ABSTRACT
The effectiveness of screening and organisational strategies to improve the recognition and management of depression in primary care published in a recent issue of Effective Health Care is reviewed.
Depression is the second most common cause of disability worldwide. In the UK, depression is one of the most common reasons for consultation in general practice.
While depressive disorders are common, they may go unrecognised. It has been reported that depressive symptoms are not recognised in about half of attending patients with depressive disorders in UK general practice. Unrecognised major depression is associated with poor treatment outcomes. Despite the frequency of presentation and the availability of effective interventions, the diagnosis and treatment of depression in primary care and by non-specialist practitioners may not be in line with current guidelines.
The “NHS Plan” recognises the importance of depression and its management in primary care, and there are plans to recruit 1000 new primary care mental health workers by 2004. An improved level of integration between primary and secondary care and a shifting of roles for healthcare professionals is seen to be integral in optimising the management of depression in primary care.
This article provides an overview of the effectiveness of strategies to improve the quality of care for those suffering from depression in primary care. The section on the use of questionnaires to detect depression in non-specialist settings is based on two systematic reviews. These reviews have been published previously and have been updated to include additional randomised and some controlled clinical trials and a related review.
The section on educational and organisational interventions to improve the management and outcome of depression in primary care settings builds upon a review of all guideline implementation strategies commissioned by the UK NHS HTA programme and a Cochrane review of mental health workers in primary care. An additional search was carried out with the support of the Cochrane Effective Practice and Organisation of Care Group (EPOC) to identify interventions not covered by the HTA review.
USING QUESTIONNAIRES TO DETECT DEPRESSION
There are a number of brief, easy to complete, standardised measures which have robust psychometric properties. These instruments can be administered in the waiting room and their results fed back to clinicians as an aid to individual clinical decision making. The hope is that the results of these questionnaires will improve recognition rates and the eventual outcome of depression in non-specialist settings. However, questions have been raised regarding whether all those with raised scores on questionnaires do have significant depressive illness.
The identified studies used two methods of randomising patients: all patients irrespective of their score on the instrument or their likelihood of having a pre-existing psychiatric disorder ("unselected"), or only those with a probable psychiatric disorder by virtue of a score above some cut off or a positive diagnostic interview ("high risk"). The second approach involves the administration, scoring, and selective feedback of positive results by an administrative assistant. All but two studies randomised individual patients, so that clinicians received feedback for some of their patients and not for others, raising the problem of cross contamination between patient participants and dilution of effect. Three studies were non-randomised controlled clinical trials. The two clustered studies were prone to a “unit of analysis error”.
To assess the recognition of depression, a meta-analysis of studies was performed. Substantial heterogeneity existed between studies which was explained by the two differing randomisation approaches ("unselected" feedback versus “high risk” feedback). Unselected feedback did not improve the recognition of depression (relative risk (RR) 0.96, 95% CI 0.83 to 1.10). This effect remained when the non-randomised studies were included in the meta-analysis. High risk feedback was shown to be effective in increasing the rate of recognition of depression (RR 2.66, 95% CI 1.78 to 3.96). This intervention increased the rate of detection of depression by 27% (95% CI 14 to 40).
Nine studies investigated the effect of the feedback of questionnaire results on the rate of intervention for emotional problems (such as referral to outside agencies and the commencement of treatment for depression). All but two showed non-significant results. Heterogeneity of methods and definition of an active intervention meant that overall pooling was not justified.
Eight studies examined the effect of routine questionnaires on the level of depression over time. No overall effect on depression was identified in seven of the eight studies. For example, in one study the Beck Depression Inventory was re-administered at 6 and 12 months and no significant difference was found between those on whom scores were fed back and controls. This study suggests that unrecognised depressive symptoms resolve over a 12 month period, irrespective of whether feedback was employed or not. Similarly, another study showed a lack of overall effect of GHQ feedback on subsequent GHQ scores.
Nine randomised and non-randomised controlled clinical trials assessing health related quality of life (HRQoL) questionnaires conducted in non-specialist settings were identified. All the instruments used included an assessment of mental well being, with specific questions relating to depression. The routine feedback of the findings of these instruments had no impact on the recognition of depression or on longer term psychosocial functioning in any of the studies. While clinicians welcomed the information these instruments imparted, their results were rarely incorporated into routine clinical decision making.
REFERENCES
1. NHS Centre for Reviews and Dissemination. Improving the recognition and management of depression in primary care. Effective Health Care 2002;7.
2. Murray CJ, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990. Boston, Mass: Harvard School of Public Health on behalf of the World Bank, 1996.
3. Singleton N, Bumpstead R, O’Brien M, et al. Office of National Statistics: psychiatric morbidity among adults living in private households, 2000. London: HMSO, 2001.
4. Shah A. The burden of psychiatric disorder in primary care. Int Rev Psychiatry 1992;4:243–50.
5. Goldberg D, Huxley P. Mental illness in the community. London: Tavistock, 1980.
6. van Hemert AM, Hengeveld MW, Bolk JH, et al. Psychiatric disorders in relation to medical illness among patients of a general medical outpatient clinic. Psychol Med 1993;23:167–73.
7. World Health Organisation. World Health Report 2001: mental health: new understanding, new hope. Geneva: WHO, 2001.
8. Marks J, Goldberg DP, Hillier VF. Determinants of the ability of general practitioners to detect psychiatric illness. Psychol Med 1979;9:337–53.
9. Freeling P, Rao BM, Paykel ES, et al. Unrecognised depression in general practice. BMJ 1985;290:1880–3.
10. Dorwick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995;311:1274–6.
S M Gilbody, P M Whitty, J M Grimshaw, R E Thomas
University of Leeds, Leeds, UK
University of Newcastle, Newcastle upon Tyne, UK
University of Ottawa, Ottawa, Canada
University of Aberdeen, Aberdeen, UK
