Small Steps over time: A longitudinal usability test of an automated interactive text messaging intervention to support self-management of depression and anxiety symptoms.

BACKGROUND: Digital mental health interventions (DMHIs) offer potential solutions for addressing mental health care gaps, but often suffer from low engagement. Text messaging is one promising medium for increasing access and sustaining user engagement with DMHIs. This paper examines the Small Steps SMS program, an 8-week, automated, adaptive text message-based intervention for depression and anxiety. METHODS: We conducted an 8-week longitudinal usability test of the Small Steps SMS program, recruiting 20 participants who met criteria for major depressive disorder and/or generalized anxiety disorder. Participants used the automated intervention for 8 weeks and completed symptom severity and usability self-report surveys after 4 and 8 weeks of intervention use. Participants also completed individual interviews to provide feedback on the intervention. RESULTS: Participants responded to automated messages on 70 % of study days and with 85 % of participants sending responses to messages in the 8th week of use. Usability surpassed established cutoffs for software that is considered acceptable. Depression symptom severity decreased significantly over the usability test, but reductions in anxiety symptoms were not significant. Participants noted key areas for improvement including addressing message volume, aligning message scheduling to individuals' availability, and increasing the customizability of content. LIMITATIONS: This study does not contain a control group. CONCLUSIONS: An 8-week automated interactive text messaging intervention, Small Steps SMS, demonstrates promise with regard to being a feasible, usable, and engaging method to deliver daily mental health support to individuals with symptoms of anxiety and depression.

Mental Health Self-Tracking Preferences of Young Adults With Depression and Anxiety Not Engaged in Treatment: Qualitative Analysis.

BACKGROUND: Despite the high prevalence of anxiety and depression among young adults, many do not seek formal treatment. Some may turn to digital mental health tools for support instead, including to self-track moods, behaviors, and other variables related to mental health. Researchers have sought to understand processes and motivations involved in self-tracking, but few have considered the specific needs and preferences of young adults who are not engaged in treatment and who seek to use self-tracking to support mental health. OBJECTIVE: This study seeks to assess the types of experiences young adults not engaged in treatment have had with digital self-tracking for mood and other mental health data and to assess how young adults not seeking treatment want to engage in self-tracking to support their mental health. METHODS: We conducted 2 online asynchronous discussion groups with 50 young adults aged 18 years to 25 years who were not engaged in treatment. Participants were recruited after indicating moderate to severe symptoms of depression or anxiety on screening surveys hosted on the website of Mental Health America. Participants who enrolled in the study responded anonymously to discussion prompts on a message board, as well as to each other's responses, and 3 coders performed a thematic analysis of their responses. RESULTS: Participants had mixed experiences with self-tracking in the past, including disliking when tracking highlighted unwanted behaviors and discontinuing tracking for a variety of reasons. They had more positive past experiences tracking behaviors and tasks they wanted to increase, using open-ended journaling, and with gamified elements to increase motivation. Participants highlighted several design considerations they wanted self-tracking tools to address, including building self-understanding; organization, reminders, and structure; and simplifying the self-tracking experience. Participants wanted self-tracking to help them identify their feelings and how their feelings related to other variables like sleep, exercise, and events in their lives. Participants also highlighted self-tracking as useful for motivating and supporting basic activities and tasks of daily living during periods of feeling overwhelmed or low mood and providing a sense of accomplishment and stability. Although self-tracking can be burdensome, participants were interested and provided suggestions for simplifying the process. CONCLUSIONS: These young adults not engaged in treatment reported interest in using self-tracking to build self-understanding as a goal in and of itself or as a first step in contemplating and preparing for behavior change or treatment-seeking. Alexithymia, amotivation, and feeling overwhelmed may serve both as barriers to self-tracking and opportunities for self-tracking to help.

A text messaging intervention to support the mental health of young adults: User engagement and feedback from a field trial of an intervention prototype.

Background: Young adults have high rates of mental health conditions, but most do not want or cannot access treatment. By leveraging a medium that young adults routinely use, text messaging programs have potential to keep young adults engaged with content supporting self-management of mental health issues and can be delivered inexpensively at scale. We designed an intervention that imparts strategies for self-managing mental health symptoms through interactive text messaging dialogues and engages users through novelty and variety in strategies (from cognitive behavioral therapy, acceptance and commitment therapy, and positive psychology) and styles of interaction (e.g., prompts, peer stories, writing tasks). Methods: The aim of this mixed-methods study was to pilot 1- and 2-week versions of an interactive text messaging intervention among young adults (ages 18-25), and to obtain feedback to guide intervention refinements. Young adults were recruited via a mental health advocacy website and snowball sampling at a North American University. We used Wizard-of-Oz methods in which study staff sent messages based on a detailed script. Transcripts of interviews were subject to qualitative analysis to identify aspects of the program that need improvements, and to gather participant perspectives on possible solutions. Results: Forty-eight individuals ages 18-25 participated in the study (mean age: 22.0). 85 % responded to the program at least once. Among those who ever responded, they replied to messages on 85 % of days, and with engagement sustained over the study period. Participants endorsed the convenience of text messaging, the types of interactive dialogues, and the variety of content. They also identified needed improvements to message volume, scheduling, and content. Conclusions: Young adults showed high levels of engagement and satisfaction with a texting program supporting mental health self-management. The program may be improved through refining personalization, timing, and message volume, and extending content to support use over a longer timeframe. If shown to be effective in randomized trials, this program has potential to help address a substantial treatment gap in young adults' mental health.