This article was downloaded by: [Pennsylvania State University] On: 15 March 2015, At: 02:57 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain a
b
b
Brian K. Ahmedani , Nuala Crotty , Muwaffak M. Abdulhak & Steven J. Ondersma a
Center for Health Policy & Health Services Research, Henry Ford Health System
b
Neuroscience Institute, Henry Ford Health System
c
c
Department of Psychiatry and Behavioral Neurosciences, Wayne State University Accepted author version posted online: 07 Dec 2013.Published online: 09 Sep 2014.
Click for updates To cite this article: Brian K. Ahmedani, Nuala Crotty, Muwaffak M. Abdulhak & Steven J. Ondersma (2015) Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain, Behavioral Medicine, 41:1, 25-32, DOI: 10.1080/08964289.2013.867827 To link to this article: http://dx.doi.org/10.1080/08964289.2013.867827
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 41: 25–32, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2013.867827
Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain Brian K. Ahmedani
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
Center for Health Policy & Health Services Research, Henry Ford Health System
Nuala Crotty, and Muwaffak M. Abdulhak Neuroscience Institute, Henry Ford Health System
Steven J. Ondersma Department of Psychiatry and Behavioral Neurosciences, Wayne State University
This pilot feasibility study investigated a brief, tailored mobile health intervention to provide brief treatment and motivate further depression treatment seeking among patients with comorbid chronic pain. The computer tablet intervention was delivered in a hospital clinic using a blended motivational interviewing and cognitive behavioral therapy approach. Individuals were at least age 18, and screened positive for depression during a visit for chronic pain. Participants completed assessments before the intervention and at two-week follow-up. The 64 participants were most often over 50 years old, female, and Caucasian. Participant ratings demonstrated an increase in interest to seek depression treatment and willingness to make life changes to mitigate symptoms. A significant reduction in mean depression score and non-significant reductions on both measures of disability were observed. This intervention was feasible and acceptable, demonstrated promise in reducing depression and increasing treatment interest, and should be tested in a trial.
Keywords: brief intervention, chronic pain, depression, mobile health Depression and chronic pain are highly prevalent and debilitating.1–3 Depression is the leading cause of years of life lived with a disability, and is projected to be the second leading condition accounting for the global burden of disease within the next decade.4–6 In addition, approximately one-third of individuals experience chronic pain in the United States.3,7 Further, these conditions are frequently comorbid: estimates suggest that those with chronic pain experience depression 1.5 to 2.5 times more often than the general public.1 One study showed that as many as half of patients with chronic pain screen positive for depression.8 Health care for individuals with chronic pain should thus include options for the concurrent treatment of depression. Correspondence should be addressed to Brian K. Ahmedani, PhD, Center for Health Policy & Health Services Research, Henry Ford Health System, 1 Ford Place 3A, Detroit, MI 48202, USA. E-mail: bahmeda1@hfhs. org
Numerous studies have shown that effective depression treatment can improve mental health and general medical outcomes for patients with chronic pain.9 Nonetheless, individuals who need psychiatric care frequently do not seek services, and continue to not receive care for a median of eight years after the onset of their condition.10–12 Since individuals typically seek care for their general medical conditions in primary care or general medical specialty settings, an opportunity exists to identify individuals with depression and encourage treatment options. Unfortunately, health professionals often do not recognize or adequately address depressive symptoms among their patients with general medical concerns.13 Thus, integrating and improving depression screening and support in general medical settings is essential. Several health care systems have begun initiatives to identify and treat patients with depression in general medical settings, but several barriers exist.14,15 Some of these
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
26
AHMEDANI ET AL.
