Coached Mobile App Platform for the Treatment of Depression and Anxiety Among Primary Care Patients: A Randomized Clinical Trial | Anxiety Disorders | JAMA Psychiatry | JAMA Network
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Ruscio  AM, Hallion  LS, Lim  CCW,  et al.  Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe.   JAMA Psychiatry. 2017;74(5):465-475. doi:10.1001/jamapsychiatry.2017.0056PubMedGoogle ScholarCrossref
Hasin  DS, Sarvet  AL, Meyers  JL,  et al.  Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States.   JAMA Psychiatry. 2018;75(4):336-346. doi:10.1001/jamapsychiatry.2017.4602PubMedGoogle ScholarCrossref
Olfson  M, Blanco  C, Marcus  SC.  Treatment of adult depression in the United States.   JAMA Intern Med. 2016;176(10):1482-1491. doi:10.1001/jamainternmed.2016.5057PubMedGoogle ScholarCrossref
Siu  AL, Bibbins-Domingo  K, Grossman  DC,  et al; US Preventive Services Task Force (USPSTF).  Screening for depression in adults: US Preventive Services Task Force Recommendation Statement.   JAMA. 2016;315(4):380-387. doi:10.1001/jama.2015.18392PubMedGoogle ScholarCrossref
O’Connor  EA, Whitlock  EP, Beil  TL, Gaynes  BN.  Screening for depression in adult patients in primary care settings: a systematic evidence review.   Ann Intern Med. 2009;151(11):793-803. doi:10.7326/0003-4819-151-11-200912010-00007PubMedGoogle ScholarCrossref
McCrone  P, Knapp  M, Proudfoot  J,  et al.  Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial.   Br J Psychiatry. 2004;185:55-62. doi:10.1192/bjp.185.1.55PubMedGoogle ScholarCrossref
Gilbody  S, Littlewood  E, Hewitt  C,  et al; REEACT Team.  Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial.   BMJ. 2015;351:h5627. doi:10.1136/bmj.h5627PubMedGoogle ScholarCrossref
Andrews  G, Basu  A, Cuijpers  P,  et al.  Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis.   J Anxiety Disord. 2018;55:70-78. doi:10.1016/j.janxdis.2018.01.001PubMedGoogle ScholarCrossref
Gilbody  S, Brabyn  S, Lovell  K,  et al; REEACT collaborative.  Telephone-supported computerised cognitive-behavioural therapy: REEACT-2 large-scale pragmatic randomised controlled trial.   Br J Psychiatry. 2017;210(5):362-367. doi:10.1192/bjp.bp.116.192435PubMedGoogle ScholarCrossref
Christensen  H, Griffiths  KM, Farrer  L.  Adherence in internet interventions for anxiety and depression.   J Med Internet Res. 2009;11(2):e13. doi:10.2196/jmir.1194PubMedGoogle Scholar
Vaish  R, Wyngarden  K, Chen  J, Cheung  B, Bernstein  MS. Twitch crowdsourcing: crowd contributions in short bursts of time. Presented at: SIGCHI Conference on Human Factors in Computing Systems; 2014; Toronto, ON, Canada.
Andrews  S, Ellis  DA, Shaw  H, Piwek  L.  Beyond self-report: tools to compare estimated and real-world smartphone use.   PLoS One. 2015;10(10):e0139004. doi:10.1371/journal.pone.0139004PubMedGoogle Scholar
Baumel  A, Muench  F, Edan  S, Kane  JM.  Objective user engagement with mental health apps: systematic search and panel-based usage analysis.   J Med Internet Res. 2019;21(9):e14567. doi:10.2196/14567PubMedGoogle Scholar
Firth  J, Torous  J, Nicholas  J,  et al.  The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials.   World Psychiatry. 2017;16(3):287-298. doi:10.1002/wps.20472PubMedGoogle ScholarCrossref
Firth  J, Torous  J, Nicholas  J, Carney  R, Rosenbaum  S, Sarris  J.  Can smartphone mental health interventions reduce symptoms of anxiety? a meta-analysis of randomized controlled trials.   J Affect Disord. 2017;218:15-22. doi:10.1016/j.jad.2017.04.046PubMedGoogle ScholarCrossref
