BMJ Open · For peer review only...

For peer review only

Competing priorities in treatment decision-making: a US national survey of individuals with depression and clinicians

who treat depression

Journal: BMJ Open

Manuscript ID: bmjopen-2015-009585

Article Type: Research

Date Submitted by the Author: 03-Aug-2015

Complete List of Authors: Barr, Paul; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice Forcino, Rachel; Dartmouth College, The Dartmouth Institute for Health

Policy and Clinical Practice Mishra, Manish; Dartmouth College, The Dartmouth Center for Health Care Delivery Science; Dartmouth College, Geisel School of Medicine Blitzer, Rachel; Dartmouth College, Geisel School of Medicine Elwyn, Glyn; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth College, The Dartmouth Center for Health Care Delivery Science

<b>Primary Subject Heading</b>:

Mental health

Secondary Subject Heading: Mental health, Patient-centred medicine, Health services research

Keywords: MENTAL HEALTH, Depression & mood disorders < PSYCHIATRY, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Competing priorities in treatment decision-making: a US national survey of individuals with

depression and clinicians who treat depression

Paul J. Barr1,2

, Rachel C. Forcino1, Manish Mishra

2,3, Rachel Blitzer

2, Glyn Elwyn

1,3

1 The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA

2 Geisel School of Medicine at Dartmouth, Hanover, NH, USA

3 The Dartmouth Center for Health Care Delivery Science, Hanover, NH, USA

Corresponding author: Paul James Barr, The Dartmouth Institute for Health Policy and Clinical

Practice, Dartmouth College, 35 Centerra Pkwy, Lebanon, NH 03766, USA. Tel. +1 603-646-2578.

Fax: +1-603-646-1269 Email: [email protected]

Key words: Shared decision making; Depression

Word count: 3,165

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ABSTRACT

Objective: To identify information priorities for consumers and clinicians making depression

treatment decisions and assess shared decision-making (SDM) in routine depression care.

Design: 20 questions related to common features of depression treatments were provided and

participants were asked to rank the five most important. Clinicians were asked to provide

rankings according to both consumer and clinician perspectives. Consumers completed

CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer

characteristics associated with CollaboRATE scores.

Setting: Online cross-sectional surveys fielded in September - December 2014.

Participants: We administered surveys to convenience samples of US adults with depression

and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender,

and educational attainment of adults with depression in the US.

Primary outcome measures: Information priority rankings; CollaboRATE.

Results: 972 consumers and 244 clinicians completed the surveys. The highest-ranked question

for both consumers and clinicians was ‘Will the treatment work?’. Clinicians were aware of

consumers’ priorities, yet did not always prioritize that information themselves, particularly

insurance coverage and cost of treatment. Only 18 percent of consumers reported high levels of

SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07-3.26) and female gender (OR 2.04; 95%

CI 1.25-3.34) were associated with top CollaboRATE scores.

Conclusions: While clinicians know what information is important to consumers making

depression treatment decisions, they do not always address these concerns. This mismatch,

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coupled with low SDM, adversely affects the quality of depression care. Development of a DESI

based on our findings can improve levels of SDM and provide clinicians and consumers with a

tool to address the existing misalignment in information priorities.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study aimed to identify information priorities for consumers and clinicians making

depression treatment decisions via a US national survey of 972 consumers and 244

clinicians.

• To our knowledge, no other study of this scale has compared the information priorities

of consumers and clinicians with regard to depression treatment decisions.

• The convenience sampling approach precludes true representativeness, though

sampling quotas were in place to approximate the prevalence of depression among US

adults on age and gender within our sample.

• The results from this study can inform the development of a decision support

intervention (DESI) to increase SDM and alignment of information priorities between

consumers and clinicians facing depression treatment decisions.

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INTRODUCTION

Treatments for individuals with depression are numerous, with multiple generations of

antidepressant medications and psychosocial interventions such as cognitive-behavioral and

problem-solving therapies now delivered both in person and online[1–5]. These treatment

options do not differ substantially in effectiveness[4,6], though patients report significant side

effects from antidepressant medications[7]. While consumers tend to prefer psychosocial

therapies[8], 75 percent of consumers use antidepressant medication and only 43 percent use

psychosocial interventions[9]. In addition, individuals with depression often do not adhere to

treatment[10–13], especially with antidepressants[11–13]. Misalignment between a consumer’s

preferred treatment and prescribed treatment can contribute to low adherence and is

detrimental to the therapeutic alliance between consumer and clinician[14]. Likewise, aligning

treatment decisions with consumer preferences results in lower rates of treatment attrition,

fewer missed appointments, higher consumer satisfaction, and better clinical outcomes[15–17].

Shared decision-making (SDM) aims to generate greater alignment between patient preferences

and chosen treatments with a view to improving subsequent treatment outcomes[18]. When

individuals with depression are involved in SDM, treatment selection, adherence, satisfaction,

and outcomes are improved[17,19,20]. Yet many individuals with depression experience

inadequate SDM. Solberg et al[21] surveyed 1168 adults with depression in Minnesota and

found moderate levels of SDM. Consumers who were older, who were in poverty, who were of

poorer general health, or who had been treated for longer than 6 weeks reported lower levels

of SDM, although the generalizability of these results is limited given that all participants were

from a primary care sample. Additionally, independent raters found very low levels of SDM

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across 287 audio-recorded encounters of standardized patients presenting to primary care

practices with symptoms of depression[22].

These low levels of SDM are not surprising: individuals with depression often are not given time

to ask questions about treatments and are dissatisfied with the amount of information they

receive[23]. Decision support intervention tools (DESIs) have been suggested as a solution[24].

DESIs increase patient knowledge about treatment options and have the potential to enhance

consumer-clinician communication[25]. DESI use has been shown to help patients develop more

informed, preference-led treatment choices[25]. Issue Cards, Decision Boxes, and Option Grids

are examples of brief tools for use during clinic visits that are shown to increase SDM[26].

However, few DESIs have been designed and tested for English-speaking patients with

depression[27], and existing DESIs have focused exclusively on comparing medication options

and do not include evidence about other equally effective psychosocial treatments[28].

DESI development requires an understanding of the information considered important by both

health care consumers and health care professionals. A search for previous work addressing this

issue did not identify any relevant studies.

We aimed to address this gap by identifying the information most important to consumers and

clinicians when making depression treatment decisions and assess the extent of SDM in routine

depression care as reported by consumers.

METHODS

Participants

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We administered parallel cross-sectional national surveys between September 2014 and January

2015 to convenience samples of: 1) individuals who were currently being treated, were awaiting

treatment, or had previously been treated for depression; and 2) clinicians who had recently

treated individuals with depression. Dartmouth College’s Committee for the Protection of

Human Subjects (CPHS) considered this project exempt from IRB review. All surveys were

completed online and hosted by Qualtrics (Qualtrics LLC, Provo, UT, USA).

Consumers

Consumers were eligible for inclusion if they had ever been diagnosed with, counseled about, or

treated for depression; were aged 18 years or older; resided in the US; and were comfortable

reading and writing in English.

Clinicians

Clinicians were eligible for inclusion if they counseled, diagnosed, or treated a person with

depression in the prior 12 months; practiced in the US; and were comfortable reading and

writing in English. We define clinician to include primary care physicians (including internal and

family medicine), psychiatrists, psychologists, psychiatric/mental health nurses, social workers,

and licensed professional counselors.

Recruitment

Participants were recruited from convenience samples. Approximately 15 US-based health care

organizations and consumer advocacy groups shared a hyperlink to the survey via email, listserv,

social media (Facebook and Twitter), or personal communication (see Appendix 1 for details).

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To ensure the sample of consumer respondents matched population distributions, we adopted

recruitment quotas based on epidemiological data[29]. These quotas helped to approximate the

lifetime prevalence of depression among US adults with regard to age, gender, and educational

attainment. Similar data was not available for the clinician sample.

We used paid advertising via Facebook to target male consumers due to low survey uptake. We

supplemented clinician recruitment with respondents from Qualtrics Panels (Qualtrics LLC,

Provo, UT, USA).

Measures

We developed a 53-item patient survey and a 63-item clinician survey (available on request).

The surveys used a combination of standard, adapted, and newly developed questions. The

surveys were informally piloted to assess survey duration, flow, and ease of interpretation.

Patient survey

The patient survey consisted of five sections: socio-demographics, health status, treatment

experience, information priorities, and shared decision-making. The information priorities

section consisted of 20 FAQs deemed pertinent to depression treatment decision-making based

on peer-reviewed literature, guidelines, existing decision support tools for depression, and

stakeholder input. Respondents were also given an opportunity to list additional information

priorities within the survey.

To assess information priorities, consumers were asked to rate 20 frequently asked questions

(FAQs) on a five-point Likert-type importance scale in response to the question, ‘How important

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is each of these questions to you when choosing a treatment for depression?’. Responses ranged

from ‘Extremely unimportant’ to ‘Extremely important’ with an additional ‘Don’t know what this

means’ response option. FAQs were divided into five blocks covering four content areas: the

process of receiving treatment, lifestyle impact, side effects, and financial considerations. The

presentation of item blocks and items within blocks was randomized to avoid order effects.

FAQs marked either important or very important were ranked to ascertain the top five

information priorities. Where ‘side effects’ were marked as important or extremely important,

respondents were asked to rank the top five from a list of 12 commonly reported side effects.

Consumers were also asked to complete CollaboRATE, a three-item validated measure of SDM,

based on the most recent clinical encounter where depression was discussed[30,31].

Clinician survey

The clinician survey consisted of five sections: socio-demographics, practice setting, depression

treatment experience, information priorities, and shared decision-making. To assess information

priorities, clinicians followed the same process as consumers. Clinicians were asked to answer

the questions from two perspectives: 1) their own perspective as clinicians (‘In order to treat

your patients’ depression, how important do you think it is to discuss the following questions?’);

and 2) the consumer perspective (‘In your experience, how important do patients believe the

following questions are when choosing a treatment for depression?’).

Analysis

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We used weighted scores to assess the five most important FAQs from each of three

perspectives: 1) the consumer’s perspective; 2) the clinician’s personal perspective; and 3) the

clinician’s view of the consumer perspective.

FAQs within a respondent’s top five were assigned weights based on their ranked order. The

most important FAQ received five points, the second most important FAQ received four points,

and so on, with the fifth most important FAQ receiving one point. FAQs outside the top five did

not receive any points as respondents were asked to rank only their top five. Overall points per

FAQ were summed and FAQs were rank-ordered; the FAQ with the most points was considered

the most important. The same weighting procedure was used to rank side effects. Subgroup

analyses of rankings were conducted by consumer age, gender, and educational attainment, and

by clinician practice specialty.

To assess the impact of consumers’ socio-demographic characteristics and treatment experience

on their experiences of SDM, we conducted multiple logistic regression analysis with

CollaboRATE top score as the outcome variable[31]. The highest possible CollaboRATE scores

(i.e., 27) were coded with a value of ‘1’; all lower scores were coded ‘0’. We calculated the

average predicted probability of obtaining a CollaboRATE score adjusting for all other variables

in the model.

Individual item analysis used pairwise deletion, while the regression analysis used listwise

deletion. Analyses were conducted using Stata 13 (StataCorp LP, College Station, TX, USA). All

tests were considered statistically significant at p ≤0.05.

Sample size

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We planned to recruit a sample of 1000 consumers, which in a similarly sized probability sample

would provide 95% confidence of estimating the population’s information priorities to within ±

3%. This also allowed for a minimum of ten observations per parameter in the multiple logistic

regression model of CollaboRATE top scores[32]. We targeted a minimum of 30 responses per

clinician specialty and purposefully sought more primary care physicians than psychiatrists, as

approximately 30 percent of all outpatient visits (initial or follow-up) for depressive disorders

occur in primary care[33].

RESULTS

Participants

1557 consumers began the survey, 1096 met all eligibility criteria, and 972 attempted to answer

survey questions. For the 972 consumers who attempted survey questions, median completion

time was 12 minutes. Five consumers spent longer than 24 hours on the survey. 471 clinicians

began the survey, of whom 300 met all eligibility criteria and 244 attempted to answer survey

questions. Clinicians’ median completion time was 11 minutes, with one clinician spending

longer than 24 hours on the survey.

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Table 1. Demographic profile of consumer respondents

Characteristic

Number of consumers

(%)

Age, years n=972

18-29 185 (19)

30-39 203 (21)

40-49 249 (26)

50-59 221 (23)

60-69 98 (10)

70+ 16 (2)

Gender n=967

Female 664 (69)

Male 295 (31)

Other 8 (1)

Education n=786

Less than college 162 (21)

Some college/College degree 465 (59)

Graduate/Professional degree 150 (19)

Prefer not to say 9 (1)

Employment status n=740

Employed 422 (57)

Not employed 318 (43)

Marital status n=740

Married 297 (40)

Single (never married) 234 (32)

Separated or divorced 179 (24)

Widowed 12 (2)


Community environment (residence) n=742

Urban/Metropolitan (50,000+) 358 (48)

Large rural city/Micropolitan (10,000-49,999) 169 (23)

Small rural city/town (2,500-9,999) 170 (23)

Isolated rural town (under 2,500, 60+ minutes to urban area) 45 (6)

Race* n=776

White 716 (92)

American Indian or Alaska Native 33 (4)

African American 28 (4)

Asian 9 (1)

Native Hawaiian or Pacific Islander 3 (0)

Other 27 (3)

Ethnicity n=768

Not Hispanic/Latino 719 (94)

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Hispanic/Latino 49 (6)

Language spoken at home n=964

English 901 (93)

Other 63 (7)

Health insurance status n=742

Insured through my current or former employer 233 (31)

Insured through a family member's current or former

employer

161 (22)

Insured through a public program (e.g., Medicare, Medicaid,

CHIP) 158 (21)

Insured through a government exchange 29 (4)

Insured directly from an insurance company 27 (4)

Not insured 88 (12)

Other 28 (4)


Mental health comorbidities* n=953

Anxiety disorder 649 (68)

Post-traumatic stress disorder 285 (30)

Obsessive-compulsive disorder 145 (15)

Other 466 (49)

None 133 (14)

Other long-term health conditions* n=925

Hypertension 82 (9)

Diabetes/Pre-diabetes 78 (8)

Arthritis 41 (4)

Asthma 38 (4)

Fibromyalgia 34 (4)

Other 442 (48)

None 513 (55) * Multiple selections allowed.

