Depression screening using patient-targeted feedback in general practices: study protocol of the German multicentre GET.FEEDBACK.GP randomised controlled trial

Clinical effectiveness of patient-targeted feedback following depression screening in general practice (GET.FEEDBACK.GP): an investigator-initiated, prospective, multicentre, three-arm, observer-blinded, randomised controlled trial in Germany

BACKGROUND

Screening for depression in primary care alone is not sufficient to improve clinical outcomes. However, targeted feedback of the screening results to patients might result in beneficial effects. The GET.FEEDBACK.GP trial investigated whether targeted feedback of the depression screening result to patients, in addition to feedback to general practitioners (GPs), leads to greater reductions in depression severity than GP feedback alone or no feedback.

METHODS

The GET.FEEDBACK.GP trial was an investigator-initiated, multicentre, three-arm, observer-blinded, randomised controlled trial. Depression screening was conducted electronically using the Patient Health Questionnaire-9 (PHQ-9) in 64 GP practices across five regions in Germany while patients were waiting to see their GP. Currently undiagnosed patients (aged ≥18 years) who screened positive for depression (PHQ-9 score ≥10), were proficient in the German language, and had a personal consultation with a GP were randomly assigned (1:1:1) into a group that received no feedback on their depression screening result, a group in which only the GP received feedback, or a group in which both GP and patient received feedback. Randomisation was stratified by treating GP and PHQ-9 depression severity. Trial staff were masked to patient enrolment and study group allocation and GPs were masked to the feedback recieved by the patient. Written feedback, including the screening result and information on depression, was provided to the relevant groups before the consultation. The primary outcome was PHQ-9-measured depression severity at 6 months after randomisation. An intention-to-treat analysis was conducted for patients who had at least one follow-up visit. This study is registered at ClinicalTrials.gov (NCT03988985) and is complete.

FINDINGS

Between July 17, 2019, and Jan 31, 2022, 25 279 patients were approached for eligibility screening, 17 150 were excluded, and 8129 patients completed screening, of whom 1030 (12·7%) screened positive for depression. 344 patients were randomly assigned to receive no feedback, 344 were assigned to receive GP-targeted feedback, and 339 were assigned to receive GP-targeted plus patient-targeted feedback. 252 (73%) patients in the no feedback group, 252 (73%) in the GP-targeted feedback group, and 256 (76%) in the GP-targeted and patient-targeted feedback group were included in the analysis of the primary outcome at 6 months, which reflected a follow-up rate of 74%. Gender was reported as female by 637 (62·1%) of 1025 participants, male by 384 (37·5%), and diverse by four (0·4%). 169 (16%) of 1026 patients with available migration data had a migration background. Mean age was 39·5 years (SD 15·2). PHQ-9 scores improved for each group between baseline and 6 months by -4·15 (95% CI -4·99 to -3·30) in the no feedback group, -4·19 (-5·04 to -3·33) in the GP feedback group, and -4·91 (-5·76 to -4·07) in the GP plus patient feedback group, with no significant difference between the three groups (global p=0·13). The difference in PHQ-9 scores when comparing the GP plus patient feedback group with the no feedback group was -0·77 (-1·60 to 0·07, d=-0·16) and when comparing with the GP-only feedback group was -0·73 (-1·56 to 0·11, d=-0·15). No increase in suicidality was observed as an adverse event in either group.

INTERPRETATION

Providing targeted feedback to patients and GPs after depression screening does not significantly reduce depression severity compared with GP feedback alone or no feedback. Further research is required to investigate the potential specific effectiveness of depression screening with systematic feedback for selected subgroups.

FUNDING

German Innovation Fund.

TRANSLATION

For the German translation of the abstract see Supplementary Materials section.

How adults with suspected depressive disorder experience online depression screening: A qualitative interview study

Background

While evidence on the effects and mechanisms of online depression screening is inconclusive, publicly available 'online depression tests' are already frequently used. To further a comprehensive understanding of online depression screening and evince the perspectives of those affected, we aimed to qualitatively explore how adults with undiagnosed but suspected depressive disorder experience the screening process.

Methods

This study is a qualitative follow-up of a German-wide, 3-arm, randomised controlled trial on feedback after online depression screening conducted between Jan 2021 and Sep 2022. A subsample of 26 participants with undiagnosed but suspected depressive disorder (Patient Health Questionnaire-9 ≥ 10; no depression diagnosis/treatment within the last year) were purposefully selected based on maximum variation in gender, age, and study arm. In-depth semi-structured telephone interviews (mean = 37 min) were conducted approximately six months after screening. Data were analysed within a contextualist theoretical framework using inductive reflexive thematic analysis.

Results

Participants were balanced in terms of gender (female/male, n = 15/11), age (range = 22 to 61 years), and study arm (no feedback/standard feedback/tailored feedback, n = 7/11/8). Reported experiences of online depression screening can be described as a two-step process: Step 1 is the initial reaction to the screening procedure and comprises the theme recognition of depressive symptoms: from denial to awareness. Step 2 describes a subsequent self-explorative process encompassing the themes cognitive positioning: rejection vs. acceptance, emotional reaction: between overload and empowerment, and personal activation: from reflection to action.

