Mental health care from the patient's perspective : a study of patients with anxiety and depression in general practice

Aim & background The aim of this PhD research was to explore care for anxiety and depressive disorders that is in keeping with evidence-based general practice guidelines on the one hand, and care that is according to patients’ own perceived needs on the other hand. Since recommendations in clinical guidelines for anxiety and depression may be in contrast with patients’ own ideas and preferences, some tension might exist between evidence-based care and patient-centred care for these common mental disorders. In addition to measuring patients’ perceived need for care and patient related factors with guideline adherence, we evaluated the clinical outcomes and costs for society in cases where guideline-concordant care was delivered in comparison with non-guideline concordant care, and the clinical outcomes and costs in cases where patients’ self-perceived needs were fulfilled or not. Methods Data from the Netherlands Study of Depression and Anxiety (NESDA) were used in most of the studies. NESDA is a naturalistic longitudinal cohort study that has included 2981 adult participants for the baseline assessment between 2004 and 2006, recruited from three different settings. We have used the ‘primary care sample’ which included 743 participants with a current (6-month recency) anxiety or depressive disorder. Data were assessed at baseline and one year later. Perceived need for care was measured by the Perceived Need for Care Questionnaire (PNCQ) during the baseline assessment of NESDA. Adherence to evidence-based general practice guidelines for anxiety and depression was defined and measured in an earlier study, based on electronic medical record data from general practices and questionnaire data. Results In general, patients prefer psychological treatment over medication. Patients’ perceived needs for information, counseling or psychotherapy are often not (fully) met while medication needs are more frequently met. Of 721 patients with anxiety and depressive disorders 39% had received guideline-concordant care. On average these patients had more severe symptoms compared to those who did not receive care according to the evidence-based guidelines. However, education level, accessibility of care and patients’ perceived needs for care were more strongly related to the delivery of guideline-concordant care than clinical need factors. After one year, both treatment groups had improved significantly, but the guideline-concordant care group had generated €1035 more costs than the non-guideline concordant care group. There were no significant differences in costs for society between patients who had their perceived needs fully met or not. Conclusions In general, patients with anxiety and depressive disorders prefer psychological treatment but this study shows that this need is not always met in general practice. A possible solution could be found in task delegation. Mental health nurse practitioners, for example, could be valuable partners of GPs to manage mental disorders within general practice. Cooperation within primary care with primary care psychologists or social work might be another option. Because of the naturalistic design, no definite conclusions can be drawn about effectiveness. So, more research is needed to draw any valid conclusions about the costs and effects of guideline-concordant care and care that has fulfilled patients needs.