HealthySMS text messaging system adjunct to adolescent group cognitive behavioral therapy in the context of COVID-19 (Let’s text)!: pilot feasibility and acceptability study
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Abstract
Background: The widespread occurrence and devastating impact of adolescent depression warrant health service research focused on feasible and acceptable digital health tools to supplement evidence-based intervention (EBI) efforts, particularly in the context of shelter-in-place guidelines disrupting youth socialization and service use in the wake of the COVID-19 pandemic. Given the promise of SMS text message interventions to enhance EBI engagement, our team developed the HealthySMS system as an adjunct to one of the most empirically supported interventions for adolescent depression: cognitive behavioral therapy (CBT) group services. The system sends daily SMS text messages requesting responses assessing mood, thoughts, and activities; weekly attendance reminder messages; daily tips about adherence (eg, a prompt for activity completion); and personalized responses based on participants’ texts. Objective: This study aims to evaluate the feasibility and acceptability of HealthySMS in a real-world setting and explore potential mechanisms of change in EBI engagement, before evaluating the system’s impact on adolescents’ group CBT engagement and, ultimately, depression outcomes. Methods: Over the course of 2020, we invited all 20 adolescents receiving CBT group services for depression at an outpatient psychiatry clinic to enroll in our HealthySMS study; ultimately, 17 (85%) adolescents agreed to participate. We tracked participant initiation and engagement with the HealthySMS system as well as the content of SMS text message responses to HealthySMS. We also invited each participant to engage in a semistructured interview to gather additional qualitative inputs on the system. Results: All (n=17, 100%) research participants invited agreed to receive HealthySMS messages, and 94% (16/17) of the participants maintained use during the first month without opting out. We uncovered meaningful qualitative themes regarding the feasibility and acceptability of HealthySMS, as well as its potential impact on EBI engagement. Conclusions: Taken together, the results of this pilot study suggest that HealthySMS adjunct to adolescent CBT group depression services is feasible and acceptable, as evidenced by high rates of HealthySMS initiation and low rates of dropout, as well as meaningful themes uncovered from participants’ qualitative feedback. In addition, the findings provide evidence regarding iterative improvements to the HealthySMS system and research protocol, as well as potential mechanisms of change for enhanced EBI engagement and, ultimately, adolescent depression outcomes, which can be used in future effectiveness research.
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The HealthySMS system, which uses daily reminders and interactive content, was shown to improve adolescent treatment adherence by enhancing their sense of involvement.
“For example, the HealthySMS system, which uses daily reminders and interactive content, was shown to improve adolescent treatment adherence by enhancing their sense of involvement (84).”
From Recent developments in bibliotherapy for adolescent depression (2025) · cites this paper as [84]
The Methods section describes daily skill reminders, mood prompts, and interactive responses. In the Discussion ('Potential Impact on EBI Engagement to Be Evaluated in Future Effectiveness Research'; page unavailable), adolescents reported that messages may have helped them participate and feel connected, but the authors say the effect on engagement remains to be measured. The paper therefore does not establish improved treatment adherence or show that a greater sense of involvement caused it. (LLM, conf=0.88)
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Recent developments in bibliotherapy for adolescent depression
Liao, F., Liang, J., Zhang, M., Liang, W., Zhang, C., & Yun, X. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1681462 · Cited by 4 · see citing works
Julius, N., Zhong, Y., Rajabzadeh, V., Racine, S., Hayhoe, B. W. J., Barber, S., & Otis, M. (2026) · doi:10.2196/preprints.90489
McAlister, K. L., Huffman, L. G., Jewell, C. C., Childs, A. W., Cox, E., & Huberty, J. (2026) · doi:10.2196/preprints.108377
Julius, N., Zhong, Y., Rajabzadeh, V., Racine, S., Hayhoe, B. W. J., Barber, S., & Otis, M. (2026) · JMIR Mental Health · doi:10.2196/90489
McAlister, K. L., Huffman, L. G., Jewell, C. C., Childs, A. W., Cox, E., & Huberty, J. (2026) · JMIR Formative Research · doi:10.2196/108377
- Authors
- Haack, L. M., Armstrong, C. C., Travis, K., Aguilera, A., & Darrow, S. M.
- Affiliations
- University of California, San Francisco (US)
- Corresponding author
- Haack, Lauren M
- Venue
- JMIR Mental Health
- Publisher
- JMIR Publications Inc.
- Published
- 2024-02-19
- Volume
- 11
- Pages
- e49317
- ISSN
- 2368-7959 (ISSN-L)
- PMC
- PMC10912989
- OpenAlex
- W4390760012
- Cited by
- 5
- References
- 53
- Citations by year
- 2026: 4 · 2025: 1
- FWCI
- 1.98
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JMIR Mental Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Social Sciences › Sociology and Political Science › Impact of Technology on Adolescents
- Keywords
- adolescent depression, cognitive behavioral therapy, group therapy, text messaging intervention, digital health, adjunctive therapy, treatment engagement, COVID-19 pandemic, shelter-in-place, feasibility and acceptability, outpatient psychiatry
- MeSH terms
- COVID-19, Adolescent, Feasibility Studies, Humans, Pilot Projects, Cognitive Behavioral Therapy, Pandemics, Text Messaging
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