obstacles include limitations on funding as well as on providers’ time and training.16 While health care remains fast-paced and integration is difficult to implement in some circumstances, technological advances may offer a solution, particularly via brief interventions that can be delivered in a single session within the clinic setting. Several examples of technology-based depression interventions have been developed and have shown effectiveness.17 For example, in a recent systematic review, Andrews and colleagues found that computerized cognitive behavioral therapy (CBT) was acceptable to patients and providers and also has been used to effectively mitigate both depression and anxiety symptoms.17 However, most interventions specifically for depression and pain have been longer-term, such as a successful short-term, 4-session CBT intervention developed for individuals with depression and temporomandibular pain,18–20 and none of them have been singlesession, tailored interventions. In addition, most interventions were not designed for use in the clinic setting to improve detection and treatment seeking among patients with both conditions. However, evidence suggests that single-session, tailored interventions have shown effectiveness to improve other health behaviors, such as drug use, among individuals in hospital settings.21 We therefore developed a single-session technologybased or mobile health (mHealth) intervention designed to address the need for a brief, proactive, primary care-based intervention addressing depression and treatment seeking among patients specifically with chronic pain. This mHealth intervention is unique, as it is brief but is also tailored to each individual based on the responses he or she provides. Thus, each participant receives a tailored brief intervention that addresses his/her specific issues, and asks follow-up questions and provides feedback that is directed to addressing those concerns. The main aim of this pilot study is to investigate the feasibility, acceptability, and preliminary effectiveness of a brief, mHealth depression intervention for individuals with chronic pain. The study examines 2-week depression, disability, and physical activity outcomes as well as interest in depression treatment seeking. We hypothesize that the intervention will be feasible to implement in the clinical setting, highly favorable to participants, and will result in lower participant-rated depression and disability, increased physical activity, and high levels of interest in seeking treatment for depression.
METHODS Participants Participants for the current study were recruited from a Spine Clinic within the Neuroscience Institute at Henry Ford Health System (HFHS). HFHS is a large health care
delivery system, which primarily serves the needs of residents in Southeastern Michigan, including Detroit and its surrounding metropolitan area. Inclusion criteria were a score of 5 or greater on the 9-item Patient Health Questionnaire (PHQ-9),22 age 18 years or older, and a primary complaint of chronic pain. This study was approved by the institutional review boards (IRB) at Henry Ford Hospital and Wayne State University (WSU). Procedures Intervention Development The basic web-based intervention software tool used for this study was developed and is managed by study team members at WSU. This overall system includes a synchronously interactive, animated narrator who talks to participants and responds to user input via reflections and summaries. This system allows for a high degree of tailoring and personalization, such that participants’ responses are used to branch them down unique pathways and/or to provide tailored feedback. The basic software template is able to be tailored for different purposes.23–25 The intervention designed for this study was based on a combination of Motivational Interviewing (MI) and cognitive behavioral therapy (CBT) models.26,27 The main goals of the intervention are to provide brief treatment for depression as well as to motivate individuals to seek further treatment with their health provider and/or to make life changes to improve their overall functioning and mitigate depressive symptoms. The intervention was organized into several sections (see Figure 1). The first section was education-based and provided information about the common occurrence of depression and chronic pain and their comorbidity. A video clip of a physician discussing these issues was integrated, and was tailored based on whether individuals were interested in improving their depression. The second section used MI principles and provided information on ways to improve depression symptoms, including multiple forms of treatment as well as self-help activities such as exercise, eating healthy, and getting enough sleep. Individuals selected which options, if any, they were interested in pursuing and when they may seek those options. The MI method focused on identifying individuals’ readiness to seek treatment and improve depression symptoms. For those who were not interested in treatment, the module supports the decision, and asks participants to identify how soon they would seek treatment and how confident they are with their decision. For those who were not interested in treatment, the intervention supports the decision and focuses on ambivalence by identifying pros and cons of treatment seeking.28 The final section used CBT principles and helped individuals identify the one thing they felt contributed most to their depressive symptoms (ie, pain, psychosocial issues, money, employment, etc.) and provided options for how it may be possible to get help. Using CBT principles as
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
BRIEF MOBILE INTERVENTION FOR DEPRESSION AND CHRONIC PAIN
27
FIGURE 1 Components in order of presentation within the mHealth intervention.
