Mobile Health Apps for Depression Focus on Mood

Mobile Health Apps for Depression Focus on Mood. Fx Raymond W. Lam, MD, FRCPC Professor and Associate Head for Research, Department of Psychiatry, University of British Columbia; Director, Mood Disorders Centre, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC; Executive Chair, Canadian Network for Mood and Anxiety Treatments (CANMAT). r. lam@ubc. ca

Disclosure Statement 2012 -2014 Dr. Raymond Lam, MD, FRCPC Ad hoc Consulting/Advisory Astra. Zeneca, Bristol Myers Squibb, CANMAT, Eli Lilly, Lundbeck, Mochida, Pfizer, Takeda Ad hoc Speaking honoraria Astra. Zeneca, Bristol Myers Squibb, CANMAT, Canadian Psychiatric Association, Lundbeck Institute, Medscape, Mochida, Otsuka, Servier. Clinical trials/research (through UBC) Bristol Myers Squibb, Canadian Institutes of Health Research, Canadian Psychiatric Association Foundation, CANMAT, Lundbeck, Merck, Ontario Brain Institute, Pfizer, St. Jude Medical, UBC Institute of Mental Health/Coast Capital Savings, University Health Network, VGH Foundation Stocks None. Patents/Copyrights Lam Employment Absence and Productivity Scale (LEAPS) Book Royalties American Psychiatric Press, Cambridge University Press, Informa Press, Oxford University Press.

Objectives At the end of this presentation, participants will be able to Describe the nature of occupational impairment in MDD. Discuss challenges in application of measurement-based care. Describe the clinical use of a free mobile web app for tracking symptoms and work functioning. www. Working. With. Depression. ca

Comparing the burden of mental and physical illness Years of Reduced Function Years of Life Lost Ø Depression ALONE Depression carries a burden that is more than the COMBINED burden of lung, colorectal, breast, and prostate cancers. Bipolar Disorder Alcohol Schizophrenia Lung, Colorectal, Breast & Prostate All Cancers Combined 0 100 200 300 Health Adjusted Life Years* Lost (in thousands) Ratnasingham S, et al. Ontario Burden of Mental Illness and Addictions Report Institute for Clinical Evaluative Science, 2012. * Health-adjusted life years (HALYs) A combination of years lived with less than full function and years lost to early death.

Impact of depression on employment Depressed workers have: 32 days unable to work in the past year (Statistics Canada report) 3 -4 times more work loss days per month, compared to non-depressed workers (ESEMed study) 2 -3 times more short-term disability, compared to non-depressed workers (United States survey of corporations) Ø Presenteeism is a greater problem than absenteeism. Ø Presenteeism = reduced productivity when people are still at work. Health Report. Statistics Canada Health Statistics Division. 2006; 17: 1 -88. Alonso et al. Acta Psychiatr Scand 2004; Suppl (420): 38 -46. Kessler et al, Health Aff 1999; 18: 163 -71.

Depression is associated with huge economic costs Work-related economic losses are estimated to cost, per year: l l In Canada: C$6 billion. In the UK: £ 8. 6 billion. In Europe: € 118 billion. In the US: US$83 billion. Health Report. Statistics Canada 2006; Stephens & Joubert, Chron Dis Canada 2001. UK House of Commons Library report, 2009; Sobocki et al, J Ment Health Policy Econ 2006; Greenberg et al, J Clin Psychiatry 2003.

Love and work are the cornerstones of our Humanness. ~ Sigmund Freud ~

Why is work important to patients? Source of income Sense of accomplishment Intellectual stimulation Regular activity schedule Social interactions

Clinical consequences of cognitive deficits Cognitive dysfunction in depression is common, broad-based and often debilitating, leading to difficulties including Impaired ability to concentrate Difficulties with memory Problems with planning Slowness in responding Hammar Å, Årdal G. Front Hum Neurosci 2009; 3: 26

Measurement-based care for depression? Can you treat hypertension without measuring blood pressure? Can you treat diabetes without measuring Hb. A 1 c? What makes us think we can treat depression without measuring it?

