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Original Investigation |

Activation, Self-management, Engagement, and Retention in Behavioral Health Care:  A Randomized Clinical Trial of the DECIDE Intervention

Margarita Alegría, PhD1,2; Nicholas Carson, MD, FRCPC1,2; Michael Flores, MPH3; Xinliang Li, MA1,2; Ping Shi, PhD4; Anna Sophia Lessios, BA1,2; Antonio Polo, PhD5; Michele Allen, MD6; Mary Fierro, PhD7; Alejandro Interian, PhD8; Aida Jimenez, PhD9; Martin La Roche, PhD2; Catherine Lee, MD3; Roberto Lewis-Fernández, MD10; Gabriela Livas-Stein, PhD11; Laura Safar, MD2; Catherine Schuman, PhD12; Joan Storey, PhD10; Patrick E. Shrout, PhD13
[+] Author Affiliations
1Center for Multicultural Mental Health Research, Cambridge Health Alliance, Somerville, Massachusetts
2Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
3Brown University, Providence, Rhode Island
4Mystic Consulting LLC, Belmont, Massachusetts
5Department of Psychology, DePaul University, Chicago, Illinois
6Program in Health Disparities Research, School of Medicine, University of Minnesota, Minneapolis
7Edward M. Kennedy Community Health Center, Worcester, Massachusetts
8Veterans Affairs New Jersey Health Care System, East Orange
9Department of Psychiatry, School of Medicine, Vanderbilt University, Nashville, Tennessee
10Department of Psychiatry, Columbia University Medical Center, New York, New York
11University of North Carolina at Greensboro, Greensboro
12Cambridge Health Alliance, Somerville, Massachusetts
13Department of Psychology, New York University, New York
JAMA Psychiatry. 2014;71(5):557-565. doi:10.1001/jamapsychiatry.2013.4519.
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Importance  Given minority patients’ unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care.

Objective  To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care.

Design, Setting, and Patients  In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes.

Interventions  Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health.

Main Outcomes and Measures  Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records.

Results  Patients assigned to DECIDE reported significant increases in activation (mean β = 1.74, SD = 0.58; P = .003) and self-management (mean β = 2.42, SD = 0.90; P = .008) relative to control patients, but there was no evidence of an effect on engagement or retention in care.

Conclusions and Relevance  The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health care.

Trial Registration  clinicaltrials.gov Identifier: NCT01226329

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Figure 1.
Flow of Study Participants Through Recruitment, Intervention, and Follow-up Assessment

Of 1473 patients approached, 724 were randomized and 647 were included in the primary outcome analysis.

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Figure 2.
Timing of Interviews and Training for Participants in the Control and Intervention Arms

CM indicates care manager; RA, research assistant.

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