Background The COVID-19 pandemic created an unprecedented need for mental health services that can be remotely delivered. Digital mental health services that offer personalized care recommendations hold promise to efficiently expand service, but evidence of the effectiveness of digitally delivered mental health care in real-world settings remains limited. Methods A retrospective cohort of adults (N = 1,852) receiving care through a digital mental health platform with elevated depressive symptoms during the COVID-19 pandemic was analyzed to estimate changes in subjective well-being and clinical improvement in depressive symptoms (using the World Health Organization-Five [WHO-5] Well-Being Index), as well as compare the relative effectiveness and cost of different care utilization patterns. Results The average improvement in WHO-5 score was 10.1 points (CI: 9.3–10.9, p<0.001) at follow-up, which constituted a medium effect size (d = 0.73). The odds of clinical improvement in depressive symptoms were significantly greater among those who utilized telecoaching (aOR = 2.45, 95%CI: 1.91–3.15, p < .001), teletherapy (aOR = 2.01, 95%CI: 1.57–2.57, p < .001), and both services (aOR = 2.28, 95%CI: 1.67–3.11, p < .001) compared to those who only utilized assessments, adjusting for baseline WHO-5 score, age, sex, and number of days between baseline and follow-up assessments. The average estimated cost of care for telecoaching was $124 per individual, which was significantly less than teletherapy ($413) or both services ($559). Conclusion Digitally delivered care with a therapist and/or coach was effective in improving subjective well-being and clinical improvement in depressive symptoms. Although clinical outcomes were similar across utilization patterns, the cost of care was lowest among those utilizing telecoaching.

Digital mental health services leverage technology to increase access to care, yet less is known about the quality of therapeutic relationships in a virtual setting. This study examined components of therapeutic alliance (a mechanism underlying successful treatment) and its association with beneficial treatment outcomes in a real-world, virtual setting. The objective is to examine (1) participant ratings of components of therapeutic alliance with providers in a virtual setting, (2) changes in subjective well-being and depressive symptoms among participants who began care with elevated depressive symptoms, and (3) the association between components of alliance and changes in participants’ well-being. Adults (N = 3,087, M age = 36 ± 9 years, 54% female) across the world with access to digital mental health benefits who engaged in videoconference sessions with a licensed therapist (18%, 555/3,087), certified coach (65%, 2,003/3,087), or both (17%, 529/3,087) between Sept. 29, 2020 and Oct. 12, 21. Participants completed 2 adapted items from the Working Alliance Inventory (goals and bonds subscales) after each session, and ratings were averaged across visits (Cronbach’s ɑ = .72). Participants’ World Health Organization-Five (WHO-5) Well-Being Index scores at the start and end of the study period were used to measure changes in subjective well-being. Descriptive and inferential statistics were conducted to examine average alliance ratings across demographics and utilization types and the association between alliance and well-being. The median adapted therapeutic alliance score was 4.8 (range: 1–5) and did not differ by age, country, or baseline well-being (Ps > .07). Females reported higher components of alliance than males (4.88 vs. 4.67, P = .01). Participants utilizing telecoaching reported higher components of alliance than those utilizing teletherapy or both telecoaching and teletherapy (4.83 v. 4.75, P = .004), though effect sizes were negligible. Among those with elevated baseline depressive symptoms (n = 835), participants reported an average WHO-5 increase of 15.42 points (95% CI 14.19–16.65, P < .001, Cohen d = 1.06) with 58% (485/835) reporting clinical recovery and 57% (481/835) reporting clinical improvement in depressive symptoms. Higher components of therapeutic alliance scores predicted greater well-being at follow-up (b = 2.04, 95% CI 0.09–3.99, P = .04) after controlling for age, sex, baseline WHO-5, and number of days in care (R2 = .06, P < .001). Exploratory analyses indicated this association did not differ by utilization type, baseline well-being, or session utilization (Ps > .34). People with access to one-on-one videoconferencing care via a digital mental health benefit formed a strong bond and sense of alignment on goals with both coaches and therapists. Higher components of alliance scores were associated with improvements in subjective well-being among participants who began care with elevated depressive symptoms, providing evidence that a positive bond and goal alignment with a provider are two of many factors influencing virtual care outcomes. Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.

