Reducing depressive symptomatology with a smartphone app: study protocol for a randomized, placebo-controlled trial

Challenges With the Use of Digital Sham: Systematic Review and Recommendations

BACKGROUND

Digital therapeutics (DTx) are software-based products that prevent, manage, or treat a medical condition and are delivered through a smartphone app, web application, or wearable device. Clinical trials assessing DTx pose challenges, foremost among which is designing appropriate digital shams (or digital placebos), which should ideally mimic DTx (in terms of design, components, and duration of treatment) while omitting the active principle or component.

OBJECTIVE

The objective of our review was to understand how digital shams are being used in clinical research on DTx in neuroscience, which is the most common therapy area for DTx.

METHODS

We conducted a systematic literature review of DTx in neuroscience (including neurodevelopmental, neurodegenerative, and psychiatric disorders) with a focus on controlled clinical trials involving digital shams. Studies were identified from trial registries (ClinicalTrials.gov, the European Union Clinical Trials Register, and Trial Trove) and through structured searches in MEDLINE and Embase (both via the Embase website) and were limited to articles in English published from 2010 onward. These were supplemented by keyword-based searches in PubMed, Google, and Google Scholar and bibliographic searches. Studies assessing DTx in neuroscience (including neurodevelopmental, neurodegenerative, and psychiatric disorders) were included. Details related to the publication, DTx, comparator, patient population, and outcomes were extracted and analyzed.

RESULTS

Our search criteria identified 461 neuroscience studies involving 213 unique DTx. Most DTx were extended reality based (86/213, 40.4%) or mobile device based (56/213, 26.3%); 313 were comparative, of which 68 (21.7%) used shams. The most common therapeutic areas assessed in these studies were stroke (42/213, 19.7%), depression (32/213, 15%), and anxiety (24/213, 11.3%). The most common treatments were cognitive behavioral therapy or behavioral therapy (67/213, 32.4%), physical rehabilitation (60/213, 28.2%), and cognitive training (41/213, 19.2%). We identified the following important issues related to the use of digital shams in neuroscience: shams were not validated before use in studies, they varied widely in design (from being nearly identical to the DTx to using different software programs altogether), and the level of patient engagement or satisfaction with the sham and the impact of the sham on study outcomes were infrequently reported.

CONCLUSIONS

Digital shams are critical for the clinical development of DTx in neuroscience. Given the importance of sham controls in evaluating DTx efficacy, we provide recommendations on the key information that should be reported in a well-designed DTx trial and propose an algorithm to allow the correct interpretation of DTx study results. Sham-controlled studies should be routinely used in DTx trials-in early-phase studies-to help identify DTx active components and-in late-phase studies-to confirm the efficacy of DTx. The use of shams early in development will ensure that the appropriate sham control is used in later confirmatory trials.

Investigating the effectiveness of a smart mental health intervention (inMind) for stress reduction during pharmacological treatment for mild to moderate major depressive disorders: Study protocol for a randomized control trial

Background

Although psychological interventions for stress relief, such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR), have been developed, they have not been widely used in treating depression. The use of mobile devices can increase the possibility of actual use by integrating interventions and reducing the difficulty and cost burden of treatment application. This study aims to determine whether "inMind," an integrated mobile application for stress reduction, developed for the general population, decreases stress for patients with mild to moderate major depressive disorder during the pharmacological treatment period.

Methods

This study is a single-blind, multicenter, randomized, controlled crossover trial. The App, developed in Republic of Korea, provides integrated interventions for stress reduction for the general population through three modules based on mindfulness-based stress reduction, cognitive behavior therapy, and relaxation sounds that are known to be effective in stress reduction ("meditation," "cognitive approach," and "relaxation sounds," respectively). Participants (n = 215) recruited via medical practitioner referral will be randomized to an App first group (fAPP) or a wait list crossover group (dAPP). The study will be conducted over 8 weeks; the fAPP group will use the App for the first 4 weeks and the dAPP group for the next 4 weeks. During all study periods, participants will receive their usual pharmacological treatment. The Depression Anxiety Stress Scale-21 is the primary outcome measure. The analysis will employ repeated measurements using a mixed-model approach.

Discussion

The App can potentially be an important addition to depression treatment because of its applicability and the comprehensive nature of the interventions that covers diverse stress-relieving models.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT05312203, identifier 2021GR0585.

Efficacy of the Digital Therapeutic sinCephalea in the prophylaxis of migraine in patients with episodic migraine: study protocol for a digital, randomized, open-label, standard treatment controlled trial

BACKGROUND

The German government implemented the Digital Healthcare Act in order to bring Digital Therapeutics into standard medical care. This is one of the first regulatory pathways to reimbursement for Digital Therapeutics (DTx). The Digital Therapeutic sinCephalea is intended to act as a prophylactic treatment of migraine by reducing the migraine days. For this, sinCephalea determines personalized nutritional recommendations using continuous glucose monitoring (CGM) data and enables the patients to follow a personalized low-glycemic nutrition. Migraine is a headache disorder with the highest socioeconomic burden. Emerging evidence shows that CGM-based personalized nutritional recommendations are of prophylactic use in episodic migraine. However, prospective data are yet missing to demonstrate clinical effectiveness. This study is designed to fill this gap.

