Background
Methods
Registration
Search strategy
Eligibility
Data extraction and critical appraisal
Analytic plan
Study details | Participants | Intervention and treatment | Outcomes and results |
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Randomization unit: municipality | Number of sites: 51 municipalities (26 intervention, 28 control) Providers: 124 (51 intervention, 73 control) PCPs Patients: 134 (66 intervention, 68 control) home-dwelling elderly patients 65 years or older Diagnosis: depression (clinical diagnosis) | Intervention: outreach visits to GPs; website that provided recommendations, tools to diagnose and manage elderly patients with depression, and online courses; CME course approved by the Norwegian Medical Association; tailored information based on profession or relation to the healthcare Comparator: UC Timing of follow-up: 8 months | Provider behaviors: Mean adherence to recommendations for the management of depression at 8 months* MD − 5.00 (95% CI − 11.87, 1.87) Patient health outcomes: Adherence to antidepressant > 0 at 8 months OR 1.33 (95% CI 0.88, 2.00) GP assessed CGI-I at 8 months MD 0.03 (95% CI − 0.20, 0.26) HADS depression at 8 months MD − 0.28 (95% CI − 1.87, 1.31) Patient assessed PGI at 8 months MD 0.10 (95% CI − 0.38, 0.58) |
Azocar [86] Country: USA Setting: managed behavioral health care organization (specialty care) Randomization unit: provider | Number of sites: NR Providers: 443 (162 guidelines only, 132 targeted guidelines, 149 control) mental health care providers Patients: 836 (273 guidelines only, 254 targeted guidelines, 309 control) all adult patients starting a new episode of care with a study clinician Diagnosis: MDD | Intervention: general guidelines or targeted guidelines. Guidelines based on United Behavioral Health best practice guidelines (based on APA and AHRQ guidelines) Comparator: UC Timing of follow-up: 4 months | Provider behaviors: Mean adjusted adherence rating (subjective) at 4 months* --General dissemination of guidelines vs no dissemination, MD − 0.03 (95% CI not calculable) --Target dissemination vs no dissemination, MD 0.11 (95% CI not calculable) Units of service (indicators of guideline adherence): combined outpatient at 4 months --General dissemination of guidelines vs no dissemination, MD 0.20 (95% CI − 0.65, 1.05) --Target dissemination vs no dissemination, MD − 0.40 (95% CI − 1.25, 0.45) Units of service (indicators of guideline adherence): outpatient medication at 4 months --General dissemination of guidelines vs no dissemination, MD 0.00 (95% CI − 0.43, 0.43) --Target dissemination vs no dissemination, MD − 0.30 (95% CI − 0.74, 0.14) Units of service (indicators of guideline adherence):outpatient psychotherapy at 4 months --General dissemination of guidelines vs no dissemination, MD 0.20 (95% CI − 0.62, 1.02) --Target dissemination vs no dissemination, MD 0.10 (95% CI − 0.75, 0.95) Patient health outcomes: NR |
Baker [57] Country: England Setting: primary care office Randomization unit: site | Number of sites: 60 (30 intervention, 30 control) Number of providers: 64 (34 intervention, 30 control) Provider target category: PCP Patients: 402 (210 intervention, 192 control) aged 18 or above attending for their first consultation with new episodes of depression. Diagnosis: depression | Intervention: guideline distribution plus tailored implementation. Guidelines developed from existing guidelines and literature reviews Comparator: other (control group received guidelines but did not receive implementation recommendations) Timing of follow-up: 12 months | Provider behaviors: Antidepressant in therapeutic dose at 12 months OR 1.12 (95% CI 0.99, 1.26) Diagnosis: 3 or more symptoms recorded at 12 months OR 1.25 (95% CI 1.03, 1.53) Reviewed at 3 weeks at 12 months OR 1.04 (95% CI 0.92, 1.18) Suicide risk assessed at diagnosis at 12 months OR 2.51 (95% CI 1.93, 3.26) Those treated are to have two or more follow-up consultations at 12 months OR 1.32 (95% CI 1.07, 1.64) Treated for 4 months at 12 months OR 1.28 (95% CI 1.00, 1.63) Treated with antidepressant or cognitive therapy at 12 months* OR 1.03 (95% CI 0.98, 1.08) Patient health outcomes: BDI < 11 at 16 week at 12 months OR 1.07 (95% CI 0.77, 1.47) BDI < 11 at 4 weeks at 12 months OR 0.83 (95% CI 0.51, 1.34) BDI < 11 at diagnosis at 12 months OR 0.61 (95% CI 0.18, 2.14) |
Country: Netherlands Setting: primary care office Randomization unit: Site | Number of sites: 34 (18 intervention, 16 control) Providers: Number NR; PCPs Patients: 145 (70 intervention, 75 control) all consecutive patients 55 years and older visiting their GP Diagnosis: depression (rating scale); Geriatric Depression Scale-15 score of 5 or higher | Intervention: training session based on the Dutch depression guideline Comparator: UC Timing of follow-up: 12 months | Provider behaviors: Received some form of mental health care (antidepressant medication or referral during the follow-up period) at 12 months* --Practitioners training group vs control group, OR 6.64 (95% CI 3.42, 12.90) Patient health outcomes: % (No.) recovered (PRIME-MD) at 12 months OR 0.90 (95% CI 0.61, 1.33) Mean QALYs gained (EQ-5D) at 12 months MD 0.05 (95% CI − 0.02, 0.12) Mean improvement in MADRS score at 12 months MD − 0.60 (95% CI − 3.76, 2.56) |
Callahan [81] Country: USA Setting: primary care office Randomization unit: patient | Number of sites: 1 Providers: 103 (number per experimental condition NR) PCPs Patients: 175 (100 intervention, 75 control) aged 60 and older Diagnosis: Depression (rating scale); ≥ 16 on the CES-D and ≥ 15 on the HAM-D | Intervention: Receipt of patient assessment feedback with recommended care. Recommendations based on literature review and expert panel consensus Comparator: UC Timing of follow-up: 6 months | Provider behaviors: Received a depression diagnosis at 6 months OR 2.67 (95% CI 1.36, 5.23) Received a psychiatry referral at 6 months 0.88 (95% CI 0.41, 1.92) Remain on antidepressants at 6 months OR 1.74 (95% CI 1.01, 2.99) Started antidepressants at 6 months OR 3.25 (95% CI 1.41, 7.50) Stopped drugs associated with depression at 6 months* OR 1.05 (95% CI 0.60, 1.82) Patient health outcomes: HAM-D ≤ 10 at 6 months (responder) at 6 months OR 1.08 (95% CI 0.49, 2.40) HAM-D score at 1 month MD 0.20 (95% CI not calculable) HAM-D score at 3 months MD 0.00 (95% CI not calculable) HAM-D score at 6 months MD 0.40 (95% CI not calculable) HAM-D score at 9 months MD 0.60 (95% CI not calculable) |
