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Journal Description

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

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

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

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

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


Recent Articles:

  • Source: Hello Sunday Morning /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Users’ Intrinsic Goals Linked to Alcohol Dependence Risk Level and Engagement With a Health Promotion Website (Hello Sunday Morning): Observational Study


    Background: Hello Sunday Morning (HSM) is a self-guided health promotion website with the aim to improve drinking culture. Members are encouraged to sign up for a 3-month period of alcohol abstention and record and track their progress and goals. Objective: This study used self-determination theory (SDT) to examine the nature of goals subscribed by HSM users to test the extent to which intrinsic goal pursuit was linked to lower alcohol dependency risk and higher engagement with the HSM website. Methods: HSM users (N=2216; 59.75%, 1324/2216, females; aged 18-79 years) completed the World Health Organization’s Alcohol Use Disorders Identification Test (WHO-AUDIT, which measures alcohol dependence risk level) at sign-up and at 4 and 6 months after sign-up. In addition, the website had a goals-subscription feature that allowed participants to share their goals. Two independent raters classified the goals according to a coding system we devised based on SDT, which proposes that intrinsic goals (eg, growth, relationships, community, and health) better promote positive outcomes than extrinsic goals (eg, wealth, fame, and image). Results: Although there was substantial (1016/2216, 45.84%) attrition of HSM users from sign-up to 6 months, the attrition rate could not be attributed to alcohol dependency risk because people in different WHO-AUDIT risk zones were equally likely to be missing at 4 and 6 months after sign-up. The SDT-driven coding of goals yielded the following categories: wealth and image (extrinsic goals); relationships, personal growth, community engagement, and physical health (intrinsic goals); and alcohol use-related goals (which were hard to classify as either extrinsic or intrinsic). Alcohol dependence risk level correlated positively with goals related to money (r=.16), personal growth (r=.17), relationships (r=.10), and alcohol use (r=.25). Website engagement correlated negatively with alcohol dependence risk level (r=.10) and positively with relationship (r=.10) and community goals (r=.12). Conclusions: HSM users with higher alcohol dependence risk tended to engage with the website less, but to the extent that they did, they tended to subscribe to goals related to alcohol use and improving their personal growth, relationships, and finances. In line with SDT, engagement with goals—particularly the intrinsic goals of connecting with close-others and the broader community—related to increased website engagement. Web-based tools intended to promote healthy behaviors in users may be effective in engaging their users if the users’ experience on the website supports the pursuit of intrinsic goals.

  • Source: Image created by the Authors; Copyright: Nils Haller; URL:; License: Creative Commons Attribution (CC-BY).

    Individualized Web-Based Exercise for the Treatment of Depression: Randomized Controlled Trial


    Background: Due to the high prevalence of depressive disorders, it is mandatory to develop therapeutic strategies that provide universal access and require limited financial and human resources. Web-based therapeutic approaches fulfill these conditions. Objective: The objective of our study was to assess the feasibility, acceptability, and efficacy of a supervised, individualized 8-week Web-based exercise intervention conducted for patients with moderate to severe depression. Methods: We recruited 20 patients with unipolar depression and randomly assigned them into 2 groups (intervention, exercise program group, n=14, and control, treatment-as-usual group, n=6). At baseline, depressive symptoms were rated via the Quick Inventory of Depressive Symptomatology (QIDS) by patients themselves (QIDS–self-report, QIDS-SR) and by a blinded psychiatrist (QIDS–clinician rating, QIDS-C). In addition, performance diagnostics (lactate analysis, spiroergometry during a treadmill walking test) were conducted. Quality of life was assessed via the Short Form-36 questionnaire (SF-36) and self-efficacy via the General Self-Efficacy scale (GSE). In addition, habitual physical activity (HPA) was determined via the Baecke questionnaire. Participants of the intervention group received exercise schedules once weekly with endurance and strength training instructions. Rating of depressive symptoms was repeated after 6-12 days and 8 weeks; performance diagnostics and the completion of all the questionnaires were repeated after 8 weeks only. Results: The severity of depression subsided significantly in the intervention group after 8 weeks (median change in QIDS-SR: −5; interquartile range, IQR: −2 to −10), although it was already evident within the first 6-12 days (median change in QIDS-SR: −6; IQR: −2 to −8). During the intervention, participants undertook a median of 75 (IQR: 63 to 98) minutes of endurance training per week or 84% (16 [IQR: 9 to 19] of 19 [IQR: 15 to 21]) recommended endurance units in total. In addition, 9 (IQR: 4 to 12) of 10 (IQR: 8 to 13) recommended strength training exercise units were conducted during the 8 weeks. Performance diagnostics revealed a substantial increase in the maximum output in Watt for the intervention group after 8 weeks. Moreover, the intervention showed a favorable effect on SF-36 items “emotional well-being” and “social functioning” as well as on GSE and HPA scores. Conclusions: Our individualized Web-based exercise intervention for moderate to severe depression was highly accepted by the patients and led to a significant and clinically relevant improvement of depressive symptoms. Trial Registration: NCT02874833; (Archived by WebCite at

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

    Efficacy and Moderation of Mobile App–Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on...


