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

Abstract

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.
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.
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.
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.
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.

Full text

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Projects and Developments
Quality improvement in depression care in the
Netherlands: the Depression Breakthrough Collaborative.
A quality improvement report
Gerdien Franx, MSc, Program manager Innovation of Care, Trimbos Institute, Netherlands Institute of Mental Health and
Addiction, P.O. Box 725, 3500 AS Utrecht, The Netherlands
Jolanda A.C. Meeuwissen, MSc, Senior Research Associate, Trimbos Institute, Netherlands Institute of Mental Health and
Addiction, P.O. Box 725, 3500 AS Utrecht, The Netherlands
Henny Sinnema, MSc, Research Associate, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, P.O. Box
725, 3500 AS Utrecht, The Netherlands
Jan Spijker, MD, PhD, Senior Research Associate, Trimbos Institute, Netherlands Institute of Mental Health and Addiction,
P.O. Box 725, 3500 AS Utrecht, The Netherlands
Jochanan Huyser, MD, PhD, Jellinek Mentrum, Amsterdam, The Netherlands
Michel Wensing, PhD, Associate Professor, IQ Healthcare, Radboud University Nijmegen Medical Centre, P.O. Box 9101,
114, 6500 HB Nijmegen, The Netherlands
Jacomine de Lange, PhD, Senior Research Associate, Trimbos Institute, Netherlands Institute of Mental Health and Addiction,
P.O. Box 725, 3500 AS Utrecht, The Netherlands
Correspondence to: Gerdien Franx, Trimbos Institute, P.O. Box 725, 3500 AS Utrecht, The Netherlands, Phone: +31-30-
2971100, Fax: +31-30-2971111, E-mail: gfranx@trimbos.nl
Abstract
Background: Improving the healthcare for patients with depression is a priority health policy across the world. Roughly, two major prob-
lems 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.
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.
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.
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 symp-
toms 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.
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
International Journal of Integrated Care – Vol. 9, 15 June 2009 – ISSN 1568-4156 – http://www.ijic.org/

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International Journal of Integrated Care – Vol. 9, 15 June 2009 – ISSN 1568-4156 – http://www.ijic.org/
Introduction
Policies aiming to create an evidence-based men-
tal healthcare system, offering appropriate care to
patients and delivering better outcomes, have not been
successful until now. According to the European Study
of the Epidemiology of Mental Disorders (ESEMED)
conducted in six western countries including the Neth-
erlands, of all patients treated for an anxiety disorder
or a depressive disorder, 57% were treated appropri-
ately in secondary care and only 23% received the
right treatment in primary care [1].
Major depressive disorder (MDD) [2] is a prevalent
condition worldwide: 12 months- prevalence of MDD
ranges from 4 to 10% and a lifetime prevalence of 15
to 17% [3–6]. In the Netherlands Mental Health Survey
and Incidence Study (NEMESIS) [6, 7] a median dura-
tion of new depressive episode of 3 months was found,
63% of those with a new episode had recovered within
6 months and 76% in 12 months. Almost 20% of those
affected had not recovered in 24 months [8]. Primary
care is the key supplier of care to patients, because
of the high prevalence of patients with depression or
depressive feelings in general practice of around 21%
[9]. Despite policy incentives to strengthen the capaci-
ties of primary care, general practitioners still refer
more patients to a more expensive form of care in
specialty care than to psychologists and social workers
in primary care [9, 10].
Two depression guidelines are actually available to
Dutch practitioners, recommending effective interven-
tions for different subgroups of patients. The Multidis-
ciplinary Guideline for Depressive Disorder, adopted
in 2005 by a range of professional organizations in
specialised mental health, and the depression stan-
dard, adopted by general practitioners in 2003 [11, 12].
Following depression guidelines can be of value to
professionals as applying the effective interven-
tions recommended in guidelines can lead to better
outcomes for patients and to lower costs to society
[13–18]. Unfortunately, the uptake of the depression
guideline recommendations in Dutch daily practice has
been slow. A study looking into evidence-based depres-
sion care in 1999, concluded that previous depression
guideline editions were considered to be too globally
formulated, giving insufficient tools to practitioners for
decision support in daily practice [19–22]. Other imple-
mentation barriers can be related to characteristics of
the professionals and the patients, and environmental
factors such as a lack of support from peers or supe-
riors, insufficient staff or time, and poor collaboration
between professionals [18, 23].
The effective treatments proposed in the most recent
depression guidelines, to be published in the Nether-
lands in the spring of 2009, range from less intensive
interventions like psycho-education or self help inter-
vention (individual or group courses), problem solv-
ing treatment (PST), and physical exercise (running
therapy), to more intensive treatments such as cogni-
tive behavioural therapy, pharmacotherapy and electro-
convulsion therapy. Considering the heterogeneous
course of MDD, the selection of the appropriate inter-
vention and the organisation of depression care needs
to be built on careful timing and paced appropriately.
Goals of treatment should be to avoid over-treatment
in those with a favourable prognosis and to prevent the
development of chronic symptoms in those depressed
individuals with an unfavourable prognosis (under-
treatment).
Over-treatment of minor and mild-major depressions is
seen in general practice where antidepressant drugs
are prescribed to 68% of the patients, regardless of
the severity of depression [21, 24]. Also, antidepres-
sants in many cases are prescribed over too long a
period of time [25]. This is contrary to guideline rec-
ommendations and recent studies that advise less
intensive treatments in mild cases because there is no
additional effectiveness of antidepressant treatment
over counseling alone [21, 26–28]. Less intensive
treatment alternatives are insufficiently known and not
made available or used by primary care profession-
als, despite the fact that they have been proven to be
effective in recent randomised controlled trials in the
Netherlands [29].
Under-treatment of patients with more severe symp-
toms, is caused by provider barriers including concerns
about patient stigma, time pressures, inadequate
knowledge about diagnostic criteria and treatment
options, and a lack of psycho-social orientation. Also,
poor recognition of depression by general practitioners
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.
Keywords
quality improvement, depression, Breakthrough Collaborative, multidisciplinary teams, stepped care, care pathway