Conclusions

Findings indicate that online depression screening with and without feedback of results is experienced as a two-step process promoting symptom recognition and subsequent self-exploration. While few participants reported negative effects, the majority described the screening process as insightful, empowering, and activating. Future research should determine to what extent online depression screening may pose a standalone form of low-threshold support for individuals with undiagnosed depressive disorder, while focusing as well on potential negative effects.

Psychological risk factors for Long COVID and their modification: study protocol of a three-arm, randomised controlled trial (SOMA.COV)

BACKGROUND

Growing evidence suggests that in addition to pathophysiological, there are psychological risk factors involved in the development of Long COVID. Illness-related anxiety and dysfunctional symptom expectations seem to contribute to symptom persistence.

AIMS

With regard to the development of effective therapies, our primary aim is to investigate whether symptoms of Long COVID can be improved by a targeted modification of illness-related anxiety and dysfunctional symptom expectations. Second, we aim to identify additional psychosocial risk factors that contribute to the persistence of Long COVID, and compare them with risk factors for symptom persistence in other clinical conditions.

METHOD

We will conduct an observer-blinded, three-arm, randomised controlled trial. A total of 258 patients with Long COVID will be randomised into three groups of equal size: targeted expectation management in addition to treatment as usual (TAU), non-specific supportive treatment plus TAU, or TAU only. Both active intervention groups will comprise three individual online video consultation sessions and a booster session after 3 months. The primary outcome is baseline to post-interventional change in overall somatic symptom severity.

CONCLUSIONS

The study will shed light onto the action mechanisms of a targeted expectation management intervention for Long COVID, which, if proven effective, can be used stand-alone or in the context of broader therapeutic approaches. Further, the study will enable a better understanding of symptom persistence in Long COVID by identifying additional psychological risk factors.

Factors associated with severity and persistence of fatigue in patients with primary biliary cholangitis: study protocol of a prospective cohort study with a mixed-methods approach (SOMA.LIV)

INTRODUCTION

Fatigue is a common symptom and the major 'unmet need' in the management of patients with primary biliary cholangitis (PBC). To date, only few prospective studies have addressed the development of PBC-associated fatigue over time. At the same time, few biological and psychosocial risk factors and mechanisms have been identified that could explain the development and maintenance of fatigue in PBC. It is the overall aim of this study to identify factors that determine the course and severity of fatigue in PBC, and to target these factors within deliverable interventions in order to improve patients' quality of life.

METHODS AND ANALYSIS

To identify biological and psychosocial risk factors for severe fatigue, a prospective 12-month cohort study with one baseline and two follow-up measurements will be conducted. In a cross-sectional part, we will simultaneously examine clinically relevant biomedical and psychosocial factors and systematically assess and compare associations and interactions between these factors and fatigue in n=240 patients with PBC (a patient group severely affected by fatigue) and n=240 patients with primary sclerosing cholangitis, a control cholestatic liver disease group much less affected by fatigue. In a prospective part, we will longitudinally monitor these variables and assess their predictive value at 12-month follow-up. Within an embedded mixed-methods design, we will conduct an experimental study and qualitative interviews in patients with newly diagnosed PBC.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10196-BO-ff). The study will shed light onto the mechanisms underlying the evolvement and maintenance of fatigue in patients with PBC and enable the development of evidence-based intervention strategies. Findings will be disseminated through peer-reviewed publications, scientific conferences and the involvement of relevant stakeholders, patients and the lay public.

TRIAL REGISTRATION NUMBER

ISRCTN14379650.

Persistence of gastrointestinal symptoms in irritable bowel syndrome and ulcerative colitis: study protocol for a three-arm randomised controlled trial (SOMA.GUT-RCT)

INTRODUCTION

Ulcerative colitis (UC) and irritable bowel syndrome (IBS) are distressing chronic diseases associated with abdominal pain and altered bowel habits of unknown aetiology. Results from previous studies indicate that, across both diseases, increased levels of illness-related anxiety and dysfunctional symptom expectations contribute to symptom persistence. Thus, comparing both disorders with regard to common and disease-specific factors in the persistence and modification of gastrointestinal symptoms seems justified. Our primary hypothesis is that persistent gastrointestinal symptoms in UC and IBS can be improved by modifying dysfunctional symptom expectations and illness-related anxiety using expectation management strategies.

METHODS AND ANALYSIS

To assess the extent to which persistent somatic symptoms are modifiable in adult patients with UC and IBS, we will conduct an observer-blinded, three-arm randomised controlled trial. A total of 117 patients with UC and 117 patients with IBS will be randomised into three groups of equal size: targeted expectation management aiming to reduce illness-related anxiety and dysfunctional symptom expectations in addition to standard care (SC, intervention 1), non-specific supportive treatment in addition to SC (intervention 2) or SC only (control). Both active intervention groups will comprise three individual online consultation sessions and a booster session after 3 months. The primary outcome is baseline to postinterventional change in gastrointestinal symptom severity.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10198-BO-ff). The study will shed light onto the efficacy and mechanisms of action of a targeted expectation management intervention for persistent gastrointestinal symptoms in patients with UC and IBS. Furthermore, the detailed analysis of the complex biopsychosocial mechanisms will allow the further advancement of aetiological models and according evidence-based intervention strategies.

