JMIR Publications

JMIR Mental Health

Internet interventions, technologies and digital innovations for mental health and behaviour 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:

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

    Patient-Driven Innovation for Mobile Mental Health Technology: Case Report of Symptom Tracking in Schizophrenia


    This patient perspective piece presents an important case at the intersection of mobile health technology, mental health, and innovation. The potential of digital technologies to advance mental health is well known, although the challenges are being increasingly recognized. Making mobile health work for mental health will require broad collaborations. We already know that those who experience mental illness are excited by the potential technology, with many actively engaged in research, fundraising, advocacy, and entrepreneurial ventures. But we don’t always hear their voice as often as others. There is a clear advantage for their voice to be heard: so we can all learn from their experiences at the direct intersection of mental health and technology innovation. The case is cowritten with an individual with schizophrenia, who openly shares his name and personal experience with mental health technology in order to educate and inspire others. This paper is the first in JMIR Mental Health’s patient perspective series, and we welcome future contributions from those with lived experience.

  • Doors illustrating choices/preference. Source: Pixabay; Copyright: Arek Socha; URL:; License: Public Domain (CC0).

    Preferences for Internet-Based Mental Health Interventions in an Adult Online Sample: Findings From an Online Community Survey


    Background: Despite extensive evidence that Internet interventions are effective in treating mental health problems, uptake of Internet programs is suboptimal. It may be possible to make Internet interventions more accessible and acceptable through better understanding of community preferences for delivery of online programs. Objective: This study aimed to assess community preferences for components, duration, frequency, modality, and setting of Internet interventions for mental health problems. Methods: A community-based online sample of 438 Australian adults was recruited using social media advertising and administered an online survey on preferences for delivery of Internet interventions, along with scales assessing potential correlates of these preferences. Results: Participants reported a preference for briefer sessions, although they recognized a trade-off between duration and frequency of delivery. No clear preference for the modality of delivery emerged, although a clear majority preferred tailored programs. Participants preferred to access programs through a computer rather than a mobile device. Although most participants reported that they would seek help for a mental health problem, more participants had a preference for face-to-face sources only than online programs only. Younger, female, and more educated participants were significantly more likely to prefer Internet delivery. Conclusions: Adults in the community have a preference for Internet interventions with short modules that are tailored to individual needs. Individuals who are reluctant to seek face-to-face help may also avoid Internet interventions, suggesting that better implementation of existing Internet programs requires increasing acceptance of Internet interventions and identifying specific subgroups who may be resistant to seeking help.

  • Man at computer with alcohol. Source: Flickr; Copyright: Ivana Vasilj; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Initial Progress Toward Development of a Voice-Based Computer-Delivered Motivational Intervention for Heavy Drinking College Students: An Experimental Study


    Background: Computer-delivered interventions have been shown to be effective in reducing alcohol consumption in heavy drinking college students. However, these computer-delivered interventions rely on mouse, keyboard, or touchscreen responses for interactions between the users and the computer-delivered intervention. The principles of motivational interviewing suggest that in-person interventions may be effective, in part, because they encourage individuals to think through and speak aloud their motivations for changing a health behavior, which current computer-delivered interventions do not allow. Objective: The objective of this study was to take the initial steps toward development of a voice-based computer-delivered intervention that can ask open-ended questions and respond appropriately to users’ verbal responses, more closely mirroring a human-delivered motivational intervention. Methods: We developed (1) a voice-based computer-delivered intervention that was run by a human controller and that allowed participants to speak their responses to scripted prompts delivered by speech generation software and (2) a text-based computer-delivered intervention that relied on the mouse, keyboard, and computer screen for all interactions. We randomized 60 heavy drinking college students to interact with the voice-based computer-delivered intervention and 30 to interact with the text-based computer-delivered intervention and compared their ratings of the systems as well as their motivation to change drinking and their drinking behavior at 1-month follow-up. Results: Participants reported that the voice-based computer-delivered intervention engaged positively with them in the session and delivered content in a manner consistent with motivational interviewing principles. At 1-month follow-up, participants in the voice-based computer-delivered intervention condition reported significant decreases in quantity, frequency, and problems associated with drinking, and increased perceived importance of changing drinking behaviors. In comparison to the text-based computer-delivered intervention condition, those assigned to voice-based computer-delivered intervention reported significantly fewer alcohol-related problems at the 1-month follow-up (incident rate ratio 0.60, 95% CI 0.44-0.83, P=.002). The conditions did not differ significantly on perceived importance of changing drinking or on measures of drinking quantity and frequency of heavy drinking. Conclusions: Results indicate that it is feasible to construct a series of open-ended questions and a bank of responses and follow-up prompts that can be used in a future fully automated voice-based computer-delivered intervention that may mirror more closely human-delivered motivational interventions to reduce drinking. Such efforts will require using advanced speech recognition capabilities and machine-learning approaches to train a program to mirror the decisions made by human controllers in the voice-based computer-delivered intervention used in this study. In addition, future studies should examine enhancements that can increase the perceived warmth and empathy of voice-based computer-delivered intervention, possibly through greater personalization, improvements in the speech generation software, and embodying the computer-delivered intervention in a physical form.

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

    Use of New Technologies in the Prevention of Suicide in Europe: An Exploratory Study


    Background: New technologies are an integral component of today’s society and can complement existing suicide prevention programs. Here, we analyzed the use of new technologies in the prevention of suicide in 8 different European countries. Objective: The aim of this paper was to assess the opinions of professionals in incorporating such resources into the design of a suicide prevention program for the region of Zamora in Spain. This investigation, encompassed within the European project entitled European Regions Enforcing Actions against Suicide (EUREGENAS), includes 11 regions from 8 different countries and attempts to advance the field of suicide prevention in Europe. Methods: Using a specifically designed questionnaire, we assessed the opinions of 3 different groups of stakeholders regarding the use, frequency of use, facilitators, content, and format of new technologies for the prevention of suicide. The stakeholders were comprised of policy and public management professionals, professionals working in the area of mental health, and professionals related to the social area and non-governmental organizations (NGOs). A total of 416 participants were recruited in 11 regions from 8 different European countries. Results: The utility of the new technologies was valued positively in all 8 countries, despite these resources being seldom used in those countries. In all the countries, the factors that contributed most to facilitating the use of new technologies were accessibility and free of charge. Regarding the format of new technologies, the most widely preferred formats for use as a tool for the prevention of suicide were websites and email. The availability of information about signs of alarm and risk factors was the most relevant content for the prevention of suicide through the use of new technologies. The presence of a reference mental health professional (MHP) was also considered to be a key aspect. The countries differed in the evaluations given to the different formats suggesting that the cultural characteristics of the country should be taken into account. Conclusions: New technologies are much appreciated resources; however they are not often underused in the field of suicide prevention. The results of this exploratory study show that new technologies are indeed useful resources and should be incorporated into suicide prevention programs.

  • Living the Example logo. Source: Mentor Foundation USA; Copyright: Mentor Foundation USA; URL:; License: Creative Commons Attribution (CC-BY).

    The Living the Example Social Media Substance Use Prevention Program: A Pilot Evaluation