Kwasny  MJ, Schueller  SM, Lattie  E, Gray  EL, Mohr  DC.  Exploring the use of multiple mental health apps within a platform: secondary analysis of the IntelliCare Field Trial.   JMIR Ment Health. 2019;6(3):e11572. doi:10.2196/11572PubMedGoogle Scholar
Chiauzzi  E, Newell  A.  Mental health apps in psychiatric treatment: a patient perspective on real world technology usage.   JMIR Ment Health. 2019;6(4):e12292. doi:10.2196/12292PubMedGoogle Scholar
Barlow  DH, Farchione  TJ, Bullis  JR,  et al.  The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial.   JAMA Psychiatry. 2017;74(9):875-884. doi:10.1001/jamapsychiatry.2017.2164PubMedGoogle ScholarCrossref
Mohr  DC, Tomasino  KN, Lattie  EG,  et al.  IntelliCare: an eclectic, skills-based app suite for the treatment of depression and anxiety.   J Med Internet Res. 2017;19(1):e10. doi:10.2196/jmir.6645PubMedGoogle Scholar
Mohr  DC, Schueller  SM, Tomasino  KN,  et al.  Comparison of the effects of coaching and receipt of app recommendations on depression, anxiety, and engagement in the IntelliCare platform: factorial randomized controlled trial.   J Med Internet Res. 2019;21(8):e13609. doi:10.2196/13609PubMedGoogle Scholar
Zhang  R, Nicholas  J, Knapp  AA,  et al.  Clinically meaningful use of mental health apps and its effects on depression: mixed methods study.   J Med Internet Res. 2019;21(12):e15644. doi:10.2196/15644PubMedGoogle Scholar
Kroenke  K, Strine  TW, Spitzer  RL, Williams  JB, Berry  JT, Mokdad  AH.  The PHQ-8 as a measure of current depression in the general population.   J Affect Disord. 2009;114(1-3):163-173. doi:10.1016/j.jad.2008.06.026PubMedGoogle ScholarCrossref
Spitzer  RL, Kroenke  K, Williams  JB, Löwe  B.  A brief measure for assessing generalized anxiety disorder: the GAD-7.   Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092PubMedGoogle ScholarCrossref
Posner  K, Brown  GK, Stanley  B,  et al.  The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults.   Am J Psychiatry. 2011;168(12):1266-1277. doi:10.1176/appi.ajp.2011.10111704PubMedGoogle ScholarCrossref
Graham  AK, Greene  CJ, Powell  T,  et al.  Lessons learned from service design of a trial of a digital mental health service: informing implementation in primary care clinics.   Transl Behav Med. In press.Google Scholar
Tomasino  KN, Noth  F, Bardsley  LR, Lattie  EG, Mohr  DC. IntelliCare Study Coaching Manual. Northwestern University: DigitalHub. Published 2016. Accessed April 13, 2020.
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure.   J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.xPubMedGoogle ScholarCrossref
Pham  Q, Graham  G, Carrion  C,  et al.  A library of analytic indicators to evaluate effective engagement with consumer mhealth apps for chronic conditions: scoping review.   JMIR Mhealth Uhealth. 2019;7(1):e11941. doi:10.2196/11941PubMedGoogle Scholar
Kraemer  HC.  Is it time to ban the P value?   JAMA Psychiatry. 2019. doi:10.1001/jamapsychiatry.2019.1965PubMedGoogle Scholar
Cuijpers  P, Van Straten  A, Warmerdam  L, Smits  N.  Characteristics of effective psychological treatments of depression: a metaregression analysis.   Psychother Res. 2008;18(2):225-236. doi:10.1080/10503300701442027PubMedGoogle ScholarCrossref
