Table 3.

General practitioners’ perceived barriers for referrals to blended internet-based psychotherapy (bPT) for depression.

Barriers (n=19)		GPsa (n=12)		Definition	Supporting quotations
		n (%)b	κc
Level of general practitioner (barriers n=4)
	Little knowledge about internet-based interventions	12 (100)	22	The GPs know little about the content and procedures of internet-based interventions or bPTd. Furthermore, they declare to have no profound scientific knowledge about their clinical effectiveness	“To date, I don’t know anything about the efficacy of internet-based interventions.” [GP059]
	Lack of feedback on referral or treatment response	9 (75)	13	The GPs need more feedback on the effectiveness of bPT for a patient, and if necessary, recommendations for further treatment. Feedback is claimed to be an essential component of the communication between GPs and other professionals in health care	“It’s important to be immediately informed of its effects on the patient [...] whether bPT was successful. Or conversely, what measures should be taken if the patient became seriously ill.” [GP084]
	Skepticism toward the internet-based intervention	6 (50)	10	The physicians are skeptical of the quality of internet-based interventions for depression. As a result, they prefer other treatment options for patients	“I would prefer traditional psychotherapy if there could be shorter waiting periods, because it’s more sustainable, a long-term treatment and more personal.” [GP026]
	Lack of habit and routine	5 (42)	10	Referrals to bPT are not a habit and not yet normal for the everyday working routine. The integration of a new procedure takes time and is a complex process. The reasons for this include lack of time, lack of familiarity with the program, or no coverage by medical insurance	“The routine is still developing. It’s not part of my role yet. [...] Referrals to bPT have not yet been embedded in my routine and my regular work, so to speak.” [GP043]
Level of patient (barriers n=11)
	Lack of familiarity with technology, internet, and media	12 (100)	22	The GPs assume that some patients are not confident in using computers, mobile phones, and new technology. They might not be familiar with these devices or have little experience using them	“I imagine not all patients are tech-savvy. Even when you provide them with a smartphone, I think, they’re scared of not being able to use new technologies.” [GP007]
	Disease-specific contraindication	10 (83)	20	The GPs assume that patients with certain diagnoses are not suitable for the internet-based intervention, for example, severe forms of depression, chronic clinical course, suicidality, lack of introspection skills, personality disorder, high comorbidity, or psychotic symptoms	“A referral is not an option if there is an acute suicide risk, a borderline disorder or eating disorders.” [GP059]
	Reservations and skepticism toward technology in treatment	9 (75)	14	The patients are skeptical of the treatment and whether therapy can be effectively implemented and delivered through internet technology	“Patients say ‘Internet? That works for depression treatment? Really?’ They are quite skeptical.” [GP097]
	Lower suitability for physically limited or older patients	8 (67)	9	Internet-based interventions for depression are often considered less suitable for patients with physical limitations. GPs would not refer older patients to internet-based interventions	“It’s clear that older patients, who have bad eyesight, won’t sit in front of their screen and do an internet-based intervention.” [GP059]
	Reservations regarding data safety	7 (58)	12	Patients express reservations regarding data safety with internet-based interventions for depression or this is assumed by the GP	“Patients are often very anxious about data safety when offering something via the Internet. They don’t believe me when I tell them that their information stays confidential.” [GP084]
	Lack of internet access or a computer	5 (42)	7	Internet-based treatment is refused or cannot take place because patients do not have the technical equipment (mobile phone and computer with internet access)	“Well, apart from not having access to the internet and a lack of trust in data security, I can’t think of any big barriers.” [GP012]
	Limited therapeutic relationship or personal contact	5 (42)	9	Internet-based intervention does not provide enough therapeutic contact for the patient. Interviewees mention that a good therapeutic relationship and good rapport cannot arise through internet-based interventions	“Maybe for some the internet-based intervention is too impersonal. Some patients might still prefer more human contact and a closer relationship.” [GP007]
	Fear of stigmatization	3 (25)	4	Having depression and starting bPT causes unpleasant feelings within patients. They fear the consequences of a psychological disease in society	“When you name the disorder, it is often hard for patients to accept it. When you say ‘Listen, the depression has to be treated and there is bPT,’ the patient often doesn’t like it.” [GP059]
	Personal effort required	3 (25)	5	Contributing actively and independently to the treatment can be burdensome for patients. It can be especially challenging for those with depression	“I say to the patients: ‘You have to work, you use your PC at home.’ [...] It involves personal effort and it is not as comfortable as sitting in the GPs’ office and going home afterwards.” [GP046]
	Language barrier	3 (25)	4	Patients who are not able to speak German, which is needed for the intervention, cannot take part in the internet-based intervention. The GPs believe there is a need for translations into other languages for immigrants and refugees	“One disadvantage is that the intervention excludes refugees and immigrants because of the language. They’re a big patient group. They need a translator.” [GP026]
	Little room for individualized treatment or personal issues	2 (17)	4	The limited number of face-to-face sessions and the therapists’ orientation toward web-based modules leave little therapeutic room for personal issues and individualized treatment	“I had a patient that struggled with bPT. The face-to-face sessions were too attached to the internet part and he wanted to talk more about himself. It was too rigid for him.” [GP007]
Level of GP practice (barriers n=1)
	Lack of time for explanations about the availability of bPT	3 (25)	3	The GPs and their office staff lack temporal resources to explain the new bPT that is available to patients	“When the counselling for depression treatment takes too much time, when I spend too much time explaining […] that there’s something new and how it works, then I won’t have enough time.” [GP043]
Level of sociopolitical circumstances (barriers n=3)
	Low awareness of bPT as a therapeutic method	7 (58)	11	Public knowledge and awareness of internet-based interventions and bPT for depression is limited, and this reduces the willingness to use bPT	“Nobody asked me or reinforced to me that I should refer to bPT. That’s too early. It isn’t well-known enough yet.” [GP046]
	No reimbursement by health insurance	6 (50)	9	Health insurance companies do not cover the reimbursement of internet-based interventions	“Health insurers should pay for it and there should be contingencies” [GP007]
	Organizational, bureaucratic, and legal requirements for care providers	5 (42)	6	Organizational, bureaucratic, or legal obstacles can avert the referral to bPT for depression. This includes the interference of health insurance companies, shortage of money, legal requirements, etc	“The bureaucracy and the legal requirements of §12 SGB V, that asks for ‘efficiency principles’, as well as the entire organization of the Association of Statutory Health Insurance Physicians are aggravating factors.” [GP046]

^aGP: general practitioner.

^bThe percentages give the proportion of all 12 general practitioners who mentioned the barrier.

^cNumber of excerpts (κ) show the number of statements regarding a barrier on a code level.

^dbPT: blended psychotherapy.