Patient Factors Associated with Guideline-concordant Treatment of Anxiety and Depression in Primary Care

NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
Journal of General Internal Medicine (Impact Factor: 3.42). 07/2010; 25(7):648-55. DOI: 10.1007/s11606-009-1216-1
Source: PubMed
ABSTRACT
To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.
Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA).
Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included.
Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners.
Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care.
This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

Full-text

Available from: Peter F M Verhaak
ORIGINAL RESEARCH
Patient Factors Associated with Guideline-concordant Treatment
of Anxiety and Depression in Primary Care
Marijn A. Prins, MSc
1
, Peter F. M. Verhaak, PhD
1
, Mirrian Smolders, PhD
2
,
Miranda G. H. Laurant, PhD
2
, Klaas van der Meer, PhD, Professor
3
, Peter Spreeuwenberg, MSc
1
,
Harm W. J. van Marwijk, PhD
4
, Brenda W. J. H. Penninx, PhD, Professor
5,6,7
, and Jozien M. Bensing,
PhD, Professor
1,8
1
NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands;
2
Scientific Institute for Quality of Healthcare, Radboud
University Nijmegen Medical Centre, Nijmegen, The Netherlands;
3
Department of General Practice, University Medical Center Groningen,
Groningen, The Netherlands;
4
Department of General Practice, VU University Medical Center, Amsterdam, The Netherlands;
5
Department of
Psychiatry/EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands;
6
Department of Psychiatry, Leiden University Medical
Center, Leiden, The Netherlands;
7
Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands;
8
Department
of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands.
OBJECTIVE: To identify associations of patient char-
acteristics (predisposing, enabling and need factors)
with guideline-concordant care for anxiety and depres-
sion in primary care.
DESIGN: Analysis of data from the Netherlands Study
of Depression and Anxiety (NESDA).
PARTICIPANTS: Seven hundred and twenty-one patients
with a current anxiety or depressive disorder, recruited
from 67 general practitioners (GPs), were included.
MEASURES: Diagnoses according to the Diagnostic
and Statistic Manual of Mental Disorders, fourth edi-
tion (DSM-IV) were made using a structured and widely
validated assessment. Socio-demographic and enabling
characteristics, severity of symptoms, disability, (under
treatment for) chronic somatic conditions, perceived
need for care, beliefs and evaluations of care were
measured by questionnaires. Actual care data were
derived from electronic medical records. Criteria for
guideline-concordant care were based on general prac-
tice guidelines, issued by the Dutch College of General
Practitioners.
RESULTS: Two hundred and eighty-one (39%) patients
received guideline-concordant care. High education level,
accessibility of care, comorbidity of anxiety and depres-
sion, and severity and disability scores were positively
associated with receiving guideline-concordant care in
univariate analyses. In multivariate multi-level logistic
regression models, significant associations with the clin-
ical need factors disappeared. Positive evaluations of
accessibility of care increased the chance (OR=1.31; 95%
CI=1.051.65; p=0.02) of receiving guideline-concordant
care, as well as perceiving any need for medication
(OR=2.99; 95%CI=1.844.85; p<0.001), c ounseling
(OR=2.25; 95%CI=1.293.95; p=0.005) or a referral
(OR=1.83; 95%CI=1.093.09; p=0.02). A lo w educa t iona l
level decreased the odds (OR=0.33; 95%CI=0.110.98;
p=0.04) of receiving guideline-concordant care.
CONCLUSIONS: This study shows that education level,
accessibility of care and patients perceived needs for care
are more strongly associated with the delivery of guide-
line -concordant care for anxiety or dep ress ion than
clinical need factors. Initiatives to improve GPs commu-
nicatio n sk ills around mental health issues, and to
improve recognition of people suffering from anxiety
disorders, could increase the number of patients receiving
treatment for depression and anxiety in primary care.
KEY WORDS: depression; psychology; guidelines; primary care; patient-
centered care.
J Gen Intern Med 25(7):64855
DOI: 10.1007/s11606-009-1216-1
© Society of General Internal Medicine 2009
INTRODUCTION
Depression and anxiety are the most prevalent mental disorders
that run a chronic course, causing considerable emotional and
physical suffering, as well as high disability and health care
costs or loss of productivity
14
. Most people with anxiety or
depression seek and receive care in primary care settings
3
,but
many receive no treatment at all
5,6
. Despite the existence of
easily accessible guidelines, like the Dutch general practice
guidelines for depression and anxiety
7,8
, depression as well as
anxiety are frequently not recognized or successfully treated in
primary care settings
912
. Therefo re, barriers that prevent
primary care from mental health care delivery according to
generally accepted guidelines should be analyzed.
Anders ens behavioral m odel of hea lth services use
13,14
provides a useful framework for considering the factors that
result in guideline-concordant care of mood disorders. This
model portrays the multiple influences (contextual and indi-
JGIM
Received March 13, 2009
Revised September 18, 2009
Accepted November 11, 2009
Published online January 5, 2010
648
Page 1
vidual characteristics) on health services use. The individual
characteristics can be distinguished into: 1) predisposing
characteristics, such as demographics, social structure and
beliefs; 2) enabling factors, such as finance and organization;
and 3) factors that determine perceived need and evaluated
(clinical) need for care
13,14
.