Patient Health Questionnaire-9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 1. Little interest or pleasure in doing things. ☐ ☐ 2. Feeling down, depressed, or hopeless. ☐ ☐ 3. Trouble falling/staying asleep, sleeping too much. ☐ ☐ 4. Feeling tired or having little energy. ☐ ☐ 5. Poor appetite or overeating. ☐ ☐ 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching TV. 8. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual. ☐ ☐ ☐ 9. Thoughts that you would be better off dead or of hurting yourself in some way. ☐ ☐ A score of 10 or higher indicates significant depression.

Measurement-based care for depression l Routine assessment with scales integrated into clinical care. Ø Symptoms, side effects, functioning, quality of life. l Timely adjustments of medication and counselling l Timely changes in treatments depending on outcomes. l Measurement-based care improves outcomes in people treated for depression Trivedi MH, et al. Am J Psychiatry. 2006; 163: 28 -40.

Doctors understand the importance of scales – but many don’t use them Type of scale Currently Would Use like to use Symptom questionnaire 50% 40% Quality of life 23% 54% Overall functioning 37% 54% Work functioning 23% 59% Survey of 115 family physicians 2/3 of psychiatrists don’t use a scale. Reasons why? Do not believe it would be clinically helpful. 28% Do not know what scale to use. 21% Takes too much time. 34% Too disruptive to practice. 19% Wasn’t trained to use them. 34% Survey of 314 psychiatrists CANMAT Needs Assessment, September 2010; Zimmerman & Mc. Glinchey, J Clin Psychiatry 2006.

Act Local Think Global

Enlist the power of the internet! 83% of adult Canadians have internet access (2012 data) 90% have high speed connection; >70% use the internet daily 59% of households used wireless handheld devices to connect to the web at home Desktop computer Laptop computer Wireless handheld device Games console Canadian Internet Use Survey 2012.

Depression apps in i. Tunes store Name Depression – screening, diagnostic • STAT Depression Screening PHQ-9 • Doctor Depression • Depression Screening/ Pro • Geriatric Depression Screening • Depression check Target audience Main purpose/ description Clinicians; patients possible Guides physicians in selecting and monitoring depression treatment. Clinicians Assessment scales to measure depressive symptoms in patients. Patients Screens depression with PHQ-9, with additional questions on suicide, psychosis, and mania. Patients Screens for geriatric depression with a 15 -item geriatric depression scale. Patients Screens, assesses risk for depression, bipolar, anxiety disorders • i. Crazy - Psychology Tests Gen. pop. Mood Tracking – depression, bipolar, etc. • Depression Monitor Patients • T 2 Mood Tracker Patients General interest, education; screening for various mental disorders • Moody. Me – Mood Diary • Mood. Panda • i. Mind & Mood • Moodtrack. com Treatment/Programs • Depression Cure – 12 week course Gen. pop. , patients Patients, Gen. pop Monitor moods and emotions (including depression, mania), medications, etc. Monitor moods: “interactive mood diary” Patients Gen. pop. Assessment & recommendations Mood tracking Patients Treatment • i. Biomed Synchronize with caregivers; social network; health records • Anti-Depression Patients, caregivers, clinicians Patients • Happy. App Patients/Gen. pop. “brainwave” synchronization, audio frequencies Patients *teenagers Patients Connection/community/ discussion/social networking Social networking, community Gen. pop. Inspire, motivate Inspire: quotes; Social: chat Social/Community Support • Depression Connect • Bipolar Disorder Connect Happiness, General Well-Being • Happiness Tips • happiness+ • Optimism Screens depression with PHQ-9 and tracks (graphs) scores over time. Mood tracking info and strategies

Mood. Fx mobile web app Partners in Measurement-based m. Health e. Health Strategy Office www. Mood. Fx. ca

Mood. Fx mobile web app www. Mood. Fx. ca l Optimized for computers, tablets, smartphones l Patient-centred focus on work functioning and depression l Assess and track outcomes using validated scales l Interactive text and email appointment reminders l Subscribe to text/email tips l Simple and easy to use

