Evaluation of MoodRing on Improving the Quality of Depression Management in Adolescents (TECH-E)

Technology and Emotion Study "TECH-E": Randomized Controlled Trial of MoodRing Compared to Usual Care: Mobile Monitoring of Adolescent Depression Phase II

The MoodRing intervention is a mobile application for adolescents, parents, and an accompanying web-based clinician portal which enables adolescents to monitor their mood through the use of passively collected smartphone data. This randomized controlled trial will evaluate whether MoodRing as compared to usual care improves the quality of depression management.

This is a randomized controlled trial to evaluate the efficacy of MoodRing as compared to usual care for adolescents who have a prior diagnosis of depression. Adolescents with depressive symptoms, their parents, and their mental healthcare providers (if interested) will participate in a 6 month study. Adolescents age 12-18 and their parent will be consented for the study and be sent an online survey to obtain baseline measures. Those who complete the baseline measures will then be randomized to receive the MoodRing intervention or treatment as usual. Adolescents and parents will be asked to complete data collection at 3 months and 6 month time points post-randomization by online survey. Additionally, data will be collected for 3 and 6 month timepoints via the adolescent's electronic health record data. At 6 months, online surveys will be sent and an invitation to interview for patients' mental healthcare providers who consent to participate in the study. Adolescent-parent dyads will be randomized at a 1:1 ratio (using randomized block sizes) to either 1) MoodRing or 2) usual care. 100 adolescent-parent dyads (200 total individuals) will be randomized to MoodRing and 100 adolescent-parent dyads (200 total individuals) will be randomized to usual care. We expect 50 clinicians will participate. In both arms, passively collected data will be obtained from adolescent smartphones as well as weekly mood surveys and monthly sleep surveys. In the 1) MoodRing arm adolescents will download the MoodRing-adolescent app, parents will download the MoodRing-parent app, and healthcare providers if interested will have access to a clinician dashboard. The randomization tables will be generated by the study statistician. The investigators hypothesize that adolescents who receive MoodRing as compared to usual care will have: H1: Improved self-management of depression as measured by change of baseline for the average score on the Partners in Health Scale EH2: The investigators will also explore whether MoodRing as compared to usual care will result in improved quality of depression management as measured by frequency of symptom reassessment, medication adherence, and therapy adherence, less healthcare utilization, decreased depression symptoms, improved sleep quality, and increased application of self-management activities through increased self-efficacy, utilization of self-management skills and knowledge and social support. H3: The investigators anticipate healthcare providers, adolescents, and parents will report satisfaction with use of MoodRing.

Adolescent, Adolescent Medicine, Mental Health Services, eHealth, Mobile Applications, Symptom Management

This study will use a parallel study design, where participants are randomized into two intervention groups (Usual Care or MoodRing) and will receive interventions in parallel.

Participants in this arm will receive no intervention and access treatment as usual per their mental health services provider. A mobile application (AWARE) which is not interactive and is only for purposes of data collection will be downloaded on the adolescents' smartphone.

Adolescent participants in this arm will download two mobile applications - a data collection non-interactive app to collect passive sensing data (AWARE) and the MoodRing (MR) mobile application with which they can visualize their data about their mood, sleep, activity, enter their own mood score, and access psychoeducational resources including links to a research-based website, SOVA. Their parents will download a parent MoodRing application which provides them with parenting resources and articles and a weekly report of their adolescents' mood as predicted by passive sensing. Clinical providers will receive access to a web portal where they can view their adolescent patients' data who are enrolled in the study.

Adolescents and parents in the MR arm will receive instructions to download the MR app and AWARE app, customize the app, utilize an app-based self-guided onboarding, and review questions with the research team. The MR app provides the adolescent and their parent a notification to view a weekly report predicting their mood score (i.e. depression severity level similar to the Patient health questionnaire-9). The MR app will provide a library of coping strategies for adolescents and opportunities to self-track their mood. Clinicians in the MR Arm will get access to a MR portal online. They will be able to view patients they are a provider for. The clinician will receive in-person and/or video-based training to use the portal.

Adolescents and parents in the usual care arm will receive instructions to download the AWARE app. This app will only track data and will not be interactive. Otherwise they will receive care as per routine by their healthcare provider team.

