A cognitive behavioural therapy smartphone app for adolescent depression and anxiety: co-design of ClearlyMe

Abstract

Adolescence is associated with heightened vulnerability to symptoms of depression and anxiety. In-person and computerised cognitive behavioural therapy (CBT) are effective treatment options, yet uptake and engagement remain low. Smartphone delivery of CBT offers an alternative, highly accessible method of delivering CBT. However, there is no freely available CBT smartphone application (app) specifically designed to reduce depression and anxiety symptoms in adolescents. The aim of this study was to design a new CBT smartphone app (ClearlyMe) that targets depressive and anxiety symptoms in adolescents. We engaged in a rigorous co-design process with adolescents (n=36), parents (n=15), and mental health professionals (n=32). Co-design involved: (1) discovery of users’ needs, views and preferences by conducting focus groups, (2) defining app features through ideation workshops and user consultations, (3) designing therapeutic CBT content and visual features, and (4) testing prototypes. Users were involved at every step and the process was iterative, with findings carried forward to ensure continued refinement of concepts and features. We found a preference for vibrant, cheerful colours and illustrations and non-endorsement of gamification and chatbots, which contrasted with findings from other studies. Preferences were largely consistent between the three user groups. However, adolescents preferred an app that could be used autonomously without professional support, whereas mental health professionals desired a product for use as a therapy adjunct to support CBT skill development. The importance of co-design, and particularly the inclusion of all stakeholders throughout the entire co-design process, is discussed in relation to the design of ClearlyMe. Key learning aims (1) To understand the co-design process that underpins the development of a new CBT smartphone app for youth with elevated symptoms of depression and anxiety. (2) To understand adolescent, parent and mental health professionals’ key preferences regarding the features and functionality of a CBT smartphone app for adolescents with elevated symptoms of depression and anxiety. (3) To understand how ClearlyMe has been designed as both a therapy adjunct and stand-alone program, and how it can be incorporated into day-to-day clinical practice.

Advances in digital CBT: where are we now, and where next?

“…The present articles also demonstrate advances in our knowledge of, and approaches to, user experiences of digital CBT. Many of the studies (Browne et al, 2022;Li et al, 2022;Patterson et al, 2022;Porter et al, 2022;Song and Foster, 2022) have incorporated at least an element of user feedback, which is perhaps a positive reflection of the value placed on this information as well as its importance in the development, refinement or delivery of interventions. Taking this one stage further, Li et al (2022) demonstrate in their study advances in how co-design principles are now being used to involve the 'end-users' of a digital product in its development from the outset.…”

“…Many of the studies (Browne et al, 2022;Li et al, 2022;Patterson et al, 2022;Porter et al, 2022;Song and Foster, 2022) have incorporated at least an element of user feedback, which is perhaps a positive reflection of the value placed on this information as well as its importance in the development, refinement or delivery of interventions. Taking this one stage further, Li et al (2022) demonstrate in their study advances in how co-design principles are now being used to involve the 'end-users' of a digital product in its development from the outset. This study describes the iterative process used, involving adolescents, parents and mental health professionals in the design of a CBT app, and highlights differences in preferences among end-users that need to be accounted for in app development (e.g.…”

“…adolescents prefer an app they can use autonomously, while mental health professionals desire an app they can use as an adjunct to therapy). Li et al (2022) highlight that co-design does not appear to be common practice, or at least that the reporting of co-design or user involvement procedures is lacking, citing a recent review that found this occurred in less than 30% of preventative mental health interventions for young people (Bergin et al, 2020). There is clearly scope for further improvement in the extent of meaningful user involvement as well as how this is described in the literature.…”

“…Taking this one stage further, Li et al . (2022) demonstrate in their study advances in how co-design principles are now being used to involve the ‘end-users’ of a digital product in its development from the outset. This study describes the iterative process used, involving adolescents, parents and mental health professionals in the design of a CBT app, and highlights differences in preferences among end-users that need to be accounted for in app development (e.g.…”

Protocol for a randomised controlled trial evaluating the effectiveness of a CBT-based smartphone application for improving mental health outcomes in adolescents: the MobiliseMe study

“…To overcome the gaps in current treatment availability, the Black Dog Institute developed ClearlyMe® - a free, self-directed CBT smartphone app that provides therapeutic content and symptom management strategies for mild to moderately severe symptoms of depression and anxiety in adolescents. Adolescents helped develop the app through extensive co-design, described in detail in Li et al [ 36 ]. The app contains 37 brief (up to 10 minutes in duration), non-sequential ‘lessons’ consisting of psychoeducation, cognitive restructuring (thought challenging and behavioural experiments), emotion awareness and acceptance, activity scheduling, behavioural activation, goal setting, problem solving, exposure, relaxation, mindfulness, and values identification.…”