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Knowledge Bites Lunch ‘n’ Learn January 31, 2019

Supportive Text Message Interventions in Mental Health

• Dr. Vincent I.O. Agyapong

MB ChB DCP DHSM PG Dip MSc MRCPsych MCPsychI MICPSM FRAMI FCRPC FAPA MD PhD Clinical Professor, Department of Psychiatry, Faculty of Medicine, University of Alberta Edmonton Zone Clinical Section Chief, Community Mental Health Addiction & Mental Health, Alberta Health Services E-mail: agyapong@ualberta.ca

Conflict of interest

No conflict of interest to declare

Supportive Text Message Interventions in Mental Health

Overview

• Previous work in this area
• Results from two Randomized controlled trials in Alberta
• Text4Mood Evaluation results
• Current developments
• Implications for practice

Supportive Text Message Interventions in Mental Health

Previous work

• Agyapong V.I.O., McLoughlin D. Farren C.K., Six-months outcomes of a randomised trial of

supportive text messaging for depression and comorbid alcohol use disorder. Journal of Affective Disorders (2013), http://dx.doi.org/10.1016/j.jad.2013.05.058i

• Agyapong V.I.O., McLoughlin D. Farren C.K., Perception of patients with Alcohol Use Disorder

and comorbid depression about the usefulness of supportive text messages- Technol Health Care. 2013 Jan 1; 21(1):31-9. doi: 10.3233/THC-120707.

• Agyapong V.I.O., McLoughlin D. Farren C.K., Supportive text messaging for alcohol use disorder

and comorbid depression: single-blind randomised trial. J. Affect. Disord. Volume 141, Issues 2–3, 10 December 2012, Pages 168-176

• Agyapong V.I.O., Farren C.K. and McLoughlin D, Mobile Phone Text Message Interventions in

Psychiatry - What are the Possibilities?, Current Psychiatry Reviews, 2011, 7 (1), 50-56

Agyapong V.I.O, Juhás M, Omeje J, Mrklas K, Suen V, Ohinmaa A, Dursun SM, Greenshaw AJ Randomized Controlled Trial of Supportive Text Messages for Patients with Depression BMC Psychiatry (2017) 17(1):286. doi: 10.1186/s12888-017-1448-2.

Supportive Text Message Interventions in Mental Health

Figure 1: Study Flow Chart

103 patients presenting with low mood were assessed for eligibility

Excluded (N=30, 29.13%)

• Did not fulfill the

DSM V criteria for Major Depressive Disorder (n=15, 14.56%)

• Did not consent

(n=10, 9.70%)

• Did not have mobile

phones (n= 5, 4.85%) 73 patients randomised Intervention group (N=35) Control group (N=38) Lost to follow-up (n=6) Lost to follow-up (n=4) Completed 3 months follow- up (N=31) Completed 3 months follow-up (N=32) Analysed (N= 35) Analysed (N=38)

Sample supportive text messages

• “What lies behind you and what lies before you are tiny matters compared to

what lies within you. Have faith in yourself and success can be yours”

• “There are 2 days in the week we should not worry about, yesterday and
• tomorrow. That leaves today, live for today”
• “Stumbling blocks can become stepping stones to a better life. You can turn

adversities into opportunities. Do not be discouraged because of today’s problems”

• “Letting go of resentment is a gift you give yourself, and it will ease your journey
• immeasurably. Make peace with everyone and happiness will be yours”

Primary Outcomes

Measure Baseline Three months measurement Mean difference in change score P-value Effect size (Cohen’s d) Text message group Control group Text message group Control group Mean Becks Depression Inventory-II (SD)

40.1 (8.6) 36.3 (8.8) 20.8 (11.7) 24.9 (11.5)

• 7.6

(-13.2 to -1.9) 0.01 0.67

Mean self- rated health index Using EQ VAS scores (SD)

44.5 (19.0) 47.1 (19.1) 65.7 (15.3) 57.4 (22.9) 10.7 (-0.2 to 21.5) 0.05 0.51

Secondary Outcomes (Health services Utilization)

Conclusions and implications

• Supportive text messages are a potentially useful psychological

intervention for depression and could help alleviate the large unmet needs, especially, the psychological treatment gap currently reported by patients in Alberta and other parts of Canada as well as globally.

