Early Client Involvement In The Design Of A Blended Smartphone Application And Dashboard For Depression (Totem)

Abstract

Technological developments can optimize therapy for depression. However, early client or user involvement is crucial. The smartphone application and dashboard ‘plaTfOrm using evidence-based inTervEntions for (Mental) health’ (TOTEM), based on cognitive behavioral therapy and behavioral activation, is being developed together with clients from the start. Objective monitoring (e.g., activity/travel-related behavior) and human-in-the-loop AI machine learning allow tailored blended care, combining face-to-face therapy with online modules and Just-in-Time Adaptive Interventions. As a first co-creation step, clients with (prior) depression or depressive complaints and psychologists evaluated the usefulness of an existing Health for Travel Behaviour (HTB) application and feedback report developed for cardio patients, which monitors and improves travel-related physical activity. Online semi-structured interviews followed an HTB demonstration. In total, 16 interviews (14 clients and 2 psychologists) were transcribed and analyzed. Participants perceived the application as user-friendly, relevant, useful, attractive, and a supplement to standard care. It encourages people to engage in activities. The feedback report was also perceived as transparent, useful, and relevant. Emotional aspects are underemphasized (e.g., assessment of feelings and mental health-related psycho-education). When tailored to depression (with attention for different recovery phases), monitoring and improving travel-related physical activity was considered helpful in supplementing standard care for depression.

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A Mobile Application for Depression (TOTEM): Early Client Involvement 97
Journal of Evidence-Based Psychotherapies,
Vol. 23, Special Issue, March 2023, 97-136.
10.24193/jebp.2023.1.5
EARLY CLIENT INVOLVEMENT IN THE DESIGN
OF A BLENDED SMARTPHONE APPLICATION
AND DASHBOARD FOR DEPRESSION (TOTEM)
Veerle Ross1,2*, Kris Brijs1, Hélène Dirix1, Geert Wets1, An Neven1,
Yves Vanrompay1, Neree Claes3,4,5, Nele Jacobs2,6
1 UHasselt, School of Transportation Sciences, Transportation Research Institute (IMOB),
Martelarenlaan 42, 3500 Hasselt, Belgium.
2 FARESA Evidence-Based Psychological Centre, 3500 Hasselt.
3 UHasselt, Faculty of Medicine and Life Sciences, Agoralaan, 3590 Diepenbeek, Belgium
4 vzw Stijn dienstencentrum Sint-Gerardus, 3590 Diepenbeek, Belgium
5 vzw Wit-Gele Kruis Limburg, 3600 Genk, Belgium
6 VUB, Brussels School of Governance, Pleinlaan 2, 1050, Brussels
Abstract
Technological developments can optimize therapy for depression. However,
early client or user involvement is crucial. The smartphone application and
dashboard ‘plaTfOrm using evidence-based inTervEntions for (Mental)
health’ (TOTEM), based on cognitive behavioral therapy and behavioral
activation, is being developed together with clients from the start. Objective
monitoring (e.g., activity/travel-related behavior) and human-in-the-loop AI
machine learning allow tailored blended care, combining face-to-face
therapy with online modules and Just-in-Time Adaptive Interventions. As a
first co-creation step, clients with (prior) depression or depressive complaints
and psychologists evaluated the usefulness of an existing Health for Travel
Behaviour (HTB) application and feedback report developed for cardio
patients, which monitors and improves travel-related physical activity.
Online semi-structured interviews followed an HTB demonstration. In total,
16 interviews (14 clients and 2 psychologists) were transcribed and analyzed.
Participants perceived the application as user-friendly, relevant, useful,
attractive, and a supplement to standard care. It encourages people to engage
in activities. The feedback report was also perceived as transparent, useful,
and relevant. Emotional aspects are underemphasized (e.g., assessment of
feelings and mental health-related psycho-education). When tailored to
depression (with attention for different recovery phases), monitoring and
improving travel-related physical activity was considered helpful in
supplementing standard care for depression.
* Correspondence concerning this article should be addressed to Veerle Ross, UHasselt, School of
Transportation Sciences, Transportation Research Institute (IMOB), Martelarenlaan 42, 3500 Hasselt,
Belgium.
Email: veerle.ross@uhasselt.be

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98 A Mobile Application for Depression (TOTEM): Early Client Involvement
Keywords: Depression; digital mental health; digital therapeutics; smartphone
applications; machine learning, just-in-time adaptive interventions; co-creation.
Depression is a leading cause of avoidable suffering worldwide.
Nevertheless, the impact of depression on societal and economic development is not
receiving sufficient attention, nor are adequate efforts being undertaken to avert and
mitigate the negative consequences of depression (Herrman et al., 2022).
Investments in mental health care have been reported to be scarce worldwide
(Chisholm et al., 2016). When people suffering from a mental health condition such
as depression want to seek help, they face important barriers, such as the stigma
related to seeking help, shortage of well-trained clinicians, and issues with
accessibility (Chisholm et al., 2016; Teepe et al., 2021). Pharmacotherapy is an
important treatment for handling depression (Shinohara, 2019), which is
considerably cheap (Richards et al., 2016; Shinohara et al., 2019). However,
pharmacotherapy (e.g., anti-depressants) often comes with adverse side effects. For
instance, relapse risk, emotional numbing, feelings of detachment, drowsiness, or
even suicidality (Read & Williams, 2018; Richards et al., 2016). Moreover, a
substantial part of the depressive population is unresponsive to anti-depressants, with
estimations as high as 20-30% for major depressive disorder (MDD) (Gillain et al.,
2022). The choice for drug treatment should not be taken lightly, only after applying
well-established evidence-based therapies, and people not responding sufficiently
(e.g., Cognitive Behavioral Therapy (CBT)). Unfortunately, waiting lists for such
treatments can be long (Pedrelli et al., 2019), leading to too many untreated cases of
depression and other mental health problems. The lack of appropriate support has
detrimental consequences for the individual and their loved ones. Considering
depression in young adults and adults, employers, insurers, health insurance and the
government are affected as well (e.g., reduced productivity or job employment,
increased expenses) (Chisholm et al., 2016). Therefore, existing therapy must be
optimized to reach more people more effectively, with fewer resources.
How Technology Can Help To Optimize Therapy For Depression
Recent technological developments can optimize existing therapy by
increasing access to care and reducing stigma since there is no need for physical
attendance, with lower costs than face-to-face therapy (Baumel et al., 2020; Messner
et al., 2019). However, technology for mental healthcare without a human
component is challenged by issues with engagement, uptake, and adherence (Bevan
Jones, 2020). Therefore, technology should not be used to replace but to supplement

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A Mobile Application for Depression (TOTEM): Early Client Involvement 99
standard care in the form of blended care, i.e., combining face-to-face therapy with
online tools. Blended care allows therapists to reduce the number of face-to-face
sessions, while clients can self-manage faster and more, increasing cost-
effectiveness (Chandrashekar, 2018; Messner et al., 2019; Van der Vaart et al.,
2014). As clients use the mental health applications between sessions, they need to
be motivated to engage in using the application in an adequate/sufficient manner,
especially at times without direct contact with the therapist. The strength and quality
of the motivation for technology adoption can be stimulated by using real-time
prompts, notifications, or gamification (Chandrashekar, 2018). Moreover,
technology-enabled care allows digital phenotyping, i.e., an ecological form of
information collection based, for instance, on app usage, screen time, sensors (e.g.,
GPS, accelerometer, wristband) and/or a digitized experience sampling method
(ESM). This type of data collection allows inclusion of the daily life context of the
client under treatment and his/her thoughts/feelings in that particular context
(Daniëls et al., 2019; Insel, 2018; Mulvenna et al., 2021). As a result, detailed
information about the client’s complaints and possibilities and opportunities are
available for analysis. Use of such information in between therapy sessions increases
the effectiveness of an application, since treatment can be personalized and
embedded in the daily life context, for instance in the form of micro-interventions
that increase engagement with little burden on the client. Micro interventions are
also referred to as just-in-time-adaptive-interventions in case they are based on
decision rules that specify which intervention should be provided at which time,
based on time-, user-, and/or environment-based information. These JITAI provide
the needed type of support in real-time at the moment when it is most needed by
monitoring vulnerability (i.e., the right time) and receptivity (i.e., availability)
(Baumel et al., 2020; Hardeman et al., 2019; Nahum-Shani et al., 2018; Teepe et al.,
2021). Importantly, JITAI should be evidence- and theory-based (Nahum-Shani et
al., 2018). A recent review showed that the use of JITAI in applications for
depression is still largely overlooked, therefore not allowing these applications to
reach their full potential (Teepe et al., 2021).
Finally, to foster user involvement, or facilitate better user experience, co-
creation throughout the design process is essential (Jones et al., 2020; Mansson et
al., 2020; Van der Vaart et al., 2014). Co-creation or co-design refers to a process of
partnership between users and stakeholders, allowing the technology development
to match the needs and preferences of the target population. This process should
apply to all technology-related aspects (e.g., content, accessibility, privacy,
implementation), and in different phases, from a scoping or discovery phase to
prototype evaluation, with opportunities for iteration (Jones et al., 2020).

