1. Home>
2. Specialties>
3. Psychiatry>
4. Summary and Comment

Depression-Rating Scales in Primary Care: Time for a Change?

Some physicians are reluctant to employ these, although patients appreciate them.

Although investigators have advocated "measurement-based care" for depression, clinicians continue to resist the routine use of rating scales. In two reports, a research team recently examined the use of such scales in U.K. general practices, which receive incentives to use them.

In a qualitative study, researchers interviewed 34 general practitioners and 24 patients. Patients had generally positive attitudes toward the scales, seeing them as helpful adjuncts to medical judgment and their use as an indication that their depressive symptoms were taken seriously. Physicians felt that scales were inferior to clinical judgment, possibly reducing the holistic, "human" element of their interactions.

The other study examined physician behavior regarding 1658 patients given the nine-item Patient Health Questionnaire (PHQ-9) and 584 given the Hospital Anxiety and Depression Scale (HADS). Greater depression severity on either scale was associated with increased likelihood of antidepressant prescriptions and follow-up appointments. However, PHQ-9 and HADS identified very different proportions of patients as moderately-to-severely depressed (83.5% vs. 55.6%), although physicians treated similar proportions of patients with antidepressants, suggesting that physicians did not rely heavily on the scale cutoffs to make their decisions. Regardless of scale scores, older patients and those with medical illness had lower antidepressant prescription rates.

Comment: Undertreatment of some patient subgroups might be consistent with the preference that physicians have for their own clinical judgment. The studies highlight the most important barrier to using psychiatric rating scales: Clinicians think that the scales are inferior. Psychiatrists, more intensively trained and skilled than generalists, might be even more likely to see scale use as superfluous.

Paradoxically, patients seem to like the scales, which might contribute to patient-centered care. The studies ignore the most important application of these scales: as tools to assess treatment response and to guide subsequent treatment decisions. Certainly, much more than a scale score is required to skillfully assess and treat a given patient. However, the finding that depression might be undertreated in medically ill patients shows that clinical decision making alone is not always optimal, either. Given these patients’ positive reactions to rating scales, why shouldn’t psychiatrists routinely employ a simple one when assessing and treating their depressed patients?

— Peter Roy-Byrne, MD

Published in Journal Watch Psychiatry April 6, 2009

Citation(s):

Dowrick C et al. Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: Qualitative study. BMJ 2009 Mar 19; 338:b663. (http://dx.doi.org/10.1136/bmj.b663)

• Original article (Subscription may be required)
• Medline abstract (Free)

Kendrick T et al. Management of depression in UK general practice in relation to scores on depression severity questionnaires: Analysis of medical record data. BMJ 2009 Mar 19; 338:b750. (http://dx.doi.org/10.1136/bmj.b750)

• Original article (Subscription may be required)
• Medline abstract (Free)