Adolescents will be asked the Partners in Health Scale The Partners in Health Scale (Battersby, 2003) assesses self-management with respect to a chronic condition, with regard to active involvement of a patient in managing their condition. Total scores range from 0 to 88 with higher scores indicating worse self-management.

Adolescents will be asked the Partners in Health Scale The Partners in Health Scale (Battersby, 2003) assesses self-management with respect to a chronic condition, with regard to active involvement of a patient in managing their condition. Total scores range from 0 to 88 with higher scores indicating worse self-management.

Attendance at a healthcare provider visit for depression symptom reassessment within the past 3 months (yes/no) measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

Out of adolescents who are taking an antidepressant, receipt of at least 60 consecutive days (yes/no) within the past 3 months, measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

Out of adolescents who are referred for psychotherapy, receipt of at least 3 sessions within the past 3 months (yes/no) measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

Number of visits for (combined total between adolescent self-report, parent self-report, and electronic health-record review): urgent care; emergency room; inpatient hospitalization; acute primary care provider visit for non-mental health related concern; medical or surgical subspecialist visit

Number of visits for (combined total between adolescent self-report, parent self-report, and electronic health-record review): urgent care; emergency room; inpatient hospitalization; acute primary care provider visit for non-mental health related concern; medical or surgical subspecialist visit

Adolescents will be asked the PHQ-9 Patient Health Questionnaire-9 measures depression severity with a score ranging from 0 to 27, a higher score indicating greater severity.

Adolescents will be asked the PHQ-9 Patient Health Questionnaire-9 measures depression severity with a score ranging from 0 to 27, a higher score indicating greater severity.

Adolescents will be asked Question 11 of Partners in Health Scale; and the average amount of time (Daily, More than once a week, Once a week, Once a month, Once a semester, Once a year, Less than once a year, Never) spent in potentially useful self-management activities: (1) created to-do lists to help me focus; (2) found strategies to create pleasurable distractions; (3) engaged in some physical activity (cycling, walking, etc.); (4) set realistic short-term goals; (5) made sure I had a good day/night routine with got enough sleep; (6) ensured enough rest to avoid getting exhausted; (7) left the house regularly; (8) ate healthy

Adolescents will be asked Question 11 of Partners in Health Scale; and the average amount of time (Daily, More than once a week, Once a week, Once a month, Once a semester, Once a year, Less than once a year, Never) spent in potentially useful self-management activities: (1) created to-do lists to help me focus; (2) found strategies to create pleasurable distractions; (3) engaged in some physical activity (cycling, walking, etc.); (4) set realistic short-term goals; (5) made sure I had a good day/night routine with got enough sleep; (6) ensured enough rest to avoid getting exhausted; (7) left the house regularly; (8) ate healthy

Adolescents will be asked the Mental Health Self-efficacy Scale (MHSES) The Mental Health Self-efficacy Scale (Clarke, 2014) measures one's belief in one's capability to perform mental health self-care behaviors. The score ranges from 6 to 60, with higher scores indicating higher confidence in mental health selfcare.

Adolescents will be asked the Mental Health Self-efficacy Scale (MHSES) The Mental Health Self-efficacy Scale (Clarke, 2014) measures one's belief in one's capability to perform mental health self-care behaviors. The score ranges from 6 to 60, with higher scores indicating higher confidence in mental health selfcare.

Adolescents will be asked the Medical Outcomes Study Social Support Survey The Medical Outcome Study Social Support Scale (Sherbourne, 1991) measures types of social support. This subscale ranges from 0-100, with higher levels associated with greater support.

Adolescents will be asked the Medical Outcomes Study Social Support Survey The Medical Outcome Study Social Support Scale (Sherbourne, 1991) measures types of social support. This subscale ranges from 0-100, with higher levels associated with greater support.

Adolescents will respond to the PROMIS Pediatric Sleep-Related Impairment scale. This scale has four questions with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 19 with higher scores indicating higher levels of sleep-related impairment.

Adolescents will respond to the PROMIS Pediatric Sleep-Related Impairment scale. This scale has four questions with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 19 with higher scores indicating higher levels of sleep-related impairment.

Adolescents will respond to the PROMIS Pediatric Sleep-Related Impairment scale. This scale has four questions with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 19 with higher scores indicating higher levels of sleep-related impairment.

Adolescents will respond to the PROMIS Pediatric Sleep Disturbance scale. This scale has four questions, the second (sleeping through the night) being reverse-scored, with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 20 with higher scores indicating higher levels of sleep disturbance.