    Background: Mindfulness-based interventions, self-compassion training, and cognitive behavioral therapy have garnered much evidence in its salutary effects on mental health. With increasing application of smartphone and mobile technology on health promotion, this study investigated the efficacy and possible moderators of mindfulness, self-compassion, and cognitive behavioral psychoeducation training mobile apps in the improvement of mental health. Objective: The aim of this study was to examine the efficacy of 3 mobile app–based programs: mindfulness-based program, self-compassion program, and cognitive behavioral psychoeducation program in improving mental well-being and reducing psychological distress. Changes in mindful awareness and self-compassion were also assessed. To further delineate the suitability of each program for different types of individuals, individual difference variables (ie, discomfort with emotions and tolerance for ambiguity) were explored for potential moderation. Methods: This study was a 3-arm, randomized, controlled, noninferiority trial examining the efficacy of mindfulness-based program, self-compassion program, and cognitive behavioral psychoeducation. Participants were randomized into either 1 of the 3 conditions. Throughout the 4-week, 28-session program, participants spent 10-15 min daily reviewing the course content and practicing various related exercises. At preprogram, postprogram, and 3-month follow-up, participants also completed Web-based measures of mental well-being, psychological distress, mindful-awareness, and self-compassion as well as the proposed moderators. Results: Among the 2161 study participants, 508 and 349 completed the post- and 3-month follow-up assessment, respectively. All 3 conditions (mindfulness-based program: N=703; cognitive behavioral psychoeducation: N=753; self-compassion program: N=705) were found to be efficacious in improving mental well-being and reducing psychological distress. All conditions enhanced mindful awareness at postprogram. Significant interaction effect was found on self-compassion; cognitive behavioral psychoeducation and self-compassion program, but not mindfulness-based program, significantly enhanced self-compassion at postprogram. No significant differences regarding usage and users’ satisfaction were found among the 3 conditions. None of the proposed moderators were found to be significant. Conclusions: Mindfulness-based, self-compassion, and cognitive behavioral psychoeducation mobile apps were efficacious in improving mental well-being and reducing psychological distress among adults at postprogram and 3-month follow-up. Future app-based psychological training programs should consider gamification and personalization of content or feedback to enhance engagement and mitigate the high attrition rates that are common in app-based health promotion programs. Trial Registration: Chinese Clinical Trial Registry (ChiCTR) ChiCTR-TRC-13003468; (Archived by WebCite at

  • A homeless person using his mobile phone in the street. Source: The Authors; Copyright: Fran Calvo; URL:; License: Licensed by JMIR.

    Using Facebook for Improving the Psychological Well-Being of Individuals Experiencing Homelessness: Experimental and Longitudinal Study


    Background: Web-based social networks are a powerful communicative element and their use is increasingly widespread. Persons living in extreme social exclusion such as individuals experiencing homelessness can benefit from the positive elements of communication and relationship associated with social networking sites. Objective: This study aimed to suggest the comparison of a Facebook training course and an office software course and their effect on psychological well-being in a group of individuals experiencing homelessness. Methods: An experimental and longitudinal study was designed. Individuals experiencing homelessness were randomly assigned to either the Facebook group or the office software group, and their social skills, self-esteem, self-efficacy, and satisfaction with life were measured on 4 occasions: pretest, at the end of the training course, 1 month later, and 3 months later. A mixed analysis of variance of repeated measures (2×4) was performed. Results: A total of 92 individuals experiencing homelessness participated in the study. The number of cases in which the 4 measurements were completed was 71 (35 in the intervention group and 36 in the control group). The mixed analysis of variance of repeated measures and the multiple regression analysis indicated a significant increase of the 4 analyzed parameters, with greater significance in the areas of social skills and self-esteem. The critical levels associated to the interaction Time×Program were significant in all variables and levels. Therefore, the scores in the 4 analyzed constructs were not equal according to the program carried out throughout the work. The effect size associated to the interaction Time×Program in the social skills scores was large (η2=0.32); in the self-esteem and self-efficacy scores, it was medium, (η2=0.13); and in the satisfaction with life scores, it was small (η2=0.09). The results of the adjustment of the different models of multiple linear regression indicate that the number of hours devoted weekly to the use of Facebook was a predictor of the increase in the scores of social skills (B=3.43, r2=.405) and self-esteem (B=.382). Age (B=.175) and self-efficacy (B=.09) were also variables, which with independence and in equal conditions, predicted self-esteem (r2=.29). Finally, self-esteem (B=.69) was also a predictor variable of the increase of satisfaction with life (r2=.195). Conclusions: These findings suggest that Facebook could be a key element in homeless psychological well-being and socialization.