Most earlier studies have focused on predisposing charac-
teristics and clinical need factors in the delivery of care for
anxiety and depressive disorders. More severely depressed
patients and those with a higher educational level had higher
chances of receiving appropriate care in one study
15
, while
others found that being white, being female
16,17
, age and
housing status
18
were also predictors of receiving guideline-
concordant care for common mental disorders. However, it
seems reasonable to expect that the delivery of care to patients
with anxiety or depressive disorders also depends on patients
beliefs or ideas and trust in the care and care provider
19,20
.
Patients who perceive a need for mental health care have been
found to be more likely to receive care for their anxiety or
depressive symptoms than patients who experience no need
for treatment
21
. While it is known that different individual
characteristics are associated with health services use, the
most influential factors remain unclear.
In this study, we examined the association of patient
characteristics with guideline-recommend anxiety and depres-
sion care. We specifically focused on the extent to which
patients beliefs, perceived needs and evaluations of received
(mental) health care are associated with guideline-concordant
care for anxiety and depression, while taking predisposing,
enabling and clinical need factors into account. Since in the
Netherlands the general practitioner (GP) serves as a gate-
keeper to the rest of the health system and all residents are
legally obligated to have health insurance, we expected no
significant associations between enabling factors and health
services use.
METHODS
Study Setting and Participants
Data were derived from the baseline wave of the Netherlands
Study of Depression and An xiety (NESDA), a longitudinal
cohort study on the long-term course of depr ession and
anxiety
22
. Adult patients were recruited from primary care
centers in the vicinity of Amsterdam, Leiden and Groningen.
Sixty-seven GPs from twenty-one practices participated, se-
lected by their use of electronic patient record systems (EMRs)
which allow uniform data extraction. Patients who attended
their GP in the last 4 months, irrespective of the reason for
consultation, were sent a questionnaire containing the Kess-
ler-10 (K10)
23
with five additional questions to screen for
anxiety or depressive disorders
24
. Nearly half of the screeners
returned were screen-positive (K-10 score of 20 or higher or a
positive score on any of the additional anxiety questions).
Womenandolderpeopleweremorelikelytoreturnthe
screener, but there were no differences in psychopathology
between responders and non-responders
22,25
.
As presented in Fig. 1, 743 patients with a current
depressive or anxiety disorder were recruited with this three-
stage screening procedure. Twenty-two patients refused to give
informed consent for the use of their health care information
from their EMR, so 721 patients from 67 different GPs were
finally included in this study. NESDA was approved by the
Central Ethics Committee on Research involving human
subjects of the participating institutes.
Dependent Variable: Actual GP Care
Information about the delivery of care given to patients with a
current anxiety or depression diagnosis was gathered from the
EMRs of GPs. Data were extracted from the year prior to
inclusion in the NESDA study to one year after inclusion. For
each included patient the following data were derived: Inter-
national Classification of Primary Care (ICPC) codes, number
and type of contacts, prescribed medication (type and dosage),
duration of prescription, and referrals. Our earlier study
26
described to which degree GPs adhered to the evidence-based
clinical depression and anxiety guidelines, issued by the Dutch
College of General Practitioners, in the delivery of care for their
anxiety and depression patients
7,8
. Patients were divided into
two groups, based on the care they had received: 1) guideline-
concordant care, and 2) non-guideline concordant care.
Guideline-concordan t care was defined as having received
psychological support, including at least five consultations in
15 weeks after documentation of the diagnosis, counseling
(only applicable to depression care), a prescription for antide-
pressant medication, or a referral to a mental health specialist.
The criterion for medication treatment of anxiety or depression
further required documentation of evaluation after 6 weeks of
medication treatment initiation and a minimal treatment
duration of 5 months, or documentation of treatment cessa-
tion in the case of no response.
Independent Variables
Predisposing characteristics such as age, gender, country of
birth (the Netherlands versus other), educational level (in three
levels) and information about partner status and personal
network size (number of persons >18 years with whom you
have regular and important contact; in six categories) were
collected by means of a questionnaire.
The enabling factors income (24 levels), general financial
situation (in three levels) and employment status (working
versus not working) were collected by means of a question-
naire. Accessibility of care was measured with a single item (I
could make an appointment within two days) of the QUOTE
instrument (see below).
Clinical need was measured by the Composite Interview
Diagnostic Instrument (CIDI), WHO version 2.1, to identify
patients with a depressive disorder (Major Depressive Disorder
(MDD), dysthymia) or an anxiety disorder (generalized anxiety
disorder, social phobia, panic disorder, agoraphobia) according
to DSM-IV criteria
27
. The World Health Organization Disability
Assessment Schedule II (WHODAS II)
28
assessed disability,
Inventory of Depressive Symptoms (IDS) assessed severity of
depressive symptoms
29
and the Beck Anxiety Inventory (BAI)
measured anxiety symptoms
30
. In order to measure somatic
comorbidity, questions about the presence of and treatment
received for 20 different chronic somatic conditions were asked.
The Perceived Need for Care Questionnaire (PNCQ) was used
to measure if patients had a self-perceived mental health
problem (yes/no), and their specific perceived needs for care.
Perceived need was defined as patients perception that a type
649Prins et al.: Patient Factors Related to Anxiety/Depression CareJGIM
Page 2
of care was needed from a health professional in the prior
period
31
. The categories of perceived need are: (1) Information
about mental illness, its treatment and available services; (2)
Medication treatment; (3) Counseling or psychotherapy to talk
about the causes of symptoms and learn to cope with
emotional problems; (4) Practical support such as help to sort
out housing or money problems or help with domestic tasks;
(5) Skills training to improve ones ability to work, or to use
ones time in other ways or help to improve ones ability to look
after self or home; and (6) Referral to a specialist. Patients were
divided into a no need (if they did not receive a certain service
and did not want to receive it) and any need (if they received a
certain service or they did not receive a certain service but felt
they needed it) category for any of the six services. One last
variable measured whether patients had no need for any
services (did not want any help). The PNCQ has acceptable
feasibility, reliability and validity for epidemiological and health
services research
31
.
Beliefs concerning mental health care were measured by four
questions: two measured confidence in professional help (Cron-
bachs alpha=0.80), and two single items measured confidence
in help from friends (its best to discuss psychological problems
with friends) and confidence in self help (psychological problems
are best kept to yourself). Items were scored on a 4-point scale,
ranging from 1 strongly disagree to 4 strongly agree, with score
2.5 as the neutral no opinion option.
Patients evaluation of different aspects of received (mental)
health care was measured by the QUOTE (QUality Of care
Through the patients Eyes) instrument
32
, revealing five sub-
scales measuring providers emotional support (Cronbachs
alpha=0.78), patient centeredness (Cronbachs alpa=0.82),
quality of care (Cronbachs alpha=0.81), information and
advice (Cronbachs alpha=0.72), and self-help advice (Cron-
bachs alpha=0.80). Items were measured on a 4-point scale,
ranging from 1 no to 4 yes, with score 2.5 as the neutral does
not know option, indicating that higher scores correspond
with positive evaluations.
Data Analysis
Data were analyzed using SPSS software version 16.0 for
Windows. Descriptive statistics were used to outline the
characteristics of the patients. As the included patients are
nested within 67 GPs from 21 practices, multi-level logistic
Figure 1. Recruitment flow of NESDA respondents in the primary care setting. *Current=presence during last 6 months, non-current=presence
before last 6 months, subthreshold symptoms defined as screen-positives or having a minor depression according to the CIDI interview. CIDI-
SF=composite interview diagnostic instrument- short form; MHO=mental health care organizations; Dep/Anx disorders=depressive or anxiety
disorders.
650 Prins et al.: Patient Factors Related to Anxiety/Depression Care JGIM
Page 3
regression analyses (software MLwiN 2.02) was required. First,
univariate multi-leve l log istic analyses were performed on
patients who received guideline-concordant care versus patients
who received non-guideline concordant care on all patient
characteristics. Second, based on the level of significance (p
0.05) in the univariate analyses, a selection of variables were put
into multivariate multi-level logistic models. As the significant
clinical need variables were highly correlated, type of disorder
and disability score were chosen as the most distinctive variables.
The WHODAS was chosen as the primary outcome measure for
severity because the extent to which patients suffer from a
mental disorder and the extent to which it interferes with their
daily activities guide GPs in their treatment plans
8
.
First, predisposing and enabling characteristics were en-
tered, followed by the selected clinical variables in the second
step. Since our research question focused on the extra
influence of patients perceived needs, beliefs and evaluations,
the variables measuring these constructs were entered into the
model in the last step.
Since some persons in our sample already had received care in
the year preceding the baseline interview, prior treatment might
have influenced patients perceptions of care and the severity of
their symptoms. To control for this potential effect, post-hoc
analyses were performed on only those patients who had not
received treatment for their anxiety or depressive disorder(s) in
the year before the baseline interview. The same multi-level
logistic analyses were performed on the patients who received
guideline-concordant care in the year after baseline versus
patients who received non-guideline concordant care.
RESULTS
Description of the Study Sample
Two-hundred and eighty-one (39%) patients received guide-
line-concordant care (Table 1). Of all predisposing and enabling
characteristics, only a high (compared to low) education level
(OR=1.83; 95%CI=1.003.36; p=0.05) and accessibility of care
(OR=1.47; 95%CI=1.201.78; p<0.001) showed significant
(positive) associations with receiving guideline-concordant care.
Patients with anxiety disorder(s) only had decreased odds
(OR=0.38; 95%CI=0.270.55; p<0.001) of receiving guide-
line-concordant care in comparison with patients suffering
from both depressive and anxiety disorders (Table 2 ). Patients
with a single episode of MDD (OR=2.13; 95%CI =1.503.02; p<
0.001), dysthymia (OR = 2.58; 95%CI=1.693.95; p<0.001),
or generalized anxiety d isorders (OR=1.84; 95%CI=1.31
2.60; p<0.001) had higher odds of receiving care a ccording to
the guidelines than patients without these disorders. Also,
patients wit h hig her disability and sever ity scores were more
likely to receive guideline-concordant care compared to those
with lower disability and severity scores.
