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In addition to the obvious physical medical impact of COVID-19, the disease poses evident threats to people’s mental health, psychological safety, and well-being. Provision of support for these challenges is complicated by the high number of people requiring support and the need to maintain physical distancing. Text4Hope, a daily supportive SMS text messaging program, was launched in Canada to mitigate the negative mental health impacts of the pandemic among Canadians.
This paper describes the changes in the stress, anxiety, and depression levels of subscribers to the Text4Hope program after 6 weeks of exposure to daily supportive SMS text messages.
We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of Text4Hope subscribers. Perceived stress, anxiety, and depression were measured with the 10-Item Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder–7 (GAD-7) scale, and the Patient Health Questionnaire–9 (PHQ-9) scale at baseline and sixth week time points. Moderate or high perceived stress, likely generalized anxiety disorder, and likely major depressive disorder were assessed using cutoff scores of ≥14 for the PSS-10, ≥10 for the GAD-7, and ≥10 for the PHQ-9, respectively. At 6 weeks into the program, 766 participants had completed the questionnaires at both time points.
At the 6-week time point, there were statistically significant reductions in mean scores on the PSS-10 and GAD-7 scales but not on the PHQ-9 scale. Effect sizes were small overall. There were statistically significant reductions in the prevalence rates of moderate or high stress and likely generalized anxiety disorder but not likely major depressive disorder for the group that completed both the baseline and 6-week assessments. The largest reductions in mean scores and prevalence rates were for anxiety (18.7% and 13.5%, respectively).
Text4Hope is a convenient, cost-effective, and accessible means of implementing a population-level psychological intervention. This service demonstrated significant reductions in anxiety and stress levels during the COVID-19 pandemic and could be used as a population-level mental health intervention during natural disasters and other emergencies.
RR2-10.2196/19292
COVID-19, an acute respiratory disease, was first reported in December 2019 in Wuhan, China. Since the outbreak was declared a pandemic by the World Health Organization [
In multiple global jurisdictions, a series of mental health concerns have arisen, including increased stress, anxiety, depression, fear, insomnia, and obsessive-compulsive behaviors. Population-level studies have summarized these effects [
The emergence of mental health issues during the COVID-19 pandemic was not entirely unexpected. There have been reports of increases in stress symptoms, confusion, anger, anxiety, and depression [
Although research has provided a description of the psychological impact of COVID-19 [
The COVID-19 pandemic has further reinforced the need and urgency of transforming the delivery of mental health services [
Previous research examining the effectiveness of supportive text messages has demonstrated positive outcomes, including reduction of depressive symptoms and high user satisfaction [
On March 23, 2020, Alberta Health Services, along with the coauthors of this paper, initiated Text4Hope, a 3-month-long, supportive daily text messaging program using principles of cognitive behavioral therapy (CBT), as an additional mental health support for people living in Alberta during the COVID-19 pandemic [
This paper evaluates the impact of Text4Hope on measures of stress, anxiety, and depression symptoms and provides estimates of prevalence rates 6 weeks into the program.
This cross-sectional comparative study sought to assess the effectiveness of community implementation of a supportive SMS text message intervention program focused on reducing symptoms of stress, anxiety, and depression during the COVID-19 pandemic. The study protocol [
In the Text4Hope program [
We were able to cross-reference clinical and demographic responses from individuals by asking clients to enter the mobile number they used for Text4Hope at the baseline and 6-week time points. No incentives were offered to respondents. Participation in the program was voluntary, and completing the survey was not required to receive the supportive SMS text messages. Subscribers could opt out at any time by texting “STOP” to the same sort code number used to enroll in the program. Baseline data collection occurred between March 23 and 30, 2020, and the sixth week follow-up data were collected between May 3 and 11, 2020.
Flowchart of subscriber participation from baseline to the sixth week.
Primary outcomes included the mean differences in scores on the PSS-10, GAD-7, and PHQ-9 scales at the sixth week versus baseline and the changes in the prevalence rates of self-reported moderate or high stress, likely generalized anxiety disorder (GAD), and likely major depressive disorder (MDD) at the sixth week from baseline.
