Experiences and barriers to implementation of clinical practice guideline for depression in Korea

Depression is an enormous health-care problem that is responsible for 11% of disability worldwide [1]. It affects the quality of life and functioning of individual patients, and its high prevalence and substantial disease burden have significant societal and economic implications. The World Health Organization predicts that by 2020, major depression will be second only to ischemic heart disease as a cause of lost disability-adjusted life-years and untimely death [2].

For practicing psychiatrists, the guidelines provide many suggestions for different forms of treatment of the many kinds of depressive patients [3]. Clinical practice guidelines are “systematically developed statements to assist practitioners’ and patients’ decisions about appropriate health care for specific clinical circumstances” [4], and they aim to incorporate research findings and evidence-based practice for significant and consistent improvements in health care [5]. Their successful implementation may lead to improved quality of care by decreasing inappropriate variation in clinical practice and expediting the application of effective advances to everyday practice [6]. Increasing efforts are being undertaken to translate guidelines into clinical practice [7‐10]; however, the implementation of guidelines is a complex process influenced by many factors, such as the behavior of the physician, the guidelines themselves, and the way they are implemented [6, 7].

By understanding which factors are associated with implementation of evidence-based guidelines for the management of depressive disorders, strategies can be identified to improve physician guideline adherence and to adapt and focus guidelines and thus improve the quality of depression care. There are numerous possible barriers to implementation, from the distribution of guidelines to the use of guidelines in practice by physicians. The literature on determinants of implementation of evidence-based guidelines on depressive disorders has primarily focused on socio-demographic patient characteristics and disease-related factors, such as patient age and severity of the disorder [11, 12]. Despite the guidelines’ potential importance, few studies have examined the influence of professional- and practice-related factors on implementation of the depression guidelines. Physician adherence to guidelines may be hindered by a variety of barriers. Studies identified barriers to guideline implementation as including several physicians’ characteristics: lack of awareness of the guidelines, disagreement with the guidelines, insufficient self-efficacy for change, and negative attitudes towards guidelines in general (“cookbook medicine”), and inertia associated with faith in existing treatment practices. In addition, external barriers such as lack of time, lack of availability, and insufficient support by the organization were also listed [6].

In Korea, since the first Korean Medication Algorithm for Major Depressive Disorder was developed [13], updated practice guidelines have been provided in 2008 and 2010. The guidelines are a good reference to assist the treatment decisions of clinicians who treat major depressive disorder patients in Korea. Barriers to using the guidelines are thus important to identify, but the few studies investigating these barriers have had limitations, such as that data is scarce for Korean populations, one study have addressed clinical practice, priority has been given to the identification of the most effective and optimal treatments rather than the most economic ones, and the Korean health insurance regulations are strict [13].

We hypothesized that the provision of guideline-recommended care is influenced by characteristics of both the physician and the practice. Understanding experiences and barriers is important for the development of effective implementation strategies. The present study, which was initiated as a quality improvement project, aims to assess the feasibility of the depression guidelines for clinical settings in Korea. In this article, we investigate barriers to the implementation of the guidelines for managing depressive disorders. We used a questionnaire to ask staff about their knowledge and use of these guidelines. Our findings can help developers of guidelines, practice directors, and health-care services researchers to design effective interventions to change physician practice.

The aim of this study was to assess the experiences and barriers to physicians’ implementing Korea’s depression guidelines. Three quarters of psychiatrists reported having read the depression guidelines, and the majority of them said they applied the guideline in their practice at least partly. They tended to use the guidelines for making general decisions in clinical practice and for selecting medications. These experts also indicated that the guidelines were useful for educating patients and their caregivers. In a recent review of the difficulties associated with implementing guidelines, researchers suggested that even when practitioners agree with guidelines, they may not entirely implement them [16]. Additionally, it is know that there is a gap between evidence and practice in health-care research [17]. Some of the surveyed experts in the current study considered the depression guidelines to be important, but they indicated that they were not experienced in application and utilization of the guidelines. Nonetheless, our results suggest that the depression guidelines often facilitate decision making in critical clinical situations, as well as fostering informative communication with patients, caregivers, and the general population.

Even though that depression is treated by general practitioners in many countries, it is difficult for general practitioners (family physicians, internal medicine practitioners in Korea) to continue prescribing antidepressants more than two months because of the restrictions of reimbursement by the national Health Insurance Review and Assessment Service. Hence, depression patients are referred to psychiatrists when they are acknowledged by the general practitioners.

Most psychiatrists in this study reported intending to use the guidelines, but some were concerned about certain inherent limitations. Reasons for reluctance to use the guidelines included the following reported opinions: using the guidelines limits their professional independence, there is a gap between practice and guidelines, and using guidelines does not improve their work. Some were skeptical about the objectivity of guidelines and considered that recommendations could not be applied to their individual patients. Moreover, the most often reported barrier for implementation of the guidelines was little knowledge and experience with them. Health system restrictions were the next more reported barrier. Previous reports have also identified barriers at the clinician, clinical, and service levels [6].

It is important to be aware of these barriers so that they may be overcome. One essential factor in successful implementation is physicians' faith in the guidelines, particularly reflected in the common physician concerns about the relevance of guideline for patients and the loss of autonomy in treatment decision making. Acceptable, built-in, guideline-based treatment alternatives – rather than a single treatment mandate – would increase adherence by permitting physicians some level of treatment choice. Guidelines must also be easy to use and understand, as well as time efficient, in order to be sustainable [18, 19]. Moreover, consideration of the health system is also needed at the service level. In this study, many psychiatrists responded that the guidelines are difficult to use due to strict national health insurance regulations and denial of individual health insurance use with the psychiatric record. Previous research has found that major obstacles for implementation of guidelines are time limitations (38.2%) and differences between guidelines and health insurance regulations (23.5%), in Korean studies of medication algorithms for bipolar disorder [20]. It is now recommended that implementation of guidelines should not be undertaken without addressing organizational level support.

Previous studies showed a number of strategies to encourage the use of clinical practice guidelines, including multifaceted interventions involving audit and feedback of treatment practices, reminders about appropriate use of guidelines, local consensus processes in adoption of guidelines, and interactive educational meetings [19]. As our survey results show, not only the relevance of the guideline but also active education and public relations to promote the guidelines with summary booklet, web-site programs, or educational sessions are needed for enhancing the applicability of the depression guidelines. Half of the surveyed psychiatrists reported high levels of confidence in using the guidelines, but very few had received any formal training on them, and many experts stated they would like more support in using the guidelines. The application of clinical practice guidelines includes dissemination and implementation. Dissemination processes include recognition, comprehension, and changing attitudes, and implementation processes include clinicians’ behavior changes in clinical practice [5]. To accomplish the goals of improving health while making more efficient use of health-care resources, even greater attention must be paid to their creation, dissemination, adoption, and re-evaluation [21, 22]. Moreover, educational interventions positively influence physicians’ behavior toward the use of guidelines [23].

There are some limitations in this study that should be acknowledged. First, the survey results may not be generalizable to all the psychiatrists who did not participate, although the response rate of 14.2% is similar with previous studies. The list of potential participants also could include retired psychiatrists. However, we could not reveal that who is retired or not on the list. The response rate might be higher if this is taken into account. Also, annual report of Korean neuropsychiatric Association does not give information on the members’ education, and other demographic data. Authors assumed that the psychiatrists who did not answer would have similar educational background but there could be other issues in generalization of the present results. Clinician have poor responses rates to surveys in general [24], and web-based surveys may have lower response rates than telephone or mailed surveys [25]. Previous survey studies using web-based methods with a randomly selected sample reported similar results with the present study [26, 27]. A second limitation is that we used a cross-sectional sampling method; it is possible that further conclusions could have been drawn from longitudinal data.

This study has demonstrated that psychiatric experts providing mental health services frequently applied the depression guidelines for general decision making, for medication selections, and for information transmission to patients and their caregivers. Physicians’ adherence is critical in translating evidence-based recommendations into improved outcomes. However, individual factors such as lack of awareness and lack of familiarity and external barriers such as the reimburse restriction can affect the employment of the guidelines in the real practice. Changes should be made to improve public health by increasing implementation of the guidelines, but proper implementation can be achieved with active promotion of the guideline contents [16] and additional efforts for the improvement of the guidelines in evidence-based and also in expert-consensus manners.