Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials

Intervention strategies for management of comorbid depression among individuals with hypertension: a scoping review protocol

INTRODUCTION

Hypertension and depression often coexisted, leading to poor health outcome and significant challenges in healthcare management. Since no guidelines or consensus are available for health professionals to manage this comorbidity, identifying interventions in current literature is crucial for gaining a clear picture of evidence and informing future research directions and clinical practice. This scoping review is designed to address this gap by systematically mapping the range of potential interventions for managing comorbid hypertension and depression.

METHODS AND ANALYSIS

Following the Joanna Briggs Institute guidelines for scoping review, this review will comprehensively search databases including PUBMED, Embase, PsycINFO, CINAHL, Cochrane Library Databases, Chinese Biomedical Literature Database and Chinese National Knowledge Infrastructure. Grey literature will be sourced from Google Scholar. A year limit of January 2004-December 2023 will be applied to retrieve the most current peer-reviewed articles in English and Chinese language only. Two reviewers will individually screen and the process will be documented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews. This review will explore a range of non-pharmacological and multicomponent interventions including psychosocial support, educational programmes, telemedicine and integrated healthcare models. Data extraction will follow the Template for Intervention Description and Replication checklist to ensure detailed and standardised reporting of intervention components. The synthesis of findings will employ both quantitative and qualitative methods to provide a comprehensive overview of the intervention landscape.

ETHICS AND DISSEMINATION

This scoping review, which involves secondary data analysis of publicly available sources, does not require ethical approval. Findings will be disseminated through peer-reviewed publications and presentations at relevant conferences.

STUDY REGISTRATION

Open Science Framework registry (osf.io/j7gt8) in Centre for Open Science on 29 January 2024.

The burden of major depressive disorder in the Middle East and North Africa region, 1990-2019

BACKGROUND

Major depressive disorder (MDD) is one of the leading causes of disability. We aimed to report the MDD-attributable prevalence, incidence and years lived with disability (YLDs) in the Middle East and North Africa (MENA) region from 1990 to 2019 by age, sex and socio-demographic index (SDI).

METHODS

Publicly available data on the burden of MDD were retrieved from the Global Burden of Disease (GBD) study 2019 for the 21 countries in MENA. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals.

RESULTS

In 2019, MDD had an age-standardised point prevalence of 3322.1 and an incidence rate of 4921.7 per 100,000 population in MENA. Furthermore, there were 4.1 million YLDs in 2019. However, there were no substantial changes in the MDD burden over the period 1990-2019. In 2019, Palestine had the highest burden of MDD. The highest prevalence, incidence and YLDs attributable to MDD were found in the 35-39 age group. In 2019, the YLD rate in MENA was higher than the global rate for almost all age groups. Furthermore, there was a broadly negative association between the YLD rate and SDI.

CONCLUSION

The study highlights the need to prevent the disorder using a multidisciplinary approach and for the provision of cost-effective treatments for those affected, in order to increase their quality of life.

Self-help mobile messaging intervention for depression among older adults in resource-limited settings: a randomized controlled trial

Scalable solutions to treat depression in older adults in low-resourced settings are urgently needed. The PRODIGITAL-D pragmatic, single-blind, two-arm, individually randomized controlled trial assessed the effectiveness of a mobile messaging psychosocial intervention in improving depressive symptomatology among older adults in socioeconomically deprived areas of Guarulhos, Brazil. Older adults (aged 60+ years) registered with 24 primary care clinics and identified with depressive symptomatology (9-item Patient Health Questionnaire (PHQ-9) scores ≥ 10) received the 6-week Viva Vida intervention based on psychoeducation and behavioral activation (n = 298) or a single message (n = 305). No health professional support was offered. The primary outcome was improvement from depressive symptomatology (PHQ-9 < 10) at 3 months. Of the 603 participants enrolled (mean age = 65.1 years; 451 (74.8%) women), 527 (87.4%) completed the follow-up assessment. In the intervention arm, 109 of 257 (42.4%) participants had an improved depressive symptomatology, compared with 87 of 270 (32.2%) participants in the control arm (adjusted odds ratio = 1.57; 95% confidence interval = 1.07-2.29; P = 0.019). No severe adverse events related to trial participation were observed. These results demonstrate the usefulness of a digital messaging psychosocial intervention in the short-term improvement from depressive symptomatology that can potentially be integrated into primary care programs for treating older adults with depression. Brazilian Registry of Clinical Trials registration: ReBEC ( RBR-4c94dtn ).

Do baseline participant characteristics impact the effectiveness of a mobile health intervention for depressive symptoms? A post-hoc subgroup analysis of the CONEMO trials

OBJECTIVE

To ascertain whether sociodemographic and health-related characteristics known from previous research to have a substantive impact on recovery from depression modified the effect of a digital intervention designed to improve depressive symptoms (CONEMO).

