JMIR Publications

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 (Impact Factor 2016: 5.175). 

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:

  • 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.

  • Role-play with therapist and simulated patient. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Assessing Therapist Competence: Development of a Performance-Based Measure and Its Comparison With a Web-Based Measure


    Background: Recent research interest in how best to train therapists to deliver psychological treatments has highlighted the need for rigorous, but scalable, means of measuring therapist competence. There are at least two components involved in assessing therapist competence: the assessment of their knowledge of the treatment concerned, including how and when to use its strategies and procedures, and an evaluation of their ability to apply such knowledge skillfully in practice. While the assessment of therapists’ knowledge has the potential to be completed efficiently on the Web, the assessment of skill has generally involved a labor-intensive process carried out by clinicians, and as such, may not be suitable for assessing training outcome in certain circumstances. Objectives: The aims of this study were to develop and evaluate a role-play–based measure of skill suitable for assessing training outcome and to compare its performance with a highly scalable Web-based measure of applied knowledge. Methods: Using enhanced cognitive behavioral therapy (CBT-E) for eating disorders as an exemplar, clinical scenarios for role-play assessment were developed and piloted together with a rating scheme for assessing trainee therapists’ performance. These scenarios were evaluated by examining the performance of 93 therapists from different professional backgrounds and at different levels of training in implementing CBT-E. These therapists also completed a previously developed Web-based measure of applied knowledge, and the ability of the Web-based measure to efficiently predict competence on the role-play measure was investigated. Results: The role-play measure assessed performance at implementing a range of CBT-E procedures. The majority of the therapists rated their performance as moderately or closely resembling their usual clinical performance. Trained raters were able to achieve good-to-excellent reliability for averaged competence, with intraclass correlation coefficients ranging from .653 to 909. The measure was also sensitive to change, with scores being significantly higher after training than before as might be expected (mean difference 0.758, P<.001) even when taking account of repeated data (mean difference 0.667, P<.001). The major shortcoming of the role-play measure was that it required considerable time and resources. This shortcoming is inherent in the method. Given this, of most interest for assessing training outcome, scores on the Web-based measure efficiently predicted therapist competence, as judged by the role-play measure (with the Web-based measure having a positive predictive value of 77% and specificity of 78%). Conclusions: The results of this study suggest that while it was feasible and acceptable to assess performance using the newly developed role-play measure, the highly scalable Web-based measure could be used in certain circumstances as a substitute for the more labor-intensive, and hence, more costly role-play method.

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

    Qualitative Exploration of the Potential for Adverse Events When Using an Online Peer Support Network for Mental Health: Cross-Sectional Survey


    Background: Online peer support networks are a growing area of mental health support for offering social connection, identity, and support. However, it has been reported that not all individuals have a positive experience on such networks. The potential for adverse events within a moderated online peer support network is a new area of research exploration. Objective: The objective of the study was to determine if use of an online moderated peer networks leads to adverse events for users. Methods: Four biannual online surveys (October 2014 to March 2016) were conducted by a large national UK mental health charity, with users of their online peer support network exploring personal safety, moderation, experiences on the site, and how the site could be improved. Data were analyzed using thematic analysis by 2 independent researchers using a priori themes: negative experiences of moderation, social exclusion, contagion, negative interactions with other users, online relationships, co-rumination and collusion, and other. Results: In total, 2353 survey responses were logged with 197 (8.37%) documenting an adverse event of negative experience. A dominant theme of negative experiences of moderation emerged (73/197, 37.1%) with evidence of social exclusion (50/197, 25.4%). Reading user posts was shown to be a cause of worry and distress for a few users, and analysis highlighted several instances of depressogenic and emotional contagion as well as some limited evidence of behavioral contagion (46/197, 23.4%). Very limited evidence of co-rumination (1/197, 0.5%) and no evidence of collusion were identified. Conclusions: Evidence of adverse events was identified at low levels in the sample of respondents, although we have no comparison data to indicate if levels are low compared with comparable platforms. Not all users of online peer support networks find them wholly beneficial. Research must explore what works for whom. The next stage of service development should consider which users may be likely to receive no benefit, or even deteriorate, as a result of using the service.

