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Mudiyanselage KWW, De Santis KK, Jörg F, Saleem M, Stewart R, Zeeb H, Busse H. The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review. BMC Public Health 2024; 24:77. [PMID: 38172713 PMCID: PMC10763181 DOI: 10.1186/s12889-023-17417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries. METHODS Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials. RESULTS Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor. CONCLUSION Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.
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Affiliation(s)
- Kalpani Wijekoon Wijekoon Mudiyanselage
- Faculty 11 Human and Health Sciences, University of Bremen, Bremen, Germany.
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany.
| | - Karina Karolina De Santis
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
| | - Frederike Jörg
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Education and Research, Friesland Mental Health Care Services, Leeuwarden, the Netherlands
| | - Maham Saleem
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
| | - Roy Stewart
- Department of Health Sciences, Community & Occupational Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hajo Zeeb
- Faculty 11 Human and Health Sciences, University of Bremen, Bremen, Germany
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
- Leibniz ScienceCampus Digital Public Health Bremen, Bremen, Germany
| | - Heide Busse
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
- Leibniz ScienceCampus Digital Public Health Bremen, Bremen, Germany
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Perret S, Alon N, Carpenter-Song E, Myrick K, Thompson K, Li S, Sharma K, Torous J. Standardising the role of a digital navigator in behavioural health: a systematic review. Lancet Digit Health 2023; 5:e925-e932. [PMID: 38000876 DOI: 10.1016/s2589-7500(23)00152-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 11/26/2023]
Abstract
As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.
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Affiliation(s)
- Sarah Perret
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noy Alon
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Keris Myrick
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kennedy Thompson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sunnie Li
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karuna Sharma
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - John Torous
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Kulikov VN, Crosthwaite PC, Hall SA, Flannery JE, Strauss GS, Vierra EM, Koepsell XL, Lake JI, Padmanabhan A. A CBT-based mobile intervention as an adjunct treatment for adolescents with symptoms of depression: a virtual randomized controlled feasibility trial. Front Digit Health 2023; 5:1062471. [PMID: 37323125 PMCID: PMC10262850 DOI: 10.3389/fdgth.2023.1062471] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/27/2023] [Indexed: 06/17/2023] Open
Abstract
Background High rates of adolescent depression demand for more effective, accessible treatment options. A virtual randomized controlled trial was used to assess the feasibility and acceptability of a 5-week, self-guided, cognitive behavioral therapy (CBT)-based mobile application, Spark, compared to a psychoeducational mobile application (Active Control) as an adjunct treatment for adolescents with depression during the COVID-19 pandemic. Methods A community sample aged 13-21, with self-reported symptoms of depression, was recruited nationwide. Participants were randomly assigned to use either Spark or Active Control (NSpark = 35; NActive Control = 25). Questionnaires, including the PHQ-8 measuring depression symptoms, completed before, during, and immediately following completion of the intervention, evaluated depressive symptoms, usability, engagement, and participant safety. App engagement data were also analyzed. Results 60 eligible adolescents (female = 47) were enrolled in 2 months. 35.6% of those expressing interest were consented and all enrolled. Study retention was high (85%). Spark users rated the app as usable (System Usability Scalemean = 80.67) and engaging (User Engagement Scale-Short Formmean = 3.62). Median daily use was 29%, and 23% completed all levels. There was a significant negative relationship between behavioral activations completed and change in PHQ-8. Efficacy analyses revealed a significant main effect of time, F = 40.60, p < .001, associated with decreased PHQ-8 scores over time. There was no significant Group × Time interaction (F = 0.13, p = .72) though the numeric decrease in PHQ-8 was greater for Spark (4.69 vs. 3.56). No serious adverse events or adverse device effects were reported for Spark users. Two serious adverse events reported in the Active Control group were addressed per our safety protocol. Conclusion Recruitment, enrollment, and retention rates demonstrated study feasibility by being comparable or better than other mental health apps. Spark was highly acceptable relative to published norms. The study's novel safety protocol efficiently detected and managed adverse events. The lack of significant difference in depression symptom reduction between Spark and Active Control may be explained by study design and study design factors. Procedures established during this feasibility study will be leveraged for subsequent powered clinical trials evaluating app efficacy and safety. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04524598.
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Affiliation(s)
- Vera N. Kulikov
- Research Department, Limbix Health, San Francisco, CA, United States
| | | | - Shana A. Hall
- Research Department, Limbix Health, San Francisco, CA, United States
| | | | | | - Elise M. Vierra
- Content Department, Limbix Health, San Francisco, CA, United States
| | - Xin L. Koepsell
- Content Department, Limbix Health, San Francisco, CA, United States
| | - Jessica I. Lake
- Science Department, Limbix Health, San Francisco, CA, United States
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Xiong S, Lu H, Peoples N, Duman EK, Najarro A, Ni Z, Gong E, Yin R, Ostbye T, Palileo-Villanueva LM, Doma R, Kafle S, Tian M, Yan LL. Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries. NPJ Digit Med 2023; 6:12. [PMID: 36725977 PMCID: PMC9889958 DOI: 10.1038/s41746-023-00764-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/21/2023] [Indexed: 02/03/2023] Open
Abstract
Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.
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Affiliation(s)
- Shangzhi Xiong
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
- Global Health Research Centre, Duke Kunshan University, Kunshan, China.
| | - Hongsheng Lu
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Ege K Duman
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
- School of Anthropology and Museum Ethnography, Oxford University, Oxford, UK
| | - Alberto Najarro
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
- The Yenching Academy of Peking University, Beijing, China
| | - Zhao Ni
- School of Nursing, Yale University, New Haven, CT, USA
| | - Enying Gong
- School of Population Medicine and Public Health, China Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruoyu Yin
- Department of Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Truls Ostbye
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
| | | | - Rinchen Doma
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Sweta Kafle
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Maoyi Tian
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Lijing L Yan
- Global Health Research Centre, Duke Kunshan University, Kunshan, China.
- Duke Global Health Institute, Duke University, Durham, NC, USA.
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- The George Institute for Global Health, Beijing, China.
- School of Health Sciences, Wuhan University, Wuhan, China.
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Rahman TFA, Nayan NM. Text Messages for Depression, Anxiety and Alcohol Abuse Therapy-Are Construction Guidelines Needed? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15701. [PMID: 36497775 PMCID: PMC9737776 DOI: 10.3390/ijerph192315701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 06/17/2023]
Abstract
Despite the effectiveness of text messaging therapy in improving mental health conditions, limited attention has been paid to how the text messages are constructed. Thus, this study questions whether there is a need to develop a model of text message construction for mental health therapy. In this backdrop, this study reviews how a text message for mental health therapy is constructed, specifically focused on the process and guidelines. This study also aims to identify the research gap regarding the guideline of text message construction for mental health therapy and to identify mental health professionals' practices in text messaging therapy. In addition, the opinions of mental health professionals on the need to develop a text message construction guideline were also gathered. The findings from the literature review confirmed that there are still limited guidelines explaining the process of constructing text messages for mental health therapy. Meanwhile, results from the online survey found that mental health professionals expressed a high need to explore and develop a model of text message construction for mental health therapy. With this research gap addressed, this study proposes further research into the development of a text message construction model for mental health therapy.
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Affiliation(s)
- Teh Faradilla Abdul Rahman
- Centre of Foundation Studies, Universiti Teknologi MARA, Cawangan Selangor, Kampus Dengkil, Dengkil 43800, Selangor, Malaysia
| | - Norshita Mat Nayan
- Institute of IR4.0, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
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Toyama M, Cavero V, Araya R, Menezes PR, Mohr DC, Miranda JJ, Diez-Canseco F. Participants’ and Nurses’ Experiences With a Digital Intervention for Patients With Depressive Symptoms and Comorbid Hypertension or Diabetes in Peru: Qualitative Post–Randomized Controlled Trial Study. JMIR Hum Factors 2022; 9:e35486. [PMID: 36107482 PMCID: PMC9523528 DOI: 10.2196/35486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background Depression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users’ experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention. Objective This study aimed to explore the RCT participants’ experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them. Methods In 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews. Results Participants’ mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions’ text simple, extending the length of the intervention, and improving the training session with long explanations. Conclusions The findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants’ experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up. Trial Registration ClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426
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Affiliation(s)
- Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Victoria Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ricardo Araya
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Paulo Rossi Menezes
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - David C Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Cavero V, Toyama M, Castro H, Couto MT, Brandt L, Quayle J, Menezes PR, Mohr DC, Araya R, Miranda JJ, Diez-Canseco F. Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system's stakeholders' perspectives. DISCOVER MENTAL HEALTH 2022; 2:12. [PMID: 35677652 PMCID: PMC9163924 DOI: 10.1007/s44192-022-00015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/17/2022] [Indexed: 12/20/2022]
Abstract
Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.
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Affiliation(s)
- V. Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - M. Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - H. Castro
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - M. T. Couto
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - L. Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J. Quayle
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - P. R. Menezes
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - D. C. Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - R. Araya
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, UK
| | - J. J. Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - F. Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Carli V, Petros NG, Hadlaczky G, Vitcheva T, Berchialla P, Bianchi S, Carletto S, Christinaki E, Citi L, Dinis S, Gentili C, Geraldes V, Giovinazzo L, Gonzalez-Martinez S, Meyer B, Ostacoli L, Ottaviano M, Ouakinin S, Papastylianou T, Paradiso R, Poli R, Rocha I, Settanta C, Scilingo EP, Valenza G. The NEVERMIND e-health system in the treatment of depressive symptoms among patients with severe somatic conditions: A multicentre, pragmatic randomised controlled trial. EClinicalMedicine 2022; 48:101423. [PMID: 35706482 PMCID: PMC9092507 DOI: 10.1016/j.eclinm.2022.101423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study assessed the effectiveness of the NEVERMIND e-health system, consisting of a smart shirt and a mobile application with lifestyle behavioural advice, mindfulness-based therapy, and cognitive behavioural therapy, in reducing depressive symptoms among patients diagnosed with severe somatic conditions. Our hypothesis was that the system would significantly decrease the level of depressive symptoms in the intervention group compared to the control group. Methods This pragmatic, randomised controlled trial included 425 patients diagnosed with myocardial infarction, breast cancer, prostate cancer, kidney failure, or lower limb amputation. Participants were recruited from hospitals in Turin and Pisa (Italy), and Lisbon (Portugal), and were randomly assigned to either the NEVERMIND intervention or to the control group. Clinical interviews and structured questionnaires were administered at baseline, 12 weeks, and 24 weeks. The primary outcome was depressive symptoms at 12 weeks measured by the Beck Depression Inventory II (BDI-II). Intention-to-treat analyses included 425 participants, while the per-protocol analyses included 333 participants. This trial is registered in the German Clinical Trials Register, DRKS00013391. Findings Patients were recruited between Dec 4, 2017, and Dec 31, 2019, with 213 assigned to the intervention and 212 to the control group. The sample had a mean age of 59·41 years (SD=10·70), with 44·24% women. Those who used the NEVERMIND system had statistically significant lower depressive symptoms at the 12-week follow-up (mean difference=-3·03, p<0·001; 95% CI -4·45 to -1·62) compared with controls, with a clinically relevant effect size (Cohen's d=0·39). Interpretation The results of this study show that the NEVERMIND system is superior to standard care in reducing and preventing depressive symptoms among patients with the studied somatic conditions. Funding The NEVERMIND project received funding from the European Union's Horizon 2020 Research and Innovation Programme under grant agreement No. 689691.
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Affiliation(s)
- Vladimir Carli
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Nuhamin Gebrewold Petros
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Gergö Hadlaczky
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Tereza Vitcheva
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, Università degli Studi di Torino, Turin, Italy
| | - Silvia Bianchi
- Research Center "E.Piaggio" and Department of Information Engineering, School of Engineering, Università di Pisa, Pisa, Italy
| | - Sara Carletto
- Department of Neuroscience "Rita Levi Montalcini", Università degli Studi di Torino, Turin, Italy
| | - Eirini Christinaki
- School of Computer Science and Electronic Engineering, University of Essex, Colchester, UK
| | - Luca Citi
- School of Computer Science and Electronic Engineering, University of Essex, Colchester, UK
| | - Sérgio Dinis
- Faculdade de Medicina and CCUL, Universidade de Lisboa, Lisbon, Portugal
| | - Claudio Gentili
- General Psychology Department, Università degli Studi di Padova, Padua, Italy
| | - Vera Geraldes
- Faculdade de Medicina and CCUL, Universidade de Lisboa, Lisbon, Portugal
| | - Lorena Giovinazzo
- Department of Clinical and Biological Sciences, Università degli Studi di Torino, Turin, Italy
| | | | | | - Luca Ostacoli
- Department of Clinical and Biological Sciences, Università degli Studi di Torino, Turin, Italy
| | - Manuel Ottaviano
- Life Supporting Technologies, Universidad Politécnica de Madrid, Madrid, Spain
| | - Silvia Ouakinin
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Tasos Papastylianou
- School of Computer Science and Electronic Engineering, University of Essex, Colchester, UK
| | | | - Riccardo Poli
- School of Computer Science and Electronic Engineering, University of Essex, Colchester, UK
| | - Isabel Rocha
- Faculdade de Medicina and CCUL, Universidade de Lisboa, Lisbon, Portugal
| | - Carmen Settanta
- Department of Clinical and Biological Sciences, Università degli Studi di Torino, Turin, Italy
| | - Enzo Pasquale Scilingo
- Research Center "E.Piaggio" and Department of Information Engineering, School of Engineering, Università di Pisa, Pisa, Italy
| | - Gaetano Valenza
- Research Center "E.Piaggio" and Department of Information Engineering, School of Engineering, Università di Pisa, Pisa, Italy
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Mavragani A, Weingarden H, Wolfe EC, Hall MD, Snorrason I, Wilhelm S. Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review. J Med Internet Res 2022; 24:e33307. [PMID: 35394434 PMCID: PMC9034419 DOI: 10.2196/33307] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Smartphone app-based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions. OBJECTIVE The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach. METHODS We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded. RESULTS Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present. CONCLUSIONS Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis.
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Affiliation(s)
| | - Hilary Weingarden
- Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Emma C Wolfe
- Massachusetts General Hospital, Boston, MA, United States
| | | | - Ivar Snorrason
- Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Sabine Wilhelm
- Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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10
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Shah A, Hussain-Shamsy N, Strudwick G, Sockalingam S, Nolan RP, Seto E. Digital Health Interventions for Depression and Anxiety Among People with Chronic Conditions: Scoping Review (Preprint). J Med Internet Res 2022; 24:e38030. [PMID: 36155409 PMCID: PMC9555324 DOI: 10.2196/38030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/12/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored. Objective This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions. Methods A scoping review of the literature was conducted using the Arksey and O’Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research. Results Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI. Conclusions As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research.
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Affiliation(s)
- Amika Shah
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
| | - Neesha Hussain-Shamsy
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
| | - Gillian Strudwick
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Sanjeev Sockalingam
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Robert P Nolan
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Cardiac eHealth, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
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11
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Molloy A, Anderson PL. Engagement with mobile health interventions for depression: A systematic review. Internet Interv 2021; 26:100454. [PMID: 34621626 PMCID: PMC8479400 DOI: 10.1016/j.invent.2021.100454] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/04/2021] [Accepted: 09/08/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Depressive disorders are a major public health problem, and many people face barriers to accessing evidence-based mental health treatment. Mobile health (mHealth) interventions may circumvent logistical barriers to in-person care (e.g., cost, transportation), however the symptoms of depression (low motivation, concentration difficulties) may make it difficult for people with the disorder to engage with mHealth. OBJECTIVE The aim of this systematic review is to examine assessment and reporting of engagement in clinical trials of mHealth interventions for depression, including objective engagement (e.g., number of times program is used), subjective engagement (e.g., qualitative data on users' experiences), and associations between engagement and other clinically important variables (e.g., symptom improvement, participant characteristics). METHODS Three electronic databases (PsycINFO, Web of Science, PubMed) were searched in February 2020 using search terms for mHealth and depression. Studies were included in the review if they tested a mHealth intervention designed for people with depressive disorders or elevated depression symptoms. RESULTS Thirty studies met inclusion criteria and were reviewed. Most studies reported objective engagement (N = 23, 76.7%), approximately half reported subjective engagement (N = 16, 53.3%), and relatively few examined associations between engagement and clinical improvement, participant characteristics, or other clinically relevant variables (N = 13, 43.3%). CONCLUSIONS Although most studies in this small but rapidly growing literature report at least one measure of engagement, there is substantial heterogeneity. Intentional, theory-driven, and consistent measurement of engagement with mHealth interventions for depression may advance the field's understanding of effective engagement to facilitate clinical improvement, identify dose-response relationships, and maximize generalizability for underserved populations.
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Affiliation(s)
- Anthony Molloy
- Department of Psychology, Georgia State University, Urban Life Bldg, 11th Floor, 140 Decatur Street, Atlanta, GA 30303, USA
| | - Page L Anderson
- Department of Psychology, Georgia State University, Urban Life Bldg, 11th Floor, 140 Decatur Street, Atlanta, GA 30303, USA
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12
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Silva EP, Emond A, Ludermir AB. Depression in childhood: The role of children's exposure to intimate partner violence and maternal mental disorders. CHILD ABUSE & NEGLECT 2021; 122:105305. [PMID: 34517271 DOI: 10.1016/j.chiabu.2021.105305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 06/08/2021] [Accepted: 08/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Intimate partner violence (IPV) is a global problem with high prevalence rates, and is linked to maternal mental disorders (MMD). Children's exposure to IPV (CEIPV) can have impacts on their physical and mental health, including depression. OBJECTIVE To analyze the associations between exposure to both CEIPV and MMD and depression in schoolchildren. PARTICIPANTS AND SETTING 630 mother-child pairs were evaluated in a poor urban district in Recife, Northeast Brazil. METHODS A cohort study investigated the effects of IPV during pregnancy, postpartum and six to nine years after delivery. Women were asked about their experience of IPV, their own mental health, and the exposure of their child to violence. The child's mood was reported by the mother, using the Short Mood and Feelings Questionnaire (SMFQ). Ten types of CEIPV, and the age of onset of exposure, were compared with the child's subsequent risk of depression. RESULTS IPV was associated with MMD in 31.9% of the women at some period of time. Depressive symptoms were reported in 15.7% of school-age children. All types of CEIPV were associated with depression at school age. Multivariable analyses of exposure to IPV and MMD at different ages showed that exposure to both IPV and MMD in the first year of life had the strongest association with childhood depression (OR = 9.1; 95% CI: 2.4-33.9). CONCLUSIONS The frequency of CEIPV and MMD, and the high prevalence of depression at school age, shows the importance of assessing MMD and identifying exposure to IPV in pregnancy and the early years.
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Affiliation(s)
- Elisabete Pereira Silva
- Universidade Federal de Pernambuco, Hospital das Clínicas, 2o andar - Av. Prof. Moraes Rêgo, s/n. Cidade Universitária, 50.670-420, Recife, PE, Brazil.
| | - Alan Emond
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road Clifton, Bristol BS8 1NU, United Kingdom
| | - Ana Bernarda Ludermir
- Universidade Federal de Pernambuco, Av. da Engenharia, s/n, Bloco "D" - 1° Andar - Cidade Universitária, 50.740-600, Recife, PE, Brazil
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13
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Six SG, Byrne KA, Tibbett TP, Pericot-Valverde I. Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis. JMIR Ment Health 2021; 8:e32199. [PMID: 34847058 PMCID: PMC8669581 DOI: 10.2196/32199] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification. OBJECTIVE The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements. METHODS A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis. RESULTS A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40). CONCLUSIONS The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.
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Affiliation(s)
- Stephanie G Six
- Department of Psychology, Clemson University, Clemson, SC, United States
| | - Kaileigh A Byrne
- Department of Psychology, Clemson University, Clemson, SC, United States
| | - Thomas P Tibbett
- SAP National Security Services, Inc, Newtown Square, PA, United States
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14
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Technology-Assisted Collaborative Care Program for People with Diabetes and/or High Blood Pressure Attending Primary Health Care: A Feasibility Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212000. [PMID: 34831756 PMCID: PMC8618659 DOI: 10.3390/ijerph182212000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 01/09/2023]
Abstract
The comorbidity of depression with physical chronic diseases is usually not considered in clinical guidelines. This study evaluated the feasibility of a technology-assisted collaborative care (TCC) program for depression in people with diabetes and/or high blood pressure (DM/HBP) attending a primary health care (PHC) facility in Santiago, Chile. Twenty people diagnosed with DM/HBP having a Patient Health Questionnaire-9 score ≥ 15 points were recruited. The TCC program consisted of a face-to-face, computer-assisted psychosocial intervention (CPI, five biweekly sessions), telephone monitoring (TM), and a mobile phone application for behavioral activation (CONEMO). Assessments of depressive symptoms and other health-related outcomes were made. Thirteen patients completed the CAPI, 12 received TM, and none tried CONEMO. The TCC program was potentially efficacious in treating depression, with two-thirds of participants achieving response to depression treatment 12 weeks after baseline. Decreases were observed in depressive symptoms and healthcare visits and increases in mental health-related quality of life and adherence to treatment. Patients perceived the CPI as acceptable. The TCC program was partially feasible and potentially efficacious for managing depression in people with DM/HBP. These data are valuable inputs for a future randomized clinical trial.
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15
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Aplicativos móveis para as sociedades menos favorecidas. ACTA PAUL ENFERM 2021. [DOI: 10.37689/acta-ape/2021ar02214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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Daley K, Hungerbuehler I, Cavanagh K, Claro HG, Swinton PA, Kapps M. Preliminary Evaluation of the Engagement and Effectiveness of a Mental Health Chatbot. Front Digit Health 2021; 2:576361. [PMID: 34713049 PMCID: PMC8521874 DOI: 10.3389/fdgth.2020.576361] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/10/2020] [Indexed: 01/21/2023] Open
Abstract
Background: Mental health difficulties are highly prevalent, yet access to support is limited by barriers of stigma, cost, and availability. These issues are even more prevalent in low- and middle-income countries, and digital technology is one potential way to overcome these barriers. Digital mental health interventions are effective but often struggle with low engagement rates, particularly in the absence of human support. Chatbots could offer a scalable solution, simulating human support at a lower cost. Objective: To complete a preliminary evaluation of engagement and effectiveness of Vitalk, a mental health chatbot, at reducing anxiety, depression and stress. Methods: Real world data was analyzed from 3,629 Vitalk users who had completed the first phase of a Vitalk program (“less anxiety,” “less stress” or “better mood”). Programs were delivered through written conversation with a chatbot. Engagement was calculated from the number of responses sent to the chatbot divided by days in the program. Results: Users sent an average of 8.17 responses per day. For all three programs, target outcome scores reduced between baseline and follow up with large effect sizes for anxiety (Cohen's d = −0.85), depression (Cohen's d = −0.91) and stress (Cohen's d = −0.81). Increased engagement resulted in improved post-intervention values for anxiety and depression. Conclusion: This study highlights a chatbot's potential to reduce mental health symptoms in the general population within Brazil. While findings show promise, further research is required.
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Affiliation(s)
| | | | - Kate Cavanagh
- School of Psychology, University of Sussex, Brighton, United Kingdom
| | - Heloísa Garcia Claro
- Department of Preventive Medicine, Medical School, University of São Paulo, São Paulo, Brazil.,School of Nursing, University of Campinas, Campinas, Brazil
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen, United Kingdom
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17
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Vera Cruz Dos Santos D, Coelho de Soárez P, Cavero V, U Rocha TI, Aschar S, Daley KL, Garcia Claro H, Abud Scotton G, Fernandes I, Diez-Canseco F, Brandt LR, Toyama M, Martins Castro HC, Miranda JJ, Araya R, Quayle J, Rossi Menezes P. A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru. JMIR Res Protoc 2021; 10:e26164. [PMID: 34643538 PMCID: PMC8552099 DOI: 10.2196/26164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/04/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022] Open
Abstract
Background Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. Objective This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. Methods The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top–down and bottom–up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. Results The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. Conclusions We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. Trial Registration ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426 International Registered Report Identifier (IRRID) DERR1-10.2196/26164
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Affiliation(s)
| | - Patrícia Coelho de Soárez
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Victoria Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Thaís I U Rocha
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Suzana Aschar
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Kate Louise Daley
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Heloísa Garcia Claro
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, Brazil
| | - George Abud Scotton
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ivan Fernandes
- CECS Centro de Engenharia, Modelagem e Ciências Sociais Aplicadas, Universidade Federal do ABC, São Bernardo do Campo, Brazil
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lena Rebeca Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ricardo Araya
- Centre for Global Mental Health and Primary Care Research, Health Service and Population Research, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Julieta Quayle
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Rossi Menezes
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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18
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Azizoddin DR, Adam R, Kessler D, Wright AA, Kematick B, Sullivan C, Zhang H, Hassett MJ, Cooley ME, Ehrlich O, Enzinger AC. Leveraging mobile health technology and research methodology to optimize patient education and self-management support for advanced cancer pain. Support Care Cancer 2021; 29:5741-5751. [PMID: 33738594 PMCID: PMC8410657 DOI: 10.1007/s00520-021-06146-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/08/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Patient education is critical for management of advanced cancer pain, yet the benefits of psychoeducational interventions have been modest. We used mobile health (mHealth) technology to better meet patients' needs. METHODS Using the Agile and mHealth Development and Evaluation Frameworks, a multidisciplinary team of clinicians, researchers, patients, and design specialists followed a four-phase iterative process to develop comprehensive, tailored, multimedia cancer pain education for a patient-facing smartphone application. The target population reviewed the content and provided feedback. RESULTS The resulting application provides comprehensive cancer pain education spanning pharmacologic and behavioral aspects of self-management. Custom graphics, animated videos, quizzes, and audio-recorded relaxations complemented written content. Computable algorithms based upon daily symptom surveys were used to deliver brief, tailored motivational messages that linked to more comprehensive teaching. Patients found the combination of pharmacologic and behavioral support to be engaging and helpful. CONCLUSION Digital technology can be used to provide cancer pain education that is engaging and tailored to individual needs. A replicable interdisciplinary and patient-centered approach to intervention development was advantageous. mHealth interventions may be a scalable approach to improve cancer pain. Frameworks that merge software and research methodology can be useful in developing interventions.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Thorn Building, Boston, MA, 13-1303, USA.
| | - Rosalind Adam
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Daniela Kessler
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Alexi A Wright
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Benjamin Kematick
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Clare Sullivan
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Haipeng Zhang
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Brigham Digital Innovation Hub, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael J Hassett
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Mary E Cooley
- Harvard Medical School, Boston, MA, USA.,Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Olga Ehrlich
- Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
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19
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Gabrielli S, Rizzi S, Bassi G, Carbone S, Maimone R, Marchesoni M, Forti S. Engagement and Effectiveness of a Healthy-Coping Intervention via Chatbot for University Students During the COVID-19 Pandemic: Mixed Methods Proof-of-Concept Study. JMIR Mhealth Uhealth 2021; 9:e27965. [PMID: 33950849 PMCID: PMC8166265 DOI: 10.2196/27965] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND University students are increasingly reporting common mental health problems, such as stress, anxiety, and depression, and they frequently face barriers to seeking psychological support because of stigma, cost, and availability of mental health services. This issue is even more critical in the challenging time of the COVID-19 pandemic. Digital mental health interventions, such as those delivered via chatbots on mobile devices, offer the potential to achieve scalability of healthy-coping interventions by lowering cost and supporting prevention. OBJECTIVE The goal of this study was to conduct a proof-of-concept evaluation measuring the engagement and effectiveness of Atena, a psychoeducational chatbot supporting healthy coping with stress and anxiety, among a population of university students. METHODS In a proof-of-concept study, 71 university students were recruited during the COVID-19 pandemic; 68% (48/71) were female, they were all in their first year of university, and their mean age was 20.6 years (SD 2.4). Enrolled students were asked to use the Atena psychoeducational chatbot for 4 weeks (eight sessions; two per week), which provided healthy-coping strategies based on cognitive behavioral therapy, positive psychology, and mindfulness techniques. The intervention program consisted of conversations combined with audiovisual clips delivered via the Atena chatbot. Participants were asked to complete web-based versions of the 7-item Generalized Anxiety Disorder scale (GAD-7), the 10-item Perceived Stress Scale (PSS-10), and the Five-Facet Mindfulness Questionnaire (FFMQ) at baseline and postintervention to assess effectiveness. They were also asked to complete the User Engagement Scale-Short Form at week 2 to assess engagement with the chatbot and to provide qualitative comments on their overall experience with Atena postintervention. RESULTS Participants engaged with the Atena chatbot an average of 78 (SD 24.8) times over the study period. A total of 61 out of 71 (86%) participants completed the first 2 weeks of the intervention and provided data on engagement (10/71, 14% attrition). A total of 41 participants out of 71 (58%) completed the full intervention and the postintervention questionnaires (30/71, 42% attrition). Results from the completer analysis showed a significant decrease in anxiety symptoms for participants in more extreme GAD-7 score ranges (t39=0.94; P=.009) and a decrease in stress symptoms as measured by the PSS-10 (t39=2.00; P=.05) for all participants postintervention. Participants also improved significantly in the describing and nonjudging facets, based on their FFMQ subscale scores, and asked for some improvements in the user experience with the chatbot. CONCLUSIONS This study shows the benefit of deploying a digital healthy-coping intervention via a chatbot to support university students experiencing higher levels of distress. While findings collected during the COVID-19 pandemic show promise, further research is required to confirm conclusions.
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Affiliation(s)
| | - Silvia Rizzi
- Digital Health Lab, Fondazione Bruno Kessler, Trento, Italy
| | - Giulia Bassi
- Digital Health Lab, Fondazione Bruno Kessler, Trento, Italy
| | - Sara Carbone
- Digital Health Lab, Fondazione Bruno Kessler, Trento, Italy
| | - Rosa Maimone
- Digital Health Lab, Fondazione Bruno Kessler, Trento, Italy
| | | | - Stefano Forti
- Digital Health Lab, Fondazione Bruno Kessler, Trento, Italy
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20
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Araya R, Menezes PR, Claro HG, Brandt LR, Daley KL, Quayle J, Diez-Canseco F, Peters TJ, Vera Cruz D, Toyama M, Aschar S, Hidalgo-Padilla L, Martins H, Cavero V, Rocha T, Scotton G, de Almeida Lopes IF, Begale M, Mohr DC, Miranda JJ. Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials. JAMA 2021; 325:1852-1862. [PMID: 33974019 PMCID: PMC8114139 DOI: 10.1001/jama.2021.4348] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
Importance Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).
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Affiliation(s)
- Ricardo Araya
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Paulo Rossi Menezes
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Heloísa Garcia Claro
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- School of Nursing, Universidade Estadual de Campinas, Campinas, Brazil
| | - Lena R. Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Kate L. Daley
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Julieta Quayle
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Tim J. Peters
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Daniela Vera Cruz
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Suzana Aschar
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Liliana Hidalgo-Padilla
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hellen Martins
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Victoria Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Thais Rocha
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - George Scotton
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Ivan F. de Almeida Lopes
- Federal University of ABC, Engineering, Modeling and Applied Social Sciences Center (CECS), Santo André, Brazil
| | - Mark Begale
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David C. Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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21
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Escobar-Viera CG, Cernuzzi LC, Miller RS, Rodríguez-Marín HJ, Vieta E, González Toñánez M, Marsch LA, Hidalgo-Mazzei D. Feasibility of mHealth interventions for depressive symptoms in Latin America: a systematic review. Int Rev Psychiatry 2021; 33:300-311. [PMID: 34102945 PMCID: PMC8318676 DOI: 10.1080/09540261.2021.1887822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Depression is a prevalent disorder and leading cause of disability in Latin America, where the mental health treatment gap is still above 50%. We sought to synthesise and assess the quality of the evidence on the feasibility of mHealth-based interventions for depression in Latin America. We conducted a literature search of studies published in 2007 and after using four electronic databases. We included peer-reviewed articles, in English, Spanish or Portuguese, that evaluated interventions for depressive symptoms. Two authors independently extracted data using forms developed a priori. We assessed appropriateness of reporting utilising the CONSORT checklist for feasibility trials. Eight manuscripts were included for full data extraction. Appropriate reporting varied greatly. Most (n = 6, 75%) of studies were conducted in primary care settings and sought to deliver psychoeducation or behaviour change interventions for depressive symptoms. We found great heterogeneity in the assessment of feasibility. Two studies used comparator conditions. mHealth research for depression in Latin America is scarce. Included studies showed some feasibility despite methodological inconsistencies. Given the dire need for evidence-based mental health interventions in this region, governments and stakeholders must continue promoting and funding research tailored to cultural and population characteristics with subsequent pragmatic clinical trials.
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Affiliation(s)
- César G. Escobar-Viera
- Center for Research on Behavioral Health, Media, and Technology, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca C. Cernuzzi
- Facultad de Ciencias y Tecnología, Universidad Católica Nuestra Señora de la Asunción, Asunción, Paraguay
| | - Rebekah S. Miller
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hugo J. Rodríguez-Marín
- Dirección de Salud Mental, Ministerio de Salud Pública y Bienestar Social, Asunción, Paraguay;,Facultad de Ciencias de la Salud, Universidad Católica Nuestra Señora de la Asunción, Asunción, Paraguay
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Magalí González Toñánez
- Facultad de Ciencias y Tecnología, Universidad Católica Nuestra Señora de la Asunción, Asunción, Paraguay
| | - Lisa A. Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Diego Hidalgo-Mazzei
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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22
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Zuccolo PF, Xavier MO, Matijasevich A, Polanczyk G, Fatori D. A smartphone-assisted brief online cognitive-behavioral intervention for pregnant women with depression: a study protocol of a randomized controlled trial. Trials 2021; 22:227. [PMID: 33757591 PMCID: PMC7985923 DOI: 10.1186/s13063-021-05179-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/10/2021] [Indexed: 12/28/2022] Open
Abstract
Background Pregnancy is strongly associated with increased risk for depression. Approximately 25% of pregnant women develop depression. Treatment for depression during pregnancy has several complexities: the use of psychiatric medications during pregnancy might result in developmental problems in the child and must be used with caution. Psychosocial interventions are effective, but they require specialized professionals. Low- and middle-income countries (LMIC) such as Brazil do not have enough mental health professionals needed to meet this demand. In this context, smartphone-based interventions show immense potential. We developed Motherly, a smartphone application (app) designed to treat maternal depression. We aim to test the efficacy of Motherly in addition to brief cognitive-behavioral therapies (CBT) to treat maternal depression. Methods We will conduct a 2-arm parallel-randomized controlled clinical trial in which 70 pregnant women aged between 16 and 40 years with depression will be randomized to intervention or active control. The intervention group will have access to Motherly, a smartphone app based on three concepts: psychoeducation, behavior monitoring, and gaming elements. Motherly is composed of a package of interventions composed of modules: mental health, sleep, nutrition, physical activity, social support, prenatal/postnatal support, and educational content. The main focus of Motherly is delivering behavioral activation (BA), a brief and structured psychological treatment. The app allows participants to schedule and engage in, and monitor activities according to a plan to avoid acting exclusively according to their mood. The active control group will have access to a simplified version of the app consisting of educational content about various aspects of pregnancy, maternal physical and mental health, and infant development (BA, activity scheduling, sleep hygiene, among other functionalities, will not be present in this version). Both groups will receive four sessions of brief CBT in 8 weeks. Participants will be evaluated by assessors blind to randomization and allocation status. Assessments will occur at baseline (T0), midpoint (T1, week 4–5), posttreatment (T2, week 8), and follow-up (T3, when the child is 2 months old). Maternal mental health (prenatal anxiety, psychological well-being, perceived stress, depression, depression severity, and sleep quality), quality of life, physical activity levels, and infant developmental milestones and social/emotional problems will be measured. Our primary outcome is the change in maternal prenatal depression from baseline to posttreatment (8 weeks). Discussion The potential of digital technology to deliver mental health interventions has been increasingly recognized worldwide. There is a growing literature on interventions using smartphone applications to promote mental health, both with or without the intermediation of a mental health professional. Our study adds to the literature by testing whether an app providing an intervention package, including CBT, psychoeducation, nutrition, physical activity, and social support, can promote maternal and child health and well-being. In particular, we aim to treat depression, for which the use of digital technologies is still scarce. Smartphone applications designed to treat maternal depression are especially relevant because of the potential to circumvent barriers that prevent pregnant women from accessing mental health care. Trial registration ClinicalTrials.gov NCT04495166. Prospectively registered on July 29, 2020.
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Affiliation(s)
- Pedro Fonseca Zuccolo
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil.
| | - Mariana O Xavier
- Department of Social Medicine, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Alicia Matijasevich
- Department of Preventive Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Guilherme Polanczyk
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel Fatori
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil
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23
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Muñoz AO, Camacho E, Torous J. Marketplace and Literature Review of Spanish Language Mental Health Apps. Front Digit Health 2021; 3:615366. [PMID: 34713093 PMCID: PMC8521936 DOI: 10.3389/fdgth.2021.615366] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/15/2021] [Indexed: 12/12/2022] Open
Abstract
Language differences between patients and providers remains a barrier to accessing health care, especially mental health services. One potential solution to reduce inequities for patients that speak different languages and improve their access to care is through the delivery of healthcare through mobile technology. Given that the Latinx community serves as the largest ethnic minority in the United States, this two-phased review examines Spanish app development, feasibility and efficacy. Phase 1 explored the commercial marketplace for apps available in Spanish, while phase 2 involved a literature review of published research centered around the creation, functions, and usability of these apps using the PubMed and Google Scholar electronic databases. Of the apps available on the database, only 14.5% of them had Spanish operability. The literature search uncovered 629 results, of which 12 research articles that tested or described 10 apps met the inclusion criteria. Of the 10 apps studied in this literature review, only four apps were translated to Spanish. Our study reveals that despite increasing interest in Spanish-language apps to address mental health, the commercial marketplace is not currently meeting the demand.
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Affiliation(s)
| | - Erica Camacho
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - John Torous
- Harvard Medical School, Boston, MA, United States
- Beth Israel Deaconess Medical Center, Boston, MA, United States
- *Correspondence: John Torous
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24
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Mari JJ, Gadelha A, Kieling C, Ferri CP, Kapczinski F, Nardi AE, Almeida-Filho N, Sanchez ZM, Salum GA. Translating science into policy: mental health challenges during the COVID-19 pandemic. ACTA ACUST UNITED AC 2021; 43:638-649. [PMID: 33710250 PMCID: PMC8639016 DOI: 10.1590/1516-4446-2020-1577] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/02/2020] [Indexed: 12/20/2022]
Abstract
Several stressors associated with the coronavirus disease 2019 (COVID-19) are expected to affect the mental health of global populations: the effects of physical distancing, quarantine, and social isolation; the emotional suffering of health and other frontline workers; neuropsychiatric sequelae in those affected by the virus; the impact to families of lives lost to the disease; differential effects for those with severe mental disorders; and the consequences of social and economic deterioration. In this context, we sought: to form a panel of Brazilian experts on child and adolescent health, neurodevelopment, health services, and adult and elderly mental health; and to compile evidence-based interventions to support suggested policy changes in Brazil to mitigate the expected increase in mental health disorders during the pandemic and its mental health consequences. The following actions are recommended: 1) invest in prevention programs for the safe return of students to schools; 2) adopt evidence-based psychosocial interventions to maintain an adequate environment for child and adolescent development; 3) target socially vulnerable populations and those experiencing discrimination; 4) train primary care teams to solve common mental health problems, provide needs-based assessments, and manage long-term, at-home care for older patients; 5) invest in technological advancements (e.g., telemedicine, e-Health, and web-based algorithms) to promote coordinated care; 6) increase access to and literacy in the use of computers and mobile phones, especially among older adults; 7) expand protocols for remote, brief psychotherapy interventions and psychoeducation to manage common mental health problems.
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Affiliation(s)
- Jair J Mari
- Departamento de Psiquiatria e Psicologia Médica, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Ary Gadelha
- Departamento de Psiquiatria e Psicologia Médica, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Christian Kieling
- Serviço de Psiquiatria da Infância e Adolescência, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Departamento de Psiquiatria e Medicina Legal, UFRGS, Porto Alegre, RS, Brazil
| | - Cleusa P Ferri
- Departamento de Psiquiatria e Psicologia Médica, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Flavio Kapczinski
- Departamento de Psiquiatria, UFRGS, Porto Alegre, RS, Brazil.,McMaster University, Hamilton, Canada
| | - Antonio E Nardi
- Instituto de Psiquiatria, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Academia Nacional de Medicina, Rio de Janeiro, RJ, Brazil.,Academia Brasileira de Ciências, Rio de Janeiro, RJ, Brazil
| | - Naomar Almeida-Filho
- Instituto de Estudos Avançados, Universidade de São Paulo, São Paulo, SP, Brazil.,Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Zila M Sanchez
- Departamento de Medicina Preventiva, Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brazil
| | - Giovanni A Salum
- Seção de Afeto Negativo e Processos Sociais, Departamento de Psiquiatria e Medicina Legal, HCPA, UFRGS, Porto Alegre, RS, Brazil
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25
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Rocha TIU, Aschar SCDAL, Hidalgo-Padilla L, Daley K, Claro HG, Martins Castro HC, dos Santos DVC, Miranda JJ, Araya R, Menezes PR. Recruitment, training and supervision of nurses and nurse assistants for a task-shifting depression intervention in two RCTs in Brazil and Peru. HUMAN RESOURCES FOR HEALTH 2021; 19:16. [PMID: 33546709 PMCID: PMC7863440 DOI: 10.1186/s12960-021-00556-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 05/24/2023]
Abstract
BACKGROUND Task-shifting and technology in psychological interventions are two solutions to increasing access to mental health intervention and overcoming the treatment gap in low and middle-income countries. The CONEMO intervention combines a smartphone app with support from non-specialized professionals, aiming to treat depression in patients with diabetes and/or hypertension. The aim of this paper is to describe the process of recruitment, training and supervision of the non-specialized professionals who participated in the CONEMO task-shifting intervention in Brazil and Peru. METHODS We described and analyzed data related to the recruitment, training and supervision of 62 nurse assistants from the health system in Sao Paulo, Brazil, and three hired nurses in Lima, Peru. The data were collected from information provided by nurses and nurse assistants, supervisor records from supervision meetings and the CONEMO platform database. RESULTS We found that task-shifting was feasible using existing resources in Sao Paulo and additional human resources in Lima. Training and supervision were found to be crucial and well received by the staff; however, time was a limitation when using existing human resources. Ensuring technological competence prior to the start of the intervention was essential. Group supervision meetings allowed non-specialized professionals to learn from each other's experiences. CONCLUSION Carefully considering recruitment, training and supervision of non-specialized professionals is important for effective task-shifting when delivering an mHealth intervention for depression. Opportunities and challenges of working in different health systems are described, which should be considered in future implementation, either for research or real settings. Trial registration NCT028406662 (Sao Paulo), NCT03026426 (Peru).
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Affiliation(s)
- Thais Izabel Ugeda Rocha
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
| | | | - Liliana Hidalgo-Padilla
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendáriz 445, Miraflores, Lima, Peru
| | - Kate Daley
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
| | - Heloísa Garcia Claro
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
| | - Hellen Carolina Martins Castro
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
| | - Daniela Vera Cruz dos Santos
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendáriz 445, Miraflores, Lima, Peru
| | - Ricardo Araya
- Centre for Global Mental Health and Primary Care Research, Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 18 De Crespigny Park, London, SE5 8AF UK
| | - Paulo Rossi Menezes
- Faculty of Medicine of Sao Paulo University-Preventive Medicine Department, Av. Dr. Arnaldo, 455-Cerqueira César, sala 2364, Sao Paulo, SP 01246-903 Brazil
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26
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Carter H, Araya R, Anjur K, Deng D, Naslund JA. The emergence of digital mental health in low-income and middle-income countries: A review of recent advances and implications for the treatment and prevention of mental disorders. J Psychiatr Res 2021; 133:223-246. [PMID: 33360867 PMCID: PMC8801979 DOI: 10.1016/j.jpsychires.2020.12.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 12/24/2022]
Abstract
In low-income and middle-income countries (LMICs), emerging digital mental health interventions should be accompanied by regular and comprehensive assessment of available scientific evidence. This review aims to support efforts to monitor progress in digital mental health research, ensuring new evidence can guide researchers, clinicians, policymakers and program managers positioned to adopt and implement these digitally-enabled treatments. In accordance with PRISMA guidelines, an electronic database search from 2016 to 2020 yielded 37 digital intervention studies for detection, diagnosis, prevention, treatment, and/or management of a broad range of mental disorders in 13 LMICs. This date range was selected to update previous reviews. Most studies involved online interventions and many reported feasibility and acceptability, reflected by participant satisfaction or program adherence. About half the studies (N = 23) reported clinical benefits based on changes in mental health. For depression and mood disorders, some digital interventions showed improvements in depressive symptoms, quality of life, treatment adherence, and recovery. However, sample sizes were small and studies focused primarily on adults. Further limiting generalizability was the lack of consistency in clinical assessment and measurement tools between studies. No studies reported worsening symptoms, negative acceptability or dissatisfaction with digital interventions, suggesting possible publication bias. While digital interventions show promise, it remains difficult to conclude that digital interventions are effective from these studies, as it is prudent to exercise caution before drawing conclusions about clinical effectiveness. This review reflects continued growth in digital mental health research in LMICs and further highlights the need for rigorous evaluation of effectiveness and cost-effectiveness.
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Affiliation(s)
- Helena Carter
- The Center for Global Mental Health, King's College London, London, UK
| | - Ricardo Araya
- The Center for Global Mental Health, King's College London, London, UK; Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kavya Anjur
- Johns Hopkins University, Baltimore, MD, USA
| | - Davy Deng
- Harvard T.H. Chan School of Public Health, Boston, MA, USA; The Mental Health for All Lab, Harvard Medical School, Boston, MA, USA
| | - John A Naslund
- The Mental Health for All Lab, Harvard Medical School, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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27
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Abstract
Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.
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Jiménez-Molina Á, Franco P, Martínez V, Martínez P, Rojas G, Araya R. Internet-Based Interventions for the Prevention and Treatment of Mental Disorders in Latin America: A Scoping Review. Front Psychiatry 2019; 10:664. [PMID: 31572242 PMCID: PMC6753742 DOI: 10.3389/fpsyt.2019.00664] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/19/2019] [Indexed: 01/14/2023] Open
Abstract
Background: There is a huge gap in the treatment of mental disorders in Latin America, especially among socioeconomically disadvantaged groups. Given the sharp increase in Internet access and the rapid penetration of smartphones in the region, the use of Internet-based technologies might potentially contribute to overcoming this gap and to provide more widely distributed and low-cost mental health care in a variety of contexts. Methods: We conducted a scoping review of the literature in order to systematically map the existing evidence on use of Internet-based interventions for prevention, treatment, and management of mental disorders across Latin American countries, as well as to identify existing gaps in knowledge. Six electronic databases were searched for published papers (PubMed, Embase, CINAHL, Web of Science, SciELO, and CENTRAL). Results: After the eligibility assessment, we identified 22 Internet-based studies carried out in Latin America for prevention, treatment, education, or facilitating self-management of mental disorders. Included studies mainly targeted depression (n = 11), substance misuse (n = 6), anxiety (n = 3), and mental health literacy for education and health professionals (n = 2). Most studies were undertaken in Brazil (n = 6), Mexico (n = 5), and Chile (n = 4). Only 3 studies were randomized controlled trials (RCTs), 4 were pilot RCTs, and 15 were naturalistic, acceptability, or feasibility studies. The three RCTs identified showed disparate results, but overall, there are challenges to face. Better results are seen in the short-term (postintervention or after 3 months), but most studies do not explore outcomes for long enough (follow-up after 6 or 12 months). Most of the feasibility and pilot studies showed reasonably good acceptability for a wide range of strategies but difficulties to engage and retain participants for long enough or adhering to established protocols. Conclusion: This study shows that Internet-based interventions for the prevention and treatment of mental disorders are growing rapidly in Latin America, but there are few studies on effectiveness and cost effectiveness, making it difficult to provide the evidence needed to justify scaling up these interventions.
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Affiliation(s)
- Álvaro Jiménez-Molina
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Millennium Nucleus in Social Development (DESOC), Santiago, Chile
| | - Pamela Franco
- Programa de Doctorado en Psicoterapia, Facultad de Ciencias Sociales and Facultad de Medicina, Pontificia Universidad Católica de Chile and Universidad de Chile, Santiago, Chile
| | - Vania Martínez
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- CEMERA, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo Martínez
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Santiago, Chile
- Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Graciela Rojas
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Millennium Nucleus in Social Development (DESOC), Santiago, Chile
- Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Ricardo Araya
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Centre for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
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Brandt LR, Hidalgo L, Diez-Canseco F, Araya R, Mohr DC, Menezes PR, Miranda JJ. Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru. JMIR Ment Health 2019; 6:e11701. [PMID: 31215511 PMCID: PMC6604501 DOI: 10.2196/11701] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 02/15/2019] [Accepted: 03/30/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. OBJECTIVE The aim of this paper was to explore the patients' perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses' feedback about their role and its feasibility to be scaled up. METHODS This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse's support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. RESULTS Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. CONCLUSIONS Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression.
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Affiliation(s)
- Lena R Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Liliana Hidalgo
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ricardo Araya
- Centre for Global Mental Health and Primary Care Research, Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - David C Mohr
- Center for Behavioral Intervention Technologies, Northwestern University, Chicago, IL, United States
| | - Paulo R Menezes
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,School of Medicine, Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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