Trajectories of Depressive Symptoms Among Web-Based Health Risk Assessment Participants

Health risk assessments (HRAs), which often screen for depressive symptoms, are administered to millions of employees and health plan members each year. HRA data provide an opportunity to examine longitudinal trends in depressive symptomatology, as researchers have done previously with other populations.

The primary research questions were: (1) Can we observe longitudinal trajectories in HRA populations like those observed in other study samples? (2) Do HRA variables, which primarily reflect modifiable health risks, help us to identify predictors associated with these trajectories? (3) Can we make meaningful recommendations for population health management, applicable to HRA participants, based on predictors we identify?

This study used growth mixture modeling (GMM) to examine longitudinal trends in depressive symptomatology among 22,963 participants in a Web-based HRA used by US employers and health plans. The HRA assessed modifiable health risks and variables such as stress, sleep, and quality of life.

Five classes were identified: A "minimal depression" class (63.91%, 14,676/22,963) whose scores were consistently low across time, a "low risk" class (19.89%, 4568/22,963) whose condition remained subthreshold, a "deteriorating" class (3.15%, 705/22,963) who began at subthreshold but approached severe depression by the end of the study, a "chronic" class (4.71%, 1081/22,963) who remained highly depressed over time, and a "remitting" class (8.42%, 1933/22,963) who had moderate depression to start, but crossed into minimal depression by the end. Among those with subthreshold symptoms, individuals who were male (P<.001) and older (P=.01) were less likely to show symptom deterioration, whereas current depression treatment (P<.001) and surprisingly, higher sleep quality (P<.001) were associated with increased probability of membership in the "deteriorating" class as compared with "low risk." Among participants with greater symptomatology to start, those in the "severe" class tended to be younger than the "remitting" class (P<.001). Lower baseline sleep quality (P<.001), quality of life (P<.001), stress level (P<.001), and current treatment involvement (P<.001) were all predictive of membership in the "severe" class.

The trajectories identified were consistent with trends in previous research. The results identified some key predictors: we discuss those that mirror prior studies and offer some hypotheses as to why others did not. The finding that 1 in 5 HRA participants with subthreshold symptoms deteriorated to the point of clinical distress during succeeding years underscores the need to learn more about such individuals. We offer additional recommendations for follow-up research, which should be designed to reflect changes in health plan demographics and HRA delivery platforms. In addition to utilizing additional variables such as cognitive style to refine predictive models, future research could also begin to test the impact of more aggressive outreach strategies aimed at participants who are likely to deteriorate or remain significantly depressed over time.