Datto [53] Country: USA Setting: primary care office Randomization unit: site | Number of sites: 35 (17 diseases management, 18 education and guidelines) Providers: 130 (74 disease management, 77 education and guidelines) other general practitioner or clinician Patients: 61 (30 disease management, 31 education and guidelines) Diagnosis: depression (rating scale); CES-D ≥ 16 | Intervention: Provider education and distribution of practice guidelines from the AHRQ practice guidelines for major depression in primary care Comparator: Other (education and practice guidelines plus nurse disease management) Timing of follow-up: 16 weeks | Provider behaviors: Clinical adherence, when controlling for symptom improvement at 16 weeks OR 0.18 (95% CI 0.05, 0.67) Clinician adherence through 12 weeks at 16 weeks* OR 0.30 (95% CI 0.08, 1.14) Clinician adherence through 12 weeks, including only patients who required treatment adjustment (n = 34) at 16 weeks OR 0.14 (95% CI 0.02, 0.97) Patient adherence through 12 weeks at 16 weeks OR 0.16 (95% CI 0.02, 1.39) Symptom improvement (CES-D < 16) at 16 weeks OR 0.25 (95% CI 0.08, 0.77) Symptom improvement (CES-D < 16) when controlling for clinician adherence, active and passive adherence at 16 weeks OR 0.71 (95% CI 0.10, 1.43) Patient health outcomes: CES-D score at 16 weeks MD 4.50 (95% CI − 0.90, 9.90) Proportion meeting major depression (MINI) at 16 weeks OR 1.92 (95% CI 0.49, 7.69) Proportion of patients below CES-D 11 at follow-up at 16 weeks OR 0.29 (95% CI 0.07, 1.18) Proportion of patients below CES-D 16 at follow-up at 16 weeks OR 0.15 (95% CI 0.04, 0.64) Proportion with at least 50% reduction in CES-D at 16 weeks OR 0.25 (95% CI 0.06, 1.09) |
Eccles [87] Country: UK Setting: Primary care trusts Randomization unit: Site | Number of sites: 73 (36 intervention, 37 control) Providers: 266 (128 intervention, 138 control) PCPs Patients: number and description NR Diagnosis: unclear | Intervention: guideline distribution with outreach visits. Guidelines developed by a multidisciplinary panel Comparator: other (guideline distribution only) Timing: 12 months/6 quarters | Provider behaviors: Items prescribed per ASTROPU: MAOIs (mean difference between intervention and control) at 6 quarters MD 0.00 (95% CI − 0.02, 0.02) Items prescribed per ASTROPU: SSRIs (mean difference between intervention and control) at 6 quarters MD 0.03 (95% CI − 0.27, 0.34) Items prescribed per ASTROPU: lofepramine (mean difference between intervention and control) at 6 quarters MD − 0.02 (95% CI − 0.16, 0.11) Items prescribed per ASTROPU: other TCAs (mean difference between intervention and control) at 6 quarters* MD − 0.02 (95% CI − 0.46, 0.42) Number of items prescribed per ASTROPU: MAOIs at 12 months MD − 0.01 (95% CI − 0.04, 0.02) Number of items prescribed per ASTROPU: other TCAs at 12 months MD 0.23 (95% CI − 1.38, 1.84) Number of items prescribed per ASTROPU: SSRIs at 12 months MD 0.41 (95% CI − 0.70, 1.52) Number of items prescribed per ASTROPU lofepramine at 12 months MD 0.05 (95% CI − 0.28, 0.38) Patient health outcomes: NR |
Country: UK Setting: general practices in health authorities (primary care) Randomization unit: site | Number of sites: 12 health authorities paired in groups of 2 randomized to receive 2 of 4 guidelines (3 pairs received antidepressant guidelines, 3 did not). 75 practices (intervention and control Ns NR) Providers: 162 (N per condition NR) PCPs Patients: 11,328 (N per condition not NR). Description NR Diagnosis: unclear | Intervention: outreach visits for providers. Guidelines developed from techniques by the North of England Guidelines Development Project and literature review Comparator: other (practices in 12 health authorities were trained in 2 of 4 guidelines; 3 of 6 health authority pairs did not receive training in antidepressant guideline) Timing of follow-up: 6 months | Provider behaviors: Number of GPs reporting application of content at 6 months* OR 0.61 (95% CI 0.42, 0.91) Patient health outcomes: NR |
Gerrity [82] Country: USA Setting: primary care office Randomization unit: provider | Number of sites: NR Providers: 56 (27 intervention, 29 control) PCPs Number of patients: 2 SPs played by 3 actors Diagnosis: unclear | Intervention: depression education training sessions. Guidelines based on AHCPR’s CPG for Depression in Primary Care Comparator: wait-list Timing of follow-up: 6 weeks | Provider behaviors: Physician discussed possibility of depression with “patient 1” at 6 weeks* OR 1.48 (95% CI 1.06, 2.06) Physician discussed possibility of depression with “patient 2” at 6 weeks* OR 1.39 (95% CI 0.86, 2.25) Physician prescribed antidepressants to “patient 1” at 6 weeks OR 1.97 (95% CI 0.85, 4.55) Physician prescribed antidepressants to “patient 2” at 6 weeks OR 1.57 (95% CI 0.89, 2.74) Physician scheduled follow-up within 2 weeks for “patient 1” at 6 weeks OR 2.23 (95% CI 1.26, 3.97) Physician scheduled follow-up within 2 weeks for “patient 2” at 6 weeks OR 2.09 (95% CI 1.19, 3.65) Physician assessed > 5 criteria for major depression in “patient 1” at 6 weeks OR 2.13 (95% CI 1.26, 3.59) Physician assessed > 5 criteria for major depression in “patient 2” at 6 weeks OR 1.70 (95% CI 0.87, 3.31) Physician assessed stresses at home in “patient 1” at 6 weeks OR 1.46 (95% CI 1.09, 1.96) Physician assessed stresses at home in “patient 2” at 6 weeks OR 1.42 (95% CI 0.96, 2.08) Physician assessed suicidal ideation in “patient 1” at 6 weeks OR 13.00 (95% CI 1.82, 92.92) Physician assessed suicidal ideation in “patient 2” at 6 weeks OR 1.04 (95% CI 0.39, 2.77) Patient health outcomes: NR |
