Psychiatry and Primary Care2A randomized trial of a depression self-care toolkit with or without lay telephone coaching for primary care patients with chronic physical conditions☆,☆☆,★,
Introduction
Depression is a frequent and protracted problem among primary care patients with chronic physical conditions [1]. Self-care (also called self-management or self-help) interventions appear to be an attractive alternative for the management of depression in this population. Indeed, in the UK, self-care interventions are recommended as Step 1 in a stepped care program for treating depression in primary care [2]. Previous trials and meta-analyses suggest that supported (guided) self-care interventions are more effective than unsupported (pure) interventions [3] and may even be as effective as psychological therapies [4]. To date, the incremental effect of coaching has not been estimated by directly comparing a supported to an unsupported intervention. Furthermore, few trials have been conducted in primary care settings where effectiveness may be lower than in volunteer populations [5], and where coaching is often provided by professional staff such as nurses or psychologists whose accessibility may be limited in some settings.
We developed a telephone-supported depression self-care intervention delivered by a trained lay coach for middle-aged and older adults with chronic physical conditions being treated in primary care, and reported on its feasibility [6]. Although patients in the feasibility study found that support from the coach was helpful, half reported that they could have used the tools on their own, without coaching [6]. We therefore modified the depression self-care toolkit (henceforth referred to as the Toolkit) and the coaching intervention to provide greater overall structure as well as guidelines for tailoring the intervention to individual needs. We conducted a randomized controlled trial (RCT) comparing the effectiveness of the Toolkit with versus without lay telephone coaching. We report here the results for: (a) depressive symptoms at 3- and 6-month follow-up); (b) satisfaction, self-efficacy, and use of health services at 6 months; and (c) baseline modifiers of the depressive symptoms outcome.
Section snippets
Design and participants
We conducted a single blind, individually randomized, pragmatic trial of a Toolkit with or without lay telephone coaching among primary care adults with depressive symptoms and comorbid chronic physical conditions. The intervention group received a Toolkit (Table 1) and was offered telephone coaching; the control group received the Toolkit only. The trial protocol was registered [7].
Patient enrolment occurred between March 2012 and May 2013. Prospective participants in primary care settings in
Results
Fig. 1 shows steps in the recruitment and follow-up of participants. Among 1046 patients who screened positive, 597 (57%) were screened for eligibility; the remainder were either no longer interested or could not be reached. After exclusion of 190 noneligible patients, 223 (55%) of 407 eligible patients consented to participate and were randomized, 10 declined participation, and 174 either failed to keep their appointment to meet the RA or did not return a signed consent form. Three-month
Discussion
This trial compared the use of a depression self-care Toolkit with or without lay telephone coaching in a primary care sample of middle-aged and older patients with a variety of chronic physical conditions including chronic pain. We found that PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were small to moderate (effect size of 0.44) and statistically significant at 3 months but smaller
Conclusions
Lay telephone coaching of depression self-care tools may have short-term but not longer-term benefits among middle-aged and older primary care patients with a variety of chronic physical conditions. Strengthening of the coaching intervention and targeting certain subgroups (e.g., those with moderate depressive symptoms) should be investigated. Further research is needed to compare the effectiveness of an uncoached Toolkit to a usual care control group.
References (46)
- et al.
Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9)
J Affect Disord
(2004) - et al.
Practical considerations on the use of the Charlson comorbidity index with administrative data bases
J Clin Epidemiol
(1996) - et al.
A simple imputation algorithm reduced missing data in SF-12 health surveys
J Clin Epidemiol
(2005) - et al.
Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis
Am J Psychiatry
(1999) NICE clinical guidelines 91—depression in adults with a chronic physical health problem: treatment and management
(2009)- et al.
What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression
Psychol Med
(2007) - et al.
Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies
Psychol Med
(2010) - et al.
Psychological treatment of depression in primary care: a meta-analysis
Br J Gen Pract
(2009) - et al.
A feasibility study of a telephone-supported self-care intervention for depression among adults with a co-morbid chronic physical illness in primary care
Ment Health Fam Med
(2012) Effectiveness of a self-care intervention for depression in primary care patients with chronic physical illnesses (DIRECT-sc)
ClinicalTrials.gov
(2012)
Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire
J Am Med Assoc
Depression: the treatment and management of depression in adults
Clinical guideline
Opportunities for cost-effective prevention of late-life depression. An epidemiological approach
Arch Gen Psychiatry
Validation of a short orientation–memory–concentration test of cognitive impairment
Am J Psychiatry
A comparative evaluation of the short orientation memory concentration test of cognitive impairment
J Neurol Neurosurg Psychiatry
Antidepressant Skills Workbook
Behavioural interventions in primary care: an implementation trial
Can J Commun Ment Health
Sortir de l'ombre: vaincre la dépression
Finding a way out of depression
A power primer
Psychol Bull
Les qualités psychométriques de la version canadienne-française du questionnaire de satisfaction du consommateur de services psychothérapeutiques (QSC-8 et QSC-18B) [The Canadian-French version of the Client Satisfaction Questionnaire]
Can J Behav Sci
Supporting autonomy to motivate patients with diabetes for glucose control
Diabetes Care
A 12-item short form health survey: construction of scales and preliminary tests of reliability and validity
Med Care
Monitoring depression treatment outcomes with the Patient Health Questionnaire-9
Med Care
Cited by (25)
Adaptation and outcomes of a lay-guided mental health self-care model: Results of six trials
2023, General Hospital PsychiatryAdaptive web-based stress management programs among adults with a cardiovascular disease: A pilot Sequential Multiple Assignment Randomized Trial (SMART)
2022, Patient Education and CounselingCitation Excerpt :Throughout the study, two female coaches were hired. The coaches were not therapists and did not have expertise in CVDs, but were familiar with the coaching model having worked with the team on previous mental health studies using the same coaching model [61–63]. Website+MI.
Self-management across chronic diseases: Targeting education and support needs
2020, Patient Education and CounselingCitation Excerpt :The Vulnerable group is of particular interest as it represents patients with the greatest need for education and support. As self-efficacy is a robust predictor of adherence to self-management behaviors [24], low self-efficacy is a key indicator of need for self-management skills training [25–27]. On average, the Vulnerable group had a lower education, were more likely to be were disabled from employment, or unemployed.
Self-management support in primary care is associated with improvement in patient activation
2019, Patient Education and CounselingCitation Excerpt :Fewer trials have specifically examined the effects on activation of depression self-management interventions, although there is some evidence that these can increase self-efficacy (a component of activation), at least in the short-term [16–18]. We had the unique opportunity to examine the relationship between perceived self-management support and activation in the context of a randomized trial that compared a lay coach-supported to a self-directed intervention for depression self-management among primary care patients with chronic physical conditions with comorbid depressive symptoms [18]. We have reported previously that both the coached and the self-directed intervention were associated with similar 6-month increases in activation [17].
Development and validation of subscales to assess perceived support for self-management of mood or emotional problems: Results from a randomized trial
2017, Patient Education and CounselingCitation Excerpt :After the first two sessions in which the Toolkit was introduced and participants were encouraged to try the three core tools, participants were offered short (∼10 min) weekly calls for up to three months, followed by monthly calls up to six months. Completion of at least the first 2 calls was considered receipt of coaching intervention [13]. Family physicians of consenting participants were asked to provide usual care.
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Conflict of interest: None.
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Funding: This research was funded under a grant from the Fonds de la recherche du Québec–Santé (FRQ-S), 2009–2016.
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Author contributions: Cole and McCusker: conception and design, obtaining funding, acquisition of data, analysis and interpretation of data, and drafting of manuscript. Yaffe: conception and design, obtaining funding, acquisition of data, and drafting of manuscript. Sussman: conception and design, obtaining funding, analysis of qualitative data, and drafting of manuscript. Sewitch, Strumpf, and Lavoie: conception and design, obtaining funding, and drafting of manuscript. Ciampi and Belzile: conception and design, obtaining funding, analysis and interpretation of data, and drafting of manuscript. Platt: analysis and interpretation of data, and drafting of manuscript.
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Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Jürgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.