JMIR Publications

ABSTRACT

Background:

Perinatal depression (depression occurring during pregnancy and/or postpartum) is increasingly recognized as a public health problem in the United States and worldwide. If untreated, there can be detrimental outcomes for both mother and child. While effective treatments exist, such as behavioral activation (BA), most women do not receive treatment. Technology, particularly the use of mobile apps, is one mechanism in which to increase access to and engagement in mental health services.

Objective:

The Guardians is a mobile game, grounded in BA principles, that seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to explore feasibility and acceptability of The Guardians among a sample of pregnant women with elevated depressive symptoms.

Methods:

This multi-method pilot test consisted of a single arm proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a depressed, pregnant sample (N=18). Participation included two virtual study visits: 1) a baseline assessment to collect demographic information and pregnancy variables and to assess clinical symptoms, and 2) an exit interview 10 weeks later to administer follow up measures and explore user experience. Participants completed biweekly questionnaires during the trial assessing depressive symptom severity among other criteria. In order to approximate real-world mobile app usage, participants were not compensated for this study, nor were they given any instructions about the app other than how to download it. Engagement with The Guardians is captured with game interaction metric data.

Results:

The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively, with an average app-related task completion rate of 69.5%. 76.0% of completed tasks resulted in participants feeling at least “a little bit better,” with participants reporting having a greater improved mood after completing “hard” tasks compared to after completing “medium” or “easy” tasks. Participants had a significantly lower average depression score (PHQ-9) at the end of the study (M=7.20, SD=3.65) than they did at baseline (M=13.00, SD=3.86), t(9)=5.03, p<0.001. Participants showed a non-significantly lower anxiety score (GAD-7) at the trial’s end (M=7.10, SD=4.12) than at baseline (M=9.20, SD=2.74), t(9)=1.20, p=0.13. Qualitative content analysis resulted in identification of the following major themes: activities (or “real life adventures”), app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications.

Conclusions:

Preliminary results from this multi-method study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double the levels of previously public mental health app usage, and use of the app was associated with a significant decrease in depressive symptom scores over the course of the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression.