This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking.
This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (
StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening.
Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it.
Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits.
Anxiety and depression are leading causes of disability worldwide, and in the wake of the COVID-19 pandemic, the personal, social, and economic costs of these conditions are expected to rise [
Digital mental health interventions (eg, web-based cognitive behavioral therapy), used alone or in blended models of care, have been highlighted as crucial tools for addressing unmet mental health treatment needs [
One way to increase the integration of digital mental health interventions into routine mental health care is to better support general practitioners (GPs) in prescribing these interventions to their patients. Digital mental health interventions can provide significant benefits in the general practice setting because GPs encounter high rates of common mental health conditions, with 1 in 4 patients experiencing depression [
To address these challenges, the Black Dog Institute developed StepCare, a web-based tool for use in general practice that offers digital mental health screening and treatment recommendations [
Initial studies of feasibility [
A key goal of the StepCare tool was to increase the use of digital mental health interventions in general practice by (1) helping GPs to identify patients who would be suitable candidates for digital interventions (ie, via screening for patients with mild to moderate symptoms), (2) assisting GPs in determining when a digital mental health intervention should be used alone or in combination with a higher-intensity intervention (eg, a psychologist), and (3) reducing GPs’ uncertainty surrounding which digital interventions to prescribe and how to introduce them to the patient in the limited time available during a consultation. StepCare has been implemented in 85 general practices across Australia, and more than 5000 patients were screened from July 2017 to March 2020. The aim of this study is to examine whether StepCare is a suitable means for identifying patients who may be candidates for digital mental health interventions and to promote the uptake of these interventions in the general practice patient population.
Information about the StepCare tool was disseminated to primary health networks (PHNs) via conferences, workshops, and networks. A total of 8 PHNs from New South Wales, Australian Capital Territory, and Victoria signed up to use StepCare during the study period (July 24, 2017, and March 31, 2020), and each PHN invited expressions of interest from general practices in their region. In total, 85 general practices expressed interest, and all GPs within these practices were invited to participate. The GPs who provided informed consent to participate were then provided with information and training from either their PHN or staff from the Black Dog Institute on how to implement StepCare in their practice. Both PHNs and the Black Dog Institute staff provided ongoing support to practices throughout the implementation period.
Adult patients who were attending a GP appointment at one of the participating practices, regardless of the reason for their visit, were invited to participate in the screening. When patients presented to the reception staff, they were handed a mobile tablet that displayed an information and consent page, and patients who agreed to participate in screening indicated their consent via button click on the tablet. To assess their eligibility for screening, an initial set of questions was administered that confirmed that the patient was aged ≥18 years, had not undergone screening in the past 6 months, and could provide either a mobile phone number or email address (required for patients to receive follow-up monitoring assessments to track symptom change over time).
This study was approved by the University of New South Wales Human Research Ethics Committee (HC15827).
This study used an uncontrolled, observational, prospective cohort design.
Depressive symptoms were screened for using the 9-item Patient Health Questionnaire (PHQ-9) [
StepCare also included 2 items that assessed whether the patient had previously discussed mental health issues with their GP and whether their current appointment was about mental health. This served as a proxy indicator of whether a patient was likely to be known to their GP as having a mental health condition. Patients were also asked sociodemographic questions, including whether they were Aboriginal or Torres Strait Islander; a carer for children, someone with a disability, someone with a chronic illness, or someone who was frail-aged; spoke a language other than English; had concerns about their accommodation or housing; and what their alcohol use habits were (Alcohol Use Disorders Identification Test) [
On presentation to the practice, the reception staff provided adult patients with an internet-enabled mobile tablet featuring the StepCare information and consent page. Patients could either consent or decline to participate by clicking a button. Those who consented were asked to provide their contact details and complete the sociodemographic questions, the PHQ-9, the GAD-7, and the Alcohol Use Disorders Identification Test. The patient’s screening results were sent directly to their GPs’ medical inbox using a secure messaging service for review during the consultation.
StepCare treatment recommendations were stratified according to the patient’s symptom severity. Digital mental health interventions were incorporated into Steps 1 and 2 as follows.
