Appropriate use and operationalisation of adherence to digital cognitive behavioural therapy for depression and anxiety in youth: A systematic review. (Preprint)

Abstract

Digital, self-guided cognitive behavioural therapy (CBT) interventions circumvent many barriers to in-person therapy for young people; although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this.

This systematic review synthesizes the literature on digital CBT interventions for depression and anxiety in young people to describe (i) how appropriate use has been defined and communicated to users as instructions for use; (ii) how adherence has been measured; and (iii) to determine the associations between adherence and treatment outcomes.

A systematic review was conducted with two reviewers extracting data independently. Four electronic databases (Embase, Medline, PsycINFO and The Cochrane library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12-24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioural-only interventions were excluded. Methodological quality was assessed using the using the Cochrane Risk of Bias Tool (ROB) and the Integrated Quality Criteria for the Review of Multiple Study designs (ICROMS).

There were 32 manuscripts that met inclusion criteria, of which 28 were unique studies (total N=16 578 youth). Definitions of appropriate use varied between the different interventions in terms of intended recipients, duration and frequency of use, and the features employed to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies were inconsistent with no study systematically describing components of appropriate use nor providing information on how recommendations for use were relayed to users. Most often definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the nine studies that examined this.

Definitions of appropriate use are unique to each digital CBT intervention. Yet, statements of appropriate use are not systematically reported in the literature. Further, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We propose a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence.

This protocol was registered with PROSPERO [CRD42020208668].