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. 2024 Jul 31:49:101142.
doi: 10.1016/j.lanwpc.2024.101142. eCollection 2024 Aug.

Clinical and cost-effectiveness of remote-delivered, online lifestyle therapy versus psychotherapy for reducing depression: results from the CALM non-inferiority, randomised trial

Adrienne O'Neil  1 , Joahna Perez  2 , Lauren M Young  1 , Tayla John  1   3 , Megan Turner  1 , Dean Saunders  1 , Sophie Mahoney  1 , Marita Bryan  1 , Deborah N Ashtree  1 , Felice N Jacka  1 , Courtney Bruscella  1 , Megan Pilon  1 , Mohammadreza Mohebbi  4 , Megan Teychenne  5 , Simon Rosenbaum  6 , Rachelle Opie  1 , Meghan Hockey  1 , Lucija Peric  1 , Samantha De Araugo  1 , Khyati Banker  1 , India Davids  1 , Monica Tembo  1 , Jessica A Davis  1 , Jerry Lai  1   7 , Tetyana Rocks  1 , Melissa O'Shea  8   2 , Niamh L Mundell  5 , Grace McKeon  6 , Murat Yucel  9 , Pilvikki Absetz  10 , Vincent Versace  11 , Sam Manger  12 , Mark Morgan  13 , Anna Chapman  14 , Craig Bennett  15 , Jane Speight  16   17 , Michael Berk  1   3 , Steve Moylan  1   3 , Lara Radovic  1 , Mary Lou Chatterton  2
Affiliations

Clinical and cost-effectiveness of remote-delivered, online lifestyle therapy versus psychotherapy for reducing depression: results from the CALM non-inferiority, randomised trial

Adrienne O'Neil et al. Lancet Reg Health West Pac. .

Abstract

Background: We conducted the first non-inferiority, randomised controlled trial to determine whether lifestyle therapy is non-inferior to psychotherapy with respect to mental health outcomes and costs when delivered via online videoconferencing.

Methods: An individually randomised, group treatment design with computer-generated block randomisation was used. Between May 2021-April 2022, 182 adults with a Distress Questionnaire-5 score = ≥8 (indicative depression) were recruited from a tertiary mental health service in regional Victoria, Australia and surrounds. Participants were assigned to six 90-min sessions over 8-weeks using group-based, online videoconferencing comprising: (1) lifestyle therapy (targeting nutrition, physical activity) with a dietitian and exercise physiologist (n = 91) or (2) psychotherapy (Cognitive Behavioural Therapy) with psychologists (n = 91). The primary outcome was Patient Health Questionnaire-9 (PHQ-9) depression at 8-weeks (non-inferiority margin ≤2) using Generalised Estimating Equations (GEE). Cost-minimisation analysis estimated the mean difference in total costs from health sector and societal perspectives. Outcomes were assessed by blinded research assistants using Computer Assisted Telephone Interviews. Results are presented per-protocol (PP) and Intention to Treat (ITT) using beta coefficients with 95% Confidence Intervals (CIs).

Findings: The sample was 80% women (mean: 45-years [SD:13.4], mean PHQ-9:10.5 [SD:5.7]. An average 4.2 of 6 sessions were completed, with complete data for n = 132. Over 8-weeks, depression reduced in both arms (PP: Lifestyle (n = 70) mean difference:-3.97, 95% CIs:-5.10, -2.84; and Psychotherapy (n = 62): mean difference:-3.74, 95% CIs:-5.12, -2.37; ITT: Lifestyle (n = 91) mean difference:-4.42, 95% CIs: -4.59, -4.25; Psychotherapy (n = 91) mean difference:-3.82, 95% CIs:-4.05, -3.69) with evidence of non-inferiority (PP GEE β:-0.59; 95% CIs:-1.87, 0.70, n = 132; ITT GEE β:-0.49, 95% CIs:-1.73, 0.75, n = 182). Three serious adverse events were recorded. While lifestyle therapy was delivered at lower cost, there were no differences in total costs (health sector adjusted mean difference: PP AUD$156 [95% CIs -$182, $611, ITT AUD$190 [95% CIs -$155, $651] ]; societal adjusted mean difference: PP AUD$350 [95% CIs:-$222, $1152] ITT AUD$ 408 [95% CIs -$139, $1157].

