JMIR MENTAL HEALTH

Furukawa et al

Original Paper

Cognitive and Behavioral Skills Exercises Completed by Patientswith Major Depression During Smartphone Cognitive Behavioral
Therapy: Secondary Analysis of a Randomized Controlled Trial
Toshi A Furukawa1, MD, PhD; Masaru Horikoshi2, PhD; Hirokazu Fujita3, MD, PhD; Naohisa Tsujino4, MD, PhD;
Ran Jinnin5, MD, PhD; Yuki Kako6, MD, PhD; Sei Ogawa1, MD, PhD; Hirotoshi Sato7, MD; Nobuki Kitagawa8, MD,
PhD; Yoshihiro Shinagawa9, MD, PhD; Yoshio Ikeda10, MD, PhD; Hissei Imai11, MD, PhD; Aran Tajika11, MD, PhD;
Yusuke Ogawa11, MPH, MD, PhD; Tatsuo Akechi1, MD, PhD; Mitsuhiko Yamada12, MD, PhD; Shinji Shimodera13,
MD, PhD; Norio Watanabe11, MD, PhD; Masatoshi Inagaki14, MD, PhD; Akio Hasegawa15, PhD
1

Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

2

Center of Cognitive-Behavior Therapy, National Center of Neurology and Psychiatry, Kodaira, Japan

3

Center to Promote Creativity in Medical Education, Kochi Medical School, Kochi University, Nankoku, Japan

4

Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan

5

Department of Psychiatry and Neurosciences, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan

6

Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan

7

Harimayabashi Clinic, Kochi, Japan

8

Hokudai-dori Mental Health Clinic, Sapporo, Japan

9

Shiki Clinic, Nagoya, Japan

10

Narumi Himwari Clinic, Nagoya, Japan

11

Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan

12

National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Japan

13

Department of Psychiatry, Kochi Medical School, Kochi University, Nankoku, Japan

14

Okayama University Hospital, Okayama, Japan

15

Advanced Telecommunications Research Institute International, Kyoto, Japan

Corresponding Author:
Toshi A Furukawa, MD, PhD
Department of Psychiatry and Cognitive-Behavioral Medicine
Nagoya City University Graduate School of Medical Sciences
Kawasumi 1, Mizuho-cho, Mizuho-ku,
Nagoya, 467-8601
Japan
Phone: 81 52 753 9491
Email: furukawa@kuhp.kyoto-u.ac.jp

Abstract
Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT),
either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consistingof several putatively effective components, and how each component may or may not contribute to the overall effectiveness of
CBT is poorly understood.
Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various componentsof the program.
Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated theeffectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patientswith drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40,
J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, andcognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the

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program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We
examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at
the median of change in depression severity.
Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0(standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during
which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed,time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and thenonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, andalso filled in more cognitive restructuring worksheets than the latter. Activities such as “test-drive a new car,” “go to a coffee
shop after lunch,” or “call up an old friend” were found to be particularly rewarding. All cognitive restructuring strategies were
found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” foundmore helpful than some other strategies.
Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating
depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The
activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of
mobile health (mHealth) in general.
Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/
ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik)(JMIR Ment Health 2018;5(1):e4) doi:10.2196/mental.9092
KEYWORDS
major depressive disorder; smartphone; cognitive therapy; telemedicine

Introduction
Cognitive behavioral therapy (CBT) is the psychotherapy withthe strongest evidence base for the treatment of depression [1-3].
CBT is indeed the only psychotherapy that has been shown tobeat the pill placebo condition, the gold standard control
condition in the evaluation of medical interventions [4]. It has
also been demonstrated to show comparable efficacy as
antidepressant pharmacotherapy, which is the mainstay of thetreatment for major depression today [5].
The broad umbrella term of CBT, however, now subsumes
various and different behavioral and cognitive skills such as
self-monitoring, behavioral activation, cognitive structuring,assertion training, structured problem solving, mindfulness, andothers [6]. The relative contributions of these various
components to the overall efficacy of CBT remain uncertainand debated [7-9]. So-called dismantling studies or component
studies to disentangle individual constituents of broadly
conceived CBT have been largely underpowered andinconclusive, as each study can only examine the value of adding
one particular component in question in a relatively limited
number of patients [10,11]. Another major issue of such studies
is whether the intended components are actually administeredby the therapists and received by the patients, although more
recent trials attempt to assure their delivery through audio orvideo recordings.
The development of information and communication
technologies, however, is opening new opportunities to monitor
the delivery of CBT skills and to study differential contributionof various components of CBT. The CBT itself can be delivered
remotely [12], and the patients’ progress can be remotely
monitored [13,14]. Ecological momentary assessment orexperience sampling enables more fine-tuned follow-up of
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patients’ usage of and responses to the program [15,16]. We
have developed a smartphone CBT app, named Kokoro-App(kokoro means mind in Japanese), with the integrated
Kokoro-Web secure server to which all the activities of thepatients with the app are uploaded. Kokoro-App teaches three
distinctive CBT skills, namely self-monitoring, behavioral
activation, and cognitive restructuring and provides interactive
worksheets that the patients can fill in for each task.
The effectiveness of the system was demonstrated in arandomized controlled trial (RCT) comparing antidepressant
medication switch plus Kokoro-App against antidepressant
medication switch alone among patients who had beenunresponsive to one or more antidepressants: the effect size ofthe intervention was a standardized mean difference of 0.40 indepression severity as measured by masked assessors (P<.001)[17]. This study aims to examine how the patients used thesmartphone CBT app during the trial and to investigate what
use characteristics differentiated the more successful users of
the CBT app from the less successful ones.

Methods
Study Design
The original study was a 9-week, multicenter, parallel-group
RCT comparing antidepressant medication switch plus
smartphone CBT against medication switch alone among
patients with antidepressant-resistant depression [17] (Japanese
Clinical Trials Registry UMIN CTR 000013693). A total of 164
patients who had not responded to one or more antidepressantsat adequate dosage for 4 or more weeks [18] were randomized
1:1 to the intervention or the control arm. The RCT has beenregistered in the Japanese trials registry (UMIN CTR
000013693).

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The randomized comparison showed that the adjunctive use ofsmartphone CBT brought about 2.5 (95% CI 1.2-3.7, P<.001)
points greater reduction in the Patient Health Questionnaire-9(PHQ-9) [19] scores and 4.1 (95% CI 1.5-6.6, P=.002) points
greater reduction in the Beck Depression Inventory-II [20] scores
after 9 weeks [17]. This study focuses on the 81 patients who
were randomized to the smartphone CBT arm and describes
and analyzes the patients’ use of Kokoro-App.

Kokoro-App
Kokoro-App is a smartphone CBT app and consists of fourparts: sessions, mind maps, actions, and thoughts (Figure 1).
There are eight sessions in which several cartoon charactersprovide psychoeducation through easy but fun conversations.
First, the welcome session explains CBT, as well as how to use
iPhone and Siri (voice recognition on iPhone). Sessions 1 and
2 explain how to self-monitor one’s reactions to various
situations according to the cognitive behavioral model. The
sessions introduce mind maps in which the patient can enter
details of the situation and his reactions to it in terms of emotion
and its degree, automatic thoughts, bodily reactions, andbehaviors. The patient chooses between four emotions of sador depressed, anxious or worried, angry, and happy and rates
its strength in five grades between 0 and 5.

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Sessions 3 and 4 explain behavioral activation according to two
principles of “When the body moves, so does the mind” and“Start small and near.” When the patient clicks on actions, listsof candidate activities for behavioral activation personal
experiments pop up. The candidates are categorized by the usual
time they require to complete into (1) less than 5 seconds, (2)less than 5 min, (3) less than 60 min, and (4) 60 min or more.
The patient chooses a candidate and rates his expected masteryand pleasure levels. When the patient completes the personal
experiment, he can enter his achieved mastery and pleasurelevels. The patient can also enter his own personal experimenttask. After his own experiments, the patient can recommend
certain activities by clicking on “Nice!” button and the numberof “Nice!”s will be shared by all the patients.
Sessions 5 and 6 explain cognitive restructuring. After providing
a rationale for cognitive restructuring, the app provides fourinteractive items to guide the patient to alternative thoughts.
The patient first picks up a mind map to work on. The first item,“fact glasses,” asks classic questions about evidence for andevidence against the automatic thought, such as “What facts do
you have to support this thought?” and “What facts are therethat do not support this thought?” Then the item combines thepatient's answers automatically and says, “So you believe XXX
but YYY. If you think this way, how do you feel now?” andasks the patient to rerate his feeling.

Figure 1. A screenshot from Kokoro-App.

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Figure 2. A screenshot from Kokoro-Web.

