Mobile Health Apps for Depression

Focus on MoodFx

Raymond W. Lam, MD, FRCPC

Professor and Associate Head for Research,
Department of Psychiatry, University of British Columbia;
Director, Mood Disorders Centre,
Djavad Mowafaghian Centre for Brain Health, Vancouver, BC;
Executive Chair, Canadian Network for Mood and Anxiety
Treatments (CANMAT).
r.lam@ubc.ca
 Disclosure Statement 2012-2014

Dr. Raymond Lam, MD, FRCPC

Ad hoc Consulting/Advisory AstraZeneca, Bristol Myers Squibb, CANMAT, Eli Lilly, Lundbeck,
Mochida, Pfizer, Takeda

Ad hoc Speaking honoraria AstraZeneca, Bristol Myers Squibb, CANMAT, Canadian Psychiatric
Association, Lundbeck, Lundbeck Institute, Medscape, Mochida, Otsuka,
Servier.

Clinical trials/research Bristol Myers Squibb, Canadian Institutes of Health Research, Canadian
(through UBC) Psychiatric Association Foundation, CANMAT, Lundbeck, Merck, Ontario
Brain Institute, Pfizer, St. Jude Medical, UBC Institute of Mental
Health/Coast Capital Savings, University Health Network, VGH Foundation

Stocks None.

Patents/Copyrights Lam Employment Absence and Productivity Scale (LEAPS)

Book Royalties American Psychiatric Press, Cambridge University Press, Informa Press,
Oxford University Press.
 Objectives

At the end of this presentation, participants will be able to

Describe the nature of occupational impairment in MDD.
Discuss challenges in application of measurement-based care.
Describe the clinical use of a free mobile web app for tracking
symptoms and work functioning.

www.WorkingWithDepression.ca
 Comparing the burden of mental and physical
illness
Years of Reduced Function Years of Life Lost

Depression  Depression ALONE

carries a burden
Bipolar Disorder that is more than the
COMBINED burden
Alcohol
of lung, colorectal,
Schizophrenia breast, and prostate
cancers.

Lung, Colorectal,
BreastAll
& Prostate
Cancers
Cancers Combined

0 50 100 150 200 250

Health Adjusted Life Years* Lost (in
thousands)
* Health-adjusted life years (HALYs)
Ratnasingham S, et al. Ontario Burden of Mental Illness and Addictions Report A combination of years lived with less than
Institute for Clinical Evaluative Science, 2012. full function and years lost to early death.
 Impact of depression on employment

Depressed workers have:

32 days unable to work in the past year
(Statistics Canada report)
3-4 times more work loss days per month,
compared to non-depressed workers
(ESEMed study)
2-3 times more short-term disability,
compared to non-depressed workers
(United States survey of corporations)

 Presenteeism is a greater problem

than absenteeism.
 Presenteeism = reduced productivity
when people are still at work.

Health Report. Statistics Canada Health Statistics Division. 2006; 17:1-88.

Alonso et al. Acta Psychiatr Scand 2004; Suppl (420):38-46.
Kessler et al, Health Aff 1999; 18:163-71.
 Depression is associated with huge
economic costs

Work-related economic losses are estimated to cost,

per year:
 In Canada: C$6 billion.
 In the UK: £8.6 billion.
 In Europe: €118 billion.
 In the US: US$83 billion.

Health Report. Statistics Canada 2006; Stephens & Joubert, Chron Dis Canada 2001.
UK House of Commons Library report, 2009; Sobocki et al, J Ment Health Policy Econ 2006;
Greenberg et al, J Clin Psychiatry 2003.
Love and work
are the
cornerstones
of our
Humanness.

~ Sigmund Freud ~
 Why is work important to patients?

Source of income
Sense of accomplishment
Intellectual stimulation
Regular activity schedule
Social interactions
 Clinical consequences of cognitive deficits

Cognitive dysfunction in depression is common, broad-based and

often debilitating, leading to difficulties including

Impaired ability to concentrate

Difficulties with memory

Problems with planning

Slowness in responding

Hammar Å, Årdal G. Front Hum Neurosci 2009;3:26

 Measurement-based care for depression?

