Effectiveness of Digital Behavioral Activation Interventions for Depression and Anxiety: A Systematic Review and Meta-analysis (Preprint)

Abstract

BACKGROUND As digital interventions gain prominence in mental health care, they present opportunities to improve access and scalability. Despite their potential, the overall impact of digital Behavioral Activation (BA) interventions across different formats and populations is not yet fully understood. Further research is necessary to evaluate their effectiveness across settings and optimize their application. OBJECTIVE This systematic review and meta-analysis aimed to assess the characteristics and functions of digital BA interventions, evaluate their effects on patient outcomes, identify limitations, and highlight gaps in the existing research to guide future directions. METHODS A comprehensive search of databases (PubMed, Embase, Web of Science, APA PsycInfo, and ClinicalTrials.gov) identified randomized controlled trials (RCTs) assessing the effectiveness of digital BA interventions for depression and anxiety. Two independent reviewers screened studies, extracted data, and assessed risk of bias using the Cochrane Risk of Bias Tool. Meta-analyses, using a random-effects model, were performed on outcomes such as depression, anxiety, quality of life (QoL), BA scores, functioning, disability, and stress. Statistical heterogeneity was evaluated with the I² statistic. Six studies that did not meet meta-analysis criteria underwent narrative synthesis. RESULTS Eighteen studies were included, covering three intervention types: (1) internet-based BA (iBA), which delivers online therapies to foster new behavioral activities for depression management; (2) electronic messaging-based BA, involving prompts to support behavior change; and (3) telehealth-based BA, providing remote healthcare services. Of these, twelve studies were included in the meta-analysis. Digital BA interventions significantly reduced depressive symptoms at 2 months (p < 0.00001, I² = 0%), 3 months (p = 0.001, I² = 51%), and 6 months (p = 0.009, I² = 29%) post-treatment, but not at 12 months (p = 0.82, I² = 89%). BA scores showed significant improvement at 6 months (p < 0.00001, I² = 0%). QoL also improved significantly at 3 months (p = 0.002, I² = 22%) and 6 months (p = 0.009, I² = 0%), while stress levels were significantly reduced at 3 months (p = 0.0005, I² = 25%). Anxiety and functioning/disability outcomes did not show significant changes at 3 or 6 months. CONCLUSIONS Digital BA interventions offer meaningful short-to-medium-term benefits for alleviating depressive symptoms and improving QoL, though their impact diminishes by 12 months. Variations in intervention types, guidance levels, and treatment durations underscore the need for future studies to refine these interventions for specific populations. Further research should address the long-term effectiveness and disentangle the role of BA in multi-component approaches.