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| ID | Type | Description | Link |
|---|---|---|---|
| R21DK123582 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) | NIH |
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This pilot randomized controlled trial seeks: (1) to determine the preliminary efficacy of our modernized collaborative care intervention for depression in improving the diabetes risk markers of hemoglobin A1c and insulin resistance and (2) to explore whether somatic depressive symptoms - i.e., hyperphagia (increased appetite/weight) and/or hypersomnia (increased sleep) - moderate the effect of the eIMPACT-DM intervention on diabetes risk markers.
Diabetes affects 31 million (12%) U.S. adults, and another 82 million (34%) adults have prediabetes, a precursor to diabetes. The ramifications of diabetes are grave and include cardiovascular disease, disability, and death. While these statistics highlight the importance of diabetes prevention, current approaches have only partial effectiveness. This has created a clear need to identify new primary prevention targets and approaches for diabetes, and depression and depression treatment are strong candidates in this regard. Over 20 years of evidence indicates that depression is an independent, clinically important, robust, biobehaviorally plausible, and modifiable risk factor for diabetes. However, research has yet to determine whether depression treatment can prevent the development of diabetes in people with prediabetes. Given that depression is still receiving limited attention in settings where diabetes prevention occurs (e.g., primary care), there is a large cohort of patients with an underdetected or undertreated diabetes risk factor (depression). This status quo and the strong state of the depression-to-diabetes science create the need for a pilot randomized controlled trial to evaluate the utility of depression treatment as a new diabetes prevention strategy. Thus, we propose a pilot RCT of 64 primary care patients (50% minority) with a depressive disorder and prediabetes. Patients will be randomized to 6 months of eIMPACT-DM (intervention) or Active Control (comparator). eIMPACT-DM is our modernized collaborative stepped care intervention consisting of (1) computerized and telephonic cognitive-behavioral therapy for depression and (2) select antidepressant medications included in an algorithm optimized for diabetes risk reduction. Our preliminary data establish the feasibility and antidepressive efficacy of eIMPACT-DM. The Active Control consists of depression education, symptom monitoring, and primary care for depression. Our primary aim is to determine the preliminary efficacy of eIMPACT-DM in improving the diabetes risk markers of hemoglobin A1c (primary outcome) and insulin resistance (secondary outcome). Our exploratory aim is to explore whether somatic depressive symptoms - i.e., hyperphagia (increased appetite/weight) and/or hypersomnia (increased sleep) - moderate the effect of eIMPACT-DM on diabetes risk markers. A positive pilot trial would pave the way to an R01-level RCT by: (1) generating critical proof-of-concept data (eIMPACT-DM can improve A1c) to support the premise of the definitive trial; (2) providing preliminary effect sizes for eIMPACT-DM on diabetes risk markers to help justify future power analyses; (3) identifying a potentially important moderator of eIMPACT-DM efficacy that may need to be incorporated into the definitive trial. Ultimately, demonstrating that depression treatment reduces diabetes risk would identify a novel target (depression) for diabetes prevention efforts, and it would equip healthcare providers with a new practical, scalable, and disseminable intervention (eIMPACT-DM) to help lower diabetes risk for a large cohort of high-risk patients. These practice changes should translate into reduced diabetes morbidity, mortality, and costs.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| eIMPACT-DM intervention | Experimental | eIMPACT-DM is a 6-month, modernized, collaborative, stepped care intervention consisting of (1) computerized and telephonic cognitive-behavioral therapy for depression and (2) select antidepressant medications included in an algorithm optimized for diabetes risk reduction. It is a collaborative care intervention in which a multidisciplinary team delivers established depression treatments consistent with patient preference. It uses a stepped, flexible, treat-to-target approach that modernizes the IMPACT intervention by harnessing technology to minimize staff and space requirements. Interventions are Good Days Ahead, Problem Solving Treatment in Primary Care, and select FDA-approved antidepressants. The treatment team consists of a depression clinical specialist, a supervising MD with expertise in primary care and IMPACT, and the patients' primary care providers (PCPs). |
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| Active Control | Active Comparator | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Good Days Ahead (GDA) | Behavioral | GDA (Empower Interactive) is an empirically supported, HIPAA compliant, computerized CBT for depression appropriate for primary care patients and people with little computer experience. GDA uses an interactive, multimedia format to deliver 9 45-minute sessions, the structure and content of which mirror face-to-face CBT. General topics include identifying and modifying automatic thoughts, using behavioral activation and other behavioral methods, identifying and modifying schemas, using effective coping strategies, and employing other core CBT methods. GDA is empirically supported - it is acceptable to patients, achieves superior depression outcomes to waitlist comparators, and yields equivalent (noninferior) depression outcomes to standard face-to-face CBT. To minimize time/transportation barriers, GDA sessions occur at the PI's lab or a location with internet access selected by the patient (patient's, family member's, or friend's home). |
