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

Depression is a burdensome disorder that affects millions worldwide. It is among the most common mental health disorders but also one of the most treatable. Nonetheless, not all individuals struggling with depression receive high-quality, evidence-based care. Clinical practice guidelines for the care of depressed patients in outpatient settings have been established, as well as evidence-based care practices to provide better diagnoses, treatment, and referral for these patients both within primary care settings and within specialty care settings. In many health care systems, however, guideline implementation has not reached acceptable levels in routine care settings, leading to under-, over-, and incorrect treatment of depression.

Interventions to increase the uptake of clinical practice guidelines and guideline-concordant practices aim to bridge the gap between what is known empirically about effective treatment, as summarized in evidence-based clinical practice guidelines, and what is being practiced in the community. These interventions aim to encourage clinician adherence to guidelines through educational, behavioral, financial, regulatory, staffing, or other organizational changes.

This review evaluates approaches that focus on changing health care provider behavior in clinical practice without additional organizational system-redesign efforts or added resources, such as care managers supporting patients. The review is aimed, in particular, at policymakers helping to decide which strategies should be used when new treatment guidelines are available for dissemination. It is intended to help providers and administrators make decisions about which intervention strategies can be most helpful to adopt within organizations to increase the use of evidence-based care for depression. The effect on health care provider behavior on guideline adherence was the primary outcome of interest. We aimed to evaluate the effect of provider interventions to increase uptake of evidence-based treatment for depression. We further set out to determine which interventions are more effective than others, how interventions function across different provider types and different care settings, and which interventions affect patients’ health. We restricted the review to randomized controlled trials (RCTs), a robust research design that supports confident evidence statements.

The following key question and subquestions guided this review:

• Key Question 1: What are the effects of interventions to increase provider uptake of evidence-based treatments for depression on health care professional behavior compared to no-intervention, wait-list control, usual care, or other provider interventions?
• Key Question 1a: Do the effects vary by type of intervention?
• Key Question 1b: Do the effects vary by type of provider?
• Key Question 1c: Do the effects vary by setting?
• Key Question 1d: Are effects on providers associated with patient outcomes?

Methods

We searched PubMed, PsycINFO, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews (CDSR) from database inception through January 2017, as well as bibliographies of existing systematic reviews and included studies, to identify English-language reports of RCTs that evaluated the effects of provider interventions. We used a variety of specific provider intervention as well as more general knowledge transfer search terms to identify health care provider interventions for the uptake of evidence-based treatment for depression.

To be eligible, studies had to evaluate interventions aiming to increase the uptake of treatment guidelines for depression in outpatient settings. Studies describing interventions aimed solely at increasing diagnosing or referral behaviors in the absence of improving treatment were excluded. We included interventions aimed at changing provider behavior in clinical practice but excluded organizational system redesign and different staffing models. To be included, studies had to report provider behavior change outcomes. Two reviewers independently screened publications using predetermined eligibility criteria, abstracted data from those studies that met the inclusion criteria, and assessed their risk of bias. Critical appraisal included the Cochrane Risk of Bias tool and the Quality Improvement Minimum Quality Criteria Set (QI-MQCS), addressing internal validity as well as study-design independent criteria for interventions aiming to improve health care.

Meta-analysis used the Hartung-Knapp method for random effects models summarizing odds ratios (OR), standardized mean differences (SMD), and incidence rate ratios (IRR) together with the 95 percent confidence interval (CI) where applicable. We conducted pre-planned subgroup analyses, assessed potential effect modifiers in meta-regressions, and conducted sensitivity analyses to assess the robustness of study results as the data allowed. We assessed the quality of evidence (QoE) for key outcomes using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach and differentiated high, moderate, low, and very low to characterize our confidence in individual evidence statements.

The review is based on a registered systematic review protocol (PROSPERO record CRD42017060460).

Results

In total, 22 RCTs met inclusion criteria. These studies took place in nine countries and included 2,149 providers and 239,477 patients. Interventions ranged from simply disseminating depression guidelines to education strategies such as academic detailing and multi-component implementation strategies that involved reminders or implementation strategies tailored to individual providers. The methodological rigor of the included studies varied.

