Monday, August 20, 2018

Are mental health apps helpful?

- Jennifer Middleton, MD, MPH

A wide variety of mental health apps are currently available. Two recent studies describe the appeal of these apps yet also advise caution with their use, as some of them may reinforce harmful messages and/or are not based on evidence-based practice. Helping our patients identify reputable apps is becoming an important element of mental health management.

The first study, from the current issue of the Annals of Family Medicine, evaluated the content of 61 mental health apps. The researchers found that many of these apps framed mental health problems as "exist[ing] for everybody" and claimed "their product could help quickly and easy." 49% of the apps provided disclaimers, "thus, app consumers were assigned responsibility not only for using an app, but also for knowing whether it was appropriate for them." Visual images in the apps were predominantly of white individuals, and comments in many apps suggested that app users were expected to be employed and/or have families, which the authors criticized as being non-inclusive. While 61% of apps included claims that their methods were scientifically-based, none cited studies or evidence to support these claims. Although the researchers identified a few reasonably reputable apps, they advise physicians to ask patients with mental health diagnoses about app use and review the above limitations with them.

The second study from June of this year aimed to formally analyze apps which claimed to be following cognitive behavioral therapy (CBT) tenets. They reviewed 31 apps which advertised CBT for depressive symptoms and found that, while user ratings of these apps tended to be quite high, only some of their features were based on CBT. 12 apps only provided 1 feature consistent with CBT; another 9 apps only included 2. They found that CBT features tended to be limited to mood tracking, recording thoughts, and dealing with negative thoughts, and they expressed concern that other CBT elements, such as addressing core beliefs, were absent. "Even though all of their descriptions mentioned CBT, only half of all features provided by apps reflected core competencies of CBT." The authors also analyzed the rating comments of these apps and found that many users appreciated their relative affordability compared to traditional therapy. Some raters describing themselves as therapists stated that they appreciated the use of these apps as adjuncts to their meetings with patients.

Many patients like using apps; many physicians and counselors like being able to recommend useful tools to patients. The challenge for patients and physicians alike is to identify apps that incorporate the best evidence-based practice into their design. Thankfully, Family Practice Management has its regular feature "SPPACES: Medical App Reviews" to help guide our decisions. (SPPACES = Source or developer, Platforms available, Pertinence to primary care, Authoritativeness/accuracy, Cost, Ease of use, and Sponsor.) Earlier this year, a SPPACES article identified "Five Mobile Apps to Help Patients with Anxiety and Depression." All five of these apps were developed by reputable experts, and a couple of them were even mentioned in the above studies as being exemplars of evidence-based practice (MoodTools and What's Up-Mental Health App).

Discussing app use with patients and guiding patients to reputable apps is, of course, only one part of good mental health care. You can read more in the AFP By Topic on Depression and Bipolar Disorder and in the AFP By Topic on Anxiety Disorders.

Tuesday, August 14, 2018

Overdiagnosis in lung cancer screening: don't tell, don't ask?

- Kenny Lin, MD, MPH

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this week in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.

Monday, August 6, 2018

Overcoming rhinitis adherence challenges

- Jennifer Middleton, MD, MPH

The current issue of AFP includes an overview of "Chronic Nonallergic Rhinitis" (the newer term for "vasomotor rhinitis"). The article includes tips to distinguish allergic from nonallergic rhinitis along with treatment regimens. Many of the medications that are useful for allergic rhinitis are also useful for nonallergic rhinitis, including intranasal corticosteroids, intranasal antihistamines, oral decongestants - with the addition of intranasal ipratropium for nonallergic symptoms. Unfortunately, patient adherence to these intranasal medications tends to be low.

For many patients, rhinitis symptoms are inconsistent and episodic, waxing and waning with seasonal changes and exposure to triggers. While not taking intranasal medications when symptoms and triggers are absent may be reasonable, taking them only when symptoms are severe (and not more moderate) can result in decreased efficacy, increased physician visits, and increased healthcare costs. Many intranasal medications for rhinitis also have unpleasant tastes and smells that can affect adherence. Cost is another factor; some of these medications are not available in generic versions and can be expensive. Interestingly, personality type and gender may also correlate with intranasal medication adherence; in one study, men with higher "neuroticism" scores were less adherent to allergy medications, while men with higher "agreeableness" or "conscientiousness" scores were more adherent. Among women in this same study, however, personality traits did not correlate with adherence.

Knowing when patients are not using their intranasal medications is important to accurately assess treatment efficacy as well as the risk of worsening co-morbid conditions like asthma. The Allergic Rhinitis Treatment Satisfaction and Preference (ARTSP) scale provides information about a patient's preferences regarding intranasal treatment, which can guide physician and patient decision-making regarding specific medications. Prescribing an intranasal medication with characteristics that patients prefer (odor, taste, comfort, delivery device, cost) may increase adherence. Other solutions for increasing adherence include problem-solving solutions to identified barriers with patients and using text messaging to send patients daily reminders to use their intranasal medications.

You can read more about rhinitis treatment by using this AFP keyword search. There's also an AFP By Topic on Allergy and Anaphylaxis, which includes this reference on "Diagnosing Rhinitis: Allergic vs. Nonallergic" and an Allergic Rhinitis Treatment Guideline from 2015.