Commentary and perspectiveImplementing practice guidelines for depression: Applying a new framework to an old problem
Introduction
Depressive disorders are common, yet often challenging to identify, evaluate and manage. Advances in screening instruments, pharmacotherapy and counseling approaches have provided promise for improved outcomes. However, multiple barriers in the health care system, stigmatization and other factors have limited attempts to reduce the significant morbidity and mortality of depression. Thus, despite the frequent presentation of depression in primary care settings and the availability of effective treatments, the diagnosis and treatment of depression by many primary care practitioners is poor [1].
For example, despite the availability of screening instruments, most primary care physicians do not recognize or properly identify depressed patients. Even when depression is properly diagnosed, primary care physicians often do not provide adequate treatment [2], [3], [4], [5]. Primary care physicians face many pressures and demands; thus, multiple approaches have been recommended to improve the delivery of care for depressed patients.
One method to improve the quality of medical care is to implement clinical practice guidelines, “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” [6].
Practice guidelines for the diagnosis and treatment of depression were one of the first guidelines addressed by the Agency for Health Care Policy and Research (AHCPR) now known as the Agency for Healthcare Research and Quality (AHRQ). This article focuses on the AHRQ guidelines to illustrate the barriers to physician guideline adherence. However, the same general principles likely apply to other guidelines that have been developed for depression [7], [8].
Well-implemented clinical practice guidelines, in general, can improve patient outcomes [9]. In primary care settings, Katon et al. found that implementation of the AHRQ guidelines for depression increased the quality of care and improved clinical outcomes [10].
However, there is evidence that the AHRQ guidelines have not been effective in changing physician practice in certain settings. For example, although the guidelines are addressed to primary care providers, several studies have documented poor awareness of the guideline [11], [12]. Using AHRQ guideline criteria, Goldberg et al., noted that primary care practitioners had low rates of diagnosing unrecognized cases of depression and continued to prescribe first generation tricyclics, versus newer, safer medications as recommended by the AHRQ guidelines [13]. In addition, Wells et al. surveyed 1,204 patients with depression from 46 primary care clinics in seven different managed care organizations and found that “only 35 to 42% of patients used antidepressant medication in appropriate dosages” using AHRQ criteria [14]. Finally, Young et al. found that only 19% of patients received appropriate care for depression also using AHRQ criteria [15].
As a result, the NIMH National Advisory Mental Health Council has encouraged the improvement of methods for both evaluating clinician implementation and adherence to treatment guidelines [16]. We have previously described a general framework to understand reasons why physicians might not follow practice guidelines [17]. The purpose of this paper is to apply these general concepts to the specific challenges of implementing clinical practice guidelines for depression in the primary care setting. By delineating the underlying barriers to adherence, different interventions which are tailored to improve physician adherence to guidelines can be utilized. We will also examine characteristics of successful attempts to improve guideline adherence and primary care of depression.
Section snippets
Barriers to guideline adherence
Multiple barriers can limit guideline adherence and translation of research into improved patient outcomes. Six primary barriers relate to individual providers, while factors associated with patients, guidelines and the practice environment constitute external barriers. These are described in detail in the following text.
Primary care physicians may not adhere to a guideline simply due to lack of awareness of a guideline’s existence. Although practice guidelines are meant to help physicians keep
Combining interventions based on the barriers
By understanding the underlying barriers, more effective interventions can be combined to address barriers that prevent physician guideline adherence (Table 1). For example, while traditional continuing medical education (CME) might be useful for improving awareness or familiarity to guidelines, more intensive interventions, such as the use of opinion leaders, may be needed for other barriers like lack of agreement. In situations were multiple barriers exist, a broader approach that combines
The need for multi-faceted interventions
Since physicians have different training, experiences and skills, multiple barriers will most likely exist and affect different steps of behavior change. As a result, multiple interventions to improve physician guideline adherence are necessary to address these multiple barriers. Studies that have demonstrated the greatest lasting effect involve intensive interventions at several levels.
Rubenstein et al. developed a multifaceted intervention to improve depression care involving 46 practices in
Characteristics of interventions that are effective
An assessment of studies that have attempted to improve guideline adherence in the primary care setting points to several characteristics of strategies that are effective. Effective strategies are multifaceted and are not exclusively physician-centered. As expected, due to the many barriers to adherence that physicians face, multi-faceted interventions are more effective than single interventions [78]. Physician-oriented educational sessions have only limited effect [79], [80], [81]. Kick et
Management of depression and the primary care system
The barriers described in this review are not unique to the management of depression and occur with other chronic illness such as hypertension and asthma. For example, multiple studies have shown that physician treatment of hypertension does not always match national guidelines for hypertension. [66], [67], [68], [69], [70]. These guidelines also encourage physicians to counsel patients about diet modification for the primary prevention of hypertension [66]. Just as in the treatment of
Recommendations
Effective implementation of the AHRQ depression guidelines can help decrease inappropriate variation in care and is one method for improving quality of care. Lack of adherence to guidelines can be due to a variety of barriers that we describe in the above framework. Just as in patient care, diagnostic strategies are needed “to determine the reasons for suboptimal performance and to identify barriers to change and to select carefully the interventions most likely to be effective in light of the
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