Delivering stepped care for depression in general practice: Results of a survey amongst general practitioners in the Netherlands

Figures & data

Table 1. Descriptive characteristics of GPs (n = 194, unless stated otherwise).

	Mean (SD) or percentage of GPs
Demographic characteristics
Age, mean age in years (SD)	46.0 (8.7)
Gender (% female)	43%
Clinical experience with depression, mean no. of years (SD)	14.9 (8.9)
Interest, training and quality improvement in depression care
Having special interest in patients with a depression	43%
Followed a training in depression care in the last three years (n = 193)	68%
Participated in an improvement project for depression care (n = 193)	36%
Collaboration
Structural collaboration with mental health professionals	32%
Structural collaboration with mental health professionals in primary care	24%
Structural collaboration with professionals in specialized mental health care	12%

Table 2. Performance of GPs (n = 194, unless stated otherwise) in their practice regarding depression identification and screening, severity assessment and stepped care treatment.

Elements of depression care	Percentage of all GPs		Reasons for not performing a specific element^a	Percentage of GPs who did not perform a specific element
	Yes	No
Identification and screening
Systematic identification of depression	37%	63%
Using a screening instrument (n = 192)	33%	67%	Reasons for not using a screening instrument (n = 120)
			Insufficient time	63%
			Unfamiliarity with screening instruments	39%
			Not necessary for recognition of depression	33%
			No or a lack of reimbursement	29%
			Insufficient knowledge and skills	26%
Severity assessment
Severity assessment of newly diagnosed depression (n = 193)	63%	37%	Reasons for not assessing depression severity (n = 66)
			Unfamiliarity with tools for determining severity	58%
			Insufficient knowledge and skills	53%
			Insufficient time	27%
			Determination of severity does not affect treatment policy	21%
Severity assessment and using an instrument (n = 122)	22%	78%	Reasons for not using an instrument (n = 94)
			Insufficient time	50%
			No instrument available	48%
			The use of an instrument is not necessary	40%
			Insufficient knowledge and skills	35%
Stepped care treatment
Allocating stepped care to ≥ 50% of patients newly diagnosed with depression (n = 187)	72%	28%	Reasons to sometimes deviate from stepped care (n = 159)^b
			Perceived patients’ preferences	49%
			Insufficient knowledge and skills	45%
			Insufficient time	33%

^aOnly reasons mentioned by ≥ 20% of GPs are shown.

^bThis question was presented to all 194 GPs, of which 18% did not fill out a response.

Table 3. Results of multivariate logistic regression analyses to assess associations between GP-related characteristics and GPs’ performance in their practice regarding depression identification, depression screening, severity assessment and stepped care treatment allocation.

GP-related characteristics	GPs’ performance
	Systematic identification of depression OR (95% CI)^a	Using a screening instrument OR (95% CI)^a	Assessing severity of newly diagnosed depression OR (95% CI)^a	Using an instrument for severity assessment OR (95% CI)^a	Allocating stepped care treatment to ≥ 50% of patients newly diagnosed with depression OR (95% CI)^a
Age
30–40 years	Reference	Reference	Reference	Reference	Reference
41–50 years	0.53 (0.21–1.34)	0.62 (0.24–1.61)	0.99 (0.41–2.40)	0.27 (0.04–1.72)	0.98 (0.36–2.69)
51–64 years	0.47 (0.16–1.34)	0.70 (0.24–2.10)	0.92 (0.30–2.80)	0.55 (0.14–2.11)	0.44 (0.12–1.65)
Being male	1.05 (0.54–2.05)	1.09 (0.54–2.19)	0.65 (0.32–1.31)	2.18 (0.69–6.83)	0.60 (0.28–1.28)
Clinical experience
1–5 years	Reference	Reference	Reference	Reference	Reference
6–15 years	0.74 (0.19–2.89)	0.74 (0.18–3.08)	2.90 (0.72–11.60)	1.99 (0.14–28.83)	5.05 (1.04–24.53)^b
16–38 years	0.41 (0.15–1.15)	0.59 (0.21–1.70)	0.98 (0.38–2.55)	0.91 (0.08–10.50)	1.93 (0.68–5.47)
Having structural collaboration with mental health professionals	2.05 (1.01–4.14)^b	1.71 (0.83–3.50)	2.45 (1.12–5.37)^b	2.09 (0.79–5.56)	0.82 (0.36–1.86)
Having special interest in depression	2.35 (1.24–4.43)^c	1.00 (0.51–1.94)	1.88 (0.97–3.63)	0.95 (0.35–2.61)	1.58 (0.76–3.29)
Followed a training in depression care	1.70 (0.84–3.44)	0.84 (0.42–1.69)	1.95 (0.99–3.84)	1.32 (0.41–4.22)	1.02 (0.48–2.16)
Participated in an improvement project for depression care	1.21 (0.62–2.38)	3.62 (1.86–7.05)^c	1.61 (0.81–3.21)	3.67 (1.34–10.04)^c	2.11 (0.95–4.70)
Assessing severity of newly diagnosed depression^d	–	–	–	–	2.36 (1.13–4.93)^b

^aOR, odds ratio; 95% CI, 95% confidence interval.

