A Digital Cognitive-Behavioral Intervention for Depression and Anxiety Among Adolescents and Young Adults

Anxiety and depression are common among adolescents and young adults (1), and the COVID-19 pandemic has increased rates of these two conditions (2). Thus, early intervention is critical. Cognitive-behavioral therapy (CBT) has been shown to be the most effective evidence-based treatment for anxiety or depression (3). However, CBT resources for adolescents and young adults are limited, and rates of treatment nonadherence are high (4).

Clinicians have sought new therapy modalities, such as digital behavioral tools, to improve care for adolescents and young adults. Evidence shows that such tools are superior to standard care in reducing emotional distress, achieving goals, and increasing adherence (5). However, these tools are available only in academic research settings or commercially without medical oversight. Accordingly, we sought to understand engagement in and effects of a coached digital cognitive-behavioral intervention (dCBI) for adolescents and young adults with anxiety or depression, implemented as part of routine outpatient pediatric care with the ability to monitor progress through electronic health records (EHRs). This quality improvement project (QRC Project ID 2073) evaluated a coached smartphone-based dCBI nested in outpatient pediatric care to explore experiences and clinical effects of the app for adolescents and young adults.

Methods

Sample

Patients were ages 16–25 years seen at 35 pediatric offices in July 2019–March 2021. Pediatricians reported an increased need for access to behavioral health care among adolescents and young adults. Clinicians identified adolescents and young adults who exhibited or self-reported emotional distress during routine care visits and prescribed a coach-enhanced dCBI (RxWell) as a first-line intervention or as a therapy adjunct. RxWell was ordered through the EHR, and patients were texted a link to the app. This project was approved by UPMC as a quality improvement project; institutional review board approval was not required because the project’s aim was to improve current behavioral health practice on the basis of existing knowledge and evidence that is generally accepted by UPMC clinicians.

Coach-Enhanced dCBI (RxWell)

RxWell is a coach-enhanced dCBI developed by UPMC Health Plan and has been tested in adult populations, in which it has shown feasibility, engagement, and benefits over time (6). The app can be used at the patient’s discretion and provides brief CBT-based skill-building techniques, including relaxation, behavioral activation, distress tolerance, cognitive reframing, and mindfulness.

RxWell health coaches communicated with users via secure in-app messaging. Coaches were bachelor-level graduates who completed motivational interviewing and CBT training and were supervised by a licensed mental health clinician. Adolescents and young adults displaying signs of increased distress through app messaging were flagged by their coach, who then followed a risk escalation protocol and notified the supervising clinician for appropriate clinical triage.

Outcomes and Analyses

We gathered deidentified demographic information and antidepressant, behavioral therapy, and app utilization data. Engagement was defined as completion of at least three CBT-based techniques (7). Anxiety was assessed with the General Anxiety Disorder–7 (GAD-7) instrument and depression with the eight-item Patient Health Questionnaire (PHQ-8); scores were collected within the app at baseline and monthly intervals.

A subset of patients who enrolled or did not enroll in RxWell participated in a structured qualitative interview. Two trained interviewers conducted phone interviews, which were audio-recorded and transcribed for content analysis. Standard qualitative procedures were applied to coding and to resolving of discrepancies to reach consensus. A subset of prescribing clinicians was asked about barriers to behavioral health access and how RxWell helped address these barriers.

Descriptive statistics were used to characterize the sample population. Changes in GAD-7 and PHQ-8 scores over time were assessed with paired t tests, means and 95% CIs, and within-subject Cohen’s d effect sizes. All tests for statistical significance were two-sided, with a p<0.05 considered statistically significant. When examining change over time, we considered both 1-month follow-up and the maximum follow-up periods across the 3-month period.

Results

Overall, 506 adolescents and young adults received an RxWell prescription. Of the 278 who enrolled, 217 (78%) were female, 240 (86%) were White, and 184 (66%) had commercial insurance; the mean±SD age was 19.0±2.6 years, and 181 (65%) were receiving therapy or antidepressants from their pediatric practice. Of 275 patients with EHR data before an RxWell order, 39 (14%) were on an antidepressant only, 74 (27%) were receiving therapy only, 66 (24%) received both an antidepressant and therapy, and 96 (35%) had received none of the two treatments. At baseline, 82% (N=228) of patients’ GAD-7 and PHQ-8 scores were consistent with an anxiety or depression diagnosis (scores >8), but for many participants, no formal diagnosis was assigned on the basis of structured diagnostic criteria during the index visit because of busy workflows at the clinic. For a subset for whom RxWell was an adjunct to behavioral treatment, the vast majority were diagnosed as having anxiety or depressive disorders.

In total, 67% (N=339) of RxWell prescriptions were from pediatricians and the remainder from embedded behavioral therapists. In total, 220 (79%) of the patients completed at least one RxWell technique, 161 (58%) engaged in the app, and 176 (63%) messaged their coach. The median number of techniques used was four; mean length of app use was 25 days, which were not necessarily consecutive. Of patients receiving behavioral health treatment before downloading the app, 81% (N=114 of 140) continued to see a therapist with RxWell supplementation.

