Between Rhetoric and Reality: Real-world Barriers to Uptake and Early Engagement in Digital Mental Health Interventions

Digital mental health interventions (DMHIs) have potential to provide effective and accessible care to entire populations, but low client uptake and engagement are significant problems. Few prior studies explore the lived experiences of non-engagers, because reaching this population is inherently difficult. We present an observational inquiry into the barriers to sign-up and early use of a DMHI, along with reasons for initial interest in the DMHI. We collected 205 online questionnaire responses and 20 interviews from self-referring participants across four healthcare ecosystems in the UK and US. Questionnaire results revealed that uncertainty about DMHI usefulness and usability were the main barriers to uptake, whereas forgetting about it, not finding time for it and not finding it useful were the main barriers to early engagement. Participants reported multiple reasons for considering the DMHI, reflecting the contextual, subjective nature of mental health. Our thematic analysis generated themes around (1) the need for human connection, (2) the impact of self-stigma on help-seeking, (3) the lack of knowledge around DMHIs and psychological therapy, (4) the desire for personally relevant care, and (5) the fluctuating, perennial nature of mental health. We discuss implications for DMHI design, implementation and future research, as well as transdisciplinary opportunities.