The Engagement Problem: a Review of Engagement with Digital Mental Health Interventions and Recommendations for a Path Forward

Purpose of the review: Digital mental health interventions (DMHIs) are an effective and accessible means of addressing the unprecedented levels of mental illness worldwide. Currently, however, patient engagement with DMHIs in real-world settings is often insufficient to see a clinical benefit. In order to realize the potential of DMHIs, there is a need to better understand what drives patient engagement. Recent findings: We discuss takeaways from the existing literature related to patient engagement with DMHIs and highlight gaps to be addressed through further research. Findings suggest that engagement is influenced by patient-, intervention-, and system-level factors. At the patient level, variables such as sex, education, personality traits, race, ethnicity, age, and symptom severity appear to be associated with engagement. At the intervention level, integrating human support, gamification, financial incentives, and persuasive technology features may improve engagement. Finally, although system-level factors have not been widely explored, the existing evidence suggests that achieving engagement will require addressing organizational and social barriers and drawing on the field of implementation science. Summary: Future research clarifying the patient-, intervention-, and system-level factors that drive engagement will be essential. Additionally, to facilitate an improved understanding of DMHI engagement, we propose the following: (a) widespread adoption of a minimum necessary 5-element engagement reporting framework, (b) broader application of alternative clinical trial designs, and (c) directed efforts to build upon an initial parsimonious conceptual model of DMHI engagement.