Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study.

BACKGROUND: Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context. OBJECTIVE: The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching. METHODS: In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated. RESULTS: Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (ß=-1.2; P<.001), generalized anxiety (ß=-1.1; P<.001), and social anxiety (ß=-2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=-2.1; P=.03). CONCLUSIONS: This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program.

Comparison of DASS-21, PHQ-8, and GAD-7 in a virtual behavioral health care setting.

BACKGROUND: Validated depression and anxiety symptom screeners are commonly used in clinical settings. How results from different brief depression and anxiety symptom assessment tools compare to each other is not well established, especially in real world healthcare settings. This study aimed to compare the Depression Anxiety Stress Scales 21 Depression scale (DASS-Depression) and Anxiety (DASS-Anxiety) scale to the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7 (GAD-7) respectively, in a real-world virtual behavioral healthcare setting. METHODS: This was a retrospective comparison study of clinical data from a population of adults who completed a consultation via telephone or secure video with a licensed therapist as part of a standardized, evidence-based, virtual behavioral therapy program for individuals with comorbid medical and behavioral health conditions. The joint distributions and correlations between scores yielded by each depression and anxiety scale were assessed using descriptive and Spearman correlation statistics. RESULTS: The DASS-Depression and PHQ-8 were highly correlated (r = .71; p=<.001); the DASS-Anxiety and GAD-7 correlation was also high (r = .61; p=<.001). The PHQ-8 categorized more individuals as having above-threshold depression scores versus the DASS-Depression (71.5% vs. 43.5%; p < .001). The GAD-7 categorized more individuals as having above-threshold anxiety scores versus the DASS-Anxiety (59.0% vs. 45.0%; p < .001). LIMITATIONS: This study compared results yielded by validated screeners, precluding conclusions related to the validity of screener results. CONCLUSIONS: The DASS-Depression and PHQ-8 and the DASS-Anxiety and GAD-7 similarly ranked symptom severity. The PHQ-8 and GAD-7 were more likely than the DASS-21 Depression or Anxiety scales to classify individuals as having above-threshold symptom severity.

Clinical and Workplace Outcomes From a Virtually Delivered Cognitive Behavioral Therapy Program for Pain.

OBJECTIVES: To evaluate clinical and workplace outcomes from an evidence-based virtual behavioral therapy program for individuals with pain and behavioral health issues. METHODS: This was a retrospective de-identified data analysis among a cohort of 1,086 participants enrolled in a standardized, evidence-based telebehavioral therapy program between September 1, 2016, and August 31, 2017 (mean age 53 ± 11.5 years; 29% male). The program was delivered over approximately 8 weeks by licensed therapists and behavior coaches by telephone or video, and tailored to the pain management and behavioral health goals of each participant. Structured measurements were documented in the electronic clinical record, including demographics, comorbidities, pain severity (Pain Intensity, Enjoyment of Life, General Activity tool), behavioral health symptoms (Depression, Anxiety and Stress Scale short form), and productivity (Work Productivity and Activity Impairment survey). RESULTS: At baseline, participants had high average pain severity (5.8/10 points), high frequencies of behavioral health symptoms (68%), and activity impairment (90%); absenteeism (34%) and presenteeism (75%) were observed among employed individuals. Pain severity and pain interference improved by 17% and 27%, respectively, over 8 weeks (P < 0.0001). Reductions in depression, anxiety, and stress symptoms were significant and associated with reductions in pain interference (P < 0.0001). Absenteeism, presenteeism, and activity impairment ratings each improved by more than 25% (P < 0.0001). DISCUSSION: Participants in a virtually delivered behavioral therapy program for pain experienced significant improvements in pain intensity, pain interference, behavioral health symptoms, and work productivity.

Fertility and Birth Outcomes in Women With Epilepsy Seeking Pregnancy.

Importance: Prior studies report lower birth rates for women with epilepsy (WWE) but have been unable to differentiate between biological and social contributions. To our knowledge, we do not have data to inform WWE seeking pregnancy if their likelihood of achieving pregnancy is biologically reduced compared with their peers. Objective: To determine if WWE without a prior diagnosis of infertility or related disorders are as likely to achieve pregnancy within 12 months as their peers without epilepsy. Design, Setting, and Participants: The Women With Epilepsy: Pregnancy Outcomes and Deliveries study is an observational cohort study comparing fertility in WWE with fertility in control women (CW) without epilepsy. Participants were enrolled at 4 academic medical centers and observed up to 21 months from November 2010 to May 2015. Women seeking pregnancy aged 18 to 40 years were enrolled within 6 months of discontinuing contraception. Exclusion criteria included tobacco use and a prior diagnosis of infertility or disorders that lower fertility. Eighteen WWE and 47 CW declined the study, and 40 WWE and 170 CW did not meet study criteria. The Women With Epilepsy: Pregnancy Outcomes and Deliveries electronic diary app was used to capture data on medications, seizures, sexual activity, and menses. Data were analyzed from November 2015 to June 2017. Main Outcomes and Measures: The primary outcome was proportion of women who achieved pregnancy within 12 months after enrollment. Secondary outcomes were time to pregnancy using a proportional hazard model, pregnancy outcomes, sexual activity, ovulatory rates, and analysis of epilepsy factors in WWE. All outcomes were planned prior to data collection except for time to pregnancy. Results: Of the 197 women included in the study, 142 (72.1%) were white, and the mean (SD) age was 31.9 (3.5) years among the 89 WWE and 31.1 (4.2) among the 108 CW. Among 89 WWE, 54 (60.7%) achieved pregnancy vs 65 (60.2%) among 108 CW. Median time to pregnancy was no different between the groups after controlling for key covariates (WWE: median, 6.0 months; 95% CI, 3.8-10.1; CW: median, 9.0 months; 95% CI, 6.5-11.2; P = .30). Sexual activity and ovulatory rates were similar in WWE and CW. Forty-four of 54 pregnancies (81.5%) in WWE and 53 of 65 pregnancies (81.5%) in CW resulted in live births. No epilepsy factors were significant. Conclusions and Relevance: Women with epilepsy seeking pregnancy without prior known infertility or related disorders have similar likelihood of achieving pregnancy, time to pregnancy, and live birth rates compared with their peers without epilepsy.

A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement.

BACKGROUND: Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-day mortality and composite morbidity in patients undergoing aortic valve replacement and (2) compare the predictive ability of 3 frailty indices in this population. METHODS: This study was a retrospective cohort study of 3088 patients 65 years old and older undergoing aortic valve replacement surgery (based on current procedure terminology codes) between the years 2006 and 2012 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index, risk analysis index, and Ganapathi indices. Outcomes measured were 30-day mortality and composite morbidity (myocardial infarction, cardiac arrest, pulmonary embolism, pneumonia, reintubation, renal insufficiency, coma >24 hours, urinary tract infections, sepsis, deep vein thrombosis, deep wound surgical site infection, superficial site infection, and reoperation). RESULTS: Frailty was a better predictor of mortality than morbidity, and it was not markedly different among any of the 3 indices. Frailty was associated with an increased risk of 30-day mortality and longer lengths of stay. CONCLUSIONS: Frailty can predict mortality in patients undergoing aortic valve replacement. Choice of frailty index does not make a difference in this patient population.

Propofol Use in the Elderly Population: Prevalence of Overdose and Association With 30-Day Mortality.

PURPOSE: Geriatric patients are more sensitive to the anesthetic effects of propofol and its adverse effects, such as hypotension, than is the general population; thus, a reduced dose (1-1.5 mg/kg) is recommended for the induction of anesthesia. The extent to which clinicians follow established dosing guidelines has not been well described. Therefore, we investigated the prevalence of propofol overdose in the elderly population to determine whether propofol overdose occurs and is associated with increased hypotension and 30-day mortality. METHODS: In this retrospective study in patients who received propofol for the induction of general anesthesia, data on demographic characteristics, preoperative medications, intraoperative management, and 30-day mortality were collected. The dose of propofol used for the induction of anesthesia and the median blood pressure in the pre- and immediate postinduction periods were determined. Hypotension was defined as either: (1) a decrease in mean arterial pressure (MAP) of >40% concurrent with a MAP of <70 mm Hg; or (2) a MAP of <60 mm Hg. FINDINGS: A total of 17,540 patients were included in the analysis; 4033 (23.0%) were aged >65 years. The median (interquartile range) propofol dose in the group aged >65 years was 1.8 (1.4-2.2) mg/kg, above the recommended dose, in comparison to 2.2 (1.9-2.5) mg/kg in younger patients. On multivariate analysis, increased propofol dose was associated with increased postinduction hypotension, especially in patients over 70 years of age, but not 30-day mortality. IMPLICATIONS: Older patients received greater-than-recommended doses of propofol for induction, which may have led to significant dose-dependent hypotension. Despite this finding, the dose of propofol for induction was not independently associated with a greater 30-day mortality rate. More education regarding geriatric concerns is needed for encouraging anesthesiologists to tailor the plan for anesthesia in geriatric patients. However, overall postsurgical mortality is a function of preoperative risk and type surgical procedure.

Continuity in the provider of home-based physical therapy services and its implications for outcomes of patients.

BACKGROUND: A growing body of research suggests that greater continuity of health care is positively associated with improved outcomes of patients. However, few studies have examined this issue in the context of physical therapy. OBJECTIVE: The purpose of this study was to evaluate whether the level of continuity in the provider (provider continuity) of physical therapy services was related to outcomes in a population of patients receiving home health care. DESIGN: This was a retrospective observational study. METHODS: Clinical and administrative records were retrieved for a population of adult patients receiving physical therapy services from a large, urban, not-for-profit certified home health care agency in 2009. Descriptive and multivariable analyses were used to examine how the level of provider continuity, calculated by use of a formula that models dispersion in contact between the patient and the providers of physical therapy services, varied across characteristics and outcomes of patients. RESULTS: Logistic regression analyses indicated that patients with lower levels of provider continuity had significantly higher odds of hospitalization (odds ratio [OR]=2.06, 95% confidence interval [CI]=1.90-2.23) and lower odds of improvements in the number of activity limitations (OR=0.85, 95% CI=0.80-0.92) and in the severity of activity limitations (OR=0.85, 95% CI=0.78-0.93) between the beginning and the end of the home health care episode. LIMITATIONS: Baseline clinical characteristics associated with continuity of care suggest some level of indication bias. Outcome measures for activities of daily living were limited to patients who were not hospitalized during their home health stay. CONCLUSIONS: These findings build upon research suggesting that continuity in the patient-provider relationship is an important determinant of outcomes of patients.

Activation among chronically ill older adults with complex medical needs: challenges to supporting effective self-management.

Successful chronic care ideally involves patient engagement, but little is known about chronically ill older adults' ability to self-manage their health. This study examines activation among hypertensive patients older than 65 years. Almost 60% of participants scored in the bottom half of the activation scale; only 8% scored at the highest level. Higher activation was associated with higher self-ratings of health, health literacy, and receipt of patient-centered care, shorter lengths of stay, and lower depression and hearing impairment levels. Effective self-management support for chronically ill elders will likely require varied strategies and may need to address depression, health literacy, and/or hearing impairments.

Differences among U.S. states in estimating the number of people living with HIV/AIDS: impact on allocation of federal Ryan White funding.

OBJECTIVE: We assessed the impact of differing laboratory reporting scenarios on the completeness of estimates of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA) in the U.S., which are used to guide allocation of federal Ryan White funds. METHODS: We conducted a four-year simulation study using clinical and laboratory data on 1,337 HIV-positive women, including 477 (36%) who did not have AIDS at baseline. We estimated the completeness of HIV (non-AIDS) case ascertainment for three laboratory reporting scenarios: CD4 < 200 cells/microL and detectable viral load (Scenario A); CD4 < 500 cells/microL and no viral load reporting (Scenario B); and CD4 < 500 cells/microL and detectable viral load (Scenario C). RESULTS: Each scenario resulted in an increasing proportion of HIV (non-AIDS) cases being ascertained over time, with Scenario C yielding the highest by Year 4 (Year 1: 69.0%, Year 4: 88.1%), followed by Scenario A (Year 1: 63.3%, Year 4: 84.5%), and Scenario B (Year 1: 43.0%, Year 4: 67.7%). Overall completeness of PLWHA ascertainment after four years was highest for Scenario C (95.8%), followed by Scenario A (94.5%), and Scenario B (88.5%). CONCLUSIONS: Differences in laboratory reporting regulations lead to substantial variations in the completeness of PLWHA estimates, and may penalize jurisdictions that are most successful at treating HIV/AIDS patients or those with weak or incomplete HIV/AIDS surveillance systems.

Self-reported moisture or mildew in the homes of Head Start children with asthma is associated with greater asthma morbidity.

This study used results from a cross-sectional survey of parents of 3- to 5-year-old children with asthma to assess the frequency of self-reported home environmental conditions that could contribute to worsening asthma and examined the relationship between these factors and the child's asthma morbidity. Participants were 149 parents drawn from the two largest agencies that provide subsidized preschool childcare services in East and Central Harlem, inner-city communities with high prevalence of asthma. The sample represented 77% of eligibles determined by a validated case-identification instrument. Data were collected on demographics, symptoms, medication use, Emergency Department visits and hospitalization, and environmental conditions in the home. One or more of these home environmental conditions were reported by 92% of participants. Controlling for other environmental conditions and demographics, associations were found between self-reported presence of moisture or mildew on ceilings, walls, or windows and higher frequency of hospitalizations for breathing-related problems (OR = 3.31; 95% CI 1.62-6.75), frequent episodes of wheezing (OR = 3.25; 95% CI 1.8-6.0), and higher frequency of night symptoms due to asthma (OR = 2.19; 95% CI 1.4-3.41). Having a carpet or rug in the child's bedroom or the living room was also associated with hospitalizations (OR = 3.23; 95% CI 1.53-6.8), and male gender was marginally associated with the frequency of night symptoms (OR = 1.51; 95% CI .95-2.4). Asthma is prevalent in the Head Start population, and exposure to home environmental conditions that may worsen asthma is common in the socially disadvantaged populations served by Head Start programs.