RxWell use was associated with a significant decrease in anxiety and depression scores between baseline and 1 month and up to 3 months (Table 1). Subgroup analyses revealed that patients receiving dCBI alone had a similar magnitude of reduction in anxiety (mean±SD change=3.6±4.5; from baseline to the last score over the 3-month period) compared with those for whom dCBI supplemented antidepressants alone (3.8±4.8), therapy alone (3.2±4.8), or both (2.9±5.3). We observed 44 risk escalations involving 38 patients, with the majority (84%, N=37) deemed being at low risk, and no serious adverse events (e.g., suicide attempts) occurred.

Interviews about app use were conducted with 24 randomly selected participants who enrolled in RxWell and 10 who did not enroll. Enrolled patients provided two main reasons for app use: current mental health symptoms and free time. Most described using the app when they were anxious or in stressful situations. Common reasons for not enrolling in the app included time constraints, other support, disliking therapy, or using other apps. Some stated that more information about the app from providers would have been beneficial.

Enrolled patients discussed the benefits of a “real person” (i.e., the coach) who provided accountability, asked how content was helpful, sent reminders, and provided reassurance. Reasons for no interaction with the coach were limited app use and lack of awareness that the coach was a real person. App users described how techniques and goal setting supported their mental health. Many shared how app content and their coach promoted their ability to stay grounded during challenging times.

When asked about barriers that RxWell helped overcome, behavioral health providers endorsed that RxWell offered support when providers were unavailable and when patients were ambivalent about therapy. The providers also believed that RxWell improved the efficiency of health care delivery.

Discussion and Conclusions

The results of this study indicate that it is feasible to embed a dCBI for emotional distress within outpatient pediatric clinics, with app enrollment rates being comparable to published rates of follow-through for in-person mental health services (8). The rate of clinical improvement in the severity of emotional distress observed in this study from baseline to ≥1 month is consistent with those reported for Internet- and computer-based therapies for adolescents and young adults (9). However, because our study design did not include a control group, we could not conclude that these improvements were due to the dCBI or determine how much dCBI enhanced outcomes over concurrent mental health treatment. Overall, enrolled patients who completed the qualitative interview shared positive experiences and believed that they had benefited from having the dCBI during a time of distress and from communicating with a real-life coach. The availability of a coach-enhanced dCBI was particularly impactful during the COVID-19 period when emotional distress among adolescents and young adults was elevated and incorporation of health technology into routine medical care became the new status quo. The use of a new digital tool to provide access to behavioral care or enhance the benefit of existing treatment for individuals making little or no treatment progress represents added value.

Strengths of this study included that the dCBI was nested within pediatric primary care, that pediatricians directly ordered the app through the EHR, and that the project included a sophisticated risk escalation protocol. We had a large sample and an empirical process for learning while RxWell was incorporated into routine care. Further studies are needed to determine a standard evidence basis for evaluating digital interventions (10), but our findings are consistent with a positive effect of the app alone and as a supplement to behavioral treatment.

Limitations included that this was an open-trial quality improvement project. An internal review board–approved, randomized controlled trial to evaluate efficacy of dCBI compared with a control group will be conducted to further validate the impact of the dCBI. This future study will recruit participants from clinics with a large minority and Medicaid population. Examination of the relationship between user engagement and outcomes would further strengthen links between the intervention and clinical improvement. It would also be of benefit to better delineate baseline characteristics of patients to determine whether those meeting diagnostic criteria for anxiety or depressive disorder would benefit from this type of dCBI as a first-line intervention in a stepped behavioral intervention or whether the dCBI would be better suited for preventing progression of mild or moderate emotional distress. Furthermore, most app users came from oversampled groups (i.e., White and female), and patients who did not enroll were more likely male and Black. The study highlights the need for steps to improve engagement for individuals from minority populations, which could include training coaches in cultural sensitivity. Additionally, we will provide culturally competent language for clinicians to use when discussing the app with patients. Some attrition occurred because self-reported assessments were captured only within the app.

As a quality improvement project, implementation changes were initiated at midpoint on the basis of lessons learned, including enhanced prescriber education, improved care coordination with therapists, and changes in messaging that emphasized that the coach was a real person. The resulting dCBI received high approval ratings by patients and was seen by prescribers as improving care.

With the next phase of planned validation and efficacy, another barrier to address will be cost reimbursement. UPMC offers RxWell as a health care app to employers, health care organizations, and health plans, enabling organizations to provide an evidence-based dCBI to their employees, members, and patients free of charge, while the organization absorbs a minimal per-use or per-eligible-member fee. Inclusion of digital tools in shared savings models or reimbursable CPT codes could provide sustainable scalable integration into clinical care. Our results indicate that it is feasible to foster engagement with digital behavioral interventions offered as part of routine pediatric primary care and that dCBI is associated with a reduction in the severity of anxiety and depression among adolescents and young adults.