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This article is published in a peer reviewed section of the International Journal of Integrated Care??
has been reported; in one study 33% of cases were
not diagnosed as depression or any other psychologi-
cal disease. Moreover, patient-provider communica-
tion concerning pharmacotherapy can be improved
[30]. Patient related causes include somatic presen-
tation of depression by patients and resistance to a
diagnosis of depression. Once pharmacotherapy is
started, compliance is low. Up to 37% of patients stop
taking medication too soon, after one or two prescrip-
tions, whereas 15–45% stop psychotherapy treatment
too early [19, 25]. System barriers include productiv-
ity pressures, limitations of mental health coverage,
restrictions of specialists and treatments, the lack
of a systematic method for detecting and managing
depressed patients and inadequate continuity of care
[22].
One of the methods to overcome barriers and improve
the content and organization of care is the Break-
through Series Collaborative, because of its ability to
enhance the rate of diffusion of existing science into
clinical practice, by using multi-institutional or multi-
site work groups [31–35]. In this article, we present the
content and results of a part of a large Breakthrough
Collaborative project targeting better outcomes for
patients suffering from depression. The information
presented is directed at the improvements for adult
patients in primary care. The collaborative was initi-
ated by the Netherlands Institute of Mental Health
and Addiction (http://www.trimbos.nl), operated from
December 2006 to April 2008, and was funded by a
national health insurers fund, as part of the depression
initiative programme [36].
In the remainder of this article, we describe the prob-
lems in depression care targeted by the participants in
this project, the improvement principles and goals, the
improvement method, the methods used to collect and
analyse the data, and the impact on key outcome and
process indicators. In the discussion, the results are
interpreted and compared to similar work, giving sug-
gestions for future quality improvement projects.
Methods
Improvement principles and goals
A national expert team of depression opinion lead-
ers and project coordinators was set in place. They
developed a project plan, containing improvement
principles, goals and suggestions for improvement
ideas. The overall improvement principle was the
implementation of a stepped care approach. In a
stepped care approach evidence-based treatment
options are ranked by their degree of intensity, looking
at the impact on the patients life, the length of treat-
ment, the setting (general practice or specialty care)
and the costs, as well as combinations of these crite-
ria [37–39]. Patients start to step in at the appropriate
intensity level, which matches their (severity) profile.
Stepped care models have the potential to improve
efficiency and effectiveness of depression care [40–
42]. Also, the implementation of a stepped care model
can lead to better collaboration and integration, involv-
ing all partners across primary and secondary care,
and making them aware of their individual contribu-
tions to the shared approach [38, 39, 42, 43].
A pragmatic stepped care model was developed (Fig-
ure 1), consisting of a depression care pathway with
two levels of treatment intensity: a first step treatment
level for patients with mild depressive symptoms and
a second step treatment level for patients with severe
depressive symptoms.
The stepped care model was based on previous projects
in Dutch mental health care and on the (inter)national
literature [37, 38]. Professionals applying all the ele-
ments of the stepped care depression model, needed
to implement the following changes in their practices:
1. Stepped diagnostics. Depressive episodes were
diagnosed as usual, with general practitioners using
the ICPC coding system for new cases. Differentia-
tion between patients with non-severe depressive
symptoms (patient group 1 in Figure 1) and patients
with severe symptoms (patient group 2 in Figure 1)
had to be made, based on a set of severity crite-
ria (see box in left lower bottom of Figure 1). For
severely depressed patients a DSM-IV assessment
was indicated.
2. Stepped treatment. Implementation of a treatment
pathway with two treatment levels: a first step level
consisting of interventions for first, mild depressive
episodes with a duration up to 3 months (treatment
pathway level 1 in Figure 1) and a second step level
mainly consisting of antidepressant medication and
effective psychotherapeutic interventions (treat-
ment pathway level 2 in Figure 1).
3. Monitoring and evaluation of the treatment plan.
The course of symptoms and treatment progress
were to be monitored in both pathways using the
Beck Depression Inventory (BDI).
Derived from this stepped care model a set of SMART-
goals was formulated; goals that are specific, measur-
able, attractive, realistic and timely (Table 1). These
two instruments, the Stepped Care Depression Model
and the set of SMART goals, provided the improvement
teams with guidance for their improvement work. The
teams made a selection of goals, developed additional
local goals if they wished and implemented changes.

