Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study.

BACKGROUND: Symptoms of depression and anxiety, suicidal ideation, and self-harm have escalated among adolescents to crisis levels during the COVID-19 pandemic. As a result, primary care providers (PCPs) are often called on to provide first-line care for these youth. Digital health interventions can extend mental health specialty care, but few are evidence based. We evaluated the feasibility of delivering an evidence-based mobile health (mHealth) app with an embedded conversational agent to deliver cognitive behavioral therapy (CBT) to symptomatic adolescents presenting in primary care settings during the pandemic. OBJECTIVE: In this 12-week pilot study, we evaluated the feasibility of delivering the app-based intervention to adolescents aged 13 to 17 years with moderate depressive symptoms who were treated in a practice-based research network (PBRN) of academically affiliated primary care clinics. We also obtained preliminary estimates of app acceptability, effectiveness, and usability. METHODS: This small, pilot randomized controlled trial (RCT) evaluated depressive symptom severity in adolescents randomized to the app or to a wait list control condition. The primary end point was depression severity at 4-weeks, measured by the 9-item Patient Health Questionnaire (PHQ-9). Data on acceptability, feasibility, and usability were collected from adolescents and their parent or legal guardian. Qualitative interviews were conducted with 13 PCPs from 11 PBRN clinics to identify facilitators and barriers to incorporating mental health apps in treatment planning for adolescents with depression and anxiety. RESULTS: The pilot randomized 18 participants to the app (n=10, 56%) or to a wait list control condition (n=8, 44%); 17 participants were included in the analysis, and 1 became ineligible upon chart review due to lack of eligibility based on documented diagnosis. The overall sample was predominantly female (15/17, 88%), White (15/17, 88%), and privately insured (15/17, 88%). Mean PHQ-9 scores at 4 weeks decreased by 3.3 points in the active treatment group (representing a shift in mean depression score from moderate to mild symptom severity categories) and 2 points in the wait list control group (no shift in symptom severity category). Teen- and parent-reported usability, feasibility, and acceptability of the app was high. PCPs reported preference for introducing mHealth interventions like the one in this study early in the course of care for individuals presenting with mild or moderate symptoms. CONCLUSIONS: In this small study, we demonstrated the feasibility, acceptability, usability, and safety of using a CBT-based chatbot for adolescents presenting with moderate depressive symptoms in a network of PBRN-based primary care clinics. This pilot study could not establish effectiveness, but our results suggest that further study in a larger pediatric population is warranted. Future study inclusive of rural, socioeconomically disadvantaged, and underrepresented communities is needed to establish generalizability of effectiveness and identify implementation-related adaptations needed to promote broader uptake in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04603053; https://clinicaltrials.gov/ct2/show/NCT04603053.

Primary care experiences of providing mental healthcare for children in the USA during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The increased demand for mental healthcare associated with the COVID-19 pandemic adds to the already high unmet mental health needs among paediatric patients, resulting in a declared 'mental health emergency'. The study objective was to describe paediatric primary care providers (PCPs') experience of meeting their patients' needs for mental healthcare during the pandemic and to identify opportunities to optimise care. METHODS: 19 paediatricians and 2 nurse practitioners completed a 30 min video interview in May 2021. Interviews were recorded and transcribed, and transcripts were analysed using consensual qualitative research methods. RESULTS: Participants reported marked increases in patient mental health needs during the COVID-19 pandemic. These included new diagnoses of anxiety and depression and increased treatment needs for patients with a prior mental health diagnosis. They identified that the mental health needs of their patients were greater, more severe and more challenging to manage with the resources currently available. While they were frustrated with the lack of communication and support from their mental health colleagues, and felt isolated and overwhelmed, they approached the increased demand for mental healthcare with a growth mindset. This outlook included providing care, seeking help to improve their skills and engaging with local resources such as the Child Psychiatry Access Project (CPAP). CONCLUSIONS: Our findings suggest that urgent action is needed to better support paediatric PCPs to provide mental healthcare in our community. Providers identified an ongoing need for timely access to and effective communication with mental health providers to guide care in the medical home. This need could be addressed immediately by providing training for new and experienced clinicians, expanding the scope of CPAP programmes to include patient assessment and supporting implementation of integrated behavioural health programmes into the medical home.

Collaborating to Advocate in Primary Care for Children During COVID-19.

The St Louis Regional Pediatric Learning Collaborative of pediatric primary care providers and infectious diseases specialists formed in March 2020 to address the needs of children and families during the coronavirus disease 2019 (COVID-19) pandemic. More than 400 pediatric primary care providers participated, using a listserv to discuss care and organize webinars to provide updates on local and national data and plan next steps. To inform local decision-making about care and testing for severe acute respiratory syndrome coronavirus 2, 95 providers from 26 practices partnered with the local practice-based research network to rapidly collect and share data about children with COVID-19-like symptoms. Of 2162 children tested for severe acute respiratory syndrome coronavirus 2, 9% had positive test results. Test result positivity was 33% if a patient was exposed to a confirmed case of COVID-19 and 4% if they had COVID-19-like symptoms and no exposure. School or day care attendance was associated with lower rates of positive test results. Although not originally planned, these findings drove local advocacy efforts by the Collaborative for increased access to testing and contact tracing and safe in-person school. Members communicated directly and collectively with local politicians, provided advice and resources for school boards and superintendent groups, and appeared on various media platforms. In these efforts, they shared local data, highlighting the lower rate of positive test results for children in school to support the idea that schools could be safely open. Outreach from trusted pediatricians sharing prospective, timely, local data sustained in-person school for some districts and aided in future in-person openings for other school districts.