    Background: Adolescent substance use rates in rural areas of the United States, such as upstate New York, have risen substantially in recent years, calling for new intervention approaches in response to this trend. The Mentor Foundation USA conducts the Living the Example (LTE) campaign to engage youth in prevention using an experiential approach. As part of LTE, youth create their own prevention messages following a training curriculum in techniques for effective messaging and then share them via social media. This paper reports on a pilot evaluation of the LTE program. Objective: To conduct a pilot test of LTE in two rural high schools in upstate New York. We hypothesized that positive antidrug brand representations could be promoted using social media strategies to complement the Shattering the Myths (STM) in-person, event-based approach (hypothesis 1, H1), and that youth would respond positively and engage with prevention messages disseminated by their peers. We also hypothesized that exposure to the social media prevention messages would be associated with more positive substance use avoidance attitudes and beliefs, reductions in future use intentions, and decreased substance use at posttest (hypothesis 2, H2). Methods: We adapted a previously published curriculum created by the authors that focuses on branding, messaging, and social media for prevention. The curriculum consisted of five, one-hour sessions. It was delivered to participating youth in five sequential weeks after school at the two high schools in late October and early November 2016. We designed a pre- and posttest pilot implementation study to evaluate the effects of LTE on student uptake of the intervention and short-term substance use and related outcomes. Working at two high schools in upstate New York, we conducted a pilot feasibility evaluation of LTE with 9th-grade students (ie, freshmen) at these high schools. We administered a 125-item questionnaire online to capture data on media use; attitudes toward social media; next 30-day personal drug use intentions; personal reasons to use drugs; reasons participants believe their peers would use drugs; self-reported exposure to the LTE program; and receptivity to the LTE program, among those reporting exposure. We constructed multivariable logistic regression models to analyze the relationship between program receptivity and outcomes. First, in a cross-sectional logistic regression model, we regressed self-reported LTE message receipt on drug use intent and actions related to LTE messaging. Then, for analysis of participants with matched pre- and posttest responses, we used multilevel generalized estimating equation (GEE) techniques to model changes in behavior from baseline to follow-up. Results: Youth reported increased intentions to use marijuana (odds ratio [OR] 2.134, P=.02) between pre- and posttest. However, youth who reported exposure and receptivity to LTE reported a significant decrease in intentions (OR 0.239, P=.008). We observed a similar pattern for sedatives/sleeping pills—an increase in intentions overall (OR 1.886, P=.07), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.210, P=.02). We saw the same pattern for use of any drug—an increase in reported intentions overall (OR 2.141, P=.02), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.111, P=.004). Conclusions: We observed some evidence of significant LTE program effects. Social media may be an effective strategy for peer-to-peer substance use prevention in the future. These findings point both to the potential of LTE and the social media diffusion model and to the need for more research on a larger scale with an expanded youth population in the future.

  • Mother using technology to help child in distress. Source: Shutterstock; Copyright: Monkey Business Images; URL:; License: Licensed by the authors.

    Perspectives of Family Members on Using Technology in Youth Mental Health Care: A Qualitative Study


    Background: Information and communication technologies (ICTs) are increasingly recognized as having an important role in the delivery of mental health services for youth. Recent studies have evaluated young people’s access and use of technology, as well as their perspectives on using technology to receive mental health information, services, and support; however, limited attention has been given to the perspectives of family members in this regard. Objective: The aim of this study was to explore the perspectives of family members on the use of ICTs to deliver mental health services to youth within the context of specialized early intervention for a first-episode psychosis (FEP). Methods: Six focus groups were conducted with family members recruited from an early intervention program for psychosis. Twelve family members participated in the study (target sample was 12-18, and recruitment efforts took place over the duration of 1 year). A 12-item semistructured focus group guide was developed to explore past experiences of technology and recommendations for the use of technology in youth mental health service delivery. A qualitative thematic analysis guided the identification and organization of common themes and patterns identified across the dataset. Results: Findings were organized by the following themes: access and use of technology, potential negative impacts of technology on youth in recovery, potential benefits of using technology to deliver mental health services to youth, and recommendations to use technology for (1) providing quality information in a manner that is accessible to individuals of diverse socioeconomic backgrounds, (2) facilitating communication with health care professionals and services, and (3) increasing access to peer support. Conclusions: To our knowledge, this is among the first (or the first) to explore the perspectives of family members of youth being treated for FEP on the use of technology for mental health care. Our results highlight the importance of considering diverse experiences and attitudes toward the role of technology in youth mental health, digital literacy skills, phases of recovery, and sociodemographic factors when engaging family members in technology-enabled youth mental health care research and practice. Innovative methods to recruit and elicit the perspectives of family members on this topic are warranted. It is also important to consider educational strategies to inform and empower family members on the role, benefits, and use of ICTs in relation to mental health care for FEP.

  • Health App Use. Source: iStock by Getty Images; Copyright: kizilkayaphotos; URL:; License: Licensed by the authors.

