This project investigates variation and patient pathways in GP depression care within the framework of the Norwegian Regular General Practice (RGP) Scheme, and the potential impact on return to work and sustainability in return to work. We also include patients, GPs’, other professional health care groups and stakeholders’ experiences of factors that promote return to work after sick leave with depression. Not least, we want to shed light on whether socioeconomic position leads to patients receiving different health services and unequal opportunities for participation in working life.
Depression is a core challenge to society. Depressive disorders require person-centered and coordinated health services with particular attention to the risk of exclusion from work life. GPs play a key role in collaborative care, but it is not known to what extent the RGP Scheme promotes equity in the delivery of depression care, and which GP services facilitate work participation.
The project follows two lines of inquiry:
1. We examine the extent to which the RGP Scheme promotes delivery of equitable depression care facilitating work participation among patients with depression across gender, age, immigrant background and socioeconomic status. The empirical base for the studies is merged data from several national health and welfare registers.
2. We investigate barriers and facilitators for GP delivery of coordinated depression care, with a focus on the needs of patients at high risk of long-term marginalisation. Here, important users including patients, GPs, psychologists, employers, and NAV counsellors provide insight into the collaborative processes through focus groups and interviews, together with a questionnaire to a national sample of GPs.
We found that Norwegian GPs practicing in rural areas provide less talking therapy and more medication than GPs in urban areas. We also find that GPs with shorter continuity of care (shorter GP-patient relationship) provide more talking therapy, more medication, but less sick leave certification than GPs with longer continuity of care. Comparing GPs’ depression care in Norway with care in the Netherlands, we found that Norwegian patients had significantly higher likelihood of being followed-up by their regular GP than the Dutch patients. However, including follow-up by mental health nurses in Dutch general practice, the difference became insignificant. A notable finding was that Dutch patients aged 60 years, or more were more likely to be followed-up by their GP than Norwegian patients, and that prescription of medication for depression was more frequently made in the Netherlands.
Overall, we find that GPs’ depression care over the past years are characterized by more talking therapy, less medication, and less sickness absence certification. However, these trends are not consistent across all patient groups. With respect to medication, we find that higher educated women are prescribed less medication and more talking therapy than all other educational/gender groups. Further, GPs prescribed more medication and less talking therapy to patients over 67 years than patients in working-age.
Moving to sickness absence with depression, we found that higher educated patients more easily attained sustainability in their return to work over the years to come. We also found that young people with depression in their early twenties had significantly higher risk of low income and need for social security benefits in their late twenties, compared to those without a depression diagnosis. This higher risk was particularly evident for those dropping out of secondary high. Interestingly we find that GPs, psychologists, employers, and NAV viewed work participation as salutary. Moreover, that collaboration could facilitate return to work by building a shared understanding of the worker’s situation, assuring proper information flow, and ensure early and timely follow-up of the worker.
Moving to the patients’ view, they wished to be included in all process, and highlighted the need for a GP who had time to listen and not prescribing antidepressants without further follow-up. In cases where the GP recommended contact with psychologist or other relevant treatments, they wished the GP could help them with contact information.
Summing up, this project points to variation in GPs’ depression care across gender, age, education, continuity of care, length of patient list and urban versus rural GP practices. In some cases, the variation is unwarranted, for example the higher prescription rate of antidepressive medication to older patients or the fact that patients in rural areas receive less talking therapy than those in urban areas. In other cases, our findings give reason to question if inequity is at stake, but not to conclude. With respect to return to work our findings support policy suggestions of timely and better collaboration to facilitate sustainability in return to work.
The project may entail outcomes related changes in competency, conduct and practice for GPs providing health care for patients with depression. As the project aimed to examine and promote equality in health care services and sustainable return to work, outcomes must be evaluated over time. We anticipate that changes toward more equality in GPs’ treatment of depressed patients and willingness to participate in timely and coordinated collaboration in follow-up of sick listed patients, will be reached in the years to come. Presently GPs are burdened with heavy workload, narrowing down the room for change. Despite these limitations we are positive that our findings will have the potential to enhance GPs’ awareness of inequality in depression care and promote change in conduct and practice. Importantly, we will prepare an article for the Norwegian audience and one for the international scientific society where findings from all present and ongoing papers in the project will be synthesized and thoroughly discussed. Here we will highlight the most critical variation in GPs' depression care and present recommendations for reducing inequality. We plan to continue bringing forward findings and recommendations in contexts where GPs meet and discuss. Moreover, the user panel in the project, consisting of representatives from one municipality, patient organisations, and health care professionals working with depression care, will bring forward the findings and recommendations in their network, and on digital platforms. This may contribute to optimizing depression care for patient groups who might suffer from unwarranted variation in care, and to highlight the urgent need for timely and collaborative efforts to better follow-up lower educated workers who are sick listed with depression.
The main objective of this research project is to investigate variations, pathways and experiences in general practitioners’ (GPs) depression care within the framework of the Norwegian Regular General Practice (RGP) Scheme, and its consequences for patients’ work participation.
Depression is a core challenge to society. Depressive disorders require person-centred, coordinated and prolonged health care services that are particularly attentive to the risk of exclusion from work life. GPs play a key role in this collaborative care, but it is unknown whether the RGP Scheme ensures equity in the deliv-ery of GPs’ depression care, and which GP services promote work participation among patients with de-pression.
The project will apply an interdisciplinary, mixed methods approach, organised into two work packages (WPs). In WP1 we examine the effectiveness of the RGP Scheme in delivering equitable depression care that promote work participation among patients with depression, including comparative analyses of GP services between Norway and the Netherlands. We have received permission to link several national health and welfare registries, and these fully anonymised registries provide the empirical base for WP1. In WP2 we investigate barriers and facilitators for GPs’ delivery of coordinated depression care. Here, crucial users such as patients and NAV counsellors will provide insight into the collaborative processes through focus group discussions, interviews, and a questionnaire to a national sample of GPs.
Through advanced epidemiological analyses and qualitative inquiries, we will answer the call to increase knowledge regarding the impact of the RGP Scheme for integrated and equitable pathways of GPs’ depres-sion care, and which pathways that promote work participation. The project will provide new knowledge re-garding service organisation features associated with better health care delivery, to inform future service developments in Norway.