described by Turner and colleagues, this component was designed to identify the most important contributor to a person’s depression (ie, pain, money troubles, relationships, etc), and reflect on how to mitigate that specific area first. Second, the intervention was designed to decrease catastrophizing and maladaptive thinking related to pain, specifically related to “all or nothing” thinking (ie, beliefs that person was completely disabled due to pain and nothing was positive in his or her life).29 Since this was a brief intervention, the goal of these steps was not to provide comprehensive CBT treatment, which is typically conducted over a series of multiple sessions, but rather to use CBT principles to support initial recognition of the most important concern and the use of maladaptive thinking. The brief intervention was also focused on identifying options to improve those factors, such as by treatment seeking and improving coping and self-management. A patient testimonial, tailored to individuals based on their age (greater or less than 50 years old), was integrated including a message about an experience with depression and chronic pain and corresponding improvement in both after seeking depression treatment. Much of the tailoring within the intervention focused on whether or not individuals were interested in seeking
depression treatment. If participants reported not being interested in treatment, then they were routed through the session using MI- and CBT-focused content that was designed to facilitate recognition of when depression may interfere in their life, and offer potential options for change, including improved sleep, healthy diet, stress relief, and talking with supportive people, as well as considering treatment options. If individuals were interested in treatment or were already seeking treatment, then the intervention sections congratulated them for, and discussed advantages to making the choice to seek treatment, while also helping them develop a personalized plan for moving forward. A combination of therapeutic material and information about depression and chronic pain were integrated throughout the module. Numerous branches existed throughout the intervention, so as to specifically tailor content to individuals’ based on their selections on previous pages. Recruitment and Data Collection Two participating physicians’ recruited individuals for the study during their initial in-person clinical visits using an IRB approved script. If patients agreed to participate in the study, they were escorted to a clinical room after their
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
28
AHMEDANI ET AL.
appointment to complete the study with a research assistant. The research assistant discussed the study with each participant, and completed the signed consent process before the study began. Then, the research assistant gave a handheld computer tablet to the participant to complete the computer-based assessment process. Participants wore headphones so as to listen to the narrated audio on each screen. They were instructed to make selections by tapping their finger or a stylus on the tablet screen to answer questions or make choices throughout the session. Clinical nurses reviewed the PHQ-9 scores for each patient and informed both the practicing physician and a research assistant if a patient was eligible to participate. After completing the assessment portion, eligible participants were then routed into the brief intervention portion of the module. Following the intervention, participants were asked a series of satisfaction questions as well as items on demographics and interest in treatment seeking. The assessment portions (before and after the intervention) of the module took approximately 10 minutes to complete, while the brief intervention portion lasted about 15 minutes. Participants were given a $20 gift card to a popular local store, and were scheduled for a two-week follow-up phone call. They were also given contact information for the behavioral health department and a crisis information hotline number. All data were captured in a secure web-based data repository using a unique study identification number. At the two-week post-intervention mark, a research assistant contacted each participant by phone during the scheduled time frame, re-administered each of the assessment measures, and then asked questions about treatment seeking and self-help related to depression. Those who did not answer their phone were re-contacted two additional times on the following successive business days by the study team. Participants were mailed an additional $10 gift card to the same local store for completing the follow-up call. The two-week follow-up time point was chosen for several reasons. First, this was a brief intervention that was designed to improve help-seeking for depression. Decisions about help-seeking are made sooner to the time of the intervention, rather than later.30 Second, the PHQ-9 measure assesses depression severity in the previous two week period. Third, longer-term follow-up was not possible given the scope of this pilot study. Measures The assessment portion of the intervention evaluated three main variables: depression (using the PHQ-9), disability (Oswestry Disability Index), and beliefs about ability to participate in physical activity (Fear and Avoidance Beliefs Questionnaire [FABQ]—Physical Activities [PA] subscale).22,31,32 These three variables were all addressed as part of the intervention. The PHQ-9 is a widely used
