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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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

Factors associated with the impact of quality improvement collaboratives in mental healthcare: An exploratory study

<p>Abstract</p> <p>Background</p> <p>Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning, and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia.</p> <p>Methods</p> <p>We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and process of care outcomes for 1,346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning, and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia.</p> <p>Results</p> <p>No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results, although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success.</p> <p>Conclusions</p> <p>No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.</p

Quality improvement in depression care in the Netherlands: the Depression Breakthrough Collaborative. A quality improvement report

Background: Improving the healthcare for patients with depression is a priority health policy across the world. Roughly, two major problems can be identified in daily practice: (1) the content of care is often not completely consistent with recommendations in guidelines and (2) the organization of care is not always integrated and delivered by multidisciplinary teams. <br><br> Aim: To describe the content and preliminary results of a quality improvement project in primary care, aiming at improving the uptake of clinical depression guidelines in daily practice as well as the collaboration between different mental health professionals. <br><br> Method: A Depression Breakthrough Collaborative was initiated from December 2006 until March 2008. The activities included the development and implementation of a stepped care depression model, a care pathway with two levels of treatment intensity: a first step treatment level for patients with non-severe depression (brief or mild depressive symptoms) and a second step level for patients with severe depression. Twelve months data were measured by the teams in terms of one outcome and several process indicators. Qualitative data were gathered by the national project team with a semi-structured questionnaire amongst the local team coordinators. <br><br> Results: Thirteen multidisciplinary teams participated in the project. In total 101 health professionals were involved, and 536 patients were diagnosed. Overall 356 patients (66%) were considered non-severely depressed and 180 (34%) patients showed severe symptoms. The mean percentage of non-severe patients treated according to the stepped care model was 78%, and 57% for the severely depressed patient group. The proportion of non-severely depressed patients receiving a first step treatment according to the stepped care model, improved during the project, this was not the case for the severely depressed patients. The teams were able to monitor depression symptoms to a reasonable extent during a period of 6 months. Within 3 months, 28% of monitored patients had recovered, meaning a Beck Depression Inventory (BDI) score of 10 and lower, and another 27% recovered between 3 and 6 months. <br><br> Conclusions and discussion: A stepped care approach seems acceptable and feasible in primary care, introducing different levels of care for different patient groups. Future implementation projects should pay special attention to the quality of care for severely depressed patients. Although the Depression Breakthrough Collaborative introduced new treatment concepts in primary and specialty care, the change capacity of the method remains unclear. Thorough data gathering is needed to judge the real value of these intensive improvement projects

Sedentary aging results in structural impairment of the neuromuscular junction and may be attenuated by voluntary endurance exercise

An increasingly prominent change in the aging body is the decrease in muscle mass and strength, a condition known as sarcopenia. This is a major cause for the instability in elderly individuals leading to falls and injuries. One possible cause of sarcopenia is the reduced exercise activity of older individuals. The neuromuscular junction (NMJ) is the connection by which nerves control muscle movement. This study mainly aims to investigates the possibility that alterations in the structures of the neuromuscular junction with ageing might contribute to impaired control and physical maintenance of aging muscle. Changes in the NMJ include the loss of nerve terminal from the postsynaptic membrane leading to denervation and fragmentation of postsynaptic clusters of acetylcholine receptors (AChRs) resulting in tiny islands of receptors. Exercise in ageing animals and humans have shown to have some positive effects on sarcopenic related changes like slowing down the rate of loss in muscle mass and strength. In the neuromuscular junction of old animals and rodents that exercised the age related changes were reported to be less severe and in some cases the NMJ recovered

The effect of local Suicide Prevention Action Networks (SUPRANET) on stigma, taboo and attitudes towards professional help-seeking: an exposure–response analysis

Purpose: In 2017, the European Alliance against Depression (EAAD) programme was introduced in the Netherlands through the creation of six local Suicide Prevention Action Networks (SUPRANET Community). This programme consists of interventions on four levels: (1) a public awareness campaign, (2) training local gatekeepers, (3) targeting high-risk persons in the community and (4) training of primary care professionals. This study aims to gain insight into the effectiveness of the SUPRANET programme on attitudinal changes in the general public by studying the exposure–response relationship. Methods: A repeated cross-sectional design, using general population surveys to measure key variables over time. The surveys were conducted in the six intervention regions (N = 2586) and in the Netherlands as a whole as a control region (N = 4187) and include questions on socio-demographic variables, brand awareness of the Dutch helpline, perceived taboo on suicide, attitudes towards depression and help-seeking. To examine the exposure–response relationship, regions were diff