Cuijpers  P, Sijbrandij  M, Koole  S, Huibers  M, Berking  M, Andersson  G.  Psychological treatment of generalized anxiety disorder: a meta-analysis.   Clin Psychol Rev. 2014;34(2):130-140. doi:10.1016/j.cpr.2014.01.002PubMedGoogle ScholarCrossref
Rollman  BL, Herbeck Belnap  B, Abebe  KZ,  et al.  Effectiveness of online collaborative care for treating mood and anxiety disorders in primary care: a randomized clinical trial.   JAMA Psychiatry. 2018;75(1):56-64. doi:10.1001/jamapsychiatry.2017.3379PubMedGoogle ScholarCrossref
Mohr  DC, Weingardt  KR, Reddy  M, Schueller  SM.  Three problems with current digital mental health research . . . and three things we can do about them.   Psychiatr Serv. 2017;68(5):427-429. doi:10.1176/ ScholarCrossref
Mohr  DC, Ho  J, Duffecy  J,  et al.  Perceived barriers to psychological treatments and their relationship to depression.   J Clin Psychol. 2010;66(4):394-409. doi:10.1002/jclp.20659PubMedGoogle Scholar
Mohr  DC, Hart  SL, Howard  I,  et al.  Barriers to psychotherapy among depressed and nondepressed primary care patients.   Ann Behav Med. 2006;32(3):254-258. doi:10.1207/s15324796abm3203_12PubMedGoogle ScholarCrossref
Graham  AK, Lattie  EG, Mohr  DC.  Experimental therapeutics for digital mental health.   JAMA Psychiatry. 2019. doi:10.1001/jamapsychiatry.2019.2075PubMedGoogle Scholar
Mohr  DC, Riper  H, Schueller  SM.  A solution-focused research approach to achieve an implementable revolution in digital mental health.   JAMA Psychiatry. 2018;75(2):113-114. doi:10.1001/jamapsychiatry.2017.3838PubMedGoogle ScholarCrossref
Mohr  DC, Lyon  AR, Lattie  EG, Reddy  M, Schueller  SM.  Accelerating digital mental health research from early design and creation to successful implementation and sustainment.   J Med Internet Res. 2017;19(5):e153. doi:10.2196/jmir.7725PubMedGoogle Scholar
Donkin  L, Christensen  H, Naismith  SL, Neal  B, Hickie  IB, Glozier  N.  A systematic review of the impact of adherence on the effectiveness of e-therapies.   J Med Internet Res. 2011;13(3):e52. doi:10.2196/jmir.1772PubMedGoogle Scholar
Fuhr  K, Schröder  J, Berger  T,  et al.  The association between adherence and outcome in an Internet intervention for depression.   J Affect Disord. 2018;229:443-449. doi:10.1016/j.jad.2017.12.028PubMedGoogle ScholarCrossref
Mohr  DC, Duffecy  J, Jin  L,  et al.  Multimodal e-mental health treatment for depression: a feasibility trial.   J Med Internet Res. 2010;12(5):e48. doi:10.2196/jmir.1370PubMedGoogle Scholar
Gilbody  S, Bower  P, Fletcher  J, Richards  D, Sutton  AJ.  Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.   Arch Intern Med. 2006;166(21):2314-2321. doi:10.1001/archinte.166.21.2314PubMedGoogle ScholarCrossref
Muntingh  AD, van der Feltz-Cornelis  CM, van Marwijk  HW, Spinhoven  P, van Balkom  AJ.  Collaborative care for anxiety disorders in primary care: a systematic review and meta-analysis.   BMC Fam Pract. 2016;17:62. doi:10.1186/s12875-016-0466-3PubMedGoogle ScholarCrossref
The MacArthur Foundation’s Initiative on Depression and Primary Care. The MacArthur Initiative on Depression and Primary Care at Dartmouth and Duke: Depression Management Toolkit. Hanover, NH: Dartmouth;2004.
Whitney  DG, Peterson  MD.  US national and state-level prevalence of mental health disorders and disparities of mental health care use in children.   JAMA Pediatr. 2019;173(4):389-391. doi:10.1001/jamapediatrics.2018.5399PubMedGoogle ScholarCrossref
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    Original Investigation
    May 20, 2020

