Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: a cluster randomised controlled trial

Implementation Science

Anton van Balkom²  Michel Wensing⁴  Berend Terluin³  Adriaan Hoogendoorn²  Daniëlle Volker¹  Maria Cristina Majo¹  Henny Sinnema¹ 

[1] Netherlands Institute of Mental Health and Addiction, Trimbos Institute, Utrecht, 3500 AS, The Netherlands;Department of Psychiatry, VU University Medical Centre and GGZinGeest, Amsterdam, 1081 HL, The Netherlands;Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, Amsterdam, 1000 SN, The Netherlands;Radboud University Medical Centre, Scientific Institute for Quality, Nijmegen, 6500 HB, The Netherlands

关键词: Cluster randomised controlled trial;    Implementation science;    Tailored interventions;    Primary care;    Depression;    Anxiety;   

Others  :  1139261
DOI  :  10.1186/s13012-015-0210-8

 received in 2014-06-19, accepted in 2015-01-22,  发布年份 2015

【 摘 要 】

Background

Anxiety and depression are not always diagnosed and treated in primary care as has been recommended. A tailored implementation programme, which addresses key barriers for change by targeted interventions, may help to remedy this.

Methods

The effectiveness of an individually tailored implementation programme, additional to standardised training and feedback on the recognition and treatment of patients with anxiety or depression in general practice, was examined in a cluster randomised controlled trial. Participants were 46 general practitioners (GPs) from 23 general practices (12 intervention, 11 control) and 444 patients aged 18 years or older (198 intervention, 246 control) who screened positive on the extended Kessler 10. In the control group, GPs received a 1-day training in guidelines for recognition and stepped treatment for anxiety and depression. Ten months after the training session, GPs received feedback on their performance over the preceding 6 months. In the intervention group, GPs received the same training and feedback as those in the control condition; in addition, they were offered support, tailored to perceived local barriers to change. The support was delivered in the format of peer group supervisions and personalised telephone consultations. Data were based on an audit of patient records and patient surveys at baseline and after 3 and 6 months.

Results

The tailored implementation programme led to recognition of a higher proportion of patients presenting with anxiety and depression (42% versus 31%; odds ratio (OR) = 1.60; 95% CI: 1.01–2.53), more consultations after recognition (IRR = 1.78; 95% CI: 1.14–2.78) and did not lead to more prescription of antidepressants (OR = 1.07; 95% CI: 0.52–2.19) or referral to specialist mental health services (OR = 1.62; 95% CI: 0.72–3.64). Patients in the intervention group reported better accessibility of care (effect size (ES) = 0.4; p < 0.05) and provision of information and advice (ES = 0.5; p < 0.05).

Conclusions

A tailored implementation programme may enhance the recognition and treatment of patients with anxiety or depression. Further development and evaluation of the programme is warranted to determine its cost-effectiveness.

Trail registration

Dutch Trial Register identifier NTR1912 webcite.

