Management of Depression in Primary Care in Catalonia: A Mixed- method Study

doi:10.21203/rs.3.rs-4693893/v1

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Research Article

Management of Depression in Primary Care in Catalonia: A Mixed- method Study

https://doi.org/10.21203/rs.3.rs-4693893/v1

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Purpose

Consultations related to major depression have increased significantly in recent years in Primary Care (PC) in Catalonia. PC is key in the approach, so we analysed the training and alignment with clinical practice guidelines (CPG) of PC professionals in Catalonia and explored their perceptions of the results obtained.

Methods

Explanatory sequential study. Cross-sectional observational study through surveys carried out on nursing and medical professionals and community emotional wellness referents (RBEC), followed by a qualitative study of phenomenological design through focus groups in the same disciplines.

Results

Most professionals feel poorly trained (63.5%) and do not consider themselves aligned (58.3%) with the CPG. In the focus groups, there was a widespread awareness of the PC approach to depression. It was detected that the lack of homogeneity in clinical practice is due to a lack of both time and resources, and a predominantly pharmacological approach. It was expressed that practical training focused on PC, together with collaborative care, unification of CPG and working with the social determinants of health could help in homogenisation. However, a certain reluctance towards eHealth in the approach to depression was detected.

Conclusions

It has been detected that professionals feel poorly trained and aligned with CPG. However, the qualitative study has made it possible to analyse the enabling factors that may explain the results obtained. The detailed analysis that has been performed may help in the development of specific strategies to improve the approach to depression in PC in Catalonia, as well as the implementation of technology in the process.

Depression

depressive disorder

Primary Health Care

clinical practice guidelines

Major depression is a serious health problem due to its high prevalence, with direct repercussions on people's quality of life and a strong social impact (1, 2). One of the most alarming consequences is the reduction in life expectancy. Liu NH. et al. showed that people with severe mental disorders such as moderate and severe depression had a reduction in life expectancy of between 10 and 20 years (3).

Moreover, in 2004, the World Health Organization (WHO) predicted that depression would be the leading cause of disease burden by 2030 and estimated that during 2022 5% of the world's population suffered from depression (1, 4). The study by Liu Q. et al. with Global Burden of Disease (GBD) data showed a 49.86% increase in the incidence of depression worldwide from 1990 to 2017 (5). However, results reported in 2018 from the WHO World Mental Health Survey showed that only one in five people in high-income countries and one in 27 people in low-income countries were receiving adequate treatment (6).

Longitudinality and universal accessibility, characteristics of Primary Care (PC) in Spain, make it one of the only healthcare settings designed to be used by all people throughout their lives. In this context, in 1975 the WHO had already recommended the integration of mental health in PC through a committee of experts (7). In 2008, a joint report by the WHO and the World Organization of Family Doctors (WONCA) showed the advantages of the PC approach to mental health. Some of the relevant advantages were that PC for many people is the first contact with health services and, being accessible to all, can ensure continuity of care for patients, as well as the fact that the integration of mental health into PC is affordable and cost-effective (8). In addition, in PC the person is approached holistically and, therefore, the substantial coexistence between mental disorders and other non-communicable diseases makes mental health management in this setting essential (6, 9). Nevertheless, in 2018 the WHO posited that, despite the evidence shown on the need for mental health integration through PC, this still remained a challenge for many countries around the world (6).

At the level of Catalonia (Spain), during 2021 it was observed through the data of the health survey of Catalonia that 12.2% of women and 5.7% of men presented moderate or severe depression (10). Furthermore, at the PC level of the Catalan territory, the prevalence between the years 2017 and 2022 of major depression and mood disorders was calculated with respect to the total population assigned to the Primary Care Centres (PCC) of the Catalan Institute of Health (ICS)(11). The results indicated that the prevalence during the period studied increased by 86.6% and that in both 2017 and 2022 women were the most affected sex, accounting for 67.2% and 66.6% respectively of the total number of affected persons.

Currently, the reasons for mental health consultations are becoming increasingly relevant in PC in Catalonia, especially among the younger population due to the SARS-CoV-2 pandemic (11–13). As there is no single standardised protocol for mental health care and there is a wide variety of clinical practice guidelines (CPG), there may be great variability in the approach to these consultations. Heterogeneity in clinical practice may be related to the training or awareness of the practitioner (14). In the context of PC in Catalonia, it seems that the biopsychosocial vision incorporated through the reform of PC in 1986 has been replaced by an increase in the use of drugs due to a predominantly biomedical vision. A report by the Catalan Health Service during the state of alarm and lockdown showed that, despite showing a decrease in the prescription of antidepressants, they remained the most prescribed psychotropic drugs from January to June 2020 (13). A recent analysis of medication related to major depression and mood disorders showed a significant increase in antidepressant use in 2022 over 2017 and showed that eHealth use in consultations led to a greater chance of taking antidepressants and anxiolytics (11). eHealth is understood as the use of information and communication technologies in support of health and, in the case of PC in Catalonia, the tools used for consultations between professionals and patients through technology are asynchronous virtual consultation (called eConsultation), telephone consultation and video consultation (15). In 2021, by assessing the possible impact of the COVID-19 pandemic in terms of mental health, the Functional Plan of the Community Emotional Wellbeing Program was developed in Catalonia (16). The objective of this Functional Plan was to incorporate Community Emotional Wellness Referent (RBEC), generally community psychologists, to the PCC of Catalonia to carry out promotion and prevention tasks in emotional health at the community level (17).

A scoping review indicated the conditions necessary to improve the treatment of common mental disorders from the point of view of PC. These were (1) that people with mental disorders should be systematically identified, (2) that sufficient mental health specialists should be available to deal with referrals of complicated cases, and (3) that PC professionals should be able to implement appropriate treatments, which implied sufficient training for diagnosis and treatment, experience in managing these cases, availability to consult with specialised mental health services, and clear, accessible, evidence-based guidelines (18).

The Catalan healthcare system is currently immersed in a digital transformation process. As envisioned in its 2021–2025 Health Plan, the incorporation of digital health into all health-related processes is necessary to facilitate putting the patient at the centre of care (19). In this context, the digitisation of the process of care for major depression is an imminent reality, although prior to this it is necessary to carry out an exhaustive analysis of how it is currently approached by PC in Catalonia. Therefore, the aim of this study is to carry out a detailed analysis of the perceptions of PC professionals in Catalonia regarding the importance of the mental health approach in PC, their training, alignment with CPG recommendations, and the causes that may favour homogenisation in clinical practice.

Study design

Mixed-methodology study with sequential explanatory design (quantitative design followed by qualitative design) (20). Firstly, a cross-sectional observational quantitative study was carried out by means of a survey of professionals clinically involved in the prevention, screening, diagnosis, treatment and follow-up of major depression between March and November 2023 to determine the perception of training, the CPG used and/or the procedure in the approach to major depression in PC of the ICS of Catalonia. Once the quantitative study was completed, a qualitative study with a phenomenological design was carried out to examine the perceptions of the professionals towards the results obtained (21). Two focus groups were organised with a semi-structured script in order to position the mental health approach in PC, explain the results obtained, and identify the causes that favour the homogenisation of clinical practice.

Quantitative study

Sample and procedure

An ad-hoc electronic self-administered survey (Additional file 1) was carried out among all professionals clinically involved in the screening, diagnosis, treatment or follow-up of depressive episodes in PC (family medicine and nursing, family medicine and nursing residents, and RBEC) and was distributed among all ICS Primary Care Teams (PCT) in Catalonia. The ICS is the main provider of health services in the public system in Catalonia and manages approximately 80% of the PCT in Catalonia and provides health coverage to approximately 5.8 million people (22–25).

In February 2024, the number of active family medicine and nursing professionals, nursing or family medicine residents, and RBEC throughout Catalonia was approximately 14,172. Thus, at least 600 responses were required to obtain 95% confidence intervals for the estimates with a precision of 4 percentage units.

Data collection covered a period of 9 months. The Research Support Units of ICS-IDIAP Jordi Gol (7 Units in total; Central Catalonia, Barcelona City, Metropolitan North, Metropolitan South, Girona, Tarragona and Terres de l'Ebre) were in charge of disseminating the survey through corporate mailings of all the professionals included in the study. The survey was conducted through Microsoft 365 Forms, a corporate tool of the ICS, where at the beginning of the survey there was a paragraph briefly explaining the purpose of the survey and informing that participation was completely voluntary and that the data collected would be anonymous. In addition, the contact information of the principal investigator was provided in case any professional had any doubts. Inclusion criteria consisted of family medicine and nursing professionals, nursing or family medicine residents, or RBEC in PC. If these criteria were not met, it was not possible to respond to the survey.

Variables

In order to carry out the ad-hoc survey, two main variables were considered in order to respond to the objective. The first variable was the professionals' perception of their training in dealing with the depressive episode. The second main variable considered was the use of CPG or the procedure of the professionals with respect to screening, diagnosis, treatment or follow-up; each based on their skills.

It was considered relevant to be able to describe the sociodemographic characteristics of the professionals who responded. These variables were gender (women, male, non-binary), age (in years), professional category, years of professional experience and type of PCT (rural, urban and semi-urban). According to the ICS, a rural PCT is considered to be one that has less than 7,500 inhabitants and less than 100 inhabitants/m², semi-urban ones have more than 7,500 inhabitants and more than 100 inhabitants/m², and urban ones have more than 100 inhabitants and more than 150 inhabitants/m² (26).

All responses were closed categories, except for age, which had to be indicated with years, and the question on whether they did not follow any CPG, which had free text. In the case of using any CPG, they could indicate as many CPG as they used.

Statistical analysis

A descriptive analysis of the sociodemographic characteristics of the sample was performed and the results of the two main variables were described in terms of the sociodemographic variables. Categorical variables have been described with absolute frequency and percentage and numerical variables with mean and standard deviation. The Chi-Square test was used to analyse the differences between the categorical variables and the t-Student test was used for the numerical variables.

Regarding the professionals who responded that they were aligned with one of the CPG, the CPG used were analysed and described with frequencies and percentages. Professionals who did not feel aligned with a CPG described what they relied on to perform screening, diagnosis, treatment or follow-up, each based on their skills. The responses were categorised by two independent researchers and a third intervened in case there was no consensus. Categorical variables were described with absolute frequency and percentage.

Finally, two logistic regressions were fitted in order to observe the effect of the variables studied on the perception of training and the use of CPG. The reference categories used were women, medical professional category, belonging to a rural centre and professionals with more than 20 years of experience. In addition, the categories of nursing residents and family medicine residents were eliminated due to the small sample size. The results were represented through the Odds Ratio (OR).

Analyses were performed with version 4.2.1 of the R software. All differences were observed at a significance level of 5% and the confidence intervals were 95%.

