Depression Decision Support in Primary Care: A Cluster Randomized Trial

  1. Steven K. Dobscha, MD;
  2. Kathryn Corson, PhD;
  3. David H. Hickam, MD, MPH;
  4. Nancy A. Perrin, PhD;
  5. Dale F. Kraemer, PhD; and
  6. Martha S. Gerrity, MD, PhD
  1. From Portland Veterans Affairs Medical Center, Oregon Health & Science University, and Oregon State University, Portland, Oregon.

    Abstract

    Background: Intensive collaborative interventions improve depression outcomes, but the benefit of less intensive interventions is not clear.

    Objective: To determine whether decision support improves outcomes for patients with depression.

    Design: Clinician-level, cluster randomized, controlled trial.

    Setting: 5 primary care clinics of 1 Veterans Affairs medical center.

    Participants: 41 primary care clinicians, and 375 patients with depression (Patient Health Questionnaire [PHQ-9] depression scores of 10 to 25 or Hopkins Symptom Checklist-20 [SCL-20] scores ≥ 1.0).

    Measurements: The primary outcome was change in depression score (SCL-20) at 6 and 12 months. Secondary outcomes were health-related quality-of-life (36-item Short Form for Veterans [SF-36V] score), patient satisfaction, antidepressant use, and health care utilization.

    Intervention: Clinicians received depression education and were randomly assigned to depression decision support or usual care. The depression decision support team, which consisted of a psychiatrist and nurse, provided 1 early patient educational contact and depression monitoring with feedback to clinicians over 12 months.

    Results: Although SCL-20 depression scores improved in both groups, the intervention had no effect compared with usual care. The difference in slopes comparing intervention and control over 12 months was 0.20 (95% CI, −0.37 to 0.78; P = 0.49), which was neither clinically nor statistically significant. Changes in SF-36V scores also did not differ between groups. At 12 months, intervention patients reported greater satisfaction (P = 0.002) and were more likely to have had at least 1 mental health specialty appointment (41.1% vs. 27.2%; P = 0.025), to have received any antidepressant (79.3% vs. 69.3%; P = 0.041), and to have received antidepressants for 90 days or more (76.2% vs. 61.6%; P = 0.008).

    Limitations: Usual care clinicians received depression education and had on-site mental health support, which may have mitigated intervention effectiveness.

    Conclusions: Decision support improved processes of care but not depression outcomes. More intensive care management or specialty treatment may be needed to improve depression outcomes.

    Article and Author Information

    • Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect those of the U.S. Department of Veterans Affairs.

    • Acknowledgments: The authors thank Ginger Hanson, MS, for assistance with statistical analysis; Megan Crutchfield, BS, and Marsha W. Perkett, BA, for assistance with chart review; and the Portland Veterans Affairs Medical Center's primary care clinicians and staff whose participation made this study possible.

    • Grant Support: By the VA Health Services Research & Development Service (Project Mental Health Initiative [MHI 20-020]).

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Steven K. Dobscha, MD, Portland Veterans Affairs Medical Center, PO Box 1034 (P3MHDC), Portland, OR 97207; e-mail, steven.dobscha{at}va.gov.

    • Current Author Addresses: Dr. Dobscha: Portland Veterans Affairs Medical Center, PO Box 1034 (P3MHDC), Portland, OR 97207.

    • Drs. Corson, Hickam, and Gerrity: Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97239.

    • Dr. Perrin: Oregon Health & Science University, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239.

    • Dr. Kraemer: Oregon State University, 840 SW Gaines, MC GH212, Portland, OR 97239-2985.

    • Author Contributions: Conception and design: S.K. Dobscha, D.H. Hickam, D.F. Kraemer, M.S. Gerrity.

    • Analysis and interpretation of the data: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.

    • Drafting of the article: S.K. Dobscha, K. Corson, D.H. Hickam, D.F. Kraemer, M.S. Gerrity.

    • Critical revision of the article for important intellectual content: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.

    • Final approval of the article: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.

    • Provision of study materials or patients: S.K. Dobscha.

    • Statistical expertise: K. Corson, N.A. Perrin, D.F. Kraemer.

    • Obtaining of funding: S.K. Dobscha, D.H. Hickam, M.S. Gerrity.

    • Administrative, technical, or logistic support: K. Corson.

    • Collection and assembly of data: S.K. Dobscha, K. Corson.

    Summary for Patients

    • Summaries for Patients:Decision Support in Primary Care and Depression Outcomes Ann Intern Med October 3, 2006 145:I-10
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    1. Ann Intern Med October 3, 2006 vol. 145 no. 7 477-487
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