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Breakthrough method
The Breakthrough method, developed by Berwick and
colleagues at the Institute for Healthcare Improve-
ment in Boston (http://www.ihi.org), was used as the
model for change during the collaborative [44]. This
method was chosen for various reasons. Firstly, Break-
through Collaboratives are attractive projects, creating
learning opportunities for professionals, offering them
knowledge, a model for change and permitting them
to spend time on testing changes and experimenting
with new behaviour. Breakthrough Collaboratives can
be especially useful for microsystem improvements,
within small units of care delivery [45]. Secondly, these
projects have become very popular over the last few
years within the Dutch Ministry of Health, which has
funded many in different health care settings. This posi-
tive reputation is only partly based on research litera-
ture. A recently published systematic review of quality
improvement collaboratives showed that the underlying
evidence is positive but limited, with modest effects on
outcomes at best [35]. In mental healthcare, the Break-
through method had rarely been applied and evaluated.
Breakthrough Collaboratives can be considered as a
multifaceted implementation strategy. Central charac-
teristics of all Breakthrough Collaboratives are: the use
of guidelines, local multidisciplinary improvement teams
consisting of professionals and a local team coordina-
tor, a national expert team consisting of depression
opinion leaders and national project coordinators, data
collection and continuous feedback loops [34, 46]. In
the Depression Breakthrough Collaborative a specific
mix of these improvement strategies was offered to the
participating teams (Table 2).
A central feature of the Breakthrough Collaboratives
is continuous feedback loops according to the Nolan
model (Figure 2). The model consists of two elements:
three questions to focus the improvement work and a
PLAN-DO-STUDY-ACT (PDSA) cycle. This model, orig-
inally developed by Langley and popularized by Nolan,
provides an overarching framework for testing change
ideas that are expected to make progressively more
complex changes along an improvement ramp. Instead
of focusing on changing the behaviour of individual pro-
viders, the focus is on gradually changing organizations
into high performing (micro)systems of care [45–47].
Figure 1. Stepped care depression model.
Table 1. The SMART goals of the Depression Breakthrough Col-
laborative
1. Within 6 months of treatment, 80% of all new patients have a
score of 10 or lower on the Beck Depression Inventory (BDI).
Obligatory goal
2. 80% of systematic follow-up visits is according to planning,
meaning 1 visit every 6 weeks until the scores on the BDI is 10
or lower. Obligatory goal
3. <10% of patients with non-severe symptoms receive antide-
pressants or psychotherapy as a first step treatment
4. All patients with severe depressive symptoms start treatment
within 1 month after diagnosis
5. <20% of all patients with severe symptoms, treated with anti-
depressants, have dropped out of treatment within the first 3
months