Country: USA Setting: primary care office Randomization unit: group practices within primary care clinics | Number of sites: 4 Providers: 95 (allocation to condition reported for 78 providers: academic detailing, 37 academic detailing + CQI team, 23 UC) PCPs Patients: 4995 (allocation to condition reported for 4051 patients: 1073 academic detailing, 1672 academic detailing + CQI team, 1306 UC) age 18 to 75 making clinic visits between February and July 1994 Diagnosis: depression (clinical diagnosis), depression (rating scale) | Intervention: academic detailing and educational sessions based on clinical practice guidelines from the AHCPR Quick Reference Guide for Clinicians Comparator: UC, other (two comparators: (1) usual care and (2) academic detailing plus continuous quality improvement teams (complex system redesign)) Timing of follow-up: 12 months | Provider behaviors: % of eligible known depressives prescribed 1st-generation tricyclics, all clinics at 12 months --Academic detailing vs AD + CQI, OR 0.93 (95% CI 0.79, 1.10) --Academic detailing vs usual care, OR 1.12 (95% CI 0.96, 1.30) % of eligible known depressives prescribed 2nd-generation tricyclics, all clinics at 12 months --Academic detailing vs AD + CQI, OR 0.92 (95% CI 0.72, 1.17) --Academic detailing vs usual care, OR 1.05 (95% CI 0.83, 1.34) % of eligible known depressives prescribed SSRIs, all clinics at 12 months --Academic detailing vs AD + CQI, OR 1.04 (95% CI 0.95, 1.15) --Academic detailing vs usual care, OR 1.02 (95% CI 0.93, 1.12) % of eligible unrecognized depressives prescribed antidepressants, All clinics at 12 months* --Academic detailing vs AD + CQI, OR 1.01 (95% CI 0.62, 1.64) --Academic detailing vs usual care, OR 0.94 (95% CI 0.56, 1.59) Patient health outcomes: SCL score in known depressives, all clinics at 12 months --Academic detailing vs AD + CQI, MD − 0.12 (95% CI not calculable) --Academic detailing vs usual care, MD − 0.09 (95% CI not calculable) SCL score in known depressives, best-case clinic at 12 months --Academic detailing vs AD + CQI, MD − 0.27 (95% CI not calculable) --Academic detailing vs usual care, MD − 0.22 (95% CI not calculable) |
Keeley [59] Country: USA Setting: primary care clinics at a federally qualified community health care system Randomization unit: site | Number of sites: 7 (3 motivational interviewing, 4 guideline only) Providers: 21 (10 motivational interviewing, 11 guideline only) PCPs Patients: 171 (85 motivational interviewing, 86 guideline only) 18 years and older Diagnosis: depression (rating scale); PHQ-9 score ≥ 10 | Intervention: distribution of practice guideline and recommendations for treatment based on APA’s Practice Guideline for the Treatment of MDD Comparator: other (guidelines plus motivational interviewing training) Timing of follow-up: 24 months | Provider behaviors: Prescription for antidepressant medication at 24 months* OR 0.85 (95% CI 0.43, 1.69) Provider recommendation for physical activity at 24 months OR 0.45 (95% CI 0.20, 1.01) Patient health outcomes: Treatment adherence: days physically active in past week at 24 months MD 1.21 (95% CI 0.37, 2.05) Treatment adherence: filled prescription at 24 months OR 0.79 (95% CI 0.29, 2.08) |
Country: USA Setting: primary care office Randomization unit: provider | Number of sites: 3 Providers: 4 (2 intervention, 2 control) PCPs Patients: 55 (32 intervention, 23 control) 18 years and older Diagnosis: MDD, depression (rating scale); ≥ 14 on HDRS-17 | Intervention: education plus practice with a computerized support decision system. Guidelines based on APA practice guidelines and consensus expert opinion developed in the Texas Medication Algorithm Project Comparator: other (UC that included initial 1 h training on guidelines) Timing of follow-up: 12 weeks | Provider behaviors: No. of treatment visits at 12 weeks* MD − 1.30 (95% CI − 2.31, − 0.29) Received an adequate antidepressant dose at 12 weeks* OR 1.05 (95% CI 0.72, 1.54) Treatment augmentation (algorithm approved) at 12 weeks OR 0.96 (95% CI 0.24, 3.88) Treatment switch (new antidepressant) at 12 weeks OR 2.52 (95% CI 0.57, 11.02) Patient health outcomes: Rate of remission on HDRS (HDRS ≤ 7) at 12 weeks OR 1.13 (95% CI 0.59, 2.15) Rate of response on HDRS (50% decrease in symptom severity) at 12 weeks OR 0.97 (95% CI 0.63, 1.50) Rate of response on QIDS-SR (≥ 50% decrease in symptom severity) at 12 weeks --Computerized decision support system vs usual care (guidelines and training), OR 1.58 (95% CI 0.70, 3.53) |
Country: USA Setting: primary care office Randomization unit: provider | Number of sites: 15 Providers: 109 (53 intervention, 56 UC) PCPs Patients: 124,893 (60,689 intervention, 64,204 UC) Diagnosis: MDD, other depression diagnosis (dysthymic, adjustment, depression NOS) from the HMOs between ages 18–64 whose ambulatory visits were below the top 15th percentile for the prior 2 consecutive years | Intervention: education with group feedback. Guidelines based on DSM-IV diagnostic criteria Comparator: UC Timing of follow-up: 12 months | Provider behaviors: 12 weeks continuous medication at 12 months* OR 0.98 (95% CI 0.81, 1.20) New antidepressant prescriptions/100 visits at 12 months* IRR 1.07 (95% CI 0.90, 1.26) Patient health outcomes: NR |
