Abstract
BackgroundSince 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.MethodsAlongside 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).ResultsThe 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.ConclusionsStepped 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.
Highlights
Since 2004, ‘stepped-care models’ have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care
In this study we present the findings of a qualitative process evaluation, within a controlled study looking at the effectiveness of a depression Quality Improvement Collaborative (QIC)
We used Gunn’s Normalisation Process Theory (NPT) framework on depression [20] to help understand and further interpret the qualitative findings. Because this framework is a ‘conceptual framework for implementing best practice depression care that is informed by NPT’ we considered the additional use of the framework of interest to generate a more in-depth understanding of the stepped-care implementation process [20]
Summary
Since 2004, ‘stepped-care models’ have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. Since 2004, ‘stepped-care models’ have been adopted in several international evidence-based clinical guidelines on depression globally [1,2,3]. Despite the positive recommendations in guidelines, the embedding of stepped depression care in normal daily primary care asks for a paradigm shift that has not been fully achieved. This is illustrated by previous research, which found that antidepressant prescription rates remained high and unrelated to symptom severity, and that cost-effective alternatives for patients with mild depression are still underused [12,13,14]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