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Results
A total of 13 teams participated in the project, consist-
ing of 101 professionals and 15 managers or staff. The
teams all had a multidisciplinary character, including at
least one or more general practitioners, and a psychia-
trist or a psychotherapist working in a specialized Men-
tal Health Organization. In total, 39 general practitioners
were involved, 14 primary care psychologists, 16 social
workers, 11 specialised mental health nurses, 8 phys-
iotherapists, 6 psychologists or psychotherapists and
7 psychiatrists. The smallest team consisted of 6 per-
sons, the largest had 15 members. The teams all had a
local team coordinator, responsible for supporting the
professionals, managing communications within the
national network, and pushing the local improvement
process forward. Most of the team coordinators were
staff employees in primary care support organizations
called Regional Support Structures (Regionale Onder-
steuning Structuur, ROS). Five hundred and forty-three
adult patients were registered by the 13 teams during
the improvement year. The inclusion ranged from 17
patients in the team with the lowest patient number
and 93 patients in the team with the highest. All teams
selected their goals for improvement (see Table 1).
SMART goals 1 and 2 were obligatory for all teams,
goal 3 and 4 were selected by 10 teams, goal 5 was
selected by four teams.
Data collection and analysis
Quantitative improvement data were collected by
the professionals of the Breakthrough Collabor-
ative’s teams. Measurements were derived from
process and outcome indicators, developed by the
national expert team to measure goal attainment on
each of the SMART goals. Data were entered and
processed in Excel by the local coordinators, who
had received training to do so. Periodically, the local
data were fed back to the teams for discussions
and adaptation of improvement plans. Aggrega-
tion and analysis of all data was done by the expert
team and data managers of the Trimbos Institute.
To maintain privacy, patient data were made anon-
ymous before being sent to be processed on a
national level. In order to monitor the change over
time, the team performances of process indicators
were analyzed as repeated measures of three-
monthly data. Teams that collected data throughout
the improvement year had four terms of 3 months to
demonstrate change. Other teams, starting to col-
lect data only later, may have produced just three
sets of data. In addition to the improvement data,
qualitative data were collected from the local team
coordinators, in the last stage of the project. For
this purpose, a questionnaire was used, with items
on: characteristics of the team, results according to
the coordinator, strengths and weaknesses of the
improvement method, influencing factors, spread
and consolidation of results. Seven coordinators,
reporting on 10 out of 13 teams, returned the com-
pleted questionnaire.
Figure 2. The Nolan model for improvement.
Table 2. Improvement strategies offered during the Depression
Breakthrough Collaborative
•
•
•
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 the Breakthrough
method and data collection;
Four conference days for all improvement teams for exchange
and learning;
One conference day for local team coordinators for more inten-
sive 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 discus-
sions and links to relevant sites;
A two-day training on problem solving treatment for
professionals;
A workshop workflow improvement.
•
•
•
•
•
•
•
•
•
•

