title: MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial.
abstract: BACKGROUND
  Worldwide, depression is rated as the fourth leading cause of disease burden and is projected to be the second leading cause of disability by 2020. Annual depression-related costs in the United States are estimated at US $210.5 billion, with employers bearing over 50% of these costs in productivity loss, absenteeism, and disability. Because most adults with depression never receive treatment, there is a need to develop effective interventions that can be more widely disseminated through new channels, such as employee assistance programs (EAPs), and directly to individuals who will not seek face-to-face care.
  
  
  OBJECTIVE
  This study evaluated a self-guided intervention, using the MoodHacker mobile Web app to activate the use of cognitive behavioral therapy (CBT) skills in working adults with mild-to-moderate depression. It was hypothesized that MoodHacker users would experience reduced depression symptoms and negative cognitions, and increased behavioral activation, knowledge of depression, and functioning in the workplace.
  
  
  METHODS
  A parallel two-group randomized controlled trial was conducted with 300 employed adults exhibiting mild-to-moderate depression. Participants were recruited from August 2012 through April 2013 in partnership with an EAP and with outreach through a variety of additional non-EAP organizations. Participants were blocked on race/ethnicity and then randomly assigned within each block to receive, without clinical support, either the MoodHacker intervention (n=150) or alternative care consisting of links to vetted websites on depression (n=150). Participants in both groups completed online self-assessment surveys at baseline, 6 weeks after baseline, and 10 weeks after baseline. Surveys assessed (1) depression symptoms, (2) behavioral activation, (3) negative thoughts, (4) worksite outcomes, (5) depression knowledge, and (6) user satisfaction and usability. After randomization, all interactions with subjects were automated with the exception of safety-related follow-up calls to subjects reporting current suicidal ideation and/or severe depression symptoms.
  
  
  RESULTS
  At 6-week follow-up, significant effects were found on depression, behavioral activation, negative thoughts, knowledge, work productivity, work absence, and workplace distress. MoodHacker yielded significant effects on depression symptoms, work productivity, work absence, and workplace distress for those who reported access to an EAP, but no significant effects on these outcome measures for those without EAP access. Participants in the treatment arm used the MoodHacker app an average of 16.0 times (SD 13.3), totaling an average of 1.3 hours (SD 1.3) of use between pretest and 6-week follow-up. Significant effects on work absence in those with EAP access persisted at 10-week follow-up.
  
