Primary Care Patients With Depression for Internet-Based Social Support

Our specific aim is to develop and pilot test two interventions that lead to at least 30% of
individuals with depression presenting to primary care engaging with an Internet-based
depression support group. We will identify primary care patients with depression who state
they have access to the Internet and are willing to consider treatment or are currently in
treatment for depression. In the primary care office they will be given one of three
interventions introducing them to the Internet depression support group site. Patients will
be randomized to three experimental groups: 1) simple card with only the name of the web
address; 2) 8"x11" paper with screen shots of the Internet site home page, a list of
features provided by the site, and two patient stories describing how the Internet site
helped them; and 3) the 8"x11" announcement (from intervention 2) plus endorsement of the
site by the primary care provider. The last two interventions will also ask patients to
provide an email address so one email reminder can be sent to them. The major outcome will
be accessing the depression Internet support group at least once in the following four
weeks.

The results of this study will provide important information on whether it is possible to
recruit a substantial proportion of primary care patients to engage in a potentially useful
and inexpensive addition to standard depression care. If this is not possible, the
likelihood of successfully completing a RCT of the effectiveness of depression Internet
support groups utilizing primary care patients would be low. Researchers trying to assess
the effectiveness of depression Internet support groups would have to go to alternative
designs such as recruiting patients with depression as they try to join the depression
Internet support groups and randomizing some to a delay in joining the group. We will also
use this study to learn more about what patient characteristics are associated with engaging
with an internet depression support group. While the focus of this study is Psychobabble,
the intent of the study is to explore ease of referral, predictors of use and participant
experiences as may relate to the general concept of Internet-based social support.

Specific AIM 1: We believe that participants randomized to the either that 8 x 11" brochure
or the recommendation by the primary care physician will be more likely to visit and use the
site than those who receive only a recommendation card (50% versus 35% versus 10%). We
hypothesize that greater levels of encouragement/recommendation will be associated with
higher levels of internet site usage. A sample size of 225 (N-110 at University of Chicago
and N=115 at Johns Hopkins) will have power of 0.8 to detect the difference between either
the card group or the brochure or physician recommendation group.

Specific Aim 2: We believe that those with higher self-efficacy and greater levels of trust
in their primary care physician will be more likely to visit the site one time. We will
conduct a logistic regression analysis to determine whether base self-efficacy and greater
levels of trust predict use of the internet site after adjusting for group assignment. We
hypothesize that higher levels of self-efficacy and physician trust will be associated with
greater internet site use. Will believe a total N=225 will be sufficient to evaluate the
relationship between 10 independent variables and the outcome of site usage (<15
cells/variable).

Specific Aim 3: We will determine if an internet based social support group is acceptable
and feasible for primary care patients. Specifically, we will evaluate whether the internet
site increased their knowledge of, or motivation for, depression treatment (Change in level
of agreement to with regard to "accepting my doctors diagnosis of depression", strongly
disagree 1, strongly agree 5). We hypothesize that levels of agreement will increase pre
to post-study. A sample size of 225 (N=110 at University of Chicago and N=115 at Johns
Hopkins) will have power of 0.8 to detect the difference of agree (4) pre-study to (5)
strongly agree post study.

Specific Aim 4: We believe that social support and knowledge gained on the internet may
influence subsequent care seeking or coping behaviors. Specifically, we will evaluate
whether they have sought care or adopted coping skills 6 weeks after study entry. We
hypothesize that both these behaviors will increase from pre to post study. A sample size
of 225 (N=110 at University of Chicago and N=115 at Johns Hopkins) will have power of 0.8 to
detect the difference of treatment participation pre-study of 0.4 versus 0.65 post study.

Specific Aim 5: We believe that social support or knowledge gained on the internet site
leading to changed behaviors may results in lower levels of depressed mood. Specifically, we
will compare levels of depressed mood at baseline and at 6 week follow-up. We hypothesize
that their will be modest decline in depressed mood from pre study baseline to post study. A
sample size of 225 (N=110 at University of Chicago and N=115 at Johns Hopkins) will have
power of 0.8 to detect the difference of treatment participation pre study CES-D score of 24
post study score of 20.

Inclusion Criteria:

1. PHQ score of 8 or above with either depressed mood or anhedonia/and or is considering
treatment for depressed mood,

2. does not reject all treatment for depression,

3. has not viewed or posted messages more than once in the last month on any Internet
depression support group website,

4. does not self-report diagnoses of bipolar disorder by a health professional,

5. age 18 years or older,

6. attends a primary care clinic and have visited in last 6 months, AND

7. has Internet access for the next four weeks, has been on the Internet at least three
times, and has used email by him/herself. We are slightly lowering the PHQ score from
the usual 10 (cutoff for major depression) to 8 because we know treatment for
depression is frequently initiated for those who do not meet formal criteria for
major depression. However we are only including patients with PHQ scores below the
usual cutoff for major depression if they are currently receiving or are considering
some form of depression treatment. University of Chicago students will need to
identify their primary care provider to be enrolled in the study.

Exclusion Criteria:

1. active bipolar disorder,

2. those with no access to the internet,

3. those who state they are not under treatment nor would they consider any form of
treatment, OR

4. those considered to be at high risk of suicide attempts. These include those with
past psychiatric hospitalization, past suicide attempts, bipolar disorder or score of
greater than 1 on the PHQ-9 suicide assessment or who reports intent for self-harm as
per assessment in the suicide prevention protocol.