    Health App Use Among Individuals With Symptoms of Depression and Anxiety: A Survey Study With Thematic Coding


    Background: Researchers have largely turned to commercial app stores, randomized trials, and systematic reviews to make sense of the mHealth landscape. Few studies have approached understanding by collecting information from target end users. The end user perspective is critical as end user interest in and use of mHealth technologies will ultimately drive the efficacy of these tools. Objective: The purpose of this study was to obtain information from end users of mHealth technologies to better understand the physical and mental health apps people use and for what purposes. Methods: People with depressive or anxious symptoms (N=176) seeking entry into a trial of mental health and well-being apps for Android devices completed online questionnaires assessing depression and anxiety (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), past and current mental health treatment-seeking behavior, overall mobile device use, and use of mobile health apps. Participants reported the physical health and mental health apps on their devices and their reasons for using them. Data were extracted from the participant self-reports and apps and app purposes were coded in order to categorize them. Results: Participants were largely white, middle-aged females from the Midwest region of the United States recruited via a health care organization and Web-based advertising (135 female, 41 male, mean age 38.64 years, age range 19-75 years.) Over three-quarters (137/176, 77.8%) of participants indicated having a health app on their device. The top 3 kinds of apps were exercise, fitness, and pedometers or heart rate monitoring apps (93/176, 52.8%); diet, food, or calorie counting apps (65/177, 36.9%); and mental health/wellness apps (46/177, 26.1%). The mean number of mobile physical and mental health apps on a participant’s phone was 2.15 (SD 3.195). Of 176 participants, 107 (60.8%) specifically reported the top 5 health apps that they used and their purposes. Across the 107 participants, a total of 285 apps were reported, with 139 being unique apps. The majority of these apps were free (129/139, 92.8%). Almost two-thirds of participants (67/107, 62.6%) reported using health apps at least on a daily basis. Conclusions: Among those seeking support for their well-being via physical and mental health apps, people are using a variety of health apps. These people use health apps on a daily basis, especially free apps. The most common reason for using a health app is to track some health-related data; for mental health apps specifically, training or habit building was the most popular reason. Understanding the end user perspective is important because it allows us to build on the foundation of previously established mHealth research and may help guide future work in mHealth. Trial Registration: NCT02176226; (Archived by WebCite at

  • Screenshot of a CBT self-help app currently available on Google Play. Copyright: Google; URL:; License: Creative Commons Attribution (CC-BY).

    Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps


    Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

  • Young woman chatting with Woebot conversational agent (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A...


    Background: Web-based cognitive-behavioral therapeutic (CBT) apps have demonstrated efficacy but are characterized by poor adherence. Conversational agents may offer a convenient, engaging way of getting support at any time. Objective: The objective of the study was to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression. Methods: In an unblinded trial, 70 individuals age 18-28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) (n=34) or were directed to the National Institute of Mental Health ebook, “Depression in College Students,” as an information-only control group (n=36). All participants completed Web-based versions of the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Positive and Negative Affect Scale at baseline and 2-3 weeks later (T2). Results: Participants were on average 22.2 years old (SD 2.33), 67% female (47/70), mostly non-Hispanic (93%, 54/58), and Caucasian (79%, 46/58). Participants in the Woebot group engaged with the conversational agent an average of 12.14 (SD 2.23) times over the study period. No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly reduced their symptoms of depression over the study period as measured by the PHQ-9 (F=6.47; P=.01) while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7 (F1,54= 9.24; P=.004). Participants’ comments suggest that process factors were more influential on their acceptability of the program than content factors mirroring traditional therapy. Conclusions: Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT.

  • Copyright: Wavebreak Media; License: Licensed by JMIR.

    Computerized Cognitive Behavioral Therapy to Treat Emotional Distress After Stroke: A Feasibility Randomized Controlled Trial


    Background: Depression and anxiety are common complications following stroke. Symptoms could be treatable with psychological therapy, but there is little research on its efficacy. Objectives: The aim of this study was to investigate (1) the acceptability and feasibility of computerized cognitive behavioral therapy (cCBT) to treat symptoms of depression and anxiety and (2) a trial design for comparing the efficacy of cCBT compared with an active comparator. Methods: Of the total 134 people screened for symptoms of depression and anxiety following stroke, 28 were cluster randomized in blocks with an allocation ratio 2:1 to cCBT (n=19) or an active comparator of computerized cognitive remediation therapy (cCRT, n=9). Qualitative and quantitative feedback was sought on the acceptability and feasibility of both interventions, alongside measuring levels of depression, anxiety, and activities of daily living before, immediately after, and 3 months post treatment. Results: Both cCBT and cCRT groups were rated as near equally useful (mean = 6.4 vs 6.5, d=0.05), while cCBT was somewhat less relevant (mean = 5.5 vs 6.5, d=0.45) but somewhat easier to use (mean = 7.0 vs 6.3, d=0.31). Participants tolerated randomization and dropout rates were comparable with similar trials, with only 3 participants discontinuing due to potential adverse effects; however, dropout was higher from the cCBT arm (7/19, 37% vs 1/9, 11% for cCRT). The trial design required small alterations and highlighted that future-related studies should control for participants receiving antidepressant medication, which significantly differed between groups (P=.05). Descriptive statistics of the proposed outcome measures and qualitative feedback about the cCBT intervention are reported. Conclusions: A pragmatic approach is required to deliver computerized interventions to accommodate individual needs. We report a preliminary investigation to inform the development of a full randomized controlled trial for testing the efficacy of computerized interventions for people with long-term neurological conditions such as stroke and conclude that this is a potentially promising way of improving accessibility of psychological support.