| Measure | Description | Time Frame |
|---|---|---|
| Hemoglobin A1c at 6 Months | Fasting blood samples were collected, and whole blood and plasma aliquots were frozen. Hemoglobin A1c will be measured by a standard method. A1c is the primary outcome because: (1) it is the gold standard measure of glycemia and a common surrogate endpoint, (2) it strongly predicts future diabetes, (3) interventions decreasing A1c improve clinical diabetes endpoints, and (4) diabetes prevention interventions targeting glycemic control result in lower rates of progression from prediabetes to type 2 diabetes. Higher hemoglobin A1c values indicate greater diabetes risk. | 6 months |
| Measure | Description | Time Frame |
|---|---|---|
| Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) Score at 6 Months | Higher HOMA-IR scores indicate greater insulin resistance. Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) scores were derived from fasting glucose and insulin values measured by standard assays. HOMA-IR score is an established index of insulin resistance that correlates highly with the more invasive euglycemic clamp and is appropriate for assessing change. Higher HOMA-IR scores indicate greater insulin resistance. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Jesse C Stewart, PhD | Indiana University-Purdue University Indianapolis (IUPUI) | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| IUPUI Department of Psychology | Indianapolis | Indiana | 46202 | United States |
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| ID | Title | Description |
|---|---|---|
| FG000 | eIMPACT-DM Intervention | eIMPACT-DM is a 6-month, modernized, collaborative, stepped care intervention consisting of (1) internet and telephonic CBT for depression and (2) select antidepressant medications in an algorithm optimized for diabetes risk reduction. A multidisciplinary team delivers established depression treatments consistent with patient preference. Good Days Ahead (GDA; MindStreet, Inc.) is an empirically supported internet CBT for depression that uses an interactive, multimedia format to deliver 9 45-minute sessions, the structure and content of which mirror face-to-face CBT. GDA sessions occurred at a location with internet access selected by the patient or the PI's lab. Problem Solving Treatment in Primary Care (PST-PC) is an empirically supported CBT. During the 6-10 30-minute sessions, patients are taught skills for solving problems contributing to depression. We delivered PST-PC by phone. Regarding medications, we first considered all FDA-approved antidepressants and excluded those with weight gain effects and those rarely used in primary care. We then made bupropion and fluoxetine our first-line and second-line antidepressants, given their association with weight loss. We made other SSRIs (escitalopram, sertraline) and SNRIs (desvenlafaxine, duloxetine, venlafaxine) our third-line antidepressants, given their negligible effects on weight. Our team made recommendations to the patient's PCP, who wrote prescriptions. Our team and the PCP collaboratively managed pharmacotherapy. |
| Title | Milestones | Reasons Not Completed | |||||
|---|---|---|---|---|---|---|---|
| Overall Study |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | May 19, 2021 |
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| Problem Solving Treatment in Primary Care (PST-PC) | Behavioral | PST-PC is an established, manualized, empirically supported CBT developed for primary care. During the 6-10 30-minute sessions, patients are taught skills for solving problems contributing to depression. We will deliver PST-PC by phone, which has been found to be feasible and efficacious. |
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| Antidepressant Medications | Drug | We first considered all FDA-approved antidepressants and excluded those with weight gain effects (tricyclics, paroxetine, mirtazapine) and those rarely used in primary care (MAOIs). Then, we used existing evidence to inform the structure. We made bupropion (an aminoketone) and fluoxetine (an SSRI) our first-line and second-line antidepressants, as meta-analyses indicate that their use is associated with weight loss. We made other SSRIs (escitalopram, sertraline) and SNRIs (desvenlafaxine, duloxetine, venlafaxine) our third-line antidepressants, given their negligible effects on weight. Our team will make recommendations to the patient's PCP, who will write prescriptions. Our team and the PCP will then collaboratively manage pharmacotherapy. |
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| Active Control | Other | (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. |
|
| 6 months |
| Depressive Symptoms | Participants completed the reliable and valid Hopkins Symptom Checklist-20 (SCL-20) to assess depressive symptoms. Total scores (mean of items responses, range: 0-4) were computed, with higher scores indicating greater depressive symptoms. | 6 months |
| FG001 | Active Control | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). Active Control: (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. |
| COMPLETED |
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| NOT COMPLETED |
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| ID | Title | Description |
|---|---|---|
| BG000 | eIMPACT-DM Intervention | eIMPACT-DM is a 6-month, modernized, collaborative, stepped care intervention consisting of (1) internet and telephonic CBT for depression and (2) select antidepressant medications in an algorithm optimized for diabetes risk reduction. A multidisciplinary team delivers established depression treatments consistent with patient preference. Good Days Ahead (GDA; MindStreet, Inc.) is an empirically supported internet CBT for depression that uses an interactive, multimedia format to deliver 9 45-minute sessions, the structure and content of which mirror face-to-face CBT. GDA sessions occurred at a location with internet access selected by the patient or the PI's lab. Problem Solving Treatment in Primary Care (PST-PC) is an empirically supported CBT. During the 6-10 30-minute sessions, patients are taught skills for solving problems contributing to depression. We delivered PST-PC by phone. Regarding medications, we first considered all FDA-approved antidepressants and excluded those with weight gain effects and those rarely used in primary care. We then made bupropion and fluoxetine our first-line and second-line antidepressants, given their association with weight loss. We made other SSRIs (escitalopram, sertraline) and SNRIs (desvenlafaxine, duloxetine, venlafaxine) our third-line antidepressants, given their negligible effects on weight. Our team made recommendations to the patient's PCP, who wrote prescriptions. Our team and the PCP collaboratively managed pharmacotherapy. |
| BG001 | Active Control | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). Active Control: (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. |
| BG002 | Total | Total of all reporting groups |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean | Standard Deviation | years |
| |||||||||||||||
| Sex: Female, Male | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | Count of Participants | Participants |
| ||||||||||||||||
| Race (NIH/OMB) | Count of Participants | Participants |
| ||||||||||||||||
| Region of Enrollment | Number | participants |
| ||||||||||||||||
| Depressive Symptoms | Participants completed the reliable and valid Hopkins Symptom Checklist-20 (SCL-20) to assess depressive symptoms. Total scores (mean of items responses, range: 0-4) were computed, with higher scores indicating greater depressive symptoms. | Mean | Standard Deviation | Score on a scale |
| ||||||||||||||
| Hemoglobin A1c | Fasting blood samples were collected, and whole blood and plasma aliquots were frozen. Hemoglobin A1c will be measured by a standard method. A1c is the primary outcome because: (1) it is the gold standard measure of glycemia and a common surrogate endpoint, (2) it strongly predicts future diabetes, (3) interventions decreasing A1c improve clinical diabetes endpoints, and (4) diabetes prevention interventions targeting glycemic control result in lower rates of progression from prediabetes to type 2 diabetes. Higher hemoglobin A1c values indicate greater diabetes risk. | Values are from observed dataset. 39 out of 46 participants had observed data. | Mean | Standard Deviation | % (percentage of total hemoglobin) |
| |||||||||||||
| HOMA-IR score | Higher HOMA-IR scores indicate greater insulin resistance. Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) scores were derived from fasting glucose and insulin values measured by standard assays. HOMA-IR score is an established index of insulin resistance that correlates highly with the more invasive euglycemic clamp and is appropriate for assessing change. Higher HOMA-IR scores indicate greater insulin resistance. | Values are from observed dataset. 39 out of 46 participants had observed data. | Mean | Standard Deviation | HOMA-IR index |
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| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Hemoglobin A1c at 6 Months | Fasting blood samples were collected, and whole blood and plasma aliquots were frozen. Hemoglobin A1c will be measured by a standard method. A1c is the primary outcome because: (1) it is the gold standard measure of glycemia and a common surrogate endpoint, (2) it strongly predicts future diabetes, (3) interventions decreasing A1c improve clinical diabetes endpoints, and (4) diabetes prevention interventions targeting glycemic control result in lower rates of progression from prediabetes to type 2 diabetes. Higher hemoglobin A1c values indicate greater diabetes risk. | Posted | Mean | Standard Deviation | % (percentage of total hemoglobin) | 6 months |
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| Secondary | Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) Score at 6 Months | Higher HOMA-IR scores indicate greater insulin resistance. Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) scores were derived from fasting glucose and insulin values measured by standard assays. HOMA-IR score is an established index of insulin resistance that correlates highly with the more invasive euglycemic clamp and is appropriate for assessing change. Higher HOMA-IR scores indicate greater insulin resistance. | Posted | Mean | Standard Deviation | HOMA-IR index | 6 months |
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| Secondary | Depressive Symptoms | Participants completed the reliable and valid Hopkins Symptom Checklist-20 (SCL-20) to assess depressive symptoms. Total scores (mean of items responses, range: 0-4) were computed, with higher scores indicating greater depressive symptoms. | Missing data was handled using within subject mean imputation when < 25% of the data was missing. | Posted | Mean | Standard Deviation | Score on a scale | 6 months |
