JMIR FORMATIVE RESEARCH

Adu et al

Original Paper

Comparing Email Versus Text Messaging as Delivery Platforms
for Supporting Patients With Major Depressive Disorder:
Noninferiority Randomized Controlled Trial
Medard K Adu1, BEd, MSc; Oghenekome Eboreime2, MD; Reham Shalaby3, MD, PhD; Ejemai Eboreime1, PhD;
Belinda Agyapong3, BSc, MEd; Raquel da Luz Dias1, PhD; Adegboyega O Sapara3, PhD; Vincent I O Agyapong1,3,
Prof Dr, PhD
1

Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada

2

Reproductive Care Program, Healthy Population & Provincial Initiatives, IWK, Halifax, NS, Canada

3

Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

Corresponding Author:
Vincent I O Agyapong, Prof Dr, PhD
Department of Psychiatry
Faculty of Medicine
Dalhousie University
5909 Veterans Memorial Lane, 8th Floor
Abbie J Lane Memorial Building, QEII Health Sciences Centre
Halifax, NS, B3H 2E2
CanadaPhone: 1 17802157771
Fax: 1 9024734887
Email: vn602367@dal.ca

Abstract
Background: The prevalence of major depressive disorder (MDD) poses significant global health challenges, with available
treatments often insufficient in achieving remission for many patients. Digital health technologies, such as SMS text
messaging–based cognitive behavioral therapy, offer accessible alternatives but may not reach all individuals. Email communication
presents a secure avenue for health communication, yet its effectiveness compared to SMS text messaging in providing mental
health support for patients with MDD remains uncertain.
Objective: This study aims to compare the efficacy of email versus SMS text messaging as delivery platforms for supporting
patients with MDD, addressing a critical gap in understanding optimal digital interventions for mental health care.
Methods: A randomized noninferiority pilot trial was conducted, comparing outcomes for patients receiving 6-week daily
supportive messages via email with those receiving messages via SMS text message. This duration corresponds to a minimumof 180 days of message delivery. The supportive messages maintained consistent length and structure across both delivery methods.
Participants (N=66) were recruited from the Access 24/7 clinic in Edmonton, Alberta, among those who were diagnosed with
MDD. The outcomes were measured at baseline and 6 months after enrollment using the Patient Health Questionnaire-9 (PHQ-9),
Generalized Anxiety Disorder-7 (GAD-7), and the World Health Organization Well-Being Index (WHO-5).
Results: Most of the participants were females (n=43, 65%), aged between 26 and 40 years (n=34, 55%), had high school
education (n=35, 58%), employed (n=33, 50%), and single (n=24, 36%). Again, most participants had had no history of any major
physical illness (n=56, 85%) and (n=61, 92%) responded “No” to having a history of admission for treatment of mood disorders.
There was no statistically significant difference in the mean changes in PHQ-9, GAD-7, and WHO-5 scores between the email
and SMS text messaging groups (mean difference, 95% CI: –1.90, 95% CI –6.53 to 2.74; 5.78, 95% CI –1.94 to 13.50; and 11.85,
95% CI –3.81 to 27.51), respectively. Both supportive modalities showed potential in reducing depressive symptoms and improving
quality of life.
Conclusions: The study’s findings suggest that both email and SMS text messaging interventions have equivalent effectivenessin reducing depression symptoms among individuals with MDD. As digital technology continues to evolve, harnessing the powerof multiple digital platforms for mental health interventions can significantly contribute to bridging the existing treatment gaps

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Adu et al

and improving the overall well-being of individuals with depressive conditions. Further research is needed with a larger sample
size to confirm and expand upon these findings.
Trial Registration: ClinicalTrials.gov NCT04638231; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552095/(JMIR Form Res 2024;8:e59003) doi: 10.2196/59003
KEYWORDS
major depressive disorder; Text4Support; SMS text messaging; email messaging; digital health; mental health; mobile phone;depressive disorder; health communication; global health; treatments; patient; text messaging-based; cognitive behavioral therapy;
communication; effectiveness; mental health support; digital intervention; digital interventions; mental health care; well-being;
depression symptoms

