title: Breaking Open the Black Box: Isolating the Most Potent Features of a Web and Mobile Phone-Based Intervention for Depression, Anxiety, and Stress.
abstract: BACKGROUND
  Internet-delivered mental health (eMental Health) interventions produce treatment effects similar to those observed in face-to-face treatment. However, there is a large degree of variation in treatment effects observed from program to program, and eMental Health interventions remain somewhat of a black box in terms of the mechanisms by which they exert their therapeutic benefit. Trials of eMental Health interventions typically use large sample sizes and therefore provide an ideal context within which to systematically investigate the therapeutic benefit of specific program features. Furthermore, the growth and impact of mobile phone technology within eMental Health interventions provides an opportunity to examine associations between symptom improvement and the use of program features delivered across computer and mobile phone platforms.
  
  
  OBJECTIVE
  The objective of this study was to identify the patterns of program usage associated with treatment outcome in a randomized controlled trial (RCT) of a fully automated, mobile phone- and Web-based self-help program, "myCompass", for individuals with mild-to-moderate symptoms of depression, anxiety, and/or stress. The core features of the program include interactive psychotherapy modules, a symptom tracking feature, short motivational messages, symptom tracking reminders, and a diary, with many of these features accessible via both computer and mobile phone.
  
  
  METHODS
  Patterns of program usage were recorded for 231 participants with mild-to-moderate depression, anxiety, and/or stress, and who were randomly allocated to receive access to myCompass for seven weeks during the RCT. Depression, anxiety, stress, and functional impairment were examined at baseline and at eight weeks.
  
  
  RESULTS
  Log data indicated that the most commonly used components were the short motivational messages (used by 68.4%, 158/231 of participants) and the symptom tracking feature (used by 61.5%, 142/231 of participants). Further, after controlling for baseline symptom severity, increased use of these alert features was associated with significant improvements in anxiety and functional impairment. Associations between use of symptom tracking reminders and improved treatment outcome remained significant after controlling for frequency of symptom tracking. Although correlations were not statistically significant, reminders received via SMS (ie, text message) were more strongly associated with symptom reduction than were reminders received via email.
  
  
  CONCLUSIONS
  These findings indicate that alerts may be an especially potent component of eMental Health interventions, both via their association with enhanced program usage, as well as independently. Although there was evidence of a stronger association between symptom improvement and use of alerts via the mobile phone platform, the degree of overlap between use of email and SMS alerts may have precluded identification of alert delivery modalities that were most strongly associated with symptom reduction. Future research using random assignment to computer and mobile delivery is needed to fully determine the most ideal platform for delivery of this and other features of online interventions.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry (ACTRN): 12610000625077; http://www.anzctr.org.au/TrialSearch.aspx? (Archived by WebCite http://www.webcitation.org/6WPqHK0mQ).
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia.
authors.forename: Alexis E
authors.identifier: 0000-0002-7944-2172
authors.initials: AE
authors.lastname: Whitton
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia ; School of Psychiatry Faculty of Medicine University of New South Wales Sydney Australia.
authors.forename: Judith
authors.identifier: 0000-0002-3872-9871
authors.initials: J
authors.lastname: Proudfoot
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia.
authors.forename: Janine
authors.identifier: 0000-0002-2652-5273
authors.initials: J
authors.lastname: Clarke
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia.
authors.forename: Mary-Rose
authors.identifier: 0000-0001-5829-5831
authors.initials: MR
authors.lastname: Birch
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia ; School of Psychiatry Faculty of Medicine University of New South Wales Sydney Australia.
authors.forename: Gordon
authors.identifier: 0000-0003-3424-5519
authors.initials: G
authors.lastname: Parker
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia ; School of Psychiatry Faculty of Medicine University of New South Wales Sydney Australia.
authors.forename: Vijaya
authors.identifier: 0000-0001-6483-7780
authors.initials: V
authors.lastname: Manicavasagar
authors.affiliation: The Black Dog Institute University of New South Wales Sydney Australia ; School of Psychiatry Faculty of Medicine University of New South Wales Sydney Australia.
authors.forename: Dusan
authors.identifier: 0000-0002-2059-3865
authors.initials: D
authors.lastname: Hadzi-Pavlovic
keywords: Web-based; anxiety; depression; eHealth; mental health; psychological stress; self-help; stress