Background The first-line treatments for mild–moderate and moderate–severe depression according to the National Institute for Health and Care Excellence clinical guidelines for the management of depression in adults are psychological therapies followed by or alongside pharmacological treatment. We conducted an audit of patient records (as recorded by general practitioners (GPs)) to compare practice to the guidelines.
Methods Incident cases were retrospectively identified from electronic primary care records (SystmOne). From 40 320 registered patients, cases were identified based on previously coded new diagnoses of depression in the 2016–2017 and 2017–2018 Quality and Outcomes Framework (QOF) years. Patient notes were screened for exclusion criteria (mental health problems that would alter management pathway) and for records of management discussions (pharmacological or psychological therapies) at the diagnostic appointment.
Results In 2016–2017 (n=315), psychological therapies for depression were discussed at 63.2% of diagnostic appointments, they were most discussed at appointments with those aged 18–29 years (70.8%), but this decreased with age to 56.3% of appointments with those aged ≥65 years. In 2017–2018 (n=244), psychological therapies were discussed at 70.9% of diagnostic appointments but were discussed at more appointments with those aged 18–29 years (81.6%) and at less appointments with those aged ≥65 years (39.4%). Discussion of pharmacological management was similar for all age groups in 2016–2017 (89.9%) and 2017–2018 (93.0%).
Implications For patients aged ≥65 years, psychological therapies are featuring less in management discussions with GPs or are not being recorded. Recommendations for change implemented at the practice included feedback of results and professional reminders throughout the 2019-2020 QOF year.
- primary care
- mental health
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Major depressive disorder (depression) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 as the experience of low mood or anhedonia plus at least four more types of depressive symptoms during the same 2-week period that cause clinically significant distress or impairment of important daily functions, and which cannot be attributed to the physiological effects of a substance or another condition.1 Severity of depression is determined by the number of symptoms and their effects on daily life. Mild depression is defined as five symptoms, moderate depression as five or more symptoms with varying functional impairment, and severe depression as five or more symptoms with significant functional impairment.1
In 2014, one in five people in the UK aged 16 years or older reported symptoms of depression or anxiety.2 Depression is also the leading cause of death in men under 50 years of age.3 The treatment of depression accounts for a significant proportion of the UK’s National Health Service (NHS) annual budget and is predicted to cost the NHS £3 billion per year by 2026.4 Effective treatment for depression is important not only because of the social impact of the condition but also because depression is the leading cause of disability in the UK, which is predicted to cost the economy £9 billion in lost earnings by 2026.3
Therapies for the treatment of depression include psychological interventions, pharmacological interventions and, for life-threatening depression, electroconvulsive therapy.5 In 2008, the Improving Access to Psychological Therapies (IAPT) service was launched in the UK.6 As the name of the service suggests, IAPT was created to improve access to psychological therapies and to give general practitioners (GPs) in the NHS a practical alternative to pharmacological therapies for the management of mild–moderate depression and an adjuvant to pharmacological therapies for the management of moderate–severe depression. NHS England’s Five Year Forward View for Mental Health has further committed to expand and improve the quality of IAPT services.7 While improving access for all is important, some groups are currently under-represented in those accessing IAPT services.8 In particular, referrals to IAPT are lowest in those aged ≥65 years, despite this age group achieving better outcomes with psychological therapies than those aged <65 years.8
Summary of evidence-based standards for the management of mild and moderate depression
In the UK, the National Institute for Health and Care Excellence (NICE) guidelines make evidence-based recommendations on the prevention and management of depression.5 NICE also develops and approves new indicators into the Quality and Outcomes Framework (QOF), a system for managing and organising performance-based payment of GPs in the NHS.9
The NICE guidelines recommend a stepped care approach based on depression severity, duration of symptoms and response to treatment.5 Guidance for the management of mild–moderate and moderate–severe depression, as indicated by NICE, is outlined in table 1. Step 4 applies only to complex and severe depression, or depression with risk to life. This has very different management approaches which are beyond the scope of this audit; therefore, step 4 is not discussed here.