While social distancing was crucial to slow the COVID-19 virus, it also contributed to social isolation and emotional strain. This pilot study evaluated the impact of stand-alone psychoeducational group sessions designed to build social connectedness and space for people to learn about mental health during the pandemic. The study examined if offering the stand-alone group sessions increased uptake of and receptivity to additional mental health services. People had access to free, online group psychoeducational sessions offered by a digital mental health platform company. Sessions were offered to (1) employees who had mental health benefits offered through their employer, and to (2) members of the general public. Session formats included discussions, didactic lectures, and workshops, were facilitated by a mental health provider, and used live video conference technology. Topics included race and identity, stress management, coping with political events, relationship issues, and self-compassion. First-time session registrations were tracked from June 2020 to July 2021 on 6723 participants (3717 benefits-eligible employees and 3006 from the general public). Among the employee subsample, 49.5% attended a group session as their first use of any available service on the platform; 52.5% of these employees sought additional services after their first session. In anonymous post-session surveys of employees and members of the general public, 86% of respondents endorsed knowledge increases, 79.5% reported improved understanding of their mental health, 80.3% endorsed gaining actionable steps to improve mental health, 76.5% said that they would consider group sessions in addition to therapy, and 43.5% said that they would consider group sessions instead of therapy. These results suggest that scalable, brief group psychoeducational sessions are a useful conduit to mental health care and have potential to reach people who may not otherwise access available mental health services.

Background Loneliness has increased since the COVID-19 pandemic and negatively impacts mental health. This study examined relationships between loneliness and mental health among adults using a digital mental health platform. Methods A purposive sample of 919 participants (97% response rate) who were newly enrolled in the platform completed a survey on loneliness, depression, anxiety, well-being, stress, social support, and comorbidities at baseline and 3 months. Platform engagement was tracked during this period. We examined baseline differences between lonely and non-lonely participants; associations between loneliness, mental health symptoms, and comorbidities; and changes in loneliness and mental health through engagement in any form of care. Results At baseline, 57.8% of the sample were categorized as lonely. Loneliness was associated with younger age, fewer years of education, and the presence of a comorbidity (p values < .05). Baseline loneliness was associated with greater depression, anxiety, and stress and lower well-being and social support (ps < .001). The percentage of lonely participants decreased at follow-up (57.6% to 52.9%, p = .03). Those who improved in loneliness improved in mental health symptoms, well-being, and social support (ps < .001). Lonely participants who engaged in any form of care reported a greater reduction in loneliness than those who did not engage (p = .04). Conclusions This study confirms previous findings of the high prevalence of loneliness among adults and risk factors for increased loneliness. Findings highlight the potential of digital platforms to reach lonely individuals and alleviate loneliness through remote mental health support.

BACKGROUND Digital mental health services are a growing employer health benefit that can improve access and remove barriers to mental health care. Stratified stepped care models, in particular, offer personalized care recommendations that can simultaneously offer clinically effective interventions while conserving resources. Nonetheless, clinical evaluation is needed to understand their benefit for mental health and use in a real-world setting. OBJECTIVE This study examined changes in clinical outcomes (i.e., depressive and anxiety symptoms, well-being) and evaluated the use of stratified stepped care among members of an employer-sponsored digital mental health benefit. METHODS In a large prospective study, we examined changes in depressive symptoms, anxiety symptoms, and well-being over 3 months in 509 participants (Mean age = 33.9 ± 8.7; 61.3% women, 34.4% men, 4.3% non-binary; 40.2% BIPOC) who were newly enrolled and engaged in care with an employer-sponsored digital mental health platform (Modern Health Inc., San Francisco, CA). We also investigated whether participants followed, underutilized, or overutilized services (i.e., therapy, coaching, or digital self-guided content) relative to the recommendations provided to them through a stratified, stepped care model. RESULTS Participants with elevated baseline symptoms exhibited significant improvement in depressive and anxiety symptoms and well-being across the study period (ps < .001), with the greatest average improvements observed in well-being (90% score increase), followed by depressive (37% score reduction) and anxiety symptoms (29% score reduction). Further, over half exhibited clinical improvement or recovery for depressive symptoms (65.8%), anxiety symptoms (59.2%), and low well-being (65.9%). Among participants with lower baseline symptoms, we found high rates of maintenance for low depressive (92.3%) and anxiety (86.2%) symptoms, and high well-being (90.2%). Two-thirds of participants (67.4%) utilized their recommended care, 16.9% stepped up their care beyond their initial recommendation, and 15.7% of participants underutilized care by not engaging with the highest level of care recommended to them. CONCLUSIONS Participants with elevated baseline depressive and/or anxiety symptoms improved their mental health significantly from baseline to follow-up, and those with no or mild symptoms successfully maintained their mental health at high rates. In addition, engagement patterns indicate that the stratified stepped care model was efficient in matching individuals with the most effective and least costly care, while also allowing them to self-determine their care and use combinations of services that best fit their needs. Overall, the results of this study support the clinical effectiveness of the platform for improving and preserving mental health, and support the utility and effectiveness of stratified stepped care models to improve access and utilization of digitally-delivered mental health services.