【 授权许可】

   
2015 Sinnema et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al.: Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004, 291:2581-90.
• [2]Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, de GG, Graaf R, Demyttenaere K, Gasquet I, et al.: Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl 2004, 420:38-46.
• [3]Gustavsson A, Svensson M, Jacobi F, Allgulander C, Alonso J, Beghi E, et al.: Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011, 21:718-79.
• [4]Verhaak PF, van Dijk CE, Nuijen J, Verheij RA, Schellevis FG: Mental health care as delivered by Dutch general practitioners between 2004 and 2008. Scand J Prim Health Care 2012, 30:156-62.
• [5]van Avendonk M, van Weel-Baumgarten E, van der Weele G, Wiersma T, Burgers JS: Summary of the Dutch College of General Practitioners’ practice guideline ‘Depression’. Ned Tijdschr Geneeskd 2012, 156:A5101.
• [6]van Avendonk MJ, Hassink-Franke LJ, Terluin B, van Marwijk HW, Wiersma T, Burgers JS: Summarisation of the NHG practice guideline ‘anxiety’. Ned Tijdschr Geneeskd 2012, 156:A4509.
• [7]Lecrubier Y: Widespread underrecognition and undertreatment of anxiety and mood disorders: results from 3 European studies. J Clin Psychiatry 2007, 68:36-41.
• [8]Piek E, Nolen WA, van der Meer K, Joling KJ, Kollen BJ, Penninx BW, et al.: Determinants of (non-) recognition of depression by general practitioners: results of the Netherlands Study of Depression and Anxiety. J Affect Disord 2012, 138:397-404.
• [9]Fernandez A, Haro JM, Martinez-Alonso M, Demyttenaere K, Brugha TS, Autonell J, et al.: Treatment adequacy for anxiety and depressive disorders in six European countries. Br J Psychiatry 2007, 190:172-3.
• [10]Smolders M, Laurant M, Verhaak P, Prins M, van Marwijk H, Penninx B, et al.: Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis. Gen Hosp Psychiatry 2009, 31:460-9.
• [11]Prins MA, Verhaak PF, Smolders M, Laurant MG, van der Meer K, Spreeuwenberg P, et al.: Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care. J Gen Intern Med 2010, 25:648-55.
• [12]Adli M, Bauer M, Rush AJ: Algorithms and collaborative-care systems for depression: are they effective and why? A systematic review. Biol Psychiatry 2006, 59:1029-38.
• [13]Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H: Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry 2004, 184:526-33.
• [14]Verhaak P, Prins MA, Spreeuwenberg P, Draisma S, van Balkom T, Bensing JM, et al.: Receiving treatment for common mental disorders. Gen Hosp Psychiatry 2009, 31:46-55.
• [15]Wittkampf KA, van Zwieten M, Smits FT, Schene AH, Huyser J, van Weert HC: Patients’ view on screening for depression in general practice. Fam Pract 2008, 25:438-44.
• [16]Tylee A, Walters P: Underrecognition of anxiety and mood disorders in primary care: why does the problem exist and what can be done? J Clin Psychiatry 2007, 68(Suppl 2):27-30.
• [17]Barley EA, Murray J, Walters P, Tylee A: Managing depression in primary care: a meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Fam Pract 2011, 12:47. BioMed Central Full Text
• [18]Smolders M, Laurant M, van Wamel A, Grol R, Wensing M: What determines the management of anxiety disorders and its improvement? J Eval Clin Pract 2008, 14:259-65.
• [19]van Dijk CE, Verheij RA, Spreeuwenberg P, van den Berg MJ, Groenewegen PP, Braspenning J, et al.: Impact of remuneration on guideline adherence: empirical evidence in general practice. Scand J Prim Health Care 2013, 31:56-63.
• [20]Baker R, Camosso-Stefinovic J, Gillies C, Shaw E, Cheater F, Flottorp S, Robertson N: Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Of Systematic Reviews (Online) 2010, 3:CD005470.
• [21]Callahan CM, Hendrie HC, Dittus RS, Brater DC, Hui SL, Tierney WM: Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc 1994, 42:839-46.
• [22]Baker R, Reddish S, Robertson N, Hearnshaw H, Jones B: Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice. Br J Gen Pract 2001, 51:737-41.
• [23]Sinnema H, Terluin B, Wensing M, Volker D, Franx G, van Balkom A, et al.: Systematic tailoring for the implementation of guideline recommendations for anxiety and depressive disorders in general practice: perceived usefulness of tailored interventions. BMC Fam Pract 2013, 14:94. BioMed Central Full Text
• [24]Forsetlund L, Bjorndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009., 15(2) Article ID CD003030
