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Knowledge Bites Lunch ‘n’ Learn January 31, 2019

Supportive Text Message Interventions in Mental Health Dr. Vincent I.O. Agyapong MB ChB DCP DHSM PG Dip MSc MRCPsych MCPsychI MICPSM FRAMI FCRPC FAPA MD PhD Clinical Professor, Department of Psychiatry, Faculty of Medicine, University of Alberta Edmonton Zone Clinical Section Chief, Community Mental Health Addiction & Mental Health, Alberta Health Services E-mail: agyapong@ualberta.ca

Conflict of interest No conflict of interest to declare

Supportive Text Message Interventions in Mental Health Overview • Previous work in this area • Results from two Randomized controlled trials in Alberta • Text4Mood Evaluation results • Current developments • Implications for practice

Supportive Text Message Interventions in Mental Health Previous work • Agyapong V.I.O., McLoughlin D. Farren C.K ., Six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder. Journal of Affective Disorders (2013), http://dx.doi.org/10.1016/j.jad.2013.05.058i • Agyapong V.I.O., McLoughlin D. Farren C.K., Perception of patients with Alcohol Use Disorder and comorbid depression about the usefulness of supportive text messages- Technol Health Care . 2013 Jan 1; 21(1):31-9. doi: 10.3233/THC-120707. • Agyapong V.I.O., McLoughlin D. Farren C.K., Supportive text messaging for alcohol use disorder and comorbid depression: single-blind randomised trial . J. Affect. Disord . Volume 141, Issues 2 – 3 , 10 December 2012 , Pages 168-176 • Agyapong V.I.O ., Farren C.K. and McLoughlin D, Mobile Phone Text Message Interventions in Psychiatry - What are the Possibilities?, Current Psychiatry Reviews , 2011, 7 (1), 50-56

Supportive Text Message Interventions in Mental Health Agyapong V.I.O , Juhás M, Omeje J, Mrklas K, Suen V, Ohinmaa A, Dursun SM, Greenshaw AJ Randomized Controlled Trial of Supportive Text Messages for Patients with Depression BMC Psychiatry (2017) 17(1):286. doi: 10.1186/s12888-017-1448-2.

Figure 1: Study Flow Chart Excluded (N=30, 103 patients presenting 29.13%) with low mood were • Did not fulfill the assessed for eligibility DSM V criteria for Major Depressive Disorder (n=15, 14.56%) 73 patients • Did not consent randomised (n=10, 9.70%) Control group Intervention • Did not have mobile (N=38) group phones (N=35) (n= 5, 4.85%) Lost to follow-up Lost to follow-up (n=4 ) (n=6) Completed 3 months follow- Completed 3 months up follow-up (N=31) (N=32) Analysed Analysed (N= 35) (N=38)

Sample supportive text messages • “What lies behind you and what lies before you are tiny matters compared to what lies within you. Have faith in yourself and success can be yours” • “There are 2 days in the week we should not worry about, yesterday and tomorrow. That leaves today, live for today” • “Stumbling blocks can become stepping stones to a better life. You can turn adversities into opportunities. Do not be discouraged because of today’s problems” • “Letting go of resentment is a gift you give yourself, and it will ease your journey immeasurably. Make peace with everyone and happiness will be yours”

Primary Outcomes Measure Baseline Three months Mean difference P-value measurement in change score Effect size (Cohen’s Text Control Text Control d) message group message group group group Mean Becks 40.1 36.3 20.8 24.9 -7.6 0.01 0.67 Depression (8.6) (8.8) (11.7) (11.5) (-13.2 to -1.9) Inventory-II (SD) Mean self- 44.5 47.1 65.7 57.4 10.7 0.05 0.51 rated health (19.0) (19.1) (15.3) (22.9) (-0.2 to 21.5) index Using EQ VAS scores (SD)

Secondary Outcomes ( Health services Utilization )

Conclusions and implications • Supportive text messages are a potentially useful psychological intervention for depression and could help alleviate the large unmet needs, especially, the psychological treatment gap currently reported by patients in Alberta and other parts of Canada as well as globally.

