A Behavioral Activation Mobile Health App for Smokers With Depression: Development and Pilot Evaluation in a Single-Arm Trial

Abstract

BackgroundThe integration of Behavioral Activation Treatment for Depression (BAT-D) into smoking cessation interventions is a promising approach to address depression as a barrier to quitting. However, this approach has only been tested as a face-to-face intervention, which has low reach.ObjectiveThe aims of the study were to develop a BAT-D mobile health app with high potential reach and determine its feasibility, acceptability, and preliminary effects on theory-based behavioral processes of behavioral activation, reduced depressive symptoms, and smoking cessation.MethodsFollowing a user-centered design process consisting of competitive analysis, focus groups, and prototype testing, we conducted a single-arm pilot trial of Actify!, a BAT-D app for depressed smokers. Participants used SmokefreeTXT along with Actify! to provide cessation content that had not yet been built into the app for this initial phase of pilot testing. Participants in the trial were current, daily smokers with mild to moderate depressive symptoms. We examined use outcomes for all enrolled participants and process and cessation outcomes at 6 weeks postenrollment for study completers (16/17, 94% retention).ResultsRegarding acceptability, average number of log-ins per participant was 16.6 (SD 13.7), and 63% (10/16) reported being satisfied overall with the app. Posttreatment interviews identified some usability challenges (eg, high perceived burden of planning and scheduling values-based activities). There was a significant decrease in depressive symptoms from baseline to follow-up (mean change in Patient Health Questionnaire–9 scores was –4.5, 95% CI –7.7 to –1.3; P=.01). Additionally, carbon monoxide (CO)-confirmed, 7-day point prevalence abstinence (PPA) at 6-week follow-up was 31% (5/16), and the 30-day PPA was 19% (3/16).ConclusionsResults demonstrate promising engagement with Actify! and potential for impact on theory-based change processes and cessation outcomes. Preliminary quit rates compare favorably to previous trials of smoking cessation apps for the general population (ie, short-term, self-reported 30-day quit rates in the 8% to 18% range) and a previous trial of face-to-face BAT-D for depressed smokers (ie, CO-confirmed, 7-day PPA rate of 17% at end of treatment).

Behavioral Activation, Depression, and Promotion of Health Behaviors: A Scoping Review

“…Heffner et al (2019) evaluated Actify! , a mobile health application, for its effects on depression, cigarette abstinence, and engagement with the program among smokers with depression.…”

“…Notably, some studies reported on non-BA comparison interventions which were similarly effective to BA (e.g., Ledari et al, 2018; Martinez-Vispo et al, 2019) or more effective than BA (e.g., Eisma et al, 2015) at reducing depression. In addition, the external validity of some of the included studies is questionable for reasons such as enrollment of female participants (Kern et al, 2019; Schneider et al, 2016; Thomas & Al-Anouti, 2018) or Veterans (Naik et al, 2019) alone, lack of a control condition (Heffner et al, 2019; Hellerstein et al, 2015; Ledari et al, 2018; Magidson et al, 2014; Solomonov et al, 2019; Tull et al, 2018), or inadequate sample size (Ledari et al, 2018; Magidson et al, 2014).…”

“…Both groups also exhibited high rates of abstinence, with no significant between-group differences in total median abstinence and median continuous abstinence days. Heffner et al (2019) evaluated Actify!, a mobile health application, for its effects on depression, cigarette abstinence, and engagement with the program among smokers with depression. Participants experienced a significant reduction in depression as measured by the PHQ-9 and a clinically significant change in symptom severity.…”

“…For example, mobile and web-based applications such as Actify! (Heffner et al, 2019) and eMotion (Lambert et al, 2018) are BA-based and were found to have decreased depressive symptomatology in participants and produced promising levels of engagement. Telephone-delivered BA-based interventions, such as HOPE (Naik et al, 2019), as well as general telephone counseling (Turner et al, 2019) facilitated similar outcomes.…”

Description of an mHealth tool for breastfeeding support: LactApp. Analysis of how lactating mothers seek support at critical breastfeeding points and according to their infant's age

“…There are countless mobile applications that aim to influence the population's health (mHealth). These applications are designed to address different issues, such as blood pressure monitoring (Wang et al, 2019), stress management (Hwang & Jo, 2019), smoking cessation counseling (Heffner et al, 2019), or weight management (Cueto et al, 2019). For maternal and neonatal care, there are also applications (Sondaal et al, 2016), focusing on child care, pregnancy, and before pregnancy (Zhang et al, 2018).…”