Evaluation of a Guided Chatbot Intervention for Young People in Jordan: Feasibility Randomized Controlled Trial
Authors: de Graaff Anne Marijn , Habashneh Rand , Fanatseh Sarah , Keyan Dharani , Akhtar Aemal , Abualhaija Adnan , Faroun Muhannad , Aqel Ibrahim Said , Dardas Latefa , Servili Chiara , van Ommeren Mark , Bryant Richard , Carswell Kenneth 
Published: December 2024

Background
Depression and anxiety are a leading cause of disability worldwide and often start during adolescence and young adulthood. The majority of young people live in low- and middle-income countries where there is a lack of mental health services. The World Health Organization (WHO) developed a guided, nonartificial intelligence chatbot intervention called Scalable Technology for Adolescents and youth to Reduce Stress (STARS) to reduce symptoms of depression and anxiety among young people affected by adversity.

Objective
The objective of this study was to evaluate the feasibility of the STARS intervention and study procedures among young people in Jordan.

Methods
A 2-arm, single-blind, feasibility randomized controlled trial was conducted among 60 young people aged 18 years to 21 years living in Jordan with self-reported elevated levels of psychological distress. Immediately after baseline, participants were randomized 1:1 into the STARS intervention or enhanced care as usual (ECAU). STARS consisted of 10 lessons in which participants interacted with a chatbot and learned several cognitive behavioral therapy strategies, with optional guidance by a trained e-helper through 5 weekly phone calls. ECAU consisted of a static web page providing basic psychoeducation. Online questionnaires were administered at baseline (week 0) and postassessment (week 8) to assess depression (Hopkins Symptom Checklist-25 [HSCL-25]), anxiety (HSCL-25), functional impairment (WHO Disability Assessment Schedule [WHODAS] 2.0), psychological well-being (WHO-Five Well-Being Index [WHO-5]), and agency (State Hope Scale). Process evaluation interviews with stakeholders were conducted after the postassessment.

Results
Participants were recruited in December 2022 and January 2023. Of 700 screening website visits, 160 participants were eligible, and 60 participants (mean age 19.7, SD 1.16 years; 49/60, 82% female) continued to baseline and were randomized into STARS (n=30) or ECAU (n=30). Of those who received STARS, 37% (11/30) completed at least 8 chatbot lessons, and 13% (4/30) completed all 5 support calls. The research protocol functioned well in terms of balanced randomization, high retention at postassessment (48/60, 80%), and good psychometric properties of the online questionnaires. Process evaluation interviews with STARS participants, ECAU participants, e-helpers, and the clinical supervisor indicated the acceptability of the study procedures and the STARS and ECAU conditions and highlighted several aspects that could be improved, including the e-helper support and features of the STARS chatbot.

Conclusions
This study demonstrated the feasibility and acceptability of the STARS intervention and research procedures. A fully powered, definitive randomized controlled trial will be conducted to evaluate the effectiveness of STARS.

Trial Registration
ISRCTN ISRCTN19217696; https://doi.org/10.1186/ISRCTN19217696