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100 A Mobile Application for Depression (TOTEM): Early Client Involvement
‘Platform Using Evidence-based Interventions For (Mental) Health’ (TOTEM)
The online ‘plaTfOrm using evidence-based inTervEntions for (Mental)
health’ (TOTEM) is developed to tackle a number of the above-described barriers
to seeking and accepting care: accessibility (availability, affordability,
acceptable time investment), low degree of self-management, and fear of
stigmatization (Mojtabai et al. 2011). TOTEM combines a smartphone
application and dashboard for people suffering from depression
†
. TOTEM is
based on CBT principles, a collaborative, individualized, psychological therapy
with long-term effects, that is empirically well-supported for a range of
psychological issues, including depression (Hofmann et al., 2012; Richards et
al., 2016). According to CBT, maladaptive cognitions contribute to maintaining
emotional distress and behavioral problems. To address these maladaptive
cognitions, CBT combines a variety of cognitive, behavioral, and emotion-
focused techniques (e.g., cognitive restructuring) (Hofmann et al., 2012). One
fundamental principle of CBT is behavioral activation (BA). BA aims to increase
positive experiences by activity scheduling, including responsibility-related and
recreational activities. These activities can produce both primary (e.g.,
enjoyment) and secondary benefits (e.g., extension of social support system). BA
was effectively applied in depression, with indications that BA can be as effective
as full CBT, even though it is easier to provide and with lower costs (Hopko et
al., 2004; Jacobsen et al., 1996; Ly, Carlbring, & Andersson, 2012; Richards et
al., 2016). Both CBT and BA have already been successfully offered via the
internet or smartphone (Ly et al., 2012; Thase et al., 2020). The Intervention
Mapping (IM) approach, a well-established framework for the planning of
theory- and evidence-based interventions (Eldredge et al., 2016; Van Agteren et
al., 2021), serves as a guide for: 1) the development of target variables that need
to be monitored and changed to reach the health-promoting goals (e.g., think
flexibly), 2) the selection of methods and techniques that need to be implemented
to reach these targets and how they can be applied in the platform, and 3) the
implementation and evaluation of the platform. As can be seen in Figure 1, the
primary health outcome (i.e., depression severity) is believed to depend upon a
set of health promoting goals (i.e., how flexible people act, feel and think) which
require the performance of specific actions (e.g., travelling in a physically active
manner, expressing emotions, observing thoughts). These so-called performance
objectives (i.e., PO: what you need to do to attain the desired outcome) in turn,
†
TOTEM is not designed for patients with severe depression who struggle with
suicidal thoughts, as they require more intense face-to-face follow-up.

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A Mobile Application for Depression (TOTEM): Early Client Involvement 101
can only be achieved if the appropriate underlying determinants (e.g., attitude,
skills, knowledge) are changed in the desired direction, which is what the term
‘change objectives’ refers to (i.e., CO: what needs to be accomplished to reach
the PO). The Theoretical Domains Framework (TDF) was used as a guide to
determine the more precise change objectives (Cane et al., 2012) while the
Behaviour Change Techniques Taxonomy v1 (Michie et al., 2013) served as an
evidence-based system for the selection of suitable behavioral change
techniques.
Figure 1. An Illustration of a Model of Change According to the IM Protocol
See Figure 2 for an illustration of the TOTEM platform. Inside TOTEM, the
‘Profiler Unit’: 1) collects (to-be-determined) (digital) biomarkers (i.e.,
quantifiable behaviors) that are derived from a set of features registered by the
smartphone and sensors (e.g., how often the smartphone screen was on/off, GPS,
accelerometer wristband). 2) monitors the current ‘state’ of the user (e.g., increased
sedentary behavior or acute stress), and 3) predicts depression severity (Abdullah
et al., 2016; Van Ballegooijen et al., 2014) by means of Ensemble learning, i.e.,
classification technique resulting in better predictive performance and higher
accuracy than single algorithms (Aleem et al., 2022; Peng et al., 2017). Profiler
Unit output serves as input for the therapist, e.g., to supplement his/her observation
and judgment with contextualized information obtained via the smartphone (i.e.,
behavior/activities), sensors (e.g., indications of stress), and ESM (i.e., assessing
thoughts and feelings). Additionally, output from the Profiler Unit serves as input
for the ‘Intervention Planner Unit’.

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102 A Mobile Application for Depression (TOTEM): Early Client Involvement
Figure 2. TOTEM Platform
The Intervention Planner Unit intelligently manages an ‘Intervention
Repository’ which contains different types of intervention formats, ranging from
more classic psycho-education modules or homework assignments, to so-called
JITAI (i.e., compact prompts triggered by and tailored to momentary needs detected
by the Profiler Unit). Selection of the most appropriate intervention format starts
from a set of specific decision points and -rules (Nahum-Shani et al., 2018) that are
initially based on expert opinion. Through reinforcement learning an algorithm
discovers which combination of interventions works best, per user and context, by
finding which activity output is the most rewarding over time (Akanksha et al.,
2021). In terms of intervention selection and execution, a blended constellation uses
both the Profiler Unit output and the therapist's judgment. As such, the therapist, or
‘the human-in-the-loop’, can follow up on the interventions and overrule
propositions made by the algorithm that are considered inappropriate. In other words,
the Intervention Planner Unit operates on input from both the Profiler Unit and the
therapist in order to set up a knowledge base, serving future users and therapists as
well. Finally, the TOTEM platform comes with a ‘Matching and Booking Unit’ that
assists the therapist in planning of face-to-face sessions and online modules.

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A Mobile Application for Depression (TOTEM): Early Client Involvement 103
The combination of these sources of information allows the therapist to map
the evolution of the depression severity and provide highly tailored blended care. For
instance, based on the (detected narrowing of the) activity pattern, it can be
determined that the client would benefit from following a module on behavioral
activation. However, the information can also be used for face-to-face sessions. For
example, the therapist can comment that high-stress levels are experienced during a
particular activity, as indicated by smartphone and sensor data. Suppose the ESM
data also suggests that the client reports negative thoughts during this activity. In that
case, it is necessary to pay attention to this (after all, biological stress can also be
positive). Perhaps it is possible to fill this activity differently, more positively. Or
the platform could send tips or an encouraging message to the client before the
activity. These JITAI can also encourage clients to complete their homework.
Aims
This study describes the first step of a co-creation development process in
which end-users (i.e., clients with depression/depressive complaints) and experts
(e.g., psychologists) evaluated the usefulness of an existing smartphone Health for
Travel Behaviour (HTB) application and feedback report. The HTB app was initially
developed for cardiac patients and allows monitoring and improvement of travel-
related physical activity, which aligns with the principles of behavioral activation
via transport-related behavior from the TOTEM platform (Batool et al., 2018, 2022).
The clients with depression/depressive complaints and psychologists assessed the
usefulness of active transportation to increase activity levels in depression. Special
attention was given to topics such as usability, gamification as a behavioral change
technique, and different phases of recovery in depression (i.e., onset, improvement,
and recovery).
Methods
Interviews and Procedure
After signing a consent form, participants filled a demographics
questionnaire and a standard questionnaire for depression diagnosis (i.e., Center for
Epidemiologic Studies Depression Scale (CES-D), score ≥16; ICC≥.70) (Devins et
al., 1988; Vilagut et al., 2016). Due to the COVID-19 pandemic, it was not possible
to have the application actively tested by participants. Therefore, online
presentations demonstrating the HTB application and feedback report were held
instead. The presentation included the following sections: (1) an introduction (e.g.,
background information and goals), (2) the HTB application (e.g., example screens,
information about the functionalities, required actions, etc.), and (3) the feedback
report (e.g., discussion per section, complete overview, etc.). After the presentations,

