A stepped care programme for depression management: an uncontrolled pre-post study in primary and secondary care in The Netherlands

INTRODUCTION: Stepped care strategies are potentially effective to organise integrated care but unknown is whether they function well in practice. This paper evaluates the implementation of a stepped care programme for depression in primary care and secondary care. THEORY AND METHODS: We developed a stepped care algorithm for diagnostics and treatment of depression, supported by a liaison-consultation function. In a 2½ year study with pre-post design in a pilot region, adherence to the protocol was assessed by interviewing 28 caregivers of 235 patients with mild, moderate, or severe major depression. Consultation and referral patterns between primary and secondary care were analysed. RESULTS: Adherence of general practitioners and consultant caregivers to the stepped care protocol proved to be 96%. The percentage of patients referred for depression to secondary care decreased significantly from 26% to 21% (p=0.0180). In the post-period more patients received treatment in primary care and requests for consultation became more concordant with the stepped care protocol. CONCLUSIONS: Implementation of a stepped care programme is feasible in a primary and secondary care setting and is associated with less referrals. DISCUSSION: Further research on all subsequent treatment steps in a standardised stepped care protocol is needed.