The socio-demographic profile of consumer respondents (Table 1) approximated lifetime

prevalence of Major Depressive Disorder in the United States on age and gender[29]. Consumer

respondents were mostly female (n=664/967; 69%), white (n=716/776; 92%), and covered a

diverse range of ages (mean 43.17, SD 13.41). Many had comorbid anxiety disorders

(n=649/953; 67%) and a majority had at least some post-secondary education (n=615/786;

79%).

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Table 2. Demographic profile of clinician respondents

Characteristic

Number of clinicians

(%)

Specialty n=244

Therapist 109 (45)

Primary care/Internal medicine physician 81 (33)

Psychiatrist 25 (10)

Psychiatric/Mental health nurse 6 (3)

Other 23 (9)

Proportion of past year's clients with depression n=243

A majority 67 (28)

A substantial portion 151 (62)

Few 25 (10)

Preferred treatment n=241

Combination talk therapy and medication 75 (31)

Talk therapy 75 (31)

Antidepressant medication 65 (27)

Lifestyle changes 18 (7)

Alternative therapy 6 (2)

Electro-convulsive therapy 2 (1)

Community environment (workplace) n=205





Race* n=204

White 179 (88)

Asian 18 (9)




Other 1 (0)

Ethnicity n=203




English 212 (87)

Other 31 (13)

* Multiple selections allowed.

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Consumer respondents were predominantly still in treatment (n=756/972; 78%) and reported

their principal clinicians to be therapists (n=338/968; 35%), psychiatrists (n=327/968; 34%), or

primary care physicians (n=235/968; 24%). Antidepressants were the most common treatment

used (n=901/970; 93%), with talk therapy (n=703/970; 72%) and lifestyle changes (n=412/970;

42%) also commonly reported (Table 2).

Table 3. Consumer treatment experience

Characteristic Number of consumers (%)

Treatment status n=972

Currently in treatment 756 (78)

Treated in the past 169 (17)

Awaiting treatment 47 (5)

Primary treating clinician n=968

Therapist 338 (35)


Primary care doctor 235 (24)

Other 47 (5)

Not sure 21 (2)

Most recent consultation about depression n=789

Less than a week ago 183 (23)

1 week to 1 month ago 222 (28)

1 month to 6 months ago 214 (27)

6 months to 12 months ago 60 (8)

12 or more months ago 110 (14)

Treatments used (lifetime)* n=970






Deep brain stimulation 9 (1) *Multiple selections allowed.

Clinician respondents were distributed across a variety of clinical specialties, with therapists

(n=109/244; 45%), primary care physicians (n=81/244; 33%), psychiatrists (n=25/244; 10%), and

other clinicians (n=29/244; 11%) represented (Table 3). On average, clinician respondents had

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15.08 years professional experience (SD 10.96). All had treated individuals for depression in the

past year, with 90% reporting that at least a substantial portion of their clients has depression.

Combination therapy (n=75/241; 31%), talk therapy (n=75/241; 31%), and antidepressant

medications (n=65/241; 27%) were clinicians’ most frequent treatment approaches. PCPs made

more frequent use of antidepressant medications than did other clinician types.

What matters most in treatment decision-making

Consumer perspective

The 742 consumers who answered ranking questions felt the most important information when

making a treatment decision was ‘Will the treatment work?’, followed by ‘What are the side

effects of this treatment?’, ‘Is the treatment covered by insurance?’, ‘How long before I feel

better?’, and ‘How much does this treatment cost?’ (Table 4). Consumers’ most concerning

potential side effect was increased risk of suicide, followed by sleep issues, weight change, heart

problems, and increased stress (see Appendix 2).

Importance rankings did not show evidence of variation by consumer age, gender, or

educational attainment (analysis available on request).

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Table 4. Top 5 Information priorities

Clinicians, from clinician perspective Information priority Weighted score N

#1 Will the treatment work? 566

#2 How long before the patient feels better? 348

#3 What are the side effects of this treatment? 318

#4 How does the treatment work? 242

#5 What is involved in using the treatment? 224

Total

202

Clinicians, from patient perspective Information priority Weighted score N



#3 How much does the treatment cost? 266

#4(tie) Is the treatment covered by insurance? 232

#4(tie) What are the side effects of this treatment? 232

Total

172

Patients Information priority Weighted score N



#3 Is the treatment covered by insurance? 1224

#4 How long before I feel better? 1147

#5 How much does this treatment cost? 984

Total 782

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Clinician perspective: What consumers need to know

202 clinicians completed rankings of what they perceived to be most important in depression

treatment decisions. When considering the information priorities from their professional

perspectives, clinicians ranked ‘Will the treatment work?’ first, followed by ‘How long before the

patient feels better?’, ‘What are the side effects of this treatment?’, ‘How does the treatment

work?’, and ‘What is involved in using the treatment?’ (Table 4). These information priorities

diverged from those of consumers in the area of cost and insurance coverage.

Slight differences in information priority rankings by clinician type are outlined in Appendix 3.

PCPs and psychiatrists ranked ‘Will this treatment affect other existing health conditions?’ much

higher than therapists. Psychiatrists and therapists ranked ‘What is involved in using this

treatment?’ higher than PCPs, while ‘How much does the treatment cost?’ was ranked higher by

PCPs than by psychiatrists or therapists. The most concerning potential side effect for clinicians

was increased risk of suicide, followed by drug-drug interactions, heart problems, weight

change, and sexual issues (see Appendix 2).

Clinician perspective: What consumers want to know

172 clinicians completed rankings of what they believe their clients find most important when

making a treatment decision. When considering the importance of the information priorities

from a consumer’s perspective, clinicians included the same priorities as consumers but in a

different order (Table 4). ‘Will the treatment work?’ again ranked number one, followed by

‘How long before the patient feels better?’, ‘How much does the treatment cost?’, ‘Is the

treatment covered by insurance?’, and ‘What are the side effects of this treatment?’. No

evidence was found for significant differences by clinician type (see Appendix 4).

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Engagement in care

Only 18 percent (n= 144/781) of consumers reported a CollaboRATE top score, indicating that a

majority of consumer respondents perceived low levels of SDM in their most recent clinical

encounters. Many consumers (n=405/789; 51%) had their most recent visits within the previous

month (Table 2).

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Table 5: Analysis of CollaboRATE top scores

Unadjusted

Regression Adjusted Regression Unadjusted

proportion (n)

Adjusted predicted proportion

(95% CI) OR (95% CI) OR (95% CI)

Clinician most frequently seen

Primary care physician 1.00 (reference) 1.00 (reference) 14% (25) 15% (9%-21%)

Psychiatrist 1.80 (1.08-3.00) 1.87 (1.07-3.26) 23% (62) 24% (19%-30%)

Therapist 1.39 (0.82-2.34) 1.31 (0.73-2.34) 19% (51) 19% (13%-24%)

Other/Not sure 0.72 (0.28-1.87) 0.80 (0.30-2.13) 11% (6) 12% (3%-21%)

Age

18-29 1.00 (reference) 1.00 (reference) 13% (19) 13% (7%-19%)

30-39 1.82 (0.99-3.35) 1.85 (0.96-3.54) 21% (34) 21% (14%-28%)

40-49 2.26 (1.26-4.03) 2.10 (1.11-3.97) 24% (48) 23% (17%-30%)

50-59 1.09 (0.58-2.09) 1.24 (0.62-2.48) 14% (24) 15% (9%-21%)

60+ 2.05 (1.01-4.13) 2.49 (1.14-5.43) 23% (19) 27% (16%-37%

Treatments used

Antidepressant medication only 1.00 (reference) 1.00 (reference) 12% (14) 14% (7%-22%)

Medication and other treatment 1.92 (1.06-3.46) 1.52 (0.80-2.91) 20% (124) 20% (17%-24%)

Non-medication treatment 0.99 (0.36-2.74) 0.93 (0.29-3.00) 12% (6) 13% (2%-25%)

Gender

Male 1.00 (reference) 1.00 (reference) 12% (25) 12% (7%-17%)

Female 2.00 (1.26-3.18) 2.04 (1.24-3.34) 21% (119) 22% (18%-26%)

Treatment status

Currently being treated 1.00 (reference) 1.00 (reference) 19% (118) 19% (15%-22%)

Awaiting treatment 0.87 (0.35-2.14) 0.93 (0.33-2.62) 17% (6) 18% (3%-33%)

Treated in the past 0.78 (0.47-1.32) 0.98 (0.56-1.71) 16% (20) 19% (11%-26%)

Education level

High school or less 1.00 (reference) 1.00 (reference) 20% (31) 22% (15%-29%)

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Some college to Bachelor's degree 0.93 (0.59-1.47) 0.77 (0.47-1.27) 19% (85) 18% (14%-22%)

Graduate/Professional degree 0.96 (0.54-1.69) 0.77 (0.42-1.44) 19% (28) 18% (11%-25%)

Health insurance

status

Private health insurance 1.00 (reference) 1.00 (reference) 19% (86) 19% (15%-23%)

Public health insurance 1.22 (0.78-1.90) 1.06 (0.66-1.71) 23% (35) 20% (13%-26%)

No insurance 0.88 (0.48-1.61) 0.89 (0.47-1.69) 17% (15) 17% (9%-25%)

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CollaboRATE top scores were more likely where the respondents were female (OR 2.14,

p=0.003) or where they worked with a psychiatrist (OR 1.91, p=0.025) (Table 5). Respondents in

older age groups appeared more likely to report a CollaboRATE top score compared to those

under 30 years old, with statistically significant associations found in the 40 to 49 years old and

over 60 years old groups (Table 5). Yet when age was analyzed as a continuous variable, no

association between age and CollaboRATE top score was found (analysis available on request).

The probability of a CollaboRATE top score where a consumer worked with a psychiatrist was

24.5% (95% CI 18.7%-30.3%), 18.5% when working with a therapist (95% CI 13.4%-23.6%), and

14.8% when working with a primary care physician (95% CI 8.9%-20.7%). The predicted

probability of females reporting a CollaboRATE top score was 22.0% (95% CI 18.2%-25.9%)

compared to males, 12.2% (95% CI 7.4%-16.9%).

DISCUSSION

The information priorities of individuals with depression in the US are not always aligned with

those of clinicians. Consumers and clinicians agree that effectiveness of treatment, side effects,

and speed of recovery are important. While treatment costs and insurance coverage are a

higher priority for consumers, explanations of how a treatment should be used and how it works

were more important for clinicians. However, when clinicians were asked to adopt a consumer

perspective, they were able to reliably report what consumers view to be most important. For

side effect rankings, there was close alignment between consumers and clinicians; however,

unlike clinicians, consumers included sleep issues and increased stress related to treatment

among the most concerning. A lack of SDM observed in the context of depression treatment

decisions may explain this misalignment in information priorities.

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Interpretation of findings

This is the first study to identify and compare consumers’ and clinicians’ information priorities

when considering depression treatment decisions. It is reassuring to find alignment in several

areas and promising to observe that clinicians are aware of consumer information priorities.

However, clinicians do not prioritize insurance and cost information, despite realizing its

importance to consumers. The importance of cost and insurance information to consumers is

consistent with previous literature[34,35]. The low priority we found clinicians give to cost and

insurance coverage information supports previous research on frequency of clinician-consumer

communication about out-of-pocket costs[36]. This lack of communication has been attributed

to time limitations within clinical encounters, the challenge of identifying consumer-specific

costs, and a belief that medical decisions should be based exclusively on needs, not costs[37,38].

Yet the cost of treatment has a significant impact on consumer well being, financial stability,

adherence, and eventual health status[39].

In contrast to other studies across many conditions[40,41] where CollaboRATE scores average

around 70%, only 18% of individuals with depression reported a top score on CollaboRATE. Our

findings support previous studies where consumers with depression report low SDM in primary

care and extend this result to other clinical specialties[21,22]. Female consumers were more

likely to report higher CollaboRATE scores. This may be explained by previous research

indicating females’ preference for more active roles in decision-making[42]. While SDM was low

across all clinician types, primary care physicians scored significantly lower than psychiatrists.

These low scores may result from additional time pressures, as Tai-Seale[43] reported that a

sample of primary care clinicians treating patients with mental health needs spent on average

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only two minutes per visit on mental health issues. Despite these differences in CollaboRATE

scores by clinician type, we can conclude that consumers generally perceived low levels of SDM.