METHODS

The CONEMO study consisted of two randomized controlled trials, one conducted in Lima, Peru, and one in São Paulo, Brazil. As a secondary trial plan analysis, mixed logistic regression was used to explore interactions between the treatment arm and subgroups of interest defined by characteristics measured before randomization - suicidal ideation, race/color, age, gender, income, type of mobile phone, alcohol misuse, tobacco use, and diabetes/hypertension - in both trials. We estimated interaction effects between the treatment group and these subgroup factors for the secondary outcomes using linear mixed regression models.

RESULTS

Increased effects of the CONEMO intervention on the primary outcome (reduction of at least 50% in depressive symptom scores at 3-month follow-up) were observed among older and wealthier participants in the Lima trial (p = 0.030 and p = 0.001, respectively).

CONCLUSION

There was no evidence of such differential effects in São Paulo, and no evidence of impact of any other secondary outcomes in either trial.

CLINICAL TRIAL REGISTRATION

NCT02846662 (São Paulo, Brazil - SP), NCT03026426 (Lima, Peru - LI).

Meta-Analysis of Studies on the Effects of Digital Therapeutics

Digital therapeutics (DTx), novel treatment methods that have the potential to surpass traditional approaches such as pills, have received considerable research attention. Various efforts have been made to explore effective treatment methods that actively integrate DTx. This review investigates DTx treatment outcomes comprehensively through a meta-analysis. The analysis-a manual search of studies on "digital therapeutics"-includes DTx studies from January 2017 to October 2022. Hedges' g is used to quantify effect size for fifteen studies analyzed, encompassing eight control groups. Further, a quality assessment is performed using the Bias Risk Assessment Tool. The Hedges' g analysis results provide weighted average effect sizes across the eight control groups, revealing a substantial value of 0.91 (95% CI: 0.62 to 1.20); this signifies a moderate to large effect size. Further refinement, which excludes one study, yields an increased weighted average effect size of 1.13 (95% CI: 0.91 to 1.36). The quality assessment results consistently indicate a low risk of bias across studies. The meta-analysis results indicate that DTx can provide significant pivotal therapeutic impacts and offer a means to personalize treatment approaches and streamline the management of patients' treatment processes.

The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review

BACKGROUND

Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries.

METHODS

Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials.

RESULTS

Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor.

CONCLUSION

Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.

Efficacy of a WeChat-Based Multimodal Digital Transformation Management Model in New-Onset Mild to Moderate Hypertension: Randomized Clinical Trial

BACKGROUND

The advantages of multimodal digitally transformed mobile health management for patients diagnosed with mild to moderate hypertension are not yet established.

OBJECTIVE

We aim to evaluate the therapeutic benefits of a novel WeChat-based multimodal digital transforming management model in mobile health blood pressure (BP) management.

METHODS

This randomized controlled clinical trial included 175 individuals with new-onset mild to moderate hypertension who were admitted to our center between September and October 2022. The patients were randomly assigned to either the multimodal intervention group (n=88) or the usual care group (n=87). The primary composite outcome was home and office BP differences after 6 months. The major secondary outcomes were 6-month quality-of-life scores, including the self-rating anxiety scale, self-rating depression scale, and Pittsburgh Sleep Quality Index.

RESULTS

The mean home BP decreased from 151.74 (SD 8.02)/94.22 (SD 9.32) to 126.19 (SD 8.45)/82.28 (SD 9.26) mm Hg in the multimodal intervention group and from 150.78 (SD 7.87)/91.53 (SD 9.78) to 133.48 (SD 10.86)/84.45 (SD 9.19) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -8.25 mm Hg (95% CI -11.71 to -4.78 mm Hg; P<.001) and -4.85 mm Hg (95% CI -8.41 to -1.30 mm Hg; P=.008), respectively. The mean office BP decreased from 153.64 (SD 8.39)/93.56 (SD 8.45) to 127.81 (SD 8.04)/ 82.16 (SD 8.06) mm Hg in the multimodal intervention group and from 151.48 (SD 7.14)/(91.31 (SD 9.61) to 134.92 (SD 10.11)/85.09 (SD 8.26) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -9.27 mm Hg (95% CI -12.62 to -5.91 mm Hg; P<.001) and -5.18 mm Hg (95% CI -8.47 to -1.89 mm Hg; P=.002), respectively. From baseline to 6 months, home BP control <140/90 mm Hg was achieved in 64 (72.7%) patients in the multimodal intervention group and 46 (52.9%) patients in the usual care group (P=.007). Meanwhile, home BP control <130/80 mm Hg was achieved in 32 (36.4%) patients in the multimodal intervention group and 16 (18.4%) patients in the usual care group (P=.008). After 6 months, there were significant differences in the quality-of-life total and graded scores, including self-rating anxiety scale scores (P=.04), self-rating depression scale scores (P=.03), and Pittsburgh Sleep Quality Index scores (P<.001), in the multimodal intervention group compared with the usual care group.

