Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study

Abstract

Background: Symptoms of depression and anxiety, suicidal ideation, and self-harm have escalated among adolescents to crisis levels during the COVID-19 pandemic. As a result, primary care providers (PCPs) are often called on to provide first-line care for these youth. Digital health interventions can extend mental health specialty care, but few are evidence based. We evaluated the feasibility of delivering an evidence-based mobile health (mHealth) app with an embedded conversational agent to deliver cognitive behavioral therapy (CBT) to symptomatic adolescents presenting in primary care settings during the pandemic.

Objective: In this 12-week pilot study, we evaluated the feasibility of delivering the app-based intervention to adolescents aged 13 to 17 years with moderate depressive symptoms who were treated in a practice-based research network (PBRN) of academically affiliated primary care clinics. We also obtained preliminary estimates of app acceptability, effectiveness, and usability.

Methods: This small, pilot randomized controlled trial (RCT) evaluated depressive symptom severity in adolescents randomized to the app or to a wait list control condition. The primary end point was depression severity at 4-weeks, measured by the 9-item Patient Health Questionnaire (PHQ-9). Data on acceptability, feasibility, and usability were collected from adolescents and their parent or legal guardian. Qualitative interviews were conducted with 13 PCPs from 11 PBRN clinics to identify facilitators and barriers to incorporating mental health apps in treatment planning for adolescents with depression and anxiety.

Results: The pilot randomized 18 participants to the app (n=10, 56%) or to a wait list control condition (n=8, 44%); 17 participants were included in the analysis, and 1 became ineligible upon chart review due to lack of eligibility based on documented diagnosis. The overall sample was predominantly female (15/17, 88%), White (15/17, 88%), and privately insured (15/17, 88%). Mean PHQ-9 scores at 4 weeks decreased by 3.3 points in the active treatment group (representing a shift in mean depression score from moderate to mild symptom severity categories) and 2 points in the wait list control group (no shift in symptom severity category). Teen- and parent-reported usability, feasibility, and acceptability of the app was high. PCPs reported preference for introducing mHealth interventions like the one in this study early in the course of care for individuals presenting with mild or moderate symptoms.

Conclusions: In this small study, we demonstrated the feasibility, acceptability, usability, and safety of using a CBT-based chatbot for adolescents presenting with moderate depressive symptoms in a network of PBRN-based primary care clinics. This pilot study could not establish effectiveness, but our results suggest that further study in a larger pediatric population is warranted. Future study inclusive of rural, socioeconomically disadvantaged, and underrepresented communities is needed to establish generalizability of effectiveness and identify implementation-related adaptations needed to promote broader uptake in pediatric primary care.

Trial registration: ClinicalTrials.gov NCT04603053; https://clinicaltrials.gov/ct2/show/NCT04603053.

Keywords: CBT; COVID-19; acceptability; adolescence; adolescent; adolescent depression; anxiety; chatbot; clinic; cognitive behavioral therapy; computer mediated; conversational agent; data; depression; digital health; feasibility; intervention; mental health; mobile health; pandemic; pediatric; primary care; psychiatry; relational conversational agent; self-harm; suicide; technology mediated; usability; youth.

Figure 1

Flowchart indicating the study procedures and schedule of events. AIM: Acceptability of Intervention Measure; FIM: Feasibility of Intervention Measure; GAD-7: 7-item Generalized Anxiety Disorder questionnaire; MHSES: Mental Health Self-Efficacy Scale; PHQ-9: 9-item Patient Health Questionnaire; SUS: System Usability Scale.

Figure 2

Participant Disposition.

Figure 3

Change in mean PHQ-9 and GAD-7 scores by treatment group over 12 weeks. GAD-7: 7-item Generalized Anxiety Disorder questionnaire; PHQ-9: 9-item Patient Health Questionnaire.