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The American Journal of Managed Care November 2013
Opioid Analgesic Treated Chronic Pain Patients at Risk for Problematic Use
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Julie A. Schmittdiel, PhD; Andrew J. Karter, PhD; Wendy T. Dyer, MS; James Chan, PharmD, PhD; and O. Kenrik Duru, MD, MSHS
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Depression Self-Management Assistance Using Automated Telephonic Assessments and Social Support
John D. Piette, MSc, PhD; James E. Aikens, PhD; Ranak Trivedi, PhD; Diana Parrish, MSW; Connie Standiford, MD; Nicolle S. Marinec, MPH; Dana Striplin, MHSA; and Steven J. Bernstein, MD, MPH
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Depression Self-Management Assistance Using Automated Telephonic Assessments and Social Support

John D. Piette, MSc, PhD; James E. Aikens, PhD; Ranak Trivedi, PhD; Diana Parrish, MSW; Connie Standiford, MD; Nicolle S. Marinec, MPH; Dana Striplin, MHSA; and Steven J. Bernstein, MD, MPH
Automated patient support calls with feedback to informal caregivers and clinicians represent a viable strategy for increasing access to depression monitoring and self-management assistance.
Objective: To understand patient participation in interactive voice response (IVR) depression monitoring and self-management support calls and estimate the workload from clinical alerts based on patients’ IVR reports.

Study Design: Observational study from program implementation in 13 community- and university-based primary care practices.

Methods: Patients with depression were identified using electronic records and enrolled by telephone. Patients were asked to complete IVR assessments weekly; those with significantly improved symptoms had the option of completing assessments monthly. Patients could enroll with an informal caregiver who received automated feedback based on patients’ IVR reports. Clinicians received alerts regarding significant changes in the scores on the Patient Health Questionnaire 9-item depression measure, antidepressant adherence problems, or suicidal ideation.

Results: A total of 387 patients were followed for 12,042 weeks. More than half (59%) opted to participate with a caregiver. Patients completed 68% of 7912 attempted IVR assessments. Assessment completion was unrelated to patients’ depressive symptoms and was higher among those who participated with a caregiver, were married, had more comorbidities, or reported missing a prior appointment. Assessment completion was lower when patients received monthly versus weekly assessment attempts. Clinical alerts were generated during 4.9% of follow-up weeks; most represented medication adherence problems (2.8%). Alerts indicating suicidal ideation were rare (0.2% of patient-weeks).

Conclusions: IVR support calls represent a viable strategy for increasing access to depression monitoring and self-management assistance in primary care. These programs generate a manageable number of alerts, most of which can be triaged with limited physician involvement.

Am J Manag Care. 2013;19(11):892-900
We found that an interactive voice response (IVR) monitoring and self-management program  for depressed patients was a viable strategy for increasing access to depression management services in primary care.

  • Most patients opted to participate with an informal caregiver, who received automated feedback based on the patient’s IVR reports.

  • Patients completed 68% of 7912 attempted IVR assessments. Completion rates were similar regardless of patients’ depressive symptoms and were higher among those  participating with a caregiver.

  • The program generated a manageable number of alerts, most of which could be triaged by allied health professionals with limited physician oversight.
Roughly 7% of Americans have major depression each year,1 and depression is expected to be the second-most burdensome disease worldwide by 2030.2 Individuals with depression are more likely to have serious medical conditions,3 have twice the mortality rate as nondepressed people,4 and incur greater healthcare costs.5 Depression is common among primary care patients,6  especially those with chronic medical illnesses.7 Comorbid depression impairs self-care and worsens medical outcomes.7

Effective depression management is impeded by inadequate provider training, limited visit time, and few resources to monitor and  support self-care.8 Cognitive-behavioral therapy is effective, but limited by the small number of providers and program cost.9 Antidepressant medications can reduce symptoms and recurrence risk, but adherence is often poor.10 For these reasons, routine depression screening is of little benefit without formal systems for follow-up.11 Evidence-based depression care typically includes telephone care management to enhance recovery. While such programs may be cost-effective,12,13 they can be unattractive to decision makers because of the sheer number of undertreated patients, staffing requirements,14 and frequent contact many patients need.15,16

Mobile health services including interactive voice response (IVR) calls address these barriers to effective depression care management. Patients with a variety of chronic conditions will respond to IVR calls17 and provide valid and reliable clinical information.18-22 Given their efficacy in other chronic diseases, IVR-based interventions may improve mental health outcomes.23,24

Another strategy for improving depression management is to enhance patients’ social support. In 1 trial, trained laypersons led  to a 65% remission rate for depressive symptoms compared with usual care (39%).25 Patients with greater social support have fewer depressive episodes26-28 and lower symptom severity, and most attribute their depression to insufficient support.29,30 However, spousal caregivers are at risk for burnout from competing demands,31-34 and few informal caregivers have the tools  needed to systematically monitor patients’ mood and support their self-care.

Here, we describe the implementation of a primary care–based intervention in which depressed patients completed weekly IVR mood and self-care telephone assessments, and received tailored messages related to antidepressant adherence,mood  monitoring, and behavioral activation. The intervention also primary care, and with informal caregivers.  We examined variation in program engagement as defined by completion of IVR calls and the frequency and types of clinical alerts sent to primary care.


Patient Eligibility and Recruitment

Patients were enrolled between March 2010 and January 2012 from 13 university-affiliated and community-based primary care practices. Eligible patients had to have 2 primary care visits in the previous 2 years and 1 in the previous 13 months, and either an active depression diagnosis or an antidepressant prescription plus billing diagnosis of depression. Patients with schizophrenia, psychosis, delusional disorder, bipolar disorder, or dementia were excluded. Potential participants were mailed an introductory letter followed by a telephone call. After providing written informed consent, patients were mailed additional program information, including materials describing effective communication with informal caregivers and clinicians. Caregivers provided oral consent to receive feedback and suggestions based on their patient-partner’s IVR assessments. The study was approved by the university human subjects committee.

Program Features

Interactive Voice Response Calling System

The intervention provided (1) patients with IVR monitoring of depressive symptoms and medication adherence, including tailored information about self-care and when to seek health services; (2) clinical teams with actionable feedback about IVR-reported problems; and (3) informal caregivers with feedback about patients’ status plus guidance on supporting self-management. Each week an assessment was scheduled (ie, call-week), the system made up to 3 call attempts on up to 3 patient-selected day/time combinations. Call contents were developed with input from psychiatrists, primary care providers, and experts in IVR design and health behavior change.  Details about the call contents and flow can be obtained by contacting the authors. 

After patients verified their identity, their depression symptoms were assessed using the Patient Health Questionnaire 9-item depression measure (PHQ-9).35 Medication adherence was assessed using a standard item: “How often during the past week did you take your depression medication exactly as prescribed?” Additional questions asked about days in bed due to mental health symptoms and perceived general health. Calls used tree-structured algorithms to present recorded queries and information, and lasted between 5 and 20 minutes. Weekly assessments were scheduled for weeks 1 through 6. Thereafter, patients with mild depressive symptoms (3 consecutive PHQ-9 scores of <10) were automatically given the option to reduce the frequency to 1 call-week per month. Patients were automatically given the option to revert to weekly calling whenever their PHQ-9 scores were 10 or higher. 

Enhanced Social Support

Patients could participate with a family member or friend  (ie, an informal caregiver) and completed the Norbeck Social Support Questionnaire36 to identify the best candidate. Eligible caregivers needed to be at least 18 years old, to report no history of psychosis or cognitive impairment, and to agree to participate. Caregivers automatically received structured e-mails based on information reported during the patient’s IVR calls, with feedback about the patient’s status and tailored self-management support advice.

Clinician Alerts

As part of a series of meetings to gain input and review the IVR call contents, clinicians (physicians and nurses) in primary care and psychiatry defined thresholds for alerting primary care teams about urgent patient reports. Alerts were designed to be actionable, have low false-positive rates, and efficiently use human resources for follow-up. The following 3 conditions triggered alerts: suicidal ideation, poor medication adherence, and increase in depressive symptom severity.

Suicidal Ideation. Alerts were generated if patients reported they “had made a specific plan to harm [themselves] or end [their] life,” or that it was “somewhat likely” or “very likely” they would “harm [themselves] or end [their] life sometime over the next few days.” Patients reporting suicidal thoughts were instructed to talk with their doctor or mental health professional as soon as possible and were told that their clinician would be alerted by fax. Patients automatically received a tollfree 24-hour suicide hotline number and could transfer there immediately. Finally, patients were informed that their caregiver (if applicable) would receive automated information by phone about assisting the patient in getting help.

Poor Medication Adherence. Alerts were generated if the patient reported “rarely or never” taking their antidepressant as prescribed, or that they had considered reducing their medication or stopping medications due to side effects in the past week.

Increase in Depressive Symptom Severity. Alerts were generated if patients’ PHQ-9 scores increased by at least 5 points since the preceding assessment, or increased from lower than 15 to 15 or higher.

Data Collection and Analysis

We analyzed data at the patient-week level (ie, 1 record for each week an assessment was attempted). At baseline we collected data on patients’ sociodemographic and clinical characteristics including PHQ-837 (the PHQ-9 without the suicidality item), the number of comorbid medical conditions (hypertension, cardiovascular disease, hyperlipidemia, stroke, arthritis, chronic lung disease, and low back pain), scores on the Medical Outcomes Study Short Form 12 (SF-12),38 hospitalizations, and missed outpatient visits in the prior year.

We examined differences in characteristics of patients who did versus did not enroll with a caregiver. We used 2 multivariable logistic regression models to examine patients’ probability of completing assessments as a function of their demographic characteristics, measures of baseline vulnerability (missed appointments, hospitalizations, depressive symptoms, SF-12 physical and mental functioning scores), and weeks of follow-up. With the exception of patients’ baseline depression scores, coefficients in the full model with P values greater than .15 were dropped from the final model. Based on model coefficients we used the prgen command in Stata version 11.239 to plot the probability of assessment completion by patients’ baseline depressive symptom scores. We fit a second logistic model to identify whether assessment completion rates were affected by whether the patient elected to receive monthly versus weekly calls. Because reporting 3 successive PHQ-9 scores lower than 10 was a criterion for monthly calls, patients who did not complete calls regularly would be less likely to be represented in the monthly call data. We minimized that bias by including only patient call-weeks for which the prior assessment was successfully completed. Both models corrected coefficient standard errors for clustering of personweeks within patients.

Finally, we examined the frequency of clinical alerts per 100 patient-weeks of program participation. We used logistic regression to identify systematic variation in the probability of each alert type across groups of patients defined by their baseline depressive symptom severity and controlling for sociodemographic covariates. In the subset of patients enrolled from the university-affiliated clinics, we reviewed medical records to characterize clinicians’ response to alerts generated based on reports of suicidal ideation.


Patient Characteristics

A total of 1330 potentially eligible patients were contacted, of which 387 primary care patients from 13 university-based (81%) and community-based (19%) clinics were enrolled. Participants tended to be female (80%) and white (90%), to have more than a high school education (80%), and to be married (62%; Table 1). There were a broad range of ages, with 31% being 21 to 45 years old and 12% being 66 years or older. At baseline, 52% reported at least moderate depressive symptoms and 26% reported at least moderately severe symptoms. Two-thirds of patients (66%) reported missing 1 or more primary care appointments in the prior year, and 24% reported being hospitalized in the prior year. Patients reported a mean of 2.1 comorbid medical conditions, with the most prevalent being arthritis (48%), hypertension (47%), back pain (39%), and chronic lung disease (31%).

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