Increasing Engagement in Smartphone Apps for Mental Health

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As you read this, think about all the apps you have on your phone. Some you use daily, if not several times a day, and others you may have downloaded with good intentions but opened once and never again. Why is that? An app has to be compelling, meet a need, and bring value to you; however, you define it for it to be used repeatedly. In the digital health space, engagement matters when you support someone’s health, whether to prevent, monitor, or manage a disease.

App companies spend a lot of time designing products that are compelling and user-friendly. Once these apps hit the app store, they enter the real world, and the monthly recurring user base will dictate whether a company with grow or fold. When we focus on digital health tools and digital therapeutics, the best app in the world is of no use if users don’t use it! Engagement is key. 

Think about the value of having blood pressure medicine that sits in the pill bottle- it won’t have the desired intent if it is not opened and taken daily. Digital health is not dissimilar. In medicine, we think about dose-response, take pill X daily, and a reliable change in a health metric can occur for most people as the effects have been studied in multi-phase trials known as randomized-controlled trials – the gold standard in clinical evidence.

I have started to think about the concept of “use-response”, and in my experience, many types of use patterns can deliver benefits where digital health is concerned. The published literature shows that by day 15, 95% of users stop using apps to support mental health- how might we build tools that deliver value to the user and keep them engaged for a more extended period.

A new paper by Ashley Wu and colleagues from Weill Cornell Medicine in New York, published in Nature Digital Medicine, addresses engagement in apps for depression and anxiety via a systematic review. Persuasive design is a framework that details what design features an app can develop to increase user engagement. When designed well, these features can support the app’s central purpose, like reducing symptoms of anxiety and leveraging social relationships to ensure users can be accountable within the app journey. The origins of persuasive design lie in human-computer interaction and have rapidly evolved as smartphone technology has gained prominence. 

The authors outline the systematic review they conducted, which consisted of twenty-five studies totaling 4159 participants. The focus was looking for engagement elements that increased app use, which was then coded within the persuasive design system. Findings suggest that effective apps at improving symptoms and anxiety and depression leveraged persuasive design elements and had more impactful outcomes. 

Some examples of these engagement elements include the concept of “reduction” – or breaking down a complex behavior into simple tasks that a user can complete and gain a sense of accomplishment over the tasks over time. This task completion increases the likelihood they will continue their journey. The authors speak to apps that address social anxiety as including a daily diary to record their daily mood, which takes on the complex task of reducing anxiety by breaking it into elements for success, such as mood tracking. Another aspect, “tunneling,” speaks to an app for depression that would deliver content in sequential lessons that can only be accessed once a previous task has been completed. This step-by-step delivery of content allows for nudges and persuasion to be applied along the way to keep a user on their journey. 

If you are currently designing an app, I encourage you to get this paper and the supplemental materials that codify the persuasive design system’s engagement elements. This paper is an essential addition to our understanding as we know well-designed apps can reduce the burden of depression and anxiety, and they are scalable. The more effective products that we have, and that we can provide access to more people in need, the more support people can get in their moment of need. Keeping people on their journey back to full health is the promise of digital health that these tools can move us toward if optimally designed and deployed.

Thanks for reading – Trina

(Opinions are my own)


Wu, A., Scult, M.A., Barnes, E.D. et al. Smartphone apps for depression and anxiety: a systematic review and meta-analysis of techniques to increase engagement. npj Digit. Med. 4, 20 (2021).

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