BACKGROUND: Smartphones could enhance access to effective cognitive behavioral therapy (CBT). Users may frequently and flexibly access bite-size CBT content on personal devices, review and practice skills, and thereby achieve better outcomes. OBJECTIVE: We explored the distribution of actual interactions participants had with therapeutic content in a trial of smartphone CBT for depression and whether interactions were within assigned treatment modules or revisits to prior module content (ie, between-module interactions). METHODS: We examined the association between the number of within- and between-module interactions and baseline and end-of-treatment symptom severity during an 8-week, single-arm open trial of a therapist-guided CBT for depression mobile health app. RESULTS: Interactions were more frequent early in treatment and modestly declined in later stages. Within modules, most participants consistently made more interactions than required to progress to the next module and tended to return to all types of content rather than focus on 1 skill. By contrast, only 15 of 26 participants ever revisited prior module content (median number of revisits=1, mode=0, IQR 0-4). More revisits were associated with more severe end-of-treatment symptom severity after controlling for pretreatment symptom severity (P<.05). CONCLUSIONS: The results suggest that the frequency of use is an insufficient metric of engagement, lacking the nuance of what users are engaging with and when during treatment. This lens is essential for developing personalized recommendations and yielding better treatment outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT05386329; https://clinicaltrials.gov/study/NCT05386329?term=NCT05386329.
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