Best Practice Guidelines for Older Adult With Depression

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Integration of Best Practice Guidelines for Older Adults with Depression in Mental Health Care

Muhammad Arsyad Subu HSR 6120: Knowledge Transfer for Health Services and Policy Research University of Ottawa

February 02, 2012

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Evidence-based practice (EBP) will integrate research findings into decision making in nursing practice. Use of EBP represents one way that nurses can improve their clinical practice effectiveness. In 1999, the RNAO launched the Best Practice Guidelines (BPGs) program. The purpose of this multi-year program is to support Ontario Nurses by providing them guidelines for client care. However, there is little evidence that specifically addresses the use of Clinical Practice Guidelines for older adult depression in clinical settings. In this paper, I will include researches that have addressed the integration of research and EBP of older adult depression in mental health settings. I will begin with a brief description of the problem, followed by solutions described in the literature and how they may relate to my setting in Indonesia. Finally, I will relate how the Knowledge to Action (KTA) Framework (Straus, Tetroe & Graham, 2009) will guide in implementing a solution to the issue of integrating BPG in older adult depression clinical practice. The challenge of translating research findings into clinical practice has been an explicit concern to the discipline and profession of nursing for decades. Little research has been conducted to identify factors that interfere with the ability of nurses to base their practice on research evidence (Retsas, 2000). Barriers to effective use of research include the gap between research and practice goals; the relevance or perceived relevance of research; poor access to research or not having time to absorb it; and research-unfriendly organizational settings (Hemsley-Brown, 2004). There are three barriers that are most commonly reported in implementing BPG in clinical settings (Ploeg, et al., 2007). Older patients are less likely to voluntarily report depressive symptoms, may view depression as a moral weakness or character flaw not an illness, and may be more likely to ascribe symptoms of depression to a physical illness and may perceive stigma of depression (Sirey, et al., 2001). A study finds that home healthcare nurses may fail to identify late-life depression (Brown, et al., 2004). Nurses may also lack specific training in depression and may be

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uncomfortable with assessing depression (Larson, Chernoff & Sweet-Holp, 2004). Lack of educational support and ease of access to mental health specialists are found to be principal barriers that accounted for nurses reluctance to uncover mental health problems (Nolan, Murray & Dallender, 1999). Barriers of institutional system may limit implementation of depression guidelines or quality of care improvements. These barriers include lack of coordination and collaboration between health care providers in primary care, long-term care and specialty mental health providers. Additionally, there are shortages of nursing and social service professionals who have training and expertise in geriatric mental health. Some challenges to Implementation of Best Practice Guidelines are scheduling and replacement of staff nurses for education session, competing initiatives on each of the units, communication with all the major stakeholders, competing patient care demands on staff time, and different organizational and unit cultures and policies (Davis &Taylor-Vaisey, 1997) The knowledge translation concept has gained popularity as a viable solution to address the research-practice gap. A possible solution to the EBP implementation problem in Indonesia is to adopt or implement RNAO Nursing Best Practice Guideline: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (RNAO, 2004). It is a resource for the support of evidence-based nursing practice in caring older adults with dementia, delirium and depression. It is based on the specific needs of the organization or mental health practice setting, as well as the needs and wishes of the patient. The adoption of an innovation such as EBP occurs via several stages, from learning about the new innovation to implementing it in clinical practice (Pagoto, 2007). There are four most commonly reported facilitators of BPG implementation in clinical (Ploeg, et al., 2007). Some facilitators to implementation of BPG include relevance to the patient population and practice on the units, expertise and collaboration of the steering committee

