Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study

Abstract

Background: Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:

1. Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and

2. Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).

Methods: After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.

Results: Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).

Conclusions: The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

Keywords: care pathways; diagnosis; major depressive disorder; treatment.

Figure 1.

Schematic of stepped care pathway for major depressive disorder. Depiction of stepped care model for recognizing and managing depression. This reflects the stepped care model presented in the NICE depression guideline (2009). Adaptations from the original are only in the following respects: (a) level of detail (minimized here for clarity), (b) addition of a “Step 0,” which we have developed in this project as the preceding stage to entering the stepped care pathway itself, and (c) in structure of presentation, as the NICE guideline does not explicitly show the setting(s) that each step takes place in. Here, the top row displays the title/summary of that step, the middle row shows the setting within which it should be managed, and the third summarizes details of management guidelines for each step. Note that Step 5 is not considered in the current treatment gaps as this is reserved for a minority of urgent or complex cases, often following the failure of previous treatment steps.

Figure 2.

WHO world mental health survey estimates of detection and treatment rates for people with major depressive disorder (MDD). Summary of status (with regard to help-seeking and treatment receipt) of those meeting criteria for depression in the World Health Organisation (WHO) international surveys. Data were gathered from a representative set of community households across 21 countries over the decade prior to publication in 2017. The 12-month prevalence of MDD was 4.6% (adults). This shows that only 16.5% of people with MDD received “minimally adequate care.” *“minimally adequate care” is defined as at least 1 month receiving pharmacological treatment including more than four medical contacts, or more than eight sessions of psychotherapy.

Figure 3.

Summary graphic integrating treatment gap estimates. For treatment gaps 1, 3, 4, and 5, this graphic summarizes the estimated proportion of individuals with each outcome. The top row represents all individuals with a major depressive episode, the second represents those with a diagnosis, and the third/fourth of those treated for depression.