Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study

Background: SMS text messaging is an inexpensive, private, and
scalable technology-mediated assessment mode that can alleviate
many barriers faced by the safety net population to receive
depression screening. Some existing studies suggest that
technology-mediated assessment encourages self-disclosure of
sensitive health information such as depressive symptoms while
other studies show the opposite effect. Objective: This study aimed
to evaluate the validity of using SMS text messaging to screen
depression and related conditions, including anxiety and functional
disability, in a low-income, culturally diverse safety net primary
care population. Methods: This study used a randomized design with
4 study groups that permuted the order of SMS text messaging and
the gold standard interview (INTW) assessment. The participants for
this study were recruited from the participants of the prior
Diabetes-Depression Care-management Adoption Trial (DCAT).
Depression was screened by using the 2-item and 8-item Patient
Health Questionnaire (PHQ-2 and PHQ-8, respectively). Anxiety was
screened by using the 2-item Generalized Anxiety Disorder scale
(GAD-2), and functional disability was assessed by using the
Sheehan Disability Scale (SDS). Participants chose to take up the
assessment in English or Spanish. Internal consistency and
test-retest reliability were evaluated by using Cronbach alpha and
intraclass correlation coefficient (ICC), respectively. Concordance
was evaluated by using an ICC, a kappa statistic, an area under the
receiver operating characteristic curve (AUROC), sensitivity, and
specificity. A regression analysis was conducted to examine the
association between the participant characteristics and the
differences in the scores between the SMS text messaging and INTW
assessment modes. Results: Overall, 206 participants (average age
57.1 [SD 9.18] years; females: 119/206, 57.8%) were enrolled. All
measurements except the SMS text messaging–assessed PHQ-2 showed
Cronbach alpha values ≥.70, indicating acceptable to good
internal consistency. All measurements except the INTW-assessed SDS
had ICC values ≥0.75, indicating good to excellent test-retest
reliability. For concordance, the PHQ-8 had an ICC of 0.73 and
AUROC of 0.93, indicating good concordance. The kappa statistic,
sensitivity, and specificity for major depression (PHQ-8 ≥8) were
0.43, 0.60, and 0.86, respectively. The concordance of the shorter
PHQ-2, GAD-2, and SDS scales was poor to fair. The regression
analysis revealed that a higher level of personal depression stigma
was associated with reporting higher SMS text messaging–assessed
PHQ-8 and GAD-2 scores than the INTW-assessed scores. The analysis
also determined that the differences in the scores were associated
with marital status and personality traits. Conclusions: Depression
screening conducted using the longer PHQ-8 scale via SMS text
messaging demonstrated good internal consistency, test-retest
reliability, and concordance with the gold standard INTW assessment
mode. However, care must be taken when deploying shorter scales via
SMS text messaging. Further regression analysis supported that a
technology-mediated assessment, such as SMS text messaging, may
create a private space with less pressure from the personal
depression stigma and therefore encourage self-disclosure of
depressive symptoms. Trial Registration: ClinicalTrials.gov
NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013

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Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study