METHODS

Patients between 18 and 65 years of age with proven migraine and a minimal disease severity of 3 migraine days per month are included. After a 4-week baseline phase as a pre-study, patients are randomized to the DTx intervention or a waiting-list control. The objective of the study is to show differences between the intervention and control groups regarding the change of migraine symptoms and of effects of migraine on daily life.

DISCUSSION

To our knowledge, this is the first systematic clinical trial with a fully digital program to enable patients with migraine to follow a personalized low-glycemic nutrition in order to reduce their number of migraine days and the migraine-induced impact on daily life. Designing a clinical study using a digital intervention includes some obstacles, which are addressed in this study approach.

TRIAL REGISTRATION

German Registry of Clinical Studies (Deutsches Register Klinischer Studien) DRKS-ID DRKS00024657. Registered on March 8, 2021.

Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review

BACKGROUND

Smartphone app-based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions.

OBJECTIVE

The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach.

METHODS

We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded.

RESULTS

Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present.

CONCLUSIONS

Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis.

User Reviews of Depression App Features: Sentiment Analysis

Background

Mental health in general, and depression in particular, remain undertreated conditions. Mobile health (mHealth) apps offer tremendous potential to overcome the barriers to accessing mental health care and millions of depression apps have been installed and used. However, little is known about the effect of these apps on a potentially vulnerable user population and the emotional reactions that they generate, even though emotions are a key component of mental health. App reviews, spontaneously posted by the users on app stores, offer up-to-date insights into the experiences and emotions of this population and are increasingly decisive in influencing mHealth app adoption.

Objective

This study aims to investigate the emotional reactions of depression app users to different app features by systematically analyzing the sentiments expressed in app reviews.

Methods

We extracted 3261 user reviews of depression apps. The 61 corresponding apps were categorized by the features they offered (psychoeducation, medical assessment, therapeutic treatment, supportive resources, and entertainment). We then produced word clouds by features and analyzed the reviews using the Linguistic Inquiry Word Count 2015 (Pennebaker Conglomerates, Inc), a lexicon-based natural language analytical tool that analyzes the lexicons used and the valence of a text in 4 dimensions (authenticity, clout, analytic, and tone). We compared the language patterns associated with the different features of the underlying apps.

Results

The analysis highlighted significant differences in the sentiments expressed for the different features offered. Psychoeducation apps exhibited more clout but less authenticity (ie, personal disclosure). Medical assessment apps stood out for the strong negative emotions and the relatively negative ratings that they generated. Therapeutic treatment app features generated more positive emotions, even though user feedback tended to be less authentic but more analytical (ie, more factual). Supportive resources (connecting users to physical services and people) and entertainment apps also generated fewer negative emotions and less anxiety.

Conclusions

Developers should be careful in selecting the features they offer in their depression apps. Medical assessment features may be riskier as users receive potentially disturbing feedback on their condition and may react with strong negative emotions. In contrast, offering information, contacts, or even games may be safer starting points to engage people with depression at a distance. We highlight the necessity to differentiate how mHealth apps are assessed and vetted based on the features they offer. Methodologically, this study points to novel ways to investigate the impact of mHealth apps and app features on people with mental health issues. mHealth apps exist in a rapidly changing ecosystem that is driven by user satisfaction and adoption decisions. As such, user perceptions are essential and must be monitored to ensure adoption and avoid harm to a fragile population that may not benefit from traditional health care resources.

Smartphone application improves fertility treatment-related literacy in a large-scale virtual randomized controlled trial in Japan

People of reproductive age have unmet needs related to deficiencies in fertility literacy. Here, we aimed to investigate whether providing fertility-related information via a smartphone application could improve fertility treatment-related literacy in participants. We performed a randomized control-group pretest posttest study and recruited participants between June 18 and 25, 2020. Participants’ fertility treatment-related literacy was assessed with a pretest that comprised of 28 questions and participants were allocated with stratified randomization to either intervention group or control group. The intervention comprised a one-week smartphone application-based provision of information on fertility-related information and the control group received general information about women’s healthcare. Effectiveness of intervention was assessed using a posttest. A total of 4137 participants were administered the questionnaire and pretest, among which 3765 participants (91.0 %) responded and were randomly allocated into either the intervention group (N = 1883) or the control group (N = 1882). A significantly higher posttest mean score was observed for the intervention group compared to the control group (P = 0.0017). We also observed that posttest scores were significantly improved compared to pretest scores in both the intervention and control group (P < 0.001). When examining by specific test question, the proportion answering correctly increased at posttest compared to pretest for both intervention and control groups (P < 0.001). Furthermore, the intervention group showed a greater mean difference between posttest and pretest scores than the control group (P < 0.001). In conclusion, educational intervention using a smartphone application contributed to enhancing fertility treatment-related literacy.

