JMIR Publications

ABSTRACT

Background:

The widespread occurrence and devastating impact of adolescent depression warrants services research focused on feasible and acceptable Evidence-Based Intervention (EBI) efforts, particularly in context of shelter-in-place guidelines disrupting youth socialization and service utilization in the wake of the COVID-19 pandemic. Group cognitive behavioral therapy (CBT) is an EBI for adolescent depression, but effectiveness is inhibited by suboptimal treatment engagement, including inconsistent group attendance, incomplete homework completion, and treatment dropout. Our team designed the mobile health (mHealth) system HealthySMS system to supplement a CBT group for adolescents with depression. The system sends daily text messages requesting responses assessing mood, thoughts, and activities; weekly attendance reminder messages; daily tips about adherence (e.g., a prompt for activity completion); and personalized responses based on participants’ texts.

Objective:

We conducted a mixed-method pilot study to implement HealthySMS adjunct to adolescent group CBT services and examine the system feasibility, acceptability, and impact on EBI engagement.

Methods:

Over the course of 2020, we invited all twenty adolescents receiving CBT group services for depression at an outpatient psychiatry clinic to enroll in HealthySMS; ultimately, seventeen agreed to participate. Of note, the majority of CBT sessions occurred via remote delivery in context of COVID-19 shelter-in-place guidelines. We tracked participant initiation and engagement with the HealthySMS system and CBT group services, as well as the content of text message responses to HealthySMS, including messages flagged for suicide risk and responses to prompts for feedback. Finally, we invited each participant to engage in a semi-structured interview to provide additional qualitative input on the system.

Results:

HealthySMS appears to be a feasible and acceptable adjunct to group CBT for adolescents with depression, as evidenced by high rates of HealthySMS initiation (i.e., 100% of those invited agreed to receive messages) and maintenance (i.e., 94% maintained usage within first month without opting-out). We uncovered meaningful qualitative themes which support promising feasibility and acceptability findings, as well as provide insight into potential system improvements to enhance feasibility and acceptability. Qualitative themes regarding potential mechanisms by which HealthySMS may enhance EBI engagement align with generally high rates of CBT group attendance (i.e., median rate of 85%) and low rates of dropout (i.e., 17%).

Conclusions:

Taken together, findings support the promise of utilizing mHealth interventions, such as HealthySMS, adjunct to EBI for adolescents with depression. Future effectiveness research is warranted to examine if enhanced EBI engagement associated with mhealth text-message interventions produces superior patient treatment outcomes.