guideline adherence. Nonetheless, we acknowledge some lim-
itations. The timeframe of 2 years (one before and one after
baseline) to assess whether patients had received guideline-
concordant care might have influenced patients’ scores at
baseline. Patients could have improved or have developed more
positive beliefs about certain treatment forms because of prior
treatment. Even though we performed post-hoc analyses on a
subsample, we should keep this limitation in mind. Further-
more, our classification into guideline-concordant and non-
guideline concordant care was based on available EMR data,
which means that the quality of registration could have
influenced our dependent variable.
Another limitation is that patient’s needs, as measured by
the PNCQ, are partly contaminated with guideline-concordant
care, as receiving medication or counseling automatically
implied a need for care and in most cases, care according to
the guidelines as well. Nevertheless, these variables can also
mean that patients believe that medication or counseling are
useful treatment options.
In conclusion, education level, accessi bility to care, and
patients’ perceived needs for care are strongly associated with
the delivery of guideline-concordant care for patients with
anxiety or depression in Dutch primary care practices. Since
inadequate doctor-patient communication can limit GPs’ abil-
ity to recognize depression and anxiety in their patients
initiatives to improve GPs’ communication skills around
mental health issues could increase the number of patients
receiving treatment for depression and anxiety. Besides, GPs
should increase their index of suspicion for patients suffering
from anxiety disorder(s) only, since this patient group often
remains unrecognized and untreated. Finally, the mechanisms
underlying the relationship between patients’ educational
attainment and receipt of guideline-concordant care for mood
disorders should be further examined to identify additional
methods for optimizing delivery of mental health care to these
Acknowledgments: The infrastructure for the NESDA study (www.
nesda.nl) is funded through the Geestkracht program of the Nether-
lands Organisation for Health Research and Development (ZonMw,
grant number 10-000-1 002) and is supported by participating
universities and mental health care organizations (VU University
Medical Center, GGZ inGeest, Arkin, Leiden University Medical
Center, GGZ Rivierduinen, University Medical Center Groningen,
Lentis, GGZ Friesland, GGZ Drenthe, Scientific Institute for Quality
of Healt hcare (IQ healthcare), Netherlands Institu te for Health
Services Research (NIVEL) and Netherlands Institute of Mental
Health and Addiction (Trimbos).
Support for data-analyses for the present study was provided by a
grant from the Health Care Efficiency Research Programme, subpro-
gram implementation (grant number 945-14-413).
The authors are also grateful to all participating GPs and patients
and the members of the NESDA primary care team.
Conflict of Interest: All authors declare to have no conflict of
Ethical approval: The NESDA study was approved centrally by
the Ethic Review Board of the VU University Medical Centre and by
local review boards of the participating institutes. After full verbal
and written information about the study, written informed consent
was obtained from all participants.
Corresponding Author: Marijn A. Prins, MSc, NIVEL, Netherlands
Institute for Health Services Research, PO box 1568, 3500 BN,
Utrecht, The Netherlands (e-mail: M.Prins@nivel.nl).
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