JMIR Publications

We are scheduled to perform a server upgrade on Thursday, November 30, 2017 between 4 and 6 PM Eastern Time.

Please refrain from submitting support requests related to server downtime during this window.

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

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.

Editorial Board members are currently being recruited, please contact us if you are interested ( at


Recent Articles:

  • How patients with major depression use and benefit from smartphone CBT (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a...


    Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as “test-drive a new car,” “go to a coffee shop after lunch,” or “call up an old friend” were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; ctr_view.cgi?recptno=R000015984 (Archived by WebCite at

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

    Technology-Assisted Behavioral Intervention to Extend Sleep Duration: Development and Design of the Sleep Bunny Mobile App


    Background: Despite the high prevalence of short sleep duration (29.2% of adults sleep <6 hours on weekdays), there are no existing theory-based behavioral interventions to extend sleep duration. The popularity of wearable sleep trackers provides an opportunity to engage users in interventions. Objective: The objective of this study was to outline the theoretical foundation and iterative process of designing the “Sleep Bunny,” a technology-assisted sleep extension intervention including a mobile phone app, wearable sleep tracker, and brief telephone coaching. We conducted a two-step process in the development of this intervention, which was as follows: (1) user testing of the app and (2) a field trial that was completed by 2 participants with short sleep duration and a cardiovascular disease risk factor linked to short sleep duration (body mass index [BMI] >25). Methods: All participants had habitual sleep duration <6.5 hours verified by 7 days of actigraphy. A total of 6 individuals completed initial user testing in the development phase, and 2 participants completed field testing. Participants in the user testing and field testing responded to open-ended surveys about the design and utility of the app. Participants in the field testing completed the Epworth Sleepiness Scale and also wore an actigraph for a 1-week baseline period and during the 4-week intervention period. Results: The feedback suggests that users enjoyed the wearable sleep tracker and found the app visually pleasing, but they suggested improvements to the notification and reminder features of the app. The 2 participants who completed the field test demonstrated significant improvements in sleep duration and daytime sleepiness. Conclusions: Further testing is needed to determine effects of this intervention in populations at risk for the mental and physical consequences of sleep loss.

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

    Effect of a Gender-Tailored eHealth Weight Loss Program on the Depressive Symptoms of Overweight and Obese Men: Pre-Post Study


    Background: Obesity and depression are of two of the largest contributors to the global burden of disease in men. Although lifestyle behavior change programs can improve participants’ weight and depressive symptoms, the evidence is limited by a lack of male participants and a reliance on face-to-face treatment approaches, which are not accessible or appealing for many men. Objective: This study examined the effect of a gender-tailored electronic health (eHealth) program on the depressive symptoms of a community sample of overweight and obese men with or without depression. A secondary aim was to determine whether the eHealth, self-directed format of the program was a feasible and acceptable treatment approach for the subgroup of men with depression at baseline. Methods: In total, 209 overweight/obese men from the Hunter Region of Australia were assessed before and after completing a self-administered eHealth weight loss program over 3 months. To increase engagement, most program elements were socio-culturally targeted to appeal specifically to men and included printed materials, a DVD, motivational text messages, online- or app-based self-monitoring, and other weight loss tools (eg, pedometer). Depressive symptoms were measured with the validated 8-item Patient Health Questionnaire (PHQ-8). Program feasibility and acceptability were assessed with a process questionnaire plus recruitment and retention rates. Changes in depressive symptoms and weight were examined using intention-to-treat linear mixed models, adjusted for the centered baseline score and other covariates. Effect sizes were estimated with Cohen’s d. Results: At baseline, the mean weight and age of the sample was 105.7 kg (standard deviation [SD] 14.0) and 46.6 years (SD 11.3), respectively. Overall, 36 men (36/209, 17.2%) were experiencing depression (PHQ-8 score ≥10). Retention rates were comparable between men with and without depression (32/36, 88.9% vs 145/173, 83.8%; P=.44). At posttest, depressive symptoms had reduced by 1.8 units (95% CI 1.3 to 2.3; P<.001; d=0.5) for the whole sample. These improvements were particularly notable in the subgroup of men with depression (-5.5 units; P<.001; d=1.0) and 72.2% (26/36) of this subgroup no longer met the criterion for depression at posttest. A corresponding, albeit smaller, intervention effect on depressive symptoms was also observed in men without depression (-1.0 units; P<.001; d=0.4). The overall intervention effect on weight was -4.7 kg (d=1.3), which did not vary significantly by depression status. Program acceptability, feasibility, and online engagement metrics were also comparable between men with and without depression. Conclusions: A gender-tailored eHealth lifestyle program generated short-term improvements in the mental health of overweight and obese men, particularly for men with depression at baseline. Despite receiving no personalized support, men with depression reported high levels of satisfaction and engagement with the program. As such, a longer-term controlled trial testing an adapted version of the program for this subgroup is warranted. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12612000749808; Trial/Registration/TrialReview.aspx?id=362575 (Archived by WebCite at

  • The Partners in Parenting (PIP) homepage (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Partners in Parenting: A Multi-Level Web-Based Approach to Support Parents in Prevention and Early Intervention for Adolescent Depression and Anxiety


    Depression and anxiety disorders in young people are a global health concern. Various risk and protective factors for these disorders are potentially modifiable by parents, underscoring the important role parents play in reducing the risk and impact of these disorders in their adolescent children. However, cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. In this paper, we propose a multi-level public health approach involving a Web-based parenting intervention, Partners in Parenting (PIP). We describe the components of the Web-based intervention and how each component was developed. Development of the intervention was guided by principles of the persuasive systems design model to maximize parental engagement and adherence. A consumer-engagement approach was used, including consultation with parents and adolescents about the content and presentation of the intervention. The PIP intervention can be used at varying levels of intensity to tailor to the different needs of parents across the population. Challenges and opportunities for the use of the intervention are discussed. The PIP Web-based intervention was developed to address the dearth of evidence-based resources to support parents in their important role in their adolescents’ mental health. The proposed public health approach utilizes this intervention at varying levels of intensity based on parents’ needs. Evaluation of each separate level of the model is ongoing. Further evaluation of the whole approach is required to assess the utility of the intervention as a public health approach, as well as its broader effects on adolescent functioning and socioeconomic outcomes.

  • RAFT “Coping with distressing feelings” webpage (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Mobile Text Message Intervention to Reduce Repeat Suicidal Episodes: Design and Development of Reconnecting After a Suicide Attempt (RAFT)


    Background: Suicide is a leading cause of death, particularly among young people. Continuity of care following discharge from hospital is critical, yet this is a time when individuals often lose contact with health care services. Offline brief contact interventions following a suicide attempt can reduce the number of repeat attempts, and text message (short message service, SMS) interventions are currently being evaluated. Objective: The aim of this study was to extend postattempt caring contacts by designing a brief Web-based intervention targeting proximal risk factors and the needs of this population during the postattempt period. This paper details the development process and describes the realized system. Methods: To inform the design of the intervention, a lived experience design group was established. Participants were asked about their experiences of support following their suicide attempt, their needs during this time, and how these could be addressed in a brief contact eHealth intervention. The intervention design was also informed by consultation with lived experience panels external to the project and a clinical design group. Results: Prompt outreach following discharge, initial distraction activities with low cognitive demands, and ongoing support over an extended period were identified as structural requirements of the intervention. Key content areas identified included coping with distressing feelings, safety planning, emotional regulation and acceptance, coping with suicidal thoughts, connecting with others and interpersonal relationships, and managing alcohol consumption. Conclusions: The RAFT (Reconnecting AFTer a suicide attempt) text message brief contact intervention combines SMS contacts with additional Web-based brief therapeutic content targeting key risk factors. It has the potential to reduce the number of repeat suicidal episodes and to provide accessible, acceptable, and cost-effective support for individuals who may not otherwise seek face-to-face treatment. A pilot study to test the feasibility and acceptability of the RAFT intervention is underway.

  • Source: Pixabay; Copyright: USA-Reiseblogger; URL:; License: Public Domain (CC0).

    Can Facebook Reduce Perceived Anxiety Among College Students? Randomized Controlled Exercise Trial Using the Transtheoretical Model of Behavior Change