It is possible to differentiate depression with suicidal ideation from mild–moderate and moderate–severe depression retrospectively as the presence/absence of suicidal ideations and risk are routinely recorded on patient notes. Similarly, it is possible to identify severe and complex depression as referrals for step 4 treatment are routinely recorded. However, it is difficult to differentiate mild–moderate and moderate–severe depression retrospectively as severity of depression is not routinely coded on GP notes and GPs are no longer incentivised through QOF to record the use of screening tools (such as the Patient Health Questionnaire (PHQ)-9) that can be used to indicate severity of depression.9 As a result, this audit is focused on the guidance for step 2 and step 3 of the NICE guidance (discussion of low/high intensity psychotherapy±antidepressants) for those with mild–moderate or moderate–severe depression.
As part of a health-needs assessment, we had previously identified that the practices audited (GPS Healthcare) have a larger proportion on elderly patients (when compared with the national average10), making them an ideal setting for this audit. Given the ageing population, we identified that there may be a potential to significantly improve care by auditing management discussions for depression. We aimed to compare management discussions (as recorded by GPs) for newly diagnosed mild–moderate and moderate–severe depression with the NICE guidelines for the management of depression by conducting an audit of patient records for both the 2016–2017 and 2017–2018 QOF years.
This audit was carried out in accordance with the NICE audit cycle; stages 1 and 2 have been described in the background and stage 3 is described here.11 Data were collected from SystmOne, the electronic primary care record software used by GPS Healthcare. A retrospective search was carried out on registered patients at GPS Healthcare within the Birmingham & Solihull Clinical Commissioning Group. From this search, retrospective incident cases were identified that met the inclusion criterion:
Previously coded new diagnoses of depression in the 2016–2017 and 2017–2018 QOF years.
Patient notes were then screened for exclusion criteria (any criteria that may require alternative treatment to step 2 or step 3 of the NICE guidelines for the management of depression):
Comorbid dementia or mental health problems (with the exception of depression, anxiety and obsessive–compulsive disorder).
Presence of suicidal ideations as recorded in the notes or a score of 3 on the PHQ-9 questionnaire item ‘Thoughts that you would be better off dead or of hurting yourself in some way?’.
If it was clear from the notes that the appointment had been miscoded as a new diagnosis of depression or the patient was clearly being managed for life-threatening depression or severe and complex depression (NICE step 4).
Finally, patient notes were screened for records of management discussions of pharmacological and non-pharmacological (psychological) therapies at the diagnostic appointment and against exclusion criteria (contraindications for psychological therapies). Recorded discussions of options were compared against step 2 and step 3 of the NICE guidelines (table 1).
Data was analysed using Pearson χ2 test of goodness of fit. STATA V.15.1 was used for data analysis. Results of the audit were presented to a GP partner at GPS Healthcare, with whom the implications of the audit and recommendations for change were developed; from this, an action plan for dissemination to practice staff was agreed. A decision was made to reaudit the practice at the end of the 2019–2020 QOF year to report stages 4 and 5 of this audit cycle11 and to assess whether there have been changes in practice following implementation of the recommendations for change.
A retrospective search of the 40 320 registered patients at GPS Healthcare within the Birmingham and Solihull Clinical Commissioning Group identified retrospective incident cases (n=382 and n=298) that met the inclusion criteria based on previously coded new diagnoses of depression in the 2016–2017 and 2017–2018 QOF years. Sixty-seven patients and 54 patients diagnosed in the 2016–2017 and 2017–2018 QOF years, respectively, were excluded from the final audit due to meeting the exclusion criteria.
In this section, ‘psychological therapy’, ‘medication’ and ‘both’ will be used to describe the results:
Psychological therapy refers to consultations where some form of psychological therapy was recorded as having been discussed with the patient.
Medication refers to consultations where antidepressant medication was recorded as having been discussed with the patient.
Both refers to consultations where both psychological therapies and medication were discussed; this includes a proportion of those patients in the psychological therapy and medication columns.
As recorded by GPs in GPS Healthcare’s electronic primary care records database, discussion of psychological therapies at diagnostic appointments increased from 2016–2017 to 2017–2018 from 63.2% to 70.9%. In 2016–2017 (n=315), the frequency of diagnostic appointments where psychological therapies for depression were discussed was greatest in those aged 18–29 years (70.8%) but decreased in each age group to 56.3% in those aged ≥65 years. In 2017–2018 (n=244), discussion of psychological therapies had increased to 81.6% in those aged 18–29 years but had decreased to 39.4% in those aged ≥65 years (table 2).
Pearson χ2 tests of goodness of fit were performed to determine whether there were statistically significant differences in the frequency of appointments where specific management options were discussed in 2016–2017 and 2017–2018, respectively. There was no statistically significant difference in the frequency of appointments where psychological therapies were discussed by age group in 2016–2017, but there was a statistically significant difference between age groups in 2017–2018.
The proportion of diagnostic appointments where pharmacological management options were discussed was statistically similar across all age groups in 2016–2017 and 2017–2018. However, in 2017–2018, there was a trend that pharmacological options for the management of depression were discussed less in those who were younger and more in those who were older. There were no statistically significant differences in the frequency of discussions of different management options between men and women.
Strengths and limitations
We were able to audit management discussions for all coded new diagnoses of depression across two QOF years for a relatively large multicentre practice within the Birmingham and Solihull CCG. As recording of the presence or lack of suicidal ideation and plans was comprehensive, as were referrals to crisis team and secondary care, we were able to exclude patients with depression with risk to life or probable severe and complex depression, for whom step 2 and step 3 management according to the NICE guidelines would not have been most appropriate. We were also able to exclude patients with comorbid conditions that may have made them inappropriate for IAPT (such as complex comorbid mental health problems). It is likely that those consultations which were included in the audit were for patients with mild–moderate or moderate–severe depression for whom the NICE guidelines recommend psychological therapies alone or psychological therapies and antidepressants. Importantly, we have investigated management discussions rather than referrals for psychological therapy or antidepressant prescriptions; thus, we have evaluated clinicians’ recommendations rather than patients’ decisions. This is important, given the current shared decision-making model for healthcare.
As severity of depression was not routinely recorded in general practice notes, we were unable to differentiate mild–moderate depression from moderate–severe depression (step 2 and step 3 of the NICE guidelines) within the newly diagnosed population. Within the patient consultations reviewed, it was very rare for only IAPT or psychological therapies to have been discussed with patients, whereas pharmacological therapies were discussed with almost all patients. The majority of patients identified were managed more in accordance with step 3 of the NICE guidelines rather than step 2, and it is not possible to identify whether this is due to step 2 not being followed, or due to recording bias in notes which would have created a selection bias in our original search. It may be that GPs were less likely to code depression in patient notes when patients first presented with mild or subthreshold depressive symptoms, as coding depression in patient notes would mean that were these patients not reviewed within 10–56 days, this would count negatively towards QOF scoring.12
This audit was a retrospective evaluation of management discussions as recorded by GPs on clinical notes. Though the recording of discussion about psychological therapies with patients was lower than the recording of discussions about pharmacological treatments, it is possible that some GPs are less likely to record discussions of psychological therapies versus pharmacological therapy with patients even when they take place.
The proportion of all initial management discussions with patients diagnosed with a new episode of depression that included discussion of psychological therapies increased from 63.2% in 2016–2017 to 70.9% in 2017–2018. According to the NICE guidelines, the discussion of psychological therapies should be included in management discussions for mild and moderate depression, prior to or alongside discussion of pharmacological therapy (depending on the severity of depression). This means that while clinicians did not record that they discussed psychological options for the management of depression for all patients in either QOF year (as the NICE guidelines recommend), overall compliance with the NICE guidelines improved from 2016–2017 to 2017–2018. This may be due to clinician or patient factors; for example, it may be that more clinicians and patients are becoming aware of IAPT services. System factors may also contribute if access to services is improving (eg, reduced waiting times for psychological therapies) or it may be that the detailed recording of management discussions with patients has increased.