  • A patient using the "askapatient" health care forum (montage). Source: /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Identifying the Underlying Factors Associated With Patients’ Attitudes Toward Antidepressants: Qualitative and Quantitative Analysis of Patient Drug Reviews


    Background: Nonadherence to antidepressants is a major obstacle to deriving antidepressants’ therapeutic benefits, resulting in significant burdens on the individuals and the health care system. Several studies have shown that nonadherence is weakly associated with personal and clinical variables but strongly associated with patients’ beliefs and attitudes toward medications. Patients’ drug review posts in online health care communities might provide a significant insight into patients’ attitude toward antidepressants and could be used to address the challenges of self-report methods such as patients’ recruitment. Objective: The aim of this study was to use patient-generated data to identify factors affecting the patient’s attitude toward 4 antidepressants drugs (sertraline [Zoloft], escitalopram [Lexapro], duloxetine [Cymbalta], and venlafaxine [Effexor XR]), which in turn, is a strong determinant of treatment nonadherence. We hypothesized that clinical variables (drug effectiveness; adverse drug reactions, ADRs; perceived distress from ADRs, ADR-PD; and duration of treatment) and personal variables (age, gender, and patients’ knowledge about medications) are associated with patients’ attitude toward antidepressants, and experience of ADRs and drug ineffectiveness are strongly associated with negative attitude. Methods: We used both qualitative and quantitative methods to analyze the dataset. Patients’ drug reviews were randomly selected from a health care forum called askapatient. The Framework method was used to build the analytical framework containing the themes for developing structured data from the qualitative drug reviews. Then, 4 annotators coded the drug reviews at the sentence level using the analytical framework. After managing missing values, we used chi-square and ordinal logistic regression to test and model the association between variables and attitude. Results: A total of 892 reviews posted between February 2001 and September 2016 were analyzed. Most of the patients were females (680/892, 76.2%) and aged less than 40 years (540/892, 60.5%). Patient attitude was significantly (P<.001) associated with experience of ADRs, ADR-PD, drug effectiveness, perceived lack of knowledge, experience of withdrawal, and duration of usage, whereas oth age (F4,874=0.72, P=.58) and gender (χ24=2.7, P=.21) were not found to be associated with patient attitudes. Moreover, modeling the relationship between variables and attitudes showed that drug effectiveness and perceived distress from adverse drug reactions were the 2 most significant factors affecting patients’ attitude toward antidepressants. Conclusions: Patients’ self-report experiences of medications in online health care communities can provide a direct insight into the underlying factors associated with patients’ perceptions and attitudes toward antidepressants. However, it cannot be used as a replacement for self-report methods because of the lack of information for some of the variables, colloquial language, and the unstructured format of the reports.

  • Still from a promotional video for the SAM anxiety app. Source: University of West England; Copyright: The Authors; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Interaction and Engagement with an Anxiety Management App: Analysis Using Large-Scale Behavioral Data


    Background: SAM (Self-help for Anxiety Management) is a mobile phone app that provides self-help for anxiety management. Launched in 2013, the app has achieved over one million downloads on the iOS and Android platform app stores. Key features of the app are anxiety monitoring, self-help techniques, and social support via a mobile forum (“the Social Cloud”). This paper presents unique insights into eMental health app usage patterns and explores user behaviors and usage of self-help techniques. Objective: The objective of our study was to investigate behavioral engagement and to establish discernible usage patterns of the app linked to the features of anxiety monitoring, ratings of self-help techniques, and social participation. Methods: We use data mining techniques on aggregate data obtained from 105,380 registered users of the app’s cloud services. Results: Engagement generally conformed to common mobile participation patterns with an inverted pyramid or “funnel” of engagement of increasing intensity. We further identified 4 distinct groups of behavioral engagement differentiated by levels of activity in anxiety monitoring and social feature usage. Anxiety levels among all monitoring users were markedly reduced in the first few days of usage with some bounce back effect thereafter. A small group of users demonstrated long-term anxiety reduction (using a robust measure), typically monitored for 12-110 days, with 10-30 discrete updates and showed low levels of social participation. Conclusions: The data supported our expectation of different usage patterns, given flexible user journeys, and varying commitment in an unstructured mobile phone usage setting. We nevertheless show an aggregate trend of reduction in self-reported anxiety across all minimally-engaged users, while noting that due to the anonymized dataset, we did not have information on users also enrolled in therapy or other intervention while using the app. We find several commonalities between these app-based behavioral patterns and traditional therapy engagement.

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

    Supported Internet-Delivered Cognitive Behavior Treatment for Adults with Severe Depressive Symptoms: A Secondary Analysis


    Background: Depression is a highly prevalent mental health issue that exacts significant economic, societal, personal, and interpersonal costs. Innovative internet-delivered interventions have been designed to increase accessibility to and cost-effectiveness of treatments. These treatments have mainly targeted mild to moderate levels of depression. The increased risk associated with severe depression, particularly of suicidal ideation often results in this population being excluded from research studies. As a result, the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) in more severely depressed cohorts is less researched. Objective: The aim of this study is to examine the effect of iCBT on symptoms of severe depression, comorbid symptoms of anxiety, and levels of work and social functioning. Methods: Retrospective consent was provided by participants with elevated scores (>28 severe depression symptoms) on the Beck Depression Inventory (BDI-II) who accessed an iCBT intervention (Space from Depression) with support for up to 8 weeks. Data were collected at baseline, posttreatment, and 3-month follow-up on the primary outcome (BDI-II), and secondary outcomes (the Generalized Anxiety Disorder-7 and the Work and Social Adjustment Scale). Results: A significant change was observed on all measures between pre- and postmeasurement and maintained at 3-month follow-up. Clinical improvement was observed for participants on the BDI-II from pre- to postmeasurement, and suicidal ideation also reduced from pre- to postmeasurement. Conclusions: Users of Space from Depression with symptoms of severe depression were found to have decreased symptoms of depression and anxiety and increased levels of work and social functioning. The intervention also demonstrated its potential to decrease suicidal ideation. Further investigation is required to determine why some individuals improve, and others do not. iCBT may have the potential to be used as an adjunct treatment for severe depression symptoms, but participants may require further treatment if they receive iCBT as a standalone intervention. Although promising, further research incorporating control groups is needed to support the utility of Space from Depression for use in or as an adjunct to treatment for severe depression.

  • MindFrame. Source: Image created by the Authors; Copyright: Monsenso ApS; URL:; License: Creative Commons Attribution (CC-BY).

    A Smartphone App to Foster Power in the Everyday Management of Living With Schizophrenia: Qualitative Analysis of Young Adults’ Perspectives


    Background: Literature indicates that using smartphone technology is a feasible way of empowering young adults recently diagnosed with schizophrenia to manage everyday living with their illness. The perspective of young adults on this matter, however, is unexplored. Objective: This study aimed at exploring how young adults recently diagnosed with schizophrenia used and perceived a smartphone app (MindFrame) as a tool to foster power in the everyday management of living with their illness. Methods: Using participatory design thinking and methods, MindFrame was iteratively developed. MindFrame consists of a smartphone app that allows young adults to access resources to aid their self-management. The app is affiliated with a website to support collaboration with their health care providers (HCPs). From January to December 2016, community-dwelling young adults with a recent diagnosis of schizophrenia were invited to use MindFrame as part of their care. They customized the resources while assessing their health on a daily basis. Then, they were invited to evaluate the use and provide their perspective on the app. The evaluation was qualitative, and data were generated from in-depth interviews. Data were analyzed using a hermeneutical approach. Results: A total of 98 individuals were eligible for the study (mean age 24.8, range 18-36). Of these, 27 used MindFrame and 13 participated in the evaluation. The analysis showed that to the young adults, MindFrame served to foster power in their everyday management of living with schizophrenia. When MindFrame was used with the HCPs consistently for more than a month, it could provide them with the power to keep up their medication, to keep a step ahead of their illness, and to get appropriate help based on their needs. This empowered them to stay on track with their illness, thus in control of it. It was also reported that MindFrame could fuel the fear of restraint and illness exacerbation, thereby disempowering some from feeling certain and secure. Conclusions: The findings demonstrate that young adults diagnosed with schizophrenia are amenable to use a smartphone app to monitor their health, manage their medication, and stay alert of the early signs of illness exacerbation. This may empower them to stay on track with their illness, thus in control of it. This indicates the potential of smartphone-based care being capable of aiding this specific population to more confidently manage their new life situation. The potentially disempowering aspect of MindFrame accentuates a need for further research to understand the best uptake and the limitations of smartphone-based schizophrenia care of young adults.

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

    Web-Based Mindfulness Interventions for Mental Health Treatment: Systematic Review and Meta-Analysis


