Original Investigation |

Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care:  A Randomized Trial

Richard L. Kravitz, MD, MSPH1,2; Peter Franks, MD2,3; Mitchell D. Feldman, MD, MPhil4; Daniel J. Tancredi, PhD2,5; Christina A. Slee, MPH6; Ronald M. Epstein, MD7,8,9; Paul R. Duberstein, PhD7,8; Robert A. Bell, PhD2,10; Maga Jackson-Triche, MD, MSHS11; Debora A. Paterniti, PhD2,12; Camille Cipri, BS2; Ana-Maria Iosif, PhD13; Sarah Olson, BA4; Steven Kelly-Reif, MD14; Andrew Hudnut, MD15; Simon Dvorak, BA16; Charles Turner, PhD16; Anthony Jerant, MD2,3
[+] Author Affiliations
1Division of General Medicine, University of California at Davis, Sacramento
2Center for Healthcare Policy and Research, University of California at Davis, Sacramento
3Department of Family and Community Medicine, University of California at Davis, Sacramento
4Division of General Internal Medicine, University of California, San Francisco
5Department of Pediatrics, University of California at Davis, Sacramento
6University of California, Davis, Medical Center, Sacramento
7Department of Family Medicine, University of Rochester, Rochester, New York
8Department of Psychiatry, University of Rochester, Rochester, New York
9Department of Oncology, University of Rochester, Rochester, New York
10Department of Communication and Public Health Sciences, University of California at Davis, Davis
11VA Northern California Health Care System, University of California at Davis, Sacramento
12Department of Internal Medicine and Sociology, University of California at Davis, Sacramento
13Department of Public Health Sciences, University of California at Davis, Davis
14The Permanente Medical Group, Sacramento, California
15Sutter Medical Foundation, Sacramento, California
16Information and Educational Technology, Academic Technology Services, University of California at Davis, Davis
JAMA. 2013;310(17):1818-1828. doi:10.1001/jama.2013.280038.
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Importance  Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.

Objective  To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.

Design, Setting, and Participants  Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire–9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.

Interventions  DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).

Main Outcomes and Measures  Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.

Results  Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, −6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, −0.2 (95% CI, −1.2 to 0.8); IMCP vs control, 0.9 (95% CI, −0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, −2.2 [90% CI, −8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, −3.3 [90% CI, −9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control, 0.9 [90% CI, −4.9 to 6.7], P = .23 for noninferiority; IMCP vs control, 0.3 [90% CI, −5.1 to 5.7], P = .16 for noninferiority).

Conclusions and Relevance  A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.

Trial Registration  clinicaltrials.gov Identifier: NCT01144104

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Place holder to copy figure label and caption
Flow of Patients Through Study

PHQ indicates Patient Health Questionnaire; DEV, depression engagement video; IMCP, interactive multimedia computer program.

aIn the depressed cohort, 559 patients were included in the primary analysis; nondepressed cohort, 308 patients.

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