This document summarizes the development and testing of Help4Mood, an eHealth tool to support people with depression. It describes stakeholder consultations and iterative user testing to design Help4Mood's features. Four case studies were conducted with women who used Help4Mood for two weeks. While it promoted self-reflection, daily use was difficult. Participants found value in tracking mood but felt the technology lacked human support during difficult times. The conclusion is that eHealth tools need to be designed for self-reflection, support/coping, and personalization to effectively help people manage depression.

1. eHealth Support for People With
Depression in the Community:
A Case Study Series
Maria Wolters
University of Edinburgh
for the Help4Mood Consortium
maria.wolters@ed.ac.uk
@mariawolters
Maria Wolters (University of Edinburgh),
Aura Szentagotai, Silviu Matu, Ramona Moldovan, Daniel David (Babes-Bolyai University),
Brian McKinstry (University of Edinburgh)
Chris Burton (University of Aberdeen)

2. Overview
❖ What is Depression?
❖ The Development of Help4Mood
❖ 4 Case Studies
❖ What Have We Learned?

3. What is Depression?

4. Mental Illness is common.
In Korea, rates vary between
2% - 7% depending on gender
and age.
http://www.cdc.gov/features/dsdepression/;
Cho and Lee (2005) Psychiatr Invest 2005; 2 (1): 22-27

5. Focus on Major Depressive Disorder
❖ persistent low mood
❖ loss of interest in things that give pleasure
❖ over two weeks or more
❖ plus other symptoms (DSM 4)

6. rosalarian.tumblr.com

7. http://www.optipess.com/2012/09/28/dressing-up/

8. depressioncomix.tumblr.com

9. Treatment Options
❖ Watchful waiting
❖ Lifestyle changes / exercise
❖ Medication:
does not always work, needs adjustment, trial and error
❖ Psychotherapy (also Internet-Based Self Help)
most forms are equivalent
Davidson, J. R. T. (2010). Major depressive disorder treatment guidelines in America and Europe.
The Journal of Clinical Psychiatry, 71 Suppl E, e04. doi:10.4088/JCP.9058se1c.04gry
Baardseth, T. P., Goldberg, S. B., Pace, B. T., Minami, T., Wislocki, A. P., Frost, N. D., … Wampold, B. E. (2013).
Cognitive-Behavioral Therapy versus Other Therapies: Redux. Clinical Psychology Review, doi:10.1016/j.cpr.2013.01.004

10. Blended Practice: Human Support Matters
Fig. 1, Johansson and
Andersson (2012), systematic
review of Internet-Based
cognitive Behaviour Therapy
0 - no support
1 - contact before treatment
2 - contact during treatment
3 - contact before and during
treatment
http://informahealthcare.com/doi/full/10.1586/ern.12.63#_i11

11. Help4Mood

12. The Team
Funding: 2011-2014, European Union Framework 7 Programme
Group of projects were funded, including
• ICT4Depression
• Monarca
• Interstress
• OPTIMI
http://www.help4mood.info

13. Help4Mood: Supporting People with Depression
• daily monitoring
• of activity using
actigraph
• of mood, thought
patterns & psycho-motor
symptoms using
talking head GUI
• weekly one-page reports
to clinicians
Maria K. Wolters, Juan Martínez-Miranda, Soraya Estevez, Helen F. Hastie, Colin Matheson (2013). Managing Data in Help4Mood AMSYS ICST DOI: 10.4108/trans.amsys.
01-06.2013.e2

14. One Help4Mood per Day
❖ Users interact with Help4Mood once a day
❖ Sessions can be short, medium, or long
❖ Planning algorithm ensures
❖ different kinds of data are collected regularly, e.g.
❖ mood: every day
❖ speech: 1-3 times per week
❖ sessions are varied

