The demand for psychiatric services far exceeds availability, and there are barriers such as cost and time to accessing services, even when they are available. Recently, various digital mental health interventions (DMHI) have been developed to help address the gap between mental health care need and publicly available services. These interventions are accessible by smartphone, available at any time, and have lower costs than personnel-delivered mental health services. 

While studies show that specific cognitive-behavioral DMHIs and Mindfulness-Based DMHIs are more effective than no-treatment controls, there is little research comparing their relative effectiveness. Horwitz et al. [JAMA Network Open] compared the relative effectiveness of five different DMHIs in reducing depressive symptoms within an adult  general outpatient psychiatric population.

The researchers recruited 2,079 adults (average age =  37 years; 68% female; 77% white) who had sought mental health services within the University of Michigan Health System and had scheduled an appointment or recently had their first appointment. Participants were paid $20 for completing the initial assessment and an additional $20 for completing the 6-week follow-up assessment. They agreed to pair their smartphones with a smartphone app, sync their smartphones with a wrist-worn activity monitor, and use the smartphone app for 6 weeks. The primary study outcome was improvement in depressive symptoms, with secondary outcomes including improvements in anxiety, substance use, and suicidal ideation.

Five digital treatment interventions were randomly  assigned to participants: 1) enhanced personal feedback (EPF), 2) cognitive-behavioral therapy, 3) mindfulness meditation, 4) cognitive-behavioral therapy + EPT, and 5) mindfulness meditation + EPT.  EPF consisted of sending pop-up notifications to smartphones twice daily. For example, if the activity monitor showed relative inactivity, a message might be sent to encourage more walking. Other notifications suggested participants be kind to others or engage more with the cognitive-behavioral and mindfulness meditation apps. 

Cognitive-behavioral therapy was delivered via the Silvercloud app, which helped participants monitor mood, activity schedule, and engage in cognitive restructuring through text, video, and journaling.  Mindfulness meditation involved access to the library of guided meditations on the Headspace app.  

The results showed that depressive symptom scores significantly decreased in all five digital intervention groups, but without between-group differences reaching significance. Depressive symptoms initially averaged 12.7 on a 27-point scale at baseline and decreased by a range of  2.1 to 2.9 points below baseline across the various interventions. 

There were similar improvements for secondary outcomes. The Headspace app interventions showed a significantly greater (but probably not clinically meaningful) decrease in suicidal ideation compared to the other intervention groups. The degree of improvement in these groups was the same regardless of whether participants attended 0, 1, 2, or more treatment meetings with therapists during the 6-week trial suggesting that clinic visits did not contribute to symptom changes across study groups.

The study shows that psychiatric outpatients experience a small but significant degree of improvement in psychiatric symptoms after being assigned digital mental health interventions regardless of intervention content.

The authors suggest that digital mental health interventions may be helpful for patients awaiting assignment for first visits to therapists. However, the study is limited by the absence of a no-treatment group to eliminate the claim that simple engagement in a research study as a participant also improves depressive symptoms. It also did not measure the extent to which participants actually used their assigned apps.

Reference:

Horwitz, A. G., Mills, E. D., Sen, S., & Bohnert, A. S. B. (2024). Comparative Effectiveness of Three Digital Interventions for Adults Seeking Psychiatric Services: A Randomized Clinical Trial. JAMA Network Open, 7(7), e2422115. 

Link to study