Strengths and limitations

Though our convenience sampling approach eliminates confidentiality concerns associated with

pre-identifying individuals with depression across the United States, we are as a result unable to

determine response rates and lack true representativeness. However, by ensuring that the

respondent sample approximated epidemiological data on lifetime depression prevalence with

regard to age and gender, we reduced the potential impact of selection bias. As we were unable

to target clinician sampling due to a lack of relevant data, the potential for selection bias

remains a concern.

Additionally, independent clinician and consumer samples preclude direct comparisons between

the groups. Further research is needed to address convergence or divergence of information

priorities within clinician-consumer dyads. However, broad inclusion criteria for consumers and

clinicians enabled thorough representation of depression care in the US, evident by consumer

responses from 49 of 50 US states and the District of Columbia.

Implications

While clinicians are aware of what matters most to consumers with depression, they do not

always prioritize this information. Low SDM combined with a misalignment in information

priorities between consumers and clinicians may explain why consumers often do not receive

their preferred treatments[44].

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Better equipping clinicians to talk to consumers about information central to consumer

decision-making, such as the cost and insurance coverage associated with different treatment

options, can lead to more engaged and empowered consumers. This is of particular interest

given the expansion of mental health coverage and depression screening resulting from the

Patient Protection and Affordable Care Act45

. Despite previous research finding SDM to be

associated with higher consumer satisfaction in depression care[20], routine clinician training in

SDM is still lacking. The current work can help inform development of a DESI for depression that

consists of key information priorities identified by consumers and clinicians. These tools have

demonstrated promise in treating other conditions and may help facilitate clinician-consumer

conversations in depression care, leading to better-informed consumers choosing treatments

that are right for them.

Conclusion

While consumers and clinicians agreed on some information priorities for depression treatment

decision-making, there was misalignment in the area of treatment cost and insurance coverage

despite clinician awareness of the importance of these issues to consumers. The low levels of

SDM reported by consumers with depression emphasize the impact of this priority mismatch.

Future work on interventions to improve depression treatment decision-making may help

narrow the existing gap between consumers’ and clinicians’ information priorities and increase

SDM, leading to treatments aligned with consumer preferences.

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AUTHOR CONTRIBUTIONS

PB conceived of the study and contributed to the design of the work, interpretation of data, and

drafting and revision of the manuscript. RF contributed to the design of the work, data analysis,

interpretation of data, and drafting and revision of the manuscript. MM contributed to the

design of the work, interpretation of data, and revision of the manuscript. RB contributed to the

design of the work and drafting of the manuscript. GE contributed to the design of the work and

drafting and revision of the manuscript.

ACKNOWLEDGEMENTS

We thank the following individuals and groups for their contributions to our study:

Jim Matthews for comments on the manuscript; Bob Drake and Mark Hegel of Dartmouth

College for feedback and advice on initial drafts of the surveys; Greg McHugo of Dartmouth

College for advice on study design; James O’Malley for advice on data analysis; and

organizations listed in Appendix 1 for help with recruitment.

COMPETING INTERESTS

Glyn Elwyn reports grants and personal fees from the Informed Medical Decision Making

Foundation, personal fees from Emmi Solutions LLC, outside the submitted work. As two of the

copyright holders of CollaboRATE, Glyn Elwyn and Paul Barr wish to declare this intellectual

conflict of interest. CollaboRATE is freely available under a Creative Commons License for non-

commercial use: CC BY-NC-ND 3.0 Unported. Glyn Elwyn also wishes to declare an intellectual

conflict of interest as the founder of the Option Grid Collaborative. Option Grids are freely

available under a Creative Commons License for non-commercial use: CC BY-NC-ND 4.0. No

other authors have conflicts of interest to report.

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FUNDING STATEMENT

This research received no specific grant from any funding agency in the public, commercial or

not-for-profit sectors.

DATA SHARING STATEMENT

Additional data is available on request to Paul Barr ([email protected]) pending IRB

approval.

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APPENDICES

Appendix 1. Survey outlets

Health care organizations, educators, and research groups

Dartmouth Hitchcock Medical Centers, Veteran Affairs (VA), American Association of

Communication in Health Care, Mental Health Research Network America, The Dartmouth CO-

OP Practice Based Research Network, The American Association of Family Practitioners (AAFP)

National Research Network, EMMI Solutions, SAMHSA SDM TTA, Revive Primary Care.

Consumer advocacy groups

Mental Health America, National Alliance on Mental Illness (NAMI), High Anxieties, Now Matters

Now, Suicide Prevention Resource Center, Depression and Bipolar Support Alliance.

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Appendix 2. Top 5 most concerning side effects

Clinicians (clinician perspective) Side effect Weighted score N

#1 Increased risk of suicide 620

#2 Drug-drug interactions 353

#3 Heart problems 270

#4 Weight change 247

#5 Sexual issues 242

Total

183

Consumers Side effect Weighted score N

#1 Increased risk of suicide 1916

#2 Sleep issues 1669

#3 Weight change 1642

#4 Heart problems 1330

#5 Increased stress 1128

Total 794

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Appendix 3. Clinician subgroup rankings

Primary care physicians (clinician perspective) Information priority Weighted score N

#1 Will this treatment work? 208



#4 (tie) Will the treatment affect other existing health conditions? 83

#4 (tie) How much does the treatment cost? 83

Total

76

Psychiatrists (clinician perspective) Information priority Weighted score N




#4 Will the treatment affect other existing health conditions? 28

#5 What is involved in using this treatment? 24

Total

22

Therapists (clinician perspective) Information priority Weighted score N



#3 What is involved in using this treatment? 145



Total

83

Primary care physicians (consumer perspective) Information priority Weighted score N




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#4 Is the treatment usually covered by insurance? 99

#5 What are the side effects? 91

Total

70

Psychiatrists (consumer perspective) Information priority Weighted score N




#4 Will the treatment affect the patient's work or daily routine? 20


Total

18

Therapists (consumer perspective) Information priority Weighted score N

#1 (tie) Will this treatment work? 167

#1 (tie) How long before the patient feels better? 167


#4 Is the treatment usually covered by insurance? 83


Total 65

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2-3

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5-6

Objectives 3 State specific objectives, including any prespecified hypotheses 6

Methods

Study design 4 Present key elements of study design early in the paper 7

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

7-8

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 7-8

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

8-9

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

8-9

Bias 9 Describe any efforts to address potential sources of bias 8

Study size 10 Explain how the study size was arrived at 11

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

10

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 10

(b) Describe any methods used to examine subgroups and interactions 10

(c) Explain how missing data were addressed 10

(d) If applicable, describe analytical methods taking account of sampling strategy 10

(e) Describe any sensitivity analyses

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

11

(b) Give reasons for non-participation at each stage 11

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

12-13

(b) Indicate number of participants with missing data for each variable of interest 12-13

Outcome data 15* Report numbers of outcome events or summary measures N/A

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

17

(b) Report category boundaries when continuous variables were categorized 12

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 16

Discussion

Key results 18 Summarise key results with reference to study objectives

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

24

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

23

Generalisability 21 Discuss the generalisability (external validity) of the study results 24

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

31

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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Competing priorities in treatment decision-making: a US national survey of individuals with depression and clinicians

who treat depression

Journal: BMJ Open

Manuscript ID bmjopen-2015-009585.R1

Article Type: Research

Date Submitted by the Author: 02-Nov-2015

Complete List of Authors: Barr, Paul; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice Forcino, Rachel; Dartmouth College, The Dartmouth Institute for Health

Policy and Clinical Practice Mishra, Manish; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth College, Geisel School of Medicine Blitzer, Rachel; Dartmouth College, Geisel School of Medicine Elwyn, Glyn; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice

<b>Primary Subject Heading</b>:

Mental health

Secondary Subject Heading: Mental health, Patient-centred medicine, Health services research, Communication

Keywords: MENTAL HEALTH, Depression & mood disorders < PSYCHIATRY, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on D

ecember 2, 2020 by guest. P

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jopen.bmj.com

/B

MJ O

pen: first published as 10.1136/bmjopen-2015-009585 on 8 January 2016. D

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1

Competing priorities in treatment decision-making: a US national survey of individuals with

depression and clinicians who treat depression

Paul J. Barr1,2

, Rachel C. Forcino1, Manish Mishra

2,3, Rachel Blitzer

2, Glyn Elwyn

1,3

1 The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA

2 Geisel School of Medicine at Dartmouth, Hanover, NH, USA

3 The Dartmouth Center for Health Care Delivery Science, Hanover, NH, USA

Corresponding author: Paul James Barr, The Dartmouth Institute for Health Policy and Clinical

Practice, Dartmouth College, 35 Centerra Pkwy, Lebanon, NH 03766, USA. Tel. +1 603-646-2578.

Fax: +1-603-646-1269 Email: [email protected]

Key words: Shared decision making; Depression

Word count: 3,539

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ABSTRACT

Objective: To identify information priorities for consumers and clinicians making depression

treatment decisions and assess shared decision-making (SDM) in routine depression care.

Design: 20 questions related to common features of depression treatments were provided.

Participants were initially asked to select which features were important, and in a second stage

they were asked to rank their top five ‘important features’ in order of importance. Clinicians

were asked to provide rankings according to both consumer and clinician perspectives.

Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis

identified consumer characteristics associated with CollaboRATE scores.

Setting: Online cross-sectional surveys fielded in September - December 2014.

Participants: We administered surveys to convenience samples of US adults with depression

and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender,

and educational attainment of adults with depression in the US.

Primary outcome measures: Information priority rankings; CollaboRATE, a three-item consumer

reported measure of SDM.

Results: 972 consumers and 244 clinicians completed the surveys. The highest-ranked question

for both consumers and clinicians was ‘Will the treatment work?’. Clinicians were aware of

consumers’ priorities, yet did not always prioritize that information themselves, particularly

insurance coverage and cost of treatment. Only 18 percent of consumers reported high levels of

SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07-3.26) and female gender (OR 2.04; 95%

CI 1.25-3.34) were associated with top CollaboRATE scores.

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Conclusions: While clinicians know what information is important to consumers making

depression treatment decisions, they do not always address these concerns. This mismatch,

coupled with low SDM, adversely affects the quality of depression care. Development of a

decision support intervention (DESI) based on our findings can improve levels of SDM and

provide clinicians and consumers with a tool to address the existing misalignment in information

priorities.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study aimed to identify information priorities for consumers and clinicians making

depression treatment decisions via a US national survey of 972 consumers and 244

clinicians.

• To our knowledge, no other study of this scale has compared the information priorities

of consumers and clinicians with regard to depression treatment decisions.

• The convenience sampling approach precludes true representativeness, though

sampling quotas were in place to approximate the prevalence of depression among US

adults on age and gender within our sample.

• The results from this study can inform the development of a decision support

intervention (DESI) to increase SDM and alignment of information priorities between

consumers and clinicians facing depression treatment decisions.

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INTRODUCTION

Treatments for individuals with depression are numerous, with multiple generations of

antidepressant medications and psychosocial interventions such as cognitive-behavioral and

problem-solving therapies now delivered both in person and online[1–5]. These treatment

options do not differ substantially in effectiveness[4,6], yet significant side effects are more

commonly reported with the use of antidepressant medications[7,8]. While consumers tend to

prefer psychosocial therapies[9], 75 percent of consumers use antidepressant medication and

only 43 percent use psychosocial interventions[10]. In addition, individuals with depression

often do not adhere to treatment[11–14], especially with antidepressants[12–14]. While lack of

access is an issue for some treatment options, misalignment between a consumer’s preferred

treatment and prescribed treatment can contribute to low adherence and is detrimental to the

therapeutic alliance between consumer and clinician[15]. Likewise, aligning treatment decisions

with consumer preferences results in lower rates of treatment attrition, fewer missed

appointments, higher consumer satisfaction, and better clinical outcomes[16–18].

Shared decision-making (SDM) aims to generate greater alignment between patient preferences

and chosen treatments with a view to improving subsequent treatment outcomes[19]. When

individuals with depression are involved in SDM, treatment selection, adherence, satisfaction,

and outcomes are improved[18,20,21]. Yet many individuals with depression experience

inadequate SDM. Solberg et al[22] surveyed 1168 adults with depression in Minnesota and

found moderate levels of SDM. Consumers who were older, who were in poverty, who were of

poorer general health, or who had been treated for longer than 6 weeks reported lower levels

of SDM, although the generalizability of these results is limited given that all participants were

from a primary care sample. Additionally, independent raters found very low levels of SDM

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across 287 audio-recorded encounters of standardized patients presenting to primary care

practices with symptoms of depression[23].

These low levels of SDM are not surprising: individuals with depression often are not given time

to ask questions about treatments and are dissatisfied with the amount of information they

receive[24]. Decision support intervention tools (DESIs) have been suggested as a solution[25].

DESIs increase patient knowledge about treatment options and have the potential to enhance

consumer-clinician communication[26]. DESI use has been shown to help patients develop more

informed, preference-led treatment choices[26]. Issue Cards, Decision Boxes, and Option Grids

are examples of brief tools for use during clinic visits that are shown to increase SDM[27].

However, few DESIs have been designed and tested for English-speaking patients with

depression[28], and those that were focus exclusively on comparing medication options and do

not include evidence about other equally effective psychosocial treatments[29]. To date only

one DESI, developed and tested in German, includes information on medication and

psychotherapy[30]. Early studies of the existing DESIs are promising, indicating increases in

consumer engagement, satisfaction, knowledge, reductions in decisional conflict and no

difference in consultation time[29,30].

