Mental wellbeing in young people is understandably a growing focus, both within the UK and around the Woodland World. There have been a range of studies looking at the implementation of universal interventions in young people to try and maintain wellbeing and prevent illness. Unfortunately, to date, the literature has shown that universal interventions are not effective at promoting wellbeing in young people (see Soffia’s recent blog on universal DBT interventions in schools).
An Ofcom report in 2023 outlined that 9 out of 10 children have a mobile phone by the age of 11 and that 98% of 16-to-17-year-olds own a smartphone. There are concerns that using smartphones may be increasing anxiety and depression in this age group (Haidt, 2024) – but could the smartphone also be a solution?
So far, studies trialling smartphone apps have tended to be small scale (e.g., less than 100 participants), which limits reliability. However, Watkins et al. (2024a; 2024b) have recently published the results of a parallel large-scale randomised controlled trial (RCT) that explored the preventative (ECoWeB PREVENT) and promotive (ECoWeB PROMOTE) effects of a mobile phone app for at-risk young people and healthy young adults, respectively.
The holy grail would be a smartphone app that is able to both promote wellbeing and prevent mental illness in young adults – but are we asking for too much?
Methods
This is an international, multi-centre, parallel, open-label RCT at four trial sites in the UK, Germany, Spain and Belgium. This was a cohort multiple RCT, meaning that an emotional competence profile was completed at baseline, and those without risk were allocated to ECoWeB PROMOTE and those with identified risk were allocated to ECOWeB PREVENT. Risk was identified as individuals scoring in the worst quartile on measures of rumination, worry, achievement appraisals, and rejection sensitivity.
Participants were excluded if they presented with or had a past episode of major depressive disorder. Other exclusion criteria were:
- Active suicidality
- Any self-reported history of severe mental health problems, such as bipolar disorder and psychosis
- Currently receiving psychological therapy, counselling, or psychiatric medication including antidepressants
- Elevated hypothesised vulnerability on the emotional competence profile based on the baseline assessment of emotional competence skills
Within each RCT, participants were randomly allocation to usual care plus either an:
- Emotional competence app;
- Cognitive-behavioural therapy (CBT) app; or
- Self-monitoring app
All outcome assessors and statisticians were masked to treatment allocation and there was follow-up for 12 months, with clinical rating scales completed at 3 and 12 months.
| Clinical Assessment Scales | PROMOTE | PREVENT | |
| Warwick-Edinburgh Mental Well Being Scale (WEMWBS) | Wellbeing | 3 and 12 months | 12 months |
| Primary Health Questionnaire-9 (PHQ-9) | Depression | 12 months | 3 and 12 months |
| Generalised Anxiety Disorder Scale-7 (GAD-7) | Anxiety | 12 months | 12 months |
| Work and Social Adjustment Scale (WSAS) | Social, home, and work or academic functioning | 12 months | 12 months |
| EQ-5D-3 Levels (EQ-5D-3L) | Health-related quality of life | 12 months | 12 months |
Results
Participant characteristics
Between October 15th 2020 and August 3rd 2021, 21,277 individuals aged 16-22 were screened; 10,030 accessed the baseline assessment and 3,794 were eligible for the ECoWeB cohorts.
| ECoWeB PROMOTE | ECOWeB PREVENT | |
| N | 2,532 | 1,264 |
| Mean age | 19.2 (SD = 1.8) | 18.8 (SD = 2.0) |
| Gender | 1,896 (75%) female, 613 (24%) male | 984 (78%) female, 253 (20%) male |
| Ethnicity | 2,203 White (87%)
135 Mixed (5%) 99 Asian (4%) 25 Black (1%) 22 Arab (1%) |
1,060 White (84%)
79 Mixed (6%) 63 Asian (5%) 22 Black (2%) 11 Arab (1%) |
| UK | 766 (30%) | 418 (33%) |
| Germany | 868 (34%) | 229 (18%) |
| Spain | 416 (17%) | 437 (35%) |
| Belgium | 482 (19%) | 178 (14%) |
| Emotional Competence app | 847 | 417 |
| CBT app | 841 | 423 |
| Self-monitoring app | 844 | 422 |
Outcomes: PROMOTE
3-month follow-up:
- Mental wellbeing did not differ between the emotional competence app and the CBT app (mean difference WEMWBS = -0.21 [95% CI –1.08 to 0.66]).
- Mental wellbeing did not differ between the emotional competence app and self-monitoring app (0.32 [–0.54 to 1.19]).
- Mental wellbeing did not differ between the CBT app and the self-monitoring app (0.53 [–0.33 to 1.39]).
12-month follow up:
- Mental wellbeing was lower in the emotional competence app than the CBT app (mean difference WEMWBS = 1.17 [95% CI –2.11 to –0.24]), but this was not a clinically significant difference.
- No difference occurred in mental wellbeing between the emotional competence app relative to the self-monitoring app (–0.76 [–1.69 to 0.18]).
- No difference occurred in mental wellbeing between the CBT app relative to the self-monitoring app (0.42 [–0.51 to 1.34]).
The results for all the secondary outcomes were similar to those for the primary outcome, with no global differences between the three groups at 3 months or 12 months.
Outcomes: PREVENT
3-month follow-up:
- Depression symptoms were significantly lower with the CBT app than the self-monitoring app (mean difference in PHQ-9 = –1.18 [95% CI –2.01 to –0.34]; p = .006).
- No difference in depression symptoms between the emotional competence app and the CBT app (0.63 [–0.22 to 1.49]; p = .15).
- No difference in depression symptoms between the emotional competence app and the self-monitoring app (–0.54 [–1.39 to 0.31]; p = .21).
- PHQ-9 scores were lower with the CBT app (59 [31%] of 191) than with the self-monitoring app (85 [43%] of 199; odds ratio [OR] = 0.50 [95% CI 0.31 to 0.81]).
- PHQ-9 scores were higher with the emotional competence app (69 [39%] of 178) than the CBT app (1.63 [1.01 to 2.64]; number needed to treat [NNT] = 8.33). PHQ-9 scores did not differ with the emotional competence app versus the self-monitoring app (0.82 [0.52 to 1.30]).
- Work or academic and social functioning and health related quality-of-life was higher with CBT app than the self-monitoring app group.
- Work or academic and social functioning and health related quality-of-life showed no benefit of the emotional competence app compared with the self-monitoring app.
There were no significant differences between groups on anxiety (GAD-7) or wellbeing (WEMWBS) at 3-month or 12-month follow up. At 12 months, there were no significant differences between any of the groups.
Contrary to the author’s hypotheses, there was no added benefit of the emotional competence app in the PROMOTE or PREVENT trial in comparison to a CBT or self-monitoring app.
Conclusions
The ECoWeB PROMOTE trial found that there was no added benefit of the emotional competence app or the CBT app relative to the self-monitoring app to promote mental wellbeing.
However, the ECoWeB PREVENT trial found that a generic CBT self-help app had beneficial protective effects compared with a self-monitoring control app on symptoms of depression, functioning, and quality of life in young people with increased vulnerability for depression.
The emotional competence app was not more beneficial than the CBT app, nor than the self-monitoring app.
Although ECoWeB PROMOTE found no significant differences between the three apps, PREVENT found that a generic CBT app had beneficial protective effects for young people at-risk of developing a mental health condition.
Strengths and limitations
It almost goes without saying that strengths include the studies using an RCT model. Recruitment from a range of European countries is refreshing to see, as it aids generalisability. There was also a targeted age group (16-22 years), which can aid the use of findings in practice. Further, all assessors and statisticians were blinded to the intervention, which reduces the risk of bias.
There wasn’t a ‘usual care’ control intervention, which is often typical within RCTs; however, I think using a self-monitoring control reduced some of the variability and inconsistency that ‘usual care’ can bring into trials like this. The authors felt that this was a limitation, but I think it may be a strength.
There were originally large sample sizes; however, a clear limitation is the reduced rate of compliance with the app and then the rates lost to follow-up. Sign up to the app was approximately 80% in both studies and the overall rate of attrition to follow up was 47.8% [95% CI 35.8 to 60.0]. The authors state that this is not unusual with app studies and felt there were still enough participants for ‘conservative estimates’, however, I feel that this also says something about the acceptability of the intervention.
The generalisability of the results is limited due to the population studied being predominantly White, female and in university education. The selection process, however, used a range of recruitment strategies: online and website advertising, a social media and press campaign, newsletters and other circulars, and noticeboards within schools, colleges, and universities to try and maximise uptake. The paper did not report what the demographics were of the final follow-up groups – this could have been interesting to consider, particularly if there were differences.
The study focussed on self-help apps and comments in relation to human involvement improving uptake are valid, although, this would completely change the study, costs and capacity.
Some might view the lack of a usual care control condition as a limitation – but as these types of conditions usually introduce variability into trials, could this actually be a strength?
Implications for practice
These results add to an evidence base suggesting that efforts at reducing the global burden of poor mental health in young people might be more effectively concentrated in prevention for selective and indicated at-risk populations rather than in universal efforts to promote mental wellbeing.
A by-product of this study is highlighting the benefits of the CBT app. The app itself is reported as automated, scalable, non-consumable and economical – as such, could this be transformed into a public mental health intervention?
The ECoWeB trial provides further evidence that universal interventions for healthy populations are not effective, and we need to move beyond this research.
With the progression of technology, we may be overlooking some of the more traditional methods of promotion or prevention of illness (e.g., connection and communication); like video killing the radio star…
Statement of interests
I have no conflicting interests in relation to this paper.
Links
Primary papers
Watkins, Edward R et al. (2024) Emotional competence self-help mobile phone app versus cognitive behavioural self-help app versus self-monitoring app to promote mental wellbeing in healthy young adults (ECoWeB PROMOTE): an international, multicentre, parallel, open-label, randomised controlled trial. The Lancet Digital Health, Online First October 4 2024 https://doi.org/10.1016/S2589-7500(24)00149-3
Watkins, Edward R et al. (2024) Emotional competence self-help app versus cognitive behavioural self-help app versus self-monitoring app to prevent depression in young adults with elevated risk (ECoWeB PREVENT): an international, multicentre, parallel, open-label, randomised controlled trial The Lancet Digital Health, Online First October 4 2024 https://doi.org/10.1016/S2589-7500(24)00148-1
Other references
OfCom Children and Parents: Media Use and Attitudes 2023 Published 29 March 2023
Haidt, J. (2024). The Anxious Generation: How the Great Rewiring of Childhood Is Causing an Epidemic of Mental Illness. Penguin Books.
Kornatska, S. (2024). Can DBT-based school intervention improve adolescent well-being? The Mental Elf.