Patients with a perceived need for care, except for practical
support, were nearly two to four times more likely to receive
guideline-concordant care than those who had no need for
these services (Table 3). Patients with more confidence in
professional help (OR=1.55; 95%CI=1.122.15; p=0.01) and
those with a more positive evaluation of their providers emotion-
al support (OR=1.38; 95%CI=1.111.73; p=0.004) and patient-
centeredness (OR=1.50; 95%CI=1.151.95; p=0.003) had
higher chances of receiving guideline-concordant care.
Factors Associated with Guideline-concordant
Care
When the predisposing, enabling and clinical need factors were
entered into the multivariate multi-level logistic regression
model, accessibility and type of disorder were still significantly
associated with guideline-concordant care (Table 4, step 2).
Patients with anxiety disorder(s) only showed lower odds (OR=
0.53; 95%CI=0.330.86; p=0.01) of receiving guideline-con-
cordant care compared with patients with both anxiety and
depressive disorders. When the perceived need, beliefs and
Table 1. Association of Patient Characteristics with Receipt of Guideline-Concordant Care for Mood Disorders
Total Guideline-concordant
care
Non-guideline
concordant care
Unadjusted OR
(95% CI)
P value
N (%) 721 (100) 281 (39) 440 (61)
Predisposing characteristics
Age, mean (SD) 44.9 (12.1) 45.0 (11.4) 44.9 (12.5) 1.00 (0.99-1.01) 0.91
Gender, female 506 (70.2) 191 (68.0) 315 (71.6) 0.84 (0.60-1.17) 0.30
Country of birth
The Netherlands 635 (88.1) 253 (90.0) 382 (86.8) 0.74 (0.45-1.21) 0.22
Education level
Low 68 (9.4) 20 (7.1) 48 (10.9) ref.
Intermediate 423 (58.7) 171 (60.9) 252 (57.3) 1.64 (0.92-2.91) 0.09
High 230 (31.9) 90 (32.0) 140 (31.8) 1.83 (1.00-3.36) 0.05
Has a partner 481 (67.2) 188 (67.1) 293 (67.2) 0.95 (0.68-1.32) 0.76
Personal network, mean (SD) 2.6 (1.1) 2.6 (1.1) 2.6 (1.1) 0.97 (0.85-1.12) 0.70
Enabling factors
Level of income, mean (SD) 9.1 (5.3) 9.2 (5.5) 9.1 (5.2) 1.00 (0.97-1.03) 0.91
Financial situation
Usually money left 321 (44.5) 124 (44.1) 197 (44.8) 0.76 (0.49-1.19) 0.23
Just enough to manage 288 (39.9) 107 (38.1) 181 (41.1) 0.75 (0.48-1.18) 0.21
Not enough to manage 112 (15.5) 50 (17.8) 62 (14.1) ref.
Employment status
Working 473 (65.6) 181 (64.4) 292 (66.4) 0.99 (0.72-1.37) 0.98
Accessibility of care, mean (SD) 3.4 (1.0) 3.6 (0.9) 3.3 (1.1) 1.47 (1.20-1.78) <0.001
OR=odds ratio; CI=confidence interval; ref.=reference category
651Prins et al.: Patient Factors Related to Anxiety/Depression CareJGIM
Page 4
evaluation factors were also included (step 3), a low (versus
high) education level (OR=0.33; 95%CI=0.110.98; p=0.05),
accessibility of care (OR=1.31; 95%CI=1.051.65; p=0.02),
and perceived need for medication (OR=2.99; 95%CI=1.84
4.85; p<0.001), counseling (OR=2.25; 95%CI=11.293.95;
p=0.005) and referral (OR=1.83; 95%CI=1.093.09; p=0.02)
turned out to be the factors most strongly associated with
receiving guideline-concordant care. The intraclass correlation
found at the level of GPs and general practices was 0.07
respectively 0.16, which means that a greater part of the
variance, unexplained by the characteristics in our model, was
at the level of the practices.
Post-hoc Analyses
For only 38 patients (who had received guideline-concordant
care), care was restricted to the year after baseline. The others
might have been already in treatment at the moment of the
interview. When we repeated our analyses with these 38 patients
versus the original non-guideline concordant care group, most of
the perceived need for care scales were still significantly different
between the two gro ups, except for self perceived mental
problem and perceived need for medication. After entering the
(eight) significant univariate associations into a multivariate
model, the presence of a generalized anxiety disorder (OR=3.10;
Table 3. Association of Patients Perceived Needs, Beliefs, and Assessments of Care with Receipt of Guideline Concordant Mental Health
Care
Total Guideline-concordant
care
Non-guideline
concordant care
OR (95% CI) P value
N (%) 721 (100) 281 (39) 440 (61)
Perceived Need for Care
Self perceived mental problem 629 (87.2) 266 (94.7) 363 (82.5) 4.09 (2.26-7.41) <0.001
Perceived need for information 371 (57.7) 183 (67.5) 188 (50.5) 2.03 (1.45-2.84) <0.001
Perceived need for medication 266 (41.6) 160 (59.5) 106 (28.6) 4.04 (2.85-5.74) <0.001
Perceived need for counseling 386 (60.3) 202 (75.1) 184 (49.6) 3.25 (2.27-4.65) <0.001
Perceived need for practical support 94 (14.7) 45 (16.7) 49 (13.2) 1.34 (0.85-2.10) 0.21
Perceived need for skills training 144 (22.5) 73 (27.2) 71 (19.1) 1.62 (1.10-2.38) 0.02
Perceived need for referral 319 (49.8) 177 (65.8) 142 (38.3) 3.00 (2.14-4.21) <0.001
No need for any service 92 (12.8) 12 (4.3) 80 (18.2) 0.20 (0.11-0.38) <0.001
Beliefs about mental health care: mean(SD)
Confidence in professional help 3.0 (0.5) 3.0 (0.5) 2.9 (0.5) 1.55 (1.12-2.15) 0.01
Confidence in help from friends 2.4 (0.6) 2.4 (0.6) 2.5 (0.5) 0.96 (0.71-1.28) 0.76
Confidence in self help 1.8 (0.8) 1.8 (0.8) 1.8 (0.7) 0.88 (0.71-1.11) 0.28
Evaluation of received care: mean(SD)
Evaluation of providers emotional support 3.0 (0.9) 3.1 (0.8) 2.9 (0.9) 1.38 (1.11-1.73) 0.004
Evaluation of patient-centeredness 3.2 (0.7) 3.3 (0.7) 3.1 (0.8) 1.50 (1.15-1.95) 0.003
Evaluation of quality of care 2.9 (0.8) 3.0 (0.8) 2.9 (0.8) 1.21 (0.96-1.52) 0.10
Evaluation of information & advice 3.1 (0.9) 3.2 (0.8) 3.1 (0.9) 1.22 (0.98-1.53) 0.08
Evaluation of self-help advice 2.9 (0.9) 3.0 (1.0) 2.9 (0.9) 1.04 (0.85-1.27) 0.72
OR=odds ratio; CI=confidence interval
Table 2. Association of Mental Health Diagnoses and Symptoms with Guideline-Concordant Mental Health Care
Total Guideline-concordant
care
Non-guideline
concordant care
OR (95% CI) P value
N (%) 721 (100) 281 (39) 440 (61)
Type of diagnosis
Anxiety disorder(s) only 298 (41.3) 81 (28.8) 217 (49.3) 0.38 (0.27-0.55) <0.001
Depressive disorder(s) only 148 (20.5) 62 (22.1) 86 (19.5) 0.71 (0.47-1.08) 0.11
Comorbidity of both depressive and anxiety disorders 275 (38.1) 138 (49.1) 137 (31.1) ref.
Depressive disorder(s)
Dysthymia 114 (15.8) 67 (23.8) 47 (10.7) 2.58 (1.69-3.95) <0.001
MDD: single episode 180 (25.0) 96 (34.2) 84 (19.1) 2.13 (1.50-3.02) <0.001
MDD: recurrent episode 218 (30.2) 88 (31.3) 130 (29.5) 1.08 (0.77-1.51) 0.66
Anxiety disorder(s)
Generalized anxiety disorder 190 (26.4) 94 (33.5) 96 (21.8) 1.84 (1.31-2.60) <0.001
Social phobia 269 (37.3) 95 (33.8) 174 (39.5) 0.81 (0.59-1.12) 0.20
Agoraphobia without panic 92 (12.8) 33 (11.7) 59 (13.4) 0.83 (0.52-1.33) 0.44
Panic with & without agoraphobia 254 (35.2) 100 (35.6) 154 (35.0) 1.06 (0.77-1.46) 0.74
WHODAS disability score: mean (SD) 31.5 (16.4) 35.6 (16.7) 28.8 (15.7) 1.03 (1.02-1.04) <0.001
Severity of depressive symptoms: mean (SD) 27.4 (11.6) 30.8 (12.1) 25.3 (10.7) 1.47 (1.20-1.78) <0.001
Severity of anxiety symptoms: mean (SD) 16.2 (10.3) 17.9 (11.3) 15.1 (9.5) 1.38 (1.11-1.73) 0.004
Under treatment for any chronic medical conditions 308 (42.7) 127 (45.2) 181 (41.1) 1.11 (0.90-1.38) 0.32
OR=odds ratio; CI=confidence interval; ref.=reference category;
WHODAS=World Health Organization Disability Assessment Schedule; MDD=major depressive disorder
652 Prins et al.: Patient Factors Related to Anxiety/Depression Care JGIM
Page 5
95%CI=1.476.52; p=0.003), and perceived need for referral
(OR=3.10; 95%CI=1.267.63; p=0.01) were significantly asso-
ciated with receiving guideline-concordant care.
DISCUSSION
Summary and Discussion of Findings
This study aimed to identify patient characteristics that are
most strongly associated with receiving guideline-concordant
care for anxiety or depression. Together with education level
and accessibility of care, patients perceived needs for medica-
tion, counseling or a referral were most strongly associated
with the delivery of guideline-concordant care. Earlier stud-
ies
33,34
already concluded that people who perceive a need for
care have higher rates of (mental) health care use. Post-hoc
analyses show that nearly all perceived needs for care variables
are still essential when only those patients who received guide-
line-concordant care after baseline interview were taken into
account. These findings provide evidence that patients perceived
needs play a major role in receiving guideline-concordant care for
anxiety or depression, and are perhaps more influential than
predisposing, enabling and clinical need factors.
With regard to the clinical need variables, some interesting
results were found. Patients with anxiety disorder(s) alone were
less likely to receive guideline-concordant care than patients with
both anxiety and depression. When anxiety patients also suffer
from a depressive disorder, the chances of receiving counseling or
pharmacotherapy increase significantly, which was found be-
fore
17
. This is consistent with the finding that, in general practice,
anxiety disorders are less frequently diagnosed than affective
disorders
35
. In addition, patients with more severe symptoms
and greater disability were most often treated according to the
guidelines, indicating that those with more clinical need for care
have greater chances of receiving it.
No differences were found on the predisposing character-
istics, except for education level. Lower educated patients seem
to be disadvantaged with respect to receiving guideline-con-
cordant care from their GP in comparison with higher educat-
ed patients, consistent with previous research
21
.This
difference could be explained by a of lack of knowledge of
available se rvices, lack of insight into their own mental
problems or a less open attitude towards disclos ing and
discussing personal problems
15
among the less well educated.
It is also possible that GPs treat lower educated patients
differently compared with their higher educated counterparts
since gender and age are also related with GPs provision of
active treatment for common mental disorders
36,37
.
As expected, patients financial situation and employment
status did not differ between the two groups, although patients
who received guideline-concordant care reported better acces-
sibility of care.
Strengths and Limitations
Strengths of this study include the large sample size and the
use of a prospective desi gn in collecting data to a ssess
Table 4. Multivariate of Patient and Multilevel Logistic Regression Analysis on Receiving Guideline-concordant Care
Random Effects Step 1 Step 2 Step 3
Variance estimate
(St. error), ICC
Variance estimate
(St. error), ICC
Variance estimate
(St. error), ICC
Level 3: general practice (n=21) 0.74 (0.33), 0.18 0.72 (0.33), 0.18 0.71 (0.37), 0.16
Level 2: general practitioners (n=63) 0.08 (0.16), 0.02 0.05 (0.16), 0.01 0.29 (0.25), 0.07
Level 1: patient (n=437) 0.95 (0.07) 0.95 (0.07) 0.91 (0.07)
Fixed Effects
Predisposing and enabling factors OR (95% CI), P-value OR (95% CI), P-value OR (95% CI), P-value
Education level
Low 0.48 (018-1.23), 0.13 0.40 (0.15-1.06), 0.07 0.33 (0.11-0.98), 0.05
Intermediate 0.80 (0.51-1.24), 0.31 0.77 (0.49-1.21), 0.25 0.70 (0.42-1.16), 0.16
High ref. ref. ref.
Accessibility of general practitioner 1.36 (1.11-1.67), 0.003 1.38 (1.12-1.69), 0.002 1.31 (1.05-1.65), 0.02
Clinical need factors
Type of disorder
Depressive disorder(s) only 0.95 (0.55-1.64), 0.85 0.96 (0.52-1.79), 0.91
Anxiety disorder(s) only 0.53 (0.33-0.86), 0.01 0.69 (0.40-1.19), 0.18
Comorbidity of both depressive and anxiety disorders ref. ref.
Disability score 1.01 (1.00-1.03), 0.06 1.01 (1.00-1.03), 0.16
Perceived needs, beliefs and evaluations
Self perceived mental problem 2.17 (0.41-11.49), 0.36
Perceived need for information 1.09 (0.65-1.84), 0.74
Perceived need for medication 2.99 (1.84-4.85), <0.001
Perceived need for counseling 2.25 (1.29-3.95), 0.01
Perceived need for skills training 1.10 (0.64-1.90), 0.72
Perceived need for referral 1.83 (1.09-3.09), 0.02
No need for any service 0.74 (0.26-2.09), 0.57
Confidence in professional help 1.14 (0.73-1.79), 0.57
Evaluation of providers emotional support 1.21 (0.89-1.66), 0.23
Evaluation of patient-centeredness 1.22 (0.83-1.78), 0.31
OR=odds ratio; CI=confidence interval; ICC=intraclass correlation; ref.=reference category.
First, predisposing and enabling factors were put into the model. Second, clinical need factors were entered, and in the third step perceived needs, beliefs
and evaluation factors were added to the (final) model
653Prins et al.: Patient Factors Related to Anxiety/Depression CareJGIM
Page 6
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 patients 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.
Conclusion
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
38
,
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
patients.
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
interests.
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).
REFERENCES
1. Alonso J, Codony M, Kovess V, et al. Population level of unmet need for
mental healthcare in Europe. Br J Psychiatry. 2007;190:299306.
2. Andrews G, Henderson S, eds. Unmet need in psychiatry. Problems,
resources, responses. Cambridge: Cambridge University Press: 2000.
3. Bijl RV, Ravelli A. Current and residual functional disability associated
with psychopathology: findings from the Netherlands Mental Health
Survey and Incidence Study (NEMESIS). Psychol Med. 2000;30:65768.
4. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major
dep ressive disorder: results from the National Comorbidity Surve y
Replication (NCS-R). JAMA. 2003;289:3095105.
