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Original Investigation |

Shared Decision Making for Antidepressants in Primary Care A Cluster Randomized Trial

Annie LeBlanc, PhD1,2,3; Jeph Herrin, PhD4,5; Mark D. Williams, MD6; Jonathan W. Inselman7; Megan E. Branda, MSc7; Nilay D. Shah, PhD1,2; Emma M. Heim2; Sara R. Dick, MSc2; Mark Linzer, MD8; Deborah H. Boehm, MPH8; Kristen M. Dall-Winther, MD9; Marc R. Matthews, MD10; Kathleen J. Yost, PhD1; Kathryn K. Shepel11; Victor M. Montori, MD2,12
[+] Author Affiliations
1Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
3Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
4Yale University School of Medicine, New Haven, Connecticut
5Health Research & Educational Trust, Chicago, Illinois
6Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
7Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
8Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
9Department of Family Medicine, Mayo Clinic Health Systems-Franciscan Healthcare, La Crosse, Wisconsin
10Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
11Media Support Services Division, Mayo Clinic, Rochester, Minnesota
12Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2015;175(11):1761-1770. doi:10.1001/jamainternmed.2015.5214.
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Importance  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.

Design, Setting, and Participants  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.

Intervention  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.

Main Outcomes and Measures  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 and Relevance  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.

Trial Registration  clinicaltrials.gov Identifier: NCT01502891

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Figure 1.
Series of 10.16 × 25.40-cm Depression Medication Choice Laminated Cards
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Figure 2.
Flowchart of Participants
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Submit a Comment
Serendipitous finding not discussed by authors
Posted on October 1, 2015
Timothy Spruill
Florida Hospital Family Medicine Residency
Conflict of Interest: None Declared
What I found fascinating about the article is the decision tool starts by answering the \"Will this medication work for me?\" By stating as a fact that \"6 out of 10 people will feel better (indicating some positive response) with the first antidepressant they try\". Although the authors did not mention it, their data indicated that after 3 months only 32% of the total sample of 298 subjects showed any positive response (which is consistent with the placebo effect) and even more interesting--after 6 months the number dropped slightly to 31%. While this slight drop is obviously not statistically significant, one would hope for a measureable if not significant improvement in outcome after six months. When it comes to remission which is harder to achieve but is most desirable, at 3 months 19% were in remission and then at 6 months the percentage dropped slightly to 18%, failing once again to show improved outcome over time. So, the data actually shows that only 3/10 instead of 6/10 get a positive response (one that is comparable to placebo) after being placed on any of the 12 medications included. One serendipitous conclusion appears to be consistent with that of numerous researchers that SSRI's fail to improve upon outcomes produced by placebos. It would have been interesting to see the results had the authors included a placebo arm though I understand that the original intent of the study did not require one.
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