title: Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.
abstract: BACKGROUND
  Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing.
  
  
  METHODS
  A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network.
  
  
  RESULTS
  A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).
  
  
  CONCLUSIONS
  An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.
authors.affiliation: Trimbos Institute, Netherlands institute of mental health and addiction, PO Box 725, 3500 AS Utrecht, the Netherlands. gfranx@trimbos.nl.
authors.forename: Gerdien
authors.initials: G
authors.lastname: Franx
authors.forename: Jochanan
authors.initials: J
authors.lastname: Huyser
authors.forename: Jan
authors.initials: J
authors.lastname: Koetsenruijter
authors.forename: Christina M
authors.initials: CM
authors.lastname: van der Feltz-Cornelis
authors.forename: Peter F M
authors.initials: PF
authors.lastname: Verhaak
authors.forename: Richard P T M
authors.initials: RP
authors.lastname: Grol
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003863:Depression / Q000188:drug therapy*; D005260:Female; D058006:General Practice; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D000928:Antidepressive Agents