T2D2 Background

Facts About Depression Care and Treatment in Primary Care

People living with depression experience problems functioning in many areas of life and poor well-being. The consequences of depression include increased work disability, increased risk of suicide, poorer outcomes from chronic medical conditions, and increased health care costs. Most adults with depression are treated by primary care physicians. In fact, depression prevalence in primary care settings is 10% − 15%. Even so, depression often goes undiagnosed and thus untreated. While primary care physicians are likely to overlook mild depression, a study of undetected cases found that more than half of undiagnosed patients met criteria for major depression one year later. Even when detected, depression is often under-treated.

Depression in Underserved Populations

Persons belonging to racial/ethnic minority groups have less access to mental health services, are less likely to receive needed mental health services, and receive lower quality of mental health care. These differences in the quality of care received by minorities versus the majority are referred to as “disparities,” and these groups are often referred to as “underserved populations.” Disparities in treatment may be partly explained by stigma, leading to a lower willingness among minorities to seek and accept help. In addition, stereotyping and poor communication between minority patients and their physicians, who are predominantly white, contributes to under-diagnosis and under-treatment of depression.

Like race and ethnicity, gender also affects depression-related help-seeking attitudes and behaviors. While depression is more common in women than in men, depressed men are less likely to seek care for depression, and they are more likely to commit suicide. Further, the growing literature on masked or male-type depression suggests that men may experience depression differently. Ironically, the men who are most in need of seeking help for depression appear to be most resistant to obtaining that help, yet studies show equivalent outcomes by sex once patients are in treatment. The importance of gender role socialization has been recognized in the professional literature and in the NIMH-sponsored Real Men, Real Depression (RMRD) campaign (2003). However, few studies have brought together in one effort medicine, marketing, and psychology to adequately address gender-related barriers to help-seeking for depression. As men and minorities are most at risk for under-treatment of depression, they may also have the most to gain from interventions targeted to their gender- or ethnicity-related concerns and/or tailored to their experience with depression, the symptoms it manifests, and their preferences for processing health information. Our research will result in the production of communication tools that specifically address barriers and concerns affecting minorities and men, potentially reducing treatment disparities.

What We Hope to Learn

We believe that depression is an important public health problem, that stigma is an important barrier to care, and that men and minorities may be especially vulnerable to depression under-treatment due to our society’s attitudes and misguided clinical judgments about depression care.

Based on the U.S. experience with direct-to-consumer advertising, we see that patient activation through multimedia campaigns can be a promising strategy for increasing the proportion of depressed patients who receive acceptable initial care. We use the phrase “patient activation” to describe the process of getting individuals with symptoms of depression to initiate a conversation with their doctor about their need for treatment. In our study, we will examine two communication strategies that have been used to promote positive health behaviors and could be used to encourage care seeking and appropriate treatment requests by individuals with depression: targeting (appealing to people based on visible traits such as gender or race) and tailoring (customizing communication based on the needs, preferences, and characteristics of individuals).

Targeted communication strategies will be developed through public service announcements (PSAs), and tailored communication strategies will be delivered through interactive multimedia computer programs (IMCP). The two strategies will be systematically compared in a study where patients visiting community clinics will be randomly assigned to one communication strategy or a placebo intervention (ie, sleep video). We feel that community-based and primary care practices are excellent settings for this study, as patients often suffer from co-morbid physical illness and choose primary care physicians for their depression-related care.

Public Service Announcements

What is Targeting?

In communication and marketing theory, targeting refers to the design and delivery of messages to fit the needs, expectations, and cultural norms of specific audiences defined by age, gender, race/ethnicity, or other readily identifiable social variables. Targeted social marketing campaigns have been effective in changing different kinds of health-related attitudes and behaviors, including use of family planning and HIV prevention services, alcohol consumption on college campuses, and stigma surrounding mental health conditions. Recent data from the Real Men, Real Depression campaign indicate that targeting may be essential for reaching populations at risk for depression.

Direct-to-Patient Advertising

We seek to develop non-commercial, depression-related PSAs that delivers the benefits of direct-to-consumer (DTC) advertising while minimizing unnecessary prescribing in the non-depressed. Out objective is to develop “portable” interventions that can be easily implemented in a variety of settings. The pharmaceutical industry recognizes the power of patient involvement in clinical decision-making. DTC advertising of prescription drugs is “any promotional effort by a pharmaceutical company to present prescription drug information to the general public.” Spending on DTC ads exceeds $4.5 billion per year, with antidepressants consistently among the top DTCA categories.

Consumer awareness of DTC advertisements is high. Up to 25% of American consumers have requested a prescription based on an ad, and 75% of those had their requests honored. DTC ads rely on the best of modern marketing appeals and clearly motivate patients to seek care. Data suggest that advertising increases antidepressant use overall but does not result in increased market share by the advertised product. Evidence from a random controlled trial conducted in 2003, also lead by our team, shows that the effects of DTCA are non-specific, increasing both appropriate and marginally inappropriate prescribing. Our team also found that depression history-taking, including inquiry about suicidality, and the quality of initial care for depression were all enhanced by patient requests.