    Background: Recent studies suggest social media may be an attractive strategy to promote mental health and wellness. There remains a need to examine the utility for individually tailored wellness messages posted to social media sites such as Facebook to facilitate positive psychological outcomes. Objective: Our aim was to extend the growing body of evidence supporting the potential for social media to enhance mental health. We evaluated the influence of an 8-week social media intervention on anxiety in college students and examined the impact of dynamic (active) versus static (passive) Facebook content on physical activity behaviors. Methods: Participants in the static group (n=21) accessed a Facebook page featuring 96 statuses. Statuses were intended to engage cognitive processes followed by behavioral processes of change per the transtheoretical model of behavior change. Content posted on the static Facebook page was identical to the dynamic page; however, the static group viewed all 96 statuses on the first day of the study, while the dynamic group received only 1 to 2 of these status updates per day throughout the intervention. Anxiety was measured using the Overall Anxiety Severity and Impairment Scale (OASIS). Time spent engaging in physical activity was assessed using the International Physical Activity Questionnaire (IPAQ). Results: The OASIS change score for the dynamic Facebook group was statistically significant (P=.003), whereas the change score for the static group was not (P=.48). A statistically significant group-by-time interaction was observed (P=.03). The total IPAQ group-by-time interaction was not statistically significant (P=.06). Conclusions: We observed a decrease in anxiety and increase in total physical activity for the dynamic group only. Dynamic social networking sites, featuring regularly updated content, may be more advantageous than websites that retain static content over time. Trial Registration: NCT03363737; (Archived by WebCite at

  • A person completing the WHODAS 2.0 online. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    The 12-item Self-Report World Health Organization Disability Assessment Schedule (WHODAS) 2.0 Administered Via the Internet to Individuals With Anxiety and...


    Background: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a widespread measure of disability and functional impairment, which is bundled with the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) for use in psychiatry. Administering psychometric scales via the Internet is an effective way to reach respondents and allow for convenient handling of data. Objective: The aim was to study the psychometric properties of the 12-item self-report WHODAS 2.0 when administered online to individuals with anxiety and stress disorders. The WHODAS 2.0 was hypothesized to exhibit high internal consistency and be unidimensional. We also expected the WHODAS 2.0 to show high 2-week test-retest reliability, convergent validity (correlations approximately .50 to .90 with other self-report measures of functional impairment), that it would differentiate between patients with and without exhaustion disorder, and that it would respond to change in primary symptom domain. Methods: We administered the 12-item self-report WHODAS 2.0 online to patients with anxiety and stress disorders (N=160) enrolled in clinical trials of cognitive behavior therapy, and analyzed psychometric properties within a classical test theory framework. Scores were compared with well-established symptom and disability measures, and sensitivity to change was studied from pretreatment to posttreatment assessment. Results: The 12-item self-report WHODAS 2.0 showed high internal consistency (Cronbach alpha=.83-.92), high 2-week test-retest reliability (intraclass correlation coefficient=.83), adequate construct validity, and was sensitive to change. We found preliminary evidence for a three-factorial structure, but one strong factor accounted for a clear majority of the variance. Conclusions: We conclude that the 12-item self-report WHODAS 2.0 is a psychometrically sound instrument when administered online to individuals with anxiety and stress disorders, but that it is probably fruitful to also report the three subfactors to facilitate comparisons between studies. Trial Registration: NCT02540317; (Archived by WebCite at; NCT02314065; (Archived by WebCite at

  • Source:; Copyright: franky242; URL:; License: Licensed by the authors.

    Sharing Family Life Information Through Video Calls and Other Information and Communication Technologies and the Association With Family Well-Being:...


    Background: The use of information and communication technologies (ICTs) for information sharing among family members is increasing dramatically. However, little is known about the associated factors and the influence on family well-being. Objective: The authors investigated the pattern and social determinants of family life information sharing with family and the associations of different methods of sharing with perceived family health, happiness, and harmony (3Hs) in Hong Kong, where mobile phone ownership and Internet access are among the most prevalent, easiest, and fastest in the world. Methods: A territory-wide population-based telephone survey was conducted from January to August 2016 on different methods of family life information (ie, information related to family communication, relationships with family members, emotion and stress management) sharing with family members, including face-to-face, phone, instant messaging (IM), social media sites, video calls, and email. Family well-being was assessed by three single items on perceived family health, happiness, and harmony, with higher scores indicating better family well-being. Adjusted prevalence ratios were used to assess the associations of sociodemographic factors with family life information sharing, and adjusted beta coefficients for family well-being. Results: Of 2017 respondents, face-to-face was the most common method to share family life information (74.45%, 1502/2017), followed by IM (40.86%, 824/2017), phone (28.10%, 567/2017), social media sites (11.91%, 240/2017), video calls (5.89%, 119/2017), and email (5.48%, 111/2017). Younger age and higher education were associated with the use of any (at least one) method, face-to-face, IM, and social media sites for sharing family life information (all P for trend <.01). Higher education was most strongly associated with the use of video calls (adjusted prevalence ratio=5.61, 95% CI 2.29-13.74). Higher household income was significantly associated with the use of any method, face-to-face, and IM (all P for trend <.05). Sharing family life information was associated with a higher level of perceived family well-being (beta=0.56, 95% CI 0.37-0.75), especially by face-to-face (beta=0.62, 95% CI 0.45-0.80) and video calls (beta=0.34, 95% CI 0.04-0.65). The combination of face-to-face and video calls was most strongly associated with a higher level of perceived family well-being (beta=0.81, 95% CI 0.45-1.16). Conclusions: The differential use of ICTs to share family life information was observed. The prevalence of video calls was low, but associated with much better family well-being. The results need to be confirmed by prospective and intervention studies to promote the use of video calls to communicate and share information with family, particularly in disadvantaged groups.