15. The Development of Help4Mood
0. Stakeholder Consultations
• across countries
• across key stakeholder groups
• across health care systems
• across care pathways
Focus Groups
Technology
Probe
(Powerpoint)
shared, agreed
script
People with
depression (All)
Psychiatrists
(All)
General Practitioners
(UK / Spain)
Clinical Psychologists
(Romania)
Community
Psychiatric Nurses
(UK)
Burton, C., Wolters, M. K., Blanco, A. S., Szentagotai, A., Ure, J., Pagliari, C., & McKinstry, B. (2012, June 5). Help4Mood: avatar-based support for treating people with major
depression in the community. International Journal of Integrated Care. (Conference Abstract, full paper to follow)

16. Patient Focused Development
1. Actigraphy
Case Studies
People with
history of depression

17. Patient Focused Development
1. Actigraphy
2. Mood Tracker +
Actigraphy
Case Studies
People with
history of depression

18. Patient Focused Development
1. Actigraphy
2. Mood Tracker +
Actigraphy
3. Mood Tracker,
Thought Patterns,
Speech + Actigraphy
Case Studies
People with
history of depression
People with
current depression

19. Patient Focused Development
1. Actigraphy
2. Mood Tracker +
Actigraphy
3. Mood Tracker,
Thought Patterns,
Speech + Actigraphy
4. Mood Tracker,
Thought Patterns,
Behavioural Activation,
Relaxation,
Speech + Actigraphy
Case Studies
Pilot RCT
People with
history of depression
People with
current depression

20. Patient Focused Development
1. Actigraphy
2. Mood Tracker +
Actigraphy
3. Mood Tracker,
Thought Patterns,
Speech + Actigraphy
4. Mood Tracker,
Thought Patterns,
Behavioural Activation,
Relaxation,
Speech + Actigraphy
Case Studies
Pilot RCT
People with
history of depression
People with
current depression

21. 4 Case Studies

22. Design
❖ Participants with Major Depressive Disorder (SCID)
❖ Use Help4Mood for 2 weeks
❖ Background measures include demographics and
attitudes to computers
❖ Pre/Post measures to establish change
❖ Qualitative interviews at intake and debriefing

23. Pre/Post Measures of Change
BDI II Depression Screening Beck Depression Inventory II
DAS-SF 2
Attitudes
Characteristic of
Depression
Dysfunctional Attitudes Scale
Short Form
QIDS-SR 16
Symptoms of
Depression
Quick Inventory of Depressive Symptoms
Self Report
EQ-5D-5F Quality of Life
Brief Quality of Life Assessment
(European Norm)

24. Participants
❖ 4 female professionals between 23-30, computer literacy
medium to good, positive attitudes to computers
❖ None formally tracked or measured their mood before,
but some used introspection
❖ Used Help4Mood 8-15 times over two weeks

25. Help4Mood as Coping
“I noticed that when I was upset
or when I was dealing with negative events
I always chose the long session, not the short one.” (P04)

26. Self-Reflection is Hard Work
“This wasn’t very pleasant.
Because you don’t go to therapy every day.
You wouldn’t go every day;
you would go maybe once a week
or two or three times maybe,
but not every day.
It’s a bit too much to use it every day.” (P01)

27. Limits of Technology
“I think there was a day
when it was really really bad.
And poor Roger he was really emphatic
and said ‘sorry to hear that’
and at some point
he offered an alternative way of thinking
which gave me like. . . an insight and it did it at the time.
But I felt like I needed more.
But I didn’t get it
and I had to be satisfied with what I had” (P01)

28. What Have We Learned?

29. It Doesn’t (Quite) Work This Way
http://imgarcade.com/1/depressed-stick-figure/
Well-Designed
Monitoring
Self-Help
Internet-Based
Therapy
+
http://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception
https://www.osneybuyside.com/forget-big-data-just-collect-smart-data/
Protected
Peer Support
http://www.clipartsfree.net/small/3977-game-piece-group-clipart.html

30. It’s a complex adaptive system
http://www.thebolditalic.com/articles/3609-the-stick-figure-guide-to-kicking-depression
Individualised monitoring
based on what person has &
does
Productive (!) self insight
and reflection
Coping and getting better:
• Twitter, exercise, kindness
• Friends
• Medications
• GP

31. Conclusions
❖ Design for self-reflection
❖ Design for support and coping
❖ Design for personalisation
maria.wolters@ed.ac.uk @mariawolters