Content uploaded by Jan Koetsenruijter
Author content
All content in this area was uploaded by Jan Koetsenruijter on Oct 12, 2014
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
Content uploaded by Michel Wensing
Author content
All content in this area was uploaded by Michel Wensing on May 28, 2014
Content may be subject to copyright.
R E S E A R C H A R T I C L E Open Access
Implementing guidelines for depression on
antidepressant prescribing in general practice: a
quasi-experimental evaluation
Gerdien Franx
1*
, Jochanan Huyser
2
, Jan Koetsenruijter
3
, Christina M van der Feltz-Cornelis
1,4,5
, Peter FM Verhaak
6,7
,
Richard PTM Grol
3
and Michel Wensing
3
Abstract
Background: Internationally, guidelines for depression recommend a stepped care approach, implying that
antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild
depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are
considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations
on antidepressant prescribing.
Methods: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up
was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a
national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for
a stepped care approach to depression. The model consisted of self-help and psychological treatment options for
patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant
prescription rates of GPs were documented for a three-year period and compared to those in a control group of
GPs, selected from an ongoing national registration network.
Results: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with
depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group
(50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).
Conclusions: An implementation program using stepped care principles for the allocation of depression interventions
resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within
the context of a QIC.
Keywords: General practice, Guidelines, Antidepressants, Implementation, Stepped care
Background
Depression is a highly prevalent condition with a range
of effective treatment options, many of which can be
offered in general practice. Since 2004, guidelines in
several countries recommend a ‘stepped care approach’
as a framework for organising depression care, putting
treatment options in a specific order and relating them
to patient severity profiles [1-5].
Derived from this framework, the national evidence-
based multidisciplinary guideline for depression in the
Netherlands, developed by a Guideline Development
Group (GDG) consisting of GPs, psychiatrists, psychologists,
allied health professionals, consumers and carers, recom-
mended that antidepressant medication should not be of-
fered as a first step treatment to patients with sub-threshold
or mild depression. Instead, brief and non-pharmaceutical
interventions including watchful waiting, (guided) self-help
based on cognitive behavioural therapy (CBT), physical
exercise and problem solving therapy were considered
appropriate choices in the beginning of a treatment epi-
sode. Antidepressant medication or psychotherapy was to
* Correspondence: gfranx@trimbos.nl
1
Trimbos Institute, Netherlands institute of mental health and addiction, PO
Box 725, 3500 AS Utrecht, the Netherlands
Full list of author information is available at the end of the article
© 2014 Franx et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Franx et al. BMC Family Practice 2014, 15:35
http://www.biomedcentral.com/1471-2296/15/35
be offered as a first step treatment option to patients with
moderate, severe or chronic symptoms [1,2].
Depression care, according to guideline recommen-
dations, does not seem to be current practice. Rates of
guideline-concordant care reported in the literature
vary depending on setting, country and criteria for
appropriateness, from 22% in the United States [6] to
42% in the Netherlands [7]. Focusing on recommenda-
tions concerning antidepressant prescribing, a number of
problems exist. Firstly, antidepressant prescription rates in
primary care are high in the Netherlands: 76% in 2002
and 70% in 2008 [8]. Although these rates appear to have
declined in recent years, they have risen strongly over the
last decades, with rises of more than 30% being reported
in different countries [9-14]. One explanation for this rise
of volume in antidepressant prescribing is the change in
the proportion of patients receiving long term treatment
[15,16]. Secondly, antidepressant prescription for depres-
sion during the first contact with the patient has also
risen, from 62% of the cases in 1993 to 73% in 1998 [17].
Thirdly, there is a strong variation in prescribing between
GPs, which can be explained by population, GP and
practice characteristics [12]. Finally, prescription of
antidepressants by GPs seems unrelated to symptom
severity [18]. In addition, effective and brief, low inten-
sity alternatives are relatively unknown as yet whereas
it is considered essential that they are implemented in
general practice [19]. As well, considering the fact that
antidepressant treatment does not comply with the prefer-
ences of a great deal of patients, many of whom give nega-
tive reports of ineffectiveness and side-effects, there seems
to be a need to change prescribing behaviour in general
practice in the direction of a more stepped care approach,
and in accordance with the clinical guidelines [18,20-23].