DESI development requires an understanding of the information considered important by both

health care consumers and health care professionals. A search for previous work addressing this

issue did not identify any relevant studies.

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We aimed to address this gap by identifying the information most important to consumers and

clinicians when making depression treatment decisions and assess the extent of SDM in routine

depression care as reported by consumers.

METHODS

Participants

We administered parallel cross-sectional national surveys between September 2014 and January

2015 to convenience samples of: 1) individuals who were currently being treated, were awaiting

treatment, or had previously been treated for depression; and 2) clinicians who had recently

treated individuals with depression. Dartmouth College’s Committee for the Protection of

Human Subjects (CPHS) considered this project exempt from IRB review. All surveys were

completed online and hosted by Qualtrics (Qualtrics LLC, Provo, UT, USA).

Consumers

Consumers were eligible for inclusion if they had ever been diagnosed with, counseled about, or

treated for depression; were aged 18 years or older; resided in the US; and were comfortable

reading and writing in English.

Clinicians

Clinicians were eligible for inclusion if they counseled, diagnosed, or treated a person with

depression in the prior 12 months; practiced in the US; and were comfortable reading and

writing in English. We define clinician to include primary care physicians (including internal and

family medicine), psychiatrists, psychologists, psychiatric/mental health nurses, social workers,

and licensed professional counselors.

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Recruitment

Participants were recruited from convenience samples. Approximately 15 US-based health care

organizations and consumer advocacy groups shared a hyperlink to the survey via email, listserv,

social media (Facebook and Twitter), or personal communication (see Appendix 1 for details).

To ensure the sample of consumer respondents matched population distributions, we adopted

recruitment quotas based on epidemiological data[31]. These quotas helped to approximate the

lifetime prevalence of depression among US adults with regard to age, gender, and educational

attainment. Similar data was not available for the clinician sample.

We used paid advertising via Facebook to target male consumers due to low survey uptake. We

supplemented clinician recruitment with respondents from Qualtrics Panels (Qualtrics LLC,

Provo, UT, USA).

Measures

We developed a 53-item patient survey and a 63-item clinician survey (see Appendices 2 and 3).

The surveys used a combination of validated, adapted, and newly developed questions (more

detail is provided below). The surveys were informally piloted with local clinicians, research

staff, and consumer representatives to assess survey duration, flow, and ease of interpretation.

Our approach modeled that of a recent survey investigating what matters most to individuals

facing contraception decisions[32].

Patient survey

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The patient survey consisted of five sections: socio-demographics, health status, treatment

experience, information priorities, and SDM. The information priorities section consisted of 20

FAQs deemed pertinent to depression treatment decision-making based on a literature review

of peer-reviewed journal articles, guidelines, existing decision support tools for depression, and

stakeholder input. Respondents were also given an opportunity to list additional information

priorities within the survey. Socio-demographic questions were based on US Census items [33–

36]; questions on health status (co-morbidities, current depression status) and treatment

experience (treatment history, treating clinician) were developed for this study.

To assess information priorities, consumers were asked to rate 20 frequently asked questions

(FAQs) on a five-point Likert-type importance scale in response to the question, ‘How important

is each of these questions to you when choosing a treatment for depression?’. Responses ranged

from ‘Extremely unimportant’ to ‘Extremely important’ with an additional ‘Don’t know what this

means’ response option. FAQs were divided into five blocks covering four content areas: the

process of receiving treatment, lifestyle impact, side effects, and financial considerations. The

presentation of item blocks and items within blocks was randomized to avoid order effects.

FAQs marked either important or very important were then included together on a subsequent

webpage and ranked by respondents to ascertain the top five information priorities. The same

process was followed for side effects: where ‘side effects’ were marked important or extremely

important, respondents were asked to rank the top five from a list of 12 commonly reported

side effects.

Consumers were also asked to complete CollaboRATE, a three-item validated measure of SDM,

based on the most recent clinical encounter where depression was discussed[37,38]. The items

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are: 1. How much effort was made to help you understand your health issues? 2. How much

effort was made to listen to the things that matter most to you about your health issues? 3.

How much effort was made to include what matters most to you in choosing what to do next?

Each of the three items was rated on a scale of 0 (‘no effort was made’) to 9 (‘every effort was

made’).

Clinician survey

The clinician survey consisted of five sections: socio-demographics, practice setting, depression

treatment experience, information priorities, and SDM. To assess information priorities,

clinicians followed the same process as consumers. Clinicians were asked to answer the

questions from two perspectives: 1) their own perspective as clinicians (‘In order to treat your

patients’ depression, how important do you think it is to discuss the following questions?’); and

2) the consumer perspective (‘In your experience, how important do patients believe the

following questions are when choosing a treatment for depression?’).

Analysis

We used weighted scores to assess the five most important FAQs from each of three

perspectives: 1) the consumer’s perspective; 2) the clinician’s personal perspective; and 3) the

clinician’s view of the consumer perspective.

FAQs within a respondent’s top five were assigned weights based on their ranked order. The

most important FAQ received five points, the second most important FAQ received four points,

and so on, with the fifth most important FAQ receiving one point. FAQs outside the top five did

not receive any points as respondents were asked to rank only their top five. Overall points per

FAQ were summed and FAQs were rank-ordered; the FAQ with the most points was considered

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the most important. The same weighting procedure was used to rank side effects. Subgroup

analyses of rankings were conducted by consumer age, gender, and educational attainment, and

by clinician practice specialty.

To assess the impact of consumers’ socio-demographic characteristics and treatment experience

on their experiences of SDM, we conducted multiple logistic regression analysis with

CollaboRATE top score as the outcome variable[38]. The highest possible CollaboRATE scores

(i.e., 27) were coded with a value of ‘1’; all lower scores were coded ‘0’. We calculated the

average predicted probability of obtaining a CollaboRATE score adjusting for all other variables

in the model. The top score is a validated method of scoring CollaboRATE and allows more

meaningful interpretation of the score, namely, the proportion of consumers who perceived a

highest possible quality SDM process compared to those who felt there was some room for

improvement.

Individual item analysis used pairwise deletion, while the regression analysis used listwise

deletion. Analyses were conducted using Stata 13 (StataCorp LP, College Station, TX, USA). All

tests were considered statistically significant at p ≤0.05.

Sample size

We planned to recruit a sample of 1000 consumers, which in a similarly sized probability sample

would provide 95% confidence of estimating the population’s information priorities to within ± 3

percent. This also allowed for a minimum of ten observations per parameter in the multiple

logistic regression model of CollaboRATE top scores[39]. We targeted a minimum of 30

responses per clinician specialty and purposefully sought more primary care physicians than

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psychiatrists, as approximately 30 percent of all outpatient visits (initial or follow-up) for

depressive disorders occur in primary care[40].

RESULTS

Participants

1557 consumers began the survey, 1096 met all eligibility criteria, and 972 attempted to answer

survey questions. For the 972 consumers who attempted survey questions, median completion

time was 12 minutes. Five consumers spent longer than 24 hours on the survey. 471 clinicians

began the survey, of whom 300 met all eligibility criteria and 244 attempted to answer survey

questions. Clinicians’ median completion time was 11 minutes, with one clinician spending

longer than 24 hours on the survey.

Table 1. Demographic profile of consumer respondents

Characteristic

Number of consumers

(%)

Age, years n=972

18-29 185 (19)

30-39 203 (21)

40-49 249 (26)

50-59 221 (23)

60-69 98 (10)

70+ 16 (2)

Gender n=967

Female 664 (69)

Male 295 (31)

Other 8 (1)

Education n=786

Less than college 162 (21)

Some college/College degree 465 (59)

Graduate/Professional degree 150 (19)


Employment status n=740

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Employed 422 (57)

Not employed 318 (43)

Marital status n=740

Married 297 (40)

Single (never married) 234 (32)

Separated or divorced 179 (24)

Widowed 12 (2)


Community environment (residence) n=742





Race* n=776

White 716 (92)



Asian 9 (1)


Other 27 (3)

Ethnicity n=768




English 901 (93)

Other 63 (7)

Health insurance status n=742

Insured through my current or former employer 233 (31)

Insured through a family member's current or former

employer

161 (22)

Insured through a public program (e.g., Medicare, Medicaid,

CHIP) 158 (21)

Insured through a government exchange 29 (4)

Insured directly from an insurance company 27 (4)

Not insured 88 (12)

Other 28 (4)


Mental health comorbidities* n=953

Anxiety disorder 649 (68)

Post-traumatic stress disorder 285 (30)

Obsessive-compulsive disorder 145 (15)

Other 466 (49)

None 133 (14)

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Other long-term health conditions* n=925

Hypertension 82 (9)

Diabetes/Pre-diabetes 78 (8)

Arthritis 41 (4)

Asthma 38 (4)

Fibromyalgia 34 (4)

Other 442 (48)

None 513 (55) * Multiple selections allowed.

The socio-demographic profile of consumer respondents (Table 1) approximated lifetime

prevalence of Major Depressive Disorder in the United States on age and gender[31]. Consumer

respondents were mostly female (n=664/967; 69%), white (n=716/776; 92%), and covered a

diverse range of ages (mean 43.17, SD 13.41). Many had comorbid anxiety disorders

(n=649/953; 67%) and a majority had at least some post-secondary education (n=615/786;

79%).

Table 2. Demographic profile of clinician respondents

Characteristic

Number of clinicians

(%)

Specialty n=244

Therapist^ 109 (45)

Primary care/Internal medicine physician 81 (33)


Psychiatric/Mental health nurse 6 (3)

Other 23 (9)

Proportion of past year's clients with depression n=243

A majority 67 (28)

A substantial portion 151 (62)

Few 25 (10)

Preferred treatment n=241

Combination talk therapy and medication 75 (31)





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Community environment (workplace) n=205





Race* n=204

White 179 (88)

Asian 18 (9)




Other 1 (0)

Ethnicity n=203




English 212 (87)

Other 31 (13) ^ ‘

Therapist’ describes non-prescribing clinicians including: Psychologist,

Social Worker, and Licensed Professional Counselor.

* Multiple selections allowed.

Consumer respondents were predominantly still in treatment (n=756/972; 78%) and reported

their principal clinicians to be therapists (n=338/968; 35%), psychiatrists (n=327/968; 34%), or

primary care physicians (n=235/968; 24%). Antidepressants were the most common treatment

used (n=901/970; 93%), with talk therapy (n=703/970; 72%) and lifestyle changes (n=412/970;

42%) also commonly reported (Table 2).

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Table 3. Consumer treatment experience

Characteristic Number of consumers (%)

Treatment status n=972

Currently in treatment 756 (78)

Treated in the past 169 (17)

Awaiting treatment 47 (5)

Primary treating clinician n=968

Therapist or Psychologist 338 (35)


Primary care doctor 235 (24)

Other 47 (5)

Not sure 21 (2)

Most recent consultation about depression n=789

Less than a week ago 183 (23)

1 week to 1 month ago 222 (28)

1 month to 6 months ago 214 (27)

6 months to 12 months ago 60 (8)

12 or more months ago 110 (14)

Treatments used (lifetime)* n=970






Deep brain stimulation 9 (1) *Multiple selections allowed.

Clinician respondents were distributed across a variety of clinical specialties, with therapists

(n=109/244; 45%), primary care physicians (n=81/244; 33%), psychiatrists (n=25/244; 10%), and

other clinicians (n=29/244; 11%) represented (Table 3). On average, clinician respondents had

15.08 years professional experience (SD 10.96). All had treated individuals for depression in the

past year, with 90% reporting that at least a substantial portion of their clients has depression.

Combination therapy (n=75/241; 31%), talk therapy (n=75/241; 31%), and antidepressant

medications (n=65/241; 27%) were clinicians’ most frequent treatment approaches. PCPs made

more frequent use of antidepressant medications than did other clinician types. When

comparing prescribers (PCPs and psychiatrists) to non-prescribers (therapists), prescribers say

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they most often request antidepressants alone (55%) followed by combination therapy (33%)

and talk therapy (3%), while non-prescribers instead favor talk therapy (59%) and combination

therapy (34%) over solely medication (1%).

What matters most in treatment decision-making

Consumer perspective

The 742 consumers who answered ranking questions felt the most important information when

making a treatment decision was ‘Will the treatment work?’, followed by ‘What are the side

effects of this treatment?’, ‘Is the treatment covered by insurance?’, ‘How long before I feel

better?’, and ‘How much does this treatment cost?’ (Table 4). Consumers’ most concerning

potential side effect was increased risk of suicide, followed by sleep issues, weight change, heart

problems, and increased stress (see Appendix 4).

Importance rankings did not show evidence of variation by consumer age, gender, or

educational attainment (analysis available on request).