depression measure that indicates severity of depression via 9 items with sum scores ranging from 0 (low) through 27 (high). It was selected for use in this study, since it is also used in the spine clinic to assess depression among all patients. A score of 5 and 10 or greater are considered equivalent to clinical minor and major depression, respectively. Previous reports indicate that the PHQ-9 has strong validity and reliability (Cronbach’s alpha: 0.89).22 The Oswestry Disability Index (ODI) is one of the most used inventories to measure disability related to chronic pain. Internal consistency has been reported as strong in multiple studies with Cronbach’s alpha values ranging from 0.76 through 0.87. The ODI correlates with SF-36 quality of life measure and has been used to validate several other pain inventories. The measure has 10 items with scores ranging from 0 (low) through 50 (high).31 The FABQ-PA has high reliability (Cronbach’s alpha: 0.77) and test–retest reproducibility. The PA subscale includes 5 items, with items 2– 5 contributing to the sum score for the subscale. Scores increase in severity and range from 0 through 24.32 Data Analysis Statistical analyses included basic descriptive statistics of the study participants. Mean scores for depression, disability, and beliefs about ability to participate in physical activities were calculated for the pre-intervention (baseline) assessment portion as well as for the two-week follow-up period. Paired samples t tests were conducted to compare scores at both time points. Then, a generalized estimating equations generalized linear model (GEE/GLM) was used to assess variation in depression scores across measurement time points with covariate adjustment for age, sex, race/ethnicity, and pre-intervention (baseline) disability score. Participant acceptability ratings of the intervention were characterized along with items on interest in treatment seeking. Analyses were conducted using Stata statistical software version 11.2.33
RESULTS A total of 130 patients were eligible for the study and were invited to participate; of these, 75 (57.7%) agreed to participate. Some technical difficulties were experienced at the beginning of the study due to wireless internet malfunctions and other software issues. These issues were quickly resolved during this initial feasibility phase, but they prevented 6 participants from completing the main intervention. The study team was unable to contact 5 additional participants for the follow-up phone call. Therefore, complete data were available for 64 individuals who completed the mHealth intervention as well as the two-week postintervention follow-up phone call. Participants were more often at least 50 years old (n D 45, 70.3%; n D 19, 29.7%
29
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
BRIEF MOBILE INTERVENTION FOR DEPRESSION AND CHRONIC PAIN
were
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain a
b
b
Brian K. Ahmedani , Nuala Crotty , Muwaffak M. Abdulhak & Steven J. Ondersma a
Center for Health Policy & Health Services Research, Henry Ford Health System
b
Neuroscience Institute, Henry Ford Health System
c
c
Department of Psychiatry and Behavioral Neurosciences, Wayne State University Accepted author version posted online: 07 Dec 2013.Published online: 09 Sep 2014.
Click for updates To cite this article: Brian K. Ahmedani, Nuala Crotty, Muwaffak M. Abdulhak & Steven J. Ondersma (2015) Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain, Behavioral Medicine, 41:1, 25-32, DOI: 10.1080/08964289.2013.867827 To link to this article: http://dx.doi.org/10.1080/08964289.2013.867827
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 41: 25–32, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2013.867827
Pilot Feasibility Study of a Brief, Tailored Mobile Health Intervention for Depression among Patients with Chronic Pain Brian K. Ahmedani
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
Center for Health Policy & Health Services Research, Henry Ford Health System
Nuala Crotty, and Muwaffak M. Abdulhak Neuroscience Institute, Henry Ford Health System
Steven J. Ondersma Department of Psychiatry and Behavioral Neurosciences, Wayne State University
This pilot feasibility study investigated a brief, tailored mobile health intervention to provide brief treatment and motivate further depression treatment seeking among patients with comorbid chronic pain. The computer tablet intervention was delivered in a hospital clinic using a blended motivational interviewing and cognitive behavioral therapy approach. Individuals were at least age 18, and screened positive for depression during a visit for chronic pain. Participants completed assessments before the intervention and at two-week follow-up. The 64 participants were most often over 50 years old, female, and Caucasian. Participant ratings demonstrated an increase in interest to seek depression treatment and willingness to make life changes to mitigate symptoms. A significant reduction in mean depression score and non-significant reductions on both measures of disability were observed. This intervention was feasible and acceptable, demonstrated promise in reducing depression and increasing treatment interest, and should be tested in a trial.
