Mobile application for monitoring and management of depressed mood in a vulnerable pregnant population

STRUCTURED ABSTRACT

Objective

Our objective was to determine whether a mobile mood tracking and alert (MTA) mobile application (app) improved mental health care delivery in a high-risk obstetric population.

Method

Pregnant women with depressive symptomatology (PHQ-9 ≥5) at <32 weeks gestation were followed for 8 weeks after randomization (1:2) to a control “portal” (PP) app alone or with the MTA app. The MTA app monitored activity, assessed mood, and alerted OB providers of signs of worsening mood.

Results

Seventy-two women enrolled (PP n = 24, MTA n = 48). MTA users had significantly more contacts addressing mental health and rated ability to manage their own health significantly better than controls. Women who received telephone contact from a provider triggered by an MTA app alert were significantly more likely to receive a mental health specialist referral.

Conclusions

A mobile MTA app improved service delivery and patient engagement in patients with perinatal depression symptoms.

INTRODUCTION

Mobile health (mHealth) strategies are a potential approach to improve patient engagement and service delivery in healthcare settings. Mobile phone application (mobile app) self-management tools have been developed for a range of chronic illnesses, and have been studied in obstetric settings for physical activity, nutrition, and gestational diabetes. These apps often provide automated feedback or cues to patients (1), but do not generally enable patients to connect directly with their healthcare team. Thus, such apps may exist in parallel to healthcare treatment, as opposed to being integrated into healthcare treatment (2). When integrated into treatment with a healthcare team, apps have the potential to extend the reach of care to the time between in-person visits, potentially improving healthcare delivery. Despite the widespread use of mobile apps, there have been few evaluations of the benefits of this technology for improving health care delivery (3), particularly regarding apps focused on mental health.

Common perinatal mental disorders, primarily depression and anxiety, are associated with poor pregnancy outcomes and infant health (4). Depression occurs in up to 20 percent of pregnant women, with markedly higher rates in low-income populations (5). Given the negative impact on the woman and her offspring, it is critical to address these disorders in the prenatal period. However, attention to mental health in obstetric settings may be inadequate due to limited resources (6), despite the fact that women may be open to discussing mental health concerns with obstetric providers (7). Mobile apps that alert the healthcare team when mood symptoms worsen between prenatal visits could enhance the ability of prenatal care sites to deliver effective, targeted care of perinatal mental health concerns, particularly in resource-limited settings.

This randomized controlled trial (RCT) aimed to assess the impact of a mood tracking and alert (MTA) mobile app on patient engagement and healthcare delivery in an obstetric setting, among low income and race/ethnic minority women with depressive symptoms. The main hypotheses were that eight weeks of MTA app use would improve patient engagement, particularly patients’ perceived ability to manage own health, improve prenatal care satisfaction (particularly sense of connectedness with providers), and enhance mental health service delivery by facilitating clinical contact when mood symptoms worsened.

METHODS

This study was an RCT drawing from a convenience sample. Pregnant women were recruited from an urban ambulatory prenatal clinic within an academic medical center serving a predominantly low income and race/ethnic minority population, from March to September 2015. Women at least 18 years of age and 32 weeks gestation or less, per electronic health record (EHR), were approached by a research coordinator at a routine prenatal appointment. Enrollment was offered to women with depressive symptoms (≥ 5 on the Patient Health Questionnaire 9 (PHQ-9)), who owned a smartphone with an iOS or Android operating system and were English speaking.

Participants were randomly assigned to one of three conditions: a mobile app allowing access to a “patient portal” (PP), standard of care available to all patients at the health center, that enabled email-like communication with providers; PP with the addition of an MTA app (Ginger.iO; San Francisco, California) that alerted providers when participant mood symptoms worsened, prompting the provider to contact the participant; or the PP app and MTA app with a lottery incentive to encourage MTA app use. Additional description of the apps is available in the online supplement. Research staff assisted participants with the application(s) download, provided information packets explaining the assigned mobile app(s), and administered a baseline interview (demographic information, prenatal care engagement and satisfaction). After eight weeks, care engagement and satisfaction were re-assessed. Service delivery data on patient-provider contacts during the 8-week period were extracted from the EHR of each participant. As an exploratory outcome, depressive and anxiety symptoms were assessed after eight weeks within the MTA group. A priori sample size calculations were based on a moderate effect size and power of 0.8. This study was approved by the Institutional Review Board of the University of Pennsylvania, conducted according to the guidelines of the Declaration of Helsinki, and registered on ClinicalTrials.gov.