The Value of PSAs in Health Care

Outside of the clinic setting, PSA impact is a function of its appeal to particular audiences and consumers’ participation rate. Through an aggressive outreach or advertising campaign, PSAs could potentially reach 50% of at-risk patients and their families within a given community, whereas traditional clinic-based interventions achieve penetration rates that are often an order of smaller magnitude. By encouraging active patient participation in care (which tends to be lower among men and minorities), the intervention also has the potential to diminish gender and racial/ethnic disparities in care.

Interactive Multimedia Computer Programs (IMCP)

What is Tailoring?

Tailoring involves customizing the communication of information to the needs, preferences, and characteristics of each specific individual. Whereas targeting involves the creation of “different messages for different groups,” tailoring adopts the strategy of “different messages for each person.” Individual characteristics have the power to impact health behaviors. A growing body of evidence suggests that interventions that are personally tailored to individual characteristics are superior to non-tailored interventions in improving various health behaviors and outcomes across a broad array of health conditions, including depression in primary care. Studies have shown that tailored health messages are better remembered, read, and perceived as relevant. However, the number of possible health messages and message combinations created for a diverse patient population with a complex health condition can be staggering. To derive the greatest benefits from brief tailored interventions, it is critical to deploy a manageable set of algorithmic focal points or “hinges.”

The research team is exploring various dimensions of tailoring. For example, how patients think about their illness may affect the type of message they are receptive to. Some patients may describe their depression in terms of bodily aches and pains, while others characterize it by the state of their emotions. We believe tailoring will help us develop an IMCP that resonates with a variety of different patients based on their individual characteristics and preferences.

The Value of IMCP Applications in Health Care

The effectiveness of the IMCP approach may be greater at the individual level, supporting future efforts to develop more intensive and reinforcing IMCP packages. Generalizability will be substantial since the principles involved in developing the IMCP can be deployed in doctors’ offices on CDROM or directly to patients via health portals on the Internet applied to a variety of medical conditions and delivered in a variety of settings.

Why the Clinical Trial Is Important

The randomized clinical trial will allow us to understand what effects communication interventions have on patients and physicians, how their experiences are affected, and how outcomes are improved.

Three groups of patients will be enrolled in the study: those who have major depression, those who have minor depression/dysthymia, and those who are non-depressed. Patients in each group will be randomized to the PSA, IMCP, or a video on sleep. Patient groups will be used to assess other possible intervention effects, such as the specific medication requests patients make.

The intervention will be administered in primary care office settings for two reasons. First, such settings are logistically convenient and permit greater control over the intervention. In addition, patients already seeking care for other reasons are closer to the “decision point” for depression care-seeking, where social marketing campaigns are likely to be more effective. However, we expect that future use of the PSAs and the IMCP will not be limited to such settings and could involve dissemination through the mass media and the Internet.

What Patients Are Saying

When we started this research program, we realized that the voices of people who had experienced depression, in themselves or a loved one, would be critical to guiding the development of the PSAs and IMCP. As the first step toward understanding patient experiences, residents of Sacramento, Calif.; Austin, Tex.; and Rochester, N.Y. were invited to participate in focus groups to discuss their experience with depression, the role that stigma played in care seeking, and how and why they developed particular preferences for treatment (ie, medication or psychotherapy). Participants were selected from neighborhoods representing households of middle- and low-income status. Participants were also selected based on gender and race/ethnicity to ensure that each group represented a variety of perspectives.

These focus group transcripts are now being analyzed to identify key themes that can be used to inform the development of the PSAs and IMCP. Below is a sample of what participants had to say about depression care and treatment.

About Depression Treatment

When asked about seeking care for depression, patients felt their doctors might:

• Be dismissive if they hadn’t experienced depression themselves,
• Treat them differently,
• Feel uncertain about how to proceed if they lacked experience in depression treatment, and
• Not take time to understand their experience and involve them in treatment decision-making.

When asked about depression treatment expectations, patients said that:

• Treatment for depression takes a long time and that effective treatment may be temporary,
• Doctors may be inclined toward medication,
• A good fit with a therapist is essential for counseling to be effective,
• Treatment choice is a very personal decision, and that
• Alternatives to medication and counseling, such as yoga, meditation, herbs, exercise, social networking, should be emphasized.

About Advertisements and Educational Materials

Participants were asked their thoughts and impressions about existing messages and advertisements in a follow up focus group. Most participants thought that too many ads start off with a depressed, sad looking person who then takes a pill and is magically happy. they felt this is an unrealistic portrayal of their depression experience. One man stated that he does not like that depression is always depicted as “sadness.” He talked about other symptoms such as confusion and numbness, and noted that the ads rarely ever speak to anything other than the sadness.

Several group participants talked about how depression ads assume they “know how you feel,” And described this approach as condescending and uninformed. One woman said that having a “commercial” about depression trivializes the experience. It [the experience of depression] is turned into a marketing issue as opposed to a health issue: “it’s marketing, not education.” She suggested that the advertisements should take the approach of: “If you think you have symptoms of depression, seek more information here…”

Patients did express some positive impact from messages and advertisement. One man spoke about an ad describing the physical pain associated with depression. He stated that the ad was “validating.” Several others talked about the message, “you are not alone,” as having a positive psychological impact.

Project Partners

• National Institute of Mental Health
• T2D2 Performance Sites: UC Davis, University of Texas-Austin, University of Rochester, UC San Francisco
• Roberts Communication
• Survey Research Group
• Daily Strength.org