Supportive Text Messaging Versus Supportive E-mail Messaging for Patients With Major Depressive Disorder - A Non-Inferiority Randomized Trial

Depression is a debilitating condition which is characterized by changes in mood, self-attitude, cognitive functioning, sleep, appetite, and energy levels. Depression causes a decrease in quality of life that leads to impairment in occupational and social functioning. In 2010, it was estimated that mental and substance use disorders were the leading cause of years lived with disability worldwide, with Depressive disorders in particular accounting for 40·5% of disability-adjusted life-years caused by mental and substance use disorders. Depression is thus a major contributor to the overall global burden of disease and it is projected by the World Health Organization, that by 2030, Major Depressive Disorder (MDD) will be the leading cause of disability worldwide.

In 2012, over 3.2 million Canadians over 15 (11.3%) years reported symptoms of major depression and a higher health and service utilization amongst patients with depression have been reported compared to other patients. Psycho-social interventions and pharmacotherapy is the preferred first-line treatment for severe mental health problems including major depression. Psychotherapies, such as cognitive behavior therapy, interpersonal psychotherapy, problem-solving and behavioral activation are common and effective forms of treatment for depression. However, access to these psychotherapies are often limited by human resource capacity constraints and most people with depressive disorders do not receive treatment. Psychosocial services are also mostly found in cities and towns, with reduced access for rural inhabitants. Even in cities and towns these services are mostly only available during the working days and day time business hours, with caregivers often dealing with double the recommended number of clients, further restricting appointment availability. Long wait times to access counselling services and the stigma associated with seeking mental health counselling also compound the problem. In the 2012 Canadian Community Health Survey on Mental Health, barriers such as lack of readily available care system, stigma and affordability of health care services, were reported by 2.3 million Canadians who expressed they had unmet or partially met mental health care needs. It is clear, that traditional ways of providing mental healthcare alone will not be able to meet the demands for services given that the prevalence of depression is so high and not likely to decrease any time soon. There is, therefore, the need to develop innovative psychological interventions which are not human resource intensive, are easily accessible, cost-effective, are geographic location independent, scalable, and can be offered to thousands of people simultaneously.

Digital technologies for the provision of health care interventions have advanced significantly in the last decade and further development of this field looks very promising. The new technologies may enhance access to mental healthcare and contribute to closing the treatment gap that has existed over the years. Current evidence supports the efficacy and cost-effectiveness of tele mental health, especially in the context of treating depressive disorders. Useful communication methods for the delivery of mental health services includes smartphone apps, text messages and e-mails.

Supportive text messages have become an appropriate and acceptable means of delivering psychological care to patients with mental health issues. It is estimated that 99% of received mobile text messages are opened, and 90% of all text messages are read within three minutes of reception and present an opportunity to aid in the closure of the psychological treatment gap for patients with depression. In three randomized controlled trials conducted in Ireland and Canada, patients with MDD who received twice-daily supportive text messages had significantly greater reductions in their depression symptom scores compared to patients who received the usual treatment. In the first of two studies conducted in Ireland, after three months, the mean difference in change Becks Depression Inventory (BID)-II scores between the intervention and the control group was -7.9 (95% CI -13.06 to -2.76, Cohen'sd=0.85) in favor of the intervention group. Similar results were reported in another Irish study with larger sample size and in a Canadian study, a significant difference was found in the 3 months mean BDI scores between the intervention and control groups: (20.8 (SD = 11.7) vs. 24.9 (SD = 11.5), respectively, F (1, 60) = 4.83, p = 0.03, ηp2 = 0.07) with an effect size (Cohen's d) of 0.67. literature review of studies conducted on the effectiveness of text messaging as an adjunct therapy for mothers with postpartum depression living in low-income countries also reported a positive outcome and the mothers noted that they would love to receive psychological care via the text messaging. Several studies have also reported high user satisfaction of the supportive text message intervention and in one of these studies, 83% of subscribers to the Text4Mood program reported that the daily messages contributed to improving their overall mental wellbeing.

Anecdotally, some people have not been able to subscribe to supportive text messaging programs such as Text4Hope and Text4Mood because they do not have active cell phone numbers, with several individuals for whom these programs have been recommended in Addiction and Mental Health clinics in Edmonton enquiring if the messages could be sent to them via email. In the participants' satisfaction survey for the Text4Hope program, majority of respondents (64%), even though they had access to cell phones, were in favor of Email messaging for as part of their health care interventions during crisis periods.