The prevalence of mental health problems is increasing amongst young people, with an estimated 22% of young people in the UK having a probable mental disorder (Newlove-Delgado et al., 2022). Particularly striking increases in depression and anxiety have been shown in this population (Rees, 2020), which may have been made worse by the COVID-19 pandemic. For example, research indicates that the rise in loneliness among young adults during lockdown was linked to a corresponding increase in depression (Lee et al., 2020).

Of particular concern is that young adults, despite being at an increased risk of developing mental health problems (Kessler et al., 2005; de Girolamo et al., 2019), are the age group least likely to be receiving treatment (Babajide et al., 2020; Roche et al., 2020). There is therefore a need for services to adapt to ensure that mental health treatment can be accessed by young people – through, for example, introducing new initiatives to reach out to groups less likely to access current services.

Cognitive Behavioural Therapy (CBT) is one of the recommended treatments for depression in adults (NICE, 2022). It typically involves reviewing the cycle between thoughts, physical feelings, and actions, and modifying unhelpful thoughts or behaviours (NHS, 2023). This blog summarises a recent paper by Mason et al. (2023a), which describes a randomised controlled trial (RCT) of CBT delivered to young adults with depression via text messages.

Methods

This study builds on a previous four-week pilot of CBT delivered via text messages (CBT-txt) conducted by the same author group (Mason et al., 2023b).

To conduct this RCT, US-based young adults aged 18-25 with depressive symptoms (“at least moderate depressive symptomatology”) were recruited using adverts on social media sites. Participants were randomly allocated to either receive the eight-week CBT-txt intervention or be allocated to a control group who were put on a waiting list for treatment.

The CBT-txt intervention was adapted from an in-person CBT manual. It consisted of an automated text-message programme which initiates a conversation with a participant and sends follow-up messages after an initial participant response. Participants received initial text messages every other day for the duration of the eight-week intervention. Each week of the intervention focused on a new topic (see Table 1 below for more details).

Table 1: Overview of the CBT-txt intervention content

Week	Content
Week 1	Introduction to CBT
Week 2	Automatic thoughts
Week 3	Behavioural activation
Week 4	Automatic thoughts and health
Week 5	Perseverative thinking
Week 6	Cognitive distortions
Week 7	More behavioural activation
Week 8	Social support and summary

Measures of depression severity, behavioural activation (increasing motivation to participate in positive activities), cognitive distortion (a negative bias to thoughts, e.g., catastrophising) and perseverative thinking (dwelling on negative thoughts or problems) were taken at monthly intervals for three months after the end of treatment.

Data was analysed using latent change score analyses. As the authors were also interested in understanding the mechanisms of change underlying the intervention (i.e., which elements of the intervention produced a change in outcomes), they conducted mediation analyses.

Results

103 participants were recruited to take part in the study, of which 50 were allocated to receive CBT-txt and 53 were allocated to the waiting list control group. The average age of participants was 22 years (SD = 2.2) and the majority (84.5%) were female. 63.1% of the participants were White, 15.5% Asian, 7.8% Hispanic or Latino, 3.9% Black or African American and 8.7% described themselves as having more than one race.

Effectiveness

Findings indicated that participants in the CBT-txt group had a significantly larger reduction in depression symptoms at each of the three-monthly follow-up points after the end of treatment, with a medium to large effect (Cohen’s d = 0.76).

In terms of clinical significance, just over half of participants in the intervention group (53%) had moved to a depression severity rating of ‘none to minimal’ at the end of the 3-month follow-up period, compared to 15% of those in the control group.

Mechanisms of change

The authors found evidence that CBT-txt resulted in higher levels of behavioural activation amongst participants in the intervention group, when compared to the control group. They also found lower levels of cognitive distortion and perseverative thinking in the participants who had received CBT-txt compared to controls. Together, these mediators explained 63% of the treatment effect of the CBT-txt intervention.

Acceptability

The authors evaluated the acceptability of the CBT-txt intervention to participants and found that 80% found the intervention helpful. The majority of participants also rated the number of text messages and the numbers of days in which texts were received as “just right”.

Conclusions

This study provides preliminary evidence to suggest that CBT delivered via text messages may be an effective and acceptable method of reducing depressive symptoms in a young adult population. The authors also highlight that:

These findings also specify 3 treatment mechanisms that each explain a significant portion of the treatment effect when separately introduced […] and even larger effects when combined.

Strengths and limitations

A particular strength of this study was that it indicates promise of a novel intervention which could help to meet the increasing demand for mental health services in young people. The intervention is based on standard CBT techniques and has the potential to be delivered on a large scale.

A limitation of the findings of this study is that whilst the CBT-txt intervention was shown to be effective in reducing depressive symptoms, this was when compared to a control group who did not receive any treatment at all (they were simply put on a waiting list). Therefore, we cannot conclude from this research alone that this intervention is as effective as CBT delivered via other methods (e.g. face-to-face or using videoconferencing platforms) to allow for direct communication with a mental health professional. It is also unclear whether the study authors were blinded to the allocation of the participants to either the intervention or control group, which may result in bias when analysing the findings.

Another potential limitation of this study is the recruitment methods used. As the young adults involved in this study were recruited from social media sites, they may have been more likely to rate a text-message delivered intervention more highly than young adults who do not use social media. The fact that the intervention is delivered over text-message also means it would not be available for young people who do not have access to technology or who do not feel comfortable talking about their mental health using a non-face-to-face method.

The majority of participants were also female, meaning more research needs to be conducted to explore whether similar results would be achieved in a sample of young men. Finally, the sample size of this study is relatively small at around 100 participants and only two-thirds of participants in the CBT-txt group completed the intervention. The authors do not state how they decided on the sample size for this study. Larger-scale studies comparing CBT-txt to an active control group should therefore be conducted to confirm the findings from this study.

