Background
Methods
Study design and selection of participants
Indicators of “optimal care”
Indicators | |
---|---|
I Early recognition and indicated prevention
| |
1.1 | Use of a screening instrument in patients who are suspected of having a depression |
II Self-management and e-health interventions
| |
2.1 | Providing self-management and/or e-health interventions to patients with depressive symptoms or a mild depression |
III Diagnosis and treatment according to the stepped care model
| |
IIIa.
|
Diagnosis and symptom severity
|
3.1 | Measurement of the severity of the depression prior to possible treatment |
IIIb.
|
Applying basic interventions
|
*3.2 | Providing educational material to patients with depression |
IIIc.
|
Providing stepped care treatment
|
3.3 | Providing first step and brief interventions to patients with a mild depression#
|
3.4 | Providing psychotherapy and/or pharmacotherapy to patients with a moderate to severe major depressive disorder or a recurrent depression#
|
3.5 | Systematically monitoring changes in the severity of the depression in patients with a validated instrument |
IV Disease management and collaborative care in recurrent or severe or prolonged depression
| |
4.1 | Making collaborative care agreements when multiple health care providers are involved in the treatment of a patient with a (severe or prolonged) depression (“who does what”) |
*4.2 | Making agreements about referral of patients from secondary mental health care to primary care |
V Relapse prevention, rehabilitation and participation
| |
5.1 | Providing relapse prevention#
|
5.2 | Providing ongoing counselling to patients with chronic depression (who are referred back from secondary care)#
|
Data collection methods
Individual interviews with the GPs
Group interviews with the GPs and mental health care professionals
Self-assessment questionnaire for the GPs
Data collection
Data analysis
Results
Study population
Characteristics per GP | GP 1 | GP 2 | GP 3 | GP 4 | GP 5 | GP 6 |
---|---|---|---|---|---|---|
Organisational preconditions for optimal depression care available*
| No | No | No | Yes | Yes | Yes |
Region of the Netherlands
| North | Middle | South | North | Middle | South |
Sex
| Woman | Man | Man | Woman | Woman | Man |
Age
| 47 | 39 | 56 | 60 | 43 | 58 |
Specific interest in depression
| No | Yes | No | Yes | Yes/No | No |
Training on depression (last 3 years)
| No | Yes | No | Yes | Yes | Yes |
Participation in quality improvement project on depression
| No | No | No | Yes | Yes | Yes |
Mental health care providers on-site
| MHN | No | No | MHN, PCP, PP | MHN, PCP, PP | MHN (2x) |
Document on collaboration within primary care
| No | No | No | Yes (limited) | No | Yes (limited) |
Document on collaboration with secondary care
| No | No | No | No | No | No |
Other disciplines in group interview
| MHN, PCP, psychiatrist | SPN, PCP (2x), GSW, AOP | Psychiatrist, pharmacist, GSW, physio-therapist | MHN, PCP (2x), PP | MHN, PCP | MHN (2x), PCP, GSW |
Research question 1: Is there a gap between routine care and optimal care?
