The Use of Text Messaging as an Adjunct to Internet-Delivered Cognitive Behavioural Therapy for Major Depressive Disorder in Youth: A Secondary Analysis (Preprint)

Abstract

As an established treatment for major depression disorder (MDD), cognitive behavioural therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT approaches (ICBT), text messaging has been associated with increased adherence and therapeutic alliance.

This study analyzed data from the intervention arm of a randomized control trial (RCT) evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (wait-list control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during RCT participation. Higher text frequency in general and in three conceptual categories (Appreciating Alliance, Alliance Building Disclosures, and Agreement Confirmation) was hypothesized to predict larger MDD symptom improvement.

Participants were young adults (18-30 years) from The Centre for Addiction and Mental Health. The frequencies of categorized texts from twenty ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by two independent coders, and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II).

Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β = -0.029, 95% CI [-0.11, 0.048]) and in each of the three categories: Appreciating Alliance (β = -0.096, 95% CI [-0.80, 0.61]), Alliance Building Disclosures (β = -0.098, 95% CI [-0.28, 0.084]), and Agreement Confirmation (β = -0.076, 95% CI [-0.40, 0.25]). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement.

The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in internet-based CBT approaches employing adjunctive modes of communication.

Trial registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052

RR2-10.2196/24380