Adolescents will respond to the PROMIS Pediatric Sleep Disturbance scale. This scale has four questions, the second (sleeping through the night) being reverse-scored, with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 20 with higher scores indicating higher levels of sleep disturbance.

Adolescents will respond to the PROMIS Pediatric Sleep Disturbance scale. This scale has four questions, the second (sleeping through the night) being reverse-scored, with response options of never, almost never, sometimes, almost always, and always, ranges from 4 to 20 with higher scores indicating higher levels of sleep disturbance.

Adolescents will respond to the School Based Sleep Habits Survey-Child Form which asks 43 questions about weekday and weeknight sleep patterns, sleep awakenings, and sleep time preferences.

Adolescents will respond to the School Based Sleep Habits Survey-Child Form which asks 43 questions about weekday and weeknight sleep patterns, sleep awakenings, and sleep time preferences.

Adolescents will respond to the School Based Sleep Habits Survey-Child Form which asks 43 questions about weekday and weeknight sleep patterns, sleep awakenings, and sleep time preferences.

Rating scale of General Mental Health A rating scale of General Mental Health (Cadigan, 2018) will be used with two questions each ranging from 1 to 5 with regard to a self-rating of general mental health. Adolescents will be asked this and parents about their perception of their adolescent's mental health.

Rating scale of General Mental Health A rating scale of General Mental Health (Cadigan, 2018) will be used with two questions each ranging from 1 to 5 with regard to a self-rating of general mental health. Adolescents will be asked this and parents about their perception of their adolescent's mental health.

The General-practice Users Perceived-need Inventory (GUPI) The General-Practice Users Perceived-Need Inventory (McNab, 2004) will be used to measure perceived need for treatment. There is no scoring. Adolescents will be asked this and parents about their perception of their adolescent's need for mental health services. The response will be evaluated by the total number of individuals who agree that they would like to or are already getting help with a) medication and b) counseling as comapred to those who respond they do not need this kind of help.

The General-practice Users Perceived-need Inventory (GUPI) The General-Practice Users Perceived-Need Inventory (McNab, 2004) will be used to measure perceived need for treatment. There is no scoring. Adolescents will be asked this and parents about their perception of their adolescent's need for mental health services. The response will be evaluated by the total number of individuals who agree that they would like to or are already getting help with a) medication and b) counseling as comapred to those who respond they do not need this kind of help.

Attendance at a healthcare provider visit for depression symptom reassessment within 3 months (yes/no) measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

Out of adolescents who are taking an antidepressant, receipt of at least 60 consecutive days (yes/no) measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

Out of adolescents who are referred for psychotherapy, receipt of at least 3 sessions within 3 months (yes/no) measured by adolescent, parent self-report and electronic health record review (yes if any are yes, no if all are no). The metric reported will be percentage of individuals per study arm with a 'yes' result.

System Usability Questionnaire (Bangor, 2008) asks 11 questions about the usability of a technological intervention. SUS scores range from 0-100. Higher scores indicate better usability.

Acceptability of Intervention Measure (AIM) (Weiner, 2017) asks 4 questions on a 1-5 Likert scale with completely disagree to completely agree with regards to acceptability of an intervention and 3 questions were added including with regards to efficiency, help taking care of patients, patient benefit from the intervention. Higher scores indicate higher acceptability. Also an open-ended question will be asked about feedback using MoodRing.

System Usability Questionnaire (Bangor, 2008) asks 11 questions about the usability of a technological intervention. SUS scores 0-100. Higher scores indicate better usability. Adolescents and Parents - only those randomized to the MoodRing arm - will be asked these questions.

Acceptability of Intervention Measure (AIM) (Weiner, 2017) asks 4 questions on a 1-5 Likert scale with completely disagree to completely agree with regards to acceptability of an intervention. Additional questions will be asked about perceived benefit, taking care of mental health, and confidence in mental health management. Higher scores indicate higher acceptability. Also an open-ended question will be asked about feedback using MoodRing. Adolescents and Parents - only those randomized to the MoodRing arm - will be asked these questions.

Adolescents will be asked the PHQ-8. Patient Health Questionnaire-8 measures depression severity with a score ranging from 0 to 24, a higher score indicating greater severity.

