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JMIR Mental Health

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


Journal Description

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

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

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

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

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


Recent Articles:

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

    Acute Effect of Alcohol Intake on Cardiovascular Autonomic Regulation During the First Hours of Sleep in a Large Real-World Sample of Finnish Employees:...


    Background: Sleep is fundamental for good health, and poor sleep has been associated with negative health outcomes. Alcohol consumption is a universal health behavior associated with poor sleep. In controlled laboratory studies, alcohol intake has been shown to alter physiology and disturb sleep homeostasis and architecture. The association between acute alcohol intake and physiological changes has not yet been studied in noncontrolled real-world settings. Objective: The aim of this study was to assess the effects of alcohol intake on the autonomic nervous system (ANS) during sleep in a large noncontrolled sample of Finnish employees. Methods: From a larger cohort, this study included 4098 subjects (55.81%, 2287/4098 females; mean age 45.1 years) who had continuous beat-to-beat R-R interval recordings of good quality for at least 1 day with and for at least 1 day without alcohol intake. The participants underwent continuous beat-to-beat R-R interval recording during their normal everyday life and self-reported their alcohol intake as doses for each day. Heart rate (HR), HR variability (HRV), and HRV-derived indices of physiological state from the first 3 hours of sleep were used as outcomes. Within-subject analyses were conducted in a repeated measures manner by studying the differences in the outcomes between each participant’s days with and without alcohol intake. For repeated measures two-way analysis of variance, the participants were divided into three groups: low (≤0.25 g/kg), moderate (>0.25-0.75 g/kg), and high (>0.75 g/kg) intake of pure alcohol. Moreover, linear models studied the differences in outcomes with respect to the amount of alcohol intake and the participant’s background parameters (age; gender; body mass index, BMI; physical activity, PA; and baseline sleep HR). Results: Alcohol intake was dose-dependently associated with increased sympathetic regulation, decreased parasympathetic regulation, and insufficient recovery. In addition to moderate and high alcohol doses, the intraindividual effects of alcohol intake on the ANS regulation were observed also with low alcohol intake (all P<.001). For example, HRV-derived physiological recovery state decreased on average by 9.3, 24.0, and 39.2 percentage units with low, moderate, and high alcohol intake, respectively. The effects of alcohol in suppressing recovery were similar for both genders and for physically active and sedentary subjects but stronger among young than older subjects and for participants with lower baseline sleep HR than with higher baseline sleep HR. Conclusions: Alcohol intake disturbs cardiovascular relaxation during sleep in a dose-dependent manner in both genders. Regular PA or young age do not protect from these effects of alcohol. In health promotion, wearable HR monitoring and HRV-based analysis of recovery might be used to demonstrate the effects of alcohol on sleep on an individual level.

  • Source: Freepik; Copyright: Dragana_Gordic; URL:; License: Creative Commons Attribution (CC-BY).

    Improving Implementation of eMental Health for Mood Disorders in Routine Practice: Systematic Review of Barriers and Facilitating Factors


    Background: Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care. Objective: This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice. Methods: A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice. Results: A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH. Conclusions: Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients’ mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided.

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

    Targeted Secure Messages to Facilitate Access to Tobacco Treatment Counseling for Veterans: Feasibility Study


    Background: Studies show that combining nicotine replacement therapy (NRT) with tobacco treatment counseling is most effective for smoking cessation. However, tobacco treatment counseling has been underutilized across the nation. A secure email message sent to patients already taking NRT was hypothesized to increase the utilization of tobacco treatment counseling among Veterans in New Jersey. Secure messaging for communication between patients and providers was implemented through a web-based password-protected, secure messaging account, where Veterans get notified through their personal email when they have a message awaiting them. Objective: The main objective of this project was to determine if there was a significant increase in adoption of tobacco treatment counseling among Veterans who received a secure message describing the options for tobacco treatment counseling available to them. Secondary objectives were to demographically characterize Veterans who were and were not enrolled in secure messaging, as well as those who opened or did not open a message. Finally, because the language and content of the messages were changed across project phases, this project also sought to determine (by analysis of response rates) the type of language that was most effective at eliciting a response. Methods: Over two phases, messages were sent to two samples of Veterans prescribed NRT within the prior 90 days of each phase. In phase 1, one message was sent in December 2015 (message 1). In phase 2, one message was sent in July 2016 (message 2) and the same message (message 3) was resent in August 2016 to persons who did not open message 2. Messages 2 and 3 were more directive than message 1. Response rates to message 1 versus message 2 were compared. A logistic regression analysis determined effect of age and gender on enrollment in secure messaging across both phases. The effectiveness of each phase at increasing tobacco treatment counseling was analyzed using a McNemar test. Results: Message 2, sent to 423 Veterans, had a significantly higher response rate than message 1, sent to 348 Veterans (18%, 17/93 vs 8%, 6/78, P=.04). Phase 2 (ie, messages 2 and 3) significantly increased utilization of tobacco treatment counseling (net increase of six tobacco treatment counseling adopters, P=.04), whereas phase 1 (ie, message 1) did not (net increase of two tobacco treatment counseling adopters, P=.48). Women (odds ratio [OR] 1.6, 95% CI 1.1-2.3) and those aged 30 to 49 years (compared to other age groups) were more likely to be enrolled in secure messaging. Gender and age were not significant predictors of opening or replying to either message. Conclusions: Although the effect was small, secure messaging was a useful modality to increase tobacco treatment counseling. Directive content with a follow-up message appeared useful. Female Veterans and/or Veterans aged between 30 and 49 years are more likely to use secure messaging.

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

    A Mobile Health Platform for Clinical Monitoring in Early Psychosis: Implementation in Community-Based Outpatient Early Psychosis Care


    Background: A growing body of literature indicates that smartphone technology is a feasible add-on tool in the treatment of individuals with early psychosis (EP) . However, most studies to date have been conducted independent of outpatient care or in a research clinic setting, often with financial incentives to maintain user adherence to the technology. Feasibility of dissemination and implementation of smartphone technology into community mental health centers (CMHCs) has yet to be tested, and whether young adults with EP will use this technology for long periods of time without incentive is unknown. Furthermore, although EP individuals willingly adopt smartphone technology as part of their treatment, it remains unclear whether providers are amenable to integrating smartphone technology into treatment protocols. Objective: This study aimed to establish the feasibility of implementing a smartphone app and affiliated Web-based dashboard in 4 community outpatient EP clinics in Northern California. Methods: EP individuals in 4 clinics downloaded an app on their smartphone and responded to daily surveys regarding mood and symptoms for up to 5 months. Treatment providers at the affiliated clinics viewed survey responses on a secure Web-based dashboard in sessions with their clients and between appointments. EP clients and treatment providers filled out satisfaction surveys at study end regarding usability of the app. Results: Sixty-one EP clients and 20 treatment providers enrolled in the study for up to 5 months. Forty-one EP clients completed the study, and all treatment providers remained in the study for their duration in the clinic. Survey completion for all 61 EP clients was moderate: 40% and 39% for daily and weekly surveys, respectively. Completion rates were slightly higher in the participants who completed the study: 44% and 41% for daily and weekly surveys, respectively. Twenty-seven of 41 (66%) EP clients who completed the study and 11 of 13 (85%) treatment providers who responded to satisfaction surveys reported they would continue to use the app as part of treatment services. Six (15%; 6/41) clients and 3 providers (23%; 3/13) stated that technological glitches impeded their engagement with the platform. Conclusions: EP clients and treatment providers in community-based outpatient clinics are responsive to integrating smartphone technology into treatment services. There were logistical and technical challenges associated with enrolling individuals in CMHCs. To be most effective, implementing smartphone technology in CMHC EP care necessitates adequate technical staff and support for utilization of the platform.

  • Student looking at SOVA site on mobile phone. Source: The Authors; Copyright: Ana Radovic; URL:; License: Creative Commons Attribution (CC-BY).

    Supporting Our Valued Adolescents (SOVA), a Social Media Website for Adolescents with Depression and/or Anxiety: Technological Feasibility, Usability, and...


    Background: Supporting Our Valued Adolescents (SOVA), a social media website for adolescents, was designed to increase mental health literacy and address negative health beliefs toward depression and/or anxiety diagnosis and treatment. This stakeholder-informed site underwent iterative user testing to evolve into its current version with daily blog posts, round-the-clock site moderation, and Web-based peer interaction to create an online support community. Objective: The aim of this study was to evaluate the technological feasibility (at least 100 users on the site, logging in 12 to 18 times in the first 6 weeks) and acceptability of the SOVA site determined by the System Usability Scale (SUS). Methods: Adolescents and young adults (aged 14-26 years) with a self-reported history of depressive and/or anxiety symptoms were recruited to access the research website ( Participants were screened out if they reported active suicidality or a prior suicide attempt. Baseline survey measures included demographics, symptomatology using the Patient Health Questionnaire-9 modified for adolescents (PHQ-9A) and Screen for Child Anxiety Related Disorders (SCARED-C), and mental health treatment history. The 6-week follow-up measures taken in addition to the symptomatology, included feasibility (total number of log-ins), usability, and acceptability of SOVA using SUS. Results: Most of the 96 participants identified as female (75% [72/96]) and white (67% [64/96]). Most participants (73% [70/96]) reported having taken prior professional psychological help. The average PHQ-9A score was 11.8 (SD 5.5), and for SCARED-C, 85% (80/94) of the participants reported a score consistent with being susceptible to a diagnosed anxiety disorder. There were 46% (41/90) of eligible users who ever logged in. Out of the total users who ever logged in, the mean of total log-ins over the entire study was 4.1 (SD 6.9). Median number of users rated the user-friendliness of the site as “good.” The average SUS score was 71.2% (SD 18.7), or a “C-grade,” which correlated to an acceptable range. The participants reported to have liked the “easy-to-understand format” and “positive, helpful atmosphere,” but they also reported a desire for greater social interaction. Iterative recruitment resulted in incremental improvements to the site. Conclusions: The SOVA site met feasibility goals of recruiting almost 100 users and establishing acceptable usability. Subsequent interventions are planned to increase site engagement and to evaluate efficacy in increasing uptake of primary care–recommended depression and/or anxiety treatment.

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

    Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience


    Background: Self-harm is common among adolescents and is associated with a number of negative psychosocial outcomes including a higher risk of suicide. Recent reviews highlight the lack of research into specific interventions for children and young people who self-harm. Developing innovative interventions that are coproduced with individuals with lived experience and that reduce self-harm are key challenges for self-harm prevention. Objective: The aim of this study was to explore the acceptability, use, and safety of BlueIce, a mobile phone app for young people who self-harm and who are attending child and adolescent mental health services (CAMHS). Methods: This study is part of a mixed methods phase 1 trial of BlueIce. Young people aged 12-17 years attending specialist CAMHS were recruited. Clinicians were invited to refer young people who were self-harming or who had a history of self-harm. On consent being obtained and baseline measures taken, participants used BlueIce as an adjunct to usual care for an initial familiarization period of 2 weeks. If after this time they wanted to continue, they used BlueIce for a further 10 weeks. Semistructured interviews were conducted at postfamiliarization (2 weeks after using BlueIce) and postuse (12 weeks after using BlueIce) to assess the acceptability, use, and safety of BlueIce. We undertook a qualitative analysis using a deductive approach, and then an inductive approach, to investigate common themes. Results: Postfamiliarization interviews were conducted with 40 participants. Of these, 37 participants elected to use BlueIce, with postuse interviews being conducted with 33 participants. Following 6 key themes emerged from the data: (1) appraisal of BlueIce, (2) usability of BlueIce, (3) safety, (4) benefits of BlueIce, (5) agency and control, and (6) BlueIce less helpful. The participants reported that BlueIce was accessible, easy to use, and convenient. Many highlighted the mood diary and mood lifter sections as particularly helpful in offering a way to track their moods and offering new strategies to manage their thoughts to self-harm. No adverse effects were reported. For those who did not find BlueIce helpful, issues around motivation to stop self-harming impeded their ability to use the app. Conclusions: BlueIce was judged to be a helpful and safe way of supporting adolescents to manage thoughts of self-harming. Adolescents reported numerous benefits of using BlueIce, and all would recommend the app to other young people who were struggling with self-harm. These preliminary findings are encouraging and provide initial support for the acceptability of BlueIce as a self-help intervention used in conjunction with the traditional face-to-face therapy.

