Testing the Pragmatic Effectiveness of a Consumer-Based Mindfulness Mobile App in the Workplace: Randomized Controlled Trial

Jennifer L Huberty, Hallie M Espel-Huynh, Taylor L Neher, Megan E Puzia, Jennifer L Huberty, Hallie M Espel-Huynh, Taylor L Neher, Megan E Puzia

Abstract

Background: Mental health and sleep problems are prevalent in the workforce, corresponding to costly impairment in productivity and increased health care use. Digital mindfulness interventions are efficacious in improving sleep and mental health in the workplace; however, evidence supporting their pragmatic utility, potential for improving productivity, and ability to reduce employer costs is limited.

Objective: This pragmatic, cluster randomized controlled trial aimed to evaluate the experimental effects of implementing a commercially available mindfulness app-Calm-in employees of a large, multisite employer in the United States. Outcomes included mental health (depression, anxiety, and stress), sleep (insomnia and daytime sleepiness), resilience, productivity impairment (absenteeism, presenteeism, overall work impairment, and non-work activity impairment), and health care use (medical visit frequency).

Methods: Employees were randomized at the work site to receive either the Calm app intervention or waitlist control. Participants in the Calm intervention group were instructed to use the Calm app for 10 minutes per day for 8 weeks; individuals with elevated baseline insomnia symptoms could opt-in to 6 weeks of sleep coaching. All outcomes were assessed every 2 weeks, with the exception of medical visits (weeks 4 and 8 only). Effects of the Calm intervention on outcomes were evaluated via mixed effects modeling, controlling for relevant baseline characteristics, with fixed effects of the intervention on outcomes assessed at weeks 2, 4, 6, and 8. Models were analyzed via complete-case and intent-to-treat analyses.

Results: A total of 1029 employees enrolled (n=585 in the Calm intervention group, including 101 who opted-in to sleep coaching, and n=444 in waitlist control). Of them, 192 (n=88 for the Calm intervention group and n=104 for waitlist) completed all 5 assessments. In the complete-case analysis at week 8, employees at sites randomized to the Calm intervention group experienced significant improvements in depression (P=.02), anxiety (P=.01), stress (P<.001), insomnia (P<.001), sleepiness (P<.001), resilience (P=.02), presenteeism (P=.01), overall work impairment (P=.004), and nonwork impairment (P<.001), and reduced medical care visit frequency (P<.001) and productivity impairment costs (P=.01), relative to the waitlist control. In the intent-to-treat analysis at week 8, significant benefits of the intervention were observed for depression (P=.046), anxiety (P=.01), insomnia (P<.001), sleepiness (P<.001), nonwork impairment (P=.04), and medical visit frequency (P<.001).

Conclusions: The results suggest that the Calm app is an effective workplace intervention for improving mental health, sleep, resilience, and productivity and for reducing medical visits and costs owing to work impairment. Future studies should identify optimal implementation strategies that maximize employee uptake and large-scale implementation success across diverse, geographically dispersed employers.

Trial registration: ClinicalTrials.gov NCT05120310; https://ichgcp.net/clinical-trials-registry/NCT05120310.

Keywords: mental health; mindfulness; mobile apps; presenteeism; workforce; workplace.

Conflict of interest statement

Conflicts of Interest: JLH and HME-H disclose that they receive an annual salary from the Calm app and hold stock within the company. However, their salary and equity are not dependent on the results of their research. MEP discloses that she is a paid contractor (ie, research coordinator) of the Calm app.

©Jennifer L Huberty, Hallie M Espel-Huynh, Taylor L Neher, Megan E Puzia. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 28.09.2022.

Figures

Figure 1
Figure 1
CONSORT (Consolidated Standards of Reporting Trials) diagram of study participation and analyzed data. *Note that participants may have been ineligible for more than one reason, all of which are reflected here. During the trial, participants could complete a subsequent assessment even if they missed a prior one.
Figure 2
Figure 2
Estimated marginal means indicating group differences in changes in mental health outcomes over time among study completers. *P<.05; **P<.01; ***P<.001. DASS-21: Depression Anxiety Stress Scale-21 item.
Figure 3
Figure 3
Estimated marginal means indicating group differences in changes in sleep outcomes over time among study completers. *P<.05; **P<.01; ***P<.001. ESS: Epworth Sleepiness Scale; ISI: Insomnia Severity Index.
Figure 4
Figure 4
Estimated marginal means indicating group differences in absenteeism and presenteeism over time among study completers. *P<.05; **P<.01; ***P<.001. WPAI: work productivity and activity impairment.
Figure 5
Figure 5
Estimated marginal means indicating group differences in changes in work and nonwork activity impairment over time among study completers. *P<.05; **P<.01; ***P<.001. WPAI: work productivity and activity impairment.
Figure 6
Figure 6
Estimated marginal means indicating group differences in costs of work impairment over time among study completers.
Figure 7
Figure 7
Average Calm app use per employee per week during the intervention period. This figure depicts the overall app use data (use of any component of the app), as well as the use of the most popular components. Less used components are not included in the figure such that the sum of the components presented does not encompass all app use.