    Coached Mobile App Platform for the Treatment of Depression and Anxiety Among Primary Care Patients: A Randomized Clinical Trial

    Author Affiliations
    • 1Center for Behavioral Intervention Technologies, Northwestern University, Chicago, Illinois
    • 2Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
    • 3Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock
    • 4Department of Preventive Medicine, Northwestern University, Chicago, Illinois
    • 5Actualize Therapy, Inc, Chicago, Illinois
    • 6Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock
    JAMA Psychiatry. 2020;77(9):906-914. doi:10.1001/jamapsychiatry.2020.1011
    Key Points

    Question  Is a mobile intervention platform composed of a suite of simple-to-use apps, supported by brief coaching, efficacious for treating depression and anxiety among primary care patients?

    Findings  In this randomized clinical trial of 146 patients with depression and anxiety, a mobile platform achieved greater reductions in depression and anxiety and higher odds of recovery compared with treatment-as-usual wait list control individuals, and effects were sustained at follow-up. Engagement with apps was high throughout the intervention period.

    Meaning  Results support the efficacy of a platform approach to mobile intervention using apps designed to fit into the fabric of users’ lives for treating patients with depression and anxiety in primary care.


    Importance  Depression and anxiety are common and disabling. Primary care is the de facto site for treating these mental health problems but is typically underresourced to meet the burden of these demands.

    Objective  To evaluate the efficacy of a mobile intervention platform, IntelliCare, for addressing depression and anxiety among primary care patients.

    Design, Setting, and Participants  Two-arm randomized clinical trial at internal medicine clinics at the University of Arkansas for Medical Sciences. Adult primary care patients (N = 146) who screened positive for depression on the Patient Health Questionnaire-8 (PHQ; score  ≥ 10) or anxiety on the Generalized Anxiety Disorder-7 (GAD-7; score ≥ 8) were recruited between July 17, 2018, and December 14, 2018.

    Interventions  The coach-supported platform composed of a suite of apps, was delivered over 8 weeks. Wait list control participants received treatment as usual for 8 weeks, then the mobile platform.

    Main Outcomes and Measures  Primary outcomes were changes in depression (PHQ-9) and anxiety (GAD-7) during the intervention period. Secondary outcomes were differences in the proportion of patients who achieved recovery (PHQ-9/GAD-7 <5 or 50% improvement from baseline), sustainment of intervention effects during 2-month follow-up, and app use during the intervention period.

    Results  One hundred forty-six patients were included (119 of 146 were women [81.5%]; mean [SD] age, 42.3 [13.8] years). Of the 146 patients, 122 (83.6%) were diagnosed as having depression and 131 (89.7%) were diagnosed as having anxiety. A greater proportion of intervention vs wait list control participants achieved recovery from depression (n = 38 of 64 [59%] vs n = 18 of 58 [31%]; odds ratio, 3.25; 95% CI, 1.54-6.86) and anxiety (n = 37 of 65 [57%] vs n = 25 of 66 [38%]; odds ratio, 2.17; 95% CI, 1.08-4.36). Sustained effects were observed for depression (slope, 0.01; 95% CI, –0.09 to 0.10; P = .92) and anxiety scores (slope, 0.02; 95% CI, –0.08 to 0.12; P = .67) during follow-up. App use was high, with a median of 93 and 98 sessions among participants with depression and anxiety, respectively.

    Conclusions and Relevance  In this trial, a mobile intervention app was effective for depression and anxiety among primary care patients. Findings also support designing digital mental health interventions as platforms containing simple, brief apps that can be bundled by users to meet their needs.

    Trial Registration Identifier: NCT03500536.