  • Source: Flickr; Copyright: daniellehelm; URL:; License: Creative Commons Attribution (CC-BY).

    Inducing Behavioral Change in Seekers of Pro-Anorexia Content Using Internet Advertisements: Randomized Controlled Trial


    Background: The influence of pro-anorexia (pro-ana) websites is debated, with studies indicating both negative and positive effects, as well as significant variation in the effects of different websites for those suffering from eating disorders (EDs) and the general population. Online advertising, known to induce behavioral change both online and in the physical world, has not been used so far to modify the search behavior of people seeking pro-ana content. Objective: The objective of this randomized controlled trial (RCT) was to examine if online advertisements (ads) can change online search behaviors of users who are looking for online pro-ana content. Methods: Using the Bing Ads system, we conducted an RCT to randomly expose the searchers for pro-ana content to 10 different ads referring people to one of the three websites: the National Eating Disorders Association, the National Institutes of Mental Health, and MyProAna. MyProAna is a pro-ana website that was found in a previous study to be associated with less pathological online behaviors than other pro-ana websites. We followed participants exposed and unexposed to the ads to explore their past and future online searches. The ads were shown 25,554 times and clicked on 217 times. Results: Exposure to the ads was associated with a decrease in searches for pro-ana and self-harm content. Reductions were greatest among those referred to MyProAna (reduction of 34.0% [73/215] and 37.2% [80/215] for pro-ana and self-harm, respectively) compared with users who were referred elsewhere (reduction of 15.47% [410/2650] and 3.21% [85/2650], respectively), and with users who were not shown the ads, who increased their behaviors (increase of 57.12% [6462/11,314] and 4.07% [461/11,314], respectively). In addition, those referred to MyProAna increased their search for treatment, as did control users, who did so to a lesser extent. However, users referred elsewhere decreased their searches for this content. Conclusions: We found that referring users interested in ED-related content to specific pro-ana communities might lessen their maladaptive online search behavior. This suggests that those who are preoccupied with EDs can be redirected to less pathological online searches through appropriate pathways. Trial Registration: NCT03439553; (Archived by WebCite at

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

    Influencing the Conversation About Masculinity and Suicide: Evaluation of the Man Up Multimedia Campaign Using Twitter Data


    Background: It has been suggested that some dominant aspects of traditional masculinity are contributing to the high suicide rates among Australian men. We developed a three-episode documentary called Man Up, which explores the complex relationship between masculinity and suicide and encourages men to question socially imposed rules about what it means to be a man and asks them to open up, express difficult emotions, and seek help if and when needed. We ran a three-phase social media campaign alongside the documentary using 5 channels (Twitter, Facebook, Instagram, YouTube, and Tumblr). Objective: This study aimed to examine the extent to which the Man Up Twitter campaign influenced the social media conversation about masculinity and suicide. Methods: We used Twitter insights data to assess the reach of and engagement with the campaign (using metrics on followers, likes, retweets, and impressions) and to determine the highest and lowest performing tweets in the campaign (using an aggregated performance measure of reactions). We used original content tweets to determine whether the campaign increased the volume of relevant Twitter conversations (aggregating the number of tweets for selected campaign hashtags over time), and we used a subset of these data to gain insight into the main content themes with respect to audience engagement. Results: The campaign generated a strong following that was engaged with the content of the campaign; over its whole duration, the campaign earned approximately 5000 likes and 2500 retweets and gained around 1,022,000 impressions. The highest performing tweets posted by the host included video footage and occurred during the most active period of the campaign (around the screening of the documentary). The volume of conversations in relation to commonly used hashtags (#MANUP, #ABCMANUP, #LISTENUP, and #SPEAKUP) grew in direct relation to the campaign activities, achieving strongest growth during the 3 weeks when the documentary was aired. Strongest engagement was found with content related to help-seeking, masculinity, and expressing emotions. A number of followers tweeted personal stories that revealed overwhelmingly positive perceptions of the content of the documentary and strongly endorsed its messages. Conclusions: The Man Up Twitter campaign triggered conversations about masculinity and suicide that otherwise may not have happened. For some, this may have been game-changing in terms of shifting attitudes toward expressing emotions and reaching out to others for help. The campaign was particularly effective in disseminating information and promoting conversations in real time, an advantage that it had over more traditional health promotion campaigns. This sort of approach could well be adapted to other areas of mental (and physical) health promotion campaigns to increase their reach and effectiveness.

