Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views

Abstract

Background Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users’ perspectives and behavior. Objective This study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined. Methods Semistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted. Results GPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs’ referrals and their self-rated pharmacotherapeutic competence, r(73)=−0.31, P<.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included “little knowledge about internet-based interventions” and “patients’ lack of familiarity with technology/internet/media” (number of statements, each k=22). Key facilitators were “perceived patient suitability, e.g. well-educated, young” (k=22) and “no conflict with GP’s role” (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned. Conclusions This study provides insights into factors influencing GPs’ referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates.

Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study

“…At least a few years ago, limited internet literacy and access were reported as being among the most important barriers to the implementation of IBIs for depression in routine care expected from the perspective of different stakeholders across 8 European countries [ 77 ]. Lack of internet access and computers along with a lack of familiarity with technology, internet, and media were reported as barriers from the perspective of an interview sample of general practitioners [ 78 ] as well as low technical affinity from the perspective of an interview sample of therapists, both with regard to the use of blended internet-based therapy for patients with depression in general [ 66 ]. Thus, improving access to high-speed internet in rural or remote areas along with the promotion of digital literacy in general might be helpful measures to break down barriers in the use of health care technologies in green professions.…”

Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study

“…They were more likely to refer patients who were early in treatment, needed extra educational support, were resistant to other treatment modalities, or were waiting for an initial BH appointment. Although the literature is limited in terms of factors influencing referrals to a dCBI, other studies exploring the decision-making process among providers referring patients to BH solutions have identified comfort with patient diagnoses, the level of familiarity with other BH resources, and patient characteristics as important facilitators of how and when a provider refers a patient to care [ 41 , 42 ].…”

Clinical and societal burden of incident major depressive disorder: A population‐wide cohort study in Stockholm

“…In this study, 13.8% of those initially seen in primary care were handled in psychiatric care related to MDD within the first year after diagnosis, which can be compared with previously reported referral rates ranging from 16 to 58%. [18][19][20] In addition to methodological differences in the studies hampering direct comparisons, country-specific differences in how healthcare systems are organized and how care is coordinated between primary and secondary care will also affect observed referral rates. Further studies are needed to investigate if and how patient referrals could be optimized.…”