Qualitative Feedback From a Text Messaging Intervention for Depression: Benefits, Drawbacks, and Cultural Differences

BackgroundCognitive Behavioral Therapy (CBT) for depression is efficacious, but effectiveness is limited when implemented in low-income settings due to engagement difficulties including nonadherence with skill-building homework and early discontinuation of treatment. Automated messaging can be used in clinical settings to increase dosage of depression treatment and encourage sustained engagement with psychotherapy.ObjectivesThe aim of this study was to test whether a text messaging adjunct (mood monitoring text messages, treatment-related text messages, and a clinician dashboard to display patient data) increases engagement and improves clinical outcomes in a group CBT treatment for depression. Specifically, we aim to assess whether the text messaging adjunct led to an increase in group therapy sessions attended, an increase in duration of therapy attended, and reductions in Patient Health Questionnaire-9 item (PHQ-9) symptoms compared with the control condition of standard group CBT in a sample of low-income Spanish speaking Latino patients.MethodsPatients in an outpatient behavioral health clinic were assigned to standard group CBT for depression (control condition; n=40) or the same treatment with the addition of a text messaging adjunct (n=45). The adjunct consisted of a daily mood monitoring message, a daily message reiterating the theme of that week’s content, and medication and appointment reminders. Mood data and qualitative responses were sent to a Web-based platform (HealthySMS) for review by the therapist and displayed in session as a tool for teaching CBT skills.ResultsIntent-to-treat analyses on therapy attendance during 16 sessions of weekly therapy found that patients assigned to the text messaging adjunct stayed in therapy significantly longer (median of 13.5 weeks before dropping out) than patients assigned to the control condition (median of 3 weeks before dropping out; Wilcoxon-Mann-Whitney z=−2.21, P=.03). Patients assigned to the text messaging adjunct also generally attended more sessions (median=6 sessions) during this period than patients assigned to the control condition (median =2.5 sessions), but the effect was not significant (Wilcoxon-Mann-Whitney z=−1.65, P=.10). Both patients assigned to the text messaging adjunct (B=−.29, 95% CI −0.38 to −0.19, z=−5.80, P<.001) and patients assigned to the control conditions (B=−.20, 95% CI −0.32 to −0.07, z=−3.12, P=.002) experienced significant decreases in depressive symptom severity over the course of treatment; however, the conditions did not significantly differ in their degree of symptom reduction.ConclusionsThis study provides support for automated text messaging as a tool to sustain engagement in CBT for depression over time. There were no differences in depression outcomes between conditions, but this may be influenced by low follow-up rates of patients who dropped out of treatment.

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“…Despite the automation of messages, they also offer a personal connection to another individual, whether it is perceived or real [13]. …”

Section: Discussionmentioning

confidence: 99%

Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial

Aguilera¹,

Bruehlman-Senecal²,

DeMasi³

et al. 2017

J Med Internet Res

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111

119

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“…Digital technology applications have been proposed as a way to reach socioeconomically and culturally diverse populations (Aguilera & Berridge, 2014;Drake, Howard, & Kinsey, 2014) and studies have addressed the feasibility, acceptability and success of using technology-based screening (Drake et al, 2014;Le, Perry, & Sheng, 2009), particularly when paired with a personal encounter (Danaher et al, 2012;Piette & Schillinger, 2007). Virtually all women of reproductive age in the United States have use of a cell phone, regardless of socioeconomic status, education, race or residence (Pew Research Center, 2017) and most also have access to other devices.…”

Section: Introductionmentioning

confidence: 99%

Measuring outcomes of digital technology‐assisted nursing postpartum: A randomized controlled trial

McCarter‐Spaulding

Demidenko

Hegel

2018

Journal of Advanced Nursing

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“…Text messaging can be used to monitor mood over time, simply and conveniently, utilizing simple ratings used in practice (e.g., “Please rate your mood from 1–9”). Though text messaging may be less familiar to older individuals, or those who may have difficulty reading small phone screens, it is more familiar and common than other mobile technologies (e.g., apps), and research shows that use is increasing (Pew 2014) and that people who do not text can learn and use it for health purposes (Aguilera & Berridge, 2014). …”

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confidence: 99%

Daily mood ratings via text message as a proxy for clinic based depression assessment

Aguilera

Schueller

Leykin

2015

Journal of Affective Disorders

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Background Mobile and automated technologies are increasingly becoming integrated into mental healthcare and assessment. The purpose of this study was to determine how automated daily mood ratings are related to the Patient Health Questionnaire–9 (PHQ-9), a standard measure in the screening and tracking of depression symptoms. Results There was a significant relationship between daily mood scores and one-week average mood scores and PHQ-9 scores controlling for linear change in depression scores. PHQ9 scores were not related to the average of two week mood ratings. This study also constructed models using variance, maximum, and minimum values of mood ratings in the preceding week and two-week periods as predictors of PHQ-9. None of these variables significantly predicted PHQ-9 scores when controlling for daily mood ratings and the corresponding averages for each period. Limitations This study only assessed patients who were in treatment for depression therefore do not account for the relationship between text message mood ratings for those who are not depressed. The sample was also predominantly Spanish speaking and low-income making generalizability to other populations uncertain. Conclusions Our results show that automatic text message based mood ratings can be a clinically useful proxy for the PHQ9. Importantly, this approach avoids the limitations of the PHQ9 administration, which include length and a higher requirement for literacy.

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Qualitative Feedback From a Text Messaging Intervention for Depression: Benefits, Drawbacks, and Cultural Differences

Cited by 65 publications

References 20 publications

Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial

Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial

Measuring outcomes of digital technology‐assisted nursing postpartum: A randomized controlled trial

Daily mood ratings via text message as a proxy for clinic based depression assessment

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