Table 3.

Quality indicators

Indicator	Source(s)	Description and/or numerator, denominator of indicator
Structure indicators
Structural domain
Governance and accountability	Shield, 2003 Worrall, 2002	Description: Written guidelines are in place to ensure that, where services are not provided locally, GPs can refer patients outside their locality (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: Specialist services are based on locally agreed written service plans and agreements which include the range, quality and volume of mental health services, including depression (‘yes/no’ response).
	Shield, 2003	Description: There is an agreed definition of depressive disorders which is explicit and standard within the practice (‘yes/no’ response).
	Shield, 2003	Description: There is a written complaints procedure which is prominently displayed regarding the provided care (‘yes/no’ response).
	Worrall, 2002	Description: There is a clear referral and feedback procedure for the practice counsellor (‘yes/no’ response).
Resources and technical provision	Shield, 2003 Worrall, 2002	Description: There is a demonstrable commitment to promote continuous professional and practice development in primary care (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: Practices are offered protected time for GPs and nurses to attend appropriate training courses (‘yes/no’ response).
Practice integration	Shield, 2003 Worrall, 2002	Description: There is a range of collaborative initiatives in place with other key agencies demonstrating effective partnerships (‘yes/no’ response).
Performance domain
Access to care	Shield, 2003 Worrall, 2002	Description: Patients are able to make a routine appointment to see a general practitioner within 2 days (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: A member of the primary health care team is available as a point of contact for all patients to talk to in an emergency; clear written practice protocols are in place for obtaining specialist help in an emergency/crisis situation (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: There is equity of access to talking treatments regardless of ethnic origin, age, place of residence, socioeconomic status, and sex (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: There is good access to integrated and community-based mental health services out of hours, as well as locally agreed written standards and protocols for the delivery of out of hours care for mental health problems (‘yes/no’ response).
	Shield, 2003	Description: There is evidence of monitoring to ensure that out of hours standards are met (‘yes/no’ response).
Organizational structure and dynamics	Shield, 2003	Description: There are agreed written protocols and guidelines, based on best available evidence, for prescribing and monitoring psychotropic medication (‘yes/no’ response).
	Shield, 2003 Worrall, 2002	Description: Confidential discussions take place in private. There is an appropriate (i.e. private, quiet, relatively non-clinical) room for counselling/visiting mental health staff (‘yes/no’ response).
	Shield, 2003	Description: The confidentiality of medical records is protected and ensured at all times; where practicable, patient consent is sought before giving information to carers (‘yes/no’ response).
Process indicators
Patient/caregiver education	Shield, 2003 CMHA, 2012 Worrall, 2002	Numerator: Number of patients from the denominator who received patient education at least once during the measurement period regarding depression, depression treatment, prescribed medication and coping strategies Denominator: Number of adult patients with a diagnosis of major depression or dysthymia during the measurement period.
Patient-provider relationship	Shield, 2003 Worrall, 2002	Description: Patients with depression are treated as individuals with individual needs and not as a ‘diagnosis of depression’. Treatment plans are individually tailored for each patient.
	Shield, 2003 Worrall, 2002	Description: Staff treats all patients with depression registered with the practice with respect, courtesy and consideration irrespective of age, sex, religious/cultural beliefs or diagnosis.
	Shield, 2003	Description: Staff are aware that patients with depression may be concerned about feelings of stigmatization and are treated in a way to minimize these feelings.
	Shield, 2003 Worrall, 2002	Description: Management time is available to support and lead change in service development; patients are not made to feel that they are wasting health professional’s time.
	Shield, 2003 Worrall, 2002	Description: Staff are aware of the potential impact of a depressive disorders on patient behaviour.
	Worrall, 2002	Description: Patient’s views about their condition are explicitly sought to help treatment adherence.
Shared decision-making	Shield, 2003 Worrall, 2002	Description: Patients are as fully involved as practicable in the formulation and delivery of their care and in any decisions about referral; where practicable, patients are informed of the reasons for referral to specialists or other professionals.
Up-to-date medical records	Shield, 2003	Description: Details of currently prescribed maintenance drugs are prominently recorded in the medical record. Medical records, including computerized records, are up to date and summarized.
