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Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959, Editor-in-Chief: John Torous MD MBI) is a PubMed-indexed, peer-reviewed journal which has a unique focus on digital health and Internet/mobile 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 related to digital psychiatry, e-mental health, and clinical informatics in psychiatry/psychology. The main themes/topics covered by this journal can be found here.

JMIR Mental Health has an international author- and readership and welcomes submissions from around the world.

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 SCIE (Science Citation Index Expanded)/WoS/JCR (Journal Citation Reports).


Recent Articles:

  • Dr. Jocelyn Howard using the website ( Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Evaluation of, a Canadian Mental Health Website Portal: Mixed Methods Assessment


  • The VR-CogAssess Platform. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    An Immersive Virtual Reality Platform for Assessing Spatial Navigation Memory in Predementia Screening: Feasibility and Usability Study


    Background: Traditional methods for assessing memory are expensive and have high administrative costs. Memory assessment is important for establishing cognitive impairment in cases such as detecting dementia in older adults. Virtual reality (VR) technology can assist in establishing better quality outcome in such crucial screening by supporting the well-being of individuals and offering them an engaging, cognitively challenging task that is not stressful. However, unmet user needs can compromise the validity of the outcome. Therefore, screening technology for older adults must address their specific design and usability requirements. Objective: This study aimed to design and evaluate the feasibility of an immersive VR platform to assess spatial navigation memory in older adults and establish its compatibility by comparing the outcome to a standard screening platform on a personal computer (PC). Methods: VR-CogAssess is a platform integrating an Oculus Rift head-mounted display and immersive photorealistic imagery. In a pilot study with healthy older adults (N=42; mean age 73.22 years, SD 9.26), a landmark recall test was conducted, and assessment on the VR-CogAssess was compared against a standard PC (SPC) setup. Results: Results showed that participants in VR were significantly more engaged (P=.003), achieved higher landmark recall scores (P=.004), made less navigational mistakes (P=.04), and reported a higher level of presence (P=.002) than those in SPC setup. In addition, participants in VR indicated no significantly higher stress than SPC setup (P=.87). Conclusions: The study findings suggest immersive VR is feasible and compatible with SPC counterpart for spatial navigation memory assessment. The study provides a set of design guidelines for creating similar platforms in the future.

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

    Young People Seeking Help Online for Mental Health: Cross-Sectional Survey Study


    Background: Young people are particularly vulnerable to experiencing mental health difficulties, but very few seek treatment or help during this time. Online help-seeking may offer an additional domain where young people can seek aid for mental health difficulties, yet our current understanding of how young people seek help online is limited. Objective: This was an exploratory study which aimed to investigate the online help-seeking behaviors and preferences of young people. Methods: This study made use of an anonymous online survey. Young people aged 18-25, living in Ireland, were recruited through social media ads on Twitter and Facebook and participated in the survey. Results: A total of 1308 respondents completed the survey. Many of the respondents (80.66%; 1055/1308) indicated that they would use their mobile phone to look online for help for a personal or emotional concern. When looking for help online, 82.57% (1080/1308) of participants made use of an Internet search, while 57.03% (746/1308) made use of a health website. When asked about their satisfaction with these resources, 36.94% (399/1080) indicated that they were satisfied or very satisfied with an Internet search while 49.33% (368/746) indicated that they were satisfied or very satisfied with a health website. When asked about credibility, health websites were found to be the most trustworthy, with 39.45% (516/1308) indicating that they found them to be trustworthy or very trustworthy. Most of the respondents (82.95%; 1085/1308) indicated that a health service logo was an important indicator of credibility, as was an endorsement by schools and colleges (54.97%; 719/1308). Important facilitators of online help-seeking included the anonymity and confidentiality offered by the Internet, with 80% (1046/1308) of the sample indicating that it influenced their decision a lot or quite a lot. A noted barrier was being uncertain whether information on an online resource was reliable, with 55.96% (732/1308) of the respondents indicating that this influenced their decision a lot or quite a lot. Conclusions: Findings from this survey suggest that young people are engaging with web-based mental health resources to assist them with their mental health concerns. However, levels of satisfaction with the available resources vary. Young people are engaging in strategies to assign credibility to web-based resources, however, uncertainty around their reliability is a significant barrier to online help-seeking.

  • Source: freepik; Copyright: katemangostar; URL:; License: Licensed by JMIR.