The second item is called “% Calculator,” which does similar
things as the fact glasses. It asks, “How confident are you inyour thought AAA?” then lets the patient choose between 1%
and 99%. Then it asks, “So you think your thought AAA is 99%
correct. But then what can there be in your other 1%?” Thepatient will then answer XXX, and the item will then ask, “So
if you think XXX, how would you feel now?” The third item
is “friend’s call.” The item says, “Ring, ring, ring. You havejust received a phone call from your best friend, saying AAA.
What advice would you give to her?” The rest is the same. The
last item is “What-now microphone.” The item goes, “Let’s justsuppose that your thought AAA is true. If so, what can be done
now?” The patient will then make an action statement, and theitem will then ask, “What if you did do XXX, how would you
be feeling?”
The epilogue session summarizes all the previous sessions andalso provides tips for relapse prevention.
Each session is expected to take 1 week. The new session canbe opened only a week after the last session was started andafter one homework has been completed.

Kokoro-Web
All the activities of the patient with Kokoro-App are uploaded
to the central server and can be viewed on Kokoro-Web (Figure2) by the patient, as well as by his treating physician.
Kokoro-Web was developed seamlessly and integratively with
Kokoro-App. The communication between the app and theserver through the Internet was certificated by Secure Sockets
Layer.

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Statistical Analyses
We first present the descriptive details of how the patients
utilized Kokoro-App. The continuous outcomes are summarized
by mean and SD and the dichotomous outcomes by number andpercentage.
We next subdivide the patients into beneficiaries andnonbeneficiaries from Kokoro-App at the median change scoreof the PHQ-9 and compare each group’s use of the Kokoro-App.
Because the same patient contributed a variable number of mind
maps, behavioral activations, or cognitive restructurings toaccount for the within-person clustering effect, we used themixed effects model where appropriate. Given the observationaland hypothesis-generating nature of this study, we set thethreshold for statistical significance for each comparison atnominal P<.05 throughout. We used STATA (StataCorp) version
14.

Results
Patient Characteristics
Table 1 summarizes the baseline demographic and clinicalcharacteristics of the cohort. Patients were typically around 40
years of age, had some higher education, slightly more than half
were in some employment, and slightly less than half were
married. They had had several depressive episodes, had beenin the current depressive episode for almost 2 years, and werein moderately to severely depression at baseline.

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Table 1. Baseline demographic and clinical characteristics of the cohort.
Mean SDa or n (%)

Characteristics
Demographic
Age (years), mean (SD)40.2 (8.8)

Women, n (%)

46 (57)

Education (years), mean (SD)14.6 (2.5)

Employment status
Employed full-time, n (%)

34 (42)

Employed part-time, n (%)

7 (9)On medical leave, n (%)

21 (26)

Housewife, n (%)

6 (7)Student, n (%)

0 (0)Retired, n (%)

0 (0)Not employed, n (%)

13 (16)

Marital status
Single, never married, n (%)

34 (42)Single, divorced, separated or widowed, n (%)

13 (16)

Married, n (%)

34 (42)ClinicalAge of onset at first episode (years), mean (SD)

31.8 (10.8)

Number of previous depressive episodes, mean (SD)

3.4 (4.9)

Length of current episode (months), mean (SD)24.2 (46.3)

PHQ-9b at baseline, mean (SD)

13.5 (5.5)

BDI-IIc at baseline, mean (SD)28.2 (11.2)

a

SD: standard deviation.

b

PHQ-9: Patient Health Questionnaire-9.

c

BDI-II: Beck Depression Inventory 2nd edition.

Kokoro-App Use Statistics
Table 2 shows the use statistics of Kokoro-App by the 81
patients.
On average, the patients completed 7.0 out of 8 sessions; it tookthem 10.8 days to complete one session, during which theyspent 62 min on the app reading the sessions and also completing
their respective homework (self-monitoring, behavioral
activation, or cognitive restructuring).
They filled in 10 mind maps, more often for sad or depressed,
or anxious or worried feelings but also for angry or happy
feelings. They performed 14 behavioral activation personal
experiments through which they had anticipated and achieved
moderate levels of mastery and pleasure. With respect tocognitive restructuring, they generated an average of six
alternative thoughts using fact glasses, % Calculator, friend’s
call, or what-now microphone almost equally frequently.