  
  CONCLUSIONS
  This randomized effectiveness trial found that the MoodHacker app produced significant effects on depression symptoms (partial eta(2) = .021) among employed adults at 6-week follow-up when compared to subjects with access to relevant depression Internet sites. The app had stronger effects for individuals with access to an EAP (partial eta(2) = .093). For all users, the MoodHacker program also yielded greater improvement on work absence, as well as the mediating factors of behavioral activation, negative thoughts, and knowledge of depression self-care. Significant effects were maintained at 10-week follow-up for work absence. General attenuation of effects at 10-week follow-up underscores the importance of extending program contacts to maintain user engagement. This study suggests that light-touch, CBT-based mobile interventions like MoodHacker may be appropriate for implementation within EAPs and similar environments. In addition, it seems likely that supporting MoodHacker users with guidance from counselors may improve effectiveness for those who seek in-person support.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT02335554; https://clinicaltrials.gov/ct2/show/NCT02335554 (Archived by WebCite at http://www.webcitation.org/6dGXKWjWE).
authors.affiliation: ORCAS, Eugene, OR, United States. abirney@orcasinc.com.
authors.forename: Amelia J
authors.identifier: http://orcid.org/0000-0001-5845-2681
authors.initials: AJ
authors.lastname: Birney
authors.forename: Rebecca
authors.identifier: http://orcid.org/0000-0001-6997-8902
authors.initials: R
authors.lastname: Gunn
authors.forename: Jeremy K
authors.identifier: http://orcid.org/0000-0001-7034-726X
authors.initials: JK
authors.lastname: Russell
authors.forename: Dennis V
authors.identifier: http://orcid.org/0000-0002-0366-1619
authors.initials: DV
authors.lastname: Ary
keywords: Internet; behavioral activation; cognitive behavioral therapy; computers; depression; mobile apps; positive psychology
references.citation: J Affect Disord. 2004 Apr;79(1-3):71-9
references.pmid: 15023482
references.citation: JMIR Mhealth Uhealth. 2015 Feb 16;3(1):e16
references.pmid: 25689790
references.citation: J Med Internet Res. 2011 Aug 12;13(3):e55
references.pmid: 21840837
references.citation: J Med Internet Res. 2012 Jun 25;14(3):e67
references.pmid: 22732135
references.citation: Psychiatr Clin North Am. 2012 Mar;35(1):1-14
references.pmid: 22370487
references.citation: Disabil Rehabil. 2003 Jul 8;25(13):722-31
references.pmid: 12791557
references.citation: Psychol Med. 2007 Dec;37(12):1797-806
references.pmid: 17466110
references.citation: BMC Psychiatry. 2013 Feb 07;13:49
references.pmid: 23391304
references.citation: Behav Ther (N Y N Y). 2012 Apr;35(4):65-73
references.pmid: 25530659
references.citation: J Abnorm Psychol. 2000 May;109(2):345-51
references.pmid: 10895574
references.citation: BMJ Open. 2014 Jan 09;4(1):e003440
references.pmid: 24413342
references.citation: J Med Internet Res. 2014 Sep 23;16(9):e209
references.pmid: 25249003
references.citation: Clin Psychol Rev. 2009 Jul;29(5):449-58
references.pmid: 19450912
references.citation: JAMA. 2007 Sep 26;298(12):1401-11
references.pmid: 17895456
references.citation: J Clin Psychol. 2013 Sep;69(9):994-1011
references.pmid: 23630010
references.citation: J Epidemiol Community Health. 2010 May;64(5):447-52
references.pmid: 19679710
references.citation: Br J Health Psychol. 2010 Feb;15(Pt 1):1-39
references.pmid: 19646331
references.citation: J Child Psychol Psychiatry. 2009 Dec;50(12):1485-94
references.pmid: 19573034
references.citation: J Med Internet Res. 2010 Dec 19;12(5):e64
references.pmid: 21169174
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):617-27
references.pmid: 15939839
references.citation: Med Care. 2001 Jan;39(1):72-85
references.pmid: 11176545
references.citation: Behav Ther. 2011 Dec;42(4):726-39
references.pmid: 22036000
references.citation: J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1433-42
references.pmid: 19034189
references.citation: Acta Psychiatr Scand. 2007 Mar;115(3):229-36
references.pmid: 17302623
references.citation: J Affect Disord. 2013 Sep 25;150(3):790-7
references.pmid: 23611536
references.citation: BMC Psychiatry. 2013 Nov 18;13:312
references.pmid: 24237617
references.citation: Prof Psychol Res Pr. 2011 Dec 1;42(6):472-478
references.pmid: 25525292
references.citation: J Nerv Ment Dis. 2010 Oct;198(10):715-21
references.pmid: 20921861
references.citation: J Med Internet Res. 2002 Dec;4(3):E14
references.pmid: 12554545
references.citation: J Affect Disord. 2007 Aug;101(1-3):65-74
references.pmid: 17156851
references.citation: Lancet. 2007 Sep 8;370(9590):851-8
references.pmid: 17826170
references.citation: Am J Psychiatry. 1999 Jan;156(1):115-23
references.pmid: 9892306
references.citation: J Pers Soc Psychol. 2003 Feb;84(2):377-89
references.pmid: 12585811
references.citation: J Clin Psychiatry. 2015 Feb;76(2):155-62
references.pmid: 25742202
references.citation: J Affect Disord. 1998 Mar;48(2-3):227-32
references.pmid: 9543213
references.citation: J Med Internet Res. 2011 Mar 10;13(1):e30
references.pmid: 21393123
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):593-602
references.pmid: 15939837
references.citation: Clin Psychol Rev. 2010 Nov;30(7):890-905
references.pmid: 20451313
references.citation: Psychol Med. 2008 May;38(5):635-9
references.pmid: 18205965
references.citation: J Med Internet Res. 2013 Apr 18;15(4):e86
references.pmid: 23598614
references.citation: J Med Internet Res. 2013 Nov 15;15(11):e247
references.pmid: 24240579
references.citation: Health Psychol Behav Med. 2014 Jan 1;2(1):841-881
references.pmid: 25750823
references.citation: Behav Res Ther. 2010 Oct;48(10):1002-11
references.pmid: 20633873
references.citation: Med J Aust. 2010 Jun 7;192(S11):S4-11
references.pmid: 20528707
references.citation: Am J Psychiatry. 2001 May;158(5):731-4
references.pmid: 11329394
references.citation: J Consult Clin Psychol. 2000 Aug;68(4):615-23
references.pmid: 10965637
references.citation: Depress Anxiety. 2010;27(1):78-89
references.pmid: 19569060
references.citation: Stud Health Technol Inform. 2013;192:657-61
references.pmid: 23920638
references.citation: J Med Internet Res. 2005 Jun 21;7(2):e16
references.pmid: 15998607
references.citation: JMIR Ment Health. 2015 Mar 04;2(1):e3
references.pmid: 26543909
references.citation: Am Psychol. 2005 Jul-Aug;60(5):410-21
references.pmid: 16045394
references.citation: Arch Gen Psychiatry. 2005 Jan;62(1):66-72
references.pmid: 15630074
references.citation: J Gen Intern Med. 2001 Sep;16(9):606-13
references.pmid: 11556941
references.citation: BMC Fam Pract. 2011 Nov 29;12:131
references.pmid: 22123031
references.citation: J Clin Psychol. 2009 May;65(5):467-87
references.pmid: 19301241
references.citation: Expert Rev Neurother. 2012 Jul;12(7):861-9; quiz 870
references.pmid: 22853793
references.citation: Pharmacoeconomics. 2013 Mar;31(3):237-50
references.pmid: 23417609
references.citation: J Consult Clin Psychol. 1995 Feb;63(1):90-100
references.pmid: 7896995
references.citation: BMC Psychiatry. 2013 Apr 15;13:113
references.pmid: 23587347
references.citation: PLoS One. 2011;6(6):e21274
references.pmid: 21712998
references.citation: Med Care. 2003 May;41(5):649-59
references.pmid: 12719689
references.citation: Psychol Med. 2004 May;34(4):613-22
references.pmid: 15099416