Beyond the trial: A systematic review of real-world uptake and engagement with digital self-help interventions for depression, low mood, or anxiety

Background: Digital self-help interventions (including online or computerized programs and apps) for common mental health issues have been shown to be appealing, engaging, and efficacious in randomized controlled trials. They show potential for improving access to therapy and improving population mental health. However, their use in the real world, that is, as implemented (disseminated) outside of research settings, may differ from that reported in trials, and implementation data are seldom reported. Objective: We aimed to review peer-reviewed articles reporting user uptake and/or ongoing use, retention, or completion data (hereafter ‘usage data’ or, for brevity, ‘engagement’) from implemented pure self-help (unguided) digital interventions for depression, anxiety, or the enhancement of mood. Methods: We conducted a systematic search of the Scopus, Embase, MEDLINE, and PsychINFO databases for studies reporting user uptake and/or usage data from implemented digital self-help interventions for the treatment or prevention of depression or anxiety, or the enhancement of mood, from 2002 to 2017. Additionally, we screened the reference lists of included articles, citations of these articles, and the titles of articles published in Internet Interventions, Journal of Medical Internet Research (JMIR), and JMIR Mental Health since their inception. We extracted data indicating the number of registrations or downloads and usage of interventions. Results: After the removal of duplicates, 970 papers were identified, of which ten met the inclusion criteria. Hand-searching identified one additional article. The included articles reported on seven publically available interventions. There was little consistency in the measures reported. The number of registrants or downloads ranged widely, from eight to over 40,000 per month. From 21% to 88% of users engaged in at least minimal use (e.g. used the intervention at least once or completed one module or assessment), while 7–42% engaged in moderate use (completing between 40% and 60% of modular fixed-length programs or continuing to use apps after four weeks). Indications of completion or sustained use (completion of all modules or the last assessment or continuing to use apps after six weeks or more) varied from 0.5% to 28.6%. Conclusions: Available data suggest that uptake and engagement vary widely among the handful of implemented digital self-help apps and programs which have reported this, and that usage may vary from that reported in trials. Implementation data should be routinely gathered and reported to facilitate improved uptake and engagement, arguably among the major challenges in digital health