  • Young person using MoodHwb (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Licensed by the authors.

    A Web-Based Psychoeducational Intervention for Adolescent Depression: Design and Development of MoodHwb


    Background: Depression is common in adolescence and leads to distress and impairment in individuals, families and carers. Treatment and prevention guidelines highlight the key role of information and evidence-based psychosocial interventions not only for individuals but also for their families and carers. Engaging young people in prevention and early intervention programs is a challenge, and early treatment and prevention of adolescent depression is a major public health concern. There has been growing interest in psychoeducational interventions to provide accurate information about health issues and to enhance and develop self-management skills. However, for adolescents with, or at high risk of depression, there is a lack of engaging Web-based psychoeducation programs that have been developed with user input and in line with research guidelines and targeted at both the individual and their family or carer. There are also few studies published on the process of development of Web-based psychoeducational interventions. Objective: The aim of this study was to describe the process underlying the design and development of MoodHwb (HwbHwyliau in Welsh): a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families, carers, friends, and professionals. Methods: The initial prototype was informed by (1) a systematic review of psychoeducational interventions for adolescent depression; (2) findings from semistructured interviews and focus groups conducted with adolescents (with depressive symptoms or at high risk), parents or carers, and professionals working with young people; and (3) workshops and discussions with a multimedia company and experts (in clinical, research, and multimedia work). Twelve interviews were completed (four each with young people, parents or carers, and professionals) and six focus groups (three with young people, one with parents and carers, one with professionals, and one with academics). Results: Key themes from the interviews and focus groups were: aims of the program, design and content issues, and integration and context of the program. The prototype was designed to be person-centered, multiplatform, engaging, interactive, and bilingual. It included mood-monitoring and goal-setting components and was available as a Web-based program and an app for mobile technologies. Conclusions: MoodHwb is a Web-based psychoeducational intervention developed for young people with, or at high risk of, depression and their families and carers. It was developed with user input using qualitative methods as well as user-centered design and educational and psychological theory. Further research is needed to evaluate the effectiveness of the program in a randomized controlled trial. If found to be effective, it could be implemented in health, education, youth and social services, and charities, to not only help young people but also families, carers, friends, and professionals involved in their care.

  • Work Addiction. Source: iStock by Getty Images; Copyright: Geber86; URL:; License: Licensed by the authors.

    Work Addiction Test Questionnaire to Assess Workaholism: Validation of French Version


    Background: Work addiction is a significant public health problem with a growing prevalence. The Work Addiction Risk Test (WART) is the gold standard questionnaire to detect workaholism. Objective: The main objective of this study was to validate the French version of the WART. Methods: Questionnaires were proposed to voluntary French workers using the WittyFit software. There were no exclusion criteria. The questionnaire was administered anonymously for initial validity testing and readministered one week later for test-retest reliability. We also assessed the workers’ sociodemographic characteristics, as well as other measurements for external validity, such as stress, well-being, and coaddictions to tobacco, alcohol, and cannabis. Several psychometric properties of the French-WART were explored: acceptability, reliability (internal consistency [Cronbach alpha coefficient] and reproducibility [Lin concordance coefficient]), construct validity (correlation coefficients and principal component analysis), and external validity (correlation coefficients). Results: Among the 1580 workers using WittyFit, 187 (11.83%) agreed to complete the WART questionnaire. Of those, 128 completed the test-retest survey (68.4%). Acceptability found that all respondents had fully completed the questionnaire, with few floor or ceiling effects. Reliability was very good with a Cronbach alpha coefficient at .90 (internal consistency) and Lin concordance coefficient at .90 (95% CI .87-.94] with a difference on the retest of .04 (SD 4.9) (95% CI −9.6 to 9.7) (reproducibility). We identified three main dimensions (construct validity). Relationships between WART and stress and well-being confirmed its external validity. Conclusions: The French version of the WART is a valid and reliable instrument to assess work addiction with satisfactory psychometric properties. Used in occupational medicine, this tool would allow the diagnosis of work addiction and can be easily implemented in current practice.

