Controlled trial of the impact of a BC adult mental health practice support program (AMHPSP) on primary health care professionals' management of depression

Abstract

Background: Depression affects over 400 million people globally. The majority are seen in primary care. Barriers in providing adequate care are not solely related to physicians' knowledge/skills deficits, but also time constraints, lack of confidence/avoidance, which need to be addressed in mental health-care redesign. We hypothesized that family physician (FP) training in the Adult Mental Health Practice Support Program (AMHPSP) would lead to greater improvements in patient depressive symptom ratings (a priori primary outcome) compared to treatment as usual.

Methods: From October 2013 to May 2015, in a controlled trial 77 FP practices were stratified on the total number of physicians/practice as well as urban/rural setting, and randomized to the British Columbia AMHPSP⎯a multi-component contact-based training to enhance FPs' comfort/skills in treating mild-moderate depression (intervention), or no training (control) by an investigator not operationally involved in the trial. FPs with a valid license to practice in NS were eligible. FPs from both groups were asked to identify 3-4 consecutive patients > 18 years old, diagnosis of depression, Patient Health Questionnaire (PHQ-9) score ≥ 10, able to read English, intact cognitive functioning.

Exclusion criteria: antidepressants within 5 weeks and psychotherapy within 3 months of enrollment, and clinically judged urgent/emergent medical/psychiatric condition. Patients were assigned to the same arm as their physician. Thirty-six practices recruited patients (intervention n = 23; control n = 13). The study was prematurely terminated at 6 months of enrollment start-date due to concomitant primary health-care transformation by health-system leaders which resulted in increased in-office demands, and recruitment failure. We used the PHQ-9 to assess between-group differences at baseline, 1, 2, 3, and 6 months follow-up. Outcome collectors and assessors were blind to group assignment.

Results: One hundred-and-twenty-nine patients (intervention n = 72; control n = 57) were analysed. A significant improvement in depression scores among intervention group patients emerged between 3 and 6 months, time by treatment interaction, likelihood ratio test (LR) chi2(3) = 7.96, p = .047.

Conclusions: This novel skill-based program shows promise in translating increased FP comfort and skills managing depressed patients into improved patient clinical outcomes⎯even in absence of mental health specialists availability.

Trial registration: #NCT01975948 .

Keywords: Depressive disorders; Mental disorders; Patient-centered outcomes; Primary care; Skill-based training.

Fig. 1

Participant Flow Diagram: Allocations, Attrition

Fig. 2

Between-group mean differences of PHQ-9 scores, group-by-time interaction