CONCLUSIONS

The WeChat-based multimodal intervention model improved the BP control rates and lowered the BP levels more than the usual care approach. The multimodal digital transforming management model for hypertension represents an emerging medical practice that utilizes the individual's various risk factor profiles for primary care and personalized therapy decision-making in patients with hypertension.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200063550; https://www.chictr.org.cn/showproj.html?proj=175816.

Potential implications of mobile applications in oral cancer

ABSTRACT

The modern era has observed vast technological advancements with a definite impact on the health sector. There has been an upsurge in mobile applications (mApps) used for varied purposes. Many mApps are available that target different arenas in dentistry including a range of oral health issues, the most important being oral cancer. These mApps with specific algorithms have been used for risk assessment, screening and diagnosis of oral potentially malignant and malignant disorders. Other benefits include remote consultation, timely referral, treatment of the disease, self monitoring and adherence to medications. Therefore, this review is designed to appraise the utility of mobile apps in oral cancer. The systematic research of the literature was done to find relevant articles regarding the development and applications of mApps in oral cancer by using specific research engines. PubMed, Cochrane and Clinical Key databases were searched electronically, irrespective of date of publication, with an assortment of several independent terms. A total of 423 articles were accessed, and screened. After applying the definite inclusion and exclusion criteria, 9 articles were finally selected which highlighted the impact of mApps in oral cancer. It was concluded that the potential of mobile applications could be harnessed judiciously to improve the screening, diagnosis and treatment of oral cancer.

Artificial intelligence in mental healthcare: an overview and future perspectives

Artificial intelligence is disrupting the field of mental healthcare through applications in computational psychiatry, which leverages quantitative techniques to inform our understanding, detection, and treatment of mental illnesses. This paper provides an overview of artificial intelligence technologies in modern mental healthcare and surveys recent advances made by researchers, focusing on the nascent field of digital psychiatry. We also consider the ethical implications of artificial intelligence playing a greater role in mental healthcare.

Efficacy, Safety, and Evaluation Criteria of mHealth Interventions for Depression: Systematic Review

BACKGROUND

Depression is a significant public health issue that can lead to considerable disability and reduced quality of life. With the rise of technology, mobile health (mHealth) interventions, particularly smartphone apps, are emerging as a promising approach for addressing depression. However, the lack of standardized evaluation tools and evidence-based principles for these interventions remains a concern.

OBJECTIVE

In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of mHealth interventions for depression and identify the criteria and evaluation tools used for their assessment.

METHODS

A systematic review and meta-analysis of the literature was carried out following the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies that recruited adult patients exhibiting elevated depressive symptoms or those diagnosed with depressive disorders and aimed to assess the effectiveness or safety of mHealth interventions were eligible for consideration. The primary outcome of interest was the reduction of depressive symptoms, and only randomized controlled trials (RCTs) were included in the analysis. The risk of bias in the original RCTs was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials.

RESULTS

A total of 29 RCTs were included in the analysis after a comprehensive search of electronic databases and manual searches. The efficacy of mHealth interventions in reducing depressive symptoms was assessed using a random effects meta-analysis. In total, 20 RCTs had an unclear risk of bias and 9 were assessed as having a high risk of bias. The most common element in mHealth interventions was psychoeducation, followed by goal setting and gamification strategies. The meta-analysis revealed a significant effect for mHealth interventions in reducing depressive symptoms compared with nonactive control (Hedges g=-0.62, 95% CI -0.87 to -0.37, I2=87%). Hybrid interventions that combined mHealth with face-to-face sessions were found to be the most effective. Three studies compared mHealth interventions with active controls and reported overall positive results. Safety analyses showed that most studies did not report any study-related adverse events.

CONCLUSIONS

This review suggests that mHealth interventions can be effective in reducing depressive symptoms, with hybrid interventions achieving the best results. However, the high level of heterogeneity in the characteristics and components of mHealth interventions indicates the need for personalized approaches that consider individual differences, preferences, and needs. It is also important to prioritize evidence-based principles and standardized evaluation tools for mHealth interventions to ensure their efficacy and safety in the treatment of depression. Overall, the findings of this study support the use of mHealth interventions as a viable method for delivering mental health care.

TRIAL REGISTRATION

PROSPERO CRD42022304684; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=304684.

