Author ORCID Identifier

Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Page L. Anderson

Second Advisor

Amanda Gilmore

Third Advisor

Laura McKee

Fourth Advisor

Emily Lattie


This European-style dissertation examines strategies to improve user attitudes, encourage uptake, and evaluate user engagement for digital mental health interventions. This research is discussed in the context of efforts to successfully design, implement, and sustain digital mental health services in clinical settings. In the first chapter, I discuss the need for digital mental health interventions and strategies to implement them sustainably. This includes the burden of mental illness in the United States, poor access to traditional mental health treatment, the efficacy of digital mental health interventions, and challenges in implementation. In the second chapter, I present an experimental study that examined the effect of a treatment rationale and financial incentive on acceptability and uptake-related behavior for Internet-based cognitive behavioral therapy. This study found that a treatment rationale significantly improves acceptability for these programs, whereas a treatment rationale and small financial incentive did not significantly impact uptake-related behavior. This study addresses the need to improve participant attitudes toward Internet-based treatment, as studies have found low acceptability for these programs. In the third chapter, I present a follow-up study that examined the effect of a treatment rationale on attitudes toward Internet-based cognitive behavioral therapy in May through July 2020, during the COVID-19 pandemic. This study found that a treatment rationale improved acceptability, but not more so during the pandemic as compared to before the pandemic. This study addresses the need to examine the influence of individual context and experiences with the COVID-19 pandemic as they relate to perceptions of digital mental health programs. In the fourth chapter, I present a systematic review of the ways that user engagement is operationalized in clinical trials of mobile health interventions for depression. This review found that many clinical trials report engagement, but that there is a wide variety in engagement reporting and significant opportunities for improvement. This area of research is important because theoretical frameworks for implementation of digital mental health interventions call for ongoing evaluation of user engagement. In the final chapter, I discuss implications of this research, contextualize it in the literature on digital mental health, and make recommendations for future research.


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