Killing the Quality and Outcomes Framework won’t decrease prescribing for depression

Gillam and Steel imply that the Quality and Outcomes Framework (QOF) has contributed to increased prescribing of antidepressants.1 Where is the evidence? Prescriptions of selective serotonin reuptake inhibitors have risen steadily since their introduction in several countries,2 only one of which has a QOF.

We found that prescription increased due to small increments in the proportion of patients put on long term treatment over time, rather than increases in diagnoses (which fell from 2000 onwards) or the proportion of cases treated.2 Consultation rates for depression continued to fall after QOF indicators were introduced,2 3 until the economic crash in 2008, after which they rose again.3 Changes in diagnosis and prescribing do not seem to be related to the QOF.

Incentivising the use of symptom questionnaires at diagnosis was aimed at improving GP assessment of severity, which is based on clinical impressions at one visit and leads to poor targeting of treatment.4 GPs often prescribe at first presentation, but a recent meta-analysis suggests that repeated assessment of possible depression improves diagnosis,5 and questionnaires were meant to encourage more reflection before prescribing.

Gillam and Steel fail to mention that the National Institute for Health and Care Excellence review of depression indicators found some benefit from measuring symptoms, but it was judged insufficient to justify continued incentivisation of questionnaires. Further research is needed. They could also have mentioned that the QOF guidance stresses the importance of family and personal history, associated disability, and patient preference in assessing treatment need, rather than relying on symptom counts.

I don’t think killing the QOF would reverse increased prescribing for depression. Isn’t polypharmacy the medical response to multimorbidity in an increasingly aged population, regardless of the QOF?