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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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

  • 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

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  • Implementing Internet-Based Self-Care Programs in Primary Care: A Qualitative Analysis of Patient and Provider Determinants of Practice

    Date Submitted: Dec 7, 2017

    Open Peer Review Period: Dec 8, 2017 - Feb 2, 2018

    Background: Access to evidence-based therapies for common mental health conditions is limited due to travel, scheduling, stigma, and provider availability. Internet-based self-care programs (ISPs) may...

    Background: Access to evidence-based therapies for common mental health conditions is limited due to travel, scheduling, stigma, and provider availability. Internet-based self-care programs (ISPs) may mitigate these barriers; however, little is known about ISP implementation in integrated U.S. healthcare systems. Objective: The objective of this study was to elicit perspectives on implementing ISPs in primary care settings at the point of care with patients and providers in an integrated healthcare system. Methods: The objective was explored through qualitative analysis of semi-structured interviews with Veterans Health Administration (VHA) primary care and primary care mental health providers and administrators. Participants were identified using a reputation-based snowball design. Interviews focused on identifying determinants of practice for the use of ISPs at the point of care in VHA primary care. Investigators utilized thematic analysis to code interview transcripts and reach consensus on key themes through group discussion. Results: Twenty interviews with physicians, psychologists, social workers, and nurses were conducted and analyzed. Among this group, ISP use was low, but enthusiasm for the platform was uniformly high. Themes were organized into patient and provider level determinants of practice. Patient level determinants included literacy, age, Internet access, patient expectations, ISP fit with patient experiences, interest/motivation, and face-to-face human contact. Provider level themes included familiarity with ISPs, changes to traditional care delivery, face-to-face human contact, competing demands, and age. Conclusions: This exploration of perspectives on ISP implementation among VHA providers and administrators revealed key determinants of practice, which can be used to develop comprehensive strategies for the implementation of ISPs in primary care settings. Clinical Trial: none

  • Identifying and Understanding Communities Using Twitter to Connect About Depression

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Background: Depression is a leading cause of disease globally and is often characterized by a lack of social connection. With the rise of social media comes reports that Twitter users are seeking conn...

    Background: Depression is a leading cause of disease globally and is often characterized by a lack of social connection. With the rise of social media comes reports that Twitter users are seeking connections about depression online. Objective: This study aimed to identify communities where Twitter users tweeted using the hashtag #MyDepressionLooksLike to connect about depression. Once identified, we wanted to understand which community characteristics correlated to Twitter-users turning to a virtual community to connect about depression. Methods: Tweets were collected using NCapture software from May 25th to June 1st, 2016 during Mental Health Awareness month (n=104) in the northeastern United States and Washington D.C. After mapping tweets, we used a Poisson multi-level regression model to predict tweets per community (county) offset by the population aged 15-44 years old, and adjusted for percent female, white, below poverty, and single-person households. We then compared predicted versus observed counts and calculated Tweeting Index Values (TIVs) based on the residuals. Last, we examined trends in community characteristics by TIV using Pearson’s correlation. Results: We found significant associations between tweet counts and area-level proportions of females, single-person households, and population aged 15-44 years. Tweeting Index Values (TIVs) were higher than expected (TIV 5) in western, inland areas of the study region. There were lower than expected tweets in the eastern, seaboard areas (TIV 1). When examining community characteristics and over- and under-tweeting by county, we observed a clear upward linear gradient in vacant housing and over-tweeting (r= 0.31, P< .001). However, we observed U-shaped relationships for most other community factors, suggesting that the same characteristics were correlated with both over- and under-tweeting. Conclusions: Lack of connection-building amenities in physical communities may lead to both the over- and under-tweeting by Twitter users seeking connections about depression. Higher rates of vacant housing are especially linked to higher levels of tweeting than expected. Future research could expand the spatiotemporal scope.

  • Engagement with a Trauma Recovery eHealth Intervention Explained with the Health Action Process Approach (HAPA)

    Date Submitted: Nov 18, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: There has been a growing trend in the delivery of mental health treatment via technology (i.e., eHealth). However, engagement with eHealth interventions is a concern and theoretically base...

    Background: There has been a growing trend in the delivery of mental health treatment via technology (i.e., eHealth). However, engagement with eHealth interventions is a concern and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress. Objective: The aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pre-treatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy. Methods: Trauma survivors from around the U.S. used the eHealth intervention for two weeks. We collected baseline demographic, social cognitive predictors and distress symptoms and measured engagement subjectively and objectively throughout the intervention. Results: The motivational phase model explained 48% of the variance and outcome expectations (β = .36), perceived need (β = .32), pre-treatment self-efficacy (β = .13), and trauma symptoms (β = .21) were significant predictors of intention (N = 440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement, B = 0.89, 95% CI[0.143, 2.605] (N = 115). Conclusions: Though many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work.