    Characterizing Participation and Perceived Engagement Benefits in an Integrated Digital Behavioral Health Recovery Community for Women: A Cross-Sectional Survey


    Background: Research suggests that digital recovery support services (D-RSSs) may help support individual recovery and augment the availability of in-person supports. Previous studies highlight the use of D-RSSs in supporting individuals in recovery from substance use but have yet to examine the use of D-RSSs in supporting a combination of behavioral health disorders, including substance use, mental health, and trauma. Similarly, few studies on D-RSSs have evaluated gender-specific supports or integrated communities, which may be helpful to women and individuals recovering from behavioral health disorders. Objective: The goal of this study was to evaluate the SHE RECOVERS (SR) recovery community, with the following 3 aims: (1) to characterize the women who engage in SR (including demographics and recovery-related characteristics), (2) describe the ways and frequency in which participants engage with SR, and (3) examine the perception of benefit derived from engagement with SR. Methods: This study used a cross-sectional survey to examine the characteristics of SR participants. Analysis of variance and chi-square tests, as well as univariate logistic regressions, were used to explore each aim. Results: Participants (N=729, mean age 46.83 years; 685/729, 94% Caucasian) reported being in recovery from a variety of conditions, although the most frequent nonexclusive disorder was substance use (86.40%, n=630). Participants had an average length in recovery (LIR) of 6.14 years (SD 7.87), with most having between 1 and 5 years (n=300). The most frequently reported recovery pathway was abstinence-based 12-step mutual aid (38.40%). Participants reported positive perceptions of benefit from SR participation, which did not vary by LIR or recovery pathway. Participants also had high rates of agreement, with SR having a positive impact on their lives, although this too did vary by recovery length and recovery pathway. Participants with 1 to 5 years of recovery used SR to connect with other women in recovery at higher rates, whereas those with less than 1 year used SR to ask for resources at higher rates, and those with 5 or more years used SR to provide support at higher rates. Lifetime engagement with specific supports of SR was also associated with LIR and recovery pathway. Conclusions: Gender-specific and integrated D-RSSs are feasible and beneficial from the perspective of participants. D-RSSs also appear to provide support to a range of recovery typologies and pathways in an effective manner and may be a vital tool for expanding recovery supports for those lacking in access and availability because of geography, social determinants, or other barriers.

  • Source: freepik; Copyright: freepik; URL:; License: Licensed by JMIR.

    Exploring Mediators of a Guided Web-Based Self-Help Intervention for People With HIV and Depressive Symptoms: Randomized Controlled Trial


  • Source: Jonathan Nash; Copyright: Jonathan Nash; URL:; License: Licensed by JMIR.

    Mindful Eating Mobile Health Apps: Review and Appraisal


    Background: Mindful eating is an emerging area of research for managing unhealthy eating and weight-related behaviors such as binge eating and emotional eating. Although there are numerous commercial mindful eating apps available, their quality, effectiveness, and whether they are accurately based on mindfulness-based eating awareness are unknown. Objective: This review aimed to appraise the quality of the mindful eating apps and to appraise the quality of content on mindful eating apps. Methods: A review of mindful eating apps available on Apple iTunes was undertaken from March to April 2018. Relevant apps meeting the inclusion criteria were subjectively appraised for general app quality using the Mobile App Rating Scale (MARS) guidelines and for the quality of content on mindful eating. A total of 22 apps met the inclusion criteria and were appraised. Results: Many of the reviewed apps were assessed as functional and had moderate scores in aesthetics based on the criteria in the MARS assessment. However, some received lower scores in the domains of information and engagement. The majority of the apps did not teach users how to eat mindfully using all five senses. Hence, they were scored as incomplete in accurately providing mindfulness-based eating awareness. Instead, most apps were either eating timers, hunger rating apps, or diaries. Areas of potential improvement were in comprehensiveness and diversity of media, in the quantity and quality of information, and in the inclusion of privacy and security policies. To truly teach mindful eating, the apps need to provide guided examples involving the five senses beyond simply timing eating or writing in a diary. They also need to include eating meditations to assist people with their disordered eating such as binge eating, fullness, satiety, and craving meditations that may help them with coping when experiencing difficulties. They should also have engaging and entertaining features delivered through diverse media to ensure sustained use and interest by consumers. Conclusions: Future mindful eating apps could be improved by accurate adherence to mindful eating. Further improvement could be achieved by ameliorating the domains of information, engagement, and aesthetics and having adequate privacy policies.

  • Source:; Copyright:; URL:; License: Licensed by JMIR.

    A Test of Feasibility and Acceptability of Online Mindfulness-Based Stress Reduction for Lesbian, Gay, and Bisexual Women and Men at Risk for High Stress:...