Agyapong V.I.O., Juhás M., Mrklas K., Hrabok M., Omeje J., Gladue I., Kozak J., Leslie M, Chue P., Greenshaw AJ. Randomized Controlled Pilot Trial of Supportive Text Messages for Patients with Alcohol Use Disorder. Journal of Substance Abuse Treatment Volume 94, November 2018, Pages 74-80 RANDOMIZED CONTROLLED TRIAL OF SUPPORTIVE TEXT MESSAGES FOR PATIENTS WITH ALCOHOL USE DISORDER

Figure 1: CONSORT 2010 Flow Diagram

Assessed for eligibility (n=70) Excluded (n=11)

 Not meeting inclusion criteria (n=2)  Declined to participate (n=9)  Other reasons (n=0)

Analysed (n=29)

 Excluded from analysis (n=0)

Lost to follow-up (not reachable) (n=4) Discontinued intervention (withdrew consent) (n=4) Allocated to intervention (n=29)

 Received allocated intervention (n=29)  Did not receive allocated intervention (n=0)

Lost to follow-up (not reachable) (n=5) Discontinued intervention (withdrew consent) (n=3) Allocated to control (n=30)

 Received allocated intervention (n=30)  Did not receive allocated intervention (n=0)

Analysed (n=30)

 Excluded from analysis (n=0)

Allocation Analysis Follow-Up

Randomized (n=59)

Enrollment

Sample supportive text messages

• “Think of your recovery as an opportunity to find new solutions in your life. Remember that

the past is gone and what you do next is what really matters.”

• “Before you think of the next drink, think of the last one and how it made you feel”
• “The thoughts of drinking will return to test you. Remember to never give up in the face of

temptation”

• “The true joy of recovery is in the fellowship and camaraderie you share with others

travelling the same path”

Distribution of baseline demographic and clinical characteristics of participants

Variable Intervention group N Control group N P-Value Gender Male 22 (75.9%) 22 (73.3%) 1.0 Female 7 (24.1%) 8 (26.7%) Age ≤ 40 16 (57.1%) 15 (51.7%) 0.79 ≥ 41 12 (42.9%) 14 (48.3%) Mean Age in years (SD) 39.4 (SD=10.6) 41.8 (SD=10.0) 0.38 Formal educational level Up to high school 11 (37.9%) 13 (43.3%) 0.79 College/University 18 (62.1%) 17 (56.7%) Employment status Employed 21 (72.4%) 23 (76.7%) 0.77 Not Employed 8 (27.6%) 7 (23.3%) Relationship status In a relationship 14 (48.1%) 18 (60.0%) 0.60 Not in a relationship 13 (51.9%) 12 (40.0%) On antidepressants before enrolment Yes 11 (42.3% 13 (46.4%) 0.79 No 15 (57.7%) 15 (53.6%) On medication for chronic physical health problems Yes 7 (25.0%) 8 (27.6%) 1.0 No 21 (75.0%) 21 (72.4%) Mean age of onset of problem drinking in years 23.0 (SD=7.5) 25.0 (SD=10.8) 0.47 Mean longest duration of sobriety since onset of problem drinking in months 214.8 (SD=550.8) 23.7 (SD=55.7) 0.09 Past treatment for alcohol abuse Yes 13 (50.0%) 9 (31.0%) 0.18 No 13 (50.0%) 20 (69.0%)

Mean scores and group difference statistics for the primary and secondary outcome measures for the intervention and control groups at three-month follow-up

Variable Intervention group Control group t P- Value Cohen’s d* Cumulative abstinence duration (CAD) at three months in days 83.5 (SD=19.3) 73.6 (SD=33.0) 1.16 0.25 .37 Number of days to first drink 60.8 (SD=31.2) 25.8 (SD=28.7) 1.94 0.09 1.17 Units of alcohol per drinking days 1.0 (SD=2.3) 1.5 (SD=2.8)

• 0.60

0.55 .20

*Cohen’s d computed. as Cohen's d = (M2 - M1) ⁄ SDpooled , where SD pooled is √((SD1

2 + SD2 2) ⁄ 2) (Effect Size Calculator (Cohen’s D) for T-Test

n.d.)