Patient engagement and care satisfaction questions addressed confidence in ability to manage own health, feeling that prenatal providers understand and respond to patients’ unique needs, feeling connected with providers, ability to communicate with prenatal providers, leaving prenatal visits with unanswered questions and general satisfaction with prenatal care; items were rated on a Likert scale ranging from “Very Poor” to “Excellent” or “Completely Agree” to “Completely Disagree”. To assess service delivery, data on patient-provider interactions were abstracted from the EHR for all encounters dated within the participant’s eight week study period. Information obtained included medical history, office visit frequency, telephone contact, secure messages sent and received via PP, mental health specialist referrals and visits, and encounters that mentioned mental health or the MTA app. To assess app acceptability, participants in the MTA group were asked eight Likert scale questions about the perceived acceptability and utility of the mobile application (see online supplement). As exploratory measures, depressive and anxiety symptoms were assessed after eight weeks in the MTA group, using the PHQ-9 (8) and the Generalized Anxiety Disorder 7-Item (GAD-7) (9).

Descriptive statistics were generated and examined for normality. Student’s t and Chi-square tests assessed differences in group demographics. Patient engagement, care satisfaction and service delivery outcomes were treated as continuous variables and analyzed with ANCOVA using baseline levels as covariates. As prenatal visits are more frequent in the later stages of pregnancy, ANCOVA analyses were adjusted for gestational age. p values were considered significant at p < 0.05; values presented are not corrected for multiple comparisons. Analyses were performed with IBM SPSS Statistics for Macintosh, version 23 (IBM Corp., Armonk, N.Y., USA).

RESULTS

The sample included 72 participants (PP control app n=24, PP plus MTA n=25, PP plus MTA with lottery n=23) of 91 screened. One did not receive the allocated intervention due to incomplete app download, one withdrew, and five were lost to follow-up. Randomization created generally equivalent groups; the only significant difference among the three groups in demographics, health or psychiatric history was gestational age, which was included as a covariate in ANCOVA analyses (Table 1). There was no difference in utilization or outcomes for the two MTA groups related to the presence of the lottery, so the groups (with and without lottery) were combined for all additional analyses.

Table 1.

Demographics and main outcome variables.

DEMOGRAPHICS	PP App		MTA App		p-value
Age (years) (Mean±SD)	26.3±4.9		26.5±6.2		0.93
Gestational age at enrollment (weeks) (Mean±SD)	17.0±6.0		21.3±6.7		0.02
Race (n, % African American)	22	95.7%	39	95.1%	0.92
Marital status (n, % Married)	1	4.3%	4	9.8%	0.44
Employment status (n, % Employed)	10	55.6%	25	62.5%	0.62
Education (n, % some college or more)	10	55.6%	18	45.0%	0.46
Insurance (n, % Medicaid/Medicare)	17	73.9%	36	87.8%	0.16
Gravida (Mean±SD)	3.3±1.9		3.6±2.5		0.61
Para (Mean±SD)	0.9±1.0		1.1±1.5		0.70
PHQ-9 at enrollment (Mean±SD)	12.1±5.2		11.0±4.6		0.37
Mental health diagnosis (n, %)	13	54%	25	61%	0.49
Prescribed psychiatric medication (n, %)	2	8.7%	1	2.4%	0.26
ENGAGEMENT & CARE SATISFACTION AT WEEK 8 (Mean, SD)	PP App		MTA App		p-value
I am confident that I am able to manage my own health.	6.1±0.8		6.1±1.0		0.87
My care team understands and responds to my unique needs	6.2±1.4		6.1±1.2		0.86
I feel connected to my care team.	5.5±1.5		5.8±1.4		0.51
How would you rate the ability to reach your prenatal provider by phone?	4.1±1.3		3.9±1.4		0.67
How often do you leave a prenatal appointment with unanswered questions?	5.6±0.7		5.7±0.7		0.53
How satisfied are you with your prenatal care?	5.8±1.3		6.1±1.0		0.37
SERVICE DELIVERY (Mean, SD)	PP App		MTA App		p-value
Prenatal Care
Number OB office visits (Mean±SD)	4.5±2.6		4.7±2.1		.89†
Number of OB visits in which mental health was mentioned (Mean±SD)	.83±1.5		.85±1.3		.82†
Number of OB telephone encounters mentioning mental health (Mean±SD)	.1±4.7		.98±1.3		.02†
Mental Health Care
Number of prenatal mental health specialist visits (Mean±SD)	.22±.6		.30±.5		.69†
Patient had OB visit that addressed mental health (n,%)	8	35%	17	42%	.60‡
Patient referred to mental health specialist (n, %)	5	22%	11	27%	.65‡
Patient attended mental health specialist visit (n, %)	1	20%	3	27%	.76 ‡
Patient had MTA app triggered contact (n, %)	-	-	17	41%	-

PHQ-9: Possible scores range from 0 to 27, with higher scores indicating greater depressive symptomatology.

^†p-value from ANCOVA with gestational age as a covariate

^‡p-value for Chi-Square

Regarding patient engagement and care satisfaction, women in the third trimester in the MTA group rated their ability to manage their own health significantly higher than the control group at the conclusion of eight weeks (F= 4.36, df=2, 47, p=.02). At Week 8, controlling for baseline care satisfaction scores, there were no significant differences in care satisfaction between the PP and MTA groups.

In terms of service delivery, compared to the PP group, the MTA group had significantly more telephone encounters with providers that mentioned mental health (F=6.0, df=1, 55, p=.02), but not significantly more participants with mental health referrals nor significantly better referral adherence than the PP group (Table 1). Within the MTA group, 17 women (41.4%) received a phone call from a provider triggered by an alert from the app. Those who received an MTA app-triggered provider contact had a significantly higher rate of referral to a mental health provider compared to women who did not receive an MTA app-triggered contact (t=−2.3, df=15, p=.03). Exploratory analysis of depressive and anxiety symptoms revealed that mean daily mood score was significantly positively correlated with number of calls that a participant received in Weeks 1–4 (p values < .05). Participants who received an MTA-triggered call had consistently higher PHQ-9 and GAD-7 scores across the eight weeks, compared to those who did not receive an MTA-triggered call. These differences were significant at Weeks 1–4 for the PHQ-9 and Weeks 3–4 for the GAD-7 (p values < .05).

Among participants randomized to the MTA app, the minimum number of days that a participant used the app was 10. The most frequent users (n=3) utilized the app daily. Mean use frequency was 42.49 (±13.32) days, or 75.9% of days (about 5.3 days per week). In terms of acceptability, after eight weeks, at least half of MTA users said that the app helped them to feel open and honest about their feelings or helped them to manage their mental health. Less than fifty percent felt that the app helped their prenatal team to understand and respond to their unique needs, or to feel more connected to their care team (Table 2, online appendix).

Among MTA users, PHQ-9 (F= 7.87, df=2.5, 47.3, p=.001), GAD-7 (F= 6.32, df=2.2, 42.1, p=.003), and self-reported daily mood scores (F= 2.62, df = 4.2, 139.9, p=.03) significantly improved over eight weeks.

DISCUSSION

The aim of this study was to assess whether an MTA mobile app employed in a high risk obstetric population would improve patient engagement and mental health care delivery, over and above a standardly-used app that connected patients to providers through a patient portal. Participants had a high rate of mental health concerns including moderate depressive symptoms and a mental health diagnosis in over half. Participants were largely African-American, unmarried, young, relatively early in pregnancy, and receiving Medicaid or Medicare, representing a highly vulnerable population.

At the conclusion of the eight week trial, women in the third trimester in the MTA group experienced a significant improvement in their perceived ability to manage their own health, while those in the PP control group did not. Previous research suggests that mHealth interventions can help patients to self-manage certain health conditions (10).

As the MTA app alerted providers when a patient was experiencing worsening mood symptoms, triggering telephone contact from the provider, it follows that the MTA users had more phone contact with their providers regarding mental health. Further, women who received an MTA app-triggered call from a provider had significantly higher mean PHQ-9 and GAD-7 scores early in the study, indicating that the app was correctly identifying women in distress. Finally, women who received an MTA app-triggered telephone contact had significantly more referrals to a mental health provider than users who did not have a triggered contact from a provider. This indicates that an app such as MTA is a feasible option to improve mental health service delivery via monitoring at-risk patients between visits, and facilitated patient-provider contact when needed, rather than relying on the patient to decide to send an electronic message to her provider through a patient portal.

While a comparison group was not available, measures of depressive and anxiety symptoms and self-reported daily mood improved over eight weeks among MTA app users. However, patients with depressive symptoms tend to improve over time (11), so we cannot make any causal claims that symptom improvement was due to app use.

This study’s strengths included randomization to the MTA app or a control app and an extended (eight week) period of app use. While greater than ninety percent of women in this clinic have smartphones, less than ten percent of all patients seen in this clinic had activated the PP app. Limitations included restricting participation to smartphone users actively seeking prenatal care, and un-blind status of the research staff. We were also underpowered to adjust our assessment of statistical significance for multiple comparisons. Also, the study was focused on care delivery rather than clinical outcomes; future studies should assess depressive and anxiety symptoms in both app and control groups to assess the role of these apps in improving these outcomes.

In conclusion, a mobile app that monitored patients between routine OB visits with targeted provider contact when needed was well accepted and improved mental health service delivery in a high-need OB practice. Tools such as this may help monitor and treat high risk women with such symptoms during pregnancy.