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JMIR Mental Health

Internet interventions, technologies and digital innovations for mental health and behavior change


Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959) is a PubMed-indexed, peer-reviewed sister journal of JMIR, the leading eHealth journal by Impact Factor. (The projected inofficial impact factor for JMIR Mental Health is about 3.0)

JMIR Mental Health focusses on digital health and Internet interventions, technologies and electronic innovations (software and hardware) for mental health, addictions, online counselling and behaviour change. This includes formative evaluation and system descriptions, theoretical papers, review papers, viewpoint/vision papers, and rigorous evaluations.

JMIR Mental Health publishes even faster and has a broader scope with including papers which are more technical or more formative/developmental than what would be published in the Journal of Medical Internet Research

JMIR Mental Health features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs. The journal is indexed in PubMed, PubMed Central, and ESCI (Emerging Sources Citation Index).

JMIR Mental Health adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics.


Recent Articles:

  • Source: Flickr; Copyright: Evgeny Pavlov; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Implementing Internet-Based Self-Care Programs in Primary Care: Qualitative Analysis of Determinants of Practice for Patients and Providers


    Background: Access to evidence-based interventions for common mental health conditions is limited due to geographic distance, scheduling, stigma, and provider availability. Internet-based self-care programs may mitigate these barriers. However, little is known about internet-based self-care program implementation in US health care systems. Objective: The objective of this study was to identify determinants of practice for internet-based self-care program use in primary care by eliciting provider and administrator perspectives on internet-based self-care program implementation. Methods: The objective was explored through qualitative analysis of semistructured interviews with primary care providers and administrators from the Veterans Health Administration. Participants were identified using a reputation-based snowball design. Interviews focused on identifying determinants of practice for the use of internet-based self-care programs at the point of care in Veterans Health Administration primary care. Qualitative analysis of transcripts was performed using thematic coding. Results: A total of 20 physicians, psychologists, social workers, and nurses participated in interviews. Among this group, internet-based self-care program use was relatively low, but support for the platform was assessed as relatively high. Themes were organized into determinants active at patient and provider levels. Perceived patient-level determinants included literacy, age, internet access, patient expectations, internet-based self-care program fit with patient experiences, interest and motivation, and face-to-face human contact. Perceived provider-level determinants included familiarity with internet-based self-care programs, changes to traditional care delivery, face-to-face human contact, competing demands, and age. Conclusions: This exploration of perspectives on internet-based self-care program implementation among Veterans Health Administration providers and administrators revealed key determinants of practice, which can be used to develop comprehensive strategies for the implementation of internet-based self-care programs in primary care settings.

  • Source: Image created by the Authors; Copyright: Robert Maunder; URL:; License: Licensed by JMIR.

    An Internet Resource for Self-Assessment of Mental Health and Health Behavior: Development and Implementation of the Self-Assessment Kiosk


    Background: Standardized measurement of physical and mental health is useful for identification of health problems. Personalized feedback of the results can influence health behavior, and treatment outcomes can be improved by monitoring feedback over time. However, few resources are available that are free for users, provide feedback from validated measurement instruments, and measure a wide range of health domains. Objective: This study aimed to develop an internet self-assessment resource that fills the identified gap and collects data to generate and test hypotheses about health, to test its feasibility, and to describe the characteristics of its users. Methods: The Self-Assessment Kiosk was built using validated health measurement instruments and implemented on a commercial internet survey platform. Data regarding usage and the characteristics of users were collected over 54 weeks. The rate of accrual of new users, popularity of measurement domains, frequency with which multiple domains were selected for measurement, and characteristics of users who chose particular questionnaires were assessed. Results: Of the 1435 visits, 441 (30.73%) were visiting for the first time, completed at least 1 measure, indicated that their responses were truthful, and consented to research. Growth in the number of users over time was approximately linear. Users were skewed toward old age and higher income and education. Most (53.9%, 234/434) reported at least 1 medical condition. The median number of questionnaires completed was 5. Internal reliability of most measures was good (Cronbach alpha>.70), with lower reliability for some subscales of coping (self-distraction alpha=.35, venting alpha=.50, acceptance alpha=.51) and personality (agreeableness alpha=.46, openness alpha=.45). The popular questionnaires measured depression (61.0%, 269/441), anxiety (60.5%, 267/441), attachment insecurity (54.2%, 239/441), and coping (46.0%, 203/441). Demographic characteristics somewhat influenced choice of instruments, accounting for <9% of the variance in this choice. Mean depression and anxiety scores were intermediate between previously studied populations with and without mental illness. Modeling to estimate the sample size required to study relationships between variables suggested that the accrual of users required to study the relationship between 3 variables was 2 to 3 times greater than that required to study a single variable. Conclusions: The value of the Self-Assessment Kiosk to users and the feasibility of providing this resource are supported by the steady accumulation of new users over time. The Self-Assessment Kiosk database can be interrogated to understand the relationships between health variables. Users who select particular instruments tend to have scores that are higher than those found in the general population, indicating that instruments are more likely to be selected when they are salient. Self-selection bias limits generalizability and needs to be taken into account when using the Self-Assessment Kiosk database for research. Ethical issues that were considered in developing and implementing the Self-Assessment Kiosk are discussed.

  • Source: Pexels; Copyright: Startup Stock Photos; URL:; License: Public Domain (CC0).

    Public Attitudes Toward Guided Internet-Based Therapies: Web-Based Survey Study


    Background: Internet interventions have been proposed to improve the accessibility and use of evidence-based psychological treatments. However, little is known about attitudes toward such treatments, which can be an important barrier to their use. Objective: This study aimed to (1) determine attitudes toward guided internet interventions, (2) assess its acceptability compared with other internet-based formats, and (3) explore predictors of acceptance. Methods: A convenience-sample Web-based survey (N=646) assessed attitudes toward guided internet therapies (ie, perceived usefulness and helpfulness, and advantage relative to face-to-face therapy), preferences for delivery modes (ie, e-preference: guided internet interventions, unguided internet interventions, or videoconferencing psychotherapy), and potential predictors of attitudes and preferences: sociodemographics, help-seeking–related variables, attachment style, and perceived stress. Results: Although most participants perceived internet interventions as useful or helpful (426/646, 65.9%), a few indicated their advantage relative to face-to-face therapy (56/646, 8.7%). Most participants preferred guided internet interventions (252/646, 39.0%) over videoconferencing psychotherapy (147/646, 22.8%), unguided internet interventions (124/646, 19.2%), and not using internet interventions (121/646, 18.8%; missing data: 1/646, 0.2%). Attachment avoidance and stress were related to e-preference (all P<.05). Moreover, preference for therapist-guided internet interventions was higher for individuals who were aware of internet-based treatment (χ26=12.8; P=.046). Conclusions: Participants assessed therapist-guided internet interventions as helpful, but not equivalent to face-to-face therapies. The vast majority (523/646, 81.0%) of the participants were potentially willing to use internet-based approaches. In lieu of providing patients with only one specific low-intensity treatment, implementation concepts should offer several options, including guided internet interventions, but not limited to them. Conversely, our results also indicate that efforts should focus on increasing public knowledge about internet interventions, including information about their effectiveness, to promote acceptance and uptake.

  • Source: Pexels; Copyright: Pexels; URL:; License: Public Domain (CC0).

    Temporal Associations Between Social Activity and Mood, Fatigue, and Pain in Older Adults With HIV: An Ecological Momentary Assessment Study


    Background: Social isolation is associated with an increased risk for mental and physical health problems, especially among older persons living with HIV (PLWH). Thus, there is a need to better understand real-time temporal associations between social activity and mood- and health-related factors in this population to inform possible future interventions. Objective: This study aims to examine real-time relationships between social activity and mood, fatigue, and pain in a sample of older PLWH. Methods: A total of 20 older PLWH, recruited from the University of California, San Diego HIV Neurobehavioral Research Program in 2016, completed smartphone-based ecological momentary assessment (EMA) surveys 5 times per day for 1 week. Participants reported their current social activity (alone vs not alone and number of social interactions) and levels of mood (sadness, happiness, and stress), fatigue, and pain. Mixed-effects regression models were used to analyze concurrent and lagged associations among social activity, mood, fatigue, and pain. Results: Participants (mean age 58.8, SD 4.3 years) reported being alone 63% of the time, on average, (SD 31.5%) during waking hours. Being alone was related to lower concurrent happiness (beta=−.300; 95% CI −.525 to −.079; P=.008). In lagged analyses, social activity predicted higher levels of fatigue later in the day (beta=−1.089; 95% CI −1.780 to −0.396; P=.002), and higher pain levels predicted being alone in the morning with a reduced likelihood of being alone as the day progressed (odds ratio 0.945, 95% CI 0.901-0.992; P=.02). Conclusions: The use of EMA elucidated a high rate of time spent alone among older PLWH. Promoting social activity despite the presence of pain or fatigue may improve happiness and psychological well-being in this population.

  • Source: Max Pixel; Copyright: Max Pixel; URL:; License: Public Domain (CC0).

    Cognitive Assessment of Patients With Alzheimer's Disease by Telemedicine: Pilot Study


    Background: Approximately 46.8 million people are living with dementia worldwide and their number will grow in the next years. Any potential treatment should be administered as early as possible because it is important to provide an early cognitive assessment and to regularly monitor the mental function of patients. Information and communication technologies can be helpful to reach and follow patients without displacing them, but there may be doubts about the reliability of cognitive tests performed by telemedicine. Objective: The purpose of this study was to evaluate the reliability of the Mini Mental State Examination (MMSE) and the Alzheimer’s Disease Assessment Scale cognitive subscale (ADAS-cog) tests administered in hospital by videoconference to patients with mild to moderate Alzheimer's disease. Methods: The tests were administered to 28 Alzheimer's disease outpatients (8 male, mean age 73.88, SD 7.45 years; 20 female mean age 76.00, SD 5.40 years) recruited and followed in the Alzheimer’s Unit of the A Cardarelli National Hospital (Naples, Italy) at baseline and after 6, 12, 18, and 24 months of observation. Patients were evaluated first face-to-face by a psychologist and then, after 2 weeks, by another psychologist via videoconference in hospital. Results: This study showed no differences in the MMSE and ADAS-cog scores when the tests were administered face-to-face or by videoconference, except in patients with more pronounced cognitive deficits (MMSE<17), in which the assessment via videoconference overestimated the cognitive impairment (face to face, MMSE mean 13.9, SD 4.9 and ADAS-cog mean 9.0, SD 3.8; videoconference, MMSE mean 42.8, SD 12.5 and ADAS-cog mean 56.9, SD 5.5). Conclusions: We found that videoconferencing is a reliable approach to document cognitive stability or decline, and to measure treatment effects in patients with mild to moderate dementia. A more extended study is needed to confirm these results.

  • Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Harnessing Social Media to Explore Youth Social Withdrawal in Three Major Cities in China: Cross-Sectional Web Survey


    Background: Socially withdrawn youth belong to an emerging subgroup of youth who are not in employment, education, or training and who have limited social interaction intention and opportunities. The use of the internet and social media is expected to be an alternative and feasible way to reach this group of young people because of their reclusive nature. Objective: The aim of this study was to explore the possibility of using various social media platforms to investigate the existence of the phenomenon of youth social withdrawal in 3 major cities in China. Methods: A cross-sectional open Web survey was conducted from October 2015 to May 2016 to identify and reach socially withdrawn youth in 3 metropolitan cities in China: Beijing, Shanghai, and Shenzhen. To advertise the survey, 3 social media platforms were used: Weibo, WeChat, and Wandianba, a social networking gaming website. Results: In total, 137 participants completed the survey, among whom 13 (9.5%) were identified as belonging to the withdrawal group, 7 (5.1%) to the asocial group, and 9 (6.6%) to the hikikomori group (both withdrawn and asocial for more than 3 months). The cost of recruitment via Weibo was US $7.27 per participant. Conclusions: Several social media platforms in China are viable and inexpensive tools to reach socially withdrawn youth, and internet platforms that specialize in a certain culture or type of entertainment appeared to be more effective in reaching socially withdrawn youth.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Recovery After Psychosis: Qualitative Study of Service User Experiences of Lived Experience Videos on a Recovery-Oriented Website


    Background: Digital interventions offer an innovative way to make the experiences of people living with mental illness available to others. As part of the Self-Management And Recovery Technology (SMART) research program on the use of digital resources in mental health services, an interactive website was developed including videos of people with lived experience of mental illness discussing their recovery. These peer videos were designed to be watched on a tablet device with a mental health worker, or independently. Objective: Our aim was to explore how service users experienced viewing the lived experience videos on this interactive website, as well as its influence on their recovery journey. Methods: In total, 36 service users with experience of using the website participated in individual semistructured qualitative interviews. All participants had experience of psychosis. Data analysis occurred alongside data collection, following principles of constructivist grounded theory methodology. Results: According to participants, engaging with lived experience videos was a pivotal experience of using the website. Participants engaged with peers through choosing and watching the videos and reflecting on their own experience in discussions that opened up with a mental health worker. Benefits of seeing others talking about their experience included “being inspired,” “knowing I’m not alone,” and “believing recovery is possible.” Experiences of watching the videos were influenced by the participants’ intrapersonal context, particularly their ways of coping with life and use of technology. The interpersonal context of watching the videos with a worker, who guided website use and facilitated reflection, enriched the experience. Conclusions: Engaging with lived experience videos was powerful for participants, contributing to their feeling connected and hopeful. Making websites with lived experience video content available to service users and mental health workers demonstrates strong potential to support service users’ recovery.

  • Addressing suicide risk in participants of online studies. Source: Image created by Authors; Copyright: Renee Garett; URL:; License: Creative Commons Attribution (CC-BY).

    Ethical Issues in Addressing Social Media Posts About Suicidal Intentions During an Online Study Among Youth: Case Study


    Due to the popularity of social media, researchers are increasingly conducting studies that monitor and analyze people’s health-related social media conversations. Because social media users can post about any topic at any time, no known best ethical practices exist as to whether and how to monitor participants’ posts for safety-related issues that might be unrelated to the study, such as expressions of suicidal intentions. This is a case study during a social media-based study on sleep and activity among freshman undergraduate students, where we by chance noticed that a student was using social media to express suicidal intentions. Although we connected the student to student psychological services in order to receive treatment, we encountered a number of barriers that initially prevented this from occurring, such as institutional review board and regulatory practices related to lack of experience with these newer types of studies. We discuss the implications of this experience for future research.

  • Participants recruited from engineering firms to receive Web-based resilience training. Source: Pixabay; Copyright: 889520; URL:; License: Public Domain (CC0).

    Team Resilience Training in the Workplace: E-Learning Adaptation, Measurement Model, and Two Pilot Studies


    Background: The majority of resilience interventions focus on the individual. Workplace resilience is a growing field of research. Given the ever-increasing interconnectedness in businesses, teamwork is a guarantee. There is also growing recognition that resilience functions at the team level. Objective: The objective of our work was to address three shortcomings in the study of workplace resilience interventions: lack of interventions focusing on group-level or team resilience, the need for brief interventions, and the need for more theoretical precision in intervention studies. Methods: The authors took an established evidence-based program (Team Resilience) and modified it based on these needs. A working model for brief intervention evaluation distinguishes outcomes that are proximal (perceptions that the program improved resilience) and distal (dispositional resilience). A total of 7 hypotheses tested the model and program efficacy. Results: Two samples (n=118 and n=181) of engineering firms received the Web-based training and provided immediate reactions in a posttest-only design. The second sample also included a control condition (n=201). The findings support the model and program efficacy. For example, workplace resilience was greater in the intervention group than in the control group. Other findings suggest social dissemination effects, equal outcomes for employees at different stress levels, and greater benefit for females. Conclusions: This preliminary research provides evidence for the capabilities of e-learning modules to effectively promote workplace resilience and a working model of team resilience.

  • A screen from the e-mental health app described in the paper. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Worker Preferences for a Mental Health App Within Male-Dominated Industries: Participatory Study


    Background: Men are less likely to seek help for mental health problems, possibly because of stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of mental health technologies men would be willing to engage with, and no app can be effective if the intended users do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations took part in an exploratory qualitative study involving participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged between 26 and 65 years, 92% (55/60) male, from male-dominated workplaces in rural (16/60, 27%), suburban (14/60, 23%), and urban (30/60, 50%) locations participated in one of the 6 workshops, resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment, and mood-fix tool were highly valued, and app characteristics such as brevity of interactions, minimal on-screen text, and a solutions-oriented approach were considered essential by participants. Some implementation strategies based on these findings are included in the discussion. Conclusions: Future mental health mobile phone apps targeting workers in male-dominated workplaces need to consider language use and preferred features, as well as balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights for mental health technologies, for men in general, and for others in high-stigma environments.

  • Source: Pxhere; Copyright: Pxhere; URL:; License: Licensed by JMIR.

    Ethical Issues for Direct-to-Consumer Digital Psychotherapy Apps: Addressing Accountability, Data Protection, and Consent


    This paper focuses on the ethical challenges presented by direct-to-consumer (DTC) digital psychotherapy services that do not involve oversight by a professional mental health provider. DTC digital psychotherapy services can potentially assist in improving access to mental health care for the many people who would otherwise not have the resources or ability to connect with a therapist. However, the lack of adequate regulation in this area exacerbates concerns over how safety, privacy, accountability, and other ethical obligations to protect an individual in therapy are addressed within these services. In the traditional therapeutic relationship, there are ethical obligations that serve to protect the interests of the client and provide warnings. In contrast, in a DTC therapy app, there are no clear lines of accountability or associated ethical obligations to protect the user seeking mental health services. The types of DTC services that present ethical challenges include apps that use a digital platform to connect users to minimally trained nonprofessional counselors, as well as services that provide counseling steered by artificial intelligence and conversational agents. There is a need for adequate oversight of DTC nonprofessional psychotherapy services and additional empirical research to inform policy that will provide protection to the consumer.

  • Source: Pxhere; Copyright: Pxhere; URL:; License: Public Domain (CC0).

    Feasibility and Acceptability of a Web-Based Treatment with Telephone Support for Postpartum Women With Anxiety: Randomized Controlled Trial


    Background: Postpartum anxiety can have adverse effects on the mother and child if left untreated. Time constraints and stigma are common barriers to postpartum treatment. Web-based treatments offer potential flexibility and anonymity. What Am I Worried About (WaWa) is a self-guided treatment based on cognitive-behavioral and mindfulness principles for women experiencing postpartum anxiety. WaWa was developed in Australia and consists of 9 modules with optional weekly telephone support. WaWa was adapted to a Web-based version for use in England (Internet-based What Am I Worried About, iWaWa). Objective: This study aimed to investigate the feasibility (engagement and usability) and acceptability (usefulness, satisfaction, and helpfulness) of iWaWa among English postpartum women with anxiety. Methods: Postpartum (<12 months) women with mild-to-severe anxiety were recruited anonymously via social media during an 8-week period. Participants were randomized to the iWaWa treatment (8 weeks) or wait-list control group. Treatment and study feasibility and acceptability were assessed after the treatment, and anxiety symptoms were assessed at baseline, 8 weeks postrandomization, and 12 weeks postrandomization (treatment group only) using Web-based questionnaires. Semistructured telephone interviews were carried out after the treatment period for a more in-depth exploration of treatment acceptability and feasibility. Results: A total of 89 eligible women were recruited through social media and randomized into the treatment (n=46) or wait-list control group (n=43). Women were predominantly Caucasian, well-educated, married, on maternity leave, first-time mothers and reported moderate levels of anxiety. Dropout rates were high, especially in the treatment group (treatment: 82%, 38/46; wait-list control: 51%, 22/43). A total of 26 women started iWaWa with only 2 women completing all 9 modules. Quantitative and qualitative data suggest iWaWa was experienced as generally useful and helpful. Participants enjoyed iWaWa’s accessibility, anonymity, and weekly reminders, as well as the introduction to the principles of cognitive-behavioral therapy (CBT) and mindfulness. However, iWaWa was also experienced as not user-friendly enough, too long, and not smartphone-friendly. Parts of the content were experienced as not always relevant and appropriate. Participants felt that iWaWa could be improved by having it in a smartphone app format and by making the content more concise and inclusive of different parenting styles. Conclusions: Despite interest in iWaWa, the results suggest that both the study and iWaWa were not feasible in the current format. However, this first trial provides useful evidence about treatment format and content preferences that can inform iWaWa’s future development, as well as research and development of Web-based postpartum anxiety treatments, in general, to optimize adherence. Trial Registration: NCT02434406; (Archived by WebCite at

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  • Priovi, an EHealth Programm for Patients with Borderline Personality Disorder to support individual face-to-face schema therapy– Pilot Study

    Date Submitted: May 6, 2018

    Open Peer Review Period: May 7, 2018 - Jul 2, 2018

    Background: EHealth programs have hardly been investigated yet for people with borderline personality disorder (BPD). However this might be very promising given both the high economic and health-relat...

    Background: EHealth programs have hardly been investigated yet for people with borderline personality disorder (BPD). However this might be very promising given both the high economic and health-related burden as well as high need for treatment in this patient group. Development and use of eHealth applications for BPD are complicated by (1) safety issues due to frequent aversive and dangerous behaviors of these patients, (2) their tendency to drop out of any type of treatment, relationship or activity, (3) long treatment duration and accordingly need for comparably long and complex eHealth interventions. Objective: We piloted the program priovi in 14 patients with BPD. Priovi was offered to support individual face-to-face schema therapy to assess whether it is feasible, safe, and potentially helpful. Methods: Priovi is a schema therapy based self-help program for patients with BPD, designed to be used over 6-12 months. The patients used priovi over a period of 12 months in addition to their individual face-to-face schema therapy. BPD symptom severity was assessed with self-reported and interview-based measures. Qualitative interviews were conducted to understand the patient’s experience with the program in more detail and to detect barriers to feasibility and safety. Results: BPD symptoms improved over one year with high effect size (Cohen’s d 1.0). Patients receiving BPD treatment for the first time improved more than chronic patients with prior treatments. Qualitative data showed that patients generally liked the program. They were well able to build up a functional relationship with priovi. Some exercises provoked mild anxiety, however no serious threads to safety could be detected. Conclusions: Priovi is a potentially helpful and safe tool to support individual schema therapy. The next step should be a larger randomized-controlled study Clinical Trial: German Clinical Trials Register DRKS-ID: DRKS00011538

  • Development and Feasibility of a Group-Based Online Intervention to Prevent Postpartum Depression

    Date Submitted: Apr 30, 2018

    Open Peer Review Period: May 2, 2018 - Jun 27, 2018

    Background: Postpartum minor and major depression (PPMD) has a 20% 3-month prevalence rate. The consequences of PPMD are significant for mother, infant, and family. There is a need for interventions t...

    Background: Postpartum minor and major depression (PPMD) has a 20% 3-month prevalence rate. The consequences of PPMD are significant for mother, infant, and family. There is a need for interventions that prevent PPMD that are effective and accessible, however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group may create an intervention with the scalability and cost effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objective: This report describes the development of a peer supported internet intervention to prevent postpartum depression and explore the feasibility and acceptability of this approach. Methods: Clinic based needs assessment and focus groups were used to develop the internet intervention. Once the intervention was developed, women who were 20-28 weeks pregnant with symptoms of depression (PHQ-9 scores of 5-14) but no major depression diagnosis were enrolled in an RCT to compare 8 weeks of a CBT based peer supported internet intervention to an individual internet intervention designed to prevent postpartum depression. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), 4 weeks and 6 weeks postpartum. Results: Twenty-four women completed the RCT. PHQ-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only one woman out of twenty-four (4%) met criteria for PPMD. There was no difference between groups in adherence to the intervention, with an average of 14.55 logins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent postpartum depression and that peer support may be a useful feature to keep participants adherent. Clinical Trial: NCT02121015

  • Effects of a theta/SMR neurofeedback training protocol on measures of impulsivity, drug craving and substance abuse in forensic psychiatric patients with substance abuse: a randomized controlled trial

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination...

    Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination of psychiatric disorders and SUD increases the risk of future violence. Chronic substance abuse can lead to a structural state of disinhibition, resulting in more drug taking and eventually loss of control over drug intake. When treating SUD, it is crucial to address high levels of impulsivity and lack of inhibitory control. Objective: The current study set out to investigate the effects of a theta/Sensorimotor rhythm (SMR) neurofeedback training protocol on levels of impulsivity, levels of drug craving and actual drug intake in a population of forensic psychiatric patients with a diagnosis of SUD. Methods: 21 participants received 20 sessions of SMR/theta neurofeedback training in combination with treatment as usual (TAU). Results were compared to 21 participants who received TAU only. Results: SMR magnitude showed a significant (P = .02) increase post-training for patients in the neurofeedback training group, whereas theta magnitude did not change (P >.05). Levels of drug craving as well as scores on the ‘motor’ subscale of the BIS-11 decreased equally for patients in the neurofeedback training group and the TAU group. Other measures of impulsivity, as well as drug intake, did not change post-treatment (P > .05). Therefore, neurofeedback + TAU was not more effective than TAU only. Conclusions: The current study demonstrated evidence that forensic psychiatric patients are able to increase SMR magnitude over the course of neurofeedback training. However, at the group level, the increase in SMR activity was not related to any of the included impulsivity or drug craving measures. Further research should focus on which patients will be able to benefit from neurofeedback training at an early stage of the employed training sessions. Clinical Trial: Dutch National Trial Register NTR5386; (Archived by WebCite at

  • Acceptability of Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions

    Date Submitted: Feb 26, 2018

    Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

    Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitat...

    Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone. Objective: This analysis assesses patient’s acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. Methods: PARTNERs is a research trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion. Results: During the consent process, 53.7% of 667 patients referred to the study declined to participate, and attributed their refusal to research-related factors (i.e., randomization and time commitment); a further 16.8% declined due to the telephone delivery of the intervention. Among 377 participants who were randomized to the one-year intervention, the overall retention rate was 81.8%. Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97.4% of comments related to the telephone components were positive, with key reported positive attributes being accessibility, convenience, and privacy. Conclusions: Our results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy. Clinical Trial: Trial registration: Identifier: NCT02345122

  • The Computerised Life Events and Assessment Record (CLEAR) online measure of life events: reliability, validity and association with depression.

    Date Submitted: Apr 3, 2018

    Open Peer Review Period: Apr 6, 2018 - Jun 1, 2018

    Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Th...

    Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Therefore, the Computerised Life Events and Assessment Record (CLEAR), based on the Life Events and Difficulties Schedule (LEDS), was developed. Objective: To test CLEAR’s reliability, validity, and association with depression. Methods: CLEAR, the General Health Questionnaire, and the List of Threatening Experiences Questionnaire (LTE-Q) was completed by 328 participants (126 students; 202 matched midlife sample: 127 controls, 75 recurrent depression cases). Test-retest reliability over 3-4 weeks was examined, and validity determined by comparing CLEAR with LEDs and LTE-Q. Both CLEAR and LTE-Q were examined in relation to depression. Results: CLEAR demonstrated good test-retest reliability for overall number of events (.89) but only fair reliability for overall agreement of events at both points (.21). Event characteristics for those that agreed had good reliability. Long-term problems (LTPs) showed similar findings. For validity, CLEAR had moderate sensitivity of 59% and specificity of 65% when compared to LEDS on matched events. Associations by category were good e.g. education (.81), work (.70) and health (.59), with high levels of specificity in these domains. CLEAR demonstrated moderate sensitivity (43.1%) and specificity (78.6%) when compared to LTE-Q. CLEAR severe LEs and LTPs were significantly associated with depression (OR = 3.50, 95% CI: 2.10-5.85, P < .001; OR = 3.38, 95% CI: 2.02-5.67, P < .001) whereas LTE-Q events were not (OR=1.06, 95% CI: .43-2.60, P =.90). Conclusions: CLEAR has acceptable reliability and validity and predicts depression. It therefore has great potential for effective use in research and clinical practice identifying stress factors in depression and related disorders.

  • Real-World Technology Use among People with Mental Illnesses: A Qualitative Study

    Date Submitted: Mar 30, 2018

    Open Peer Review Period: Mar 31, 2018 - May 26, 2018

    Background: There is growing interest in using technology-based tools to support mental health recovery. Yet, despite evidence suggesting widespread access to technology among people with mental illne...

    Background: There is growing interest in using technology-based tools to support mental health recovery. Yet, despite evidence suggesting widespread access to technology among people with mental illnesses, interest in using technology to support mental health, and effectiveness of technology-based tools developed by researchers, such tools have not been widely adopted within mental health settings. Little is currently known about how mental health consumers are using technology to address mental health needs in real-world settings outside of controlled research studies. Objective: This qualitative study examined current practices and orientations toward technology among consumers in three mental health settings in the U.S. Methods: Ethnographic observations and semi-structured interviews were conducted. Observations focused on if and how technology was salient within the setting and documented relevant behaviors, interactions, and dialogue in fieldnotes. Ethnographic data informed the development of a semi-structured interview that inquired into technology use and interest among consumers (n=15) in a community mental health setting. Fieldnotes and interview transcripts were reviewed and coded by multiple researchers. Key concepts and patterns identified were refined by the research team to develop the main findings. Results: Ownership of technology, although common, was not ubiquitous and was varied across the sites. Participants had varying levels of awareness regarding the key capabilities of modern technologies. Participants used technology for many purposes, but there was limited evidence of technology use to support mental health. Technology-based tools specific to mental health were not routinely used although some participants found widely available mobile apps to be helpful in recovery. Conclusions: Qualitative findings suggest that most but not all clients will be interested in using technology to support mental health needs. The variability in type and quality of technology owned by participants suggests the need to design for a range of functionality in the development of mental health tools. Findings also suggest thinking broadly about using existing platforms and widely available tools to support consumers in mental health recovery.