Does using a clinical prediction tool to triage and tailor treatment improve outcomes for patients with depressive symptoms? Results of the Target-D randomised controlled trial

Conference:

SAPC ASM 2019 - Exeter

Talk Code:

6B.2

Presenter:

Jane Gunn

Twitter:

@GunnJane

Co-authors:

Jane Gunn, Susan Fletcher, Caroline Wachtler, Sandra Davidson, Cathrine Mihalopoulos, Victoria Palmer, Kelsey Hegarty, Amy Coe, Elizabeth Murray, Christopher Dowrick, Gavin Andrews and Patty Chondros

Author institutions:

University of Melbourne, Karolinska Institutet, Deakin University, University College London, University of Liverpool, University of New South Wales

Problem

About a quarter of primary care patients have depressive symptoms. This heterogeneous group spans mild symptoms which may spontaneously remit, to severe symptoms needing complex treatment approaches. Stepped care approaches are recommended but few tools exist to assist GPs target depression management to individual need. We have developed a Clinical Prediction Tool (the diamond CPT) to address this gap. The diamond CPT predicts depressive symptom severity at three months and classifies individuals into three groups (mild, moderate, severe). This study aimed to test whether embedding the CPT in an online platform, to triage individuals with depressive symptoms into symptom severity-appropriate treatment, reduces depressive symptoms at three months compared with usual care.

Approach

Adult patients attending general practices in Victoria, Australia were invited to participate in this stratified individually randomised controlled trial. After eligibility screening and informed consent, all participants completed the diamond CPT on a purpose-built online platform which included a randomisation function. The comparison arm received usual care plus attention control (asked for feedback on research in primary care and their approach to managing emotional health and wellbeing). The intervention arm received feedback on their CPT responses, were asked to set priorities and reflect on their motivation to change, and given an evidence-based treatment recommendation matched to their predicted depressive symptom severity. Participants in the mild group were recommended online self-help, those in the moderate group received a referral to guided online cognitive behavioural therapy, and those in the severe symptom group were offered nurse-led collaborative care. The presentation of feedback and treatment recommendations, and the collaborative care intervention, were informed by principles of motivational interviewing. Follow up assessments were completed online at 3 and 12 months. The primary outcome was depression severity at 3 months, measured on the Patient Health Questionnaire-9. Secondary outcomes included quality of life (Assessment of Quality of Life scale), anxiety (Generalised Anxiety Disorder scale), self-efficacy (Mental Health Self-Efficacy Scale), and health service use (Resource Use Questionnaire). Parallel process and economic evaluations were also conducted (to be reported separately).

Findings

We recruited 1868 patients from 14 general practice waiting rooms, with retention of 70% and 66% at 3 and 12 months respectively. Intention-to-treat analyses commence in March 2019. Between-arm differences in outcomes will be estimated using linear mixed-effects models. Differences between study arms overall and stratified by symptom severity groups will be presented. Results will be reported for the first time in this presentation.

Consequences

This is the first prognosis-based stratification system for depression management in primary care. Our findings will inform whether the implementation of the Target-D model of depression care into routine practice could reduce unnecessary treatment burden and improve allocation of treatment resources.

Submitted by:

Susie Fletcher

Funding acknowledgement:

Target-D is funded by a grant from the National Health and Medical Research Council (NHMRC) (ID: 1059863)