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Case identification and formal assessmentidentify different anxiety disorders? Should an avoidance question be addedto improve case identification? (See Appendix 11 for further details.)5.3 FORMAL ASSESSMENT OF THE NATURE AND SEVERITYOF COMMON MENTAL HEALTH DISORDERS5.3.1 IntroductionAssessment of depressionSince April 2006, the UK GP contract QOF has incentivised GPs to measure the severityof depression at the outset of treatment in all diagnosed cases using validated questionnaires(British Medical Association & NHS Employers, 2006). The aim is to improvethe targeting of treatment of diagnosed cases, particularly antidepressant prescribing, tothose with moderate to severe depression, in line with the NICE guidelines.The three recommended severity measures are the PHQ-9 (Kroenke et al., 2001),the depression subscale of the HADS (Wilkinson & Barczak, 1988; Zigmond &Snaith, 1983) and the BDI-II (Beck, 1996; Arnau et al., 2001). In general, a higherscore on these measures indicates greater severity requiring greater intervention.However, the QOF guidance, again in line with the NICE guidance, also recommendsthat clinicians consider the degree of associated disability, previous history andpatient preference when assessing the need for treatment rather than relyingcompletely on the questionnaire score (British Medical Association & NHSEmployers, 2006).Data on the completion of the measures from the NHS Information Centre showedthat they were used in a mean of 91% of diagnosed cases across all UK practices in2007–08, up from 81% in 2006–07 (NHS Information Centre, 2008). The accuracyand utility of the measures has been questioned by GPs, however, suggesting thateven if they use the questionnaires they may ignore the scores when deciding abouttreatment or referral (Jeffries, 2006).Analysis of anonymous record data showed that prescriptions for antidepressantsand referrals for psychiatric, psychological or social care were significantly associatedwith higher severity measure scores. However, overall rates of treatment andreferral were very similar for service users assessed with different questionnairemeasures, despite the fact that the different measures categorised differing proportionsof service users as having major depression. These results suggested that practitioners(as would be expected given that factors such as associated functionalimpairment, duration of symptoms, patient preference and previous treatment) do notdecide on drug treatment or referral on the basis of severity questionnaire scores alone(Kendrick et al., 2009).Furthermore, qualitative interviews with GPs participating in the same study(Kendrick et al., 2009) showed that they were generally cautious about the validityand utility of identification tools, and sceptical about the motives for their introduction.The practitioners considered their practical wisdom and clinical judgement to bemore important than identification tools and were concerned that the latter reduced119
Case identification and formal assessmentthe ‘human element’ of the consultation. Some even avoided coding patients’ symptomsas depression in favour of other diagnostic labels, to avoid completing the severitymeasures and to save time in the consultation (Dowrick et al., 2009b). Thisemphasises the importance of ensuring that the introduction of new diagnostic techniquesis done in such a way that it fits with existing practice and systems of care, andtakes into account possible developmental or training needs of the practitionersexpected to use the techniques.Moreover, the recent Depression guidelines (NICE, 2009a and 2009b) haveattempted to move away from focusing on any one aspect of the disorder, such assymptom severity, which can have the unwanted effect of leading to an oversimplifiedcategorisation of depression, and influencing treatment choice, on a singlefactor such as symptom count. An important consideration was to provide a strongsteer away from only using symptom counting to make the diagnosis of depressionand by extension to emphasise that the use of symptom severity rating scales by themselvesshould not be used to make a diagnosis, although they can be important as anaid in assessing severity and response to treatment.To make a diagnosis of depression requires assessment of three linked but separatefactors: (i) severity, (ii) duration and (iii) impairment. The diagnosis of ‘major depression’is based not only on the severity of depression, but also on its persistence, thepresence of other symptoms and the degree of functional and social impairment.Individual symptoms should be assessed for severity and impact on function, and bepresent for most of every day. Service users who fulfil criteria for major depression ofrecent onset may improve spontaneously, and for those with mild depression or otherswhose symptom trajectory is showing improvement, it may be appropriate to ask theservice user to come back for a review of symptoms in 1 to 2 weeks because a proportionwill respond within a few weeks following some reassurance, psychoeducationand support from primary care staff without recourse to a formal intervention.It is also important to emphasise that there appears to be no hard-and-fast ‘cut off’between ‘clinically significant’ and ‘normal’ degrees of depression; the greater theseverity of depression, the greater the morbidity and adverse consequences (Kessing,2007; Lewinsohn et al., 2000). When taken together with other aspects that need to beconsidered, such as duration, stage of illness and treatment history, there are considerablechallenges when attempting to classify depression into simple categories.In recent years there has been a greater recognition of the need to consider depressionthat is ‘subthreshold’, that is, depression that does not meet the full criteria for adepressive/major depressive episode. Persistent subthreshold depressive symptoms –the preferred term in the Depression guidelines (NICE, 2009a and 2009b) – can causeconsiderable morbidity, and human and economic costs, and are more common inthose with a history of major depression as well as being a risk factor for future majordepression (Rowe & Rapaport, 2006).Diagnosis using the three aspects listed above (severity, duration and impairment)provides a partial characterisation of the individual experience of depression.Depressed people vary in the pattern of symptoms they experience, their familyhistory, personalities, pre-morbid difficulties (for example, sexual abuse), psychologicalmindedness, and current relational and social problems – all of which may120
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Commonmental healthdisordersTHE NIC