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Behavioral Activations
We analyzed the behavioral activations completed by thepatients according to their frequencies, the level of mastery andpleasure they achieved, and how unexpectedly good they were.
The most frequently chosen behavioral activations were, in thedescending order, “Listen to favorite music,” “Read books andmagazines,” “Brew and drink coffee,” and so on (Table 3). The
levels of mastery or pleasure expected or achieved were typicallyin the range 3 to 5 on a scale of 0 to 10.
However, when selected for the levels of achieved mastery orpleasure, very different sets of activities emerged (Tables 4 and
5). These tables are limited to such activities that were reported
at least three times. Activities that achieved very high levels ofmastery or pleasure included “Test-drive a new car,” “Go to acoffee shop after lunch,” “Call up an old friend,” and “Exercise.”

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Table 2. Use statistics of Kokoro-App.
Use statistics

Mean (SDa), range, and medianOverall
Sessions completed, mean (SD), range

7.0 (1.4), 1-8

Days taken to complete one session, mean (SD), range

10.8 (4.2), 6.3-31

Actual time (min) per session, mean (SD), range, median62.3 (96.30), 0-677, 39

Self-monitoring
Mind maps, no. completed per person, mean (SD), range

10.4 (10.5), 0-45

Mind maps, no. completed per person, by emotion
Sad or depressed, mean (SD), range

3.2 (3.7), 0-16

Anxious or worried, mean (SD), range

3.0 (3.3), 0-18

Angry, mean (SD), range

2.4 (3.4), 0-16

Happy, mean (SD), range

1.9 (3.1), 0-20

Level of emotion recorded (on a scale of 0-5)
Sad or depressed, mean (SD)

3.4 (1.3)

Anxious or worried, mean (SD)

3.5 (1.3)

Angry, mean (SD)

3.5 (1.3)

Happy, mean (SD)

3.2 (1.3)

Behavioral activation
Behavioral activations, no. completed per person, mean (SD), range

13.8 (17.3), 0-118

Level of mastery or pleasure by behavioral activation (on a scale of 0-10)
Mastery expected, mean (SD)

4.5 (2.8)

Mastery achieved, mean (SD)

4.3 (3.0)

Pleasure expected, mean (SD)

4.8 (2.7)

Pleasure achieved, mean (SD)

4.7 (2.9)

Cognitive restructuring
Cognitive restructuring, no. completed per person, mean (SD), range

6.2 (6.3), 0-31

Cognitive restructuring items used, per person
Fact glasses, mean (SD), range

2.0 (2.0), 0-11

% Calculator, mean (SD), range

1.5 (1.8), 0-10

Friend’s call, mean (SD), range

1.5 (1.6), 0-7

What-now microphone, mean (SD), range

1.4 (1.5), 0-7a

SD: standard deviation.

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Table 3. Behavioral activations: top 10 activities in terms of frequency and their mastery or pleasure levels.
ActivityFrequency (number of reports) Mastery

Pleasure

Expected

Achieved

Expected

Achieved

Mean (SDa)Mean (SD)

Mean (SD)

Mean (SD)Listen to favorite music95

5.2 (3.0)

5.0 (3.3)

5.9 (2.7)

5.7 (2.9)

Read books and magazines71

4.9 (3.0)

4.5 (3.3)

5.3 (2.7)

4.8 (2.8)

Brew and drink coffee50

3.5 (3.2)

3.1 (2.6)

3.8 (2.2)

3.8 (2.5)

Hum a tune

41

2.9 (2.5)

2.3 (1.9)

3.8 (2.1)

3.4 (2.2)

Take a long bath36

3.6 (2.0)

3.9 (2.5)

4.4 (1.9)

4.5 (2.4)

Throw away something you don’t need from the drawer33

4.3 (1.9)

3.9 (2.4)

3.6 (2.0)

3.5 (2.1)

Go to a coffee shop after lunch27

8.4 (1.8)

8.3 (2.2)

8.4 (1.8)

8.3 (2.1)

Put some bath powder in the bathtub24

2.9 (2.0)

3.3 (2.1)

4.1 (2.0)

4.4 (2.0)

Close your eyes for 3 min

21

2.9 (1.7)

2.6 (2.2)

2.7 (1.1)

2.5 (2.3)

Take a different route on the way back home20

3.0 (1.4)

3.4 (2.3)

3.1 (1.1)

3.3 (2.2)a

SD: standard deviation.

Table 4. Behavioral activations: top 10 activities in mastery achieved and their frequencies.
ActivityFrequency (number of reports) Mastery achieved, mean (SDa)

Test-drive a new car

3

9.7 (0.6)

Go to a coffee shop after lunch27

8.3 (2.2)

Exercise3

8.3 (2.9)

Call up an old friend

4

7.8 (2.9)

Go to yoga with a friend

6

7.2 (1.2)

Go to a hairdresser

3

6.7 (1.5)

Go to a gym

7

6.6 (3)

Walking

8

6.5 (0.8)

Get a haircut

4

6.5 (3)Go to a meal with a friend

13

6.3 (2.8)a

SD: standard deviation.