Digital interventions for common mental disorders in low- and middle-income countries: A systematic review and meta-analysis

Background

In low-resource settings, e-mental health may substantially increase access to evidence-based interventions for common mental disorders. We conducted a systematic literature search to identify randomised trials examining the effects of digital interventions with or without therapeutic guidance compared to control conditions in individuals with anxiety and/or depression symptoms in low- and middle-income countries (LMICs).

Methods

The main outcome was the reduction in symptoms at the post-test. Secondary outcomes included improvements in quality of life and longer-term effects (≥20 weeks post-randomisation). The effect size Hedges' g was calculated using the random effects model.

Results

A total of 21 studies (23 comparisons) with 5.296 participants were included. Digital interventions were more effective than controls in reducing symptoms of common mental disorders at the post-test (g = -0.89, 95% confidence interval [CI] -1.26 to -0.52, p < 0.001; NNT = 2.91). These significant effects were confirmed when examining depressive (g = -0.77, 95% CI -1.11; -0.44) and anxiety symptoms separately (g = -1.02, 95% CI -1.53 to -0.52) and across all other sensitivity analyses. Digital interventions also resulted in a small but significant effect in improving quality of life (g = 0.32, 95% CI 0.19 to 0.45) at the post-test. Over the longer term, the effects were smaller but remained significant for all examined outcomes. Heterogeneity was moderate to high in all analyses. Subgroup and meta-regression analyses did not result in significant outcomes in any of the examined variables (e.g., guided vs. unguided interventions).

Conclusions

Digital interventions, with or without guidance, may effectively bridge the gap between treatment supply and demand in LMICs. Nevertheless, more studies are needed to draw firm conclusions regarding the magnitude of the effects of digital interventions.

Health status and quality of life in comorbid physical multimorbidity and depression among adults aged ⩾50 years from low- and middle-income countries

BACKGROUND

Data on the clinical and functional significance of comorbid depression in physical multimorbidity in middle-aged and older adults and from low- and middle-income countries (LMICs) are lacking.

AIMS

This study aims to determine the association of comorbid depression in physical multimorbidity with health outcomes and quality of life among adults aged ⩾50 years from six LMICs.

METHODS

Cross-sectional, nationally representative data from the Study on Global Ageing and Adult Health were analyzed. DSM-IV Depression was based on past 12-month symptoms. Eleven chronic physical conditions were assessed. Health status was based on scales ranging from 0 (best) to 100 (worse). The quality of life (8-item WHO Quality of Life) scale ranged from 0 (worse) to 100 (best). Multivariable linear regression analyses were conducted.

RESULTS

Data on 34,129 individuals aged ⩾50 years [mean (SD) age 62.4 (16.0) years; 52.1% females] were analyzed. Among people with physical multimorbidity, having comorbid depression was associated with significantly worse health status in terms of sleep/energy (β = 14.71: 95% CI [12.23, 17.20]), self-care (13.23: [8.66, 17.82]), pain/discomfort (13.03: [9.59, 16.47]), mobility (11.06: [6.91, 15.21]), cognition (10.41: [7.31, 13.50]), perceived stress (8.35: [4.71, 11.99]), interpersonal activities (7.81: [3.71, 11.91]), and lower quality of life (-8.81: [-10.74, -6.88]).

CONCLUSIONS

Comorbid depression in physical multimorbidity was associated with lower quality of life and poorer scores in multiple domains of health status. Treatment of depression in people with physical multimorbidity may potentially lead to better clinical outcomes, but future studies are needed to determine the most effective intervention to address this comorbidity in LMICs.

A System for Rapidly Yet Rigorously Evaluating the Quality of Randomized Controlled Trials

ABSTRACT

This tutorial describes a system for rapidly yet rigorously assessing the quality of randomized controlled trials (RCTs). The system has 7 criteria, represented by the acronym "BIS FOES." The BIS FOES system directs readers to assess RCTs based on the following 7 criteria: the RCT's use (or not) of effective (1) Blinding; the RCT's use (or not) of (2) Intent-to-Treat Analysis; the RCT's (3) Size and other information reflecting the effectiveness of randomization; the amount of sample lost during (4) Follow-up; the (5) Outcomes examined by the RCT (specifically, the outcome measures used by the RCT), the (6) Effects reported (ie, the statistical and clinical significance of the RCT's primary, secondary, and safety findings), and any (7) Special Considerations (ie, additional strengths, limitations, or notable features of the RCT). The first 6 criteria are of basic importance to the assessment of every RCT, whereas the Special Considerations criteria allows the system to be expanded to include virtually any other important aspect of the RCT. This tutorial explains the importance of these criteria and how to assess them. This tutorial also describes how many BIS FOES criteria can be initially assessed from the RCT Abstract while also directing readers to specific locations in the RCT article where additional important information can be found. We hope that the BIS FOES system will help healthcare trainees, but also potentially clinicians, researchers, and the general public, rapidly and thoroughly assess RCTs.

Health-promoting behavior to enhance perceived meaning and control of life in chronic disease patients with role limitations and depressive symptoms: a network approach

The association between health-related role limitations in the mental and physical subdomains and clinical status (i.e., chronic disease and comorbid depressive symptoms) is mediated by health-promoting behaviors. To enhance health-promoting behaviors in adults with chronic disease, it is necessary to identify item-level associations among targets of health-related monitoring and management. Therefore, the current study used a network approach to examine associations among health-related role limitations, depressive symptoms, existential well-being, socioeconomic position, and health-promoting behavior in adults with chronic disease. A total of 535 adults (mean ± SD age = 62.9 ± 11.9 years; males, n = 231, females, n = 304) who were regularly visiting an outpatient clinic for chronic disease treatment participated in this cross-sectional study. Data on participant demographics, chronic disease diagnoses, socioeconomic status, health-related role limitations (12-item short form survey scores), depressive symptoms (patient health questionnaire-9 scores), existential well-being (scores for four items of the McGill quality of life questionnaire-Revised), and health-promoting behavior (Healthy Habits Questionnaire scores) were acquired. "Undirected regularized partial correlations" and "directional joint probability distributions" among these variables were calculated using a mixed graphical model (MGM) and directed acyclic graph (DAG). In the MGM, the most influential nodes were emotional well-being, feelings of failure, and health-related limitations affecting usual role and physical activities. According to both the MGM and DAG, the relationship between emotional well-being and feelings of failure mediated the relationships of health-related role limitations with concentration difficulty and suicidal ideation. A positive mindset was dependent on the probability distributions of suicidal ideation, controllability of life, and positive self-image. Both the meaning of life and a positive mindset had direct associations with proactive living. Specifically, proactive living was associated with a balanced diet, regular exercise, volunteering in the community, and nurturing intimacy in social interactions. The meaning and controllability of life in individuals with chronic diseases could mediate the relationships of health-promoting behavior with health-related limitations related to usual role activities, physical activities, and depressive symptoms. Thus, interventions targeting health-promoting behaviors should aim to enhance the meaning and controllability of life (as it pertains to limitations in usual role and physical activities), as well as promote proactive screening and timely psychiatric treatment of depressive symptoms including feelings of failure, concentration difficulties, and suicidal ideation.

Effectiveness of Digital Mental Health Tools to Reduce Depressive and Anxiety Symptoms in Low- and Middle-Income Countries: Systematic Review and Meta-analysis

BACKGROUND

Depression and anxiety contribute to an estimated 74.6 million years of life with disability, and 80% of this burden occurs in low- and middle-income countries (LMICs), where there is a large gap in care.

OBJECTIVE

We aimed to systematically synthesize available evidence and quantify the effectiveness of digital mental health interventions in reducing depression and anxiety in LMICs.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Embase, and Cochrane databases from the inception date to February 2022. We included randomized controlled trials conducted in LMICs that compared groups that received digital health interventions with controls (active control, treatment as usual, or no intervention) on depression or anxiety symptoms. Two reviewers independently extracted summary data reported in the papers and performed study quality assessments. The outcomes were postintervention measures of depression or anxiety symptoms (Hedges g). We calculated the pooled effect size weighted by inverse variance.

RESULTS

Among 11,196 retrieved records, we included 80 studies in the meta-analysis (12,070 participants n=6052, 50.14% in the intervention group and n=6018, 49.85% in the control group) and 96 studies in the systematic review. The pooled effect sizes were -0.61 (95% CI -0.78 to -0.44; n=67 comparisons) for depression and -0.73 (95% CI -0.93 to -0.53; n=65 comparisons) for anxiety, indicating that digital health intervention groups had lower postintervention depression and anxiety symptoms compared with controls. Although heterogeneity was considerable (I²=0.94 for depression and 0.95 for anxiety), we found notable sources of variability between the studies, including intervention content, depression or anxiety symptom severity, control type, and age. Grading of Recommendations, Assessments, Development, and Evaluation showed that the evidence quality was overall high.

CONCLUSIONS

Digital mental health tools are moderately to highly effective in reducing depression and anxiety symptoms in LMICs. Thus, they could be effective options to close the gap in depression and anxiety care in LMICs, where the usual mental health care is minimal.

TRIAL REGISTRATION

PROSPERO CRD42021289709; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=289709.

The mediating role of social support in the relationship between nurses' psychological capital and depression during public health emergencies in tertiary medical institutions

OBJECTIVE

To explore the effect of social support in nurses who have depression during public health emergencies in tertiary medical institutions.

METHODS

This retrospective analysis was conducted in Wuhan from July 2021 to December 2021. We distributed a self-made demographic questionnaire, Depression Scale (CES-D 10), Social Support Rating Scale (SSRS), and Psychological Capital Questionnaire (PCQ-24) through Questionnaire Star, and conducted a questionnaire survey with nurses in multiple tertiary medical institutions during the public health emergency in Wuhan. At the same time, a questionnaire survey was conducted with the general population during the public health emergency in Wuhan through the Self-made demographic questionnaire and Social Support Rating Scale (SSRS) issued by questionnaire star. In the end, 1052 valid questionnaires were obtained, including 526 valid questionnaires for nurses and 526 valid questionnaires for the general population. The social support scores of nurses and the general population were analyzed. The association between social support and nurse depression was analyzed by multiple linear regression. The asymptotic policy was used to examine social support as a potential mediator of the association between psychological capital and depressive symptoms.

RESULTS

There were no remarkable differences in age, marital condition, monthly revenue, professional title, occupational condition, smoking, and drinking among nurses (all P>0.05). The impersonal social support score, support utilization score, and total support score of nurses were lower than in the general Chinese population (P<0.05). Both lower subjective support scores and lower objective support scores of nurses were interrelated with major depressive symptoms (β=0.257, P<0.01; β=-0.314, P=0.026). Regression analysis with psychological capital as the independent variable and social support as the control variable showed that social support was negatively correlated with depressive symptoms (β=-0.205, P<0.01), social support had a positive moderating effect on the relationship between psychological capital and depressive symptoms (β=0.047, P<0.05). Self-efficacy was taken as an independent variable in regression analysis, after social support was added as the control variable, social support was negatively interrelated with depressive symptoms (β=-0.118, P<0.01), and self-efficacy was negatively interrelated with depressive symptoms (β=-0.251, P<0.01), the effect between social support and self-efficacy was interrelated with depressive symptoms (β=0.144, P<0.05). Hope was taken as an independent variable in regression analysis, after social support was added as the control variable, social support was negatively interrelated with depressive symptoms (β=-0.296, P<0.01), and hope was negatively correlated with depressive symptoms (β=-0.157, P<0.01). When the social support dimension was added, the effect of psychological capital on depressive symptoms increased (P<0.01).

CONCLUSIONS

Social support is a key external intervention factor to alleviate nurses' depressive symptoms, and psychological capital is a key internal positive psychological support resource to combat nurses' depressive symptoms. Social support can increase the influence of psychological capital on depressive symptoms.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Effectiveness of integrated care for older adults with depression and hypertension in rural China: A cluster randomized controlled trial

BACKGROUND

Effectiveness of integrated care management for common, comorbid physical and mental disorders has been insufficiently examined in low- and middle-income countries (LMICs). We tested hypotheses that older adults treated in rural Chinese primary care clinics with integrated care management of comorbid depression and hypertension (HTN) would show greater improvements in depression symptom severity and HTN control than those who received usual care.

METHODS AND FINDINGS

The study, registered with ClinicalTrials.gov as Identifier NCT01938963, was a cluster randomized controlled trial with 12-month follow-up conducted from January 1, 2014 through September 30, 2018, with analyses conducted in 2020 to 2021. Participants were residents of 218 rural villages located in 10 randomly selected townships of Zhejiang Province, China. Each village hosts 1 primary care clinic that serves all residents. Ten townships, each containing approximately 20 villages, were randomly selected to deliver either the Chinese Older Adult Collaborations in Health (COACH) intervention or enhanced care-as-usual (eCAU) to eligible village clinic patients. The COACH intervention consisted of algorithm-driven treatment of depression and HTN by village primary care doctors supported by village lay workers with telephone consultation from centrally located psychiatrists. Participants included clinic patients aged ≥60 years with a diagnosis of HTN and clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10). Of 2,899 eligible village residents, 2,365 (82%) agreed to participate. They had a mean age of 74.5 years, 67% were women, 55% had no schooling, 59% were married, and 20% lived alone. Observers, older adult participants, and their primary care providers (PCPs) were blinded to study hypotheses but not to group assignment. Primary outcomes were change in depression symptom severity as measured by the Hamilton Depression Rating Scale (HDRS) total score and the proportion with controlled HTN, defined as systolic blood pressure (BP) <130 mm Hg or diastolic BP <80 for participants with diabetes mellitus, coronary heart disease, or renal disease, and systolic BP <140 or diastolic BP <90 for all others. Analyses were conducted using generalized linear mixed effect models with intention to treat. Sixty-seven of 1,133 participants assigned to eCAU and 85 of 1,232 COACH participants were lost to follow-up over 12 months. Thirty-six participants died of natural causes, 22 in the COACH arm and 14 receiving eCAU. Forty COACH participants discontinued antidepressant medication due to side effects. Compared with participants who received eCAU, COACH participants showed greater reduction in depressive symptoms (Cohen's d [±SD] = -1.43 [-1.71, -1.15]; p < 0.001) and greater likelihood of achieving HTN control (odds ratio [OR] [95% CI] = 18.24 [8.40, 39.63]; p < 0.001). Limitations of the study include the inability to mask research assessors and participants to which condition a village was assigned, and lack of information about participants' adherence to recommendations for lifestyle and medication management of HTN and depression. Generalizability of the model to other regions of China or other LMICs may be limited.

CONCLUSIONS

The COACH model of integrated care management resulted in greater improvement in both depression symptom severity and HTN control among older adult residents of rural Chinese villages who had both conditions than did eCAU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01938963 https://clinicaltrials.gov/ct2/show/NCT01938963.

A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (PROACTIVE): a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial

BACKGROUND

There is an urgent need to reduce the burden of depression among older adults in low-income and middle-income countries (LMICs). We aimed to evaluate the efficacy of a task-shared, collaborative care psychosocial intervention for improving recovery from depression in older adults in Brazil.

METHODS

PROACTIVE was a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial conducted in Guarulhos, Brazil. Primary care clinics (clusters) were stratified by educational level and randomly allocated (1:1) to either enhanced usual care alone (control group) or to enhanced usual care plus the psychosocial intervention (intervention group), which involved a 17-week psychosocial programme based on psychoeducation and behavioural activation approaches. Individuals approached for the initial screening assessment were selected randomly from a list of individuals provided by the Health Secretariat of Guarulhos. Face-to-face baseline assessments were conducted among adults aged 60 years or older registered with one of the primary care clinics and identified with clinically significant depressive symptomatology (9-item Patient Health Questionnaire [PHQ-9] score ≥10). Community health workers delivered the programme through home sessions, supported by a dedicated tablet application. Masking of clinic staff and community health workers who delivered the intervention was not feasible; however, research assistants conducting recruitment and follow-up assessments were masked to trial allocation. The primary outcome was recovery from depression (PHQ-9 score <10) at 8-month follow-up. All primary analyses were performed by intention to treat with imputed data. Adaptations to the protocol were made due to the COVID-19 pandemic; recruitment and intervention home sessions were stopped, and follow-up assessments were conducted by telephone. This trial is registered with the ISRCTN registry, ISRCTN57805470.

FINDINGS

We identified 24 primary care clinics in Guarulhos that were willing to participate, of which 20 were randomly allocated to either the control group (ten [50%] clusters) or to the intervention group (ten [50%] clusters). The four remaining eligible clusters were kept as reserves. Between May 23, 2019, and Feb 21, 2020, 8146 individuals were assessed for eligibility, of whom 715 (8·8%) participants were recruited: 355 (49·7%) in the control group and 360 (50·3%) in the intervention group. 284 (80·0%) participants in the control group and 253 (70·3%) in the intervention group completed follow-up at 8 months. At 8-month follow-up, 158 (62·5%) participants in the intervention group showed recovery from depression (PHQ-9 score <10) compared with 125 (44·0%) in the control group (adjusted odds ratio 2·16 [95% CI 1·47-3·18]; p<0·0001). These findings were maintained in the complete case analysis. No adverse events related to the intervention were observed.

INTERPRETATION

Although the COVID-19 pandemic altered delivery of the intervention, the low-intensity psychosocial intervention delivered mainly by non-mental health professionals was highly efficacious in improving recovery from depression in older adults in Brazil. Our results support a low-resource intervention that could be useful to reduce the treatment gap for depression among older people in other LMICs.

FUNDING

São Paulo Research Foundation and Joint Global Health Trials (UK Department for International Development, Medical Research Council, and the Wellcome Trust).

Participants’ and Nurses’ Experiences With a Digital Intervention for Patients With Depressive Symptoms and Comorbid Hypertension or Diabetes in Peru: Qualitative Post–Randomized Controlled Trial Study

Background

Depression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users’ experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention.

Objective

This study aimed to explore the RCT participants’ experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them.

Methods

In 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews.

Results

Participants’ mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions’ text simple, extending the length of the intervention, and improving the training session with long explanations.

Conclusions

The findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants’ experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up.

Trial Registration

ClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426

Digital psychosocial intervention for depression among older adults in socioeconomically deprived areas in Brazil (PRODIGITAL-D): protocol for an individually randomised controlled trial

BACKGROUND

Depression in older adults is a challenge for health systems in most low- and middle-income countries (LMICs). Digital strategies for the management of this condition have been emerging worldwide, but the effectiveness of most of them is still unclear, especially among older adults. Thus, we aim to assess the effectiveness and cost-effectiveness of a digital psychosocial intervention to treat depression among older adults living in socioeconomically deprived areas in Guarulhos, Brazil.

METHODS

We will conduct a two-arm individually randomised controlled trial with 1:1 allocation ratio. Five hundred older adults aged 60 years or over with depressive symptomatology (9-item Patient Health Questionnaire score, PHQ-9 ≥ 10) and registered with one of the primary care clinics will be recruited to participate in this study. A 6-week digital psychosocial programme, named Viva Vida, will be delivered via WhatsApp to participants allocated to the intervention arm. The Viva Vida will send psychoeducational and behavioural activation audio and visual messages 4 days a week for 6 weeks. The control arm will only receive a single message with general information about depression. The primary outcome will be the proportion of depression recovery (PHQ-9 < 10) assessed at 3 months. The cost-effectiveness of the intervention will be assessed at 5 months. A detailed process evaluation will be used to explore context and important implementation outcomes.

DISCUSSION

This programme was based on the PROACTIVE intervention and designed to be delivered without face-to-face contact. If effective, it could be a simple treatment option, appropriate not only when social distancing is required, but it could also be included as a regular public health programme to initiate depression treatment, particularly in LMICs where resources allocated to mental health are scarce.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC), RBR-4c94dtn. Registered on 22 October 2021 (submitted on 03 August 2021).

Effects of internet-delivered behavioral activation on individuals with depressive symptoms: A systematic review and meta-analysis

BACKGROUND

Behavioral activation is recognized as a stand-alone, evidence-based therapy for depression. Internet-delivered psychological interventions are easy to access and low cost. Therefore, it is important to determine whether internet-delivered behavioral activation (iBA) is an effective option for improving depressive symptoms and other health-related outcomes. This systematic review and meta-analysis aimed to examine the effects of iBA on individuals with depressive symptoms.

METHODS

A comprehensive search was conducted within four databases to identify randomized controlled trials (RCTs) that involved iBA for people with depressive symptoms. The quality of the included RCTs was assessed using the Cochrane Collaboration risk-of-bias tool. Depending on I² statistic values for heterogeneity, either a random effects model or fixed effects model was used. Subgroup analyses were conducted according to the type of control groups.

RESULTS

Twenty RCTs met the eligibility criteria. Meta-analyses showed iBA had small to medium effects on depressive symptoms, anxiety, quality of life, functioning, perceived social support, and behavioral activation (BA) in people suffering from depressive symptoms at the immediate posttest and follow-up compared to control conditions.

LIMITATIONS

Relatively fewer studies were conducted to compare effects of iBA on outcomes other than depressive symptoms and BA process measures compared to comparison or control conditions. The overall risk of bias across the included RCTs was unclear.

CONCLUSIONS

Further high-quality studies are needed to verify the effects of iBA on varied health outcomes and BA process measures for individuals with depressive symptoms.

Multimorbidity

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system's stakeholders' perspectives

Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.

A Pilot Study of Brief, Stepped Behavioral Activation for Primary Care Patients with Depressive Symptoms

In a prior pilot study with primary care patients experiencing depressive symptoms, we observed positive outcomes for a behavioral activation protocol involving one visit and three calls. We aimed to pilot test a stepped version with flexible numbers of contacts. Fifteen primary care patients scoring 5–14 on the Patient Health Questionnaire-9 engaged in the three-tiered telephone-based intervention: (1) two calls (15–20 min each); (2) one 30–60 min encounter followed by two calls; and (3) one to six calls. Participants completed assessments at pre-treatment, post-treatment, and three months later. Participants improved from baseline to post-treatment and three months later for depressive symptoms, anxiety symptoms, and disability. Most participants (9 of 15) engaged in the first tier only, averaging less than one hour of contact, and reported benefits and high satisfaction. This intervention showed preliminary evidence of feasibility, acceptability, satisfaction, and benefits, warranting further pilot testing with primary care personnel.

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome

Background

Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process.

Methods

First, an initial treatment manual was conceptualized based on the team’s prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions).

Results

The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising.

Conclusions

BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment.

Trial registration

ClinicalTrials.gov Identifier: NCT04158219

Multimorbidity matters in low and middle-income countries

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru

Background

Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development.

Objective

This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both.

Methods

The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top–down and bottom–up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds.

Results

The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021.

Conclusions

We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries.

Trial Registration

ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426

International Registered Report Identifier (IRRID)

DERR1-10.2196/26164