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Preliminary Evaluation of the Engagement and Effectiveness of a Mental Health Chatbot
Open accessAbstract
Background: Mental health difficulties are highly prevalent, yet access to support is limited by barriers of stigma, cost, and availability. These issues are even more prevalent in low- and middle-income countries, and digital technology is one potential way to overcome these barriers. Digital mental health interventions are effective but often struggle with low engagement rates, particularly in the absence of human support. Chatbots could offer a scalable solution, simulating human support at a lower cost. Objective: To complete a preliminary evaluation of engagement and effectiveness of Vitalk, a mental health chatbot, at reducing anxiety, depression and stress. Methods: Real world data was analyzed from 3,629 Vitalk users who had completed the first phase of a Vitalk program (“less anxiety,” “less stress” or “better mood”). Programs were delivered through written conversation with a chatbot. Engagement was calculated from the number of responses sent to the chatbot divided by days in the program. Results: Users sent an average of 8.17 responses per day. For all three programs, target outcome scores reduced between baseline and follow up with large effect sizes for anxiety (Cohen's d = −0.85), depression (Cohen's d = −0.91) and stress (Cohen's d = −0.81). Increased engagement resulted in improved post-intervention values for anxiety and depression. Conclusion: This study highlights a chatbot's potential to reduce mental health symptoms in the general population within Brazil. While findings show promise, further research is required.
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“These intervention strategies based on positive psychology, CBT, and mindfulness practices have been recently deployed by fully automated conversational agents targeting anxiety, stress, and depression, with promising results in terms of efficacy and acceptability by users [10,16,24,25].”
From Engagement and effectiveness of a healthy-coping intervention via chatbot for university students during the COVID-19 pandemic: Mixed methods proof-of-concept study (2021) · cites this paper as [25]
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“depression [10,24,25]”
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“as well as their effectiveness in reducing perceived stress [16-25]”
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“thereby improving symptoms of anxiety [10,23-25]”
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“Overall, our quantitative and qualitative findings are aligned with recent chatbot evaluation studies [10,23-25] and will inform our design decisions for future developments.”
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BackgroundChatbot features for anxiety and depression: a scoping review
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“In addition, evaluations need to assess the ability of such platforms to reduce symptoms of mental illness [16] while also enhancing user well-being and ensuring that patients feel understood [13].”
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“Our study Although some research has indicated that mental health chatbots can decrease stress in nonclinical populations [18,22], no significant reductions in stress were found in our chronic disease sample, at least in terms of the quantitative data.”
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“For example, Daley et al. 45 evaluated the engagement and effectiveness of a mental health chatbot (Vitalk), delivering mental health content in a conversational format, showing decreased anxiety, depression, and stress levels.”
User Experiences of Well-Being Chatbots
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InfluentialUser experience with a parenting chatbot micro intervention
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Naturalistic Evaluation of HeadGear: A Smartphone App to Reduce Depressive Symptoms in Workers
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“There are over 20 available mental health chatbots pur-portedly to help users manage different mental illnesses such as anxiety, postpartum depression, and substance abuse [5], [6], [7].”
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Li, X., Tao, C., Gao, J. Z., & Guo, H. (2022) · IEEE International Conference on Artificial Intelligence Testing (AITest) · doi:10.1109/aitest55621.2022.00021 · Cited by 13
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“Other notable mentions include Vitalk (Daley et al. 2020; Hungerbuehler et al. 2021), Wysa (Inkster, Sarda, and Subramanian 2018), Woebot (Fitzpatrick, Darcy, and Vierhile 2017), Youper (Mehta et al. 2021), Owlie (Falala-Séchet et al. 2019), Help4Mood (Burton et al. 2016), and Elena + (Ollier et al. 2023).”
Mental Healthcare Chatbot Based on Custom Diagnosis Documents Using a Quantized Large Language Model
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“A preliminary evaluation of Vitalk, a mental health chatbot in Brazil, has demonstrated the potential of chatbots in reducing anxiety, depression, and stress symptoms [9].”
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“On the other hand, Daley et al. (2020) clarified that they did not pursue ethical approval for their study involving human participants, citing that it was not mandated by local laws or institutional guidelines.”
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“In addition to relatively simple indicators of user engagement such as the frequency of user inputs and interactions [149, 150], measures like gaze patterns, backchannel responses (e.g., nodding, verbal acknowledgments such as “uh-huh”), facial expressions, and body postures can effectively serve…”
Anxiety Assistance Mobile Apps Chatbot Using Cognitive Behavioural Therapy
Sulaiman, S., Mansor, M., Wahid, R. A., & Azhar, N. A. A. N. (2022) · International Journal of Artificial Intelligence · doi:10.36079/lamintang.ijai-0901.349 · Cited by 7
“A study conducted in Brazil using a chatbot to improve mental health within one month shows a promising result [14].”
BackgroundKo, S., & Woo, H. (2025) · JMIR mhealth and uhealth · doi:10.2196/64622 · Cited by 6
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“Among other groups, primarily general adult populations residing in underserved areas [40, 41, 44, 45] the topics examined included mental health [41, 45] promotion of healthy lifestyles [40] and HIV prevention [44].”
InfluentialMental Health Status and Influencing Factors of College Students
Yang, L. (2023) · International Journal of Fuzzy System Applications · doi:10.4018/ijfsa.334233 · Cited by 5
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“The use of the chatbot improved the overall treatment experience for patients, and the findings are consistent with those of other chatbot studies [36,37].”
Hopman, K., Richards, D., & Norberg, M. M. (2025) · Behaviour and Information Technology · doi:10.1080/0144929x.2025.2477757 · Cited by 4
“Digital technology has been widely promoted as offering potential opportunity to tackle both structural (location and availability of services) and attitudinal (perceived stigma in accessing psychological services) barriers (Daley et al. 2020; Tiel-man et al. 2017).”
Quantum-Powered Industry 6.0 Innovations for Enhanced Catastrophe Management
Das, S., Chowdhury, A., & Sil, R. (2024) · Advances in Science, Technology & Innovation/Advances in science, technology & innovation · doi:10.1007/978-3-031-73350-5_5 · Cited by 4
Why Would University Students Use ChatGPT for Health Discourses? A Moderated Mediation Analysis
Vu, C. B., & Park, D. Y. (2025) · Journal of Consumer Health on the Internet · doi:10.1080/15398285.2025.2491042 · Cited by 4
“They have proven to be a scalable substitute for mental health support, such as alleviating symptoms of stress, anxiety, and depression by providing appropriate responses based on users’ input (Daley et al. 2020; Park and Kim 2023; Raile 2024).”
Inclusive AI-Driven Music Chatbots for Older Adults
Aziz, F., Law, E. L., Li, L., & Chen, S. (2025) · Lecture notes in computer science · doi:10.1007/978-3-031-91760-8_6 · Cited by 3
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“These expected results will contribute to the growing literature that supports CA use in improving health-and wellness-related outcome (Daley, 2020; Fitzpatrick et al., 2017; Gardiner et al., 2017; Hudlicka, 2013).”
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“…for digital health interventions (Baumel et al., 2019; Birnbaum et al., 2015; Meyerowitz-Katz et al., 2020; Pratap et al., 2020; Torous et al., 2020; Yeager & Benight, 2018) and engagement has been positively associated with improved mental health (Daley et al., 2020; Inkster et al., 2018).”
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MacNeill, A. L., MacNeill, L., Yi, S., Goudreau, A., Luke, A., & Doucet, S. A. (2024) · JBI Evidence Synthesis · doi:10.11124/jbies-23-00029 · Cited by 2
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“[6, 7, 9, 22, 23] According to therapists, chatbots have the potential to enhance patient engagement in therapy goals and assist in completing assigned tasks, leading to faster progress.”
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Metadata
- Authors
- Daley, K., Hungerbuehler, I., Cavanagh, K., Claro, H. G., Swinton, P. A., & Kapps, M.
- Affiliations
- University of Sussex (GB)
- Universidade de São Paulo (BR)
- Robert Gordon University (GB)
- Corresponding author
- Daley, Kate
- ORCID
- Venue
- Frontiers in Digital Health
- Publisher
- Frontiers Media SA
- Published
- 2020-11-30
- Volume
- 2
- Pages
- 576361-576361
- ISSN
- 2673-253X (ISSN-L)
- PMC
- PMC8521874
- OpenAlex
- W3110570584
- Cited by
- 101
- References
- 35
- Citations by year
- 2026: 15 · 2025: 29 · 2024: 26 · 2023: 24 · 2022: 5 · 2021: 2
- FWCI
- 6.99
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Digital Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Sussex Research Online (University of Sussex) (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Open Access Institutional Repository at Robert Gordon University (Robert Gordon University) (submittedVersion, cc-by)
- OSF Preprints (OSF Preprints) (submittedVersion)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Psychology › Social Psychology › Social Robot Interaction and HRI
- Keywords
- mental health chatbots, user engagement, anxiety, depression, stress, digital mental health interventions, low- and middle-income countries, Brazil
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