Project objectives

Aim

To determine how the GP management of depression has changed in England since 2003, exploring the effects of the recession, NICE guidelines, and the Quality and Outcomes Framework (QOF).

Research questions

Have antidepressant prescriptions increased because of an increase in the number of people treated, in particular since the economic recession, or because GPs are prescribing longer courses of treatment? Did prescribing and referral patterns change following the introduction of symptom questionnaires incentivised through the QOF? Was treatment appropriately targeted towards patients with higher symptom scores at diagnosis and follow-up?

Changes to project objectives

We were unable to look at whether treatment was appropriately targeted towards patients with higher symptom scores at diagnosis and follow-up, because practice computer systems do not routinely record the scores on symptom questionnaires, only the fact that they’ve been administered.

Brief summary

Methods

Time trend analyses of quarterly rates of GP recording of depression incidence, prevalence, and antidepressant treatment were conducted on anonymised consultation data from 142 English practices contributing to the Clinical Practice Research Datalink, April 2003-March 2013, to determine the significance of any changes after the introduction of NICE guidelines on depression (from January 2005), the economic recession (from April 2008), and the introduction of QOF depression indicators (from April 2006).

Results

Incidence and prevalence

Between the 142 practices, 293,596 patients had recorded computer codes for depressive diagnoses or symptoms over the 10 year period. Incidence of first-ever depression codes fell from 11.9 (95% CI 11.7, 12.1) per 1000 person years at risk (PYAR) in 2003/2004 to 9.5 (9.3, 9.7) in 2008/2009, rising to 10.0 (9.8, 10.2) in 2012/1203. Prevalence of depression codes fell from 44.6 (95% CI 44.2, 45.0) per 1000 PYAR in 2003/2004 to 38.0 (37.7, 38.3) in 2008/2009, rising to 39.5 (39.2, 39.9) in 2012/2013. Prevalence increased in men but not women following the recession, more so in economically deprived areas, and was associated with increased unemployment in men.

Effects of NICE guidelines and the QOF on treatment rates

Sustained reductions were found in the proportion of first-ever depression episodes treated within 12 months, of 4.2% (95% C.I. 1.0%-7.3%) following introduction of the NICE guideline, and 4.4% (2.3%-6.5%) following introduction of the QOF. Following introduction of the QOF, GPs used more non-QOF-qualifying symptom or administrative codes rather than QOF-qualifying diagnostic codes for new episodes, such that fewer than 50% of patients with depressive symptoms were included in the denominator for the QOF. Treatment rates for QOF-qualifying episodes increased to around 90% while rates for non-QOF-qualifying episodes fell to around 60%. As a result, treatment rates for first-ever episodes fell from 72.5% (70.8%-74.1%) in Quarter 2 (Q2) 2003 to 61.0% (59.3%-62.7%) in Q1 2012, but treatment rates for recurrent episodes increased from 74.3% (72.8%-75.8%) to 77.8% (76.5%-79.1%), so overall rates remained around 70%.

Mean prescriptions per patient per year doubled from 2.06 (2.05-2.07) to 3.98 (3.97-3.99). The large majority (81%) of prescription items were prescribed to patients with intermittent or chronic depression over a five year period from diagnosis. Referral rates also increased over time, and referrals were often in addition to antidepressants, rather than an alternative.

Limitations

Clinical data recording is probably incomplete. Participating practices were relatively large and not representative across English regions.

Conclusions

Rates of recorded depression in English general practices were falling prior to the economic recession but increased again subsequently, among men, associated with increased unemployment. GPs responded to the QOF by switching from diagnostic to symptom codes, removing most depressed patients from the denominator for measuring GP performance in assessing depression. Rates of GP antidepressant treatment for patients with incident depression fell following introduction of NICE depression guidelines and the QOF, but treatment rates for recurrent depression increased. Prescription numbers increased due to longer treatment courses.

To impact on antidepressant prescribing rates, guidelines and performance indicators must address recurrent and long-term prescribing, rather than initial treatment decisions.

