The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

Robert M Bossarte, Ronald C Kessler, Andrew A Nierenberg, Ambarish Chattopadhyay, Pim Cuijpers, Angel Enrique, Phyllis M Foxworth, Sarah M Gildea, Bea Herbeck Belnap, Marc W Haut, Kari B Law, William D Lewis, Howard Liu, Alexander R Luedtke, Wilfred R Pigeon, Larry A Rhodes, Derek Richards, Bruce L Rollman, Nancy A Sampson, Cara M Stokes, John Torous, Tyler D Webb, Jose R Zubizarreta, Robert M Bossarte, Ronald C Kessler, Andrew A Nierenberg, Ambarish Chattopadhyay, Pim Cuijpers, Angel Enrique, Phyllis M Foxworth, Sarah M Gildea, Bea Herbeck Belnap, Marc W Haut, Kari B Law, William D Lewis, Howard Liu, Alexander R Luedtke, Wilfred R Pigeon, Larry A Rhodes, Derek Richards, Bruce L Rollman, Nancy A Sampson, Cara M Stokes, John Torous, Tyler D Webb, Jose R Zubizarreta

Abstract

Background: Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

Methods: Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

Discussion: The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

Trial registration: ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Keywords: Antidepressant medication; Appalachian Mind Health Initiative (AMHI); Heterogeneity of treatment effects; Major depressive disorder; Remission from depression; i-CBT.

Conflict of interest statement

In the past 3 years, RCK has been a consultant for Datastat, Inc, Sage Pharmaceuticals, and Takeda. WRP consulted for CurAegis Technologies and received clinical trial support from Pfizer, Inc and Abbvie, Inc. AE and DR are employees of SilverCloud Health, developers of computerized psychological interventions for depression, anxiety, stress, sleep, resilience, and comorbid long-term conditions. In the past 3 years, JT has received research support from Otsuka. MWH has received funding from Insightec and has been a paid grand rounds speaker for Medtronic and Atrium Health. AAN serves on scientific advisory boards for Alkermes, Jazz Pharmaceuticals, Sage Pharmaceuticals, Otsuka, and Neuronetics; was a consultant for Acadia Pharmaceuticals, Esai, Myriad, Merck, Ginger, Protogenics, Neurogenics and Clexio; and also reports receiving honoraria from Sunovion and Neurostar.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Participant timeline

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