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Motivational Interviews for Depression in Primary Care

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ClinicalTrials.gov Identifier: NCT01114334
Recruitment Status : Completed
First Posted : May 3, 2010
Results First Posted : April 20, 2017
Last Update Posted : June 6, 2018
Sponsor:
Information provided by (Responsible Party):
Denver Health and Hospital Authority

Tracking Information
First Submitted Date  ICMJE April 29, 2010
First Posted Date  ICMJE May 3, 2010
Results First Submitted Date  ICMJE October 17, 2016
Results First Posted Date  ICMJE April 20, 2017
Last Update Posted Date June 6, 2018
Study Start Date  ICMJE April 2010
Actual Primary Completion Date December 2012   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: March 9, 2017)
Depression Remission [ Time Frame: 36 weeks ]
The primary outcome is depression remission ascertained with the Patient Health Questionnaire-9. A score of less than 5 is considered to represent remission. The secondary clinical outcome is the continuous measure of depressive symptoms.
Original Primary Outcome Measures  ICMJE
 (submitted: April 30, 2010)
Depression Remission [ Time Frame: 6, 12 and 36 weeks ]
The primary outcome is depression remission ascertained with the Patient Health Questionnaire-9. A score of less than 5 is considered to represent remission.
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: March 9, 2017)
  • Adherence to Treatment With Antidepressant Medication [ Time Frame: 36 weeks ]
    Antidepressant Adherence will be measured with Computerized Pharmacy Records. Adherence will be operationalized as "non-persistence," or time to discontinuation. Non-persistence will be considered to have occurred if the days of medication supply from the previous prescription plus a 30-day grace period exceed the number of days between the previous prescription date and the current prescription fill date. Filling no prescriptions, 'initiation failure,' will be treated as non-persistence. Minimally adequate persistence was defined as at least three 30-day fills of an antidepressant medication at a usual dose as defined in the American Psychiatric Association guideline without a 30-day gap in refills. The count of participants receiving minimally adequate persistence with antidepressant medication is reported for each study group.
  • Patient Health Questionnaire-9 Instrument for Assessing Depressive Symptoms [ Time Frame: 36 weeks ]
    Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9) instrument. The PHQ-9 is a nine item survey to assess depressive symptoms over the previous 2 weeks. The patient may answer "not at all" (scored as a 0) , "several days" (scored as a 1), "more than half the days" (scored as a 2), or "nearly every day" (scored as a 3) for each item. The range in total scores is from 0 (no depressive symptoms or best outcome) to 27 (severe depressive symptoms or worst outcome). For this randomized trial mean total scores are reported.
Original Secondary Outcome Measures  ICMJE
 (submitted: April 30, 2010)
Adherence to Treatment With Antidepressant Medication [ Time Frame: 6, 12, and 36 weeks ]
Antidepressant Adherence will be measured with Computerized Pharmacy Records. Adherence will be operationalized as "non-persistence," or time to discontinuation. Non-persistence will be considered to have occurred if the days of medication supply from the previous prescription plus a 30-day grace period exceed the number of days between the previous prescription date and the current prescription fill date. Filling no prescriptions, 'initiation failure,' will be treated as non-persistence.
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Motivational Interviews for Depression in Primary Care
Official Title  ICMJE Motivational Interviews Adapted to Improve Depression Treatment in Primary Care
Brief Summary The purpose of the study is to determine whether motivational interviewing with guideline-based medical management for depression will significantly improve time to depression recovery and increase the proportion of subjects in recovery compared to guideline-based medical management alone over 9 months.
Detailed Description

Setting Denver Health is an integrated healthcare system. During the time period that the trial was conducted, 2010 to 2012, Denver Health comprised eight federally qualified community health facilities serving primarily uninsured and Medicaid patients in Denver, Colorado, USA. The mainstay treatment for depression was antidepressant medication only, as access to specialty mental health counseling or psychiatric services was not readily available at the participating primary care facilities during the time frame of the trial.