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

    Techniques for Improving Communication of Emotional Content in Text-Only Web-Based Therapeutic Communications: Systematic Review


    Background: Web-based typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be used to convey emotion during Web-based text communication, there has been no critical review of these data in patients with chronic conditions. Objectives: The objective of this review was to identify the techniques used to convey emotion in written or typed Web-based communication and assess the empirical evidence regarding impact on communication and psychological outcomes. Methods: An electronic search of databases, including MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Library was conducted to identify literature published from 1990 to 2016. Searches were also conducted using Google Scholar, manual searching of reference lists of identified papers and manual searching of tables of contents for selected relevant journals. Data extraction and coding were completed by 2 reviewers (10.00% [573/5731] of screened papers, at abstract/title screening stage; 10.0% of screened [69/694] papers, at full-text screening stage). Publications were assessed against the eligibility criteria and excluded if they were duplicates, were not published in English, were published before 1990, referenced animal or nonhuman subjects, did not describe original research, were not journal papers, or did not empirically test the effect of one or more nonverbal communication techniques (for eg, smileys, emoticons, emotional bracketing, voice accentuation, trailers [ellipsis], and pseudowords) as part of Web-based or typed communication on communication-related variables, including message interpretation, social presence, the nature of the interaction (eg, therapeutic alliance), patient perceptions of the interaction (eg, participant satisfaction), or psychological outcomes, including depression, anxiety, and distress. Results: A total of 6902 unique publications were identified. Of these, six publications met the eligibility criteria and were included in a narrative synthesis. All six studies addressed the effect of smileys or emoticons on participant responses, message interpretation, or social presence of the writer. None of these studies specifically targeted chronic conditions. It was found that emoticons were more effective in influencing the emotional impact of a message than no cue and that smileys and emoticons were able to convey a limited amount of emotion. No studies addressed other techniques for conveying emotion in written communication. No studies addressed the effects of any techniques on the nature of the interaction (eg, therapeutic alliance), patient perceptions of the interaction (eg, participant satisfaction), or psychological outcomes (depression, anxiety, or distress). Conclusions: There is a need for greater empirical attention to the effects of the various proposed techniques for conveying emotion in Web-based typed communications to inform health service providers regarding best-practice communication skills in this setting.

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

    Stopping Antidepressants and Anxiolytics as Major Concerns Reported in Online Health Communities: A Text Mining Approach


    Background: Internet is a particularly dynamic way to quickly capture the perceptions of a population in real time. Complementary to traditional face-to-face communication, online social networks help patients to improve self-esteem and self-help. Objective: The aim of this study was to use text mining on material from an online forum exploring patients’ concerns about treatment (antidepressants and anxiolytics). Methods: Concerns about treatment were collected from discussion titles in patients’ online community related to antidepressants and anxiolytics. To examine the content of these titles automatically, we used text mining methods, such as word frequency in a document-term matrix and co-occurrence of words using a network analysis. It was thus possible to identify topics discussed on the forum. Results: The forum included 2415 discussions on antidepressants and anxiolytics over a period of 3 years. After a preprocessing step, the text mining algorithm identified the 99 most frequently occurring words in titles, among which were escitalopram, withdrawal, antidepressant, venlafaxine, paroxetine, and effect. Patients’ concerns were related to antidepressant withdrawal, the need to share experience about symptoms, effects, and questions on weight gain with some drugs. Conclusions: Patients’ expression on the Internet is a potential additional resource in addressing patients’ concerns about treatment. Patient profiles are close to that of patients treated in psychiatry.

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

    Pregnant Women’s Perceptions of the Risks and Benefits of Disclosure During Web-Based Mental Health E-Screening Versus Paper-Based Screening: Randomized...


    Background: Pregnant women’s perceptions of the risks and benefits during mental health screening impact their willingness to disclose concerns. Early research in violence screening suggests that such perceptions may vary by mode of screening, whereby women view the anonymity of e-screening as less risky than other approaches. Understanding whether mode of screening influences perceptions of risk and benefit of disclosure is important in screening implementation. Objective: The objective of this randomized controlled trial was to compare the perceptions of pregnant women randomized to a Web-based screening intervention group and a paper-based screening control group on the level of risk and benefit they perceive in disclosing mental health concerns to their prenatal care provider. A secondary objective was to identify factors associated with women’s perceptions of risk and benefit of disclosure. Methods: Pregnant women recruited from maternity clinics, hospitals, and prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a computer tablet, whereas the control group completed them on paper. The primary outcome was women’s perceptions of the risk and benefits of mental health screening using the Disclosure Expectations Scale (DES). A completer analysis was conducted. Statistical significance was set at P<.05. We used t tests to compare the means of the risk and benefit subscales between groups. Results: Of the 675 eligible women approached, 636 (94.2%) agreed to participate and were randomized to the intervention (n=305) and control (n=331) groups. There were no significant baseline differences between groups. The mode of screening was not associated with either perceived risk or benefit of screening. There were no differences in groups in the mean scores of the risk and benefit of disclosure subscales. Over three-quarters of women in both intervention and control groups perceived that mental health screening was beneficial. However, 43.1% (272/631) of women in both groups reported feeling very, moderately, or somewhat vulnerable during mental health screening. We found that women of low income, those treated previously for depression or anxiety, and those pregnant with their first child were more likely to perceive greater risk. However, these associations were very small. Conclusions: Pregnant women in both the e-screening and paper-based screening groups perceived benefit and risk of disclosure similarly, suggesting that providers can implement the mode of screening that is most ideal for their clinical setting. Regardless of the mode of screening, a substantial number of women reported feeling vulnerable during mental health screening, highlighting the importance of the need to reduce women’s vulnerability throughout the screening process with strategies such as addressing women’s concerns, explaining the rationale for screening, and discussing how results will be used. Trial Registration: NCT01899534; (Archived by WebCite at

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

    A Transmedia Storytelling Intervention With Interactive Elements to Benefit Latinas’ Mental Health: Feasibility, Acceptability, and Efficacy


    Background: Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs. Objective: The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both. Methods: A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression. Results: All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (F2,54=9.0, P<.001) and anxiety (F2,54=18.7, P<.001) significantly reduced across time. Higher levels of confidence were significantly associated with actions taken at 1 (P=.005) and 6 weeks (P=.04), and higher levels of importance were significantly associated with actions taken at 1 (P=.009) and 6 weeks (P=.003). Higher levels of confidence were associated with lower levels of depression (P=.04) and anxiety (P=.01) at 6 weeks. Conclusions: Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression.

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

    #MyDepressionLooksLike: Examining Public Discourse About Depression on Twitter


    Background: Social media provides a context for billions of users to connect, express sentiments, and provide in-the-moment status updates. Because Twitter users tend to tweet emotional updates from daily life, the platform provides unique insights into experiences of mental health problems. Depression is not only one of the most prevalent health conditions but also carries a social stigma. Yet, opening up about one’s depression and seeking social support may provide relief from symptoms. Objective: The aim of this study was to examine the public discourse of the trending hashtag #MyDepressionLooksLike to look more closely at how users talk about their depressive symptoms on Twitter. Methods: We captured 3225 original content tweets for the hashtag #MyDepressionLooksLike that circulated in May of 2016. Eliminating public service announcements, spam, and tweets with links to pictures or videos resulted in a total of 1978 tweets. Using qualitative content analysis, we coded the tweets to detect themes. Results: The content analysis revealed seven themes: dysfunctional thoughts, lifestyle challenges, social struggles, hiding behind a mask, apathy and sadness, suicidal thoughts and behaviors, and seeking relief. Conclusions: The themes revealed important information about the content of the public messages that people share about depression on Twitter. More research is needed to understand the effects of the hashtag on increasing social support for users and reducing social stigma related to depression.

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

    Mental and Emotional Self-Help Technology Apps: Cross-Sectional Study of Theory, Technology, and Mental Health Behaviors


    Background: Mental and emotional self-help apps have emerged as potential mental illness prevention and treatment tools. The health behavior theory mechanisms by which these apps influence mental health–related behavior change have not been thoroughly examined. Objective: The objective of this study was to examine the association between theoretical behavior change mechanisms and use of mental and emotional self-help apps and whether the use of such apps is associated with mental health behaviors. Methods: This study utilized a cross-sectional survey of 150 users of mental or emotional health apps in the past 6 months. Survey questions included theory-based items, app engagement and likeability items, and behavior change items. Stata version 14 was used to calculate all statistics. Descriptive statistics were calculated for each of the demographic, theory, engagement, and behavior variables. Multiple regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior after controlling for potentially confounding variables. Results: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. Engagement (P<.001) was positively associated with the reported changes in theory items, whereas perceived behavior change was positively associated with theory (P<.001), engagement (P=.004), frequency of use of apps (P=.01), and income (P=.049). Conclusions: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. This increase in perceptions, beliefs, and attitudes surrounding their mental and emotional health was considerably associated with perceived change in behavior. There was a positive association between the level of engagement with the app and the impact on theory items. Future efforts should consider the value of impacting key theoretical constructs when designing mental and emotional health apps. As apps are evaluated and additional theory-based apps are created, cost-effective self-help apps may become common preventative and treatment tools in the mental health field.