Qualitative study

Sample and procedure

For the qualitative study, it was considered appropriate to establish two focus groups with professionals from the disciplines of the previous study. Thus, purposive sampling was carried out among family medicine and nursing professionals, nursing and family medicine residents, and RBEC from primary care centres in Central Catalonia. Each focus group consisted of a total of 8 participants (2 professionals from each discipline per group, except in the case of residents where 1 resident from each discipline per group participated). They were held in person at the Territorial Management of Central Catalonia of the Catalan Institute of Health during the month of January 2024 and the sessions were recorded. The inclusion criteria were that they belonged to the aforementioned professional categories, since they are clinically related to the management of the depressive episode, and that they performed their healthcare work in PC. Using a previously prepared script, the objective of the groups was to analyse the importance given by professionals to the approach to mental health in primary care, to discuss the results obtained in the survey and to identify the causes that may favour the homogenisation of clinical practice. The professionals signed the informed consent to participate prior to the beginning of the session and were audio-recorded.

Variables

In order to carry out the script, it was considered relevant to work with three main themes: (1) importance and positioning of professionals with respect to the approach to mental health in PC, (2) considerations on the results obtained in the surveys, (3) causes that favour the homogenisation of clinical practice in the management of depression. The thematic script was prepared by two members of the research team, the script was not pilot-tested but was reviewed by all team members, and the pertinent modifications were made until consensus was reached. The script can be found in Additional file 2.

Thematic analysis

The content of the voice recordings was transcribed, reviewed and coded using Nvivo Release 1.7.1 software. A deductive analysis was carried out, starting from 3 general themes aligned with the main objectives of the research. Manual coding was used, and the analysis was carried out independently by two people. Disagreements among team members regarding the qualitative analysis were discussed and changes were made as required until consensus was reached.

Quantitative study

Description of the sociodemographic profile of the sample

In total, 797 nursing and family medicine professionals, internal nursing residents (INR), internal medicine residents (IMR), and RBEC participated, with a response rate of 5.62%. An analysis of the sociodemographic profile of the 797 responses obtained was carried out. As shown in Table 1, 83.1% were women with an average age of 45.5 years (Standard Deviation (SD) = 11.0) and the majority indicated that they had more than 20 years of experience (49.6%). The professional category with the highest response was nursing (56.3%), followed by medicine (33.9%). Regarding the characteristics of the PCT, 51.7% of people worked in urban PCTs.

Table 1

Description of the sample
	Total sample N (%) (N = 797)
Gender
Women	662 (83.1%)
Men	130 (16.3%)
Non-binary	5 (0.63%)
Age (mean (SD))	45.5 (11.0)
Professional category
INR	5 (0.63%)
Nursing	449 (56.3%)
Medicine	270 (33.9%)
IMR	11 (1.38%)
RBEC	62 (7.78%)
Types of PCT
Rural	218 (27.4%)
Semi-urban	167 (21.0%)
Urban	412 (51.7%)
Experience
< 5 years	105 (13.2%)
> 5–10 years	126 (15.8%)
> 10–20 years	171 (21.5%)
> 20 years	395 (49.6%)

Perceptions of training and alignment with CPG

Regarding the perception of training in the approach to depression, 63.5% stated that they did not feel well trained (Table 2). However, a significant difference in gender was observed, with women expressing that they felt less trained (87.9%). In terms of age, significant differences were also observed, with the youngest professionals being the ones who most expressed not feeling well trained. Moreover, significant differences were observed between the professional categories, with the nursing category being the one that most expressed feeling poorly trained (74.7%) and the medical category the one that felt better trained (57.4%). With respect to the type of PCT and the years of experience of the professionals, no significant differences were observed in the perception of training.

With regard to feeling aligned with any CPG, 58.3% of the professionals surveyed did not feel aligned with any CPG. There were significant differences in professional category, with nursing professionals feeling the least aligned with any CPG (65.2%) and medical professionals the most (46.4%). No significant differences were observed regarding gender, type of PCT or years of experience of the professionals.

Table 2. Training and use of clinical practices
	Training			Alignment with CPG
	Yes N (%)	No N (%)	P-value	Yes N (%)	No N (%)	P-value
Total (N = 797)	291 (36.5%)	506 (63.5%)	-	332 (41.7%)	465 (58.3%)	-
Gender			< 0.001			0.621
Women	217 (74.6%)	445 (87.9%)		271 (81.6%)	391 (84.1%)
Men	72 (24.7%)	58 (11.5%)		59 (17.8%)	71 (15.3%)
Non-binary	2 (0.69%)	3 (0.59%)		2 (0.60%)	3 (0.65%)
Age (mean (SD))	47.1 (11.2)	44.6 (10.7)	0.002*	45.5 (10.9)	45.5 (11.1)	0.985*
Professional category			< 0.001			< 0.001
INR	0 (0.00%)	5 (0.99%)		0 (0.00%)	5 (1.08%)
Nursing	71 (24.4%)	378 (74.7%)		146 (44.0%)	303 (65.2%)
Medicine	167 (57.4%)	103 (20.4%)		154 (46.4%)	116 (24.9%)
IMR	2 (0.69%)	9 (1.78%)		5 (1.51%)	6 (1.29%)
RBEC	51 (17.5%)	11 (2.17%)		27 (8.13%)	35 (7.53%)
Types of PCT			0.352			0.551
Rural	83 (28.5%)	135 (26.7%)		92 (27.7%)	126 (27.1%)
Semi-urban	53 (18.2%)	114 (22.5%)		75 (22.6%)	92 (19.8%)
Urban	155 (53.3%)	257 (50.8%)		165 (49.7%)	247 (53.1%)
Experience			0.141			0.212
< 5 years	44 (15.1%)	61 (12.1%)		42 (12.7%)	63 (13.5%)
> 5–10 years	42 (14.4%)	84 (16.6%)		55 (16.6%)	71 (15.3%)
> 10–20 years	52 (17.9%)	119 (23.5%)		82 (24.7%)	89 (19.1%)
> 20 years	153 (52.6%)	242 (47.8%)		153 (46.1%)	242 (52.0%)
P-values of the X2 test.
*P-value of the T-test