Keywords: brief intervention, chronic pain, depression, mobile health Depression and chronic pain are highly prevalent and debilitating.1–3 Depression is the leading cause of years of life lived with a disability, and is projected to be the second leading condition accounting for the global burden of disease within the next decade.4–6 In addition, approximately one-third of individuals experience chronic pain in the United States.3,7 Further, these conditions are frequently comorbid: estimates suggest that those with chronic pain experience depression 1.5 to 2.5 times more often than the general public.1 One study showed that as many as half of patients with chronic pain screen positive for depression.8 Health care for individuals with chronic pain should thus include options for the concurrent treatment of depression. Correspondence should be addressed to Brian K. Ahmedani, PhD, Center for Health Policy & Health Services Research, Henry Ford Health System, 1 Ford Place 3A, Detroit, MI 48202, USA. E-mail: bahmeda1@hfhs. org
Numerous studies have shown that effective depression treatment can improve mental health and general medical outcomes for patients with chronic pain.9 Nonetheless, individuals who need psychiatric care frequently do not seek services, and continue to not receive care for a median of eight years after the onset of their condition.10–12 Since individuals typically seek care for their general medical conditions in primary care or general medical specialty settings, an opportunity exists to identify individuals with depression and encourage treatment options. Unfortunately, health professionals often do not recognize or adequately address depressive symptoms among their patients with general medical concerns.13 Thus, integrating and improving depression screening and support in general medical settings is essential. Several health care systems have begun initiatives to identify and treat patients with depression in general medical settings, but several barriers exist.14,15 Some of these
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
26
AHMEDANI ET AL.
obstacles include limitations on funding as well as on providers’ time and training.16 While health care remains fast-paced and integration is difficult to implement in some circumstances, technological advances may offer a solution, particularly via brief interventions that can be delivered in a single session within the clinic setting. Several examples of technology-based depression interventions have been developed and have shown effectiveness.17 For example, in a recent systematic review, Andrews and colleagues found that computerized cognitive behavioral therapy (CBT) was acceptable to patients and providers and also has been used to effectively mitigate both depression and anxiety symptoms.17 However, most interventions specifically for depression and pain have been longer-term, such as a successful short-term, 4-session CBT intervention developed for individuals with depression and temporomandibular pain,18–20 and none of them have been singlesession, tailored interventions. In addition, most interventions were not designed for use in the clinic setting to improve detection and treatment seeking among patients with both conditions. However, evidence suggests that single-session, tailored interventions have shown effectiveness to improve other health behaviors, such as drug use, among individuals in hospital settings.21 We therefore developed a single-session technologybased or mobile health (mHealth) intervention designed to address the need for a brief, proactive, primary care-based intervention addressing depression and treatment seeking among patients specifically with chronic pain. This mHealth intervention is unique, as it is brief but is also tailored to each individual based on the responses he or she provides. Thus, each participant receives a tailored brief intervention that addresses his/her specific issues, and asks follow-up questions and provides feedback that is directed to addressing those concerns. The main aim of this pilot study is to investigate the feasibility, acceptability, and preliminary effectiveness of a brief, mHealth depression intervention for individuals with chronic pain. The study examines 2-week depression, disability, and physical activity outcomes as well as interest in depression treatment seeking. We hypothesize that the intervention will be feasible to implement in the clinical setting, highly favorable to participants, and will result in lower participant-rated depression and disability, increased physical activity, and high levels of interest in seeking treatment for depression.