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The adverse event monitoring period for each participant was 6 months, corresponding to the time from each participant's pre-treatment visit (i.e., randomization date) to the completion of their post-treatment visit.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | eIMPACT-DM Intervention | eIMPACT-DM is a 6-month, modernized, collaborative, stepped care intervention consisting of (1) internet and telephonic CBT for depression and (2) select antidepressant medications in an algorithm optimized for diabetes risk reduction. A multidisciplinary team delivers established depression treatments consistent with patient preference. Good Days Ahead (GDA; MindStreet, Inc.) is an empirically supported internet CBT for depression that uses an interactive, multimedia format to deliver 9 45-minute sessions, the structure and content of which mirror face-to-face CBT. GDA sessions occurred at a location with internet access selected by the patient or the PI's lab. Problem Solving Treatment in Primary Care (PST-PC) is an empirically supported CBT. During the 6-10 30-minute sessions, patients are taught skills for solving problems contributing to depression. We delivered PST-PC by phone. Regarding medications, we first considered all FDA-approved antidepressants and excluded those with weight gain effects and those rarely used in primary care. We then made bupropion and fluoxetine our first-line and second-line antidepressants, given their association with weight loss. We made other SSRIs (escitalopram, sertraline) and SNRIs (desvenlafaxine, duloxetine, venlafaxine) our third-line antidepressants, given their negligible effects on weight. Our team made recommendations to the patient's PCP, who wrote prescriptions. Our team and the PCP collaboratively managed pharmacotherapy. | 0 | 24 | 0 | 24 | 1 | 24 |
| EG001 | Active Control | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). Active Control: (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. | 0 | 22 | 0 | 22 | 3 | 22 |
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| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Blood pressure above the call order levels | Cardiac disorders | Systematic Assessment |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Jesse C. Stewart, PhD., Principal Investigator | Indiana University-Purdue University Indianapolis (IUPUI) | 317-274-6761 | jstew@iupui.edu |
| Aug 24, 2023 |
| Prot_SAP_000.pdf |
| ICF | No | No | Yes | Informed Consent Form | May 6, 2021 | Aug 24, 2023 | ICF_001.pdf |
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| ID | Term |
|---|---|
| D003863 | Depression |
| D003865 | Depressive Disorder, Major |
| D019263 | Dysthymic Disorder |
| D003924 | Diabetes Mellitus, Type 2 |
| D011236 | Prediabetic State |
| D007333 | Insulin Resistance |
| ID | Term |
|---|---|
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
| D003866 | Depressive Disorder |
| D019964 | Mood Disorders |
| D001523 | Mental Disorders |
| D003920 | Diabetes Mellitus |
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D004700 | Endocrine System Diseases |
| D006946 | Hyperinsulinism |
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| ID | Term |
|---|---|
| D015928 | Cognitive Behavioral Therapy |
| D011320 | Primary Health Care |
| D016642 | Bupropion |
| D017367 | Selective Serotonin Reuptake Inhibitors |
| D000068760 | Serotonin and Noradrenaline Reuptake Inhibitors |
| ID | Term |
|---|---|
| D001521 | Behavior Therapy |
| D011613 | Psychotherapy |
| D004191 | Behavioral Disciplines and Activities |
| D003191 | Comprehensive Health Care |
| D010346 | Patient Care Management |
| D006298 | Health Services Administration |
| D011427 | Propiophenones |
| D007659 | Ketones |
| D009930 | Organic Chemicals |
| D014179 | Neurotransmitter Uptake Inhibitors |
| D049990 | Membrane Transport Modulators |
| D045504 | Molecular Mechanisms of Pharmacological Action |
| D020228 | Pharmacologic Actions |
| D020164 | Chemical Actions and Uses |
| D018377 | Neurotransmitter Agents |
| D018490 | Serotonin Agents |
| D045505 | Physiological Effects of Drugs |
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| OG001 | Active Control | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). Active Control: (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. |
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| OG001 | Active Control | Active Control (AC) consists of depression education (study staff), symptom monitoring (study staff), and primary care for depression (clinical staff). Active Control: (1) The graduate research assistant (RA) will have a 50-minute call with AC patients to review depression materials. The RA will provide a list of Eskenazi Health mental health services and will encourage patients to follow-up with their PCP. We will then send an electronic health record message to the PCP encouraging them to address their patient's depression, note that there are no care restrictions, and provide the same list of services. (2) The RA will call AC patients every 4 weeks to assess depressive symptoms and will notify clinical staff to encourage additional care when indicated. (3) AC patients will receive current primary care for depression. The Eskenazi Health primary care clinics utilize a team care approach, with PCPs supported by embedded behavioral health clinicians and affiliated psychiatrists. |
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