Background
Prioritised recommendations | Full recommendation to be discussed in the groups and interviews |
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1. Social contact | Primary care physicians and other health care professionals should discuss social contact with elderly patients with depression, and recommend actions (e.g. group activities) for those who have limited social contact When needed, regular social contact with trained volunteers, recruited from centres for voluntary organisations, the red cross, mental health or community day care centres When possible, the patient’s relatives should be involved in the plan to improve social contact |
2. Collaborative care plan | All municipalitiesa should develop a plan for collaborative care for patients with moderate to severe depression. The plan should describe the responsibilities and communication between professionals who have contact with the patient, within primary care and between primary and specialist care. In addition, the plan should appoint depression case managers who have a responsibility for following the patient. The plan should describe routines for referral to specialist care |
3. Depression case manager | Primary care physicians should offer patients with moderate to severe depression regular contact with a depression case manager |
4. Counselling | Primary care physicians or qualified health care professionals should offer advice to elderly patients with depression regarding: Self-assisted programs, such as literature or web-based programs based on cognitive behavioural therapy principles Structured physical activity programmes, individually or group-based Healthy sleeping habits Anxiety coping strategies Problem solving therapy |
5. Mild depression | Primary care physicians should usually not prescribe antidepressants to patients with mild depression. Primary care physicians may consider prescribing antidepressant medication to patients who suffer from a mild episode of depression and have previously responded to antidepressant medication when moderately or severely depressed |
6. Severe depression, recurrent and chronic depression and dysthymia | Primary care physicians should offer these patients a combination of antidepressant medication and psychotherapy. If the physician is not trained to provide the patient with psychotherapy, patients should be referred to trained health care professionals |
Research | Norwegian (elderly patients with depression) publications | Cross-country TICD publications |
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Project protocol | Wensing et al. [3] (protocol) | |
Identification of determinants | Aakhus et al. [14] | Krause et al. [34] |
Selection of interventions to address the identified determinants | This paper | |
Cluster randomised trials to address the identified determinants | Aakhus et al. [4] (Study protocol) (a report of the results has not yet been completed or submitted for publication) | Baker et al. [10] (a future update of this review will include the results of the TICD trials) |
Process evaluations to address the validity of the tailoring methods | A report of the process evaluation has not yet been completed or submitted for publication | Jager et al. [18] (protocol) (a report of the results has not yet been completed or submitted for publication) |
Methods
Domain |
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1. Support for a collaborative care plan for elderly patients with moderate or severe depression |
a. Development of the plan (offer templates and reminders that were essential for the plan, and that could be tailored to each municipality) |
b. Content of the plan (suggested content, including recommendations, that describes the management of depression in the elderly that the municipality could include in the plan) |
2. Resources for GPs and other health care personnel (leaflets, templates, manuals) |
3. Resources for patients and their relatives (leaflets, manuals) |
4. Outreach visits for GPs (presentation of recommendations, the evidence for the recommendations, determinants of practice for the recommendation and any local circumstances that may impede or facilitate adherence that would imply an adjustment of the strategy to local determinants) |
5. Educational courses for GPs, other health care professionals, patients and their relatives, including CME courses for GPs and courses approved for nurses and other healthcare professionals |
6. Online services (a web-site with all the resources, including e-learning courses) |
Recommendation | Determinant [14] |
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Social contact | Finding volunteers |
Lack of awareness of local community/services | |
Social withdrawal in elderly patients with depression | |
Lack of connection between the patient and volunteers | |
Requires organising the service | |
Collaborative care plan | 1. Actionable plans with shared ownership increases the plan’s feasibility |
2. Lack of coordination within municipalities, especially between GPs and other municipal services | |
3. Implementation of the plan | |
Depression case manager | 1. A description for how the doctor should proceed |
2. Good relationship between patient and depression case manager | |
3. If the person is completely alone in the task | |
Counselling | 1. GP’s time constraint |
2. Health professionals believe self-help program is not beneficiary for this population | |
3. There is a shortage of this type of service | |
4. Lack of expertise for counselling among GPs and other health professionals | |
Antidepressants in mild depression | 1. GPs time constraint |
2. Patient information that drugs do not help in mild depression | |
3. Difficult to reverse a trend where the doctor has been told that they prescribe antidepressants too seldom | |
4. Lack of other types of services makes it difficult to adhere | |
5. GP wants to “do something”, drugs are simple actions | |
Severe, recurrent and chronic depression, dysthymia | 1. GPs do not have this expertise (psychotherapy) |
2. Elderly are not prioritised for this type of service | |
3. Lack of health professionals who can provide this type of service |
Setting and sample
Group interviews
Deviation from the common TICD protocol
Analysis
Recommendation: social contact | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Collaborative care plan
