Design
This study utilised a single arm, uncontrolled pilot study. The study was approved by the UNSW Human Research Ethics Committee (HC180108).
Study recruitment, consent, and reimbursement
Recruitment of practices and GPs took place between May and August 2018 in New South Wales, Australia. The study advert was sent to practices via Primary Health Networks (Australian government-funded independent-run organisation that coordinates and supports primary health services within a specific geographical area) and Black Dog Institute newsletters and mailing lists. Inclusion criteria was the use of Best Practice or Medical Director software, HealthLink Messaging Service, and Wi-Fi internet in the practice. Interested practices were asked to contact the research team, after which a practice visit was arranged. During the visit, the researcher collected signed consent forms, demographics, and information about GP and practice staff interest and training in mental health, and then presented and demonstrated the service in detail and provided training. At the completion of the study, practices were reimbursed with a gift voucher ($500AUD). GPs were offered free access to accredited professional development and training (valued at 360AUD). Youth patients were recruited for 93 days, between the 20th August until the 21st November 2018. Practice staff were instructed to offer the tablet to all eligible youth patients who presented to their appointment with their parent. Together with their child, the parent was asked to review the service information and instructions on the mobile tablet and provide their online consent. Youth were eligible to use the service if they were: i) aged between 14 to 17 years; ii) accompanied by a consenting parent or guardian; iii) have a valid mobile phone number or email address; and iv) the ability to read and speak English. Youth patients who were considered by the GP or practice staff to be too unwell for screening (e.g., vomiting, weak, experiencing psychosis, cognitively impaired) were excluded.
Service Procedure
The service consisted of three components: i) screening, ii) treatment recommendations, and iii) patient monitoring (Figure 1).
Youth StepCare was delivered to a young person on a mobile tablet while they awaited their GP appointment. Practice staff were instructed to invite all youth patients to use the service regardless of their appointment reason. After providing consent on the mobile tablet, the young person registered using their mobile phone number or email, date of birth, and gender. They were then asked to report whether their current or previous appointments were for mental health reasons. The service then delivered two self-report measures including the Patient Health Questionnaire-9 (PHQ-9; 31) for depressive symptoms and the Generalized Anxiety Scale (GAD-7; 32) for anxiety symptoms. Suicidal ideation was assessed during the initial screener only using participants’ responses to item nine on the PHQ-9 which asked “In the past two weeks, have you been bothered by any thoughts that you would be better off dead or of hurting yourself” rated 0 (not at all) to 3 (nearly every day). Using the highest total score from either scale, the service automatically assigned each patient to one of four treatment steps with treatment recommendations matched to symptom severity (see Table 1). A report with this information was then sent to the GP’s medical software within 3 minutes via a secure health messaging service. Patients received brief empathic feedback on the mobile tablet which reflected their responses to the screening items (e.g. “it looks like things have been a bit tough for you lately”) and if symptomatic, received help-seeking resources and services (e.g. telephone helplines and websites) and a prompt to talk to their GP in their consult about how they were feeling. All patients were reminded that their results would be immediately shared with their GP. After reviewing the feedback, the patient was then instructed to return the mobile tablet to the practice staff. The fortnightly monitoring surveys were automatically initiated for all symptomatic patients at baseline and delivered via SMS or email (see Table 1). Patients who reported worsening symptoms in the monitoring surveys were advised to schedule an appointment with their GP. GPs also received notifications for any patient who failed to complete the monitoring or who reported that their symptoms had deteriorated, improved, or remained unchanged for four consecutive weeks.
Table 1. Youth StepCare Treatment Model
Step
|
Symptom Severity
|
PHQ-9
(GAD-7) score range
|
Suicidal
Ideation
|
Treatment Recommendation
|
Monitoring
|
0
|
Nil-Minimal
|
0 – 4
(0 – 4)
|
0
|
No action required
|
Not required
|
1
|
Mild
|
5 – 9
(5 – 9)
|
1
|
Referral to a Web-based psychoeducation program
|
Fortnightly for 12 weeks
|
2
|
Moderate
|
10 – 19
(10 – 14)
|
2
|
Referral to a psychologist;
Consider referral to Child and Adolescent psychiatrist;
Referral to web-based psychoeducation program and online cognitive-behaviour therapy (CBT).
|
Fortnightly for 12 weeks
|
3
|
Severe
|
20+
(15+)
|
3
|
Referral to a psychologist or Child and Adolescent psychiatrist;
Referral to Web-based psychoeducation program and online CBT.
|
Fortnightly for 12 weeks
|
Measures
The timeline for each of the measures used is presented in Table A.1 (see Appendix A).
Service uptake: Measured by the proportion of GPs and practice staff who agreed to use the service and the proportion of youth who accepted the mobile tablet from practice staff.
Service need: Measured by the number of new cases (i.e. symptomatic youth who had not sought care previously and were not seeing a GP at the current visit for mental health) and the number of GPs who agreed that there was a need for the service.
Perceived effectiveness: Measured by the proportion of GPs who followed the treatment recommendations, the proportion of patients who had their treatment modified due to the service recommendations, and improvements in GPs’ ratings of their confidence to provide quality care and ability to identify and monitor their young patients’ mental health (answered on a self-rated 5-point Likert scale ranging from 1 = not at all to 5 = completely).
Operational feasibility: Defined as the likelihood of the service being easily embedded into existing workflows and measured by the number of technical difficulties experienced, ratings for how much the service changed usual practice, and how well the service aligned with existing practice software and processes (answered on a self-rated 5-point Likert scale ranging from 1 = not at all to 5 = completely).
Acceptability: Defined by satisfaction, likely future use, and practice staff comfort using the service. Satisfaction was measured by rating how satisfied they were with the service and whether it fits with their beliefs and philosophies about general practice (answered on a self-rated 5-point Likert scale ranging from 1 = not at all to 5 = completely). Likely future use was measured by the number who reported they would use the service again in the future and recommend it to others. Comfort was measured by the number of practice staff who stated they were comfortable offering the service to eligible youth.
Data collection and analysis
The data collected by the service was stored securely on the Black Dog Institute e-health platform hosted on the University of New South Wales servers in Australia. Data was then downloaded into Microsoft Excel and exported to SPSS Version 24.0 (SPSS Inc., Chicago, Il, USA) for analysis. Basic descriptive statistics were conducted and reported for all relevant data.