    Background: In conservative and rural areas, where antidiscrimination laws do not exist, lesbian, gay, and bisexual (LGB) people are at risk for excess stress arising from discrimination. Stress-reducing interventions delivered via innovative channels to overcome access barriers are needed. Objective: This study aimed to investigate the feasibility and acceptability of online mindfulness-based stress reduction (OMBSR) with LGB people in Appalachian Tennessee at high risk for stress. Methods: In 2 pilot studies involving pre-post test designs, participants completed 8 weeks of OMBSR, weekly activity logs, semistructured interviews, and surveys of perceived and minority stress. Results: Overall, 24 LGB people enrolled in the study and 17 completed OMBSR. In addition, 94% completed some form of mindfulness activities daily, including meditation. Participants enjoyed the program and found it easy to use. Perceived stress (Cohen, perceived stress scale-10) decreased by 23% in women (mean 22.73 vs mean 17.45; t10=3.12; P=.01) and by 40% in men (mean 19.83 vs mean 12.00; t5=3.90; P=.01) between baseline and postprogram. Women demonstrated a 12% reduction in overall minority stress (Balsam, Daily Experiences with Heterosexism Questionnaire) from baseline to 12-week follow-up (mean 1.87 vs mean 1.57; t10=4.12; P=.002). Subscale analyses indicated that women’s stress due to vigilance and vicarious trauma decreased by 21% and 20%, respectively. Conclusions: OMBSR may be a useful tool to help LGB people reduce general and minority-specific stress in socially conservative regions lacking antidiscrimination policies.

  • Source: Freepik; Copyright: jannoon028; URL:; License: Licensed by JMIR.

    Reimbursement of Apps for Mental Health: Findings From Interviews


    Background: Although apps and other digital and mobile health tools are helping improve the mental health of Americans, they are currently being reimbursed through a varied range of means, and most are not being reimbursed by payers at all. Objective: The aim of this study was to shed light on the state of app reimbursement. We documented ways in which apps can be reimbursed and surveyed stakeholders to understand current reimbursement practices. Methods: Individuals from over a dozen stakeholder organizations in the domains of digital behavioral and mental health, care delivery, and managed care were interviewed. A review of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCSPCS) codes was conducted to determine potential means for reimbursement. Results: Interviews and the review of codes revealed that potential channels for app reimbursement include direct payments by employers, providers, patients, and insurers. Insurers are additionally paying for apps using channels originally designed for devices, drugs, and laboratory tests, as well as via value-based payments and CPT and HCSPCS codes. In many cases, it is only possible to meet the requirements of a CPT or HCSPCS code if an app is used in conjunction with human time and services. Conclusions: Currently, many apps face significant barriers to reimbursement. CPT codes are not a viable means of providing compensation for the use of all apps, particularly those involving little physician work. In some cases, apps have sought clearance from the US Food and Drug Administration for prescription use as digital therapeutics, a reimbursement mechanism with as yet unproven sustainability. There is a need for simpler, more robust reimbursement mechanisms to cover stand-alone app-based treatments.

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

    A Smart Toy Intervention to Promote Emotion Regulation in Middle Childhood: Feasibility Study


    Background: A common challenge with existing psycho-social prevention interventions for children is the lack of effective, engaging, and scalable delivery mechanisms, especially beyond in-person therapeutic or school-based contexts. Although digital technology has the potential to address these issues, existing research on technology-enabled interventions for families remains limited. This paper focuses on emotion regulation (ER) as an example of a core protective factor that is commonly targeted by prevention interventions. Objective: The aim of this pilot study was to provide an initial validation of the logic model and feasibility of in situ deployment for a new technology-enabled intervention, designed to support children’s in-the-moment ER efforts. The novelty of the proposed approach relies on delivering the intervention through an interactive object (a smart toy) sent home with the child, without any prior training necessary for either the child or their carer. This study examined (1) engagement and acceptability of the toy in the homes during 1-week deployments, and (2) qualitative indicators of ER effects, as reported by parents and children. In total, 10 families (altogether 11 children aged 6-10 years) were recruited from 3 predominantly underprivileged communities in the United Kingdom, as low SES populations have been shown to be particularly at risk for less developed ER competencies. Children were given the prototype, a discovery book, and a simple digital camera to keep at home for 7 to 8 days. Data were gathered through a number of channels: (1) semistructured interviews with parents and children prior to and right after the deployment, (2) photos children took during the deployment, and (3) touch interactions automatically logged by the prototype throughout the deployment. Results: Across all families, parents and children reported that the smart toy was incorporated into the children’s ER practices and engaged with naturally in moments the children wanted to relax or calm down. Data suggested that the children interacted with the toy throughout the deployment, found the experience enjoyable, and all requested to keep the toy longer. Children’s emotional connection to the toy appears to have driven this strong engagement. Parents reported satisfaction with and acceptability of the toy. Conclusions: This is the first known study on the use of technology-enabled intervention delivery to support ER in situ. The strong engagement, incorporation into children’s ER practices, and qualitative indications of effects are promising. Further efficacy research is needed to extend these indicative data by examining the psychological efficacy of the proposed intervention. More broadly, our findings argue for the potential of a technology-enabled shift in how future prevention interventions are designed and delivered: empowering children and parents through child-led, situated interventions, where participants learn through actionable support directly within family life, as opposed to didactic in-person workshops and a subsequent skills application.

