Digital Screening for Depression

In a recent randomized controlled experiment published in The Lancet Digital Health, researchers looked at how two types of automated feedback after internet-based depression screening affected the degree of depression.

They discovered that automated feedback did not significantly reduce the degree of depression or result in effective depression care in those who had not previously been diagnosed with depression but experienced it.

Background

Depressive disorders are extremely disabling and widespread, but they frequently go undiagnosed and untreated, resulting in chronic illnesses, treatment resistance, higher healthcare expenses, and an increased disease burden. Though controversial, standardized depression screening has the potential to aid in early detection.

Feedback on screening findings may inspire people to detect problems and seek help. Previous trials produced mixed outcomes in terms of depression severity but improved patient-physician communication and access to therapy.

In a groundbreaking study known as the “DISCOVER” trial, researchers sought to assess the efficacy of two types of automated feedback following internet-based screening for moderate to severe depression, focusing on the effect on initiating evidence-based care, depression-related behaviors, and potential negative consequences.

About the study

The current investigation was an observer-masked, randomized controlled trial with three arms that took place in Germany between 2021 and 2022. A total of 1,178 participants aged ≥18 years with Patient Health Questionnaire-9 (PHQ-9) scores ≥10 (moderate depression severity) and no recent depression diagnosis or treatment were randomly assigned in a 1:1:1 ratio.

Researchers examined the effects of automated customized feedback (n = 394), automated non-tailored feedback (n = 393), and no feedback (n = 391) on depression severity six months following internet-based screening.

The no-feedback group received no more information after screening. In contrast, participants in the two feedback groups got quick access to feedback via a clickable link on the website.

Individuals with depressive disorders helped design the feedback material. It was divided into four sections: 1) presenting screening results, 2) urging consultation with a healthcare professional, 3) providing general information about depression, and 4) outlining treatment choices based on German clinical guidelines.

The tailored feedback personalized content based on participants’ symptom profiles, desired specialist type, health insurance provider, symptom attributions, and location.

The average age of the three groups was 37.1 years, with 70% women, 29% men, 1% reporting other genders, and 10% having a migrant background. The majority were well-educated (49%), single (41%), worked (72%), and lived in major cities (51%).

At the six-month follow-up, 965 participants submitted PHQ-9 data. The primary objective was the change in depression severity six months after randomization using the PHQ-9 scale, which assesses nine depressive symptoms on a range of 0 to 3, with scores ranging between 0 to 27.

Secondary outcomes included receiving evidence-based depression care, being diagnosed with depressive disorder by healthcare professionals, engaging in depression-related health behaviors, health-related quality of life, anxiety severity, somatic symptom severity, and safety monitoring for suicidal ideation.

The statistical analysis included covariance, intention-to-treat analysis, per-protocol analysis, subgroup analysis, multiple imputations for missing data, Cohen’s d calculation, and the closed testing principle.

Results and discussion

Six months following random assignment, depression intensity decreased similarly across groups: by 3.4 points in the no-feedback group, 3.5 points in the non-tailored feedback group, and 3.7 points in the tailored feedback group, with no significant differences between groups (p=0.72).

Secondary outcome analyses revealed no significant intervention effects among groups. There were just a few reports of negative effects (<1%), including emotional strain and distress from study participation.

The rates of major depressive disorder diagnosis using SCID (short for standardized clinical interview for DSM disorders) criteria and treatment initiation were found to be comparable among the groups. Sensitivity analyses did not affect the findings.

Overall, the research found that, while digital depression screening can uncover undiscovered depression, it does not guarantee evidence-based therapy, highlighting the need for more effective measures to improve access to care after screening.

A large sample size strengthens the trial by allowing for a high follow-up rate and the capacity to isolate the effects of screening and feedback, such as untreated depressed patients, representative recruiting, and diagnostic interviews for efficacy analyses.

However, the trial’s limitations include the lack of a no-screening control group, recruiting that did not specifically target those seeking depression information, dependence on self-reported help-seeking data, potential self-selection bias, and the potential influence of repeated evaluations on depression outcomes.

Conclusion

In conclusion, the DISCOVER study found that automated feedback following internet-based depression screening did not reduce depression severity or prompt evidence-based care.

These findings should be examined by healthcare practitioners and used to develop guidelines for early depression detection, emphasizing the need for additional research to better understand individuals’ journeys from early detection to effective treatment.

For more information: Sebastian et al., (2024) The efficacy of automated feedback after internet-based depression screening (DISCOVER): an observer-masked, three-armed, randomized controlled trial in Germany. Kohlmann, The Lancet Digital Health, 6(7):e446 – e457. doi: 10.1016/S2589-7500(24)00070-0.https://www.thelancet.com/journals/landig/article/PIIS2589-7500(24)00070-0/fulltext