The self-guided digital mental health intervention myCompass [
Guided web-based therapy via the MindSpot Clinic or face-to-face therapy with a clinical psychologist was recommended for patients with moderate symptoms. MindSpot offers therapist-guided web-based courses and has been found to produce significant improvements in depression and anxiety [
Referral to a clinical psychologist and pharmacotherapy were recommended for patients with severe symptoms. The GP was encouraged to consider referral to a psychiatrist for pharmacotherapy management.
For patients who scored 1 or higher on item 9 of the PHQ-9, StepCare also provided GPs with several options to assist them in supporting patients who reported suicidal thoughts, including providing prompts to help initiate a discussion with the patient regarding their responses on the screener, steps for further assessing risk, information describing how to develop a safety plan for patients who are actively suicidal, and links to relevant local and national crisis services.
During the consultation, GPs were asked to record the treatment they prescribed by filling in checkboxes accessible via the patient’s screening report. Although GPs were strongly encouraged to record prescribed treatments, to minimize the burden on GP workflow, this was not mandatory.
Individuals who screened positive for depression or anxiety were invited to complete follow-up assessments every 2 weeks for 18 weeks to monitor symptoms (those with nil-minimal symptoms were not followed up). These follow-up assessments captured key outcome measures, including depressive symptom severity (PHQ-9) and anxiety symptom severity (GAD-7). In addition to these outcome measures, patients were asked to indicate, via checkboxes, which of a series of mental health treatments they had used in the past 2 weeks. Follow-up assessments were not mandatory, and patients could opt out of receiving assessment reminders at any time.
Each time a patient completed a follow-up assessment, a report was sent to their GP’s medical inbox. This report displayed the patient’s PHQ-9 and GAD-7 scores, their score on item 9 of the PHQ-9 (indicating suicidal thoughts), and a line graph showing symptom improvement from baseline. Accompanying this report was also a series of alerts that notified GPs of patients who showed signs of improvement, as well as those who showed evidence of deterioration, severe symptoms that did not improve, and nonadherence to monitoring assessments. Improvement was defined as a patient whose PHQ-9 or GAD-7 scores had improved by at least one severity category compared with the previous fortnight; deterioration was flagged when a patient’s PHQ-9 or GAD-7 score increased by at least one severity category relative to the previous fortnightly period; severe and unchanging symptoms were flagged where a patient with PHQ-9 or GAD-7 scores in the severe range at baseline had not improved by at least one severity category by week 4; and nonadherence to assessments was flagged when a patient who screened positive for depressive or anxious symptoms at baseline had not completed two consecutive follow-up assessments. For patients who did not improve, or who deteriorated, the GP was encouraged to consider scheduling a follow-up appointment with the patient to review their treatment plan.
For the purposes of our statistical analyses, we defined
Descriptive statistics were used to quantify patient symptoms, treatment use, and GP prescription patterns. The number needed to screen (NNS) was calculated using methods aligned with those adopted in multiarm clinical trials, as described by Rembold [
This was supplemented with an intention-to-treat analysis examining symptom improvement over the follow-up period using data from all assessment points (mixed model for repeated measures analysis with random intercepts and slopes; implemented in Stata [version 13.1; StataCorp LP]). We also performed a completer analysis to examine the rates of response and remission.
The funder had no role in the study design, data collection, analysis, manuscript writing, or in the decision to publish the manuscript.
Of the 5138 patients who were offered the tool, 3777 (73.51%) completed screening and 3314 (64.50%) met the eligibility criteria (sample characteristics are shown in
Characteristics of baseline sample (N=3314).