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Table 4. Top 5 Information priorities

Clinicians, from clinician perspective Information priority Weighted score N





#5 What is involved in using the treatment? 224

Total

202

Clinicians, from patient perspective Information priority Weighted score N




#4(tie) Is the treatment covered by insurance? 232

#4(tie) What are the side effects of this treatment? 232

Total

172

Patients Information priority Weighted score N



#3 Is the treatment covered by insurance? 1224

#4 How long before I feel better? 1147

#5 How much does this treatment cost? 984

Total 782

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Clinician perspective: What consumers need to know

202 clinicians completed rankings of what they perceived to be most important in depression

treatment decisions. When considering the information priorities from their professional

perspectives, clinicians ranked ‘Will the treatment work?’ first, followed by ‘How long before the

patient feels better?’, ‘What are the side effects of this treatment?’, ‘How does the treatment

work?’, and ‘What is involved in using the treatment?’ (Table 4). These information priorities

diverged from those of consumers in the area of cost and insurance coverage.

Slight differences in information priority rankings by clinician type are outlined in Appendix 5.

PCPs and psychiatrists ranked ‘Will this treatment affect other existing health conditions?’ much

higher than therapists. Psychiatrists and therapists ranked ‘What is involved in using this

treatment?’ higher than PCPs, while ‘How much does the treatment cost?’ was ranked higher by

PCPs than by psychiatrists or therapists. The most concerning potential side effect for clinicians

was increased risk of suicide, followed by drug-drug interactions, heart problems, weight

change, and sexual issues (see Appendix 2).

Clinician perspective: What consumers want to know

172 clinicians completed rankings of what they believe their clients find most important when

making a treatment decision. When considering the importance of the information priorities

from a consumer’s perspective, clinicians included the same priorities as consumers but in a

different order (Table 4). ‘Will the treatment work?’ again ranked number one, followed by

‘How long before the patient feels better?’, ‘How much does the treatment cost?’, ‘Is the

treatment covered by insurance?’, and ‘What are the side effects of this treatment?’. No

evidence was found for significant differences by clinician type (see Appendix 4).

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Engagement in care

Only 18 percent (n= 144/781) of consumers reported a CollaboRATE top score, indicating that a

majority of consumer respondents perceived low levels of SDM in their most recent clinical

encounters. Many consumers (n=405/789; 51%) had their most recent visits within the previous

month (Table 2).

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Table 5: Analysis of CollaboRATE top scores

Unadjusted

Regression Adjusted Regression Unadjusted

proportion (n)

Adjusted predicted proportion

(95% CI) OR (95% CI) OR (95% CI)

Clinician most frequently seen

Primary care physician 1.00 (reference) 1.00 (reference) 14% (25) 15% (9%-21%)

Psychiatrist 1.80 (1.08-3.00) 1.87 (1.07-3.26) 23% (62) 24% (19%-30%)

Therapist 1.39 (0.82-2.34) 1.31 (0.73-2.34) 19% (51) 19% (13%-24%)

Other/Not sure 0.72 (0.28-1.87) 0.80 (0.30-2.13) 11% (6) 12% (3%-21%)

Age

18-29 1.00 (reference) 1.00 (reference) 13% (19) 13% (7%-19%)

30-39 1.82 (0.99-3.35) 1.85 (0.96-3.54) 21% (34) 21% (14%-28%)

40-49 2.26 (1.26-4.03) 2.10 (1.11-3.97) 24% (48) 23% (17%-30%)

50-59 1.09 (0.58-2.09) 1.24 (0.62-2.48) 14% (24) 15% (9%-21%)

60+ 2.05 (1.01-4.13) 2.49 (1.14-5.43) 23% (19) 27% (16%-37%

Treatments used

Antidepressant medication only 1.00 (reference) 1.00 (reference) 12% (14) 14% (7%-22%)

Medication and other treatment 1.92 (1.06-3.46) 1.52 (0.80-2.91) 20% (124) 20% (17%-24%)

Non-medication treatment 0.99 (0.36-2.74) 0.93 (0.29-3.00) 12% (6) 13% (2%-25%)

Gender

Male 1.00 (reference) 1.00 (reference) 12% (25) 12% (7%-17%)

Female 2.00 (1.26-3.18) 2.04 (1.24-3.34) 21% (119) 22% (18%-26%)

Treatment status

Currently being treated 1.00 (reference) 1.00 (reference) 19% (118) 19% (15%-22%)

Awaiting treatment 0.87 (0.35-2.14) 0.93 (0.33-2.62) 17% (6) 18% (3%-33%)

Treated in the past 0.78 (0.47-1.32) 0.98 (0.56-1.71) 16% (20) 19% (11%-26%)

Education level

High school or less 1.00 (reference) 1.00 (reference) 20% (31) 22% (15%-29%)

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Some college to Bachelor's degree 0.93 (0.59-1.47) 0.77 (0.47-1.27) 19% (85) 18% (14%-22%)

Graduate/Professional degree 0.96 (0.54-1.69) 0.77 (0.42-1.44) 19% (28) 18% (11%-25%)

Health insurance

status

Private health insurance 1.00 (reference) 1.00 (reference) 19% (86) 19% (15%-23%)

Public health insurance 1.22 (0.78-1.90) 1.06 (0.66-1.71) 23% (35) 20% (13%-26%)

No insurance 0.88 (0.48-1.61) 0.89 (0.47-1.69) 17% (15) 17% (9%-25%)

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CollaboRATE top scores were more likely where the respondents were female (OR 2.14,

p=0.003) or where they worked with a psychiatrist (OR 1.91, p=0.025) (Table 5). Respondents in

older age groups appeared more likely to report a CollaboRATE top score compared to those

under 30 years old, with statistically significant associations found in the 40 to 49 years old and

over 60 years old groups (Table 5). Yet when age was analyzed as a continuous variable, no

association between age and CollaboRATE top score was found (analysis available on request).

The probability of a CollaboRATE top score where a consumer worked with a psychiatrist was

24.5% (95% CI 18.7%-30.3%), 18.5% when working with a therapist (95% CI 13.4%-23.6%), and

14.8% when working with a primary care physician (95% CI 8.9%-20.7%). The predicted

probability of females reporting a CollaboRATE top score was 22.0% (95% CI 18.2%-25.9%)

compared to males, 12.2% (95% CI 7.4%-16.9%).

DISCUSSION

The information priorities of individuals with depression in the US are not always aligned with

those of clinicians. Consumers and clinicians agree that effectiveness of treatment, side effects,

and speed of recovery are important. While treatment costs and insurance coverage are a

higher priority for consumers, explanations of how a treatment should be used and how it works

were more important for clinicians. However, when clinicians were asked to adopt a consumer

perspective, they were able to reliably report what consumers view to be most important. For

side effect rankings, there was close alignment between consumers and clinicians; however,

unlike clinicians, consumers included sleep issues and increased stress related to treatment

among the most concerning side effects. A lack of SDM observed in the context of depression

treatment decisions may explain this misalignment in information priorities.

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Interpretation of findings

This is the first study to identify and compare consumers’ and clinicians’ information priorities

when considering depression treatment decisions. It is reassuring to find alignment in several

areas and promising to observe that clinicians are aware of consumer information priorities.

However, clinicians do not prioritize insurance and cost information, despite realizing its

importance to consumers. The importance of cost and insurance information to consumers is

consistent with previous literature[41,42]. The low priority we found clinicians give to cost and

insurance coverage information supports previous research on frequency of clinician-consumer

communication about out-of-pocket costs[43]. This lack of communication has been attributed

to time limitations within clinical encounters, the challenge of identifying consumer-specific

costs, and a belief that medical decisions should be based exclusively on needs, not costs[44,45].

Yet the cost of treatment has a significant impact on consumer well being, financial stability,

adherence, and eventual health status[46].

In contrast to other studies across many conditions[47,48] where CollaboRATE scores average

around 70%, only 18% of individuals with depression reported a top score on CollaboRATE. Our

findings support previous studies where consumers with depression report low SDM in primary

care and extend this result to other clinical specialties[22,23]. Female consumers were more

likely to report higher CollaboRATE scores. This may be explained by previous research

indicating females’ preference for more active roles in decision-making[49]. While SDM was low

across all clinician types, primary care physicians scored significantly lower than psychiatrists.

These low scores may result from additional time pressures, as Tai-Seale[50] reported that a

sample of primary care clinicians treating patients with mental health needs spent on average

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only two minutes per visit on mental health issues. Despite these differences in CollaboRATE

scores by clinician type, we can conclude that consumers generally perceived low levels of SDM.

Strengths and limitations

Though our convenience sampling approach eliminates confidentiality concerns associated with

pre-identifying individuals with depression across the United States, we are as a result unable to

determine response rates and lack true representativeness; a probability sample would address

this concern. However, by ensuring that the respondent sample approximated epidemiological

data on lifetime depression prevalence with regard to age and gender, we reduced the potential

impact of selection bias. In addition, clinicians in our survey are likely to treat a broad spectrum

of individuals with depression; therefore a wide range of consumers informs their views of what

is most important to consumers. That these views match the views prioritized by the consumer

sample is reassuring. As we were unable to target clinician sampling due to a lack of relevant

data, the potential for selection bias remains a concern.

Additionally, independent clinician and consumer samples preclude direct comparisons between

the groups. Further research is needed to address convergence or divergence of information

priorities within clinician-consumer dyads. However, broad inclusion criteria for consumers and

clinicians enabled thorough representation of depression care in the US, evident by consumer

responses from 49 of 50 US states and the District of Columbia.

Implications

While clinicians are aware of what matters most to consumers with depression, they do not

always prioritize this information. Low SDM combined with a misalignment in information

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priorities between consumers and clinicians may explain why consumers often do not receive

their preferred treatments[51].

Better equipping clinicians to talk to consumers about information central to consumer

decision-making, such as the cost and insurance coverage associated with different treatment

options, can lead to more engaged and empowered consumers. This is of particular interest

given the expansion of mental health coverage and depression screening resulting from the

Patient Protection and Affordable Care Act. Despite previous research finding an association

between SDM and higher consumer satisfaction in depression care[21], routine clinician training

in SDM is still lacking. The current work can help inform development of a DESI for depression

that consists of key information priorities identified by consumers and clinicians. These tools

have demonstrated promise in treating other conditions and may help facilitate clinician-

consumer conversations in depression care, leading to better-informed consumers choosing

treatments that are right for them. We are currently in the process of developing a DESI based

on our findings and testing understanding, comprehensiveness, and acceptability with key

stakeholders (consumers, general public, and clinicians) through cognitive interviews.

Conclusion

While consumers and clinicians agreed on some information priorities for depression treatment

decision-making, there was misalignment in the area of treatment cost and insurance coverage

despite clinician awareness of the importance of these issues to consumers. The low levels of

SDM reported by consumers with depression emphasize the impact of this priority mismatch.

Future work on interventions to improve depression treatment decision-making may help

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narrow the existing gap between consumers’ and clinicians’ information priorities and increase

SDM, leading to treatments aligned with consumer preferences.

AUTHOR CONTRIBUTIONS

PB conceived of the study and contributed to the design of the work, interpretation of data, and

drafting and revision of the manuscript. RF contributed to the design of the work, data analysis,

interpretation of data, and drafting and revision of the manuscript. MM contributed to the

design of the work, interpretation of data, and revision of the manuscript. RB contributed to the

design of the work and drafting of the manuscript. GE contributed to the design of the work and

drafting and revision of the manuscript.

ACKNOWLEDGEMENTS

We thank the following individuals and groups for their contributions to our study:

Jim Matthews for comments on the manuscript; Bob Drake and Mark Hegel of Dartmouth

College for feedback and advice on initial drafts of the surveys; Greg McHugo of Dartmouth

College for advice on study design; James O’Malley for advice on data analysis; and

organizations listed in Appendix 1 for help with recruitment.

COMPETING INTERESTS

Glyn Elwyn reports grants and personal fees from the Informed Medical Decision Making

Foundation, personal fees from Emmi Solutions LLC, outside the submitted work. As two of the

copyright holders of CollaboRATE, Glyn Elwyn and Paul Barr wish to declare this intellectual

conflict of interest. CollaboRATE is freely available under a Creative Commons License for non-

commercial use: CC BY-NC-ND 3.0 Unported. Glyn Elwyn also wishes to declare an intellectual

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conflict of interest as the founder of the Option Grid Collaborative. Option Grids are freely

available under a Creative Commons License for non-commercial use: CC BY-NC-ND 4.0. No

other authors have conflicts of interest to report.

FUNDING STATEMENT

This research received no specific grant from any funding agency in the public, commercial or

not-for-profit sectors.

DATA SHARING STATEMENT

No additional data available.

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Appendix 1. Survey outlets

Health care organizations, educators, and research groups

Dartmouth Hitchcock Medical Centers, Veteran Affairs (VA), American Association of Communication in Health Care, Mental Health Research Network America, The Dartmouth CO-‐OP Practice Based Research Network, The American Association of Family Practitioners (AAFP) National Research Network, EMMI Solutions, SAMHSA SDM TTA, Revive Primary Care.

Consumer advocacy groups

Mental Health America, National Alliance on Mental Illness (NAMI), High Anxieties, Now Matters Now, Suicide Prevention Resource Center, Depression and Bipolar Support Alliance.

