Development and Pilot Testing of PracticePal, a Conversational Agent to Support the delivery of a brief behavioural activation treatment for depression in rural India.
Authors: AGRAWAL RAVINDRA , Monteiro Kimberley , Narasimhamurti Nityasri Sankha , Sharma Shreya , Suryawanshi Amruta , Bariya Aman , Narvekar Shravani , Bagnoli Lilianna , Saxena Mohit , Magoun Lauren , Parsekar Shradha S , Pozuelo Julia R , Lesh Neal , Sood Mohit , Sharma Tanushri , Yadav Harshita , Bhan Anant , Nadkarni Abhijit , Patel Vikram 
Published: November 2024

Abstract

Introduction: Brief psychosocial interventions such as the Healthy Activity Program (HAP), based on behavioural activation and delivered by non-specialist providers (NSPs), have emerged as cost-effective solutions for the treatment of depression. HAP treatment outcomes are improved by the engagement of patients in, and their adherence to, activation-focused homework assignments during therapy. Currently, patients are expected to complete these homework assignments using a paper workbook. The aim of this study was to describe the user-centred development process of PracticePal – a chatbot designed to enhance patient engagement and homework adherence – and to evaluate its feasibility and acceptability as a therapy-aid in India.
Methods: We used a user-centred approach to co-develop PracticePal, incorporating conversational flows and video scripts in Hindi. The chatbot was piloted with 30 participants with depression who were receiving HAP from 15 non-specialist counsellors in primary care in rural Madhya Pradesh, India. The feasibility and acceptability of PracticePal were assessed through engagement data, in-depth interviews with a subset of six participants, and focus group discussions with eleven counsellors. Treatment completion rates and changes in depressive symptoms were explored as secondary outcomes.
Results: Average patient engagement spanned 29 days (95% CI: 24-34) during the 60-day treatment period. The engagement of patients with PracticePal increased as their treatment progressed, particularly after the third HAP session. 75% of patients accessed more than half of the multimedia content available on the chatbot. On average, each patient had a greater frequency of self-initiated engagement (85%) compared to reminder prompts (15%). All 30 patients completed treatment and experienced reduction in the mean PHQ-9 score from 13 (95% CI: 12.6 to 13.6, signifying moderate severity) to 4 (95% CI: 2.9 to 4.7, signifying None/minimal severity). Patients found the chatbot’s reminders for activities, mood tracking, and video messages helpful and observed that it could help others in their social network. NSPs also reported improved participation of patients in the homework tasks compared to the paper workbook. A few patients faced challenges with low internet bandwidth, and those with limited literacy suggested increasing the amount of video content for easier accessibility.
Conclusion: The PracticePal chatbot is a feasible and acceptable therapy-aid to complement a psychological treatment, with promising potential to enhance the effectiveness of NSP-delivered psychosocial interventions in low-resource settings. Future steps include conducting a fully powered randomised controlled trial to assess its effectiveness in improving mental health outcomes.