# Influence of patient satisfaction, system usability, and working alliance on depressive symptom improvement in blended cognitive behavioral therapy (bCBT): Secondary analysis of an open trial data

## TL;DR

This study explores how patient satisfaction, system usability, and working alliance with therapists affect depression improvement in blended therapy.

## Contribution

The study identifies patient satisfaction as a key predictor of treatment success in blended cognitive behavioral therapy.

## Key findings

- Patient satisfaction, usability, and working alliance are associated with depressive symptom improvement in blended therapy.
- The full model of these factors explains 16.6% of the variance in depression improvement.
- Further research is needed to understand how these predictors interact.

## Abstract

Blended cognitive behavioral therapy (bCBT), which involves the use of a digital application to support face-to-face psychotherapy, is increasingly offered to patients with depression amid a growing body of research on its efficacy. However, there is still limited understanding of the factors that influence the efficacy of this novel treatment method. To investigate the effects of potential factors such as patient satisfaction with the received treatment, patients' self-rated working alliance with their therapist, and patients' rating of system usability of the digital application, this secondary analysis study focused on a sample of 66 university students who completed an effective 6-week bCBT program that included weekly sessions with a therapist and access to a digital mental health application. We examined whether those three potential factors predict patients' improvement in depressive symptoms in a bCBT treatment. Patient satisfaction and working alliance are known predictors of treatment success in standard psychotherapy, yet their importance in blended treatment is largely unstudied. System usability is a factor that is frequently addressed while describing digital treatment programs, yet its contribution to the success of treatments has been mostly omitted. All the variables analyzed displayed a significant positive correlation with improvement in depressive symptoms. When taken together, all the factors account for 16.6 % of the variance in the outcome. However, when three variables were added in the backward multiple linear regression with stepwise elimination, only patient satisfaction emerged as a predictor of the outcome. Although there are significant correlations between working alliance and system usability and the improvement of depression in the bCBT program, their lack of predictive power in comparison to patient satisfaction renders the results inconclusive. Future studies could explore the potential contribution of additional variables to the improvement of depressive symptoms.

•Patient satisfaction, usability, and working alliance are associated with depressive symptom improvement in a bCBT program.•Pairs of positive correlations among patient satisfaction, usability, and working alliance were significant.•When three factors are analyzed together, the full model explained 16.6 % of the variance in depressive symptom improvement.•How different predictors interact and are interlinked with one another needs further exploration.

Patient satisfaction, usability, and working alliance are associated with depressive symptom improvement in a bCBT program.

Pairs of positive correlations among patient satisfaction, usability, and working alliance were significant.

When three factors are analyzed together, the full model explained 16.6 % of the variance in depressive symptom improvement.

How different predictors interact and are interlinked with one another needs further exploration.