Pilot study of psychotherapeutic text messaging for depression

Background Text messaging services could increase access to psychotherapeutic content for individuals with depression by avoiding barriers to in-person psychotherapy such as cost, transportation, and therapist availability. Determining whether text messages reflecting different psychotherapeutic techniques exhibit differences in acceptability or effectiveness may help guide service development. Objectives We aimed to determine: (1) the feasibility of delivering a psychotherapy-based text messaging service to people with depression identified via the internet, (2) whether there is variation in satisfaction with messages according to the type of psychotherapeutic technique they represent, and (3) whether symptoms of depression vary according to receipt of each message type and participants' satisfaction with the messages they received. Methods For this study 190 US adults who screened positive for a major depressive episode (Patient Health Questionnaire (PHQ-9) score ≥10) were recruited from online advertisements. Participants received a daily psychotherapy-based text message 6 days per week for 12 weeks. Text messages were developed by a team of psychiatrists, psychologists, and social workers to reflect three psychotherapeutic approaches: acceptance and commitment therapy (ACT), behavioural activation, and cognitive restructuring. Each week the message type for the week was randomly assigned from one of the three types, allowing for repeats. Participants were asked daily to rate each message. On the 7th day of each week, participants completed a two-item depression screener (PHQ-2). Web-based surveys at baseline, 6, and 12 weeks were used as the primary measure of depressive symptoms (PHQ-9). Results Of the 190 participants enrolled, 85 (45%) completed the 6-week web survey and 67 (35%) completed the 12-week survey. The mean baseline PHQ-9 score was 19.4 (SD 4.2) and there was a statistically significant mean improvement in PHQ-9 scores of -2.9 (SD 6.0; p < 0.001) at 6 weeks and -4.8 (SD 6.6; p < 0.001) at 12 weeks. Mean satisfaction ratings did not vary across message types. There was generally no association between the number of weeks in which participants received a given message type and PHQ-9 scores at follow-up. However, among individuals with more severe depression at baseline (PHQ-9 ≥ 20; n = 30), the number of weeks of behavioural activation messages received was associated with less symptom improvement (ρ = 0.37; p = 0.04) at 12 weeks. Participants who gave higher satisfaction ratings to messages regardless of type had greater reductions in PHQ-9 scores at 6 weeks. Conclusions Study participants exhibited borderline clinically significant improvement in depressive symptoms at 12 weeks suggesting the effects of the intervention, if any, were small. Although there was no overall variation in changes in PHQ-9 according to users' exposure to the three message types, effectiveness among severely depressed participants could potentially be improved by tailoring towards fewer behavioural activation messages. Controlled studies to determine effectiveness of texting interventions such as this one are indicated considering that even small effects may be cost effective given the low cost of delivering text messages.