Table 4.

General practitioners’ perceived facilitators for referrals to blended internet-based psychotherapy for depression.

Facilitators (n=29)		GPsa (n=12)		Definition	Supporting quotations
		n (%)b	κc
Level of general practitioner (facilitators n=11)
	No conflict with GP’s role	12 (100)	16	Referral to a bPTd is not in conflict with professional standards and the GP’s role identity. Interviewees integrate the referral into their job role without problems	“I don’t see a role conflict. As a GP you’re not a specialist for everything, therefore it belongs to my daily routine to refer patients to a specialist. My competence is recognizing patients being in need of a specialist.” [GP084]
	High level of self-efficacy regarding the referral	11 (92)	15	The GPs feel able to do the referral to bPT in a promising and successful way. They describe no difficulties for the referral process	“The referral to bPT is not very complicated. It already works quite well.” [GP084]
	Optimistic attitude	11 (92)	15	The interviewees are open toward the new internet-based approach. Physicians are confident that the bPT will work well and the treatment will be successful	“I am very confident that bPT can be a great support. Definitely.” [GP007]
	Support through information and training	11 (92)	19	The GPs would benefit from more information, further education and training, and the opportunity to try out the tool themselves. This increases the likelihood of a referral	“I think a 2-3 hours training session would be nice. A short introduction into the disorder, the diagnostic process of the GP and information about the blended treatment.” [GP026]
	Positive self-appraisal regarding own skills	9 (75)	10	The GPs rate their own skills as very high which are needed for a successful referral. Those include, for example, the diagnosis of depression and counseling techniques	“The main skill is actually interviewing. I learnt most the things by doing further educational courses. As a GP, my main weapon is talking.” [GP084]
	Positive beliefs about treatment success	9 (75)	12	The physicians expect the blended depression treatment to be associated with positive consequences for the patient	“I can imagine, that a certain group of patients could benefit a lot from it. [...] I think it is a step forward.” [GP084]
	Positive attention and decision-making process	9 (75)	16	Positive attention and decision-making processes are supported by the following: the referral option is remembered, GPs get reminders (flyers and mails) from the therapy institution, and patients give positive responses to the treatment	“I really remember it all the time. I have the flyer on my desk and every patient that seems suitable to me gets one from me.” [GP026]
	Expectation of social reinforcement	9 (75)	9	The GPs expect positive reactions within their social environment for the referral of patients to bPT	“I would expect interest and curiosity about bPT from others.” [GP012]
	Perception of patients’ consent	9 (75)	9	The physicians feel that patients are willing to take part in blended depression treatment. They expect patients to give consent when they express a referral offer	“Yes, patients are willing to participate in the bPT.” [GP007]
	Positive emotions	8 (67)	8	Pleasant emotions arise when the GPs consider referring a patient to bPT for depression	“It feels good to be able to refer a patient to bPT.” [GP007]
	Personal contact with the therapists and provider	7 (58)	11	Personal contact with therapists and staff of the provider reinforces the GP’s referral behavior	“It was helpful to know the staff.” [H026]
Level of patient (facilitators n=9)
	Perceived patient suitability (eg, well-educated or young)	12 (100)	22	bPT is an up-to-date intervention, which is close to patients’ everyday media use. It is especially suitable for people of a younger age and a medium to high level of education	“Patients with a higher educational level are more suitable.” [GP012]
	Intervention for minor-to-moderate depression or dysthymia	10 (83)	22	The GPs perceive bPT to be appropriate for patients who are affected by minor-to-moderate depression or dysthymia	“I would refer patients suffering from mild to moderate depressive disorders. I don’t consider bPT to be sufficient for severe forms.” [GP012]
	Motivation and willingness for treatment	7 (58)	13	The interviewees are ready to recommend the blended treatment if the patient shows motivation and willingness to start the treatment	“If a patient shows interest and wants to be informed about the bPT, I am open and ready to recommend the offer.” [GP012]
	Smaller inhibition threshold and barrier for usage	7 (58)	15	Patients have fewer inhibitions about taking part in internet-based interventions for depression and taking advantage of this offer. One can reach new patient groups, who were not previously open for treatment	“Another facilitating factor is maybe the low threshold, particularly for younger patients, to contact a psychologist online.” [GP012]
	Time- and location-independent internet-based intervention	6 (50)	8	The internet-based components of the treatment are neither bound to place nor to time, so they can be easily integrated into daily life. The patient works through the internet-based modules in a flexible way	“The advantage is surely that bPT is not time bound, at least for the internet-based part of the treatment.” [GP046]
