mHealth for Antenatal Mental Health (AMHS)

Tablet Computers for Implementing NICE Antenatal Mental Health Guidelines - Feasibility Study

The aim of this study is to determine the feasibility of using mobile technology for:

1. Implementing the recommendations of the Antenatal and postnatal mental health: clinical management and service guidance NICE guideline for recognising depression (i.e., Whooley questions followed by a validated screening instrument such as the Edinburgh Postnatal Depression Scale) during pregnancy using iPad Air tablets in the waiting area of general practices, midwifery services, or hospitals during antenatal clinics; and
2. Using a bespoke app running on pregnant women's own smartphones to monitor mood and symptoms of depression throughout pregnancy.

Study Overview

• Status: Completed
• Conditions: Depression; Pregnancy
• Intervention / Treatment: Other: Whooley Questions; Other: Edinburgh Postnatal Depression Scale; Other: Momentary questions; Other: Contextual questions

Detailed Description

As part of our first aim, we will assess the psychometric properties of the Whooley questions, by comparing the answers given to these questions against the scores obtained on the Edinburgh Postnatal Depression Scale, and we will manipulate the survey questionnaire layout of the Whooley Questions and the Edinburgh Postnatal Depression Scale in order to ensure that this survey design choice does not affect data quality. As part of our second aim, we will compare two prospective sampling protocols on patient compliance and engagement with the app.

We will use a parallel, randomised control trial study design. Participation in each part of the study (i.e., iPads in antenatal clinics, or app running on own handset) will be independent from each other. Those participants consenting to get involved in the part of the study assessing the use of iPads in antenatal clinics will be randomly assigned to complete (i) an app version of the Whooley questions and the Edinburgh Postnatal Depression Scale in which the questionnaires are presented using a scrolling layout (i.e., App screening - Scrolling), or (ii) an app version of the Whooley questions and the Edinburgh Postnatal Depression Scale in which the questionnaires are presented using a paging layout (i.e., App screening - Paging).

Participants consenting to get involved in the part of the study assessing the use of an app running on participants' own devices will be randomly allocated to one of two sampling protocols: (i) a prospective sampling protocol of 6 months consisting of the Edinburgh Postnatal Depression Scale and 5 momentary questions related to mood; or (ii) a prospective sampling protocol of 6 months consisting of the Edinburgh Postnatal Depression Scale.

We will utilise a block randomisation procedure (with blocks of 4) to generate our allocation sequence. Random numbers will be generated using Stata 13.0. Researchers conducting participant recruitment will not be involved in this randomisation procedure in order to avoid recruitment bias.

• Study Type: Observational
• Enrollment (Actual): 946

Contacts and Locations

Study Locations

• United Kingdom
  • Blackburn, United Kingdom
    • East Lancashire
  • Bolton, United Kingdom
    • Royal Bolton Hospital
  • Burton, United Kingdom
    • Burton Hospitals
  • Crumpsall, United Kingdom
    • The Pennine Acute Hospitals
  • Huntingdon, United Kingdom
    • Hinchinbrooke Hospital
  • Lincoln, United Kingdom
    • East Midlands CRN
  • London, United Kingdom
    • Chelsea & Westminster Hospital
  • London, United Kingdom
    • Northwick Park Hospital
  • London, United Kingdom
    • Hillingdon Hospitals
  • London, United Kingdom
    • West Middlesex Hospital
  • Newcastle, United Kingdom
    • North of England
  • Shrewsbury, United Kingdom
    • Shrewsburty & Telford Hospital
  • Stoke-on-Trent, United Kingdom
    • University Hospitals of North Midlands
  • Wigan, United Kingdom
    • Wrightington, Wigan and Leigh NHS

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

• Sampling Method: Probability Sample

Study Population

Pregnant women who are 18 years old or older.

Description

Inclusion Criteria:

• Pregnant women attending antenatal clinics

Exclusion Criteria:

• Diagnosis of any common mental health disorder (i.e., depression or anxiety disorders) as specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
• Receiving treatment for any common mental health disorder
• Recent personal history of any common mental health disorder (i.e., within the past 12 months)
• Not comfortable reading and writing in English

Participants enrolled in the study assessing an app for the monitoring of mood and symptoms of depression need to own an iPhone or any Android-compatible smartphone.

Study Plan

How is the study designed?

