Skip to main content Accessibility help
×
×
Home

Information:

  • Access
  • Cited by 92
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Bramesfeld, Anke Grobe, Thomas G. and Schwartz, Friedrich Wilhelm 2007. Who is diagnosed as suffering from depression in the German statutory health care system? An analysis of health insurance data. European Journal of Epidemiology, Vol. 22, Issue. 6, p. 397.

    Bramesfeld, Anke Grobe, Thomas and Schwartz, Friedrich Wilhelm 2007. Who is treated, and how, for depression?. Social Psychiatry and Psychiatric Epidemiology, Vol. 42, Issue. 9, p. 740.

    Cibis, A. and Hegerl, U. 2008. Das Deutsche Bündnis gegen Depression. Prävention und Gesundheitsförderung, Vol. 3, Issue. 3, p. 187.

    Blanca-Tamayo, M. Sicras-Mainar, A. Pizarro-Paixa, I. and Gómez-Lus, S. 2008. Utilización de antidepresivos en pacientes con trastorno de ansiedad generalizada comparada con otras indicaciones en atención primaria. Farmacia Hospitalaria, Vol. 32, Issue. 4, p. 252.

    Smolders, Mirrian Laurant, Miranda Verhaak, Peter Prins, Marijn van Marwijk, Harm Penninx, Brenda Wensing, Michel and Grol, Richard 2009. Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis. General Hospital Psychiatry, Vol. 31, Issue. 5, p. 460.

    Muntingh, Anna DT van der Feltz-Cornelis, Christina M van Marwijk, Harm WJ Spinhoven, Philip Assendelft, Willem JJ de Waal, Margot WM Hakkaart-van Roijen, Leona Adèr, Herman J and van Balkom, Anton JLM 2009. Collaborative stepped care for anxiety disorders in primary care: aims and design of a randomized controlled trial. BMC Health Services Research, Vol. 9, Issue. 1,

    Craske, Michelle G. Roy-Byrne, Peter P. Stein, Murray B. Sullivan, Greer Sherbourne, Cathy and Bystritsky, Alexander 2009. Treatment for anxiety disorders: Efficacy to effectiveness to implementation. Behaviour Research and Therapy, Vol. 47, Issue. 11, p. 931.

    Roca, M. Gili, M. Garcia-Garcia, M. Salva, J. Vives, M. Garcia Campayo, J. and Comas, A. 2009. Prevalence and comorbidity of common mental disorders in primary care. Journal of Affective Disorders, Vol. 119, Issue. 1-3, p. 52.

    Hämäläinen, Juha Isometsä, Erkki Sihvo, Sinikka Kiviruusu, Olli Pirkola, Sami and Lönnqvist, Jouko 2009. Treatment of major depressive disorder in the Finnish general population. Depression and Anxiety, Vol. 26, Issue. 11, p. 1049.

    Ziegelstein, Roy C. Thombs, Brett D. Coyne, James C. and de Jonge, Peter 2009. Routine Screening for Depression in Patients With Coronary Heart Disease. Journal of the American College of Cardiology, Vol. 54, Issue. 10, p. 886.

    Smolders, Mirrian Laurant, Miranda Verhaak, Peter Prins, Marijn van Marwijk, Harm Penninx, Brenda Wensing, Michel and Grol, Richard 2010. Which Physician and Practice Characteristics are Associated With Adherence to Evidence-Based Guidelines for Depressive and Anxiety Disorders?. Medical Care, Vol. 48, Issue. 3, p. 240.

    Sicras-Mainar, Antoni Blanca-Tamayo, Milagrosa Gutiérrez-Nicuesa, Laura Salvatella-Pasant, Jordi and Navarro-Artieda, Ruth 2010. Impacto de la morbilidad, uso de recursos y costes en el mantenimiento de la remisión de la depresión mayor en España: estudio longitudinal de ámbito poblacional. Gaceta Sanitaria, Vol. 24, Issue. 1, p. 13.

    Fassaert, Thijs Nielen, Mark Verheij, Robert Verhoeff, Arnoud Dekker, Jack Beekman, Aartjan and de Wit, Matty 2010. Quality of care for anxiety and depression in different ethnic groups by family practitioners in urban areas in the Netherlands. General Hospital Psychiatry, Vol. 32, Issue. 4, p. 368.