CPG and procedures in the approach to major depression

The 332 (41.7%) professionals who responded that they felt aligned with a CPG were asked to identify the CPG. As can be seen in Fig. 1, 44.3% stated that they were aligned with the CPG incorporated in the electronic health record of PC (eCAP), which is the Therapeutic Guide of the Catalan Institute of Health of 2018 and only gives guidelines for pharmacological treatment (27). Next, it was observed that 20.8% were aligned with the Electronic Clinical Practice Guideline for Major Depression (eCPG), also incorporated in eCAP (28). This electronic guide supports the PC professional by offering dynamic recommendations based on the clinical context of each patient and can be used synchronously during the consultation with the individual.

In addition, the 332 professionals who felt aligned with a CPG were asked in which phase or phases they considered using a CPG the most (screening, diagnosis, treatment or follow-up). It was observed that 160 (48.8%) professionals consulted the CPG more at treatment, 108 (32.5%) professionals at screening, 104 (31.3%) professionals at follow-up and 83 (25.0%) professionals at diagnosis.

Of the 465 (58.3%) professionals who stated that they did not feel aligned with any CPG, they were asked on what basis they proceeded in the screening, diagnosis, treatment or follow-up, with the understanding that each professional responded according to their competences in the approach to depression. It was a free-text response, and 7 different categories were established according to the answers obtained. As seen in Fig. 2, 126 (27.57%) of the professionals stated that they relied on their professional experience, followed by 121 (26.48%) professionals who relied on the clinical presentation of the patient. To a lesser extent, 82 (17.94%) professionals indicated that they used different scales and assessment tools.

Finally, two logistic regression models were fitted to see the effect of the different variables studied on the perception of training for the approach to major depression and on alignment with CPG (Table 3).

Regarding the perception of training for the approach to the depression, it was observed that nursing professionals perceived to be less trained than the medical category (OR:0.12; 95%CI:0.078; 0.17) and the RBEC considered themselves to be more trained than the medical category (OR:7.43; 95%CI:2.93; 18.85). Finally, professionals with less than 5 years of experience indicated being less trained than professionals with more than 20 years of experience (OR:0.30; 95%CI:0.11; 0.83).

Regarding alignment with CPG, the model was adjusted with the professionals' responses as to whether they felt aligned with any CPG. The results showed that the nursing category felt significantly less aligned with any CPG than the medical category (OR: 0.36; 95%CI:0.25; 0.50).

Table 3

OR of sociodemographic variables for training and the use of guidelines
		Training		Use of guidelines
		OR (IC)	*P-value	OR (IC)	*P-value
Gender
	Men	1.39 (0.87; 2.23)	0.171	0.90 (0.60; 1.35)	0.605
Age (in years)		1.02 (0.99; 1.05)	0.306	1.0 (0.97; 1.02)	0.837
Professional category
	Nursing	0.12 (0,078; 0.17)	< 0.001	0.36 (0.25; 0.50)	< 0.001
	RBEC	7.43 (2.93; 18.85)	< 0.001	0.65 (0.33; 1.27)	0.207
Type of PCT
	Semi-urban	0.91 (0.55; 1.52)	0.721	1.15 (0.75; 1.77)	0.510
	Urban	1.07 (0.71; 1.63)	0.739	0.95 (0.67; 1.36)	0.791
Experience (in years)
	<=5	0.30 (0.11; 0.83)	0.020	0.97 (0.44; 2.11)	0.931
	> 5–10	0.52 (0.24; 1.11)	0.089	1.03 (0.55; 1.96)	0.917
	> 10–20	0.67 (0.38; 1.16)	0.152	1.39 (0.88; 2.21)	0.162
*P-values of the Wald test.
Reference categories: Women, medical, rural, more than 20 years of experience

Qualitative study

The two focus groups lasted 85 minutes on average. A thematic analysis of the content was performed. In the analysis, 8 topics and 4 sub-themes emerged from the 3 main themes, which are shown in Table 4:

Table 4

Themes, topics and sub-themes resulting from focus groups
1. Importance of the approach to mental health in PC	1.1. Awareness
	1.2. Lack of resources
2. Response to survey results	2.1. Neither well trained nor aligned with CPG	2.1.2. Need for investment in mental health
		2.1.3. Need for practical training
	2.2. Nursing	2.2.1. Pharmacological approach
		2.2.2. Recording social determinants of health
3. Factors favouring the homogenisation of clinical practice	3.1. Collaborative care
	3.2. Unifying CPG
	3.3. Identifying the real needs of professionals
	3.4. Digital health

1. Importance of the approach to mental health in PC

1.1. Awareness

All participants considered themselves aware of the mental health approach. Although they expressed that their closest professional environment was aware, the majority considered it to be quite dependent on both the professional and on the relationship established between the professional and the patient. Moreover, reference was made to the increase in public awareness, possibly due to a breaking of the taboo related to mental health and accentuated by the COVID-19 pandemic.

"I think it depends a lot on the person, on the professional who is treating you, and also on the doctor-patient relationship. I mean, because you might have a good connection with someone and you feel you can help them a lot.”

