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Depression Prevention (Managing Your Mood)

The Depression Prevention (Managing Your Mood) program is a computer-tailored intervention for adults who are experiencing at least mild symptoms of depression. The program is based on the Transtheoretical Model of Behavior Change (TTM), which conceptualizes change as a process that occurs over time and in five stages: precontemplation, contemplation, preparation, action, and maintenance. The goal of the program is to help individuals take proactive steps to recognize, manage, and reduce their depression symptoms and to prevent the onset of major depression. Improvement in physical functioning is also targeted, given the link between depression, medical illness, and physical functioning.

The intervention components include (1) a series of three brief assessments spaced at least 1 month apart and (2) workbook activities completed after each assessment. The total duration of the program is about 3-6 months depending on the time elapsed between assessments. The program can be completed entirely online as a self-guided intervention, or by telephone or in person using trained "health coaches" or clinicians to collect the assessment data. At each assessment, a computerized program automatically analyzes the participant's responses and generates an individualized report that provides feedback on:

  • The participant's current level of depression
  • The benefits of using methods known to prevent or reduce depression, including controlling negative thinking; engaging in healthy, pleasant activities; practicing stress management; exercising; and getting professional help when needed
  • The participant's current stage of change for using those effective methods
  • The participant's current use of each of the five specific methods
  • Up to seven stage-matched principles and processes of change that can help transition the participant to the next stage of change

The workbook builds on the reports by providing exercises and tools to facilitate progress toward the next stage of change. Each report refers the participant to the workbook sections that will be most helpful based on the last assessment. The workbook also provides tips on how to monitor one's mood and keep up depression prevention activities in the action and maintenance stages.

No specialized staff are required to implement the online Depression Prevention program. The health coaches delivering the program by telephone or in person should have a bachelor's or master's degree in the health or social sciences (e.g., nursing, nutrition, public health, psychology).

The clinical trial reviewed for this summary used the version of the program that included telephone assessments with feedback reports and a print manual delivered to the home.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: March 2012
1: Level of depression
2: Onset of major depression
3: Physical functioning
Outcome Categories Mental health
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Home
Geographic Locations Urban
Suburban
Implementation History Although exact usage data are not available, the developer estimates that the Depression Prevention (Managing Your Mood) program has been disseminated to thousands of individuals in the United States since 2006, primarily through employers and insurers.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: No
Adaptations The program has been adapted for primary care patients who were recently prescribed an antidepressant medication by tailoring assessments and individualized feedback to this group and by adding a booklet with questions and answers on antidepressants. It also has been adapted for Veterans receiving services at a VA hospital.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: March 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Levesque, D. A., Van Marter, D. F., Schneider, R. J., Bauer, M. R., Goldberg, D. N., Prochaska, J. O., & Prochaska, J. M. (2011). Randomized trial of a computer-tailored intervention for patients with depression. American Journal of Health Promotion, 26(2), 77-89.  Pub Med icon

Supplementary Materials

Supporting Information for Depression Prevention Study

Outcomes

Outcome 1: Level of depression
Description of Measures Level of depression was assessed at baseline and 9-month follow-up using the Beck Depression Inventory, 2nd Edition (BDI-II). The BDI-II is a 21-item, self-report measure of depression severity. In contrast to its predecessors, the BDI-II assesses all of the DSM diagnostic criteria for depression. Participants were considered to have experienced "clinically significant" improvement if their BDI-II scores met both of the following criteria: (a) the follow-up score was at least 5 points lower than at baseline, and (b) the follow-up score was less than or equal to 9 points.
Key Findings Study participants were adults experiencing at least mild symptoms of depression but not involved in or planning to seek treatment for depression. Participants were recruited from their primary care clinic and were randomly assigned to the intervention and control groups. The intervention group participated in telephone interviews at baseline, 1 month postbaseline, and 3 months postbaseline and received three computer-tailored reports and a workbook. The control group received usual care but did not receive contact during the study other than the baseline assessment and 9-month follow-up. At all assessments, intervention and control participants were called by a site clinician if their BDI-II scores indicated suicide risk (called within 1 hour) or severe depression (called within 24 hours).

From baseline to 9-month follow-up, the intervention group experienced significantly greater improvements in level of depression, with an average decrease of 7.9 (SD = 9.6) points on the BDI-II, whereas scores for the control group decreased an average of 4.8 (SD = 7.7) points (p < .001). This result had a small effect size (Cohen's d = .36). Participants in the intervention group were more likely than those in the control group to have experienced a clinically significant improvement in depression, based on an analysis of the two statistical criteria used to define clinically significant change; 35.3% of the intervention group had a clinically significant improvement, compared with 23.3% of the control group (p < .05). This result had a small effect size (Cohen's d = .27).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 2: Onset of major depression
Description of Measures Major depression was assessed at baseline and 9-month follow-up using the 9-item Patient Health Questionnaire (PHQ-9), the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Items are based on the nine DSM-IV criteria for depression. Respondents indicate how often they experienced symptoms in the past 2 weeks (e.g., "little interest or pleasure in doing things"; "feeling down, depressed, or hopeless") using a scale from 0 (not at all) to 3 (almost every day).
Key Findings Study participants were adults experiencing at least mild symptoms of depression but not involved in or planning to seek treatment for depression. Participants were recruited from their primary care clinic and were randomly assigned to the intervention and control groups. The intervention group participated in telephone interviews at baseline, 1 month postbaseline, and 3 months postbaseline and received three computer-tailored reports and a workbook. The control group received usual care but did not receive contact during the study other than the baseline assessment and 9-month follow-up. At all assessments, intervention and control participants were called by a site clinician if their BDI-II scores indicated suicide risk (called within 1 hour) or severe depression (called within 24 hours).

