I have just been asked by a colleague for more information on my support for the use of the PHQ-9 depression rating scale in General Practice. Many feel it interferes with the flow of the GP consultation and reduces it to a tick-box exercise. This has been exacerbated by the GMS contract we work to that incentivises its use at diagnosis and at 5-12 weeks of treatment. Here is my response: –
- The PHQ has become a core part of that process based on the fact that what we call depression is really just a common pattern of patient response that can be self sustaining repetetive and a truly miserable experience.
- The questionaire is handily based on the ICD-10 criteria for the diagnosis and to make the diagnosis it would be reasonable to ask about all these symtoms in any case
- The responses can be inputted to the 5 areas sheet that forms a shared understanding with the patient on the problem
- I agree with the evidence that we should only be prescribing at the most severe end of the spectrum and it is therefore obvious we need to assess the severity in an objective way
- My patients seem to take comfort from being able to “peer reference” their symptoms, in a manner that John Sassal would concurr with in “A Fortunate Man”
- It appears to have validity to assess a patients progress to recovery, a static score is a reason to stop and take stock whilst an improvement is an objective reason to celebrate.
The 5 areas is the next part of the jigsaw. Interpreting the patients story with this tool helps me to ensure my approach is comprehensive, demonstrates the fact that I have heard and understood the situation and leads on to a discussion on what approach would be best to pursue in their case. The “situational” box is explained as something the patient may not have a lot of control over but may lend itself to a problem solving approach. The emotional area is where our antidepressants’s work and the cognitive and behavioural areas lend themselves to a discussion on the role of talking therapies. I also will try to include advice on the “building blocks of a healthy life” and a discussion of risk reduction if appropriate.
Many people think this is un-realistic in a 15minute consultation and of course they are right. You can however acheive it in closer to 20 mins and it works for me as a way of structuring my approach to work as effectivly as possible.
The tool is not perfect but does have a role. Introducing it as an empirical measure of quality is clearly missguided. What we really need is a way to measure the warm glow of satisfaction on the occasions when we realise we have made a difference…
A recent letter from Tony Kendrick and Paul Little in the BJGP supports this blog (3). Unfortunately I fear the QoF has been it’s downfall and PHQ will not recover. This concerns me. GPs should be assessing severity if we are to advise on the correct treatment and we do need to monitor response. PHQ, despite its falliabilities can do both.
2. “Improving consultation skills using cognitive-behavioural therapy: a new ‘cognitive-behavioural model’ for general practice” David, Lee; Freeman, George. Education for Primary Care, Volume 17, Number 5, September 2006 , pp. 443-452(10)
3. Use of PHQ-9 scores to guide treatment decisions in primary care: Kendrick, Tony; Little, Paul. British Journal of General Practice, Volume 63, Number 613, August 2013 , pp. 405-406(2)