In a sixth-week evaluation report, 77% of subscribers to the related Text4Mood program indicated that the daily supportive text messages helped them to manage their depression and anxiety [
With a projection that daily supportive text messages would result in a 25% reduction in mean PSS-10, GAD-7, and PHQ-9 scores at the sixth week from baseline, a population variance of 5.0 for each scale mean score, a one-sided significance level α=.05, and an acceptable difference between sample mean and population mean score for each scale of zero (μ – μ0 = 0), we estimated that a sample size of 686 would be sufficient to detect mean differences between the baseline and 6-week PSS-10, GAD-7, and PHQ-9 scores with a power of 80% (β=.2).
Data analysis was undertaken using SPSS for Windows version 26 (IBM Corporation) [
Of the 766 individuals who completed both the baseline and 6-week surveys, 73 (9.6%) identified as male, 678 (88.7%) identified as female, and 13 (1.7%) identified as other gender.
Demographic characteristics of respondents who completed both surveys by identified gender (N=766), n (%). Note that some category totals do not sum to N due to incomplete data.
Variable | Male | Female | Other | Total | |
|
|||||
|
≤25 | 5 (6.9) | 53 (7.9) | 5 (38.5) |
63 (8.3) |
|
26-40 |
17 (23.6) | 207 (30.8) | 6 (46.2) | 230 (30.3) |
|
41-60 | 33 (45.8) | 337 (50.1) | 1 (7.7) | 371 (48.9) |
|
60 | 17 (23.6) | 76 (11.3) | 1 (7.7) | 94 (12.4) |
|
|||||
|
White | 55 (75.3) | 590 (87.0) | 11 (84.6) | 656 (85.9) |
|
Indigenous | 1 (1.4) | 16 (2.4) | 0 (0) | 17 (2.2) |
|
Asian | 4 (5.5) | 18 (2.7) | 0 (0) | 22 (2.9) |
|
Other | 13 (17.8) | 54 (8.0) | 2 (15.4) | 69 (9.0) |
|
|||||
|
Less than high school diploma | 5 (6.8) | 14 (2.1) | 1 (7.7) | 20 (2.6) |
|
High school diploma | 7 (9.6) | 53 (7.8) | 1 (7.7) | 61 (8.0) |
|
Postsecondary education | 61 (83.6) | 606 (89.4) | 11 (84.6) | 678 (88.7) |
|
Other education | 0 (0) | 5 (0.7) | 0 (0) | 5 (0.7) |
|
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|
Employed | 52 (71.2) | 496 (73.2) | 7 (53.8) | 555 (72.6) |
|
Unemployed | 10 (13.7) | 79 (11.7) | 2 (15.4) | 91 (11.9) |
|
Retired | 9 (12.3) | 58 (8.6) | 1 (7.7) | 68 (8.9) |
|
Student | 2 (2.7) | 33 (4.9) | 3 (23.1) | 38 (5.0) |
|
Other | 0 (0) | 12 (1.8) | 0 (0) | 12 (1.6) |
|
|||||
|
Married, cohabiting, or partnered | 49 (67.1) | 452 (66.8) | 6 (46.2) | 507 (66.4) |
|
Separated or divorced | 6 (8.2) | 64 (9.5) | 1 (7.7) | 71 (9.3) |
|
Widowed | 2 (2.7) | 16 (2.4) | 0 (0) | 18 (2.4) |
|
Single | 15 (20.5) | 137 (20.2) | 6 (46.2) | 158 (20.7) |
|
Other | 1 (1.4) | 8 (1.2) | 0 (0) | 9 (1.2) |
|
|||||
|
Own a home | 49 (67.1) | 465 (69.0) |
7 (53.8) | 521 (68.6) |
|
Living with family | 7 (9.6) | 56 (8.3) | 3 (23.1) | 66 (8.7) |
|
Renting | 16 (21.9) | 147 (21.8) | 2 (15.4) | 165 (21.7) |
|
Other | 1 (1.4) | 6 (0.9) | 1 (7.7) | 8 (1.1) |
There was a reduction in the mean score on the GAD-7 scale of 19.0% at the sixth week compared to the baseline scores. The reduction in the PSS-10 scores at six weeks compared to the baseline scores, although statistically significant, was much smaller (4.1%). There was no statistically significant within-subjects difference between the baseline and sixth week PHQ-9 mean scores (
Comparison of the baseline and 6-week mean scores on the PSS-10, GAD-7, and PHQ-9 scales for subscribers who completed both the baseline and sixth week surveys (N=766).
