Depression decision support in primary care: a cluster randomized trial.
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.


METHODS
Clinician-level, cluster randomized, controlled trial.


METHODS
5 primary care clinics of 1 Veterans Affairs medical center.


METHODS
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 > or = 1.0).


METHODS
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.


METHODS
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).


CONCLUSIONS
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.
Dobscha
Steven K
SK
Portland Veterans Affairs Medical Center, Oregon Health & Science University, and Oregon State University, Portland, Oregon 97207, USA. steven.dobscha@va.gov
Corson
Kathryn
K
Hickam
David H
DH
Perrin
Nancy A
NA
Kraemer
Dale F
DF
Gerrity
Martha S
MS
D000328:Adult; D000368:Aged; D003863:Depression / Q000628:therapy*; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D005791:Patient Care / Q000592:standards; D010348:Patient Care Team; D017060:Patient Satisfaction; D011320:Primary Health Care / Q000379:methods* / Q000592:standards*; D016896:Treatment Outcome