QOF depression tool causing over-diagnosis

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QOF depression tool causing over-diagnosis

07 Jan 08

By Georgie Hobbs

GPs using a `blunt' QOF assessment tool for depression may be

dramatically over-diagnosing patients, with fears that large numbers

of patients are being inappropriately treated with drugs.

Researchers are calling for a review of QOF guidance after finding

that diagnostic rates varied dramatically depending on the assessment

tool used.

The most commonly used NICE-backed tool to diagnose depression, the

Patient Health Questionnaire (PHQ-9), classified twice as many

patients with moderate or severe depression as a second tool, the

Hospital Anxiety and Depression Scale (HADS).

In the study, both tools were used on the same 544 patients, with PHQ-

9 diagnosing 74% of patients as moderately to severely depressed,

compared with 37% using HADS.

The University of Aberdeen researchers warned that if GPs who used

the PHQ-9 strictly adhered to the NICE stepped-care model, three

quarters of depressed patients would be offered an antidepressant.

Half would be offered one if tested via HADS.

Ms Isobel Cameron, who led the research – published in January's

British Journal of General Practice - said GPs should `exercise

caution' in interpreting the test scores.

`The measures endorsed by the QOF may well have a place but we need

to find out more about how well they categorise the severity of

depression. At the moment we don't know whether both or one of them

is getting this wrong.'

Ms called the huge disparity in results `disappointing'

while GPs said it was `worrying' - particularly because GPs are

incentivised to use PHQ-9 since it is free.

Dr Manning, chief executive of Primary Care Mental Health and

Education, called the tools `blunt' and warned `Often GPs don't act

on the findings because they don't know what to do next. The QOF has

unskilled a lot of people - they seem to be forgetting their holistic

skills.'

But Dr Stott, a GP in Tadworth, said that no matter what tool

was used, there was not enough evidence base for QOF inclusion to

treat the majority of patients.

`By and large we use the depression indicators within a population

with chronic illness

Anti-depressants or cognitive treatment have never been proven to

work with patients with diabetes, heart disease and other chronic

illnesses. No matter what test is used, what's the point if you can't

treat it?'

Choosing a depression tool

-

Three depression severity measures are endorsed in QOF

Patient Health Questionnaire (PHQ-9)

• Free to download

• Nine patient-reported questions

• Take around three minutes

• Uses DSM IV criteria to categorise severity as minimal, mild,

moderate, moderately severe and severe

Hospital Anxiety and Depression Scale (HADS-D)

• Costs £60 for manual and recording forms

• Seven patient-reported questions

• Takes around five minutes

• Categorises depression as normal, mild, moderate and severe

Beck Depression Inventory II (BDI-II)

• Costs $140 (£70) for manual and recording forms

• 21 patient-reported items

• Takes around five minutes

• Uses DSM-IV criteria to categorise severity as minimal, mild,

moderate and severe

Source BMA

This study compared PHQ-9 and HADS-D and found:

• Both scales accurately measured changes in severity

• Both reliably identified depressed individuals

• PHQ-9 identified 74% of 544 patients as needing antidepressants

compared to 37% using HADS

BJGP 2008;58:32-36