General Practice and Primary Care - Research Publications
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ItemMatching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial(ROYAL COLL GENERAL PRACTITIONERS, 2021-02)BACKGROUND: Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required. AIM: To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care. DESIGN AND SETTING: Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care. METHOD: The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months. RESULTS: In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported. CONCLUSION: Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.
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ItemPatient reported self-help strategies and the perceived benefits for managing sub-threshold depressive symptoms: A nested qualitative study of Australian primary care attendees(WILEY, 2022-09-01)BACKGROUND: Subthreshold depression is common in primary care, but there is little information about the self-help strategies that patients use and the perceived benefits of these. AIM: This study sought to elicit the self-help strategies that primary care attendees identified as beneficial for the self-management of subthreshold depressive symptoms and the implications for general practitioners. METHOD: Semi-structured telephone interviews were conducted with 14 people (April-May 2017) from the Target-D randomised controlled trial (RCT). Target-D investigated whether using a patient-centred clinical prediction tool and an e-health platform to match mental health management options to prognosis was beneficial for improving depressive symptoms at 3 months compared to usual care. Interviews were thematically analysed to identify self-help strategies and their perceived benefits. RESULTS: Four overarching domains for the self-management strategies were identified: social, cognitive, behavioural and restorative. Interviewees reported using strategies across multiple domains, which included undertaking enjoyable, immersive activities, that provided relief from automatic negative thoughts and had a perceived cognitive benefit. Differences in the perceived sense of agency were noted around the self-regulation of mood, which indicated more explicit direction to patient-identified self-help management strategies by general practitioners for some may be of benefit in routine care. CONCLUSION: Some of the reported self-management strategies aligned with evidence-based approaches such as physical activity and mindfulness for mental health symptom management. These findings can inform low-intensity interventions within stepped care models for mental health in primary care, social prescribing models and, help to guide the management of patients by GPs for subthreshold depression.
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ItemA Mobile Phone App to Improve the Mental Health of Taxi Drivers: Single-Arm Feasibility Trial(JMIR Publications, 2020-01-15)Background: Psychological distress among taxi drivers is 5 times higher than that in the general population, and more than half of all drivers have experienced 3 or more potentially traumatic events in their lifetime. Nevertheless, help-seeking for mental health problems in this male-dominated, predominately immigrant workforce is low. Mobile technologies have the potential to increase mental health awareness, teach self-help skills, and encourage help-seeking in this hard-to-reach population. Objective: This study aimed to assess the feasibility, acceptability, and potential efficacy of Driving to Health, a mobile phone–friendly mental health website app designed for people working as taxi drivers. Methods: Drivers (n=46) were recruited from the Melbourne Airport Taxi Holding Yard to participate in a single-arm trial. Self-reported, paper-based assessments were completed at baseline and at 1 month. Feasibility was measured by completion rates, representativeness of study participants, and levels of use. Acceptability was assessed by measuring users’ perception of the quality of the app and anticipated levels of future use. The efficacy of Driving to Health to increase awareness, self-help behaviors, and intentions to seek help was assessed using the user version of the Mobile App Rating Scale (uMARS) and the General Help-Seeking Questionnaire (GHSQ). Psychological symptoms were measured using the short form of the Depression, Anxiety, and Stress Scale (DASS-21). Data were analyzed using complete case analysis. Results: In total, 42 participants comprising drivers from 10 different countries of origin, and 14 different languages, completed pre- and poststudy measures (42/46, 91% completion rate). Just under half (45%) of all users used the app more than once with an average visit of 4 min 8 seconds. Responding to the uMARS, 62% (26/42) of the participants said that they would recommend the app to many people. Nearly all (40/42, 95%) participants said that Driving to Health increased awareness of their own mental health; 86% (36/42) said that it increased their mental health knowledge; and 76% (32/42) said that it increased their self-help behaviors. Increases in help-seeking intentions on the GHSQ were not significant, and increases on all 3 scales of DASS-21 were not reliable or meaningful. Conclusions: This study suggests that Driving to Health is an acceptable and feasible electronic health intervention for a hard-to-reach population. Our findings also suggest that Driving to Health results in increases in mental health awareness, behaviors, and willingness to seek help.
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ItemNo Preview AvailableDevelopment of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: User-Centered Design(JMIR PUBLICATIONS, INC, 2018-04)BACKGROUND: Around the world, depression is both under- and overtreated. The diamond clinical prediction tool was developed to assist with appropriate treatment allocation by estimating the 3-month prognosis among people with current depressive symptoms. Delivering clinical prediction tools in a way that will enhance their uptake in routine clinical practice remains challenging; however, mobile apps show promise in this respect. To increase the likelihood that an app-delivered clinical prediction tool can be successfully incorporated into clinical practice, it is important to involve end users in the app design process. OBJECTIVE: The aim of the study was to maximize patient engagement in an app designed to improve treatment allocation for depression. METHODS: An iterative, user-centered design process was employed. Qualitative data were collected via 2 focus groups with a community sample (n=17) and 7 semistructured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoypes of the app. RESULTS: Iterative development resulted in 3 prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the clinical prediction tool, but there was a need for a personalized treatment recommendation made in conjunction with a consultation with a health professional. CONCLUSIONS: User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool that allows users to feel hope, engage in self-reflection, and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial.
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ItemTarget-D: a stratified individually randomized controlled trial of the diamond clinical prediction tool to triage and target treatment for depressive symptoms in general practice: study protocol for a randomized controlled trial(BMC, 2017-07-20)BACKGROUND: Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months' time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care. METHODS: The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group. DISCUSSION: To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data.