Accepted for/Published in: Journal of Medical Internet Research
Date Submitted: Jul 25, 2019
Date Accepted: Oct 20, 2019
Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: A Mixed-Methods Study
ABSTRACT
Background:
User engagement is key to the effectiveness of digital mental health interventions. Considerable research has examined the clinical outcomes of overall engagement with mental health apps (e.g., frequency and duration of app use). Yet few studies have examined how specific app use behaviors can drive change in outcomes. Understanding the clinical outcomes of more nuanced app use could inform the design of mental health apps that are more clinically effective to users.
Objective:
This study aims to classify use behaviors in a suite of mental health apps and examine how different use behaviors are related to depression and anxiety outcomes. We also compare the outcomes of more nuanced app use with those of generic app use (i.e., intensity and duration of app use) to better understand what aspects of app use may drive symptom improvement.
Methods:
We conducted a secondary analysis of system use data from an 8-week randomized trial of a suite of 13 mental health apps. We categorized use behaviors through a mixed-methods analysis combining qualitative content analysis and principal component analysis. Regression analyses were used to assess the association between app use and levels of depression and anxiety at the end of treatment.
Results:
Three distinct clusters of app use behaviors were identified: “Learning and Practicing”, “Goal Setting”, and “Self-Tracking”. Each specific behavior had varied effects on outcomes. Self-Tracking at varying levels of intensity led to reduced depressive symptoms, whereas only moderate intensity of Learning and Practicing and Goal Setting predicted improvement in depression. Notably, the combination of these three types of use behaviors, what we termed “clinically meaningful use,” accounted for roughly the same amount of variance as explained by the overall intensity of app use (i.e., total number of app use sessions). Yet anxiety outcomes were neither associated with specific behaviors nor generic app use. This suggests that our categorization of use behaviors succeeded in capturing app use associated with better outcomes.
Conclusions:
This paper presents the first granular examination of user interactions with mental health apps and their effects on mental health outcomes. This work has important implications for mHealth interventions that aim to achieve greater user engagement and improved clinical efficacy. Clinical Trial: Clinicaltrials.gov NCT02801877
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