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Background: Body dysmorphic disorder (BDD) is an often chronic and impairing psychiatric condition. Research shows that smartphone-delivered cognitive behavior therapy (CBT) with coaching may be a scalable and effective treatment for BDD. However, evidence for long-term gain maintenance is limited., Objectives: The aim of the current study was to examine the long-term outcomes of a smartphone-based CBT for BDD., Method: Adults with a primary diagnosis of BDD who completed a 12-week course of smartphone-delivered CBT with coach support were evaluated 3- and 12-months posttreatment. Symptom severity, remission and responder status were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale modified for BDD (BDD-YBOCS). Secondary outcomes were also evaluated and included BDD-related insight, depression, functioning and quality of life. Data were analyzed using four different approaches to missing data, with maximum likelihood estimation as the main approach., Results: There was significant attrition from posttreatment ( n  = 57) to 3-month ( n  = 49) and 12-month ( n  = 33) follow-up. The mean BDD-YBOCS severity score remained stable during the follow-up period [Estimated Mean (SE) at posttreatment, 3-months, and 12-months = 18.7(1.1), 18.9(1.2) and 18.8(1.3), respectively]. The proportion of participants responding to treatment and in remission remained relatively unchanged as well (63 % responders and 46 % remitters at posttreatment, 54 % and 35 % at 3-month follow-up, and 61 % and 37 % at 12-month follow-up, respectively). Posttreatment gains in BDD-related insight, functioning, and quality of life were maintained; there were small increases in depression (ES = 0.36) from posttreatment to 12-month follow-up., Conclusions: Improvements after coach-supported smartphone-based CBT for BDD are maintained one year after treatment., Competing Interests: Dr. Snorrason, Dr. Hoeppner, Dr. Vanderkruik, Dr. Bernstein, Ms. Berger-Gutierrez and Mr. Klare have received research support from Koa Health. Dr. Weingarden has received research support from Koa Health and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Additionally, Dr. Weingarden has a consulting agreement with Hello Therapeutics, Inc. Dr. Greenberg has received research support from Koa Health and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has also received speaking honoraria from L'Oreal (SkinCeuticals) and RBC Consultants (CeraVe) and honoraria for advisory board participation from RBC Consultants (CeraVe). Dr. Bernstein has received research support from Koa Health, and is on the advisory board for AugMend Health, Inc., and is a consultant for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. Wilhelm has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America and the Centers for Disease Control and Prevention, and from NAMI (National Alliance on Mental Illness). In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc. for her role as Associate Editor on the journal Depression & Anxiety. Dr. Wilhelm has also received honoraria from One-Mind for her role in PsyberGuide Scientific Advisory Board. Dr. Wilhelm is also on the Scientific Advisory Board for Koa Health, Inc. and for Noom, Inc. Dr. Wilhelm has received research support from Koa Health, Inc. Dr. Harrison is Founder/CEO of Koa Health Limited, a digital mental health company that collaborated with Dr. Wilhelm and her team at MGH to build Perspectives. Dr. Harrison also serves on the WHO Roster of Experts for Digital Health, sits on the Board of EMPOWER (a non-profit organization promoting the training of community health workers to provide mental healthcare), is a member of the Expert Panel for implementing the Wellcome Trust's mental health strategy, and is The Royal Society Entrepreneur in Residence in Healthcare AI at Oxford University., (© 2025 The Authors.)

Background: Body dysmorphic disorder (BDD) is severe and undertreated. Digital mental health could be key to expanding access to evidence-based treatments, such as cognitive behavioral therapy for BDD (CBT-BDD). Coach guidance is posited to be essential for effective uptake of digital interventions. However, little is known about how different patients may use coaching, what patterns correspond to meaningful outcomes, and how to match coaching to patient needs., Methods: Participants were 77 adults who received a 12-week guided smartphone CBT-BDD. Bachelor's-level coaches were available via asynchronous messaging. We analyzed the 400 messages sent by users to coaches during treatment. Message content was coded using the efficiency model of support (i.e., usability, engagement, fit, knowledge, and implementation). We aimed to clarify when and for what purposes patients with BDD used coaching, and if we can meaningfully classify patients by these patterns. We then assessed potential baseline predictors of coach usage, and whether distinct patterns relate to clinical outcomes., Results: Users on average sent 5.88 messages (SD = 4.51, range 1-20) and received 9.84 (SD = 5.74, range 2-30). Regarding frequency of sending messages, latent profile analysis revealed three profiles, characterized by: (1) peak mid-treatment (16.88 %), (2) bimodal/more communication early and late in treatment (10.39 %), and (3) consistent low/no communication (72.73 %). Regarding content, four profiles emerged, characterized by mostly (1) engagement (51.95 %), (2) fit (15.58 %), (3) knowledge (15.58 %), and (4) miscellaneous/no messages (16.88 %). There was a significant relationship between frequency profile and age, such that the early/late peak group was older than the low communication group, and frequency profile and adherence, driven by the mid-treatment peak group completing more modules than the low contact group. Regarding content, the engagement and knowledge groups began treatment with more severe baseline symptoms than the fit group. Content profile was associated with dropout, suggesting higher dropout rates in the