  • Mobile device being used to access the Internet for health care (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Who is More Likely to Use the Internet for Health Behavior Change? A Cross-Sectional Survey of Internet Use Among Smokers and Nonsmokers Who Are Orthopedic...


    Background: eHealth presents opportunities to provide population groups with accessible health interventions, although knowledge about Internet access, peoples’ interest in using the Internet for health, and users’ characteristics are required prior to eHealth program development. Objective: This study surveyed hospital patients to examine rates of Internet use, interest in using the Internet for health, and respondent characteristics related to Internet use and interest in using the Internet for health. For patients who smoke, preferences for types of smoking cessation programs for use at home and while in hospital were also examined. Methods: An online cross-sectional survey was used to survey 819 orthopedic trauma patients (response rate: 72.61%, 819/1128) from two public hospitals in New South Wales, Australia. Logistic regressions were used to examine associations between variables. Results: A total of 72.7% (574/790) of respondents had at least weekly Internet access and more than half (56.6%, 357/631) reported interest in using the Internet for health. Odds of at least weekly Internet usage were higher if the individual was born overseas (OR 2.21, 95% CI 1.27-3.82, P=.005), had a tertiary education (OR 3.75, 95% CI 2.41-5.84, P<.001), or was a nonsmoker (OR 3.75, 95% CI 2.41-5.84, P<.001). Interest in using the Internet for health increased with high school (OR 1.85, 95% CI 1.09-3.15, P=.02) or tertiary education (OR 2.48, 95% CI 1.66-3.70, P<.001), and if household incomes were more than AUS $100,000 (OR 2.5, 95% CI 1.25-4.97, P=.009). Older individuals were less interested in using the Internet for health (OR 0.98, 95% CI 0.97-0.99, P<.001). Conclusions: Online interventions may be a potential tool for health care in this hospitalized population. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001147673; (Archived by WebCite at

  • Source:; License: Fair use/fair dealings.

    Diversity in eMental Health Practice: An Exploratory Qualitative Study of Aboriginal and Torres Strait Islander Service Providers


    Background: In Australia, mental health services are undergoing major systemic reform with eMental Health (eMH) embedded in proposed service models for all but those with severe mental illness. Aboriginal and Torres Strait Islander service providers have been targeted as a national priority for training and implementation of eMH into service delivery. Implementation studies on technology uptake in health workforces identify complex and interconnected variables that influence how individual practitioners integrate new technologies into their practice. To date there are only two implementation studies that focus on eMH and Aboriginal and Torres Strait Islander service providers. They suggest that the implementation of eMH in the context of Aboriginal and Torres Strait Islander populations may be different from the implementation of eMH with allied health professionals and mainstream health services. Objective: The objective of this study is to investigate how Aboriginal and Torres Strait Islander service providers in one regional area of Australia used eMH resources in their practice following an eMH training program and to determine what types of eMH resources they used. Methods: Individual semistructured qualitative interviews were conducted with a purposive sample of 16 Aboriginal and Torres Strait Islander service providers. Interviews were co-conducted by one indigenous and one non-indigenous interviewer. A sample of transcripts were coded and thematically analyzed by each interviewer and then peer reviewed. Consensus codes were then applied to all transcripts and themes identified. Results: It was found that 9 of the 16 service providers were implementing eMH resources into their routine practice. The findings demonstrate that participants used eMH resources for supporting social inclusion, informing and educating, assessment, case planning and management, referral, responding to crises, and self and family care. They chose a variety of types of eMH resources to use with their clients, both culturally specific and mainstream. While they referred clients to online treatment programs, they used only eMH resources designed for mobile devices in their face-to-face contact with clients. Conclusions: This paper provides Aboriginal and Torres Strait islander service providers and the eMH field with findings that may inform and guide the implementation of eMH resources. It may help policy developers locate this workforce within broader service provision planning for eMH. The findings could, with adaptation, have wider application to other workforces who work with Aboriginal and Torres Strait Islander clients. The findings highlight the importance of identifying and addressing the particular needs of minority groups for eMH services and resources.

