Digital intervention prior to appointment: using a digital mental health tool in Behavioral Health (Preprint)

BACKGROUND The long wait for an appointment puts the patient at risk for worsening mental health symptoms. An intervention is needed to provide therapeutic support to referred patients while they wait for an appointment to be scheduled. There are very few studies of digital mental health interventions in the Primary Care Setting. A pilot study was developed to provide a digital mental health tool that offers therapeutic support to patients referred to Adult Behavioral Health Integration (BHI) to initiate treatment while waiting for an appointment OBJECTIVE To determine the effectiveness of a digital cognitive behavioral therapy (Thrive) in improving PHQ-9 scores in patients referred to Behavioral Health while waiting for their appointment. METHODS Thrive is a web-based, on-demand Digital Cognitive Behavior Therapy (CBT) program for patients with mild to moderate depression and anxiety. Two pilots were conducted from October 2021-November 2022. Pilot #1 involved 10 Primary Care providers selected to endorse usage and enrollment of Thrive when referring to BHI. Pilot #2 involved all Primary Care providers with the active participation of BHI psychotherapists. Invitations were sent to patients referred to Behavioral Health by the Primary Care providers to enroll in the Thrive program. A Digital Navigator tracked program enrollment, average patient logins and lessons completed, and PHQ-9 questionnaire scores of enrolled patients. The Digital Navigator also provided patient support and outreach through calls and e-mail messaging. Patients with high-risk PHQ-9 questionnaire scores received outreach calls to help facilitate an appointment. RESULTS Pilot 1: 2954 invitations were sent, 504 patients enrolled, and 55% of them had appointments (89% with BHI psychotherapists and 11% with medical management). Pilot 2: 2934 invitations were sent, 582 patients enrolled, and 57% of them had appointments (83% with BHI psychotherapists, and 17% with medical management). For Pilot 1, the patients who had appointments were more likely to use the program indicated by higher average logins and lessons completed. Pilot 2 showed that patients without appointments used the program more. This could be due to many factors including this group of patients really needed to speak with a therapist, but in lieu of an appointment, they made full use of their Thrive enrollment. Less than 20% of enrolled patients from both pilots answered the PHQ-9 twice or more. 60-88% of this population, whether they had any Behavioral Health appointment, showed a decrease in their scores by an average of 3 points. 61% of patients from pilot 2 who had appointments with BHI psychotherapists also showed a decrease in their PHQ-9 questionnaire scores on Epic. The changes in the PHQ-9 scores in Epic of this same group of patients were matched with a randomly selected comparison group of BHI patients who were not enrolled in Thrive: there was a higher percentage of patients with decreased PHQ-9 scores (61% vs 53%, respectively) for the group enrolled in Thrive and this may be attributed to their use of the Thrive program. 64% of Thrive patients identified as high-risk who had appointments with BHI psychotherapists also showed a decrease in their PHQ-9 questionnaire scores on Epic. CONCLUSIONS This study showed that 60% of patients who used Thrive and answered the PHQ-9 questionnaire more than once showed a decrease in PHQ-9 scores by an average of 3 points while still in the Primary Care setting. Providing free digital mental health tools as options for therapeutic support for Behavioral Health patients is an equitable and inclusive approach to providing adjunctive care because they are accessible to most, can be used on any device, and context-appropriate with guidance from providers and a digital navigator.