5. Thornicroft G. Most people with mental illness are not treated. Lancet.
2007;370(9590):8078.
6. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health
services for anxiety, mood, and substance disorders in 17 countries in
the WHO world mental health surveys. Lancet. 2007;370:84150.
7. NHG Standaard Depressieve stoornis (depressie) [Dutch college of
general practitioners, Practical guideline Depressive disorder (de-
pression)]. M44 (2003, October). Available at: http://nhg.artsennet.nl/
kenniscentrum/k_richtlijnen/k_nhgstandaarden/Samenvattings
kaartje-NHGStandaard/M44_svk.htm. Accessed November 24, 2009.
8. NHG Standaard Angststoorni s (angst) [Dutch college of general
practitioners, Practical guideline Anxiety disorder]. M62 (2004,
January). Available at: http://nhg.artsennet.nl/kenniscentrum/k_rich
tlijnen/k_nhgstandaarden/Samenvattingskaartje-NHGStandaard/
M62_svk.htm. Accessed November 24, 2009.
9. Thompson C, Kinmonth AL, Stevens L, et al. Effects of a clinical
practice gui deline and practice-based education on detection and
outcome of depression in primary care: Hampshire Depression Project
randomised controlled trial. Lancet. 2000;355:18591.
10. Weel-Baumgarten EM, van den Bosch WJ, Hekster YA, van den
Hoogen HJ, Zitman FG. Treatment of depression related to recurrence:
10-year follow-up in general practice. J Clin Pharm Ther. 2000;25:616.
11. Cardol M, van Dijk L, de Jong JD, de Bakker DH, Westert GP. Tweede
Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk.
Huisartsenzorg: wat doet de poortwachter? [Second Dutch National
Survey of General Practice. General practice care: what does the
gatekeeper?]; 2004. Utrecht/Bilthoven: NIVEL/RIVM; 2004.
12. Olssøn I, Mykletun A, Dahl AA. Recognition and treatment recommen-
dations for generalized anxiety disorder and major depressive episode: a
cross-sectional study among general practitioners in Norway. Prim Care
Companion J Clin Psychiat. 2006;8:3407.
13. Andersen RM. Revisiting the Behavioural Model and access to care: does
it matter? J Health Soc Behav. 1995;36:110.
14. Andersen RM. National health surveys and the behavioral model of
health services use. Med Care. 2008;46:64753.
15. Van Os TWDP, van den Brink RHS, van der Meer K, Ormel J. The care
provided by general practitioners for persistent depression. Eur Psy-
chiatr. 2006;21:8792.
16.
Wang PS, Berglund P, Kessler RC. Recent care of common mental
disorders in the United States: prevalence and conformance with
evidence-based recommendations. J Gen Intern Med. 2000;15:28492.
17. Stein MB, Sherbourne CD, Craske MG, et al. Quality of care for
primary care patients with anxiety disorders. Am J Psychiatry.
2004;161:22307.
18. Raine R, Lewis L, Sensky T, Hutchings A, Hirsch S, Black N. Patient
determinants of mental health interventions in primary care. Br J Gen
Pract. 2000;50:6205.
19. Nutting PA, Rost K, Smith J, Werner JJ, Elliot C. Competing demands
from physical problems: effect on initiating and completing depression
care over 6 months. Arch Fam Med. 2000;9:105964.
20. Nutting PA, Rost K, Dickinson M, et al. Barriers to initiating depression
treatment in primary care practice. J Gen Intern Med. 2002;17:10311.
21. Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for
depressive and anxiety disorders in the United States. Arch Gen
Psychiatry. 2001;58:5561.
22. Penninx BW, Beekman AT, Smit JH, et al. The Netherlands Study of
Depression and Anxiety: rationale, objectives and methods. Int J
Methods Psychiatr Res. 2008;17:12140.
654 Prins et al.: Patient Factors Related to Anxiety/Depression Care JGIM
Page 7
23. Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious
mental illness in the general population. Arch Gen Psychiatry. 2003;
60:1849.
24. Donker T, Comijs HC, Cuijpers P, et al. The validity of the extended
K10 screening scale for depressive and anxiety disorders. Psychiatry Res.
in press.
25. Van d er Veen WJ, van der Meer K, Penninx BW. Screening for
depression and anxiety: analysis of cohort attrition using general
practice data on psychopathology. Int J Methods Psych Res. in press.
26. Smolders M, Laurant M, Verhaak P, et al. Adherence to evidence-based
guidelines for depression and anxiety disorders is associated with
recording of the diagnosis. Gen Hosp Psychiatry. 2009;31:46069.
27. American Psychiatric Association. Diagnostic and Statistic Manual of
Mental Disorders, fourth edition. Washington: 2001.
28. 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;56:50714.
29. Rush AJ, Gullion CM, Basco MR, Jarrett RB, Trivedi MH. The
Inventory of Depressive Symptomatology (IDS): psychometric properties.
Psychol Med. 1996;26:47786.
30. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring
clinical anxiety: psychometri c properties. J Consult Clin Psychol.
1988;56:8937.
31. Meadows G, Harvey C, Fossey E, Burgess P. Assessing perceived need
for mental health care in a community survey: development of the
Perceived Need for Care Questionnaire (PNCQ). Soc Psychiatry Psychiatr
Epidemiol. 2000;35:42735.
