Online Messaging Effective, Efficient for Depression Follow-up

Fran Lowry

June 30, 2011

June 30, 2011 — Organized follow-up care for depression can be effectively and efficiently delivered through online messaging, according to a randomized controlled trial.

"Follow-up care after an antidepressant prescription is typically poor," lead study author Gregory E. Simon, MD, MPH, of the Group Health Research Institute, Seattle, Washington, told Medscape Medical News. "Medications work slowly; people who are depressed tend to become discouraged and give up."

The study is published in the July issue of Journal of General Internal Medicine.

Dr. Simon said that in previous work, he and his colleagues have successfully delivered organized care for depression using telephone calls. But, he said, reaching people by telephone is time-consuming and inconvenient.

"Recently, for each phone contact with a patient, we've wasted a half hour on playing phone tag.

"Online messaging is much more efficient and convenient. But it's also less personal. We were interested in testing whether we could improve follow-up care using online messaging as an alternative to the telephone," he said.

Multicenter Study

The messaging system used in this study is similar to email, Dr. Simon explained, but, for security reasons, it lives inside a specific Web site.

Dr. Gregory E. Simon

"Many people have probably used similar 'embedded' messaging systems within Web sites, like e-Bay or Facebook," he said.

In the study, which was conducted in 9 primary care clinics in the Group Health Cooperative, an integrated health system that serves approximately 600,000 members in the Pacific Northwest, Dr. Simon and his team randomized 208 patients 18 years and older starting antidepressant treatment for depression to receive usual primary care treatment or to primary care supported by online care management.

The online support consisted of 3 online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment of severity of depression, medication adherence, and side effects, algorithm-based feedback to the patient and treating physician, and facilitation of follow-up care, as needed.

After 3 months, the patients offered the intervention had higher rates of antidepressant adherence than patients in the usual group. Eighty-one percent of patients receiving the online support continued their antidepressant treatment compared with 61% of patients in the usual care group (P = .001).

High Rate of Satisfaction

After 5 months, the patients offered the online intervention had lower Symptom Checklist depression scores compared with those in the usual care group (0.95 vs 1.17, P = .043), and they also had greater satisfaction with their treatment for depression, with 53% saying they were "very satisfied" compared with 33% of patients getting usual care.

"Patients were very satisfied with the program, and we did not encounter concerns about confidentiality or concerns that online communication was impersonal," Dr. Simon noted. "But only about two-thirds of our patients use online messaging, so a program like this will not reach everyone."

He added that improving follow-up care for depression should be a priority in primary care practice.

"Our study shows that online messaging is an effective and efficient way to do this. Online patient-provider communication is growing, and we hope our study helps to accelerate that growth."

One Size May Not Fit All

Commenting on the study for Medscape Medical News, Michele Riba, MD, professor of psychiatry at the University of Michigan, Ann Arbor, and associate director of the University of Michigan Depression Center, said the study "will help us think through the best way to help our patients because not everybody is the same and different people will respond to different things."

Dr. Riba also noted that the patients in this study were probably quite sophisticated because they are used to using electronic medical records.

"Also the doctors are all part of the same group health consortium, and they were able to do this because it was a closed group. I would never do this with depressed patients without talking to their primary care doctors who may not be here at the University of Michigan."

She also said that having a trained nurse available was important.

"You really have to have a caveat that there has to be somebody available in case patients are in distressed or suicidal."

Dr. Simon reports that he is an employee of the Group Health Permanente Medical Group and has no other relevant financial relationships. Dr. Riba has disclosed no relevant financial relationships.

J Gen Intern Med. 2011;26:698-704. Abstract