Dobscha 2006.

Methods	Cluster‐randomised trial of a decision support intervention compared to standard care
Participants	Consumers (n = 375): consumers of participating clinicians with Patient Health Questionnaire (PHQ)‐9 depression scores of 10 to 25 at screening and between 10 to 20 or a score of at least 1 on the Hopkins Symptom checklist (SCL‐20) at enrolment. Major depression 49%, dysthymia 47%, moderate‐great pain 68%, alcohol disorder 17%, panic disorder 14%, other anxiety disorder 25%, PTSD 39%, taking antidepressant at study entry 41%. Their mean age 56.8 years, 349 were male; white 177, non‐white 10, not recorded 188. Excluded: received specialist mental health treatment in previous six months, dementia, psychotic or bipolar disorder terminal illness, and people referred for urgent care because of PHQ‐9 scores of 25 or more and/or active dangerous ideation. Primary care providers (n = 41): full and part time physicians (28), physician assistants or nurse practitioners (13). Mean age 45.1 years; female 21. Mean time since training 15.1 years. Mental health specialists (n = 2): One psychiatrist 4 hours per week and one nurse care manager 8 hours per week in the intervention group. An on‐site mental health consultation team was also available to both groups. Setting: five Veterans Affairs medical clinics (3 urban, 2 rural), Portland USA, 2002‐3.
Interventions	1. Depression decision support (n = 189) Mental health specialist/consumer: the Depression Support Team nurse called the consumer 1 to 2 weeks after enrolment to discuss education, barriers, adherence, and communicating with the primary care provider. Consumers were also mailed educational materials and invited to a two‐hour depression education programme. For 76% of consumers this was only contact with mental health specialists; psychiatrists met with 13% and rang 1%; education sessions attended by 8% Mental health specialist/primary care provider: all primary care providers were also offered two four‐hour training sessions in the recognition and management of depression (communication, skills and knowledge). A treatment progress report based on monthly file review by the decision support team for each consumer was mailed to the primary care provider every three months. The review considered appointments, medications, symptom severity, PTSD and alcohol screening. If the primary care provider did not respond to an initial PHQ‐9 score of 15 or more, or the consumer did not improve over time, the primary care provider was contacted by the team to discuss treatment, offer psychiatric consultation (with the primary care provider or consumer), or facilitate referral to ongoing speciality care. The Depression Support Team communicated with primary care providers or their nurses an average of 2.2 times. Primary care provider/consumer: interaction not reported. 2. Standard care (n = 186) Mental health specialist/primary care provider: prior to the study, all primary care providers were offered two four‐hour training sessions in the recognition and management of depression (as were intervention primary care providers). An onsite mental health consultation team was also available. Providers received notification that the consumer was enrolled in the study and their baseline and follow‐up PHQ‐9 scores were made available in patient charts. Mental health specialist/consumer: none aside from depression measurement at baseline, 1, 3, 6, 9 and 12 months.
Outcomes	1. Consumer Symptoms: SCL‐20 at 6 and 12 months, Patient Health Questionnaire (PHQ‐9) scores at 1, 3, 6, 9 and 12 months. Health status: health‐related Quality of Life Short Form for Veterans (SF‐36V) scores at 6 and 12 months. Satisfaction: rated poor to excellent on a five‐point Likert scale at 6 and 12 months. Adherence: attended at least three mental health appointments. Healthcare visits: attended three or more primary care appointments. 2. Provider Diagnosis: consumers assessed for depression over 12 months. Prescribing: prescribed antidepressants. Adherence: at least one follow‐up depression‐related action. Adequate treatment: minimally effective dose for at least 90 days.
Notes	SCL‐20 means and standard errors estimated from graph, PHQ‐9 scores but not variance were also graphed. Diagnosis and provider adherence reported for a subsample not receiving antidepressants at the beginning of the study.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Stratified randomisation 'using a random‐number generator' by clinician to ensure distribution across type of clinician, clinic site and caseload.
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding (performance bias and detection bias) All outcomes	High risk	Data was collected by a blinded research assistant via phone or posted questionnaires, however data were self‐reported and both consumers and providers are likely to have been aware whether they were in the active group.
Incomplete outcome data (attrition bias) All outcomes	High risk	Data were reported for those available at follow‐up, loss to follow‐up at 6 months 16%, 12 months 15%.
Selective reporting (reporting bias)	Unclear risk	SF‐36V scores were not reported, diagnosis, referrals and healthcare visits reported for subsample.
Other bias	Unclear risk	More participants in the standard care group had PTSD (44% vs 35%).