RANDOMIZED CONTROLLED TRIAL OF SUPPORTIVE TEXT MESSAGES FOR PATIENTS WITH ALCOHOL USE DISORDER Agyapong V.I.O. , Juhás M., Mrklas K., Hrabok M., Omeje J., Gladue I., Kozak J., Leslie M, Chue P., Greenshaw AJ. Randomized Controlled Pilot Trial of Supportive Text Messages for Patients with Alcohol Use Disorder. Journal of Substance Abuse Treatment Volume 94, November 2018, Pages 74-80

Figure 1: CONSORT 2010 Flow Diagram Enrollment Assessed for eligibility (n=70) Excluded (n=11)  Not meeting inclusion criteria (n=2)  Declined to participate (n=9)  Other reasons (n=0) Randomized (n=59) Allocation Allocated to intervention (n=29) Allocated to control (n=30)  Received allocated intervention (n=29)  Received allocated intervention (n=30)  Did not receive allocated intervention (n=0)  Did not receive allocated intervention (n=0) Follow-Up Lost to follow-up (not reachable) (n=4) Lost to follow-up (not reachable) (n=5) Discontinued intervention (withdrew consent) Discontinued intervention (withdrew consent) (n=4) (n=3) Analysis Analysed (n=29) Analysed (n=30)  Excluded from analysis (n=0)  Excluded from analysis (n=0)

Sample supportive text messages • “Think of your recovery as an opportunity to find new solutions in your life. Remember that the past is gone and what you do next is what really matters.” • “Before you think of the next drink, think of the last one and how it made you feel” • “The thoughts of drinking will return to test you. Remember to never give up in the face of temptation” • “The true joy of recovery is in the fellowship and camaraderie you share with others travelling the same path”

Distribution of baseline demographic and clinical characteristics of participants Variable Intervention group Control group N P-Value N Gender Male 22 (75.9%) 22 (73.3%) 1.0 Female 7 (24.1%) 8 (26.7%) Age ≤ 40 16 (57.1%) 15 (51.7%) 0.79 ≥ 41 12 (42.9%) 14 (48.3%) Mean Age in years (SD) 39.4 (SD=10.6) 41.8 (SD=10.0) 0.38 Formal educational level Up to high school 11 (37.9%) 13 (43.3%) 0.79 College/University 18 (62.1%) 17 (56.7%) Employment status Employed 21 (72.4%) 23 (76.7%) 0.77 Not Employed 8 (27.6%) 7 (23.3%) Relationship status In a relationship 14 (48.1%) 18 (60.0%) 0.60 Not in a relationship 13 (51.9%) 12 (40.0%) On antidepressants before enrolment Yes 11 (42.3% 13 (46.4%) 0.79 No 15 (57.7%) 15 (53.6%) On medication for chronic physical Yes 7 (25.0%) 8 (27.6%) 1.0 health problems No 21 (75.0%) 21 (72.4%) Mean age of onset of problem drinking in years 23.0 (SD=7.5) 25.0 (SD=10.8) 0.47 Mean longest duration of sobriety since onset of problem drinking in 214.8 (SD=550.8) 23.7 (SD=55.7) 0.09 months Past treatment for alcohol abuse Yes 13 (50.0%) 9 (31.0%) 0.18 No 13 (50.0%) 20 (69.0%)

Mean scores and group difference statistics for the primary and secondary outcome measures for the intervention and control groups at three-month follow-up Variable Intervention group Control group t P- Cohen’s d* Value Cumulative abstinence duration 83.5 (SD=19.3) 73.6 (SD=33.0) 1.16 0.25 .37 (CAD) at three months in days Number of days to first drink 60.8 (SD=31.2) 25.8 (SD=28.7) 1.94 0.09 1.17 Units of alcohol per drinking 1.0 (SD=2.3) 1.5 (SD=2.8) -0.60 0.55 .20 days 2 + SD 2 * Cohen’s d computed . as Cohen's d = ( M 2 - M 1 ) ⁄ SD pooled , where SD pooled is √(( SD 1 2 ) ⁄ 2) ( Effect Size Calculator (Cohen’s D) for T-Test n.d.)

Table 3: Health services utilisation at three months for the intervention and control groups Variable Intervention Control group t P- Cohen’s group Value d* Mean number of visits to Family 1.3 (SD=2.1) 1.7(SD=1.9) -0.65 0.52 .20 Physician Mean number of visits to 1.0 (SD=2.7) 0.64 (SD=1.2) 0.48 0.63 .17 Psychiatrist Mean number of visits to other 0.24 (SD=0.62) 0.45 (SD=2.1) -0.45 0.66 .14 specialists Mean number of visits to the 0.24 (SD=0.54) 0.41(SD=1.1) -0.64 0.52 .20 Emergency Department Mean number of counselling 3.0 (SD=3.3) 4.7 (SD=5.6) -1.18 0.25 .37 sessions attended 2 + SD 2 *Cohen’s d computed . as Cohen's d = ( M 2 - M 1 ) ⁄ SD pooled , where SD pooled is √(( SD 1 2 ) ⁄ 2) ( Effect Size Calculator (Cohen’s D) for T-Test n.d.)

Conclusions and implications • The number of days to first drink was longer in the intervention than control group (large effect size, although not statistically significant). • Text messaging is a feasible and effective opportunity for follow-up care in patients discharged from residential AUD treatment.