Intended for healthcare professionals


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

BMJ 2009; 338 doi: (Published 19 March 2009) Cite this as: BMJ 2009;338:b663
  1. Christopher Dowrick, professor of primary medical care1,
  2. Geraldine M Leydon, senior research fellow2,
  3. Anita McBride, research fellow2,
  4. Amanda Howe, professor of primary care3,
  5. Hana Burgess, academic foundation trainee2,
  6. Pamela Clarke, research assistant1,
  7. Sue Maisey, research associate3,
  8. Tony Kendrick, professor of primary medical care2
  1. 1University of Liverpool School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool L69 3GB
  2. 2University of Southampton Primary Medical Care Group, Aldermoor Health Centre, Southampton SO16 5ST
  3. 3University of East Anglia School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ
  1. Correspondence to: C Dowrick cfd{at}
  • Accepted 29 January 2009


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.


  • We are grateful for the advice we received on the design, conduct, and interpretation of the study from Simon Gilbody, Michael Moore, Robert Peveler, Deborah Sharp, and Andre Tylee. Becky Rowles, clinical studies officer at the Mental Health Research Network North West hub, helped with patient recruitment.

  • 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. GML led the analysis with HB and AMcB, with contributions from CD, TK, and AH. CD prepared the first draft of the manuscript, and all authors contributed to each section of the final draft of the manuscript. CD is the guarantor.

  • 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, East Anglia, West, and North West 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 Lilly, Lundbeck, Servier, and Wyeth pharmaceuticals, manufacturers of 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 advisors for the UK GP contract quality and outcomes framework, which recommended the inclusion of the incentives for using depression severity questionnaires in the contract.

  • Ethical approval: Liverpool Paediatric Research Ethics Committee gave ethical permission for the study (reference 07/Q1502/23), and approval was obtained from local ethics committees and NHS 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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