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ANNALS OF CLINICAL PSYCHIATRY
AACP.com Annals of Clinical Psychiatry | Vol. 34 No. 4 | November 2022 e1
ANNALS OF CLINICAL PSYCHIATRY 2022;34(4):e1-e8 doi: 10.12788/acp.0091 RESEARCH ARTICLE
BACKGROUND: The newly developed app TellUs is a digital offering for psy-
chiatric outpatient treatment that includes diagnostic and therapeutic
tools. The aim of this study was to test the clinical efficiency and patient
satisfaction of TellUs.
METHODS: Sixty-four patients with depressive disorder took part in the
study for 3 months. The intervention group was treated digitally with
TellUs and the control group received visiting treatment (treatment as
usual) during that time.
RESULTS: In both groups, a significant decrease of depressive symptoms and
general strain through psychological symptoms, along with an increase of
quality of life in the psychological domain, was shown. Furthermore, both
groups were highly satisfied with the treatment.
CONCLUSIONS: TellUs was shown to be equivalent to treatment as usual in
terms of clinical efficiency and patient satisfaction.
Telemedicine for outpatient treatment
of depressive disorders
CORRESPONDENCE
Georg Juckel, MD, PhD
Department of Psychiatry
LWL-University Hospital
Ruhr University Bochum
Alexandrinenstr.1, 44791
Bochum, Germany
EMAIL
georg.juckel@ruhr-uni-bochum.de
Georg Juckel, MD, PhD
Eva Neumann, PhD
Arnd Jäger, MA
Magnus Welz, MA
Jessica Heinrich, MD
Katharina Pehnke, MD
Ida S. Haussleiter, MD
Barbara Emons, PhD
Department of Psychiatry
LWL-University Hospital
Ruhr University Bochum
Bochum, Germany
TELEMEDICINE APP FOR DEPRESSION
November 2022 | Vol. 34 No. 4 | Annals of Clinical Psychiatrye2
INTRODUCTION
Telemedicine support structures are a hitherto underuti-
lized offering in psychiatric care, as outpatient treatments
still largely take place in the traditional in-person out-
reach setting. There are several reasons it seems appropri-
ate to expand the treatment framework to include digital
offerings. For example, it has been noted that there are
bottlenecks in outpatient treatment.1 This can lead to
individuals who were previously treated as inpatients
receiving inadequate outpatient follow-up care, which
increases the risk of relapse. Telemedicine support struc-
tures can contribute to improving this bottleneck.2 These
services are low-threshold, flexible, and can be accessed
quickly and easily. They are economical and could at
least in part replace more costly outreach treatment.
The coronavirus pandemic has abruptly brought
further reasons for the digitization of psychiatric services
to public attention.3 Face-to-face contacts are risky dur-
ing a pandemic and therefore should largely be avoided.
Telemedicine support structures offer psychiatry the alter-
native possibility of moving diagnostic and therapeutic
services into the digital space. In this way, they can help
ensure basic psychiatric care remains available even dur-
ing a pandemic.
There are other settings in which outreach treatment
is associated with difficulties. Therefore, alternative digital
offerings may be useful. For example, digital offerings could
be helpful for people with severe physical disabilities who
have limited mobility. Patients with pronounced social
anxiety may be more motivated to receive therapy if they
did not have to visit a psychiatric or psychological facility in
person, at least initially, but could complete the first steps of
therapy in the digital space.
Numerous innovative projects have already looked at
the use of telemedicine support structures in psychiatric
care. However, most of the new approaches do not yet offer
the possibility of interaction between patient and thera-
pist; rather, they are based on the principle that the patient
applies the programs independently and without contact
with a therapist. They offer assistance for self-help.
