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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: Freepik; Copyright: sirinarth; URL:; License: Licensed by JMIR.

    Measurement of Symptom Change Following Web-Based Psychotherapy: Statistical Characteristics and Analytical Methods for Measuring and Interpreting Change


    Background: Accurate measurement of treatment-related change is a key part of psychotherapy research and the investigation of treatment efficacy. For this reason, the ability to measure change with accurate and valid methods is critical for psychotherapy. Objective: The aims of this study were to (1) explore the underlying characteristics of depressive symptom change, measured with the nine-item Patient Health Questionnaire (PHQ-9), following psychotherapy, and (2) compare the suitability of different ways to measure and interpret symptom change. A treatment sample of Web-based psychotherapy participants (n=1098) and a waitlist sample (n=96) were used to (1) explore the statistical characteristics of depressive symptom change, and (2) compare the suitability of two common types of change functions: linear and proportional change. Methods: These objectives were explored using hypotheses that tested (1) the relationship between baseline symptoms and the rate of change, (2) the shape of symptom score distribution following treatment, and (3) measurement error associated with linear and proportional measurement models. Results: Findings demonstrated that (1) individuals with severe depressive baseline symptoms had greater reductions in symptom scores than individuals with mild baseline symptoms (11.4 vs 3.7); however, as a percentage measurement, change remained similar across individuals with mild, moderate, or severe baseline symptoms (50%-55%); (2) positive skewness was observed in PHQ-9 score distributions following treatment; and (3) models that measured symptom change as a proportional function resulted in greater model fit and reduced measurement error (<30%). Conclusions: This study suggests that symptom scales, sharing an implicit feature of score bounding, are associated with a proportional function of change. Selecting statistics that overlook this proportional change (eg, Cohen d) is problematic and leads to (1) artificially increased estimates of change with higher baseline symptoms, (2) increased measurement error, and (3) confounded estimates of treatment efficacy and clinical change. Implications, limitations, and idiosyncrasies from these results are discussed.

  • Source: Dreamstime; Copyright: Oleksandr Brylov; URL:; License: Licensed by the authors.

    Patients’ Experiences of Web- and Mobile-Assisted Group Therapy for Depression and Implications of the Group Setting: Qualitative Follow-Up Study


    Background: Blended group therapy combines group sessions with Web- and mobile-based treatment modules. Consequently, blended group therapy widens the choice within blended interventions at reasonable costs. This is the first qualitative study on blended group therapy. Objective: The objective of this study was to investigate the patient-centered feasibility of blended group therapy for major depression, with special emphasis on the fit and dynamic interplay between face-to-face and internet-based elements. Methods: A total of 22 patients who had a variety of experiences through participating in one of the two blended group therapy interventions were interviewed following a semistructured interview guide. In-depth interviews were analyzed by three trained psychologists, using thematic analysis and a rule-guided internet-based program (QCAmap). The transcript of the interviews (113,555 words) was reduced to 1081 coded units, with subsequent extraction of 16 themes. Results: Web- and mobile-based elements were described as a treatment facilitator and motivator, increasing the salience and consolidation of cognitive behavioral therapy materials, resulting in in- and inter-session alignment to the treatment. Additionally, patients valued the option of intimate Web-based self-disclosure (by lateral patient-therapist communication), and therapists were provided with tools for between-session monitoring and reinforcement of exercising. In this context, group phenomena seemed to back up therapists’ efforts to increase treatment engagement. The dissonance because of noncompliance with Web-based tasks and the constriction of in-session group interaction were considered as possible negative effects. Finally, issues of tailoring and structure seemed to fulfill different preconditions compared with individual therapy. Conclusions: Blended group therapy constitutes a structured and proactive approach to work with depression, and the integration of both modalities initiates a beneficial interplay. Results support the patient-centered value of blended group therapy and provide the first insight into blended group therapy’s role in fostering therapeutic treatment factors. However, potential negative effects should be considered carefully.

  • Source:; Copyright: Bloomicon; URL:; License: Licensed by the authors.

    Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans


    Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45%), problematic drinking (243/584, 42%), major depression (164/586, 28%), and suicidality (132/585, 23%). Approximately half of the survey participants (285/587, 49%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an “incentive” or “sharing” headline. These 2 ads were also the most cost-effective, at US $4.88 and US $5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). Conclusions: Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups.

  • Source: Flickr; Copyright: The home of Fixers on Flickr; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Predicting Social Anxiety From Global Positioning System Traces of College Students: Feasibility Study


    Background: Social anxiety is highly prevalent among college students. Current methodologies for detecting symptoms are based on client self-report in traditional clinical settings. Self-report is subject to recall bias, while visiting a clinic requires a high level of motivation. Assessment methods that use passively collected data hold promise for detecting social anxiety symptoms and supplementing self-report measures. Continuously collected location data may provide a fine-grained and ecologically valid way to assess social anxiety in situ. Objective: The objective of our study was to examine the feasibility of leveraging noninvasive mobile sensing technology to passively assess college students’ social anxiety levels. Specifically, we explored the different relationships between mobility and social anxiety to build a predictive model that assessed social anxiety from passively generated Global Positioning System (GPS) data. Methods: We recruited 228 undergraduate participants from a Southeast American university. Social anxiety symptoms were assessed using self-report instruments at a baseline laboratory session. An app installed on participants’ personal mobile phones passively sensed data from the GPS sensor for 2 weeks. The proposed framework supports longitudinal, dynamic tracking of college students to evaluate the relationship between their social anxiety and movement patterns in the college campus environment. We first extracted the following mobility features: (1) cumulative staying time at each different location, (2) the distribution of visits over time, (3) the entropy of locations, and (4) the frequency of transitions between locations. Next, we studied the correlation between these features and participants’ social anxiety scores to enhance the understanding of how students’ social anxiety levels are associated with their mobility. Finally, we used a neural network-based prediction method to predict social anxiety symptoms from the extracted daily mobility features. Results: Several mobility features correlated with social anxiety levels. Location entropy was negatively associated with social anxiety (during weekdays, r=−0.67; and during weekends, r=−0.51). More (vs less) socially anxious students were found to avoid public areas and engage in less leisure activities during evenings and weekends, choosing instead to spend more time at home after school (4 pm-12 am). Our prediction method based on extracted mobility features from GPS trajectories successfully classified participants as high or low socially anxious with an accuracy of 85% and predicted their social anxiety score (on a scale of 0-80) with a root-mean-square error of 7.06. Conclusions: Results indicate that extracting and analyzing mobility features may help to reveal how social anxiety symptoms manifest in the daily lives of college students. Given the ubiquity of mobile phones in our society, understanding how to leverage passively sensed data has strong potential to address the growing needs for mental health monitoring and treatment.

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

    A New Online Mental Health Training Program for Workplace Managers: Pre-Post Pilot Study Assessing Feasibility, Usability, and Possible Effectiveness


    Background: Mental health has become the leading cause of sickness absence in high-income countries. Managers can play an important role in establishing mentally healthy workplaces and coordinating their organization’s response to a mentally ill worker. Objective: This pilot study aims to evaluate the feasibility, usability, and likely effectiveness of a newly developed online training program for managers called HeadCoach. HeadCoach aims to build managers’ confidence in supporting the mental health needs of staff and promote managerial behavior most likely to result in a more mentally healthy workplace. Methods: In total, 66 managers from two organizations were invited to participate in this pre-post pilot study of HeadCoach, which was made available to managers to complete at their own pace over a 4-week period. Data were collected at baseline and post intervention via an online research platform. The difference in mean scores for each outcome between these two time points was calculated using paired samples t tests. Results: Of all the invited managers, 59.1% (39/66) participated in the trial, with complete pre–post data available for 56.4% (22/39) of the participants. The majority of respondents reported positive engagement with the program. During the study period, managers’ knowledge regarding their role in managing mental health issues (P=.01) and their confidence in communicating with employees regarding mental illness (P<.001) significantly increased. In addition, a significant increase was observed from the baseline in managers’ self-reported actions to use strategies to prevent and decrease stress among their team members (P=.02). Conclusions: Although caution is needed due to the absence of a control group, preliminary results of this study suggest that HeadCoach could be a feasible, acceptable, and efficient method of training managers in best workplace practices to help support the mental health needs of their staff.

  • Behavioral activation for treating depression. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Data-Driven Learning in High-Resolution Activity Sampling From Patients With Bipolar Depression: Mixed-Methods Study


    Background: Behavioral activation is a pen and paper-based therapy form for treating depression. The patient registers their activity hourly, and together with the therapist, they agree on a plan to change behavior. However, with the limited clinical personnel, and a growing patient population, new methods are needed to advance behavioral activation. Objective: The objectives of this paper were to (1) automatically identify behavioral patterns through statistical analysis of the paper-based activity diaries, and (2) determine whether it is feasible to move the behavioral activation therapy format to a digital solution. Methods: We collected activity diaries from seven patients with bipolar depression, covering in total 2,480 hours of self-reported activities. A pleasure score, on a 1-10 rating scale, was reported for each activity. The activities were digitalized into 6 activity categories, and statistical analyses were conducted. Results: Across all patients, movement-related activities were associated with the highest pleasure score followed by social activities. On an individual level, through a nonparametric Wilcoxon Signed-Rank test, one patient had a statistically significant larger amount of spare time activities when feeling bad (z=–2.045, P=.041). Through a within-subject analysis of covariance, the patients were found to have a better day than the previous, if that previous day followed their diurnal rhythm (ρ=.265, P=.029). Furthermore, a second-order trend indicated that two hours of daily social activity was optimal for the patients (β2=–0.08, t (63)=–1.22, P=.23). Conclusions: The data-driven statistical approach was able to find patterns within the behavioral traits that could assist the therapist in as well as help design future technologies for behavioral activation.

  • Source:; Copyright: Simple Texting; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    eMental Healthcare Technologies for Anxiety and Depression in Childhood and Adolescence: Systematic Review of Studies Reporting Implementation Outcomes


    Background: Anxiety disorders and depression are frequent conditions in childhood and adolescence. eMental healthcare technologies may improve access to services, but their uptake within health systems is limited. Objective: The objective of this review was to examine and describe how the implementation of eMental healthcare technologies for anxiety disorders and depression in children and adolescents has been studied. Methods: We conducted a search of 5 electronic databases and gray literature. Eligible studies were those that assessed an eMental healthcare technology for treating or preventing anxiety or depression, included children or adolescents (<18 years), or their parents or healthcare providers and reported findings on technology implementation. The methodological quality of studies was evaluated using the Mixed Methods Appraisal Tool. Outcomes of interest were based on 8 implementation outcomes: acceptability (satisfaction with a technology), adoption (technology uptake and utilization), appropriateness (“fitness for purpose”), cost (financial impact of technology implementation), feasibility (extent to which a technology was successfully used), fidelity (implementation as intended), penetration (“spread” or “reach” of the technology), and sustainability (maintenance or integration of a technology within a healthcare service). For extracted implementation outcome data, we coded favorable ratings on measurement scales as “positive results” and unfavorable ratings on measurement scales as “negative results.” Those studies that reported both positive and negative findings were coded as having “mixed results.” Results: A total of 46 studies met the inclusion criteria, the majority of which were rated as very good to excellent in methodological quality. These studies investigated eMental healthcare technologies for anxiety (n=23), depression (n=18), or both anxiety and depression (n=5). Studies of technologies for anxiety evaluated the following: (1) acceptability (78%) reported high levels of satisfaction, (2) adoption (43%) commonly reported positive results, and (3) feasibility (43%) reported mixed results. Studies of technologies for depression evaluated the following: (1) appropriateness (56%) reported moderate helpfulness and (2) acceptability (50%) described a mix of both positive and negative findings. Studies of technologies designed to aid anxiety and depression commonly reported mixed experiences with acceptability and adoption and positive findings for appropriateness of the technologies for treatment. Across all studies, cost, fidelity, and penetration and sustainability were the least measured implementation outcomes. Conclusions: Acceptability of eMental healthcare technology is high among users and is the most commonly investigated implementation outcome. Perceptions of the appropriateness and adoption of eMental healthcare technology were varied. Implementation research that identifies, evaluates, and reports on costs, sustainability, and fidelity to clinical guidelines is crucial for making high-quality eMental healthcare available to children and adolescents.

  • Source: Freepik; Copyright: katemangostar; URL:; License: Licensed by JMIR.

    Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review


    Background: Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH). Objective: The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT. Methods: We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes. Results: After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre–post studies, and 1 mHealth randomized controlled trial. Conclusions: The review found that ACT is effective in reducing SI in the 2 pre–post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH.

  • Researcher studying a flowchart of the process for using neural networks with routine electronic health records to identify suicide risk in patients (mock-up). Source: Image created by the authors/; Copyright: JMIR publications; URL:; License: Creative Commons Attribution (CC-BY).

    Using Neural Networks with Routine Health Records to Identify Suicide Risk: Feasibility Study


    Background: Each year, approximately 800,000 people die by suicide worldwide, accounting for 1–2 in every 100 deaths. It is always a tragic event with a huge impact on family, friends, the community and health professionals. Unfortunately, suicide prevention and the development of risk assessment tools have been hindered by the complexity of the underlying mechanisms and the dynamic nature of a person’s motivation and intent. Many of those who die by suicide had contact with health services in the preceding year but identifying those most at risk remains a challenge. Objective: To explore the feasibility of using artificial neural networks with routinely collected electronic health records to support the identification of those at high risk of suicide when in contact with health services. Methods: Using the Secure Anonymised Information Linkage Databank UK, we extracted the data of those who died by suicide between 2001 and 2015 and paired controls. Looking at primary (general practice) and secondary (hospital admissions) electronic health records, we built a binary feature vector coding the presence of risk factors at different times prior to death. Risk factors included: general practice contact and hospital admission; diagnosis of mental health issues; injury and poisoning; substance misuse; maltreatment; sleep disorders; and the prescription of opiates and psychotropics. Basic artificial neural networks were trained to differentiate between the suicide cases and paired controls. We interpreted the output score as the estimated suicide risk. System performance was assessed with 10x10-fold repeated cross-validation, and its behavior was studied by representing the distribution of estimated risk across the cases and controls, and the distribution of factors across estimated risks. Results: We extracted a total of 2604 suicide cases and 20 paired controls per case. Our best system attained a mean error rate of 26.78% (SD 1.46; 64.57% of sensitivity and 81.86% of specificity). While the distribution of controls was concentrated around estimated risks < 0.5, cases were almost uniformly distributed between 0 and 1. Prescription of psychotropics, depression and anxiety, and self-harm increased the estimated risk by ~0.4. At least 95% of those presenting these factors were identified as suicide cases. Conclusions: Despite the simplicity of the implemented system, the proposed methodology obtained an accuracy like other published methods based on specialized questionnaire generated data. Most of the errors came from the heterogeneity of patterns shown by suicide cases, some of which were identical to those of the paired controls. Prescription of psychotropics, depression and anxiety, and self-harm were strongly linked with higher estimated risk scores, followed by hospital admission and long-term drug and alcohol misuse. Other risk factors like sleep disorders and maltreatment had more complex effects.

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

    Open Notes in Swedish Psychiatric Care (Part 2): Survey Among Psychiatric Care Professionals


    Background: This is the second of two papers presenting the results from a study of the implementation of patient online access to their electronic health records (here referred to as Open Notes) in adult psychiatric care in Sweden. The study contributes an important understanding of both the expectations and concerns that existed among health care professionals before the introduction of the Open Notes Service in psychiatry and the perceived impact of the technology on their own work and patient behavior after the implementation. The results from the previously published baseline survey showed that psychiatric health care professionals generally thought that Open Notes would influence both the patients and their own practice negatively. Objective: The objective of this study was to describe and discuss how health care professionals in adult psychiatric care in Region Skåne in southern Sweden experienced the influence of Open Notes on their patients and their own practice, and to compare the results with those of the baseline study. Methods: We distributed a full population Web-based questionnaire to psychiatric care professionals in Region Skåne in the spring of 2017, which was one and a half years after the implementation of the service. The response rate was 27.73% (699/2521). Analyses showed that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between health professional groups and attitudes to the Open Notes Service. Results: A total of 41.5% (285/687) of the health care professionals reported that none of their patients stated that they had read their Open Notes. Few health care professionals agreed with the statements about the potential benefits for patients from Open Notes. Slightly more of the health care professionals agreed with the statements about the potential risks. In addition, the results indicate that there was little impact on practice in terms of longer appointments or health care professionals having to address patients’ questions outside of appointments. However, the results also indicate that changes had taken place in clinical documentation. Psychologists (39/63, 62%) and doctors (36/94, 38%) in particular stated that they were less candid in their documentation after the implementation of Open Notes. Nearly 40% of the health care professionals (239/650, 36.8%) reported that the Open Notes Service in psychiatry was a good idea. Conclusions: Most health care professionals who responded to the postimplementation survey did not experience that patients in adult psychiatric care had become more involved in their care after the implementation of Open Notes. The results also indicate that the clinical documentation had changed after the implementation of Open Notes. Finally, the results indicate that it is important to prepare health care professionals before an implementation of Open Notes, especially in medical areas where the service is considered sensitive.

  • Purple heart US Serviceman returning home. Source: Road Home Program at Rush; Copyright: Road Home Program at Rush; URL:; License: Creative Commons Attribution (CC-BY).

    Veterans’ Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study


    Background: The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data. Objective: The aim of this study was to gain an understanding of patients’ motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit? Methods: We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis. Results: We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship. Conclusions: To integrate wearable data into mental health treatment programs, it is important to understand the patient’s perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

  • Ask the Experts. Source: Shutterstock, Inc; Copyright: bleakstar / Shutterstock, Inc; URL:; License: Licensed by the authors.

    Expert Consensus Survey on Digital Health Tools for Patients With Serious Mental Illness: Optimizing for User Characteristics and User Support


    Background: Digital technology is increasingly being used to enhance health care in various areas of medicine. In the area of serious mental illness, it is important to understand the special characteristics of target users that may influence motivation and competence to use digital health tools, as well as the resources and training necessary for these patients to facilitate the use of this technology. Objective: The aim of this study was to conduct a quantitative expert consensus survey to identify key characteristics of target users (patients and health care professionals), barriers and facilitators for appropriate use, and resources needed to optimize the use of digital health tools in patients with serious mental illness. Methods: A panel of 40 experts in digital behavioral health who met the participation criteria completed a 19-question survey, rating predefined responses on a 9-point Likert scale. Consensus was determined using a chi-square test of score distributions across three ranges (1-3, 4-6, 7-9). Categorical ratings of first, second, or third line were designated based on the lowest category into which the CI of the mean ratings fell, with a boundary >6.5 for first line. Here, we report experts’ responses to nine questions (265 options) that focused on (1) user characteristics that would promote or hinder the use of digital health tools, (2) potential benefits or motivators and barriers or unintended consequences of digital health tool use, and (3) support and training for patients and health care professionals. Results: Among patient characteristics most likely to promote use of digital health tools, experts endorsed interest in using state-of-the-art technology, availability of necessary resources, good occupational functioning, and perception of the tool as beneficial. Certain disease-associated signs and symptoms (eg, more severe symptoms, substance abuse problems, and a chaotic living situation) were considered likely to make it difficult for patients to use digital health tools. Enthusiasm among health care professionals for digital health tools and availability of staff and equipment to support their use were identified as variables to enable health care professionals to successfully incorporate digital health tools into their practices. The experts identified a number of potential benefits of and barriers to use of digital health tools by patients and health care professionals. Experts agreed that both health care professionals and patients would need to be trained in the use of these new technologies. Conclusions: These results provide guidance to the mental health field on how to optimize the development and deployment of digital health tools for patients with serious mental illness.

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  • The Social, Emotional and Economic empowerment thru Knowledge of Group Support Psychotherapy (SEEK-GSP) Cluster Randomized Trial: Recruitment and Baseline characteristics

    Date Submitted: Jul 13, 2018

    Open Peer Review Period: Jul 14, 2018 - Sep 8, 2018

    Background: Psychosocial characteristics including self-esteem, perceived social support, coping skills, stigma, discrimination and poverty are strongly correlated with depression symptoms. However, d...

    Background: Psychosocial characteristics including self-esteem, perceived social support, coping skills, stigma, discrimination and poverty are strongly correlated with depression symptoms. However, data on the extent of these correlations among persons living with HIV, and the correlations between psychosocial characteristics and HIV treatment outcomes is limited in sub-Saharan Africa. Objective: This paper aims to describe the recruitment and correlations among baseline characteristics of a sample of HIV positive men and women in a cluster randomized trial designed to examine the effects of group support psychotherapy delivered by trained lay health workers for depression treatment. Methods: Thirty eligible primary care health centers across three districts were randomly allocated to have their lay health workers trained to deliver group support psychotherapy (intervention arm) or group HIV education and treatment as usual (control arm) to PLWH with depression. Screening and recruitment procedures were documented. Baseline demographic, socio-economic and psychosocial characteristics were collected via interviewer administered questionnaires. Among eligible participants, differences between those enrolled versus those who refused enrollment were assessed using Chi-square for categorical variables and t-tests for continuous variables.Spearman rank-order correlation analyses were conducted to determine associations between baseline depression symptoms, adherence to antiretroviral therapy (ART), viral load suppressionand other psychosocial variables. Results: The study screened 1,473 people of which 1,140 were eligible and enrolled over a 14 week recruitment period. Participants recruited comprised of 95% of the target sample size of 1,200. The sample mean age was 38.46(SD=10.97) and both genders were well represented (males 46.32%). Most participants met diagnostic criteria for major depressive disorder (96.9%), had significant post-traumatic stress symptoms (72.54%), reported moderate suicide risk (52.54%), primary or no formal education (86.23%), lack of income generating activity (70%), and food insecurity (81.87%). Baseline mean scores for disability days in the past month, functioning, self-esteem, and social support were low while mean scores for internalized stigma were high.Among eligible participants, 48(4.2%) refused to participate in the interventions and these were more likely to be males (χ2 =4.01; p-value =0.045) and have significantly lower depression symptoms scores (t =2.36; p-value =0.01) than those who enrolled and participated in the interventions. Several significant positive and negative correlations were found between psychosocial variables and depression. There was a significant positive correlation between viral load suppression and number of trauma events experienced (ρ = 0.12, p < 0.05). Adherence to ART was positively correlated with perceived social support (ρ = 0.15, p < 0.01) but negatively correlated with depression symptoms (ρ = -0.11, p < 0.05) and stigma (ρ = - 0.14, p < 0.01). Conclusions: In this study population, men and womenwith HIV and major depression are vulnerable on multiple levels and disadvantaged across many social and economic determinants of health. Therefore, psychological therapy to support these individuals should be tailored to the cultural context, and have the ingredients to address not only multiple emotional problems but also the socio-economic disadvantage. Clinical Trial: This trial is registered with The Pan African Clinical Trials Registry; PACTR201608001738234.

  • Qualitative analysis of UK and USA open mental health Facebook groups for mental health support

    Date Submitted: Jul 5, 2018

    Open Peer Review Period: Jul 6, 2018 - Aug 31, 2018

    Background: Facebook is still the most popular social networking site in the world. A growing number of people with mental health issues are using open Facebook groups as a source of informational and...

    Background: Facebook is still the most popular social networking site in the world. A growing number of people with mental health issues are using open Facebook groups as a source of informational and emotional support, and to provide peer support to others with mental illness. Facebook groups specifically tailored for mental health can provide a safe, less stigmatised environment for people to share their personal experiences with others who understand, and gain information and advice from those with similar experiences. The peer support people gain from other group members can reduce feelings of isolation, helping them feel more connected and less alone. Objective: The aim of the research was to gain an understanding of how people use open Facebook groups for their emotional and mental health needs, and to gain an insight into how they support each other through these groups. Specifically, the study explored the ways people in the UK and USA interact via open Facebook mental health groups about mental health issues, and how they sought, provided and received the support. Methods: A systematic search of all mental health related open Facebook groups was conducted in January 2016 using mental health related keywords, which yielded a total of 158 groups. Only groups that had an administrator that was clearly based in the UK or USA, and displayed group member engagement through comments and posts were considered for analysis. This resulted in 14 UK Facebook groups and 11 USA Facebook groups appropriate for analysis. All posts over a three-month period were copied and pasted for analysis. The resulting data set consisted of 1,901 pages of UK Facebook posts and comments, and 1,900 pages of USA Facebook posts and comments. Thematic analysis was conducted to extract key themes from the data set using NVivo software Results: Findings support the literature that general online support is beneficial to those with mental illness. Using open Facebook groups specifically can provide people with informational and emotional support for their mental illness, increasing the perceived level of social support. Additionally, online support from Facebook groups can increase feelings of connectedness, reduce feelings of isolation, and provide a platform for comparison of perspectives relating to their own experiences. Furthermore, group membership may offer hope and increase feelings of empowerment in those using Facebook as a support mechanism for their mental illness. Conclusions: This study adds to the current growing body of research examining how people with mental illness use open Facebook groups specifically to seek and provide emotional and informational support online. The study highlights the positive impact of shared personal experiences, and offers a greater understanding of the benefits of online peer support in relation to their mental health and wellbeing. Furthermore, it poses questions for group administrators and health professionals relating to their utilisation and moderation of such open Facebook mental health groups.

  • A review of websites for perinatal anxiety: Advice for healthcare professionals and users

    Date Submitted: Jul 2, 2018

    Open Peer Review Period: Jul 6, 2018 - Aug 31, 2018

    Background: There are many websites available with information and resources for perinatal anxiety, however, there is limited research on the quality and content of these sites. Objective: To identify...

    Background: There are many websites available with information and resources for perinatal anxiety, however, there is limited research on the quality and content of these sites. Objective: To identify what sites are available on perinatal anxiety, identify any information and therapeutic advice given, and review its accuracy and website design. Methods: This study conducted a systematic review of websites for perinatal anxiety. Eligible websites (n=50) were evaluated for accuracy of information, resources for mothers, website quality and readability. Results: Information was often incomplete and focused on symptoms, rather than risk factors or impact of untreated perinatal anxiety. Websites often had information on treatment (92%), but much less on screening (38%). Most sites provided at least some resources to support mothers (98%) and active, guided support was infrequent (50%). Website quality was extremely variable, and mostly difficult to read (84%). Conclusions: The study recommends the top 4 websites on perinatal anxiety for healthcare professionals and users. There is a need for websites to be developed that provide accurate evidence-based information that women can relate to with quality support resources. These sites should also be easy to use and readable.

  • The WorkingWell Smartphone App for Individuals with Serious Mental Illnesses: A Proof-of-Concept, Mixed Methods Feasibility Study

    Date Submitted: Jun 23, 2018

    Open Peer Review Period: Jun 24, 2018 - Aug 19, 2018

    Background: The disparities in employment for individuals with serious mental illnesses (SMI) have been well documented, as have the benefits of work. The benefits of mobile technology in providing ac...

    Background: The disparities in employment for individuals with serious mental illnesses (SMI) have been well documented, as have the benefits of work. The benefits of mobile technology in providing accessible, in-the-moment support for these individuals has been demonstrated. The WorkingWell mobile app was developed to meet the need for accessible follow-along supports for individuals with SMI in the workplace. Objective: We explore the usability, usage, usefulness and overall feasibility of the WorkingWell mobile app with individuals with SMI receiving community-based services and actively employed. Methods: In this proof-of-concept, mixed methods, two-month feasibility study (N=40), employed individuals with SMI were recruited in mental health agencies. Participants completed surveys regarding background characteristics and cellphone use at enrollment; and responded to interview items regarding app usability, usage and usefulness in technical assistance calls at one, two, four and six weeks of study participation and in the exit interview at 8 weeks. Data on the frequency of app usage were downloaded and monitored on a daily basis. A version of the System Usability Scale (SUS) was administered in the exit interview. Feasibility was determined by the percent of users completing the study. General impressions were obtained from users regarding user support materials, technical assistance, and study procedures. Results: Over half of the participants were male (60%, 24/40). The majority were age 55 or under (70%, 28/40), Caucasian (80%, 32/40), had less than a 4-year college education (78%, 31/40), were employed part-time (98%, 39/40), had been working more than six months (60%, 24/40), and indicated a diagnosis of bipolar, schizoaffective or depressive disorder (84%, 16/25). The vast majority of participants owned cellphones (95%, 38/40), using them multiple times per day (83%, 33/40). Their average rating on SUS usability items was 3.93 (SD = 0.77; range = 1.57 to 5.00), reflecting positive responses. Participants, in general, indicated WorkingWell was “very easy”, “straightforward”, “simple”, and “user-friendly”. Usability challenges were related to personal issues (e.g., memory) or to difficulties with the phone or app. Data on app usage varied considerably. The most frequent navigations were to the home screen, followed by Rate My Day and My Progress, and then by Manage the Moment and Remind Me. The app was described as useful by most study participants; 86% (30/35) agreed the app would help them manage better on the job. Thirty-five of the 40 original participants (87%) completed the study. Conclusions: The WorkingWell app is a feasible approach to providing accessible, as-needed employment support for individuals with SMI. The app would benefit from additional modifications to address recommendations from feasibility testing. Controlled research with larger samples, more diverse in individual characteristics and workplace settings, is essential to demonstrating the effectiveness of the app. Clinical Trial: This trial was not registered because it did not fulfill the criteria for registration under the FDAAA 801 definition of an "applicable clinical trial". The study was excluded from registration and results submission requirements of FDAAA 801 as it was a “Small clinical trials to determine the feasibility of a device or a clinical trial to test prototype devices, where the primary outcome measure relates to feasibility and not to health outcomes” (from Small feasibility studies do not require registration.

  • Online positive affect journaling improves mental distress and well-being in general medical patients: Evidence from a preliminary randomized controlled trial

    Date Submitted: Jun 13, 2018

    Open Peer Review Period: Jun 20, 2018 - Aug 15, 2018

    Background: Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for online dissem...

    Background: Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for online dissemination to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical conditions. Objective: This study examined the impact of a 12-week online PAJ intervention on psychological distress and quality of life in general medical patients. Methods: Seventy adults with various medical conditions were recruited from local clinics and randomly assigned to an online PAJ intervention (n=35) or usual care (n=35). The intervention group completed 15-minute online PAJ sessions on three days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed. Results: Patients evidenced moderate sustained adherence to online intervention. PAJ was associated with decreased mental distress (p’s≤.045) and increased well-being (p’s ≤.046) relative to baseline. PAJ was also associated with less depressive symptoms (p=.047) and anxiety (p=.01) after one month, and greater resilience after the first (p=.044) and second month (p=.01), relative to usual care. Conclusions: Online PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical care to improve quality of life. Clinical Trial: NCT01873599