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Araya R, Menezes PR, Claro HG, Brandt LR, Daley KL, Quayle J, Diez-Canseco F, Peters TJ, Vera Cruz D, Toyama M, Aschar S, Hidalgo-Padilla L, Martins H, Cavero V, Rocha T, Scotton G, de Almeida Lopes IF, Begale M, Mohr DC, Miranda JJ. Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials. JAMA 2021; 325:1852-1862. [PMID: 33974019 PMCID: PMC8114139 DOI: 10.1001/jama.2021.4348] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
Importance Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).
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Affiliation(s)
- Ricardo Araya
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Paulo Rossi Menezes
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Heloísa Garcia Claro
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- School of Nursing, Universidade Estadual de Campinas, Campinas, Brazil
| | - Lena R. Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Kate L. Daley
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Julieta Quayle
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Tim J. Peters
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Daniela Vera Cruz
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Suzana Aschar
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Liliana Hidalgo-Padilla
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hellen Martins
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Victoria Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Thais Rocha
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - George Scotton
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Ivan F. de Almeida Lopes
- Federal University of ABC, Engineering, Modeling and Applied Social Sciences Center (CECS), Santo André, Brazil
| | - Mark Begale
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David C. Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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