Engagement, Satisfaction, and Mental Health Outcomes Across Different Residential Subgroup Users of a Digital Mental Health Relational Agent: Exploratory Single-Arm Study

Abstract

Background Mental illness is a pervasive worldwide public health issue. Residentially vulnerable populations, such as those living in rural medically underserved areas (MUAs) or mental health provider shortage areas (MHPSAs), face unique access barriers to mental health care. Despite the growth of digital mental health interventions using relational agent technology, little is known about their use patterns, efficacy, and favorability among residentially vulnerable populations. Objective This study aimed to explore differences in app use, therapeutic alliance, mental health outcomes, and satisfaction across residential subgroups (metropolitan, nonmetropolitan, or rural), MUAs (yes or no), and MHPSAs (yes or no) among users of a smartphone-based, digital mental health intervention, Woebot LIFE (WB-LIFE). WB-LIFE was designed to help users better understand and manage their moods and features a relational agent, Woebot, that converses through text-based messages. Methods We used an exploratory study that examined data from 255 adults enrolled in an 8-week, single-arm trial of WB-LIFE. Analyses compared levels of app use and therapeutic alliance total scores as well as subscales (goal, task, and bond), mental health outcomes (depressive and anxiety symptoms, stress, resilience, and burnout), and program satisfaction across residential subgroups. Results Few study participants resided in nonmetropolitan (25/255, 10%) or rural (3/255, 1%) areas, precluding estimates across this variable. Despite a largely metropolitan sample, nearly 39% (99/255) resided in an MUA and 55% (141/255) in an MHPSA. There were no significant differences in app use or satisfaction by MUA or MHPSA status. There also were no differences in depressive symptoms, anxiety, stress, resilience, or burnout, with the exception of MUA participants having higher baseline depressive symptoms among those starting in the moderate range or higher (Patient Health Questionnaire-8 item scale≥10) than non-MUA participants (mean 16.50 vs 14.41, respectively; P=.01). Although working alliance scores did not differ by MHPSA status, those who resided in an MUA had higher goal (2-tailed t203.47=2.21; P=.03), and bond (t203.47=1.94; P=.05) scores at day 3 (t192.98=2.15; P=.03), and higher goal scores at week 8 (t186.19=2.28; P=.02) as compared with those not living in an MUA. Conclusions Despite the study not recruiting many participants from rural or nonmetropolitan populations, sizable proportions resided in an MUA or an MHPSA. Analyses revealed few differences in app use, therapeutic alliance, mental health outcomes (including baseline levels), or satisfaction across MUA or MHPSA status over the 8-week study. Findings suggest that vulnerable residential populations may benefit from using digital agent–guided cognitive behavioral therapy. Trial Registration ClinicalTrials.gov NCT05672745; https://clinicaltrials.gov/study/NCT05672745

Feasibility and utility of mobile health interventions for depression and anxiety in rural populations: A scoping review

“…Nine present data for feasibility, acceptability, or outcomes from the evaluation of mHealth interventions ( Bauer et al, 2017 ; Bhatia et al, 2021 ; Bhuiyan et al, 2021 ; Knutson et al, 2021 ; Maharjan et al, 2021 ; Seshu et al, 2021 ; Silfee et al, 2021 ; Vigil-Hayes et al, 2021 ; Forman-Hoffman et al, 2023 ) and two are study protocols describing development, deployment, or evaluation of future mHealth interventions ( Arenas-Castañeda et al, 2020 ; Moffett et al, 2022 ). Of these eleven studies, six were conducted in the U.S. ( Bauer et al, 2017 ; Bhuiyan et al, 2021 ; Knutson et al, 2021 ; Silfee et al, 2021 ; Vigil-Hayes et al, 2021 ; Forman-Hoffman et al, 2023 ) while the others were conducted in Mexico ( Arenas-Castañeda et al, 2020 ), Canada ( Bhatia et al, 2021 ), Nepal ( Maharjan et al, 2021 ), South Africa ( Moffett et al, 2022 ), and India ( Seshu et al, 2021 ). All included user depression and anxiety symptoms among the problems they were designed to address.…”

“…All included user depression and anxiety symptoms among the problems they were designed to address. Sample sizes ranged from N = 14 ( Knutson et al, 2021 ) to N = 7044 ( Bhuiyan et al, 2021 ) and included youth and adults with bipolar disorder or PTSD ( Bauer et al, 2017 ), chronic pain ( Bhatia et al, 2021 ), Native Americans ( Vigil-Hayes et al, 2021 ), perinatal women ( Maharjan et al, 2021 ; Seshu et al, 2021 ), transgender and nonbinary individuals ( Knutson et al, 2021 ), and otherwise healthy adults ( Bhuiyan et al, 2021 ; Forman-Hoffman et al, 2023 ). Most studies included rural users of specific mHealth applications, two studies included providers only ( Silfee et al, 2021 ), and one included both users and providers ( Bauer et al, 2017 ; Forman-Hoffman et al, 2023 ).…”

“… - Rural/urban status does not appear to drive differences in outcomes among Calm users. Forman-Hoffman et al, 2023 United States Explore differences in mental health outcomes, user satisfaction, app usage, and therapeutic alliances across residential subgroups among users of WB-LIFE, a digital mental health intervention. - Woebot LIFE (WB-LIFE) is a smartphone-based mobile health intervention that aims to help users better understand their moods.…”

“…Nine mHealth interventions are designed to provide psychoeducation and support: (SPIRIT) ( Bauer et al, 2017 ), Manage My Pain ( Bhatia et al, 2021 ), Calm ( Bhuiyan et al, 2021 ), WB-LIFE ( Forman-Hoffman et al, 2023 ), TExT ( Knutson et al, 2021 ), Kuamsha ( Moffett et al, 2022 ), IVRS ( Seshu et al, 2021 ), RxWell ( Silfee et al, 2021 ), and ARORA ( Vigil-Hayes et al, 2021 ). Kuamsha ( Moffett et al, 2022 ) is under development and will employ an interactive narrative game to engage and support adolescents with depressive symptoms living in rural South Africa.…”

“…There were no significant main effects from urban versus rural status on either outcome. Forman et al ( Forman-Hoffman et al, 2023 ) aimed to explore differences in usage, therapeutic alliance, satisfaction, and mental health outcomes between metropolitan, non-metropolitan, and rural users of the WB-LIFE app but lacked sufficient power for the proposed analyses.…”