"My general feeling in primary care centres is that every healthcare professional is aware of the importance of preventing mental health problems.”

They agreed that mental health is a matter of urgency and great importance in which, although progress has been made, there is still much work to be done. In this sense, the incorporation of RBEC into primary care in Catalonia represented a step forward in raising awareness and providing resources to PC, although it was agreed that this was a minimal response to the real demand.

"With these new incorporations a small gap opens up for us; something that allows us to say "well, we are already on the path of this mental health awareness so we won't just automatically give a medical prescription if it is not necessary" and enter psychoeducational groups or other workshops aimed at promoting this approach (...). But until now there were no tools and resources, and I think they are still lacking now, you know?”

Despite believing that awareness in this area is necessary to be able to approach it properly, there was agreement on the need for good continuous training. However, it was identified that there is little training in this area and that it is often focused mainly on medicalisation. Moreover, reference was made to the short time available in PC care per visit and, therefore, a limitation for a good clinical appointment.

"They train us to medicate. I mean, they train us to say which antidepressant, which anxiolytic is the best, but that's it. But the other aspects? I mean, accompaniment, psychotherapy...? With the 12 minutes you have..."

"But of course, as you say, courses such as... first, anamnesis: ask the right questions. You refer them to psychiatry and that's it... and hospital care has nothing to do with primary care. There is a lack of training focused more on primary care."

"I think that professionals should have continuous training, you know? All of us throughout our professional career, because in the end it is no use to have a very good training that may be obsolete ten years from now."

To counteract this lack of time, the longitudinality of PC, and thus a comprehensive knowledge of the patient's life history, was identified as a clear advantage. In this sense, the close relationship between the professional and the patient makes it easier to detect changes in mood.

"We get to know our patients very well, and we connect much better with their life stories. There is a very longitudinal follow-up. I mean, throughout this life course, having this information also increases our level of concern about their well-being and improvement"

1.2. Lack of resources

Despite the progress in raising awareness of mental health, since until recently one of the only resources available was medical prescription, the problem of the lack of resources in PC and, more specifically, in mental health re-occurred on numerous occasions. Among them, they highlighted the lack of time, training and tools to build a good approach.

"We all agree, we all want the same course of action, the same performance, but there is not the time to be able to create these projects or these internal procedures among the same team. (...) And the will on the part of all primary care health professionals is there, but the resource is not there."

"In the end I think that the appearance of the figure of the RBEC is a minimal response to a... macro need. But it does reflect the intention to do something. The thing is, of course, it's almost like playing with the problem."

Furthermore, little communication and connection is also identified between PC and specialised mental health care and, therefore, there is a feeling of unease regarding those referrals that are sent back without explanation. In this regard, it was mentioned that there is a marked pathway among patients with more severe disorders, while there is a difficulty in approaching patients with mild and moderate disorders.

"At the hospital there is more contact with the cardiologist, rheumatologist... In psychiatry, on the other hand, I don't remember ever doing anything."

"The link between primary care and the hospital in my PCC is very unstable because you refer a patient because you think that is what they need, and then when they get there, they take them somewhere else (...).”

"We must be able to somehow create strategic plans, to facilitate and streamline the whole issue of communication, case tracking, and knowing where to locate each case. Because, depending on the severity, perhaps they can be attended directly from primary care and then there are cases that have to be worked on directly from the CSMA (Adult Mental Health Centre)."

2. Response to survey results

2.1. Neither well trained nor aligned with CPG

It was found that, through the results of the surveys, the majority of professionals did not feel well trained or aligned with the CPG. Most of the professionals, with the exception of the RBEC who have specific training in dealing with depression, agreed that they do not feel well trained and, therefore, that they do not feel confident in carrying out consultations related to depression. However, they agreed that they did not feel aligned with the CPG because there is a large volume and that there is a lack of unification and updating of criteria by the institution.

"Of course, I believe that if you are and feel well trained, when you carry out a consultation with a person with depression, you will feel more secure, you will transmit this security, and a better bond will be formed. I mean, I think it's full of positives."

"First of all, there is a lack of homogenisation of criteria, and I suppose there is a demand for the need to feel well trained. I believe that since it is such a high percentage, it is a general need." -

2.1.1. Need for investment in mental health

The professionals detected that there had been a destigmatisation of mental health and that resources were beginning to be allocated, albeit insufficient. It was pointed out that there is currently a high demand among the population, although there are not enough resources to meet the demand.

"More investment in mental health. A lot more investment, because we are here to talk about depression, but mental health encompasses everything from addictions to everything pathological. I mean, it's very broad."

"Now I think people talk about it more, but until recently it was a case of just receiving a lot of training in acute illnesses, fatal illnesses, and morbimortality. In the end this patient ends up seeing a decrease in their quality of life, but not a decrease in their mortality, right? This is now becoming more well-known. We're probably too late because between a pandemic and everything else there’s such a big volume that we're behind on it all, but..."

"It's a vicious circle because now general health psychologists can be fully present in our primary care centre. And at least I speak for myself, but I feel overwhelmed already. In other words, I am already waiting three or four months to start a group and we do six every week. (...) There comes a time when everyone may be aware of the problem, but you don't have the tools to deal with everything that’s happening. And so, I believe that in this sense there is also a lack of investment in figures specialised in helping people."

2.1.2. Need for practical training

Special emphasis was placed on collaborative care among the different PC professionals to deal with this type of visit. The importance of practical training was emphasised, where each professional can detect their difficulties when dealing with these consultations and work on what they really need to feel confident during clinical practice.