Table 5. Behavioral activations: top 10 activities in pleasure achieved and their frequencies.
ActivityFrequency (number of reports) Pleasure achieved, mean (SDa)

Test-drive a new car

3

9.7 (0.6)

Call up an old friend

4

9.0 (1.4)

Exercise3

8.7 (2.3)

Go to a coffee shop after lunch27

8.3 (2.1)

Go to yoga with a friend

6

7.8 (1)

Call up a family and hear their voice5

7.4 (1.5)

Go to a meal with a friend

13

7.2 (2.3)

Go out for a luxurious lunch17

6.8 (2.9)

Take a walk8

6.6 (2)Nail art4

6.3 (3.8)a

SD: standard deviation.

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Some activities brought greater levels of mastery and pleasurethan initially expected. Such pleasant surprises included“Exercise,” “Do a makeup,” “Buy a comic book at aconvenience store,” “Call up an old friend,” or “Go out for aluxurious lunch” (Tables 6 and 7).

Cognitive Restructurings
All the cognitive restructuring items showed statisticallysignificant reductions in sad or depressed, anxious or worried,or angry feelings when the emotion levels were comparedpre-post within each situation that the patient worked on (Table
8). Typically, the level of emotion went down fromapproximately 3.5 to 2.1, showing a reduction greater than 1
point, on a scale of 0 to 5.
When the four tools were compared against each other, again
within each situation, friend’s call and % Calculator bothoutperformed fact glasses. The average change in emotion level
was −1.6 (SD 1.3), −1.5 (SD 1.3), −1.4 (SD 1.3), and −1.3 (1.3),

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respectively, for friend’s call, what-now microphone, %calculator, and fact glasses.

Contrasts Between Beneficiaries and Nonbeneficiaries
of Kokoro-App
The median of the final change score on PHQ-9 was 4. We
therefore split the cohort into beneficiaries from Kokoro-App(change greater than 4: n=31) and nonbeneficiaries (change of
4 or less: n=49, including six who showed deterioration frombaseline).
Although the beneficiaries tended to complete more sessions,need fewer days to complete one session, and spent more time
per session, the group differences were not statisticallysignificant (Multimedia Appendix 1).
Neither did the numbers of mind maps completed, overall andby emotion differ between the two groups, although thebeneficiaries tended to report a slightly higher level of happy
emotion.

Table 6. Behavioral activations: top 10 activities in unexpected mastery and their frequencies.
ActivityFrequency (number of reports) Mastery achieved-expected, mean (SDa)

Exercise3

1.3 (2.3)

Buy a comic book at a convenience store

4

1.0 (1.4)

Call up an old friend

3

1.0 (1.7)

Do a makeup

5

0.8 (1.3)

Call up a family and hear their voice5

0.8 (1.3)

Go see a movie

4

0.8 (1.0)

Test-drive a new car

30.7 (0.6)

Nail art3

0.7 (2.1)

Take a long bath32

0.6 (1.7)

Put some bath powder in the bathtub21

0.5 (1.0)a

SD: standard deviation.

Table 7. Behavioral activations: top 10 activities in unexpected pleasure and their frequencies.
ActivityFrequency (number of reports) Pleasure achieved-expected, mean (SDa)Do a makeup

5

1.0 (1.7)

Call up an old friend

3

1.0 (1.7)

Test-drive a new car

30.7 (0.6)

Go out for a luxurious lunch15

0.6 (1.9)

Say hurray!

90.6 (0.7)

Borrow and watch a DVD

8

0.6 (2.7)

Go to a gym

7

0.6 (2.9)

Put some bath powder in the bathtub21

0.5 (1.0)

Take a long bath31

0.4 (1.2)

Throw away something you don’t need from the drawer25

0.4 (1.7)a

SD: standard deviation.