    Sicras-Mainar, Antoni Navarro-Artieda, Ruth Blanca-Tamayo, Milagrosa Gimeno-de la Fuente, Victoria and Salvatella-Pasant, Jordi 2010. Comparison of escitalopram vs. citalopram and venlafaxine in the treatment of major depression in Spain: clinical and economic consequences. Current Medical Research and Opinion, Vol. 26, Issue. 12, p. 2757.

    Dietrich, S. Mergl, R. Freudenberg, P. Althaus, D. and Hegerl, U. 2010. Impact of a campaign on the public's attitudes towards depression. Health Education Research, Vol. 25, Issue. 1, p. 135.

    Fernández, Anna Pinto-Meza, Alejandra Bellón, Juan Angel Roura-Poch, Pere Haro, Josep M. Autonell, Jaume Palao, Diego José Peñarrubia, María Teresa Fernández, Rita Blanco, Elena Luciano, Juan Vicente and Serrano-Blanco, Antoni 2010. Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study. General Hospital Psychiatry, Vol. 32, Issue. 2, p. 201.

    ten Have, M. de Graaf, R. Ormel, J. Vilagut, G. Kovess, V. and Alonso, J. 2010. Are attitudes towards mental health help-seeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders. Social Psychiatry and Psychiatric Epidemiology, Vol. 45, Issue. 2, p. 153.

    King, M. Bottomley, C. Bellón-Saameño, J. A. Torres-Gonzalez, F. Švab, I. Rifel, J. Maaroos, H.-I. Aluoja, A. Geerlings, M. I. Xavier, M. Carraça, I. Vicente, B. Saldivia, S. and Nazareth, I. 2011. An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA. Psychological Medicine, Vol. 41, Issue. 08, p. 1625.

    Aubá Guedea, E. Manrique Astiz, E. Seva Fernández, A. and Jiménez Cortés, M. 2011. Enfermedad psiquiátrica en Atención Primaria. Medicine - Programa de Formación Médica Continuada Acreditado, Vol. 10, Issue. 85, p. 5759.

    Roberge, Pasquale Fournier, Louise Duhoux, Arnaud Nguyen, Cat Tuong and Smolders, Mirrian 2011. Mental health service use and treatment adequacy for anxiety disorders in Canada. Social Psychiatry and Psychiatric Epidemiology, Vol. 46, Issue. 4, p. 321.

    ×

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Treatment adequacy for anxiety and depressive disorders in six European countries
        Available formats
        ×

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Treatment adequacy for anxiety and depressive disorders in six European countries
        Available formats
        ×

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Treatment adequacy for anxiety and depressive disorders in six European countries
        Available formats
        ×
Export citation

Summary

The aims of this study areto describe the adequacy of treatment for anxiety and depressive disorders in Europe and how it differs between providers, using data from the ESEMeD study The overall proportion of adequate treatment was 45.8% (57.4% in the specialised sector and 23.3% in the general medical care sector). Between-country differences were found in treatment adequacy in the specialised setting. Organisational and political aspects may explain these findings.

Footnotes

Declaration of interest

Partial funding from several drug companies involved in the manufacture of antidepressant medication; full acknowledgements in a data supplement to the online version of this paper.

Research on quality of care for mental disorders has systematically reported low rates of treatment guideline adherence (Ramana et al, 1999; McConnell et al, 2002; Oquendo et al, 2002; Kessler et al, 2003; Wang et al, 2005). This has significant health consequences, since treatments meeting clinical guidelines are cost-effective and decrease years lived with disability (Andrews et al, 2004). The majority of previous studies have been conducted in the USA, and little is known about treatment adequacy in Europe.

This study is based on a European epidemiological study of the prevalence and treatment of mental disorders. Our aims are to describe treatment adequacy for anxiety and depressive disorders in Europe, how it differs between countries and providers, and which factors are associated with appropriate care.

METHOD

The European Study of the Epidemiology of Mental Disorders (ESEMeD) project is a cross-sectional household survey representative of the non-institutionalised adults of Belgium, France, Germany, Italy, The Netherlands and Spain. A stratified, multistage, clustered area, probability sample without replacement design was used. Data for the project were provided by 21 425 respondents. A description of the ESEMeD methodology has been provided by Alonso et al (2004). Response rates ranged from 45.9% in France to 78.6% in Spain.