Randomization and Masking We recruited seven primary care facilities housing 10 independent care teams (clusters). Three facilities had two teams each, and four had one team. Although staff and providers from different facilities and teams attend role-specific training together and may share managers, each team has unique support staff, providers, and patient panels. We used a blocked design to limit the possibility of patients crossing over from a team assigned to one randomization group to one in the other group (contamination). Because of a negative association between minority race/ ethnicity and depression diagnosis and treatment receipt, we stratified the teams by the race/ ethnicity of the respective patient populations at each facility (plurality Hispanic, non-Hispanic black, or non-Hispanic white). Prior to randomization, we blocked eight of 10 teams into four pairs within strata because they: (a) shared the same facility (three facilities with two teams each); or (b) were from closely located neighborhoods (two facilities with one team each).

Outcome assessors who obtained written consent, conducted the baseline depression assessment, and collected clinical outcomes were blinded to cluster allocation and were not involved in other study procedures. Patient participants were blinded to group assignment. Participating providers were not blinded.

Protocol Change Prior to recruiting patients into the intention-to-treat (ITT) groups, we changed the primary outcome at the trial registration site on 4/29/10 from the outcome specified in the original 2008 protocol, "adherence to antidepressant medication", to "remission from depression." However, detecting remission, defined as an event where depressive symptoms fall below a clinically significant level for a prolonged period, entails weekly or bi-weekly outcome assessments (Nierenberg, 2001; Rush et al., 2006). Limited study resources precluded closely spaced outcome assessments over 36 weeks. Therefore, to better understand trajectories of clinical outcome for the primary care patients assigned to teams staffed by providers trained to discuss depression with Motivational Interviewing versus those patients assigned to teams staffed by untrained providers, measures of both continuous depressive symptoms and a binary outcome measure (Patient Health Questionnaire-9 (PHQ-9) score < 5) were calculated for each group at 6, 12, and 36 weeks.

Primary Care Providers In May 2009, the research team emailed 53 providers from 13 primary care teams (eligible clusters) in eight facilities with an invitation to participate in a study of "training for a new counseling method for treating depression." Inclusion criteria included working at least 1.5 days per week in outpatient care, previous experience treating depression, and availability for a one-day baseline MI training on 7/25/09. We obtained consent from providers prior to randomization.

Patients During the recruitment phase, the research team called sequential eligible patients 2 to 3 days prior to scheduled visits with participating providers. The team assessed for initial exclusion criteria and invited those not excluded to complete an audio-recorded partial waiver of consent and stage-I depression screen, the Patient Health Questionnaire-2 (PHQ-2). Prior to the visit, a recruiter met patients scoring 2 or higher on either item of the PHQ-2, described the study, obtained written informed consent, and invited consenting patients to complete the PHQ-9.

Patients were excluded if they were attending a one-time disability qualification examination, had no personal phone, were homeless, were treated for depression with antidepressant medication within the previous 3 months, were currently in therapy provided by a mental health specialist, had impaired memory, had a life-threatening physical disease, expressed severe suicidal ideation, were pregnant or breastfeeding, or exhibited alcohol/ drug dependence, bipolar disorder or current psychosis assessed with a diagnostic schedule.

The recruiter notified the provider and patient prior to the clinical encounter when patients scored 10 or higher on the PHQ-9, signifying 'probable major depression' . A board-certified psychiatrist, blinded to patient allocation, diagnosed depression and determined additional exclusion criteria. Patients diagnosed with a major depressive episode, not excluded for other reasons, and completing a subsequent baseline telephone interview within 8 days, were enrolled as the Intention-To-Treat (ITT) sample.

Intervention - MI with Standard Management of Depression The MI training approach included interactive learning for the core MI skills. An 8-hour classroom training on 7/25/09 consisted of a brief overview of MI, videos and discussion of core MI skills and "MI Spirit," as well as skill-building practice. Providers learned how to use "OARS" and summaries to elicit change talk, how to implement the elicit-provide-elicit technique, and how to craft action plans with patients. Providers practiced using 0-10 Ruler questions to assess and increase patient importance and confidence in changing.