Plain English summary

Background

There is concern that the number of antidepressant prescriptions given out by GPs in England has been increasing every year since the early 1990s, and now more than 1 in 10 adults are taking them, a similar figure to other western countries. This is in spite of guidelines on the treatment of depression being published by the NHS watchdog NICE in December 2004, which advised GPs not to prescribe for mild depression. This advice was backed up by payments to GPs for measuring the severity of depression introduced through the quality and outcomes framework (QOF) pay for performance scheme in April 2006.

The reasons for this rise in prescriptions are not clear, but could include a rise in the number of people with depression following the economic recession of April 2008, due to unemployment and hardship. Alternatively, it could be that a greater proportion of people with depression are being given antidepressants, or that people are being treated for longer and having more prescriptions each. So we set out to look at the effects of the recession, NICE guidelines, and the QOF on rates of depression and antidepressant prescribing in general practice.

Findings

We looked at the anonymous medical records of patients seen with depression in more than 140 practices across England between 2003 and 2013 and used a method of analysing trends in the diagnosis and treatment of depression before and after the three events above, called time series analysis. We found rates of depression were falling prior to the recession but increased again after April 2008, among men, which was associated with increased unemployment. However, between 2008 and 2013, rates of depression increased by only 4% while antidepressant prescriptions increased by 48%. Rates of GP antidepressant treatment for patients with a new onset of depression fell following the introduction of both the NICE depression guidelines and the QOF, but treatment rates for repeated episodes of depression increased, so overall the rate of treatment stayed at around 70% of patients. Prescription numbers per year increased due to longer courses of antidepressant treatment, which doubled in duration on average over the 10 years.

Conclusions

If they are to do anything to reduce antidepressant prescribing rates, guidelines and performance indicators must advise GPs more about appropriate prescribing for people with repeated episodes and long-term depression, rather than just advising about initial treatment decisions when people attend with their first episode.

Dissemination

Published articles

1. Kendrick, Tony, Stuart, Beth, Newell, Colin, Geraghty, Adam W.A. and Moore, Michael (2015). Changes in rates of recorded depression in English primary care 2003-2013: time trend analyses of effects of the economic recession, and the GP contract quality outcomes framework (QOF). Journal of Affective Disorders, 180, 68-78. doi:10.1016/ j.jad.2015.03.040.
   http://www.sciencedirect.com/science/article/pii/S0165032715001792
2. Kendrick, Tony, Stuart, Beth, Newell, Colin, Geraghty, Adam W.A. and Moore, Michael (2015). Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003-2013. Journal of Affective Disorders, 186, 171-177. doi: 10.1016/ j.jad.2015.06.052.
   http://www.jad-journal.com/article/S0165-0327(15)30331-1/fulltext

Public involvement

We enlisted the help of Sue Collinson, a service user who is experienced in assisting with primary care research and was Chair of the Service Users in Research Advisory Board for the Mental Health Research Network. In addition, Ali Bowser of the Research Design Service facilitated a meeting with three service users including BP, a member of Depression Alliance in Southampton, and MB and DR from Portsmouth, who between them have histories of depression and treatment ranging from GP treatment to inpatient care. Tony Kendrick also gave a talk about the study to 18 people at a Southampton Depression Alliance meeting, and received useful feedback on the likely acceptability and utility of QOF symptom questionnaires to patients with depression. The service users contributed a PPI perspective on the emerging findings and their meaning to patients and the public.

Impact

Academic

Impact includes the two published papers above, a poster presentation of the findings by Tony Kendrick at the NAPCRG meeting in New York in November 2014, an oral presentation by Tony Kendrick at the SAPC meeting in Oxford in July 2015, and an invited plenary presentation by Tony Kendrick at the British Association for Behavioural and Cognitive Psychotherapies (BABCP) annual scientific meeting at the University of Warwick in July 2015.

Policy

Tony Kendrick is a member of the NICE Depression guideline update committee, and is feeding in the findings on the increased rates of prescribing for recurrent and long-term depression, seeking greater guidance on appropriate longer-term prescribing.

Practice

Tony Kendrick was interviewed by Pulse Magazine and the work was reported on the Pulse Today website in an article about rising consultations for depression, on 20th April 2015: http://www.pulsetoday.co.uk/clinical/mental-health/gp-consultations-for-depression-have-risen-since-financial-crisis-hit/20009748.article#.VbY2vbNViko

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 214)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.