Medication review	Shield, 2003	Numerator: Number of patients from the denominator who were on repeat maintenance drugs and offered regular reviews of their medication including monitoring for possible side effects and interactions with other drugs. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia during the measurement period.
Depression comprehensive assessment/diagnosis	Shield, 2003 Worrall, 2002	Description: Physical symptoms in patients with depression are taken seriously and not automatically considered as psychosomatic; assessment takes into account language barriers, the needs of people with disabilities, ethnic, cultural and religious preferences.
	VHA/DOD, 2000 Hermann, 2004	Numerator: Number of patients from the denominator with a diagnosis of major depression or dysthymia during the previous 12 months. Denominator: Number of adult patients seen in a general medicine, primary care, women’s or mental health primary care clinic, during the previous 12 months.
Screening for and recognizing depression	Nakajima, 2007 Hermann, 2004 VHA/DOD, 2000 Shield, 2003 (NQF-endorsed)	Numerator: Number of patients from the denominator who were screened for depression using an age appropriate standardized tool and had follow-up plan documented, during the initial primary care evaluation and annually. Denominator: Number of adult patients seen in a general medicine, primary care, women’s or mental health primary care clinic, during the previous 12 months.
Documenting depression symptoms	Nakajima, 2007 Shield, 2003	Numerator: Number of patients from the denominator who have in the medical record at least three of the nine DSM-IV target symptoms for major depression were documented within 2 weeks of diagnosis. Denominator: Number of adult patients newly diagnosed with major depression or dysthymia during the measurement period.
Suicidal ideation	Nakajima, 2007 Hermann, 2004 Shield, 2003 (NQF-endorsed)	Numerator: Number of patients from the denominator who were assessed for suicidal ideation at initial evaluation. Denominator: Number of adult patients newly diagnosed with major depression or dysthymia during the measurement period.
Evaluate for comorbid conditions	Nakajima, 2007	Numerator: Number of patients from the denominator who had been evaluated for substance dependence or abuse for men, and hypothyroidism for women, within 1 month or in the prior 3 months. Denominator: Number of adult patients who were diagnosed with a new episode of major depression or dysthymia during the measurement period.
Initiating depression treatment	Nakajima, 2007 Shield, 2003	Numerator: Number of patients from the denominator who were offered antidepressant treatment, psychotherapy or electroconvulsive therapy within 2 weeks after diagnosis. Denominator: Number of adult patients who diagnosed with a new episode of major depression or dysthymia during the measurement period.
Treatment/monitoring	Shield, 2003	Description: No drug is prescribed unless the health professional understands the potential efficacy and side effects; prescribing for depression is based on up to date evidence and, where available, local management protocols.
	Shield, 2003	Numerator: Number of patients from the denominator who were not responding to first line drug treatment at the therapeutic dosage and were asked about adherence. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia during the measurement period.
	Shield, 2003	Numerator: Number of patients from the denominator who were experiencing difficulties undertaking withdrawal from medication and were offered referral to a mental health worker. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia during the measurement period.
Antidepressant choice	Nakajima, 2007 (‘Negative indicator’)	Numerator: Number of patients from the denominator who were prescribed antidepressants using tertiary amine tricyclics, MAOIs (unless atypical depression is present), benzodiazepines or stimulants (except methylphenidate) as first- or second-line therapy. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia during the measurement period.
	Hermann, 2006 Hermann, 2004 (‘Negative indicator’)	Numerator: Number of patients from the denominator who were prescribed anticholinergic antidepressants as first- or second-line therapy. Denominator: Number of patients aged 65 and older with a diagnosis of major depression or dysthymia during the measurement period.
	Shield, 2003	Description: Choice of medication is based on individual patient factors including the desirability of sedation, previous response to a drug treatment including adverse reactions, co-morbid psychiatric or medical conditions, concurrent drug treatment and relative risk of medication in overdose.
Interactions with monoamine oxidase inhibitor (MAOI)	Nakajima, 2007	Description: If a patient with a diagnosis of major depression or dysthymia is taking an selective serotonin reuptake inhibitor (SSRI), then an MAOI should not be used for at least 2 weeks after termination of the SSRI and vice versa.