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members, enthusiasm of the staff nurses, organizational and stakeholder support, and use of multiple strategies to promote the program (Davis &Taylor-Vaisey, 1997). A summary of these articles reviews is presented in Appendix A, and the quality assessments of the reviews using AMSTAR (Shea et. al., 2007) are provided in Appendix B. Some literatures provide descriptions of strategies the integration of evidence based practice in nursing care for older adult with depression. Researchers have also begun to identify key factors in the dissemination and implementation of evidence based quality of care improvements (Pearson, et al., 2003). Some studies emphasize the importance of integrating mental health specialists and strategies within primary care (Sherbourne, et al., 2001). There is strong evidence of effective methods to identify and evaluate depression in older adults. Additionally, there is strong evidence that treatment is effective in reducing depressive symptoms and improving quality of life. Health care providers are increasingly more likely to detect and treat depression in elderly patients. Compelling evidence of elder need, the availability of effective treatments, and the recent evidence of effective strategies to address even some of the more intransigent healthcare system barriers to care demand even greater commitment to and advocacy for evidence-based depression practice in a society whose population of elderly is growing (Bartels, 2003);Lyness, 2004). Treatment of mental health problems in Indonesia becomes one of the challenges to deal with. It is estimated that suicide rate in Indonesia is 24/100,000 population (WHO, 2005). Depression as the most leading causes of disabilities is often under-diagnosed and well-treated. Depression and suicide cases were often only reported by mass media (Kaligis, Amir, & Diatri,, 2011). Unfortunately, there are very limited articles available that discuss the implementation of EBP or clinical guidelines for older adult with depression in Indonesia. However, I have witnessed in Indonesia that in caring for older adult with depression, there is not specific mention of what

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evidence based guidelines being referred to, and from this, it is problematic in decided these guidelines will be included in mental health practices. Although a care plan template is used in clinical care activities, nurses are not required to cite evidence for the rationale for their nursing interventions. Nurses engage in anecdotal daily reporting but there is no reflection on the evidence that may support a practice change. Most nurses lack adequate educational or clinical training of best practice guidelines to have the appropriate skills as mental health professionals. Nurses are lacking adequate experience in integrating research to their practice. They are not sure how to integrate new EBP easily in their institution. There is a gap between current practice as described and the solutions mentioned earlier. This has resulted in the lack of a systematic approach to the integration of best practice guideline and concepts of EBP concept in clinical care for older adult with depression. I will relate how the Knowledge to Action (KTA) Framework (Straus, Tetroe & Graham, 2009) will guide in implementing a solution to the issue of integrating BPG in older adult depression clinical practice. Knowledge to Action (KTA) framework (Straus, Tetroe & Graham, 2009) will be used to implement of solutions around this issue, The KTA framework is relevant for two reasons. First, as one of the challenges of the depression nursing care is its vagueness on the specific care process changes to adopt and on the ways to implement them. Nurses need to choose an appropriate implementation approach and apply it for specific KT interventions. Second, KTA highlights the role of the end users of the knowledge in the translation process, hence making sure that the knowledge is both relevant and applicable for the specific context (Straus,Tetroe, & Graham, 2011). In addition, specific areas of relevance in the framework include the adaptation of knowledge, assessing barriers to knowledge use, selecting, tailoring and planning for implementation, planning for the monitoring of knowledge use, and evaluating outcomes.

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References Altpeter, M.,Bryant, L., Schneider, E., & Whitelaw, N. (2006). Evidence-Based Health Practice: Knowing and Using What Works for Older Adults. Home Health Care Services Quarterly, 25 (1-2). DOI: 10.1300/J027v25n01_01. Andreescu, C, Reynolds, C.F. (2011). Late-life depression: evidence-based treatment and promising new directions for research and clinical practice. Psychiatric Clinics of North America, 34 (2):335-55. Azocar, F., Cuffel, B., Goldman, W., & McCarter, L. (2003). The impact of evidence based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. Journal of Behavioral Health Services & Research, 30(1), 109-18. Badan Pusat Statistik (BPS) (2010). Population by Age Group and Sex 2010. Retrieved from: http://www.bps.go.id/aboutus.php?sp=1 Banerjee, S., Shamash, K., Macdonald, A.J.D., & Mann, A.H. (1996). Randomized controlled trial of effect of intervention by a psychogeriatric team on depression in frail elderly people at home. British Medical Journal, 13, 1058-1061. Bartels, S.J., Dums, A.R., Oxman, T.E., Schneider, L.S., Aren, P.A., Alexopoulos, G.S.,&Jeste, D.V. (2002). Evidence-based practices in geriatric mental health care. Psychiatric Services, 53(11), 1419-31. Bartels, S.J. (2003). Improving the system of care for older adults with mental illness in the United States: Findings and recommendations for the Presidents New Freedom Commission on Mental Health. American Journal of Geriatric Psychiatry, 11, 486-497.

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Brown, E.L., Bruce, M.L., McAvay, G.J., Raue, P.J., Lachs, M.S., & Nassisi, P. (2004). Recognition of late-life depression in home care: Accuracy of the outcome and assessment Information Set. Journal of the American Geriatrics Society, 52, 995-999. Carper, B. A. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing Science, 1(1), 13-23. Chou, A.F., Vaughn, T.E., McCoy, K.D., & Doebbeling, B.N. (2011). Implementation of evidence-based practices: Applying a goal commitment framework. Health Care Manage Review, 36(1), 4-17. Davis, D. A, Taylor-Vaisey, A. (1997). Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ, 157; 408-16. Ell, K. (2006) Depression care for the elderly: reducing barriers to evidence-based practice. Home Health Care Services Quarterly, 25, (1-2) 115-148. Forsner, T., Hansson. J., Brommels, M., Wistedt, A.A., & Forsell, Y. (2010). Implementing clinical guidelines in psychiatry: a qualitative study of perceived facilitators and barriers. BMC Psychiatry, 20; 10:8. Hemsley-Brown, J.( 2004). Facilitating research utilization: A cross-sector review of research evidence. The International Journal of Public Sector Management; 17(6): 534-552. Kaligis, F., Amir, N., & Diatri, H. (2011). How depression is treated in Indonesia. Department of Psychiatry, Faculty of medicine, University of Indonesia, Jakarta. Retrieved from: http://www.jspn.or.jp/journal/symposium/jspn106/pdf/ss042-045_bgsdng10.pdf. Larson, J.S., Chernoff, R., & Sweet-Holp, T.J. (2004). An evaluation of provider educational needs in geriatric care. Evaluation & the Health Professions, 27, 95-103.

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Lyness, J.M. (2004). Treatment of depressive conditions in later life. JAMA, 291, 16261627. Lyness, J.M., Cox, C., Curry, J., Conwell, Y., King, D.A.,& Caine, E.D. (1995). Older age and the underreporting of depressive symptoms. Journal of American Geriatrics Society, 43, 216221. Moghabghab, R., Adler, L., Banez, C., Boutcher, F., Perivolaris, A., Rancoeur, D., Spevakow, D., Tully, S., Wallace, S., and Kevin Woo, K. (2003). The Experience of Implementing Nursing Best Practice Guidelines for the Screening of Delirium, Dementia and Depression in the Older Adult. Geriatrics & Aging, 6 (10), 39-41 Nolan, P., Murray, E., & Dallender, J. (1999). Practice nurses perceptions of services for clients with psychological problems in primary care. International Journal of Nursing Studies, 36, 97-104. Pagoto, S.L. et al. ( 2007). Barriers and Facilitators of Evidence-Based Practice Perceived by Behavioral Science Health Professionals. Journal of Clinical Psychology, 63(7), 695705. Pearson, B., Katz, S.E., Soucie, V., Hunkeler, E., Meresman, J., Rooney, T., & Amick, B.C. (2003). Evidence-based care for depression in Maine: Dissemination of the Kaiser Permanente Nurse Telecare Program. Psychiatric Quarterly, 74(1), 91-102. Ploeg, J., Davies, B., Edwards, N., Gifford, W., & Miller, P.E. (2007). Factors Influencing Best-Practice Guideline Implementation: Lessons Learned from Administrators, Nursing Staff, and Project Leaders. Worldviews on Evidence-Based Nursing, 4(4):210-219. Retsas, A. (2000). Barriers to using research evidence in nursing practice. Journal of Advanced Nursing, 31:599-606. Rubenstein, L.V., Jackson-Triche M.,Untzer, J., Miranda, J., Minnium, K., Pearson, M.