References

    1. Terlizzi EP, Villarroel MA. Centers for Disease Control and Prevention. Hyattsville, MD, USA: National Center for Health Statistics; 2020. Sep, [2022-04-15]. Symptoms of generalized anxiety disorder among adults: United States, 2019. .
    1. Brody D, Pratt L, Hughes J. Centers for Disease Control and Prevention. Hyattsville, MD, USA: National Center for Health Statistics; 2018. Feb, [2022-04-15]. Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013–2016.
    1. Cooke JE, Eirich R, Racine N, Madigan S. Prevalence of posttraumatic and general psychological stress during COVID-19: a rapid review and meta-analysis. Psychiatry Res. 2020 Oct;292:113347. doi: 10.1016/j.psychres.2020.113347. S0165-1781(20)32644-5
    1. Kessler RC. Epidemiology of women and depression. J Affect Disord. 2003 Mar;74(1):5–13. doi: 10.1016/s0165-0327(02)00426-3.S0165032702004263
    1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617–27. doi: 10.1001/archpsyc.62.6.617. 62/6/617
    1. Ferrie JE, Kumari M, Salo P, Singh-Manoux A, Kivimäki M. Sleep epidemiology--a rapidly growing field. Int J Epidemiol. 2011 Dec;40(6):1431–7. doi: 10.1093/ije/dyr203. dyr203
    1. Hammen C, Kim EY, Eberhart NK, Brennan PA. Chronic and acute stress and the prediction of major depression in women. Depress Anxiety. 2009;26(8):718–23. doi: 10.1002/da.20571.
    1. Miloyan B, Joseph Bienvenu O, Brilot B, Eaton WW. Adverse life events and the onset of anxiety disorders. Psychiatry Res. 2018 Jan;259:488–92. doi: 10.1016/j.psychres.2017.11.027. S0165-1781(17)30520-6
    1. Fan LB, Blumenthal JA, Watkins LL, Sherwood A. Work and home stress: associations with anxiety and depression symptoms. Occup Med (Lond) 2015 Mar;65(2):110–6. doi: 10.1093/occmed/kqu181. kqu181
    1. Haddadi P, Besharat MA. Resilience, vulnerability and mental health. Procedia Soc Behav Sci. 2010;5:639–42. doi: 10.1016/j.sbspro.2010.07.157.
    1. Horenstein A, Heimberg RG. Anxiety disorders and healthcare utilization: a systematic review. Clin Psychol Rev. 2020 Nov;81:101894. doi: 10.1016/j.cpr.2020.101894.S0272-7358(20)30082-9
    1. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003 Aug 01;54(3):216–26. doi: 10.1016/s0006-3223(03)00273-7.S0006322303002737
    1. Novak M, Mucsi I, Shapiro CM, Rethelyi J, Kopp MS. Increased utilization of health services by insomniacs--an epidemiological perspective. J Psychosom Res. 2004 May;56(5):527–36. doi: 10.1016/j.jpsychores.2004.02.007.S0022399904000248
    1. Birnbaum HG, Kessler RC, Kelley D, Ben-Hamadi R, Joish VN, Greenberg PE. Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. Depress Anxiety. 2010;27(1):78–89. doi: 10.1002/da.20580.
    1. Marciniak M, Lage MJ, Landbloom RP, Dunayevich E, Bowman L. Medical and productivity costs of anxiety disorders: case control study. Depress Anxiety. 2004;19(2):112–20. doi: 10.1002/da.10131.
    1. Rosekind MR, Gregory KB, Mallis MM, Brandt SL, Seal B, Lerner D. The cost of poor sleep: workplace productivity loss and associated costs. J Occup Environ Med. 2010 Jan;52(1):91–8. doi: 10.1097/JOM.0b013e3181c78c30.
    1. Evans-Lacko S, Knapp M. Global patterns of workplace productivity for people with depression: absenteeism and presenteeism costs across eight diverse countries. Soc Psychiatry Psychiatr Epidemiol. 2016 Nov;51(11):1525–37. doi: 10.1007/s00127-016-1278-4. 10.1007/s00127-016-1278-4
    1. Bartlett L, Martin A, Neil AL, Memish K, Otahal P, Kilpatrick M, Sanderson K. A systematic review and meta-analysis of workplace mindfulness training randomized controlled trials. J Occup Health Psychol. 2019 Mar;24(1):108–26. doi: 10.1037/ocp0000146.2019-05630-002
    1. Lomas T, Medina JC, Ivtzan I, Rupprecht S, Hart R, Eiroa-Orosa FJ. The impact of mindfulness on well-being and performance in the workplace: an inclusive systematic review of the empirical literature. Eur J Work Organ Psychol. 2017 Apr 19;26(4):492–513. doi: 10.1080/1359432x.2017.1308924.
    1. Lomas T, Medina JC, Ivtzan I, Rupprecht S, Eiroa-Orosa FJ. Mindfulness-based interventions in the workplace: an inclusive systematic review and meta-analysis of their impact upon wellbeing. J Positive Psychol. 2019;14(5):625–40. doi: 10.1080/17439760.2018.1519588.
    1. Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194–200. doi: 10.1080/10705500802222972.901471909
    1. Vonderlin R, Biermann M, Bohus M, Lyssenko L. Mindfulness-based programs in the workplace: a meta-analysis of randomized controlled trials. Mindfulness. 2020 Mar 02;11(7):1579–98. doi: 10.1007/s12671-020-01328-3.
    1. Sheerin CM, Lind MJ, Brown EA, Gardner CO, Kendler KS, Amstadter AB. The impact of resilience and subsequent stressful life events on MDD and GAD. Depress Anxiety. 2018 Feb;35(2):140–7. doi: 10.1002/da.22700.
    1. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993 Nov;4(5):353–65. doi: 10.2165/00019053-199304050-00006.
    1. Johnson JR, Emmons HC, Rivard RL, Griffin KH, Dusek JA. Resilience training: a pilot study of a mindfulness-based program with depressed healthcare professionals. Explore (NY) 2015;11(6):433–44. doi: 10.1016/j.explore.2015.08.002.S1550-8307(15)00146-9
    1. Bartlett L, Lovell P, Otahal P, Sanderson K. Acceptability, feasibility, and efficacy of a workplace mindfulness program for public sector employees: a pilot randomized controlled trial with informant reports. Mindfulness. 2017;8(3):639–54. doi: 10.1007/s12671-016-0643-4.
    1. Wolever RQ, Bobinet KJ, McCabe K, Mackenzie ER, Fekete E, Kusnick CA, Baime M. Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. J Occup Health Psychol. 2012 Apr;17(2):246–58. doi: 10.1037/a0027278.2012-04383-001
    1. Bartlett L, Martin AJ, Kilpatrick M, Otahal P, Sanderson K, Neil AL. Effects of a mindfulness app on employee stress in an Australian public sector workforce: randomized controlled trial. JMIR Mhealth Uhealth. 2022 Feb 10;10(2):e30272. doi: 10.2196/30272. v10i2e30272
    1. Cherniack M, Lahiri S. Barriers to implementation of workplace health interventions: an economic perspective. J Occup Environ Med. 2010 Sep;52(9):934–42. doi: 10.1097/JOM.0b013e3181f26e59.
    1. Hannon PA, Hammerback K, Garson G, Harris JR, Sopher CJ. Stakeholder perspectives on workplace health promotion: a qualitative study of midsized employers in low-wage industries. Am J Health Promot. 2012;27(2):103–10. doi: 10.4278/ajhp.110204-QUAL-51.
    1. Ilvig PM, Bredahl TV, Justesen JB, Jones D, Lundgaard JB, Søgaard K, Christensen JR. Attendance barriers experienced by female health care workers voluntarily participating in a multi-component health promotion programme at the workplace. BMC Public Health. 2018 Dec 04;18(1):1340. doi: 10.1186/s12889-018-6254-3. 10.1186/s12889-018-6254-3
    1. Bostock S, Crosswell AD, Prather AA, Steptoe A. Mindfulness on-the-go: effects of a mindfulness meditation app on work stress and well-being. J Occup Health Psychol. 2019 Mar;24(1):127–38. doi: 10.1037/ocp0000118. 2018-19565-001
    1. Falcone G, Jerram M. Brain activity in mindfulness depends on experience: a meta-analysis of fMRI studies. Mindfulness. 2018 Feb 2;9(5):1319–29. doi: 10.1007/s12671-018-0884-5.
    1. Haahr M. : True random number service. . 2022. [2021-08-01]. .