Introduction
Overview
Major depressive disorder (MDD) is one of the most prevailingmental health conditions, impacting over 300 million individuals
worldwide [1]. The lifetime prevalence of MDD is purged at
15% [2], presenting a significant socioeconomic burden and an
estimated annual cost of approximately US $236 billion in the
United States and €91 billion (equivalent to US $96 billion) in
Europe [3,4]. According to data, the lifetime prevalence of MDD
in Canada is at 9.9% [5], with an associated yearly economic
cost of around US $12 billion [6]. Data suggest that, despite therobust first-line treatment available for individuals diagnosed
with MDD, about 50% of these patients do not attain remission,
with two-thirds requiring additional treatment attempts before
achieving remission [7,8]. Therefore, MDD is a significant
contributor to the global burden of disease, and it is projectedby the World Health Organization to emerge as the leading
cause of global disability by 2030 [9].
Psychopharmacological and nonpharmacological agents, suchas psychosocial interventions, are some of the first-line treatment
strategies for the management of individuals diagnosed with
MDD. Nevertheless, access to these psychotherapies is restricted
due to limitations in human resource capacity, which leaves the
majority of individuals with MDD going untreated [10,11].
Geographical location further limits access as most of these
psychosocial treatment modalities are commonly found withincities and towns compared to rural areas [12,13]. Even within
the urban areas, these services are mostly available during
regular working daytime and business hours. Consequently,
caregivers frequently find themselves grappling with workloads
that are 2 or more times the recommended amount, significantly
reducing the availability of appointments [14,15]. The problem
is further compounded by prolonged patient wait times forcounseling services and the related stigma with seeking these
services.
Evidence in the literature underscores the effectiveness and cost
efficiency of emerging health service technologies such as thetele mental health with its potential to enhance improvement inaccess to mental health care and, thereby, aiding in the closureof the prevailing treatment gaps [16,17]. Some effective meansof providing health services include email messaging,smartphone apps, and SMS text messaging [17,18]. Careproviders must adopt these evolving trends in the digital spacefor care delivery, especially in mental health care.
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According to a data report in 2019, approximately 97% of the
global population lived in communities with access to mobile
cellular signals [19]. This presupposes the widespread
accessibility of mobile networks. The surge in mobile phone
usage has significantly created a high possibility for advancing
health promotion and care delivery leading to an exponential
growth in mobile health (mHealth) in recent years [20]. A global
survey conducted in 2015 on the usage of internet services
among Western countries highlighted Canada’s high internet
usage around 90%. The data also demonstrated that about 67%
of Canadians owned smartphones [21].
Though some evidence in the literature supports the clinicaland cost-effectiveness of internet-based mental health services[22], most health care givers have, until recently, been slow to
adopt
this
clinicaltreatment
approach[23,24].
Technology-powered cognitive behavioral therapy (CBT)interventions such as supportive SMS text messages arerecognized as an innovative, accessible, and cost-effective means
for the delivery of psychological care to individuals and thegeneral public with mental health concerns [25]. Data suggest
an estimated 99% of SMS text messages received are opened,
and about 90% of these messages are read within 3 minutes of
their reception [26], thus offering an essential, accessible meansof delivering quality, cost-effective psychological care with thepotential of closing the huge treatment gap that exists forpatients with depressive conditions [27].
Text4Support is an SMS text message–based form of CBT thatallows individuals diagnosed with MDD to receive daily
supportive SMS text messages that seek to correct or alter
negative thought patterns through positive reinforcement.
Text4Support is part of the ResilienceNHope [28] suite ofsupportive SMS text messages offered by the Global
Psychological eHealth Foundation [29]. The program provides
users with daily supportive SMS text messages created by ateam of CBT therapists and mental health experts incollaboration with mental health service users. Text4Support
is designed to improve the mood of individuals diagnosed with
MDD using positive reinforcement to correct distorted or
negative thought patterns.
The effectiveness of Text4Support is backed by data generated
from randomized control trials conducted in persons diagnosed
with major depressive illness and who received twice daily
supportive SMS text messages. The studies revealed that there
was a significant reduction in the participants’ depressive
symptoms [30,31]. After 3 months of daily supportive SMS text
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messages to participants, the initial study conducted in Ireland
recorded a mean difference of –7.9 (95% CI –13.06 to –2.76;
Cohen d=0.85) in Becks Depression Inventory (BDI)-II scores
between the intervention and the control group [30]. A
subsequent Irish study with a larger sample size recorded similarfindings. In the study conducted on a Canadian sample, after 3
months of exposure to daily supportive SMS text messages tothe participants, the results demonstrated a significant differencein the means of the intervention and control groups as recordedon the BDI scale 20.8 (SD 11.7) versus 24.9 (SD 11.5),
respectively, F1, 60=4.83; P=.03; ηp2=0.07, with thecorresponding effect size (Cohen d) of 0.67 [31].
While the popularity and patronage of supportive SMS text
messaging interventions are generally high, anecdotally, someindividuals were faced with challenges preventing them fromsubscribing to some of the supportive SMS text messaging
interventions, such as the Text4Mood [27] and Text4Hope [32]programs due to the lack of personal and active cell phones. As
part of the satisfaction survey conducted for the Text4Hopeintervention, about 64% of the participants registered apreference to receive health care support via email during crises[32].

Adu et al
telephone, or in-person meetings, email provides the opportunity
to send a specific question that can be answered later, potentially
hours or days after. Email communication, whether through anenterprise email platform such as Outlook (Microsoft
Corporation) or a patient portal, offers various uses and benefits[40]. Given the limited data regarding the use and effectivenessof email for health care interactions, this study seeks todetermine whether delivering supportive messages via email
can be as effective as SMS text messaging in providing mental
health support for patients diagnosed with MDD.

