Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru

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Abstract

Background

Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders.

Objective

This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs).

Methods

Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up.

Results

The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings.

Conclusions

The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.

Related collections

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Major depressive disorder (MDD) is a leading cause of disability worldwide.

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The costs of depression.

Ronald C Kessler (2012)

The data reported herein show clearly that major depression is a commonly occurring and burdensome disorder. The high prevalence, early age of onset, and high persistence of MDD in the many different countries where epidemiologic surveys have been administered confirm the high worldwide importance of depression. Although evidence is not definitive that MDD plays a causal role in its associations with the many adverse outcomes reviewed here, there is clear evidence that depression has causal effects on a number of important mediators, making it difficult to assume anything other than that depression has strong causal effects on many dimensions of burden. These results have been used to argue for the likely cost -effectiveness of expanded depression treatment from a societal perspective. Two separate, large-scale, randomized, workplace depression treatment effectiveness trials have been carried out in the United States to evaluate the cost effectiveness of expanded treatment from an employer perspective. Both trials had positive returns on investment to employers. A substantial expansion of worksite depression care management programs has occurred in the United States subsequent to the publication of these trials. However, the proportion of people with depression who receive treatment remains low in the United States and even lower in other parts of the world. A recent US study found that only about half of workers with MDD received treatment in the year of interview and that fewer than half of treated workers received treatment consistent with published treatment guidelines. Although the treatment rate was higher for more severe cases, even some with severe MDD often failed to receive treatment. The WMH surveys show that treatment rates are even lower in many other developed countries and consistently much lower in developing countries. Less information is available on rates of depression treatment among patients with chronic physical disorders, but available evidence suggests that expanded treatment could be of considerable value. Randomized, controlled trials are needed to expand our understanding of the effects of detection and treatment of depression among people in treatment for chronic physical disorders. In addition, controlled effectiveness trials with long-term follow-ups are needed to increase our understanding of the effects of early MDD treatment interventions on changes in life course role trajectories, role performance, and onset of secondary physical disorders.

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Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature

John A. Naslund, Kelly Aschbrenner, Ricardo Araya … (2017)

Few individuals living with mental disorders around the globe have access to mental health care, yet most have access to a mobile phone. Digital technology holds promise for improving access to, and quality of, mental health care. We reviewed evidence on the use of mobile, online, and other remote technologies for treatment and prevention of mental disorders in low-income and middle-income countries. Of the 49 studies identified, most were preliminary evaluations of feasibility and acceptability. The findings were promising, showing the potential effectiveness of online, text-messaging, and telephone support interventions. We summarised the evaluations as: technology for supporting clinical care and educating health workers, mobile tools for facilitating diagnosis and detection of mental disorders, technologies for promoting treatment adherence and supporting recovery, online self-help programmes for individuals with mental disorders, and programmes for substance misuse prevention and treatment. Continued research is needed to rigorously evaluate effectiveness, assess costs, and carefully consider potential risks of digital technology interventions for mental disorders, while determining how emerging technologies might support the scale-up of mental health treatment and prevention efforts across low-resource settings.

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Author and article information

Contributors

Paulo Menezes:

Department of Preventive MedicineUniversity of São PauloRua Doutor Arnaldo 455, Cerqueira CésarSão Paulo, 01246903Brazil55 1130617093pmenezes@usp.br

ORCID: http://orcid.org/0000-0001-6330-3314

Journal

Journal ID (nlm-ta): JMIR Ment Health

Journal ID (iso-abbrev): JMIR Ment Health

Journal ID (publisher-id): JMH

Title: JMIR Mental Health

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 2368-7959

Publication date Collection: April 2019

Publication date (Electronic): 26 April 2019

Volume: 6

Issue: 4

Electronic Location Identifier: e11698

Affiliations

[1 ] Population Mental Health Research Centre Department of Preventive Medicine Universidade de São Paulo São Paulo Brazil

[2 ] Department of Preventive Medicine University of São Paulo São Paulo Brazil

[3 ] Faculdade Israelita de Ciências da Saúde Albert Einstein São Paulo Brazil

[4 ] Centre of Excellence in Chronic Diseases Universidad Peruana Cayetano Heredia Lima Peru

[5 ] Department of Medicine School of Medicine Universidad Peruana Cayetano Heredia Lima Peru

[6 ] National Institute of Mental Health National Institutes of Health Bethesda, MD United States

[7 ] Center for Behavioral Intervention Technologies Northwestern University Chicago, IL United States

[8 ] 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

Author notes

Corresponding Author: Paulo Menezes pmenezes@ 123456usp.br

Author information

Paulo Menezes http://orcid.org/0000-0001-6330-3314

Julieta Quayle http://orcid.org/0000-0003-3325-0922

Heloísa Garcia Claro http://orcid.org/0000-0003-1504-7074

Simone da Silva http://orcid.org/0000-0002-2460-3557

Lena R Brandt http://orcid.org/0000-0001-7800-8473

Francisco Diez-Canseco http://orcid.org/0000-0002-7611-8190

J Jaime Miranda http://orcid.org/0000-0002-4738-5468

LeShawndra N Price http://orcid.org/0000-0003-2632-8605

David C Mohr http://orcid.org/0000-0002-5443-7596

Ricardo Araya http://orcid.org/0000-0002-0420-5148

Article

Publisher ID: v6i4e11698

DOI: 10.2196/11698

PMC ID: 6658291

PubMed ID: 31025949

SO-VID: 09540690-00c9-4b16-8b69-0e7ef7e2444b

Copyright © ©Paulo Menezes, Julieta Quayle, Heloísa Garcia Claro, Simone da Silva, Lena R Brandt, Francisco Diez-Canseco, J Jaime Miranda, LeShawndra N Price, David C Mohr, Ricardo Araya. Originally published in JMIR Mental Health (http://mental.jmir.org), 26.04.2019.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/.as well as this copyright and license information must be included.

History

Date received : 26 July 2018

Date revision requested : 8 October 2018

Date revision received : 21 December 2018

Date accepted : 23 January 2019

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