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  • A randomized controlled trial and process evaluation of a web-based therapy plus telephone support by a coach, compared with information about web-based resources, in depressed patients referred to secondary mental health care

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 20, 2017 - Sep 14, 2017

    Background: The evidence for the effectiveness of web-based therapies comes mainly from non-clinical populations with a few studies in primary care. There is little evidence from patients referred to...

    Background: The evidence for the effectiveness of web-based therapies comes mainly from non-clinical populations with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. A problem with web-based therapies is that a high proportion of people fail to complete the courses. One way to address this is to create a new health service role – an e-coach – to guide people through the therapy which has been shown to increase adherence. Objective: The objective was to test in people referred to secondary care with depression if a web-based therapy (The Journal supported by an e-coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about on-line resources after twelve weeks. Methods: We conducted a randomized controlled trial with two parallel arms and a process evaluation. The e-coach had a background in occupational therapy. Participants were recruited face to face. Results: We recruited 63 people into the trial (intervention 35 control 28). There were no statistically significant differences in the change in PHQ-9 scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group t-test 1.05 p=0.3; mean difference 2.3, 95% confidence interval -2.1 to 6.7). People who were offered The Journal attended on average about one less out-patient appointment compared with usual care although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group t=- 0.80 p=0.43; mean difference 1.3 95% confidence interval -4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 SD 1.9 (with a range of 0 to 6) and the number of contacts with the e-coach was a mean of 8.1 SD 4.4 (range 0 to 17). The qualitative interviews highlighted the problem of engaging clinicians in the research and their resistance to recruitment; technical difficulties with The Journal which prevented people logging in easily; difficulty accessing The Journal as it was not available at the time on smartphones or tablets; participants finding lesson three difficult; and participants saying they were too busy to complete the sessions. Conclusions: The study demonstrated that is feasible to use an e-coach in this setting, that people found it helpful and that it did not conflict with other care that participants were receiving. In the future trials need to engage clinicians at an early stage to articulate where web-based therapies fit into existing clinical pathways; web-based therapies should be available on mobile devices; and logging in should be easy. The role of the e-coach should be explored in larger trials. Clinical Trial: Australian and New Zealand Clinical Trials Registry ACTRN: ACTRN12613000015741

  • Partners in Parenting: A multi-level web-based approach to support parents in prevention and early intervention for adolescent depression and anxiety

    Date Submitted: Jul 17, 2017

    Open Peer Review Period: Jul 18, 2017 - Sep 12, 2017

    Depression and anxiety disorders in young people are a global health concern. Various risk and protective factors for these disorders are potentially modifiable by parents, underscoring the important...

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

  • ‘Wish you were here’: Examining assumptions about missing cases from psychotherapeutic trials

    Date Submitted: Jul 6, 2017

    Open Peer Review Period: Jul 12, 2017 - Sep 6, 2017

    Background: Missing cases are common in clinical psychotherapeutic trials, and pose a challenge to the accuracy of measuring clinical outcomes [1]. However, little is known about the characteristics o...