Such programs are available for patients with
depressive disorders. To complement the treatment
of depressed patients, a cognitive bias modification
(CBM) program was developed.4 A review of clinical
efficacy found that this program led to a reduction in
depressive symptoms.5 More broadly in terms of con-
tent is the program “iFightDepression.”6 The 6 modules
of this self-management program (based on the cognitive-
behavioral approach) are designed for behavioral activa-
tion, sleep and mood monitoring, and cognitive restructur-
ing. Another cognitive-behavioral therapy program offers
at least initial approaches to patient-therapist communica-
tion.7 Here, patients work through a sequence of 9 modules
on the internet, with the therapist staying in contact with
the patient via email and participating in the process in this
manner. In a follow-up, this program proved effective at
reducing the likelihood of relapse.7
For our study, the TellUs app was developed and
empirically tested. Programming was performed by an
external IT company (Healthy Projects Düsseldorf). Data
protection and data security were reviewed by a com-
pany that specializes in these aspects, Datatree/ISDSG
Dortmund, which also provided the related programming.
TellUs is aimed at psychiatric patients receiving
outpatient treatment. The app goes beyond the afore-
mentioned programs in that in addition to modules for
self-management, diagnostic procedures and therapeu-
tic sessions can also be conducted online in direct con-
tact with a treating clinician (ie, the medical doctor or
therapist) who assesses information from the patient’s
input in real time as well during the online streaming
dates. TellUs offers the following functions:
• Timeline: The timeline function shows all the
patient’s activities in the app and provides access to all
functionalities
• Scheduling: The scheduling function enables the
organization of appointments (appointment request by the
patient, confirmation or offer of alternative appointments
by the clinic, appointment cancellation)
• Messages/reminders: This function allows both
the patient and the treatment team to write messages.
Furthermore, the patient receives initial notifications about
upcoming appointments and then again 30 minutes before
the appointment
• Medication: Here the patient can view and edit their
medication schedule, including feedback possibilities and
viewing laboratory results
• Prescription request: If an initial prescription exists,
the patient can use this function to request a new prescrip-
tion for medication
• Test diagnostics/information: This function allows
the patient to complete psychometric tests and keep
mood and activity diaries. Furthermore, professional
information, including psychoeducational manuals, are
available here
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ANNALS OF CLINICAL PSYCHIATRY
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• Online groups and individual therapy: This is the
central function of the app, as online treatments are pro-
vided through it. Both individual and group sessions are
possible.
The aim of our study was to examine the clinical
effectiveness of TellUs. Furthermore, patients’ satisfaction
with the treatment and with the app was investigated. For
this purpose, TellUs was used in a sample of patients with
depressive disorder. The selection of this disorder type is
supported by the fact that depression is one of the most
common mental disorders.8,9 Depression is associated
with wide-ranging limitations and is the most common
cause of disability.10 Accordingly, depressive disorders
are frequently found in inpatient and outpatient mental
health care settings.
This study was conducted in the psychiatric outpa-
tient clinic of the LWL-Hospital Bochum. A sample of
patients from this outpatient clinic participated in the
study for 3 months. The study had a pre/post control
group design. Data collection took place at the begin-
ning and end of the 3-month period, for which self-
assessment questionnaires were used. In the control
group, treatment was provided as treatment as usual
(TAU), meaning all steps of treatment occurred on-site
in person. The intervention group was treated using
TellUs in the digital space.
We expected both groups to show improvement
in clinical symptoms and quality of life, and especially
a decrease in depressive symptoms. The intervention
group was expected to show similar improvements to
the control group.