GP 1 | GP 2 | GP 3 | GP 4 | GP5 | GP 6 | |
---|---|---|---|---|---|---|
Organisational preconditions for optimal depression care available
$
| No | No | No | Yes | Yes | Yes |
1.1 Use of a screening instrument in patients who are suspected of having a depression
| Yes* | Yes | No* | Yes | No | Yes |
25-50%#
| 1-25% | 0% | 75-100% | 0% | 50-75% | |
2.1 Providing self-management and/or e-health interventions to patients with depressive complaints or a mild depression.
| Yes | Yes | No | Yes | No | Yes |
1-25% | 75-100% | 0% | 25-50% | 0% | 25-50% | |
3.1 Measurement of the severity of the depression prior to possible treatment
| Yes | No | No | No | No | Yes |
1-25% | 0% | 0% | 0% | 0% | 50-75% | |
3.2 Providing educational material to patients with depression
| Yes | Yes | No | Yes | Yes | Yes |
75-100% | 1-25% | 0% | 1-25% | 1-25% | 25-50% | |
3.3 Providing first step and brief interventions to patients with a mild depression
| Yes | Yes | Yes | Yes | Yes | Yes |
50-75% | 75-100% | 25-50% | 75-100% | 25-50% | 50-75% | |
3.4 Providing psychotherapy and/or pharmacotherapy to patients with a moderate to severe major depressive disorder or a recurrent depression
| Yes | Yes | Yes | Yes | Yes | Yes |
50-75% | 75-100% | 75-100% | 50-75% | 25-50% | 75-100% | |
3.5 Systematically monitoring changes in the severity of the depression with a validated instrument
| No | No | No | No | No | yes |
0% | 0% | 0% | 0% | 0% | 25-50% | |
4.1 Making collaborative care agreements when multiple health care providers are involved in the treatment of a patient with a (severe or prolonged) depression (“who does what”)
| Yes | No | No | Yes | Yes | No |
25-50% | 0% | 0% | ? | 25-50% | 0% | |
4.2 Making agreements about referral of patients from secondary mental health care to primary care
| No | No | No | No | No | Yes |
5.1 Providing relapse prevention
| Yes | Yes | Yes | Yes | Yes | Yes |
25-50% | 75-100% | 75-100% | ? | 25-50% | 1-25% | |
5.2 Providing ongoing counselling to patients with chronic depression (who are referred back from secondary care)
| No | No | No | Yes | No | No |
0% | 0% | 0% | 50-75% | 0% | 0% |
Research question 2: What factors influenced the delivery of optimal care?
Factors on the level of the … | Facilitators | Barriers |
---|---|---|
Innovation itself | • A screening or monitoring instrument can help in talking with patients about their symptoms (indicator 1.1) | • Unclear for which patient subgroups certain interventions are appropriate (indicator 2.1) |
Individual professional | • Having a special interest in mental health problems (indicator 3.3) | • Contentment with the current routine care (the GPs considered the provision of pharmacological and psychological interventions the most important elements of depression care, and they could provide these interventions to their patients) (indicators 3.3, 3.5, 5.1) |
• The perceived proximity of primary mental health care providers (indicators 4.1 and 4.2) | ||
• The availability of instruments or interventions that have practical clinical usefulness (indicators 1.1, 2.1, 3.1, 3.3, 3.5) | ||
• Unfamiliarity with certain interventions or tools (e.g. e-health interventions, relapse prevention, interventions for patients with chronic depression) (indicators 1.1, 2.1, 3.1, 3.2, 3.3, 3.5, 5.1, 5.2) | ||
Patient | • Patient preferences for certain interventions (indicator 2.1, 3.3, 3.4) | • Not having internet access, e-health interventions therefore unavailable (indicators 2.1, 3.2) |
• The GP cannot lose sight of the patients; they go to the GP now and then anyway for other reasons than psychological problems (indicators 5.1, 5.2) | ||
• Costs associated with health care use (patients prefer care that is without charges) (indicator 3.3) | ||
• Poor adherence to treatment (indicator 5.2) | ||
Organisational context | • An MHN is available in primary care (who has, for example, more time to assess and monitor symptom severity systematically) (indicators 1.1, 3.1, 3.5, 4.1, 5.1, 5.2) | • Lack of collaboration between primary care and secondary mental health care (e.g. no agreements in place with secondary care about care delivery) (indicators 3.4, 4.1, 4.2, 5.1) |
• Easy access to interventions (indicator 3.2) | ||
• Close collaboration and regular consultation within primary care (indicators 1.1, 2.1, 3.3, 5.1) | • Lack of proper and timely reports from secondary to primary care about referred patients (indicators 4.1, 4.2) | |
• Participation in a quality improvement project on depression care (indicators 1.1, 3.1, 3.3, 3.5, 4.1, 5.2) | • Investing in education, time and effort to achieve knowledge and experience (indicator 5.2) | |
• Having agreements on indication criteria and treatment policy within primary care (indicators 1.1, 3.1, 3.3, 4.1) | ||
Economic and political context | • Financial incentives to improve collaboration between primary and secondary mental health care (indicators 4.1, 4.2, 5.1, 5.2) | • The different financial structures for primary and secondary care (indicators 2.1, 4.1, 4.2, 5.1) |
• Financial contributions that patients have to pay for certain care providers (indicators 3.3, 3.4, 4.1, 4.2) | ||
• Financial incentives to promote the referral of patients back to primary care when appropriate (indicator 5.1) | ||
• Lack of incentives from the professional association of GPs (indicators 3.2, 5.2) |