Stepped care for depression is easy to recommend, but harder to implement: results of an explorative study within primary care in the Netherlands

Abstract

BackgroundDepression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care.MethodsOptimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire.ResultsSix GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs.ConclusionsThe management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.

Psychotherapists’ perspectives on collaboration and stepped care in outpatient psychotherapy—A qualitative study

“…enough time for personal encounters between health care providers that the interviewees considered as crucial to create networks. Hermens et al [17] equally underline the importance of stakeholder support, e.g. through politically established financial incentives for collaboration.…”

“…However, to date, stepped care has been evaluated from the viewpoint of e.g. general practitioners (GPs) and patients [16][17][18]. Despite a generally high acceptance of the concept among providers and patients [16], previous implementations were often hindered by structural barriers in everyday practice (e.g.…”

“…Skepticism was expressed towards pre-determined treatment steps, especially the low-intensity treatment options [18,19], and partly towards monitoring when based on questionnaires instead of clinical evaluation [19]. GPs welcomed the idea of stepped care especially for improved collaboration [17]. For patients, the access to a stepped care pathway via their GP seems to be an acceptable and helpful way to mental health care [19].…”

Norwegian General Practitioners’ Perspectives on Implementation of a Guided Web-Based Cognitive Behavioral Therapy for Depression: A Qualitative Study

“…GPs are often the first point of professional contact for individuals with depression, and most of these patients are currently treated in primary care [1,18]. In Norway, the mental health provider in primary care is most often the GP [19].…”

Evaluation of the Role of Training in the Implementation of a Depression Screening and Treatment Protocol in 2 Academic Outpatient Internal Medicine Clinics Utilizing the Electronic Medical Record

“…16,17 Often, the protocols are adopted incompletely, and providers do not use standardized tools to assess depression. 18 Adoption of protocols varies by both primary care provider and clinic site. 19 …”