JMIR Publications

ABSTRACT

Background:

Major Depression is highly prevalent and frequently managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended Psychotherapy (bPT) combines internet-based interventions with traditional treatments and could overcome their limitations. An effective implementation of bPT in routine care requires an understanding of professional users behavior and perception.

Objective:

The study aimed to identify GPs perceived barriers and facilitators as influencing factors on their referrals to bPT. Different explanations for high variations in the referral rates of GPs were examined to understand their referral behavior.

Methods:

Semi-structured interviews with twelve GPs from the German randomized-controlled trial within the E-COMPARED project were conducted to investigate barriers and facilitators for referrals to bPT for depression (ten online-modules, app-ratings and six face-to-face sessions). The interview guide was informed by the theoretical domains framework. The interviews were audio-recorded, transcribed verbatim, and qualitative content analyzed by two independent coders. A follow-up survey enabled the validation of emerged themes by all GPs. Group differences (e.g. high-/low-referrers) in identified themes were analyzed. Variations in identified hindering and facilitating factors among groups with different characteristics (e.g. GPs with high-/low referral rates or high/low experience or training in psychotherapy or not) were analyzed.

Results:

The average number of referrals was quite low (interviewed GPs: M=6.34; all RCT-GPs: M=2.65), but differed much between the GPs (SD=9.42, Min=0, Max=26). The qualitative findings revealed 19 barriers (B) and 29 facilitators (F) on the main levels of GPs’ office (B=1, F=3), patient (B=11, F=9), GP (B=4, F=11) and socio-political circumstances (B=3, F=6). Key barriers stated by all GPs were amongst others ‘little knowledge about internet-based interventions’ and ‘patients’ lack of familiarity dealing with technology/internet/media’ (number of statements, each k=22). Key facilitators were ‘perceived suitability of patients, e.g. young aged’ (k=22) and ‘no conflict with GP’s role’ (k=16). The follow-up validation assessment by the interviewed GPs showed a very high agreement rate of at least 75% for 35 (73%) of the identified themes. The quantitative findings indicated no statistically significant differences (all U<=25.500, P>=.24) regarding the reported number of barriers and facilitators for the following group characteristics (high/low referrer, high/low experience, yes/no psychotherapist). Similarly, Fisher’s Exact Test indicated no significant associations (P>=.08) between any of those groups and the emerging barriers or facilitators (categorical yes/no mentioning).

Conclusions:

This study provides insights into implementation determinants influencing GPs’ referral behavior to bPT as gatekeeper to depression care. The identified barriers and facilitators should be considered for designing implementation strategies to enhance GPs’ referral rates to bPT and improve patients’ access to care. In total, GPs reported to be ready as stakeholders to integrate digital interventions blended with face-to-face psychotherapy in their depression management options.