title: Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines.
abstract: OBJECTIVE
  The aim of this study is to investigate factors contributing to the failure of a randomized clinical trial designed to implement and test clinical practice guidelines for the treatment of depression in primary health care (PHC).
  
  
  BACKGROUND
  Although the occurrence of depression is increasing globally, many patients with depression do not receive optimal treatment. Clinical practice guidelines for the treatment of depression, which aim to establish evidence-based clinical practice in health care, are often underused and in need of operationalization in and adaptation to clinical praxis. This study explores a failed clinical trial designed to implement and test treatment of depression in PHC in Sweden.
  
  
  METHODS
  Qualitative case study methodology was used. Semi-structured interviews were conducted with eight participants from the clinical trial researcher group and 11 health care professionals at five PHC units. Additionally, archival data (ie, documents, email correspondence, reports on the clinical trial) from the years 2007-2010 were analysed.
  
  
  RESULTS
  The study identified barriers to the implementation of the clinical trial in the project characteristics, the medical professionals, the patients, and the social network, as well as in the organizational, economic and political context. The project increased staff workload and created tension as the PHC culture and the research activities clashed (eg, because of the systematic use of questionnaires and changes in scheduling and planning of patient visits). Furthermore, there was a perception that the PHC units' management did not sufficiently support the project and that the project lacked basic incentives for reaching a sustainable resolution. Despite efforts by the project managers to enhance and support implementation of the innovation, they were unable to overcome these barriers. The study illustrates the complexity and barriers of performing clinical trials in the PHC.
authors: 1PhD Student,Department of Public Health and Clinical Medicine,Unit for Epidemiology and Global Health,Umeå University,Umeå,Sweden.
authors: Linda
authors: L
authors: Richter-Sundberg
authors: 3Senior Lecturer,Department of Learning,Informatics,Management and Ethics,Medical Management Center,Karolinska Institutet,Stockholm,Sweden.
authors: Monica Elisabeth
authors: ME
authors: Nyström
authors: 5Associate Professor/District Physician,Center for Family and Community Stockholm County Council,Karolinska Institutet,Stockholm,Sweden.
authors: Ingvar
authors: I
authors: Krakau
authors: 6Professor of Social and Behavioral Sciences,Department of Learning,Informatics,Management and Ethics,Medical Management Center,KarolinskaInstitutet,Stockholm,Sweden.
authors: Christer
authors: C
authors: Sandahl
mesh_terms: D001291:Attitude of Health Personnel; D003866:Depressive Disorder / Q000628:therapy*; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods*; D036301:Qualitative Research; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D012107:Research Design; D011795:Surveys and Questionnaires; D013548:Sweden
keywords: randomized clinical trial