title: Shared Decision Making for Antidepressants in Primary Care: A Cluster Randomized Trial.
abstract: OBJECTIVE
  For antidepressants, the translation of evidence of comparative effectiveness into practice is suboptimal. This deficit directly affects outcomes and quality of care for patients with depression. To overcome this problem, we developed the Depression Medication Choice (DMC) encounter decision aid, designed to help patients and clinicians consider the available antidepressants and the extent to which they improved depression and other issues important to patients.
  
  
  OBJECTIVE
  Estimate the effect of DMC on quality of the decision-making process and depression outcomes.
  
  
  METHODS
  We conducted a cluster randomized trial of adults with moderate to severe depression considering treatment with an antidepressant. Primary care practices in 10 rural, suburban, and urban primary care practices across Minnesota and Wisconsin were randomly allocated to treatment of depression with or without use of the DMC decision aid.
  
  
  METHODS
  Depression Medication Choice, a series of cards, each highlighting the effect of the available options on an issue of importance to patients for use during face-to-face consultations.
  
  
  METHODS
  Decision-making quality as judged by patient knowledge and involvement in decision making, patient and clinician decisional comfort (Decisional Conflict Scale) and satisfaction, encounter duration, medication adherence, depression symptoms, and the Patient Health Questionnaire for depression (PHQ-9).
  
  
  RESULTS
  We enrolled 117 clinicians and 301 patients (67% women; mean [SD] age, 44 [15] years; mean [SD] PHQ-9 score, 15 [4]) into the trial. Compared with usual care (UC), use of DMC significantly improved patients' decisional comfort (DMC, 80% vs UC, 75%; P = .02), knowledge (DMC, 65% vs UC, 56%; P = .03), satisfaction (risk ratio [RR], from 1.25 [P = .81] to RR, 2.4 [P = .002] depending on satisfaction domain), and involvement (DMC, 47% vs UC, 33%; P<.001). It also improved clinicians' decisional comfort (DMC, 80% vs UC, 68%; P < .001) and satisfaction (RR, 1.64; P = .02). There were no differences in encounter duration, medication adherence, or improvement of depression control between arms.
  
  
  CONCLUSIONS
  The DMC decision aid helped primary care clinicians and patients with moderate to severe depression select antidepressants together, improving the decision-making process without extending the visit. On the other hand, DMC had no discernible effect on medication adherence or depression outcomes. By translating comparative effectiveness into patient-centered care, use of DMC improved the quality of primary care for patients with depression.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01502891.
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Robert D. and Patricia E. Kern Mayo Clinic Center for the Scie.
authors.forename: Annie
authors.initials: A
authors.lastname: LeBlanc
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut5Health Research & Educational Trust, Chicago, Illinois.
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.affiliation: Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Williams
authors.affiliation: Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Inselman
authors.affiliation: Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
authors.forename: Megan E
authors.initials: ME
authors.lastname: Branda
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota.
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
authors.affiliation: Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota.
authors.forename: Emma M
authors.initials: EM
authors.lastname: Heim
authors.affiliation: Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota.
authors.forename: Sara R
authors.initials: SR
authors.lastname: Dick
authors.affiliation: Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota.
authors.forename: Mark
authors.initials: M
authors.lastname: Linzer
authors.affiliation: Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota.
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Boehm
authors.affiliation: Department of Family Medicine, Mayo Clinic Health Systems-Franciscan Healthcare, La Crosse, Wisconsin.
authors.forename: Kristen M
authors.initials: KM
authors.lastname: Dall-Winther
authors.affiliation: Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Marc R
authors.initials: MR
authors.lastname: Matthews
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
authors.forename: Kathleen J
authors.initials: KJ
authors.lastname: Yost
authors.affiliation: Media Support Services Division, Mayo Clinic, Rochester, Minnesota.
authors.forename: Kathryn K
authors.initials: KK
authors.lastname: Shepel
authors.affiliation: Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota12Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use*; D002755:Choice Behavior; D016000:Cluster Analysis; D057186:Comparative Effectiveness Research; D003657:Decision Making; D003661:Decision Support Techniques; D003863:Depression / Q000175:diagnosis / Q000188:drug therapy* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D008875:Middle Aged; D008910:Minnesota; D017063:Outcome Assessment, Health Care; D010358:Patient Participation / Q000523:psychology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data; D011569:Psychiatric Status Rating Scales; D014922:Wisconsin
chemical_list: D000928:Antidepressive Agents