Online Follow-up Reduces Depression, Boosts Therapy Adherence

Megan Brooks

March 22, 2011

March 22, 2011 — For patients starting antidepressant treatment, follow-up care can be "effectively and efficiently" delivered through online messaging provided by trained psychiatric nurses, new research suggests.

In the study, patients who received online follow-up care had higher rates of antidepressant adherence and lower depression scores and were more satisfied with their care than those receiving usual care.

"The quality of antidepressant treatment remains disturbingly poor," Gregory E. Simon, MD, MPH, and colleagues from the Group Health Research Institute in Seattle, Washington, note in their report. "Rates of medication adherence and follow-up contact are especially low in primary care."

Dr. Gregory E. Simon

The study was published online March 8 in the Journal of General Internal Medicine.

Previously, Dr. Simon and colleagues demonstrated that organized follow-up care for depression delivered over the telephone significantly improved quality and outcomes of depression treatment.

"But telephone programs are relatively inconvenient and expensive," Dr. Simon told Medscape Medical News. A lot of time can be wasted playing "phone tag," he added.

The current study, he said, shows that organized follow-up care by online messaging has some of the same benefits and is more convenient.

"We found that the online messaging program significantly improved medication adherence, patients' satisfaction with treatment, and clinical outcomes," he noted.

Nurse-Led Messaging

The study involved 208 adults starting antidepressant therapy from 9 primary care clinics affiliated with the Group Health Cooperative, an integrated health system serving roughly 600,000 members in the Pacific Northwest. One hundred six patients were randomly assigned to receive online care management and 102 were assigned to usual care.

With online care management, psychiatric nurses periodically sent secure electronic messages through Group Health's existing EpicCare (Epic Systems) electronic medical record system. The system includes a tool for providers and patients to communicate online. Automated e-mail reminders alert members to new messages. All of the clinics that participated in the study had experience using the system.

Each online contact, initiated by a trained psychiatric nurse care manager, was designed to determine the level of current depressive symptoms, whether the patients were taking their antidepressant medication as prescribed, whether it was working for them, and whether changes in dose or drug were needed.

"The core of the program is structured [online] follow-up and use of a simple algorithm to adjust treatment," Dr. Simon said.

Online Advantage

Participants were predominantly women in their forties with moderate depression. After 5 months, mean Symptom Check List (SCL) depression scale scores were lower in the online care group than the usual care group (0.95 vs 1.17; P = .043).

In a linear model adjusted for relevant factors, depression severity was significantly lower in the online care group (adjusted difference, 0.29; 95% confidence interval [CI], 0.06 - 0.51).

The investigators note that the 0.29 effect size for improvement in depressive symptoms is larger than the effect sizes of 0.23 and 0.19 in 2 previous telephone follow-up programs conducted at these same clinics. In addition, it is approximately equal to the effect sizes of 0.25 and 0.30 seen with telephone depression programs in other primary care settings.

They also report that more patients in the online care group than the usual care group experienced at least a 50% decrease in SCL depression score between baseline and 5 months (55% vs 41%; odds ratio, 1.8; 95% CI, 1.0 - 3.1).

Patients in the online program were also more apt to take their antidepressant as prescribed (81% continued treatment more than 3 months vs 61% in the usual care group; P = .001).

More patients in the online care group than the usual care group reported being "very satisfied" with their care (53% vs 33%; P < .004). "We worried that patients might need live voice contact in real time to be understood and feel supported," Dr. Simon said, but that was not the case.

Staff time required to provide depression follow-up care by online messaging was less than half of that required for telephone programs, the investigators note.

But Dr. Simon cautions that a program such as this could be implemented only in practices that can communicate by online messaging, "but it is certain that the number of practices able to do this will increase."

The investigators acknowledge that, for the moment, online health communication, whether by physician or nonphysician provider, is not reimbursed by most US health insurance companies. However, increasing attention to the patient-centered medical home may facilitate reimbursement for services other than in-person physician visits, they point out.

The study was funded by the National Institute of Mental Health. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online March 8, 2011.