Two-way messaging therapy for depression and anxiety: longitudinal response trajectories

Thomas D Hull, Matteo Malgaroli, Philippa S Connolly, Seth Feuerstein, Naomi M Simon, Thomas D Hull, Matteo Malgaroli, Philippa S Connolly, Seth Feuerstein, Naomi M Simon

Abstract

Background: Telemedicine is a strategy for overcoming barriers to access evidence-based psychotherapy. Digital modalities that operate outside session-based treatment formats, such as ongoing two-way messaging, may further address these challenges. However, no study to date has established suitability criteria for this medium.

Methods: A large outpatient sample (n = 10,718) engaged in daily messaging with licensed clinicians from a telemedicine provider. Patients consisted of individuals from urban and rural settings in all 50 states of the US, who signed up to the telemedicine provider. Using a longitudinal design, symptoms changes were observed during a 12 week treatment course. Symptoms were assessed from baseline every three weeks using the Patient Health Questionnaire (PHQ-9) for depression, and the Generalized Anxiety Disorder (GAD-7) for anxiety. Demographics and engagement metrics, such as word count for both patients and therapists, were also assessed. Growth mixture modeling was used to tease apart symptoms trajectories, and identify predictors of treatment response.

Results: Two subpopulations had GAD-7 and PHQ-9 remission outcomes (Recovery and Acute Recovery, 30.7% of patients), while two others showed amelioration of symptoms (Depression and Anxiety Improvement, 36.9% of patients). Two subpopulations experienced no changes in symptoms (Chronic and Elevated Chronic, 32.4% of patients). Higher use of written communication, patient characteristics, and engagement metrics reliably distinguished patients with the greatest level of remission (Recovery and Acute Recovery groups).

Conclusions: Remission of depression and anxiety symptoms was observed during delivery of psychotherapy through messaging. Improvement rates were consistent with face-to-face therapy, suggesting the suitability of two-way messaging psychotherapy delivery. Characteristics of improving patients were identified and could be used for treatment recommendation. These findings suggest the opportunity for further research, to directly compare messaging delivery with a control group of treatment as usual.

Trial registration: Clinicaltrials.gov Identifier: NCT03699488, Retrospectively Registered October 8, 2018.

Keywords: Anxiety; Depression; Digital health; Longitudinal design; Messaging therapy; Telemedicine; Text therapy.

Conflict of interest statement

Hull is an employee of the messaging platform used for this study. In the past 36 months Dr. Malgaroli has received minor consulting fees from Talkspace, outside the submitted work. Dr. Feuerstein serves as an advisor and/or Board member to Vibrant!, Groop Internet Platform, Athyrium, LP, and Magellan Health.

Figures

Fig. 1
Fig. 1
Observed cross-sectional mean PHQ-9 and GAD-7 scores over 12 weeks of two-way messaging treatment (N = 10′718). Error bars represent 95% CI. (Dotted line is PHQ-9)
Fig. 2
Fig. 2
Parallel Growth Trajectories of PHQ-9 and GAD-7 estimated scores. Each Class is teased based on their longitudinal course of both depression and anxiety symptoms over 12 weeks of treatment (N = 10,718). (Dotted line is PHQ-9)

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