A multicomponent digital program with and without human support reduces anxiety and depression symptoms, compared with usual care, in adults with chronic medical conditions.

“People living with chronic illness need support not just for the disease, but also for the experience of living with the disease,” Puneeta Tandon, MD, professor of medicine at the University of Alberta in Edmonton, told Medscape News Canada. “As clinicians, we are good at treating organ-specific problems, but the whole-person burden of chronic illness — the anxiety, low mood, and exhaustion — is often where patients have fewer practical options.”

Treatments are available, however, and this program is one option. “While these [digital] skills don’t replace medication or mental health care when those are needed, they do give people a practical place to start — something they can do for themselves at home,” said Tandon.

Of note, the version of the program that paired the self-directed digital content with brief weekly telephone check-ins from trained nonclinicians did not perform better than the self-directed version alone.

The findings were published online on August 20 in PLOS Medicine.

Notable Improvement in Fatigue

The researchers enrolled 825 adults (mean age, 56 years; 84% women) with self-reported, physician-diagnosed chronic medical conditions — including primary biliary cholangitis, chronic digestive diseases, posttransplant status, cirrhosis, and heart failure — from 13 countries, mostly Canada and the US.

Participants were randomly assigned to a wait list control group; eMPower, a self-directed digital program integrating video-guided movement, breathwork, meditation practices, a psychology-based coping skills curriculum, and disease education; or eMPower plus weekly telephone check-ins (15 minutes or less) from nonclinician staff trained in motivational interviewing.

The primary outcome was change in the Hospital Anxiety and Depression Scale (HADS) total score at 12 weeks. Secondary outcomes included HADS anxiety and depression subscales, fatigue (Modified Fatigue Impact Scale), and health-related quality of life (Short Form-12 mental and physical component scores and EQ-5D-5L index score).

At follow-up, the eMPower plus support group showed a roughly 20% greater improvement than the control group. HADS total score and anxiety and depression subscales improved significantly.

In the prespecified primary comparison, eMPower plus human support was associated with a 2.9-point improvement in the HADS total score. Patients also reported improved quality of life and less fatigue. In exploratory analyses, the self-directed eMPower group also was associated with significantly improved HADS total score compared with the control group (2.6-point greater improvement).

Tandon was “struck by the fatigue result,” which showed a 19% relative improvement in the intervention groups. “Fatigue is one of the hardest symptoms to treat in chronic illness,” she said. “Patients frequently tell us how much fatigue affects their day-to-day lives, so seeing an improvement there was really meaningful.”

Overall, no significant differences were observed between the two program formats for any outcome, although the trial was not designed or powered to compare them directly. No intervention-related adverse events were reported in any group.

“We expected the weekly one-to-one check-ins to add benefit, Tandon said. “In our exploratory analysis, they did not. The self-directed and human-supported groups performed similarly, which has implications for scalability and cost.”

The researchers acknowledged the study’s limitations. For example, the 12-week follow-up could only assess short-term effects. Human support was provided by nonclinicians, and findings might be different with mental health professionals. The total number of chronic conditions per participant was not collected, which precluded any assessment of multimorbidity burden, which could influence treatment response. For the most part, the researchers relied on self-reported diagnoses for most participants, and the predominantly female and highly educated sample may limit the generalizability of the results.

Furthermore, the trial was conducted fully online, and 57% of participants lived outside urban areas. “While digital delivery can improve access for people who live farther from care, it can also create new barriers,” Tandon said. “Future versions will continue to improve accessibility, including offline access, additional languages, and more support for people with lower digital literacy.”

Nevertheless, the authors concluded that the study supports the program’s value. “Rather than developing separate digital programs for each condition, a single cross-condition approach with tailoring for disease-specific education is effective in addressing shared symptoms,” they wrote. “Comparable benefits between self-directed and supported formats highlight the feasibility of scalable, low-intensity delivery and reinforce the potential for real-world implementation to meet the needs of a growing population living with chronic conditions.”

‘Low-Risk’ Intervention

Commenting on the findings, Allison Grupski, PhD, a clinical psychologist at the National Center for Weight and Wellness in Washington, DC, said that the trial was well designed, with interventions based on well-studied models. The findings made sense and raised “no red flags.” Grupski is a specialist in health behavior change who was not involved in the study.

“This study was not designed to treat anxiety or depression, and the population was a medical one, not a psychiatric one,” she told Medscape News Canada. 

“The HADS is a screening tool and cannot diagnose depression or anxiety,” Grupski added. “More importantly, the baseline scores for the anxiety and depression subscales of the HADS were low or borderline for the participants in this study.”

“The difference between the baseline and 12-week scores was statistically significant and also meaningful, based on previously reported studies cited in the paper, but it’s not clear that the changes are practically meaningful,” she said.

The effect on fatigue was more notable, she added, “given the greater burden that fatigue had on the population at baseline.”

The lack of benefit from added telephone support, Grupski suggested, could result from the fact that the trial wasn’t powered to detect differences between the self-led and guided groups. The interventionists were not clinicians, and the guidance lasted for only 15 minutes or less per week, which is not comparable to traditional therapy. Moreover, patients with more severe psychiatric symptoms, who might benefit most from structured support, were excluded from the study.

Nevertheless, Grupski concluded, “Well designed, evidence-based digital interventions are low risk and can complement and maybe even improve some clinical outcomes — fatigue especially — in patients with chronic medical conditions.”

This study received funding from the Canadian Institutes of Health Research, Mitacs through the Canadian PBC Society and HeartLife, and from TRIANGLE. Tandon and Grupski declared having no relevant financial relationships. 

Marilynn Larkin, MA, is an award-winning medical writer and editor based in New York City whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.