Table 2.

Summary of recommendations to improve care pathways for people with depression.

Treatment gap addressed		Summary of recommendation
Enhance detection/pathway entry	1a	Improved information provision to patients and those around them—how to seek help and what to expect. Should be multidomain (e.g., Internet, in care settings, other public domain, workplace, and education).
	1b	Increased service availability (GP appointment number and flexibility in terms of timing and format).
	1c	Increased duration of appointments, to maximize likelihood of depression screening. Also applies to follow-up meetings to ensure ascertainment of tolerability, adherence, and effectiveness of treatments.
	1d	Integrate self-management e-mental health tools with healthcare practice.
Improve treatment provision	2a	Development and evidence support for computerized decision-support tools to support treatment selection in line with guidelines.
	2b	Tools for robust information provision to patients about benefits and harms of different treatments. Ideally verbal discussion, otherwise, for example, (e)leaflet or in self-management tool. Must be clear, detailed, and evidence-based.
	2c	Practical information provision about psychological therapy options (different types, waiting lists, and costs).
	2d	Although 2b and 2c can inform patient preference, clinicians to encourage and enable treatment selection as per patient preference (requires additional resources for expanding treatment options).
	2e	Removal of barriers for patients to access more time intensive treatments where indicated (e.g., legal and cultural facilitation for time out of work/education).
	2f	Prescribing support tools, integrated with electronic health records to increase efficiency, and accurate detection of, for example, contraindications to treatment.
	2g	Increased provision of different psychological therapies (where appropriately evidenced)—ensuring appropriate trained therapists, appropriate dose/duration, cost, and provision of transition after completion.
	2h	Shared-care arrangements, for example, psychiatrists design procedures for nursing/pharmacy staff to follow with patients to manage treatment initiation (e.g., suitability, prescription, and titration).
	2i	Adding mental health workers (e.g., nurses) to primary care, for wider support to physicians, for example, psychoeducation and side effects monitoring.
Continuity of care/follow-up after treatment	3a	Optimize self-management tools, to support patients in managing their condition, for example, monitoring symptoms, side effects, and adherence, and/or accessing psychoeducation and advice.
	3b	Utilization of e-tools for healthcare practitioners to monitor patients’ self-rated symptoms/side effects and indicate need for increased or reduced follow-up appointments after treatment initiation.
	3c	Standardized assessment of symptoms and side effects by clinicians to better monitor response and tolerability (measurement-based care), with this encouraged but not mandated as a target-based exercise.
	3d	Screen for risk factors to indicate if more (or less) follow-up needed, for example, polypharmacy, history of recurrent or treatment-resistant depression, risk for bipolar or suicidality, and history of low treatment adherence.
	3e	Automatic appointment scheduling and reminders at suitable intervals after new treatment initiation.
	3f	Increased service provision (number and flexibility of appointments) to ensure adequate monitoring as above.
	3g	Further provision of electronic appointments (e.g., video and app) to increase ongoing care access. Must not replace overall increased resource but permit patients and clinicians to choose between electronic and face-to-face.
Access to specialist care a	4a	Enhanced training programs for primary care physicians to obtain mental health specialist expertise. This is (a) to support people who will not reach secondary care (not replace secondary care) and (b) not to be a wide outreach program as it is considered important that overall GPs remain generalists who are adept across the health spectrum.
	4b	Integrate psychiatrists into primary care, to support GPs and with similar aims as above.
	4c	Equip GPs with increase knowledge of which patients should be referred into secondary mental health care services, and at which stage (see also 4d).
	4d	Service reforms to enable patients’ referrals to secondary care accepted (at present refusals are common despite meeting criteria as specified in guidelines, that is, nonresponse to two antidepressants).
	4e	Enhance training programs for doctors into psychiatry (to increase provision in secondary care services).
	4f	Enhance education programs to train psychiatrists and other secondary care practitioners to achieve specialism in mood disorders.
	4g	Implement systems to improve transition for people after discharge from secondary care (e.g., joint working between psychiatric and general physicians, and occasional follow-ups in secondary care after discharge).
	4h	Process for specialist services to establish structured long-term management/follow-up plan for all individuals (incorporating any comorbidities, social support, coping strategies, active involvement of people close to the patient, etc.) to ensure patients do not “fall through the cracks” in the long term.
	4i	Early screening for patients at risk of needing specialist treatment earlier in care pathways (e.g., history of treatment resistance or risk for bipolar disorder).
	4j	Resource input to create more specialist mood disorders centers.

Abbreviation: GP, general practitioner.

^aApplies to both secondary and tertiary care, and although most of these items refer specifically to secondary care, these can also apply to secondary care.