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01.12.2014 | Research article | Ausgabe 1/2014 Open Access

BMC Family Practice 1/2014

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

BMC Family Practice > Ausgabe 1/2014
Marleen LM Hermens, Anna Muntingh, Gerdien Franx, Peter T van Splunteren, Jasper Nuyen
Wichtige Hinweise

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MH drafted the manuscript. JN and GF conceived the study. MH, GF, PvS, and JN designed the methods. MH, AM, PvS, and JN collected the data. AM, GF and MH performed the qualitative content analysis. AM, GF, PvS, and JN helped to draft the manuscript. All authors have read and approved the final manuscript.



Depression 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.


Optimal 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.


Six 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.


The 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.
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