title: Process evaluation of a stepped-care program to prevent depression in primary care: patients' and practice nurses' experiences.
abstract: BACKGROUND
  Depression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable. Recently, a cluster randomized trial of stepped care to prevent depression among patients with DM2 and/or CHD and subthreshold depression in Dutch primary care (Step-Dep) versus usual care showed no effectiveness. This paper presents its process evaluation, exploring in-depth experiences from a patient and practice nurse perspective to further understand the results.
  
  
  METHODS
  A qualitative study was conducted. Using a purposive sampling strategy, data were collected through semi-structured interviews with 24 participants (15 patients and nine practice nurses). All interviews were audiotaped and transcribed verbatim. Atlas.ti 5.7.1 software was used for coding and structuring of themes. A thematic analysis of the data was performed.
  
  
  RESULTS
  The process evaluation showed, even through a negative trial, that Step-Dep was perceived as valuable by both patients and practice nurses; perceived effectiveness on improving depressive symptoms varied greatly, but most felt that it had been beneficial for patients' well-being. Facilitators were: increased awareness of mental health problems in chronic disease management and improved accessibility and decreased experienced stigma of receiving mental health care. The Patient Health Questionnaire 9 (PHQ-9), used to determine depression severity, functioned as a useful starting point for the conversation on mental health and patients gained more insight into their mental health by regularly filling out the PHQ-9. However, patients and practice nurses did not widely support its use for monitoring depressive symptoms or making treatment decisions. Monitoring mental health was deemed important in chronically ill patients by both patients and practice nurses and was suggested to start at the time of diagnosis of a chronic disease. Appointed barriers were that patients were primarily motivated to participate in scientific research rather than their intrinsic need to improve depressive symptoms. Additionally, various practice nurses preferred offering individually based therapy over pre-determined interventions in a protocolled sequence and somatic practice nurses expressed a lack of competence to recognise and treat mental health problems.
  
  
  CONCLUSIONS
  This study demonstrates both the benefits and unique demands of programs such as Step-Dep. The appointed facilitators and barriers could guide the development of future studies aiming to prevent depression in similar patient groups.
authors.affiliation: Department of Health Sciences and the EMGO Institute for Health and Care Research, Vrije Universiteit, Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.|Department of General Practice & Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: Alide D
authors.identifier: http://orcid.org/0000-0001-8682-338X
authors.initials: AD
authors.lastname: Pols
authors.affiliation: Department of Medical Humanities, EMGO+ Institute, VU Medical Centre (VUmc), Amsterdam, The Netherlands.
authors.forename: Karen
authors.initials: K
authors.lastname: Schipper
authors.affiliation: Department of General Practice & Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: Debbie
authors.initials: D
authors.lastname: Overkamp
authors.affiliation: Department of Health Sciences and the EMGO Institute for Health and Care Research, Vrije Universiteit, Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Susan E
authors.initials: SE
authors.lastname: van Dijk
authors.affiliation: Department of Health Sciences and the EMGO Institute for Health and Care Research, Vrije Universiteit, Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Judith E
authors.initials: JE
authors.lastname: Bosmans
authors.affiliation: Department of General Practice & Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.|CLAHRC Greater Manchester and NIHR School for Primary Care Research, the University of Manchester, Manchester, UK.
authors.forename: Harm W J
authors.initials: HW
authors.lastname: van Marwijk
authors.affiliation: Department of Health Sciences and the EMGO Institute for Health and Care Research, Vrije Universiteit, Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands. marcel.adriaanse@vu.nl.
authors.forename: Marcel C
authors.initials: MC
authors.lastname: Adriaanse
authors.affiliation: Department of Health Sciences and the EMGO Institute for Health and Care Research, Vrije Universiteit, Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Maurits W
authors.initials: MW
authors.lastname: van Tulder
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D003327:Coronary Disease / Q000175:diagnosis / Q000523:psychology*; D003866:Depressive Disorder / Q000453:epidemiology / Q000517:prevention & control* / Q000628:therapy; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000523:psychology*; D005260:Female; D058005:General Practitioners / Q000458:organization & administration; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009743:Nursing, Practical / Q000458:organization & administration*; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D036301:Qualitative Research; D012720:Severity of Illness Index
keywords: Coronary heart disease; Diabetes mellitus type 2; Major depressive disorder; Process evaluation; Qualitative study; Stepped care; Subthreshold depression