Provider Interventions to Increase Uptake of Evidence-Based Treatment for Depression: A Systematic Review

by Eric R. Pedersen, Ryan Kandrack, Marjorie Danz, Aneesa Motala, Marika Booth, Jody Larkin, Susanne Hempel

This Article

RAND Health Quarterly, 2020; 9(1):6


The objective of this systematic review was to synthesize the effectiveness of health care provider interventions that aim to increase the uptake of evidence-based treatment of depression in routine clinical practice. This study summarizes results of comprehensive searches in the quality improvement, implementation science, and behavior change literature. Studies evaluated diverse provider interventions such as sending out depression guidelines to providers, education and training such as academic detailing, and combinations of education with other components such as targeting implementation barriers. A detailed critical appraisal process assessed risk of bias and study quality. The body of evidence was graded using established evidence synthesis criteria. Twenty-two randomized controlled trials promoting uptake of clinical practice guidelines and guideline-concordant practices met inclusion criteria. Results were heterogeneous and analyses comparing interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies. There was some evidence that interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated that more complex interventions may be associated with more favorable outcomes. However, we did not identify types of interventions that were consistently associated with improvements across indicators of guideline adherence and across studies. Due to the small number of studies reporting team interventions or approaches tested in specialty care we did not identify robust evidence that effects vary by provider group or setting. Low quality of evidence and lack of replication of specific intervention strategies limited conclusions that can be drawn from the existing research.

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Leading and mentoring soldiers is the primary mission of the U.S. Army's noncommissioned officers (NCOs). Per Army Doctrine Reference Publication 6–22, “confident, competent, and informed leadership intensifies the effectiveness of the other elements of combat power” (Headquarters, Department of the Army, 2012, p. 1–1). Accordingly, the Army desires effective leaders and mentors because they motivate their soldiers to perform better. NCOs who do a better job at these tasks will be more likely to accomplish their mission and produce junior personnel who themselves go on to become strong leaders and mentors.

Given the central role of leadership and mentorship, it is somewhat surprising that past research has placed little emphasis on determining the relationship between NCOs and the performance of the junior soldiers under their command. However, given the complex nature of interactions among Army personnel and the frequent relocations that personnel undergo, relating a junior soldier's success to aspects of his or her leadership is difficult.

This study examined the influence of NCO leaders on their soldiers and whether the Army promotion process is capturing and retaining effective leaders. We linked junior and senior enlisted personnel and then tested the hypothesis that senior leaders' experience is related to the performance of junior personnel. We used three different variables to measure the performance of junior enlisted personnel: (1) attrition rates, (2) promotion rates, and (3) demotion rates. These three metrics were chosen to capture performance at various points along an enlisted soldier's career path. We tested several different measures of senior leaders' experience and included measures of leaders' other characteristics. The data used to conduct the analysis were drawn primarily from the Total Army Personnel Database.

As in other research, individual characteristics have a strong and significant relationship with early-term attrition, fast promotion, and likelihood of demotion. However, even when we corrected for individual characteristics of the junior soldiers, the characteristics and experience of senior leaders help predict differences in these junior soldier outcomes, and junior personnel have lower early-term attrition in cases in which senior leaders possess key types of experience. For example, attrition rates are higher among junior personnel under senior personnel who have less than 22 years of service. However, more experience is not always a positive factor; rates are also slightly higher under senior personnel with more than 25 years of service. We find similar patterns with the number of months deployed; attrition rates are lowest when senior personnel have substantial deployment experience (20–39 months), but the attrition rate for junior personnel is higher when the senior leader has either less than 20 months or more than 39 months of deployment experience. This suggests that it is only certain types of leadership experience that improve the performance of junior soldiers. Furthermore, additional experience is not always preferable.

Having a leader with the right mix of experience can potentially generate substantial savings. To obtain a rough estimate of the potential savings, we compared the predicted attrition rates at two similar units that have different levels of senior leader experience. Our regression results indicate that a small unit with 100 junior soldiers would be expected to have an attrition rate between 12.4 percent and 14.4 percent, depending on the specific leadership characteristics. Thus, lowering attrition by 2 percentage points would mean that two additional soldiers would complete their initial terms of service, rather than leaving approximately two years prior to completing the term. Thus, senior leader experience can be expected to translate into about four additional years of service. This suggests that the Army would need to recruit about one fewer soldier for each unit with a leader of typical experience than for one with a less experienced leader.

Recruiting and training are expensive; recent estimates suggest that recruiting and training one soldier costs roughly $60,000. This suggests that having a more-experienced leader could translate into cost savings of as much as $60,000 even for a small unit. Of course, more-experienced leaders also require higher pay. Pay differences at the same rank but with different years of service are relatively modest, whereas pay grade differences are larger but still much less than the projected savings. These rough calculations suggest that the difference in cost between the least experienced leaders and leaders with desirable levels of experience is more than offset by the savings associated with lower levels of attrition. The $60,000 figure could be an under- or overestimate of the true cost, depending on what other changes within the Army structure are required to obtain leaders with desirable levels of experience at the unit level. Additionally, we acknowledge but do not examine the role of midgrade NCOs; to the extent that senior enlisted leaders with optimal levels of experience also assist in creating positive leadership skills among midgrade NCOs, our estimates may be conservative.

Given that experience matters in senior leaders and there is value to that experience, it is concerning that the Army promotion process captures only a limited amount of this experience since it solely considers deployment experience when promoting to E-5 and E-6. Additionally, Army doctrine and interviews with junior enlisted personnel identify multiple competencies and attributes associated with effective leadership, none of which is explicitly captured in the promotion process until promotion to E-7. These observations suggest that the Army may not be identifying soldiers with leadership potential early in their careers and fostering them accordingly. As a result, the Army may be losing effective leaders early and limiting the pool of senior NCOs. At this point, the mechanisms behind the relationship between experience and leadership skills are not yet clear, but there are a variety of ways in which the Army could account for time in service or grade in promotions to capture those benefits after gaining a better understanding of these mechanisms. For example, the Army may want to consider some elements of the NCO Evaluation Report earlier in the promotion pipeline to identify and encourage soldiers who demonstrate leadership potential. Potential quantitative approaches include considering promotion exams to identify knowledgeable soldiers and those proficient in their military occupational specialties.


Headquarters, Department of the Army, other, Army Leadership, Washington, D.C.: Army Doctrine Reference Publication 6-22, August 2012.

This research is sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

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