Discussion
depression, mental illness, anxiety, unhealthy behaviors
SECONDARY, RECRUITMENT
This study suggested it is possible to offer a digital self-help tool for healthy lifestyle promotion to primary care patients with mental health problems, who are receiving TAU. The overall recruitment rate was 21%, where improved recruitment routine at clinic B led to inclusion of around 40% of possible participants compared to 10% at clinic A. Women over 40 with moderate symptoms of depression and anxiety predominated among participating patients. Unhealthy lifestyle behaviors were present among 38% of the participants. Intervention adherence varied between clinics, where 70% of those randomized to the digital lifestyle intervention logged on to the platform at least once at clinic B, compared to 30% at clinic A. When MI counseling was available at clinic B, 29% opted to receive it. Results from the embedded recruitment trial showed that follow-up rates differed somewhat between groups: 88% in the TAU group and 73% in the intervention group. No between-group changes in depression, anxiety, or lifestyle behaviors occurred.In sum, this study showed that it was possible to deliver a structured digital self-help intervention, with a focus on lifestyle behaviors, to patients who seek help for mental health problems in a primary care setting, when involving health professionals in the recruitment procedure, as in the second location. One striking result in this study was that the behaviors exhibited in this patient group did not seem particularly unhealthy, compared to the population in general. For instance, 5% in this study reported daily smoking compared to the 7% prevalence of daily smokers in the Swedish population (Makenzius, 2019). The smoking rate among study participants was surprisingly low since prior research indicates that mental health problems are associated with unhealthy lifestyle behaviors (Firth The findings raise the question of whether primary care patients seeking help for common mental health problems should be considered a risk group concerning unhealthy behaviors. It may be that the primary care sample in this study differs from the samples reported in the literature, in that the level of severe mental illness was lower in this sample. The recruitment rate was low at 21% and might improve should the intervention be offered only to patients with unhealthy lifestyle behaviors. An additional aspect is that it could be worthwhile to explore whether it is optimal to offer a lifestyle intervention when the patient has initially sought help, or whether it might be preferable to offer the intervention as a complement after patients complete treatment for mental health problems.In this study, about one-third of the participants from clinic B opted to receive an MI counseling session. This session was offered in order to assess interest for an additional personal intervention, beyond the digital content of the Health Profile. An MI session is part of the original, paper-and-pencil version of the HP, and offering the intervention including MI was, as noted in the introduction, associated with healthy changes both in lifestyle and biometric outcomes (Blomstrand Regarding secondary outcomes from the embedded trial, no significant differences were found in short-term depression and anxiety outcomes between the group that received the digital lifestyle intervention with TAU and the TAU group, nor were there any significant differences in unhealthy behavior change between the two groups. The lack of significant effects for unhealthy behaviors may have been due to several factors. Patients were included whether they had unhealthy behaviors or not, and one important finding was that the majority of the patients did not exhibit any particularly unhealthy behaviors at baseline. Unhealthy behaviors in this group are of lower priority or could require more time.