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Despite the well-known adverse health conditions and negative economic outcomes associated with mental health problems, accessing treatment is difficult due to reasons such as availability and cost. As a solution, digital mental health services have flooded the industry, and new studies are quickly emerging that support their potential as an accessible and cost-effective way to improve mental health outcomes. However, many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Yet, many individuals that seek out care do not have clinical symptomatology and thus, traditional clinical measures may not adequately capture symptom improvement in general well-being. As an alternative, this study used the health-related quality of life (HRQoL) tool from the Centers for Disease Control and Prevention “Healthy Days” measure. This subjective measure of well-being is an effective way to capture HRQoL and might be better suited as an outcome measure for treatments that include both clinical and subclinical individuals.
The purpose of this study was to describe changes in HRQoL in clinical and subclinical members assessing virtual care and to examine the association between text-based behavioral coaching and virtual clinical sessions with changes in HRQoL.
A total of 288 members completed the 4-item HRQoL measure at baseline and at 1 month following use of the Ginger on demand behavioral health platform. Baseline anxiety and depression levels were collected using the GAD-7 and PHQ-9, respectively.
Members completed on average 1.92 (SD 2.16) coaching sessions and 0.91 (SD 1.37) clinical sessions during the assessment month. Paired samples
To our knowledge, this study is one of the first to use the HRQoL measure as an outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Further follow-up of reported HRQoL over several months is needed.
Nearly 1 in 5 adults in the United States (51.5 million people) experience mental health issues [
Despite the well-known adverse health conditions and negative economic outcomes, accessing treatment for common mental health problems is difficult [
Many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7) for assessing initial and treatment outcomes of depressive and anxiety symptoms, respectively. As behavioral coaching focuses on goal-oriented behavior and typically targets those with subclinical symptomatology, traditional clinical measures may not adequately capture symptom improvement in general mental health and well-being. State and federal health agencies have supported the population surveillance of health-related quality of life (HRQoL), which is a multidimensional concept that examines overall health related to perceived physical and mental health as well as daily functioning [
The purpose of this study was to examine self-reported HRQoL among members using an on demand digital health platform and the association of short-term text-based behavioral health coaching and virtual clinical sessions with healthy days over time. To that end, the study will describe baseline characteristics of members in terms of reported unhealthy days and changes over 1 month, describe changes in unhealthy days as a function of baseline anxiety and depressive symptoms, and examine the association between member engagement and changes in unhealthy days.
Participants were members who had access to the Ginger on demand behavioral health platform as part of their employer or health plan benefits. Internal clinical protocols include exclusionary criteria where self-directed telehealth is likely not appropriate and where more specialized and urgent psychiatric services are required (eg, active suicide ideation or active high-risk self-harm behavior; see Kunkle et al [
The Ginger platform provides members with access to virtual behavioral health coaching, teletherapy, telepsychiatry, and self-guided content and assessments, primarily via a mobile app platform. After downloading the mobile app, members can start texting with a behavioral health coach within minutes of requesting to connect. Ginger coaches are full-time employees who have an advanced degree in a field related to mental health or have accredited coach certification. While many members are solely engaged with text-based coaching services, some will request or require escalation to clinical services (teletherapy or telepsychiatry) depending on preference or clinical severity. When members are escalated to therapy or psychiatry, they may continue working with a coach provided they also seek additional specialized care concurrently. Additional detail regarding Ginger can be found in prior publications [
The Healthy Days measure was administered to members 4 times across the span of 4 months (once per month). Data were collected externally using the Survey Monkey platform. Only responses from survey items pertaining to the number of unhealthy mental health days and impacted days were of focus for this study. The PHQ-9 and GAD-7 were typically completed at intake within 1 month of the Healthy Days baseline assessment.
The CDC Healthy Days measure contains four items: (1) “Would you say that in general your health is excellent, very good, good, fair, or poor?” (2) “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” (3) “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” and (4) “During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?” (referred to here as impacted days). For this study a change variable was calculated by subtracting reported unhealthy scores from time 1 from scores from time 2, where positive values indicate an increase in unhealthy days, whereas negative values indicate a reduction in unhealthy days.
The PHQ-9 is a 9-item self-report questionnaire that assesses the frequency and severity of depression symptomatology within the previous 2 weeks. Each of the 9 items is based on the
The GAD-7 is a valid brief self-report tool to assess the frequency and severity of anxious thoughts and behaviors over the past 2 weeks. Each of the 7 items are based on the
Member engagement with Ginger services was quantified as the number of coaching and clinical sessions. Coaching sessions were operationalized as the number of unique days where both members and coaches each sent at least 5 text messages. Ginger coaching is an on demand text-based service, and the operationalization of a “text-based coach session” has not been predetermined in the literature. As such, our threshold was decided based upon internal work that highlighted approximately 5 texts each way as the number of text messages needed to capture a productive conversation between members and their coaches. Clinical sessions were operationalized as the number of completed video sessions with a clinician.
Analyses were conducted using RStudio (version 1.4.1717; RStudio, PBC). Data were first screened for outliers and normality. Descriptive statistics were used to describe baseline member characteristics. For changes in reported unhealthy days, paired sample
This is a secondary analysis of pre-existing deidentified data. The authors do not have access to participant identifying information and do not intend to recontact participants. Ginger’s research protocols and supporting policies have been reviewed and approved by Advarra’s institutional review board (Pro00046797) in accordance with the US Department of Health and Human Services regulations at 45 CFR 46.