    Background: Missing cases are common in clinical psychotherapeutic trials, and pose a challenge to the accuracy of measuring clinical outcomes [1]. However, little is known about the characteristics of psychotherapy participants with missing values, their likely clinical outcomes, or suitability of different statistical assumptions that can characterise missing cases. Objective: Using a large sample, undergoing psychotherapy for depressive symptoms (n=820), this study aimed to explore the characteristics of missing cases (n=138), their likely treatment outcomes, and compare between statistical methods for replacing missing values. Methods: Initially, common participant and treatment features were tested through binary logistic regression, identifying variables that predict missing cases. Secondly, the same variables were screened for their ability to increase, or impede the rate of symptom remission. Third, using recontacted cases at three-month follow-up, to proximally measure treatment outcomes, simulated replacement scores and observed clinical outcomes were compared. Results: Missing cases were dominantly predicted by lower treatment adherence and increased symptoms at pre-treatment, and report symptom that are 30% higher than average at follow-up. Longitudinal statistical methods (GEE or MIXED models) that adjusted their estimates for missing values by treatment adherence rates and baseline symptoms severity (under the MAR assumption), predicted follow-up missing cases outcomes minimal measurement bias (<8%). Conclusions: Missing cases demonstrated characteristics, which can jointly be associated with likelihood of becoming missing and lesser clinical improvement. Under such circumstances, treatment effects can become concealed. Statistical methods that ignore these characteristics can overlook an important clinical phenomenon and generate inaccurate treatment outcome replacement estimates (-32% to 70% off the mark).

  • School counsellor perspectives on the factors influencing uptake of an online stepped care mental health service for schools: A cross-sectional online survey

    Date Submitted: Jul 6, 2017

    Open Peer Review Period: Jul 11, 2017 - Sep 5, 2017

    Background: Mental health problems are common among high school aged youth and School Counsellors play a key role in the provision of school-based mental healthcare. However, school counsellors occupy...

    Background: Mental health problems are common among high school aged youth and School Counsellors play a key role in the provision of school-based mental healthcare. However, school counsellors occupy a multi-specialist role that makes it difficult for them to provide care to all of those who are in need in a timely manner. Internet-delivered (i.e. “online”) mental health services that offer screening, psychological therapy, and monitoring, may help counsellors manage time and yet still provide oversight. However, for such a model to be implemented successfully, school counsellors’ views about the value and potential implementation of services needs to be measured. Objective: The current study aimed to examine school counsellors’ acceptability of a proposed online mental health service, the feasibility of providing this type of service in the school context, and the barriers and facilitators of implementation. Methods: This study utilised a mixed-methods, online, cross sectional survey to evaluate school counsellors’ perspectives. Results: A total of 145 school counsellors completed the survey. Overall, a total of 82% (n=119) thought that the proposed service would be helpful to students. One third reported that they would recommend the proposed model, with the majority reporting potential concerns. Although background factors were not found to influence the levels of comfort, issues such as personal beliefs, knowledge and awareness, internet accessibility, privacy and confidentiality, were found to influence, both positively and negatively, the likelihood of school counsellors implementing a school-based online mental health service. Conclusions: This study confirms that greater support and resources are needed to facilitate what is already a challenging and emotionally demanding role for school counsellors. Mental health issues among students are dominant, and school counsellors are time poor. While the school counsellors in the current study were open to the proposed service model, the issues identified must be carefully addressed if implementation is to be successful.

  • French validation of the Work Addiction Risk Test questionnaire

    Date Submitted: Jun 30, 2017

    Open Peer Review Period: Jul 10, 2017 - Sep 4, 2017

    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”. Objecti...

    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 was to validate the French version of the WART. Methods: Questionnaires were proposed to voluntary French workers using the Wittyfit software. There were no exclusions criteria. The questionnaire was administered anonymously for initial validity testing and readministered one week later for test-retest reliability. We also assessed the workers’ socio-demographic characteristics, as well as other measurements, for external validity such as stress, well-being, and co-addictions for tobacco, alcohol and cannabis. Several psychometric properties of the French-WART were explored: acceptability, reliability (internal consistency – Cronbach’s 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 (11.8%) agreed to complete the WART questionnaire. Of those, 128 completed the test-retest survey (68.5%). Acceptability found that all respondents had fully completed the questionnaire, with few floor or ceiling effects. Reliability was very good with a Cronbach’s alpha coefficient at 0.90 (internal consistency) and Lin concordance coefficient at 0.903 (95% CI 0.871–0.935) with a difference on the retest of 0.039±4.92 (95% CI -9.61–9.69) (reproducibility). We identified three main dimensions (construct validity). Relationships between the 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 may be easily implemented in current practice. Clinical Trial: NCT02596737;