The effect of targeted and tailored patient depression engagement interventions on patient-physician discussion of suicidal thoughts: a randomized control trial

The efficacy of automated feedback after internet-based depression screening (DISCOVER): an observer-masked, three-armed, randomised controlled trial in Germany

BACKGROUND

Despite the availability of effective treatments, most depressive disorders remain undetected and untreated. Internet-based depression screening combined with automated feedback of screening results could reach people with depression and lead to evidence-based care. We aimed to test the efficacy of two versions of automated feedback after internet-based screening on depression severity compared with no feedback.

METHODS

DISCOVER was an observer-masked, three-armed, randomised controlled trial in Germany. We recruited individuals (aged ≥18 years) who were undiagnosed with depression and screened positive for depression on an internet-based self-report depression rating scale (Patient Health Questionnaire-9 [PHQ-9] ≥10 points). Participants were randomly assigned 1:1:1 to automatically receive no feedback, non-tailored feedback, or tailored feedback on the depression screening result. Randomisation was stratified by depression severity (moderate: PHQ-9 score 10-14 points; severe: PHQ-9 score ≥15 points). Participants could not be masked but were kept unaware of trial hypotheses to minimise expectancy bias. The non-tailored feedback included the depression screening result, a recommendation to seek professional diagnostic advice, and brief general information about depression and its treatment. The tailored feedback included the same basic information but individually framed according to the participants' symptom profiles, treatment preferences, causal symptom attributions, health insurance, and local residence. Research staff were masked to group allocation and outcome assessment as these were done using online questionnaires. The primary outcome was change in depression severity, defined as change in PHQ-9 score 6 months after random assignment. Analyses were conducted following the intention-to-treat principle for participants with at least one follow-up visit. This trial was registered at ClinicalTrials.gov, NCT04633096.

FINDINGS

Between Jan 12, 2021, and Jan 31, 2022, 4878 individuals completed the internet-based screening. Of these, 1178 (24%) screened positive for depression (mean age 37·1 [SD 14·2] years; 824 [70%] woman, 344 [29%] men, and 10 [1%] other gender identity). 6 months after random assignment, depression severity decreased by 3·4 PHQ-9 points in the no feedback group (95% CI 2·9-4·0; within-group d 0·67; 325 participants), by 3·5 points in the non-tailored feedback group (3·0-4·0; within-group d 0·74; 319 participants), and by 3·7 points in the tailored feedback group (3·2-4·3; within-group d 0·71; 321 participants), with no significant differences among the three groups (p=0·72). The number of participants seeking help for depression or initiating psychotherapy or antidepressant treatment did not differ among study groups. The results remained consistent when adjusted for fulfilling the DSM-5-based criteria for major depressive disorder or subjective belief of having a depressive disorder. Negative effects were reported by less than 1% of the total sample 6 months after random assignment.

INTERPRETATION

Automated feedback following internet-based depression screening did not reduce depression severity or prompt sufficient depression care in individuals previously undiagnosed with but affected by depression.

FUNDING

German Research Foundation.

Ethical and methodological challenges slowing progress in primary care-based suicide prevention: Illustrations from a randomized controlled trial and guidance for future research

INTRODUCTION

Despite the pressing need for primary care-based suicide prevention initiatives and growing acknowledgement of recruitment difficulties and Institutional Review Board (IRB) challenges in suicide research, we are aware of no illustrative examples describing how IRB decisions in the design of a primary care trial can compound recruitment challenges.

METHODS

The CDC-funded trial (NCT02986113) of Men and Providers Preventing Suicide aimed to examine the effects of a tailored computer program encourage men with suicidal thoughts (n = 304, ages 35-64) to discuss suicide with a primary care clinician and accept treatment. Before a visit, participants viewed MAPS or a non-tailored control video. Post-visit, both arms were offered telephone collaborative care, as mandated by the institutional review board (IRB). We previously showed that exposure to MAPs led to improvements in communication about suicide in a primary care visit. In this paper, we report data on the study's primary outcome, suicide preparatory behaviors.

RESULTS

After screening nearly 4100 men, 48 enrolled. Recruitment challenges, which were exacerabted by an IRB mandate narrowing post-intervention patient management differences between trial arms, limited detection of the effects of MAPS on suicide preparatory behaviors.

CONCLUSIONS

While primary care settings are key sites for suicide prevention trials, issues such as recruitment difficulties and overly restrictive IRB requirements may limit their utility. Methodological innovation to improve recruitment and ethical guidance to inform IRB decision-making are needed.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

The efficacy of automated feedback after internet-based depression screening: Study protocol of the German, three-armed, randomised controlled trial DISCOVER

BACKGROUND

Depression is one of the most disabling disorders worldwide, yet it often remains undetected. One promising approach to address both early detection and disease burden is depression screening followed by direct feedback to patients. Evidence suggests that individuals often seek information regarding mental health on the internet. Thus, internet-based screening with automated feedback has great potential to address individuals with undetected depression.

OBJECTIVES

To determine whether automated feedback after internet-based depression screening reduces depression severity as compared to no feedback.

METHODS

The internet-based, observer-blinded DISCOVER RCT aims to recruit a total of 1074 individuals. Participants will be screened for depression using the Patient Health Questionnaire (PHQ-9). In case of a positive screening result (PHQ-9 ≥ 10), participants with undetected depression will be randomised into one of three balanced study arms to receive either (a) no feedback (control arm), (b) standard feedback, or (c) tailored feedback on their screening result. The tailored feedback version will be adapted to participants' characteristics, i.e. symptom profile, preferences, and demographic characteristics. The primary hypothesis is that feedback reduces depression severity six months after screening compared to no feedback. The secondary hypothesis is that tailored feedback is more efficacious compared to standard feedback. Further outcomes are depression care, help-seeking behaviour, health-related quality of life, anxiety, somatic symptom severity, intervention acceptance, illness beliefs, adverse events, and a health economic evaluation. Follow-ups will be conducted one month and six months after screening by self-report questionnaires and clinical interviews. According to a statistical analysis plan, the primary outcome will be analysed on an intention-to-treat basis applying multilevel modelling.

DISCUSSION

The results of the DISCOVER RCT will inform about how automated feedback after internet-based screening could improve early detection and resolution of depression. Ways of dissemination and how the trial can contribute to an understanding of help-seeking behaviour processes will be discussed. If the results show that automated feedback after internet-based depression screening can reduce depression severity, the intervention could be easily implemented and might substantially reduce the disease burden of individuals with undetected depression.

ETHICAL APPROVAL

The study is approved by the Ethics Committee of the Hamburg Medical Association.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov in November 2020 (identifier: NCT04633096).

Educating outdoor workers using tailored and financial messages to encourage safe-sun behaviors

Excessive and unsafe sun exposure represents a concerning hazard to the health of individuals. Of particular interest are those who are most susceptible to sun exposure, such as outdoor workers. The current study used a 3 × 2 between-subjects design to investigate the effectiveness of messages that varied the extent of personalization (i.e. generic message; occupation targeted message; individual tailored message) and the inclusion of content regarding financial consequences of skin cancer. Participants (N = 304) were recruited from the USA through Amazon's Mechanical Turk and randomly assigned to view a generic message, occupation targeted message, or individual tailored message. Additionally, participants were randomly assigned to view messages in which financial information was either present or not. Participants responded to questions assessing pre- and post-test sun protection behaviors. Individual tailored messaging was as effective as occupation targeted messaging, with both being more effective than generic messaging. This finding indicates that some degree of personalization is necessary when promoting safe-sun practices to outdoor workers, but that tailoring to individuals may not always be necessary. Inclusion of financial content in messaging resulted in greater intentions to practice sun protection behaviors. Results provide insight into effective methods for promoting sun protection.

Tailored Activation of Middle-Aged Men to Promote Discussion of Recent Active Suicide Thoughts: a Randomized Controlled Trial

PURPOSE

Middle-aged men are at high risk of suicide. While about half of those who kill themselves visit a primary care clinician (PCC) shortly before death, in current practice, few spontaneously disclose their thoughts of suicide during the visits, and PCCs seldom inquire about such thoughts. In a randomized controlled trial, we examined the effect of a tailored interactive computer program designed to encourage middle-aged men's discussion of suicide with PCCs.

METHODS

We recruited men 35-74 years old reporting recent (within 4 weeks) active suicide thoughts from the panels of 42 PCCs (the unit of randomization) in eight offices within a single California health system. In the office before a visit, men viewed the intervention corresponding to their PCC's random group assignment: Men and Providers Preventing Suicide (MAPS) (20 PCCs), providing tailored multimedia promoting discussion of suicide thoughts, or control (22 PCCs), composed of a sleep hygiene video plus brief non-tailored text encouraging discussion of suicide thoughts. Logistic regressions, adjusting for patient nesting within physicians, examined MAPS' effect on patient-reported suicide discussion in the subsequent office visit.

RESULTS

Sixteen of the randomized PCCs had no patients enroll in the trial. From the panels of the remaining 26 PCCs (12 MAPS, 14 control), 48 men (MAPS 21, control 27) were enrolled (a mean of 1.8 (range 1-5) per PCC), with a mean age of 55.9 years (SD 11.4). Suicide discussion was more likely among MAPS patients (15/21 [65%]) than controls (8/27 [35%]). Logistic regression showed men viewing MAPS were more likely than controls to discuss suicide with their PCC (OR 5.91, 95% CI 1.59-21.94; P = 0.008; nesting-adjusted predicted effect 71% vs. 30%).

CONCLUSIONS

In addressing barriers to discussing suicide, the tailored MAPS program activated middle-aged men with active suicide thoughts to engage with PCCs around this customarily taboo topic.

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

Stakeholder views regarding a planned primary care office-based interactive multimedia suicide prevention tool

OBJECTIVES

Nearly half of all men who die by suicide visit a primary care clinician (PCC) in the month before death, yet few disclose suicide thoughts. We solicited stakeholders' views to guide development of a tailored multimedia program to activate middle-aged men experiencing suicide thoughts to engage with PCCs.

METHODS

We conducted semi-structured interviews with 44 adults self-identifying as: suicide attempt survivor; family member/loved one of person(s) who attempted or died by suicide; PCC; non-PCC office staff; health administrator; and/or prevention advocate. We coded recorded interview transcripts and identified relevant themes using grounded theory.

RESULTS

Two thematic groupings emerged, informing program design: structure and delivery (including belief the program could be effective and desire for use of plain language and media over text); and informational and motivational content (including concerns about PCC preparedness; fear that disclosing suicide thoughts would necessitate hospitalization; and influence of male identity and masculinity, respectively, in care-seeking for and interpreting suicide thoughts).

CONCLUSION

Stakeholder input informed the design of a primary care tailored multimedia suicide prevention tool.

PRACTICE IMPLICATIONS

In revealing a previously unreported barrier to disclosing suicide thoughts to PCCs (fear of hospitalization), and underscoring known barriers, the findings may suggest additional suicide prevention approaches.

Suicide in the Elderly: A Multidisciplinary Approach to Prevention

Suicide in the elderly is a growing problem. The elderly population is increasing, and elderly patients have multiple issues that place them at higher risk of suicidality. These issues include physical illnesses, mental illness, loss of functional status, isolation, and family, financial, and social factors. Access to firearms is another significant risk factor, because elderly patients are more likely to use firearms in suicide attempts; interventions to reduce firearms mortality may save lives. Tackling the difficult problem of suicide in the elderly may require a multidisciplinary, community-based series of interventions.

Does patient time spent viewing computer-tailored colorectal cancer screening materials predict patient-reported discussion of screening with providers?

