Guideline adherence rates and interprofessional variation in a vignette study of depression

OBJECTIVE: To assess the appropriateness of and variation in intention-to-treat decisions in the management of depression in the Netherlands. DESIGN: Mailed survey with 22 paper cases (vignettes) based on a population study. SETTING: A random sample from four professional groups in the Dutch mental healthcare system. SUBJECTS: 264 general practitioners, psychiatrists, psychotherapists, and clinical psychologists. MAIN OUTCOME MEASURES: Each vignette contained information on a number of patient characteristics taken from three national depression guidelines. The distribution of patient characteristics was based on data from a population study. Respondents were asked to choose the best treatment option and the best treatment setting. For each vignette we examined which of the selected treatments was appropriate according to the recommendations of the three published Dutch clinical guidelines and a panel of experts. RESULTS: 31% of all intention-to-treat decisions were not consistent with the guidelines. Overall, less severe depression, alcohol abuse, psychotic features, and lack of social resources were related to more inappropriate judgements. There was considerable variation between the professional groups: psychiatrists made more appropriate choices than the other professions although they had the highest rate of overtreatment. CONCLUSIONS: There is sufficient variation in the intentions to treat depression to give it priority in quality assessment and guideline development. Efforts to achieve appropriate care should focus on treatment indications, referral patterns, and overtreatment