In order to bring about this change and implement
key recommendations of the national depression guidelines
in the Netherlands, a QIC with a three year follow-up
was run from December 2006 until March 2008, as part
of the National Depression Initiative [24]. QICs are
multifaceted implementation strategies, offered to clinical
care teams to rapidly improve performance and outcomes
[25-28]. Parallel to the QIC, an implementation study was
performed to determine the impact of the Depression
QIC on antidepressant prescribing by GPs.
Methods
Adopting a stepped care model for the management of
depression is a major change and thus makes it difficult
to allocate randomly to healthcare professionals, be-
cause of the risk of low inclusion rates and withdrawal
at professional level because of discontentment with
the randomization procedure. Therefore we performed a
quasi-experimental evaluation with a non-equivalent natur-
alistic control group and a three year follow-up period.
Study population
The study included two study groups (‘QIC’and ‘usual
care’, see below) and three measurement moments in
each group. The health professionals in the intervention
group were GPs (who provide all primary medical care
in the Netherlands) participating in the depression QIC
programme, described in detail elsewhere [29]. At the start
of the QIC, all thirty-nine GPs were invited to participate
in the study, alongside their implementation work. In
order to participate, they had to consent to comply with
data collection procedures. Practices were paid a fee for
the time spent on research activities. Finally, twenty GPs
consented and were included in the study.
The control group included GPs from practices par-
ticipating in the Netherlands Information Network of
General Practice (LINH), the principle national database
in the Netherlands for general practice research, holding
longitudinal and nationally representative data on mor-
bidity, prescribing, and referrals [30]. In principle, pa-
tients receiving care as usual, had access to all types of
depression treatment, including the low intensity treat-
ments, although these were relatively unknown by primary
care providers [19]. LINH physicians and the QIC physi-
cians were considered to be proper naturalistic comparison
groups, since participation in both programmes required
the GPs’commitment to register practice data for research
and quality improvement purposes. LINH-practices were
only included in the study if the Electronic Medical Record
(EMR) provided information about at least 90% of the three
years study duration.
The included patients in both groups were aged 18–
65, with a newly recorded diagnosis of depression as
documented by the GPs in the EMR, along with an
International Classification of General Practice (ICPC)
diagnosis of depressive feelings (ICPC code P03) or de-
pression (ICPC code P76) [31-33].
Ethical approval was provided by the METIGG, a national
ethics committee in mental healthcare in the Netherlands.
Intervention
A Depression QIC was executed over fifteen months. A
QIC is an implementation strategy applied in many coun-
tries for various clinical problems, and generally has five
essential features: (1) a focus on a specific topic with gaps
between best and current practice; (2) clinical experts pro-
viding ideas and support for improvement; (3) multidiscip-
linary teams from multiple sites participate; (4) there is a
model for improvement (setting targets, collecting data and
testing changes); and (5) a collaborative process with a series
of structured activities in a given time frame [28,34,35].
These structured activities, which were offered to the partic-
ipants during the Depression QIC, are listed in Table 1.
The focus of the Depression QIC was a stepped care
model for depression treatment (see Figure 1), developed
Franx et al. BMC Family Practice 2014, 15:35 Page 2 of 7
http://www.biomedcentral.com/1471-2296/15/35
by the QIC’s clinical expert team and based on both the
multidisciplinary guidelines and previous projects [1,36,37].
The model consisted of two pathways for patients with dif-
ferent severity profiles. Severity criteria were derived from
the Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition (DSM IV) and based on the expert team’s
opinion. Antidepressant medication was not an option in
treatment pathway 1, but could be considered after a first
step intervention had not resulted in sufficient treatment
response. Antidepressants and psychotherapy were first line
treatment options in pathway 2. The model served to guide
clinicians in their improvement work.
Data collection
The primary outcome was antidepressant prescribing, de-
fined as the volume of antidepressant prescriptions for the
depressed general practice population (prescription rates),
issued by GPs as a first line treatment choice within one
month after the diagnosis. The secondary outcome was
referral by the GPs to clinicians providing psychological
treatment. In both groups, all relevant data of patients
with ICPC P03 or ICPC P76 were extracted from the
EMRs of the general practices. Documentations by the
physicians of co-morbid anxiety, using ICPC codes P01
(anxious, nervous, tensed feelings), P74 (anxiety disorder,
condition of anxiety) and P75 (hysteria, hypochondria),
were also extracted. Data extraction in the QIC group was
performed by the physicians’assistants who had received a
detailed protocol for computerised searching and support
from the researchers. Data extraction in the control group
was performed by the staff from the LINH database.