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104 A Mobile Application for Depression (TOTEM): Early Client Involvement
semi-structured interviews were conducted. A prospective perspective was used
because participants did not formulate their opinions based on actual user
experience.
Sample
Two participant groups were recruited through criterion and convenience
sampling to obtain a purposive sample. The first group (n = 14) consisted of clients
who had previously received treatment, or were currently under active treatment, for
depression or depressive symptoms by a psychologist from an ambulant private
clinical practice. The following inclusion criteria were set: 1) Must have or have had
depressive symptoms in the past six months, 2) Over 18 years of age, 3) Ongoing or
completed treatment with a psychologist, 4) No serious suicidal risk, and 5) No
bipolar diagnosis.
The second target group that was included consisted of psychologists,
experts, and/or therapists (n = 2); only one inclusion criterion was used: currently
working with depressive clients as a psychologist/therapist.
The primary focus of the study was on the client population. No exact
number of participants that needed to be included was prespecified. Interviews were
conducted until no new themes or topics emerged (i.e., data saturation). Therapists
were recruited to provide additional opinions on the app and feedback report because
of their relevant expertise.
Table 1. Overview of the Depression Group’s Demographics
Depression group (n = 14)
Males (n = 4)
Females (n = 10)
Age group, n (%)
18 – 30 years old
3 (21.4%)
-
3 (30%)
31 – 45 years old
3 (21.4%)
2 (50%)
1 (10%)
46 – 60 years old
8 (57.2%)
2 (52%)
6 (60%)
Living situation, n (%)
Alone
3 (21.4%)
-
3 (30%)
With partner, no children
4 (28.6%)
-
4 (40%)
With partner and children
2 (14.3%)
1 (25%)
1 (10%)
With parents
4 (28.6%)
2 (50%)
2 (20%)
Other
1 (7.1%)
1 (25%)
-
Work situation, n (%)
Student
2 (14.3%)
-
2 (20%)
Part-time
1 (7.1%)
1 (25%)
-
Full-time
6 (42.9%)
3 (75%)
3 (30%)
Temporary sick leave
2 (14.3%)
-
2 (20%)
Permanent sick leave
2 (14.3%)
-
2 (20%)
Other
1 (7.1%)
-
1 (10%)
CES-D score
Range
3 – 45
11 – 33
3 – 45
Mean score (X ± SD)
23.5 (11.148)
21.25 (9.032)
24.4 (12.123)

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A Mobile Application for Depression (TOTEM): Early Client Involvement 105
Table 2. Overview of Signs and Symptoms Experienced by Participants
during Depressive Episodes
Group
Males
Females
Drowsiness
13 (92.9%)
3 (75%)
10 (100%)
Loss of interest
9 (64.3%)
3 (75%)
6 (60%)
Feeling worthless and hopeless
12 (85.7%)
3 (75%)
9 (90%)
Sleep issues
11 (78.6%)
3 (75%)
8 (80%)
Weight change
4 (28.6%)
1 (25%)
3 (30%)
Panic and anxiety
11 (78.6%)
3 (75%)
8 (80%)
Easily irritable
9 (64.3%)
2 (50%)
7 (70%)
Restlessness or tardiness
12 (85.7%)
2 (50%)
10 (100%)
Indecisiveness
10 (71.4%)
2 (50%)
8 (80%)
Feeling guilty
9 (64.3%)
2 (50%)
7 (70%)
Memory and/or concentration issues
8 (57.1%)
2 (50%)
6 (60%)
Neglect of social contacts
9 (64.3%)
1 (25%)
8 (80%)
Suicidal thoughts
6 (42.9%)
1 (25%)
5 (50%)
Emotional outbursts
7 (50%)
1 (25%)
6 (60%)
Fatigue and low energy
11 (78.6%)
4 (100%)
7 (70%)
Health for Travel Behaviour (HTB) Application and Feedback Report
The HTB application (Figure 3) monitors travel behavior by collecting: 1) GPS-
based location data of the trips and activities performed throughout the day, 2) Duration,
start- and end-time of the activities and trips that are executed throughout the day,
3) Detection of the used transport mode: motorized transport, cycling, and walking (but
unable to correctly distinguish between different types of motorized transport modes,
such as car, bus, or motorcycle), and 4) Covered distance during the trips. Moreover,
three additional parameters are manually provided by the patient: 1) activity type
(e.g., home, work, shopping), travel partner (e.g., spouse, friends), and motorized
transport mode (e.g., car driver, car passenger) (Batool et al., 2022).
Figure 3. HTB Interface

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106 A Mobile Application for Depression (TOTEM): Early Client Involvement
A feedback report is generated based on monitoring data of each individual
for three weeks, summarizing the duration, distance, and weekly frequency of active
transportation mode trips (i.e., walking and cycling). The Active Travel Score (ATS)
is reported as well, defined as the physical activity gained by using active
transportation modes. Physical activity is defined as the energy cost or amount of
oxygen consumed during rest (i.e., Metabolic Equivalent (MET)). The ATS is based
on the standard recommendation of 150 min/week of moderate-intensity physical
activity spread over 5 days. Calculated for a week, the ATS ranges from 7.5 to 15
Kcal/w*kg. The algorithm allocated each patient to one of the following categories:
1) inactive, 2) low active, 3) sufficiently active, 4) active, and 5) highly active. The
report also compares the category allocation with that of peers, allowing the user to
check if they perform below or above average. Furthermore, the report included the
simple home-based trips (i.e., home-activity-home) executed as driver or passenger,
taxi or motorcycle, that could be replaced by active transport, together with the
impact on the ATS (Batool et al., 2018, 2022). For more detailed information on the
calculation of the ATS score and the definition of simple home-based trips, we refer
to (Batool et al., 2022).
The content of the feedback report was based on the transtheoretical model
of change (TTM), containing Stages of Change (SOC) and Processes of Change
(POC). The included SOC referred to: Pre-contemplation (i.e., when people are still
unaware and thus do not acknowledge any problem), Contemplation (i.e., people
realize what the benefits of behavior change can be, but the costs of change are
considered as being too high), Preparation (i.e., the decision for future change is
made, together with small steps towards the set goal), Action (i.e., people are now
actively changing their behavior or acquiring desired behavior) and Maintenance
(i.e., the required behavior change is not only established but also maintained over
time) (Prochaska & DiClemente, 1983). The POC refer to strategies used for
changing behavior while progressing through the SOC. Experiential processes are
typically considered successful in the earlier SOC and refer to perceptions, thoughts,
or feelings concerning the behavior (e.g., thinking about consequences). Meanwhile,
behavioral processes are considered successful in the later SOC and refer to
observable situational and social strategies (e.g., controlling environmental cues). In
the current version of the HTB feedback report, the POC are included without
considering the respective SOC. This approach was followed to check whether
people in certain SOC indeed prefer the POC as suggested by literature. However, it
is also possible to measure their respective SOC and only include POC based on the
respective stage. Besides containing information that should support the SOC (e.g.,
facts concerning the benefits of active transportation and support for setting goals),
the HTB feedback report included some fixed parts that include psycho-education
concerning the health benefits of travel-related physical activity. The remaining
sections related to user’s individual performance: physical activity level from active
transport, encouraging comments linked to their ATS score, and the impact of trips
that could potentially be replaced with active transport (Batool et al., 2018, 2022).

