Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial

Abhishek Pratap, Brenna N Renn, Joshua Volponi, Sean D Mooney, Adam Gazzaley, Patricia A Arean, Joaquin A Anguera, Abhishek Pratap, Brenna N Renn, Joshua Volponi, Sean D Mooney, Adam Gazzaley, Patricia A Arean, Joaquin A Anguera

Abstract

Background: Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches.

Objective: This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control).

Methods: We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys.

Results: We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=-2.66, P=.006) over the treatment course, outcomes did not vary by treatment app.

Conclusions: Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of "low-touch" research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement.

Trial registration: Clinicaltrials.gov NCT01808976; https://ichgcp.net/clinical-trials-registry/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz).

Keywords: Hispanics; Latinos; clinical trial; cognition; depression; mHealth; minority groups; mobile apps; problem solving; smartphone.

Conflict of interest statement

Conflicts of Interest: AG is cofounder, chief science advisor, and shareholder of Akili Interactive Labs, a company that develops cognitive training software. AG has a patent for a game-based cognitive training intervention, “Enhancing cognition in the presence of distraction and/or interruption,” on which the cognitive training app (Project: EVO) that was used in this study was based. No other author has any conflict of interest to report.

©Abhishek Pratap, Brenna N Renn, Joshua Volponi, Sean D Mooney, Adam Gazzaley, Patricia A Arean, Joaquin A Anguera. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.08.2018.

Figures

Figure 1
Figure 1
Overall BRIGHTEN V2 study schematic showing participant recruitment, consent, enrollment, and randomization workflow along with weekly and daily data collection. EVO: Project Evolution; GPS: Global Positioning System; PHQ-2: 2-item Patient Health Questionnaire; PHQ-9: 9-item Patient Health Questionnaire; SDS: Sheehan Disability Scale.
Figure 2
Figure 2
US map showing the location of people who were screened (gray) and enrolled (red) in the BRIGHTEN V2 Study.
Figure 3
Figure 3
The Consolidated Standards of Reporting Trials flow diagram. iPST: internet-based problem-solving therapy; EVO: Project Evolution; N/A: not available.
Figure 4
Figure 4
Comparison of self-reported income satisfaction and baseline Patient Health Questionnaire-9 (PHQ-9) score between Hispanic/Latino and non-Hispanic/Latino participants.
Figure 5
Figure 5
Comparison of participant attrition in the study across survey types and passive data stratified by Hispanic/Latinos and Non-Hispanic/Latinos. GPS: Global Positioning System; PHQ-2: 2-item Patient Health Questionnaire; PHQ-9: 9-item Patient Health Questionnaire; SDS: Sheehan Disability Scale.
Figure 6
Figure 6
Comparison of Kaplan-Meier survival estimates for Hispanic/Latino and non-Hispanic/Latino participants during the course of the study (1-84) days.
Figure 7
Figure 7
Comparison of number of days participants were active across different treatment arms in the study. EnR: enrolled but not randomized; EVO: Project Evolution; HTips: health tips; iPST: internet-based problem-solving therapy.
Figure 8
Figure 8
Comparison of weekly mean Patient Health Questionnaire-9 (PHQ-9) scores with mean SEs stratified by baseline depression state.

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