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L, Wells, K. B. (1999). Evidence-based care for depression in managed primary care practices. Health Aff (Millwood), 18(5):89-105. Shea, B.J., Grimshaw, J.M., Wells, G.A., Boers, M., Andersson, N., Hamel, C. et al. (2007). Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews. BMC Medical Research Methodology, 7(10). doi:10.1186/1471-2288-7-10. Sherbourne, C.D., Wells, K.B., Duan, N., Miranda, J., Untzer, J., Jaycox, L. et al. (2001). Long-term effectiveness of disseminating quality improvement for depression in primary care. Archives of General Psychiatry, 58(7), 696-703. Sirey, J.A., Bruce, M.L., Alexopoulos, G.S., Perlick, D.A., Raue, P., Friedman, S.J., & Meyers, B.S. (2001). Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry, 158(3), 479-81. Straus S., Tetroe, J. Graham I.D. (2009) Knowledge Translation in Health Care: Moving from Evidence to Practice. Oxford: Wiley-Blackwell. Straus, S.E, Tetroe, J.M., Graham, I.D. (2011). Knowledge translation is the use of knowledge in health care decision making. Journal of Clinical Epidemiology; 64:610. doi: 10.1016/j.jclinepi.2009.08.016. World Health Organization (2005). Mental Health Atlas. WHO. Zeiss, A.M (2003). Depression in older adults: Evidence-based treatment and the current gaps in the evidence base. The Gerontologist, 43(2). 279-283

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Appendix A

Literature Review Results A list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs.

Intervention studies Author, year Method (Altpeter, et.al., This article provides an 2006) overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. This study tests whether a (Azocar, et al., managed behavioral health 2003) care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N = 443) under one of three conditions. (Banerjee, et al., Members of the intervention 1996) group received an individual package of care that was formulated by the community psychogeriatric team in their catchment area and implemented by a researcher working as a member of that team. The control group received normal general practitioner care. RCT with blind follow up six months after recruitment. This study evaluated the accuracy of home care nurses' ratings of the Outcome and Assessment Information Set (OASIS) depression items.

No effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression.

This did not seem to be a simple effect of antidepressant prescription: use of antidepressants at follow up did not have a significant effect (multiply adjusted odds ratio 0.3 (0.0 to 1.9)).

(Brown, et al, 2004)

Home care nurses

often do not accurately rate OASIS depression items for older adult patients.

Best Practice Guidelines for Older Adult With Depression The accuracy of home care nurses' depression assessments was studied by comparing nurse ratings of OASIS depression items with a research diagnostic assessment based on the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study used hierarchical generalized linear modeling to assess implementation outcomes. Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians' performance or health care outcomes were emphasized. This paper provides an overview of five key bodies of evidence identifying characteristics of depression among older adults, effective interventions, known barriers to depression care, effective organizational and educational strategies to reduce barriers to depression care; and key factors in translating research into practice. This qualitative study was conducted. The implementation activities at

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(Chou, et al., 2011)

(Davis &TaylorVaisey, 1997)

Having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening. Serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic. There is strong empirical support for implementing strategies to improve depression care for older adults.

(Ell, K. 2006)

(Forsner, et al., 2010)

The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major

Best Practice Guidelines for Older Adult With Depression one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Content analysis was used to identify themes emerging from the interview data. This paper focuses on the barriers to research utilization and the most effective strategies for facilitating the use of research by managers in the public sector, based on research evidence. Key themes to emerge from this review were the accessibility and relevance of research, trust and credibility; the gap between researchers and users, and organizational factors. Providers of geriatric care in Arkansas USA were surveyed to determine the desire for more information on their specialty as well as opportunities for further training. Specifically, information was sought in the areas of dementia, depression, and memory loss. The RNAO BPGScreening for Delirium, Dementia and Depression in the Older Adult, was implemented as a pilot project on eight different units. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses.

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categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies.

(Hemsley-Brown, 2004).

Research use can be facilitated through: support and training; collaboration and partnership; dissemination strategies; networks; and strong, visible leadership.

(Larson, Chernoff & Sweet-Holp, 2004).

Improvement in geriatric care in the future should focus on nursing education and on raising the level of knowledge and academic prestige in the treatment of elderly patients, especially in the mental health areas.