Antidepressant medication covered the subgroup N06A of
the Anatomical Therapeutic Chemical (ATC) Classification
System of the World Health Organization. Referrals in-
cluded a documentation of a referral to a primary care
psychologist or a specialised psychologist, a psychiatrist, a
psychotherapist, an institution for ambulatory care or a
mental health hospital. Data collection covered a three
year period: the year 2006 indicates the baseline measure-
ment before the QIC, the year 2007 indicates the year of
the intervention and the year 2008 largely indicates the
follow-up measurement, after the QIC had ended.
Table 1 Structured activities of the depression QIC
Structured activities offered
•A network of multidisciplinary teams
•An expert team, teaching the stepped care model;
•SMART goal setting, a set of indicators to monitor results and an
excel worksheet;
•A training for local team coordinators on breakthrough method
and data collection;
•Four conference days for all improvement teams for exchange
and learning;
•One conference day for local team coordinators for intensive
exchange with the expert team;
•Five meetings between local team coordinators, with the expert
team present;
•Team visits of experts and national project coordinators;
•Telephone contact between local and national coordinators;
•Written feedback on improvement reports and data charts;
•A virtual network environment for exchange of best-practices,
a Toolkit of instruments and treatment protocols, online discussions
and links to relevant sites;
•A two days training problem solving treatment for professionals;
•A workshop workflow Improvement.
Figure 1 Stepped care depression model.
Franx et al. BMC Family Practice 2014, 15:35 Page 3 of 7
http://www.biomedcentral.com/1471-2296/15/35
Data analysis
Descriptive statistics were calculated within the groups.
Using a t-test, we examined the changes during the three
year follow-up within both study groups. To determine the
effect of participation in the implementation programme
and to correct for the clustering effect, we applied a multi-
level logistical regression analysis with a two-level structure
with patients nested within general practices. A statis-
tical analysis was performed in MLwiN 2.15 comparing
the outcomes between the two conditions, with anti-
depressant prescription (yes or no) or referral to mental
healthcare (yes or no) as outcomes, and the following
predictors to test the difference in changes between the
two conditions: group (QIC or usual care), patient age and
gender, co-morbid anxiety (yes or no ICPC P01, P74, P75),
year (2006, 2007, 2008) and an interaction term with year
and group.
Results
Twenty GPs from seventeen practices participated in the
intervention group, and 115 GPs from forty-one practices
were selected as controls. In the intervention group, the
data of 400 patients were extracted for analysis, and in
the control group this number was 3956.
Characteristics of the patient population
In the QIC group, the mean age of patients with an ICPC
documentation of P03 and P76 was 39.8 years, and 41.9 years
in the control group. In the QIC group, the proportion of
younger persons was higher (37.5% versus 32.3%), whereas
the control group consisted of a larger proportion of older
persons (23.3% versus 29.2%) (Table 2).
Antidepressant prescription
Table 3 shows the changes in professional performance
within both groups in terms of antidepressant prescribing
and referrals. During the three year follow up, a decrease
of 23.3% in the prescription of antidepressant medication
occurred in the QIC group (from 49.4% in 2006 to 26.1%
in 2008). The usual care group did not change prescrip-
tion rates (from 50.3% in 2006 to 52.6% in 2008).
Referral rates
Overall, referral rates of GPs in the QIC practices were
somewhat higher than in the usual care practices during
the three years study interval. In 2006, 11.5% of the patients
in QIC practices were referred within a month after diagno-
sis to a psychologist, a primary care psychologist, a psych-
iatrist, a psychotherapist, an institution for ambulatory care
or a mental health hospital. In 2008, this rate remained at
the same level of 11.2%. With regards to baseline referral
by GPs, in the usual care practices, a non-significant decline
occurred from 10.1% in 2006 to 9% in 2008 (Table 3).
Factors associated with antidepressant medication and
referral to mental healthcare
Table 4 shows the factors associated with the changes
between the two study groups during our study period.