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Analyses
A topic list was drafted containing all themes considered relevant for the
further development of the application and the feedback report in relation to
depression disorders. Based on this topic list, a semi-structured interview guideline
(Appendix 1) was prepared to ensure that all predetermined topics were covered
during the interview.
The interviews were analyzed using the deductive thematic analysis method.
The thematic analysis method allows for identification, analysis, and reporting of
themes in one’s data (Braun & Clarke, 2008). Themes can be analyzed in two ways,
deductively (e.g., Merriman et al., 2021) and inductively (e.g., Herrick et al., 2020).
The deductive thematic analysis is a top-down coding approach that starts from a
predetermined set of codes because one expects to find information about them in
the data (Saldana, 2013). Accordingly, the topics predetermined at the start of the
study were used as an initial set of codes during the analyses. Even though the
original codebook changed during the coding (i.e., some codes were restructured,
some codes were removed, and new codes were added), the codebook still reflected
the data structure, which is considered very important (Si & Hubbard, 2021).
After the interviews, data processing was based on the thematic analysis
method of Braun & Clarke (2008): 1) Data familiarization: transcribing and reading
the data, writing down non-verbal clues, 2) Generating initial codes: code larger
sections with a broad code name and write down notes, 3) Searching for themes:
merge different codes into one potential theme, 4) Reviewing themes: check if the
themes still relate to the initial coding and study purpose, 5) Final themes: decide on
the final themes and matching names, and 6) Producing the report: preparing a report
disclosing the findings, related to the research questions.
After conducting the qualitative analyses, some descriptive statistics were
calculated (e.g., age, gender, living situation, etc.). These statistics are included in
the results section to allow readers to assess the generalizability of the findings
(Gibbs et al., 2007).
Results
This section first presents the results for the client group, followed by those
for the therapists. For both groups, the following themes will be discussed:
(1) application-related topics, (2) depression-related topics linked to the application,
(3) modifications to the application in function of depression-related characteristics,
(4) feedback report-related topics, (5) depression-related topics linked to the
feedback report and (6) modifications to the feedback report in function of the
depression-related characteristics. Each theme is then further divided into subthemes
like user-friendliness, perceived usefulness, etc.

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108 A Mobile Application for Depression (TOTEM): Early Client Involvement
Client
Application
Figure 4. Schematic Overview of Application Themes – Clients
At the beginning of each interview, participants were asked to score the
application between 0 and 10. All scores ranged from 6 to 10, averaging 7.75/10.
Participants stated that the app gave a professional impression but is currently
focusing heavily on the physical aspect. Some participants also noted that in the
beginning, it would not be easy for them to use the app because of their limited
technological knowledge.

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A Mobile Application for Depression (TOTEM): Early Client Involvement 109
Figure 5. Overall Score on the HTB Application
Note. This graph demonstrates the percentage of client participants for each given score out of ten on the HTB
application (n = 14).
Application-related topics
User-friendliness. All participants stated that the app looks user friendly.
The two most prominent reasons to support this were: (1) the daily trip- timeline is
already created automatically, and (2) there is not much to enter yourself.
Furthermore, the app also appears to be quite learnable. A few older participants
commented that it might take them some more time to use the application properly.
Parameter annotation. When the daily trip-timeline needs to be completed,
participants can select most of the information from drop-down lists which limits the
average completion time to a few minutes per day, which was appreciated. Some
also indicated that it would make them more likely to fill in the timeline, even in the
beginning or onset phase.
Some participants were somewhat concerned that the timeline could only be
completed the day after since memory problems are a common depression symptom.
On the one hand, people might forget completing the timeline, on the other hand,
correctly reconstructing trip history from the day before can be challenging.
Participants would prefer more flexibility in terms of when to fill out the trip
timeline.
Clarity. All participants perceived the application as clear and well-
organized. It immediately provides a clear representation of the timeline, and there
is no need to search for relevant items which makes the application accessible to all
persons (i.e., those with much or little knowledge of technology). Suppose the
application is to be modified to suit Participants recommend that, for people with

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110 A Mobile Application for Depression (TOTEM): Early Client Involvement
depression as the targeted users, not too many elements should be added to maintain
the current level of clarity.
Personalization. None of the participants considered personalization a
decisive factor for using the application in the future. About half of the participants
did not think it was necessary at all while the other half would appreciate an option
to adjust color, icons, and/or font to personal preference. A few commented they
would not be interested in personalizing the app in the early phases of recovery since
it would cost too much energy.
Attractiveness. Opinions in terms of appeal were divided with half of them
stating they found the application sufficiently attractive, the majority of these being
participants saying personalization was not necessary. Others indicated the
application could be a bit more colorful and with additional visual elements to avoid
it looks a bit monotonous.
Depression-related topics linked to the application
Perceived usefulness.
Motivator. The application may have a motivating function in an
individual’s recovery process because it can objectively show a person’s progress.
Moreover, one might want to travel more actively because the app records it.
However, some indicated that there is a high possibility that the application would
lack of a sufficient motivating effect in the initial phase of recovery.
Distraction. Having to fill out the application can distract from somber
thoughts as it requires thinking about what one did yesterday or the previous days. It
also helps one to come up with ideas on how to travel more actively.
Reflection. It can be helpful for individuals to see what they have been doing
recently. On the one hand, this can be confrontational and will encourage changes in
behavior. On the other hand, the app can show improvement and correct biased
opinions in the case happening.
Combination with therapy. Some participants indicated that the app would
only be helpful if used in treatment, especially in the onset. The data should be
further discussed with the therapist, and the treatment adjusted accordingly.
Preventive function. The application can be helpful in recovery. When a
person is already in the recovery phase, the application can detect relapses more
quickly, meaning it can also have a preventive function.
Not useful. two participants indicated that they did not see the application’s
usefulness.
Personal relevance.
Trigger. Many participants indicated that the application could motivate
them to go outside on difficult days and also remind them that it is vital to keep doing
things, yet, to a lesser extent in the early phases of depression recovery according to
some of the respondents.

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Objective mapping. Some participants would use the app to objectively map
themselves because they tend to view everything more negatively. The app could
support them to drift less likely into negative thoughts.
Active life. Some participants are already highly active, exercising, counting
their steps, etc., all activities they would also like to track in the app. Others indicated
that walking was an outlet during their depression and that the app fits well with that
too. Not relevant. The two participants who did not consider the application
useful also indicated that the application would not be relevant to them. However,
they were open to revising their opinions in the event of future modifications.
User intention. The majority of the participants would want to use the
application, should it be currently available for download. Even in the recovery
phase, some would still be inclined to use it as it can be a certain form of control.
Others, in turn, were not convinced to use the application for various reasons, such
as not using applications much, being too lazy, or not seeing the use of it.
Behavioral activation and behavioral change. According to most
participants, the application can be behavior-activating because it may motivate and
trigger clients to travel more actively. Furthermore, it clearly maps out where there
is still room for improvement. However, participants indicated that there are also
some prerequisites for using the app and to achieve behavioral activation such as a
sufficient amount of notifications and reminders, therapist involvement in the
follow-up, and avoidance of people overdosing themselves with too much and/or too
heavy challenges.
Phases of depression recovery & problems linked to depression.
Uniformity. Most participants felt the app should not be tailored in function
of the recovery phase. A uniform app creates a familiar environment, and
participants felt that was more important. Many indicated that it is important not to
start with the application independently, especially in the beginning, but to always
do so in consultation with a therapist. When entering recovery, guidance can be
adjusted accordingly.
Onset. some participants indicated it would be best to keep the application
as simple as possible, certainly in the beginning to prevent people would drop out
due to worries in terms of time and effort needed to complete the travel diary
correctly and regularly.
Memory problems. Memory difficulties are an often-reported problem
among people with depression. The majority of the participants believed it crucial
that notifications remind them to complete their timeline.
Vision problems. Persons with depression may also experience temporary
problems with their vision. The ability to adjust text size could for instance be helpful
in this regard.

