Depression and anxiety: biopsychosocial assessment at diagnosis

Indicators

IND103: The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis.

IND104: The percentage of patients with a new diagnosis of depression (in the preceding 1 April to 31 March) who have been reviewed within 10 to 35 days of the date of diagnosis.

Introduction

This report covers two new indicators relating to depression. These indicators are part of the NICE menu of potential Quality and Outcomes Framework (QOF) indicators for 2013/14, following the recommendations of the independent QOF advisory committee in June 2012. The indicators have been piloted as part of the NICE QOF indicator development process.

This report considers the likely cost impact of incentivising the clinical interventions associated with the proposed indicators in terms of the number of additional interventions provided and the cost of each intervention. Costs to NHS commissioners are outlined where relevant, along with the cost of additional activity at general practices.

It is proposed that the above indicators would replace the current QOF indicators:

DEP6: ‘In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the time of diagnosis using an assessment tool validated for use in primary care’.

DEP7: ‘In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 2 to 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care’.

The rationale for the current indicator DEP6 is that it is essential to the assessment of severity in patients with depression to decide on appropriate interventions and improve the quality of care. NICE's guideline on depression in adults describes the stepped care model of depression which states that an assessment of severity as close as possible to the time of diagnosis enables a discussion with the patient about relevant treatment and options.

The rationale for the current indicator DEP7 is derived from the recognition that depression is often a chronic disease, yet treatment is often episodic and short lived.

The rationale for IND103 is to encourage a holistic (bio-psychosocial) assessment of people with depression and record this at the point a formal diagnosis of depression is entered into the patient’s notes.

Indicator IND104 encourages timely follow-up of all people with depression and for the following to be reviewed:

• side effects and efficacy of medication
• depression symptoms
• social support
• other treatment options
• progress of other referrals
• suicidal ideation (as appropriate)
• reinforce messages about duration of medication because early cessation of treatment is associated with a greater risk of relapse.

Cost implication

Number of people affected

QOF data for England 2010/11 show that 4,878,188 people aged 18 and over were on GP practices’ depression registers, representing an estimated prevalence rate of 11.2%.

Current care

For the current DEP6 indicator the 3 suggested severity measures validated for use in a primary care setting are the 9 item PHQ-9, the BDI-11 and the HADS. PHQ-9 takes around 3 minutes to complete, and BDI-11 and HADS take about 5 minutes to complete.

No achievement data for the current DEP6 and DEP7 indicators have yet been published by the Health and Social Care Information Centre – these were new indicators in 2012/13. The 2010/11 England levels of achievement for the corresponding predecessor indicators were 92.1% for DEP2 and 74.5% for DEP3.

Resource impact

Assessment of depression severity is already undertaken as part of standard care under QOF indicators DEP6 and DEP7. The proposed indicators extend this to include a biopsychosocial assessment and review within 7 to 35 days of diagnosis. We cannot be sure that this is not already being carried out. There may be some additional costs associated with in-house awareness training but implementation of this indicator is not expected to result in significant costs.

It is reasonable to assume the workload needed for these 2 new QOF indicators would be similar to the current indicators DEP6 and DEP7.

Related QOF indicators 

Current QOF indicator	Numerator	Denominator	Underlying achievement
DEP2: In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care.	373,233	405,358	92.1%
DEP3: In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 5 to 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care.	243,123	326,372	74.5%

Note:

• DEP2 was superseded in April 2011by DEP4 (‘outset of treatment’ reworded to ‘time of diagnosis’). No data are yet available for DEP4, which was itself superseded in April 2012 by DEP6 (same wording as DEP4).
• DEP3 was superseded in April 2011by DEP5 (‘5-12 weeks’ replaced by ‘4-12 weeks’). No data are yet available for DEP5, which was itself superseded in April 2012 by DEP7 (‘4-12 weeks replaced by ‘2-12 weeks’).

References

Kates N, Mach M (2007) Chronic disease management for depression in
primary care: a summary of the current literature and implications for practice. Canadian Journal of Psychiatry 52: 77–85

Health and Social Care Information Centre (2011) QOF 2010/11 data [online].
University of Birmingham and University of York Health Economics Consortium Health (NICE External Contractor), Development feedback report on piloted indicators, 2012