Effective and efficient care for patients with anxiety disorders and/or depression in primary care.

Goal: To acquire knowledge and insight into the effect of tailored strategies focused on the implementation of guideline recommendations for the recognition, diagnosis and stepped care allocation in primary care for patients of 18 years and older with a first or new episode of anxiety disorders and/or depression, to achieve better outcomes and more efficient use of implementation strategies.

Design: randomised controlled trial with two-arms perform in 40 general practitioner practices. Clusterrandomisation. Measurs at baseline, 6, and 24 months after inclusion.
A process evaluation is carried out to acquire knowledge about how tailoring of implementation strategies deal with implementation barriers by professionals and in the organizational context.

Study population: patients who visit the general practitioner and by whose first score on the Dutch version of the extended Kessler-10 (EK-10) is 20 or higher and/or at least once a yes on the added questions 11 till 16.

Interventions:

1. The structural use of a screening instrument, the Four-dimensional Symptom Questionnaire;

2. Making the diagnosis and recording this in the General Practitioner Information System;

3. Making the distinction between mild- and severe problems;

4. Discussion of the diagnosis and treatment options with the patient and providing psycho-education to diagnosed patients.

Implementation strategies: depending on the barriers for successful implementation strategies are being tailored.

Outcome measures: Primary outcome measurement is change in the symptoms of anxiety and depression measured with the Four Dimensional Symptom Questionnaire.

Sample size calculation/data analysis: based on a power calculation we have to include 572 patients. All analyses will be conducted in accordance with the intention-to-treat principle. Patients are recruited in the Netherlands.

Economic evaluation: in the economic evaluation we will study both the costs and benefits of tailored strategy in comparison with the control group.

Anxiety disorders and depression are common illnesses that have a negative impact on everyday functioning, cause great suffering, and entail both high care costs and loss of production. Recognition, diagnosis and stepped care allocation of treatment in primary care could be improved. For both disorders national guidelines excist and following guidelines can lead to significant reduction of the burden of disease, significantly greater symptom reduction and improvement of social functioning. Adherence to guidelines should be improved.

There can be several barriers which hinder the adherence to guidelines. There is relatively little known about which implementation strategies are effective in which context.
This study is based on the hypothesis that the
implementation strategy offered should be sufficiently aligned with specific characteristics and barriers in the
local context.

The objective of this study is to improve the quality of care and outcomes for patients with anxiety disorders and depression and to acquire knowledge and insight into the effect of tailored strategies focused on the implementation of guideline recommendations for the recognition, diagnosis and stepped care allocation in primary care for patients of 18 years and older with a first or new episode of anxiety disorders and/or depression.

1. At patientlevel: at baseline, 3 and 6 months;

2. At GP level: data on outcomes were gathered from a retrospective patient medical record search, which took place between 6 months before and 6 months after patients completed the EK-10.

The interventions to be implemented in both groups are derived from the national guidelines for anxiety disorders and depression and comprise the phase of recognition, diagnosis and needs assessment for stepped care. Both groups get information about the interventions. The selected interventions are:

1. Structural use of a screening instrument, the Four-dimensional Symptom Questionnaire (4DSQ), for high-risk patients. Criteria are described in the national guidlines;

2. Making the diagnosis and recording this in the General Practitioner Information System;

3. Discussion of the diagnosis and treatment options with the patient and providing psycho-education to diagnosed patients in accordance with the protocol;

4. Making the distinction between mild/non-complex problems and severe/complex problems and determining suitable initial treatment on this basis (stepped care allocation), in consultation with the patient. This is minimal treatment in the case of mild problems and medication or psychotherapy for people with severe problems.



Tailoring of strategies:

In the first months of the project, a list will be prepared of possible barriers to better screening, diagnosis, the provision of information and needs assessment for stepped care in the general practice. The digital barrier list will be used to carry out the analysis of the local context with the general practitioners in the intervention group. Barriers will be coupled directly to concrete strategies, creating combinations of strategies that are geared to the local context.