    Background: Web-based mindfulness interventions are increasingly delivered through the internet to treat mental health conditions. Objective: The objective of this study was to determine the effectiveness of web-based mindfulness interventions in clinical mental health populations. Secondary aims were to explore the impact of study variables on the effectiveness of web-based mindfulness interventions. Methods: We performed a systematic review and meta-analysis of studies investigating the effects of web-based mindfulness interventions on clinical populations. Results: The search strategy yielded 12 eligible studies. Web-based mindfulness interventions were effective in reducing depression in the total clinical sample (n=656 g=−0.609, P=.004) and in the anxiety disorder subgroup (n=313, g=−0.651, P<.001), but not in the depression disorder subgroup (n=251, P=.18). Similarly, web-based mindfulness interventions significantly reduced anxiety in the total clinical sample (n=756, g=−0.433, P=.004) and the anxiety disorder subgroup (n=413, g=−0.719, P<.001), but not in the depression disorder group (n=251, g=−0.213, P=.28). Finally, web-based mindfulness interventions improved quality of life and functioning in the total sample (n=591, g=0.362, P=.02) in the anxiety disorder subgroup (n=370, g=0.550, P=.02) and mindfulness skills in the total clinical sample (n=251, g=0.724, P<.001). Conclusions: Results support the effectiveness of web-based mindfulness interventions in reducing depression and anxiety and in enhancing quality of life and mindfulness skills, particularly in those with clinical anxiety. Results should be interpreted with caution given the high heterogeneity of web-based mindfulness interventions and the low number of studies included.

  • Source: iStock by Getty Images; Copyright: Dean Mitchell; URL:; License: Licensed by the authors.

    Using Mobile Technology to Provide Personalized Reminiscence for People Living With Dementia and Their Carers: Appraisal of Outcomes From a...


    Background: Dementia is an international research priority. Reminiscence is an intervention that prompts memories and has been widely used as a therapeutic approach for people living with dementia. We developed a novel iPad app to support home-based personalized reminiscence. It is crucial that technology-enabled reminiscence interventions are appraised. Objective: We sought to measure the effect of technology-enabled reminiscence on mutuality (defined as the level of “closeness” between an adult living with dementia and their carer), quality of carer and patient relationship, and subjective well-being. Methods: A 19-week personalized reminiscence intervention facilitated by a program of training and a bespoke iPad app was delivered to people living with dementia and their family carers at their own homes. Participants (N=60) were recruited in dyads from a cognitive rehabilitation team affiliated with a large UK health care organization. Each dyad comprised a person living with early to moderate dementia and his or her family carer. Outcome measurement data were collected at baseline, midpoint, and intervention closure. Results: Participants living with dementia attained statistically significant increases in mutuality, quality of carer and patient relationship, and subjective well-being (P<.001 for all 3) from baseline to endpoint. Carers attained nonsignificant increases in mutuality and quality of carer and patient relationship and a nonsignificant decrease in subjective well-being. Conclusions: Our results indicate that individual-specific reminiscence supported by an iPad app may be efficient in the context of early to moderate dementia. A robust randomized controlled trial of technology-enabled personalized reminiscence is warranted.

  • Elderly woman using virtual reality. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Digital Technology for Caregivers of People With Psychosis: Systematic Review


    Background: Psychotic disorders are severe mental health conditions that adversely affect the quality of life and life expectancy. Schizophrenia, the most common and severe form of psychosis affects 21 million people globally. Informal caregivers (families) are known to play an important role in facilitating patient recovery outcomes, although their own health and well-being could be adversely affected by the illness. The application of novel digital interventions in mental health care for patient groups is rapidly expanding; interestingly, however, far less is known about their role with family caregivers. Objective: This study aimed to systematically identify the application of digital interventions that focus on informal caregivers of people with psychosis and describe their outcomes. Methods: We completed a search for relevant papers in four electronic databases (EMBASE, MEDLINE, PsycINFO, and Web of Science). The search also included the Cochrane database and manual search of reference lists of relevant papers. The search was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Results: The search identified 9 studies derived from 8 unique datasets. Most studies were assessments of feasibility and were undertaken in the United States. Interventions were predominately Web-based, with a focus on improving the caregivers’ knowledge and understanding about psychosis. Conclusions: This study offers preliminary support for the feasibility and acceptability of digital interventions for psychosis in informal caregiver populations. However, the findings underpin a clear need for greater development in the range of caregiver-focused digital approaches on offer and robust evaluation of their outcomes. The use of digital approaches with caregiver populations seemingly lags someway behind the significant developments observed in patient groups.

  • Source: Image created by the Authors; Copyright: Alicia Heraz; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Recognition of Emotions Conveyed by Touch Through Force-Sensitive Screens: Observational Study of Humans and Machine Learning Techniques