The impact of a suicide prevention awareness campaign on stigma, taboo and attitudes towards professional help-seeking

Background: In 2017, the European Alliance against Depression (EAAD) was introduced in The Netherlands through the creation of six Suicide Prevention Action Networks (SUPRANET Community). The intervention was launched with a national suicide prevention awareness campaign. This campaign aims to encourage the general public to talk about suicide. This study aimed to gain insight into the effectiveness of the campaign in achieving attitudinal change in the general public, as stigmas related to mental health disorders and -services are an important reason for insufficient help-seeking. Methods: A repeated cross-section design, using general population surveys (N = 6,773) to measure key variables over time. The survey includes questions on socio-demographic variables, campaign visibility, brand awareness of the Dutch helpline, perceived taboo on suicide, attitudes towards depression and help-seeking. Results: The public awareness campaign was predominantly visible among the younger generation. Respondents who indicated having seen the public awareness campaign showed more openness towards seeking professional help and were considerably more likely to be familiar with the Dutch helpline than those who reported not having seen the campaign. Campaign awareness also seemed to relate to a higher perceived taboo on suicide and a lower estimation o

A multi-method psychological autopsy study on youth suicides in the Netherlands in 2017:Feasibility, main outcomes, and recommendations

Objectives: In the Netherlands, there was a sharp increase in the number of suicides among 10- to 19-year-olds in 2017. A multi-method psychological autopsy study (PA) was conducted to assess feasibility, identify related factors, and study the interplay of these factors to inform suicide prevention strategies. Methods: Coroners identified youth suicides in 2017 in their records and then general practitioners (GPs) contacted the parents of these youths. Over a period of 7 months, 66 qualitative interviews were held with the parents, peers, and teachers, providing information on precipitating factors and five topics involving 35 cases (17 boys and 18 girls, mean age 17 years). Furthermore, 43 parents and care professionals filled in questionnaires to examine risk and care-related factors. Qualitative and quantitative analyses were performed. Results: Although registration problems faced by coroners and resistance to contacting bereaved families by GPs hampered the recruitment, most parents highly appreciated being interviewed. Several adverse childhood experiences played a role at an individual level, such as (cyber) bullying, parental divorce, sexual abuse, as well as complex mental disorders, and previous suicide attempts. Two specific patterns stood out: (1) girls characterized by insecurity and a perfectionist attitude, who developed psychopathology and dropped out of school, and (2) boys with a developmental disorder, such as autism, who were transferred to special needs education and therefore felt rejected. In addition, adolescents with complex problems had difficulty finding appropriate formal care. Regarding potential new trends, contagion effects of social media use in a clinical setting and internet use for searching lethal methods were found. Conclusion: This first national PA study showed that, as expected, a variety of mostly complex clusters of problems played a role in youth suicides. An infrastructure is needed to continuously monitor, evaluate, and support families after each youth suicide and thereby improve prevention strategies

Implementing a stepped-care approach in primary care: results of a qualitative study

Contains fulltext : 108260.pdf (publisher's version ) (Open Access)BACKGROUND: Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands. METHODS: Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT). RESULTS: The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process. CONCLUSIONS: Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process

Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care

Contains fulltext : 96261.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care. The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors. Designing implementation strategies tailored to prospectively identified barriers could lead to more guideline-recommended care. Although tailoring of implementation strategies is promoted in practice, little is known about the effect on improving the quality of care for the early recognition, diagnosis, and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice. This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone. METHODS: In this cluster randomised controlled trial, a total of 22 general practices will be assigned to one of two conditions: (1) training, feedback, and tailored interventions and (2) training and feedback. The primary outcome measure is the proportion of patients who have been recognised to have anxiety and/or depressive disorder. The secondary outcome measures in patients are severity of anxiety and depressive symptoms, level of functioning, expectation towards and experience with care, quality of life, and economic costs. Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups. Secondary outcome measures in general practitioners are adherence to guideline-recommended care in care that has been delivered, the proportion of antidepressant prescriptions, and number of referrals to specialised mental healthcare facilities. Data will be gathered from the electronic medical patient records from the patients included in the study. In a process evaluation, the identification of barriers to change and the relations between prospectively identified barriers and improvement interventions selected for use will be described, as well as the factors that influence the provision of guideline-recommended care. DISCUSSION: It is hypothesised that the adherence to guideline recommendations will be improved by designing implementation interventions that are tailored to prospectively identified barriers in the local context of general practitioners. Currently, there is insufficient evidence on the most effective and efficient approaches to tailoring, including how barriers should be identified and how interventions should be selected to address the barriers. TRIAL REGISTRATION: NTR1912