JMIR Publications

ABSTRACT

Background:

Digital cognitive behavioral therapy (CBT) interventions can effectively prevent and treat depression and anxiety, but engagement with these programs is often low. While extensive research has evaluated program usage as a proxy for engagement, the extent to which users acquire knowledge and enact skills from these programs has been largely overlooked.

Objective:

(1) investigate how skill enactment and knowledge acquisition have been measured, (2) evaluate changes in skill enactment and knowledge at post-intervention, (3) examine whether mental health outcomes are associated with skill enactment or knowledge acquisition, and (4) evaluate predictors of skill enactment and knowledge acquisition.

Methods:

PubMed, PsycInfo, and the Cochrane CENTRAL Register of Controlled Trials were searched for randomized controlled trials (RCTs) published between 2000 and 26 July 2022, with the start date selected to coincide with publications related to the first digital interventions. We included RCTs comparing digital CBT against any comparison group in adolescents or adults (aged ≥12 years) for anxiety or depression. Eligible studies reported a quantitative measure of skill enactment or knowledge acquisition. The methodological quality of studies was assessed using the JBI Critical Appraisal Checklist for RCTs. Narrative synthesis was used to address the review questions.

Results:

Forty-three papers met inclusion criteria, of which 29 reported a measure of skill enactment and 15 a measure of knowledge acquisition. Skill enactment measures included indicators of formal skill enactment (n=13) and intervention-specific (n=9) or standardized (n=8) questionnaires. Knowledge acquisition measures included tests of CBT knowledge (n=6) or mental health literacy (n=5) and self-report questionnaires (n=6). Seventeen studies evaluated changes in skill enactment or knowledge acquisition at post-intervention, and findings were mostly significant for change in skill enactment (6/8 studies), CBT knowledge (6/6 studies), and mental health literacy (4/5 studies). Twelve studies evaluated the association between skill enactment and post-intervention mental health outcomes, with most reporting ≥1 significant positive findings on standardized questionnaires (4/4 studies), formal skill enactment indicators (5/7 studies), or intervention-specific questionnaires (1/1 studies). None of the 4 studies that evaluated the association between knowledge acquisition and primary mental health outcomes reported significant results. Thirteen studies investigated predictors of skill enactment, and only type of guidance and improvements in negative thinking and savoring were associated with increased skill enactment in ≥2 analyses. Predictors of knowledge acquisition were evaluated in 2 studies.

Conclusions:

Digital CBT for depression and anxiety can improve skill enactment and knowledge. However, only skill enactment appears to be associated with mental health outcomes, and this may be dependent upon the type of measure examined. Additional research is needed to understand what types and levels of skill enactment and knowledge are most relevant for outcomes and to identify predictors of these constructs. Clinical Trial: PROSPERO CRD42021275270; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=275270