A self-help mobile messaging intervention to improve subthreshold depressive symptoms among older adults in a socioeconomically deprived region of Brazil (PRODIGITAL): a pragmatic, two-arm randomised controlled trial

Carina Akemi Nakamura; Nadine Seward; Tim J Peters; Thiago Vinicius Nadaleto Didone; Felipe Azevedo Moretti; Marcelo Oliveira da Costa; Caio Hudson Queiroz de Souza; Gabriel Macias de Oliveira; Monica Souza Dos Santos; Luara Aragoni Pereira; Mariana Mendes de Sá Martins; Pepijn van de Ven; William Hollingworth; Ricardo Araya; Marcia Scazufca

doi:10.1016/j.lana.2024.100897

A self-help mobile messaging intervention to improve subthreshold depressive symptoms among older adults in a socioeconomically deprived region of Brazil (PRODIGITAL): a pragmatic, two-arm randomised controlled trial

Lancet Reg Health Am. 2024 Oct 7:39:100897. doi: 10.1016/j.lana.2024.100897. eCollection 2024 Nov.

Authors

Carina Akemi Nakamura^{1

2}, Nadine Seward^{3

4}, Tim J Peters⁵, Thiago Vinicius Nadaleto Didone¹, Felipe Azevedo Moretti¹, Marcelo Oliveira da Costa¹, Caio Hudson Queiroz de Souza¹, Gabriel Macias de Oliveira¹, Monica Souza Dos Santos¹, Luara Aragoni Pereira⁶, Mariana Mendes de Sá Martins¹, Pepijn van de Ven⁷, William Hollingworth⁸, Ricardo Araya³, Marcia Scazufca^{1

6}

Affiliations

¹ Departamento de Psiquiatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.
² Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
³ Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁴ Department of Clinical Psychology, Health and Social Science, University of Edinburgh, Edinburgh, UK.
⁵ Bristol Dental School, University of Bristol, Bristol, UK.
⁶ Instituto de Psiquiatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
⁷ Health Research Institute, University of Limerick, Limerick, Ireland.
⁸ Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.

Abstract

Background: Subthreshold depression is a risk factor for major depression and is associated with increased morbidity and mortality, especially in older adults. There is emerging evidence that digital interventions, including self-help interventions, may reduce depressive symptoms. We aimed to evaluate the effectiveness of a mobile messaging intervention at reducing subthreshold depressive symptoms among older adults in Brazil.

Methods: PRODIGITAL was a single blind, two-arm, individually randomised controlled trial conducted in 46 primary care clinics in the city of Guarulhos, Brazil. Individuals aged 60+ years were contacted by phone following a randomly ordered list for a screening assessment. Those who presented with anhedonia and/or depressed mood (Patient Health Questionnaire (PHQ)-2≥1), and who subsequently scored between 5 and 9 on the PHQ-9 were invited to participate. The intervention arm received the 'Viva Vida' digital self-help intervention consisting of automated multi-media messages sent via WhatsApp. Forty-eight audio and visual messages based on psychoeducation and behavioural activation were automatically delivered over six weeks. The control arm received a single message containing information about depression. The primary outcome was the difference in mean PHQ-9 scores between treatment arms at the three-month follow-up. All primary analyses were performed according to allocated arm with imputed data. The trial is registered with ReBEC, RBR-6c7ghfd.

Findings: Participants were recruited between 8 September 2021 and 19 August 2022. Of the 454 participants enrolled, 223 were randomised to the intervention arm, 231 to the control arm. Participants' mean age was 65.3 years (SD 5.0) and 64.0% (n = 292) were female. A total of 385 (84.8%) completed the three-month follow-up assessment; no difference in mean PHQ-9 scores between the treatment arms was observed (adjusted difference: -0.61; 95% CI: -1.75, 0.53; p = 0.29).

Interpretation: These results demonstrate that the Viva Vida digital self-help intervention did not help to improve subthreshold depressive symptoms amongst older adults. Further research is needed to understand why this self-help intervention was not effective in this population, and to explore how it might be adapted to achieve this goal.

Funding: São Paulo Research Foundation and UK Joint Global Health Trials.

Keywords: Brazil; Depression; Digital intervention; LMIC; Older adults; Primary healthcare; Psychosocial intervention; Randomised controlled trial; Subthreshold depression.