FROM JAMA INTERNAL MEDICINE
A new tool, the Depression Medication Choice decision aid, helped adults with moderate to severe depression and their primary care physicians choose appropriate medications together, according to a report published online Sept. 28 in JAMA Internal Medicine.
Researchers developed the Depression Medication Choice (DMC) tool to enhance patient involvement in the decision-making process, in the hope that taking their preferences and circumstances into account would improve adherence and stave off premature discontinuation of antidepressants. The investigators then performed a cluster-randomized trial to assess the usefulness of the decision aid in real-world practice, said Annie LeBlanc, Ph.D., of the Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester ,Minn.
The study involved 297 adults treated during a 2-year period by 117 clinicians in 10 rural, urban, and suburban private practices across Minnesota and Wisconsin. These demographically diverse patients had moderate to severe depression as measured by scores of 10 or higher on the Patent Health Questionnaire–9 and were considering antidepressant therapy. They were randomly assigned to clinicians who chose antidepressant therapy in the usual manner (139 patients in the control group) or to clinicians who used the DMC to choose antidepressant therapy together (158 patients in the intervention group).
The DMC tool comprised several laminated 10-by-25-cm cards that presented general information about antidepressant efficacy and adverse effects “in terms that matter to patients: weight change, sleep, libido, discontinuation, and cost,” as well as a leaflet for patients to take home, Dr. LeBlanc and her associates wrote.
Participating clinicians received training in using these cards to prompt discussion during a regular office consultation. Use of the decision aid did not add to the duration of office visits, which is key to routine implementation, the investigators said.
At 3- and 6-month follow-up, patients in the intervention group reported significantly greater comfort with the choice of antidepressant, with a mean difference between the two study groups of 5.3 out of a possible 100 points on a “comfort” scale. Patients in the intervention group also were more knowledgeable about antidepressants (OR, 9.5) and satisfied with their health care (RR, 1.25-2.40), compared with the control group.
Clinicians also were more comfortable with treatment decisions, with a mean difference between the two study groups of 11.4 out of 100 possible points. And clinicians who used the DMC tool reported being more satisfied with the decision-making process (RR, 1.64).
However, there were no significant differences between patients in the two groups regarding control of depression symptoms, remission rate, or rate of response to treatment, as measured by mean PHQ-9 scores. There also was no significant difference in medication adherence. Since most of the clinicians in this study used the DMC tool with very few patients, “it is possible that our trial underestimates the efficacy of the decision aid when used repeatedly and expertly,” Dr. LeBlanc and her associates noted (JAMA Intern Med. 2015 Sep 28. doi: 10.10001/jamainternmed.2015.5214 ).
“Policy makers will have to decide whether the value of decision aids as promoters of patient-centered care and informed patient engagement, as demonstrated in this trial, argue on their own merit for priority,” they noted.