TRIAL REGISTRATION NUMBER

ISRCTN30800023.

Clinical effectiveness of patient-oriented depression feedback in primary care: The empirical method of the GET.FEEDBACK.GP multicenter randomized controlled trial

GET.FEEDBACK.GP₁ is a multicenter randomized controlled trial testing the efficacy of patient-oriented depression feedback in primary care. This paper describes the complex methods and procedures of the trial. The primary outcome is depression severity six months after feedback, and we vary who is the target of the feedback as follows: no one receives feedback, only general practitioners receive feedback, and both patients and general practitioners receive feedback. The procedure includes a baseline assessment in primary care practices and three telephone follow-up interviews after one, six, and twelve months. The patients completed a baseline assessment, which determined their depression severity. Those with at least a moderate depression severity (PHQ-9₅ ≥ 10) were randomly allocated to three groups stratified by depression severity. A standardized mean difference of d = 0.25 with power 1 - β = 0.80 required a total sample size of N = 699. The patients provided responses regarding the primary and secondary outcomes at follow-up. The extensive planning for GET.FEEDBACK.GP involved experts from diverse medical specialties and external corporations. Of particular importance were (a) blinding in the study inclusion and random assignment with data capture software, (b) representative and unbiased patient selection in practice waiting rooms, (c) a data management and safety plan supplied by a specialized trial center, and (d) the use of participant pseudonyms supplied by a specialized service (Mainzelliste). The data collection started in July 2019 and will continue until June 2022. Five university study centers in Germany are participating in the trial.

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).

[Early Detection of Psychological Comorbidity in Patients Admitted to Dermatological and Internal Medicine Wards: A New Care Model for Psychosomatic Consultation Service]

This article explains the development and implementation of a psychosomatic screening and consultation service for inpatient somatic care. Approximately one in six somatic inpatients has a mental disorder. It is estimated that only half of these cases are properly identified. Consequently, a large proportion of patients remains untreated. To address this gap in care, a psychosomatic early detection programme was developed by an interdisciplinary working group. This programme is based on the Patient Health Questionnaire-4 (PHQ-4), a psychometrically very well evaluated ultra-short screening questionnaire for the detection of depressive and anxiety disorders. For implementation in routine inpatient care, the PHQ-4 was programmed as a form in the electronic medical record and administered by nursing staff during the admission interview. If the PHQ-4 screening result indicates the presence of a mental comorbidity and the patient expresses a wish for assessment of this disorder, a psychosomatic consultation is automatically ordered. The PHQ-4 was implemented into the clinical routine in four internal medicine and three dermatology wards of the University Medical Center Hamburg-Eppendorf. Documentation of the early diagnosis in the electronic patient record is a minimally costly, less time-consuming and practicable method of providing patients with holistic care through rapid interdisciplinary referral. An evaluation of cost-effectiveness, clinical efficiency, and acceptance is still pending.

GPs’ views on the use of depression screening and GP-targeted feedback: a qualitative study

Purpose

The first aim of this qualitative study was to identify general practitioners’ (GPs’) views on depression screening combined with GP-targeted feedback in primary care. The second aim was to determine the needs and preferences of GPs with respect to GP-targeted feedback to enhance the efficacy of depression screening.

Methods

A semistructured qualitative interview was conducted with officially registered GPs in Hamburg (Germany). Interviews were audio recorded and transcribed verbatim. An inductive approach was used to code the transcripts.

Results

Nine GPs (27 to 70 years; 5 male) from Hamburg, Germany, participated. Regarding depression screening combined with GP-targeted feedback, five thematic groups were identified: application of screening; screening and patient–physician relationships; GPs’ attitudes towards screening; benefits and concerns related to screening; and GPs’ needs and preferences regarding feedback. While the negative aspects of screening can be described in rather general terms (e.g., screening determines the mental health competence, screening threatens the doctor–patient relationship, revealing questions harm the patients), its advantages were very specific (e.g., promoting the identification of undetected cases, relief of the daily workload, wider communication channel to reach more patients). Standardized GP-targeted feedback of the screening results was perceived as helpful and purposeful. GPs preferred feedback materials that eased their clinical workload (e.g., short text with visuals, pictures, or images).

Conclusion

Addressing GPs’ needs is essential when implementing depression screening tools in clinical practice. To overcome prejudices and enhance the efficacy of screening, further education for GPs on the purpose and application on depression screening may be needed. Standardized GP-targeted feedback in combination with depression screening could be the missing link to improve the detection of depression in primary care.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02703-2) contains supplementary material, which is available to authorized users.