Digital therapy outperforms referrals to campus clinics among college students

UNIVERSITY PARK, Pa. — College students with anxiety, depression and eating disorders may be more likely to start and to respond more positively to therapy offered via a digital app compared to referrals to in-person campus clinics, according to a study led by Penn State researchers and published today (May 7) in the journal Nature Human Behaviour.

Globally, an estimated 40% to 60% of college students experience a mental health disorder at some point, and the need for campus counseling services has increased faster than institutions’ capacity to provide these services, according to the researchers. The research team wanted to see if a proactive intervention using a digital therapy app could effectively treat anxiety disorders, depression and eating disorders, as well as address the increased need for psychological services. The commercially available app incorporates cognitive behavioral therapy (CBT) principles that coach individuals through identifying negative thinking patterns and developing skills and behavioral changes to address these patterns.

The researchers found that students receiving the digital intervention were more likely to report being symptom free at the six-week, six-month and two-year marks, and that these students were more likely to engage these services compared to the campus referral group. Specifically, services uptake — or when a person actually receives a service — was seven times greater for college students assigned to a digital intervention than to on-campus clinic referrals. Approximately 74% of individuals given access to the digital intervention started the program, compared to 30% of individuals who were given a referral to a campus clinic and received at least one therapy session or a new medication prescription.

“One of the challenges with any digital intervention is that people sometimes download an app but then do not use it,” said lead author Michelle Newman, professor of psychology and psychiatry at Penn State. “We were also interested in learning the extent to which people actually received services after being randomized to the app or on-campus counseling center. We found that uptake was significantly better in the digital intervention than referral to the counseling center.”

To test the effectiveness of the digital intervention, the researchers worked with 26 colleges and universities across the U.S. to send an email to the entire student body — what researchers call a population-level approach — inviting them to take part in a mental health screening. Of the 39,194 individuals who completed the screening, 6,205 had clinical levels of or were at high risk for developing generalized anxiety disorder, panic disorder, social anxiety disorder, depression or an eating disorder. Those individuals completed an additional baseline survey and were randomized into one of two groups. One group received access to the coached digital intervention for six months, while the other group received referrals to their campus counseling center.

The therapy app offered six to eight 20-minute-long modules for each mental health problem. Participants in the digital therapy group completed an average of 2.4 modules and received about 15 messages from a trained therapy coach. Newman explained that individuals in the digital therapy group began with modules addressing their main mental health concern and then worked with their coaches to receive additional modules that addressed co-occurring issues.

“A unique aspect of the work was that we screened for five disorders — generalized anxiety disorder, social anxiety disorder, panic disorder, depression and eating disorders — and measured all disorders at every point in the treatment, because we know that disorders like depression and anxiety often co-occur, but that co-occurrence doesn’t necessarily happen simultaneously,” Newman said. “The digital intervention overall had a significantly larger number of individuals who had no disorders at every timepoint in the study. We did not just treat individuals with clinical levels of these disorders, but we also prevented the onset in more of those in the digital intervention who screened to be at risk.”

For example, compared to the campus referral group, those who used the digital intervention had a 4.3% lower prevalence of having any mental health disorder at the six-week mark, 4.9% lower prevalence at the six-month mark and 3.8% lower prevalence at the two-year follow-up. This result showed that the coached digital intervention both prevented the development of new disorders as well as treated disorders that were present before the intervention.

The researchers conducted the study during the height of the COVID-19 pandemic, recruiting participants from October 2019 to November 2021 and completing their data collection by October 2023. The results, they said, highlight the effectiveness of digital interventions at times when access to traditional, in-person services may have been constrained.

The population-level screening and digital therapy approach can complement existing in-person services beyond college campuses, Newman said.

“This approach could potentially be used anywhere where you have access to a full population in terms of email addresses, like at a company, to help disseminate mental health services that people might not think about seeking,” she said, explaining that the proactive screening process taken in the study helped individuals prevent disorders for which they were at high risk of developing and treated disorders for which they may not have sought face-to-face services.

Next steps will make use of work led by Penn State graduate student Adam Calderon and Newman, who will use data from the current study and previous work by Newman’s lab to examine which individual characteristics may predict who would benefit from digital interventions, Newman said.

The National Institute of Mental Health supported this work. In addition to Newman, other study co-authors include Penn State doctoral candidates Seung Yeon Baik and Adam Calderon; Ellen Fitzsimmons-Craft, Washington University in St. Louis and Washington University School of Medicine, St. Louis; Nur Hani Zainal, National University of Singapore; Gavin Rackoff, Boston University; Marie-Laure Firebaugh, Washington University School of Medicine, St. Louis; Elsa Rojas-Ashe, Palo Alto University and Stanford University School of Medicine; Yan Leykin, Palo Alto University; Daphne Lew, Washington University in St. Louis; Daniel Eisenberg, University of California-Los Angeles; C. Barr Taylor, Palo Alto University and Stanford University School of Medicine; and Denise Wilfley, Washington University School of Medicine, St. Louis.