Effect of a multifaceted approach to detecting and managing depression in primary careBMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7370.951 (Published 26 October 2002) Cite this as: BMJ 2002;325:951
- Jan Scott, professor of psychological treatments research ()a,
- Alison Thorne,, research and development workerb,
- Peter Horn,, consultant psychiatristc
- aDivision of Psychological Medicine, PO 96, Institute of Psychiatry, De Crespigny Park, London SE5 8AF,
- bWhole System Mental Health Project, North Tyneside NE29 0DW
- cFriarage Hospital, Northallerton DL6 1JG
- Correspondence to: J Scott
- Accepted 27 June 2002
Abstract Problem: Need to improve the detection and management of depression in primary care.
Design: Prospective, before and after study of changes in detection and management following attempts to introduce a chronic disease management approach.
Background and setting: Two representative general practices in the north east of England that differed markedly in resources available and populations served.
Key measures of improvement: Number of cases on a depression register, number of cases accurately diagnosed, adherence to own clinical management guidelines.
Strategies for change: Multifaceted intervention to meet the needs of each practice modified by in-house steering group, including resources to develop a case register, an education and training programme on detection and management agreed by consensus, facilitation of meetings with secondary care staff, and support in developing a practice guideline.
Effects of change: Practice A (with six partners and serving a predominantly affluent white British population) improved case detection rate by 23%, reduced prescribing of sub-therapeutic doses of antidepressants by 36%, and adhered to the preferred treatment regimens. At Practice B (with three partners and two surgeries located in deprived urban inner city areas with high levels of unemployment and large ethnic minority populations) improvement in the sensitivity of case detection was accompanied by a reduction in specificity. The practice did not reach consensus on its own guideline and was unable to sustain the model.
Lessons learnt: A simple practice based approach improved the detection and management of depression in a team familiar with the philosophy of chronic disease management, with the capacity to commit to the programme, and with a critical mass of team members being open to change. This model failed to affect depression management when staff engagement with the project was passive rather than active and the practice was less well resourced and served an economically deprived and ethnically diverse population.
Background and setting
The prevalence of depression is 3-9%.1 It is more common than diabetes and asthma and, by 2020, will rank second only to ischaemic heart disease as a worldwide disease burden.2 About 90% of episodes of depression are managed in primary care. However, case identification and treatment are suboptimal. 3 4Interventions that focus on any one component of the identification or management process have demonstrable research efficacy but limited clinical effectiveness.5Models that target several aspects of depression management simultaneously may be more beneficial.6 This paper describes attempts to introduce such a multifaceted model.
Newcastle and North Tyneside District Health Authority met the costs of the project and provided a list of five general practices that might participate. From these, we recruited one large practice serving a population with low levels of deprivation and a less well resourced practice serving a more deprived area (see table 1 for details).
Practice A- The first practice had a list size of about 10 000 and served a predominantly affluent white British population. The practice team comprised six partners and 13 other staff, including a counsellor and a psychologist.
Practice B- The second practice had about 5500 registrations. It had two surgeries located in deprived urban inner city areas with high levels of unemployment and large ethnic minority populations. There were three partners, with a series of locums employed to cover one partner's study leave. The surgeries had access to a counselling service for individuals from ethnic minority groups. Each surgery referred cases to different community mental health teams.
The problem was how to implement effective methods of identifying and managing adult depression in general practice without distorting normal working patterns. We applied a “chronic disease management” approach, aiming to establish an integrated care pathway.7 A potential barrier to implementation was that primary care teams were under pressure to make other changes and had limited time and resources available. We seconded an H grade mental health nurse to facilitate the project, and a specialist registrar provided sessional input.
Key measures for improvement
We used a prospective before and after design to evaluate changes in depression management. We defined five measures of improvement in advance:
All identified cases of depression to be placed on a register; an appropriate indicator would be if about 6% of patients aged 18-65 years were registered
Antidepressants to be prescribed at agreed doses for the acute, continuation, and maintenance phases of depression
Drugs to be prescribed from an agreed practice formulary reflecting clinical and cost effectiveness data (in practice A the drug of choice would be lofepramine8) and the “Northern Regional Quality Marker” (which states that selective serotonin reuptake inhibitors should comprise <25% of prescribed antidepressants)
A call and recall system to be instituted so that patients newly prescribed antidepressants would be reviewed at two and six weeks
Referrals to secondary care to be for reasons agreed at the “interface meetings” with mental health services (see below) and would comprise no more than 10% of cases seen.
We assessed staff views of the intervention using a modified version of the client satisfaction questionnaire.9 This was rated on a 1-4 scale (1=strongly disagree, 4=strongly agree).
Strategies for change
The project facilitator worked alongside a steering group at each practice to devise and deliver
Staff training to enable reliable detection of cases of depression
Specific computer codes that flagged cases and their clinical status on a register
In-house treatment guidelines to aid case management
Referral and shared care procedures agreed jointly with mental health services.
Case register— AT and PH reviewed a 50% sample of case notes at practice A stratified by age and sex to identify patients aged 18-65 years currently being treated for depression. A series of computer codes were used to categorise cases on a practice register (see table 1). This proved difficult at practice B as some data were not computerised. Information was presented to the teams regarding actual versus predicted numbers of cases.
Case detection— With ethical approval, we asked patients attending surgeries held by each general practitioner to complete a hospital anxiety and depression scale questionnaire10 We defined patients with a depression subscale score of eight or more as depressed. At practice B, we employed interpreters to facilitate completion of the questionnaire. The general practitioners completed a practice activity card11for each patient indicating whether they identified any psychological problems. We presented the sensitivity and specificity findings at a practice meeting and provided each general practitioner with private feedback on his or her case identification skills. We held training sessions on identifying and diagnosing depression, problem based interviewing skills, 12 13 basic support techniques, and psychopharmacology. After training, the case detection exercise was repeated.
Case management— The steering groups drafted practice-specific treatment guidelines using two published evidence based guidelines as a template. 3 4 8 14 Criteria for in-house referrals to counselling were reviewed. This process took practice A staff about two hours. Consensus on the guideline was not achieved at practice B.
Primary and secondary care interface— Audit data were used to inform meetings on referral and shared care procedures with the sector consultant psychiatrist and a community psychiatric nurse. At practice B these meetings were repeated for each of the two sector teams covering the practice. This took about one to two hours of staff time. We used a quasi-experimental design to explore the immediate impact of introducing the package and the adherence of each team to the agreed practice at six months after the active phase of the project.
Effects of change
Practice A— At baseline, 285 cases of depression were known to practice A, compared with the predicted 399 (95% confidence interval 331 to 414). After intervention, 362 cases (6.6%) were registered (see table 2). Although only 66% (51/77) of new cases of depression were placed on the register, all other aspects of case management improved after the intervention. There was no record of prescribing not in accord with the guideline, and lofepramine comprised 56% of the antidepressants prescribed. The mean client satisfaction questionnaire score for staff (n=9) was 3.3 (SD 0.8).
Practice B— The predicted number of cases of depression for practice B was 208 (95% confidence interval 137 to 292). At baseline, 52 cases (1.6%) were identified, and after the intervention 71 cases were registered (2.2%). An improvement in sensitivity after training was countered by a decrease in specificity (see table 2). No systematic data were available from the practice after the active phase. The mean client satisfaction questionnaire score for staff (n=5) was 2.9 (SD 0.7).
Lessons learnt and next steps
The results of our intervention might have been easy to predict given the contrasting resources and capacity available in the two practices. Certainly, a key handicap at practice B was the more primitive information technology system and the greater reliance on handwritten information. Familiarity with the philosophy of chronic disease management probably affected engagement with the project. Staff at practice A had previous knowledge and experience of integrated care pathways for hypertension and diabetes; those at practice B did not. The completion of the planned intervention was more difficult at practice B because it was harder to maintain the involvement of the same core staff at each stage. The general practitioners in particular found it difficult to attend training sessions unless locums were provided, and training exercises sometimes had to be repeated. This partly explains the failure to complete the process: it proved impossible for everyone to meet to agree the in-house treatment guideline.
Key learning points
A simple practice based approach improved the detection and management of depression in a team familiar with the philosophy of chronic disease management
Active ownership of and participation with the project plus external support to develop the depression case register were important elements in implementation
This multifaceted approach failed to affect depression management in a less well resourced practice serving an economically deprived and ethnically diverse population
Creating a sustainable system for the effective management of depression applicable in a wide variety of practice settings remains a challenge
Beyond these tangible barriers, other elements were also important. For example, ownership of the project at practice A clearly extended beyond the steering group. Several individuals, including the practice manager, provided active leadership. Team members seemed committed to the process and showed willingness to review and change their practice. At practice B there was no consensus onhow depression should be managed, and difficulties in giving priority to the project meant that a shared understanding never developed. Once the input of the project team was withdrawn, staff at practice B could not sustain their planned work on the register or their guideline.
Practice B is far removed from the research settings where models of primary care management ofdepression are usually tested. This project suggests that further modifications of the depression management model are needed if it is to help staff and patients in more disadvantaged circumstances. It may not be feasible to introduce this model unless a practice has prior experience of chronic disease management and computerised records are used routinely. If these components are in place, two basic challenges remain—namely, active leadership from within the primary care team and sufficient incentives for a critical mass of team members to engage in the process. Even then, prioritising this work over other commitments is unlikely without a strong steer from primary care trusts and strategic health authorities.
In summary, attempts to implement “whole system” approaches to depression management in primary care produce inconsistent results.15–17The key elements for success are probably organisational change combined with individual commitment to behavioural change. However, the basic challenge of creating and maintaining an effective system of management of depression in primary care without the artificial support of a research project remains.17
We thank the staff of both primary care teams who took part in this project. Identifying information is withheld in accordance with an agreement made before undertaking the project with the district health authority and the practices.
Contributors: JS designed the project, obtained funding, supervised the work of AT and PH, and wrote the first and final drafts of this article. AT was the key link to the practices, working with each practice steering group on the development of the depression register and the clinical practice guideline on depression, providing training input, and drafting detailed reports for the health authority. PH identified cases of depression and treatments prescribed in each practice and contributed to the training programme and the drafting of reports.
Funding Newcastle and North Tyneside District Health Authority paid the salary for the project facilitator and met other costs related to the project (such as travel, questionnaires)
Competing interests None declared.