I. Depression background
Depression, less commonly known as unipolar major depression or major depressive disorder, is likely a variety of disorders that present similarly. It is characterized by nine cardinal symptoms: dysphoria (depressed mood), anhedonia (loss of interest or pleasure), change in appetite or weight, sleep disturbance, anergia (fatigue), neurocognitive dysfunction (such as trouble concentrating or remembering), psychomotor disturbances, feelings of worthlessness or guilt, and suicidal ideation and behavior.1 A combination of internal factors (such as genetics, neuroticism, and anxiety), external factors (substance misuse), and adversity (history of divorce, low education, etc.) contribute to its development.
Depression is widespread and becoming more common. In the United States, it was the leading cause of disability for people between 15 and 44 years of age in 2010, costing an estimated $210 billion for 400 million disability days.2 Lifetime prevalence is estimated at 17 percent.3
II. Current standard of care
Most cases of depression are best treated with a combination of pharmacotherapy and psychotherapy.4 Many patients find pharmacotherapy (most commonly SSRIs) more convenient;5 however, psychotherapy, including cognitive behavioral therapy and interpersonal therapy, has been shown to have longer lasting effects, better preventing relapse after treatment is discontinued.6 Severe cases, which are minimally responsive to standard care, have been treated effectively with electro convulsive therapy (ECT). While the most efficacious treatment, the potential risks and adverse effects mean that ECT is used as a last resort.7
More recently, the IMPACT model of depression care has emerged as one of the largest treatment trials for depression in adults over 60 years of age. The model centers around collaborative treatment, including a primary care physician, psychiatrist, and Depression Care Manager (DCM) who meet once a week to discuss patients. The model emphasizes the use of the PHQ-9 as a monitoring tool, and has helped to validate it as sensitive to changes in symptoms over time 13, 14, 15.
III. Telemedicine in depression treatment
A growing body of research attempts to assess the efficacy of telemedicine in caring for patients with depression. Findings suggest that telemedicine can help increase access to care when an in-person visit is not possible8,9, improve rates of homework completion in CBT10, and that adding telephone and texting to usual care are an improvement11. Furthermore, patient feedback about their experiences was often positive10.
One study especially relevant to EpxDepression showed that text-based mood scores (1-9) from the previous day and previous week had significant predictive value for PHQ-9, a commonly used and well validated mood scale12. PHQ-9 questionnaires were administered in the office.
EpxDepression monitors the symptoms of depression at regular intervals and alerts providers to changes, especially those that require attention. A successful EpxDepression tool will catch suicidal ideation prior to an attempt and ensure that appropriate action is taken, demonstrate better improvement in symptoms compared to usual care, and allow a patient to feel good about using it – whether it’s because it makes them feel more in touch with their provider, or helps them be more mindful of how they are feeling.
The tool administers the questions of the PHQ-9 once or twice a month, depending on the patient’s needs, over the course of three days. To monitor overall mood on a more frequent basis, it also asks for mood ratings on a 1-7 scale (with 4 being neutral) three times a week. Low mood scores, significant drops in mood score, and screening positive for suicidal ideation trigger additional, more specific questions, send alerts to the provider, and immediately connect the patient to a help line.
Several pilots are being conducted with various health groups in the St. Louis and greater Midwestern area. Preliminary data from a previous version that also evaluated quality of sleep shows significant correlation between 1-month mood and sleep ratings and PHQ-9 scores, suggesting that recent mood and sleep reflects depressive symptoms. Patients were surveyed following usage of the intervention. Feedback was promising, and included positive comments such as “Easy to use,” “It encourages me to be more aware of how I am feeling on a daily basis,” and “It’s comforting to know that someone cares and that help is immediately available at the other end if I need it.” Importantly, while the system is completely automated, users still felt that it was an organic extension of the care team. For this trial, we did receive helpful feedback to ask questions less frequently and ask follow-up questions, which have been implemented in the current version of EpxDepression.
Work on EpxDepression began with a review of the literature. Past studies involving texting, mood scales, and PHQ-9 usage helped guide us in the right direction. Meetings with psychiatrists, psychologists, psychiatric nurses, and primary care physicians to discuss the intervention and how it might be used and improved upon helped sort out the details – how should we word our questions? How should we follow up if a patient displays suicidal ideation? Other obstacles, such as finding the balance between maximizing the information gathered versus the number of texts sent, are trial-and-error.
In the near future, we are looking to standardize practices in the clinic surrounding EpxDepression usage. In the meantime, we will continue to monitor the system through data and feedback, making adjustments along the way.
Guest Author, Nan Zhao
Independent Clinical Researcher, Epx Research Center, Washington University in St. Louis School of Medicine
Saint Louis University School of Medicine, Class of 2019
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Belmaker RH, Agam G. Major depressive disorder. N Engl J Med 2008; 358:55.
- Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
- Cuijpers P, Dekker J, Hollon SD, Andersson G. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009; 70:1219.
- American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010.
- Parikh SV, Segal ZV, Grigoriadis S, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord 2009; 117 Suppl 1:S15.
- Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006; 63:1337.
- Egede LE et al. Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial. Lancet Psychiatry, The, 2015-08-01. 2;8: 693-701.
- Lichstein KL et al. Telehealth cognitive behavior therapy for co-occurring insomnia and depression symptoms in older adults. J Clin Pschol. 2013 Oct; 69(10):1056-65.
- Aguilera et al. (2011) Text Messaging as an Adjunct to CBT in Low-Income Populations: A usability and Feasibility Pilot Study. Prof Psychol Res, 2011; 42(6): 472-8.
- van den Berg N et al. (2015) A Telephone- and Text Message-Based Telemedicine Concept for Patients with Mental Health Disorders: Results of a Randomized Controlled Trial. Psychother Psychosom, 2015; 84(2):82-89.
- Aguilera et al. (2015) Daily mood ratings via text message as a proxy for clinic based depression assessment. J Affect Discord, 2015; 175: 471-4.
- Unützer J, et al. Collaborative-care management of late-life depression in the primary care setting: a randomized controlled trial. Journal of the American Medical Association. 2002; 288:2836-2845.
- Hunkeler EM, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. British Medical Journal. 2006; 332(7536): 259-263.
- Williams J Jr., et al. The effectiveness of depression care management on diabetes-related outcomes in older patients. Annals of Internal Medicine. 2004 Jun 15;140(12):1015-24.