Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial (Preprint)

Abstract

Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. Self-guided treatment for depression and anxiety has established evidence of efficacy, and use has intensified because of the COVID-19 pandemic. Although self-guided treatment is effective for many patients, engagement remains important as dose-response relationships have been observed. Platforms such as Facebook, LinkedIn, and Twitter strategically employ principles of behavioral economics to increase platform engagement. We hypothesized that the use of similar concepts would increase engagement in self-guided digital health courses.

This three-arm randomized controlled trial tested whether members of Overcoming Anxiety and Overcoming Depression, two self-guided digital health courses, would engage with behavioral nudges and prompts. Our primary hypothesis was that if presented, members would click on two features: Tips and a To-Do Checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in Arm 2, versus social proof and present bias tips in Arm 3. Our tertiary hypothesis was that the addition of rotating Tips and a To-Do Checklist would increase completion rates with course tools. The results of this study will form a baseline for future AI-directed research.

Between November 2021 and May 2022 13,224 new members registered for Evolution Health’s self-guided treatment courses for anxiety and depression. All members were randomized into one of three arms. The control arm featured a member home page without any nudges or prompts. The second arm featured a member home page with a Tip-of-the-Day section. The third arm featured a member home page with a Tip-of-the-Day and a To-Do Checklist.

Arm 3 was significantly younger (F(2,4564)=40.97, p<0.001) and had significantly more females (Χ2(4)=92.21, p<0.001) than the other two arms. Members in the control arm (1,788) completed an average of 1.5 course components. Members in arm 2 (865) clicked on an average of 5 Tips and completed an average of 1.8 course components. Members in arm 3 (1,914) clicked on an average of 5 Tips, completed 2.7 out of 8 To-Do Checklist items, and completed an average of 2.11 course components. There were no statistically significant differences between tips clicked on in arm 2 versus arm 1 (p>0.05). Completion rates of six of eight measurable course components increased in both experiment arms from baseline usage in arm 1. Completion rates in arm 2 were greater than arm 1 (z=3.37, p.001), and completion rates in arm 3 were greater than arm 1 (z=12.23, p<0.0001). Engagement in all eight components in Arm 3 was higher than Arm 2 (z=1.31, p<0.0001).

Members engaged with behavioral nudges and prompts, and the addition of Tips and a To-Do Checklists increased completion of course components. To our knowledge, this is the first randomized controlled trial designed to test the implementation of behavioral nudges and prompts in online self-guided courses for mood disorders. The results of this study may be important as efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field.