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112 A Mobile Application for Depression (TOTEM): Early Client Involvement
Modifications to the application for depression-related characteristics
Missing items and adjustments.
Social activity. An exclusive focus on active traveling may not be
sufficiently recovery-enhancing for persons with depression problems, social
contacts are also important. The application should allow collection of information
about what activity one did and with whom, and this data should also be incorporated
into the feedback report.
Mood indication. Individual mood should be questioned one or several times
a day, for instance requesting individuals to give a score on a scale (e.g., 7-point
Likert scale) in terms of how they feel. The option of adding additional information
would be helpful, but not be made mandatory.
Recovery phases of depression. For some participants, it should be possible
to adjust how much information should be entered into the app, depending on the
phase. If the application cannot be adapted, it is recommended to start by partly
filling out the application and to systematically build this up (e.g., first week: one
displacement, second week: two, etc.).
Children and adolescents. Two participants commented that it might be
interesting to create two versions of the app, one for adults and one for children and
adolescents. Most of them are technology-minded, so that the app could be a valuable
addition to their treatment.
Attractiveness. Some participants would appreciate opportunities to
customize certain aspects of the app, such as color, layout, font, etc. Also, more
graphical elements could be added to increase its attractiveness.
Drop-down lists. Some participants commented that not all modes of
transportation are currently included in the drop-down lists. However, this may be
relevant for the monitoring of social activities are (e.g., airplane, scooter, etc.). Thus,
the application should provide an option where users can add options to the drop-
down lists.
No adjustments. Two participants considered the app useful in its current
form and did not need additional modifications.
Therapeutic interaction and relevance.
Complementary. Most participants indicated that the application should
always be combined with therapy. Several reasons are given for this: (1) the app is
not going to be used enough without a therapist, (2) human interaction is essential
for recovery from depression, and (3) the application can be a good starting point for
conversation.
No human interaction. Some participants are more in favor of separating
face-to-face therapy from the application because not everyone needs therapeutic
interaction to the same extent. Since the app may also have a preventive function,
there is a possibility that people may not be in therapy when using the app. However,

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if wanted or needed, a user can still decide to provide the report to the therapist after
some time and start working with it.
Solid introduction. Some participants felt it is the therapist’s job to explain
the application clearly and help them get started, if not, some people might quickly
stop using it.
Feedback Report
Figure 6. Schematic Overview of Feedback Report Themes – Clients
Participants gave the feedback report an average score of 7.3 out of 10. The
primary focus of the report was on the physical implications of increased activity
levels with little emphasis on social activities or emotional aspects of depression.
This will probably have affected the evaluation of the feedback report.

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114 A Mobile Application for Depression (TOTEM): Early Client Involvement
Figure 7. Overall Score on the Feedback Report
Note. This graph demonstrates the percentage of client participants for each given score out of ten on the
feedback report (n = 14).
Feedback report-related topics
Content & user-friendliness. The overall impression was that the report
currently focuses too much on the physical aspect of recovery, without attention for
the mental, emotional and social aspects. Nevertheless, the report is clear according
to most participants and contains suggestions that can be implemented immediately.
Clarity. Most participants felt that the report is clear and well-organized. It
clearly shows what is important and uses well-known icons. Furthermore,
subdivision into different sections was positively evaluated since it improves
searchability of information. Also in terms of accessibility, the reported scored well,

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albeit some participants indicated that it contained too much text sometimes which
generated a loss of interest.
Attractiveness. All but two participants indicated that the visuals included
in the report could be further improved for instance, through the addition of color
and graphics in combination with less textual information. These comments explain
why some participants felt that the report was not that appealing.
Report structure.
Overview of active travel. Opinions were strongly divided. Some found it
pleasing that only the active trips were included in the overview, while others found
that the passive trips should also be included. After all, these can also contribute to
recovery; for example, a passive trip can serve a social function.
ATS score. Has a clear structure and is also nicely presented from a visual
point of view. Moreover, it may motivate people to travel in a physically more active
way. However, the score range was considered too narrow. As a result, improving
the score may sometimes be difficult, resulting in the score being demotivating rather
than motivating. Furthermore, the current score is only about active travel, which
might be a too narrow approach in the context of depression treatment.
Achieved ATS score. Participants unanimously agreed that the group score
should not be included in the report as it can be confrontational and stressful for
clients. It felt too much like a competition.
Feedback ATS score. Formulation of feedback on the ATS score is described
as too negative. In the early phases of depression recovery, it can be tough to do
anything that will prevent a person from achieving a high ATS score. Nonetheless,
positive reinforcement is highly important during that time.
Tips to enhance the ATS score. Participants were enthusiastic about this part
of the report, especially about the usefulness of tips on how to get started.
Furthermore, this section was attractive because it contains more visual elements and
concisely conveys the message.
Motivational messages. Currently, the motivational messages focus too
much on the physical aspect and not enough on the mental and social aspects of
depression. Participants did agree that the motivational messages should continue to
have a prominent place in the report, although increased levels of personal tailoring
would be appreciated.
Format of the report. Participants are satisfied with the report being sent by
email because it allows them to choose with whom they want to share the report, and
they can do so easily. An important condition, however, is the dosing of those
messages, i.e., how regularly these mails are sent.
Frequency of the report. The vast majority of participants felt that users
should be able to decide for themselves how often they want to receive a report. The
volume should be determined based on personal preference and depression severity.
Moreover, there should be a minimum number of days between each report so that
sufficient progress can be made.

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Depression-related topics linked to the feedback report
Perceived usefulness.
Self-monitoring. The report may motivate persons with depression to keep
doing things or to begin doing things again. It clearly demonstrates where
improvement is needed and possible and may help people regain control. Using the
scores and statistics, the report also allows individuals to see progress over time
which can be an additional motivating factor.
Self-reflection. The report may help people see why engaging in physical
activity is important and make them reflect on their actions.
User intention. Most participants would like to make active use of the
feedback report. Some indicated that they would read the report in its entirety each
time, while others would only read the entire report the first time and, from then on,
only those parts they consider relevant. Three people indicated they had no intention
of using the feedback report in its current version. However, they would use it when
tailored more towards depression.
Behavioral activation and behavioral change. According to most
participants, the feedback report can be behaviorally activating as it may motivate
and trigger clients to travel more actively and achieve better scores. However, it is
important to add more explicit links with the emotional and social aspects of
depression. As a result, a person’s self-awareness can be increased, which may
increase intervention effectiveness. Finally, some participants mentioned that the
feedback report could stimulate behavioral activation and change but to a more
limited extent in the onset phase where even small progress requires big effort.
Recovery phases of depression. Half of the participants believed the report
should not be tailored in function of recovery phases. Similarity creates uniformity
and support. Depending on the current situation, people could choose to ignore some
report sections. The other participants felt the report should be adapted in the
beginning because it can be overwhelming, with too many distracting factors.
According to them, it is better to progressively add report sections report instead of
providing all the information at once.
Modifications to the feedback report for depression-related characteristics
Missing items and adjustments.
Visualization. The report contains too much text and not enough visuals and
color. By adding these elements, people may find the report more appealing and
work with it more.
Emotional well-being score. Collection of mood-related data and calculation
of an emotion-related score included in the feedback report would be an essential
addition..
Socio-emotional well-being. The report should also account for users’ socio-
emotional well-being and elaborate on this, for example, in the tips and motivational
messages. Participants mentioned they would be willing to work on this particular
aspect, if it would be possible to follow up on it via the feedback report.