METHODS
Description of the sample
A total of 87 patients at the institute’s outpatient clinic
with a clinical diagnosis of depressive disorder (ICD-10:
F3) were included in the study at baseline; 64 patients
regularly terminated study participation after 3 months
(dropout rate: 27%). The 64 patients for whom data from
both measurement time points are available constitute
the sample of this study. Contact with the remaining 23
patients was lost shortly after study inclusion. The inter-
vention group consisted of 43 patients who received
their outpatient treatment digitally via the TellUs app,
TABLE
Sociodemographic data
Control group
(n = 21)
Intervention group
(n = 43)
Age, y
M
45.52
SD
13.28
M
33.35
SD
11.44
T
3.79
P
<.001
n % n % Chi-square P
Gender Female 11 52 27 63 .63 .43
Male 10 48 16 37
Partnership No 838 17 41 .03 .86
Yes 13 62 25 59
Children No 13 62 30 75 1.14 .29
Yes 838 10 25
School graduation Without degree 0 0 1 2 7.42 .06
Intermediate diploma 11 52 921
(Technical) high school diploma 943 32 75
Other degree 1 5 1 2
Professional status In training 2 9 1 2 4.10 .25
Working part-time 524 13 31
Working full-time 419 15 36
Not employed 10 48 13 31
TELEMEDICINE APP FOR DEPRESSION
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and 21 patients who underwent routine outpatient clinic
treatment served as the control group.
The sociodemographic data of the participants are
shown in the TABLE. Patients in the intervention group
were younger and more of them had a high school
diploma. All patients received medication with stable
dosages, mainly selective serotonin reuptake inhibitor
treatment with sertraline (up to 200 mg) or escitalopram
(up to 20 mg), or with another antidepressant, such as
venlafaxine (up to 225 mg), duloxetine (up to 120 mg),
or mirtazapine (up to 45 mg). There were no hospitaliza-
tions or suicide attempts during the study period.
Measurement tools
Beck Depression Inventory (BDI). The BDI is a 21-item
instrument for self-assessment of the severity of depres-
sive symptoms.11,12 Based on DSM-IV criteria, each item
describes a symptom of a depressive episode. Four state-
ments are available as possible answers, which are coded
0 to 3 and express disagreement to agreement with the
respective symptom. The answer that best describes the
patient’s mental state in the last week is selected. The BDI
score is the sum of all responses. BDI scores ≥20 indicate a
depressive episode of at least moderate severity.
Symptom Checklist Short Version 9 (SCL-K9).
The SCL-K9 is a one-dimensional short version of the
SCL-90.13 The 9 items are used for self-assessment of
impairment by psychological symptoms such as vulner-
ability, excessive worry, and tension in the past 7 days,
for which a 5-point scale from 0 (not at all) to 4 (very
much) is available. The sum score of the responses pro-
vides information about the degree of impairment by
psychological symptoms, similar to the Global Severity
Index, the total score of the SCL-90.
Short Form Health Survey (SF-12). The SF-12, a
short form of the SF-36, is used to assess health-related
quality of life, distinguishing between mental and
physical quality of life.14 The 12 items are divided into
2 scales: the psychological sum score (PSK) and the
physical sum score (KSK). The higher the score on each
scale, the higher the self-assessed quality of life in the
respective area.
FIGURE 1
Severity of depressive symptoms (BDI) from the first to the second
measurement timepoint
BDI: Beck Depression Inventory.
35
30
25
20
15
10
5
0
BDI
Control group
Intervention group
28.58
25
23.84
19.67
Start End
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ANNALS OF CLINICAL PSYCHIATRY
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Questionnaire measuring patient satisfaction
(ZUF-8). The ZUF-8, a German adaptation of the Client
Satisfaction Questionnaire (CSQ),15,16 is used to record
satisfaction with treatment. The 8 items relate in content
to different aspects of treatment and the facility in which
it takes place and are answered on a 4-point rating scale
from 1 (least favorable) to 4 (most favorable). The instru-
ment is unidimensional and the responses are summed
to give a total score that can range from 8 to 32.
System Usability Scale (SUS). The SUS is a ques-
tionnaire consisting of 10 items to evaluate the usabil-
ity of a system regardless of the technology used.17 In
this study, the SUS was used to evaluate the TellUs app.
The 10 items relate to the extent to which the system is
perceived as complex and how quickly individuals can
learn how to use it. The 5-point Likert scale for answer-
ing ranges from 0 (strongly disagree) to 4 (strongly
agree). The responses are summed and multiplied
by 2.5 so the SUS total score lies in the range 0 to 100.
Values ≥68 indicate at least good usability of the evalu-
ated system.
RESULTS
Clinical efficacy
FIGURE 1, FIGURE 2, FIGURE 3, and FIGURE 4 show the mean
values of the BDI, SCL-K9, and SF-12 scores in the control
and intervention groups at the beginning and end of the
3-month study period. The significance of the effects of
measurement timing and intervention on psychological
and physical symptomatology was tested using multivar-
iate analyses of variance with repeated measures.
The BDI showed a highly significant effect of mea-
surement timing [F(1,62) = 14.37, P < .001]. As shown in
FIGURE 1, BDI values decreased in both groups from the
beginning to the end of therapy. The effects of group
[F(1,62) = 1.27, P = .27] and the interaction of measure-
ment timepoint and group [F(1,62) = .05, P = .83] did not
become significant.
An analogous pattern of results was seen with the
SCL-K9. Again, the effect of measurement timing became
significant [F(1,61) = 6.56, P < .05]. FIGURE 2 shows the
SCL-K9 sum score decreased from the beginning to the
FIGURE 2
Burden of psychological symptoms (SCL-K9) from the first to the second
measurement timepoint
SCL-K9: Symptom Checklist Short Version 9.
18
17
16
15
14
13
12
11
10
SCL-K9
Control group
Intervention group
16.16
15.6
14.05
13.67
Start End
TELEMEDICINE APP FOR DEPRESSION
November 2022 | Vol. 34 No. 4 | Annals of Clinical Psychiatrye6
end of therapy. The effects of group [F(1,61) = .00, P = .96]
and the interaction of measurement timepoint and group
[F(1,61) = .35, P = .55] did not become significant.
The SF-12 psychological sum score again showed a
significant effect of measurement timing [F(1,58) = 4.71,
P =.05]. As FIGURE 3 shows, the psychological sum score
increased from the beginning to the end of therapy. The
effect of group also became significant [F(1,58) = 4.12,
P < .05]; the control group had higher scores than the
intervention group at both measurement timepoints. The
interaction of measurement timepoint and group did not
become significant [F(1,58) = .33, P = .57].
For the SF-12 physical sum score, shown in FIGURE 4,
none of the effects tested became significant: mea-
surement timepoint [F(1,58) = 2.26, P = .14]; group
[F(1,58) = 2.81, P = .10]; or interaction of measurement
timepoint and group [F(1,58) = .26, P =.62].
Satisfaction with treatment and the app
Both groups had equally high scores for satisfaction with
treatment, recorded with the ZUF-8. At baseline, mean
(SD) scores were 27.52 (3.57) in the control group, and
25.71 (4.88) in the intervention group. The slight differ-
ence between the 2 groups did not become significant
in the t test [t(57) = 1.49, P = .14]. At the end of therapy,
the average ratings were mean 27.76 (3.13) in the control
group and mean 26.17 (5.14) in the intervention group.
Again, the t test showed no significant difference between
the groups [t(61) = 1.30, P = .20].
The intervention group’s assessment of the app pro-
duced a high satisfaction score. The SUS score was mean
83.08 (13.68) at baseline, and almost identical at the end:
mean 83.26 (18.35).
DISCUSSION
This study showed that telemedicine support structures
could be a helpful new approach in outpatient psychiatric
care. To test the clinical effectiveness and user satisfaction
of these structures, the TellUs app, which provides various
diagnostic and therapeutic tools for outpatient treatments,
FIGURE 3
Psychological quality of life (SF-12 PSK) from the first to the second measurement timepoint
SF-12 PSK: Short Form Health Survey psychological sum score.
