Table 4.

Summary of facilitators and barriers to optimal care for depression

Factors on the level of the …	Facilitators	Barriers
Innovation itself	• A screening or monitoring instrument can help in talking with patients about their symptoms (indicator 1.1)	• Unclear for which patient subgroups certain interventions are appropriate (indicator 2.1)
Individual professional	• Having a special interest in mental health problems (indicator 3.3)	• Contentment with the current routine care (the GPs considered the provision of pharmacological and psychological interventions the most important elements of depression care, and they could provide these interventions to their patients) (indicators 3.3, 3.5, 5.1)
	• The perceived proximity of primary mental health care providers (indicators 4.1 and 4.2)
	• The availability of instruments or interventions that have practical clinical usefulness (indicators 1.1, 2.1, 3.1, 3.3, 3.5)
		• Unfamiliarity with certain interventions or tools (e.g. e-health interventions, relapse prevention, interventions for patients with chronic depression) (indicators 1.1, 2.1, 3.1, 3.2, 3.3, 3.5, 5.1, 5.2)
Patient	• Patient preferences for certain interventions (indicator 2.1, 3.3, 3.4)	• Not having internet access, e-health interventions therefore unavailable (indicators 2.1, 3.2)
	• The GP cannot lose sight of the patients; they go to the GP now and then anyway for other reasons than psychological problems (indicators 5.1, 5.2)
		• Costs associated with health care use (patients prefer care that is without charges) (indicator 3.3)
		• Poor adherence to treatment (indicator 5.2)
Organisational context	• An MHN is available in primary care (who has, for example, more time to assess and monitor symptom severity systematically) (indicators 1.1, 3.1, 3.5, 4.1, 5.1, 5.2)	• Lack of collaboration between primary care and secondary mental health care (e.g. no agreements in place with secondary care about care delivery) (indicators 3.4, 4.1, 4.2, 5.1)
	• Easy access to interventions (indicator 3.2)
	• Close collaboration and regular consultation within primary care (indicators 1.1, 2.1, 3.3, 5.1)	• Lack of proper and timely reports from secondary to primary care about referred patients (indicators 4.1, 4.2)
	• Participation in a quality improvement project on depression care (indicators 1.1, 3.1, 3.3, 3.5, 4.1, 5.2)	• Investing in education, time and effort to achieve knowledge and experience (indicator 5.2)
	• Having agreements on indication criteria and treatment policy within primary care (indicators 1.1, 3.1, 3.3, 4.1)
Economic and political context	• Financial incentives to improve collaboration between primary and secondary mental health care (indicators 4.1, 4.2, 5.1, 5.2)	• The different financial structures for primary and secondary care (indicators 2.1, 4.1, 4.2, 5.1)
		• Financial contributions that patients have to pay for certain care providers (indicators 3.3, 3.4, 4.1, 4.2)
	• Financial incentives to promote the referral of patients back to primary care when appropriate (indicator 5.1)
		• Lack of incentives from the professional association of GPs (indicators 3.2, 5.2)

Overview of the barriers and facilitators that were put forward by the participants, categorised according to five levels [26]: the innovation itself, the individual professional, the patient, the organisation and the economic and political context. A reference to one or more indicators of the indicator set (Table 1) is given, to illustrate for which element of care the influencing factor was put forward by the study participants.