Accepted for/Published in: Journal of Medical Internet Research
Date Submitted: Jan 23, 2021
Date Accepted: Apr 11, 2021
Exploring the Role of Persuasive Design in Unguided ICBT for Depression and Anxiety Among Adults: Systematic Review, Meta-Analysis, and Meta-Regression
ABSTRACT
Background:
Internet-delivered cognitive behavioural therapy (ICBT) is an effective treatment that can overcome barriers to care. Various research groups have suggested that unguided ICBT (i.e., ICBT without therapist support) and other eHealth interventions can be designed in ways that enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical support that persuasive design is related to clinical outcomes in unguided ICBT.
Objective:
One objective of this study was to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety. Another objective was to describe the use of persuasive design in such interventions. A third objective was to employ meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety.
Methods:
We conducted a systematic review of five databases to find randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random-effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included two steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design.
Results:
We identified 4,471 articles in our search, 46 of which were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges’ g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 for anxiety interventions, with no evidence that results were inflated by bias. Included interventions were identified as employing an average of 4.88 persuasive design principles. The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=.27, B=0.04, P=.02) but not anxiety (R2 change=.05, B=0.03, P=.17).
Conclusions:
These findings provide preliminary support for the proposition that more persuasively designed ICBT interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT. Clinical Trial: PROSPERO (https://www.crd.york.ac.uk/prospero/) CRD42020153466
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