Table 3: Health services utilisation at three months for the intervention and control groups Variable Intervention group Control group t P- Value Cohen’s d* Mean number of visits to Family Physician 1.3 (SD=2.1) 1.7(SD=1.9)

• 0.65

0.52 .20 Mean number of visits to Psychiatrist 1.0 (SD=2.7) 0.64 (SD=1.2) 0.48 0.63 .17 Mean number of visits to other specialists 0.24 (SD=0.62) 0.45 (SD=2.1)

• 0.45

0.66 .14 Mean number of visits to the Emergency Department 0.24 (SD=0.54) 0.41(SD=1.1)

• 0.64

0.52 .20 Mean number of counselling sessions attended 3.0 (SD=3.3) 4.7 (SD=5.6)

• 1.18

0.25 .37

*Cohen’s d computed. as Cohen's d = (M2 - M1) ⁄ SDpooled , where SD pooled is √((SD1

2 + SD2 2) ⁄ 2) (Effect Size Calculator (Cohen’s D) for T-Test n.d.)

Conclusions and implications

• The number of days to first drink was longer in the

intervention than control group (large effect size, although not statistically significant).

• Text messaging is a feasible and effective opportunity for

follow-up care in patients discharged from residential AUD treatment.

Evaluating Text4Mood: Mobile health program to reduce psychological treatment gap in mental healthcare in Alberta through daily supportive text messages

• Agyapong VIO, Mrklas K, Juhás M, Omeje J, Ohinmaa A, Dursun SM, Greenshaw AJ.

Cross-sectional Survey Evaluating Text4Mood: Mobile health program to reduce psychological treatment gap in mental healthcare in Alberta through daily supportive text

• messages. BMC Psychiatry (2016) 16:378. DOI 10.1186/s12888-016-1104-2

Text4Mood

Search “Text4Mood” on YouTube https://youtu.be/SSVJ4g4FeCk

Evaluating Text4Mood

• The aim of this study was to evaluate the impact of the

Text4Mood program on subscribers' self-reported mental wellbeing as well as attitudes towards the mobile health intervention.

Evaluating Text4Mood Results

• 4111 active subscribers to the Text4Mood program
• 894 completed the survey
• Overall response rate of 21.7%.

Table 1: Demographic and clinical characteristics of respondents

Table 1: Demographic and clinical characteristics of respondents

Why Respondents Signed up for Text4Mood, n=893*

51.6% 49.3% 24.5% 19.7% 15.9% 0% 20% 40% 60% 80% 100%

Elevate my mood Help me feel better Help me worry less Novelty/fun Other

• Of those respondents who selected the ‘other’ category, the majority of the respondents

signed up for this program to get support, motivation, inspiration and encouragement and to exercise positive thinking.

• They use the program to remind themselves to practice mindfulness and view life from a

different perspective.

• In addition, a few respondents signed up to address specific concerns such as, “ground

my anxiety,” help with “potential postpartum depression,” and “to help fight an addiction.”

• “To switch my focus to positive thoughts.”
• “Provides hope.”
• “Start my day with something positive.”

How Often Respondents Read the Text Messages, n=720

90.0% 8.1% 1.5% 0.3% 0.1% 0% 20% 40% 60% 80% 100% Always Often Sometimes Rarely Never

What Happened when Respondents Received the Text Messages, n=893*

65.4% 33.0% 28.9% 17.9% 0.9% 0.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% I read the text and reflected I returned to read the text for support more than once I read the text and took a positive action I read the text and took no action I did not read the text I read the text and took a negative action

How Often Did the Respondents Understand the Text Messages, n=720

75.7% 22.9% 1.4% 0.0% 0.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Always Mostly Sometimes Rarely Never

How did the Text Messages make People Feel, n=727

75.0% 6.5% 1.1% 17.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Supported Made no difference Annoyed Other

• Some mentioned that they share them with friends and families to spread the inspiration and thought.
• “…they are so positive and uplifting everyone should be having access to this wonderful tool.”
• “When everything is going bad, that message brightens my day. I look forward to it every day.”
• “They just help me to get or stay more positive when I am struggling.”
• Some respondents highlighted that they had mixed feelings about the text messages. They found some

messages to be inspiring and supportive, while other messages were ineffective and frustrating.

• “I am grateful for them, and basically after reading it, I tucked it away in my notes. Sometimes they made a

LOT of sense for that particular day/moment, but I do not really feel like they, in and of themselves saved

• me. They are like a treat each day, and some days I share them, some days they really hit home and other

days they made me feel upset, anxious and guilty. But I DO NOT want to stop getting them!!”

