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Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation

Gerdien Franx1*, Jochanan Huyser2, Jan Koetsenruijter3, Christina M van der Feltz-Cornelis145, Peter FM Verhaak67, Richard PTM Grol3 and Michel Wensing3

Author Affiliations

1 Trimbos Institute, Netherlands institute of mental health and addiction, PO Box 725, 3500 AS Utrecht, the Netherlands

2 Arkin, PO Box 75848, 1070 AV Amsterdam, the Netherlands

3 Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO Box 9101, 114, 6500 HB Nijmegen, the Netherlands

4 Tilburg University, Tranzo, Tilburg School of Social and Behavioral Sciences, PO Box 90153, 5000 LE Tilburg, the Netherlands

5 Clinical Centre for Body, Mind and Health, GGz Breburg, PO Box 770, 5000 AT Tilburg, the Netherlands

6 Nivel, Netherlands institute for health services research, PO Box 1568, 3500 BN Utrecht, the Netherlands

7 Rijksuniversiteit Universiteit Groningen, University Medical Centre Groningen, dep. General Practice, PO Box 196, FA20, 9700 AD Groningen, the Netherlands

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BMC Family Practice 2014, 15:35  doi:10.1186/1471-2296-15-35

Published: 19 February 2014



Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing.


A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network.


A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).


An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

General practice; Guidelines; Antidepressants; Implementation; Stepped care