title: Quality of care for major depression and its determinants: a multilevel analysis.
abstract: BACKGROUND
  Numerous studies highlight an important gap in the quality of care for depression in primary care. However, basic indicators were often used. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The purpose of this study was to estimate the proportion of primary care patients with a major depressive episode (MDE) who receive adequate treatment and to examine the individual and organizational (i.e., clinic-level) characteristics associated with the receipt of at least one minimally adequate treatment for depression.
  
  
  METHODS
  The sample used for this study included 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for MDE during the 12 months preceding the survey (T1), and nested within 65 primary care clinics. Data reported in this study were obtained from the "Dialogue" project. Adherence rates for 27 quality indicators selected to cover the most important components of depression treatment were estimated. Multilevel analyses were conducted.
  
  
  RESULTS
  Adherence to guidelines was high (>75%) for one third of the quality indicators that were measured but was low (<60%) for nearly half of the measures. Just over half of the sample (52.2%) received at least one minimally adequate treatment for depression. At the individual level, determinants of receipt of minimally adequate care included age, having a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and the severity of depression. At the clinic level, determinants included the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration.
  
  
  CONCLUSIONS
  Our findings suggest that interventions are needed to increase the extent to which primary mental health care conforms to evidence-based recommendations. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration.
authors.affiliation: CRCHUM (Centre de recherche du Centre Hospitalier de l'Université de Montréal), Edouard-Asselin Pavilion, 264, René-Lévesque Blvd, East, Montreal, QC, Canada H2X 1P1. arnaud.duhoux@umontreal.ca
authors.forename: Arnaud
authors.initials: A
authors.lastname: Duhoux
authors.forename: Louise
authors.initials: L
authors.lastname: Fournier
authors.forename: Lise
authors.initials: L
authors.lastname: Gauvin
authors.forename: Pasquale
authors.initials: P
authors.lastname: Roberge
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003865:Major Depressive Disorder / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D008875:Middle Aged; D055361:Multilevel Analysis; D010349:Patient Compliance; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D011569:Psychiatric Status Rating Scales; D019984:Quality Indicators, Health Care / Q000592:standards; D011792:Quebec; D055815:Young Adult