	Anonymity	5 (42)	7	Patients also participate because of the given anonymity of the web-based section of bPT and appreciate this anonymity	“The anonymity is an advantage. If patients can register on their own on an online platform, it will surely help. Some just have this threshold and are frightened to speak about their problem in face-to-face contact.” [GP007]
	Technical affinity	4 (33)	4	Working with technical tools and new media is an incentive to join internet-based interventions for depression. People who have an affinity for technical tools are attracted to this new technology	“Younger patients, who are often technophiles, are especially interested in bPT, I think.” [GP012]
	Preventive approach for subclinical symptoms	3 (25)	7	The GPs believe the bPT is suitable for subclinical symptoms of depression. It can also be used for prevention	“I think it is an in-between treatment. I need it for people diagnosed with a depressive adaptation disorder who are still at a beginning point with subclinical symptoms.” [GP007]
	Short duration of treatment	2 (17)	3	The treatment only lasts 13 weeks, which is a manageable amount of time for patients	“The behavior-centered working, six sessions in a short-term, therefore a manageable thing. I like that.” [GP084]
Level of GP practice (facilitators n=3)
	Methods facilitating GPs’ work and referral process	11 (92)	40	Working routines that help GPs to treat depressive patients and to refer them, for example, information flyer, poster in the waiting room, newsletter, standardized referral documents, digital feedback about diagnostic and treatment findings	“Concerning one patient, I underestimated the severity of the disorder and I received diagnostic feedback from his therapist. I called a neurologist for an appointment in the near term. I saw this positively since I don’t claim that I can recognize everything.” [GP084]
	GPs’ perception of a high demand	11 (92)	14	Additional treatment options for the referral of depressive patients are strongly needed in GPs’ offices	“There is an increased prevalence of depression, especially in younger patients. Those providing outpatient therapy are overloaded. There is a high need.” [GP098]
	Saving GPs’ office resources	7 (58)	14	Referrals to bPT saves GPs’ resources. Patients can apply for therapy on their own via an web-based link. Physicians do not have to bridge the time with a treatment in their own office until a patient starts a traditional treatment	“Referrals to bPT are relatively time saving, don’t need many resources, are quickly executed and actually quite feasible.” [GP012]
Level of sociopolitical circumstances (facilitators n=6)
	Short waiting time for internet-based intervention	11 (92)	38	The waiting time for internet-based interventions is essentially shorter than for traditional face-to-face psychotherapy. Depressive patients can be treated promptly, and as such, psychological strain is reduced	“The main advantage is that there’s no time delay. You can offer your patient a treatment immediately.” [GP012]
	Quick and easy availability	10 (83)	18	Internet-based intervention is quickly and easily accessible for patients without any large organizational and temporal effort	“Everybody can start the treatment very easily at home and almost immediately. The patient doesn’t need to arrange an appointment for the first contact, he can start online.” [GP059]
	Additional therapy approach as new pillar in health care	9 (75)	21	The GPs benefit from the provision of an additional up-to-date treatment offer in the health care system. bPT can close the care gap and has the potential for nationwide coverage	“bPT closes a gap in our range of therapeutic treatments. It is a very good additional option. Access to psychotherapy is limited and everything additional is something positive.” [GP026]
	Integration within guidelines as evidence-based treatment	6 (50)	11	bPT for depression should be established in the health care system as an intervention with approved evidence. The GPs should be informed about the guidelines and the recommendation of bPT as a treatment for depression	“Well, GPs are treating patients according to guidelines and it would help, if bPT were to be integrated into these guidelines. We have to be sure, that we can work with this treatment without hesitation.” [GP053]
	Media coverage improves awareness and evaluation of bPT	3 (25)	5	Media reports about the possibility of bPT for depression as an approved therapeutic approach improves GPs’ and patients’ perceptions of it and their willingness to use it	“A kind of public relation would be helpful. I benefit from the media coverage. If my patients get aware of this bPT through TV reporting, then I can say ‘Yes, I’m a part of it, too’.” [GP084]
	Bridging the waiting time for traditional psychotherapy	2 (17)	4	Long waiting times for specialized therapeutic care are a burden for the patient. Short-term bPT for depression can be used while patients wait for the start of a long-term traditional therapy. It helps to prevent the deterioration of symptoms	“I wonder if I should refer my patient first to your bPT short-term treatment and hope it will help, or should I choose a referral to a long-term psychotherapy with long waiting lists. I have to admit, I sometimes did both.” [GP026]

^aGP: general practitioner.

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

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

^dbPT: blended psychotherapy.