The usual care clinicians did not change their prescribing
behaviour in 2007 (OR 0.92) or 2008 (OR 0.87). In the
QIC group, antidepressant prescribing as a first line treat-
ment option did not change in 2007, but the frequency of
prescribing decreased in 2008 in almost half of the cases,
Table 2 Characteristics of the patient population
(in percentages)
QIC practices
(n = 400)
Usual care practices
(n = 3956)
Age 18-35 37.5 32.3
36-50 39.3 38.5
51-65 23.3 29.2
Mean 39.8 41.9
Male 30.0 35.1
Female 70.0 64.9
Comorbid anxiety 4.0 5.8
Table 3 Patients with first or new depressive symptoms
receiving an antidepressant prescription or being referred
to mental healthcare within one month (in percentages of
the total of patients with a first or new depressive episode)
QIC practices Usual care practices
2006 2007 2008 2006 2007 2008
Antidepressant
prescription
49.4 32.2* 26.1* 50.3 47.0 52.6
Referral to mental
healthcare
11.5 16.4 11.2 10.1 13.0* 9.0
N 87 152 161 1261 996 1699
*sign. < 0,05 compared with baseline (2006).
Table 4 Factors associated with antidepressant prescribing
and referral to mental healthcare
Antidepressant
prescribing
Referral to mental
healthcare
OR (95% CI) OR (95% CI)
Age of patient 1,03* (1,03 - 1,04) 0,97* (0,96 - 0,98)
Sexe of patient (male = ref) 0,98 (0,86 - 1,12) 0,71* (0,58 - 0,85)
Co-morbid anxiety 1,66* (1,26 - 2,18) 0,71 (0,45 - 1,13)
Participation in collaborative 0,98 (0,57 - 1,70) 0,93 (0,36 - 2,39)
Year (CAU) 2006 (ref)
2007 0,92 (0,69 - 1,21) 1,12 (0,68 - 1,86)
2008 0,87 (0,66 - 1,15) 1,28 (0,77 - 2,11)
Year* collaborative 2006 (ref)
2007 0,60 (0,29 - 1,24) 1,11 (0,32 - 3,81)
2008 0,44* (0,21 - 0,92) 0,71 (0,20 - 2,52)
ICC 0.067 0.193
*p < 0,05, n = 4356.
Franx et al. BMC Family Practice 2014, 15:35 Page 4 of 7
http://www.biomedcentral.com/1471-2296/15/35
compared to the usual care group (OR 0.44). QIC GPs
tended to prescribe more frequently to older patients and
to those who had additional anxiety problems. Multivariate
analysis, however, showed that these characteristics did
not account for the effect of the intervention and that
participation in the QIC over time accounted for a signifi-
cant decline in prescription rates (OR 0.44), compared to
the usual care group. There was no significant change of
referral behaviour in either group.
Discussion and conclusions
Summary
We found a substantial change in the professional per-
formance of GPs participating in a quality improvement
programme, in terms of lowered antidepressant prescrip-
tion rates as a first step treatment choice for patients with
depression. GPs providing usual care did not change their
prescribing behaviour during the three year course of the
study. In both groups, there was no change in referral
rates to mental health clinicians.
The results seem to support the hypothesis that a
QIC aimed at adherence to depression guidelines reduces
antidepressant prescription rates of GPs, whereas GPs
who have access to guidelines but who do not receive
an intervention aimed at their implementation, don’t
change their prescribing behaviour. Two other qualitative
studies, performed parallel to this controlled study, showed
that instead of medication, the GPs started to offer
low-intensity interventions to their patients during the
QIC, such as guided self-help or brief psychotherapy,
and that because of these alternative treatment options they
felt more at ease in reducing antidepressant prescriptions
for patients with mild symptoms [29,38]. The second result
of the study, the lack of a significant change in referral rates
in both groups, could point at the fact that the QIC partici-
pants did not replace the medication by a more specialised
psychological intervention by a primary care psychologist
or a specialist in the mental health sector, but by an inter-
vention in general practice or by ‘watchful waiting’,namely
psycho-education and pro-active follow up.
Strengths and limitations
A particular strength of this study was the evaluation
of an ambitious quality improvement initiative with a direct
comparison between two naturalistic groups, which makes
the study appropriate to be included in an evidence review
of quality improvement interventions [39]. Other strengths
included the large numbers of patients and the substantial
effect on the primary outcome.