Interpretation: Remote-delivered lifestyle therapy was non-inferior to psychotherapy with respect to clinical and cost outcomes. If replicated in a fully powered RCT, this approach could increase access to allied health professionals who, with adequate training and guidelines, can deliver mental healthcare at comparable cost to psychologists.

Funding: This trial was funded by the Australian Medical Research Future Fund (GA133346) under its Covid-19 Mental Health Research Grant Scheme.

Keywords: Digital health; Lifestyle psychiatry; Mental health; Non-inferiority; Psychotherapy.

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Conflict of interest statement

This trial was funded by the National Health and Medical Research Council’s (NHMRC) Medical Research Future Fund–COVID-19 Mental Health Research Australian Government Department of Health (GA133346). AO is supported by a NHMRC Emerging Leader 2 Fellowship (2009295). FNJ is supported by an NHMRC Investigator Grant (#1194982). FNJ has received fellowship funding support from the National Health and Medical Research Council (#1194982) and payment or honorariums for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the Malaysian Society of Gastroenterology and Hepatology, JNPN Congress, American Nutrition Association, Personalised Nutrition Summit, and American Academy of Craniofacial Pain, is a Scientific Advisory Board member of Dauten Family Centre for Bipolar Treatment Innovation (unpaid) and Zoe Nutrition (unpaid), has written two books for commercial publication on the topic of nutritional psychiatry and gut health, and is the principal investigator for the MicroFit Study. She is Director of the Food & Mood Centre, Deakin University, which has received research funding support from Be Fit Food, Bega Dairy and Drinks, and the a2 Milk Company and philanthropic research funding support from the Waterloo Foundation, Wilson Foundation, the JTM Foundation, the Serp Hills Foundation, the Roberts Family Foundation, and the Fernwood Foundation. SR is supported by an NHMRC Investigator Grant (2017506). MB is supported by a NHMRC Senior Principal Research Fellowship and Leadership 3 Investigator grant (1156072 and 2017131). MTey is supported by a NHMRC Emerging Leadership Fellowship (APP1195335). JS is supported by core funding to the Australian Centre for Behavioural Research in Diabetes provided by the collaboration between Diabetes Victoria and Deakin University. VV is supported by the Rural Health Multidisciplinary Training program. SMah has received funding from Education in Nutrition to provide a professional development presentation and Red Island Olive Oil for social media promotion. MMor has received research grants related to antimicrobial stewardship, discharge medication, consulting fees from Primary Health Networks of Gold Coast and Western Australia related to Primary Sense software. Australian Health Policy Collaboration, RACGP, Australian Department of Health and Aged Care (DoHAC), conference support from RACGP various as chair of Expert Committee for Quality Care, participation in DSMBs for Primary Sense and DoHAC and is a member of Arthritis Australia and Bond University Boards. The contents of the published material are solely the responsibility of the individual authors and do not reflect the views of the funding bodies. The authors have no interests to declare.

Figures

Fig. 1
Fig. 1
Session Content, by treatment arm.
Fig. 1
Fig. 1
Session Content, by treatment arm.
Fig. 1
Fig. 1
Session Content, by treatment arm.
Fig. 2
Fig. 2
Participant flow chart.
Fig. 3
Fig. 3
Mean (and Standard Error) PHQ9 depression scores over 8 weeks by treatment arm against representative sample of the Victorian population over comparable time period.
See this image and copyright information in PMC

References

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Further reading

    1. Services Australia . Commonwealth of Australia; 2023. Medicare item reports [online]http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp
    1. Independent Hospital Pricing Authority . IHPA; 2020. National hospital cost data collection report, public sector, round 22-24 (financial year 2019-20)https://www.ihacpa.gov.au/resources/national-hospital-cost-data-collecti...
    1. Department of Health Victoria Ambulance fees 2023. https://www.health.vic.gov.au/patient-care/ambulance-fees
    1. Services Australia . Commonwealth of Australia; 2023. Pharmaceutical benefits schedule item reports [online]http://medicarestatistics.humanservices.gov.au/statistics/pbs_item.jsp
    1. Australian Institute of Health and Welfare Health expenditure Australia 2021-20. 2021. https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expend...

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