Linden [92] Country: Germany Setting: psychiatry private practice (specialty care) Randomization unit: provider | Number of sites: NR Providers: 103 (20 guidelines plus training, 20 guidelines only, 43 control) mental health care providers Patients: 497 (100 guidelines plus training, 196 guidelines only, 202 control) Diagnosis: unclear | Intervention: receipt of depression guideline alone or with training on WHO depression guidelines and detailed recommendations on patient counseling and management Comparator: UC Timing of follow-up: 12 weeks | Provider behaviors: Adverse drug reactions at 12 weeks --WHO guideline only vs control group, MD − 0.01 (95% CI − 0.04, 0.02) --WHO guideline + training vs control group, MD − 0.01 (95% CI − 0.04, 0.01) Prescribed dosages of mirtazapine, mean mg/day at 12 weeks* --WHO guideline only vs control group, MD − 1.41 (95% CI − 2.87, 0.05) --WHO guideline + training vs control group, MD − 2.38 (95% CI − 4.07, − 0.69) Patient health outcomes: CGI severity at 12 weeks --WHO guideline only vs control group, MD − 0.07 (95% CI − 0.29, 0.15) --WHO guideline + training vs control group, MD − 0.31 (95% CI − 0.57, − 0.05) Patient depression rating at 12 weeks --WHO guideline only vs control group, MD − 1.13 (95% CI − 2.63, 0.37) --WHO guideline + training vs control group, MD − 1.53 (95% CI − 3.33, 0.27) Psychiatrist depression rating at 12 weeks --WHO guideline only vs control group, MD − 2.27 (95% CI − 4.49, − 0.05) --WHO guideline + training vs control group, MD − 3.23 (95% CI − 5.89, − 0.57) |
Nilsson [93] Country: Sweden Setting: continuing medical education groups and health care centers (primary care) Randomization unit: provider | Number of sites: 6 health care centers and 3 CME groups Providers: 50 (40 participated: 18 in hypertension group, 8 in peptic ulcer/dyspepsia group, 14 in depression group) other general practitioners or clinicians Patients: 45,982; description NR Diagnosis: unclear | Intervention: pharmacotherapy education group. Guidelines based on literature review and recent national and local recommendations on treatment Comparator: other (delivery of education and feedback regarding non-depression control areas (hypertension and peptic ulcers)) Timing of follow-up: 12 months | Provider behaviors: Fractional prescribing rate: selective serotonin reuptake inhibitors at 12 months MD − 3.80 (95% CI − 12.96, 5.36) Fractional prescribing rate: tricyclic antidepressants at 12 months* MD 2.70 (95% CI − 6.08, 11.48) Prescribed DDDs/1000 patients per year at 12 months* IRR 0.78 (95% CI 0.75, 0.81) Prescribed DDDs/GP at 12 months IRR 1.00 (95% CI 0.97, 1.03) Patient health outcomes: NR |
Country: USA Setting: academically affiliated primary care practice Randomization unit: provider | Number of sites: 1 Providers: 17 (16 enrolled: 6 active care, 5 passive care, 5 usual care) PCPs Patients: 227 (78 active care, 78 passive care, 71 usual care) Diagnosis: depression (clinical diagnosis) | Intervention: reminders of patients’ depression diagnosis with or without recommendations from AHRQ’s Depression Panel’s Guideline for the treatment of major depression Comparator: UC Timing of follow-up: 6 months | Provider behaviors: # of contacts with any PCP at 6 months --EMR—active care vs EMR—usual care, MD − 0.50 (95% CI not calculable) --EMR—passive care vs EMR—usual care, MD 0.08 (95% CI not calculable) # of contacts with usual PCP at 6 months1 --EMR—active care vs EMR—usual care, MD − 0.40 (95% CI not calculable) --EMR—passive care vs EMR—usual care, MD − 0.09 (95% CI not calculable) # of office visits with usual PCP at 6 months --EMR—active care vs EMR—usual care, MD − 0.91 (95% CI not calculable) --EMR—passive care vs EMR—usual care, MD − 0.69 (95% CI not calculable) ≥ 3 contacts with usual PCP at 6 months --EMR—active care vs EMR—usual care, OR 1.58 (95% CI 1.12, 2.21) --EMR—passive care vs EMR—usual care, OR 1.50 (95% CI 1.06, 2.11) Antidepressant medication not offered at 6 months --EMR—active care vs EMR—usual care, OR 1.48 (95% CI 0.93, 2.36) --EMR—passive care vs EMR—usual care, OR 1.45 (95% CI 0.92, 2.29) Antidepressant meds baseline regimen continued without modification at 6 months --EMR—active care vs EMR—usual care, OR 2.43 (95% CI 0.68, 8.76) --EMR—passive care vs EMR—usual care, OR 2.66 (95% CI 0.75, 9.38) Antidepressant meds suggested/prescribed or baseline regimen modified at 6 months --EMR—active care vs EMR—usual care, OR 1.14 (95% CI 0.83, 1.56) --EMR—passive care vs EMR—usual care, OR 1.11 (95% CI 0.81, 1.52) Depression mentioned in ≥ 3 contacts with usual PCP at 6 months --EMR—active care vs EMR—usual care, OR 1.74 (95% CI 0.91, 3.31) --EMR—passive care vs EMR—usual care, OR 1.77 (95% CI 0.94, 3.35) Depression mentioned in any contact with usual PCP at 6 months* --EMR—active care vs EMR—usual care, OR 1.07 (95% CI 0.88, 1.29) --EMR—passive care vs EMR—usual care, OR 1.17 (95% CI 0.99, 1.40) Depression treatment mentioned in ≥ 3 contacts with usual PCP at 6 months --EMR—active care vs EMR—usual care, OR 1.33 (95% CI 0.67, 2.63) --EMR—passive care vs EMR—usual care, OR 1.29 (95% CI 0.65, 2.56) Mental health referral suggested at 6 months --EMR—active care vs EMR—usual care, OR 0.75 (95% CI 0.44, 1.25) --EMR—passive care vs EMR—usual care, OR 1.01 (95% CI 0.64, 1.59) PCP counsels patient for depression at 6 months --EMR—active care vs EMR—usual care, OR 1.19 (95% CI 0.63, 2.25) --EMR—passive care vs EMR—usual care, OR 0.95 (95% CI 0.49, 1.87) Patient health outcomes: HRS-D score at 3 months --EMR—active care vs EMR—usual care, MD − 1.50 (95% CI not calculable) --EMR—passive care vs EMR—usual care, MD 0.50 (95% CI not calculable) HRS-D score at 6 months --EMR—active care vs EMR—usual care, MD − 1.50 (95% CI not calculable) --EMR—Passive care vs EMR—usual care, MD − 1.50 (95% CI not calculable) Recovery rate (HRS-D ≤ 7) at 6 months --EMR—active care vs EMR—usual care, OR 0.98 (95% CI 0.50, 1.91) --EMR—passive care vs EMR—usual care, OR 1.05 (95% CI 0.55, 2.00) |
Country: Iran Setting: primary care office Randomization unit: provider | Number of sites: NR Providers: 192 (96 intervention, 96 control) PCPs Patients: 10 SPs Diagnosis: other depression diagnosis (SPs with depressive symptoms) | Intervention: continuing medical education course tailored toward self-reported stage of change. Guidelines generated by researchers based on literature review Comparator: other (guidelines and education without tailoring to stage of change) Timing of follow-up: 2 months | Provider behaviors: Performance score on appropriate treatment (prescription, lab tests, referrals) at 2 months* --Intervention—large group vs control—large group, MD − 24.00 (95% CI − 44.08, − 3.92) --Intervention—small group vs control—small group, MD − 36.00 (95% CI − 46.76, − 25.24) --Tailored education vs ceducation, MD − 27.00 (95% CI − 35.60, − 18.40) Patient health outcomes: NR |
Simon [52] Country: USA Setting: primary care office Randomization unit: patient | Number of sites: 5 Providers: number NR; PCPs Number of patients: 613 patients at participating five primary care clinics who had received new prescriptions for antidepressants, with “new” defined as no antidepressant use in the previous 120 days Diagnosis: depression (clinical diagnosis) | Intervention: receipt of detailed patient report and treatment recommendations based on a computerized algorithm. Guidelines not specified Main dichotomous outcome: patients who receive adequate pharmacotherapy (low dose, > 90 days) Comparator: UC, other (feedback intervention plus care management) Timing of follow-up: 6 months | Provider behaviors: Mental health visits to non-prescribing provider at 6 months --Feedback only vs feedback plus care management, MD − 0.10 (95% CI − 0.93, 0.73) --Feedback only vs usual care, MD 0.22 (95% CI − 1.11, 1.55) Mental health visits to prescribing provider at 6 months* --Feedback only vs feedback plus care management, MD − 0.04 (95% CI − 0.48, 0.40) --Feedback only vs usual care, MD − 0.01 (95% CI − 0.49, 0.47) Patients who receive adequate pharmacotherapy (low dose, > 90 days) at 6 months* --Feedback only vs feedback plus care management, OR 0.91 (95% CI 0.74, 1.13) --Feedback only vs usual care, OR 1.10 (95% CI 0.87, 1.39) Patients who receive adequate pharmacotherapy (moderate dose, > 90 days) at 6 months --Feedback only vs feedback plus care management, OR 0.70 (95% CI 0.50, 0.98) --Feedback only vs usual care, OR 1.17 (95% CI 0.79, 1.73) Patient health outcomes: Depression score at 6 months --Feedback only vs feedback plus care management, MD 0.14 (95% CI not calculable) --Feedback only vs usual care, MD − 0.01 (95% CI not calculable) Major depression by DSM-IV at 6 months --Feedback only vs feedback plus care management, OR 0.53 (95% CI 0.30, 0.94) --Feedback only vs usual care, OR 1.00 (95% CI 0.63, 1.58) Probability of showing 50% decrease in depression score at 6 months --Feedback only vs feedback plus care management, OR 0.79 (95% CI 0.65, 0.95) --Feedback only vs usual care, OR 1.10 (95% CI 0.88, 1.38) |
Sinnema [51] Country: Netherlands Setting: general practices (solo practices, group practices or health centers) (primary care) Randomization unit: site | Number of sites: 23 (12 intervention, 11 control) Providers: 46 (23 intervention, 23 control) PCPs Patients: 444 (198 intervention, 246 control) 18 years or older attending participating practices Diagnosis: depression (rating scale); screen positive (≥ 20) on Extended Kessler 10 screening instrument | Intervention: training and consultations from experts with incorporation of personal barriers to guideline implementation on the Dutch College of General Practitioner’s guidelines for depression and anxiety Comparator: other (1-day training from experts on implementing guidelines but no tailored intervention on barriers) Timing of follow-up: 6 months | Provider behaviors: Number of consultations at 6 months* IRR 1.78 (95% CI 1.14, 2.78) Prescribing antidepressants at 6 months* OR 1.07 (95% CI 0.52, 2.19) Referral to specialist mental health services at 6 months OR 1.62 (95% CI 0.72, 3.64) Patient health outcomes: 4DSQ depression at 6 months MD 0.06 (95% CI − 0.52, 0.64) WHODAS II at 6 months MD 1.02 (95% CI − 2.08, 4.12) |
van Eijk [65] Country: Netherlands Setting: GPs and pharmacists in peer review groups (primary care) Randomization unit: site | Number of sites: 21 (7 individual intervention, 7 group intervention, 7 control) Providers: 122 (70 GPs and 14 pharmacists in individual intervention, 52 GPs and 9 pharmacists in group intervention, 68 GPs and 13 pharmacists in control) Number of patients: 46,078 people aged 60 years old or over on 1 January 1996 (about 50,000 people) living in the southwest Netherlands health district and insured Diagnosis: unclear | Intervention: group-based on individual-based academic detailing session and review of group- or individual-based performance. Guidelines not specified Comparator: UC Timing of follow-up: 4 months | Provider behaviors: Rate of incident prescriptions of less anticholinergic antidepressants after intervention at 4 months* --Group educational visits vs control group, IRR 1.66 (95% CI 0.97, 2.85) --Individual educational visits vs control group, IRR 2.02 (95% CI 1.24, 3.30) Rate of incident prescriptions of highly anticholinergic antidepressants after intervention: prescriptions/1000 patient years at 4 months --Group educational visits vs control group, IRR 1.79 (95% CI 0.87, 3.57) --Individual educational visits vs control group, IRR 1.47 (95% CI 0.85, 2.56) Patient health outcomes: NR |
Worrall [62] Country: Canada Setting: family practice research networks (primary care) Randomization unit: provider | Number of sites: NR Number of providers: 42 PCPs Number of patients: 147, description NR Diagnosis: depression (rating scale) | Intervention: workshop on clinical practice guidelines with follow-up consultations. Guidelines based on Canadian Medical Association’s CPGs Comparator: other (receipt of clinical practice guidelines without education) Timing of follow-up: 6 months | Provider behaviors: Mean no. of office visits per patient at 6 months* MD 0.60 (95% CI − 1.94, 3.14) No. of patients prescribed an antidepressant on first visit at 6 months* OR 1.02 (95% CI 0.91, 1.14) No. of referrals to other mental health professional at 6 months OR 10.53 (95% CI 0.62, 179.01) No. of referrals to psychiatrist at 6 months OR 1.85 (95% CI 0.39, 8.83) Patient health outcomes: CES-D score—patient at 6 months MD 2.80 (95% CI − 1.35, 6.95) CES-D score gain—patient at 6 months MD − 3.80 (95% CI − 8.70, 1.10) No. of patients taking medication at 6-month follow-up at 6 months OR 1.43 (95% CI 0.98, 2.07) No. of patients who took antidepressant for full 6 months at 6 months OR 1.23 (95% CI 0.82, 1.84) |