METHODS Participants Participants for the current study were recruited from a Spine Clinic within the Neuroscience Institute at Henry Ford Health System (HFHS). HFHS is a large health care
delivery system, which primarily serves the needs of residents in Southeastern Michigan, including Detroit and its surrounding metropolitan area. Inclusion criteria were a score of 5 or greater on the 9-item Patient Health Questionnaire (PHQ-9),22 age 18 years or older, and a primary complaint of chronic pain. This study was approved by the institutional review boards (IRB) at Henry Ford Hospital and Wayne State University (WSU). Procedures Intervention Development The basic web-based intervention software tool used for this study was developed and is managed by study team members at WSU. This overall system includes a synchronously interactive, animated narrator who talks to participants and responds to user input via reflections and summaries. This system allows for a high degree of tailoring and personalization, such that participants’ responses are used to branch them down unique pathways and/or to provide tailored feedback. The basic software template is able to be tailored for different purposes.23–25 The intervention designed for this study was based on a combination of Motivational Interviewing (MI) and cognitive behavioral therapy (CBT) models.26,27 The main goals of the intervention are to provide brief treatment for depression as well as to motivate individuals to seek further treatment with their health provider and/or to make life changes to improve their overall functioning and mitigate depressive symptoms. The intervention was organized into several sections (see Figure 1). The first section was education-based and provided information about the common occurrence of depression and chronic pain and their comorbidity. A video clip of a physician discussing these issues was integrated, and was tailored based on whether individuals were interested in improving their depression. The second section used MI principles and provided information on ways to improve depression symptoms, including multiple forms of treatment as well as self-help activities such as exercise, eating healthy, and getting enough sleep. Individuals selected which options, if any, they were interested in pursuing and when they may seek those options. The MI method focused on identifying individuals’ readiness to seek treatment and improve depression symptoms. For those who were not interested in treatment, the module supports the decision, and asks participants to identify how soon they would seek treatment and how confident they are with their decision. For those who were not interested in treatment, the intervention supports the decision and focuses on ambivalence by identifying pros and cons of treatment seeking.28 The final section used CBT principles and helped individuals identify the one thing they felt contributed most to their depressive symptoms (ie, pain, psychosocial issues, money, employment, etc.) and provided options for how it may be possible to get help. Using CBT principles as
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
BRIEF MOBILE INTERVENTION FOR DEPRESSION AND CHRONIC PAIN
27
FIGURE 1 Components in order of presentation within the mHealth intervention.
described by Turner and colleagues, this component was designed to identify the most important contributor to a person’s depression (ie, pain, money troubles, relationships, etc), and reflect on how to mitigate that specific area first. Second, the intervention was designed to decrease catastrophizing and maladaptive thinking related to pain, specifically related to “all or nothing” thinking (ie, beliefs that person was completely disabled due to pain and nothing was positive in his or her life).29 Since this was a brief intervention, the goal of these steps was not to provide comprehensive CBT treatment, which is typically conducted over a series of multiple sessions, but rather to use CBT principles to support initial recognition of the most important concern and the use of maladaptive thinking. The brief intervention was also focused on identifying options to improve those factors, such as by treatment seeking and improving coping and self-management. A patient testimonial, tailored to individuals based on their age (greater or less than 50 years old), was integrated including a message about an experience with depression and chronic pain and corresponding improvement in both after seeking depression treatment. Much of the tailoring within the intervention focused on whether or not individuals were interested in seeking
depression treatment. If participants reported not being interested in treatment, then they were routed through the session using MI- and CBT-focused content that was designed to facilitate recognition of when depression may interfere in their life, and offer potential options for change, including improved sleep, healthy diet, stress relief, and talking with supportive people, as well as considering treatment options. If individuals were interested in treatment or were already seeking treatment, then the intervention sections congratulated them for, and discussed advantages to making the choice to seek treatment, while also helping them develop a personalized plan for moving forward. A combination of therapeutic material and information about depression and chronic pain were integrated throughout the module. Numerous branches existed throughout the intervention, so as to specifically tailor content to individuals’ based on their selections on previous pages. Recruitment and Data Collection Two participating physicians’ recruited individuals for the study during their initial in-person clinical visits using an IRB approved script. If patients agreed to participate in the study, they were escorted to a clinical room after their
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
28
AHMEDANI ET AL.