Engagement with smartphone-delivered behavioural activation interventions: a study of the MoodMission smartphone application

BACKGROUND

Despite increased research interest in smartphone mental health applications (MHapps), few studies have examined user engagement and its determinants. MoodMission is a MHapp that targets low mood and anxiety via evidence-based techniques including behavioural activation (BA).

AIMS

The present study aimed to investigate (i) whether BA interventions delivered with visual psychoeducation had greater engagement than BA interventions delivered with solely written psychoeducation, (ii) whether BA interventions targeting mastery would have greater engagement than those targeting pleasure, and (iii) the relationship between level of engagement and MHapp benefit.

METHOD

Participants downloaded MoodMission and completed activities and within-app evaluations over a 30-day period. Data from 238 MoodMission users were analysed via multi-level modelling and linear regression.

RESULTS

The average number of app-based activities completed was 5.46 and the average self-reported engagement level was in the low to moderate range. As hypothesized, higher levels of engagement significantly predicted more positive activity appraisal.

CONCLUSIONS

The results suggest that BA technique beliefs are involved in MHapp engagement and future research examining user appraisals of techniques is warranted.

Is a Self-Monitoring App for Depression a Good Place for Additional Mental Health Information? Ecological Momentary Assessment of Mental Help Information Seeking among Smartphone Users

Mobile devices and apps offer promising opportunities for both patients and healthcare professionals, for example, to monitor and assess health status, and also to provide relevant health information. However, health information seeking within a mood-tracking app has not yet been addressed by research. To bridge this gap, the depression-related health information seeking of 6,675 users of a mood-tracking smartphone app was unobtrusively monitored. The study shows that self-monitored depressive symptoms are associated with higher depression-related information seeking within the app. Health information seeking was low in general, with differences across 12 depression-related topics (e.g., depressive thoughts, a depression diagnosis, or depression facts), but the findings are also promising as the smartphone app was shown to be a place where users can inform themselves about health topics related to the main purpose of the app. Smartphone apps would therefore seem to be a vehicle through which to provide additional health information about, for example, comorbidities, or pre- or post-interventions, even going beyond the original purposes of such mobile health (mHealth) monitoring apps.

Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses

BACKGROUND

Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied.

OBJECTIVE

This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far.

METHODS

Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up.

CONCLUSIONS

This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

BACKGROUND

Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective.

OBJECTIVE

This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features.

RESULTS

We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods.

CONCLUSIONS

There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders.

Methodological Challenges in Randomized Controlled Trials on Smartphone-Based Treatment in Psychiatry: Systematic Review

BACKGROUND

Smartphone-based technology is developing at high speed, and many apps offer potential new ways of monitoring and treating a range of psychiatric disorders and symptoms. However, the effects of most available apps have not been scientifically investigated. Within medicine, randomized controlled trials (RCTs) are the standard method for providing the evidence of effects. However, their rigidity and long time frame may contrast with the field of information technology research. Therefore, a systematic review of methodological challenges in designing and conducting RCTs within mobile health is needed.

OBJECTIVE

This systematic review aimed to (1) identify and describe RCTs investigating the effect of smartphone-based treatment in adult patients with a psychiatric diagnosis, (2) discuss methodological challenges in designing and conducting individual trials, and (3) suggest recommendations for future trials.

METHODS

A systematic search in English was conducted in PubMed, PsycINFO, and EMBASE up to August 12, 2019. The search terms were (1) psychiatric disorders in broad term and for specific disorders AND (2) smartphone or app AND (3) RCT. The Consolidated Standards of Reporting Trials electronic health guidelines were used as a template for data extraction. The focus was on trial design, method, and reporting. Only trials having sufficient information on diagnosis and acceptable diagnostic procedures, having a smartphone as a central part of treatment, and using an RCT design were included.

RESULTS

A total of 27 trials comprising 3312 patients within a range of psychiatric diagnoses were included. Among them, 2 trials were concerning drug or alcohol abuse, 3 psychosis, 10 affective disorders, 9 anxiety and posttraumatic stress disorder, 1 eating disorder, and 1 attention-deficit/hyperactivity disorder. In addition, 1 trial used a cross-diagnostic design, 7 trials included patients with a clinical diagnosis that was subsequently assessed and validated by the researchers, and 11 trials had a sample size above 100. Generally, large between-trial heterogeneity and multiple approaches to patient recruitment, diagnostic procedures, trial design, comparator, outcome measures, and analyses were identified. Only 5 trials published a trial protocol. Furthermore, 1 trial provided information regarding technological updates, and only 18 trials reported on the conflicts of interest. No trial addressed the ethical aspects of using smartphones in treatment.

CONCLUSIONS

This first systematic review of the methodological challenges in designing and conducting RCTs investigating smartphone-based treatment in psychiatric patients suggests an increasing number of trials but with a lower quality compared with classic medical RCTs. Heterogeneity and methodological issues in individual trials limit the evidence. Methodological recommendations are presented.

Optimizing Expectations via Mobile Apps: A New Approach for Examining and Enhancing Placebo Effects

There is growing interest in interventions that enhance placebo responses in clinical practice, given the possibility that this would lead to better patient health and more effective therapy outcomes. Previous studies suggest that placebo effects can be maximized by optimizing patients' outcome expectations. However, expectancy interventions are difficult to validate because of methodological challenges, such as reliable blinding of the clinician providing the intervention. Here we propose a novel approach using mobile apps that can provide highly standardized expectancy interventions in a blinded manner, while at the same time assessing data in everyday life using experience sampling methodology (e.g., symptom severity, expectations) and data from smartphone sensors. Methodological advantages include: 1) full standardization; 2) reliable blinding and randomization; 3) disentangling expectation effects from other factors associated with face-to-face interventions; 4) assessing short-term (days), long-term (months), and cumulative effects of expectancy interventions; and 5) investigating possible mechanisms of change. Randomization and expectancy interventions can be realized by the app (e.g., after the clinic/lab visit). As a result, studies can be blinded without the possibility for the clinician to influence study outcomes. Possible app-based expectancy interventions include, for example, verbal suggestions and imagery exercises, although a large number of possible interventions (e.g., hypnosis) could be evaluated using this innovative approach.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of the breadth of research studies published from April 2017 to April 2018 on mobile-based interventions for mental health, with a special emphasis on smartphone-based interventions.

RECENT FINDINGS

Several studies during the review period have described the process of applying user-centred design in the development of mental health apps and novel approaches to enhance user-engagement. Studies on consumer perspectives indicate largely positive findings about open-ness to utilize mental health apps. There is a scarcity of similar studies on health providers. Efficacy studies have provided evidence for apps for a variety of psychiatric disorders. There are fewer studies on preventive and promotive interventions. Although a plethora of mental health apps is available for public, most have not undergone scientific evaluation. Many well researched apps are not accessible to public. The potential of smartphone technology in enhancing healthcare service delivery in low-resource settings has also been examined in a few studies.

SUMMARY

Evidence for acceptability, feasibility and efficacy of mobile-based mental health interventions for facilitating recovery is on the rise. More research is needed on implementation and integration of these interventions in diverse real-world clinical and community contexts.

Development and Pilot Testing of an Internet-Based Self-Help Intervention for Depression for Indian Users

There is a dearth of published research on uptake and utility of mental health apps in India, despite a rising global trend in the application of technology in the field of mental health. We describe the development and pilot testing of a self-help intervention for depression, PUSH-D (Practice and Use Self-Help for Depression) for urban Indians. This guided self-help app, with essential and optional zone sections, was developed to provide a comprehensive coverage of therapeutic strategies drawn from cognitive behavior therapy, interpersonal therapy, supportive psychotherapy, and positive psychology. Pilot testing was carried out using a single group pre-, post- and follow-up design in 78 eligible participants. Participants were typically young adults with major depression or dysthymia and significant impairment in functioning. Almost two-thirds of the participants had never sought professional mental health help. Significant reductions in depression and improvement in the functioning and well-being were notedon standardized measures in participants completing all 10 essential zone sections. These gains were maintained at follow-up. The results were similar for partial completers, who completed fiveout of the 10 essential sections. PUSH-D is one of the first indigenously developed self-help apps for depression and it shows promise in reducing the treatment gap for depression in India.

The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (ICBT) in the treatment of psychiatric disorders. ICBT’s effectiveness has been investigated in treating and managing conditions like depression, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. ICBT’s role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. Furthermore, this study elaborates on its cost-effectiveness and its impact in rural areas. We conducted a thorough literature search using PubMed and Google Scholar with no restrictions on the date. ICBT's role in treating and controlling psychiatric illnesses has been established in the literature. From the data compiled, we conclude that ICBT is useful in treating mental health and medical illnesses with psychiatric comorbidities. It has also been found to be cost-effective for patients and society. ICBT is a potential tool emerging with modern day technological advancements and is useful in rural and urban settings, across various languages and cultures, and on a global scale. Larger randomized control trials on its use in clinical practice and in reaching rural populations are bound to shed more light on the effectiveness of this tool along with spreading awareness among physician and patient communities.