JMIR Publications

ABSTRACT

Background:

Internet-based depression screening is frequently used and promoted by mental health providers. Recent evidence, however, indicates that it does not create substantial health benefit and there is criticism that it might be associated with unnecessary harm. Yet, systematic empirical evidence on postulated negative effects is missing.

Objective:

We aimed to examine whether automated feedback after internet-based depression screening is associated with misdiagnosis, mistreatment, deterioration in depressive symptoms, deterioration in emotional response to symptoms, and deterioration in suicidal ideation.

Methods:

This secondary analysis entails data from the German-wide, randomised controlled DISCOVER trial testing the efficacy of automated feedback after internet-based depression depression. Undiagnosed but affected individuals with a positive depression screening score (Patient Health Questionnaire-9, PHQ-9 ≥ 10 points) were randomised 1:1:1 to receive no, nontailored feedback, or tailored feedback on their screening result together with recommendations to seek professional diagnostic advice. Participants were followed-up at one and six months via online questionnaires. Misdiagnosis and mistreatment were operationalised as having received a depression diagnosis by a health professional and as having started psychotherapy or antidepressant medication since screening while not meeting the DSM-5 criteria of a major depression (diagnostic telephone interviews). Deterioration in depressive symptoms was defined as a pre-post change of ≥ 4.4 points in the PHQ-9, deterioration in emotional response to symptoms as a pre-post change of ≥ 3.1 points in a composite scale based on the Brief Illness Perception Questionnaire, and deterioration in suicidal ideation as a pre-post change of ≥ 1 point in the PHQ-9 suicide item. Outcome rates were compared between both feedback arms and the no feedback arm in terms of relative risks (RR). Data collection was conducted between Jan 12, 2021, and Sept 30, 2022.

Results:

In the per protocol sample of 948 participants (72% female; mean [SD] age, 37.3 [14.1] years), rates of misdiagnosis (six months; 3.5%-4.9%), mistreatment (six months; 7.2%-8.3%), deterioration in depression severity (one and six months; 2%-6.8%), deterioration in emotional response (one and six months; 0.7%-2.9%), and deterioration in suicidal ideation (six months; 6.8%-13.1) were not higher in the feedback arms compared to the no feedback arm (RRs ranging between 0.46 and 1.96, ps ≥ 0.128). The rate for deterioration in suicidal ideation at one month was higher in the nontailored feedback arm (RR=1.92; p = 0.014), but not in the tailored feedback arm (RR=1.26, P=0.427), with rates of 12.3%, 8.1%, and 6.4% in the nontailored, the tailored, and the no feedback arm, respectively. All but one sensitivity analyses supported the general findings and there were no indications for differential effects in the subgroup of false positive screens.

Conclusions:

The results indicate that feedback after internet-based depression screening is not associated with negative effects such as misdiagnosis, mistreatment, and deterioration in depression severity or in emotional response to symptoms. However, it cannot be ruled out that nontailored feedback may increase the risk of experiencing deterioration in suicidal ideation. Robust prospective research on negative effects and particularly suicidal ideation is needed and should inform current practice of public internet-based depression screening. Clinical Trial: Trial Registration: ClinicalTrials.gov (NCT04633096) Preregistration of data analysis: OSF.io (https://osf.io/tzyrd)