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Patient Depression Information Priorities What Matters Most? Information Priorities for Treatment of Depression Depression is the most common mental health disorder among Americans, and recognition and treatment are increasing. This survey seeks to identify patient information priorities in the treatment of depression. Dr. Paul Barr of The Dartmouth Center for Health Care Delivery Science at Dartmouth College, Hanover, NH is conducting this research project. Your participation is voluntary. We are inviting adults who have been treated for depression, live in the U.S., and are comfortable reading and writing in English to participate. Participation involves completion of an anonymous online survey that should take about 10 minutes. The information collected will be maintained anonymously. No names or other identifying information will be collected. There are no right or wrong answers. You may choose not to answer any or all of the questions. Completing this study might cause you to think about past experiences that could cause concern or discomfort. Should you wish to talk to someone, please contact your mental health care provider, primary care physician, National Suicide Prevention Lifeline at 1-‐800-‐273-‐8255, or call 911. The information you provide can help improve treatment decisions for patients in the future. Questions about this project may be directed to: Dr. Paul Barr, Assistant Professor, The Dartmouth Institute of Health Policy and Clinical Practice, The Dartmouth Center for Health Care Delivery Science, Hanover, NH 03755 Tel: 603-‐646-‐2578 | Email: [email protected]. Please click on the green arrow button to continue. Thank you for your interest in this survey. Please take a few moments to answer the following questions. How old are you (in years)? Are you comfortable reading and writing in English? m Yes m No Do you speak a language other than English at home? m Yes (please specify below) ____________________ m No

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Where in the United States do you live? m Alabama m Alaska m Arizona m Arkansas m California m Colorado m Connecticut m Delaware m District of Columbia m Florida m Georgia m Hawaii m Idaho m Illinois m Indiana m Iowa m Kansas m Kentucky m Louisiana m Maine m Maryland m Massachusetts m Michigan m Minnesota m Mississippi m Missouri m Montana m Nebraska m Nevada m New Hampshire m New Jersey m New Mexico m New York m North Carolina m North Dakota m Ohio m Oklahoma m Oregon m Pennsylvania m Rhode Island m South Carolina

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m South Dakota m Tennessee m Texas m Utah m Vermont m Virginia m Washington m West Virginia m Wisconsin m Wyoming m Other US territory m I live outside the US Are you currently being treated or awaiting treatment for depression? m Yes, currently being treated m Yes, awaiting treatment m No Answer If Are you currently being treated or awaiting treatment for depression? No Is Selected Have you been treated for depression in your lifetime? m Yes m No What is your gender? m Male m Female m Other

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Which treatment(s) for depression are you currently using or used in the past? Please select all that apply. q Antidepressant medication q Talk therapy (e.g., Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Problem-‐

solving Therapy) q Alternative therapy q Lifestyle changes q Electroconvulsive therapy q Deep-‐brain stimulation q I am still awaiting treatment Please select any treatments that you would like to learn more about or would be interested in trying. q Antidepressant medication q Talk therapy (e.g., Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Problem-‐

solving Therapy) q Alternative therapy q Lifestyle changes q Electroconvulsive therapy q Deep-‐brain stimulation q Other (please list below) ____________________

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With which type of health care provider have you most frequently talked about depression? m Primary care doctor m Psychiatrist m Psychologist m Social worker m Not sure m Other (please specify below) ____________________

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Do you have any other mental health conditions? Please select any that apply. q Anxiety disorder q Post-‐traumatic stress disorder q Obsessive-‐compulsive disorder q Attention deficit hyperactivity disorder q Intermittent explosive disorder q Substance (alcohol and drug) use disorders q Other (please specify) ____________________ q I do not have any other mental health conditions Do you have any other long term health conditions? m Yes (please list below) ____________________ m No We want to know what matters most to you when choosing a treatment for depression.Please click the green arrow button below to continue. How important is each of these questions to you when choosing a treatment for depression? How does this treatment work? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Who provides this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means

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How long before I feel better? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Will this treatment work? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How important is each of these questions to you when choosing a treatment for depression? Can I drink alcohol while using this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Can I take recreational drugs with this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How easy is it to keep this treatment private? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means

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Will this treatment affect my daily routine? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How important is each of these questions to you when choosing a treatment for depression? Will this treatment change my personality? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Is this treatment addictive? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Will this treatment affect other existing health conditions? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means

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Answer If What is your gender? Male Is Not Selected Can I have this treatment if I'm pregnant? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means What are the side effects of this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How important is each of these questions to you when choosing a treatment for depression? How long will I need to be treated? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means What is involved in using this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means

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What is involved in stopping this treatment? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How quickly can this treatment commence? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means How important is each of these questions to you when choosing a treatment for depression? How much does this treatment cost? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Is this treatment usually covered by insurance? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means Can I use alternative treatments? m Extremely Unimportant m Unimportant m Neutral m Important m Extremely Important m Don't know what this means

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Are there other important treatment decision questions that we did not touch upon? If so, please check the box and specify below. q Question 1 ____________________ q Question 2 ____________________

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Answer If How does this treatment work? Extremely Important Is Selected Or How does this treatment work? Important Is Selected Or Who provides this treatment? Extremely Important Is Selected Or Who provides this treatment? Important Is Selected Or How long before I feel better? Extremely Important Is Selected Or How long before I feel better? Important Is Selected Or Will this treatment work? Extremely Important Is Selected Or Will this treatment work? Important Is Selected Or Can I drink alcohol while using this treatment? Extremely Important Is Selected And Can I drink alcohol while using this treatment? Important Is Selected Or Can I take recreational drugs with this treatment? Extremely Important Is Selected Or Can I take recreational drugs with this treatment? Important Is Selected Or How easy is it to keep this treatment private? Extremely Important Is Selected Or How easy is it to keep this treatment private? Important Is Selected Or Will this treatment affect my daily routine? Extremely Important Is Selected Or Will this treatment affect my daily routine? Important Is Selected Or Will this treatment change my personality? Extremely Important Is Selected Or Will this treatment change my personality? Important Is Selected Or Is this treatment addictive? Extremely Important Is Selected Or Is this treatment addictive? Important Is Selected Or Will this treatment affect other existing health conditions? Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Important Is Selected Or Can I have this treatment if I'm pregnant? Extremely Important Is Selected Or Can I have this treatment if I'm pregnant? Important Is Selected Or What are the side effects of this treatment? Extremely Important Is Selected Or What are the side effects of this treatment? Important Is Selected Or How long will I need to be treated? Extremely Important Is Selected Or How long will I need to be treated? Important Is Selected Or What is involved in using this treatment? Extremely Important Is Selected Or What is involved in using this treatment? Important Is Selected Or What is involved in stopping this treatment? Extremely Important Is Selected Or What is involved in stopping this treatment? Important Is Selected Or How quickly can this treatment commence? Extremely Important Is Selected Or How quickly can this treatment commence? Important Is Selected Or How much does this treatment cost? Extremely Important Is Selected Or How much does this treatment cost? Important Is Selected Or Is this treatment usually covered by insurance? Extremely Important Is Selected Or Is this treatment usually covered by insurance? Important Is Selected Or Can I use alternative treatments? Extremely Important Is Selected Or Can I use alternative treatments? Important Is Selected Thank you for answering.Below are the questions which you rated "important" or "extremely important" when considering treatment for depression. Please rank only your TOP FIVE questions in order of most to least important by dragging the most important question to position 1, the second most important question to position 2, and so on. The order of any remaining questions can be disregarded. If How does this treatment work? Extremely Important Is Selected Or How does this treatment work? Important Is Selected

______ How does this treatment work? If Who provides this treatment? Extremely Important Is Selected Or Who provides this treatment? Important Is Selected

______ Who provides this this treatment?

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If How long before I feel better? Extremely Important Is Selected Or How long before I feel better? Important Is Selected

______ How long before I feel better? If Will this treatment work? Extremely Important Is Selected Or Will this treatment work? Important Is Selected

______ Will this treatment work? If Can I drink alcohol while using this treatment? Extremely Important Is Selected Or Can I drink alcohol while using this treatment? Important Is Selected

______ Can I drink alcohol with this treatment? If Can I take recreational drugs with this treatment? Extremely Important Is Selected Or Can I take recreational drugs with this treatment? Important Is Selected

______ Can I take recreational drugs with this treament If How easy is it to keep this treatment private? Extremely Important Is Selected Or How easy is it to keep this treatment private? Important Is Selected

______ How easy is it to keep this treatment private? If Will this treatment affect my daily routine? Extremely Important Is Selected Or Will this treatment affect my daily routine? Important Is Selected

______ Will this treatment affect my work/daily routine? If Will this treatment change my personality? Extremely Important Is Selected Or Will this treatment change my personality? Important Is Selected

______ Will this treatment change my personality? If Is this treatment addictive? Extremely Important Is Selected Or Is this treatment addictive? Important Is Selected

______ Is this treatment addictive? If Will this treatment affect other existing health conditions? Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Important Is Selected

______ Will this treatment affect other existing health conditions? If Can I have this treatment if I'm pregnant? Extremely Important Is Selected Or Can I have this treatment if I'm pregnant? Important Is Selected

______ Can I have this treatment if I am pregnant? If What are the side effects of this treatment? Extremely Important Is Selected Or What are the side effects of this treatment? Important Is Selected

______ What are the side effects of this treatment? If How much does this treatment cost? Extremely Important Is Selected Or How much does this treatment cost? Important Is Selected

______ How much does this treatment cost? If Is this treatment usually covered by insurance? Extremely Important Is Selected Or Is this treatment usually covered by insurance? Important Is Selected

______ Is this treatment usually covered by insurance? If Can I use alternative treatments? Extremely Important Is Selected Or Can I use alternative treatments? Important Is Selected

______ Can I use alternative treatments?

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If How long will I need to be treated? Extremely Important Is Selected Or How long will I need to be treated? Important Is Selected

______ How long will I need to be treated? If What is involved in using this treatment? Extremely Important Is Selected Or What is involved in using this treatment? Important Is Selected

______ What is involved in using this treatment? If What is involved in stopping this treatment? Extremely Important Is Selected Or What is involved in stopping this treatment? Important Is Selected

______ What is involved in stopping this treatment? If Below are the questions which you rated "important" or "extremely important" when considering treatment for depression. Please rank only your TOP FIVE questions in order of most to least ... 6 Is Selected Or Below are the questions which you rated "important" or "extremely important" when considering treatment for depression. Please rank only your TOP FIVE questions in order of most to least ... 5 Is Selected

______ How quickly can this treatment commence?

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Please review the following possible side effects of depression treatment. Please rank only your TOP FIVE most concerning side effects in order of most to least important by dragging the most important side effects to the top. The most important side effect should be in position 1, the second most important in position 2, and so on. The order of the remaining side effects can be disregarded. ______ Weight change ______ Sleep issues ______ Nausea/vomiting ______ Constipation ______ Diarrhea ______ Sexual issues ______ Increased risk of suicide ______ Harm to an unborn child ______ Drug-‐drug interactions ______ Seizures ______ Heart problems ______ Increased stress Are there important side effects not listed? m No m Yes (please list below) ____________________ Please think back to the last time you had a visit with a health care practitioner where a decision was made about how to treat your depression. Who decided what treatment you would use? m I decided which treatment I would use by myself m I decided which treatment I would use after seriously considering my clinician's opinion m My clinician and I decided together which treatment I would use m My clinician decided which treatment I would use after seriously considering my opinion m My clinician decided which treatment I would use by his or herself

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Again, please think back to the last time you had a visit with a health care provider where a decision was made about how to treat your depression.When this decision was being made... How much effort was made to help you understand your health issues? m No effort at all 1 m 2 m 3 m 4 m 5 m 6 m 7 m 8 m 9 m Every effort was made 10 How much effort was made to listen to the things that matter most to you about your health issues? m No effort at all 1 m 2 m 3 m 4 m 5 m 6 m 7 m 8 m 9 m Every effort was made 10 How much effort was made to include what matters most to you in choosing what to do next? m No effort at all 1 m 2 m 3 m 4 m 5 m 6 m 7 m 8 m 9 m Every effort was made 10

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When was the last time you talked to a health care provider about depression? m Less than a week ago m Between a week and a month ago m Between a month and six months ago m Between six months and a year ago m More than a year ago What is your ethnicity? m Hispanic or Latino/a m Not Hispanic or Latino/a What is your race? Please check all that apply q American Indian or Alaska Native q Asian q Black or African American q Native Hawaiian or Other Pacific Islander q White q Other (please specify) ____________________

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What is the highest grade of school you have completed, or the highest degree you have received? m No school completed, or less than 1 year m Nursery, kindergarten, and elementary (grades 1-‐8) m High school (grades 9-‐12, no diploma) m High school graduate or equivalent (i.e. GED) m Some college (1-‐4 years, no degree) m Trade/technical/vocational training m Associate's degree (including occupational or academic degree) m Bachelor's degree (BA, BS, AB, etc) m Master's degree (MA, MS, MENG, MSW, etc) m Professional degree (MD, DDC, JD, etc) m Doctorate degree (PhD, EdD, etc) m I prefer not to say Are you currently employed? m Yes m No

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Which of the following best describes the area in which you live? m Urban/Metropolitan (50,000 people or more) m Large Rural City/Micropolitan (10,000 -‐ 49,000 people) m Small Rural City/Town (2,500-‐9,999 people) m Isolated Rural Town (under 2,500 and a commute of greater than 60 minutes to an Urban

area) What is your marital status? m Single (never married) m Married m Separated or divorced m Widowed m I prefer not to say

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Do you currently have health insurance coverage? m Yes m No m I prefer not to say Answer If Do you currently have health insurance? Yes Is Selected How do you obtain your health insurance coverage? m Through your current or former employer m Through a family member's current or former employer m Through a public program (e.g., Medicare, Medicaid, CHIP) m Through a government exchange m Directly from a health insurance company m Other (please specify below) ____________________

