Abstract
BackgroundDepression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients’ reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Both targeted and tailored communication strategies offer promise for fomenting discussion and reducing barriers to appropriate initial treatment of depression.Methods/designThe Activating Messages to Enhance Primary Care Practice (AMEP2) Study is a stratified randomized controlled trial comparing two computerized multimedia patient interventions --- one targeted (to patient gender and income level) and one tailored (to level of depressive symptoms, visit agenda, treatment preferences, depression causal attributions, communication self-efficacy and stigma)--- and an attention control. AMEP2 consists of two linked sub-studies, one focusing on patients with significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] scores ≥ 5), the other on patients with few or no depressive symptoms (PHQ-9 < 5). The first sub-study examined effectiveness of the interventions; key outcomes included delivery of components of initial depression care (antidepressant prescription or mental health referral). The second sub-study tracked potential hazards (clinical distraction and overtreatment). A telephone interview screening procedure assessed patients for eligibility and oversampled patients with significant depressive symptoms. Sampled, consenting patients used computers to answer survey questions, be randomized, and view assigned interventions just before scheduled primary care office visits. Patient surveys were also collected immediately post-visit and 12 weeks later. Physicians completed brief reporting forms after each patient’s index visit. Additional data were obtained from medical record abstraction and visit audio recordings. Of 6,191 patients assessed, 867 were randomized and included in analysis, with 559 in the first sub-study and 308 in the second.DiscussionBased on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians. Our computer-based enrollment and randomization procedures ensured that randomization was fully concealed and data missingness minimized. Analyses will focus on the interventions’ potential benefits among depressed persons, and the potential hazards among the non-depressed.Trial registrationClinicialTrials.gov Identifier: http://NCT01144104
Highlights
Depression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated
Based on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians
Silence in the face of depression can be an effective way of avoiding stigmatization and its consequences, including social rejection, overt discrimination, and personal shame [26,27,28,29]. Some groups, such as AfricanAmericans, Latinos, and men, are less likely than others to seek care for depression, due in part to such factors as greater perceived stigma and poorer access to high quality health care [25,30,31,32,33,34,35,36,37,38,39,40]. To address these primary care barriers to patient discussion of and initial acceptance of treatment for depression, we developed two alternative communication interventions designed for use by primary care practices [41,42,43,44]
Summary
Depression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients’ reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Silence in the face of depression can be an effective way of avoiding stigmatization and its consequences, including social rejection, overt discrimination, and personal shame [26,27,28,29] Some groups, such as AfricanAmericans, Latinos, and men, are less likely than others to seek care for depression, due in part to such factors as greater perceived stigma and poorer access to high quality health care [25,30,31,32,33,34,35,36,37,38,39,40]
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