32. Sixma HJ, Kerssens JJ, Campen CV, Peters L. Quality of care from the
patients' perspective: from theoretical concept to a new measuring
instrument. Health Expect. 1998;1:8295.
33. Codony M, Alonso J, Almansa J, et al. Perceived need for mental health
care and service use among adults in western Europe: Results of the
ESEMeD project. Psychiatr Serv. 2009;60:10518.
34. Verhaak PFM, Prins MA, Spreeuwenberg P, et al. Receiving treatment
for common mental disorders. Gen Hosp Psychiatry. 2009;31:4655.
35. Verhaak PFM, Schellevis FG, Nuijen J, Volkers AC. Patients with a
psychiatric disorder in general practice: determinants of general practi-
tioners' psychological diagnosis. Gen Hosp Psychiatry. 2006;28:12532.
36. Hyde J, Evans J, Sharp D, et al. Deciding who gets treatment for
depression and anxiety: a study of consecutive GP attenders. Br J Gen
Pract. 2005;55:84653.
37. Kisely S, Linden M, Bellantuono C, et al. Why are patients prescribed
psychotropic drugs by general practitioners? Results of an international
study. Psychol Med. 2000;30:121725.
38. Sleath B, Rubin RH. Gender, ethnicity, and physician-patient commu-
nication about depression and anxiety in primary care. Patient Educ
Couns. 2002;48:24352.
655Prins et al.: Patient Factors Related to Anxiety/Depression CareJGIM
Page 8
  • Source
    • "– GPs' guideline adherence To evaluate GPs' guideline adherence, we used existing quality indicators based on the guidelines of the Dutch College of General Practitioners [27].Table 1 shows a summary of these indicators. Assessment of guideline adherence in CMD used a set of indicators used in previous studies on guideline adherence in treatment of CMD282930 and was defined as: 1) at least five additional GP consultations within the same illness episode, 2) and/or short/long-term prescription of antidepressants, 3) and/or a referral to a mental healthcare specialist. Guideline adherence in DMII care was defined as compliance with at least four of the following eight rules [31], including testing in the past year of: 1) HbA1c; 2) serum LDL cholesterol; 3) plasma creatinine level; 4) proteinuria; 5) blood pressure measurement; 6) weight; 7) a foot examination; and 8) registration of a smoking habit. "
    [Show abstract] [Hide abstract] ABSTRACT: Background A high prevalence of mental and physical ill health among refugees resettled in the Netherlands has been reported. With this study we aim to assess the quality of primary healthcare for resettled refugees in the Netherlands with chronic mental and non-communicable health problems, we examined: a) general practitioners’ (GP) recognition of common mental disorders (CMD) (depression and anxiety, and post-traumatic stress disorder (PTSD) symptoms); b) patients’ awareness of diabetes type II (DMII) and hypertension (HT); and c) GPs’ adherence to guidelines for CMD, DMII and HT. Methods From 172 refugees resettled in the Netherlands, interview data (2010–2011) and medical records (n = 106), were examined. Inclusion was based on medical record diagnoses for DMII and HT, and on questionnaire-based CMD measures (Hopkins Symptom Checklist for depression and anxiety; Harvard Trauma Questionnaire for PTSD). GP recognition of CMD was calculated as the number of CMD cases registered in the medical record compared with those found in interviews. Patient awareness of HT and DMII was scored as the percentage of subjects diagnosed by the GP who reported their condition during the interview. GPs’ adherence to guidelines for CMD, DMII and HT was measured using established indicators. Results We identified 37 resettled refugees with CMD of which 18 (49%) had been recognised by the GP. We identified 16 refugees with DMII and 14 with HT from the medical record; 24 (80%) were aware of their condition. Thirty-five out of these 53 (66%) resettled refugees with chronic mental and non-communicable disorders received guideline-adherent treatment. Conclusion This study shows that awareness in resettled refugees of GP diagnosed DMII and HT is high, whereas GP recognition of CMD and overall guideline adherence are moderate.
    Full-text · Article · Sep 2014 · BMC Family Practice
  • Source
    • "Perceived patients' preferences may impede stepped care allocation while severity assessment is positively associated with allocating stepped care [35]. Another Dutch study showed that patients' preferences as well as the education level of the patient are more strongly associated with the delivery of guideline-concordant care than clinical need factors [36]. Investigators in the UK found that GPs prescribe medication based on their clinical judgment of the severity of the depression [21]. "
    [Show abstract] [Hide abstract] ABSTRACT: Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care. Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire. Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs. The management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.
    Full-text · Article · Jan 2014 · BMC Family Practice
  • Source
    • "Our findings confirm that patients' lack of perceived need plays a major role in not receiving care worldwide (Prins et al. 2010). In addition, there is no agreement among cases on what should be considered need for mental health care (Alonso et al. 2007). "
    [Show abstract] [Hide abstract] ABSTRACT: To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders. Method Data were from the World Health Organization (WHO) World Mental Health (WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 636 78) and analyzed at different levels of clinical severity. Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders). Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.
    Full-text · Article · Aug 2013 · Psychological Medicine
Show more