Measure | Responses, na | Scores | Mean difference (95% CI) | Effect size (Cohen d) | ||||||||
Baseline score, mean (SD) | Six-week score, mean (SD) | Change from baseline, % | ||||||||||
PSS-10b | 684 | 20.35 (6.7) | 19.51 (7.0) | 4.1 | –0.83 (0.42 to 1.24) | <.001 | 3.99 | 0.2 | ||||
PHQ-9c | 630 | 8.94 (6.0) | 8.74 (5.8) |
2.2 | –0.20 (–0.17 to 0.57) | .28 | 1.08 | 0.2 | ||||
GAD-7d | 612 | 9.62 (5.6) | 7.82 (5.2) |
18.7 | –1.80 (1.44 to 2.16) | <.001 | 9.86 | 0.4 |
aNot all subscribers completed all three scales; therefore, n for each scale is less than the total N.
bPSS-10: 10-Item Perceived Stress Scale.
cPHQ-9: Patient Health Questionnaire-9.
dGAD-7: Generalized Anxiety Disorder–7.
To assess the generalizability of our data, based on the mental health burden in our baseline samples, we examined the clinical parameters between people who only responded to the baseline survey versus those who responded to both surveys (baseline and sixth week) (
Comparison of the baseline and 6-week prevalence of moderate or high stress, likely generalized anxiety disorder, and likely major depressive disorder.
Condition | Prevalence, n/total responses (%) | Change in prevalence rate (sixth week from baseline), % | χ2 (df) | ||
|
Baseline | Sixth week |
|
|
|
Moderate or high stressa | 642/748 (85.8) | 582/742 (80.4) | –5.4 | 7.78 (1) | .01 |
Likely major depressive disorderb | 288/723 (39.8) | 262/688 (38.1) | –1.7 | 0.46 (1) | .50 |
Likely generalized anxiety disorderc | 326/712 (45.8) | 220/682 (32.3) | –13.5 | 26.76 (1) | <.001 |
aAssessed using a cutoff score of ≥14 on the 10-Item Perceived Stress Scale.
bAssessed using a cutoff score of ≥10 on the Patient Health Questionnaire-9.
cAssessed using a cutoff score of ≥10 on the Generalized Anxiety Disorder-7.
Comparison of the prevalence rates of moderate or high stress, likely generalized anxiety disorder, and likely major depressive disorder between subscribers who only completed the baseline survey and subscribers who completed both the baseline and 6-week surveys.
Condition | Prevalence rate at baseline, n/total responses (%) | χ2 (df) | ||
|
Subscribers who completed the baseline assessment but not the 6-week assessment | Subscribers who completed both the baseline and 6-week assessments |
|
|
Moderate or high stress | 4065/4798 (84.7) | 642/748 (85.8) | 0.62 (1) | .43 |
Likely major depressive disorder | 1848/4447 (41.6) | 288/723 (39.8) | 0.76 (1) | .38 |
Likely generalized anxiety disorder | 2040/4364 (46.7) | 326/712 (45.8) | 0.23 (1) | .63 |
Comparison of the mean scores on the PSS-10, GAD-7, and PHQ-9 scales between subscribers who only completed the baseline survey and subscribers who completed both the baseline and 6-week surveys.
Scale | Score at baseline, mean (SD) | Independent |
||
|
Subscribers who completed the baseline assessment but not the 6-week assessment | Subscribers who completed both the baseline and 6-week assessments |
|
|
PSS-10a | 20.55 (6.77) | 20.30 (6.71) | 0.96 | .34 |
PHQ-9b | 9.03 (6.22) | 8.94 (6.0) | 0.35 | .73 |
GAD-7c | 9.64 (5.93) | 9.56 (5.65) | 0.37 | .72 |
aPSS-10: 10-Item Perceived Stress Scale.
bPHQ-9: Patient Health Questionnaire-9.
cGAD-7: Generalized Anxiety Disorder–7.
Similarly, we examined the clinical parameters between subscribers who responded to the 6-week survey only and subscribers who responded to both surveys (
Comparison of the prevalence rates of moderate or high stress, likely generalized anxiety disorder, and likely major depressive disorder between subscribers who completed both the baseline and 6-week surveys and subscribers who only completed the 6-week survey.