"Seeing a patient and saying "okay, now this is where my limitations are," meaning "I've been able to get this far, but I don't know how to continue" because I don't have the tools for whatever it is. Then the alternative would be to medicate them, but it may not be necessary, and that medication will also need time to take effect. So, in that moment, when you have the problem, that's when you really need things. Being able to rely on a qualified professional for this can resolve your doubts. And you can say, "okay, next time when I come across this again it will probably be easier for me to make a decision. So, yes, practical training is necessary. Because in terms of theoretical training, more or less anyone can have that..."

"The feeling is a bit like that... that we're making do with what we have. And of course, obviously I do believe that the figure of the general health psychologist who has been incorporated into primary care is very important, but there is a lack of training because if everything were to reach them it would be impossible. So it's like it should be de-escalated a little bit and the nurse should have practical resources that the medical professional should also have..."

2.2. Nursing

It was found that, through the results of the surveys, the nursing category was the one that felt significantly less trained and less aligned with CPG. Although recurring sub-themes emerged in other topics such as the lack of time and practical training to know how to approach the consultation and the existing resources, special emphasis was placed on the more personal relationship between the nurse and the patient, the problem of the mostly pharmacological approach to depression, and the need to work with diagnoses related to the social determinants of health.

"You know the patient and they're not normally like this... You get involved because you would like to get to the bottom of the issue and solve it... but then what do you do? You don’t want to take them to the doctor so they just give them a pill and that’s it... No, you want to know what the problem is... That's what we should know, right? The resources, where can we send them... whether to here, whether to there... maybe doing something ourselves... Not just giving them a diazepam and letting them go. That can't be the solution..."

2.2.1. Pharmacological approach

It was shown that the approach to depression in PC is mostly based on pharmacological management.

"Because these illnesses are very pharmacologically focused."

However, they made reference to the fact that nursing has a much more personal relationship with the patient, which means that they often have a conversation that is not recorded in the patient's medical record.

"We take a more holistic approach to the patient. Maybe the patient comes to you for a cure, but you ask them something and then you ask them about their grandchild... and from there you find out a lot of things. So of course, the guidelines that exist are very medical, very pharmacological. So, we... I don't know. In the end I think we become like mini psychologists”

However, family medicine reinforced the argument that they probably feel more aligned with CPG because they need to consult pharmacological treatment and performance regarding referral criteria.

"Sometimes it's so deeply entrenched in our procedures to make sure the referral doesn't get sent back to me and to align myself with the treatment. Then you use it to diagnose or to treat. But beyond that..."

2.2.2. Recording social determinants of health

In relation to the nurse-patient relationship, it was felt that the recording of Z codes should certainly be enhanced. These codes are diagnoses related to a person's social and family conditions that influence health status and are detailed in Chap. 21 of the International Classification of Diseases (ICD-10) widely used in PC (33, 34). The recording of this coding promotes the biopsychosocial model and favours a holistic and global vision of the person who has the consultation. In this way, it makes it possible to record a given situation that affects the person's state of health and that can also aggravate the diagnoses of depression.

"Well maybe it will be something we can bring to the table and say "wait, is anyone taking sadness codes into account?" Because in nursing we can work on it and we have more tools, too."

"These diagnostic codes can be worked on to give us a little more ease of management as well."

"(...) many sad people and many people who do not know how to manage their emotions come to us, and we diagnose them with anxiety, depression, etc., and maybe the line is sometimes blurred, you know?

3. Factors favouring the homogenisation of clinical practice

3.1. Collaborative care

It was agreed that care between different disciplines in PC for depression can be a good way to enhance the homogenisation of clinical practice, with an impact on improving health outcomes among the population. Furthermore, it was considered necessary to establish a coordinated approach among the different professionals, both PC and specialised care, in order to provide a real response to the patient's needs. In addition, reference was again made to the lack of coordination between PC and mental health centres.

"(...) in the end it wouldn't be a case of ‘this person has a problem, who do I pass it on to?’ Rather, we put the person at the centre and all professionals really look at what we can do"

"That's why I think it would have to be something more coordinated and maybe with the social worker, if they could even look for a third centre, like: if CSMA visits them every three months, primary school also visits them every three months and there is another third centre that also visits them..."

3.2. Unifying CPG

It was agreed that CPG are large, complex documents and that there is a large volume of them. In this regard, it would be important for the institution to work to unify the CPG and updating it where necessary. However, although the majority stated that they did not feel aligned with any CPG, professionals considered that CPG are necessary for evidence-based practice, although in day-to-day practice they are not very useful due to their length and complexity. In addition, as previously mentioned, it was identified that the lack of protocolisation of the procedures often means that patients with a diagnosis of mild or moderate depression do not have access to all the existing resources.

"The ICS has a guide, but it should also have a mini guide that is very practical and that you can have a quick look at."

"Guides should have a practical summary to be useful (…)"

"I believe that if everything were more protocolised, we would have a clearer idea of what to do. (...) A clinical practice guideline is dense, and I refer to that in complex cases. And then, I need something quick for day-to-day things. I believe that one thing cannot exist without the other."

3.3. Identifying the real needs of professionals

The need for practical training among professionals in order to homogenise clinical practice was expressed many times. Reference was made to the fact that it was essential to identify the needs of professionals to address depression consultations. In this sense, most professionals agreed that many professionals have theoretical knowledge of depression, but that practical training in a clinical interview is more necessary to be able to detect at what point the professional needs help to address this consultation.

