Background New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness. Objective This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy. Methods We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study. Results This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability. Conclusions Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.
BACKGROUND New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them due to geographical, social, or cost-related barriers. Digital interventions for depression are novel, however low patient engagement could limit their effectiveness. OBJECTIVE This systematic literature review (SLR) assessed how patient adherence to and engagement with digital interventions for depression has been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy. METHODS We focused on a patient population of adults aged 18 and older with depression or major depressive disorder (MDD) as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions to treat depression, such as digital therapeutics and digital health (eg, mental health apps). We screened 756 unique records published between January 1, 2000 and April 15, 2022 and analyzed 94 that met the inclusion criteria. RESULTS The majority of the studies in this SLR were published in 2017 or after and encompassed results from 20,111 patients in studies using 47 unique web-based interventions (with an additional 10 web-based interventions that were not described by name in the studies), 15 mobile app interventions, 5 app-based interventions also accessible via the web, and 1 CD-ROM intervention. Adherence was most often measured as the percentage of patients who completed all available modules. Fewer than half (44.2%) of patients completed all modules; however, patients did finish 61.1% of the modules on average. Although patient engagement with digital interventions was measured in a variety of ways, the most common was the number of modules completed, with a mean of 6.4 (means ranged from 1.0 to 19.7 modules). The mean amount of time patients spent engaging with the interventions overall was 3.9 hours (means ranged from 0.7 to 8.4 hours). The majority of studies of web-based (75.6%) and app-based (88.9%) interventions found the intervention group had substantially greater improvement for at least 1 outcome compared with the control group (eg, care as usual, waitlist, active control). Nine of the 14 studies (64.3%) that investigated the relationship between engagement and patient outcomes found that increased engagement with the digital intervention was significantly associated with improved patient outcomes. CONCLUSIONS Patient adherence to and engagement with digital interventions for depression have been reported in the literature using a variety of metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations. CLINICALTRIAL NA
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