50
48
46
44
42
40
38
36
34
32
30
SF-12 PSK
Control group
Intervention group
31.79
35.92
33.97
39.65
Start End
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ANNALS OF CLINICAL PSYCHIATRY
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was developed. The app was used over a 3-month period
for patients with depressive disorder who were receiv-
ing outpatient treatment. Comparison of patients whose
treatment was purely digital (via TellUs) and patients
treated in the traditional outreach setting during the same
period showed that psychological well-being improved
equally in the 2 treatment settings. There was a signifi-
cant decrease in depressive symptoms in both groups,
which is in line with the main hypothesis of the present
work. Furthermore, the general burden of psychological
symptoms decreased and the perceived quality of life in
the psychological domain increased. Again, these effects
occurred in both groups. Only the quality of life in the
physical domain did not show any significant changes.
The measured changes were the same for both groups,
meaning there was no superiority of either treatment set-
ting. Due to the fact we had significantly more dropout
within the routine care group, it can be assumed the offer
of a digital treatment program that allowed patients to
maintain contact with their doctor was a great advantage
in favor of TellUs, especially during a pandemic.
Findings on satisfaction with treatment and with the
app were also promising. Patients rated the treatments
very positively; the mean scores of the ZUF-8, which
has a range of 8 to 32, were between 25 and 27 for both
groups, indicating that patients were very satisfied with
the treatment regardless of the setting. Patients treated
with TellUs who received all services in the digital space
apparently did not perceive as disadvantageous the fact
that they had no face-to-face interaction with their treat-
ing clinicians during the study.
The group that used TellUs also rated the app very
positively. On the SUS, whose values can range from 0 to
100, mean values >80 were reported, which corresponds
to a very high level of satisfaction.
Limitations
A limiting condition of the present study is that the con-
trol and intervention groups differed in 2 demographic
characteristics. On average, patients in the intervention
group were younger and more likely to have a high school
education than patients in the control group. It can be
FIGURE 4
Physical quality of life (SF-12 KSK) from the first to the second measurement timepoint
SF-12 KSK: Short Form Health Survey physical sum score.
50
48
46
44
42
40
38
36
34
32
30
SF-12 KSK
Control group
Intervention group
44.71
40.5
47.19
42.83
Start End
TELEMEDICINE APP FOR DEPRESSION
November 2022 | Vol. 34 No. 4 | Annals of Clinical Psychiatrye8
assumed that these characteristics are associated with a
higher affinity for digital offerings and, as a consequence,
higher digital literacy. These affinities and empowerments
may have led to a slight overestimation of the positive
effects of TellUs in the intervention group. Subsequent
studies could therefore specifically address the question
of whether patient groups in which low affinity for digi-
tal offerings can be assumed (eg, older or less educated
patients) also view telemedical support structures such as
TellUs positively and can achieve a reduction in the sever-
ity of psychological symptoms as a result.
Furthermore, the data of this study are based exclu-
sively on self-assessment questionnaires. Although the
study used established measurement instruments whose
reliability and validity have been tested many times, the
use of other methods, especially procedures for third-party
or expert assessment, could possibly lead to deviating find-
ings. Therefore, it would be interesting to verify whether
the treating clinicians could also confirm improvements in
clinical symptoms reported by the patients through tele-
medical support structures such as TellUs.
CONCLUSIONS
In this study, the newly developed TellUs app proved
to be just as effective in the outpatient treatment of
depressive disorders as traditional outreach treatment.
Participating patients experienced a decrease in depres-
sive symptoms over the 3-month study period, regardless
of whether they received digital or traditional in-person
treatment. In addition, TellUs users rated the app very
positively. Digital services such as TellUs thus represent a
useful complement to outreach treatments. ■
DISCLOSURES: This study was supported by the Ministry
for Innovation, Science and Research of the fed-
eral state of Nordrhein Westfalia in the framework of
Clustertechnique competition “Innovative Medicine
in a Digital Society.” Mr. Welz is an employee of
Datatree. The other authors report no financial rela-
tionships with any companies whose products are
mentioned in this article, or with manufacturers of
competing products.