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

    Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled...


    Background: Mental disorders have become a major health issue, and a substantial number of afflicted individuals do not get appropriate treatment. Web-based interventions are promising supplementary tools for improving health care for patients with mental disorders, as they can be delivered at low costs and used independently of time and location. Although psychodynamic treatments are used frequently in the face-to-face setting, there has been a paucity of studies on psychodynamic Web-based self-help interventions. Objective: The objective of this study was to determine the feasibility and preliminary efficacy of a transdiagnostic affect-focused psychodynamic Web-based self-help intervention designed to increase emotional competence of patients with mental disorders. Methods: A total of 82 psychotherapy inpatients with mixed diagnoses were randomized into two groups. Following discharge, the intervention group (IG) got access to a guided version of the intervention for 10 weeks. After a waiting period of 10 weeks, the wait-list control group (WLCG) got access to an unguided version of the intervention. We reported the assessments at the beginning (T0) and at the end of the intervention, resp. the waiting period (T1). The primary outcome was satisfaction with the treatment at T1. Secondary outcome measures included emotional competence, depression, anxiety, and quality of life. Statistical analyses were performed with descriptive statistics (primary outcome) and analysis of covariance; a repeated measurement analysis of variance was used for the secondary outcomes. Effect sizes were calculated using Cohen d and data were analyzed as per protocol, as well as intention-to-treat (ITT). Results: Patients were chronically ill, diagnosed with multiple diagnoses, most frequently with depression (84%, 58/69), anxiety (68%, 47/69), personality disorder (38%, 26/69), and depersonalization-derealization disorder (22%, 15/69). A majority of the patients (86%, 36/42) logged into the program, of which 86% (31/36) completed the first unit. Satisfaction with the units mastered was rated as good (52%, 16/31) and very good (26%, 9/31). However, there was a steady decline of participation over the course of the program; only 36% of the participants (13/36) participated throughout the trial completing at least 50% of the sessions. According to the ITT analysis, participants improved statistically significantly and with moderate effect sizes (Cohen d) compared with the WLCG regarding depression (d=0.60), quality of life (d=0.53), and emotional competence (d=0.49). Effects were considerably stronger for the completers with respect to depression (d=1.33), quality of life (d=0.83), emotional competence (d=0.68), and general anxiety (d=0.62). Conclusions: Although overall program satisfaction and benefit of the program were favorable with respect to the indicators of emotional disorders, the rate of completion was low. Our findings point to the need to target the intervention more specifically to the needs and capabilities of participants and to the context of the intervention. Trial Registration: NCT02671929; (Archived by WebCite at

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  • Ethical Challenges in Consumer Digital Psychotherapy

    Date Submitted: Nov 14, 2017

    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    This article focuses on the ethical challenges presented by digital psychotherapy services that are direct-to-consumer and do not involve oversight by a professional mental health provider. These serv...

    This article focuses on the ethical challenges presented by digital psychotherapy services that are direct-to-consumer and do not involve oversight by a professional mental health provider. These services include apps that connect users to peer counseling and counseling steered by artificial intelligence and conversational agents. These services can potentially assist in improving access to mental health care for the many people would otherwise not have the resources or ability to connect with a therapist. However, the lack of adequate regulation in this area exacerbates concerns over how safety, privacy, liability, and other ethical obligations to protect a client are addressed by these services. In the traditional therapeutic relationship, there are ethical obligations that serve to protect the interests of the client and provide warnings. In contrast, in a direct-to-consumer therapy app, there are not clear lines of accountability or associated ethical obligations to protect the user seeking mental health services. There is a need for increased oversight of direct-to-consumer non-professional psychotherapy services to better protect the consumer.

  • Development and feasibility testing of internet-delivered Acceptance and Commitment Therapy (iACT) for severe health anxiety

    Date Submitted: Nov 5, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the DSM-5, is characterised by preoccupation with fear of suffering from a serious illness in spite of med...

