Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial

Susan Fletcher; Patty Chondros; Konstancja Densley; Elizabeth Murray; Christopher Dowrick; Amy Coe; Kelsey Hegarty; Sandra Davidson; Caroline Wachtler; Cathrine Mihalopoulos; Yong Yi Lee; Mary Lou Chatterton; Victoria J Palmer; Jane Gunn

doi:10.3399/BJGP.2020.0783

Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial

Br J Gen Pract. 2021 Jan 28;71(703):e85-e94. doi: 10.3399/BJGP.2020.0783. Print 2021.

Affiliations

¹ Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia.
² Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; professor of eHealth and primary care, Research Department of Primary Care and Population Health, University College London, London, UK.
³ Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; professor of primary medical care, Department of Health Services Research, University of Liverpool, Liverpool, UK.
⁴ Department of General Practice, Melbourne Medical School, University of Melbourne; director, Centre for Family Violence Prevention, The Royal Women's Hospital, Melbourne, Australia.
⁵ Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; family medicine resident, Department of General Practice and Primary Care, Karolinska Institutet, Solna, Sweden.
⁶ Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia.
⁷ Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong; honorary fellow, School of Public Health, University of Queensland, Brisbane; health economist, Policy and Epidemiology Group, Queensland Centre for Mental Health Research, Brisbane, Australia.
⁸ Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne; chair of primary care research, Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia.

Abstract

Background: Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required.

Aim: To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care.

Design and setting: Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care.

Method: The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months.

Results: In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported.

Conclusion: Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.

Keywords: clinical prediction rule; general practice; mental health; primary health care; randomised controlled trial.

Publication types

Randomized Controlled Trial

MeSH terms

Adolescent
Adult
Aged
Australia
Depression* / diagnosis
Depression* / therapy
Humans
Middle Aged
Primary Health Care*
Prognosis
Quality of Life
Treatment Outcome
Young Adult