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Passive travel. Passive traveling for social purposes should be included in
the feedback report as it may help to promote recovery.
Long-term progress. Currently, the report only shows the ATS score of the
past period. To remain motivated, it is recommended to show progression over a
more extended period (e.g., three months, a year, etc.). Most participants indicated
that this progress is best shown as a graph so it can be understood at a glance.
Positivity. The tone of voice of the report is currently rather negative.
Messages should be rephrased in a friendlier and more encouraging manner. Less or
slower progress should also be positively endorsed. Areas for improvement should
be communicated as well, but always in a positively reinforcing frame.
Link between social activity and mood. Inclusion of the correlation between
activities and mood states would give clients more insight into their functioning and
feelings, which may stimulate behavioral change.
Less text. The report currently contains too much textual information. Less
text and more graphics would increase willingness to engage with the feedback
report. Therapeutic interaction. Most participants agreed that discussing the report
with their therapist would be best. This allows the client to gain more insight into
his/her own functioning by putting things in the proper perspective. Furthermore, the
therapist can help determine which parts of the report may be relevant at that
moment, and personal goals can be linked to the report. Finally, all participants
agreed that the report should only be sent to the client and that the client should be
able to choose whether or not to share it with the therapist.
Gamification.
Individualization. Opinions were strongly divided for gamification features.
Autonomy on the side of users in terms of which features to use and which not was
important.
Personal goals. According to participants, personal goals should not be
mandatorily imposed and be discussed with the therapist so that they are adequately
tailored to the individual. Poorly aligned goals may lead to increased stress and
pressure, which may negatively affect the recovery process.
Rewards/badges. Opinions on receiving rewards or being able to collect
badges are divided. Some participants did not see the added value while others
thought it could be symbolically motivating. Badge collection should not be
stressful, but encouraging.
Ranking and group goals. Most participants agreed that adding rankings and
group goals is not suited in the context of a depression recovery process. It may
demotivate people if they perform worse than other group members and create
pressure to perform.
Online forum. An online forum can make clients feel less alone, enable them
to get in touch with peers, and exchange tips and tricks. Essential for this to be
successful is that such a forum must be strictly monitored so that no unwanted or

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118 A Mobile Application for Depression (TOTEM): Early Client Involvement
false messages can be posted and that users do not begin to take on a therapeutic
role. Score for social activity.
For the majority, it was unsure what this should look like. Additionally, most
thought it would not be easy to score social activity since the need for it differs
between persons. Some participants suggested that instead of assigning a score, it
would be better to focus on the relationship between social activity and mood.
Therapeutic conversations could then be based on these relationships, and the
treatment plan could be adjusted accordingly.
Therapists
Application
Figure 8. Schematic Overview of Application Themes – Therapists
Immediately after the presentation, participants were asked to score the
application in its current form from 0 to 10. The therapists gave an average score of

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7.5 out of 10 as the application may be useful, but only targets a partial portion of
depression.
Application-related topics
User-friendliness. The app is very user-friendly. It contains a lot of
information and is very easy to use as you do not need to add much information next
to the drop-down menus.
Parameter annotation. Clients need to spend a few minutes per day to
update their timelines. The primary use of drop-down menus was positive because it
significantly facilitates the process. However, it might be problematic for clients with
memory problems that the timeline can only be completed one day later.
Clarity. Both therapists reported that the application was very clear. Only
the color coding was not entirely clear to one therapist, and should be explained
better. Personalization. At the moment, the application is not customizable.
According to the therapists, it would be nice to configure some aspects to the client’s
preferences, such as color and font. However, it was certainly not a necessity.
Attractiveness. According to both therapists, the application contains a good
balance between simplicity and attractiveness. Since color and shapes are used, it is
sufficiently appealing. If changes are made to the application in the future, it is
critical to carefully monitor the balance between simplicity and attractiveness to
avoid overstimulating clients.
Depression-related topics linked to the application
Perceived usefulness.
Overview. The application clearly displays all active movements at a glance.
This may be helpful to clients as it allows to maintain better overview, achieving
greater self-awareness.
Therapeutic added value. Nowadays, clients are often asked to monitor their
entire day with pen and paper. However, the application is much more efficient and
discrete. Afterward, the information from the application could be a starting point
during therapy to ask specific questions and tailor therapeutic interventions to a
person’s activities.
User intention. Both therapists were open to using the application in
therapy. If the application were available, they would recommend it to their clients.
Behavioral activation and behavioral change. The app itself will not result
in behavioral activation and/or behavioral change, but will instead have a supportive
function. Nevertheless, in case the therapist asks questions about the data in the
application, it may result in increased self-awareness on behalf of the client, which
in turn may positively affect behavioral activation. The application requires a certain
level of commitment. As a result, the clients are more involved in the recovery
process and can regain control over their situation.

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120 A Mobile Application for Depression (TOTEM): Early Client Involvement
Recovery phases of depression & problems linked to depression.
Recovery phases of depression. To preserve uniformity, the therapists
believed that it is unnecessary to adapt the app to the phases. However, the use of
the application should differ depending on the phase. For example, initially, only
complete one activity per day. Put differently, the counseling that accompanies the
application should be adapted to the phases.
Memory problems. Memory problems are common in persons with
depression. Therefore, they need optional reminders and notifications, reminding
them to complete the required information. Otherwise, many could forget to
complete their timeline.
Modifications to the application for depression-related characteristics
Missing items and adjustments.
Mood. Once or several times a day, the application should assess how a
person feels or has felt throughout the day. With this information, therapists can
tailor their questions. Over time, it may be possible to see connections between
activities and state of mind. The therapists disagreed on whether adding additional,
optional information to this assessment should be possible. On the one hand, it may
provide further clues during therapy; on the other hand, it may lead to internal
speculation in the client, which can hinder the recovery process.
Extra activity information. The app should permit adding more details to the
completed activities. Currently, it monitors where a person travels to and with whom.
It also monitors the type of activity (e.g., working, social activity, etc.). However, it
does not specify what activity specifically was undertaken (e.g., shopping, eating
out, etc.), not with whom. Not only physical activity but also social activity is vital
for recovering from depression, and linking these two together would, therefore,
make the app much better suited for the target group.
Drop-down lists. Participants should be able to add locations, etc., in
addition to the drop-down lists. This increases the ease of use of the application.
Accessibility to others. The application may contain sensitive information
about a person, which can lead to suspicion from the users. In addition, it is possible
that clients do not want their partner, family, etc., to be able to see what is being
entered in the application. It should be made possible to make certain data, or the
application itself, inaccessible to others.
Therapeutic interaction and relevance.
Follow-up during therapy. The application and the therapy are
complementary but cannot replace each other. The data from the application can be
used to guide the therapy. At the start, clear agreements about the follow-up need to
be set, to avoid unrealistic expectations (e.g., the therapist cannot monitor every
client daily outside the therapy sessions).
Number of therapy sessions. Although the app cannot replace therapy,
individuals may need fewer therapy sessions at a later recovery phase, due to self-
monitoring via the app.

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Feedback Report
Figure 9. Schematic Overview of Feedback Report Themes – Therapists
As with the overall score for the application, therapists also give an average
score of 7.5/10 on the feedback report. Adjustments are needed as physical activity
is only a part of depression.
Feedback report-related topics
Content.
Content. The therapists found that the report insufficiently focused on
depression-related characteristics, as physical activity is only a part of depression.
Negative. The messages in the report are being conveyed too negatively. In
the recovery process from depression, positive reinforcement is essential, which is
not sufficiently included in the report.

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Clarity. The report in its current form is straightforward, both visually and
content-wise. It presents everything quickly and clearly without much distraction.
Attractiveness.
The report is supported by pictograms and different colors, making it
visually appealing. Yet again, caution must be taken with report modification, so that
clients are not overstimulated.
Components of the report.
Suggestions for improvement. This section is very useful according to the
therapists; clients can immediately get started with this, which lowers the barrier to
getting started.
Motivational messages. Currently, these do not adequately address
emotional and psychological aspects of depression. Changing these messages is
necessary.
Format of the report. It was good that the report is sent to the client via
email. In fact, if the report is only available in the application, it could be overlooked.
Furthermore, a PDF document is larger and easier to read. Lastly, the report is easy
to forward via email, making it more convenient for the client to provide it to the
therapist.
Frequency of the report. The therapists disagreed with each other on the
frequency of the feedback report. One liked to receive the report on a weekly basis.
In contrast, the other thought that it should be adapted to the current recovery phase
a person is in. Someone in the later recovery phase needs less intensive follow-up,
and thus less frequent reports.
Depression-related topics linked to the feedback report
Perceived usefulness. The feedback report currently lacks some essential
sections to make it sufficiently useful for persons with depression issues. Meaningful
and social activities, combines with state of mood also need to be addressed.
Behavioral activation and behavioral change. In its current form, the report
will not lead to behavioral activation and/or change. However, it has a supportive
role. Clients themselves need to put less effort into keeping track of everything and
will also be stimulated by the report to think about their own recovery. Combined
with therapy, this may lead to behavioral activation and/or change. Again, it should
be noted that the report would be much more effective when more attention is being
paid to a person’s mood and activities.
Recovery phases of depression. As with the application, the therapists
preferred a uniform report that is not adapted to the phase a person is in. Again, the
therapist can discuss with the client how and to what extent the report will be used,
adjusting therapy accordingly.