Adolescents will be asked the GAD-7 Generalized Anxiety Disorders 7-item Questionnaire measures extent of anxiety symptoms. The total score ranges from 0 to 21 with a higher score indicating greater severity.

Adolescents will be asked the GAD-7 Generalized Anxiety Disorders 7-item Questionnaire measures extent of anxiety symptoms. The total score ranges from 0 to 21 with a higher score indicating greater severity.

M-PACS (The Parent-Adolescent Communication Scale (Olson, 1985) modified for mental health) asks 20 questions with regards to communication between parents and adolescents, with responses 1-5 from strongly disagree to strongly agree. Some items are reverse scored with a higher scale score indicating better communication. Both adolescents and parents will be asked these questions.

M-PACS (The Parent-Adolescent Communication Scale (Olson, 1985) modified for mental health) asks 20 questions with regards to communication between parents and adolescents, with responses 1-5 from strongly disagree to strongly agree. Some items are reverse scored with a higher scale score indicating better communication. Both adolescents and parents will be asked these questions.

The CPCS (Child Parent Connectedness Scale) asks 5 questions from a scale of 1-5 from strongly disagree to strongly agree with regards to connectedness and relationship satisfaction with each other. A higher score indicates higher child-parent connectedness. Both adolescents and parents will be asked these questions.

The CPCS (Child Parent Connectedness Scale) asks 5 questions from a scale of 1-5 from strongly disagree to strongly agree with regards to connectedness and relationship satisfaction with each other. A higher score indicates higher child-parent connectedness. Both adolescents and parents will be asked these questions.

Adolescents who respond with anything besides "none" to the 9th question of the PHQ-9 will be asked to complete the brief CSSR-S scale. This scale asks two questions, have you (the participant) wished you (the participant) were dead or wished you (the participant) could go to sleep and not wake up? (yes/no) and have you (the participant) actually had any thoughts of killing yourself? (yes/no). Positive answers indicate suicidal thinking. These will be asked on an online survey. Those adolescents responding positively will complete a full CSSR-S interview.

Adolescents who respond with anything besides "none" to the 9th question of the PHQ-9 will be asked to complete the brief CSSR-S scale. This scale asks two questions, have you (the participant) wished you (the participant) were dead or wished you (the participant) could go to sleep and not wake up? (yes/no) and have you (the participant) actually had any thoughts of killing yourself? (yes/no). Positive answers indicate suicidal thinking. These will be asked on an online survey. Those adolescents responding positively will complete a full CSSR-S interview.

Adolescents who respond with positive answers to the brief CSSR-S will complete the full CSSR-S interview. The Columbia-Suicide Severity Rating Scale (C-SSRS) consists of interview questions regarding suicidal ideation, intensity of ideation, and suicidal behavior and will be asked with regards to preceeding 3 months. Researchers evaluate responses and categorize suicide severity based on these.

Adolescents who respond with positive answers to the brief CSSR-S will complete the full CSSR-S interview. The Columbia-Suicide Severity Rating Scale (C-SSRS) consists of interview questions regarding suicidal ideation, intensity of ideation, and suicidal behavior and will be asked with regards to preceeding 3 months. Researchers evaluate responses and categorize suicide severity based on these.

Inclusion Criteria: Adolescent: age 12 -18 prior or present history of depression per self-report and/or clinician diagnosis scores between 5 or higher on PHQ-9 consistent with at least mild symptoms of depression read and understand English has an Android or iOS smartphone compatible with AWARE mobile application and access to a smartphone data plan currently in United States Parent/Guardian: adolescent qualifies for study and assents to enroll understands English currently in United States has a smartphone device that can download the intervention application Healthcare Provider: - involved in providing mental health treatment (psychotherapy or antidepressant prescribing or making referrals) to adolescent participant - can be a primary care provider, therapist, subspecialist, psychiatrist Exclusion Criteria: Adolescent: currently actively suicidal (have suicidal thoughts and plan with an intent to act on it) plans to travel to countries belonging to the European Union (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, The Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden), the United Kingdom (England, Scotland, Wales, and Northern Ireland), Norway, Iceland, or Lichtenstein in the next 6 months for more than 2 weeks at a time Parent: - If their adolescent child is excluded Healthcare Provider: - None

Trial outcome data can be accessed by contacting the study principal investigator. Otherwise there is currently no formal plan for data sharing.