Training Doctors to Support Patient Self-Care of Depression

Many primary care patients struggle with health behaviors that can reduce depressive
symptoms, such as adhering to prescribed treatments. Bolstering patient self-efficacy can
improve health behaviors and outcomes, including those related to depression. However,
current self-efficacy interventions are provided outside of primary care, and so cannot
harness the power of therapeutic primary care provider (PCP)-patient relationships. Teaching
PCPs to employ self-efficacy enhancing interviewing techniques (SEE IT) with patients would
build upon existing therapeutic relationships, greatly increasing the reach of self-efficacy
enhancement. The randomized controlled trial (RCT) in this proposal will examine whether, as
compared with an attention control condition, a brief (< 1 hour) office-based intervention
for practicing PCPs will lead to significantly greater use of SEE IT during unannounced
follow-up SP encounters (postintervention and 3 months). The interventions will be delivered
to PCPs during their regular office hours by standardized patient (SP) instructors. All
study SPs will portray patients with both depression and diabetes, since these conditions
commonly co-occur and entail a heavy burden of health-enhancing behaviors. Exploratory (due
to limited statistical power) analyses will explore intervention effects on the following
outcomes among real patients with co-occurring depression and diabetes: self-efficacy for
depression and diabetes self-care, actual self-care behaviors (e.g. medication adherence),
symptom severity, and health status. Further exploratory (due to limited statistical power)
analyses will explore intervention effects on the following outcomes among real patients
with various chronic conditions (ie, not limited to depression and diabetes): self-care
self-efficacy, actual self-care behaviors, symptom severity, and health status. Pre- and
post-RCT focus groups with stakeholders (PCPs, office staff, patients, and SP instructors)
will guide refinement of the SEE IT intervention. The proposed research activities will
inform the design (e.g. sample size) and conduct of a future R01-funded, multi-center,
cluster RCT of the finalized intervention, adequately powered to examine effects on a range
of patient outcomes; sustainability of effects on PCP interviewing over time; and
generalizability to other practice settings and common co-morbid mental health and physical
illness clusters. The SEE IT intervention begins to address the broader health needs of
individuals with depression in primary care, and has unique potential to reduce the
tremendous burden of mental illness related morbidity and mortality.

Inclusion Criteria: Physicians (targeted enrollment=56; actual enrollment=50)

- Currently in practice at a participating office within one of the 2 participating
health systems (University of California Davis Primary Care Network, Sutter
Sacramento Health System)

- Trained as a family physician, general practitioner, and/or general internist

- Able to read and speak English

Inclusion Criteria: Group of patients with diabetes and depressive symptoms (targeted
enrollment=168; actual enrollment=15)

- Receive primary health care in one of the participating offices, from one of the
participating primary care physicians

- Aged 18 years or older

- Able to read and speak English

- Self-report of adequate vision, hearing, and hand function to complete
self-administered questionnaires on a touch screen notebook computer

- Have concurrent diagnoses of depression and diabetes, determined via medical record
review

- Have at least mild depressive symptoms, manifested by a score of 10 or greater on a
telephone-administered Patient Health Questionnaire (PHQ-9).

- Have an office visit scheduled with their assigned primary care provider within 1
month of study eligibility screening

- Made 2 or more of their primary care office visits during the preceding year with
their assigned primary care provider

Inclusion Criteria: Group of patients with various health conditions, ie, not limited to
diabetes and depression (targeted enrollment=336; actual enrollment=117)

- Receive primary health care in one of the participating offices, from one of the
participating primary care physicians

- Aged 18 years or older

- Able to read and speak English

- Self-report of adequate vision, hearing, and hand function to complete
self-administered questionnaires on a touch screen notebook computer

- Have an office visit scheduled with their assigned primary care provider within 1
month of study eligibility screening

- Made 2 or more of their primary care office visits during the preceding year with
their assigned primary care provider

Exclusion Criteria: Patients (applies to all study patients)

- Self-report or medical record evidence of unstable overall medical status

- Self-report or medical record evidence of terminal illness

- Self-report or medical record evidence of bipolar disorder, chronic psychosis
(schizophrenia or other), or personality disorder

- Self-report or medical record evidence of a history of attempted suicide

- Planned transfer of care to a health system other than the 2 participating systems
within 6 months

- Inability to understand any of the screening questions, after appropriate explanation
(e.g. due to cognitive impairment, developmental delay, or other reasons)