    Background: Emotions affect our mental health: they influence our perception, alter our physical strength, and interfere with our reason. Emotions modulate our face, voice, and movements. When emotions are expressed through the voice or face, they are difficult to measure because cameras and microphones are not often used in real life in the same laboratory conditions where emotion detection algorithms perform well. With the increasing use of smartphones, the fact that we touch our phones, on average, thousands of times a day, and that emotions modulate our movements, we have an opportunity to explore emotional patterns in passive expressive touches and detect emotions, enabling us to empower smartphone apps with emotional intelligence. Objective: In this study, we asked 2 questions. (1) As emotions modulate our finger movements, will humans be able to recognize emotions by only looking at passive expressive touches? (2) Can we teach machines how to accurately recognize emotions from passive expressive touches? Methods: We were interested in 8 emotions: anger, awe, desire, fear, hate, grief, laughter, love (and no emotion). We conducted 2 experiments with 2 groups of participants: good imagers and emotionally aware participants formed group A, with the remainder forming group B. In the first experiment, we video recorded, for a few seconds, the expressive touches of group A, and we asked group B to guess the emotion of every expressive touch. In the second experiment, we trained group A to express every emotion on a force-sensitive smartphone. We then collected hundreds of thousands of their touches, and applied feature selection and machine learning techniques to detect emotions from the coordinates of participant’ finger touches, amount of force, and skin area, all as functions of time. Results: We recruited 117 volunteers: 15 were good imagers and emotionally aware (group A); the other 102 participants formed group B. In the first experiment, group B was able to successfully recognize all emotions (and no emotion) with a high 83.8% (769/918) accuracy: 49.0% (50/102) of them were 100% (450/450) correct and 25.5% (26/102) were 77.8% (182/234) correct. In the second experiment, we achieved a high 91.11% (2110/2316) classification accuracy in detecting all emotions (and no emotion) from 9 spatiotemporal features of group A touches. Conclusions: Emotions modulate our touches on force-sensitive screens, and humans have a natural ability to recognize other people’s emotions by watching prerecorded videos of their expressive touches. Machines can learn the same emotion recognition ability and do better than humans if they are allowed to continue learning on new data. It is possible to enable force-sensitive screens to recognize users’ emotions and share this emotional insight with users, increasing users’ emotional awareness and allowing researchers to design better technologies for well-being.

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  • Profiling commenters on eating disorder-related online discussion forums based on the other forums to which they contribute

    Date Submitted: Oct 19, 2018

    Open Peer Review Period: Oct 22, 2018 - Dec 17, 2018

    Background: Understanding the characteristics of commenters on mental health-related online discussion forums is vital for the development of effective psychological interventions in these communities...

    Background: Understanding the characteristics of commenters on mental health-related online discussion forums is vital for the development of effective psychological interventions in these communities. Previous research has typically investigated these characteristics using surveys or textual analyses of online content. However, the way in which commenters interact with each other can also elucidate the characteristics of these commenters. Objective: The current study applied text-mining and network analyses to profile eating disorder-related (EDR) forum commenters in terms of the other forums to which they tended to contribute. Methods: The researchers identified all public EDR-forums with ≥1000 comments posted between March 2017 and February 2018 on a large online discussion platform (Reddit), compiled lists of commenters (N=14024) on each of these forums, and identified other forums in which the commenters posted. Text-mining and a network analytic approach enabled the identification of four subgroups of forums (e.g., pro-eating disorder, thinspiration). Then, for each subgroup, further network analyses were conducted using the EDR-forum commenter-overlap between 50 forums on which the subgroup’s commenters also posted. Results: The results focus on two subgroups – pro-eating disorder and thinspiration – and communities of commenters within both subgroups. Within the pro-eating disorder subgroup, five communities of commenters were detected who posted on forums regarding the body, eating and exercise, women and appearance, mental health, and self-harm. Regarding the thinspiration subgroup, 75% of the commenters had also posted on pornographic subreddits, and 29% on forums concerning the body and eating. These thinspiration communities overlapped, with over a third of the commenters posting on body and eating-related subreddits also contributing to pornographic forums. Conclusions: The findings provide insight into the characteristics (i.e., interests) of EDR-forum commenters, and have implications for the design of online interventions. With the publicly available data and code provided, researchers can easily reproduce the analyses, or conduct the same analyses with different groups of commenters.

  • Technological interventions for medication adherence in adult mental health and substance use disorders: a systematic scoping review

    Date Submitted: Oct 17, 2018

    Open Peer Review Period: Oct 17, 2018 - Dec 12, 2018

    Background: Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decisi...