A first study limitation was the lack of a randomisation
procedure, which was not an option since the researchers
had no control over the allocation of GPs to a particu-
lar condition. By conducting a randomised clinical trial,
effects in terms of causality would have been stronger
supported. However, RCTs may have the disadvantage of
low inclusion rates and withdrawal at professional level be-
cause of discontentment with the randomization procedure,
especially in implementation studies, thus introducing
other problems of selection bias and lack of general-
isibility of the results. Therefore, we considered the quasi-
experimental design of this study valid for the exploration
of our research question and dealt with this risk of selection
bias by choosing the best possible comparison group in the
Netherlands. This national database of GP performance,
considered as the ‘golden standard’for measuring care as
usual because of the adequate documentation by these doc-
tors who sign an agreement to document ICPC diagnosis
and treatments provided. Unfortunately, this did not enable
us to use patient reported depression outcomes, since these
were not documented in the databases of routinely col-
lected clinical data.
Another well known challenge in observational studies
is the risk of bias due to confounding, which in our
study could have occurred in terms of factors other than
the QIC causing the observed changes. We were able to
control for age, gender and co-morbid conditions of
both study groups, but other factors may have played a
role as well. Nevertheless, it is improbable that any one
of these other factors would have caused a decline of
23% in prescription in the intervention group, which is
considered to be quite substantial in the implementation
literature. A second limitation of our study was the EMR
data-extraction which was performed by administrative
assistants in the different practices, who were very well
known with the systems. We limited this risk of bias by
providing all persons with the same instructions and by
performing all data analysis by one research group.
Comparison with existing literature
Our study can be compared to the Depression QIC,
organised by the Institute for Healthcare Improvement
in the United States in 2000–2001 and based on Wagner’s
Chronic Care Model (CCM) [40]. The American QIC, also
involving seventeen general practices, led to successful
changes in the depression delivery and information
system, which were also the most often sustained over
time [41]. Organisational structure and leadership sup-
port were the most common facilitators, while staff re-
sistance, time constraints, and information technology
were the most common barriers.
Our study also relates to several initiatives in the United
Kingdom to implement the guidelines of the National
Institute for Health and Care Excellence (NICE). The
Scottish study, ‘Doing Well’, incorporated the routine
use of a depression severity measure with continuous
outcome monitoring, a prompt access to guided self-help
and a ‘step-up’to more formal psychological therapy
or medical care, if indicated. As a result, daily doses of
Franx et al. BMC Family Practice 2014, 15:35 Page 5 of 7
http://www.biomedcentral.com/1471-2296/15/35
antidepressants increased less rapidly than in other areas
[42]. A British implementation study into stepped care ser-
vices reported a considerable variation in the design and
implementation of the stepped care guideline recommenda-
tions [43]. The large scale guideline implementation,
Improving Access to Psychological Therapies (IAPT),
focused on increasing the availability of evidence-based
psychological treatments, both the high intensity therapies
(CBT) and the low intensity therapies such as guided self-
help, psycho-education groups and behavioural activation
[44]. Three year results showed that most patients received
guideline-concordant care and that patients had a higher
chance of recovery if the treatment sites showed higher
step-up rates from low to high intensity treatment in
case of insufficient response, as well as if they received
an adequate number of sessions [44].
Implications for research and practice
This study has shown that antidepressant prescribing by
GPs can be changed by a multifaceted implementation
strategy based on national guidelines and the time and
support to implement these in a multidisciplinary context.
This message is relevant for clinicians, managers and policy
makers, both in Europe and beyond, who are motivated to
implement guidelines for depression and to move from an
overemphasis on psychopharmacological treatments
for depression [45] to stepped depression care, where
patients with mild symptoms receive less intensive treat-
ments, such as medication. Policy initiatives aimed at
strengthening general practice and reducing unnecessary
antidepressant treatment in general practice can use our in-
formation, by addressing GPs, psychologists, social workers
and specialised mental health nurses to recognise, treat and
monitor depression in a stepped care manner, offering
guided self-help and brief interventions when possible,
and antidepressant medication when necessary [46].
Researchers charged with the task of evaluating such
programs are recommended to consider adopting a
randomised controlled design, to enable stronger state-
ments about the effect of stepped care approaches and
a useful cost effectiveness analysis. Although recruit-
ment of participants to this type of implementation
study is challenging, if feasible at all, useful frameworks
exist to guide researchers in developing and evaluating
these complex interventions [47].
Conclusions
GPs can learn to change antidepressant prescribing be-
haviour in the context of an improvement programme.
Our study should be considered as one of the first
studies focusing on the issue of the over prescribing of
antidepressant treatment in general practice. It presents
data indicating that GPs can change prescribing behav-
iour, provided that they have access to alternatives and
implementation support. Future implementation studies
should expand on this and investigate the stepped care
delivery of all depression treatments, recommended in the
guidelines. Fortunately, in the Netherlands and beyond,
implementation of clinical guidelines followed by process
and outcome monitoring for depression are gradually be-
coming mandatory and better supported by information
technology. This is a hopeful message for those trying to
improve the care for this patient group.