Study Aims and Objectives
This study aims to evaluate and compare the effectiveness of
SMS text messaging and email messaging strategies fordelivering CBT-based supportive messages to patients with
MDD. The specific objectives were to compare the meandifferences in the Patient Health Questionnaire-9 (PHQ-9) scale,the Generalized Anxiety Disorder-7 (GAD-7) scale, and theWorld Health Organization Well-Being Index (WHO-5) scoresfrom baseline to 6 months for the participants receiving daily
supportive email messages with those receiving daily supportive
SMS text messages.

Hypothesis

Email is widely used as a means of communication on a global
scale and has become integral to the daily lives of many
individuals, both personally and for professional concerns.
Despite its prevalence, its adoption within the health care sector
has been comparatively lower than in other industries. Emails,
widely used in web-based interventions, offer asynchronous,
low-cost support [33,34]. However, variations in their usage
make comparisons challenging, leading to mixed clinical results[35-37]. Automated emails require minimal monitoring, while
individually crafted ones demand more effort [34].

Given that the same supportive messages were delivered throughboth the email and SMS text messaging programs, our research
hypothesis was that the email messaging program would not be
inferior to the SMS text messaging program. That is, there would
be no significant differences in the mean change scores frombaseline to 6 weeks in participants based on the mode of deliveryof the messages.

As e-mental health apps gain prominence, emails have becomea secure avenue of health communication, especially in theinteractions between patients and their care providers [38]. The
unique attributes of email messages, for example, are theflexibility of the length of messages, fast message delivery, andasynchronous communication, which contribute to its
distinctiveness [39]. Furthermore, enhanced communication
via email allows patients to ask questions they may haveforgotten during previous encounters, while physicians canprovide detailed information and offer further assistance if
needed. Electronic correspondence enhances the perception ofprovider availability and enables real-time reporting of results,
reducing the time to inform patients. Additionally, transmitting
treatment instructions electronically can decrease patient visits,
mitigate disease transmission risks, improve patient flow, andreduce copays without sacrificing care quality in areas withprevalent communicable diseases such as COVID-19 [40].
Currently, there is limited understanding of how patients use
email for health care interactions, but such insights are crucial
for evaluating the effectiveness of proposed policies and theimpact of email communication. Key factors influencing the
adoption of email communication between patients and healthcare professionals include patient health status, disparities indigital access, and the potential effects on health care service
use. Compared to immediate interactions through video,

Study Design, Participants, and Settings

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Methods
This study is a randomized noninferiority pilot trial testing thecomparative effectiveness of SMS text message versus email
daily supportive SMS text messages for mitigating depression
symptoms in patients diagnosed with MDD. Participants wererecruited from the Alberta Health Services Addiction and Mental
Health Access 24/7 clinic located in Edmonton, Alberta, Canada,a zone-wide centralized intake clinic for addiction and mental
health. Patients with mental health concerns can self-present or
be referred by a primary care provider to the Access 24/7 clinic
for assessments and connection to other community mental
health clinics for follow-up or to other community supports asnecessary. Patients who had been assessed by a psychiatrist at
the Access 24/7 clinic and diagnosed with an MDD according
to the DSM-5 (Diagnostic and Statistical Manual for Mental
Disorders [Fifth Edition]) using a structured clinical interview
were offered an information leaflet about the study and, if
agreeable, were invited to participate in the study by signing a
consent form.

Inclusion Criteria
Participants were included if they were (1) aged 18 years andolder who could provide informed consent, (2) patients who
had been assessed using structured clinical interviews for DSM-5
and diagnosed with an MDD, (3) patients who had a cell phone
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with an active line and a functional email address could accessboth email messages and SMS text messages, and (4) patients
who provided informed consent.
Based on the clinical assessment conducted by the psychiatrists
at the Access 24/7 clinic, patients were ineligible if they had
active psychotic disorders or mental health conditions otherthan MDD or resided outside of regular cell phone and internet
connection areas. Also, patients were ineligible if they werepreviously or currently subscribed to a supportive SMS text
messaging program.

Sample Size Calculation
The effect sizes (Cohen d) achieved in 2 previous randomized
trials (n<80 for each trial), which compared daily supportive
SMS text messages plus treatment as usual for the managementof patients with MDD were 0.85 and 0.67, using a 2-sided
significance level (α) of .05, and a power of 80% (β=.2). Thus,in this pilot trial, we anticipate that a similar sample size of 80
patients with MDD, with 40 patients allocated into each study
arm, will be adequate to detect differences in outcome measures
between the 2 interventions.

Randomization
The study used a computer-generated block randomization toensure balance between the 2 intervention groups.
Randomization codes were provided via SMS text message
directly to the blinded researcher’s password-protected phoneline with a secure online backup. This occurred during
enrollment as each participant signed the consent form.
Participants were asked to use either the email address or phone
number with which they received messages as their study ID
on the follow-up online surveys.