Continuing antidepressant medication treatment in acute phase	Hermann, 2004 Hermann, 2006 VHA/DOD, 2000 (NQF-endorsed)	Numerator: Number of patients from the denominator who responded to antidepressant medication and remained on an antidepressant treatment for at least 3 months (12 weeks). Denominator: Number of adult patients who diagnosed with a new episode of depression or dysthymia during the measurement period.
	Nakajima, 2007 CMHA, 2012	Numerator: Number of patients from the denominator who had no meaningful symptom response after 6 weeks of psychotherapy treatment (without medication) and for whom the medication treatment has been initiated, a patients was referred to a psychiatrist by the 8th week of depression treatment. Denominator: Number of adult patients who diagnosed with a new episode of major depression or dysthymia, during the measurement period.
	Nakajima, 2007 CMHA, 2012	Numerator: Number of patients from the denominator who had no meaningful symptom response after 6 weeks of drug treatment and the drug dose was optimized or changed, or a patient was referred to a psychiatrist by the 8th week of depression treatment. Denominator: Number of adult patients who diagnosed with a new episode of major depression or dysthymia, during the measurement period.
Continuing depression therapy in continuation phase	Nakajima, 2007 Hermann, 2006 Hermann, 2004 (NQF-endorsed)	Numerator: Number of patients from the denominator who responded to antidepressant medication, remained on the drug at the same dose for at least 6 months. Denominator: Number of adult patients newly diagnosed with and treated for major depression or dysthymia, during the measurement period.
	Nakajima, 2007 CMHA, 2012	Numerator: Number of patients from the denominator who experienced three or more episodes of depression and received maintenance antidepressant medication with the same type and dose of medication for at least 24 months, with at least four office or telephone visits for depression during that period. Denominator: Number of adult patients newly diagnosed with and treated for major depression or dysthymia during the measurement period.
Effectiveness	VHA/DOD, 2000 CMHA, 2012	Numerator: Number of patients from the denominator who had a systematic symptom assessment at 12 weeks following diagnosis, or if in remission by week 12, then a systematic symptom assessment is performed at the time of remission. Denominator: Number of adult patients newly diagnosed with and treated for major depression or dysthymia during a 12-month period.
Psychotic depression treatment	Nakajima, 2007 Hermann, 2004	Numerator: Number of patients from the denominator who had been referred to a psychiatrist or received treatment with a combination of an antidepressant and an antipsychotic. Denominator: Number of adult patients with a diagnosis of major depression with psychotic features, during the measurement period.
Visits during acute phase treatment of depression	Hermann, 2006 Hermann, 2004	Numerator: Number of patients from the denominator who received at least three medication visits or at least eight psychotherapy visits in a 12-week period. Denominator: Number of adult patients who diagnosed with a new episode of major depression or dysthymia, during the measurement period.
Depression follow-up	Shield, 2003 CMHA, 2012	Description: Patients with severe depression are offered regular appointments to monitor and follow up treatment, symptoms, side effects and adherence.
Outcome indicators
Depression remission at 6 months	National Quality Measures Clearinghouse (NQMC) (NQF-endorsed)	Numerator: Number of patients from the denominator with an initial PHQ-9 score greater than nine who achieve remission at 6 months as demonstrated by a 6-month (±30 days) PHQ-9 score of less than five. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine, during the measurement period.
Depression re-emission at 12 months	National Quality Measures Clearinghouse (NQMC) (NQF-endorsed)	Numerator: Number of patients from the denominator with an initial PHQ-9 score greater than nine who achieve remission at 12 months as demonstrated by a 12-month (±30 days) PHQ-9 score of less than five. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine, during the measurement period.
Depression response at 6-month progress towards remission	National Quality Measures Clearinghouse (NQMC) (NQF-endorsed)	Numerator: Number of patients from the denominator with an initial PHQ-9 score greater than nine who achieve a response at 6 months as demonstrated by a 6-month (±30 days) PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine, during the measurement period.
Depression response at 12-month progress towards remission	National Quality Measures Clearinghouse (NQMC) (NQF-endorsed)	Numerator: Number of patients from the denominator with an initial PHQ-9 score greater than nine who achieve a response at 12 months as demonstrated by a 12-month (±30 days) PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score. Denominator: Number of adult patients with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine.