Shared Decision-Making for Elderly Depressed Primary Care Patients

Shared Decision Making (SDM) may be particularly relevant for depressed individuals, as it
seeks to enhance their autonomy and empowerment in a manner that directly addresses the
helplessness and hopelessness associated with depression. Shared decision-making
interventions are being developed for depression in primary care, but have yet to be
adequately tested. It is also unknown whether the same premises regarding shared
decision-making's ability to enhance autonomy and empowerment pertain to elderly
populations.

This randomized study will recruit elderly depressed primary care patient subjects and
evaluate the impact of a three-session SDM nursing intervention on their (1) adherence to
antidepressant medication or psychotherapy and on (2) their reduction in depressive
symptoms. The comparison group will be physician-recommended Usual Care (UC). The focus of
the SDM intervention is to empower elderly depressed primary care patients and help them
efficiently arrive at a treatment decision that can be successfully implemented.

The study randomizes physicians to provide their depressed patients with SDM or UC. A total
of 210 elderly depressed patient subjects whose physicians recommend starting depression
treatment, will receive either Shared Decision-Making (SDM) or the physician recommended
Usual Care (UC) comparison condition. Participants will be assessed at baseline and at weeks
4, 8, 12, and 24 to determine treatment adherence and depressive status. Nurses currently
employed by the participating physicians will administer the SDM intervention.

Inclusion Criteria:

- Age: 65 years and older;

- Medical outpatient presenting to Lincoln Hospital, Bronx NY, the New York City Health
and Hospitals Corporation (HHC);

- Screen positive (PHQ-9 score>15) for depression, in addition to primary care
physician recommendation for depression treatment.

Exclusion Criteria:

- Presence of significant alcohol or substance abuse, psychotic disorder, or bipolar
disorder;

- High suicide risk, i.e. intent or plan to attempt suicide in near future;

- Current treatment with antidepressant medication or psychotherapy prior to index
physician visit (with the exception of low doses of antidepressant medication for
pain disorders);

- Cognitive impairment: MMSE score <24 or clinical diagnosis of dementia;

- Acute or severe medical illness, i.e., delirium, metastatic cancer, decompensated
cardiac, liver, or kidney failure, major surgery, stroke or myocardial infarction
during the three months prior to entry; or drugs often causing depression, e.g.,
steroids, reserpine, alpha-methyl-dopa, tamoxifen, vincristine;

- Aphasia interfering with communication.