Respondent’s Perception of the Text Messages, n=720

69.6% 62.2% 28.3% 32.5% 38.3%

4.9% 13.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Positive Supportive To the point On-topic Always Mostly Sometimes Rarely Never

11.5% 42.2% 45.1% 48.2%

Level of Agreement about Text4Mood Outcomes, n=720

77.2% 57.0% 23.9% 73.8% 78.1% 19.6% 35.1% 65.8% 22.9% 19.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cope with stress Cope with loneliness Manage suicidal thoughts Monitor my mood Remember my goals

Benefits of Text4Mood, n=720

75.2% 81.7% 56.0% 76.7% 72.5% 19.4% 16.9% 31.3% 20.3% 22.5% 14.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Feel connected to a support system Feel hopeful I can manage issues in my life Know where to get help for depression or anxiety Feel that I am the one in charge of managing depression or anxiety Feel like I know how to stay on track with life or when everyday stressors come up

Agreement Neither agree nor disagree Disagreement

Benefits of Text4Mood, n=720

58.6% 77.0% 70.8% 83.1% 72.1% 36.0% 20.4% 26.0% 15.1% 25.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Feel like I am making a change Feel like I can bounce back if I make a mistake Make better choices Improve my overall mental well-being Enhance my quality of life Strongly agree Neither agree nor disagree Disagreement

Respondent Satisfaction with Text Message Frequency, n= 720

56.0% 39.0% 4.0% 1.0% 0.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied

Preferred Text Message Frequency, n= 720

68.0% 17.0% 12.0% 3.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Once a day Twice a day Once every other day Once a week

Opinions About Use of Technology-based Services as part of Healthcare, n= 720

42.1% 31.2% 25.1% 56.8% 49.3% 52.2% 27.5% 29.4% 24.2% 26.8% 27.5% 28.9% 16.4% 18.5% 24.2% 9.4% 11.9% 12.9% 11.1% 17.5% 22.2% 9.4%

0% 20% 40% 60% 80% 100% Web-based counselling Telephone counselling Consultation by video conferencing Text messaging for managing medical appointments Emails for managing medical appointments Text support for follow-up care Most Certainly Probably Not Sure Probably Not Certainly Not

Current developments and future directions

• Text4Support
• Supportive text messages targeting symptom clusters
• Reminder text messages
• Edmonton Peer Support System (EPSS)
• Enhancing uptake of online CBT with text messaging
• Text4Menopause
• Provides psychological support and psychoeducation for Depression in menopausal women
• Text4Hope
• Provides psychological support for residents of communities affected by natural disasters
• Text4Health
• Provide psychological support and psychoeducation for university and college students

Implications of Supportive Text Messaging for Practice-Closing the psychological treatment gap

• Recognized as a mental health innovation by the MHIN headquartered at

the WHO: http://www.mhinnovation.net/innovations/text4mood

• Cost Effective: It cost only about 10 dollars to deliver daily supportive text

messages to patients for up to a year, compared to about 1800 Dollars for 12 sessions of CBT

• Equity and Digital Divide:
• High mobile phone penetration rate in Alberta (over 90%)
• Text messaging is free to end-users, can be used on any mobile technology (regardless of

sophistication), does not require technological skills on the part of the user, and does not require expensive data plans.

Implications of Supportive Text Messaging for Practice-Closing the psychological treatment gap

• No waitlist: Supportive text message interventions can be delivered

immediately to thousands of patients simultaneously

• No geographical barriers to access: Supportive text message interventions

are location-independent and can be delivered to patients in remote northern locations with cellular connectivity

• Reduce need for face-to-face counselling: Many patients receiving daily

supportive text messages could get better and not require more intensive treatments from therapists and psychologists.

Acknowledgements

• Co-authors on related publications
• St Patrick’s Mental Health Services, Dunlin, Ireland
• Operational Leadership of the Alberta Health Services North Zone
• Department of Psychiatry, University of Alberta
• Psychiatrists and MHTs in Fort McMurray
• Management and staff of the Northern Addiction Treatment Centre in Grande Prairie
• AHS Evaluation Services
• AHS SCN for Addiction and Mental Health
• Edmonton Zone AHS AMH
• Edmonton Mental Health Foundation
• Royal Alexandra Hospital Foundation

Questions?

Please use the Skype chat box. Any remaining questions will be sent to Dr. Agyapong to answer after the presentation.

• Dr. Vincent I.O. Agyapong

E-mail: agyapong@ualberta.ca

Thank you