Can you treat hypertension without

measuring blood pressure?
Can you treat diabetes without
measuring HbA1c?
What makes us think we can treat
depression without measuring it?
 Patient Health Questionnaire-9
(PHQ-9)

Over the last 2 weeks, how often have you been More than Nearly
Not at all Several
half the every
(0) days (1)
bothered by any of the following problems? days (2) day (3)

1. Little interest or pleasure in doing things. ☐ ☐ ☐ ☐

2. Feeling down, depressed, or hopeless. ☐ ☐ ☐ ☐

3. Trouble falling/staying asleep, sleeping too much. ☐ ☐ ☐ ☐

4. Feeling tired or having little energy. ☐ ☐ ☐ ☐

5. Poor appetite or overeating. ☐ ☐ ☐ ☐

6. Feeling bad about yourself, or that you are a failure, or have let ☐ ☐ ☐ ☐
yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper ☐ ☐ ☐ ☐
or watching TV.
8. Moving or speaking so slowly that other people could have ☐ ☐ ☐ ☐
noticed. Or the opposite; being so fidgety or restless that you
have been moving around more than usual.
9. Thoughts that you would be better off dead or of hurting yourself ☐ ☐ ☐ ☐
in some way.

A score of 10 or higher indicates significant depression.

 Measurement-based care for depression

 Routine assessment with scales integrated into clinical care.

 Symptoms, side effects, functioning, quality of life.

 Timely adjustments of medication and counselling

 Timely changes in treatments depending on outcomes.

 Measurement-based care improves outcomes

in people treated for depression

Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40.

 Doctors understand the importance
of scales – but many don’t use them

Currently Would
Type of scale
Use like to use
Symptom questionnaire 50% 40%
2/3 of psychiatrists don’t use a scale.
Quality of life 23% 54% Reasons why?
Overall functioning 37% 54% Do not believe it would be
28%
Work functioning 23% 59% clinically helpful.
Do not know what scale to use. 21%
Survey of 115 family physicians
Takes too much time. 34%
Too disruptive to practice. 19%
Wasn’t trained to use them. 34%
Survey of 314 psychiatrists

CANMAT Needs Assessment, September 2010;

Zimmerman & McGlinchey, J Clin Psychiatry 2006.
Act Local Think Global
 Enlist the power of the internet!

83% of adult Canadians have internet access (2012 data)

90% have high speed connection; >70% use the internet daily
59% of households used wireless handheld devices to
connect to the web at home

Desktop computer

Laptop computer

Wireless handheld device

Games console

Canadian Internet Use Survey 2012.

 Depression apps in iTunes store

Name Target audience Main purpose/ description

Depression – screening, diagnostic
• STAT Depression Screening PHQ-9 Clinicians; patients possible Guides physicians in selecting and monitoring depression treatment.
• Doctor Depression Clinicians Assessment scales to measure depressive symptoms in patients.
• Depression Screening/ Pro Patients Screens depression with PHQ-9, with additional questions on suicide,
psychosis, and mania.
• Geriatric Depression Screening Patients Screens for geriatric depression with a 15-item geriatric depression scale.
• Depression check Patients Screens, assesses risk for depression, bipolar, anxiety disorders
• iCrazy - Psychology Tests Gen. pop. General interest, education; screening for various mental disorders
Mood Tracking – depression, bipolar, etc.
• Depression Monitor Patients Screens depression with PHQ-9 and tracks (graphs) scores over time.
• T2 Mood Tracker Patients Mood tracking
• MoodyMe – Mood Diary Gen. pop., patients Monitor moods and emotions (including depression, mania), medications, etc.
• MoodPanda Patients, Gen. pop Monitor moods: “interactive mood diary”
• iMind & Mood Patients Assessment & recommendations
• Moodtrack.com Gen. pop. Mood tracking
Treatment/Programs
• Depression Cure – 12 week course Patients Treatment
• iBiomed Patients, caregivers, Synchronize with caregivers; social network; health records
clinicians
• Anti-Depression Patients info and strategies
• HappyApp Patients/Gen. pop. “brainwave” synchronization, audio frequencies
Social/Community Support
• Depression Connect Patients *teenagers Connection/community/ discussion/social networking
• Bipolar Disorder Connect Patients Social networking, community
Happiness, General Well-Being
• Happiness Tips Gen. pop. Inspire, motivate
• happiness+ Gen. pop. Inspire: quotes; Social: chat
• Optimism Gen. pop.
 MoodFx mobile web app

Partners in Measurement-based mHealth

eHealth
Strategy
Office

www.MoodFx.ca
 MoodFx mobile web app

 Optimized for computers, tablets,

smartphones
 Patient-centred focus on work
functioning and depression
 Assess and track outcomes using
validated scales
 Interactive text and email
appointment reminders
www.MoodFx.ca
 Subscribe to text/email tips
 Simple and easy to use
 Validated scales used in MoodFx