• [25]Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al.: Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012., 6Article ID CD000259
• [26]Sinnema H, Franx G, Volker D, Majo C, Terluin B, Wensing M, et al.: Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care. Implement Sci 2011, 6:75.
• [27]Donker T, Comijs H, Cuijpers P, Terluin B, Nolen W, Zitman F, et al.: The validity of the Dutch K10 and extended K10 screening scales for depressive and anxiety disorders. Psychiatry Res 2010, 176:45-50.
• [28]Terluin B, van Heest F, van der Meer K, Neomagus G, Hekman J, Aulbers L, et al.: Dutch College of General Practitioners guideline: anxiety disorder, first revision [NHG-Standaard Angststoornissen, eerste herziening. In Dutch]. Huisarts en Wetenschap 2004, 47:26-37.
• [29]Richtlijnwerkgroep Multidisciplinaire richtlijnen Angststoornissen en Depressie: Multidisciplinary guideline anxiety disorders: guideline for diagnostics and treatment of adult clients with an anxiety disorder, first revision [Multidisciplinaire richtlijn Angststoornissen. Trimbos-instituut, Utrecht; 2009.
• [30]Van Marwijk HWJ, Grundmeijer HGLM, Bijl D, Van Gelderen MG, De Haan M, Van Weel-Baumgarten EM: Dutch College of General Practitioners guideline: depression, first revision [NHG-Standaard Depressieve stoornis (depressie). Eerste herziening. In Dutch]. Huisarts Wetenschap 2003, 46:614-23.
• [31]Terluin B, van Marwijk HW, Ader HJ, de Vet HC, Penninx BW, Hermens ML, et al.: The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 2006, 6:34. BioMed Central Full Text
• [32]Haaga DA: Introduction to the special section on stepped care models in psychotherapy. J Consult Clin Psychol 2000, 68:547-8.
• [33]Katon W, von Korff M, Lin E, Simon G, Walker E, Unutzer J, et al.: Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999, 56:1109-15.
• [34]Von Korff M, Tiemens B: Individualized stepped care of chronic illness. West J Med 2000, 172:133-7.
• [35]van Rijswijk E, van Hout H, van de Lisdonk E, Zitman F, van Weel C: Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced by family physicians; a focus group study. BMC Fam Pract 2009, 10:52. BioMed Central Full Text
• [36]Henke RM, Chou AF, Chanin JC, Zides AB, Scholle SH: Physician attitude toward depression care interventions: implications for implementation of quality improvement initiatives. Implement Sci 2008, 3:40. BioMed Central Full Text
• [37]Smith L, Walker A, Gilhooly K: Clinical guidelines of depression: a qualitative study of GPs’ views. J Fam Pract 2004, 53:556-61.
• [38]Lamberts HWM: International Classification of Primary Care (ICPC). Oxford University Press, Oxford; 1990.
• [39]Liddy C, Wiens M, Hogg W: Methods to achieve high interrater reliability in data collection from primary care medical records. Ann Fam Med 2011, 9:57-62.
• [40]Chwastiak LA, Von Korff M: Disability in depression and back pain Evaluation of the World Health Organization Disability Assessment Schedule (WHO DAS II) in a primary care setting. J Clin Epidemiol 2003, 56:507-14.
• [41]Ustun TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Epping-Jordan J, et al.: Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ 2010, 88:815-23.
• [42]Sixma HJ, Kerssens JJ, van Campen C, Peters L: Quality of care from the patients’ perspective: from theoretical concept to a new measuring instrument. Health Expect 1998, 1:82-95.
• [43]Hickie IB, Davenport TA, Scott EM, Hadzi-Pavlovic D, Naismith SL, Koschera A: Unmet need for recognition of common mental disorders in Australian general practice. Med J Aust 2001, 175(Suppl):S18-24.
• [44]Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L, et al.: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004, 8(6):1-72. iii-iv
• [45]Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ: Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol 2004, 57:785-94.
• [46]Twisk JWR: Applied multilevel analysis. Cambridge University Press, Cambridge; 2006.
• [47]Royston P, White IR: Multiple Imputation by Chained Equations (MICE): implementation in stata. J Stat Softw 2011, 45:1-20.
• [48]van Buuren S, Boshuizen HC, Knook DL: Multiple imputation of missing blood pressure covariates in survival analysis. Stat Med 1999, 18:681-94.
• [49]Morris SB: Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods 2008, 11:364-86.
• [50]Hingstman L, Kenens RJ: Figures from the registration of general practitioners: survey 2010 [in Dutch]. NIVEL, Utrecht; 2010.