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Table 8. Changes in emotion levels by cognitive restructuring items. The statistical test was done with within-situation paired t test.
Before, mean (SDa)

After, mean (SD)

Change, mean (SD)P value

Sad or depressed (n=68)

3.5 (1.3)

2.4 (1.3)−1.5 (1.3)<.001

Anxious or worried (n=61)

3.7 (1.1)

2.2 (1.4)−1.5 (1.2)<.001

Angry (n=44)

3.8 (1.2)

2.3 (1.3)−1.1 (1.3)<.001

Sad or depressed (n=48)

3.5 (1.3)

2.2 (1.2)−1.3 (1.3)<.001

Anxious or worried (n=49)

3.7 (1.1)

2.1 (1.4)−1.6 (1.2)<.001

Angry (n=33)

3.8 (1.3)

2.2 (1.1)−1.5 (1.3)<.001

Sad or depressed (n=50)

3.6 (1.3)

2.1 (1.2)−1.5 (1.3)<.001

Anxious or worried (n=46)

3.7 (1.2)

2.1 (1.2)−1.7 (1.3)<.001

Angry (n=30)

3.4 (1.3)

2.0 (1.1)−1.4 (1.3)<.001

Sad or depressed (n=41)

3.4 (1.3)

2.0 (1.2)−1.4 (1.3)<.001

Anxious or worried (n=45)

3.9 (1.1)

2.1 (1.2)−1.8 (1.2)<.001

Angry (n=30)

3.6 (1.3)

2.4 (1.2)−1.2 (1.3)<.001

Item and emotion
Fact glasses% Calculator

Friend’s call

What-now microphonea

SD: standard deviation.

The use of behavioral activation differed significantly in many
aspects between the successful users and the less successful
ones. The former conducted almost twice as many behavioral
activations and expected and achieved greater levels of masteryor pleasure. The kinds of behavioral activation tasks chosenwere significantly different: differences by more than 3% were
found for activities such as “Listen to favorite music,” “Readbooks and magazines,” “Go to a coffee shop after lunch” (allmore frequent among the beneficiaries), and “Take a long bath”(more frequent among nonbeneficiaries). The time categories
of activities chosen were also different: the beneficiaries chose
activities likely to require 60 min, whereas the nonbeneficiaries
chose activities requiring 5 min or less.

To the best of our knowledge, this study is the first study to
examine specific details of behavioral activation or cognitive
restructuring tasks conducted by the patients undergoing remote
CBT or face-to-face CBT among a sizable number of clinicalpatients. Very interesting pictures emerged. Although patients
often conducted activities with expected and achieved masteryor pleasure levels, around 4 to 5, a number of candidate activities
emerged that achieved higher than expected mastery or pleasure.
Such activities included, among others, “Test-drive a new car,”“Go to a coffee shop after lunch,” “Exercise,” “Call up an oldfriend,” “Do a makeup,” and “Go out for a luxurious lunch.”
All the cognitive restructuring items were able to reduce theemotion levels significantly.

The successful users of Kokoro-App also conducted morecognitive restructuring than the less successful ones, especiallythose using fact glasses and % Calculator. The decrease inemotion levels, however, was significantly different between
the two groups only when using % Calculator.

Discussion

The study is also the first to compare details of the behavioral
and cognitive skills practiced by the patients with regard to theoutcome. The successful users of Kokoro-App conducted twice
as many behavioral experiments of different kinds and ofdifferent time requirements than those who were less successful.
The former also conducted significantly more cognitive
restructuring tasks, especially using % Calculator.

Summary of Findings

Limitations of the Study

Kokoro-App was well accepted among the patients who had
been unresponsive to one or more antidepressants and weremoderately to severely depressed at baseline. The patientsproceeded with the sessions in Kokoro-App at their own pace,spending approximately 60 min across 10 days for each session.
Over the course of 9 weeks, on average, they completed 10mind maps for self-monitoring own emotions and thoughts,
conducted 14 behavioral activation personal experiments, andfilled in six cognitive restructuring worksheets.

These are several caveats in the interpretation of the current
findings. First, although the original study was an RCT
examining the value of adjunctive use of Kokoro-App, this study
is by nature an observational study of the users of Kokoro-App.
The current results therefore indicate association but notnecessarily causation. The amount and nature of behavioral
activation tasks or cognitive restructuring worksheets arepotential mediators in the causative process from using thesmartphone CBT to reduction in depressive symptomatology.
It is possible that the beneficiaries of Kokoro-App got better