Characteristic | Participants |
Age (years), mean (SD) | 43.4 (17.0) |
Female, n (%) | 2316 (69.89) |
Aboriginal or Torres Strait Islander, n (%) | 165 (4.98) |
English as second language, n (%) | 423 (12.76) |
Cares for children, n (%) | 1079 (32.56) |
Cares for frail or disabled individuals, n (%) | 305 (9.20) |
Accommodation issues, n (%) | 94 (2.84) |
Seeing general practitioner for mental health reasons, n (%) | 745 (22.48) |
Seen general practitioner for mental health reasons previously, n (%) | 1519 (45.84) |
In total, 1428 individuals with symptoms of anxiety or depression were identified through screening (detection rate: 1428/3314, 43.09%). Of the baseline sample, 13.82% (458/3314) had mild symptoms, 17.68% (586/3314) had moderate symptoms, and 11.59% (384/3314) had severe symptoms. Furthermore, just under one third (454/1428, 31.79%) of symptomatic individuals reported suicidal ideation or thoughts of self-harm. Overall, depressive symptoms (1333/3314, 40.22%) were more common than anxiety symptoms (855/3314, 25.80%). There were no differences in the proportion of males and females who screened positive for either depressive or anxious symptoms (both values of
For patients who screened in the mild symptom severity range, most screened positive for depressive symptoms only (346/458, 75.5%) with fewer screening positive for anxiety symptoms only (54/458, 11.8%) or both depressive and anxious symptoms (49/458, 10.7%). In contrast, as symptom severity increased, patients were more likely to screen positive for both depressive and anxious symptoms. Specifically, in the moderate range, 59.6% (349/586) screened positive for both depressive and anxious symptoms [depressive symptoms only (202/586, 34.5%); anxious symptoms only (28/586, 4.8%)], and in the severe range, 94.3% (362/384) screened positive for both depressive and anxious symptoms [depressive symptoms only (7/384, 1.8%); anxious symptoms only (13/384, 3.4%)].
Of the 1428 patients who screened positive for depressive or anxious symptoms, 335 (23.46% of symptomatic sample or 10.11% of patients overall) had never seen their GP for mental health reasons, including at the time of screening. These previously unidentified or untreated patients were older than symptomatic patients who had previously seen their GP for mental health reasons (44.73 vs 38.58;
Of the 5138 patients who underwent screening, 335 (6.52%) had anxious or depressive symptoms that were previously unidentified or untreated. Accordingly, the AR for recognizing previously unidentified symptoms via screening was ARscreening=335/5138=0.0652. Although this was not an RCT, under a hypothetical
Therefore, the ARD can be calculated as ARscreening–ARno screening:
An NNS can be calculated as the inverse of the ARD:
This indicates that for every 16 patients who are offered mental health screening, 1 individual with previously unidentified or untreated depressive or anxious symptoms will be identified.
GP prescription data were available for 23.39% (334/1428) of patients. These included 30.2% (101/334) patients with mild symptoms, 41.9% (140/334) with moderate symptoms, and 27.8% (93/334) with severe symptoms. Separate independent samples 2-tailed
Although digital and high-intensity (ie, psychologists, psychiatrists, and pharmacotherapy) interventions were recommended by the StepCare tool at roughly equal rates (digital interventions were recommended for 241/334, 72.2% of patients; high-intensity interventions were recommended for 233/334, 69.8% of patients; categories not mutually exclusive), GPs prescribed high-intensity interventions nearly twice as often as low-intensity digital interventions. Specifically, a high-intensity intervention was prescribed by the GP for 56.3% (188/334) of patients, whereas a digital mental health intervention was prescribed by the GP for 30.8% (103/334) of patients. A side-by-side comparison of the treatments recommended by StepCare, relative to the treatments prescribed by GPs, is shown in
Comparison of StepCare treatment recommendations for all symptomatic patients (n=1428) versus GPa prescribed treatments in symptomatic patients with GP prescribing data available (n=334).
Treatmentb | Proportion of all symptomatic patients (n=1428) who were recommended a specific treatment by StepCare, n (%) | Proportion of symptomatic patients with GP prescribing data (n=334) who were prescribed a specific treatment by their GP, n (%) |
Web-based self-help | 458 (32.1) | 60 (18) |
Guided web-based therapy | 586 (41) | 54 (16.2) |
Psychologist | 970 (67.9) | 135 (40.4) |
Medication | 970 (67.9) | 109 (32.6) |
Psychiatrist | 384 (26.9) | 31 (9.3) |
aGP: general practitioner.
bColumn percentage totals do not sum to 100% as patients could be prescribed multiple treatments or no treatment at all.
General practitioner prescribing patterns as a function of patient baseline symptom severity (N=334).