This audit also demonstrates that for those aged ≥65 years, GPs management discussions around psychological therapies were being carried out or recorded less than in younger patients and that this gap has increased from the 2016–2017 to 2017–2018 QOF years. Though it is not possible to know with certainty whether there are systematic differences in management discussions or whether there are systematic differences in the recording of them by age, nationally, IAPT also records that this age group are under-represented among those accessing services. Patients aged ≥65 years are also directly referred less than younger patients despite them achieving better outcomes with IAPT.8 13 However, as most patients diagnosed with depression in general practice will be encouraged to self-refer to psychological therapy services (including IAPT) and very few are directly referred, management discussions may be at least partially responsible for reduced self-referral to psychological therapy services in older age groups.
Future qualitative research could explore why clinicians believe psychological therapies may not be being mentioned as frequently in management discussions for newly diagnosed depression in those aged ≥65 years and explore patient perceptions of such treatment. IAPT have identified four barriers to older people accessing their services,8 with ‘perceptions’ being the barrier most relevant for primary care clinicians. This barrier encompasses both potential patient and clinician factors. Patient factors may include reduced awareness of talking therapies. Awareness may also be lower among certain demographics, who may be less likely to suggest psychological therapies to their clinician or prompt a discussion on non-pharmacological management options as a result. Clinician factors could include beliefs that more elderly patients will be less likely to accept or to benefit from psychological management options.
Recommendations for change
The recommendations for change were formulated by the authors and developed in collaboration with one of the GP partners whom the results were initially presented to. The recommendations made to the practice were as follows:
GPS Healthcare to circulate results and request all GPs to explicitly record whether discussions about psychological therapies have taken place when new cases of depression present.
IAPT psychological well-being practitioner, CBT therapist, counsellor or representative to attend a monthly GP meeting within GPS Healthcare to summarise its service and outline suitable patient groups for referral.
Audit cycle to be completed after 12 months to assess the impact of the recommendations for change during the 2019–2020 QOF year.
The practices involved have circulated the results of the audit and recommendations for change to their GPs. The practices will be audited for the 2019–2020 QOF year to evaluate whether changes in practices occurred following implementation of the recommendations for change.
NICE guidelines recommend psychological therapies as the first-line treatment for mild and moderate depression.
General practitioners (GPs) are recording that they discuss psychological therapies as a management option for depression less with patients ≥65 years of age.
This difference in recorded management cannot be explained by comorbid mental health conditions alone.
Current research questions
Can interventions to improve awareness among GPs of the benefits of psychological therapies for depression in patients ≥65 years of age result in increased discussion of psychological therapies with these patients?
Does this lead to more equitable access to psychological therapies?
Does increasing the proportion of patients ≥65 years of age who choose to access psychological therapy services for depression affect the difference in outcomes between this age group and younger age groups?
What is already known on the subject
Patients who are ≥65 years of age are under-represented among those accessing IAPT services.8
Patients who are ≥65 years of age are directly referred to IAPT services less than younger patients despite them achieving better outcomes.13
Patients who are ≥65 years of age who access IAPT services achieve better outcomes from psychological therapies through the IAPT service than those from younger age groups.8
The authors thank the administrative staff at GPS Healthcare for their assistance with the search, and Dr Louise Stacey and Dr Michael Baker for their support in conducting the audit and in contributing to and implementing our recommendations for change.
Correction notice This article has been corrected since it appeared Online First. Typographical errors have been corrected, and author initials have been amended.
Contributors JPL drafted the manuscript. JPL and JP conceived the idea for this audit, developed the protocol and extracted the data. JPL, JP and NM revised the protocol and manuscript for important intellectual content and approved the final version for submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Ethical approval was not required as this was an audit and was carried out by staff and students employed by or attached to the practice.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data may be obtained from a third party and are not publicly available. All relevant de-identified data has been presented in the manuscript.
Author note JP and JPL are medical students at the University of Warwick and undertook this work while on placement at GPS Healthcare. NM is a qualified low-intensity psychological well-being practitioner. This work does not reflect the views of GPS Healthcare, the NHS Birmingham and Solihull CCG, the Birmingham and Solihull Mental Health NHS Foundation Trust or the Coventry and Warwickshire Partnership NHS Trust.
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