Determinants of adherence to recommendations for depressed elderly patients in primary care: A multi-methods study

Abstract

Objective. It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression. Design and setting. Group and individual interviews and a survey were conducted in Norway. Method. Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants. Participants. Physicians and nurses from primary and specialist care, psychologists, researchers, and patients. Main outcome measures. Determinants of adherence to recommendations for depressed elderly patients in primary care. Results. A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners’ time constraints, the low prioritization of elderly patients with depression, and the patients’ or relatives’ wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions. Implications. The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.

Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies

“…Studies reflected both publicly funded and insurance-based systems. Qualitative data were mostly collected via interviews 18,19,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] and/or focus groups 34,39,[43][44][45][46] with two ethnographic studies, 47,48 one conference and nominal group technique, 49 one mixedmethods survey, 50 and one multiple case study. 51 Two-thirds of studies were of good/ very good overall quality (Table 1); most met the checklist criteria and the vast majority were well reported ( Table 2).…”

“…Most HCPs were sampled from primary and community healthcare (for example GPs, practice nurses, or home health nurses), 18,19,28,29,31,32,34,[39][40][41][42]44,47,48,50 with six studies sampling both primary and secondary care professionals, 27,35,45,46,49,51 and a small number studying HCPs in care settings. 33,38,43 One study sampled community psychiatric nurses (CPNs) 36 and one included practice counsellors.…”

“…This was further complicated by widespread views from GPs and nurses that addressing depression in some way was essential: 18,19,27,31,32,[39][40][41]43 'GPs tended to acknowledge social and emotional causes that required non-drug interventions they could not always provide and, although antidepressants offered a solution to some patient's problems, there appeared to be sense of unease about prescribing a medical intervention for a social cause.' 31 'Social solutions' 41 (for example, day centres) were considered the mostappropriate approach; 19,34,35,39,41,44,45 however, although these addressed the perceived cause, they were not always regarded as effective, leading to therapeutic pessimism: ' ..."a man who is clearly isolated ... taking him out to the day centre, that'lI be good for him won't it, sit in a room with other demented, depressed people, and make your mood lift. It's not gonna happen."…”

“…37 Decision-making power in late-life depression rested chiefly with professionals. Some HCPs (mainly GPs) assumed that older adults were uninterested in talking therapies or that they would be ineffective, 19,31,32,35,37,46 particularly if they were computer based (such as online cognitive behavioural therapy), 42 and so were likely to dismiss these as an option. 35 This did not always preclude referrals if other treatments were ineffective, but ageist stereotypes were also evident in psychological therapists and CPNs, who felt that older people were unwilling to change -'"… it would not be obvious to me at 76 what would improve."…”

Patients’ perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care

“…To improve the treatment of depression, more research is needed to pinpoint successful methods and find the determinants that increase adherence to treatment and provides a long-term and sustainable outcome. [27]…”