    1. Bower JE, Irwin MR. Mind-body therapies and control of inflammatory biology: a descriptive review. Brain Behav Immun. 2016 Jan;51:1–11. doi: 10.1016/j.bbi.2015.06.012. S0889-1591(15)00165-8
    1. Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008 Mar;31(1):23–33. doi: 10.1007/s10865-007-9130-7.
    1. Gethin R. The Foundations of Buddhism. Oxford, UK: Oxford University Press; 1998.
    1. Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol. 2005 Jun;44(Pt 2):227–39. doi: 10.1348/014466505X29657.
    1. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scale. Sydney, Australia: Psychology Foundation; 1995.
    1. Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001 Jul;2(4):297–307. doi: 10.1016/s1389-9457(00)00065-4.S1389945700000654
    1. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540–5. doi: 10.1093/sleep/14.6.540.
    1. Kendzerska TB, Smith PM, Brignardello-Petersen R, Leung RS, Tomlinson GA. Evaluation of the measurement properties of the Epworth sleepiness scale: a systematic review. Sleep Med Rev. 2014 Aug;18(4):321–31. doi: 10.1016/j.smrv.2013.08.002.S1087-0792(13)00088-9
    1. Karmiloff-Smith A. Beyond Modularity: A Developmental Perspective on Cognitive Science. Cambridge, MA, USA: MIT Press; 1992.
    1. Lofland JH, Pizzi L, Frick KD. A review of health-related workplace productivity loss instruments. Pharmacoeconomics. 2004;22(3):165–84. doi: 10.2165/00019053-200422030-00003.2233
    1. Ferrari MD. The economic burden of migraine to society. Pharmacoeconomics. 1998 Jun;13(6):667–76. doi: 10.2165/00019053-199813060-00003.
    1. Huberty JL, Green J, Puzia ME, Larkey L, Laird B, Vranceanu AM, Vlisides-Henry R, Irwin MR. Testing a mindfulness meditation mobile app for the treatment of sleep-related symptoms in adults with sleep disturbance: a randomized controlled trial. PLoS One. 2021 Jan 7;16(1):e0244717. doi: 10.1371/journal.pone.0244717. PONE-D-20-19805
    1. Nakada Y, Sugimoto A, Kadotani H, Yamada N. Verification of effect of sleep health education program in workplace: a quasi-randomized controlled trial. Ind Health. 2018 Mar 07;56(1):20–9. doi: 10.2486/indhealth.2017-0022. doi: 10.2486/indhealth.2017-0022.
    1. Bostock S, Luik A, Espie C. Sleep and productivity benefits of digital cognitive behavioral therapy for insomnia: a randomized controlled trial conducted in the workplace environment. J Occup Environ Med. 2016 Jul;58(7):683–9. doi: 10.1097/JOM.0000000000000778.
    1. Vanhove AJ, Herian MN, Perez AL, Harms PD, Lester PB. Can resilience be developed at work? A meta-analytic review of resilience-building programme effectiveness. J Occup Organ Psychol. 2016 Jun;89(2):278–307. doi: 10.1111/joop.12123.
    1. McCoy E. Understanding the intention-to-treat principle in randomized controlled trials. West J Emerg Med. 2017 Oct;18(6):1075–8. doi: 10.5811/westjem.2017.8.35985. wjem-18-1075
    1. Chakraborty H, Gu H. A Mixed Model Approach for Intent-to-Treat Analysis in Longitudinal Clinical Trials with Missing Values. Research Triangle Park, NC, USA: RTI Press; 2009.
    1. Xi W, Pennell ML, Andridge RR, Paskett ED. Comparison of intent-to-treat analysis strategies for pre-post studies with loss to follow-up. Contemp Clin Trials Commun. 2018 Sep;11:20–9. doi: 10.1016/j.conctc.2018.05.008. S2451-8654(17)30194-1
    1. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Mahwah, NJ, USA: Lawrence Earlbaum Associates; 1969.
    1. Feingold A. Effect sizes for growth-modeling analysis for controlled clinical trials in the same metric as for classical analysis. Psychol Methods. 2009 Mar;14(1):43–53. doi: 10.1037/a0014699. 2009-02702-003
    1. Fang H, Tu S, Sheng J, Shao A. Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019 Apr;23(4):2324–32. doi: 10.1111/jcmm.14170. doi: 10.1111/jcmm.14170.
