0
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.
Text Size: A A A
Published online

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

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

Figures

Place holder to copy figure label and caption
Figure.
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.

Graphic Jump Location

Tables

References

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles
Jobs
brightcove.createExperiences();