REFERENCES
1. Schneider F, Falkai P, Maier W. Versorgungssituation
in Deutschland. In: Schneider F, Falkai P, Maier W, eds.
Psychiatrie 2020 Plus. Springer; 2011:25-46.
2. van den Berg N, Grabe HJ, Stentzel U, et al.
Telemedizin in der Psychiatrie. In: Marx G, Rossaint R,
Marx N, eds. Telemedizin. 1st ed. Springer; 2021:193-202.
3. Richter D, Zürcher S. Psychiatrische Versorgung
während der COVID-19-pandemie [Mental health care
services during the COVID-19 pandemic]. Psychiatr Prax.
2020;47:173-175.
4. Tendolkar I, Vrijsen JN, Becker ES. “Cognitive
bias modification“ als mögliche Add-on-Therapie bei
Depression. Psychotherapeut. 2019;64:180-185.
5. Vrijsen JN, Dainer-Best J, Witcraft SM, et al. Effect
of cognitive bias modification-memory on depressive
symptoms and autobiographical memory bias: two
independent studies in high-ruminating and dysphoric
samples. Cogn Emot. 2019;33:288-304.
6. Arensman E, Koburger N, Larkin C, et al. Depression
awareness and self-management through the internet:
protocol for an internationally standardized approach.
JMIR Res Protoc. 2015;4:e99.
7. Holländare F, Johnsson S, Randestad M, et al.
Randomized trial of Internet-based relapse prevention
for partially remitted depression. Acta Psychiatr Scand.
2011;24:285-294.
8. Jacobi F, Höfler M, Siegert J, et al. Twelve-month
prevalence, comorbidity and correlates of mental
disorders in Germany: the Mental Health Module of
the German Health Interview and Examination Survey
for Adults (DEGS1-MH). Int J Methods Psychiatr Res.
2014;23:304-319.
9. Wittchen HU, Jacobi F, Rehm J, et al. The size and
burden of mental disorders and other disorders of the
brain in Europe 2010. Eur Neuropsychopharmacol.
2011;21:655-679.
10. Ustün TB, Ayuso-Mateos JL, Chatterji S, et al. Global
burden of depressive disorders in the year 2000. Br J
Psychiatry. 2004;184:386-392.
11. Beck AT, Steer RA, Brown GK. Manual for the Beck
Depression Inventory-II. Psychological Corporation;
1996.
12. Hautzinger M, Keller F, Kühner C. BDI-II. Beck-
Depressions-Inventar. 2nd revised ed. Pearson; 2009.
13. Klaghofer R, Brähler E. Konstruktion und
teststatistische Prüfung einer Kurzform der SCL-90-R
[Construction and test statistical evaluation of a short
version of the SCL-90–R]. Z Klin Psychol Psychiatr
Psychother. 2001;49:115-124.
14. Morfeld M, Kirchberger I, Bullinger M. SF-36.
Fragebogen zum Gesundheitszustand. Hogrefe; 2011.
15. Attkisson CC, Zwick R. The client satisfaction
questionnaire. Psychometric properties and correlations
with service utilization and psychotherapy outcome. Eval
Program Plann. 1982;5:233-237.
16. Schmidt J, Lamprecht F, Wittmann WW.
Zufriedenheit mit der stationären Versorgung. Entwicklung
eines Fragebogens und erste Validitätsuntersuchungen
[Satisfaction with inpatient management. Development
of a questionnaire and initial validity studies].
Psychother Psychosom Med Psychol. 1989;39:
248-255.
17. Brooke J. SUS–A quick and dirty usability scale.
In: Jordan PW, Thomas B, Weerdmeester BA, et al,
eds. Usability Evaluation in Industry. Taylor & Francis;
1996:189-194.
