In Reply

We thank the authors of the letters to the editor for their positive feedback, but also for their further comments and constructive criticism to our analysis. The study aimed to provide as broad an overview of the care situation of patients with diagnosed depression (1). We are thankful for the comment that the diagnosis ICD-10 F33.4 is a specific diagnosis and not an unspecific diagnosis in the sense of the formed category. The article focused on severity assessment and classification, which form the basis of an evidence-based therapy, so we knowingly accepted this inaccuracy. Only 11,100 of the altogether 1.28 million diagnoses of depression were based on the ICD-10 code F33.4. No effects on the results are therefore to be expected. Expanding our considerations of medication provision to include all substance classes for the ATC group “N” did not strike us as expedient in an overview of the state of care. The focus should be on the specific medication classes or drug combinations recommended according to the guideline. When considering specific groups of patients—for example, patients with certain comorbidities—further relevant classes of active substances could obviously be included.

Further, we regard the suggestion to consider specifically individual groups of patients—for example, older patient—or a more in-depth consideration of care—for example, about the analysis of combination treatment of psychotherapy and pharmacotherapy or treating/prescribing groups of doctors—as starting points for further and follow-up analyses.

We consider the conclusions of our article—with the focus that indications exist that patients are not always receiving guideline-conform treatment and that more intensive training needs to be provided in continuing medical education on important aspects such as correct diagnosis, severity estimation, as well as the initiation of guideline-oriented therapy—as confirmed in any case by our analyses and in spite of the limitations of analyzing health insurance data. It is debatable why for so many patients no severity assessment exists, even though this is the basis of guideline conform therapy. The reasons why doctors did not initiate severity assessments could not be determined in our analyses. Unawareness, lack of knowledge of the guideline or a lack of time in everyday clinical practice may be among the reasons. In any case, further training and continuing medical education form the basis and an appropriate means for improving the awareness/knowledge of guideline recommendations regarding diagnosis and therapy. Further obstacles to implementing guideline-conform therapy—whether process related or structural—will however, inevitably be considered. The routine use of simple clinical tools, the implementation of standardized processes via practice software systems, or specific disease management programs can help improve guideline conformity of treatment. The extent to which the development of additional care services contributes to abolishing healthcare deficits and thereby lowering the disease burden is the subject of controversial discussion (2).