(Moghabghab, et al., 2003)

Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

Best Practice Guidelines for Older Adult With Depression (Nolan, Murray & Dallender, 1999). The present questionnairebased study sought to elicit the types of mental health problems encountered by practice nurses in primary care, the interventions they provide and the skills they utilize. This paper discusses ways of meeting the needs of practice nurses and of improving collaboration in primary care settings Progress in implementing evidence-based behavioral practices has been slow. A qualitative study was performed to characterize the major facilitators and barriers to evidence-based practice (EBP) perceived by behavioral professionals. This paper describes the program model, implementation and preliminary results from a dissemination of a nurse case management program for treating depression in primary care. The program design was modeled after the Kaiser Permanente Nurse TeleCare program, which in a RCT had previously demonstrated significant improvement in depression outcomes and patient satisfaction over usual care. This paper reports the perceptions of administrators, staff, and project leaders about factors influencing implementation of nursing best practice guidelines.

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Practice nurses

care for people with a wide variety of mental health problems ranging from mild to severe. Many feel unprepared for this type of work and are reluctant to get too involved with clients in case they uncover problems they are not able to cope with. Lack of access to appropriate educational support is identified as the main problem currently faced by practice nurses alongside poor inter-professional relationships with mental health personnel. Seven themes to describe both barriers and facilitators: training, attitudes, consumer demand, logistical considerations, institutional support, policy, and evidence.

(Pagoto, et al., 2007)

(Pearson, et al., 2003).

It is possible to implement successful interventions in smaller primary care practices in community-based settings.

(Ploeg, et al, 2007)

Facilitators included learning about the guideline through group interaction, positive staff attitudes and beliefs, leadership support, champions, teamwork and collaboration, professional association support, and

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Twenty-two organizations, in clusters of two to five, implemented one of seven guidelines in acute, community and long-term care settings. Qualitative thematic analysis was conducted. (Retsas, 2000) Using factor analysis The most important factor was perceived procedures, barriers to the use to be organizational support, particularly of research evidence in in relation to providing time to use and nursing practice. conduct research. (Rubenstein, et al., This study evaluates whether Based on evaluation of adherence to the 1999) externally designed, evidence- intervention protocol, local practice based interventions for leaders are able to implement improving care for depression predesigned interventions for improving can be locally implemented in depression care. Adherence rates for managed care organizations. most key intervention activities were The interventions were carried above 70 percent, and many were near out as part of a randomized 100 percent. Three intervention activities trial involving forty-six fell short of the goal of 70 percent practices within six diverse, implementation and should be targets for nonacademic managed care future improvement. plans. (Sherbourne, et al., In this study, the sample For most outcomes, differences between 2001) included 1299 patients with intervention and UC patients were not current depressive symptoms sustained for the full 2 years. However, and 12-month, lifetime, or no QI-therapy reduced overall poor depressive disorder from 46 outcomes compared with UC by about 8 primary care practices in 6 percentage points throughout 2 years, managed care organizations. and by 10 percentage points compared Clinics were randomized to with QI-meds at 24 months. Both UC or 1 of 2 QI programs that interventions improved patients' clinical included training local experts and role outcomes, relative to UC, over and nurse specialists to 12 months (e.g., a 10-11 and 6-7 provide clinician and patient percentage point difference in probable education, assessment, and depression at 6 and 12 months, treatment planning, plus either respectively). nurse care managers for medication follow-up (QImeds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. Appendix B AMSTAR assessment of quality of systematic review

inter-organizational collaboration and networks. Barriers included negative staff attitudes and beliefs, limited integration of guideline recommendations into organizational structures and processes, time and resource constraints, and organizational and system level change.

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Pagoto, S.L. et al. ( 2007). Barriers and Facilitators of Evidence-Based Practice Perceived by Behavioral Science Health Professionals. Journal of Clinical Psychology, 63(7), 695705. 1. Was an a priori design provided? The research question and inclusion criteria should be established before the conduct of the review. 2. Was there duplicate study selection and data extraction? There should be at least two independent data extractors and a consensus procedure for disagreements should be in place. 3. Was a comprehensive literature search performed? At least two electronic sources should be searched. The report must include years and databases used (e.g. Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found. 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc. 5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided. X Yes No Cant answer Not applicable Yes X No Cant answer Not applicable X Yes No Cant answer Not applicable

Yes X No Cant answer Not applicable

Yes X No Cant answer Not applicable X Yes No Cant answer Not applicable

6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analyzed e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported.

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7. Was the scientific quality of the included studies assessed and documented? A priori methods of assessment should be provided (e.g., for effectiveness studies if the author(s) chose to include only randomized, double-blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant. 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. 9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi-squared test for homogeneity, I). If heterogeneity exists a random effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?). 10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or statistical tests (e.g., Egger regression test). 11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies.

X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable Yes X No Cant answer Not applicable

Yes X No Cant answer Not applicable Yes X No Cant answer Not applicable

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Davis, D. A, Taylor-Vaisey, A. (1997). Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ, 157; 408-16. 1. Was an a priori design provided? The research question and inclusion criteria should be established before the conduct of the review. 2. Was there duplicate study selection and data extraction? There should be at least two independent data extractors and a consensus procedure for disagreements should be in place. 3. Was a comprehensive literature search performed? At least two electronic sources should be searched. The report must include years and databases used (e.g. Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found. 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc. 5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided. X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analyzed e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported.

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7. Was the scientific quality of the included studies assessed and documented? A priori methods of assessment should be provided (e.g., for effectiveness studies if the author(s) chose to include only randomized, double-blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant. 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. 9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi-squared test for homogeneity, I). If heterogeneity exists a random effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?). 10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or statistical tests (e.g., Egger regression test). 11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies.

X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable Yes X No Cant answer Not applicable

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Pearson, B., Katz, S.E., Soucie, V., Hunkeler, E., Meresman, J., Rooney, T., & Amick, B.C. (2003). Evidence-based care for depression in Maine: Dissemination of the Kaiser Permanente Nurse Telecare Program. Psychiatric Quarterly, 74(1), 91-102. 1. Was an a priori design provided? The research question and inclusion criteria should be established before the conduct of the review. 2. Was there duplicate study selection and data extraction? There should be at least two independent data extractors and a consensus procedure for disagreements should be in place. 3. Was a comprehensive literature search performed? At least two electronic sources should be searched. The report must include years and databases used (e.g. Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found. 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc. 5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided. X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analyzed e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported.

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7. Was the scientific quality of the included studies assessed and documented? A priori methods of assessment should be provided (e.g., for effectiveness studies if the author(s) chose to include only randomized, double-blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant. 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. 9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi-squared test for homogeneity, I). If heterogeneity exists a random effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?). 10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or statistical tests (e.g., Egger regression test). 11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies.

X Yes No Cant answer Not applicable

X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

Yes X No Cant answer Not applicable Yes X No Cant answer Not applicable

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Sherbourne, C.D., Wells, K.B., Duan, N., Miranda, J., Untzer, J., Jaycox, L. et al. (2001). Longterm effectiveness of disseminating quality improvement for depression in primary care. Archives of General Psychiatry, 58 (7), 696-703. 1. Was an a priori design provided? The research question and inclusion criteria should be established before the conduct of the review. 2. Was there duplicate study selection and data extraction? There should be at least two independent data extractors and a consensus procedure for disagreements should be in place. 3. Was a comprehensive literature search performed? At least two electronic sources should be searched. The report must include years and databases used (e.g. Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found. 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc. 5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided. X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable X Yes No Cant answer Not applicable

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6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analyzed e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported.

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7. Was the scientific quality of the included studies assessed and documented? A priori methods of assessment should be provided (e.g., for effectiveness studies if the author(s) chose to include only randomized, double-blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant. 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. 9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi-squared test for homogeneity, I). If heterogeneity exists a random effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?). 10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or statistical tests (e.g., Egger regression test). 11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies.

X Yes No Cant answer Not applicable

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Yes X No Cant answer Not applicable Yes X No Cant answer Not applicable