Interventions
Commencing 1 day after enrollment, participants received daily
supportive messages, either through SMS text message or email.
However, the study did not specify the device upon which theemail group should receive the emails. The contents of bothtypes of messages were the same and were designed by mental
health professionals and mental health service users, based on
the principles of CBT, including addressing automatic thoughts,
cognitive distortions, and the underlying beliefs that perpetuate
depressive symptoms. The delivery time for each message wasset for 10 AM Mounty Time and participants received thesemessages for 6 months regardless of whether they were delivered
via SMS text message or email. This duration corresponds to aminimum of 180 days of message delivery. The supportive
messages maintained consistent length and structure across bothdelivery methods (SMS text message and email). A sample ofthe supportive messages include, (1) if you feel overwhelmedor unable to cope, reach out for help. Talk to your friends,
family, and mental health team. We all need help at some pointin our lives. We all need help at some point in ourlives!—Michael Holley; (2) we can change the way we feel bychanging the way we think and behave. The first step to change
is knowing yourself better. For a couple of days, journal yourthoughts, emotions, and behaviors; and (3) depression zaps ourenergy and our desire to do things. The problem is we stop doing
things that make us feel better, so we feel worse. Make an effort
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to do things that you enjoy, such as watching a movie withfamily or going for a walk.
While individual preferences for supportive messages may vary,these CBT-based supportive SMS text messages have beenpreviously successfully used in 2 randomized controlled trials
involving individuals with MDD and were selected to addresscommon challenges and encourage coping strategies relevant
to individuals experiencing depression or similar mental healthconcerns [31,32].

Data Collection
After the signing of the informed consent, participants wererandomized into 1 of the 2 groups (email message or SMS text
message) and asked to complete a baseline assessment
questionnaire encompassing both demographic and clinical data.
This was done in person. Further, at 6 months, an online survey
link along with an invitation to complete the assessment wassent to all participants either via email or SMS text messages.
Data were collected between January and July 2021. Also, there
was no compensation plan in any form included in our protocol.

Outcome Measures
To assess the effectiveness of the 2 interventions under study,
the mean scores of the outcome measures were compared on
specified scales at baseline and at 6 months for both study arms.
The depression symptom scores were generated from the 9-item
PHQ-9 scale [41]. This validated instrument with a Cronbach
α of 0.89 is mostly used for diagnosing and gauging the severityof depression in general medical and mental health care settings.
Each of the 9 questionnaire items is graded on a scale of 0 (notat all) to 3 (nearly every day). Higher scores on the scale indicate
an elevated level of depression. The PHQ-9 has demonstrated
good convergent validity with related constructs and possesses
adequate internal consistency [42].
For symptoms of anxiety, the GAD-7 scale [43] was used toevaluate the levels of anxiety at baseline and 6 months for eachparticipant in both study arms. The 7-item validated GAD-7
scale with a Cronbach α of 0.92 gauges self-reported anxiety
levels in respondents, with each item on the scale scoredbetween 0 (not at all) to 3 (nearly every day). Higher scores on
the scale signify elevated levels of anxiety. The quality of lifeof participants was evaluated using the WHO-5 [44]. This brief
5-item questionnaire assesses the subjective well-being of
respondents and has proven validity as an outcome measure inclinical trials and as a generic scale for tracking well-being overtime or between groups. The WHO-5 was good (Cronbach
α=0.858) [45,46]. The use of these 3 scales (PHQ-9, GAD-7,
and WHO-5) stems from their established validity, reliability,
and widespread use in clinical and research settings of the study
area.

Statistical Analyses
Data were analyzed using SPSS (version 26; IBM Corp) for
Windows [47] and were reported following the CONSORT(Consolidated Standards of Reporting Trials) guidelines(Multimedia Appendix 1) [48]. Descriptive data for baseline
parameters were presented using frequencies and percentages

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among the 2 intervention groups and compared by chi-square
for categorical variables.
To compare the effectiveness of the 2 interventions in the
management of depressive symptoms, a 1-way between-groups
analysis of covariance (ANCOVA) was used to compare thechanges in mean score from baseline to 6 months on all themeasuring scales used while controlling for baseline scores.
Before conducting the ANCOVA test, preliminary checks were
performed to ensure no violation of assumptions of normality,
linearity, homogeneity of variance, homogeneity of regression
slopes, or reliable measurement of the covariate. Theintervention group served as the independent variable, while
the dependent variable consisted of the 6-month score on thevarious measures (PHQ-9, GAD-7, and WHO-5), and thecovariates consisted of the baseline scores on the measures. The
significance criterion for statistical tests was set at a 2-tailed
α-level of P≤.05.

Ethical Considerations
All study participants were provided with an information leaflet
and offered the opportunity to ask questions about the study
before being asked to provide written informed consent toparticipate in the study. Data collection occurred online throughpatient self-completed rating scales. Participants were equippedwith resources for support in case of mental or psychologicaldistress. Specifically, we included contact details for the Alberta
Health Services emergency helpline, along with information
about the principal investigator, in the patient information
leaflet, the consent form, and as part of the introductory SMS
text message or email message to patients. The study received
institutional review board approval from the University ofAlberta Human Ethics Review Board (Pro00105429), and thetrial was registered at ClinicalTrials.gov (NCT04638231).