  • Source: Wikimedia Commons; Copyright: MC4 Army; URL:; License: Creative Commons Attribution (CC-BY).

    Open Notes in Swedish Psychiatric Care (Part 1): Survey Among Psychiatric Care Professionals


    Background: When the Swedish version of Open Notes, an electronic health record (EHR) service that allows patients online access, was introduced in hospitals, primary care, and specialized care in 2012, psychiatric care was exempt. This was because psychiatric notes were considered too sensitive for patient access. However, as the first region in Sweden, Region Skåne added adult psychiatry to its Open Notes service in 2015. This made it possible to carry out a unique baseline study to investigate how different health care professionals (HCPs) in adult psychiatric care in the region expect Open Notes to impact their patients and their practice. This is the first of two papers about the implementation of Open Notes in adult psychiatric care in Region Skåne. Objective: The objective of this study was to describe, compare, and discuss how different HCPs in adult psychiatric care in Region Skåne expect Open Notes to impact their patients and their own practice. Methods: A full population Web-based questionnaire was distributed to psychiatric care professionals in Region Skåne in late 2015. The response rate was 28.86% (871/3017). Analyses show that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between different professionals and attitudes to the Open Notes service. Results: The results show that the psychiatric HCPs are generally of the opinion that the service would affect their own practice and their patients negatively. The most striking result was that more than 60% of both doctors (80/132, 60.6%) and psychologists (55/90, 61%) were concerned that they would be less candid in their documentation in the future. Conclusions: Open Notes can increase the transparency between patients and psychiatric HCPs because patients are able to access their EHRs online without delay and thus, can read notes that have not yet been approved by the responsible HCP. This may be one explanation as to why HCPs are concerned that the service will affect both their own work and their patients.

  • Participant using the "My Self-Help Tool" decision aid. Source: Pixabay; Copyright: Kathy Bugajsky; URL:;

    Web-Based Decision Aid to Assist Help-Seeking Choices for Young People Who Self-Harm: Outcomes From a Randomized Controlled Feasibility Trial


    Background: Adolescents who self-harm are often unsure how or where to get help. We developed a Web-based personalized decision aid (DA) designed to support young people in decision making about seeking help for their self-harm. Objective: The aim of this study was to evaluate the feasibility and acceptability of the DA intervention and the randomized controlled trial (RCT) in a school setting. Methods: We conducted a two-group, single blind, randomized controlled feasibility trial in a school setting. Participants aged 12 to 18 years who reported self-harm in the past 12 months were randomized to either a Web-based DA or to general information about mood and feelings. Feasibility of recruitment, randomization, and follow-up rates were assessed, as was acceptability of the intervention and study procedures. Descriptive data were collected on outcome measures examining decision making and help-seeking behavior. Qualitative interviews were conducted with young people, parents or carers, and staff and subjected to thematic analysis to explore their views of the DA and study processes. Results: Parental consent was a significant barrier to young people participating in the trial, with only 17.87% (208/1164) of parents or guardians who were contacted for consent responding to study invitations. Where parental consent was obtained, we were able to recruit 81.7% (170/208) of young people into the study. Of those young people screened, 13.5% (23/170) had self-harmed in the past year. Ten participants were randomized to receiving the DA, and 13 were randomized to the control group. Four-week follow-up assessments were completed with all participants. The DA had good acceptability, but qualitative interviews suggested that a DA that addressed broader mental health problems such as depression, anxiety, and self-harm may be more beneficial. Conclusions: A broad-based mental health DA addressing a wide range of psychosocial problems may be useful for young people. The requirement for parental consent is a key barrier to intervention research on self-harm in the school setting. Adaptations to the research design and the intervention are needed before generalizable research about DAs can be successfully conducted in a school setting. Trial Registration: International Standard Randomized Controlled Trial registry: ISRCTN11230559; (Archived by WebCite at

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  • Changes in Coping Self-Efficacy Predicting Change in Posttraumatic Distress Utilizing My Trauma Recovery

    Date Submitted: Mar 6, 2018

    Open Peer Review Period: Mar 6, 2018 - May 1, 2018

    Background: Technology offers a unique platform for delivering trauma interventions (i.e., eHealth) to support traumatized populations. A challenge of eHealth for trauma survivors is to find out a me...