  • Source: Shutterstock; Copyright: Monkey Business Images; URL:; License: Licensed by the authors.

    School Counselors’ Perspectives of a Web-Based Stepped Care Mental Health Service for Schools: Cross-Sectional Online Survey


    Background: Mental health problems are common among youth in high school, and school counselors play a key role in the provision of school-based mental health care. However, school counselors occupy a multispecialist position that makes it difficult for them to provide care to all of those who are in need in a timely manner. A Web-based mental health service that offers screening, psychological therapy, and monitoring may help counselors manage time and provide additional oversight to students. However, for such a model to be implemented successfully, school counselors’ attitudes toward Web-based resources and services need to be measured. Objective: This study aimed to examine the acceptability of a proposed Web-based mental health service, the feasibility of providing this type of service in the school context, and the barriers and facilitators to implementation as perceived by school counselors in New South Wales (NSW), Australia. Methods: This study utilized an online cross-sectional survey to measure school counselors’ perspectives. Results: A total of 145 school counselors completed the survey. Overall, 82.1% (119/145) thought that the proposed service would be helpful to students. One-third reported that they would recommend the proposed model, with the remaining reporting potential concerns. Years of experience was the only background factor associated with a higher level of comfort with the proposed service (P=.048). Personal beliefs, knowledge and awareness, Internet accessibility, privacy, and confidentiality were found to influence, both positively and negatively, the likelihood of school counselors implementing a Web-based school mental health service. Conclusions: The findings of this study confirmed that greater support and resources are needed to facilitate what is already a challenging and emotionally demanding role for school counselors. Although the school counselors in this study were open to the proposed service model, successful implementation will require that the issues outlined are carefully addressed.

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

    Exploring Working Relationships in Mental Health Care via an E-Recovery Portal: Qualitative Study on the Experiences of Service Users and Health Providers


    Background: The quality of working relationships between service users and health providers is fundamental in the processes of recovery in mental health. How Internet-based interventions will influence these relationships for persons with long-term care needs, and the measures that can be taken to maintain and enhance working relationships through Internet, is still not well understood. Objective: The aim of this study was to gain insights into how service users and health providers experience their working relationships when they are offered the option of supplementing ongoing collaboration with an e-recovery portal. Methods: In this exploratory and descriptive study, an e-recovery portal was used by service users and their health providers in 2 mental health communities in Norway for at least 6 months and at most 12 months (2015-2016). The portal consists of secure messaging, a peer support forum, and a toolbox of resources for working with life domains including status, goals and activities, network map, crisis plan, and exercises. The portal was owned and managed by the service user while health providers could remotely access parts of the service user–generated content. The participants could use the portal in whatever way they wished, to suit their collaboration. Data from 6 focus groups, 17 individual interviews, and an interview with 1 dyad about their experiences of use of the portal over the study period were inductively coded and thematically analyzed. Results: The thematic analysis resulted in 2 main themes: (1) new relational avenues and (2) out of alignment, illustrated by 8 subthemes. The first main theme is about dyads who reported new and enriching ways of working together through the portal, particularly related to written communication and use of the goal module. Illustrative subthemes are ownership, common ground, goals and direction, and sense of presence and availability. The second main theme illuminates the difficulties that arose when service users’ and health providers’ expectations for portal use were not aligned, and the consequences of not addressing these difficulties. Illustrative subthemes are initiative and responsibility, waiting for the other, feeling overwhelmed, and clarifications and agreements. Conclusions: The degree to which dyads benefited from using the e-recovery portal appeared to be mainly associated with the degree to which the dyads’ relations were open and flexible before the portal was introduced. For those who experienced frustrations, the portal may have both exposed and added to suboptimal working relationships. Use of the goal module appeared to strengthen the person-centered nature of collaboration. A key question is how health providers balance between enabling service users’ greater control over their care, without relinquishing responsibility for the quality of the working relationship, also when using an e-recovery portal. Implications for implementation are discussed.

