A new study led by faculty from the Department of Family Medicine at the University of Michigan has found that weekly automated telephone calls, coupled with support from caregivers and care teams, can create a significant clinical difference in low-income patients with moderate to severe depression.
The paper, titled, “Technology-Facilitated Depression Self-Management Linked with Lay Supporters and Primary Care Clinics: Randomized Controlled Trial in a Low-Income Sample,” was recently published online in Telemedicine Journal and E-Health, the official publication of the American Telemedicine Association.
The study’s lead author is Professor James E. Aikens, Ph.D., of the Department of Family Medicine. Co-authors include Research Professor Ananda Sen, Ph.D., a member of Family Medicine who is also part of the Department of Biostatistics at U-M. Other authors come from the University of Michigan, the VA Ann Arbor Center for Clinical Management Research, Cherry Health in Grand Rapids, and Michigan State University College of Human Medicine.
Between 2013 and 2017, 204 low-income patients receiving treatment for depression in eight primary care centers in Michigan were recruited to participate in the randomized controlled trial. Half of the centers from which patients were recruited were federally qualified health centers.
All 204 patients designated up to four people as CarePartners – friends or relatives outside of the home setting -- who could help the patient manage their depressive symptoms. Researchers encouraged patients to designate someone outside of the home as a CarePartner to avoid caregiver burnout and potential conflicts that might arise within the household. Study coordinators encouraged CarePartners to discuss depression self-management with the patient on a weekly basis.
Ninety-six of these patients were assigned to a control group, which received enhanced standard care for depressive symptoms, including information sheets about depression self-management. CarePartners of patients in the control group were also encouraged by study coordinators at the beginning of the trial to discuss depression self-management with the patient on a weekly basis.
The remaining 108 patients received 12 months of weekly five- to 10-minute automated interactive voice response (IVR) calls during which they used their telephone keypad to answer a set of prerecorded questions related to symptom severity and adherence to medication. The phone system then provided prerecorded self-management guidance and suggestions tailored to the patient’s responses.
The IVR system aggregated this data into a patient report which was then delivered to each patient’s CarePartners, with suggestions on how the CarePartner could provide the patient with self-management support. The system also contacted the patient’s primary care team when warranted.
Researchers found that 57% of people in the intervention arm experienced improvements in their depression symptoms, compared to 33% of patients in the control arm. Study coordinators checked in with patients at the six-month mark and found Patient Health Questionnaire-9 (PHQ-9) scores had decreased by 2.5 points more for those receiving intervention than those in the control arm, signifying improvement in their depressive symptoms.
By the 12-month market, those in the intervention arm had experienced a lowering of an additional 2.5 points on the PHQ-9 as compared to those in the control arm. The intervention was also over twice as likely to lead to a 50% or greater reduction in symptom severity by month six and a decrease of five PHQ-9 points by the 12-month mark.
Aikens said that the team also was able to infer from the data that certain people – particularly those with severe depression and those with little to no support at the beginning of the study – reaped significant benefits from the weekly calls delivered by IVR technology.
“They reported that it made then feel like someone was paying attention to them,” Aikens said. “Someone was giving them clinical attention. They could always count on the call.”
Given the project’s encouraging results, the research team is now interested in evaluating the intervention’s especially strong benefit to patients within the sample who had the most severe depression and/or lowest levels of social support. This research could help determine if more intensive follow-up for these patients can provide greater benefits.
The research group is considering developing an intervention with increased touchpoints including a website with more interactive activities to help with self-manage symptoms and increased check-ins by clinicians or lay counselors to reinforce these activities.
The paper’s authors argue that another of the intervention’s benefits is to help alleviate the workload of primary care staff, especially in smaller clinics, which may not have formal processes in place to help those experiencing depression.
“This could help patients with between-visit contact,” Aikens said. “Visits could be less frequent. It could be a way for doctors to monitor a panel of patients easily.”
The authors note in the Discussion section of their paper that the expense of setting up an IVR system – which include purchases of software and equipment, as well as maintenance costs -- are far less than the costs of more frequent in-person care.
“This system is geared to be completely remote, and yet it would integrate with the primary care physician’s office. “There’s very little babysitting of the system once it’s up,” Aikens said. “I think it fits well with the ongoing (COVID-19) pandemic.”
Article citation: Aikens, J. E., Valenstein, M., Plegue, M. A., Sen, A., Marinec, N., Achtyes, E., & Piette, J. D. (2022). Technology-facilitated depression self-management linked with lay supporters and primary care clinics: Randomized controlled trial in a low-income sample. Telemedicine and e-Health, 28(3), 399–406. https://doi.org/10.1089/tmj.2021.0042