Yawn [64] Country: USA Setting: family medicine research network practices (primary care) Randomization unit: site | Number of sites: 28 (14 intervention, 14 control) Providers: NR (teams) Number of patients: 2343 (1353 intervention, 990 control) women aged at least 18 years, were 5 to 12 weeks’ postpartum Diagnosis: depression (rating scale) | Intervention: education and a set of tools for postpartum depression. Guidelines not specified Comparator: UC Timing of follow-up: 12 months | Provider behaviors: Medication plus counseling at 12 months OR 1.62 (95% CI 1.32, 2.00) Received 2nd call after successful 1st call (women diagnosed with depression) at 12 months* OR 103.48 (95% CI 6.43, 1665.63) Received counseling at 12 months OR 1.82 (95% CI 1.13, 2.93) Treatment with medication at 12 months OR 1.60 (95% CI 1.28, 1.98) Patient health outcomes: Improved PHQ-9, if history of depression at 12 months OR 1.24 (95% CI 0.86, 1.79) Improved PHQ-9, if postpartum depression was diagnosed at 12 months OR 1.10 (95% CI 0.77, 1.56) |
Results
Main indications of adherence to depression guidelines
Intervention type and outcome measure | Number of RCTs and participants | Reasons for downgrade | Direction and magnitude of relative effect | Grade |
---|---|---|---|---|
Effects of provider intervention on healthcare professional behavior | ||||
Provider intervention vs UCP | ||||
Odds of achieved provider adherence (main indication) | N = 3158 | H | Provider interventions not statistically significantly different from comparator groups (OR 1.60; CI 0.76, 3.37) | Moderate |
Mean difference in achieved provider adherence (main indication) | N = 1236 | H, DE | Provider interventions not statistically significantly different from comparator groups (SMD 0.17; CI − 0.16, 0.50) | Low |
Incidence rate of achieved provider adherence (main indication) | N = 63,588 | H, IMP | Provider interventions not statistically significantly different from comparator groups (IRR 1.16; CI 0.63, 2.14) | Low |
Odds of improved medication prescribing | N = 4116 | H, IMP | Provider interventions statistically significantly different from comparator groups (OR 1.42; CI 1.04, 1.92) favoring the intervention | Low |
Mean difference in improved medication prescribing | 3 RCTs [86] N = 414 | DE, IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.15; CI − 0.48, 0.79) | Low |
Incidence rate of improved medication prescribing | N = 63,144 | H, IMP | Provider interventions not statistically significantly different from comparator group (IRR 1.02; CI 0.44, 2.36) | Low |
Odds for increased contact with patients | N = 710 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 6.40; CI 0.13, 322.40) | Low |
Mean difference in contact with patients | N = 225 | IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.17; CI − 0.84, 1.19) | Moderate |
Incidence rate of number of consultations (contact with patients) | 1 RCT [51] N = 444 | S | Provider intervention statistically significantly different from comparator group (IRR 1.78; CI 1.14, 2.78) favoring the intervention | Very low |
Odds of general adherence to intervention | N = 1375 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 2.26; CI 0.50, 10.28) | Low |
Mean difference in general adherence to intervention | N = 597 | H, DE, IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.23; CI − 1.42, 1.89) | Very low |
Odds of referral offered to patient | N = 896 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.11; CI 0.33, 3.70) | Moderate |
Provider intervention vs practice redesign | ||||
Odds of achieved provider adherence (main indication) | N = 867 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 0.81; CI 0.30, 2.19) | Moderate |
Mean difference in achieved provider adherence (main indication) | 1 RCT [52] N = 24 | S | Provider intervention not statistically significantly different from comparator group (SMD 0.07; CI − 0.73, 0.87) | Low |
Odds of improved medication prescribing | N = 1738 | DE, IMP | Provider interventions not statistically significantly different from comparator groups (OR 0.96; CI 0.18, 5.08) | Low |
Mean difference in contact with patients | 1 RCT [52] N = 24 | S | Provider intervention not statistically significantly different from comparator group (SMD 0.07; CI − 0.73, 0.87) | Low |
Odds of general adherence to intervention | 1 RCT [53] N = 61 | Poor RoB, IP, S | Provider interventions not statistically significantly different from comparator groups (OR 0.30; CI 0.08, 1.14) | Very low |
Provider intervention vs other interventions | ||||
Odds of achieved provider adherence (main indication) | 1 RCT [59] N = 171 | S, IMP, PND | Provider intervention not statistically significantly different from comparator group (OR 0.85; CI 0.43, 1.69) | Very low |
Odds of improved medication prescribing | 1 RCT [59] N = 171 | S, IMP, PND | Provider intervention not statistically significantly different from comparator group (OR 0.85; CI 0.43, 1.69) | Very low |
Odds of general adherence to intervention | 1 RCT [59] N = 171 | S, IMP, PND | Provider intervention not statistically significantly different from comparator group (OR 0.45; CI 0.20, 1.01) | Very low |
Effects by intervention type | ||||
Comparative effectiveness | ||||
Guideline distribution plus implementation recommendations vs guideline distribution alone: odds of achieved provider adherence (main indication) | 1 RCT [57] N = 378 | S, IMP, IP | Provider interventions not statistically significantly different (OR 1.62; CI 0.64, 4.06) | Very low |
