title: Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).
  
  
  METHODS
  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
  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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01144104.
authors.affiliation: Division of General Medicine, University of California at Davis, Sacramento2Center for Healthcare Policy and Research, University of California at Davis, Sacramento.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Kravitz
authors.forename: Peter
authors.initials: P
authors.lastname: Franks
authors.forename: Mitchell D
authors.initials: MD
authors.lastname: Feldman
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Tancredi
authors.forename: Christina A
authors.initials: CA
authors.lastname: Slee
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Epstein
authors.forename: Paul R
authors.initials: PR
authors.lastname: Duberstein
authors.forename: Robert A
authors.initials: RA
authors.lastname: Bell
authors.forename: Maga
authors.initials: M
authors.lastname: Jackson-Triche
authors.forename: Debora A
authors.initials: DA
authors.lastname: Paterniti
authors.forename: Camille
authors.initials: C
authors.lastname: Cipri
authors.forename: Ana-Maria
authors.initials: AM
authors.lastname: Iosif
authors.forename: Sarah
authors.initials: S
authors.lastname: Olson
authors.forename: Steven
authors.initials: S
authors.lastname: Kelly-Reif
authors.forename: Andrew
authors.initials: A
authors.lastname: Hudnut
authors.forename: Simon
authors.initials: S
authors.lastname: Dvorak
authors.forename: Charles
authors.initials: C
authors.lastname: Turner
authors.forename: Anthony
authors.initials: A
authors.lastname: Jerant
mesh_terms: D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D003142:Communication; D003863:Depression / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D019212:Multimedia; D010817:Physician-Patient Relations; D011320:Primary Health Care; D012017:Referral and Consultation; D012737:Sex Factors; D012984:Software; D013813:Therapy, Computer-Assisted; D014741:Video Recording
chemical_list: D000928:Antidepressive Agents