Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review

Abstract

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.

Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial

“…As recommended by Aschbacher et al [ 68 ] in a recent study involving digital mental health and dose responses, machine learning models can help enable precision by analyzing engagement patterns over time. Combined with another recent paper by Forbes et al [ 24 ] analyzing digital interventions for depression, which noted that it is important to develop standardized ways of reporting adherence and engagement so that effective comparisons across different interventions could be measured, baseline outcomes need to be established.…”

“…A recent paper by Forbes et al [ 24 ] analyzing patient adherence with digital interventions for depression noted that it is important to standardize reporting adherence and engagement. Our future work will focus on establishing baseline metrics.…”

“…Patients’ use of, and trust, in these interventions has been intensified by the COVID-19 pandemic. The use of self-guided digital health interventions for mental health concerns is growing [ 22 , 23 ] because of access barriers such as high cost, stigma, and lack of access due to a shortage of professionals who can meet this growing demand [ 24 , 25 ].…”

Development and Evaluation of a Digital App for Patient Self-Management of Opioid Use Disorder: Usability, Acceptability, and Utility Study

“…However, this may indicate a need to make the KIOS app more engaging, since participants could use the app daily if desired. Focusing the content on participants earlier in OUD treatment who may want more recovery advice or improving the experience by augmenting personalization could make the app more engaging [ 33 , 34 ]. Revisions to the app will include more explicit recommendations to continue in OUD treatment and more varied suggestions about mindfulness-oriented and positive self-care activities.…”

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“…Addressing depression’s multifaceted challenges requires a comprehensive and multidisciplinary approach involving mental health professionals, support networks, and policy changes to improve access to mental health care [ 12 ]. Ongoing research and advancements in understanding depression are crucial for developing more effective and personalized treatment strategies.…”