    Background: Technology offers a unique platform for delivering trauma interventions (i.e., eHealth) to support traumatized populations. A challenge of eHealth for trauma survivors is to find out a mechanism of reducing posttraumatic stress symptoms (PTSS). Objective: The present study evaluated a proactive, scalable, and individually responsive eHealth intervention for trauma survivors, called My Trauma Recovery (MTR). MTR is an eHealth intervention aiming to support trauma survivors and consists of six modules: relaxation, triggers, self-talk, professional help, unhelpful coping, and social support. It was designed to enhance trauma coping self-efficacy (CSE-T). We tested the hypothesis that improvements in CSE-T perceptions while working with the website will directly relate to reductions in overall PTSS. We also evaluated the importance of module order on CSE-T. Methods: Ninety-two traumatized individuals (84.8% females, mean age = 34.80 years old) participated. The present study consisted of three sessions one week apart. Participants completed the baseline online survey assessing PTSS and CSE-T. Each session included completing assigned modules followed by the online survey assessing CSE-T. At the end of the last module, participants completed the online survey assessing PTSS and CSE-T. Results: Significant increases in CSE-T throughout sessions 1 and 2, F = 8.31, P < .001 were found. No significant change in CSE-T was found during session 3 (N = 92). A multiple regression analysis showed that change in CSE-T during the session 2 triggers module (β = -.46, P = .01) and session 2 relaxation modules (β = -.53, P = .01) were significant predictors of post-intervention PTSS. However, these effects were only found when participants worked on relaxation module first in session 1, (R2 = .37). Conclusions: The findings of the present study demonstrate that CSE-T is an important self-appraisal factor linked to reductions in PTSS. The results also show that the module presentation order is important to consider on the relationship between changes in CSE-T and changes in PTSS. These findings have important implications for trauma eHealth interventions.

  • Mindfulness-based online interventions for mental health treatment: A systematic review and meta-analysis

    Date Submitted: Mar 1, 2018

    Open Peer Review Period: Mar 4, 2018 - Apr 29, 2018

    Background: Mindfulness-based online interventions (MOI) are increasingly being delivered through the Internet to treat mental health conditions. Objective: To determine the effectiveness of MOI in cl...

    Background: Mindfulness-based online interventions (MOI) are increasingly being delivered through the Internet to treat mental health conditions. Objective: To determine the effectiveness of MOI in clinical mental health populations. Secondary aims are to explore the impact of study variables on the effectiveness of MOI. Methods: Systematic review and meta-analysis of studies investigating the effects of MOI in clinical populations. Results: The search strategy yielded 9 eligible studies. MOI were effective in reducing depression in the total clinical sample (n=545 g=-0.748, p=0.004) and in the anxiety disorder subgroup (n=237 g=-0.730, p=0.000) but not in the depression disorder subgroup (n=308, p=0.11). Similarly, MOI significantly reduced anxiety in the total clinical sample (n=645, g=-0.398, p=0.003) and the anxiety disorder subgroup (n=337, g=-0.551, p=0.003) but not in the depression disorder group (n=308, p=0.28). Finally, MOI improved quality of life in the anxiety disorder subgroup (n=234, g=0.711, p=0.004) and mindfulness skills in the total clinical sample (n=281, g=0.615, p=0.005). Conclusions: Results support the effectiveness of MOI for reducing depression and anxiety, and enhancing quality of life and mindfulness skills, particularly in those with clinical anxiety. Results should be interpreted with caution given the high heterogeneity of MOI and the low number of studies included.

  • An Iterative Method for Adapting the Coordinated Anxiety Learning Management (CALM) Program for Use within Veterans Affairs Community-Based Outpatient Clinics

    Date Submitted: Mar 1, 2018

    Open Peer Review Period: Mar 4, 2018 - Apr 29, 2018

    Background: A national priority at the U.S. Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilit...