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Diagnostic skills
General practitioners were asked to differenti-
ate between severely depressed and non-severely
depressed patients. The label severe depression was
considered appropriate if the patient previously had
depressive symptoms lasting 6 months or longer,
and/or showed an insufficient response to a former
treatment and/or reported suicidal ideation, psychotic
features or a high level of social malfunctioning. Out
of the 543 patients registered during the project, 536
patients were diagnosed to have either non-severe
or severe depressive symptoms (Figure 3). Over-
all 356 patients (66%) were considered non-severely
depressed and 180 (34%) showed severe symptoms
according to the general practitioners. Figure 3 also
shows a large variability between the teams in the
proportion of patients in each category, with the propor-
tion of severely depressed patients ranging from 2%
(team 12) to 83% (team 6). The team with the largest
patient group (n=93) registered 76 non-severe depressed
patients (82%) and 17 severe patients (18%).
Stepped care approach
The overall goal of the improvement teams was the
implementation of a stepped care model, a depression
care pathway with two levels of treatment intensity: a
first step treatment level for patients with non-severe
depressive symptoms and a second step level for
patients with severe depressive symptoms (Figure 4).
The teams registered treatment data of a total of
514 patients, 346 (67%) patients with a non-severe
depression and 168 (33%) patients with a severe
depression. The overall mean percentage of the non-
severe patient group receiving a first step treatment
according to the stepped care model was 78%, rang-
ing from 53% in the worst performing team to 100%
in three best performing teams. The mean percent-
age of the severely depressed patient group was
57%, ranging from 25 to 100% between the teams.
The patient groups were extremely small in cer-
tain teams, thus accounting for these wide ranges.
Although the scores in the non-severe group did not
reach the level of 90%, there was a positive trend
towards this target. This is in line with the reports
of the local team coordinators, indicating that gen-
eral practitioners did learn to offer patients with few
or mild symptoms a brief or first step intervention
instead of antidepressant treatment, once these
first step interventions were made available in pri-
mary care. According to the stepped care model, all
patients with severe symptoms should have received
psychotherapy or antidepressant treatment within 1
month, either in primary or in specialty care. Unfor-
tunately, the improvement teams were not able to
move good quality treatment for severely depressed
patients close to the targeted 100%. In total 72 (43%)
severely depressed patients did not receive antide-
pressant treatment or psychotherapy within 1 month
or were offered treatment options of a too low inten-
sity. This number includes 23 patients whom were
referred to specialty care within 1 month, where they
might have received proper treatment in time. The
team coordinators indicated improvement in terms
of a growing consciousness amongst professionals
of the needs of severely depressed patients, better
referral procedures and more attention to psycho-
therapy as an alternative for antidepressants.
Figure 3. Number of severe and non-severe depression per team.

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Monitoring of depressive symptoms
The professionals were asked to monitor depressive
symptoms with the BDI until recovery, defined as a
BDI-score of 10 or lower. Table 3 shows that the teams
succeeded in following around 70% of their patients
during a period of 6 months. Repeated BDI monitoring
by itself, was conceived to be very difficult to organize,
especially since integration of the BDI measurements
in existing ICT systems was lacking.
During the project, 477 patients received BDI monitoring
at baseline, within 2 weeks after diagnosis. Four hun-
dred and seventy-four patients (99%) scored more than
10, of whom 270 patients (57%) received a follow-up
measurement within 3 months. Of this group 76 persons
(28%) had recovered according to the BDI score of 10 or
lower. Of the 194 non-recovered patients, 103 patients
had another follow-up measurement at 6 months (53%).
Of this group, another 28 patients (27%) had recovered,
75 patients (73%) had a BDI score higher than 10.
Overall, 91 non-severely depressed and 50 severely
depressed patients had BDI monitoring at baseline and
within 3 to 6 months. Eighty-two percent non-severely
depressed patients improved during that period, of
whom 30% recovered and 17% of the patients wors-
ened with increased scores on the BDI. Of the severely
depressed group, 88% of the patients improved, 24%
recovered and 8% patients worsened.
Collaboration and integration
In addition to the data, the comments of the team coor-
dinators on the project were asked in a questionnaire.
All team coordinators indicated that the project had a
positive impact on collaboration within primary care. Pro-
fessionals grew to know each other during the project,
and as a consequence developed a mutual language
on depression care, a better understanding of the con-
tent and added value of each of the different competen-
cies and a more reliable collaborative relationship. This
was a good basis for a regionally shared approach and
responsibility in depression care. Teams also reported
better collaboration in daily practice. Collaboration
improved in terms of easier and faster consultation of
a psychiatrist or psychologist when the patient’s con-
dition was unclear, better access to specialty care for
primary care patients, and general practitioners staying
better informed after referral. Improved collaboration
was restricted to the professionals in the improvement
teams, and did not really spread beyond this group.
Knowledge and guidelines
Another effect mentioned by the coordinators was
improved knowledge of depression amongst the profes-
sionals and improved competence in terms of diagnosing
and treating depressive symptoms. Some teams inten-
Figure 4. Percentage of patients receiving first step treatment according to stepped care model.
Table 3. Depression symptoms at 6 months
Non-severely
depressed patients
(n=91)
Severely depressed
patients (n=50)
Improved/recovered
Stable
Worse
75 (82%)/27 (30%)
3 (3%)
13 (17%)
44 (88%)/12 (24%)
2 (4%)
4 (8%)