A total of 1496 members completed the Healthy Days measure at time 1 (intake), 351 (23.5%) members at time 2 (~30 days following intake; mean 31.9, SD 1.48 days), 114 members at time 3 (~60 days following intake), and 37 members at time 4 (~90 days following intake). The current analyses examined only members who had completed surveys at both time 1 (intake) and at time 2 (N=288). Data were missing at random for all primary outcome variables (
Descriptive statistics for the primary variables are presented in
Descriptive statistics among primary variables.
|
Values, mean (SD) | Min | Max |
Physical health (time 1) | 5.1 (7.8) | 0 | 30 |
Mental health (time 1) | 16.0 (8.8) | 0 | 30 |
Impacted health (time 1) | 10.9 (9.6) | 0 | 30 |
Physical health (time 2) | 5.6 (8.3) | 0 | 30 |
Mental health (time 2) | 13.2 (9.0) | 0 | 30 |
Impacted health (time 2) | 8.2 (8.5) | 0 | 30 |
Coaching sessions | 1.9 (2.2) | 0 | 12 |
Clinical sessions | 0.9 (1.4) | 0 | 5 |
Depression score (PHQ-9a) | 11.3 (6.1) | 1 | 27 |
Anxiety Score (GAD-7b) | 9.8 (5.7) | 0 | 21 |
aPHQ-9: Patient Health Questionnaire-9.
bGAD-7: General Anxiety Disorder-7.
Correlations among primary variables. Note: Insignificant correlations where
Members reported on average nearly 3 fewer unhealthy mental health days (mean –2.71, SD 8.03) between baseline and 1 month later. Of the analytical sample, 61% (n=175) of members reported an improvement in unhealthy mental health days, whereas 39% (n=113) reported no improvement or an increase in unhealthy mental health days. Paired sample
Display of means across the items from the Healthy Days measure at time 1 and time 2 (N=288).
Subclinical members showed trending reductions in reported unhealthy mental health days between time 1 (mean 9.92, SD 6.78 days) and time 2 (mean 8.44, SD 7.83 days;
Similarly, subclinical members showed significant reductions in reported impacted days at time 1 (mean 5.15, SD 6.64 days) compared to time 2 (mean 3.47, SD 5.3 days;
The linear regression model predicting changes in reported unhealthy mental health days was significant (
Summary of regression coefficients (N=288).
|
Beta (SE) | ||||
|
|||||
|
(Intercept) | –2.71 (0.43) | <.001 | ||
|
Unhealthy mental health days (baseline) | –3.32 (0.43) | <.001 | ||
|
Prior coaching sessions | 0.39 (0.47) | .42 | ||
|
Prior clinical sessions | 0.59 (0.47) | .21 | ||
|
Clinical sessions | –0.96 (0.47) | .04 | ||
|
Coaching sessions | 0.61 (0.47) | .19 | ||
|
|||||
|
(Intercept) | –2.75 (0.38) | <.001 | ||
|
Unhealthy impacted days (baseline) | –3.87 (0.38) | <.001 | ||
|
Prior coaching sessions | –0.30 (0.42) | .48 | ||
|
Prior clinical sessions | 0.10 (0.41) | .80 | ||
|
Clinical sessions | –0.40 (0.41) | .33 | ||
|
Coaching sessions | 0.43 (0.41) | .30 |
This study evaluated the real-world association between digital care utilization in members with both subclinical and clinical symptoms of anxiety or depression. HRQoL at baseline suggested that members were, on average, demonstrating “frequent distress” and reporting more
Not all individuals seeking out care exceeded industry clinical thresholds. Thus, additional outcome measures, such as the Healthy Days measure, are needed to evaluate the effects of digital mental health care beyond clinically focused measures (eg, PHQ-9 and GAD-7). To our knowledge, we are one of the first to use the Healthy Days measure within this population (ie, individuals seeking out virtual mental health care). Overall, members reported a reduction of 2.71 unhealthy mental health days. Extrapolating from the Humana data [
Our results found a significant association between the reduction in the number of reported unhealthy mental health days and member engagement with clinical sessions, but not with coaching sessions. Coaching, and even more so text-based coaching, differs fundamentally in their objectives and practices compared to clinical care [
There are several limitations to consider. One limitation is the potential for bias in our estimates and the increased likelihood that our results may not generalize to all individuals who engage with teletherapy. Furthermore, our cohort design did not have a comparison group or random assignment to the treatment intervention. Thus, our ability to draw causal inferences is limited and improvements in reported unhealthy days could simply be due to a passage of time; however, we were able to demonstrate significant changes in members with both subclinical and clinical symptoms using real-world longitudinal data. Even though data were missing at random and may not bias results, future studies should implement procedures (eg, incentives) to encourage and capture more complete follow-up data. Future studies can also examine obstacles and facilitators for engagement in teletherapy. The study was also limited to available self-reported outcome data, and there was a large amount of attrition in members reporting unhealthy days over time. This could be due to most members not experiencing clinically meaningful baseline symptomatology and potentially quick improvements in functioning. It is also possible that because the survey was administered outside of the Ginger platform (ie, Survey Monkey), the additional step of completing the measure might have been an added time burden. However, this approach allowed us to pilot and demonstrate the real-world attrition rate when using external data collection platforms.
To our knowledge, this study is one of the first to use the HRQoL measure as a primary outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Virtual care represents a scalable and well-suited approach to meet the growing need for mental health services that has outpaced the in-person availability of clinical mental health professionals. Future studies should examine the long-term impact of text-based coaching and clinical support on HRQoL.
Centers for Disease Control and Prevention
Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)
General Anxiety Disorder-7
health-related quality of life
Patient Health Questionnaire-9
We are grateful for the participation of the members who completed the survey, as well as the hard work and dedication of Ginger coaches and clinicians.
All authors are paid employees of Ginger.