Currently, 14% of adolescents meet criteria for depression and 32% for an anxiety disorder, but few receive treatment (Merikangas et al., 2011). We propose to develop a mobile application (app) based on Acceptance and Commitment Therapy (ACT) that targets depression and anxiety in adolescents. By combining ACT, an evidence-based treatment shown to be effective in decreasing depression and anxiety symptoms, with innovative gaming activities, we will provide a free, readily accessible intervention to help prevent the onset of symptoms as well as reduce existing symptoms among adolescents. We will engage in a design-based research process to facilitate integration between ACT content and the app’s necessary game mechanics, intended to aid adolescents’ transformative experiences (Foster & Mishra, 2009; Barab & Squire, 2004).
Most adolescents with depression and/or anxiety disorders do not receive therapy, and of those who do, about 50% drop out within a month, leaving millions of American youth to suffer without treatment (Harpaz-Rotem et al., 2004; Merikangas, 2011). Mental health apps provide an opportunity for increasing access to treatment in a platform that is appealing to young people (Harrison & Goozee, 2014; Kenny et al., 2014). For adolescents unlikely to receive therapy due to barriers (e.g., stigma over therapy; lack of interest; poor insurance coverage; distance from a provider), clinically-informed apps can help them learn healthier coping and decision making skills, leading to decreases in depression and anxiety symptoms. Moreover, the availability of an engaging app that consolidates the learning of such skills can expedite treatment progress for adolescents who do attend therapy.
Acceptance and Commitment Therapy (ACT), a recently developed form of Cognitive Behavioral Therapy (CBT), may be more effective than traditional CBT in treating depression (Ruiz, 2012). ACT uses activities that are a good fit for app platforms, and has been shown by Swain et al. (2015) to be effective in treating anxiety among adolescents. We will create the first game-based app using ACT in treating adolescents’ depression and anxiety disorders. By reaching the 85% of U.S. youth who own a smartphone, this interactive ACT App will increase access to behavioral health knowledge and resources for those who are often less likely to receive mental health services. The app will be offered to adolescents who screen high for depression during visits to Drexel University affiliated clinics. Once validated, it can be made available to adolescents in underserved areas (e.g., with limited behavioral healthcare) throughout the world.
We propose to offer a free, readily downloadable game app that allows adolescents to learn and practice ACT-based skills (e.g., identification of core values, enactment of behaviors consistent with one’s core values, mindfulness, compassionate tolerance for one’s negative thoughts and emotions). Once our ACT App is created and made available to adolescents, there will be no additional costs for this treatment, potentially supporting consumers’ ability to find and receive other sources of clinical support. The ACT App will deliver a behavioral health intervention with the potential to reach thousands of adolescents at no cost. Additionally, hospitals, clinics, and therapists may also use the app in conjunction with therapy to reinforce their clinical preventions and interventions and their patients’ coping, learning, and decision making skills.
Our app will be the first to specifically target ACT towards adolescents, and also use a game-based platform to facilitate their engagement in learning ACT-based coping skills. Currently, the vast majority of mental health apps are not actually tested for their effectiveness in increasing adaptive behaviors or decreasing symptoms. In our development phase, we will assess and validate the app by collecting data to examine users’ changes in skill mastery and reductions in depressive and anxiety symptoms during game play. We will also advance research in ACT by indicating which of its six components are most often practiced by adolescents, and which are most strongly associated with decreases in adolescents’ depressive and anxiety symptoms.
ACT App involves leadership from Drexel University’s College of Medicine (Psychiatry and Pediatrics Departments), School of Education, Westphal College of Media Arts and Design, and College of Nursing and Health Professions. As an open source app, our platform will be readily available for individuals and organizations to download for free (e.g., through the App Store and Drexel website). Our app can facilitate the learning of ACT not only by adolescents, but also by therapists in clinical settings that are not currently employing such treatments for adolescent depression and anxiety disorders. As an open-source app, our platform could be modified to address other behavioral health areas such as substance abuse, eating disorders and anger management.
Minimal funds are required to sustain the ACT App. Financial support for student labor will be required to intermittently maintain and update the app’s technology after its development. One of our goals is to use the ACT App as a template for creating similar behavioral healthcare apps and building health informatics infrastructure at Drexel. While we are requesting funds for app design from the Scattergood Foundation, we will need to secure additional funding for app development and testing. We will seek support from multiple sources by applying to private and federal foundations and entering the ACT App in annual competitions at Drexel. Drexel’s Office of Institutional Advancement will continue to support the project, bringing together multi-disciplinary collaborators to further the University’s goal of providing leadership in the emerging field of health informatics.
A major advantage of the ACT App is its ability to be readily downloaded for free by other organizations, thus facilitating its use by clinicians who treat adolescents worldwide. While many interventions require clinicians at new organizations to receive extensive training in order for patients to acquire a satisfactory level of treatment adherence, the ACT App will provide skills training modules for adolescents in a uniform manner. In addition, the app’s open-source nature will make it easily adaptable (with some modifications) for different mental health problems and demographic populations such as older adults, while still being useable by organizations of varying size and scope such as hospitals and community mental health centers.
With Scattergood support, we will complete the design for an innovative app with all necessary architecture and content. We will then build the technological platform, which, when validated, will provide a basis for game developers to create similar apps and products. We will assess the design process to facilitate integration between the ACT content and the game mechanics. During the later development phase, for which we will use a rapid-prototyping approach to modify after testing, we will track several important outcomes: 1) percentage of adolescents who use the app following recommendation by a health care provider, 2) how often and for what length of time is it used, 3) to what extent adolescents master ACT skills taught within the context of the app, and 4) the extent to which depressive and anxiety symptoms decrease with use of the app, as measured by the Revised Children's Anxiety and Depression Scale.