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sively discussed the guidelines at the start of the project,
whereas other teams considered the Depression Break-
through Collaborative as their knowledge base.
Strengths and weaknesses of the
breakthrough method
The top-down goal setting appeared to be a success
factor in primary care, general practitioners being in
favour of practical tools, standards and clear instruc-
tions. Another successful element was the outcome
monitoring using the BDI. Although hard to implement,
it shifted the focus of professionals from their own clini-
cal judgements to more objective results that could be
shared with others. The Toolkit, describing the content
of interventions in detail (number of sessions needed,
topics to inform the patient about) served as a fidelity
tool for correct development and implementation and
as a basis for team discussions.
Weaknesses of the project, experienced by the team
coordinators, were related to a mismatch between
the project’s design and the primary care working cul-
ture. PDSA cycles were hard to apply and did not fit
into the existing culture of primary care profession-
als, who were not used to discussing care processes
and reflecting on results. Also the website, the main
source of information and communication, was of no
help to individual professionals, who were not used to
virtual project environments. Other negative aspects of
the project were the obligatory reports that needed to
be sent to the national expert team and the changing
planning of conference days and other happenings.
Influencing factors
Factors facilitating the project were: the presence of
a strong local team coordinator, enthusiastic team
members (particularly the general practitioner as the
key player in the team), financial support for time
spent on the project from an insurance company, and
the embedment of the project within a broader quality
improvement policy of the Mental Health Organization
or primary care health centre. Most of the local team
coordinators were employed by the so-called Regional
Support Structures, rather new organizations in Dutch
primary care, created by the Ministry of Health to help
professionals improve the quality of care. Some of the
health care insurance companies reimbursed general
practitioners for the time spent on the project and paid
for the team coordinator to support the team.
Factors hindering the project were: a lack of interest by
the management, a lack of dedicated time for participat-
ing professionals, a lack of patients with new depres-
sive symptoms in primary care during the project,
and the short length of the project’s duration. Most
teams felt the time frame of the project was too short
for real change, especially in smaller teams, with only
one general practitioner. Focusing on a longer change
period and continuing improvement activities after the
project’s formal ending, was the way most teams dealt
with these frustrations.
Discussion
Thirteen multidisciplinary teams participated in the qual-
ity improvement project. In total 101 health profession-
als 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 model was 78%, and
57% for the severely depressed patient group. Com-
pared to numbers mentioned in the literature of 23% of
patients with anxiety and depression receiving the right
treatment in primary care, this could be considered
as relatively high [1]. The proportion of non-severely
depressed patients receiving the right first step treat-
ment slightly improved during the project, but 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 BDI score of 10 and lower, and another
27% recovered between 3 and 6 months. Collabora-
tion between primary care and specialty care and within
primary care improved but did not spread beyond the
teams. The team coordinators indicated that a break-
through, although still fragile, was being achieved in
terms of professionals improving their knowledge of
depression and depression guidelines, learning to use
new and less intensive treatments in mild cases instead
of antidepressant treatment and improving collabora-
tion within and between the settings, so that access to
specialty care for severely primary care improved.
In total, 39 practitioners identified 536 new cases, a
mean of 14 patients per general practitioner. This is lower
than expected, considering the national incidence rate
of 24 patients in a general practice of 2300 subscribed
patients, suggesting that the general practitioners
did not identify all patients with depressive symptoms
or did not include all patients who were identified [24].
The diagnostic performances suggest that the project
served as a platform for general practitioners to change
their behaviour and start to differentiate between severe
and non-severe depressive symptoms. Whether this
was done in a reliable way, reflecting the true propor-
tions, is not clear. The large variability between the
general practitioners suggests that, apart from epide-
miological differences, several professional related