Key Question 1: Effects of Provider Interventions

Analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies reporting on categorical outcomes (OR 1.60; CI 0.76, 3.37; 13 RCTs; I² 82%; moderate QoE). Pooled analyses for continuous outcomes also did not show a statistically significant difference (SMD 0.17; CI –0.16, 0.50; 9 RCTs; I² 86%; low QoE). Four studies reported data as an incidence risk ratio (IRR 1.16; CI 0.63, 2.15; 4 RCTs; I² 91%; low QoE); the difference between intervention and control groups was also not statistically significant. However, all analyses showed substantial heterogeneity. For example, effect estimates for continuous outcomes ranged from SMD –0.44 (CI –0.68, –0.20) for a guideline distribution only study favoring the comparator to SMD 0.89 (CI 0.59, 1.18) associated with an intervention that evaluated education plus other components.

Regarding more specific changes in provider behavior, there was some evidence that interventions improved medication prescribing compared to usual clinical practice. The intervention improved medication prescribing measured categorically (OR 1.42; CI 1.04, 1.92; 11 RCTs; I² 53%; low QoE), but the intervention effect was not statistically significant in other analyses (SMD 0.15; CI –0.48, 0.79; 3 RCTs; I² 37%; low QoE; IRR 1.02; CI 0.44, 2.36; 3 RCTs; I² 90%; low QoE). Other outcomes, including increased recommended contacts with patients, intervention adherence as specified in individual interventions, or the offering of mental health referrals to patients did not show statistically significant differences across studies.

We identified three studies comparing the intervention to practice redesign. The comparison did not show statistically significant differences in the main adherence indicator (OR 0.81; CI 0.30, 2.19; 3 RCTs, I² 20%; moderate QoE) or other outcomes but the direction of effect favored practice redesign efforts in most studies.

Key Question 1a: Effects by Type of Intervention

Interventions evaluated unique strategies to increase the update of guidelines and guideline-consistent practices. We broadly categorized the interventions and differentiated studies that included simple dissemination of guidelines with no formal education component (guideline distribution), formal education and training of providers with minimal follow-up (education only), and formal education plus additional components, such as outreach to providers, follow-up consultations, or continued evaluation of providers’ progress throughout the intervention period (education plus other components):

Guideline Distribution

• Mailing general or targeted guidelines to providers, emphasizing the importance of adhering to depression treatment guidelines
• Distributing guidelines to providers and making tailored implementation recommendations to overcome personal barriers to adopting depression treatment guidelines, such as confidence in abilities
• Sending letters to clinicians that reported patients’ depression score interviews along with recommended care for initiating, managing, and monitoring antidepressant medications in elderly patients
• Distributing the American Psychiatric Association’s practice guideline for the treatment of Major Depressive Disorder (MDD)
• Distributing World Health Organization (WHO) depression guidelines
• Providing clinicians with reminders of patients’ depression diagnosis, with or without specific details for how to treat the patient

Education Only

• Training session based on the Dutch depression guideline, with education and information, drug therapy guidelines, and supportive contacts
• Provider education and distribution of the Agency for Healthcare Research and Quality (AHRQ) practice guidelines for major depression in primary care
• Guideline distribution with outreach visits from pharmaceutical advisers to encourage implementation, offer recommendations, and provide feedback
• Outreach sessions from pharmacists with educational handouts and academic detailing to encourage routine first-line use of tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI) for second-line use
• Depression education training sessions based on AHRQ’s clinical practice guidelines for depression in primary care
• Training in the use of WHO depression guidelines
• Pharmacotherapy education group meetings consisting of feedback and interactive problem-oriented educational material to improve diagnostic strategies and to increase prescribing of antidepressants

Education Plus Other Components

• Outreach visits to providers with tools to diagnose and manage elderly patients with depression, such as online courses with treatment recommendations
• Academic detailing, educational sessions led by opinion leaders, and follow-up sessions from pharmacists
• Education plus practice with a computerized support decision system based on the Texas Medication Algorithm Project algorithm for MDD
• Education with group interactive discussion, role-play, academic detailing, feedback, and review of patient progress with a psychiatric consultant
• Continuing medical education focused on treatment and differential diagnosis of depression disorders based on provider’s reported stage of change
• Providers’ receipt of detailed patient reports after initial prescription with patient data and treatment recommendations based on a computerized algorithm
• Training and consultations from experts based on Dutch College of General Practitioners’ guidelines for depression and anxiety addressing barriers to implementing the guidelines
• Group-based or individual-based academic detailing session emphasizing the unique therapeutic difficulties of treating older people and problems of anticholinergic side effects, followed by review of group- or individual-based performance
• Workshops based on the Canadian Medical Association’s clinical practice guidelines for depression, with follow-up psychiatrist consultations
• Education and a set of tools to facilitate diagnosis, follow-up, and management of postpartum depression

Comparative effectiveness data from studies that compared two different provider interventions directly were only available in unique dyads of interventions and comparators. No two studies reported on a similar intervention and comparator in head-to-head comparisons. An indirect comparison across interventions indicated that effects may be associated with the intensity of the intervention (p = 0.03), favoring more complex interventions over passive guideline distribution interventions.

