Depressive disorders place a tremendous burden on individuals, the health care system, and society as a whole. Follow-up after an initial antidepressant prescription remains one of the poorest quality performances of the US healthcare system. Telephone care management programs for depression have proven effective in improving both quality of care and clinical outcomes. The added cost of these programs, however, remains a significant barrier to widespread dissemination. Electronic patient-provider communication through email or secure messaging creates an opportunity to significantly reduce the cost and speed the dissemination of effective care management for depression. We propose a pilot study of depression care management delivered by secure electronic messages. If this pilot study supports the acceptability, feasibility, and potential effectiveness of this approach, then a full-scale effectiveness trial would be in order. The study will be conducted in approximately 40 primary care practices at Group Health Cooperative (GHC), over-sampling practices with higher rates of minority enrollment. Within participating practices, computerized records would be used to identify primary care patients initiating antidepressant treatment for depression. The sample would be limited to patients using secure messaging technology in the last year. Participants will be contacted by secure messaging and invited to participate. Those not responding to the initial secure message invitation will also be contacted by telephone. Consenting participants (n=200) will be randomly assigned to either continued usual care or a secure messaging care management program described below. All participants in the intervention and usual care groups will be contacted by secure message 6 months later for structured assessment of clinical outcome. Structure and content of the secure messaging care management program will closely follow the telephone care management programs proven effective in previous research. Each patient will receive an initial welcome message followed by scheduled outreach messages approximately 2, 6, and 10 weeks after beginning treatment. Each outreach message will include a structured assessment of depression severity, medication adherence, medication side effects, and other barriers to medication adherence. Patients not responding to an initial outreach message will receive up to two electronic reminders. Care managers will follow specific algorithms and scripts to respond to assessment results. As needed, care managers will communicate with treating providers, coordinate in-person or telephone follow-up, facilitate any urgent or emergent care, and facilitate specialty referrals. Data collected will be used to evaluate the feasibility of study methods (recruitment and data collection by secure messaging) and to evaluate the acceptability and potential effectiveness of this new model for depression care management. Telephone care management programs clearly improve the quality and outcomes of depression care, but the cost of telephone outreach is a barrier to implementation. Secure messaging technology (secure email between patients and providers) offers an opportunity to significantly reduce the cost and increase the implementation of effective care management for depression. We propose a pilot study of a depression care management program delivered by electronic secure messaging.
| Simon, Gregory E; Ralston, James D; Savarino, James et al. (2011) Randomized trial of depression follow-up care by online messaging. J Gen Intern Med 26:698-704 |