Treatment prescribed by general practitionera | Patients with mild symptoms (n=101), n (%) | Patients with moderate symptoms (n=140), n (%) | Patients with severe symptoms (n=93), n (%) |
Prescribed web-based self-help | 33 (32.7) | 15 (10.7) | 12 (12.9) |
Prescribed guided web-based therapy | 11 (10.9) | 28 (20) | 15 (16.1) |
Prescribed psychologist | 22 (21.8) | 59 (42.1) | 54 (58.1) |
Prescribed medication | 8 (7.9) | 50 (35.7) | 51 (54.8) |
Prescribed psychiatrist | 2 (2) | 8 (5.7) | 21 (22.6) |
aPercentages reflect the percentage of patients in each symptom severity category; column percentage totals do not sum to 100% as patients in the same symptom severity category could be prescribed multiple treatments or no treatment at all.
Treatment use data were available for 42.44% (606/1428) of patients. Most patients (525/606, 86.6%) reported the use of at least one form of mental health treatment during the follow-up period. Patients with treatment use data had higher baseline PHQ-9 (t1426=3.98;
Of the 606 patients who provided treatment use data, 165 (27.2%) also had GP prescribing data available, which allowed us to determine whether a patient used the treatment prescribed by their GP. More than two-thirds of patients (35/52, 67%) who were prescribed a digital mental health intervention (either alone or in combination with a high-intensity intervention) reported using one of these digital interventions over the follow-up period. The rates of treatment uptake were also high for high-intensity interventions; nearly all patients (96/102, 94.1%) who were prescribed a high-intensity intervention by their GP reported that they had used a high-intensity intervention over the follow-up period. The patient use of GP-prescribed interventions is shown in detail in
Data show the rate at which patients used the treatment that was prescribed to them by their general practitioner. Values are expressed as a proportion of symptomatic patients for whom both patient adherence and general practitioner prescribing data were available (n=165).
The intention to treat (mixed model for repeated measures) analysis revealed a significant main effect of
Changes in depressive symptom severity (9-item Patient Health Questionnaire) over time.
Time point | Estimated marginal, mean (SE) | Modeled change from baseline, mean (95% CIa) | |
Baseline | 12.05 (0.16) | N/Ac | N/A |
Week 2 | 10.22 (0.22) | −1.84 (−2.23 to −1.44) | <.001 |
Week 4 | 9.75 (0.24) | −2.31 (−2.75 to −1.86) | <.001 |
Week 6 | 9.15 (0.25) | −2.90 (−3.37 to −2.43) | <.001 |
Week 8 | 8.86 (0.26) | −3.19 (−3.70 to −2.69) | <.001 |
Week 10 | 8.81 (0.28) | −3.24 (−3.78 to −2.69) | <.001 |
Week 12 | 8.76 (0.29) | −3.30 (−3.87 to −2.73) | <.001 |
Week 14 | 8.33 (0.31) | −3.72 (−4.31 to −3.13) | <.001 |
Week 16 | 8.42 (0.32) | −3.63 (−4.25 to −3.01) | <.001 |
Week 18 | 8.43 (0.33) | −3.62 (−4.27 to −2.97) | <.001 |
aThe 95% CI refers to the change from baseline.
b
cN/A: not applicable.
Change in anxious symptom severity (7-item Generalized Anxiety Disorder scale) over time.
Time point | Estimated marginal, mean (SE) | Modeled change from baseline, mean (95% CIa) | |
Baseline | 8.67 (0.18) | N/Ac | N/A |
Week 2 | 8.56 (0.20) | −0.11 (−0.51 to 0.29) | .58 |
Week 4 | 8.26 (0.21) | −0.41 (−0.83 to 0.01) | .06 |
Week 6 | 7.86 (0.22) | −0.81 (−1.27 to −0.36) | <.001 |
Week 8 | 7.63 (0.24) | −1.04 (−1.54 to −0.55) | <.001 |
Week 10 | 7.33 (0.25) | −1.34 (−1.85 to −0.83) | <.001 |
Week 12 | 7.27 (0.25) | −1.40 (−1.92 to −0.88) | <.001 |
Week 14 | 7.18 (0.27) | −1.49 (−2.05 to −0.93) | <.001 |
Week 16 | 7.48 (0.30) | −1.20 (−1.81 to −0.58) | <.001 |
Week 18 | 7.22 (0.30) | −1.45 (−2.07 to −0.83) | <.001 |
aThe 95% CI refers to the change from baseline.
b
cN/A: not applicable.
