# Improving adherence to an online intervention for low mood by a virtual coach or personalized motivational feedback messages: A three-arm pilot randomized controlled trial

## TL;DR

A study tested if adding automated motivational support to an online mental health program improved user adherence, but found no significant benefits.

## Contribution

This study is the first to compare virtual coaches and personalized messages for improving adherence in unguided online mental health interventions.

## Key findings

- Automated support did not significantly improve adherence or reduce depression symptoms.
- Participants reported moderate to high satisfaction but low usability scores for the online platform.
- Results suggest a need to better align motivational strategies with user needs and improve platform usability.

## Abstract

Online psychological interventions like behavioural activation (BA) can be provided with or without human support. Unguided online interventions require no human contact and are therefore easier to implement on a large scale than guided interventions. However, effectiveness and adherence rates to these interventions are generally lower. One way to increase adherence to unguided online interventions is to offer automated motivational support.

This pilot randomized controlled trial (RCT) examined whether adherence to unguided online BA for low mood could be improved by adding automated support in the form of smartphone-delivered personalized motivational messages or a motivational virtual coach.

A three-arm pilot RCT (n = 106) was conducted that compared an online intervention delivered with automated motivational support by a virtual coach (n = 35), or by automated personalized messages on their smartphone (n = 35), to the same intervention without support (control condition; n = 36). The primary outcome was level of adherence, operationalized as (1) the number of webpages of the intervention visited, and (2) the number of mood ratings completed on the smartphone application, both retrieved from participants' logfiles. Secondary outcomes were satisfaction with the intervention (CSQ-I), usability (SUS) depression scores (HADS), and motivation for treatment (SMFL), measured through online questionnaires administered at baseline or after 4 weeks.

Adherence was moderate overall, with participants visiting on average 23 pages of 55 webpages and completing on average 50 of 84 requested mood ratings. No evidence for differences in adherence rates were observed between the intervention conditions and the control condition. Satisfaction with the intervention was moderate to high. Usability scores were below the desirable threshold of 68. Depression symptoms did not change significantly across all participants (p = .053). No significant changes in motivation were found over time or between groups.

Adding automated support to unguided online BA for depression did not improve overall adherence. The limited effectiveness may reflect a misalignment between the motivational strategies and the needs of the target population, who reported mild symptoms and high intrinsic motivation. The findings highlight the need to further improve both the quality of automated support and the usability of online platforms. Future research should explore additional adherence-related factors and investigate how personalization can better address different symptom severities in unguided mental health interventions.

International Clinical Trials Registry Platform: trialsearch.who.int/Trial2.aspx?TrialID=NL8110.

•Pilot RCT tested automated motivational support to improve adherence in unguided online BA for low mood.•Compared personalized motivational messages and a virtual coach to no support•Automated support did not significantly improve adherence or depression outcomes.•Findings suggest need to refine motivational strategies and improve platform usability.•Results inform future personalization of unguided digital mental health interventions.

Pilot RCT tested automated motivational support to improve adherence in unguided online BA for low mood.

Compared personalized motivational messages and a virtual coach to no support

Automated support did not significantly improve adherence or depression outcomes.

Findings suggest need to refine motivational strategies and improve platform usability.

Results inform future personalization of unguided digital mental health interventions.