Mental health status was assessed with the Composite International Diagnostic Interview 3.0 (Kessler & Ustun, 2004). The diagnoses included in this paper were DSM–IV major depressive episode and anxiety disorders (social phobia, generalised anxiety disorder and panic disorder) (American Psychiatric Association, 1994). Individuals reporting any use of health services as a result of their ‘emotions or mental health problems’ in the 12 months before the interview were asked to select whom they visited from a list including psychiatrist, psychologist, general practitioner (GP) or any other medical doctor. Psychiatrists and psychologists constituted the specialised mental health category; GPs and other doctors formed the general medical care category.

Criteria for minimally adequate treatment were receiving antidepressant pharmacotherapy (for depression) or antidepressant or anxiolytic pharmacotherapy (for anxiety) for at least 2 months plus at least four visits with a psychiatrist, a GP or any other doctor; or at least eight sessions with a psychologist or a psychiatrist lasting an average of 30 min (American Psychiatric Association, 1998, 2000; Guidelines Advisory Committee, 2001; Kessler et al, 2003; Royal Australian and New Zealand College of Psychiatrists, 2003; National Institute for Clinical Excellence, 2004; Wang et al, 2005).

Data were weighted to adjust for the multistage probability sampling. Population projection weights were used to restore the representativeness of the sample regarding age and gender distribution in each country. A logistic model was used to analyse factors associated with treatment adequacy. Since the same individual could have received treatment in both the specialised and general medical sectors, a generalised estimating equation model was used, including two observations for those treated in both sectors (Zeger & Liang, 1986). Statistical analyses were carried out using Stata version 8.0 and SAS veresion 9.1 for Windows.

RESULTS

An average of 29.5% (429 individuals) of those with a diagnosis of major depressive episode or anxiety disorder in the past 12 months had consulted any health service during that period. Of these individuals, 59 lived in Belgium, 89 in France, 49 in Germany, 36 in Italy, 62 in The Netherlands and 134 in Spain. The overall proportion of treatment adequacy for any disorder was 45.8% (95% CI 39.2–52.4), ranging between 45.8% (95% CI 38.47–53.05) for major depressive episode and 54.5% (95% CI 44.78–64.19) for anxiety disorder. By setting, rate of treatment adequacy for any disorder was 57.4% (95% CI 49.7–65.1) in the specialised care category and 23.3% (95% CI 16.7–29.8) in the general medical care category (specialised care as reference, OR=0.25, 95% CI 0.16–0.38). The same pattern was observed for both types of disorder.

By country, overall proportions of adequacy varied from 32.5% (95% CI 21.5–43.2) in Spain to 55.4% (95% CI 40.3–70.5) in The Netherlands (P=0.11). The proportion of individuals receiving minimally adequate treatment in the specialised care varied widely, from 29.2% (95% CI 17.4–41.0) in Spain to 78.2% (95% CI 65.4–91.0) in France (P<0.001). In the general medical setting, proportions varied between 14.9% (95% CI 1.0–28.7) in Belgium and 33.6% (95% CI 14.4–52.9) in Italy (P=0.54).

Being treated by a general medical provider was associated with a lower probability of receiving adequate treatment in Belgium (OR=0.24, 95% CI 0.19–0.64), France (OR=0.09, 95% CI 0.04–0.23), Germany (OR=0.16, 95% CI 0.05–0.56) and The Netherlands (OR=0.35, 95% CI 0.18–0.69). Provider differences in each country according to disorder were similar to the overall differences.

Two different models were run in order to ascertain the factors associated to treatment adequacy. After adjusting by gender, age (centralised around median value, 42 years old), urbanicity (living in a city with >100,000 inhabitants v. smaller), presence or absence of chronic illness, and health state assessed using the EuroQol, only type of provider and country were related to treatment adequacy. As some interaction between provider and country was detected, we adjusted a second model. In this model, provider by itself was not significant (taking specialised care as reference, OR=0.76, 95% CI 0.34–1.71). Using Spain as reference, living in France (OR=8.91, 95% CI 3.37–23.55), Germany (OR=5.16, 95% CI 1.81–14.18) and The Netherlands (OR=5.14, 95% CI 1.94–13.62) was related to increased probability of receiving adequate treatment. Only the interactions between provider (generalised care) and France (OR=0.10, 95% CI 0.03–0.35) or Germany (OR=0.20, 95% CI 0.05–0.84) were statistically significant. (The results are summarised in a data supplement to the online version of this paper.)

DISCUSSION

Results should be interpreted considering the following limitations. First, information about treatment was self-reported. Second, the final sample considered was small and data should be interpreted with caution. Third, we have not been able to analyse how national differences in response rate affect the results. Finally, we might have underestimated treatment inadequacy owing to the loose criteria used.

