Treatment of Depression Using a Mobile Application in the Dominican Republic

Study design: The investigators will implement an Optimization, Effectiveness and Implementation (OEI) Hybrid Trial, based upon preliminary work. During the first six months, the investigators will upgrade and modify the mental health app, EBCM, to improve the interface and user friendliness. Aim 1 (Optimization): Investigators will integrate app enrollment within a mental health hotline staffed by research assistants who are licensed psychologists. Protocols will be developed and produced for all hotline volunteers, including depression screening, evaluation and criteria for referral, and recruitment of individuals for study participation. Facilitators will receive extensive training for encouraging and guiding participants in usage of the app, and for facilitating chat rooms among the EBCM-G study arm. Process outcomes assessed among the app facilitators will include 1) feasibility, 2) fidelity, 3) acceptability of the training, and 4) perceived confidence in identifying and managing patients' symptoms of depression. Aim 2 (Effectiveness and Implementation): Investigators will conduct an RCT with 120 participants who will be randomized to receive either the group treatment modality (El Buen Consejo Móvil-Group; EBCM-G) or the individual treatment modality (El Buen Consejo Móvil-Individual; EBCM-I). Participants will be followed for the duration of the 6-week intervention. Participants randomized to EBCM-G will be placed in groups of five participants within the app. Their version of the app will have the functionality to connect individuals to one another via a facilitator-guided chat room where they may respond to suggested strategies within the app and communicate with each other or their facilitator using voice or text. Participants randomized to EBCM-I will receive the same program contents without the group functionality. Procedures: For study recruitment, research assistants staffing the hotline will screen patients initially with the PHQ-2,and GAD-2 followed by the PHQ-9 and/or GAD-7 if positive, and will refer individuals with mild to moderate depression to the research team for an explanation of the study and the informed consent process. Study participants will undergo baseline data collection after providing informed consent, and will then be provided with one week of prepaid internet access to allow them to download and begin using the EBCM app. Upon installing the app, participants will watch an an introductory video on how to navigate the app. After initial log-in, participants will be randomized to EBCM-G or EBCM-I using a computer-generated randomization series. After demonstrating engagement with the app during the first week, participants will receive additional prepaid internet access to continue using the app during the subsequent five weeks. EBCM will be delivered in twice daily 1-3-minute presentations. The facilitators will undergo extensive training and will also formally consent to study participation. They will participate in mock-trials of dissemination, and interviews concerning implementation of the app. For their training in facilitation of treatment engagement, they will first receive two days of training in the scripted protocol for app coaching including the previously developed EMPDA Motivational Interviewing intervention, such as the use of supportive dialogue such as praise, reminders, non-judgmental suggestions. Facilitators will also be trained in criteria for referral in the event of symptom exacerbation or suicidal ideation as well as confidentiality and privacy during this first phase of training. Second, the facilitators will participate in a one-week trial period of the EBCM app where supportive dialogue will be modeled by the PI's responses to comments within the app. Third, through the administration of the Internet-delivered CBT - Therapist Rating Scale (ICBT-TRS), the investigators will provide feedback to the facilitators related to their fidelity to CBT principles. During the first week, monitoring and responses will be provided on a daily basis according to a scripted protocol, while during the second and third weeks, the facilitators will review the responses to each session three times/week and offer feedback to each participant. Finally, during Weeks 4-6, participants will receive responses on a twice weekly basis. The facilitators will participate in weekly in group discussions with the PI (Dr. Susan Caplan) and Co-Investigator (Lic. Angelina Sosa Lovera) using a secure group platform to share information and reinforce best practices.