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Modifications to the feedback report for depression-related characteristics
Missing items and adjustments.
Mood. The report should also include some sort of mood score based on the
– yet to be included – assessments in the app (i.e., an average score of all the
measures, not a score calculated based on the person’s activities). In the slightly
longer term, the report could then also include correlations between mood and
activity (e.g., if someone performs this activity, it is notable that their score for mood
on those days is significantly lower than on other days).
Social activity. Not only physical activities are important, social activities
can be recovery-enhancing. When clients have to add what and with whom they
performed activities in the app, the report can give an overview of this. This overview
should include the activities linked to active travel and those related to inactive travel
(e.g., driving to a friend’s house to go shopping, in which shopping is a social
activity).
Motivational messages. Motivational messages should focus more on the
psychological, emotional, and social aspects of depression. Furthermore, messages
may be conveyed more positively to enhance recovery.
Smaller milestones. The report currently works with big milestones. For
example, the range of the ATS score is relatively narrow, so one already has to put
in quite a lot of effort to improve their score. By taking a smaller-step approach,
people will have more successful experiences, making them more likely to be
motivated to keep using the report.
Personal progress. Graphs should be used to visualize long-term evolution.
This can be both confrontational and motivational for clients. Based on this, personal
goals can be established together with the therapist.
Therapeutic interaction. Therapeutic involvement is essential when
interpreting the feedback report. Through conversation, the results can be discussed
in more depth and detail, next treatment steps can be determined, and clients can
reach increased self-awareness.
Gamification.
Individualization. Overall, care should be taken when adding gamification
principles, as this could have positive and negative effects. It could motivate clients
to perform better. However, it could be an additional stress factor that hinders
recovery. Therefore, it is essential to evaluate for each client whether or not it is good
to work with gamification elements.
Personal goals. It should be possible to define personal goals in the
application, which are then addressed in the feedback report. However, these goals
should always be set in consultation with the therapist so that they can be sufficiently
individualized.
Rewards/badges. It is unnecessary to include rewards or badges. It may even
hinder the therapeutic process since recovering from depression is not as easy as
achieving a badge. Getting a compliment or motivational words upon achieving a
goal are worthy alternatives.

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124 A Mobile Application for Depression (TOTEM): Early Client Involvement
Ranking and group goals. Both are more prone to have a negative effect
because clients may start comparing themselves to each other, which can potentially
be demotivating. Furthermore, this causes intrinsic motivation to diminish, making
relapse more likely.
Online forum. This could be interesting, but the therapists were wondering
to what extent it will be feasible. After all, such a forum must be heavily monitored
and moderated to prevent the spreading of negative and/or false information.
Score for social activity. Both therapists agreed that a score for social
activity is a delicate matter. On the one hand, it may lead to stress because one wants
to get as high a score as possible, which can negatively influence recovery. On the
other hand, just because someone has had many social contacts does not mean that
they were enjoyable or meaningful. Therefore, currently, it seems better to refrain
from such a score in the report.
Discussion
The current study served as a first step in the co-creation development
process of TOTEM, in which clients with depression and psychologists evaluated
the usefulness of the HTB application and feedback report aimed at increasing travel-
related physical activity for depression. Participants were enthusiastic about the
application and perceived the app as user-friendly, relevant, clear, useful, and
attractive. Among others, it was indicated that the application should supplement
standard care (e.g., weekly consultations). It would encourage people to engage in
more activities, and most individuals would be interested in using the app as an
external motivator. However, emotional aspects were currently underemphasized in
the app (e.g., assessment of feelings). Increased tailoring and appropriately dosed
push notifications would be useful as well. Most participants were also quite
enthusiastic about the feedback report. Participants did indicate that the report should
be better tailored to depression. For example, the psycho-education currently offered
too much physical aspects instead of mental health and social activities.
Nevertheless, participants perceived the feedback report as clear, useful, and
relevant. About half of the participants thought that the feedback report could take
phases of depression recovery into account, e.g., too much information for the early
phases. Similarly, experts also stressed that in case the application and feedback
report would be used in therapy, the counseling should be tailored towards different
phases of depression recovery.
The results mainly hinged toward the usefulness of TOTEM as an external
motivator. That being said, functionalities offered in the platform are aimed at
developing intrinsic motivation over time (e.g., goal-setting, scaffolding, choice
options, therapeutic alliance, opportunities for social activities), targeting the needs
forwarded by the self-determination theory (SDT). This theory posits a continuum

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of motivation, ranging from extrinsically controlled types of motivation to self-
directed or ‘intrinsic’ motivation. Intrinsic motivation is driven by self-awareness
and elicits inherent satisfaction, resulting in more sustained behavior change. In
contrast, extrinsic motivation is more driven by an instrumental orientation, resulting
in less stable behavior change (Kushnir et al., 2016), for detailed categories and a
test of the continuum structure, see Howard et al. 2017 (Howard et al., 2017). In
addition to motivational profiles, SDT posits three basic intrinsic needs that operate
as motivational resources: 1) Need for competence: feelings of success and
efficiency, 2) Need for autonomy: psychological (or decision) freedom and volition,
acting without pressure or enforcement from an external source (or task
meaningfulness), and 3) Need for social relatedness: belonging, attachment, and care
with respect to significant others or a group (Sailer et al., 2017). Indeed, TOTEM is
an elaborate extension of HTB. For instance, by allowing clients to add planned
social activities and the person(s) that accompanied them during that activity.
Moreover, it will proactively encourage clients to perform social activities, e.g., in
the form of JITAI. Actual user experience with the HTB application and feedback
report, as a component of TOTEM, could have offered the opportunity for candidate
users to experience the potential for increasing developing and/or increasing levels
of intrinsic motivation as well, besides external motivation.
By demonstrating the potential of increasing travel-related physical activity
as an addition to standard care for depression, the current study showed promise for
the use of TOTEM, which builds further on this by incorporating principles of CBT
and behavioral activation, digital phenotyping, and JITAI into a blended care format.
In its current form, TOTEM is especially applicable for (young) adults with an
affinity for technology. Although this group is highly relevant due to its presence in
the labor market, other target populations may benefit less from the platform in its
current format. For instance, with coming age, elderly are prone to (mental) health
issues and require enhanced support that may go beyond the care that health care
professionals can provide (Lara et al., 2020; Messner et al., 2019). Therefore, once
established in its current format, TOTEM should also target the older adults, for
instance, by using different designs or incorporating technology training. Another
relevant group that could be targeted is people with low health literacy, who are more
likely to delay or forsake appropriate care (Levy & Janke, 2016).
TOTEM is currently aimed at secondary care, with psychologists, among
others, using the application to supplement their current practice. A challenge for
wider implementation of TOTEM in secondary care consists of sufficient adoption
by the practitioners. Therefore, future research on the effectiveness of TOTEM is
essential. The same goes for general practitioners, who would now serve as
gatekeepers that guide patients with depressive symptoms to respective caretakers
that implement the platform, instead of relying on psycho-pharmacology as the first
line of defense. However, TOTEM could be used for primary care as well, when it
would be widely distributed as a standalone application for mild depressive
symptoms that goes beyond standard psycho-education. General practitioners would