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Is there anything important that we didn't cover? Please describe below. How did you hear about this survey? m Online community/Blog post m Friend/Colleague m Listserv email m Print advertising m Online advertising m Survey Service m Other ____________________

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Would you like us to share the findings of this study with you? (If you choose to provide your email address, it will be stored securely. We will only contact you for the reason described and we will not share it with any third party.) m Yes, my email address is: ____________________ m No May we invite you to participate in research studies like this one in the future? (You can always choose not to participate if we contact you.) m Yes, my email address is: ____________________ m No

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Clinician Depression Information Priorities What Matters Most? Information Priorities for Treatment of Depression Depression is the most common mental health disorder among Americans, and recognition and treatment are increasing. This survey seeks to identify information priorities in the treatment of depression. Dr. Paul Barr of the Dartmouth Center for Health Care Delivery Science at Dartmouth College, Hanover, NH, USA is conducting this research project. Your participation is voluntary. We are inviting clinicians who have counseled about, diagnosed, or treated patients for depression, live in the U.S., and are comfortable reading and writing in English to participate. Participation involves completion of an anonymous online survey that should take about 10 minutes. The information collected will be maintained anonymously. No names or other identifying information will be collected. There are no right or wrong answers. You may choose not to answer any or all of the questions. Questions about this project may be directed to: Dr. Paul Barr, Assistant Professor, The Dartmouth Institute for Health Policy and Clinical Practice, The Dartmouth Center for Health Care Delivery Science, Hanover, NH 03755, Tel: 603-‐646-‐2578 | Email: [email protected]. Please click on the green arrow button to continue. Thank you for your interest in this survey. Please take a few moments to answer the following questions about depression treatment options. How old are you (in years)? If How old are you (in years)? Is Less Than 18, Then Skip To End of Block Are you comfortable reading and writing in English? m Yes m No If No Is Selected, Then Skip To End of Block Do you speak a language other than English at home? m Yes (please specify below) ____________________ m No

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Where in the United States do you practice? m Alabama m Alaska m Arizona m Arkansas m California m Colorado m Connecticut m Delaware m District of Columbia m Florida m Georgia m Hawaii m Idaho m Illinois m Indiana m Iowa m Kansas m Kentucky m Louisiana m Maine m Maryland m Massachusetts m Michigan m Minnesota m Mississippi m Missouri m Montana m Nebraska m Nevada m New Hampshire m New Jersey m New Mexico m New York m North Carolina m North Dakota m Ohio m Oklahoma m Oregon m Pennsylvania m Rhode Island m South Carolina

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m South Dakota m Tennessee m Texas m Utah m Vermont m Virginia m Washington m West Virginia m Wisconsin m Wyoming m Other US territory m I practice outside the US If I practice outside the US Is Selected, Then Skip To End of Block In the past twelve months, have you counseled, diagnosed, or treated patients with depression? m Yes m No If No Is Selected, Then Skip To End of Block Which option best describes your primary professional role/training? m Primary Care/Internal Medicine Physician m Psychiatrist m Psychologist m Psychiatric/Mental Health Nurse m Social Worker m Licensed Professional Counselor m Other (please specify below) ____________________ How many years since you finished your training? In the last year, approximately what percentage of your patients had depression diagnoses (new or pre-‐existing), regardless of treatment? m A majority of my patients m A substantial portion of my patients m Few of my patients

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Which depression treatment do you most commonly provide or request? m Antidepressant medication m Talk therapy (e.g., Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Problem-‐

solving Therapy) m Alternative therapy m Lifestyle changes m Combination talk therapy and medication m Electroconvulsive therapy m Deep-‐brain stimulation Over the next five screens, we will ask you to evaluate the importance of discussing some common questions about depression treatment from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions? 2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression? Please click on the green arrow button to continue. Please evaluate the questions below from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions?2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression? How does this treatment work?

Extremely Unimportant

Unimportant Neutral Important Extremely Important

Don't know

what this means

Clinician Perspective m m m m m m

Patient Perspective m m m m m m

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Who will be providing this treatment?



Don't know

what this means



Will this treatment work?



Don't know

what this means



How long before the patient feels better?



Don't know

what this means



Please evaluate the questions below from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions?2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression?

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How long will the patient need to be treated?



Don't know

what this means



How quickly can this treatment commence?



Don't know

what this means



What is involved in using this treatment?



Don't know

what this means



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What is involved in stopping this treatment?



Don't know

what this means



Please evaluate the questions below from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions?2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression? What are the side effects of this treatment?



Don't know

what this means



Can the patient have this treatment while they are pregnant?



Don't know

what this means



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Is this treatment addictive?



Don't know

what this means



Will this treatment change the patient's personality?



Don't know

what this means



Will this treatment affect other existing health conditions?



Don't know

what this means



Please evaluate the questions below from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions?2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression?

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Can the patient drink alcohol with this treatment?



Don't know

what this means



Can the patient take recreational drugs with this treatment?



Don't know

what this means



How easy is it to keep this treatment private?



Don't know

what this means



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Will this treatment affect the patient's work/daily routine?



Don't know

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Please evaluate the questions below from the following two perspectives: 1. Clinician perspective: In order to treat your patient's depression, how important do you think it is to discuss the following questions?2. Patient perspective: In your experience, how important do patients believe the following questions are when choosing a treatment for depression? How much does treatment cost?



Don't know

what this means



Is this treatment usually covered by insurance?



Don't know

what this means



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Can the patient use alternative treatments?



Don't know

what this means



Are there other important treatment decision questions that we did not touch upon? If so, please check the box and specify below. q Question 1 ____________________ q Question 2 ____________________ Answer If How does this treatment work? -‐ Extremely Important Is Selected Or How does this treatment work? -‐ Important Is Selected Or Who will be providing this treatment? -‐ Extremely Important Is Selected Or Who will be providing this treatment? -‐ Important Is Selected Or Will this treatment work? -‐ Extremely Important Is Selected Or Will this treatment work? -‐ Important Is Selected Or How long before the patient feels better? -‐ Extremely Important Is Selected Or How long before the patient feels better? -‐ Important Is Selected Or How long will the patient need to be treated? -‐ Extremely Important Is Selected Or How long will the patient need to be treated? -‐ Important Is Selected Or How quickly can this treatment commence? -‐ Extremely Important Is Selected Or How quickly can this treatment commence? -‐ Important Is Selected Or What is involved in using this treatment? -‐ Extremely Important Is Selected Or What is involved in using this treatment? -‐ Important Is Selected Or What is involved in stopping this treatment? -‐ Extremely Important Is Selected Or What is involved in stopping this treatment? -‐ Important Is Selected Or What are the side effects of this treatment? -‐ Extremely Important Is Selected Or What are the side effects of this treatment? -‐ Important Is Selected Or Can the patient have this treatment while they are pregnant? -‐ Extremely Important Is Selected Or Can the patient have this treatment while they are pregnant? -‐ Important Is Selected Or Is this treatment addictive? -‐ Extremely Important Is Selected Or Is this treatment addictive? -‐ Important Is Selected Or Will this treatment change the patient's personality? -‐ Extremely Important Is Selected Or Will this treatment change the patient's personality? -‐ Important Is Selected Or Will this treatment affect other existing health conditions? -‐ Extremely Important Is Selected Or Will this treatment affect other existing health conditions? -‐ Important Is Selected Or Can the patient drink alcohol with this treatment? -‐ Extremely Important Is Selected Or Can the patient drink alcohol with this treatment? -‐ Important Is Selected Or Can the patient take recreational drugs with this treatment? -‐ Extremely Important Is Selected Or Can the patient take recreational drugs with this treatment? -‐ Important Is Selected Or How easy is it to keep this treatment private? -‐ Extremely Important Is Selected Or How easy is it to keep this

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treatment private? -‐ Important Is Selected Or Will this treatment affect the patient's work/daily routine? -‐ Extremely Important Is Selected Or Will this treatment affect the patient's work/daily routine? -‐ Important Is Selected Or How much does treatment cost? -‐ Extremely Important Is Selected Or How much does treatment cost? -‐ Important Is Selected Or Is this treatment usually covered by insurance? -‐ Extremely Important Is Selected Or Is this treatment usually covered by insurance? -‐ Important Is Selected Or Can the patient use alternative treatments? -‐ Extremely Important Is Selected Or Can the patient use alternative treatments? -‐ Important Is Selected On the next two pages, we will ask you to rank the most important questions from the previous two perspectives; first as a clinician, and second as a patient. Please click on the green arrow button to continue.

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Answer If How does this treatment work? Clinician Perspective -‐ Extremely Important Is Selected Or How does this treatment work? Clinician Perspective -‐ Important Is Selected Or Who will be providing this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or Who will be providing this treatment? Clinician Perspective -‐ Important Is Selected Or Will this treatment work? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment work? Clinician Perspective -‐ Important Is Selected Or How long before the patient feels better? Clinician Perspective -‐ Extremely Important Is Selected Or How long before the patient feels better? Clinician Perspective -‐ Important Is Selected Or How long will the patient need to be treated? Clinician Perspective -‐ Extremely Important Is Selected Or How long will the patient need to be treated? Clinician Perspective -‐ Important Is Selected Or How quickly can this treatment commence? Clinician Perspective -‐ Extremely Important Is Selected Or How quickly can this treatment commence? Clinician Perspective -‐ Important Is Selected Or What is involved in using this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What is involved in using this treatment? Clinician Perspective -‐ Important Is Selected Or What is involved in stopping this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What is involved in stopping this treatment? Clinician Perspective -‐ Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Important Is Selected Or Can the patient have this treatment while they are pregnant? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient have this treatment while they are pregnant? Clinician Perspective -‐ Important Is Selected Or Is this treatment addictive? Clinician Perspective -‐ Extremely Important Is Selected Or Is this treatment addictive? Clinician Perspective -‐ Important Is Selected Or Will this treatment change the patient's personality? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment change the patient's personality? Clinician Perspective -‐ Important Is Selected Or Will this treatment affect other existing health conditions? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Clinician Perspective -‐ Important Is Selected Or Can the patient drink alcohol with this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient drink alcohol with this treatment? Clinician Perspective -‐ Important Is Selected Or Can the patient take recreational drugs with this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient take recreational drugs with this treatment? Clinician Perspective -‐ Important Is Selected Or How easy is it to keep this treatment private? Clinician Perspective -‐ Extremely Important Is Selected Or How easy is it to keep this treatment private? Clinician Perspective -‐ Important Is Selected Or Will this treatment affect the patient's work/daily routine? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment affect the patient's work/daily routine? Clinician Perspective -‐ Important Is Selected Or How much does treatment cost? Clinician Perspective -‐ Extremely Important Is Selected Or How much does treatment cost? Clinician Perspective -‐ Important Is Selected Or Is this treatment usually covered by insurance? Clinician Perspective -‐ Extremely Important Is Selected Or Is this treatment usually covered by insurance? Clinician Perspective -‐ Important Is Selected Or Can the patient use alternative treatments? Clinician Perspective -‐ Extremely

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Important Is Selected Or Can the patient use alternative treatments? Clinician Perspective -‐ Important Is Selected Below are the questions which you rated "important" or "extremely important" from the clinician perspective when considering treatment for depression. Please rank your TOP FIVE questions as a clinician in order of most to least important. Please drag these questions to the top. The most important question should be in position 1, the second most important in position 2, and so on. The order of any remaining questions can be disregarded. If Will this treatment work? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment work? Clinician Perspective -‐ Important Is Selected

______ Will this treatment work? If How long before the patient feels better? Clinician Perspective -‐ Extremely Important Is Selected Or How long before the patient feels better? Clinician Perspective -‐ Important Is Selected

______ How long before the patient feels better? If Will this treatment affect other existing health conditions? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Clinician Perspective -‐ Important Is Selected

______ Will this treatment affect other existing health conditions? If Can the patient use alternative treatments? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient use alternative treatments? Clinician Perspective -‐ Important Is Selected

______ Can the patient use alternative treatments? If How long will the patient need to be treated? Clinician Perspective -‐ Extremely Important Is Selected Or How long will the patient need to be treated? Clinician Perspective -‐ Important Is Selected

______ How long will the patient need to be treated? If What is involved in using this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What is involved in using this treatment? Clinician Perspective -‐ Important Is Selected

______ What is involved in using this treatment? If What is involved in stopping this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What is involved in stopping this treatment? Clinician Perspective -‐ Important Is Selected

______ What is involved in stopping this treatment? If Will this treatment affect the patient's work/daily routine? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment affect the patient's work/daily routine? Clinician Perspective -‐ Important Is Selected

______ Will this treatment affect the patient's work/daily routine? If Is this treatment usually covered by insurance? Clinician Perspective -‐ Extremely Important Is Selected Or Is this treatment usually covered by insurance? Clinician Perspective -‐ Important Is Selected

______ Is this treatment usually covered by insurance?

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If Is this treatment addictive? Clinician Perspective -‐ Extremely Important Is Selected Or Is this treatment addictive? Clinician Perspective -‐ Important Is Selected

______ Is this treatment addictive? If Will this treatment change the patient's personality? Clinician Perspective -‐ Extremely Important Is Selected Or Will this treatment change the patient's personality? Clinician Perspective -‐ Important Is Selected

