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

Abstract

ObjectiveTo identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.DesignAnalysis of data from the Netherlands Study of Depression and Anxiety (NESDA).ParticipantsSeven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included.MeasuresDiagnoses 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.ResultsTwo 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.ConclusionsThis 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.

Access to psychotherapy for primary care patients with anxiety disorders.

“…CBT is the most consistently efficacious psychological treatment for anxiety disorders (Butler, Chapman, Forman, & Beck, 2006;Canadian Psychiatric Association, 2006;Norton & Price, 2007) and was the only recommended psychological treatment for anxiety disorders in the 2006 clinical practice guideline from the Canadian Psychiatric Association (2006). Low rates of treatment adequacy based on clinical practice guidelines have also been found in prior studies for anxiety disorders in primary care samples (Prins et al, 2010;Smolders et al, 2009;Stein et al, 2011;Stein et al, 2004;Wittchen et al, 2002) as well as epidemiological surveys (Fernán-dez et al, 2007;Roberge et al, 2011;Wang et al, 2005;Young et al, 2008). For instance, we previously observed in a Canadian epidemiological survey that 10,6% of individuals meeting criteria for panic disorder, agoraphobia, or social anxiety disorder had received a minimum of seven outpatient visits with a specialized mental health provider in the past 12 months (Roberge et al, 2011).…”

Barriers to mental health treatment: results from the WHO World Mental Health surveys

“…Negative experience with a provider is commonly reported by severe cases. Patients reject the passive role assigned to them, probably having a different evaluation of need than providers and little ability to evaluate the quality of services received (Prins et al, 2010). Structural factors and health beliefs could interact, therefore increasing the likelihood for dropping out (Ngui et al, 2010).…”

Houding van huisartsen ten aanzien van preventie van angst en depressie bij ouderen

“…[28][29][30][31][32][33][34] Een hoog opleidingsniveau van de patiënt is bijvoorbeeld sterk gerelateerd aan een betere richtlijnopvolging door de huisarts. 35 In ons onderzoek blijken huisartsen bij ouderen met een lage sociaaleconomische status minder alert te zijn op symptomen van angst en depressie en minder vaak ongevraagd te adviseren in vergelijking met ouderen met somatische en/of psychosociale risicofactoren. Door bij ouderen met een lage sociaaleconomische status extra alert te zijn en ongevraagd te adviseren zou het verschil in richtlijnopvolging kunnen worden verkleind.…”

“…24,41 Barriè res voor het actief aanbieden van preventie In de literatuur komen barrières naar voren, zoals het vertrouwen van de arts in zijn/haar eigen deskundigheid, de beschikbare tijd, de behandelingsmogelijkheden, het getraind zijn in vaardigheden en de samenwerking met GGZ-professionals. 31,32,35,42 Praktische barrières werden in ons onderzoek wel het vaakste genoemd. Het zijn vooral het oordeel van de huisarts over de mate waarin de ouderen gemotiveerd zijn en het oordeel over de beschikbare preventieve interventies die het verschil tussen meer of minder preventief aanbod bepalen.…”