  • Source: Chris Bauer (Fred Says); Copyright: Robert Garofalo; URL:; License: Creative Commons Attribution (CC-BY).

    A Web-Based Study of Dog Ownership and Depression Among People Living With HIV


    Background: People living with human immunodeficiency virus (PLHIV) are approximately twice as likely to be depressed compared with HIV-negative individuals. Depression is consistently associated with low antiretroviral therapy (ART) adherence, an important step within the HIV care continuum related to HIV disease progression and overall health. One factor that may have positive psychosocial benefits and promote ART adherence is dog ownership. Research indicates that dog ownership is associated with lower depression, and initial evidence suggests its positive impact on psychosocial outcomes for PLHIV. Objective: The aim of our study was to expand the existing research by examining the relationship between current dog ownership and depression for a sample of PLHIV while controlling for demographic characteristics and other potential confounders. Methods: Participants aged 18 years or older and who self-reported an HIV diagnosis were recruited via social media into When Dogs Heal, a cross-sectional Web-based survey to collect data among adult PLHIV. The research visit was conducted via a Web-based survey, and there was no in-person interaction with the participant. Primary outcome measures included demographic questions (age, race, ethnicity, gender, and sexual orientation), pet ownership (type of pet owned and current dog ownership), depression (Center for Epidemiologic Studies Depression Scale, 10 items), and resilience (Resilience Research Centre Adult Resilience Measure, 28 items). Results: A total of 252 participants were enrolled into the study in January 2016, with a final analytic sample of 199 participants. Mean age was 49 years, 86.4% (172/199) of participants were male, and 80.4% (160/199) were white. Current dog ownership was prevalent among the sample (68.3%, 136/199). Bivariate analysis indicated that there was no significant relationship between depression and demographic characteristics (age, race, ethnicity, gender, and sexual orientation), with P>.05. The multivariate logistic regression, including age, race, ethnicity, gender, resilience, and current dog ownership, was significant, with P<.001. Of the 6 predictor variables, only 2 were statistically significant: dog ownership and resilience. Noncurrent dog owners had 3 times higher odds of depression in comparison with current dog owners: odds ratio 3.01; 95% CI 1.54-6.21. Conclusions: Growing evidence suggests that dog ownership reduces the likelihood of depression and, therefore, may confer long-term health benefits on PLHIV. Future studies should explore whether dog-specific interventions are a feasible and efficacious intervention to improve outcomes among PLHIV.

  • Source: Pixabay; Copyright: 27707; URL:; License: Public Domain (CC0).

    Use of the Internet and Mobile Phones for Self-Management of Severe Mental Health Problems: Qualitative Study of Staff Views


    Background: Researchers are currently investigating the feasibility, acceptability, and efficacy of digital health interventions for people who experience severe mental health problems such as psychosis and bipolar disorder. Although the acceptability of digital health interventions for severe mental health problems appears to be relatively high and some people report successfully using the Internet and mobile phones to manage their mental health, the attitudes of mental health care staff toward such approaches have yet to be considered. Objective: The aim of this study was to explore mental health care staff experiences of clients with severe mental health problems engaging with the Internet and mobile phones to self-manage their mental health and their views toward these behaviors. The study also sought to examine the opinions expressed by mental health care staff toward digital health interventions for severe mental health problems to identify potential facilitators and barriers to implementation. Methods: Four focus groups were conducted with 20 staff working in mental health care services in the North West of the England using a topic guide. Focus groups involved 12 staff working in secondary care psychological services (7 participants in focus group 1 and 5 participants in focus group 4), 4 staff working in a rehabilitation unit (focus group 2), and 4 staff working in a community mental health team (focus group 3). Focus groups were transcribed verbatim, and transcripts were analyzed thematically to identify key themes that emerged from the data. Results: Four overarching themes, two with associated subthemes, were identified: (1) staff have conflicting views about the pros and cons of using Web-based resources and digital health interventions to manage mental health; (2) digital health interventions could increase access to mental health support options for severe mental health problems but may perpetuate the digital divide; (3) digital health interventions’ impact on staff roles and responsibilities; and (4) digital health interventions should be used to enhance, not replace, face-to-face support. Conclusions: This study is the first, to our knowledge, to qualitatively explore the experiences and attitudes of mental health care staff toward individuals with severe mental health problems using the Internet, mobile phones, and digital health interventions to self-manage their mental health. Understanding the positive and negative experiences and views shared by staff toward both current and potential digital health intervention use has enabled the identification of several considerations for implementation. Additionally, the findings suggest mental health care staff need clear guidance and training in relation to their responsibilities in recommending reputable and secure websites, forums, and digital health interventions and in how to manage professional boundaries on the Internet. Overall, the study highlights that digital health interventions could be well received by staff working in mental health services but importantly, such management options must be presented to frontline staff as an avenue to enhance care and extend choice, rather than as a method to reduce costs.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Latest Submissions Open for Peer-Review:

