For the purposes of increasing attendance at psychotherapy sessions, younger participants appear to benefit more from the use of supportive testing interventions compared with older individuals. A study on the subject was conducted among individuals who attended a group cognitive behavioral therapy (GCBT) session in a primary care clinic and participated in a supportive automated text messaging intervention. Results of the analysis were published in the Telemedicine and e-Health.1

Although CBT is an established treatment for patients with depression, its success is frequently hampered by low attendance. The investigators sought to 1) identify subgroups of texting and attending behavior during the use of a supportive text messaging intervention for GCBT known as “Moodtext” and 2) examine the associations between increased texting engagement and higher attendance. Total texting responsiveness was defined as the total number of text messages that necessitated a mood score to which the participants responded. Regarding the second objective, the response rate from the prior week was defined as the percentage of texts to which participants responded in the prior week.

A total of 73 participants who attended GCBT were included in the study. Overall, 90% of the participants were Spanish-speaking, 75% were female, and 73% did not have a high school diploma. The mean participant age was 51.5±12.1 years. The study comprised mainly low-income individuals who were served in a public urban hospital and had been referred by their primary care providers if they expressed qualitative symptoms of depression or screened positive for depression on the 9-item Participant Health Questionnaire (PHQ-9).2 Individuals with a PHQ-9 score of ≥10 at initial evaluation were considered eligible for GCBT. All of the participants received a mobile phone if they did not have one.

The study, which took place between January 2014 and May 2018, was conducted in 2 phases. Phase 1 of the study, a nonrandomized, controlled trial of 35 participants, occurred until August 2016.3 Participants in phase 1 did not receive any compensation.3 In contrast, phase 2 was a naturalistic study in which 38 individuals received the text-messaging adjunct and a $25 gift card for their participation.

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The mean number of group sessions that were attended by the participants was 6.7±4.7, and the participants responded to a mean number of 49.5±35.6 messages during the entire study period. A total of 4 clusters were identified, which were classified according to the combination of total texting responsiveness and attendance: “Unengaged” (n=19), “Mostly Mobile” (n=16), “Mostly Live” (n=10), and “Fully Engaged” (n=28).

Distinct profiles in age and prior texting knowledge were observed among the 4 clusters. Response rates to texts in the week prior to the GBCT were not associated with GCBT attendance, but the relationship was impacted by the participant’s age, with a positive relationship observed among younger, but not older, participants. Furthermore, attending GCBT was linked to a higher response rate in the week following an attended session.

The investigators concluded that the findings show that user groups of study engagement differed according to their texting knowledge and their age. These results may help in the tailoring of digital interventions to particular user groups in order to avoid the risk for failure, and they contribute to understanding the therapeutic effects of these interventions. In fact, supportive digital intervention and face-to-face contact may enhance the effectiveness of each other.


1. Figueroa CA, DeMasi O, Hernandez-Ramos R, Aguilera A. Who benefits most from adding technology to depression treatment and how? An analysis of engagement with a texting adjunct for psychotherapy [published online March 26, 2020]. Telemed J E Health.

doi: 10.1089/tmj.2019.0248.

2. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

3. Aguilera A, Bruehlman-Senecal E, Demasi O, Avila P. Automated text messaging as an adjunct to cognitive behavioral therapy for depression: a clinical trial. J Med Internet Res. 2017;19(5):e148.