^bP ≤ 0.05.

^cP ≤ 0.01.

^dUsed as an additional independent variable in the regression models for stepped care treatment; reference category: GPs who indicated not to assess severity of newly diagnosed depression.

Table 4. Allocated interventions for newly diagnosed depression as indicated by GPs.

Type of intervention, in order of intensity according to the ‘stepped care model’^a	Percentage of GPs providing the intervention to ≥ 50% of patients newly diagnosed with depression
Watchful waiting approach (n = 181)	29%
Psycho education (n = 185)	69%
(Online) self-help (n = 176)	10%
Brief therapy (n = 183)	50%
Psychotherapy (n = 182)	40%
Antidepressants (n = 190)	42%
Combination of antidepressants and psychotherapy (n = 183)	45%

^aThe intervention categories were not mutually exclusive.

Table 5. Results of multivariate logistic regression analyses to assess associations between GP-related characteristics and the allocation of interventions by GPs to ≥ 50% of patients newly diagnosed with depression.

GP-related characteristics	Allocation to ≥ 50% of patients newly diagnosed with depression
	Watchful waiting approach OR (95% CI)^a	Psycho- education OR (95% CI)^a	(Online) self-help OR (95% CI)^a	Brief therapy OR (95% CI)^a	Psychotherapy OR (95% CI)^a	Antidepressants OR (95% CI)^a	Combination of antidepressans and psychotherapy OR (95% CI)^a
Age
30–40 years	Reference	Reference	Reference	Reference	Reference	Reference	Reference
41–50 years	0.59 (0.23–1.53)	1.29 (0.48–3.42)	0.85 (0.22–3.25)	1.61 (0.65-3.99)	1.59 (0.66–3.85)	1.48 (0.62–3.50)	1.31 (0.55–3.14)
51–64 years	1.41 (0.45–4.46)	0.52 (0.17–1.60)	1.78 (0.28–11.39)	0.86 (0.31–2.43)	0.87 (0.31–2.48)	1.21 (0.45–3.31)	0.89 (0.32–2.47)
Being male	1.05 (0.51–2.13)	0.99 (0.48–2.06)	0.85 (0.30–2.45)	0.47 (0.24–0.91)^b	0.58 (0.30–1.12)	1.20 (0.63–2.30)	0.65 (0.34–1.25)
Clinical experience
1–5 years	Reference	Reference	Reference	Reference	Reference	Reference	Reference
6–15 years	0.40 (0.09–1.67)	1.98 (0.47–8.31)	0.73 (0.08–7.06)	2.46 (0.63–9.62)	1.01 (0.26–3.84)	0.58 (0.16–2.14)	1.48 (0.39–5.63)
16–38 years	0.86 (0.30–2.44)	1.24 (0.45–3.44)	1.69 (0.30–9.39)	1.00 (0.37–2.65)	0.89 (0.34–2.31)	0.62 (0.25–1.56)	1.41 (0.54–3.67)
Having structural collaboration with mental health professionals	1.01 (0.48–2.13)	1.65 (0.75–3.63)	1.72 (0.59–5.05)	1.67 (0.83–3.37)	0.84 (0.42–1.71)	0.76 (0.37–1.53)	0.67 (0.33–1.36)
Having special interest in depression	0.85 (0.43–1.67)	2.67 (1.31–5.46)^c	1.78 (0.62–5.09)	1.70 (0.90–3.20)	1.51 (0.80–2.85)	1.12 (0.60–2.07)	1.19 (0.63–2.24)
Followed a training in depression care	0.90 (0.44–1.84)	1.38 (0.68–2.80)	2.27 (0.61–8.49)	1.22 (0.62–2.42)	1.44 (0.72–2.88)	0.69 (0.36–1.33)	0.64 (0.33–1.24)
Participated in an improvement project for depression care	1.09 (0.55–2.18)	0.82 (0.40–1.67)	1.24 (0.42–3.63)	0.95 (0.49–1.83)	0.67 (0.35–1.32)	0.69 (0.36–1.31)	0.64 (0.33–1.21)
Assessing severity of newly diagnosed depression	1.16 (0.57–2.40)	1.09 (0.53–2.22)	0.67 (0.22–2.03)	0.68 (0.34–1.36)	1.51 (0.76–3.01)	1.17 (0.60–2.27)	0.69 (0.35–1.34)

^aOR, odds ratio; 95% CI, 95% confidence interval.

^bP ≤ 0.05.

^cP ≤ 0.01.