ABSTRACT
BACKGROUND: There are a range of effective pharmacological and behavioral treatments for depression. However, approximately one-third of patients discontinue antidepressants within the first month of treatment and 44% discontinue them by the third month of treatment. The major reasons reported for discontinuation were side effect burden, patients experiencing that the medications were not working, and patients wanting to resolve their depression without using medication. OBJECTIVE: This study tested the acceptability, feasibility, and preliminary effectiveness of an SMS messaging intervention designed to improve antidepressant adherence and depression outcomes in veterans. The intervention specifically targeted the key reasons for antidepressant discontinuation. For example, the secure message included reminders that it can take up to 6 weeks for an antidepressant to work, or prompts to call their provider should the side effect burden become significant. METHODS: This pilot was a 3-armed randomized controlled trial of 53 veterans undergoing depression treatment at the Iowa City Veterans Affairs Health Care System. Veterans starting a new antidepressant were randomized to secure messaging only (SM-Only), secure messaging with coaching (SM+Coach), or attention control (AC) groups. The intervention lasted 12 weeks with follow-up assessments of key outcomes at 6 and 12-weeks. This included a measure of antidepressant adherence, depressive symptom severity, and side effect burden. RESULTS: The 2 active interventions (SM-Only and SM+Coach) demonstrated small to moderate effect sizes (ESs) in improving antidepressant adherence and reducing side effect burden. They did not appear to reduce the depressive symptom burden any more than in the AC arm. Veteran participants in the SM arms demonstrated improved medication adherence from baseline to 12 weeks on the Medication Adherence Rating Scale compared with those in the AC arm, who had a decline in adherence (SM-Only: ES=0.09; P=.19; SM+Coach: ES=0.85; P=.002). Depression scores on the 9-Item Patient Health Questionnaire decreased for all 3 treatment arms, although the decline was slightly larger for the SM-Only (ES=0.32) and the SM+Coach (ES=0.24) arms when compared with the AC arm. The 2 intervention arms indicated a decrease in side effects on the Frequency, Intensity, and Burden of Side Effects Ratings, whereas the side effect burden for the AC arm increased. These differences indicated moderate ES (SM-Only vs AC: ES=0.40; P=.07; SM+Coach: ES=0.54; P=.07). CONCLUSIONS: A secure messaging program targeting specific reasons for antidepressant discontinuation had small-to-moderate ES in improving medication adherence. Consistent with prior research, the intervention that included brief synchronic meetings with a coach appeared to have a greater benefit than the SMS-alone intervention. Veterans consistently engaged with the SMS messaging in both treatment arms throughout the study period. They additionally provided feedback on which texts were most helpful, tending to prefer messages providing overall encouragement rather than specific wellness recommendations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03930849; https://clinicaltrials.gov/study/NCT03930849.
ABSTRACT
BACKGROUND: The Measurement Based Care in Mental Health Initiative launched by the Department of Veterans Affairs in 2016 is an example of an evidence-based practice that uses patient-reported outcome measures (PROMs) to improve patient outcomes. The acceptance of measurement-based care (MBC) among Veterans Affairs providers is relatively high. However, there are barriers to MBC for telehealth providers. Health information technologies might afford opportunities to address some of the barriers related to the uptake of MBC. OBJECTIVE: This paper reports on an implementation effort to integrate MBC into mental health care telehealth practice using eHealth solutions. METHODS: Qualitative data were generated from 22 semistructured interviews with psychiatrists (n=4), psychologists (n=3), social workers (n=3), nurses (n=6), a pharmacist (n=1), and administrative staff (n=5) who provide telemental health care through a community-based outpatient clinic in the rural Midwestern United States. The interviews were conducted during the pilot phase of an implementation initiative to increase the adoption of MBC by revising clinic workflows to integrate the use of eHealth technologies. Data were analyzed using thematic analysis. RESULTS: Time burden and workflow issues were the most common barrier to provider adoption of MBC; sharing and reviewing pencil-and-paper measures and results in the same room was no longer possible in novel telehealth workflows necessitated by the COVID-19 pandemic. Providers voiced concerns about how long it would take to collect, adequately score, interpret, share, and document the PROMs during the telehealth visit. Concerns about time might also correspond to a gap in providers' familiarity with these assessments, greater comfort in assessing symptoms through clinical interviews, and being accustomed to using the assessments as screening tools more so than longitudinal outcome measures. Capacities associated with eHealth technologies may address workflow concerns and promote providers' understanding and use of the measures as tracking tools. CONCLUSIONS: The need to use limited appointment time well was a top priority for telemental health providers. eHealth technologies provided operative supports that protect time in appointments by shifting when and how PROMs are collected. Bolstering providers' familiarity with how to use PROMs in the course of treatment may impact providers' buy-in by encouraging them to reconsider how sharing and acting on PROMs could be time well spent.
ABSTRACT
BACKGROUND: The effectiveness of technology-assisted interventions designed to ameliorate depressive symptoms and improve antidepressant medication adherence is hampered by diminished usage over time and poor integration with clinical care. OBJECTIVE: This manuscript presents patient perspectives on a texting and secure messaging intervention designed to engage providers and patients during a targeted transition period when patients were initiating a new antidepressant medication. PATIENT INVOLVEMENT: Development of the intervention was guided by feedback from a presentation and discussion with an engagement panel of local stakeholders, including patients, who meet quarterly with research investigators. METHODS: Semi-structured, qualitative, telephone interviews were conducted with 21 participants. Interviews were designed to identify the themes of self-determination and planned behavior in using the text messaging intervention. Qualitative analysis of participants' experiences used inductive and deductive coding, as well as pile sorting. RESULTS: The intervention prompted participants to reflect about how they manage their mood, engage in behaviors guided by their values, and commit to making positive changes in how they acted in real-time. Elements of the intervention facilitated participant conversations with trusted friends and family over time about what had influenced their actions and feelings. DISCUSSION: The texting intervention appeared to help participants live a life consistent with their values. However, we were unable to recruit mental health providers to participate. PRACTICAL VALUE: Technology to promote self-reflection and an "observing self" may work best when done in dialogue with important others, including mental health providers. Future directions of this research should find ways to understand provider buy-in, or lack thereof, in e-health interventions.
