Mobile Technology to Engage and Link Patients and Providers in Antidepressant Treatment

Major depressive disorder (MDD) is common and imposes a very high societal burden in terms
of cost, morbidity, suffering, and mortality. While primary care is the de facto site for
treatment of MDD, outcomes in primary care are poor. Two principal reasons for the poor
outcomes in primary care are poor patient adherence to antidepressant medications (ADMs) and
the failure of physicians to provide guideline-congruent care. This problem is aggravated by
a lack of communication between patients and the care team.

A growing body of research indicates that primary care-centered strategies aimed at
enhancing guideline-congruent care have not been effective. Interventions aimed at improving
adherence in the patient have been successful in changing patient adherence behavior;
however these frequently fail to improve depression outcomes, particularly when there is no
intervention on the physician side to encourage optimization of ADMs. Recent developments in
information and communications technologies (ICT) have opened new opportunities to improve
health and mental health care, and to link patients and their providers. This study
harnesses these advances to develop and pilot a system where ADM adherence will be passively
measured using an electronic pill dispenser. The dispenser is connected to a mobile
smartphone via Global System for Mobile Communications (GSM), so that targeted, timely
reminders can be provided when the patient fails to take the ADM. When the patient is
adherent, the patient will not be bothered with reminders. Depressive symptoms and
side-effects will be periodically monitored weekly via the phone. Every 4 weeks, or if
indicated (e.g intolerable side effects or urgent situations), primary care teams will
receive notifications via the electronic medical record that include a summary of patient
data on treatment response and side effects, guideline-congruent treatment recommendations
based on patient data and a recommendation to contact the patient, if indicated.
Simultaneously, a similar message will be provided to the patient via short message service
(or text), including feedback, possible treatment options, and a recommendation to contact
the physician's office. Thus, both the patient and care team will be activated to provide,
request and adhere to guideline-congruent care.

The aim of this study is to develop and pilot the medLink system. Development will employ an
iterative user-centered approach. The pilot trial will compare 12 weeks of the medLink
system to a treatment as usual control among primary care patients with MDD initiating ADM
treatment. Outcomes will include patient adherence to ADM, physician adherence to treatment
guidelines, and depression.

Inclusion Criteria:

- Has been prescribed an antidepressant medication by a Primary Care Provider, but has
not yet initiated treatment

- Has depression determined by primary care physician

- Is familiar with the use of mobile phones

- Is able and willing to carry the mobile phone

- Is able to speak and read English

- Is at least 18 years of age

Exclusion Criteria:

- Is current taking an antidepressant medication or has taken one in the previous 3
months

- Has visual, hearing, voice, or motor impairment that would prevent completion of
study procedures or use of mobile phone

- Is diagnosed with a psychotic disorder, bipolar disorder, dissociative disorder,
current substance dependence, or other diagnosis for which participation in this
trial is either inappropriate or dangerous. Patients with substance dependence
diagnoses who have been clean and sober for 12 months will be admitted if otherwise
eligible

- Is severely suicidal (has ideation, plan, and intent)