"The guide would be not so much theoretical as practical, but aligned with saying what is the real need and demand of the healthcare professional, and where exactly is the professional getting stuck? Has anyone detected that? Because we are always talking about depression or risk of suicide, and such... But where we get stuck in the clinical session, in the interview with the user. What happened? Is it because of the crying? Why is it such a difficult and taboo topic?"

3.4. Digital health

They were asked directly whether technology could help in the homogenisation of clinical practice. Many professionals agreed that they did not identify processes where technology could help them. Many of the professionals even expressed that asynchronous teleconsultations often ended up becoming calls, and even face-to-face visits.

"There are questions they ask you via eConsultation and I end up calling them, because I think ‘how am I going to answer this here, over the chat?’. I will answer them because I have to close the eConsultation, but I don't know... I don't want it to be misunderstood..."

However, some of the professionals identified that digital health could be a resource to counteract the lack of time and psychology professionals were the ones who expressed that they already used digital resources in order to give tools to patients.

"I understand that digital tools can work well for us as a resource for this lack of time."

"For example, there’s a psychoeducational group running a workshop in which we work on anxiety symptomatology, and what we do is offer resources, particularly digital resources: YouTube, I don't know, relaxation, diaphragmatic breathing, so that they can start to get a feel for it and when they leave these 8 or 10 sessions, they already have a series of resources and tools to use"

Lastly, it was mentioned that it would be interesting to create an interactive guide to help visitors to cope with the visit. In other words, to help the professional to guide the clinical interview in order to approach depression in the best way.

"Perhaps what would be practical would be to create a not-so-specific interactive guide. That is to say, to give a general idea, but not to go looking for: "you have to ask such a..." I don't know if it's possible, though. But it would be good to look for a model like that which is a little more open and that helps with the things we struggle with the most. To have a few guiding tools to help you get out of this situation a little more gracefully."

The objective of the quantitative study was to analyse training in the approach to major depression, as well as the alignment with CPG or procedures in the screening, diagnosis, treatment or follow-up phases. The results have shown that most professionals do not feel well trained and do not feel aligned with any CPG. The aim of the qualitative study was to analyse the importance given by professionals to the approach to depression in PC, to respond to the results observed in the survey, and to detect how clinical practice could be standardised. The results of the focus groups have shown that PC professionals and the population are aware of the need to address depression, although an increase in both personal and economic resources is necessary to meet the real demand. However, the need for practical training and collaborative care in order to improve the approach to these consultations has been recurrent.

CPG can be considered as a tool for translating complex scientific results into recommendations for clinical practice and, therefore, improving clinical decision making. CPG have been defined as "statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options" (35). However, it must be kept in mind that CPG must be adapted to the context in which they are to be applied. In this sense, the results may cause some concern related to the poor alignment of PC professionals with CPG for the management of major depression, since despite the existence of CPG adapted to the context of the Catalan health system, it has been observed that they are still not used. On the other hand, as shown by Gené-Badia et al. (36), not only is adaptation to the context where the CPG is implemented necessary, but also specific implementation strategies to reduce professional resistance.

Taking into account all of the above, properly adapted and implemented CPG have the potential to contribute to the quality of health care, as they can reduce interprofessional variability. According to the Fòrum Català d'Atenció Primària (Catalan Primary Care Forum), variability is directly related to training, care practice orientation and the awareness of each professional (14). In this context, the detailed analysis of the low use of CPG due to the high volume and low practical training, the relationship between training and age, the relationship between training and professional category, as well as the awareness of the mental health approach in PC and collaborative care can provide an answer to an improvement in the homogenisation of clinical practice.

While the quantitative results showed poor alignment with CPG, the qualitative study provided an answer to this poor alignment. Professionals in the focus groups expressed the need for CPG, although they considered it necessary to turn them into actual practice (14). They considered that the professionals generally had attained theoretical knowledge and were attuned to the approach to depression. However, it was stated that the large volume of CPG, the lack of homogenisation of guidelines by the institution, and the mostly pharmacological orientation led to heterogeneity in practice, especially among categories without pharmacological competence. Therefore, a general need for unification of CPG was detected, as well as practical training focused on PC professionals. One of the solutions identified to reduce variability in clinical practice was collaborative care. The objective of collaborative care models is the pursuit of patient-centred, personalised and individualised care, in which the roles and levels of responsibility of the different professionals are determined. In this way, the shared approach is a tool that helps to make decisions in a homogeneous way, based on the available evidence and putting the patient at the centre of care. Several studies have shown over the years that collaborative care models from PC delivered by multidisciplinary teams of professionals improve depression outcomes (37–40).

Regarding the relationship between age and training, it was found that younger professionals were those who perceived themselves to be less trained. In the National Program for the specialties of nursing and family and community medicine, mental health training during residency is expected to be 3 months and 1.5 months respectively (41, 42). In this regard, some studies suggest that although PC professionals have reasonable knowledge about mental health, it is sometimes not enough to be able to approach the consultation comfortably (43, 44). The qualitative study reinforced these results, since the professionals expressed the low applicability of the knowledge acquired during the specialty to specialised mental health services in PC. However, reference was also made to the focus of university medical and nursing degrees on traditional, organ-centred medicine that cures diseases, probably without taking into account the approach to mental health.