View All Open Peer Review Articles
  • Preliminary Evaluation of a Web-Based Psychological Screening Tool in Adolescents Undergoing Minimally Invasive Pectus Surgery

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 12, 2018 - Jan 22, 2018

    Background: Preoperative anxiety and depression are predominant risk factors for increased postoperative pain. Thoracic wall deformities in adolescents often cause low self-esteem, which contributes t...

    Background: Preoperative anxiety and depression are predominant risk factors for increased postoperative pain. Thoracic wall deformities in adolescents often cause low self-esteem, which contributes to psychological concerns. Several studies have suggested a relationship between preoperative mental health treatment and enhanced recovery after surgery. Objective: This study investigated the validity of screening questionnaires concerning psychological trait and state characteristics via a patient-specific online platform. Methods: Patients scheduled for elective pectus surgery between June 2017 and August 2017 were invited to participate in clinical interviews and online self-report questionnaires. All patients were recruited in the Anesthesiology Department, Antwerp University Hospital, Belgium. This single-center observational cohort study was performed in accordance with the ethical standards of Good Clinical Practice guidelines (ICH-GCP) and the Declaration of Helsinki after obtaining study approval by the Institutional Review Board and Ethics Committee of the Antwerp University Hospital, Belgium (study identifier: 17/08/082). Patients with a history of a psychiatric disease, chronic opioid use (more than three months) or revision surgery were excluded. A preoperative psychological inventory was performed using the Rosenberg self-esteem scale (RSES), Hospital Anxiety and Depression Scale (HADs) and State-Trait Anxiety Inventory (STAI). The results were postoperatively compared with pain intensity and interference using the Multidisciplinary Pain Inventory (MPI), Coping Pain Questionnaire (CPQ) and numeric pain rating scale assessment (NRS). Results: Of the 22 patients, 21 used our web-based psychological perioperative screening platform. A “success” was reported by 85% of the patients for the smartphone application, 89% for individual online platform usability and 95% for accessibility. A total of 89% of the patients rated the effort of generating answers to the online questionnaire as low. The results from the completed questionnaires indicated a strong negative correlation between self-esteem and the anxiety trait (R = -0.72, p < 0.01) and overall anxiety characteristics (R = -0.49, p = 0.04). There was a positive correlation between depressive and anxiety characteristics and the anxiety trait (R = 0.52, p = 0.03; R = 0.6, p = 0.02, respectively). Moreover, preoperative anxiety was positively correlated with postoperative pain interference (R = 0.58, p = 0.02). Finally, there was a negative correlation between self-esteem and pain interference (R = -0.62, p = 0.01). Conclusions: Perioperative screening of psychological symptoms and trait characteristics with specific treatment, if necessary, could further improve postoperative pain and overall health status. Research on E-health technology, even for psychological patient care, is rapidly increasing. Clinical Trial: NCT03100669

  • Combining online and offline peer support groups in mental health care: A qualitative study of service users’ experiences

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 9, 2018 - Mar 6, 2018

    Background: Peer support groups for people with long-term mental health problems are at the heart of recovery-oriented approaches in mental health care. When conducted face-to-face (offline) or on the...

