statistics.gov.uk
- Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ primary case study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaires. JAMA 1999; 282 (18): 1737–1744.
- World Health Organization. International Classification of Diseases (ICD-10). Geneva: WHO, 1992.G