Questionnaire severity measures for depression: a threat to the doctor-patient relationship?

BACKGROUND: Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients. AIM: To gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF. DESIGN OF STUDY: Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis. SETTING: Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk. METHOD: GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views. RESULTS: Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs' identities as professionals with expertise, constructed as integral to the process of diagnosis. CONCLUSION: GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.

Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study.

OBJECTIVE: To gain understanding of general practitioners' and patients' opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. DESIGN: Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. PARTICIPANTS: 34 general practitioners and 24 patients. SETTING: 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. RESULTS: Patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment ("phronesis") to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. CONCLUSIONS: Despite general practitioners' caution about measures of severity for depression, these may benefit primary care consultations by increasing patients' confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires.

Management of depression in UK general practice in relation to scores on depression severity questionnaires: analysis of medical record data.

OBJECTIVE: To determine if general practitioner rates of antidepressant drug prescribing and referrals to specialist services for depression vary in line with patients' scores on depression severity questionnaires. DESIGN: Analysis of anonymised medical record data. SETTING: 38 general practices in three sites-Southampton, Liverpool, and Norfolk. Data reviewed Records for 2294 patients assessed with severity questionnaires for depression between April 2006 and March 2007 inclusive. MAIN OUTCOME MEASURES: Rates of prescribing of antidepressants and referrals to specialist mental health or social services. RESULTS: 1658 patients were assessed with the 9 item patient health questionnaire (PHQ-9), 584 with the depression subscale of the hospital anxiety and depression scale (HADS), and 52 with the Beck depression inventory, 2nd edition (BDI-II). Overall, 79.1% of patients assessed with either PHQ-9 or HADS received a prescription for an antidepressant, and 22.8% were referred to specialist services. Prescriptions and referrals were significantly associated with higher severity scores. However, overall rates of treatment and referral were similar for patients assessed with either measure despite the fact that, with PHQ-9, 83.5% of patients were classified as moderately to severely depressed and in need of treatment, whereas only 55.6% of patients were so classified with HADS. Rates of treatment were lower for older patients and for patients with comorbid physical illness (including coronary heart disease and diabetes) despite the fact that screening for depression among such patients is encouraged in the quality and outcomes framework. Conclusions General practitioners do not decide on drug treatment or referral for depression on the basis of questionnaire scores alone, but also take account of other factors such as age and physical illness. The two most widely used severity questionnaires perform inconsistently in practice, suggesting that changing the recommended threshold scores for intervention might make the measures more valid, more consistent with practitioners' clinical judgment, and more acceptable to practitioners as a way of classifying patients.

Health promotion in the acute hospital setting: the receptivity of adult in-patients.

There is a growing international awareness and development of health promotion in hospitals. For patients, this involves encouraging them to take an active participatory role according to their specific health potentials. The aim of this study was to investigate their receptivity to health promotion in an acute hospital setting. Data are drawn from a questionnaire survey of 320 adult in-patients (100% response rate), excluding terminally ill patients for ethical reasons. In general, respondents supported the development of health promotion in the hospital setting. Concerns were expressed over the knowledge base and the ability of professionals to deliver health education interventions that met their specific needs. Non-smokers were more supportive than those who smoked. For effectiveness, the hospital needs to be considered as a 'whole system' where policies and practices are mutually supportive and integrated into the culture of the organisation. The survey identified that this is not always in evidence.

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