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BMJ Open. 2019 Apr 8;9(4):e025375. doi: 10.1136/bmjopen-2018-025375.

Healthcare Options for People Experiencing Depression (HOPE*D): the development and pilot testing of an encounter-based decision aid for use in primary care.

Author information

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.
Department of Psychiatry, Oregon Health & Science University School of Medicine, Portland, Oregon, USA.
The Department of Rehabilitation Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA.
Patent Partner, Hanover, New Hampshire, USA.
Patient Partner, Piermont, New York, USA.
Departments of Psychiatry and Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.



To develop and pilot an encounter-based decision aid (eDA) for people with depression for use in primary care.


We developed an eDA for depression through cognitive interviews and pilot tested it using a one-group pretest, post-test design in primary care. Feasibility, fidelity of eDA use and acceptability were assessed using recruitment rates and semistructured interviews with patients, medical assistants and clinicians. Treatment choice and shared decision-making (SDM) were also assessed.


Interviews with adult patients and the public were conducted in a mall and library in Grafton County, New Hampshire, while clinician interviews took place by phone or at the clinician's office. Pilot testing occurred in a New Hampshire primary care practice.


Cognitive interviews were conducted with adults, ≥18 years, who could read English from the following stakeholder groups: history of depression, the public and clinicians. Patients with a Patient Health Questionnaire-9 score of ≥5 were recruited for piloting.


Three stages of cognitive interviews were conducted (n=28). Changes to eDA included moving the combination therapy information and access to treatment information, adding colour, modifying pictograms and editing the talk-therapy description. Clinician concerns about patient health literacy were not reflected in patient interviews. Of 59 patients who reviewed study information, 56 were eligible and agreed to participate in pilot testing; however, only 29 could be reached for follow-up. The eDA was widely accepted, though clinicians did not always use it as intended. We found no impact of eDA use on SDM, though patients chose a wider range of treatment options.


We demonstrated the feasibility of the use of an eDA for depression in primary care that was widely accepted. Further research is needed to improve the fidelity with which the eDA is used and to assess its impact on SDM and related health outcomes.


decision aid; decision support; depression; mental health care; primary care; shared decision-making

Conflict of interest statement

Competing interests: GE has edited and published books that provide royalties on sales by the publishers: the books include Shared Decision Making (Oxford University Press) and Groups (Radcliffe Press). He has in the past provided consultancy for organizations, including (1) Emmi Solutions LLC who developed patient decision support tools; (2) National Quality Forum on the certification of decision support tools; (3) Washington State Health Department on the certification of decision support tools and (4) SciMentum LLC, Amsterdam (workshops for shared decision-making). He is currently the Director of &think LLC, which owns the registered trademark for Option Grids patient decision aids. He provides consultancy in the domain of shared decision-making and patient decision aids to (1) Access Community Health Network, Chicago (Federally Qualified Medical Centers) and (2) EBSCO Health Option Grids patient decision aids. GE’s academic interests are focused on shared decision-making and coproduction. He founded the Option Grid Collaborative. He owns the copyright in measures of shared decision-making and care integration, namely collaboRATE, integRATE, Observer OPTION-5 and Observer OPTION-12. These measures are freely available for use.

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