Among patients who had mild symptoms of depression at baseline (not experiencing major depression), rates of onset of major depression at 9-month follow-up were 2.2% for the intervention group vs. 15.7% for the control group (p < .05). This result had a medium effect size (Cohen's d = .52).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 3: Physical functioning
Description of Measures Physical functioning was assessed at baseline and 9-month follow-up using selected subscales of the 20-item Medical Outcomes Study Short Form-20 (SF-20) questionnaire. The SF-20 measures six aspects of health status: physical functioning (6 items), role functioning (2 items), social functioning (1 item), mental health (5 items), general health perceptions (5 items), and bodily pain (1 item). An overall measure of physical functioning was derived by taking the mean of the physical functioning, role functioning, health perceptions, and pain subscales, after each was linearly transformed to range from 0-100. Higher mean scores indicated better physical functioning.
Key Findings Study participants were adults experiencing at least mild symptoms of depression but not involved in or planning to seek treatment for depression. Participants were recruited from their primary care clinic and were randomly assigned to the intervention and control groups. The intervention group participated in telephone interviews at baseline, 1 month postbaseline, and 3 months postbaseline and received three computer-tailored reports and a workbook. The control group received usual care but did not receive contact during the study other than the baseline assessment and 9-month follow-up. At all assessments, intervention and control participants were called by a site clinician if their BDI-II scores indicated suicide risk (called within 1 hour) or severe depression (called within 24 hours).

Between baseline and 9-month follow-up, the intervention group experienced significantly greater improvements in physical functioning compared with the control group (p < .05). The intervention group improved an average of 6.5 (SD = 16.9) points on the physical functioning measure, whereas the control group improved an average of 1.2 (SD = 17.3) points. This result had a small effect size (Cohen's d = .31).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult) 		67% Female
33% Male 		55% White
25% Black or African American
13% Race/ethnicity unspecified
7% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Level of depression 4.0 4.0 3.5 3.3 3.3 4.0 3.7
2: Onset of major depression 4.0 3.8 3.5 3.3 3.3 4.0 3.6
3: Physical functioning 4.0 4.0 3.5 3.3 3.3 4.0 3.7

Study Strengths

The three outcome measures used in the study are established instruments with good reliability and validity and have been used in numerous studies conducted by different investigators. Intervention fidelity was ensured through the use of senior researchers following a computer-assisted telephone interview protocol to collect the assessment data and by the use of preprogrammed decision rules to tailor the intervention based on assessment results. The randomization process was well described, and appropriate statistical analyses were performed, including power calculations and computation of effect sizes.

Study Weaknesses

Attrition in the intervention and control groups was high enough to be a limitation of the study, despite the use of intent-to-treat and multiple imputation analyses to address potential bias from missing data and differential attrition. The study included only one follow-up at 9 months postbaseline.
Readiness for Dissemination
Review Date: March 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Pro-Change Behavior Systems, Inc. (2006). Mastering change: A coach's guide to using the Transtheoretical Model.

Pro-Change Behavior Systems, Inc. (2009). TTMX user manual.

Program Web site, http://www.prochangelifestyle.com

Training Web site, http://www.prochange.com/e-learning

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
3.5 3.3 3.5 3.4

Dissemination Strengths

Both the printed and online materials are high quality and professional in appearance, and the online materials make good use of multimedia. The computerized program tailors the intervention based on the individual's responses and provides immediate feedback; there is also an option to provide feedback by telephone. The training materials are presented in an easy-to-use, engaging format. A train-the-trainer option is available for larger implementation sites. A comprehensive technical assistance manual describes system requirements and outlines the user and administrator functions, including how to generate participant reports. The program is designed to generate preprogrammed choices for response, so clients with similar concerns receive consistent feedback. Program modules cannot be altered without contacting the developer's programmers, which contributes to overall fidelity. Aggregate and individual progress can be tracked through the program's reporting functions, and participants can print out reports with action steps customized to the responses they have given.

Dissemination Weaknesses

Some of the rating scales used in the assessments do not align well with the questions asked. Although the program is largely automated, some implementers may not have the technical knowledge and experience to be comfortable implementing a program of this nature without additional support. It is unclear whether there is a process in place to collect participant feedback for ongoing program improvement. No guidance is provided on how implementers should use quality assurance data to improve program delivery.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Program license $35 per year per individual user

Or

$20 per year per individual user (organizational rate)

Or

$40,000 annual flat rate for large-scale implementation

 		Yes
TTMX User Manual (used for organizational and large-scale implementation only) Free Yes
Coach's Guide $20 each No
4-hour "Basic TTM Training" online course $100 per person No
On-site training on TTM for health coaches $3,000 per day plus travel expenses No
On-site training for trainers $3,000 per day plus travel expenses No
Phone and email support/technical assistance $180 per hour No
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Janice M. Prochaska, Ph.D.
(401) 360-2971
jmprochaska@prochange.com

To learn more about research, contact:
Deborah A. Levesque, Ph.D.
(401) 360-2975
dlevesque@prochange.com

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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