Use and Engagement with Low-Intensity Cognitive Behavioral Therapy Techniques Employed Within an App to Support Worry Management: Analysis of Log Data.

BACKGROUND: Low-Intensity Cognitive Behavioral Therapy (CBT) self-help has been implemented into mental health service delivery to manage excessive worry associated with Generalized Anxiety Disorder (GAD) and support emotional wellbeing. However, being predominantly available within a written format presents barriers to access limiting scalability. A solution could be to incorporate low-intensity CBT techniques derived from an evidence-based protocol within a mental health wellbeing app for worry management supported through an algorithmically driven conversational agent.

OBJECTIVE: Examine engagement with the Iona Mind Wellbeing smartphone app for Worry (IMWW) to help people manage their worries by teaching them evidence-based skills and techniques from low-intensity CBT. Specific attention was directed towards interaction with specific techniques and potential to reduce symptoms of anxiety.

METHODS: Log data was examined with respect to a sample of 153 'engaged' users that had completed at least one lesson related to the Worry Time and Problem Solving in-app modules that represented the 'minimum dose'. Paired samples t-tests were undertaken to examine the potential for IMWW to reduce worry and anxiety, with multivariate linear regressions examining the extent to which completion of each of the techniques led to reductions in worry and anxiety.

RESULTS: Users engaged with 1108 low-intensity CBT sessions (x̄=7.2; SD=7.7), with an average session length of 6.2 minutes (SD=6.2). With 114 (75%) of users engaging with Problem Solving, the conversational agent was successfully employed where lower levels of engagement were experienced. Of the 147 users (96%) engaging with Worry Time, 50 (34%) did so using in-app tools, with 97 (66%) engaging with the technique out-of-app. Of the 153 engaged users, lower levels of engagement were associated 54 users (35%) completing the PHQ-8 and GAD-7 routine outcome measures and 58 (38%) users undertaking the weekly reflections. Despite difficulties in collection of endpoint data, there was a significant reduction in severity for both anxiety [t(53)=5.5; P<.001; 95%CI=2.4-5.2] and low mood [t(53)=2.3; P=.025; 95%CI=2-3.3]. A statistically significant linear model was also fitted to GAD-7 [F(2,51)=6.73; P< .001], whilst the model predicting changes in the PHQ-8 did not reach significance [F(2,51)=2.33; P=.11]. This indicates that reduction in these measures was affected by engagement with in-app Worry Time and Problem Solving techniques.

CONCLUSIONS: Engaged users were able to successfully interact with the low-intensity CBT specific techniques informed by an evidence-based protocol, although there was poor completion of routine outcome measures and weekly reflections. Successful interaction with the specific techniques potentially contributes to promising data indicating that IMWW may be effective in the management of excessive worry. A relationship between dose and improvement justifies the use of adopting log data to inform future developments. However, attention needs to be directed towards enhancing interaction with wider features of the app given that larger improvements were associated with greater engagement.