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Young adults experience the highest rates of depression yet face persistent barriers to accessing mental health care, resulting in unmet treatment need. Digitally delivered interventions offer a scalable solution with high potential reach. However, engagement with digital mental health interventions remains a challenge, due in part to limited incorporation of end-user input during development. From an implementation science perspective, poor uptake and engagement are critical barriers to effectiveness. User-centered design (UCD)—the systematic integration of end-user feedback into intervention development—can be conceptualized as an implementation strategy to improve acceptability, appropriateness, and engagement, key determinants of reach and effectiveness. This study examines whether iteratively incorporating end-user feedback into a text message–delivered cognitive behavioral therapy intervention (CBT-txt) improves implementation-relevant outcomes among young adults with depression.
Methods
Data were drawn from two pilot randomized controlled trials evaluating CBT-txt among 205 young adults (ages 18–25) with moderate depressive symptoms recruited nationwide via social media. In Trial 1, participants received a 4-week fully automated CBT intervention delivered via text messaging. Following Trial 1, quantitative indicators of acceptability (treatment satisfaction) and qualitative feedback (perceived appropriateness, usability, and engagement barriers) were analyzed alongside an updated literature review to inform iterative adaptation. Adaptations included extending the intervention to 8 weeks, increasing content depth, enhancing opportunities for skill practice, and improving personalization and delivery flexibility. Trial 2 evaluated the adapted intervention using a similar randomized design. Participants in both trials completed standardized satisfaction measures and provided open-ended feedback. Qualitative thematic analysis identified implementation-relevant themes, and comparative descriptive and chi-square analyses examined differences in feedback across trials.
Results
The direct treatment effect improved over the first trial (Cohen d=−0.63 to Cohen d=−0.76), and significant treatment effects were found at 3 months after enrollment compared with 1 month after enrollment in the initial 4-week trial. Across both trials, participants reported high levels of acceptability, reflected in strong ratings of perceived helpfulness and skills use. In Trial 1, qualitative findings identified key barriers to engagement and appropriateness, including limited personalization, insufficient interactivity and accountability, impersonal language, and constraints in scheduling flexibility. Following UCD-informed adaptations, participants in Trial 2 reported substantially fewer implementation barriers. Significant reductions were observed in feedback related to personalization, accountability features, language tone, and scheduling constraints, suggesting improved appropriateness and usability. Overall, fewer suggested improvements reflect enhanced alignment between the intervention and user needs.
Conclusions & Implications
Findings support UCD as an effective implementation strategy for improving acceptability, appropriateness, and engagement in digital mental health interventions. Although satisfaction remained high across trials, the reduction in identified barriers following iterative adaptation suggests improved implementation quality. These findings have implications for scalability and public health impact, as optimizing engagement is essential for maximizing reach and effectiveness. Text message–delivered CBT represents a low-burden, scalable modality well-suited to young adults when refined through user-informed processes. Future work should link UCD-driven adaptations to implementation outcomes (e.g., reach, adoption, sustained engagement) and examine downstream effects on clinical outcomes in larger and more diverse populations.