Guideline distribution and education vs guideline distribution, education, and nurse disease management (system redesign): odds of achieved provider adherence (main indication) | 1 RCT [53] N = 61 | S, IMP, poor RoB, IP | Provider interventions not statistically significantly different (OR 0.30; CI 0.08, 1.14) | Very low |
Academic detailing vs academic detailing plus continuous quality improvement: odds of achieved provider adherence (main indication) | 1 RCT [58] N = 389 | S, IMP | Provider interventions not statistically significantly different (OR 1.01; CI 0.48, 2.11) | Very low |
Guideline distribution vs guideline distribution and motivational interviewing training: odds for achieved provider adherence (main indication) | 1 RCT [59] N = 171 | S, IMP, PND | Provider interventions not statistically significantly different (OR 0.85; CI 0.43, 1.69) | Very low |
Education plus additional training sessions vs education alone: odds for achieved provider adherence (main indication) | 1 RCT [60] N = 55 | S, IMP, PND | Provider interventions not statistically significantly different (OR 1.17; CI 0.33, 4.19) | Very low |
Education plus additional training sessions vs education alone: mean difference in achieved provider adherence (main indication) | 1 RCT [60] N = 55 | S, IMP, PND | Provider interventions not statistically significantly different (SMD 0.67; CI 0.06, 1.28) | Very low |
Patient-specific treatment recommendations vs recommendations and care management: odds for achieved provider adherence (main indication) | 1 RCT [52] N = 417 | S, IMP | Provider interventions not statistically significantly different (OR 0.85; CI 0.58, 1.25) | Very low |
Patient-specific treatment recommendations vs recommendations and care management: mean difference in achieved provider adherence (main indication) | 1 RCT [52] N = 417 | S, IMP | Provider interventions not statistically significantly different (SMD 0.07; CI − 0.73, 0.87). | Very low |
Training plus tailored implementation vs training alone: odds for achieved provider adherence (main indication) | 1 RCT [51] N = 444 | S, IMP | Provider interventions not statistically significantly different (OR 1.07; CI 0.52, 2.19). | Very low |
Training plus tailored implementation vs training alone: incidence rate for achieved provider adherence (main indication) | 1 RCT [51] N = 444 | S, IMP | Provider interventions statistically significantly different (IRR 1.78; CI 1.14, 2.78), favoring the intervention of training plus tailored implementation | Very low |
Guideline distribution plus workshop and consultation vs guideline distribution alone: odds of achieved provider adherence (main indication) | 1 RCT [62] N = 147 | S, IMP | Provider interventions not statistically significantly different (OR 1.25; CI 0.40, 3.90) | Very low |
Guideline distribution plus workshop and consultation vs guideline distribution alone: mean difference in achieved provider adherence (main indication) | 1 RCT [62] N = 147 | S, IMP | Provider interventions not statistically significantly different (SMD − 0.08; CI − 0.42, 0.26) | Very low |
Education plus other components vs guidelines and education without tailoring to stages of change: mean difference in achieved provider adherence (main indication) | 1 RCT [63] N = 36 | S, IMP | Provider interventions statistically significantly different (SMD 0.89; CI 0.59, 1.18), favoring intervention with education plus other components tailored toward stages to change | Very low |
Guideline distribution (passive) vs guideline distribution (active): odds of achieved provider adherence (main indication) | 1 RCT [61] N = 138 | S, IMP, IP | Provider interventions not statistically significantly different (OR 1.76; CI 0.64, 4.86) | Very low |
Indirect comparison | ||||
Meta-regression education only vs education plus for odds of achieved provider adherence (main indication) | N = 2957 | I, IMP | No systematic effect detected (p = 0.574) | Very low |
Meta-regression education only vs education plus for mean difference in achieved provider adherence (main indication) | N = 712 | I, IMP | No systematic effect detected (p = 0.238) | Very low |
Meta-regression unidimensional vs multidimensional for odds of achieved provider adherence (main indication) | N = 2953 | I, IMP | No systematic effect detected (p = 0.707) | Very low |
Meta-regression unidimensional vs multidimensional for mean difference in achieved provider adherence (main indication) | N = 1236 | I, IMP | No systematic effect detected (p = 0.055) | Very low |
Meta-regression unidimensional vs multidimensional for odds of improved medical prescribing | N = 2678 | I, IMP | No systematic effect detected (p = 0.317) | Very low |
Meta-regression unidimensional vs multidimensional for odds of referral offered to patients | N = 896 | I, IMP | No systematic effect detected (p = 0.195) | Very low |
Meta-regression intervention intensity for odds of achieved provider adherence (main indication) | N = 3158 | I, IMP | No systematic effect detected (p = 0.973) | Very low |
Meta-regression intervention intensity for mean difference in achieved provider adherence (main indication) | N = 1236 | I, IMP | The analysis suggested that the intensity of the intervention is associated with the effect size (p = 0.033) | Very low |
Meta-regression intervention intensity for odds of improved medical prescribing | N = 2678 | I, IMP | No systematic effect detected (p = 0.414) | Very low |
Meta-regression intervention intensity for odds of general adherence to intervention | N = 2411 | I, IMP | No systematic effect detected (p = 0.542) | Very low |
Subgroup analyses by intervention type | ||||
Guideline distribution only: odds of achieved provider adherence (main indication) | N = 683 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.28; CI 0.75, 2.19) | Low |