Abbreviations
ATC: Anatomical therapeutic chemical; CBT: Cognitive behavioural therapy;
CCM: Chronic care model; DSM IV: Diagnostic and statistical manual of mental
disorders fourth edition; EMR: Electronic medical record; GDG: Guideline
development group; GP: General practitioner; ICPC: International classification of
general practice; LINH: Netherlands information network of general practice;
METIGG: National ethics committee in mental healthcare; NICE: National
institute for health and care excellence; QIC: Quality improvement collaborative.
Competing interest
The authors declare that they have no competing interests.
Authors’contributions
GF carried out the design of the study, the acquisition, analysis and
interpretation of data and the draft of the manuscript. JK carried out the
statistical analysis of the data and participated in the draft of the manuscript.
JH, CvdF and PV have been involved in data interpretation and revising the
manuscript for important intellectual content. RG and MW have made
substantial contributions to the design of the study, the analysis and
interpretation of data and the revision of the manuscript. All authors read
and approved the final manuscript.
Acknowledgements
The data used in this study were made available by the primary care
physicians participating in the study. We thank all of them, as well as the
other clinicians participating in the study, their assistants and staff. This study
was part of the Depression Initiative, a nationwide initiative lead by the
Trimbos Institute to improve depression care according to the guidelines for
depression. The Depression Initiative started in 2006 and ended in 2012. The
study was funded by the Healthcare Insurance Innovation Fund (Innovatiefonds
Zorgverzekeraars) and the Netherlands organisation for Health Research and
Development (ZonMw, grant number 10-000-1002). Open access publication
was financially supported by the Netherlands Organisation for Scientific
Research (NWO).
Author details
1
Trimbos Institute, Netherlands institute of mental health and addiction, PO
Box 725, 3500 AS Utrecht, the Netherlands.
2
Arkin, PO Box 75848, 1070 AV
Amsterdam, the Netherlands.
3
Scientific Institute for Quality of Healthcare,
Radboud University Nijmegen Medical Centre, PO Box 9101, 114, 6500 HB
Nijmegen, the Netherlands.
4
Tilburg University, Tranzo, Tilburg School of Social
and Behavioral Sciences, PO Box 90153, 5000 LE Tilburg, the Netherlands.
5
Clinical Centre for Body, Mind and Health, GGz Breburg, PO Box 770, 5000 AT
Tilburg, the Netherlands.
6
Nivel, Netherlands institute for health services
research, PO Box 1568, 3500 BN Utrecht, the Netherlands.
7
Rijksuniversiteit
Universiteit Groningen, University Medical Centre Groningen, dep. General
Practice, PO Box 196, FA20, 9700 AD Groningen, the Netherlands.
Received: 21 October 2013 Accepted: 30 January 2014
Published: 19 February 2014
References
1. Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling in de GGZ:
Multidisciplinary guideline depression: guideline for diagnostics and treatment
of adult clients with a major depressive disorder. Utrecht: Trimbos-instituut;
2005 [in Dutch].
2. Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling in de GGZ:
Revision of the Multidisciplinary guideline for Depression. Guideline for the
Franx et al. BMC Family Practice 2014, 15:35 Page 6 of 7
http://www.biomedcentral.com/1471-2296/15/35
diagnosis, treatment and care of adult patients with a depressive disorder.
Utrecht: Trimbos-instituut; 2010 [in Dutch].
3. National Collaborating Centre for Mental Health: Depression: the treatment
and management of depression in adults: NICE clinical guideline 90. London:
National Institute for Health and Clinical Excellence; 2009.
4. New Zealand Guidelines Group: Identification of common mental disorders
and management of depression in primary care. Wellington: New Zealand
Guidelines Group; 2008.
5. Whitty P, Gilbody S: NICE, but will they help people with depression? The
new National Institute for Clinical Excellence depression guidelines.
Br J Psychiatry 2005, 186:177–178.
6. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ,
Walters EE, Wang PS: The epidemiology of major depressive disorder:
results from the National Comorbidity Survey Replication (NCS-R). JAMA
2003, 289(23):3095–3105.