The main aim is to examine whether patients' viewing time on information about colorectal cancer (CRC) screening before a primary care physician (PCP) visit is associated with discussion of screening options during the visit. We analyzed data from a multi-center randomized controlled trial of a tailored interactive multimedia computer program (IMCP) to activate patients to undergo CRC screening, deployed in primary care offices immediately before a visit. We employed usage time information stored in the IMCP to examine the association of patient time spent using the program with patient-reported discussion of screening during the visit, adjusting for previous CRC screening recommendation and reading speed.On average, patients spent 33 minutes on the program. In adjusted analyses, 30 minutes spent using the program was associated with a 41% increase in the odds of the patient having a discussion with their PCP (1.04, 1.59, 95% CI). In a separate analysis of the tailoring modules; the modules encouraging adherence to the tailored screening recommendation and discussion with the patient's PCP yielded significant results. Other predictors of screening discussion included better self-reported physical health and increased patient activation. Time spent on the program predicted greater patient-physician discussion of screening during a linked visit.Usage time information gathered automatically by IMCPs offers promise for objectively assessing patient engagement around a topic and predicting likelihood of discussion between patients and their clinician.

Technology-enhanced suicide prevention interventions: A systematic review

Objective

Suicide prevention is a high priority. Scalable and sustainable interventions for suicide prevention are needed to set the stage for population-level impact. This systematic review explores how technology-enhanced interventions target suicide risk and protective factors, using the Centers for Disease Control and Prevention (CDC, 2015) Risk and Protective Factors Ecological Model.

Methods

Information databases (PsycINFO, PubMed and CINAHL) were systematically searched and records including technology-enhanced interventions for suicide prevention ( n = 3764) were reviewed. Records with varying technologies and diverse methodologies were integrated into the search.

Results

Review of the records resulted in the inclusion of 16 studies that utilized technology-enhanced interventions to address determinants of suicidal behaviour. This includes the use of standalone or, in most cases, adjunct technology-enhanced interventions for suicide prevention delivered by mobile phone application, text message, telephone, computer, web, CD-ROM and video.

Conclusion

Intervention effectiveness was variable, but several technology-enhanced interventions have demonstrated effectiveness in reducing suicidal ideation and mental health co-morbidities. Large-scale research and evaluation initiatives are needed to evaluate the costs and long-term population-level impact of these interventions.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

OBJECTIVES

To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.

METHOD

Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.

RESULTS

Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.

CONCLUSION

Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

Choosing Healthcare Options by Involving Canada's Elderly: a protocol for the CHOICE realist synthesis project on engaging older persons in healthcare decision-making

INTRODUCTION

While patient and citizen engagement has been recognised as a crucial element in healthcare reform, limited attention has been paid to how best to engage seniors-the fastest growing segment of the population and the largest users of the healthcare system. To improve the healthcare services for this population, seniors and their families need to be engaged as active partners in healthcare decision-making, research and planning. This synthesis aims to understand the underlying context and mechanisms needed to achieve meaningful engagement of older adults in healthcare decision-making, research and planning.

METHODS AND ANALYSIS

The CHOICE Knowledge Synthesis Project: Choosing Healthcare Options by Involving Canada's Elderly aims to address this issue by synthesising current knowledge on patient, family, and caregiver engagement. A realist synthesis will support us to learn from other patient and citizen engagement initiatives, from previous research, and from seniors, families and caregivers themselves. The synthesis will guide development or adaptation of a framework, leading to the development of best practice guidelines and recommendations for engagement of older people and their families and caregivers in clinical decision-making, healthcare delivery, planning and research.

ETHICS AND DISSEMINATION

The components of this protocol involving consultation with patients or caregivers have received ethics clearance from the University of Waterloo, Office of Research Ethics (ORE#19094). After completion of the project, we will amalgamate the information collected into a knowledge synthesis report which will include best practice guidelines and recommendations for patient, family and caregiver engagement in clinical and health system planning and research contexts.

RESULTS

Will be further disseminated to citizens, clinicians, researchers and policymakers with the help of our partners.

TRIAL REGISTRATION NUMBER

CRD42015024749.