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© The British Psychological Societ
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Contents6 FURTHER ASSESSMENT OF RIS
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Guideline development group members
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Preface1 PREFACEThis guideline has
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Prefacecollaborative manner using t
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PrefaceThe experience of people wit
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Common mental health disorders2.2 T
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Common mental health disordersto ho
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Common mental health disordersManua
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Common mental health disordershighe
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Common mental health disordersNegat
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Common mental health disorderscours
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Common mental health disordersover
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Common mental health disorders2.2.6
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Common mental health disordersTable
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Common mental health disorders1996)
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Common mental health disordersSumma
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Common mental health disordersTable
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Common mental health disordersappli
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Common mental health disorderspatie
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Methods used to develop this guidel
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Access to healthcare4. ACCESS TO HE
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Access to healthcareunder the Menta
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Access to healthcare4.2.3 Studies c
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Access to healthcareIndividual-leve
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Access to healthcareJUNG2003 review
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Further assessment of risk and need
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Summary of recommendations8.1.1.6 S
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Summary of recommendationsFigure 12
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Summary of recommendations●Genera
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Summary of recommendations8.4 STEPS
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Summary of recommendations●●a g
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Summary of recommendationsDiscuss w
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Summary of recommendationsinclude p
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Appendices9 APPENDICESAppendix 1: S
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Appendix 1of a depressive disorder
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Appendix 1b) Assessment of anxiety
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Appendix 2APPENDIX 2:DECLARATIONS O
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Appendix 2Mr Mike BessantEmployment
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Appendix 2Personal non-pecuniary in
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Appendix 2Actions takenMr Rupert Su
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Appendix 2Personal family interestN
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Appendix 3APPENDIX 3:STAKEHOLDERS A
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Appendix 4ClinicalpopulationPeople
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Appendix 4Case identificationNo. Pr
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Appendix 5APPENDIX 5:REVIEW PROTOCO
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Appendix 7APPENDIX 7:METHODOLOGY CH
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Appendix 9APPENDIX 9:METHODOLOGY CH
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Appendix 92.10 Are all important pa
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Appendix 9case also excludes costs
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Appendix 9For consistency, the EQ-5
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Appendix 9Answer ‘yes’ if the a
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Appendix 9Answer ‘yes’ if the e
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Appendix 9Answer ‘yes’ if appro
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Appendix 10APPENDIX 10: EVIDENCE TA
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Appendix 11APPENDIX 11:HIGH PRIORIT
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Appendix 11discussion of options bu
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Appendix 13APPENDIX 13:GENERALIZED
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ReferencesAndlin-Sobocki, P., Jöns
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ReferencesBower, P., Gilbody, S., R
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ReferencesCooper, S., Smiley, E., M
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ReferencesEhlers A., Gene-Cos N. &
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ReferencesGiles, D. E., Jarrett, R.
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ReferencesHorowitz, M. J., Wilner,
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ReferencesKnapp, M. & Ilson, S. (20
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ReferencesMarks, J., Goldberg, D. P
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ReferencesNCCMH (forthcoming) Self-
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ReferencesOzer, E. J., Best, S. R.,
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ReferencesSartorius, N. (2002) Eine
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ReferencesTiemens, B. G., Ormel, J.
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ReferencesWilkinson, M. J. B. & Bar
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Glossarybeliefs and interpretations
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Glossaryto learn to become more awa
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Abbreviations12 ABBREVIATIONSADDADS
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AbbreviationsOASISOCDONSORPHQ (-A,
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