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126 A Mobile Application for Depression (TOTEM): Early Client Involvement
then recommend the platform directly, without intervention by a therapist.
Nevertheless, care should be taken in case that those requiring additional support
(i.e., with indications of moderate to severe symptoms) would still be referred to a
clinician for help. Although not entirely ruled-out for the future, plans for use in
tertiary care are not being made so far.
Limitations
The current study consists of a first step in the development process of
TOTEM, which is subjected to co-creation and extensive future testing. Current
ideas, efforts, and results are preliminary, and more theorizing, development, and
research should be implemented before the contribution of TOTEM to standard care
receives the required empirical support. Due to Covid-19, we made use of online
interviews. Although a recommended method during lockdowns (Moises &
Torrentina, 2020), which was already becoming mainstream before that time
(O’Connor & Madge, 2017), there are some downsides to it (e.g., technical issues,
more distance between interviewee and researcher) (O’Connor & Madge, 2017).
Moreover, we used a semi-structured interview guide covering predefined topics,
which could have hindered participants from spontaneously providing new topics
(Dirix et al., 2022).
Conclusions
Both end-users and experts considered an application with a feedback report
to monitor and improve travel-related physical activity as a valuable addition to
standard care for depression. Clearly, the application needs to be tailored towards
people with depression (e.g., more focus on other activities than physical activities)
and cannot be used as a standalone application. Ecological momentary assessment
could increase attention for feelings and emotions. The current insights will be
applied to the TOTEM platform that additionally incorporates principles of CBT and
BA, together with digital phenotyping and JIAI, after which it will be subjected to
further co-creation before implementation.
Authors’ note
Veerle Ross https://orcid.org/0000-0002-7830-7892
Kris Brijs https://orcid.org/0000-0002-1542-5496
Hélène Dirix https://orcid.org/0000-0001-7652-1070
Geert Wets https://orcid.org/0000-0002-5485-9705

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A Mobile Application for Depression (TOTEM): Early Client Involvement 127
An Neven https://orcid.org/0000-0003-0165-1799
Yves Vanrompay https://orcid.org/0000-0002-4208-5925
Neree Claes https://orcid.org/0000-0003-2887-380X
Declarations: The authors declare that there is no conflict of interest is.
The current received IOF POC funding (grant number: IOF19-POC-002).
Acknowledgments: The study was approved by the Social-Societal Ethics
Committee (SSEC) at Hasselt University (REC/SMEC/VRAI/190/124). The authors
would like to thank the clients and therapists who participated in the current study.
They would also like to thank Xante Janssens, Dries Knuts and Jelte Huibers for
transcribing the interviews. Moreover, they would like to thank Lies De Deygere for
her assistance with editorial changes.
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Attachment 1. Semi-structured Interview Guide
Topic List
1) General: first impression after the demonstration
2) HTB-app
3) Feedback report
4) Closing questions
General Questions
Before we start the interview about the app and the feedback report, I’m going to give you
some information and ask some general questions.
 Remember that you have signed an informed consent. You have the right to stop the
interview at any time. Can you verbally confirm if you agree to the use and
processing of your data, anonymously of course.
 The interview will be about the app and the feedback report of which you just got a
presentation. Was everything clear in the presentation? If you have any questions,
you can ask them now or during the interview. There are no right or wrong answers
to the questions. If you want to give a negative answer about the app in the feedback
report, this can be done. We learn the most from honest answers. This will not affect
anything such as the therapy, availability of the app in the long term, etc.
 Can you briefly introduce yourself? Do you use the smartphone a lot, do you know
anything about apps, what do you use the smartphone for, etc.
 What is your reason/motivation for participating?
 What do you hope the app could have done for you during your depression? (if
difficult question, it will be asked again later on in the interview).
Questions related to the Health & Travel Behavior (HTB) application and feedback report
Questions related to the application. This part of the interview is mainly focused on
the HTB app, so try to answer the questions from this perspective as well. The feedback
report will be discussed in a subsequent section. If during the interview you suddenly
come up with something about the feedback report, this can of course be mentioned and
you do not have to wait until the next part. (show slide 9)
 Overall, what is your first impression about the app?
o Score between 0 and 10?
o What is the reason for giving this particular score?
 If the app is available, would you like to use the app yourself? Why/why not?
 What would be the main reason(s) for you to start using the app?
 When do you have expectations for a human interaction? When do you think this is
desirable? Or do you prefer to keep this anonymous and independent.
 You just saw some sample screens of the app in the presentation. Did you find this
attractive enough? Did they speak to you?
 While seeing the images, did the app seem clear to you? What was clear/what was
unclear?
 Is the app clear?
 After an initial introduction, how user-friendly does the app seem to you?

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134 A Mobile Application for Depression (TOTEM): Early Client Involvement
 Do you think it’s okay that you still have to fill in things yourself and that this can
only be done a day later?
 Is it necessary to adapt the layout to people with depression? Because of cognitive
complaints. Do you have tips?
o May also depend on the phase of recovery from depression: onset, improvement,
recovery
 Does it seem realistic to you to fill in all the requested information? Depending on
the phase you are in: start, improvement, recovery.
 Do you think that the app can be useful for people with depression? Why/why not?
 Behavioral activation is difficult with depression, how could the app help?
o Would a buddy system be useful for that activation (therapist, fellow patient,
…)? If so, who should that buddy be?
 This app was originally developed for cardio patients and is therefore also designed
from this perspective. When we now look at depression from the point of view, are
there things that you think are missing or that need to be adjusted?
 The recovery from depression follows a certain course: onset, improvement,
recovery. Do you have the feeling that you need different things from the app in the
different phases? For example: in an initial phase where there are still many
complaints or in a subsequent phase where you already know some recovery but still
need guidance.
 Which useful therapist interventions do you think could be digitized?
 Did you find the app sufficiently customizable to personal preferences? Why/why
not?
 Do you have any comments to improve the app?
Questions related to the feedback report. This part of the interview focuses mainly on the
feedback report, so try to answer the questions from this perspective as well. If during the
interview you suddenly come up with something about the HTB app, this can of course be
mentioned, so it does not matter that we are already went over this part.
 Overall, what is your first impression about the feedback report?
o Score between 0 and 10?
o What is the reason for giving this particular score?
 What do you think of the content of the feedback report?
 Would the feedback report motivate you enough to increase the number of physical
activities that you perform?
 Behavioral activation is difficult with depression, how could the feedback report
help?
o Would a buddy system be useful for that activation (therapist, fellow patient,
…)? If so, who should that buddy be?
 If you used the app, would you actively use the feedback report? For example:
follow the recommendations, read quotes, etc. Do you have suggestions that could
motivate?
 You saw some examples from the feedback report in the presentation. Did you find
this attractive enough? Did they speak to you?
 When you saw the images, did the report seem clear to you? What was clear/unclear?

Articles Section
A Mobile Application for Depression (TOTEM): Early Client Involvement 135
 Do you think that the use of the feedback report can be useful for people with
depression problems? Why/why not?
 If not useful, what should be changed to make the report useful for people with
depression?
 As already mentioned, everything was originally developed for people with heart
problems and is therefore also based on this approach. Looking now from the
standpoint of depression issues, are there things that you think are missing or need
to be changed from the feedback report?
 The recovery from depression has a certain course: beginning, improvement,
recovery. Do you feel that you need different things from the feedback report in the
different phases? For example: in an initial phase where there are still many
complaints or in a post-phase where you already know some recovery but guidance
is still needed.
 Nowadays, a lot of attention goes to the concept of ‘gamification’. Gamification is
the application of game principles and techniques in a non-gaming context. I am
now going to give some examples that could possibly be used in the future, you can
then indicate what you think of each example:
o Possibility of rewards (financial, material, badge, points, …)
o Challenges
o Leaderboard (anonymous)
o Personal progress: graph with evolution over time
o Working around group goals
o Tips and advice that can be exchanged through a forum.
 The ATS score concerns movement. To tackle depression, the focus should not only
lay on being physically active but also about being socially active. This currently
receives little attention in the app. The ‘pointer for exercise’, what would this look
like for social activity?
 Currently, the feedback report is being sent by e-mail. Are you satisfied with this or
would you like to see an adjustment?
 How often would you like to receive a feedback report?
 Do you have any comments to improve the feedback report?
Closing section
We have arrived to the end of the interview. Are there any topics or things we haven’t
discussed about the app or the feedback report? Or are there other things you would like
to mention?
‘Briefly summarize the interview, thank the participant and ask for feedback on the
interview.’