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Table 5 Description of interventions and results of studies with development and dissemination of guidelines/collaborative care package/quality improvement interventions

From: Interventions to improve the detection of depression in primary healthcare: systematic review

Citation (author, year)

Description of the intervention

Duration of intervention, length of follow-up

Outcome measures

Estimate of effect/summary result

Bermejo et al. (2007) [76]

Evidence-based guideline training on the identification of depressive syndromes by GPs designed as a multifaceted, interdisciplinary intervention, combining benchmarking, interactive continuous medical education, and interdisciplinary quality circles

Six sessions, each of 3 h within a 10-month period, posttest at the end of the intervention and follow-up at 12 months

The German depression module of the Patient Health Questionnaire. For each patient, the physicians evaluated whether the patient had a depressive disorder

In the follow-up assessment, the concordance rate increased from 51.2 to 57.1%.

• Intervention group sensitivity: 26.4% vs 51.1% vs 56.2%

• Control group sensitivity: 47.2% vs 54.5%

• Intervention group specificity: 87% vs 87.3% vs 80.9%

• Control group specificity: 81.5% vs 81.9%

Croudace et al. (2003) [77]

Local development and dissemination of the WHO ICD-10 PHC guidelines (1996 version, which was “current” at that time). Participating GPs were provided with the opportunity to adapt the WHO guidelines in a shared-ownership model with colleagues from local psychiatric services. Participating GPs received a personal, desktop copy of the guidelines. Educational meetings were then organized in each intervention practice

One year, 1 year for practice and GP level outcomes and 3 months for patient-level clinical outcome

A GHQ–12 score of > 3 was used to define a case. Functioning was recorded using the Brief Disability Questionnaire. Quality of life was recorded by the European Quality of Life instrument. A single question assessed satisfaction with care

Detection rate (sensitivity) for GPs in the guideline practices was 47% and 55% in the usual care. After adjustment for baseline sensitivity, the difference was 76.6% (95% CI 719.0 to 5.9%; z = 1.03%, P = 0.304). The crude specificities achieved by guideline and usual-care practices were 86% and 79%, respectively. After adjustment for baseline specificity, this difference increased slightly to 6.2% (95% CI 74.4 to 16.8%; z = 1.14, P = 0.255)

Dwinnells et al. (2015) [78]

Behavioral health Screening, Brief Intervention, and Referral to Treatment (SBIRT) program: Before SBIRT implementation, the medical and clerical staff received 3 educational sessions to learn about the SBIRT. Patients were screened for depression, alcohol, and substance use. Those eliciting positive responses were given appropriate, quantifiable standardized tests

Six months, 6 months

The screening tool, consisting of 5 dichotomous questions adapted from the Oregon Health & Science University’s SBIRT program; standardized tests (e.g., PHQ-9)

Compared with 11.4% of the control site patients, 25.3% of the SBIRT intervention site patients had positive findings for depression, alcohol, or substance use (P < .001)

Jordans et al. (2019) [79]

A Mental Health Care Plan (MHCP) developed and implemented in Nepal, in partnership with the Ministry of Health. Comprised interventions at the community, health facility, and health service organization levels. Packages included training and supervision for health workers to detect, diagnose, and initiate treatment for a priority disorder (i.e., depression, psychosis, AUD, and epilepsy)

Cross-sectional surveys with independent sampling were conducted before MHCP implementation and approximately 6 months and 24 months after initiating the MHCP

PHQ-9

At baseline, 186/1252 were positive (15%); of those 186, 179 seen by professionals and 8.9% diagnosed as having depression. At post intervention increased to 24.6% after 6 months (ES = 0.432) and at 24 months 19.2% (ES = 0.301)

Nakku et al. (2019) [80]

MHCP and mhGAP implementation

Twelve months, every 3onths for a year

PHQ-9

At baseline, 325/1290 were PHQ-9 positive of which 85 were new (85/1290 = 6.7%), and at end line, 452/3481 (12.9%) were PHQ-9 positive. The improvement in detection of depression at 3 months was not sustained over 12 months

Petersen et al. (2019) [81]

Comprised five components: (i) PHC nurses functioned as case managers, oriented to the ICSM, trained in communication skills, and provided with mental health training, (ii) doctors were oriented to the importance of mental health and upskilled to prescribe antidepressants, (iii) referral pathways for psychosocial counseling were strengthened, and (v) a referral form to monitor nurse referrals to the counselor was introduced

Twelve months

PHQ-9 (with a cutoff of ≥ 10) detection by clinicians was assessed by asking screen positives

Using the narrow definition, detection of depressive symptoms increased from 5.2% (6/102) to 16.2% (19/116). Using the broad definition, detection of depressive symptoms increased from 14.2% (14/102) to 26.7% (31/116)

Sherman et al. (2004) [82]

Evidence-based quality improvement intervention: The intervention development process consisted of four steps: setting of priorities for managing depression, expert adaptation of the priorities, development of the QI Plan, and implementation of the QI Plan

Ten months

Ten-item questionnaire and 2-item questionnaire from PRIME-MD to screen patients for depression. Detection of depression assessed by looking at the action they took in the medical chart or notes

At pre-implementation, 97/264 (37%) were positive for depressive symptoms, and only 11 (30%) were recognized by the provider as having depressive symptoms. At post-implementation, 90% of the patients were screened, and of them, 20–25% were screened as positive

Scott et al. (2002) [83]

A “chronic disease management” approach: The intervention was multifaceted, including resources to develop a case register, training program on detection, facilitation of meetings with secondary care staff, and support in developing a practice guideline

Not stated

Hospital Anxiety and Depression Scale and GPs diagnosis

At practice A, sensitivity improved by 23% (from 60 to 83%), and specificity decreased from 62 to 60%. At practice B, sensitivity increased by 25% (25 to 50%), and specificity decreased from 94 to 72%

Upton et al. (1999) [84]

Introduction of ICD-10 guideline which consisted of a study day and the provision of a book of guidelines for mental disorders. The guidelines consist of a brief description of the disorder, a list of diagnostic features, and cross-references to differential diagnoses. The management guidelines consist of information for the patient and family, medical, psychological and social interventions, and referral criteria. The study day consisted of an overview of mental disorders in PHC, the development of ICD-10 PHC, and role plays

Eleven weeks before and 11 weeks after the introduction of the guidelines

GP diagnosis, GHQ-12, and clinical interview schedule

Prevalence of depression diagnosis before was 238 per 10,000 consultations and after 305 per 10,000 (difference = 0.7%, 95% CI 0.2–1.1). Kappa (95% CI) before vs. after was 0.31 (0.1–0.52) fair vs. 0.11 (0–0.34) slight. Of those scoring 2 or more in GHQ12, the GPs identified about 51% before and 54% after as having a mental health disorder

Rinke et al. (2019) [85]

Quality improvement collaborative which is an organized, multifaceted collaborative approach to QI with (1) a specific topic for improvement with large practice variation; (2) clinical and QI experts sharing best practices; (3) multidisciplinary teams from multiple sites willing to improve; (4) a model for improvement with measurable targets, data feedback, and small tests of change; and (5) a series of structured activities to advance improvement, exchange ideas, and share experiences

Two-day interactive video learning session plus monthly video conferences, 8 months

PHQ-9 modified and clinical judgment

The adjusted percentage of patients with depression, dysthymia, or subsyndromal depression diagnoses is 6.6% in the control phase and 10.5% in intervention phase (risk difference (RD) 3.9%; P < 0.0001). Practices sustained these increases during the second (RD −0.4%, P = 0.642) and third action periods (RD −0.1%, P = 0.911)

  1. GPs General practitioners, WHO World Health Organization, ICD International Classification of Diseases, PHC Primary healthcare, GHQ General Health Questionnaire, CI Confidence interval, SBIRT Behavioral health screening, brief intervention, and referral to treatment, PHQ Patient health questionnaire, ES Effect size, MHCP Mental health action plan, mhGAP Mental Health Gap Action Programme, QI Quality improvement, PRIME-MD Primary Care Evaluation of Mental Disorders, RD Risk difference