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DIADA Hub Project Summary


DR. MARSCH: Welcome to our presentation on Project DIADA, focused on scaling up science-based mental health interventions in Latin America.  My name is Lisa Marsch, and I have the opportunity to serve as one of the multiple principal investigators on this project, along with my colleague, Dr. Carlos Gomez-Restrepo, and this is a project that's focused on leveraging digital technology to facilitate the screening and treatment of depression and unhealthy alcohol use in primary care systems in the country of Colombia.

We were delighted to receive support for this project from the National Institute of Mental Health, through a cooperative agreement, and this is a partnership with our Center for Technology and Behavioral Health at Dartmouth College in the United States, and at Javeriana University in Bogota, and with our colleagues at the U.S. National Institute of Mental Health, as well as many excellent partners across the country of Colombia.

In terms of background, in the country of Colombia, depression and unhealthy alcohol use are prevalent conditions.  Dr. Gomez has conducted national epidemiological studies looking at the prevalence of these disorders, and recent data show that about 4.3 percent of the population meet criteria for depressive disorders, more in women than males.  We also see high rates of unhealthy alcohol use in the region, particularly among younger individuals 18 to 44 years of age, and particularly among males.  But also among males over age 45, we see high rates of unhealthy alcohol use, as high as 10.3 percent.

Unfortunately, there are a number of barriers in accessing mental healthcare in the region.  Surely we know that there's stigma in seeking care for a mental health disorder.  We know that in the region that there's a lack of training.  There aren't many trained mental health professionals in the country, and many of those who are trained are confined either to urban settings and/or specialty psychiatric hospitals.

We also know that there are a number of cultural barriers to recognizing that you have a mental health disorder and seeking treatment for it, and there's little or no self-recognition of mental health challenges. 

The DIADA project was focused on trying to scale up at a population level science-based mental health screening and treatment across the region and to implement this across primary care systems, particularly targeting depression and alcohol use disorders.  We had the opportunity to conduct a pretty large-scale implementation project and to evaluate the impact of this new model of care through both qualitative and quantitative data collection.  We also launched and supported an integrated data management system to systematically collect data tracking outcomes both at the care level, the system level, looking at increased capacity for treatment in the region, and the clinical workflow of embedding treatment for mental health into primary care systems, but we also looked at the impact of this on patient outcomes. 

We additionally set up a learning collaborative, where we worked with partners all over Colombia, as well as some partnering Latin American countries, to really evolve and grow this model over time and improve it and its impact, and then to also build research capacity in the region along the way.

The overall structure of the DIADA model is reflected here.  Again, we worked with primary care partners across six different areas of Colombia, and we had training of providers in that setting, in treatment and screening of depression and unhealthy levels of alcohol use.  But we used digital technology to support the entire workflow of embedding this into the primary care system.

It started with a digital screening, so we used clinically validated screeners of depression symptoms and of alcohol use and delivered those to patients in primary care through a digital interface.  We then had a digital decision-support tool that providers, general practitioners in primary care, could use to do a more thorough diagnostic assessment of whether or not a patient met criteria for depressive disorder and/or unhealthy levels of alcohol use, and they were provided with tools and resources on this digital platform to help them provide best practices, best treatment, to individuals, based on their profile of needs.

And then every patient who met a diagnostic criterion for one of these conditions, in addition to the treatment they received in primary care, also received access to a digital therapeutic, and a digital therapeutic refers to software that delivers behavioral treatment to individuals in an interactive way on a digital platform that has been shown to be effective in helping people manage depression and helping people reduce rates of unhealthy alcohol use.

Here are some images of the flow here.  Patients would come into primary care.  They would go to one of these screening kiosks, and they would log in, and they would be asked to complete in this digital interface the clinically validated screeners for depression symptoms and for levels of alcohol use.  And then the general practitioner would have a digital interface, as you see here, this is the decision support tool that would tell the practitioners about a given patient's scores on these screening measures, and then it would help guide them through doing a full-blown diagnostic assessment with the patient to see if they meet diagnostic criteria for one of these conditions.  It would also provide them with recommendations for best practices of what they could offer to patients who were struggling with one of these conditions.

As I mentioned, all the patients were given a digital therapeutic.  It's called Laddr.  It was customized for the language and culture of Colombia, and it's a digital therapy that takes therapeutic processes that have shown to be effective in helping people manage depression and helping people reduce their levels of alcohol use and to sustain those behavior changes over time, and all of this is delivered on a mobile device accessible 24/7 to individuals either on their mobile devices or on a digital platform available in the primary care setting.

