Original Investigation
November 2015

Shared Decision Making for Antidepressants in Primary CareA Cluster Randomized Trial

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

Copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2015;175(11):1761-1770. doi:10.1001/jamainternmed.2015.5214

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