Automated text reminders boost mental health for health care workers

Health care workers have reported spikes in feeling burnt out in the time since the COVID-19 pandemic began, with nearly half saying it took a toll in 2022 compared to 32 percent in 2018. But a new study shows that easy-to-use and accessible platforms may help reverse this trend. Regular, automated text message reminders connecting staff to a mental health platform called "Cobalt," drove significant improvements in both depression and anxiety scores among employees, according to a new JAMA Network Open study from the Perelman School of Medicine at the University of Pennsylvania.

What we found shows that touching base with people, letting them know that help is available and easy to access, goes a long way toward maximizing digital mental health interventions and platforms, which leads to important, tangible results. Mental health platforms continue to grow and evolve, but, to this point, there hasn't been enough research about them and how to optimize their use, particularly among health care workers. Work like ours is important as health systems across the country seek to better assist their staff with the challenges they face."

Anish Agarwal, MD, MPH, MS, study's lead author, assistant professor of Emergency Medicine and deputy director of the Center for Insights to Outcomes

Available as an open-source, web-based platform for any health system, COBALT is designed specifically to support health care employees seeking mental health help. It includes resources such as podcasts, articles, and worksheets, pathways to schedule one-on-one sessions with therapists, doctors, resiliency coaches, and also features group sessions focused on specific issues, such as mindfulness or antiracism. The platform also includes access to urgent intervention for those in need of emergency attention.

Since COBALT's launch at Penn Medicine in spring 2020, two other institutions also adopted the platform. The platform launched in just two weeks amid the first wave of the COVID-19 pandemic. Within 30 days, more than 5,000 people had accessed the platform. Now, more than 100,000 individuals, in total, have access to the platform across the three institutions using it.

The new study showed that users' self-reported depression symptom scores improved by roughly 11 percent six months after employees engaged with COBALT. This was measured by the Patient Health Questionnaire (PHQ-9), in which answers to a survey result in a score used to help assess potential levels of depression. Participating employees included doctors, nurses, technicians, registrars, and others. There were two groups: an intervention arm, which received monthly, automated reminder text messages on mental health and the availability of COBALT, and a control group, which just had access to the free platform but no proactive outreach. At nine months, across both groups, scores improved by just over 22 percent.

While overall scores did show improvement across the board, the effect seen in the intervention group receiving text message reminders about the program was demonstrably larger. Scores improved by more than 20 percent six months after these participants initially connected with COBALT, and 30 percent at nine months. According to PHQ-9's scale, the latter took the average score from the lower end of "mild depression symptoms" to just a hair above "no symptoms."

The control arm, receiving no messages, improved by about 5 percent at six months and 12 percent at nine.

"This study is one of very few evidenced-based approaches which have been shown to improve mental health of health care workers after the pandemic," said the study's senior author, Raina Merchant, MD, the University of Pennsylvania Health System chief transformation officer and a professor of Emergency Medicine. "Our work shows that health systems have the unique opportunity to provide substantial support for this critical workforce."

When it came to anxiety-;measured similarly to depression with a tool named Generalize Anxiety Disorder assessment (GAD-7)-;the control group did not experience a significant improvement in their score at six months (roughly 4 percent), but the nine-month assessment saw a significant improvement of 13 percent.

Again, the intervention arm of the study had greater improvements in the symptom score at both six and nine months: approximately 17 and 30 percents, respectively. As with the depression symptom scores, the average nine-month anxiety score was just shy of indicating no symptoms.

"Overall, these numbers clearly indicate that the reception of the digital push was very positive, welcomed, and helped people prioritize their mental health and feel cared for," said Lisa Bellini, MD, senior vice dean for Academic Affairs and a professor of Medicine at the Perelman School of Medicine.

Moving forward, the study team hopes to further improve the pathway to connecting the workforce with COBALT to overcome the barriers for health care workers to connect to mental health care and make the approach easy to apply to other health systems.

"COBALT is a simple, user-friendly, and scalable way of reaching our workforce," said Agarwal. "Mental health is so important, yet many of us don't take the time to check in with ourselves or remember where to go when we need help. This approach provides insights on ways to reach people and move toward making it even simpler to connect to care."

This study was funded by the National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Mental Health (NIMH), and the National Institute on Minority Health and Health Disparities (NIMHD) (1R01MH127686-01).