7. Smolders M, Laurant M, Verhaak P, Prins M, van Marwijk H, Penninx B, Wensing
M, Grol R: Adherence to evidence-based guidelines for depression and anxiety
disorders is associated with recording of the diagnosis. Gen Hosp Psychiatry
2009, 31(5):460–469.
8. Nuijen J, Van Dijk CE, Verhaak PFM, Verheij RA: Trendreport Mental Healthcare.
In Trendreport Mental Healthcare 2010, par t 2. Access and consumption of care.
Edited by Nuijen J. Utrecht: Trimbos-instituut; 2010:181–235 [in Dutch].
9. Helgason T, Tomasson H, Zoega T: Antidepressants and public health in
Iceland. Time series analysis of national data. Br J Psychiatry 2004,
184:157–162.
10. Hemels ME, Koren G, Einarson TR: Increased use of antidepressants in
Canada: 1981–2000. Ann Pharmacother 2002, 36(9):1375–1379.
11. McManus P, Mant A, Mitchell PB, Montgomery WS, Marley J, Auland ME:
Recent trends in the use of antidepressant drugs in Australia, 1990–1998.
Med J Aust 2000, 173(9):458–461.
12. Morrison J, Anderson MJ, Sutton M, Munoz-Arroyo R, McDonald S, Maxwell M,
Power A, Smith M, Wilson P: Factors influencing variation in prescribing of
antidepressants by general practices in Scotland. Br J Gen Pract 2009,
59(559):e25–e31.
13. Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA: National trends
in the outpatient treatment of depression. JAMA 2002, 287(2):203–209.
14. Stichting Farmaceutische Kengetallen: Antidepressant use increases
strongly. Pharm Weekbl 2005, 140(23):10 [in Dutch].
15. Moore M, Yuen HM, Dunn N, Mullee MA, Maskell J, Kendrick T: Explaining
the rise in antidepressant prescribing: a descriptive study using the
general practice research database. BMJ 2009, 339:b3999.
16. Piek E, van der Meer K, Hoogendijk WJ, Penninx BW, Nolen WA: Most
antidepressant use in primary care is justified; results of the Netherlands
Study of Depression and Anxiety. PLoS One 2011, 6(3):e14784.
17. Van Marwijk HW, Bijl D, Ader HJ, de Haan M: Antidepressant prescription
for depression in general practice in The Netherlands. Pharm World Sci
2001, 23(2):46–49.
18. Spies T, Mokking H, de Vries RP, Grol R: GP often chooses antidepressants
independent of depression severity. Huisarts Wet 2004, 47(8):364–367 [in Dutch].
19. Zwaanswijk M, Verhaak PFM: Effective brief interventions for psychological
problems; a synthesis of the evidence on applicability in general practice.
Utrecht: Nivel; 2009 [in Dutch].
20. Prins MA, Verhaak PFM, Bensing JM, van der Meer K: Health beliefs and
perceived need for mental health care of anxiety and depression–the
patients' perspective explored. Clin Psychol Rev 2008, 28(6):1038–1058.
21. Van Geffen EC, van der Wal SW, van Hulten R, de Groot MC, Egberts AC,
Heerdink ER: Evaluation of patients' experiences with antidepressants
reported by means of a medicine reporting system. Eur J Clin Pharmacol
2007, 63(12):1193–1199.
22. 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.
23. Van Schaik DJ, Klijn AF, van Hout HP, Van Marwijk HW, Beekman AT, de
Haan M, van Dyck R: Patients' preferences in the treatment of depressive
disorder in primary care. Gen Hosp Psychiatry 2004, 26(3):184–189.
24. Van der Feltz-Cornelis CM: Towards integrated primary health care for
depressive disorder in the Netherlands. The depression initiative. Int J
Integr Care 2009, 9:e83.
25. Chin MH: Quality improvement implementation and disparities: the case
of the health disparities collaboratives. Med Care 2010, 48(8):668–675.
26. Katzelnick DJ, Von KM, Chung H, Provost LP, Wagner EH: Applying
depression-specific change concepts in a collaborative breakthrough
series. Jt Comm J Qual Patient Saf 2005, 31(7):386–397.
27. Øvretveit J, Bate P, Cleary P, Cretin S, Gustafson D, McInnes K, McLeod H,
Molfenter T, Plsek P, Robert G, Shortell S, Wilson T: Quality collaboratives:
lessons from research. Qual Saf Health Care 2002, 11(4):345–351.
28. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP:
Evidence for the impact of quality improvement collaboratives:
systematic review. BMJ 2008, 336(7659):1491–1494.
29. Franx G, Meeuwissen JA, Sinnema H, Spijker J, Huyser J, Wensing M, de
Lange J: Quality improvement in depression care in the Netherlands: the
Depression Breakthrough Collaborative. A quality improvement report.
Int J Integr Care 2009, 9:e84.
30. Verheij RA, van Dijk CE, Stirbu-Wagner I, Abrahamse H, Davids R, Braspenning J,
Van Althuis T, Korevaar JC: National Information Network General Practice: facts
and numbers about Dutch general practice. Utrecht/Nijmegen: NIVEL/IQ; 2009
[in Dutch].
31. Lamberts HWM: International Classification of Primary Care (ICPC). Oxford:
Oxford University Press; 1990.
32. Nuijen J, Volkers AC, Verhaak PFM, Schellevis FG, Groenewegen PP, van den
Bos GA: Accuracy of diagnosing depression in primary care: the impact
of chronic somatic and psychiatric co-morbidity. Psychol Med 2005,
35:1185–1195.
33. WONCA: International Classification of Health Problems in Primary Care
(ICHPPC-2-Defined). Oxford: Oxford University Press; 1983.
34. Berwick DM: Developing and testing changes in delivery of care.
Ann Intern Med 1998, 128(8):651–656.
35. Hulscher M, Schouten L, Grol R: Quest for Quality and Improved Performance:
Collaboratives. London: The Health Foundation; 2009.
36. Franx G, Spijker J, Huyser J, de Doelder P: Reduction in depression:
Breakthrough method reduces over treatment. Medisch Contact 2006,
61(40):1592–1595.
37. Meeuwissen JA, van der Feltz-Cornelis CM, van Marwijk HW, Rijnders PB,
Donker MC: A stepped care programme for depression management: an
uncontrolled pre-post study in primary and secondary care in The
Netherlands. Int J Integr Care 2008, 8:e05.
38. Franx G, Oud M, de Lange J, Wensing M, Grol R: Implementing a stepped-care
approach in primary care: results of a qualitative study. Implement Sci 2012, 7:8.
39. Danz MS, Rubenstein LV, Hempel S, Foy R, Suttorp M, Farmer MM, Shekelle
PG: Identifying quality improvement intervention evaluations: is
consensus achievable? Qual Saf Health Care 2010, 19(4):279–
283.
40. Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D,
Carver P, Sixta C: Quality improvement in chronic illness care: a
collaborative approach. Jt Comm J Qual Improv 2001, 27(2):63–80.
41. Meredith LS, Mendel P, Pearson M, Wu SY, Joyce G, Straus JB, Ryan G, Keeler
E, Unützer J: Implementation and maintenance of quality improvement
for treating depression in primary care. Psychiatr Serv 2006, 57(1):48–55.
42. Smith MJ: "Doing Well": an initiative to improve depression care [MD Thesis].
Glasgow: University of Glasgow; 2010.
43. Richards DA, Bower P, Pagel C, Weaver A, Utley M, Cape J, Pilling S, Lovell K,
Gilbody S, Leibowitz J, Owens L, Paxton R, Hennessy S, Simpson A, Gallivan
S, Tomson D, Vasilakis C: Delivering stepped care: an analysis of
implementation in routine practice. Implement Sci 2012, 7:3.
44. Clark DM: Implementing NICE guidelines for the psychological treatment
of depression and anxiety disorders: The IAPT experience. Int Rev
Psychiatry 2011, 23:318–327.
45. Frank RG, Huskamp HA, Pincus HA: Aligning incentives in the treatment of
depression in general practice with evidence-based practice. Psychiatr
Serv 2003, 54(5):682–687.
46. Verhaak PFM, Ten Have JJIM, Scholte MM: Competition in psychological
care. Medisch Contact 2007, 40(2):1642–1645 [in Dutch].
47. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M:
Developing and evaluating complex interventions: the new Medical
Research Council guidance. BMJ 2008, 337:a1655.
doi:10.1186/1471-2296-15-35
Cite this article as: Franx et al.:Implementing guidelines for depression
on antidepressant prescribing in general practice: a quasi-experimental
evaluation. BMC Family Practice 2014 15:35.
Franx et al. BMC Family Practice 2014, 15:35 Page 7 of 7
http://www.biomedcentral.com/1471-2296/15/35