Regarding the relationship between training and professional category, it was detected through the surveys that the nursing professional category felt significantly less trained and less aligned with CPG. The qualitative study provided an answer, detecting that the approach to depression in PC is mostly based on pharmacological management, often in order to make a correct pharmacological prescription or to ensure a correct referral. This mostly pharmacological management indicated in the focus groups was also reinforced by the results of the surveys, as the majority of professionals who said they were aligned with CPG indicated that they used the 2018 Therapeutic Guide of the Catalan Institute of Health, only with guidelines for pharmacological treatment (27). Furthermore, it was also detected that the closer relationship between nurses and patients possibly led to underreporting, highlighting the lack of recording codes related to social and psychosocial factors that influence health status. Rodoreda-Pallàs et al. (45) developed a guide to social determinants of health in the context of the Catalan health system. The professionals stated that the coding of Z codes in PC was an added value in the comprehensive care of the person.

Finally, although the Catalan health system is in the midst of a digital transformation and this is contemplated in its 2021–2025 Health Plan (19), the qualitative study detected a lack of awareness of the concept of "digital health" and a certain scepticism as to how technology could help them in the approach to mild/moderate depression. The results of a previous study in Catalonia showed that consultations made through virtual channels (eConsultation, telephone consultation and video-consultation) increased the chances of prescribing antidepressant drugs (46). The results of the study, together with the reluctance observed among professionals, emphasise the need to develop strategies focused on the implementation of technology in the healthcare system in order to reduce resistance on the part of stakeholders, as well as to ensure consistency in clinical practice.

Strengths and limitations

The main strength of the study is the mixed-design methodology, which has made it possible to obtain a thorough quantitative analysis of the perceptions of the use of CPG and of training in the approach to depression in PC, while the qualitative study has made it possible to respond to the quantitative results by collecting those aspects that are not reflected in the quantitative data, such as the concerns, perceptions and points of view of active PC professionals.

The main limitation of the study has been the low response rate obtained in the surveys, since although the necessary sample size has been reached, more collaboration was expected from the professionals.

In addition, the study is a detailed analysis of the approach to major depression in PC in Catalonia and, therefore, the results cannot be extrapolated to contexts other than the public health system in Catalonia.

Most PC professionals do not feel well trained or aligned with CPG, which have the potential to reduce variability in clinical practice, improving the quality of care. However, the large volume of CPG, the lack of practical training, and the fact that training is not very focused on the PC setting and is mostly pharmacological are factors identified for not following the recommendations. Widespread awareness among professionals, unification of CPG, as well as collaborative care have been identified as possible solutions to improve interprofessional variability. Despite the health system's commitment to the digitisation of healthcare processes, professionals are reluctant to see how eHealth can help them in dealing with consultations for mild/moderate depression. Therefore, the exhaustive topical analysis that has been carried out can help in the design of specific strategies to improve the approach to depression in PC in Catalonia, as well as in the implementation of technology in the process.

CPG

Clinical Practice Guidelines

CSMA

Adult Mental Health Centre

GBD

Global Burden of Disease

ICS

Catalan Institute of Health

IMR

Internal medicine residents

INR

Internal nursing residents

Primary Care

PCC

Primary Care Centres

PCT

Primary Care Team

RBEC

Community Emotional Wellness Referent

WHO

World Health Organization

WONCA

World Organization of Family Doctors

Ethics approval and consent to participate

The study protocol was approved by the University Institute for Primary Care Research (IDIAP) Jordi Gol Health Care Ethics Committee (Code 23/013-P) and the informed consent was obtained from all participants prior to inclusion in the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used or analysed during the current study will be available from the corresponding author on reasonable request.

Competing interests

The author(s) declare that they have no competing interests.

Funding

The principal investigator has been awarded a pre-doctoral fellowship by IDIAPJGol and the Catalan Institute of Health: “Convocatòria pública per a la realització del Doctorat per part dels professionals sanitaris de l'àmbit de l'Atenció Primària de l'ICS”.

Authors' contributions

AFC was responsible for leading all aspects of the study. She distributed the survey, and she assisted in the quantitative analysis. In the qualitative part, she designed the focus group script, facilitated the focus groups, conducted the analysis together with another author, and wrote the first draft of the manuscript

QMC carried out the statistical analysis and assisted in writing the quantitative part of the paper

SM assisted and supervised the focus groups and participated in the qualitative analysis. She also assisted in writing the paper

JVA supervised all aspects of the study and assisted in writing the paper

CC supervised all aspects of the study and assisted in writing the paper

Acknowledgements

We are grateful for the support of all ICS Research and Innovation Units in disseminating the survey to all professionals.

We would also like to make special mention of and thank all the professionals who voluntarily participated in the focus groups, as well as those who responded to the survey.

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No competing interests reported.

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Management of Depression in Primary Care in Catalonia: A Mixed- method Study

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Abstract

Purpose

Methods

Results

Conclusions

Figures

Background

Methods

Study design

Quantitative study

Sample and procedure

Variables

Statistical analysis

Qualitative study

Sample and procedure

Variables

Thematic analysis

Results

Quantitative study

Description of the sociodemographic profile of the sample

Perceptions of training and alignment with CPG

CPG and procedures in the approach to major depression

Qualitative study

1. Importance of the approach to mental health in PC

1.1. Awareness

1.2. Lack of resources

2. Response to survey results

2.1. Neither well trained nor aligned with CPG

2.1.1. Need for investment in mental health

2.1.2. Need for practical training

2.2. Nursing

2.2.1. Pharmacological approach

2.2.2. Recording social determinants of health

3. Factors favouring the homogenisation of clinical practice

3.1. Collaborative care

3.2. Unifying CPG

3.3. Identifying the real needs of professionals

3.4. Digital health

Discussion

Strengths and limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1