A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial

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Abstract

Background

Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support.

Objective

The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care.

Methods

A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers.

Results

Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (−1.83 points, 95% CI −2.85 to −0.82) and GAD-7 score (−1.55 points, 95% CI −2.42 to −0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group.

Conclusions

The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions.

Trial Registration

ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO)

Related collections

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Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care. This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart. The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale. Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

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Joseph Firth, John Torous, Jennifer Lynn Nicholas … (2017)

The rapid advances and adoption of smartphone technology presents a novel opportunity for delivering mental health interventions on a population scale. Despite multi-sector investment along with wide-scale advertising and availability to the general population, the evidence supporting the use of smartphone apps in the treatment of depression has not been empirically evaluated. Thus, we conducted the first meta-analysis of smartphone apps for depressive symptoms. An electronic database search in May 2017 identified 18 eligible randomized controlled trials of 22 smartphone apps, with outcome data from 3,414 participants. Depressive symptoms were reduced significantly more from smartphone apps than control conditions (g=0.38, 95% CI: 0.24-0.52, p<0.001), with no evidence of publication bias. Smartphone interventions had a moderate positive effect in comparison to inactive controls (g=0.56, 95% CI: 0.38-0.74), but only a small effect in comparison to active control conditions (g=0.22, 95% CI: 0.10-0.33). Effects from smartphone-only interventions were greater than from interventions which incorporated other human/computerized aspects along the smartphone component, although the difference was not statistically significant. The studies of cognitive training apps had a significantly smaller effect size on depression outcomes (p=0.004) than those of apps focusing on mental health. The use of mood monitoring softwares, or interventions based on cognitive behavioral therapy, or apps incorporating aspects of mindfulness training, did not affect significantly study effect sizes. Overall, these results indicate that smartphone devices are a promising self-management tool for depression. Future research should aim to distil which aspects of these technologies produce beneficial effects, and for which populations.

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Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials.

Joseph Firth, John Torous, Jennifer Lynn Nicholas … (2017)

Various psychological interventions are effective for reducing symptoms of anxiety when used alone, or as an adjunct to anti-anxiety medications. Recent studies have further indicated that smartphone-supported psychological interventions may also reduce anxiety, although the role of mobile devices in the treatment and management of anxiety disorders has yet to be established.

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Author and article information

Contributors

Jennifer M Hensel:

Women's College Institute for Health Systems Solutions and Virtual Care76 Grenville StToronto, ON, M5S 1B2Canada1 416 323 6400 ext 51261 416 323 6004jennifer.hensel@wchospital.ca

ORCID: http://orcid.org/0000-0003-4194-6049

Journal

Journal ID (nlm-ta): J Med Internet Res

Journal ID (iso-abbrev): J. Med. Internet Res

Journal ID (publisher-id): JMIR

Title: Journal of Medical Internet Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Print): 1439-4456

ISSN (Electronic): 1438-8871

Publication date Collection: June 2019

Publication date (Electronic): 04 June 2019

Volume: 21

Issue: 6

Electronic Location Identifier: e10838

Affiliations

[1 ] Women's College Institute for Health Systems Solutions and Virtual Care Toronto, ON Canada

[2 ] Department of Psychiatry University of Toronto Toronto, ON Canada

[3 ] Department of Psychiatry University of Manitoba Winnipeg, MB Canada

[4 ] Women's College Research Institute Toronto, ON Canada

[5 ] Department of Family and Community Medicine University of Toronto Toronto, ON Canada

[6 ] Institute for Health Policy, Management and Evaluation University of Toronto Toronto, ON Canada

[7 ] Li Ka Shing Knowledge Institute St Michael's Hospital Toronto, ON Canada

[8 ] Department of Medicine University of Toronto Toronto, ON Canada

Author notes

Corresponding Author: Jennifer M Hensel jennifer.hensel@ 123456wchospital.ca

Author information

Jennifer M Hensel http://orcid.org/0000-0003-4194-6049

James Shaw http://orcid.org/0000-0002-9522-0756

Noah M Ivers http://orcid.org/0000-0003-2500-2435

Laura Desveaux http://orcid.org/0000-0003-3429-1865

Simone N Vigod http://orcid.org/0000-0002-2736-9639

Ashley Cohen http://orcid.org/0000-0002-8613-3351

Nike Onabajo http://orcid.org/0000-0001-9817-0275

Payal Agarwal http://orcid.org/0000-0001-5625-7532

Geetha Mukerji http://orcid.org/0000-0002-6477-9848

Rebecca Yang http://orcid.org/0000-0002-3181-7799

Megan Nguyen http://orcid.org/0000-0002-2413-1406

Zachary Bouck http://orcid.org/0000-0003-3145-1915

Ivy Wong http://orcid.org/0000-0002-0830-7504

Lianne Jeffs http://orcid.org/0000-0002-6845-459X

Trevor Jamieson http://orcid.org/0000-0002-1050-3918

R Sacha Bhatia http://orcid.org/0000-0001-6206-5318

Article

Publisher ID: v21i6e10838

DOI: 10.2196/10838

PMC ID: 6684216

PubMed ID: 31165710

SO-VID: 067e89fd-929b-41d2-a3b2-5b2730215eff

Copyright © ©Jennifer M Hensel, James Shaw, Noah M Ivers, Laura Desveaux, Simone N Vigod, Ashley Cohen, Nike Onabajo, Payal Agarwal, Geetha Mukerji, Rebecca Yang, Megan Nguyen, Zachary Bouck, Ivy Wong, Lianne Jeffs, Trevor Jamieson, R Sacha Bhatia. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.06.2019.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/.as well as this copyright and license information must be included.

History

Date received : 20 April 2018

Date revision requested : 22 March 2019

Date revision received : 26 April 2019

Date accepted : 26 April 2019

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