  • Mobile Based Quantitative Measure of Stress

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 19, 2017 - Jan 14, 2018

    Background: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. In this interactive app, the use...

    Background: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. In this interactive app, the user places his finger on the mobile`s camera lens, through which information related to the user’s blood flow, heart rate, and heart rate variability (HRV) is extracted. Physiological signals are then being filtered and processed through a certain machine- algorithm, resulting in a quantitative estimation of the user’s stress level. Method: a mixed sex group of 50 volunteers were recruited to participate in a standardized laboratory experiment, where a psychosocial stress protocol (Trier Social Stress Test-TSST) was implemented. Throughout the course of the experiment, physiological stress response was measured using both salivary cortisol level and Serenita app, hence, using a within subject design. Results: Serenita algorithm was able to effectively detect changes in the participant`s estimated stress level, as expected by the different experimental conditions and followed the robust physiological response pattern usually obtained by the TSST protocol. In addition, a cross correlation of .93 was obtained between the estimated stress level, using Serenita`s algorithm, and Cortisol level measures. Conclusions: these results serve a double validation for Serenita as an effective tool to quantitatively measure physiological stress response. This innovative technique bears important implications for the field of stress research and treatment, providing to the best of our knowledge the first clinically validated non-lab based quantitative physiological stress measurement tool. Objective: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. Methods: The current study was designed to validate and fine-tune the algorithms supporting the stress estimation function in this mobile application, under a clinical setting. In order to validate Serenita as an adequate stress estimator it was necessary to build a standardized experimental protocol able to i) effectively induce stress on a set of volunteers, ii) and properly quantify the stress variation. To this end, we adopted the Trier Social Stress Test (TSST -Kirschbaum, Pirke, & Hellhammer, 1993) as this well documented laboratory procedure, was shown to reliably induce stress in human research participants and used extensively in the field of stress studies (e.g., Kudielka, Hellhammer, Kirschbaum, Harmon-Jones, & Winkielman, 2007; Allen, Kennedy, Cryan, Dinan, & Clarke, 2014). The efficiency of TSST as a stress inducer, was explored not only through properly calibrated questionnaires but also with the analysis of the Cortisol, as physiological stress indicator, which is extensively used in clinical setting to determine stress levels and the response to stressful events. Similarly, the current study followed the typical experimental protocol. However, its novelty lies in combining traditional as solid stress inducer (TSST) and indicator (saliva cortisol), with an innovative digital-health assessment tool (Serenita application). Utilizing both tools to measure physiological stress in the course of the experiment, will not only comply with our research goal of establishing reliability and validity, but also will neutralize any potential variability in stress response that might be stemming from sex differences (e.g., Kirschbaum, Klauer, Filipp, & Hellhammer, 1995; Kelly, Tyrka, Anderson, Price, & Carpenter, 2008). Results: Serenita algorithm was able to effectively detect changes in the participant`s estimated stress level, as expected by the different experimental conditions and followed the robust physiological response pattern usually obtained by the TSST protocol. In addition, a cross correlation of .93 was obtained between the estimated stress level, using Serenita`s algorithm, and Cortisol level measures. Conclusions: these results serve a double validation for Serenita as an effective tool to quantitatively measure physiological stress response. This innovative technique bears important implications for the field of stress research and treatment, providing to the best of our knowledge the first clinically validated non-lab based quantitative physiological stress measurement tool. Conclusions: The present study aimed at investigating if the stress estimation algorithm, used by the Serenita app, was able to accurately estimate variations on stress levels. The TSST widely established as the standard protocol for stress induction was used to induce stress on a controlled clinical environment. The estimated stress levels show a high agreement rate with the expected stress response of the TSST. Furthermore, the analysis of salivary cortisol levels provided an objective measure of the real variation on stress levels, the average cortisol curve has a correlation index of 0.93 with the estimated stress provided by Serenita’s stress algorithm, supporting the stress estimation algorithm as a feasible way to estimate stress. Finally, in many stress monitoring applications it is useful to know, not just the relative change in stress along the time, but also to obtain a quantitative value for the stress level at any given time. Due to the highly subject-dependent nature of the basal level of stress (and cortisol) this task is relatively complex, however using a priori information such as age, gender, health condition, among others, it is possible to project the stress function into a bounded quantitative stress scale e.g. 0 − 100%. As far as we know this is the first time where an application is providing a quantitative and validated method comparable to measuring stress with a lab test. This tool could serve as a research tool in stress studies.

  • 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: