Engagement and attrition in digital mental health: current challenges and potential solutions

Katharine A Smith^{1

2

3}, Thomas Ward^{4

5}, Sinéad Lambe^{6

7}, Edoardo G Ostinelli^{8

6

9}, Charlotte Blease¹⁰, Thomas Gant^{4

5}, Stefan M Gold^{11

12

13}, Emily A Holmes¹⁰, Ivana Paccoud¹⁴, Anastasia Vinnikova¹⁵, Jochen Klucken^{14

16}, Peter J Uhlhaas¹⁷, Carolina Garcia Sanchez¹⁰, Kate Haining¹⁸, Kerem Böge^{11

12}, Sofiia Lahutina^{19

20}, Luisa Tomelleri²¹, Sean Ryan²², John Torous^#²², Andrea Cipriani^#^{8

6

9}

Affiliations

¹ Department of Psychiatry, University of Oxford, Oxford, UK. katharine.smith@psych.ox.ac.uk.
² Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK. katharine.smith@psych.ox.ac.uk.
³ Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK. katharine.smith@psych.ox.ac.uk.
⁴ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁵ South London & Maudsley NHS Foundation trust, London, UK.
⁶ Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
⁷ Department of Experimental Psychology, University of Oxford, Oxford, UK.
⁸ Department of Psychiatry, University of Oxford, Oxford, UK.
⁹ Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.
¹⁰ Department of Women's and Children's Health, Uppsala University, Uppsala, Uppsala County, Sweden.
¹¹ Charité - Universitätsmedizin Berlin, Dept Psychiatry and Dept Psychosomatic Medicine, Campus Benjamin Franklin, Berlin, Germany.
¹² German Center for Mental Health (DZPG), Partner Site Berlin/Potsdam, Berlin, Germany.
¹³ INIMS, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
¹⁴ Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, Esch-sur-Alzette, Luxembourg.
¹⁵ Independent researcher (Patient and Public Involvement and Engagement (PPIE) representative), London, UK.
¹⁶ Centre Hospitalier de Luxembourg (CHL), Luxembourg, Luxembourg.
¹⁷ Dept. of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité - Universitätsmedizin, Berlin, Germany.
¹⁸ School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK.
¹⁹ German National Academy of Sciences Leopoldina, Halle, Germany.
²⁰ Centrum für Affektive Neurowissenschaften, Charité - Universitätsmedizin Berlin, Berlin, Germany.
²¹ Santa Giuliana Hospital, Verona, Italy.
²² Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

^# Contributed equally.

PMID: 40604240
PMCID: PMC12223045
DOI: 10.1038/s41746-025-01778-w

Engagement and attrition in digital mental health: current challenges and potential solutions

Katharine A Smith et al. NPJ Digit Med. 2025.

. 2025 Jul 2;8(1):398.

doi: 10.1038/s41746-025-01778-w.

Authors

Affiliations

¹ Department of Psychiatry, University of Oxford, Oxford, UK. katharine.smith@psych.ox.ac.uk.
² Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK. katharine.smith@psych.ox.ac.uk.
³ Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK. katharine.smith@psych.ox.ac.uk.
⁴ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁵ South London & Maudsley NHS Foundation trust, London, UK.
⁶ Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
⁷ Department of Experimental Psychology, University of Oxford, Oxford, UK.
⁸ Department of Psychiatry, University of Oxford, Oxford, UK.
⁹ Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.
¹⁰ Department of Women's and Children's Health, Uppsala University, Uppsala, Uppsala County, Sweden.
¹¹ Charité - Universitätsmedizin Berlin, Dept Psychiatry and Dept Psychosomatic Medicine, Campus Benjamin Franklin, Berlin, Germany.
¹² German Center for Mental Health (DZPG), Partner Site Berlin/Potsdam, Berlin, Germany.
¹³ INIMS, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
¹⁴ Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, Esch-sur-Alzette, Luxembourg.
¹⁵ Independent researcher (Patient and Public Involvement and Engagement (PPIE) representative), London, UK.
¹⁶ Centre Hospitalier de Luxembourg (CHL), Luxembourg, Luxembourg.
¹⁷ Dept. of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité - Universitätsmedizin, Berlin, Germany.
¹⁸ School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK.
¹⁹ German National Academy of Sciences Leopoldina, Halle, Germany.
²⁰ Centrum für Affektive Neurowissenschaften, Charité - Universitätsmedizin Berlin, Berlin, Germany.
²¹ Santa Giuliana Hospital, Verona, Italy.
²² Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

^# Contributed equally.

PMID: 40604240
PMCID: PMC12223045
DOI: 10.1038/s41746-025-01778-w

Abstract

In digital mental health engagement rates are consistently low, which may limit its effects. Using an international multidisciplinary consensus method, including lived experience expertise and a systematic review, we identified three key challenges: (i) lack of agreed metrics for engagement; (ii) lack of evidence on how better engagement improves outcomes; (iii) lack of standards for user involvement. Three potential solutions encompassed: (i) standardisation of frameworks for reporting engagement metrics and optimal doses of digital tools, (ii) measuring engagement with more precise reporting of outcomes, including potential harms; (iii) defining standards of user involvement (including appropriate diversity, and clinician as well as user input). Digital interventions have real potential in meeting the shortfall in service provision for mental health, but this will require focus on high quality research studies of the underlying mechanisms of engagement and optimal outcomes. Our findings identify and highlight the next best steps in this process.

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Conflict of interest statement

Competing interests: K.A.S., C.B., C.G.S., K.H., I.P., T.W., T.G., L.T., S.R. declare no competing interests. S.M.G. reports honoraria from Hexal, Angelini, and Tegus. PJU reports honoraria from Boehringer. E.A.H. reports honoraria from Angelini to attend the meeting at which this paper was discussed. E.A.H. receives occasional honoraria for keynotes and workshops, and royalties on 2 books. E.A.H. developed the ICTI intervention (ANEMONE™) and founded Afterimagery. AB. K.B. reports honoraria from Böhringer Ingelheim and from publishers and training institutes for workshops, books and lectures on psychotherapy. He is co-founder of two digital mental health start-ups. JK has shares in Portabiles HCT, Germany; reports advisory activities and honoraria from Angelini, Bial, Biogen, BMS, Celgene, Desitin, EverPharma, Lundbeck-Foundation, Medical Valley Digital Health Application Center, Novartis, RoxHealth, StreamedUp, Bauerfeind, Remepy. J.K. reports board activities for European national HTA bodies, Michael J Fox Foundation for Parkinson’s Research (MJFF), Bertelsmann Foundation, Germany, Hans Seidel Stiftung, Germany. AC has received research, educational and consultancy fees from INCiPiT (Italian Network for Paediatric Trials), CARIPLO Foundation, Lundbeck and Angelini Pharma. JT is the editor-in-chief of JMIR Mental Health and associate editor of npj Digital Medicine.

References

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Engagement and attrition in digital mental health: current challenges and potential solutions

Affiliations

Engagement and attrition in digital mental health: current challenges and potential solutions

Authors

Affiliations

Abstract

Conflict of interest statement

References

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