Limitations
ideation, anxiety, active suicidal ideation, depressive, depressive symptoms, depression
This study did not control for participant contact with the research personnel. This lack of control means that we cannot observe whether the symptom changes were due to the treatment delivered or other extraneous factors such as time and contact with research personnel within a clinical trial. As this study involved 3 assessment time points for the Life Flex program–only participants, future research is required to replicate and evaluate the study findings taking this into consideration. This study also did not have a control condition for the nonresponders, meaning that we are unable to determine whether these participants would have disengaged and whether they improved relative to receiving therapist assistance. Participants who engaged or showed symptom improvement were also only given the option of continuing in the Life Flex program–only condition. Therefore, the possible impact of assigning a therapist to the participants who engaged or showed symptom improvement cannot be determined within this study design.As the trial excluded participants with severe suicidal ideation, this study cannot present the baseline magnitude of depressive severity for individuals who presented with active suicidal ideation. Therefore, trial results are limited to participants experiencing depressive symptoms without active suicidal ideation, which potentially limits the generalizability of the results as it is not representative of conditions in routine clinical practice. Masking of participants and therapists to treatment condition was not possible, introducing a possible risk of bias; however, therapists did not have access to participant preference data, nor were they aware of the study’s objectives. This study also did not ask participants about their previous treatment experiences, which may have affected their preferences and mental health literacy. The study was also conducted during the global COVID-19 pandemic, which may have posed several challenges, including participants’ self-selection into the clinical trial in the hope of accessing therapist assistance and their commitment to the trial being negatively affected, as well as their symptoms of anxiety or depression because of the considerable uncertainty present in the community throughout data collection. However, the diagnostic status results at the postintervention time point and 3-month follow-up are promising of considerable symptom changes.