Major depressive disorder (MDD) is prevalent and one of the leading causes of disability in the United States. Although screening for depression is recommended by guidelines, routine screening is often not done, and only half of patients with symptoms are identified. Of those who are identified and receive a diagnosis of depression, only two-thirds are treated, and half of those treated receive inadequate treatment. Improving screening has been associated with improved depression treatment and outcomes. The Computerized Adaptive Test for Mental Health (CAT-MH) is a validated test that uses algorithms in real time to assess mental health symptoms, including depression. In general, CATs could be ideal for engaging patients in providing patient-reported outcomes (PROs) because these tests are precise and brief.

This research used the CAT-MH to screen for depression via a patient portal and compared that approach to usual care, with an aim of increasing the number of patients screened and monitored for depression.

The specific aims of the research were as follows:

• Determine whether portal-based CAT-MH depression screening increases the number of screenings compared to usual care among primary care patients who are due for depression screening.
• Determine whether patients with active MDD who receive portal-based depression measurement have higher rates of MDD remission compared to patients with active MDD who receive usual care.

The research team conducted two randomized controlled trials: the first was a 10-month screening trial; the second was a 12-month monitoring trial. Adult patients with active portal accounts from an outpatient internal medicine clinic were randomized to usual care of in-clinic depression screening and monitoring or to “population health”: usual care plus invitations to complete depression screening or monitoring via the patient portal. In the “population health” group, invitations were sent regardless of whether or not the patient had a scheduled appointment. Positive results were automatically sent to the patient’s primary care provider. During the study, the usual care protocol had to be paused for 4 months due to the COVID-19 pandemic, while portal invitations continued uninterrupted throughout the trial.

The “population health” group had statistically significant higher rates of both screening (43 percent versus 33 percent) and monitoring (59 percent versus 18 percent) compared to usual care. Depression symptoms were more common and more severe among people who completed assessments via the portal than in clinic. More patients with moderate to severe symptoms completed at least one followup assessment in the “population health” group than usual care. Of note, portal response rates differed by both race and insurance. Likely barriers to use included less access to devices and the internet, comfort with technology, concerns about confidentiality, and mental health stigma. The researchers proposed tailored portal messages and greater efforts to encourage use as a way to overcome some of these barriers to portal use. This research showed that utilizing a patient portal significantly increases the number of patients screened and monitored for depression.