    Background: Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decision making and the increased street value of controlled substances. A wide range of interventions designed to improve adherence in mental health and substance use disorders have been studied; recently, many have incorporated information technology (e.g., smartphone apps, electronic pill dispensers, and telehealth). Many of the same intervention components have been used across different disorders. Further, many interventions incorporate multiple components, making it difficult to evaluate the effect of individual components in isolation. Objective: To conduct a systematic scoping review of the literature in order to develop a literature-driven, transdiagnostic taxonomic framework of technology-based medication adherence intervention and measurement components used in mental health and substance use disorders. Methods: This review was conducted based on a published protocol (PROSPERO: CRD42018067902) in accordance with the PRISMA systematic review guidelines. We searched 7 electronic databases: MEDLINE, EMBASE, PsycINFO, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Engineering Village, and from January 2000 to September 2018. Two reviewers independently conducted title and abstract screens, full-text screens, and data extraction. We included all studies which evaluate populations or individuals with a mental health or substance use disorder, and which contain at least one technology-delivered component (e.g., website, smartphone app, biosensor, algorithm) designed to improve medication adherence or the measurement thereof. Given the wide variety of studied interventions, populations, and outcomes, we did not conduct a risk of bias assessment or quantitative meta-analysis. We developed a taxonomic framework for intervention classification and applied it to multi-component interventions across mental health disorders. Results: The initial search identified 19,280 results - following duplicate removal and two-stage screening, 128 included studies remained (Cohen’s kappa: 0.8, 0.72-0.87). Major intervention component categories include reminders, support messages, social support engagement, care team contact capabilities, data feedback, psychoeducation, adherence-based psychotherapy, remote care delivery, secure medication storage, and contingency management. Adherence measurement components include daily self-reports, remote direct visualization, fully-automated computer vision algorithms, biosensors, smart pill bottles, ingestible sensors, pill counts, and utilization measures. Intervention modalities included short message service (SMS), smartphone apps, websites, and interactive voice response (IVR). We provide graphical representations of intervention component categories and an element-wise breakdown of multicomponent interventions. Conclusions: Many technology-based medication adherence and monitoring interventions have been studied across psychiatric disease contexts. Interventions that are useful in one psychiatric disorder may be useful in other disorders, and further research is necessary to elucidate the specific effects of individual intervention components. Our framework is directly developed from the substance use disorder and mental health treatment literature, and allows for transdiagnostic comparisons and an organized conceptual mapping of interventions.

  • Gaming against stigma: An analysis of mental illness messages in video games

    Date Submitted: Oct 5, 2018

    Open Peer Review Period: Oct 11, 2018 - Dec 6, 2018

    Background: Video game playing is a daily activity for many youths that replaces other media forms (e.g., TV watching) and serves as an important source of knowledge, with the potential to impact thei...

    Background: Video game playing is a daily activity for many youths that replaces other media forms (e.g., TV watching) and serves as an important source of knowledge, with the potential to impact their attitudes and behaviors. Researchers are concerned about the impact of video gaming on youth (e.g., for promoting prosocial or antisocial behaviour). Studies have also begun to explore players’ experience of gameplay and video game messages about violence, sexism, and racism; however, little is known about the impact of commercial video games in the sharing/shaping of knowledge and/or messages about mental illness. Objective: This study aims to review and examine messages about, and representations of mental illness, especially psychosis, and its context of care in commercial video games. Methods: On Steam (a popular PC gaming platform), we performed keyword searches on games made available between January 2016 to June 2017. A total of 789 games were identified and reviewed to assess whether their game content was related to mental illness. At the end of the screening phase, a total of 100 games were retained. Results: We used a game elements framework (characters, game environment/atmosphere, goals, etc.) to describe and then unpack messages about mental health and illness in video games. The majority of the games we reviewed (97%) portray mental illness in negative, partial, misleading, and problematic ways (e.g., associating it with violence, scary, insanity, hopelessness, etc.). Furthermore, some games portrayed mental illness as manifestations or consequences of supernatural phenomena or paranormal experiences. As mental illness was often associated with mystery, unpredictable, and as an obscure illness; its treatment was also associated with uncertainties, as game characters with mental illness had to undergo “experiment treatment” to get better. Unfortunately, little or no hope for recovery was present in the identified video games, where mental illness was often presented as ongoing straggle as well as endless battle with their mind and themselves. Conclusions: The game elements of a large number of commercial video games included mental illness, about which many perpetuated well-known stereotypes and prejudices. We discuss the key findings further in relation current evidence on the impact of media portrayals of mental illness and stigma; the ability of serious video games, to promote alternative messages around mental illness and clinical practices. Future research is needed to investigate the impact that such messages have on players and to explore the role that video games can play in fostering alternative messages to reduce stigma associated with mental illness.

  • Using computer games to support adolescent mental health interventions: lessons from a deployment study

    Date Submitted: Oct 5, 2018

    Open Peer Review Period: Oct 11, 2018 - Dec 6, 2018

    Background: Recent research has highlighted the “naturalistic uptake challenge” as a key barrier that limits the impact of technologies designed to support mental health interventions. While there...