For work functioning = LEAPS

Lam Employment Absence and Productivity Scale

For depression = PHQ-9

Sensitivity and specificity for diagnosis of Major Depressive
Disorder (MDD) = 83% and 83%

For anxiety = GAD-7

Sensitivity and specificity for diagnosis of anxiety disorder =
 For GAD: 89% and 82%
 For Others: 66-74% and 80-81%

For cognition = PDQ-D-5

Perceived Deficits Questionnaire for Depression
The Lam Employment Absence and
Productivity Scale (LEAPS)

10-item, self-rated scale assessing

symptoms and function at work.
Designed specifically for depressed
patients in primary care and
specialty clinic settings.
Takes only 3–5 minutes to complete.
Used to track progress and to help in
work/off work decisions.

© Lam RW, University of British Columbia, 2009

 Perceived Deficits Questionnaire – Depression
5-item version

The following questions describe problems people may have with their memory, attention or
concentration. Please select the best response based on your experiences during the past 7 days
Often Very often
Never in the past Rarely Sometimes
(about once (more than
During the past 7 days, how often did you… 7 days (once or twice) (3 to 5 times)
a day) once a day)

Have trouble getting things organised? 0 1 2 3 4

Have trouble concentrating on what you

0 1 2 3 4
were reading?

Forget the date unless you looked it up? 0 1 2 3 4

Forget what you talked about after a telephone

0 1 2 3 4
conversation?

Feel like your mind went totally blank? 0 1 2 3 4

Add up score in each column:

TOTAL SCORE: _________

Copyright: Professor Sullivan, McGill University
MoodFx mobile web app

www.MoodFx.ca
 Summary

Depressive symptoms cause significant

interference in work functioning.

Measurement-based care can involve

patients in tracking outcomes to improve
collaboration with their clinicians

New mobile web apps like MoodFx can

utilize technology to support measurement-
based care

www.MoodFx.ca
 Thanks to our collaborators and funders

Collaborators in workplace mental health:

 Melady Preece  Sagar Parikh  CV Manjunath
 Paula Cayley  Andrew Clarke  Trish Nolan
 Anne Walker  Dorothy Shaw  David Bond
 Debra Wolinsky  Erica Frank  Lakshmi Yatham
 Erin Michalak  Cindy Woo  Auby Axler
 Ellen Anderson  Marie-Josee Filteau  Kendall Ho

Funding partners:
 Canadian Institutes
of Health Research
 Michael Smith Foundation
for Health Research
 Mathematics of Information
Technology and Advanced
Computing
 Canadian Psychiatric
Association Foundation
 Canadian Network for Mood and Anxiety
Treatments
 UBC Institute of Mental Health /
Coast Capital Savings
 Lundbeck Canada
 AstraZeneca Canada
 Pfizer Canada
 Optum

www.WorkingWithDepression.ca
 Depressive symptoms and impairment in
work functioning

Percentage of depressed patients (n=164) reporting that

depressive symptom interfered with work functioning
“Very much” or “So much that I had to stop working”
70
60
52%
50
Patients (%)

40
30
20
10
0
Anergia Low Tension Cognitive
Cognitive Insomnia Guilt Pain Appetite Suicidal
mood Difficulty
difficulty

52% of depressed patients report that cognitive difficulty

severely interferes with their occupational functioning

Anergia = lack of motivation, low energy, physically slowed down, sleepy during day;
Tension = anxious / tense / nervous, irritability / anger; Adapted from
Cognitive difficulty = trouble concentrating, trouble with memory Lam RW et al. Depress Res Treat 2012;2012:630206
 Evaluation of MoodFx in an
Employee Assistance Program (EAP)

Employee and Family Assistance Programs (EAPs) are the

“first line of defence” for workers with depression
Ongoing collaboration with Optum (previously PPC Canada),
an accredited EAP provider to over 350 organizations across
Canada
Randomized controlled trial of MoodFx vs. standard care in
clients attending EAP services
N=50 Optum clinicians and 750 clients
Outcomes to include symptoms and work functioning
 Knowledge translation and dissemination for
MoodFx

Continuing Professional Development activities

Webinars for clinicians
Lunch and learn sessions
CME conferences and events

Aids for users – fridge magnets, online videos,

whiteboards, social media

Evaluation using RE-AIM principles, including users and

clinicians