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

BMJ 2009; 338 doi: (Published 19 March 2009) Cite this as: BMJ 2009;338:b750
  1. Tony Kendrick, professor of primary medical care1,
  2. Christopher Dowrick, professor of primary medical care2,
  3. Anita McBride, research fellow1,
  4. Amanda Howe, professor of primary care3,
  5. Pamela Clarke, research assistant2,
  6. Sue Maisey, research associate3,
  7. Michael Moore, senior lecturer1,
  8. Peter W Smith, professor of social statistics4
  1. 1University of Southampton Primary Medical Care Group, Aldermoor Health Centre, Southampton SO16 5ST
  2. 2University of Liverpool School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool L69 3GB
  3. 3University of East Anglia School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ
  4. 4Southampton Statistical Sciences Research Institute, University of Southampton, Southampton SO17 1BJ
  1. Correspondence to: T Kendrick A.R.Kendrick{at}
  • Accepted 19 February 2009


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.


  • We thank the participating practices and their staff, and the PCT pharmaceutical advisers for their help with data collection. We also thank Simon Gilbody, Geraldine M Leydon, Robert Peveler, Deborah Sharp, and Andre Tylee for advice on the design, conduct, and interpretation of the study.

  • Contributors: TK and CD devised the idea of the study and designed the methods. TK raised the funding. AMcB, PC, and SM were responsible for implementing the study. PWS led the analysis with TK, with contributions from CD, MM, and AH. TK prepared the first draft of the manuscript, and all authors contributed to each section of the final draft of the manuscript. TK is guarantor for this study.

  • Funding: This study was funded by an unrestricted educational grant from Lilly, Lundbeck, Servier, and Wyeth pharmaceuticals. It also received funding from Southampton City Primary Care Trust and the Mental Health Research Network, West, North West, and East Anglia hubs. None of the above bodies had any role in study design; the collection, analysis, and interpretation of data; the writing of the paper; or the decision to submit this paper for publication. The study was sponsored by the University of Liverpool.

  • Competing interests: The study was funded by pharmaceutical companies that manufacture antidepressants. TK has received fees for presenting at educational meetings from Lilly, Lundbeck, Wyeth, and Pfizer pharmaceuticals. TK and CD are members of the mental health expert panel of advisers for the UK general practice contract quality and outcomes framework, which recommended the inclusion of the incentives for using depression severity questionnaires in the contract.

  • Ethical approval: Permission for the study was obtained from Liverpool Paediatric Research Ethics Committee, reference 07/Q1502/23, and approval was obtained from local ethics committees and primary care trust research governance offices at all three sites.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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