    Background: A national priority at the U.S. Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet, many veterans, particularly those who use remote outpatient VA clinics, still do not receive much-needed evidence-based treatment. Strategies for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) in translating their clinical training to routine practice are needed. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy by providers in outpatient settings to patients with anxiety, including posttraumatic stress disorder, and depression. Objective: The objectives of the present study were to 1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups, 2) develop a prototype of the adapted program, and 3) determine the acceptability and feasibility of the modified program. Mental health stakeholders included VA leaders in the implementation of evidence-based psychotherapies within VA (n=4), VA experts in cognitive behavioral therapy (n= 4), VA CBOC mental health providers (n=8) and veterans (n = 8) receiving treatment in a VA CBOC and diagnosed with a mental health condition treated by the CALM program. Methods: An iterative approach comprising three waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. Results: The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype of the modified program was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. Results: Key stakeholders suggested modifications to the original CALM program that altered the appearance of the modules by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered the content to better reflect the demographic characteristics and experiences of rural veterans. Feedback from the stakeholder groups indicates that the changes will help VA patients to identify with program content, potentially enhancing veterans' treatment engagement. Conclusions: The development model used in this study is effective for economically gathering actionable recommendations from stakeholders to adapt computer-based programs and can result in development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in evidence-based psychotherapy.

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

    Date Submitted: Feb 26, 2018

    Open Peer Review Period: Feb 27, 2018 - Apr 24, 2018

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

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

  • Measurement of symptom change following web based psychotherapy – statistical characteristics and analytical methods for measuring and interpreting change

    Date Submitted: Feb 23, 2018

    Open Peer Review Period: Feb 23, 2018 - Apr 20, 2018

    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 ac...

    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: Objective: The aims of this study were to (1) explore the underlying characteristics of depressive symptom change (PHQ9) 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: Methods: These objectives were explored using hypotheses which 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: Result: Findings demonstrated that: (1) individuals with severe depressive baseline symptoms reduced by greater 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 PHQ9 score distributions following treatment; (3) models that measured symptom change as a proportional function resulted in greater model-fit, and reduced measurement error (< 30%). Conclusions: 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 (e.g., Cohen’s 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.

  • Smartwatch Applications for Mental Health: A Qualitative Analysis of the Users’ Perspectives

    Date Submitted: Feb 15, 2018

    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Lifestyle diseases continuously rise, with aging, epidemics, and life stressors altogether contributing to a growing need for solutions in mental health care. Mobile and wearable solutions...

    Background: Lifestyle diseases continuously rise, with aging, epidemics, and life stressors altogether contributing to a growing need for solutions in mental health care. Mobile and wearable solutions have a large potential in this domain. Despite a significant growth in the availability of mobile apps in the past years, little is known about the characteristics of these applications and the end users’ perspectives about them, especially considering novel smart watch applications dedicated to promote mental health. Objective: To understand the current state-of-the-art smartwatch solutions for mental health, characterizing them in terms of features, benefits and drawbacks focusing on the end users’ perspectives, to identify opportunities to improve next-generation solutions. Methods: A comprehensive analysis of the existing applications for Apple Watch dedicated to mental health care, to characterize their state-of-the-art and provide a unified view of existing solutions, an analysis of their purposes, features, and users’ perspectives from online reviews and discussion boards to identify the main benefits and drawbacks with existing solutions Results: The smart watch applications analyzed focus mainly on intervention, rather than monitoring and tracking users’ affective states; they also focus on wellness and wellbeing and the sources tend to be non-medical; multimodal contents are explored to provide interventions, including audio, images and vibration; users enjoy the customization options and tend to use the applications in a regular basis, mainly to improve sleep quality, to focus, relax, meditate and distract themselves in adverse situations. Conclusions: There is a vast potential for wrist-worn applications for solutions in mental health, but the domain is still underexplored. Existing applications focus on interventions, and further development and research efforts are needed to advance on monitoring and personalized interventions. Privacy-enhanced solutions for access control and protection of human subjects and their data are essential in the development of mobile applications for mental health, still those remain as open questions to be addressed in the future.