We did not identify intervention types that showed consistently statistically significant provider effects across studies. Interventions that involved simple distribution of treatment guidelines had no statistically significant effect on categorical outcomes (OR 1.28; CI 0.75, 2.19; 3 RCTs; I² 0%) or continuous outcomes (SMD –0.44; CI –0.68, –0.20; 1 RCT); however, this latter effect was observed only in a single study with high risk of bias. Analyses of educational interventions displayed conflicting results, showed wide confidence intervals, and did not indicate a systematic intervention effect (OR 3.04; CI 0.01, 756.17; 3 RCTs; I² 96%; SMD 0.15; CI –0.48, 0.79; 3 RCTs; I² 37%). The subgroup analysis of interventions that included education plus other components also did not indicate a statistically significant effect across studies (OR 1.17; CI 0.62, 2.18; 7 RCTs; I² 44%; SMD 0.37; CI –0.16, 0.90; 5 RCTs; I² 80%), and only one of the individual studies reported a statistically significant difference between groups. Results for individual outcomes varied across studies within and across subgroups.

Key Question 1b: Effects by Type of Provider

Included studies reported on primary care physicians, nurses, mental health care providers such as psychiatrists, and general practitioners. We did not identify studies that directly compared intervention approaches in different health care provider groups. Rather, we used indirect comparisons to explore differences between team and sole provider interventions. Two studies evaluated an intervention that targeted different members of staff in the health care organization, such as primary care physicians and nurses, while the other interventions targeted only the individual health care provider. We did not identify robust evidence that intervention effects varied by targeted provider group. A meta-regression was statistically significant (p = 0.034) but, since only one study contributed to the team intervention category, results should be interpreted with caution.

Key Question 1c: Effects by Setting

We did not identify studies that compared effects of interventions across different settings. Overall, 20 studies took place in primary care settings, and two were conducted in specialty care. Primary care settings were academically affiliated primary care practices, general practices (solo practices, group practices, or health centers), family medicine research network practices, family practice research networks, general practices in health authorities, primary care trusts, and primary care clinics in a federally qualified community health care system. Specialty care settings included managed behavioral health care organizations and a private psychiatry practice. The review was limited to interventions for outpatient care settings.

Indirect comparisons did not indicate systematic effect differences by setting (p = 0.385). However, since only two studies provided data on specialty care settings, the analysis was unlikely to have sufficient statistical power to adequately address the review question.

Key Question 1d: Effects on Patients’ Health

Fourteen studies reported on patient outcomes in addition to provider outcomes. Results were mixed across studies and outcomes. Significant effects were found for the number of patients responding to depression treatment (OR 1.12; CI 1.04, 1.21; 6 RCTs; I² 0%; moderate QoE), such that patients under the care of providers in intervention conditions were more likely than those in usual clinical practice to report a meaningful change in their depression at follow-up. We did not detect statistically significant effects for depression rating scale scores, depression remission, or treatment adherence.

Conclusions

The available evidence on provider interventions to increase the uptake of evidence-based treatment for depression includes interventions that distribute guidelines, education approaches such as academic detailing, and complex interventions with multiple components such as training and follow-up feedback on performance or exploring individual barriers to implementing guidelines. The interventions did not result in statistically significant effects across indicators of guideline adherence, but there was some evidence for improvement in individual outcomes such as medication prescribing. Indirect comparisons indicated that more complex interventions (i.e., interventions that go beyond the dissemination of guidelines or educating providers) may be associated with larger intervention effects. However, the result was based on very low QoE and we did not identify types of interventions that were consistently associated with improved adherence to depression guidelines across studies. The low QoE and lack of replication of specific intervention strategies across studies limit the conclusions that can be drawn from the literature. Intervention approaches and outcomes varied widely and complicated the synthesis. More research is needed to identify interventions that effectively promote provider uptake of depression treatment guidelines and guideline-concordant practices in routine clinical care. Research should be supported by a framework of provider interventions that allows for more structured assessments. More research is also needed to compare interventions targeting multidisciplinary teams with those targeting individual health care providers and research in specialty care settings.