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Open Access Study protocol

Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study

Daniel J Tancredi14*, Christina K Slee2, Anthony Jerant3, Peter Franks3, Jasmine Nettiksimmons4, Camille Cipri4, Dustin Gottfeld4, Julia Huerta4, Mitchell D Feldman5, Maja Jackson-Triche6, Steven Kelly-Reif7, Andrew Hudnut8, Sarah Olson9, Janie Shelton4 and Richard L Kravitz10

Author Affiliations

1 UC Davis Department of Pediatrics and Center for Healthcare Policy and Research, 2103 Stockton Blvd Suite 2224, Sacramento, CA, 95817, USA

2 UCDHS Clinical Affairs, 2315 Stockton Blvd., Sherman Bldg, Suite 1300, Sacramento, CA, 95817, USA

3 UC Davis Department of Family and Community Medicine, 4860 Y Street, Suite 2300, Sacramento, CA, 95817, USA

4 UC Davis Center for Healthcare Policy and Research, 2103 Stockton Blvd Suite 2224, Sacramento, CA, 95817, USA

5 University of California, San Francisco, 1545 Divisadero, Suite 315, San Francisco, CA, 94143-0320, USA

6 VA Northern California Health Care System, UC Davis School of Medicine, 10535 Hospital Way-116, California, Mather, 95655, USA

7 Kaiser-Permanente Northern California, The Permanente Medical Group-Sacramento/Roseville, 2025 Morse Avenue, Sacramento, CA, 95825, USA

8 Sutter Medical Research Institute, 2801 Capitol Avenue, Suite 400, Sacramento, CA, 95816, USA

9 University of California, San Francisco, 530 Parnassus Avenue, Suite 366, San Francisco, CA, 94143, USA

10 UC Davis Division of General Medicine, 4150 V. Street, Suite 2400 PSSB, Sacramento, CA, 95817, USA

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BMC Health Services Research 2013, 13:141  doi:10.1186/1472-6963-13-141

Published: 17 April 2013

Abstract

Background

Depression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients’ reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Both targeted and tailored communication strategies offer promise for fomenting discussion and reducing barriers to appropriate initial treatment of depression.

Methods/design

The Activating Messages to Enhance Primary Care Practice (AMEP2) Study is a stratified randomized controlled trial comparing two computerized multimedia patient interventions --- one targeted (to patient gender and income level) and one tailored (to level of depressive symptoms, visit agenda, treatment preferences, depression causal attributions, communication self-efficacy and stigma)--- and an attention control. AMEP2 consists of two linked sub-studies, one focusing on patients with significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] scores ≥ 5), the other on patients with few or no depressive symptoms (PHQ-9 < 5). The first sub-study examined effectiveness of the interventions; key outcomes included delivery of components of initial depression care (antidepressant prescription or mental health referral). The second sub-study tracked potential hazards (clinical distraction and overtreatment). A telephone interview screening procedure assessed patients for eligibility and oversampled patients with significant depressive symptoms. Sampled, consenting patients used computers to answer survey questions, be randomized, and view assigned interventions just before scheduled primary care office visits. Patient surveys were also collected immediately post-visit and 12 weeks later. Physicians completed brief reporting forms after each patient’s index visit. Additional data were obtained from medical record abstraction and visit audio recordings. Of 6,191 patients assessed, 867 were randomized and included in analysis, with 559 in the first sub-study and 308 in the second.

Discussion

Based on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians. Our computer-based enrollment and randomization procedures ensured that randomization was fully concealed and data missingness minimized. Analyses will focus on the interventions’ potential benefits among depressed persons, and the potential hazards among the non-depressed.

Trial registration

ClinicialTrials.gov Identifier: http://NCT01144104 webcite

Keywords:
Depression; Primary care; Health communication; Tailoring; Targeting; Patient engagement