Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study.

BACKGROUND: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement. METHODS: This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records. RESULTS: 721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes. CONCLUSION: The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Mental health service use and treatment adequacy for anxiety disorders in Canada.

BACKGROUND: This study examined mental health service use, minimal standards of treatment adequacy and correlates of service use and treatment adequacy for anxiety disorders in Canada. METHOD: Data were drawn from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2, 2002). Respondents (n = 1,803) met criteria for panic disorder, agoraphobia and/or social phobia in the past 12 months. Multiple logistic regression models were used to estimate patterns of associations between respondent characteristics, service use and treatment adequacy. RESULTS: The prevalence of service use for mental health problems in the past 12 months was approximately 36.9% among respondents with anxiety disorders. The rates of minimal standards of treatment adequacy ranged from 36.8% among those consulting exclusively in primary care to 51.5% among those consulting exclusively in specialised mental health services, and reached 79.5% for respondents consulting healthcare professionals in both sectors of care. Correlates of treatment adequacy included age, education level, marital status, urbanicity medical insurance, acceptability of care, comorbid mental disorders and limitations of activities. CONCLUSION: These findings emphasize the need to improve the access to mental health services and the quality of care for individuals with anxiety disorders in primary care.

Which physician and practice characteristics are associated with adherence to evidence-based guidelines for depressive and anxiety disorders?

BACKGROUND: Research on quality of care for depressive and anxiety disorders has reported low rates of adherence to evidence-based depression and anxiety guidelines. To improve this care, we need a better understanding of the factors determining guideline adherence. OBJECTIVE: To investigate how practice- and professional-related factors are associated with adherence to these guidelines. DESIGN: Cross-sectional cohort study. PARTICIPANTS: A total of 665 patients with a composite interview diagnostic instrument diagnosis of depressive or anxiety disorders, and 62 general practitioners from 21 practices participated. MEASURES: Actual care data were derived from electronic medical record data. The measurement of guideline adherence was based on performance indicators derived from evidence-based guidelines. Practice-, professional-, and patient-related characteristics were measured with questionnaires. The characteristics associated with guideline adherence were assessed by multivariate multilevel regression analysis. RESULTS: A number of practice and professional characteristics showed a significant univariate association with guideline adherence. The multivariate multilevel analyses revealed that, after controlling for patient characteristics, higher rates of guideline adherence were associated with stronger confidence in depression identification, less perceived time limitations, and less perceived barriers for guideline implementation. These professional-related determinants differed among the overall concept of guideline adherence and the various treatment options. CONCLUSIONS: This study showed that rates of adherence to guidelines on depressive and anxiety disorders were not associated with practice characteristics, but to some extent with physician characteristics. Although most of the identified professional-related determinants are very difficult to change, our results give some directions for improving depression and anxiety care.

Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care.

OBJECTIVE: To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression 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 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. RESULTS: 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. CONCLUSIONS: 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.

How well do GPs fulfill their educator role in consultations for depression and anxiety?

OBJECTIVE: To assess general practitioners' (GPs) provision of patient education with respect to patients with depression or anxiety. METHODS: The study relied on the prospective self-recording of patient consultations by GPs. The participating GPs (n = 78) completed 385 registration forms. For each performance indicator, an indicator score was calculated by dividing the number of clinical situations in which the GPs actually offered patient education by the total number of situations demanding for the provision of such education. RESULTS: High indicator scores (> 85%) were found for the provision of patient education about the effect and side effects of antidepressant medication in depression care. Moderate indicator scores (60-85%) were found for the provision of patient education about the prevalence and the course of both depression and anxiety. Giving advice to depressed patients to place restrictions upon the amount of demands the patient places on himself showed a substantial gap between recommended and actual care. Furthermore, a low indicator score was also found for patient education about the side effects of antidepressant medication in anxiety care (indicator scores < 60%). The variance across GPs was considerable. The clinical characteristic that had the most robust relationship with a variety of performance indicators was first or follow-up consultation for depression or anxiety. CONCLUSION: GPs' provision of patient education in depression and anxiety care ranged from poor to excellent, depending on the type of educational item. PRACTICE IMPLICATIONS: Insight into both the actual clinical performance of GPs and determinants of variation in their performance contributes to select the most appropriate means for quality improvement in depression and anxiety care.

Recognition of anxiety disorders by family physicians after rigorous medical record case extraction: results of the Netherlands Study of Depression and Anxiety.

OBJECTIVE: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition. METHOD: A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included. RESULTS: Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age. CONCLUSION: FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem.

The costs of guideline-concordant care and of care according to patients' needs in anxiety and depression.