Here's our timeline.  We started with a pilot study in Javesalud, which is in Bogota, and then we kicked off the formal study in year 2 in Javesalud, and then as you see over time, expanded to working with partners in Santa Rosa and Tundama and Guasca and Soacha and Armero-Guayabal, and then, COVID hit, and then in March of 2020, everything shut down, including a big shift to remote models of care, and we'll talk a bit about how that impacted this project.

Here are the study sites, you see on the map where our six different partners are located in the country of Colombia, and here are the names of the different institutions that worked with us, and it's been just a delight.  We were so appreciative of the wonderful partnership with all of these great healthcare systems.

Now, I'll turn it over to my colleague, Carlos.

DR. GOMEZ-RESTREPO: I will present some of the outcomes that we have in the implementation of DIADA.  Here is the first one.  This is about the screening.  We begin with zero positive screening with depression and alcohol in primary care settings.  The majority of patients that goes to the primary care, they are not diagnosed by the doctors. 

Here, we see from the beginning in February 2018 that we made up to 22,000 of the screenings among 16,000 of patients.  And they screen positive 12 percent in alcohol and depression and they were comparing with diagnosis by 8 percent.  So we get from 0 to 8 percent of diagnosis in both entities.  The overall performance of the model was that we get 10 percent of depression, of those that go to primary care settings, and unhealthy use 1.3 percent.  Here with mild symptoms, moderate, and severe and also in alcohol. 

During that evolution of the study, we had a follow-up in month 3, in month 6, 9 and 12, and we can see that the green, the first visit that they had a score, a greater score, in depression they go down very rapidly in three months to score that is not with depression.  And here in alcohol also, at the beginning 15 more or less of the score in unhealthy, they go down to around 8 or 9, and then in the 12 month they go down up to 3.  So the model was working very well to add the healthcare of the patients.

Also, we made some measurements around the behavioral integration of the mental healthcare in primary care.  Here we can see that score, overall score, that it goes from 2.04 to 2.64 in different domains, in this green and continuity of care, you can see here the baseline and how goes up and in different sites.  In site number 1, 2, 3, and 4, in all of them we get some integration of mental healthcare in the primary care settings.

Also, we made the cost in time-driven activity-based costs, here's the model that we applied.  We pulled out all the steps to get the treatment, and we made that calculation of all the cost in each place in that time they get of direct in each step, and the model, we have a difference between before and after of $1.89 U.S., and this has potential cost-effective due to early care.

DR. MARSCH: Now I'll just briefly summarize some of the lessons learned in this project.  Overall, we saw across the six partnering sites that this technology-enhanced model of screening and treatment for mental healthcare was generally quite acceptable and feasible to implement in Colombia, including across six very diverse sites that we were able to partner with in Colombia. 

And we are excited that the project significantly expanded capacity for delivering science-based mental healthcare to meet a large unmet population-level need in Colombia.  So with the training and the technological support provided in this project, general practitioners were able to go from screening literally no one for these conditions in primary care, to screening and then diagnosing patients with depression and unhealthy alcohol use, and as you saw, we were able to identify 10 percent of the patient population suffering from depression and also 1.3 percent with unhealthy rates of alcohol use.

So although we focused on depression and high rates of alcohol use in this particular intervention, this platform could surely be expanded to accommodate other areas of mental health, including severe mental illness, and also could be expanded to address other areas of chronic disease management and health promotion, based on needs in various communities and priorities in mental health.

We hope that this project not only has a marked impact on care models in Colombia, but also could serve as an important demonstration project to other settings, where there's high population-level mental health needs and low resources and to leverage this type of approach of training and technology-enhanced care to tackle the burden of mental health that we see across the globe and to really scale up access to state-of-the-science mental health treatments.

Also, the project has provided training and tools that can improve the recognition and the provision of treatment for these conditions, depression and unhealthy alcohol use, in primary care, and as you saw from the data Carlos presented, we saw some very striking impacts on patient outcomes, really dramatic reductions in their problematic symptoms within three months after their diagnosis and exposure to this treatment model, with those clinical gains sustained for that whole year of follow-up that we were able to assess their clinical status.

Finally, although we don't have enough time to share this in detail here today, we did a very systematic evaluation of the impact of COVID-19 on people's mental health and on patient outcomes in the study, and in general, we found that the pandemic markedly affected the food security and the economic security of many of our participants.  Mental healthcare access was surely affected and not accessible in the same way, in person, with the pandemic, and really underscored the importance of healthcare systems prioritizing mental health to reduce these significant burdens.

So thank you so much.  We're delighted to share this information about project DIADA with you.