Condition | Prevalence rate at sixth week, n/total responses (%) | χ2 (df) | ||
|
Subscribers who completed the 6-week assessment but not the baseline assessment | Subscribers who completed both the baseline and 6-week assessments |
|
|
Moderate or high stress | 1217/1518 (80.2) | 582/724 (80.4) | 0.01 (1) | .91 |
Likely major depressive disorder |
483/1378 (35.1) | 262/688 (38.1) | 1.83 (1) | .18 |
Likely generalized anxiety disorder | 430/1361 (31.6) | 220/682 (32.3) | 0.09 (1) | .76 |
Comparison of the mean scores on the PSS-10, GAD-7, and PHQ-9 between subscribers who completed both the baseline and 6-week surveys and subscribers who only completed the 6-week survey.
Scale | Score at sixth week, mean (SD) | Independent |
||
|
Subscribers who completed the sixth-week assessments but not the baseline assessments | Subscribers who completed both the baseline and sixth week assessments |
|
|
PSS-14a | 19.36 (7.12) | 19.44 (7.05) | –0.25 | .80 |
PHQ-9b | 8.20 (5.79) | 8.69 (5.75) | –1.79 | .07 |
GAD-7c | 7.55 (5.40) | 7.71 (5.21) | –0.66 | .51 |
aPSS-10: 10-Item Perceived Stress Scale.
bPHQ-9: Patient Health Questionnaire-9.
cGAD-7: Generalized Anxiety Disorder–7.
The Text4Hope program was provided as an intervention tool for the general population to support the mental well-being of individuals living in the Canadian province of Alberta during the global COVID-19 pandemic. Other technology-based interfaces have been deployed during the COVID-19 pandemic to track the disease spread in populations [
The self-reported rates of anxiety symptoms in our study at baseline were higher than those reported in other studies [
Our findings indicate that there was a modest effect of the program on improving stress symptoms, with greater benefit than other internet-based cognitive behavioral theory (iCBT) platforms [
There was no significant change between baseline and 6-week mean scores for likely MDD. Comparing our results with other remotely delivered health services yielded variable results. Two meta-analyses found that the effectiveness of iCBT programs, including MoodGYM, in mitigating depressive symptoms showed small effect sizes, especially in short-term assessments [
Three months after the launch of the Text4Hope program, the dropout rate was 13.5%. A high withdrawal rate is not uncommon for a texting service provided via SMS. When Bendsten and Bendsten [
Our study has several limitations. For ethical reasons, we lacked a comparative control group that did not receive the Text4Hope intervention during the same phase of the pandemic against which the recorded changes in stress, anxiety, and depression levels could be compared. It is therefore possible that the reductions in stress, anxiety, and depression levels are not all attributable to the Text4Hope intervention. Second, we relied on self-rated scales to assess stress, anxiety, and depression symptomatology, which could potentially overestimate the levels of these mental disorders when compared with prevalence rates that would have been obtained using structured clinical interviews with the
Finally, the effect sizes in our study were relatively small, which may minimize the strength of the produced results. However, interventions that do not include therapists often report low effect sizes compared to those including therapists [
The Text4Hope program resulted in statistically significant reductions in mean scores on the PSS-10 and GAD-7 scales but not the PHQ-9 scale at the sixth week from baseline. The program also resulted in statistically significant reductions in subscribers’ prevalence rates of moderate or high stress and likely GAD but not of likely MDD. The largest reductions in the mean scores and prevalence rates were observed for anxiety symptoms. It should be noted this paper reports data from the midpoint of the Text4Hope program implementation, and the rates of change for outcomes for stress, anxiety, and depression may differ after the program ends at 3 months.
The relatively large improvements in anxiety symptoms achieved in our sample after 6 weeks of receiving the intervention during the COVID-19 pandemic suggest that the Text4Hope program is a useful intervention that can be deployed during natural and humanitarian disasters to support individuals at the population level. Over half of Canadians have reported that their mental health needs are not fully met [
Beck Depression Inventory
cognitive behavioral therapy
generalized anxiety disorder
Generalized Anxiety Disorder–7
internet-based cognitive behavioral therapy
major depressive disorder
Patient Health Questionnaire–9
10-Item Perceived Stress Scale
Support for the project was received from Alberta Health Services and the University of Alberta. This study was supported by grants from the Mental Health Foundation, the Edmonton and Calgary Community Foundations, the Edmonton Civic Employees Foundation, the Calgary Health Trust, the University Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation, and the Alberta Cancer Foundation. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
VIOA conceived and designed the study, including the Text4Hope program. MH and RS drafted the initial manuscript with VIOA. AG, WV, and SS participated in data collection. All authors contributed to the study design and revised and approved the final draft of the manuscript.
None declared.