Implications for practice

This study shows promising findings for the use of CBT delivered via text message, but there is lots of uncertainty around this trial. My own research focusing on young adults who still have ongoing mental health needs after leaving child and adolescent mental health services (CAMHS) has found that they can struggle to find accessible services to meet their mental health needs (Appleton et al., 2020). An approach to delivering CBT on a wider scale could therefore help to meet some of this current unmet need, whilst also improving access to mental health care for those who may not be able to engage with traditional forms of CBT due to stigma, caring responsibilities or difficulties travelling to attend a face-to-face appointment. This intervention could also be delivered to offer some form of support to young adults who are on waiting lists for more traditional types of mental health care, as we also know that waiting lists can be a barrier to treatment for this population (Punton et al., 2022).

However, further research is needed to find out how effective CBT-txt is compared to other forms of treatment, such as CBT delivered face-to-face or using videoconferencing software, involving direct communication with a mental health professional. This is important, as a strong therapeutic alliance between the clinician and patient can improve outcomes from CBT (Kazantzis & Dobson, 2022) and reduce drop-out rates (Murphy et al., 2022). A recent Mental Elf blog explored the dimensions of a therapeutic relationship with mental health apps, and concluded more research is needed as this field is still in its infancy. The move to deliver mental health care remotely for some patients due to the COVID-19 pandemic also disadvantaged some patients, for example those who do not or cannot use technology, or those who prefer face-to-face communication (Schlief et al., 2022; Vera San Juan et al., 2021). When considering implementing  interventions such as CBT-txt, it is therefore important that individual’s choices and preferences are taken into consideration, and these interventions are not used as an alternative to offering face-to-face support.

Statement of interests

None.

Links

Primary paper

Mason, M. J., Coatsworth, J. D., Zaharakis, N., Russell, M., Brown, A., & McKinstry, S. (2023a). Testing Mechanisms of Change for Text Message–Delivered Cognitive Behavioral Therapy: Randomized Clinical Trial for Young Adult Depression. JMIR mHealth and uHealth, 11, e45186.

Other references

Appleton, R., Elahi, F., Tuomainen, H., Canaway, A., & Singh, S. P. (2021). “I’m just a long history of people rejecting referrals” experiences of young people who fell through the gap between child and adult mental health services. European Child & Adolescent Psychiatry, 30(3), 401-413.

Babajide A, Ortin A, Wei C, Mufson L, Duarte CS. (2020). Transition Cliffs for Young Adults with Anxiety and Depression: Is Integrated Mental Health Care a Solution? Journal of Behavioural Health Services Research, 47(2), 275-292.

De Girolamo, G., McGorry, P. D., & Sartorius, N. (Eds.). (2019). Age of onset of mental disorders: Etiopathogenetic and treatment implications. Cham: Springer International Publishing.

Jacob, J. (2023). Is it possible to form a digital therapeutic alliance with a mental health app?. The Mental Elf.

Kazantzis, N., & Dobson, K. S. (2022). Therapeutic relationships in cognitive behavioral therapy: Theory and recent research. Psychotherapy Research, 32(8), 969-971.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.

Lee, C. M., Cadigan, J. M., & Rhew, I. C. (2020). Increases in loneliness among young adults during the COVID-19 pandemic and association with increases in mental health problems. Journal of Adolescent Health, 67(5), 714-717.

Mason, M.J., Coatsworth, J.D., Zaharakis, N., Russell, M., Wallis, D., Brown, A. and Hale, C., (2023b). Treating Young Adult Depression With Text-Delivered Cognitive Behavioral Therapy: A Pilot Randomized Clinical Trial. Behavior Therapy, 54(2), pp.315-329.

Murphy, S. T., Garcia, R. A., Cheavens, J. S., & Strunk, D. R. (2022). The therapeutic alliance and dropout in cognitive behavioral therapy of depression. Psychotherapy Research.

National Institute for Health and Care Excellence (Great Britain). (2022). Depression in adults: treatment and management. National Institute for Health and Care Excellence (NICE). [Accessed 31.10.23]

Newlove-Delgado T, Marcheselli F, Williams T, Mandalia D, Davis J, McManus S, et al. (2022). Mental Health of Children and Young People in England, 2022-wave 3 follow up to the 2017 survey. 

NHS. (2023). Overview – Cognitive behavioural therapy (CBT). [Accessed 31.10.23]

Punton, G., Dodd, A. L., & McNeill, A. (2022). ‘You’re on the waiting list’: An interpretive phenomenological analysis of young adults’ experiences of waiting lists within mental health services in the UK. PLOS One, 17(3), e0265542.

Rees, E. (2020). Young people’s well-being in the UK 2020. Office for National Statistics. [Accessed 31.10.23]

Roche, E., O’Sullivan, R., Gunawardena, S., Cannon, M., & Lyne, J. P. (2020). Higher rates of disengagement among young adults attending a general adult community mental health team: Time to consider a youth‐specific service?. Early Intervention in Psychiatry, 14(3), 330-335.

Schlief, M., Saunders, K. R., Appleton, R., Barnett, P., San Juan, N. V., Foye, U., … & Johnson, S. (2022). Synthesis of the evidence on what works for whom in telemental health: rapid realist review. Interactive Journal of Medical Research, 11(2), e38239.

Vera San Juan, N., Shah, P., Schlief, M., Appleton, R., Nyikavaranda, P., Birken, M., … & Johnson, S. (2021). Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis. PLOS One, 16(9), e0257270.

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