Effectiveness and Implementation of a Text Messaging Intervention to Reduce Depression and Anxiety Symptoms Among Latinx and White Adults During the COVID-19 Pandemic

Abstract

Background SMS text messaging interventions are increasingly being used to help people manage mental health symptoms due to the COVID-19 pandemic. Despite the widespread adoption of SMS text messaging interventions, little is known about racial and ethnic differences in effectiveness, feasibility, and implementation factors. Objective A hybrid type 1 mixed-methods study was conducted to compare the effectiveness and implementation of the StayWell intervention for Latinx and non-Latinx White (White) adults using elements of the RE-AIM framework. Methods Adults using the StayWell intervention received daily mood inquiries and skills–based text messages for 60 days and reported symptoms via online surveys and the HealthySMS portal. Reach was assessed by the share of adults reached via distinct recruitment methods, and effectiveness was evaluated using the Personal Health Questionnaire (PHQ-8) depression scale and General Anxiety Disorder (GAD-7) scale. Adoption was assessed with user engagement, defined as the share of responses to the (60) daily mood inquiries. Implementation was evaluated based on user feedback on the number/timing of messages, the difficulty of using the program, and the System Usability Scale. Maintenance was assessed with user reports of the likelihood of continuing and recommending the program. Quantitative RE-AIM indicators were assessed using a t test for continuous outcomes and a chi-square test for categorical outcomes. Mixed-effects linear regressions examined heterogeneity among Latinx and White users in the outcomes’ (ie, PHQ-8 and GAD-7) changes over time. A thematic text analysis of responses to an open-ended question about participant experiences of the program was conducted to help contextualize differences in the effectiveness and implementation of StayWell between Latinx and White users. Results Among 398 users, 262 (65.8%) responded to the postintervention assessment. Upon completion, depressive (–1.48; P=.001) and anxiety (–1.38; P=.001) symptoms decreased among all users. Compared to White adults, Latinx adults reported an additional –1.45 (P<.05) decline in PHQ-8 scores, adjusting for demographics, recruitment sample, and engagement. Among Latinx adults, StayWell resulted in a greater improvement of depression symptoms (25.8% vs 13.8% reduction; P=.02) but not in anxiety symptoms (21.2% vs 15.9% reduction; P=.23). Despite Latinx adults reporting lower usability (76.8 vs 83.9; P=.001) than White adults, they were more likely to report interest in continuing the program (7.5 vs 6.2; P=.001) and recommend StayWell to a family member or friend (7.8 vs 7.0; P=.013). Repetitive content was a critical barrier to engaging Latinx adults in StayWell; among Latinx adults, support groups and bidirectional messages were considered important program modifications. Conclusions Although anxiety and depressive symptoms decreased among all StayWell users after receiving 2 messages daily for 60 days, Latinx users experienced greater reductions in depression symptoms compared to White users. Bidirectional text messaging using contextual information and ecological momentary analysis of mood data are promising adaptations to enable the tailoring of messages and improved usability of StayWell, which may be especially effective in improving Latinx user engagement. Trial Registration ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 Conflicts of Interest None declared.

The effect of cognitive behavioral therapy text messages on mood: A micro-randomized trial

“…Our prior work with the StayWell at Home program indicated that the intervention was associated with overall reductions in depression and anxiety symptoms as rated by the PHQ and GAD [ 7 , 8 ]. Here, we extend those findings to the outcome of daily mood ratings to better understand continuous symptom fluctuations at the daily level and to develop the evidence of text-messaging programs for supporting mental health outcomes among diverse communities disproportionately affected by the COVID-19 pandemic [ 4 ].…”

“…The delivery of text messages and collection of self-reported mood ratings was conducted via a HIPPA-compliant platform, HealthySMS. The University of California Berkeley Institutional Review Board reviewed and approved all study procedures [ 7 , 8 ].…”

“…The Phase 2 StayWell at Home intervention and implementation procedures are similar to those reported earlier in Phase 1. However, we made two modifications; first, we included a new message category representing Social Support tips and an option for not sending a tip message [ 8 ]. Social support tips examples include: “Taking the time to share your feelings and listen and support others will go a long way during the pandemic , especially during the holidays” and “The positive social contacts you have had today can help you tomorrow .…”

“…As a response to the social distance mandates, our team implemented the StayWell at Home intervention via two independent trials. The results of these independent studies indicated participants experienced significant reductions in depressive and anxiety symptoms after 60 days of exposure to the text messages [ 7 , 8 ]. A secondary outcome of the StayWell at Home intervention was daily mood ratings.…”

“…Thus, within a micro-randomized trial (MRT), we examine two components of Stay-Well at Home to inform the mechanisms of action that improve mood: 1) text messages delivering CBT-informed coping strategies (i.e., behavioral activation, other coping skills, or social support) and 2) time at which messages were sent. MRTs help examine the proximal effects of intervention components and can provide empirical data for personalizing digital health interventions [9] and optimizing just-in-time mHealth adaptive interventions (8). MRTs have been used to examine mHealth physical activity and substance use interventions [12][13][14].…”