miscellaneous/no contact group and reduced rates in the engagement group. There was no relationship between profile membership and other outcomes., Discussion: The majority of participants initiated little contact with their coach and the most common function of communications was to increase engagement. Results suggest that older individuals may prefer or require more support than younger counterparts early in treatment. Additionally, whereas individuals using coaching primarily for engagement may be at lower risk of dropping out, those who do not engage at all may be at elevated risk. Findings can support more personalized, data-driven coaching protocols and more efficient allocation of coaching resources., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Bernstein has received research support from Koa Health Digital Solutions LLC. Dr. Bernstein is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Dr. Bernstein has a consulting agreement with Otsuka Pharmaceutical Development & Commercialization, Inc. and is on the Scientific Advisory Board for AugMend Health Inc. Dr. Greenberg has received research support from Koa Health Digital Solutions LLC and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received speaking honoraria from L'Oreal (for a presentation at a SkinCeuticals cosmetic surgery and dermatology conference) and RBC Consultants for the CeraVe Psychodermatology Advisory Board. Dr. Weingarden has received research support from Koa Health Digital Solutions LLC and the National Institute of Mental Health (NIMH) (K23MH119372) and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Dr. Weingarden has a consulting agreement with Hello Therapeutics, Inc. Dr. Snorrason has received research support from Koa Health. Dr. Summers has no potential conflicts to report. Ms. Williams has no potential conflicts to report. Ms. Quist has no potential conflicts to report. Dr. Curtiss has received research support from Koa Health. Dr. Harrison is Founder/CEO of Koa Health, a digital mental health company that collaborated with Dr. Wilhelm and her team at MGH to build Perspectives. Dr. Harrison also serves on the WHO Roster of Experts for Digital Health, sits on the Board of EMPOWER (a non-profit organization promoting the training of community health workers to provide mental healthcare), and is a member of the Expert Panel for implementing the Wellcome Trust's mental health strategy. Dr. Harrison is a Royal Society Entrepreneur in Residence in healthcare AI at Oxford University. Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received royalties from Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America, and the Centers for Disease Control and Prevention. In addition, she received honoraria for her role on the Scientific Advisory Board for One-Mind (PsyberGuide), Koa Health Digital Solutions LLC, and Noom, Inc. Dr. Wilhelm has received research support from Koa Health Digital Solutions LLC., (© 2024 The Authors. Published by Elsevier B.V.)

Smartphone psychotherapies are growing in popularity, yet little is understood about (1) how people prefer to engage with psychotherapy apps, or (2) which engagement patterns constitute effective engagement. The present study uses secondary data from a 12-week randomized waitlist-controlled trial of smartphone-delivered cognitive behavioral therapy (CBT) for body dysmorphic disorder (BDD) ( N  = 77) to address these aims. Additionally, using the present study as a use-case, we seek to provide a roadmap for how researchers may improve upon methodological limitations of existing smartphone psychotherapy engagement research. We measured behavioral engagement via 19 objective variables derived from phone analytics data, which we reduced via factor analysis into two factors: 1) use volume and frequency, and 2) session duration. Cluster analysis based on engagement factors yielded three engager types, which mapped onto "deep" users, "samplers," and "light" users. The clusters did not differ significantly in improvement in BDD severity across treatment, although deep users improved more than light users at a marginally significant level. Results suggest that varying patterns of preferred engagement may be efficacious. Moreover, the study's methods provide an example of how researchers can measure and study behavioral engagement comprehensively and objectively. Trial Registration: ClinicalTrials.gov Identifier: NCT04034693., Competing Interests: Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America, and the Centers For Disease Control and Prevention. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor of the Behavior Therapy journal and John Wiley & Sons, Inc. for her role as Associate Editor of the journal Depression & Anxiety. Dr. Wilhelm has also received honoraria from One-Mind for her role on PsyberGuide Scientific Advisory Board. Dr. Wilhelm is also on the Scientific Advisory Board for Koa Health, Inc. and Noom, Inc. Dr. Wilhelm has received research and salary support from Koa Health, Inc. Dr. Weingarden receives salary support from Koa Health and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Additionally, Dr. Weingarden has a consulting agreement with Hello Therapeutics, Inc. Dr. Greenberg has received salary support from Koa Health and is a presenter for the 10.13039/100005294Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Drs. Hoeppner, Bernstein, and Snorrasson and Ms. Quist receive salary support from Koa Health. Drs. Garriga Calleja and Matic are employees of Koa Health. Dr. Harrison is Founder/CEO of Koa Health, a digital mental health company that collaborated with Dr. Wilhelm and her team at MGH to build Perspectives. Dr. Harrison also serves on the WHO Roster of Experts for Digital Health, sits on the Board of EMPOWER (a non-profit organization promoting the training of community health workers to provide mental healthcare), and is a member of the Expert Panel for implementing the Wellcome Trust's mental health strategy., (© 2023 The Authors. Published by Elsevier B.V.)