    Background: Peer support groups for people with long-term mental health problems are at the heart of recovery-oriented approaches in mental health care. When conducted face-to-face (offline) or on the Internet (online), peer support groups have proven to have differing strengths and weaknesses. Little is known about the benefits and challenges of combining the two formats. Objective: The aim of this study was to gain insights into the benefits and challenges of combining online and offline peer support groups facilitated through an Internet intervention designed to support recovery processes. Methods: In this exploratory and descriptive study, an e-recovery portal called ReConnect was used by service users in two mental health communities in Norway for 6-12 months. The portal included an online peer support forum which also facilitated participation in local in-person ReConnect-cafés. Both formats of peer support were facilitated by an employed service user consultant with lived experience of mental health problems and with training in peer support. Qualitative data about service users’ experiences of using the portal were collected through focus groups and individual interviews and inductively analyzed thematically with focus on benefits and challenges of peer support online and offline. Results: A total of 14 service users 22-63 years of age with various diagnoses, receiving services at both primary and specialist levels of mental health care participated in three focus groups and 10 individual interviews. Two main themes were identified in the analysis: 1) balancing anonymity and openness, and 2) enabling connectedness. These themes are further illustrated with the subthemes: i) dilemmas of anonymity and confidentiality, ii) towards self-disclosure and openness, iii) new friendships, and iv) networks in the local community. Three of the subthemes mainly describe benefits. Challenges were more implicit and cut across the subthemes. Identified challenges were linked to transitions from anonymity to revealing one’s identity, how to protect confidentiality, or to participation at face-to-face meetings in the local community. Conclusions: Our study suggests that online peer support groups and offline meetings complement each other, and the combination is mainly beneficial to users. The identified benefits appeared to arise from participants’ options of one format or the other, or that they could combine formats in ways that suited their individual values and comfort zones. We also identified challenges related to combination of formats, and both formats require appropriate facilitation of peer support. Combining online formats that enable anonymity, a non-judgmental atmosphere, and 24/7 accessibility regardless of location, with offline formats that foster local, in-person community ties, is a promising concept for facilitating recovery-oriented care, and warrants continued research.

  • Temporal associations between social activity and mood, fatigue, and pain in older adults with HIV: An ecological momentary assessment study

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 9, 2018 - Mar 6, 2018

    Background: Social isolation is associated with increased risk for mental and physical health problems. Older persons living with HIV (PLWH) are more socially isolated than their younger counterparts...

    Background: Social isolation is associated with increased risk for mental and physical health problems. Older persons living with HIV (PLWH) are more socially isolated than their younger counterparts or older persons without HIV; however, little is known about factors related to engagement in social activity among older PLWH. Objective: To examine real-time relationships among social activity, mood, fatigue, and pain in a sample of older PLWH. Methods: Twenty older PLWH, recruited from UCSD’s HIV Neurobehavioral Research Program in 2016, completed smartphone-based ecological momentary assessment (EMA) surveys five times/day for one week. Participants reported current social activity (alone vs. not alone; number of social interactions), and levels of mood (sadness, happiness, 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) reported being alone 63% of time on average during waking hours. Being alone was related to lower concurrent happiness (b=-0.300; p=0.008). In lagged analyses, social activity predicted higher levels of fatigue later in the day (b=-1.089; p=0.002), and higher pain levels predicted being alone in the morning with a reduced likelihood of being alone as the day progressed (b=0.945; p=0.021). Conclusions: Use of EMA elucidated a high rate of time spent alone among older PLWH. Promoting social activity despite presence of pain or fatigue may improve happiness and psychological well-being in this population.

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

    Date Submitted: Jan 5, 2018

    Open Peer Review Period: Jan 5, 2018 - Mar 2, 2018

    Background: Digital technology is increasingly being used to enhance healthcare in various areas of medicine. In the area of serious mental illness (SMI), it is important to understand the special cha...

    Background: Digital technology is increasingly being used to enhance healthcare in various areas of medicine. In the area of serious mental illness (SMI), it is important to understand the special characteristics of target users that may influence motivation and competence to use digital health tools (DHTs), as well as the resources and training necessary for these patients to facilitate the use of this technology. Objective: To conduct a quantitative expert consensus survey to identify key characteristics of target users (patients and healthcare professionals [HCPs]), barriers and facilitators for appropriate use, and resources needed to optimize the use of DHTs in patients with SMI. 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 3 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 confidence interval of the mean ratings fell, with a boundary >6.5 for first line. Here, we report experts’ responses to 9 questions (265 options) that focused on (1) user characteristics that would promote or hinder the use of DHTs, (2) potential benefits/motivators and barriers/unintended consequences of DHT use, and (3) support and training for patients and HCPs. Results: Among patient characteristics most likely to promote use of DHTs, 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, a chaotic living situation) were considered likely to make it difficult for patients to use DHTs. Enthusiasm among HCPs for DHTs and availability of staff and equipment to support their use were identified as variables to enable HCPs to successfully incorporate DHTs into their practices. The experts identified a number of potential benefits of and barriers to use of DHTs by patients and HCPs. Most experts agreed that both HCPs 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 DHTs for patients with SMI.

