Barriers and Facilitators of User Engagement With Digital Mental Health Interventions for People With Psychosis or Bipolar Disorder: Systematic Review and Best-Fit Framework Synthesis

BACKGROUND: Digital mental health interventions (DMHIs) to monitor and improve the health of people with psychosis or bipolar disorder show promise; however, user engagement is variable, and integrated clinical use is low. OBJECTIVE: This prospectively registered systematic review examined barriers and facilitators of clinician and patient engagement with DMHIs, to inform implementation within real-world settings. METHODS: A systematic search of 7 databases identified empirical studies reporting qualitative or quantitative data about factors affecting staff or patient engagement with DMHIs aiming to monitor or improve the mental or physical health of people with psychosis or bipolar disorder. The Consolidated Framework for Implementation Research was used to synthesize data on barriers and facilitators, following a best-fit framework synthesis approach. RESULTS: The review included 175 papers (150 studies; 11,446 participants) describing randomized controlled trials; surveys; qualitative interviews; and usability, cohort, and case studies. Samples included people with schizophrenia spectrum psychosis (98/150, 65.3% of studies), bipolar disorder (62/150, 41.3% of studies), and clinicians (26/150, 17.3% of studies). Key facilitators were a strong recognition of DMHIs' relative advantages, a clear link between intervention focus and specific patient needs, a simple, low-effort digital interface, human-supported delivery, and device provision where needed. Although staff thought patients would lose, damage, or sell devices, reviewed studies found only 11% device loss. Barriers included intervention complexity, perceived risks, user motivation, discomfort with self-reflection, digital poverty, symptoms of psychosis, poor compatibility with existing clinical workflows, staff and patient fears that DMHIs would replace traditional face-to-face care, infrastructure limitations, and limited financial support for delivery. CONCLUSIONS: Identified barriers and facilitators highlight key considerations for DMHI development and implementation. As to broader implications, sustainable business models are needed to ensure that evidence-based DMHIs are maintained and deployed. TRIAL REGISTRATION: PROSPERO CRD42021282871; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=282871.