Digital interventions to improve mental health and lifestyle behaviors for primary care patients

Background: Common mental health problems (CMHPs) give rise to large costs and much unnecessary suffering. Most patients with these problems are found in primary care. Positive effects of psychological treatment are well documented, but primary care is failing in the implementation of evidence-based treatments.

Aims: The overarching aim of this thesis was to contribute to the comprehension of how digital and transdiagnostic interventions can enhance accessibility to interventions to improve lifestyle behaviors and mental health in primary care settings. Study I aimed to explore two aspects: a) healthcare clinicians' perceptions and experiences of working with lifestyle behaviors, and b) their preferences and requirements for adopting a more systematic approach in the future. Study II aimed to assess the feasibility of a digital lifestyle behavior intervention for patients seeking help for CMHPs. Participants were offered a digital support giving feedback on their lifestyle behaviors and offering guidance on making lifestyle changes. Study III aimed to investigate the feasibility of a transdiagnostic video-based course designed for patients seeking psychological treatment for CMHPs in primary care. Study IV sought to elucidate the documented effects of transdiagnostic digital interventions for patients with depression and/or anxiety in a systematic review and meta-analysis.

Methods: In Study I, semi-structured focus group interviews were carried out at 10 primary care clinics in Sweden. Participants were health care professionals from different professions (N=46). Data was analyzed using a phenomenological-hermeneutic model. Study II was a pilot study with an embedded randomized controlled trial (RCT; N=152), and also measured feasibility outcomes such as the inclusion rate, proportion of unhealthy lifestyle behaviors in the sample, adherence to the protocol and missing data. Participants in both groups also completed depression and anxiety self-ratings at baseline and 10 weeks later. Study III employed a single-group prospective cohort design (N=91). Main feasibility measures included participant satisfaction, attendance rates, the percentage of participants in need of additional psychological intervention when the course was finished, and proportion of clinically significant improvement. Study IV was a systematic review and meta-analysis of RCTs investigating internet-delivered transdiagnostic treatments for individuals with clinical depression, anxiety, or both. All age groups, all treatment schools and both guided and unguided interventions were included.

Results: In Study I, two major themes emerged: 1) the need for structured professional practice and 2) deficient professional practice as an obstacle for implementation of healthy lifestyle promotion. In Study II, the recruitment rate was initially low but increased after further involvement of the clinicians and an increased frequency of contact with the patients. The 10-week missing data rate was 33/152 (22%). Fewer than half of the participants (38%, n=58/152) had at least one type of high-risk behavior at baseline. Psychiatric symptoms were moderate at baseline and declined in both groups after 10 weeks (d=0.57-0.75), but there were no between-group differences. In Study III, the mean score on the Client Satisfaction Questionnaire-8 was 21.8 (SD=4.0, 9-32, n= 86), just below the a priori target of 22. On average, the participants attended 5.0/6 sessions (SD=1.6, range 0-6, n=91). Almost half of the sample (46%; 37/81) reported not needing further psychological treatment after the course. Of patients with elevated anxiety symptoms, 59% (27/46) showed clinically significant improvement. The corresponding improvement for depression was 48% (22/46). The missing data rate at post treatment was 5/91 (5%). No serious adverse events were reported. In Study IV, 57 trials with 21795 participants were included. Large within-group reductions were seen for working age adults in symptoms of depression (g=0.90; 95% CI 0.81-0.99) and anxiety (g=0.87; 95% CI 0.78-0.96). Compared to treatment-as-usual and waitlist controls (WLC’s), the added effects were moderate (depression: g = 0.52; 95% CI 0.42-0.63; anxiety: g=0.45; 95% CI 0.34-0.56). Compared to attention/engagement controls, the added effects were small (depression: g=0.30; 95% CI 0.07-0.53; anxiety: g=0.21; 95% CI 0.01-0.42). Heterogeneity was substantial. Two trials concerned adolescents and reported mixed results. One trial concerned older adults and reported promising results. Three trials reported having been conducted in a primary care setting.

Conclusions: Study I showed that it was crucial to explicitly define digital interventions as complements to face-to-face meetings in primary care, in an effort to promote evidence-based practice and lighten the burden of health professionals. In Study II, recruitment routines seemed to be decisive for reaching as many patients as possible. The relatively low rate of unhealthy lifestyle behaviors and small effect sizes suggest that the Health Profile intervention evaluated may only suit patients at risk. In Study III, it appeared feasible to deliver an early access mental health course through video in a primary care setting, indicating that it would be of interest to evaluate course effects in a future RCT. In Study IV, internet-delivered transdiagnostic treatments for both depression and anxiety showed added effects that were small to moderate, varying by control condition. Research is needed regarding routine care and age groups other than working-age adults.

List of scientific papers

I. Berman, A. H., Kolaas, K., Petersén, E., Bendtsen, P., Hedman, E., Linderoth, C., Müssener, U., Sinadinovic, K., Spak, F., Gremyr, I. & Thurang, A. (2018). Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care. BMC Family Practice. 19:139.
https://doi.org/10.1186/s12875-018-0829-z

II. Kolaas, K., Axelsson, E., Hedman-Lagerlöf, E. & Berman, A.H. (2023). Digital self-help for lifestyle behavior changes among primary care patients with mental health problems: A pragmatic randomized pilot trial. Primary Health Care Research & Development. [Accepted]
https://doi.org/10.1017/S146342362300049X

III. Kolaas, K., Berman, A. H., Hedman-Lagerlöf, E., Zakrevska, A., Epstein, M., af Winklerfelt Hammarberg, S., & Axelsson, E. (2023). Feasibility of a video-delivered mental health course for primary care patients: a single-group prospective cohort study. BMC Primary Care. 24(1), 1-11.
https://doi.org/10.1186/s12875-023-01989-8

IV. Kolaas, K., Berman, A.H., Hedman-Lagerlöf, E., Lindsäter E., Hybelius J., & Axelsson, E. Internet-delivered transdiagnostic psychological treatments for individuals with either primary depression, primary anxiety, or both: a systematic review and meta-analysis of randomized controlled trials. [Submitted]