    1. Yap Y, Slavish DC, Taylor DJ, Bei B, Wiley JF. Bi-directional relations between stress and self-reported and actigraphy-assessed sleep: a daily intensive longitudinal study. Sleep. 2020 Mar 12;43(3):zsz250. doi: 10.1093/sleep/zsz250. 5586815
    1. Huberty J, Puzia ME, Green J, Vlisides-Henry RD, Larkey L, Irwin MR, Vranceanu A. A mindfulness meditation mobile app improves depression and anxiety in adults with sleep disturbance: analysis from a randomized controlled trial. Gen Hosp Psychiatry. 2021;73:30–7. doi: 10.1016/j.genhosppsych.2021.09.004. S0163-8343(21)00132-8
    1. Jamieson SD, Tuckey MR. Mindfulness interventions in the workplace: a critique of the current state of the literature. J Occup Health Psychol. 2017 Apr;22(2):180–93. doi: 10.1037/ocp0000048.2016-44823-001
    1. Hoge EA, Guidos BM, Mete M, Bui E, Pollack MH, Simon NM, Dutton MA. Effects of mindfulness meditation on occupational functioning and health care utilization in individuals with anxiety. J Psychosom Res. 2017 Apr;95:7–11. doi: 10.1016/j.jpsychores.2017.01.011.S0022-3999(17)30066-1
    1. Klatt MD, Sieck C, Gascon G, Malarkey W, Huerta T. A healthcare utilization cost comparison between employees receiving a worksite mindfulness or a diet/exercise lifestyle intervention to matched controls 5 years post intervention. Complement Ther Med. 2016 Aug;27:139–44. doi: 10.1016/j.ctim.2016.05.008.S0965-2299(16)30061-9
    1. Bondar J, Babich Morrow C, Gueorguieva R, Brown M, Hawrilenko M, Krystal JH, Corlett PR, Chekroud AM. Clinical and financial outcomes associated with a workplace mental health program before and during the COVID-19 pandemic. JAMA Netw Open. 2022 Jun 01;5(6):e2216349. doi: 10.1001/jamanetworkopen.2022.16349. 2793174
    1. Mordecai D, Histon T, Neuwirth E, Heisler WS, Kraft A, Bang Y, Franchino K, Taillac C, Nixon JP. How Kaiser permanente created a mental health and wellness digital ecosystem. NEJM Catalyst. 2021 Jan 1;2(1):CAT.20.0295. doi: 10.1056/cat.20.0295.
    1. Burton A, Burgess C, Dean S, Koutsopoulou GZ, Hugh-Jones S. How effective are mindfulness-based interventions for reducing stress among healthcare professionals? A systematic review and meta-analysis. Stress Health. 2017 Mar;33(1):3–13. doi: 10.1002/smi.2673.
    1. Montero-Marin J, Kuyken W, Gasión V, Barceló-Soler A, Rojas L, Manrique A, Esteban R, Campayo JG. Feasibility and effectiveness of a workplace-adapted mindfulness-based programme to reduce stress in workers at a private sector logistics company: an exploratory mixed methods study. Int J Environ Res Public Health. 2020 Mar 03;17(5):1643. doi: 10.3390/ijerph17051643. ijerph17051643
    1. Quirk H, Crank H, Carter A, Leahy H, Copeland RJ. Barriers and facilitators to implementing workplace health and wellbeing services in the NHS from the perspective of senior leaders and wellbeing practitioners: a qualitative study. BMC Public Health. 2018 Dec 10;18(1):1362. doi: 10.1186/s12889-018-6283-y. 10.1186/s12889-018-6283-y
    1. Seward MW, Goldman RE, Linakis SK, Werth P, Roberto CA, Block JP. Showers, culture, and conflict resolution: a qualitative study of employees' perceptions of workplace wellness opportunities. J Occup Environ Med. 2019 Oct;61(10):829–35. doi: 10.1097/JOM.0000000000001671.
    1. Puzia ME, Green J, Clarke C, Cloonan S, Huberty J. Examining the associations of using the Calm app with team mindfulness and psychological safety in remote workers. Environ Occup Health Pract. 2022;4(1):2022-0001-OA. doi: 10.1539/eohp.2022-0001-oa.

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