Results
The study realized a total of 66 participants who wererandomized into the 2 intervention groups. Thus, 37 participants
were enrolled in the email messages group, while 29 participants
were placed in the SMS text messages group. Figure 1 is thestudy flowchart.
Table 1 provides the baseline distribution of sociodemographic
and clinical characteristics of the 2 study groups. Most of theparticipants were females (n=43, 65%), aged between 26 and40 years (n=34, 55%), had high school education (n=35, 58%),
employed (n=33, 50%), single (n=24, 36%), and belonged tohttps://formative.jmir.org/2024/1/e59003

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the Caucasian ethnic group (n=49, 74%). Except for age (P=.01),
the chi-square analysis revealed no statistically significant
differences in baseline sociodemographic characteristics between
the 2 intervention groups (email messages and SMS text
messages; P>.05).
Regarding clinical variables, 56 (85%) had no history of any
major physical illness and 61 (92%) responded “No” to having
a history of admission for treatment of mood disorders. With
medication, respondents having a history of being on
antidepressants were 30 (46%), a history of mood stabilizers
was 1 (2%), a history of antipsychotics was 1 (2%), a history
of nocturnal sedation was 1 (2%), and history of tranquilizers
was 1 (2%). Like the sociodemographic variables, the chi-squareanalysis revealed no statistically significant differences inbaseline clinical characteristics between the 2 intervention
groups (email messages and SMS text messages) indicated by
the respective P values (P>.05).
As displayed in Table 2, a 1-way between-group ANCOVA
was performed to compare the effectiveness of the 2interventions (email and SMS text messages). After adjustingfor the baseline scores on the PHQ-9, there was no significant
difference in the means between the 2 intervention groups at 6
months. After imputation of baseline data for missing 6-monthdata, there remains no significant difference in the mean changes
in PHQ-9 scores from baseline to 6 months between the email
messages and SMS text messages groups (P>.05). Overall, only
2.1% of the variance in the dependent variable (6 months PHQ-9
scores) was explained by the independent variable.
On the GAD-7 scale after controlling for the baseline scores,
there were no significant differences between the 2 intervention
groups at 6 months. After data imputation, there was no
significant difference in the mean changes in GAD-7 scoresfrom baseline to 6 months between the email message and SMS
text message groups (P>.05). There was a relationship between
the baseline intervention score and the 6-month intervention
score on the GAD-7 scale, as evidenced by the partial η2 valueof 0.09. The intervention type explained only 2.6% of thevariance in the dependent variable (6-month mean GAD-7
scores).
For the World Health Organization (WHO), after adjusting forbaseline scores, there were no significant differences between
the groups at 6 months, as shown in Table 2. Furthermore, only
1.1% of the variance in the dependent variable (6 months mean
WHO-5 score) was explained by the independent variable.

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Figure 1. Study flowchart. GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; TRD: Treatment Resistant Depression;
WHO-5: World Health Organization Well-Being Index.

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Table 1. Distribution of baseline demographic and clinical characteristics between the 2 study groups.
Variable

Email, n (%)

SMS text message, n (%)

Total, n (%)

Sex
Male

16 (43)7 (24)

23 (35)

Female21 (57)22 (76)43 (65)Age (years)≤25

12 (36)1 (3)

13 (21)26-40

14 (42)20 (69)34 (55)≥41

7 (21)

8 (28)

15 (24)

Formal educational level
Elementary

1 (3)

2 (7)

3 (5)

High school

19 (58)16 (59)35 (58)

College or university

13 (39)9 (33)

22 (37)

Employment status
Employed

17 (46)16 (55)33 (50)

Unemployed

14 (38)11 (38)25 (38)Retired

1 (3)

2 (7)

3 (5)

Student

5 (14)

0 (0)

5 (8)

Marital status
Single15 (41)9 (31)

24 (36)

Partnered

9 (24)

3 (10)

12 (18)

Cohabiting

4 (11)

6 (21)

10 (15)

Married

3 (8)

6 (21)

9 (14)

Divorced or separated

6 (16)

5 (17)

11 (17)Ethnicity
Caucasian28 (76)21 (72)49 (74)

Indigenous

3 (8)

2 (7)

5 (8)

Asian

4 (11)

4 (14)

8 (12)

Black

1 (3)

1 (3)

2 (3)

Other

1 (3)

1 (3)

2 (3)

History of major physical illnessYes

5 (14)

5 (18)

10 (15)No

32 (87)24 (83)56 (85)

History of admission for treatment of mood disorders
Yes

2 (5)

3 (10)5 (8)No

35 (95)26 (90)61 (92)

History of antidepressantsYes

15 (41)15 (52)30 (46)No

22 (60)14 (48)36 (55)

History of mood stabilizers
Yes

1 (3)

0 (0)

1 (2)

No

36 (97)29 (100)65 (99)

History of antipsychotics
Yes
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1 (3)

0 (0)

Chi-square (df)

P value

2.6 (1).11

10.2 (2).010.7 (2).70

4.8 (3).19

5.1 (4).28

0.2 (4).99

0.2 (1).68

0.6 (1).45

0.8 (1).37

0.8 (1).37

0.8 (1).37

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VariableNo

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Email, n (%)

SMS text message, n (%)

Total, n (%)

36 (97)29 (100)65 (99)

History of nocturnal sedation
Yes

0 (0)

1 (3)

1 (2)

No

37 (100)

28 (97)65 (99)

History of tranquilizers
Yes

1 (3)

0 (0)

1 (2)

No

36 (97)29 (100)65 (99)Chi-square (df)

P value

1.3 (1).26

0.8 (1).37

Table 2. Descriptive mean scores of outcome measures and ANCOVAa test parameters for the email message and SMS text message groups.
MeasureaBaseline, mean (SD)

Discharge, mean (SD)

Mean difference (95% CI)

F test (df)

P value

Partial eta

Email

SMS text mes- Emailsage

SMS text message

PHQ-9b

19.65 (5.37)

19.76 (5.05)

12.05 (8.97)

15.47 (5.55)–1.90 (–6.53 to 2.74)

0.70 (1, 32) .41

0.02

GAD-7c14.70 (5.55)

15.66 (4.59)

18.75 (14.24)

15.33 (9.70)

5.78 (–1.94 to 13.50)

2.33 (1, 32) .14

0.07

WHO-5d15.24 (14.48)

15.85 (13.02)

31.80 (25.87)

19.71 (17.85)

11.85 (–3.81 to 27.51)

2.38 (1, 31) .13

0.07

ANCOVA: analysis of covariance.

b

PHQ-9: Patient Health Questionnaire-9.

c

GAD-7: Generalized Anxiety Disorder-7.

dWHO-5: World Health Organization Well-Being Index.

Discussion
Principal Findings
This noninferiority pilot trial involved 66 participants who wererandomized to receive either CBT-based daily supportive email
or SMS text messages for 6 months. Descriptive data indicatedno significant differences in sociodemographic and clinicalcharacteristics between the 2 groups under study. The analysis
followed an intention-to-treat approach and the result revealed
none of the 2 modalities was inferior to the other, as
demonstrated by the no significant differences in the meanscores of depression, anxiety levels, and well-being scales
between the 2 groups. The positive findings related to depression
and well-being symptom improvement, although not conclusive,
offer insights into the effectiveness of these innovative e-mental
health interventions in addressing depression symptoms andimproving well-being. Our result is consistent with a previous
study in which the Kokoro app (Apple Inc), a smartphone-based
CBT program, was found to show feasibility and acceptability
as an add-on therapy for treatment-resistant depression [49].
Furthermore, in a related systematic review, the findings
suggested that mobile phone–based technology could be used
to deliver psychotherapeutic interventions across a range ofmental health disorders. These positive findings may be because
mobile phone apps allow patients and health care providers to
track symptoms and early changes collaboratively; hence,
facilitating a need-based allocation of resources promptly [50].
Interestingly, anxiety symptoms did not improve with theintervention and worsened in the group that received themessages via email, although the change in mean anxiety
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symptom scores was not statistically different between the 2groups. The fact that patients recruited into this study have a
primary MDD diagnosis and the CBT-based messages were
designed to address anxiety symptoms may explain the lack ofpositive impact of the messages on anxiety symptoms incomparison to depression and well-being symptoms as seen in
results of the population level Text4Hope program, which
produced the highest reductions in anxiety symptoms [51-53].
The impact of the program messages on depression symptom
using both modalities align with previous studies, indicating asignificant reduction in depressive symptoms among participants[30,31].
The effectiveness of email as a communication tool can be
examined through the framework of media richness theory [54],which suggests that a medium’s ability to convey information
depends on whether it is used during periods of uncertainty thus,
when there is insufficient information or when there is confusion
or ambiguity. Email is positioned on the less rich end of thespectrum primarily due to its limited provision of immediate
feedback and multiple cues. However, email can effectively
address uncertainty by accommodating a large volume of
information [55]. The exploration of email as an alternative
delivery method for supportive messages for individuals withmental health concerns is timely. Emails offer uniqueadvantages, such as longer message lengths and asynchronous
communication. While emails have established themselves as
secure channels for health communication, their efficacy indelivering mental health interventions remains underexplored.
This study’s findings come in handy in helping to bridge thisknowledge gap, albeit with a smaller-than-anticipated sample
size. Though our study findings did not display any clear
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superiority of 1 modality over the other as demonstrated on allmeasures, both intervention groups (email and SMS text
messaging) demonstrated potential in reducing depressive
symptoms and enhancing the quality of life of the participants.
This lack of a significant difference between the interventions
suggests that both modalities could be viable options for mental
health care delivery, depending on individual preferences andcircumstances.
Delving into the clinical relevance of the findings is crucial forunderstanding their implications in real-world settings. While
the results may indicate no statistically significant differences
between interventions, it is essential to highlight the practicalsignificance for both patients and health care providers. For
patients, even subtle differences in platforms or interventions
could have meaningful implications for their experience andoutcomes. Factors such as ease of access, user interface, andthe overall patient-provider interaction can significantly impact
patient satisfaction, engagement with treatment, and ultimately,
treatment outcomes. Therefore, even if statistically noninferior,
identifying any trends or patterns in patient preferences orexperiences across different platforms can inform theoptimization of interventions to better meet patient needs andenhance overall care quality.
From the perspective of health care providers, understanding
the practical significance of differences between interventions
can inform decision-making regarding resource allocation,intervention implementation, and patient management strategies.
For example, identifying specific features or aspects ofinterventions that contribute to patient satisfaction or
engagement can guide the selection and customization ofinterventions to align with patient preferences and optimize
treatment delivery. Moreover, considering the broader context
of health care delivery, such as resource constraints,
technological infrastructure, and health care disparities, canfurther illuminate the practical implications of the findings. For
instance, interventions that are more accessible, cost-effective,
and scalable may hold greater relevance and potential for
widespread adoption, particularly in settings with limited
resources or underserved populations.
Therefore, while the absence of statistical differences between
interventions is noteworthy, evaluating their clinical relevanceprovides valuable insights into their potential impact on patientcare, treatment outcomes, and health care delivery practices.
By considering the practical significance of findings, we canbetter inform decision-making, enhance patient-centered care,and ultimately improve health outcomes in real-world settings.
By interpreting the study findings against the existing literature,
it is essential to acknowledge that this study used anoninferiority trial design. This design aimed to demonstratethat the new intervention (email messaging) is not worse
compared to the standard intervention (SMS text messaging)in delivering daily supportive messages for the management of
MDD. Therefore, the focus is on equivalence rather thansuperiority. Hence, it is imperative to consider the context ofcomparative efficacy when translating the findings.
The study findings aligned with those of a randomized
comparative investigation titled “Web- and Mobile App–Basedhttps://formative.jmir.org/2024/1/e59003

