Des soins de qualité pour la dépression en première ligne : une contribution à l’amélioration de l’état de santé de la population québécoise

Background Numerous studies, using a variety of quality indicators, highlight an important gap in the quality of care for depression in primary care. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The objectives of this study were to i) systematically review indicators used to measure the quality of depression treatment in primary care, ii) estimate the proportion of primary care patients with a MDE who receive adequate treatment, iii) examine the individual and organizational characteristics associated with the receipt of minimally adequate treatment for depression, iv) examine the association between receiving minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6 and 12 months. Methods The literature on the quality of depression treatment was reviewed using a set of keywords (depression, depressive disorder, quality, treatment, indicator, adequacy, adherence, concordance, clinical guideline and guideline) and « 360search », a federated search engine. Data were obtained from a cohort study including 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for previous-year MDE, and nested within 65 primary care clinics in Quebec, Canada. Multilevel analyses were conducted. Results  Though mostly based on recommendations from clinical practice guidelines, a great variety of indicators were observed. Most studies used rudimentary indicators to measure the quality of depression treatment, especially for psychotherapy. Studies also differed greatly with respect to the methods used, thus limiting the comparability of results. However, whatever the chosen method, most studies reveal that a large proportion of people with depression do not receive minimally adequate treatment in primary care settings. In our sample, adherence to guidelines was high (> 75 %) for one third of the quality indicators that were measured but was low (< 60 %) for nearly half of the measures. Just over half of the sample (52.2 %) received at least one minimally adequate treatment for depression. At the individual level, young adults (18-24) et older people (>65) had a lower probability of receiving at least one minimally adequate treatment. This probability was higher for people with a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and a more severe depression. At the clinic level, the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration perceived as adequate were associated with more adequate treatment. Results also showed that i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. Conclusions  Our findings suggest that interventions are needed to increase the quality of depression treatment in primary care. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration. This study also shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions.

Keyphrases: Depression, Major depressive episode, Mental health, Quality of care, Quality indicator, Adequacy of treatment, Clinical guideline, Multilevel analysis, Primary care