AIM: To describe the direct and indirect costs for people with anxiety and depressive disorders where guidelines are adhered to and patients' perceived needs are fully met. METHOD: Data were derived from the Netherlands Study of Depression and Anxiety. At baseline, adult patients were interviewed and they completed questionnaires to measure DSM-IV diagnoses, socio-demographic characteristics and perceived need for care. Actual care data were also derived from electronic medical records. Criteria for guideline adherence were based on general practice guidelines, issued by the Dutch College of General Practitioners. Direct and indirect costs were inferred from the Perceived Need for Care Questionnaire administered at baseline, and the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness administered at 1-year follow-up. RESULTS: For 568 patients with a current anxiety or depressive disorder a complete dataset on health care use and absenteeism was available. Guideline adherence was significantly associated with increased care use and corresponding costs, while fully met perceived need was unrelated to costs. Socio-demographic characteristics, severity of symptoms and guideline adherence all affected the societal costs of patients with fully met perceived needs compared with patients with perceived unmet needs. CONCLUSION: It appears that guideline-concordant care for anxiety and depression costs more than non-concordant care, while care that has fulfilled all of a patient's needs seems not to be more expensive than care that has not met all perceived needs. However, randomized controlled trials should first confirm this conclusion.

[Appropriate care for anxiety and depression]. / Gepaste zorg voor mensen met angst of depressie.

OBJECTIVE: To evaluate care received for anxiety and depression, to identify which patient-, GP- and practice factors obstruct delivery of care in accordance with Dutch College of General Practitioners' (NHG) practice guidelines, and to evaluate the costs and effects of guideline-concordant care. DESIGN: Descriptive study. METHODS: During the baseline assessment of the Netherlands study of depression and anxiety--which has followed a large number of adults with and without psychiatric complaints since 2004--various questionnaires and diagnostic interviews were completed. At one year follow-up, the severity of symptoms of anxiety and depression, overall functioning or dysfunction, healthcare use and absenteeism from employment over the past year were assessed. Data from electronic medical patient records were studied to determine whether NHG practice guidelines had been followed. RESULTS: Of the 721 patients with an anxiety or depressive disorder, 57% (n = 413) indicated receiving some form of care; two-thirds of this group received appropriate care according to NHG practice guidelines (n = 281). At patient level the severity of depressive symptoms, the self-evaluated need for care, a high level of education and accessibility of care were most strongly associated with guideline adherence; at general practitioner level, collaboration with other mental health professionals was most strongly associated with guideline adherence. On average, all patients had symptoms that were less serious than a year previously, irrespective of which care they had received. Guideline-concordant care was significantly more expensive. CONCLUSION: Half of the patients who had not received care did not think that they needed it. Of those who had received care, those with more severe symptoms and greatest need for care were most likely to have received guideline-concordant care. Both patients and general practitioners seemed well able to assess whether care was needed or not.

Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis.

OBJECTIVES: To assess professionals' adherence to evidence-based guidelines and to investigate whether or not this is influenced by recording of the diagnosis and symptom severity. METHOD: Analysis of baseline cross-sectional data of a cohort study of 721 primary care patients with a confirmed diagnosis of a depressive or anxiety disorder. Information on the management of depressive and anxiety disorders was gathered from the electronic medical patient records. Guideline adherence was measured by an algorithm, based on performance indicators. RESULTS: Forty-two percent of the patients with a depressive disorder was treated in accordance with the guideline, whereas 27% of the patients with an anxiety disorder received guideline-consistent care. The provision of care in line with current depression and anxiety guidelines was around 50% for persons with both types of disorders. Documentation of an International Classification of Primary Care diagnosis of depression or anxiety disorder appeared to have a strong influence on guideline adherence. Symptom severity, however, did not influence guideline adherence. CONCLUSIONS: Adherence to depression and anxiety guidelines can be improved, even when the general practitioner makes the diagnosis and records it. Data on actual health care delivery and quality of care provide insight and may be useful in developing quality improvement activities.

What determines the management of anxiety disorders and its improvement?

INTRODUCTION: Although anxiety disorders are highly prevalent, lack of correct diagnosis and related concerns about treatment are serious clinical problems. Several factors affect, positively or negatively, management of anxiety and its improvement. A literature review and thematic analysis was executed to obtain an overview of the types of determinants of anxiety care and its improvement. METHODS: Literature was identified from electronic database searching (January 1995-March 2006), contact with authors of studies, and searching of websites of organizations concerned with mental health. By using a template analysis approach, a set of strong themes relating to determinants of anxiety care and its improvement was identified. RESULTS: The 15 eligible studies identified 43 factors that impeded or facilitated optimal anxiety care and its improvement. Individual characteristics of both patients (n = 13) and professionals (n = 6) were most frequently reported as determinants of anxiety care and its improvement. A considerable number of factors were related to the organizational context (n = 12), such as practice type and location. Some factors related to the social context (n = 4), the economic context (n = 2), or to the innovation itself (n = 6) were identified. CONCLUSION: The findings show that there is a multitude of barriers and facilitators to optimal anxiety care and its improvement. Some determinants are modifiable, and thus responsive to interventions. Examples are collaboration within and between organizations, financial resources and assignment of both an opinion leader and responsible staff. The quality of anxiety care can be improved by systematically designing innovation strategies which are tailored to a selection of the determinants identified in this study.

Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety.

OBJECTIVE: To summarize current evidence on the effectiveness of different knowledge transfer and change interventions for improving primary and ambulatory anxiety care to provide guidance to professionals and policy-makers in mental health care. METHOD: We searched electronic medical and psychological databases, conducted correspondence with authors, and checked reference lists. Studies examining the effectiveness of knowledge transfer and interventions targeted at improvement of the recognition or management of anxiety in primary and ambulatory health care settings were included. Methodological details and outcomes were independently extracted and checked by 2 reviewers. Where appropriate, data concerning the impact of interventions on symptoms of anxiety were pooled using metaanalytical procedures. RESULTS: We identified 24 studies that met our inclusion criteria. Seven professional-directed interventions and 17 organizational interventions (including patient-oriented interventions) were identified. The methodological quality of studies was variable. Professional-directed interventions only impact the process and outcome of care when embedded in some sort of organizational intervention. Metaanalysis (n = 8 studies) showed no effect of diverse organizational interventions on patients' anxiety symptoms (effect size, -0.08; 95% confidence interval, -0.31 to 0.15; P = 0.50). Collaborative care interventions proved to be the most effective organizational intervention strategies. Six studies reported economic results: 4 studies showed that intervention had a high probability of being cost-effective. CONCLUSIONS: Collaborative care seems to be very promising for improving primary and ambulatory care for anxiety. At the level of management and policy, the results of this review mandate the need to offer fair and reasonable reimbursement for collaborative care programs.

Depressed and a co-morbid condition: more psychotropics prescribed!

BACKGROUND: Depression often occurs simultaneously with a variety of somatic, psychiatric, and social conditions. Knowledge about differences in the pharmacological treatment of depressed patients with and without co-morbidity is lacking. OBJECTIVE: To compare GPs' pharmacological treatment of depressed patients with and without co-morbidity. METHODS: Data were extracted from the computerized medical records of 77 general practices participating in the Dutch National Information Network of General Practice (LINH). We used diagnosis and prescription data of newly diagnosed depressed patients aged 18-65 years (n=4372). A mixed-model technique was used for analyzing the medical data. RESULTS: During the year after diagnosing depression, depressed patients who also suffered from chronic somatic or psychiatric morbidity were prescribed more psychotropics than patients with depression only. Prescription patterns of psychotropic drugs for depressed patients with and without co-morbid social problems differed only during the first 3 months after diagnosis. For the whole 1-year period after diagnosis, the pharmacological treatment of depression in patients with and without co-morbid social problems did not differ. CONCLUSION: Our results indicate that chronic somatic or psychiatric co-morbidity in depressed patients leads to higher GP prescription levels of psychotropics, whereas co-morbid social problems do not seem to influence GPs' pharmacological treatment decisions for depression.

The impact of co-morbidity on GPs' pharmacological treatment decisions for patients with an anxiety disorder.

BACKGROUND: Co-morbidity may influence GPs' treatment decisions for patients with anxiety. However, knowledge about differences in the pharmacological treatment of anxiety disorders in patients with and without co-morbidity is lacking. OBJECTIVE: To compare GPs' pharmacological treatment patterns for anxiety in patients with and without co-morbidity. METHODS: Data were extracted from computerized medical records of 77 general practices participating in the Dutch National Information Network of General Practice (LINH). We used diagnosis and prescription data of patients, aged 18-65 years, with a newly diagnosed anxiety disorder (n=4604). A mixed model technique was used to determine if there was a difference in the pharmacological treatment of anxiety with and without co-morbidity. RESULTS: During the year after diagnosing anxiety, anxious patients who also suffered from chronic somatic morbidity or social problems were prescribed more benzodiazepines (effect size [ES]=0.44, 95% confidence interval [CI]=0.16-0.72 and ES=0.67, 95% CI=0.22-1.25, respectively) but no more antidepressants than patients with anxiety only. Compared to patients with a single diagnosis of anxiety, anxious patients who suffered simultaneously from other psychiatric conditions received twice as many antidepressant prescriptions (ES=2.07, 95% CI=1.89-2.56) as well as twice as many benzodiazepine prescriptions (ES=1.98, 95% CI=1.84-2.60) during the year after diagnosing anxiety. For all subgroups, the prescription rate of benzodiazepines remained high throughout the year after diagnosing anxiety. CONCLUSION: Our results indicate that psychiatric co-morbidity in anxious patients leads to higher prescription levels of both antidepressants and benzodiazepines. Chronic somatic co-morbidity and co-morbid social problems also lead to higher prescription levels of benzodiazepines, but does not seem to influence GPs' prescribing of antidepressants. The prescription pattern of benzodiazepines was inconsistent with guideline recommendations.