    Background: Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the DSM-5, is characterised by preoccupation with fear of suffering from a serious illness in spite of medical reassurance. It is a debilitating, prevalent disorder associated with increased health care utilisation. Still, there is a lack of easily accessible specialised treatment for severe health anxiety. Objective: The present paper has two objectives; 1) to describe the development and setup of a new internet-delivered Acceptance and Commitment Therapy (iACT) programme for patients with severe health anxiety using self-referral and a video-based assessment, and 2) to examine the feasibility and potential clinical efficacy of iACT for severe health anxiety. Methods: Fifteen self-referred patients with severe health anxiety were diagnostically assessed by a video-based interview. They received 7 sessions of clinician-supported iACT comprising self-help texts, video clips, audio files and worksheets over 12 weeks. Self-report questionnaires were obtained at baseline, post-treatment and at 3-month follow-up (3MFU). The primary outcome was Whiteley-7 index measuring health anxiety severity. Depressive symptoms, health-related quality of life (HRQoL), life satisfaction and psychological flexibility were also assessed. A within-group design was employed. Means, standard deviations (SD) and effect sizes using the Standardized Response Mean were estimated. Post-treatment interviews were conducted to evaluate the patient experience of the usability and acceptability of the treatment setup and programme. Results: Self-referral and video-based assessment were well received. Most patients 12/15 (80%) completed the treatment, and only one patient dropped out. Post-treatment data were available for almost all patients 14/15 (93%) and 3MFU data for 12/15 (80%). Paired t-tests showed significant improvements on all outcome measures both at post-treatment and 3MFU except on one physical component subscale of HRQoL. Health anxiety symptoms decreased with 33.9 points at 3MFU (95% CI 13.6 to 54.3, t(11) = 3.66, P=0.004) with a large within-group effect size measured by the standardised response mean (SRM=1.06). Conclusions: Treatment adherence and potential efficacy suggest that iACT may be a feasible treatment for health anxiety. The uncontrolled design and small sample size limit the robustness of the findings. Therefore, the findings should be replicated in a randomised controlled trial. Potentially, iACT may increase availability and accessibility of specialised treatment for health anxiety. Clinical Trial: The study was approved by the Danish Data Protection Agency, Central Denmark Region (ID no. 1-16-02-427-14). URL:

  • Digital access in working age and older adults and their carers attending psychiatry outpatient clinics

    Date Submitted: Oct 6, 2017

    Open Peer Review Period: Oct 8, 2017 - Dec 3, 2017

    Background: Background: It has been suggested that improving access to mental health services, supporting self-management and increasing clinical productivity can be achieved through the delivery of...

    Background: Background: It has been suggested that improving access to mental health services, supporting self-management and increasing clinical productivity can be achieved through the delivery of technology-enabled care via personal mobile and internet-based services, but there is little evidence available about whether working age and older adults with mental health problems or their carers have access to these technologies, or their confidence with these technologies. Objective: To ascertain the prevalence and range of devices used to access the internet in patients and carers attending general and older adult psychiatry outpatient services, and their confidence in using these technologies. Methods: We conducted an anonymous survey of 77 patients and carers from a general psychiatry and old age psychiatry clinic to determine rates of internet access and device ownership, and attitudes to technology enabled care. Results: We found high levels of internet access and confidence in using the internet in working age adults, their carers, and older adult carers but not in older adult patients. Smartphone usage predominated in working age adults and their carers. Older adult carers were more likely to use desktop or laptop computers. In our sample, tablets were the least popular form factor. Conclusions: Access rates and uptake of internet based services have the potential to be high in working age adults and their carers, but are likely to be significantly lower among older adult patients attending psychiatry clinics. Applications designed for tablets are likely to have low uptake. All groups identified appointment reminders as likely to be beneficial.

  • Lamotrigine therapy for bipolar depression: Analysis of self-reported patient data

    Date Submitted: Sep 23, 2017

    Open Peer Review Period: Sep 24, 2017 - Nov 19, 2017

    Lamotrigine is an anticonvulsant used for the treatment of bipolar disorder, especially for depressive episodes. A randomized placebo controlled trial was conducted and self-reported mood scores were...

    Lamotrigine is an anticonvulsant used for the treatment of bipolar disorder, especially for depressive episodes. A randomized placebo controlled trial was conducted and self-reported mood scores were collected over a period of 52 weeks. Different features were computed from the weekly time series produced by each subject. The coefficient of variation (σ/μ) and detrended fluctuation analysis scaling exponent (α), a measure of scaling and long-range persistence (long memory) in time series, were selected as having the most explanatory power. Data from patients taking lamotrigine show a general decrease in depression score in comparison to the patients taking placebo. The time series of lamotrigine patients tend to be rougher than the placebo group. A classifier was built and, based on the two chosen metrics, we are able to achieve a classification accuracy of more than 60% in predicting the treatment mode.