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This article is published in a peer reviewed section of the International Journal of Integrated Care??
factors could have influenced the diagnosis. For
instance, the sensitivity of some of the general practitio-
ners to picking up on mild or early depressive symptoms,
and their ability to discuss their findings with the patient,
could have been more or less developed. Also, a doctor
feeling uncomfortable with a particular label and the
corresponding treatment level could have adapted the
treatment criteria to his own perception.
The monitoring indicators showed that the teams were
able to monitor depression symptoms to a reasonable
extent during the first 6 months of the treatment. This
can be considered as a rather big improvement, con-
sidering the lack of routine, infrastructure and ICT sup-
port. When patients had stopped visiting the practices,
possibly because of diminishing symptoms, continuous
monitoring proved to be problematic.
The data suggest an improvement ramp pushing the
quality of care for patients with non-severe depres-
sion forward. This in line with data from a previous
Depression Breakthrough Collaborative that served
as a pilot project. In that project, data of precollabo-
rative treatment were compared to the improvement
data, showing a very sudden drop in unnecessary anti-
depressant prescriptions for non-severely depressed
patients from 61 to 11%, during the very first weeks
of the collaborative [48]. In the current project, no pre-
post trend can be shown, so nothing can be said about
the actual change introduced during the collaborative.
The recovery rates are in line with the Sequenced Treat-
ment Alternatives to Relieve Depression (STAR*D)
study, a naturalistic study showing that only one-third
of patients achieves remission with initial treatment
and that remission rates decline with successive treat-
ment failures [49]. The results of our project, although not
based on research data, confirm the suggestion derived
from the scientific research into collaboratives, showing
modest effects on outcomes at best [35].
Our project also builds on reports of other improvement
work in depression care that show a positive impact
on the quality of care and on patient outcomes. In the
American version of the Depression Breakthrough Col-
laborative, the chronic care model was implemented,
also based on the assumption that depression care is
fragmented and that there is a gap between guideline
recommended and actual care [50]. The change con-
cepts considered to be essential in the American project
turned out to be establishing and maintaining a patient
register, care coordination, diagnostic assessment and
pro-active follow-up. Factors facilitating that project
were: the support of organizational leadership showing
the essential role of the top management, and a small
practice size [50, 51]. Some of the essential change
concepts show overlap with the positive experiences
in our project concerning diagnostic assessment and
pro-active follow-up. Still, the stepped care approach,
introducing different patient categories and correspond-
ing treatment levels, with much attention to other than
pharmacological approaches, can be considered dis-
tinctive and of relevance to international readership.
There are several limitations to this project. Firstly, reg-
istration of improvement indicators was hampered in
various ways and the quality of data gathering during the
project varied. Although some teams managed to collect
most data for their patients, the overall database showed
many missing values. A second limitation was the poor
insight in the actual implementation of the interventions.
The data are based on reports of the professionals; it is
unclear whether patients actually received care accord-
ing to the protocol or guidelines. Thirdly, the twelve
months duration of the project; this may have been too
short to measure any impact on the care processes.
It is clear that the information derived from these data
does not pretend to serve as new, generalizable knowl-
edge on causal mechanisms in healthcare, but as a
mirror for reflection and discussion on processes of
change in depression care. Quality improvement is a
growing topic of interest to many managers and profes-
sionals in this sector, also stimulated by policy makers
and insurance companies. Although changing depres-
sion care is on the agenda of many, the question of how
to go about it is still unanswered. The data presented
here may help to find some of the answers. Parallel to
these quality improvement data, a quasi-experimental
trial was conducted, comprising rigorous quantitative
and qualitative process and outcome data-gathering
on the patient, the professional and the team level, and
a comparison between the collaborative study popu-
lation and a care as usual group. The results of that
study will be published from 2010 onwards.
Conclusions
A stepped care approach seems acceptable and feasi-
ble in primary care, introducing different levels of care
for different patient groups. 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 this
intensive improvement project.
Acknowledgements
This project is part of the depression initiative of the
Trimbos Institute that is supported by a grant from the
Innovation Fund of Healthcare Insurers (Innovatiefonds
Zorgverzekeraars). We wish to thank the professionals
and project leaders in the Depression Breakthrough

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?0
International Journal of Integrated Care – Vol. 9, 15 June 2009 – ISSN 1568-4156 – http://www.ijic.org/
Collaborative teams for sharing their improvement
experiences.
Reviewers
Christopher Dowrick, BA, MSc, MD, CQSW, FRCGP,
FFPHM, Professor of Primary Medical Care, University
of Liverpool, Liverpool, UK
David Perkins, Associate Professor, Director Centre
For Remote Health Research, Broken Hill Department
of Rural Health, University of Sydney, Broken Hill NSW,
Australia
M.A. Prins, Drs, Junior-investigator, NIVEL the Neth-
erlands Institute for Health Services Research, Utre-
cht, The Netherlands
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