a. Include key personnel, e.g. leaders for voluntary organisations who can help identifying voluntary | Such as Centre for volunteers, Centre for healthy life, charity organisations (Lions, Red Cross), congregations and fitness centres | Identify key personnel in each municipality | Finding volunteers |
Collaborative care plan. Provide a model agreement between the municipality and voluntary organisations that clarifies expectations, responsibilities follow-up and monitoring | Provide a model agreement between the municipality and voluntary organisations that clarifies expectations, responsibilities (such as a contact or an office), communications (such as, for instance, a website, neighbourhood/local newspaper, posters), follow-up and monitoring | ||
Educational resources. Educate voluntary in communication with depressed patients | |||
Collaborative care plan. Inform relatives, use existing local knowledge within the community (e.g. home-based nurse staff, voluntary organisations, congregations) | Identify persons who possess local knowledge on voluntary organisations and volunteers | ||
Collaborative care plan. Include key personnel | Such as family, GP, home based nursing services, health centre for the elderly, municipality’s cultural agency, Council or the elderly and the union for retirees. | Lack of awareness of local community/services | |
Collaborative care plan. Help to obtain an overview of services in the community | Such as obtain an overview in one place, e.g. by the home based nurse services administration, responsible for contacting voluntary organisations for an overview | ||
Collaborative care plan. Provide information via brochures, advertisements in the local newspaper, the municipalities’ website | Information tailoredb to each community | ||
Collaborative care plan. Outreach activities (e.g. letter to all over 80, information in the media | Social withdrawal in elderly patients with depression | ||
Resources for patients and their relatives. Information to patients and their relatives on social contact, alternatives to antidepressants and counselling | Such as brochures aimed at patients and their families, contacting elderly who do not attend consultations or their relatives) | ||
Collaborative care plan. Describe the role of senior centres and health clinics for the elderly to reduce social withdrawal | |||
Resources for GPs and other health care professionals. Provide contact information for physical activity, voluntary organizations, senior centres, etc. | e.g. a contact/coordinator of the municipal/district, using brochures | Templates for how the municipality could publish contact | Lack of connection between the patient and the volunteer |
Collaborative care plan. Create a job description that helps the municipality to find suitable persons who can lead the efforts | Create templates with a job description that each municipality could fit to local routines | Requires organisation | |
Collaborative care plan. Consider the financial resources to motivate people to take this work |
Recommendation: collaborative care plan | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Collaborative care plan. Including key personnel in the development of the plan | Key personnel such as coordinator/office for approval of health services, GP/GP committees, Community based psychiatric centres, and impose key personnel to help in the development of the plan | Template for the plan should be adapted to each municipality and include key personnel | Actionable plans with shared ownership increases the plan’s feasibility |
Collaborative care plan. Include The Norwegian Association of Local and Regional Authorities (KS) and local opinion leaders in the work with the plan and presentation of recommendations | |||
Collaborative care plan. Help to make it convenient to implement the plan (e.g., to create a comprehensive plan for psychiatry, where seniors also have a place) | |||
Collaborative care plan. Help to develop a dissemination and implementation plan | |||
Collaborative care plan. The plan must be consistent with the national collaboration reform | |||
Collaborative care plan. Exchange experiences (good/bad) across municipalities | |||
Online services. Support for electronic communication between health care personnel in the community and specialists if possible | Lack of coordination within municipalities, especially between GPs and other municipal services | ||
Collaborative care plan. Help to develop a dissemination and implementation plan | Implementation of the plan | ||
Collaborative care plan—content. Describe the recruitment of care managers to obtain suitable personnel (use local knowledge to identify particularly suitable people) | Provide templates for a job description that could be adapted to each municipality and provide help to identify suitable professionals | ||
Collaborative care plan—content. Clarify the individual tasks with clear guidelines and support for them to adhere | Assign one person to the responsibility for the plan (e.g. CMO) | Name the person or the applied role in the system that carry the responsibility for the plan | |
Collaborative care plan—development. Include The Norwegian Association of Local and Regional Authorities (KS) and local opinion leaders in the work with the plan and presentation of the recommendations | The plan should be politically/administratively anchored | ||
Collaborative care plan—content. Help to implement the plan in practice | e.g. through regular meetings. If necessary; compel health professionals to implement the plan | ||
Collaborative care plan. Arrangements for monitoring and evaluation of the plan (e.g. via notification systems, involving health committee) | |||
Collaborative care plan—development. A model plan with a checklist of both the process to make the plan and the content of the plan | |||
Online services. Web page with all the resources and recommendations | |||
Collaborative care plan. Arrangements for dissemination and implementation of the plan |
Recommendation: depression case manager | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Outreach visits to GPs. Inform GPs about the concept and evidence supporting the CM, and how referral should be done | A description for how the GP should proceed | ||
Resources for GPs and other health care professionals—Structured referral forms to case manager, web-based and integrated in journal | Provide templates for referral that can be adjustedb to each municipality | ||
