Analyzing the Impact of Mobile App Engagement on Mental Health Outcomes: Secondary Analysis of the Unwinding Anxiety Program

Abstract

Background App-based interventions provide a promising avenue for mitigating the burden on mental health services by complimenting therapist-led treatments for anxiety. However, it remains unclear how specific systems’ use of app features may be associated with changes in mental health outcomes (eg, anxiety and worry). Objective This study was a secondary analysis of engagement data from a stage 1 randomized controlled trial testing the impact of the Unwinding Anxiety mobile app among adults with generalized anxiety disorder. The aims of this study were 2-fold: to investigate whether higher microengagement with the primary intervention feature (ie, educational modules) is associated with positive changes in mental health outcomes at 2 months (ie, anxiety, worry, interoceptive awareness, and emotional reactivity) and to investigate whether the use of adjunctive app features is also associated with changes in mental health outcomes. Methods We analyzed the intervention group during the stage 1 trial of the Unwinding Anxiety mobile app. The total use of specific mobile app features and the use specific to each feature were calculated. We used multivariate linear models with a priori significance of α=.05 to investigate the impact of cumulative app use on anxiety, worry, interoceptive awareness, and emotional regulation at 2 months, controlling for baseline scores, age, and education level in all models. Significant relationships between system use metrics and baseline participant characteristics were assessed for differences in use groupings using between-group testing (ie, 2-tailed t tests for continuous data and chi-square analyses for categorical data). Results The sample was primarily female (25/27, 93%), and the average age was 42.9 (SD 15.6) years. Educational module completion, the central intervention component, averaged 20.2 (SD 11.4) modules out of 32 for the total sample. Multivariate models revealed that completing >75% of the program was associated with an average 22.6-point increase in interoceptive awareness (b=22.6; SE 8.32; P=.01; 95% CI 5.3-39.8) and an 11.6-point decrease in worry (b=−11.6; SE 4.12; P=.01; 95% CI −20.2 to −3.1). In addition, a single log unit change in the total number of meditations was associated with a 0.62-point reduction in the Generalized Anxiety Disorder-7 scale scores (b=0.62; SE 0.27; P=.005; 95% CI −1.2 to −0.6), whereas a single log unit use of the stress meter was associated with an average of a 0.5-point increase in emotional regulation scores (Five Facet Mindfulness Questionnaire; b=0.5; SE 0.21; P=.03; 95% CI 0.1-0.9). Conclusions This study offers a clearer understanding of the impact of engagement with app features on broader engagement with the health outcomes of interest. This study highlights the importance of comprehensive investigations of engagement during the development of evidence-based mobile apps.

Leveraging Mobile Health to Manage Mental Health/Behavioral Health Disorders: Systematic Literature Review

“…A total of 11 themes and 2 individual observations were identified by the reviewers for a total of 48 occurrences in the literature, whereas 11 themes and 7 observations were noted for a total of 95 observations. In the 33 studies analyzed, 26 (79%) showed an improvement in symptoms of depression [25,26,[28][29][30][31][32][33][35][36][37][40][41][42][43][44][46][47][48][49][50][51][52][54][55][56], while 19 (58%) showed an improvement in anxiety [26][27][28][29][30][31][32][33]36,[38][39][40][44][45][46][53][54][55][56]. Only 11/33 (33%) reported that at least one symptom was not statistically significant when compared with results from the control group, but the improvement was still noted [25]…”

“…The following observations only occurred once in the literature: decrease in anger [26], decrease in decision conflict [30], decrease in decision regret [30], decreased digestive disturbance [26], decreased pain [26], increased medication adherence [41], and the intervention had no effect on self-efficacy [34]. [25,26,[28][29][30][31][32][33][35][36][37][40][41][42][43][44][46][47][48][49][50][51][52][54][55][56] 19 Reduced anxiety [26][27][28][29][30][31][32][33]36,[38][39][40][44][45][46][53]…”

“…Following the PRISMA checklist [20] and the Kruse protocol [21], we extracted the following data fields: participants, intervention, comparison with the control or other group, medical outcomes, and study design (PICOS; Table 1) as a way to summarize study characteristics, as required by PRISMA. Of the 33 studies analyzed over the 1-year period, 17 were from 2021 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] and 16 were from 2022 [42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57]. All studies were RCTs involving adults, and 48% (16/33) involved an average age of 50 years or above.…”

“…The only difference was 1 study [34] reported no effect on depression or anxiety. [36,41,44,49,54,56,57] 5 Increased mental well-being/cognitive flexibility [45][46][47]49,57] 4 Decreased distress [30,36,43,53] 4 Increased sleep [26,45,47,50] 4 Increased self-efficacy [41,42,44,57] 2 Decreased fatigue/increased resilience [45,46] 1 Decreased anger [26] 1 Decreased decision conflict [30] 1 Decreased decision regret [30] 1 Decreased digestive disturbance [26] 1 Decreased pain [26] 1 Increased medication adherence [41] 1 None [34]…”

“…Two studies reported no effects on mental health from the intervention [34,57]. [25,26,[28][29][30][31][32][33][35][36][37][40][41][42][43][44][46][47][48][49][50][51][52][54][55][56] 19 Reduced anxiety [26][27][28][29][30][31][32][33]36,[38][39][40][44][45][46][53][54][55][56] 7 Increased quality of life [36,41,44,49,…”