Guideline distribution only: mean difference for achieved provider adherence (main indication) | 1 RCT [86] N = 281 | S, IMP, PND | Provider intervention statistically significantly different from comparator group (SMD − 0.44; CI − 0.68, − 0.20), favoring the comparator | Very low |
Guideline distribution only: odds of improved medication prescribing | N = 854 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.52; CI 0.60, 3.86) | Low |
Guideline distribution only: odds of increased provider contact with patients | 1 RCT [61] N = 130 | S, IMP, IP | Provider intervention statistically significantly different from comparator group (OR 2.71; CI 1.24, 5.94) | Very low |
Guideline distribution only: odds of general adherence to intervention | N = 679 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 0.95; CI 0.17, 5.17) | Very low |
Education only: odds of achieved provider adherence (main indication) | N = 338 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 3.04; CI 0.01, 756.17) | Low |
Education only: mean difference in achieved provider adherence (main indication) | 3 RCTs [86] N = 414 | IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.15; CI − 0.48, 0.79) | Moderate |
Education only: odds of improved medication prescribing | 1 RCT [82] N = 48 | S, IMP | Provider intervention not statistically significantly different from comparator group (OR 2.78; CI 0.80, 9.59) | Very low |
Education only: odds of increased provider contact with patients | 1 RCT [82]) N = 48 | S, IMP | Provider intervention statistically significantly different from comparator group (OR 6.42; CI 1.78, 23.18) | Very low |
Education only: odds of general adherence to intervention | N = 399 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 2.03; CI 0.06, 73.30) | Very low |
Education plus other components: odds for achieved provider adherence (main indication) | N = 2090 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.17; CI 0.62, 2.18) | Moderate |
Education plus other components: mean difference in achieved provider adherence (main indication) | N = 938 | H, IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.37; CI − 0.16, 0.90) | Low |
Education plus other components: odds of improved medical prescribing | N = 1710 | H | Provider interventions not statistically significantly different from comparator groups (OR 1.21; CI 0.85, 1.71) | Low |
Education plus other components: odds of increased provider contact with patients | 1 RCT [64] N = 483 | S, IMP | Provider interventions statistically significantly different from comparator group (OR 101.34; CI 6.17, 1664.08) | Very low |
Education plus other components: odds of general adherence to intervention | 1 RCT [64] N = 482 | S | Provider interventions statistically significantly different from comparator group (OR 2.56; CI 1.65, 3.97) | Very low |
Effects by provider type | ||||
Meta-regression single provider vs team for odds of achieved provider adherence (main indication) | N = 3158 | I, IMP | The analysis suggested that the type of provider is associated with the effect size (p = 0.034); however, the analysis is based on only 1 team intervention | Very low |
Subgroup analysis by provider type | ||||
Single provider interventions: odds for achieved provider adherence (main indication) | N = 1334 | H, IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.42; CI 0.74, 2.73) | Low |
Team provider interventions: odds of achieved provider adherence (main indication) | 1 RCT [64] N = 482 | S, IMP | Provider intervention statistically significantly different from comparator group (OR 101.34, CI 6.17, 1664.08), favoring the intervention | Very low |
Effect by setting | ||||
Meta-regression primary care vs specialty care setting for mean difference in achieved adherence (main indication) | N = 1236 | I, IMP | No systematic effect detected (p = 0.385); however, the analysis is based on only 2 specialty care interventions | Very low |
Patient outcomes | ||||
Provider intervention vs UCP | ||||
Mean difference in depression rating scale scores | N = 2196 | DE | Provider interventions not statistically significantly different from comparator groups (SMD − 0.06; CI − 0.14, 0.01) | Moderate |
Odds of depression treatment response | N = 1312 | DE | Provider interventions statistically significantly different from comparator groups (OR 1.12; CI 1.04, 1.21) favoring the intervention | Moderate |
Odds of depression recovery | N = 1274 | DE | Provider interventions not statistically significantly different from comparator groups (OR 1.02; CI 0.91, 1.15) | Moderate |
Odds of depression treatment adherence | N = 281 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 1.52; CI 0.70, 3.31) | Moderate |
Provider intervention vs system redesign | ||||
Mean difference in depression rating scale scores | N = 861 | IMP | Provider interventions not statistically significantly different from comparator groups (SMD 0.09; CI − 0.48, 0.67) | Moderate |
Odds of depression treatment response | N = 478 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 0.53; CI 0.01, 40.38) | Moderate |
Odds of depression recovery | N = 478 | IMP | Provider interventions not statistically significantly different from comparator groups (OR 0.41; CI 0.01, 17.89) | Moderate |
Odds of depression treatment adherence | 1 RCT [53] N = 61 | S | Provider interventions not statistically significantly different from comparator groups (OR 0.16; CI 0.02, 1.39) | Very low |
Provider intervention vs other interventions | ||||
Odds of depression treatment adherence | 1 RCT [59] N = 171 | S, IMP | Provider intervention not statistically significantly different from motivational interviewing (OR 0.79; CI 0.30, 2.08) | Very low |
Mean difference in treatment adherence | 1 RCT [59] N = 171 | S | Provider intervention not statistically significantly different from motivational interviewing (SMD − 0.43; CI − 0.76, − 0.11) | Very low |