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because they engaged in more behavioral activations, or it isalso possible that they conducted more behavioral activations
because they had already felt better and had more energy.
Second, in accordance with the observational nature of the study,
we did not correct for multiple statistical testing and the analyses
remain hypothesis-generating rather than confirmatory. The
insights gained need be examined in future confirmatory
experiments to provide ultimate guidance on how to conduct
CBT. Third, strictly speaking, the findings only apply to
Kokoro-App and the Japanese patients with moderate to severe
depression on an antidepressant treatment. Whether they would
apply to other smartphone or Internet CBT (iCBT), or whether
they apply to Japanese nonclinical populations or to
non-Japanese patients when they use Kokoro-App cannot betaken for granted. For example, “Take a long bath” or “Put somebath powder in the bathtub” may be particularly comforting for
the Japanese people who traditionally take great pleasure in
taking baths and may not necessarily apply to people living indifferent cultural traditions. The candidate activities list mustcertainly be culturally adapted when Kokoro-App is transferred
to different countries. It must also be emphasized that app
contents need be contextualized for each user’s age, sex,
personal relationships, disabilities, and so on to make them more
specific.

Implications of the Study Findings
Nonetheless, our findings have important implications at threelevels. First, they suggest how Kokoro-App can be improvedin the next upgrade. Currently Kokoro-App lists the candidate
activities according to the number of “Nice!”s that the patients
have voted. This is probably a good feature of the app, creating
an atmosphere of a therapeutic community. The next versionof Kokoro-App can probably add another dimension to therecommendation by highlighting such activities that may not

Furukawa et al
have been experimented by many but which turned out toproduce great mastery or pleasure. The next version of
Kokoro-App may also choose to emphasize % Calculator, andpossibly do away with fact glasses as the latter has been foundto be less effective than the other items. % Calculator and fact
glasses aim to derive the same kinds of information, namely
evidence for and evidence against the automatic thoughts but
through different Socratic questions. % Calculator may be easierto understand for the users.
Second, they provide some insight on how iCBT and CBT ingeneral can be better practiced. Our results suggest thatbehavioral activation best distinguishes the more from the lesssuccessful users of smartphone CBT. This finding is in line witha growing number of RCTs showing similar effectiveness of
behavioral activation in comparison with the full CBT package,
including cognitive restructuring [7-9]. However, these studies
compared the different versions of CBT in the face-to-facesettings. Whether the iCBT may as well consist only of
behavioral activation or need to include cognitive restructuring
is an empirical question warranting a direct randomized
comparison.
Third, they also provide suggestions for the next generation ofmobile health (mHealth). Providing the mHealth intervention
on the Web or via a smartphone increases accessibility of theintervention but is only taking advantage of one aspect of thetechnology. The program can be used to collect valuable
information of what the users of the program do or feel. It may
also be combined with habit formation activities. Developmentof such an e-monitoring system has its own difficulties andcomplexities, including privacy, integration, and customization[21] but our Kokoro-Web presents one successful example andour study an example of how such a system enables collectionof important and fertile information.

Acknowledgments
The study was funded by the Ministry of Health, Labor, and Welfare, Japan (H-22-Seishin-Ippan-008) from April 2013 to March2014 and thereafter by the Japan Foundation for Neuroscience and Mental Health (JFNMH). The JFNMH received donations
from Asahi Kasei, Eli-Lilly, GSK, Janssen, MSD, Meiji Seika, Mitsubishi-Tanabe, Mochida, Otsuka, Pfizer, Shionogi, and Taisho.
The study was supported in part by JSPS KAKENHI (Grant-in-Aid for Scientific Research) grant number 17K19808 to TAF. A
complete list of participating centers and investigators in the Fun to Learn to Act and Think through Technology (FLATT) trial
appears in Multimedia Appendix 2.

Authors' Contributions
TAF conceived the study. TAF, MH, and NY designed the study. KF, NT, RJ, YK, SO, HS, NK, YS, YI, HI, AT, YO, NT, TA,
MY, SS, NW, MI, and AH carried out the study. TAF conducted the analyses and wrote the first draft manuscript. All authors
contributed to the critical revision of the draft and read and approved the final manuscript.

Conflicts of Interest
TAF has received lecture fees from Eli Lilly, Janssen, Meiji, MSD, Otsuka, Pfizer, and Tanabe-Mitsubishi and consultancy feesfrom Takeda Science Foundation. He has received royalties from Igaku-Shoin and Nihon Bunka Kagaku-sha publishers. He hasreceived research support from Mochida and Tanabe-Mitsubishi. He is diplomate of the Academy of Cognitive Therapy. MH
has received royalties from Igaku Shoin, Shogakukan Shuei-sha Production, Shindan-to-Chiryo-sha, Sogen-sha, Kango-Kyokai,
Kitaoji-Shobo, and Kongo-Shuppan publishers. HF has received lecture fees from Meiji and Mochida. NT has received speaking
fees from Astellas, Shionogi, Novartis, FUJIFILM RI Pharma, Meiji, Mochida, Janssen, Eli Lilly, and Dainippon-Sumitomo. He
has received royalties from Igaku-Shoin, Nanzando, Medical View, and Kanehara publishers. YK has received speaking fee from
Otsuka, Yoshitomi, Tanabe-Mitsubishi, Dainippon-Sumitomo, and Eli Lilly. SO has received speaking fee from Eli Lilly andhttp://mental.jmir.org/2018/1/e4/

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Furukawa et al

Mochida. He has received royalties from Igaku-Shoin and Nihon-Hyoron-sha publishers. NK has received lecture fees from Eli
Lilly, Janssen, Dainippon-Sumitomo, and Otsuka and consultancy fees from Meiji and Otsuka. He has received royalties from
Igaku-Shoin, Nakayama-Shoten, Seronjihou-sha, and Iwasakigakujutu-Shuppan publishers. He has received research funds from
Shionogi, Pfizer, and Meiji-Seika. YO has received honoraria for speaking at meetings sponsored by Eli Lilly. NT has received
lecture fees from Otsuka and Meiji. AT has received honoraria for speaking at a meeting sponsored by Eli Lilly andTanabe-Mitsubishi. He has received royalties from Kagaku-Hyoron-sha. TA has received speaking fees or research funds from
Daiichi-Sankyo, Eizai, Hisamitsu, Lilly, MSD, Meiji, Mochida, Otsuka, Pfizer, Novartis, and Terumo. He has received royalties
from Igaku-Shoin, Nanzando, and Nankodo publishers. MY has received speaking fees from Meiji and has contracted researchwith Nippon Chemiphar. MI has received lecture fees from Pfizer, Mochida, Shionogi, Daiichi-Sankyo, Meiji, Takeda, andSumitomo Dainippon Pharma. He has received royalties from Nippon-Hyoron-Sha, Nanzando, Seiwa-Shoten, Igaku-Shoin, andTechnomics. SS has received lecture fees from Otsuka, MSD, Meiji, Eli Lilly, Mochida, Pfizer, and Tanabe-Mitsubishi. He hasreceived royalties from Seiwa-Shoten. He has received royalties from Sentan-Igaku-sha, Chuohoki, and Medical Review publishers.
NW has received royalties from Sogen-sha, Paquet and Akatsuki publishers.

Multimedia Appendix 1
Beneficiaries and nonbeneficiaries of Kokoro-App.
[PDF File (Adobe PDF File), 63KB - mental_v5i1e4_app1.pdf ]Multimedia Appendix 2
FLATT investigators and committee members.
[PDF File (Adobe PDF File), 29KB - mental_v5i1e4_app2.pdf ]References
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Abbreviations
CBT: cognitive behavioral therapy
iCBT: Internet cognitive behavioral therapy
mHealth: mobile health
SD: standard deviation

Edited by G Eysenbach; submitted 03.10.17; peer-reviewed by N Bragazzi, S Aggarwal; comments to author 08.11.17; revised version
received 16.11.17; accepted 17.11.17; published 11.01.18
Please cite as:
Furukawa TA, Horikoshi M, Fujita H, Tsujino N, Jinnin R, Kako Y, Ogawa S, Sato H, Kitagawa N, Shinagawa Y, Ikeda Y, Imai H,
Tajika A, Ogawa Y, Akechi T, Yamada M, Shimodera S, Watanabe N, Inagaki M, Hasegawa A
Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral
Therapy: Secondary Analysis of a Randomized Controlled Trial
JMIR Ment Health 2018;5(1):e4
URL: http://mental.jmir.org/2018/1/e4/
doi:10.2196/mental.9092
PMID:29326098©Toshi A Furukawa, Masaru Horikoshi, Hirokazu Fujita, Naohisa Tsujino, Ran Jinnin, Yuki Kako, Sei Ogawa, Hirotoshi Sato,
Nobuki Kitagawa, Yoshihiro Shinagawa, Yoshio Ikeda, Hissei Imai, Aran Tajika, Yusuke Ogawa, Tatsuo Akechi, Mitsuhiko
Yamada, Shinji Shimodera, Norio Watanabe, Masatoshi Inagaki, Akio Hasegawa. Originally published in JMIR Mental Health(http://mental.jmir.org), 11.01.2018. 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 Mental Health, is properly cited. The complete bibliographic
information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must
be included.

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