Completer analyses focused on symptomatic patients who completed at least one follow-up assessment (708/1428, 49.58%). Of this sample, 26.1% (185/708) scored in the asymptomatic range on the PHQ-9 and GAD-7 at follow-up and were classified as
This study examined the performance of a digital mental health screening and treatment recommendation tool (
Our findings align with prior studies showing high rates of depressive and anxious symptoms in general practice populations and the ability for mental health screening to identify patients with untreated symptoms [
Our finding that 1 in every 16 patients invited for screening had unidentified or untreated depressive or anxious symptoms positions mental health screening favorably when compared with other diseases routinely screened for in primary care. For example, type 2 diabetes screening for adults aged ≥40 years yields a detection rate of 1 in 32 [
We note that the rates of depressive and anxious symptoms in our study were higher than the population prevalence estimates of depression and anxiety, and there are several possible reasons for this. First, population prevalence estimates are based on individuals who meet the diagnostic criteria for depression or anxiety rather than individuals who demonstrate a positive result on a brief screening measure of depressive or anxious symptoms. In our study, it is likely that a subset of patients who screened positive for depression or anxiety would not have met the diagnostic criteria for depression or anxiety in further follow-up assessments with their GP. Second, it is likely that some participants who screened positive were experiencing transient symptoms rather than a persistent condition, with prior studies indicating that approximately one-fifth of patients who screened positive for depression in primary care no longer met the criteria after 2 weeks [
A fourth factor that likely underpinned our higher prevalence rates was the fact that several practices used StepCare to selectively screen high-risk patients (as recommended by the Royal Australian College of General Practitioners) [
Regarding GP prescribing patterns, our findings suggest that although digital mental health interventions may be well suited to a substantial portion of the symptomatic general practice population, GPs show a preference for prescribing high-intensity treatments. Why might this be? Common barriers to use reported by GPs include uncertainty about a digital intervention’s evidence base and insufficient knowledge of how to refer a patient to a digital intervention [
This study has some limitations. First, this was an uncontrolled observational study of a tool used in a clinical setting. RCTs are needed to determine whether the opportunity costs of mental health screening in general practices are offset by superior patient outcomes. Second, GP prescribing data and patient treatment use data were available for only a portion of patients because completion of these surveys was optional. Greater tracking of prescription and treatment use patterns via electronic health records will be critical for providing a comprehensive perspective on digital intervention uptake. Finally, an important question that must be addressed in future research is whether patients who are prescribed digital mental health interventions show sufficient levels of engagement with these interventions to yield therapeutic benefits. If the rates of initial uptake are high when referred by a GP, but ongoing engagement remains low, then this may warrant consideration of alternative modes of delivery. Delivery methods that combine digital mental health interventions with face-to-face services, such as blended care [
In conclusion, our findings indicate that a digital mental health screening and treatment recommendation tool may increase the opportunities to use digital mental health interventions in general practice. Leveraging these opportunities will be critical in addressing increased mental health treatment needs arising from the COVID-19 pandemic and in reducing existing disparities in access to affordable, evidence-based mental health care.
absolute risk
absolute risk detection
7-item Generalized Anxiety Disorder scale
general practitioner
number needed to screen
number needed to treat
primary health network
9-item Patient Health Questionnaire
randomized controlled trial
The authors wish to thank Mariam Faraj and other staff of the Central and Eastern Sydney PHN for their involvement in the co-design of StepCare, as well as all the GPs, staff, and patients who participated in the research. This research was funded by the Paul Ramsay Foundation. Associate Professor JMN was supported by an Australian Medical Research Future Fund Fellowship.
StepCare was designed and developed by Proudfoot, Anderson, Cockayne, O’Moore, Gale, and Christensen. PHNs in Australia pay a small fee to the Black Dog Institute to use StepCare in their general practices, which contributes to the operational, information technology infrastructure, and personnel costs associated with implementing StepCare, hosting the data, and providing technical support. The authors of this study derive no personal financial benefits from StepCare.