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Adu et al
Mental Health Promotion Intervention Comparing Email, Short
Message Service, and Videoconferencing Support for a Healthy
Cohort.” In this study, significant improvements were noted
within each group from pre- to postintervention across all
outcome measures (P≤.001). However, there were no significant
differences between groups for any outcome measure, including
mental health (P=.77), vitality (P=.65), depression (P=.93),
anxiety (P=.25), and stress (P=.57). This indicates that SMS
text messages did not yield significant advantages overautomated email support [56]. However, conversely, to ourfindings and in a related study on a mobile phone–based service
preferences among 75 patients, with 49.3% diagnosed withbipolar disorder and 50.7% with schizophrenia, the majority
preferred SMS text messages (n=14, 19%) over email (n=1,1%) as their service delivery medium [57]. Additionally, asystematic review and meta-analysis examining web-based
interventions using supplementary support methods indicatedthat SMS exhibited substantial effects (d=0.81) compared toemail (d=0.18) [58]. This preference may stem from the easeand convenience of SMS text messaging, especially during
symptom fluctuation or cognitive challenges associated withbipolar disorder and schizophrenia. The study findings
contribute to a deeper understanding of the transformative
potential of digital mental health care platforms in addressing
the global burden of MDD. Aligning the findings with standard
knowledge emphasizes the relevance and potential therapeutic
impact of incorporating technology in mental health caredelivery. The study’s recognition of the extensive accessibilityof mobile networks globally is consistent with literature
affirming the rapid rise in internet accessibility and mobile
phone usage [19-21]. The integration of mHealth in the deliveryof mental health interventions is consistent with the increasing
reliance on digital platforms for health care.
The finding that SMS text messages and emails may havecomparable effectiveness in mitigating depression symptoms
in patients with MDD could be attributed to several factors.
While both mediums offer a means of delivering supportive
content, they differ in their immediacy, format, and perceived
level of personalization. SMS text messages are often perceived
as more immediate and personal due to their shorter length anddirect delivery to individuals’ phones. On the other hand, emails
may offer a more formal and comprehensive platform forconveying information, potentially allowing for more detailed
messages and attachments. Additionally, individual preferences
and access to technology may play a role in how patients engage
with and respond to messages delivered via SMS text message
or email. Further research exploring these differences in message
delivery and their impact on patient outcomes could provide
valuable insights into optimizing digital interventions for mental
health support.

Study Implications
The study’s findings contribute to the growing body of literature
on digital mental health interventions. While both email and
SMS text messaging interventions demonstrated comparable
outcomes, the distinctive circumstances of participants lacking
active personal cell phones and telephone numbers highlightthe significance of considering alternative means of health careservice delivery. The study’s aim of exploring novel
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JMIR FORMATIVE RESEARCH
psychotherapeutic interventions that are cost-effective, scalable,
and accessible emphasizes the growing call in the literature forembracing digital solutions in mental health care practices.
Understanding subtle differences in interventions is crucial forboth patients and health care providers as it impacts patientsatisfaction, engagement, and treatment outcomes, informing
decision-making for resource allocation, intervention
implementation, and patient management strategies, especiallywhen considering broader health care contexts such asaccessibility and cost-effectiveness. With these patients who
were disadvantaged by having no cell phones could still bereached and supported via emails. Patients have the option tochoose between the 2 approaches, as they are equally effective.
Also, not all patients will have either a cell phone or a functional
and accessible email account, but most patients will have atleast 1 of these communication modalities which means the
supportive messages can reach more patients. Future studies
should build on these findings to refine and expand the scope
and use of digital interventions for the management of
individuals diagnosed with depressive conditions. The study
addresses a critical gap in the literature by exploring theeffectiveness of email messaging as a secure digital mode formental health communication. Thus, depending on an
individual’s preferences, needs, and technological access, mental
health service providers can offer a range of digital solutions,from email to app-based platforms, ensuring a more personalized
approach to care.

Limitations and Future Directions
The smaller-than-expected sample size may have impacted thestatistical power of our analyses. Therefore, the results of thestudy should be interpreted with caution, and a further study
with a larger sample size is needed to validate the findings.
Another important limitation is that the study used self-reported
instruments as opposed to a formal diagnostic interview toevaluate clinical variables. It is important to note that whilethese instruments are validated scales, they do not serve as
diagnostic tools. Furthermore, the study’s noninferiority design
assumes that both interventions (email and SMS text messaging)are equally effective as an augmentation treatment forindividuals with depression concerns, which may not accountAdu et alfor potential differences in user experience or engagement.
Again, the study did not specify the electronic devices used forreceiving the email messages and, hence, did not control thedevices. This intervention was designed as supplementary
support for individuals with MDD rather than a stand-alone
treatment. We did not assess the different types of therapies
patients were receiving. Thus, it is possible that the overall
improvement in mood symptoms reported in both groups is not
attributable to the supportive SMS text messages or email
messages. However, this research supplements previous
randomized controlled studies which involved controlled patient
populations [31,32] and other naturalistic controlled
population-level studies [59,60] which have established theeffectiveness of daily supportive SMS text message interventions
as an adjunctive therapy for treating MDD.
Future directions from the study include the need for larger
sample sizes to validate findings, particularly in confirming
email messaging’s effectiveness compared to SMS text
messaging for mental health intervention. Further exploration
into user experience and engagement differences between theseplatforms is needed, alongside implementing controls for device
use. Additionally, future research could explore the synergistic
effects of the daily supportive messages either via SMS text
message or email in combination with different therapeutic
approaches to optimize treatment outcomes for individuals with
MDD.

Conclusions
This randomized pilot trial provides preliminary insights into
the pot of email messaging as an alternative delivery mode forsupportive content to patients with MDD. The findings did notreveal evidence of the inferiority of email messaging comparedto the more established SMS text messaging approach over the
6-month study period. While email and SMS text message
groups demonstrated comparable outcomes on depression,anxiety, and well-being measures, the small sample size limits
definitive conclusions regarding their therapeutic equivalence.
These early-phase results lend cautious support to the premisethat widely accessible platforms such as emails could expand
options for delivering supportive mental health content.

Acknowledgments
This study was supported by a grant from the Alberta Mental Health Foundation. The funders had no role in the design andconduct of the study.

Data Availability
The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions
VIOA contributed to the conceptualization. MKA, OE, and VIOA performed the data curation. MKA and VIOA performed theformal analysis. VIOA, RdLD, and BA did the funding acquisition, investigation, and project administration. MKA, RS, EE, and
VIOA contributed to the methodology. VIOA performed supervision. MKA contributed to writing—original draft. MKA, OE,
RS, BA, RdLD, EE, AOS, and VIOA contributed to writing—review and editing.

Conflicts of Interest
None declared.
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Adu et alMultimedia Appendix 1
CONSORT-eHEALTH (V 1.6.1).
[PDF File (Adobe PDF File), 1090 KB-Multimedia Appendix 1]

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Abbreviations
ANCOVA: analysis of covariance
BDI: Becks Depression Inventory
CBT: cognitive behavioral therapy
CONSORT: Consolidated Standards of Reporting Trials
DSM-5: Diagnostic and Statistical Manual for Mental Disorders (Fifth Edition)
GAD-7: Generalized Anxiety Disorder-7
MDD: major depressive disordermHealth: mobile health
PHQ-9: Patient Health Questionnaire-9
WHO-5: World Health Organization Well-Being Index
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JMIR FORMATIVE RESEARCH

Adu et al

Edited by A Mavragani; submitted 30.03.24; peer-reviewed by M Ambrosio, L Shalev, L Wu, M Rosenlund; comments to author
01.05.24; revised version received 26.05.24; accepted 01.07.24; published 09.09.24
Please cite as:
Adu MK, Eboreime O, Shalaby R, Eboreime E, Agyapong B, da Luz Dias R, Sapara AO, Agyapong VIO
Comparing Email Versus Text Messaging as Delivery Platforms for Supporting Patients With Major Depressive Disorder: Noninferiority
Randomized Controlled Trial
JMIR Form Res 2024;8:e59003
URL: https://formative.jmir.org/2024/1/e59003
doi: 10.2196/59003
PMID: 39250182©Medard K Adu, Oghenekome Eboreime, Reham Shalaby, Ejemai Eboreime, Belinda Agyapong, Raquel da Luz Dias, Adegboyega
O Sapara, Vincent I O Agyapong. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.09.2024.
This is an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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