The training was designed according to Arkowitz and Burkes' (2008) recommendation for a three-component framework when using MI to discuss depression. In this framework, the provider first helps explore the patient's negative emotions through reflective listening. Second, the provider uncovers contributors to the negative emotions. Third, the patient's own ideas about how to handle their negative emotions are elicited.

To optimize treatment integrity, 4-hour refresher sessions were offered after 4 and 12 months. Over the first 14 months, feedback was provided via email and face-to face regarding audio-taped encounters (total two to four feedbacks per provider).

Control - Standard Management of Depression Alone All providers randomized to either intervention or to control received a 1-hour slideshow and the "American Psychiatric Association Practice Guideline for the Treatment of Major Depressive Disorder" (APA depression guideline) (2010). The resources recommended antidepressant medications and psychotherapy as evidence-based treatments for depression.

Measurements Baseline Descriptors. In addition to demographics, provider information included training (M.D. versus mid-level) and certification (Family Practitioner, General Internist, Physician's Assistant, or Nurse Practitioner), and years of clinical experience. Patient descriptors included generalized anxiety disorder (past 6 months), federal poverty level, and previous suicidal behavior.

Treatment Variables. Time spent discussing depression at the index visit was assessed from audio-recorded encounters. Two measures of follow-up over 36 weeks, total primary care visits dichotomized at the median and at least three or more visits with documented discussion of mental health were abstracted from the electronic medical record. Receipt of antidepressant medication and specialty mental health counseling was also determined.

Statistical Analysis Missing Data. Total missingness and whether missingness was differential by group or cluster was assessed. Little's likelihood ratio test was used to test the hypothesis that data is Missing Completely at Random (MCAR). To determine plausibility of Missing at Random (MAR), correlations between baseline or auxiliary variables and missingness by group at each time point were calculated.

Prior to performing the ITT analyses, Multiple Imputation through Chained Equations (MICE) was conducted to deal with missing data. The Fully Conditional Specification algorithm in the SAS MI procedure was used to generate 30 imputed datasets. The effects of the intervention on depressive symptoms and on remission were determined on each imputed data set. MI repetition results were combined to generate final estimates of parameters and confidence intervals for depressive symptoms. Rubin's rules were used to combine the parameter estimates and errors into a single set of results.

Treatment Outcomes. Analyses of treatment outcomes were run by ITT. Generalized linear mixed effects models, adjusted for clustering of patients within care team, were used to examine differences in outcomes by randomization group. Whereas randomization was stratified by class (race/ ethnicity), the interaction between class and treatment group as well as class itself were included in all multivariate analyses.

Main Effects. Main outcome analyses were run by ITT utilizing imputed datasets. General linear mixed effects models, or generalized models for a binary outcome, were used to examine whether the group x time interactions for outcomes depressive symptoms and remission were significant. The general linear mixed model assumed unstructured variance-covariance matrices, maximum likelihood (method = ML) estimation, and adjusted for clustering of patients within care teams and repeated measures within patients. Whereas the random effect of clustering patients within care teams on remission in the adjusted model was zero, patients were not clustered within care teams in the generalized model for the binary outcome.

Moderator hypothesis: A hypothesis concerning moderator variables was included in the Colorado Multiple Institutional Review Board (COMIRB) protocol for the trial. In the protocol approved with a COMIRB stamp on 2/3/10, specific aim #2 was "ii. Specific Aim #2: Aim 2 is to explore for moderators and mediators of the effect of AMI-TAD on adherence and outcome. We hypothesize that higher baseline patient self-efficacy will differentially increase the effect of AMI-TAD with SCD." AMI-TAD is an earlier abbreviated name for the the MI training intervention.

Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description:
Cluster Randomized Clinical Trial
Masking: Double (Participant, Outcomes Assessor)
Primary Purpose: Health Services Research
Condition  ICMJE Major Depression
Intervention  ICMJE
  • Behavioral: Guideline-Based Medical Management
    We used the Colorado Clinical Guidelines Collaborative treatment guideline for Major Depression. It recommends treatment options e.g. specialty mental health counseling, antidepressant treatment, physical activity, depending upon presenting symptoms severity and other factors. The assessor notifies the clinician at the baseline visit about the patient's PHQ-9 depressive symptom severity score.
    Other Name: GBMM
  • Behavioral: Motivational Interviewing for Depression
    Intervention providers receive training to utilize Motivational Interviewing to frame discussions around depression, and to improve treatment uptake and treatment adherence for depression. Primary care providers are encouraged to apply MI to a broad conceptualization of 'treatment' including specialty mental health referral, antidepressant treatment, physical activity, and to targeting contributing factors e.g. loss of job or physical health problems.
    Other Name: MI with GBMM
Study Arms  ICMJE
  • Active Comparator: Guideline-based Medical Management

    Manual-based GBMM training will be provided to both intervention and control physicians. A note on the patient's chart will apprise the primary care provider that the patient screened positive for moderate or more severe depressive symptoms, and has agreed to participate in the study.

    The evidence-based algorithm covers medical management of depression including indications for treatment, selection of initial therapy, starting dosages, dose escalation, switching or augmenting treatment, assessing efficacy, treatment goals and duration, a schedule of follow-up visits and referral indications

    Intervention: Behavioral: Guideline-Based Medical Management
  • Experimental: Motivational Interview with GBMM
    Motivational Interviewing for Depression combined with guideline-based medical management for depression
    Interventions:
    • Behavioral: Guideline-Based Medical Management
    • Behavioral: Motivational Interviewing for Depression
Publications * Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Completed
Actual Enrollment  ICMJE
 (submitted: March 9, 2017)
168
Original Estimated Enrollment  ICMJE
 (submitted: April 30, 2010)
160
Actual Study Completion Date  ICMJE December 2012
Actual Primary Completion Date December 2012   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  1. Women and men aged 18 or older presenting at one of the seven DHH study clinics with a new treatment episode for depression will be considered for the study.
  2. The PHQ-9 is used to define depression category with a sensitivity and specificity for MDD of at least 88%. Patients must have PHQ-9≥10 to ensure sufficient severity to warrant intervention.
  3. A new treatment episode is defined as no treatment with an antidepressant medication for emotional problems over the previous 90 days, nor evidence-based psychotherapy for depression.
  4. The subjects must have major depression as determined by diagnostic schedule.

Exclusion Criteria:

  1. Receipt of an antidepressant medication in the previous 90 days other than a low-dose TCA for pain or Trazodone for sleep (e.g. amitriptyline ≤ 50 mg a day or Trazodone ≤ 100 mg at night).
  2. Current interpersonal or cognitive behavioral psychotherapy that focuses on depression.
  3. Female subjects who are either pregnant or nursing.
  4. Subjects with drug or alcohol dependency or abuse (except for nicotine or caffeine) within the preceding 6 months.
  5. High risk for suicide.
  6. Inability to communicate in English.
  7. No personal telephone or homeless.
  8. Lifetime bipolar disorder.
  9. Psychosis.
  10. Subjects with a lifetime history of autism, mental retardation, or pervasive developmental disorders.
  11. Subjects with uncorrected hypothyroidism or hyperthyroidism.
  12. Serious, unstable illnesses including hepatic, renal, gastroenterologic, respiratory, cardiovascular (including ischemic heart disease), endocrinologic, neurologic, immunologic, or hematologic disease.
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE Contact information is only displayed when the study is recruiting subjects
Listed Location Countries  ICMJE United States
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT01114334
Other Study ID Numbers  ICMJE K23MH082997( U.S. NIH Grant/Contract )
Has Data Monitoring Committee Yes
U.S. FDA-regulated Product Not Provided
IPD Sharing Statement  ICMJE
Plan to Share IPD: Undecided
Plan Description: We will be working in the coming year on a plan to share data. We have been able to share data in the past.
Responsible Party Denver Health and Hospital Authority
Study Sponsor  ICMJE Denver Health and Hospital Authority
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Robert D Keeley, MD MSPH Denver Health and University of Colorado, Department of Family Medicine
PRS Account Denver Health and Hospital Authority
Verification Date May 2018

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP