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The rationale for such follow-up measurement is derived from the recognition that depression is often a chronic disease, yet treatment is often episodic and short-lived.
The change to the wording of this indicator, from 5 – 12 weeks to 4 – 12 weeks, recognises that in clinical practice most prescriptions or follow-up appointments are given for one, two or four weeks at this stage in the illness.
If treatment with antidepressants is initiated, patients should be followed-up regularly for several months. The NICE clinical guideline 90 recommends that ‘for people started on antidepressants who are not considered to be at increased risk of suicide, normally see them after two weeks. See them regularly thereafter, for example at intervals of two to four weeks in the first three months and then at longer intervals if the response is good. ’Early cessation of treatment is associated with a greater risk of relapse.
The guideline also suggests that a person who has benefited from taking an antidepressant should continue medication for at least six months after remission of an episode of depression. However, one study showed that only up to one-third of patients prescribed antidepressants were still receiving medication at four to six months.
Analysis of the GP Research Database for the years 1993 to 2005 has confirmed this finding: more than half of patients treated with antidepressants for a new diagnosis of depression during those years received prescriptions for only one or two months of treatment, and that this pattern had not changed over the 13 year period.
If drug treatment is not started after the initial diagnosis, patients should in any case be reassessed to see whether their symptoms have resolved or worsened to the point where treatment becomes advisable.
Recent research into the use of severity measures has shown that patients whose GPs used the measures for follow-up in addition to initial assessment valued having repeated scores to help monitor their progress and assess the effectiveness of treatment115. Most of the GPs interviewed for the same study believed that there was value in repeating the score as a way of monitoring patients’ progress.
The nine item Patient Health Questionnaire (PHQ-9) has been shown to be a responsive and reliable measure for gauging response to treatment in individual patient care.
Kates
and Mach, Canadian Journal of Psychiatry 2007; 52(2): 77–85
Donoghue et al, Acta Psychiatrica Scandinavica 2000; 101: (suppl 403) 57-61
Kendrick et al, Society for Academic Primary Care Annual Scientific Meeting,
London, July 2007
Dowrick et
al, British Medical Journal, in press
Lowe
et al, Medical Care 2004; 42: 1194-1201
The practice reports the percentage of patients with a new diagnosis of depression whose notes record that they have had an assessment of severity 4 – 12 weeks (inclusive) after the initial recording of the assessment of severity related to a new diagnosis of depression. New diagnoses are those which have been made between the preceding 1 April to 31 March. To be included in the numerator for this indicator a patient needs to have had both an initial and a subsequent severity assessment.
Practices also report in each patient record which of the three assessment tools they used.
Verification – may require randomly selecting a number of case records of patients with a new diagnosis of depression to verify that their notes record a follow-up assessment of severity 4 – 12 weeks after the initial assessment of severity.
Timeframe
The DEP3 indicator was introduced to QOF in April 2009 and for that reason,
the first line of the supporting business rules excluded patients newly diagnosed
before April 2009. The business rules for DEP3, like DEP2 (now DEP4), were structured
to take account of the crossyear issue which ensures fair and consistent payment
to practices and good patient care. The business rules therefore look back 68
weeks to address this issue.
DEP3 was reviewed and updated through the NICE process and replaced by DEP5 in April 2011. The above explanation for the timeframe and the business rules still applies.
Prepared By Jean Keenan