  • The Self-Assessment Kiosk: Development and implementation of an internet resource for self-assessment of mental health and health behavior

    Date Submitted: Jan 3, 2018

    Open Peer Review Period: Jan 4, 2018 - Mar 1, 2018

    Background: Standardized measurement of aspects of physical and mental health is useful for screening and identification of health problems. Personalized feedback of the results of standardized measur...

    Background: Standardized measurement of aspects of physical and mental health is useful for screening and identification of health problems. Personalized feedback of the results of standardized measurement can additionally influence health behavior. Treatment outcomes can be improved by monitoring feedback about health status over time. However, few resources are available that (i) are free for users, (ii) provide feedback from validated scales, and (iii) measure a wide range of health domains. Objective: Our goals were (i) to develop an internet self-assessment resource that met the criteria above and would also collect data that could be used to generate and test hypotheses about health, (ii) test its feasibility as a self-assessment and research tool, and (iii) describe the characteristics of its users. Methods: The Self-Assessment Kiosk was built using previously validated health measurement instruments and implemented on a commercial internet survey platform. Data regarding its usage and the characteristics of its users was collected over 54 weeks. The rate of accrual of new users, popularity of particular measurement domains, frequency with which multiple domains were selected for measurement and characteristics of users who chose particular questionnaires were assessed. Results: Of 1,435 visits, 570 users completed at least one measure and consented to research. Growth in the number of users over time was approximately linear. Users were skewed towards old age, higher income and higher education. More than half (55.2%) reported at least one medical condition. The median number of questionnaires completed on the first visit was four. The most commonly chosen questionnaires measured depression (61%), anxiety (60%), attachment insecurity (44%) and coping (41%). Depression and anxiety scores (both mean scores and proportion above a clinical cut-off) were intermediate between previously studied populations with and without mental illness. With respect to the sample size required to study relationships between specific domains, it was found that two to three times greater participant accrual was required for a three-variable study than for a single variable study. 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 its first year of availability in response to modest marketing. Completion of multiple measurement instruments will allow the Self-Assessment Kiosk database to be interrogated to understand the relationships between health variables. Users who select particular instruments tend to have scores that are higher than found in the general population, indicating that instruments are more likely to be selected when they are salient to users. Self-selection bias limits generalizability and needs to be taken into account when using the Self-Assessment Kiosk database as a research resource. Ethical issues that were considered in developing and implementing the Self-Assessment Kiosk are also discussed.

  • An Exploration of Eating Disorders and Emotional States: An Infodemiological Study of Tweets Among Followers of Pro-Eating Disorder Sites

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: Studies have shown that individuals with eating disorders (ED) often suffer from negative emotional arousal as well. Increasingly, studies have been utilizing social media as a tool to bet...

    Background: Studies have shown that individuals with eating disorders (ED) often suffer from negative emotional arousal as well. Increasingly, studies have been utilizing social media as a tool to better understanding public health issues. Objective: The aim of the study was to explore whether Twitter users who show signs of ED also show signs of negative emotional states and can be identified by their tweets. Methods: Using the Twitter API, six pro-ED Twitter accounts were identified. Twenty-percent of account followers were randomly extracted and screened for ED-related content (N=2139). Tweets from identified followers were analyzed using LIWC and MALLET to test for signs of depression. Machine learning was used to build a model to classify individuals as having an eating disorder or not based on the language used in their Tweets. Results: Twitter users with ED mentioned terms related to negative emotions, anxiety, anger, and sadness significantly more often than non-ED Twitter users; they also mentioned terms related to positive emotion less often. It was found that word clusters formed by ED users’ tweets were related to negative arousal and self-harm. It was also determined that people with eating disorders can be accurately classified using machine learning (sensitivity: 0.89, specificity: 0.94, positive predictive value: 0.94, negative predictive value: 0.88). Conclusions: Users who show signs of ED on Twitter also show signs of negative emotions on Twitter, and models induced with machine learning can accurately differentiate those with eating disorders from those without.