The mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically.

Retrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841–69,413 primary care patients.

Substantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1–85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4–0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4–0.8]). More patients were referred to psychologists and psychiatrists.

We found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels.

To describe the service use and clinical outcomes associated with the implementation of a complex intervention designed to improve care for people with depression in a primary care setting.

Health systems have limited capacity to provide appropriate psychological and pharmacological treatments for people with depression. Guidance on the treatment of depression in primary care in the United Kingdom was clarified by the National Institute for Clinical Excellence in 2004. However, there is little evidence so far of substantial changes in practice: antidepressant prescriptions continue to rise, there is limited access to psychological therapies and uncertainty persists about who should be treated for what and how. Although the welfare of staff is critical to their therapeutic engagement with patients, this is rarely an explicit focus of health systems design.

An observational study examining the implementation of a complex intervention to improve depression care called ‘Doing Well’, based in 14 general practices in a mixed urban-rural area in Scotland, United Kingdom. A small team of clinicians implemented a programme for people with low mood, depression and adjustment disorder, based on primary care. This programme incorporated a number of changes in standard mental health care, including the following: no ‘severity threshold’ for referral to secondary care; routine use of an objective measure of depression severity with continuous outcome monitoring; prompt access to guided self-help; prompt ‘step-up’ care to more formal psychological therapy or medical care, if indicated; and careful attention to staff training and satisfaction.

There was good fidelity to the model of care designed by the programme. There was a high demand for the new service (1.8% of the catchment population each year) but the programme had the capacity to manage this adequately. Clinical outcomes were satisfactory, and antidepressant use adhered to the guidelines.