Can mortality monitoring in general practice be made to work?

Routine monitoring of UK GPs’ mortality rates has been recommended by the Shipman Inquiry, and is likely to be implemented soon. In this Journal, Mohammed et al are to be applauded for their rigorous attempt to address the potential problems of such monitoring. In particular, they describe the application of structured investigation to practices with unexpectedly high or low mortality rates that is a potential model for any national system. Ultimately though, many uncertainties remain. Crucially, what mortality monitoring is intended to achieve needs to be clearly articulated, and reflected in monitoring system design. The two purposes usually identified are, first to deter or detect indications for antidepressants; the unprecedented publicity given to the serotonin-selective reuptake inhibitors, and the promotion of these drugs by the pharmaceutical companies; and perhaps, a greater openness about depression and an accompanying willingness to seek help. However, the fact that help has often come in the form of antidepressants may not be a response to the patients’ agenda: an opinion poll among lay people in 1996 found that 85% believed counselling to be effective but were against antidepressants, and that 78% of those questioned regarded antidepressants as addictive. GPs may feel they have little else to offer their unhappy patients. All the evidence suggests that we do not need to identify more cases of depression in primary care, but rather, increase the effectiveness of our management of those that have been identified. Kendrick et al found that although GPs prescribed antidepressants on the perceived severity of the depression, their ratings did not agree well with a validated screening instrument, and their assessment of patients’ attitudes to treatment were only moderately related to patients’ selfreports. In other words, we may not be delivering antidepressants to those who are most likely to benefit from them, and our assessment of our patients’ attitudes to treatment are not as accurate or sensitive as we would wish. This means that we need to look more closely at the diagnostic criteria that GPs use to inform their management decisions, at who is being prescribed antidepressants, and what is happening to them. The multifaceted interventions described by Weingarten et al include provider and patient education and feedback, and structured follow-up. This model of chronic disease management for asthma and diabetes is now a part of primary care. We cannot afford to ignore the evidence that this approach may be at least as effective in depression.