______ Will this treatment change the patient's personality? If How does this treatment work? Clinician Perspective -‐ Extremely Important Is Selected Or How does this treatment work? Clinician Perspective -‐ Important Is Selected

______ How does this treatment work? If How much does treatment cost? Clinician Perspective -‐ Extremely Important Is Selected Or How much does treatment cost? Clinician Perspective -‐ Important Is Selected

______ How much does treatment cost? If How easy is it to keep this private? Clinician Perspective -‐ Extremely Important Is Selected Or How easy is it to keep this private? Clinician Perspective -‐ Important Is Selected

______ How easy is it to keep this treatment private? If Who will be providing this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or Who will be providing this treatment? Clinician Perspective -‐ Important Is Selected

______ Who will be providing this treatment? If Can the patient drink alcohol with this treatment? Clinician Perspective -‐ Extremely Important Is Selected

______ Can the patient drink alcohol with this treatment? If Can the patient take recreational drugs with this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient take recreational drugs with this treatment? Clinician Perspective -‐ Important Is Selected

______ Can the patient use recreational drugs with this treatment? If Can the patient have this treatment while they are pregnant? Clinician Perspective -‐ Extremely Important Is Selected Or Can the patient have this treatment while they are pregnant? Clinician Perspective -‐ Important Is Selected

______ Can the patient have this treatment while they are pregnant? If How quickly can this treatment commence? Clinician Perspective -‐ Extremely Important Is Selected Or How quickly can this treatment commence? Clinician Perspective -‐ Important Is Selected

______ How quickly can this treatment commence? If What are the side effects of this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Important Is Selected

______ What are the side effects of this treatment?

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Answer If How does this treatment work? Patient Perspective -‐ Extremely Important Is Selected Or How does this treatment work? Patient Perspective -‐ Important Is Selected Or Who will be providing this treatment? Patient Perspective -‐ Extremely Important Is Selected Or Who will be providing this treatment? Patient Perspective -‐ Important Is Selected Or Will this treatment work? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment work? Patient Perspective -‐ Important Is Selected Or How long before the patient feels better? Patient Perspective -‐ Extremely Important Is Selected Or How long before the patient feels better? Patient Perspective -‐ Important Is Selected Or How long will the patient need to be treated? Patient Perspective -‐ Extremely Important Is Selected Or How long will the patient need to be treated? Patient Perspective -‐ Important Is Selected Or How quickly can this treatment commence? Patient Perspective -‐ Extremely Important Is Selected Or How quickly can this treatment commence? Patient Perspective -‐ Important Is Selected Or What is involved in using this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What is involved in using this treatment? Patient Perspective -‐ Important Is Selected Or What is involved in stopping this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What is involved in stopping this treatment? Patient Perspective -‐ Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Important Is Selected Or Can the patient have this treatment while they are pregnant? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient have this treatment while they are pregnant? Patient Perspective -‐ Important Is Selected Or Is this treatment addictive? Patient Perspective -‐ Extremely Important Is Selected Or Is this treatment addictive? Patient Perspective -‐ Important Is Selected Or Will this treatment change the patient's personality? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment change the patient's personality? Patient Perspective -‐ Important Is Selected Or Will this treatment affect other existing health conditions? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Patient Perspective -‐ Important Is Selected Or Can the patient drink alcohol with this treatment? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient drink alcohol with this treatment? Patient Perspective -‐ Important Is Selected Or Can the patient take recreational drugs with this treatment? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient take recreational drugs with this treatment? Patient Perspective -‐ Important Is Selected Or How easy is it to keep this treatment private? Patient Perspective -‐ Extremely Important Is Selected Or How easy is it to keep this treatment private? Patient Perspective -‐ Important Is Selected Or Will this treatment affect the patient's work/daily routine? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment affect the patient's work/daily routine? Patient Perspective -‐ Important Is Selected Or How much does treatment cost? Patient Perspective -‐ Extremely Important Is Selected Or How much does treatment cost? Patient Perspective -‐ Important Is Selected Or Is this treatment usually covered by insurance? Patient Perspective -‐ Extremely Important Is Selected Or Is this treatment usually covered by insurance? Patient Perspective -‐ Important Is Selected Or Can the patient use alternative treatments? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient use alternative treatments? Patient Perspective -‐ Important Is Selected

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Below are the questions which you rated "important" or "extremely important" from the patient perspective when considering treatment for depression. Please rank your TOP FIVE questions from the patient perspective in order of most to least important. Please drag these questions to the top. The most important question should be in position 1, the second most important in position 2, and so on. The order of any remaining questions can be disregarded. If Will this treatment work? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment work? Patient Perspective -‐ Important Is Selected

______ Will this treatment work? If How long before the patient feels better? Patient Perspective -‐ Extremely Important Is Selected Or How long before the patient feels better? Patient Perspective -‐ Important Is Selected

______ How long before the patient feels better? If Will this treatment affect other existing health conditions? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment affect other existing health conditions? Patient Perspective -‐ Important Is Selected

______ Will this treatment affect other existing health conditions? If Can the patient use alternative treatments? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient use alternative treatments? Patient Perspective -‐ Important Is Selected

______ Can the patient use alternative treatments? If How long will the patient need to be treated? Patient Perspective -‐ Extremely Important Is Selected Or How long will the patient need to be treated? Patient Perspective -‐ Important Is Selected

______ How long will the patient need to be treated? If What is involved in using this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What is involved in using this treatment? Patient Perspective -‐ Important Is Selected

______ What is involved in using this treatment? If What is involved in stopping this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What is involved in stopping this treatment? Patient Perspective -‐ Important Is Selected

______ What is involved in stopping this treatment? If Will this treatment affect the patient's work/daily routine? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment affect the patient's work/daily routine? Patient Perspective -‐ Important Is Selected

______ Will this treatment affect the patient's work/daily routine? If Is this treatment usually covered by insurance? Patient Perspective -‐ Extremely Important Is Selected Or Is this treatment usually covered by insurance? Patient Perspective -‐ Important Is Selected

______ Is this treatment usually covered by insurance? If Is this treatment addictive? Patient Perspective -‐ Extremely Important Is Selected Or Is this treatment addictive? Patient Perspective -‐ Important Is Selected

______ Is this treatment addictive?

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If Will this treatment change the patient's personality? Patient Perspective -‐ Extremely Important Is Selected Or Will this treatment change the patient's personality? Patient Perspective -‐ Important Is Selected

______ Will this treatment change the patient's personality? If How does this treatment work? Patient Perspective -‐ Extremely Important Is Selected Or How does this treatment work? Patient Perspective -‐ Important Is Selected

______ How does this treatment work? If How much does treatment cost? Patient Perspective -‐ Extremely Important Is Selected Or How much does treatment cost? Patient Perspective -‐ Important Is Selected

______ How much does treatment cost? If How easy is it to keep this private? Patient Perspective -‐ Extremely Important Is Selected Or How easy is it to keep this private? Patient Perspective -‐ Important Is Selected

______ How easy is it to keep this treatment private? If Who will be providing this treatment? Patient Perspective -‐ Extremely Important Is Selected Or Who will be providing this treatment? Patient Perspective -‐ Important Is Selected

______ Who will be providing this treatment? If Can the patient drink alcohol with this treatment? Patient Perspective -‐ Extremely Important Is Selected

______ Can the patient drink alcohol with this treatment? If Can the patient take recreational drugs with this treatment? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient take recreational drugs with this treatment? Patient Perspective -‐ Important Is Selected

______ Can the patient use recreational drugs with this treatment? If Can the patient have this treatment while they are pregnant? Patient Perspective -‐ Extremely Important Is Selected Or Can the patient have this treatment while they are pregnant? Patient Perspective -‐ Important Is Selected

______ Can the patient have this treatment while they are pregnant? If How quickly can this treatment commence? Patient Perspective -‐ Extremely Important Is Selected Or How quickly can this treatment commence? Patient Perspective -‐ Important Is Selected

______ How quickly can this treatment commence? If What are the side effects of this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Important Is Selected

______ What are the side effects of this treatment?

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Answer If What are the side effects of this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Important Is Selected Please review the following possible side effects of depression treatment. As a clinician, what are the top FIVE most concerning side effects?Please drag these side effects to the top. The most important side effect should be in position 1, the second most important in position 2, and so on. The order of the remaining side effects can be disregarded. ______ Weight change ______ Sleep issues ______ Nausea/Vomiting ______ Constipation ______ Diarrhea ______ Increased risk of suicide ______ Harm to an unborn child ______ Drug-‐drug interactions ______ Heart problems ______ Seizures ______ Sexual issues ______ Increased stress Answer If What are the side effects of this treatment? Clinician Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Clinician Perspective -‐ Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Extremely Important Is Selected Or What are the side effects of this treatment? Patient Perspective -‐ Important Is Selected Are there important side effects not listed? m No m Yes (please list below) ____________________ In your practice, which of the following best describes how decisions about depression treatment are made? m The patient makes the decision about treatment m The patient makes the decision about treatment, after seriously considering my opinion m The patient and I make the decision about treatment jointly m I make the decision about treatment, after seriously considering the patient's opinion m I make the decision about treatment

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What is your gender? m Male m Female m Other What is your ethnicity? m Hispanic or Latino/a m Not Hispanic or Latino/a

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What is your race? (Please select all that apply.) q American Indian or Alaska Native q Asian q Black or African American q Native Hawaiian or Other Pacific Islander q White q Other (please specify below) ____________________ Which of the following best describes the area in which you practice? m Urban/Metropolitan (50,000 people or more) m Large Rural City/Micropolitan (10,000 -‐ 49,000 people) m Small Rural City/Town (2,500-‐9,999 people) m Isolated Rural Town (under 2,500 and commute of greater than 60 minutes to an Urban

area)

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Is there anything important that we didn't cover? Please describe below. How did you hear about this survey? m Colleague/Friend m Professional Organization m Listserv email m Print advertising m Online advertising m Other ____________________

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Would you like us to share the findings of this study with you? (If you choose to provide your email address, it will be stored securely. We will only contact you for the reason described and we will not share it with any third party.) m Yes, my email address is: ____________________ m No May we invite you to participate in research studies like this one in the future? (You can always choose not to participate if we contact you.) m Yes, my email address is: ____________________ m No

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Appendix 4. Top 5 most concerning side effects Clinicians (clinician perspective) Side effect Weighted score N #1 Increased risk of suicide 620

#2 Drug-‐drug interactions 353 #3 Heart problems 270 #4 Weight change 247 #5 Sexual issues 242 Total

183

Consumers Side effect Weighted score N #1 Increased risk of suicide 1916

#2 Sleep issues 1669 #3 Weight change 1642 #4 Heart problems 1330 #5 Increased stress 1128 Total 794

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Appendix 5. Clinician subgroup rankings Primary care physicians (clinician perspective) Information priority Weighted score N #1 Will this treatment work? 208

#2 What are the side effects of this treatment? 144 #3 How long before the patient feels better? 122 #4 (tie) Will the treatment affect other existing health conditions? 83 #4 (tie) How much does the treatment cost? 83 Total

76

Psychiatrists (clinician perspective) Information priority Weighted score N #1 Will this treatment work? 97

#2 What are the side effects of this treatment? 65 #3 How long before the patient feels better? 34 #4 Will the treatment affect other existing health conditions? 28 #5 What is involved in using this treatment? 24 Total

22

Therapists (clinician perspective) Information priority Weighted score N #1 Will this treatment work? 225

#2 How does the treatment work? 149 #3 What is involved in using this treatment? 145 #4 How long before the patient feels better? 144 #5 What are the side effects of this treatment? 74 Total

83

Primary care physicians (consumer perspective) Information priority Weighted score N #1 Will this treatment work? 193

#2 How long before the patient feels better? 144 #3 How much does the treatment cost? 114

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#4 Is the treatment usually covered by insurance? 99 #5 What are the side effects? 91 Total

70

Psychiatrists (consumer perspective) Information priority Weighted score N #1 Will this treatment work? 63

#2 What are the side effects? 44 #3 How long before the patient feels better? 38 #4 Will the treatment affect the patient's work or daily routine? 20 #5 How much does the treatment cost? 18 Total

18

Therapists (consumer perspective) Information priority Weighted score N #1 (tie) Will this treatment work? 167

#1 (tie) How long before the patient feels better? 167 #3 How much does the treatment cost? 94 #4 Is the treatment usually covered by insurance? 83 #5 What are the side effects? 73 Total 65

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2-3

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5-6

Objectives 3 State specific objectives, including any prespecified hypotheses 6

Methods

Study design 4 Present key elements of study design early in the paper 7

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

7-8

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 7-8

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

8-9

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

8-9

Bias 9 Describe any efforts to address potential sources of bias 8

Study size 10 Explain how the study size was arrived at 11

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

10

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 10

(b) Describe any methods used to examine subgroups and interactions 10

(c) Explain how missing data were addressed 10

(d) If applicable, describe analytical methods taking account of sampling strategy 10

(e) Describe any sensitivity analyses

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

11

(b) Give reasons for non-participation at each stage 11

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

12-13

(b) Indicate number of participants with missing data for each variable of interest 12-13

Outcome data 15* Report numbers of outcome events or summary measures N/A

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

17

(b) Report category boundaries when continuous variables were categorized 12

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 16

Discussion

Key results 18 Summarise key results with reference to study objectives

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

25

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

23

Generalisability 21 Discuss the generalisability (external validity) of the study results 24

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

28

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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