Validated scales used in Mood. Fx For work functioning = LEAPS Lam Employment Absence and Productivity Scale For depression = PHQ-9 Sensitivity and specificity for diagnosis of Major Depressive Disorder (MDD) = 83% and 83% For anxiety = GAD-7 Sensitivity and specificity for diagnosis of anxiety disorder = § For GAD: 89% and 82% § For Others: 66 -74% and 80 -81% For cognition = PDQ-D-5 Perceived Deficits Questionnaire for Depression

The Lam Employment Absence and Productivity Scale (LEAPS) 10 -item, self-rated scale assessing symptoms and function at work. Designed specifically for depressed patients in primary care and specialty clinic settings. Takes only 3– 5 minutes to complete. Used to track progress and to help in work/off work decisions. © Lam RW, University of British Columbia, 2009

Perceived Deficits Questionnaire – Depression 5 -item version The following questions describe problems people may have with their memory, attention or concentration. Please select the best response based on your experiences during the past 7 days Never in the past 7 days Rarely (once or twice) Sometimes (3 to 5 times) Often (about once a day) Very often (more than once a day) Have trouble getting things organised? 0 1 2 3 4 Have trouble concentrating on what you were reading? 0 1 2 3 4 Forget the date unless you looked it up? 0 1 2 3 4 Forget what you talked about after a telephone conversation? 0 1 2 3 4 Feel like your mind went totally blank? 0 1 2 3 4 During the past 7 days, how often did you… Add up score in each column: TOTAL SCORE: _____ Copyright: Professor Sullivan, Mc. Gill University

Mood. Fx mobile web app www. Mood. Fx. ca

Summary Depressive symptoms cause significant interference in work functioning. Measurement-based care can involve patients in tracking outcomes to improve collaboration with their clinicians New mobile web apps like Mood. Fx can utilize technology to support measurementbased care www. Mood. Fx. ca

Thanks to our collaborators and funders Collaborators in workplace mental health: Ø Ø Ø Melady Preece Paula Cayley Anne Walker Debra Wolinsky Erin Michalak Ellen Anderson Funding partners: Ø Ø Ø CV Manjunath Trish Nolan David Bond Lakshmi Yatham Auby Axler Kendall Ho Ø Ø Ø Sagar Parikh Andrew Clarke Dorothy Shaw Erica Frank Cindy Woo Marie-Josee Filteau Ø Canadian Network for Mood and Anxiety Treatments UBC Institute of Mental Health / Coast Capital Savings Lundbeck Canada Astra. Zeneca Canada Pfizer Canada Optum Canadian Institutes of Health Research Michael Smith Foundation for Health Research Mathematics of Information Technology and Advanced Computing Canadian Psychiatric Association Foundation Ø Ø Ø www. Working. With. Depression. ca

Depressive symptoms and impairment in work functioning Percentage of depressed patients (n=164) reporting that depressive symptom interfered with work functioning “Very much” or “So much that I had to stop working” Patients (%) 52% Cognitive Difficulty 52% of depressed patients report that cognitive difficulty severely interferes with their occupational functioning Anergia = lack of motivation, low energy, physically slowed down, sleepy during day; Tension = anxious / tense / nervous, irritability / anger; Cognitive difficulty = trouble concentrating, trouble with memory Adapted from Lam RW et al. Depress Res Treat 2012; 2012: 630206

Evaluation of Mood. Fx in an Employee Assistance Program (EAP) Employee and Family Assistance Programs (EAPs) are the “first line of defence” for workers with depression Ongoing collaboration with Optum (previously PPC Canada), an accredited EAP provider to over 350 organizations across Canada Randomized controlled trial of Mood. Fx vs. standard care in clients attending EAP services N=50 Optum clinicians and 750 clients Outcomes to include symptoms and work functioning

Knowledge translation and dissemination for Mood. Fx Continuing Professional Development activities Webinars for clinicians Lunch and learn sessions CME conferences and events Aids for users – fridge magnets, online videos, whiteboards, social media Evaluation using RE-AIM principles, including users and clinicians