Design Details

• Observational Models: Other
• Time Perspectives: Prospective

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Screening - Scrolling layout; Participants will be asked to complete a survey consisting of three sections using an iPad Air tablet: Section 1: Demographic information survey; Section 2: Whooley questions; Section 3: Edinburgh Postnatal Depression Scale All questions will be presented on a single screen. This means that participants will have to scroll vertically in order to answer all the questions.	Other: Whooley Questions; The Whooley questions are a case-finding instrument for depression in primary care. This 2-question instrument screens for depressed mood and anhedonia that have been present during the past month. Respondents are required to answer Yes or No to each of these questions. An affirmative answer to any of them should be followed by further assessment, including the use of a validated screening instrument or referral to a general practitioner or a mental health practitioner.; Other: Edinburgh Postnatal Depression Scale; The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered survey that screens for symptoms such as feelings of guilt, sleep disturbance, reduced energy levels, anhedonia and suicidal ideation that have been present during the 7 days preceding its administration. Each question is scored on a 4-point scale ranging from 0 to 3 points. Overall scores between 10 and 12 points suggest increased risk for depression; scores of 13 points or above indicate that the diagnostic criteria for major depression disorder have probably been met. In addition, item 10 deals with suicidal thoughts. The EPDS is a valid and reliable tool for identifying women at risk of depression, both during pregnancy and postpartum, and is sensitive to changes in the severity of depression over time.
Screening - Paging layout; Participants will be asked to complete a survey consisting of three sections using an iPad Air tablet: Section 1: Demographic information survey; Section 2: Whooley questions; Section 3: Edinburgh Postnatal Depression Scale Only one question will be presented at any given time. This means that participants will have to navigate through multiple pages in order to answer all the questions.	Other: Whooley Questions; The Whooley questions are a case-finding instrument for depression in primary care. This 2-question instrument screens for depressed mood and anhedonia that have been present during the past month. Respondents are required to answer Yes or No to each of these questions. An affirmative answer to any of them should be followed by further assessment, including the use of a validated screening instrument or referral to a general practitioner or a mental health practitioner.; Other: Edinburgh Postnatal Depression Scale; The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered survey that screens for symptoms such as feelings of guilt, sleep disturbance, reduced energy levels, anhedonia and suicidal ideation that have been present during the 7 days preceding its administration. Each question is scored on a 4-point scale ranging from 0 to 3 points. Overall scores between 10 and 12 points suggest increased risk for depression; scores of 13 points or above indicate that the diagnostic criteria for major depression disorder have probably been met. In addition, item 10 deals with suicidal thoughts. The EPDS is a valid and reliable tool for identifying women at risk of depression, both during pregnancy and postpartum, and is sensitive to changes in the severity of depression over time.
Retrospective plus momentary assessment; Participants in this group will be asked to download and install an app onto their own smartphones. After that, they will be asked to complete a sampling protocol consisting of 6 consecutive days, once a month for 6 months. During the 6 assessment days, participants will be required to complete the Edinburgh Postnatal Depression Scale, 5 momentary questions on a 5-point pictorial scale, and 2 contextual questions.	Other: Edinburgh Postnatal Depression Scale; The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered survey that screens for symptoms such as feelings of guilt, sleep disturbance, reduced energy levels, anhedonia and suicidal ideation that have been present during the 7 days preceding its administration. Each question is scored on a 4-point scale ranging from 0 to 3 points. Overall scores between 10 and 12 points suggest increased risk for depression; scores of 13 points or above indicate that the diagnostic criteria for major depression disorder have probably been met. In addition, item 10 deals with suicidal thoughts. The EPDS is a valid and reliable tool for identifying women at risk of depression, both during pregnancy and postpartum, and is sensitive to changes in the severity of depression over time.; Other: Momentary questions; These will consist of 5 questions on a 5-point pictorial scales, assessing participants' mood, sleep, energy, enjoyment and worry.; Other: Contextual questions; Two questions asking for participants' location and activity at the time they were asked to complete the momentary questions.
Retrospective assessment; Participants in this group will be asked to download and install an app onto their own smartphones. After that, they will be asked to complete a sampling protocol consisting of one day a month for 6 months. The assessment days will consist of a single administration of the Edinburgh Postnatal Depression Scale.	Other: Edinburgh Postnatal Depression Scale; The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered survey that screens for symptoms such as feelings of guilt, sleep disturbance, reduced energy levels, anhedonia and suicidal ideation that have been present during the 7 days preceding its administration. Each question is scored on a 4-point scale ranging from 0 to 3 points. Overall scores between 10 and 12 points suggest increased risk for depression; scores of 13 points or above indicate that the diagnostic criteria for major depression disorder have probably been met. In addition, item 10 deals with suicidal thoughts. The EPDS is a valid and reliable tool for identifying women at risk of depression, both during pregnancy and postpartum, and is sensitive to changes in the severity of depression over time.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Responding Affirmatively to at Least One Whooley Question According to Survey Layout	Comparison of the number of participants answering affirmatively to at least one Whooley question in each experimental group. This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups.	One-off assessment immediately after recruitment
Median EPDS Scores According to Survey Layout	This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups. Median scores on the Edinburgh Postnatal Depression Scale according to group allocation. The EPDS consists of 10 questions each rated on a 4-point scale ranging from 0 to 3 points. Overall scores are obtained by adding the scores of all the individual questions, and range from 0 points to 30 points. Overall scores of 0 to 9 points suggest a low risk of perinatal depression. Overall scores between 10 and 12 points suggest an increased risk of perinatal depression. Overall scores of 13 points or more suggest that the respondent is likely to have met the diagnostic criteria for perinatal depression. Moreover, scores of 1 point or more on question 10 of the EPDS ought to be explored further as this question deals with ideas of self-harm.	One-off assessment immediately after recruitment
Number of Participants at Each EPDS Scoring Interval According to Survey Layout	Number of participants scoring at each of the scoring intervals that have been reported for the Edinburgh Postnatal Depression Scale: 0 to 9 points - low risk; 10 to 12 points - moderate risk; 13 points or more - high risk. This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups.	One-off assessment immediately after recruitment
Number of Participants According to Their Score on Question 10 of the EPDS According to Survey Layout	Number of participants scoring 1 point or more on question 10 of the Edinburgh Postnatal Depression Scale, which deals with thoughts of self-harm. This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups.	One-off assessment immediately after recruitment
Adherence With a 6-month Follow-up Protocol	This outcome was measured on the retrospective plus momentary assessment and retrospective assessment groups only. Participants who completed at least one expected assessment during each sampling period	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time Needed to Complete the Whooley Questions and the EPDS According to Survey Layout	This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups. Time elapsed (in seconds) between the participants starting to read the basic instructions on how to complete the survey questionnaires and the participant completing the EPDS. These actions will be indicated by participants pressing the Start button on the device screen and when a message acknowledging that they have completed the survey questionnaires is displayed on the device screen. This component will be broken down further into the individual survey questionnaires that participants will be required to complete (i.e., personal demographic information, Whooley questions, and EPDS). In addition, we will account for the time that participants spend experiencing problems, distractions or making requests for help or clarification.	One-off assessment immediately after recruitment
Proportion of Participants Requesting Technical Assistance According to Survey Layout	This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups. Number of participants who made no requests for technical assistance, and those who requested technical assistance	One-off assessment immediately after recruitment
Number of Requests for Technical Assistance by Type of Request and According to Survey Layout	This outcome was only measured in the Screening - Scrolling layout and in the Screening - Paging layout groups. Total number of requests for technical assistance made in each experimental group according to type of request.	One-off outcome assessment conducted up to 24 hours after obtaining written, informed consent

Collaborators and Investigators

• Sponsor: Imperial College London
• Investigators: Principal Investigator: Jose S Marcano Belisario, Imperial College London; Principal Investigator: Josip Car, Imperial College London; Principal Investigator: Cecily Morrison, Imperial College London; Principal Investigator: John O'Donoghue, Imperial College London; Study Chair: Ajay Gupta, Imperial College London; Study Chair: Paul Ramchandani, Imperial College London; Principal Investigator: Gavin Doherty, University of Dublin, Trinity College; Principal Investigator: Kevin Doherty, University of Dublin, Trinity College

Publications and helpful links

General Publications

• Marcano-Belisario JS, Gupta AK, O'Donoghue J, Morrison C, Car J. Tablet computers for implementing NICE antenatal mental health guidelines: protocol of a feasibility study. BMJ Open. 2016 Jan 22;6(1):e009930. doi: 10.1136/bmjopen-2015-009930.
• Marcano Belisario JS, Doherty K, O'Donoghue J, Ramchandani P, Majeed A, Doherty G, Morrison C, Car J. A bespoke mobile application for the longitudinal assessment of depression and mood during pregnancy: protocol of a feasibility study. BMJ Open. 2017 May 29;7(5):e014469. doi: 10.1136/bmjopen-2016-014469.
• Marcano-Belisario JS, Gupta AK, O'Donoghue J, Ramchandani P, Morrison C, Car J. Implementation of depression screening in antenatal clinics through tablet computers: results of a feasibility study. BMC Med Inform Decis Mak. 2017 May 10;17(1):59. doi: 10.1186/s12911-017-0459-8.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2015
• Primary Completion (Actual): February 1, 2018
• Study Completion (Actual): August 1, 2018

Study Registration Dates

• First Submitted: July 20, 2015
• First Submitted That Met QC Criteria: August 4, 2015
• First Posted (Estimate): August 6, 2015

Study Record Updates

• Last Update Posted (Actual): September 23, 2019
• Last Update Submitted That Met QC Criteria: September 20, 2019
• Last Verified: September 1, 2019

More Information

Terms related to this study

• Keywords: Telemedicine; Screening; mHealth; Mental health; Prenatal Care; Mood disorders; Perinatal depression; Edinburgh Postnatal Depression Scale; Antenatal care; Whooley Questions; Data collection
• Additional Relevant MeSH Terms: Behavioral Symptoms; Depression
• Other Study ID Numbers: 15IC2687

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided