Some years ago, when I worked in an urban practice where mild to moderate depression was far more common than it is in my island retreat, I went through a phase of using the Hospital Anxiety and Depression Scale to assess my patients. I can't remember whether this was as a result of attending a training session — the Defeat Depression campaign was in top gear at the time — or from reading an enthusiastic article on the subject, but it must have seemed a good idea at the time. By totting up the ticks I was able to see that not only was the person in front of me pretty depressed, let's say, but also rather anxious; or sometimes jolly anxious but not really very depressed. The exercise seemed to add a touch of objectivity to what had hitherto seemed a rather intuitive and subjective exercise in diagnosis and assessment.
After a few months I abandoned the use of the HAD tool. It had become a distraction, and I found that it rarely if ever influenced my management. The latter remained — and remains to this day — an eclectic mix of attentive listening, some problem-solving suggestions, referral for counselling or psychological therapy, and the use of medication. I often use doses of antidepressants that the experts insist are sub-therapeutic, and remain convinced that this can be a useful practice.
Now, to my dismay, I discover that the latest revision of the Quality and Outcomes Framework (QOF) is decreeing that the HAD scale, or one of two other assessment tools (the Patient Health Questionnaire (PHQ-9), or the Beck Depression Inventory Second Edition (BDI-II)) is to become the litmus test of my competence in managing depression. I think this is outrageous.
The published rationale behind the QOF indicators for depression makes reference to various studies, meta-analyses, NICE guidelines and, tellingly, guidelines from the British Association for Psychopharmacology. The evidence quoted is generally of Grade B or C, and, although I am not motivated enough to read or re-read the studies cited, I am very skeptical that there exists any high grade evidence to show, specifically, that regular use of any or all of these rating scales has a consistent beneficial effect on long-term outcome in depression treated in primary care. Of course the tools have their place, most obviously in research, but also for those GPs who feel happier with this kind of approach than with a more interpersonal, intuitive one. In the same way, there may for all I know be many GPs who take great interest in whether their fat patients have a BMI of 29.9 rather than 30.1. For my part, whether I'm dealing with depression or obesity (or both) I'm more interested in the life history and situation of the person in front of me than in the numbers.
Quite apart from the question of the predictive validity of such rating scales I am worried by the way that they reinforce the concretized, medical model of depression. There are other ways of approaching the subject, and Christopher Dowrick1 presents just such a thoughtful and provocative alternative, in his words, ‘… focusing attention not on particular symptoms and thresholds for diagnosing depression but instead on the many and varied people who are feeling distressed when they come to see their doctors, whose experiences can be understood within the thought “something bad is happening to me”.’ I recommend his book to anyone who feels uncomfortable with the relentless pressure to diagnose and treat depression as though it were a clear-cut disease entity with a predictable natural history and cure.
For my part, I hope I shall have the courage to spurn the pounds that come with the gaining of these particular points. But make no mistake: this and other revisions and additions to the QOF of the not-so-new GP contract demonstrate just how effective a Trojan horse it has proved in its aim of subverting general practice to the ends of the Department of Health, the pharmaceutical industry, and their academic comrades-in-arms. From a profession distinguished by its variety of independent practitioners, all bringing their own ideas and approaches to bear on their daily work, we are being turned into a homogeneous regiment of government agents, bribed and browbeaten into toeing the party line. How does that make you feel? Depressed? Anxious? Completed HAD scales to the Editor please.