    Background: Recent research has highlighted the “naturalistic uptake challenge” as a key barrier that limits the impact of technologies designed to support mental health interventions. While there is increasing evidence regarding the efficacy of computerised interventions, as demonstrated through randomised controlled trials (RCTs), there is also increasing evidence that technologies are not succeeding as expected when deployed in real-world settings. Objective: This paper describes the results of a naturalistic, or uncontrolled, deployment of Pesky gNATs, a computer game designed to support Cognitive Behavioural Therapy (CBT) interventions for young people experiencing anxiety or low mood. The game is intended for use in face-to-face clinical sessions involving one therapist and young person. The design draws on several key principles in developmental and clinical psychology and in human computer interaction, with the aim of making CBT more accessible and engaging for young people. Methods: Pesky gNATs has been made available to mental health professionals worldwide through a not-for-profit organisation. After one year of use, we collected usage and user experience data from therapists who have used the game through an online survey and follow-up semi-structured interviews. The data collection addressed the expectations and experiences of both therapists and young people and also sought opinions on key themes including the flexibility of the technology and attitudes towards user-generated versus automated adaptations in future versions. We used thematic analysis across survey and interviews to identify key themes in the data. Results: 21 therapists who used the game with a total of 95 children completed the online survey. Five therapists participated in the follow-up interview. Confirming previous assessments, data suggests that the game can be helpful in delivering therapy and that the young people generally liked the approach. However, therapists shared diverse opinions regarding the young people for whom they deem the game appropriate. The following three themes were identified: 1) stages of use; 2) impact on the delivery of therapy; 3) further developments. We discuss therapists' reflections on the game with regard to their work practices and consider the question of customisation, including the delicate balance of adaptable interaction versus the need for fidelity to a therapeutic model. Conclusions: This research provides further evidence that therapeutic games can be helpful in the delivery of therapy in real intervention settings. However, therapists’ autonomy and decisions on when, with who and how to use technology varies strongly. This needs to be considered when designing technologies.

  • Framing Mental Health within Digital Games: A Case Study of Hellblade: Senua's Sacrifice

    Date Submitted: Oct 5, 2018

    Open Peer Review Period: Oct 11, 2018 - Dec 6, 2018

    Background: Researchers and therapists have increasingly turned to digital games for new forms of treatments and interventions for people suffering from a variety of mental health issues. Yet, the dep...

    Background: Researchers and therapists have increasingly turned to digital games for new forms of treatments and interventions for people suffering from a variety of mental health issues. Yet, the depiction mental illness within digital games typically promote stigmatized versions of those with mental health concerns. Recently, more games have attempted to implement more realistic and respectful depictions of mental health conditions. Objective: This paper presents an analysis of a new game which has the potential to change the way researchers and game designers approach topics of mental health within the context of gaming. Methods: A case study of Hellblade: Senua's Sacrifice was conducted using Goffman's (1974) frame analysis to show how design choices and player reception for this game present the potential for new ways of approaching games and mental health. Results: Research shows that both mental health researchers and game designers have struggled to develop successful guidelines for collaborations. The depiction of psychosis within Hellblade: Senua's Sacrifice shows how research-informed design can lead to innovative use of technology and game mechanics to create embodied experiences of mental health to promote empathetic understanding or mental health interventions. Conclusions: This paper highlights an exemplary case of collaborative game design with relation to mental health. Understanding the success of Hellblade's depiction of psychosis can improve serious games research and design. Further research must continue to provide deeper analysis of not only games, but also contextualize the experience of those who play these games.

  • The co-creative development of the QoL-ME: a visual and personalised quality of life assessment app for people with severe mental health problems

    Date Submitted: Oct 1, 2018

    Open Peer Review Period: Oct 6, 2018 - Dec 1, 2018

    Background: Quality of Life (QoL) is a prominent outcome measure in mental health. Conventional methods for QoL assessment, however, rely heavily on language‐based communication, and may therefore n...

    Background: Quality of Life (QoL) is a prominent outcome measure in mental health. Conventional methods for QoL assessment, however, rely heavily on language‐based communication, and may therefore not be optimal for all individuals with severe mental health problems. Additionally, QoL assessment is usually based on a fixed number of life domains. This approach conflicts with the notion that QoL is influenced by individual values and preferences. A digital assessment app facilitates both the accessibility and personalisation of QoL assessment and may therefore help to further advance QoL assessment among individuals with severe mental health problems. Objective: This study focuses on the development of an innovative, visual and personalised QoL assessment app for people with severe mental health problems: the QoL-ME. Methods: A group of 59 participants contributed to the six iterations of the co-creative development of the QoL-ME. In the brainstorm stage, consisting of the first iteration, participants’ previous experiences with questionnaires and smartphone applications (apps) were explored. Participants gave their feedback on initial designs and wireframes in the second to fourth iterations that made up the design stage. In the usability stage that comprised the final two iterations, the usability of the QoL-ME was evaluated. Results: In the brainstorm stage, participants stressed the importance of privacy and data security, and of receiving feedback when answering questionnaires. Participants in the design stage indicated a preference for paging over scrolling, linear navigation, a clean and minimalist layout, the use of touchscreen functionality in various modes of interaction, and the use of Visual Analogue Scales (VAS). The usability evaluation in the usability stage revealed good to excellent usability. Conclusions: The co-creative development of the QoL-ME resulted in an app that corresponds to the preferences of participants and that has strong usability. Further research is needed to evaluate the psychometric quality of the QoL-ME, and to investigate its usefulness in practice. Clinical Trial: Not applicable