Over the past decade, there’s been a notable uptick in common mental health disorders among young people around the world, as they face a world with mounting challenges — political conflicts, climate change, disasters, widespread uncertainty, and the pervasive impact of the COVID-19 pandemic.
Due to a shortage of trained professionals and the stigma associated with admitting one has a mental disorder, traditional face-to-face treatment alone is unable to meet the increasing needs of mental healthcare. Many governments and organizations are turning to digital mental health interventions, which are scalable treatment options delivered through online platforms and mobile devices.
A recent study led by NYU Shanghai Professor of Global Public Health Brian J. Hall, published in Translational Psychiatry, was the first randomized controlled trial in China to investigate the effectiveness and implementation of Step-by-Step (SbS), a digital intervention to address depression. Results showed that using SbS was effective in reducing depressive symptoms among Chinese university students in the short term and improving psychological well-being in the longer term, indicating a promising future for digital mental health interventions. The study was first-authored by former NYU Shanghai postdoc fellow Li Gen, in collaboration with researchers from the Center for Macau Studies and the Student Affairs Office of the University of Macau.
“Roughly one in four Chinese young adults will experience a common mental disorder like depression, and the stress and pressures of academics and emerging into the workforce can be a significant burden,” Hall explained. Oftentimes, he added, inadequate mental health literacy, cultural stigma around seeking mental health treatment, and lack of robust treatment options hinder young people from receiving proper care. “In this technological era, with nearly everyone using technology on a daily basis, especially in China, our team wanted to harness these trends and deliver intervention within an ecosystem and a methodology that people would more easily accept,” he said.
Step-by-Step is a digital mental health treatment app developed by the World Health Organization. It uses an illustrated story of a person who has learned ways to deal with their stress, anxiety, and depression to teach users behavioral activation and stress management strategies. Program users also receive 15-20 minutes of guidance per week over the phone or through chat messaging with an online peer supporter, who is a trained and supervised non-specialist.
Hall and fellow researchers engaged in focus groups of mental health care providers and young people to inform the creation of intervention content by illustrators, writers, and software developers. The result is a cultural adaptation of the digital mental health intervention Step-by-Step for Chinese young adults.
Before the launch of the trial, Hall’s team spent several months working with focus groups to adapt Step-by-Step’s content for a Chinese context — story, visuals, and language. A feasibility trial was then conducted to gather feedback and ensure seamless implementation of the following large-scale definitive trial. The formal trial was conducted over a one-year time frame with a total of 371 participants enrolled. The whole intervention took eight weeks to complete with weekly checkups on effectiveness. Post-treatment measurement and follow-ups were conducted at eight weeks and three months, respectively, after the intervention sessions.
According to the team’s findings, participants rated the intervention’s effectiveness as a stress reduction tool a seven on a scale of one to ten. Most participants found Step-by-Step to have more content and better structure than they expected before downloading the app. Over half of the participants reported learning new knowledge and skills for mood regulation, making plans, and overcoming negative moods. The results support Step-by-Step as an evidence-based mental health intervention with the potential to be adopted by universities and potentially other treatment settings to improve the mental well-being of young adults in China.
“Though there are a ton of apps for mental health improvement, very few of them have clinical trial results to back up their effectiveness,” said Hall. “Through rigorous science, our study showed evidence that Step-by-Step was a robust intervention tool for improving depression among Chinese young adults.” He said the team hopes the study can better serve the public by enriching the available mental health solutions.
While digital interventions aren’t really replacing traditional therapy methods, Hall hopes that the study can help popularize the use of these digital mental health tools. “With scientific evidence to support its effectiveness, we hope that society would embrace digital interventions as a supplement and front line treatment for depression. Now that Step-by-Step is considered evidence-based intervention, WHO will roll out this intervention to all UN member States. This program can be easily adapted and implemented among different populations around the world,” he said. He added that NYU Shanghai’s Center for Global Health Equity plans to carry out a larger scale implementation of Step-by-Step and other digital interventions in more Chinese universities and with broader populations. “We want to further explore the potential of digital interventions in order to inform better policy and public health framework,” he said.