In spite of the limitations, our results suggest that treatment adequacy rates for anxiety disorders and major depressive episodes in Belgium, France, Germany, Italy, The Netherlands, and Spain are similar to those found by Wang et al (2005) in the USA. Rates of minimal adequate treatment in the USA were 52.0% in the specialised setting and 14.9% in the general medical setting; in Europe the rates were 57.4% and 23% respectively. However, Wang's study included all DSM–IV diagnoses, whereas we focused on only two types of disorder.

Although overall rates of adequacy were similar across Europe, the differences between providers varied. In the northern countries (Belgium, France, Germany and The Netherlands) treatment adequacy was higher in the specialised sector, whereas in the southern countries (Italy and Spain) there was no difference. This result was not anticipated, since published studies systematically report that those treated in a specialised setting are more likely to receive adequate treatment (Knieser et al, 2005; Wang et al, 2005).

Differences in European healthcare systems might explain these variations. Spain and Italy have a national health service financed by general taxation; the other countries have a system of compulsory social health insurance. In Spain and Italy a GP referral is usually needed to access specialised care. Practice guidelines could also explain differences. Practice guidelines have, at least theoretically, an important role in France, Germany and The Netherlands. In France, the National Agency for Accreditation and Evaluation of Health Care has published a depression guideline; Germany has an Institute for Quality and Efficiency that promotes evidence-based treatments; and in The Netherlands both GPs and psychiatrists publish guidelines for depression (more information on the healthcare systems of these countries can be obtained from the European Observatory, http://www.euro.who.int/observatory). However, the role of practice guidelines has been questioned by Gilbody et al (2003), who highlight the point that simple guideline creation is ineffective. The finding that France and Germany have a high overall adequacy rate but low adequacy in the general medical setting, whereas The Netherlands has one of the highest rates of treatment adequacy in the general medical setting, could be explained by the fact that guidelines in The Netherlands were developed by both primary care physicians and specialists, supporting the hypothesis that collaborative care improves quality of care.

References

Alonso, J., Angermeyer, M. C., Bernert, S., et al (2004) Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica Supplement, 420, 820.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA.
American Psychiatric Association (1998) Practice Guidelines for Treatment of Patients with Panic Disorder. APA.
American Psychiatric Association (2000) Practice Guideline for Treatment of Patients with Major Depressive Disorder. APA.
Andrews, G., Issakidis, C., Sanderson, K., et al (2004) Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment often mental disorders. British Journal of Psychatry, 84, 526533.
Gilbody, S., Whitty, P., Grimshaw, J., et al (2003) Educational and organizational interventions to improve the management of depression in primary care. JAMA, 289, 31453151.
Guidelines Advisory Committee (2001) Outpatient Management of Depress on. CAG. http://www.gacguidelines.ca
Kessler, R. C., Berglund, P., Demler, O., et al (2003) The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA, 289, 30953105.
Kessler, R. C. & Ustun, T. B. (2004) The World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatry Research, 3, 93121.
Knieser, T. J., Powers, R. H. & Croghan, T.W. (2005) Provider type and depression treatment adequacy. Health Policy, 72, 321332.
McConnell, P., Bebbington, P., McClelland, R., et al (2002) Prevalence of psychiatric disorder and the need for psychiatric care in Northern Ireland: population study in the District of Derry. British Journal of Psychiatry, 8, 214219.
National Institute for Clinical Excellence (2004) Management of Depression in Primary and Secondary Care. NICE. http://www.nice.org.uk
Oquendo, M. A., Kamali, M., Ellis, S. P., et al (2002) Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: a prospective study. American Journal of Psychiatry, 59, 17461751.
Ramana, R., Paykel, E. S., Surtees, P. G., et al (1999) Medication received by patients with depression following the acute episode: adequacy and relation to outcome. British Journal of Psychiatry, 74, 128134.
Royal Australian and New Zealand College of Psychiatrists (2003) Australian and New Zealand clinical guidelines for the treatment of panic disorder and agoraphobia, Austral an and New Zealand Journal of Psychiatry, 37, 641656.
Wang, P. S., Lane, M., Olfson, M., et al (2005) Twelve month use of mental health services in the US: Results from the National Comorbidity Survey Replication (NCS-R). Archves of General Psychiatry, 62, 629640.
Zeger, S. L. & Liang, K.Y. (1986) Longitudinal data analysis for discrete and continuous outcomes. Biometrics, 42, 121–30.