Collaborative care plan—content. Establish CM services in each municipality and effective referral practices of GPs to CM | Consider initiating contact between doctor, patient and CM. CM can be a GP assistant in the GP practice or another appropriate person in primary care | ||
Collaborative care plan—content. A plan for support/guidance/counselling for CM | Good relationship between patient and depression case manager | ||
Educational resources. Training in communication with depressed patients for CMs | |||
Educational resources. Inform CM that family members should be involved when necessary | |||
Collaborative care plan—content. A plan for support/guidance/counselling for CM | e.g. establish groups for CMs, supervised by GPs, psychiatric nurses or specialist health care | If the person is completely alone on the task | |
Online services. Integrate recommendations and resources to medical records systems |
Recommendation: counselling | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees | GPs’ time constraint | ||
Outreach visits to GPs. Clarify to GPs that older with moderate to severe depression profit from counselling | Targetb and adjust this information to each outreach visit | ||
Outreach visits to GPs. Consider if other health professionals than GPs can offer counselling | Identify personnel that exhibit these skills in each municipality during outreach visits | ||
Outreach visits to GPs. Emphasize for GPs that we have alternatives to antidepressants for mild depression that are more effective and less harmful | Health professionals believe self-help program is not beneficiary for this population | ||
Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals |
Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals | There is a shortage of this type of service | |
Collaborative care plan. Identify services to determine if it is right that the services are missing | As part of the plan | ||
Outreach visits. Identify services to determine if it is right that the services are missing | As part of outreach visits | ||
Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals | Lack of skills to provide counselling among GPs and healthcare | ||
Educational resources. Courses for GPs must merit for the speciality (CME credits) (15 h) and can be a combination of web-based courses and educational meetings | |||
Educational resources. E-learning courses and other forms of informing healthcare professionals about the recommendations and in particular techniques for counselling and motivation, | Training for GPs should be designed as a clinical topic course and merit for CME credits |
Recommendation: antidepressants in mild depression | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees | GPs’ time constraint | ||
Resources for patients and their relatives. Information to patients and their relatives on social contact, alternatives to antidepressants and counselling | e.g. information presented in brochures and on websites | Information forms that allow the GP to tailor information to patients | Patient information that drugs do not help in mild depression |
Outreach visits to GPs. Provide evidence for not using antidepressants for mild depression and inform that we have better alternatives | Difficult to reverse a trend where the doctor has been told that they prescribe antidepressants too rarely | ||
Outreach visits to GPs. Emphasize for GPs the need for grading the severity of depression using appropriate tools, such as MADRS, for diagnosis and follow-up | |||
Outreach visits to GPs. Discuss the idea that GPs feel that they are accused of prescribing antidepressants too seldom | |||
Resources for GPs and other healthcare professionals. Offer monitoring and feedback to GPs, preferably in groups | Use existent groups or discuss with leaders of local GP groups whether new groups could be created | ||
Educational courses. Provide training in counselling as problem solving therapy, anxiety coping and sleep habits, for instance as e-learning courses | Lack of other types of services makes it difficult to adhere | ||
Educational courses. Courses for GPs must merit for the speciality (15 h) and can be a combination of web-based courses and meetings | |||
Educational courses. E-courses and other courses to inform healthcare professionals about the recommendation, and in particular techniques for counselling and motivation | |||
Outreach visits to GPs. Discuss this with GPs. Suggest strategies to avoid prescribing antidepressants | GP wants to “do something”, drugs are simple actions |
Recommendation: Antidepressants and psychotherapy in severe and recurrent depression | |||
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Draft plan from the research team | Modifications or new interventions from the group sessions | Adaptation to municipalities or practices | Targeted determinant (see Table 3) |
Resources for general practitioners and other health care professionals. Structured referral forms to psychotherapy | to private specialists, district based psychiatric centres and old age psychiatry | Templates for referral may be adjusted to each municipality | GPs do not have this expertise (psychotherapy) |
Resources for patients and their relatives. Information to patients and their families about the combined treatment (psychotherapy and antidepressants) | Elderly are not prioritised for this type of service | ||
Collaborative care plan—development. Include key personnel in the development of the plan (managers, administrators, specialists in private practices, GPs, GPs’ committees, nurses, specialist care, patients and relatives) | |||
Collaborative care plan—content. A clear message in the plan about access to psychotherapy for the elderly with severe depression with community based psychiatric centres and private practitioners | Templates for the description of specialist care adjusted to the municipality and the collaborating specialists/specialist services | ||
Collaborative care plan—content. State that the recommendations are in accordance with national guidelines | e.g. in the media | ||
Outreach visits. Clarify that older with moderate to severe depression profit from psychotherapy | |||
Educational courses. Training in cognitive therapy for general practitioners and psychiatric nurses for those who want it | Lack of health professionals who can provide this type of service | ||
Resources for GPs and other healthcare professionals. Structured referral forms to psychotherapy | Templates for referral forms adjusted to each municipality |