appointment to complete the study with a research assistant. The research assistant discussed the study with each participant, and completed the signed consent process before the study began. Then, the research assistant gave a handheld computer tablet to the participant to complete the computer-based assessment process. Participants wore headphones so as to listen to the narrated audio on each screen. They were instructed to make selections by tapping their finger or a stylus on the tablet screen to answer questions or make choices throughout the session. Clinical nurses reviewed the PHQ-9 scores for each patient and informed both the practicing physician and a research assistant if a patient was eligible to participate. After completing the assessment portion, eligible participants were then routed into the brief intervention portion of the module. Following the intervention, participants were asked a series of satisfaction questions as well as items on demographics and interest in treatment seeking. The assessment portions (before and after the intervention) of the module took approximately 10 minutes to complete, while the brief intervention portion lasted about 15 minutes. Participants were given a $20 gift card to a popular local store, and were scheduled for a two-week follow-up phone call. They were also given contact information for the behavioral health department and a crisis information hotline number. All data were captured in a secure web-based data repository using a unique study identification number. At the two-week post-intervention mark, a research assistant contacted each participant by phone during the scheduled time frame, re-administered each of the assessment measures, and then asked questions about treatment seeking and self-help related to depression. Those who did not answer their phone were re-contacted two additional times on the following successive business days by the study team. Participants were mailed an additional $10 gift card to the same local store for completing the follow-up call. The two-week follow-up time point was chosen for several reasons. First, this was a brief intervention that was designed to improve help-seeking for depression. Decisions about help-seeking are made sooner to the time of the intervention, rather than later.30 Second, the PHQ-9 measure assesses depression severity in the previous two week period. Third, longer-term follow-up was not possible given the scope of this pilot study. Measures The assessment portion of the intervention evaluated three main variables: depression (using the PHQ-9), disability (Oswestry Disability Index), and beliefs about ability to participate in physical activity (Fear and Avoidance Beliefs Questionnaire [FABQ]—Physical Activities [PA] subscale).22,31,32 These three variables were all addressed as part of the intervention. The PHQ-9 is a widely used
depression measure that indicates severity of depression via 9 items with sum scores ranging from 0 (low) through 27 (high). It was selected for use in this study, since it is also used in the spine clinic to assess depression among all patients. A score of 5 and 10 or greater are considered equivalent to clinical minor and major depression, respectively. Previous reports indicate that the PHQ-9 has strong validity and reliability (Cronbach’s alpha: 0.89).22 The Oswestry Disability Index (ODI) is one of the most used inventories to measure disability related to chronic pain. Internal consistency has been reported as strong in multiple studies with Cronbach’s alpha values ranging from 0.76 through 0.87. The ODI correlates with SF-36 quality of life measure and has been used to validate several other pain inventories. The measure has 10 items with scores ranging from 0 (low) through 50 (high).31 The FABQ-PA has high reliability (Cronbach’s alpha: 0.77) and test–retest reproducibility. The PA subscale includes 5 items, with items 2– 5 contributing to the sum score for the subscale. Scores increase in severity and range from 0 through 24.32 Data Analysis Statistical analyses included basic descriptive statistics of the study participants. Mean scores for depression, disability, and beliefs about ability to participate in physical activities were calculated for the pre-intervention (baseline) assessment portion as well as for the two-week follow-up period. Paired samples t tests were conducted to compare scores at both time points. Then, a generalized estimating equations generalized linear model (GEE/GLM) was used to assess variation in depression scores across measurement time points with covariate adjustment for age, sex, race/ethnicity, and pre-intervention (baseline) disability score. Participant acceptability ratings of the intervention were characterized along with items on interest in treatment seeking. Analyses were conducted using Stata statistical software version 11.2.33
RESULTS A total of 130 patients were eligible for the study and were invited to participate; of these, 75 (57.7%) agreed to participate. Some technical difficulties were experienced at the beginning of the study due to wireless internet malfunctions and other software issues. These issues were quickly resolved during this initial feasibility phase, but they prevented 6 participants from completing the main intervention. The study team was unable to contact 5 additional participants for the follow-up phone call. Therefore, complete data were available for 64 individuals who completed the mHealth intervention as well as the two-week postintervention follow-up phone call. Participants were more often at least 50 years old (n D 45, 70.3%; n D 19, 29.7%
29
Downloaded by [Pennsylvania State University] at 02:57 15 March 2015
BRIEF MOBILE INTERVENTION FOR DEPRESSION AND CHRONIC PAIN
were