  • Source: Freepik; Copyright: freepik; URL:; License: Licensed by JMIR.

    Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study


    Background: Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care. Objective: The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns. Methods: Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years). Results: Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement. Conclusions: Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care.

  • Source: freepik; Copyright: freepik; URL:; License: Licensed by JMIR.

    Predicting Posttraumatic Stress Disorder Risk: A Machine Learning Approach


    Background: A majority of adults in the United States are exposed to a potentially traumatic event but only a handful go on to develop impairing mental health conditions such as posttraumatic stress disorder (PTSD). Objective: Identifying those at elevated risk shortly after trauma exposure is a clinical challenge. The aim of this study was to develop computational methods to more effectively identify at-risk patients and, thereby, support better early interventions. Methods: We proposed machine learning (ML) induction of models to automatically predict elevated PTSD symptoms in patients 1 month after a trauma, using self-reported symptoms from data collected via smartphones. Results: We show that an ensemble model accurately predicts elevated PTSD symptoms, with an area under the curve (AUC) of .85, using a bag of support vector machines, naive Bayes, logistic regression, and random forest algorithms. Furthermore, we show that only 7 self-reported items (features) are needed to obtain this AUC. Most importantly, we show that accurate predictions can be made 10 to 20 days posttrauma. Conclusions: These results suggest that simple smartphone-based patient surveys, coupled with automated analysis using ML-trained models, can identify those at risk for developing elevated PTSD symptoms and thus target them for early intervention.

  • Source: pixabay; Copyright: Pexels; URL:; License: Licensed by JMIR.

    Digital Games and Mindfulness Apps: Comparison of Effects on Post Work Recovery


    Background: Engagement in activities that promote the dissipation of work stress is essential for post work recovery and consequently for well-being. Previous research suggests that activities that are immersive, active, and engaging are especially effective at promoting recovery. Therefore, digital games may be able to promote recovery, but little is known about how they compare with other popular mobile activities, such as mindfulness apps that are specifically designed to support well-being. Objective: The aim of this study was to investigate and compare the effectiveness of a digital game and mindfulness app in promoting post work recovery, first in a laboratory setting and then in a field study. Methods: Study 1 was a laboratory experiment (n=45) in which participants’ need for recovery was induced by a work task, before undertaking 1 of 3 interventions: a digital game (Block! Hexa Puzzle), a mindfulness app (Headspace), or a nonmedia control with a fidget spinner (a physical toy). Recovery in the form of how energized participants felt (energetic arousal) was compared before and after the intervention and how recovered participants felt (recovery experience) was compared across the conditions. Study 2 was a field study with working professionals (n=20), for which participants either played the digital game or used the mindfulness app once they arrived home after work for a period of 5 working days. Measures of energetic arousal were taken before and after the intervention, and the recovery experience was measured after the intervention along with measures of enjoyment and job strain. Results: A 3×2 mixed analysis of variance identified that, in study 1, the digital game condition increased energetic arousal (indicative of improved recovery) whereas the other 2 conditions decreased energetic arousal (F2,42=3.76; P=.03). However, there were no differences between the conditions in recovery experience (F2,42=.01; P=.99). In study 2, multilevel model comparisons identified that neither the intervention nor day of the week had a significant main effect on how energized participants felt. However, for those in the digital game condition, daily recovery experience increased during the course of the study, whereas for those in the mindfulness condition, it decreased (F1,18=9.97; P=.01). Follow-up interviews with participants identified 3 core themes: detachment and restoration, fluctuations and differences, and routine and scheduling. Conclusions: This study suggests that digital games may be effective in promoting post work recovery in laboratory contexts (study 1) and in the real world, although the effect in this case may be cumulative rather than instant (study 2).

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  • Examining the Self-harm and Suicide Contagion Effects Related to the Portrayal of Blue Whale Challenge on YouTube and Twitter

    Date Submitted: Aug 22, 2019

    Open Peer Review Period: Aug 22, 2019 - Oct 17, 2019

    Background: Research suggests that direct exposure to suicidal behavior and acts of self-harm through social media may increase suicidality through imitation and modeling, with adolescents representin...

    Background: Research suggests that direct exposure to suicidal behavior and acts of self-harm through social media may increase suicidality through imitation and modeling, with adolescents representing a particularly vulnerable population. One example of viral self-harming behavior that could potentially be propagated through social media is the Blue Whale Challenge (BWC). Objective: We investigate how people portray BWC on social media and the potential harm this may pose to vulnerable populations. Methods: We first used a grounded approach coding 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced BWC. We deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) Messaging guidelines. Results: Overall, 83.33%, 28.33%, and 68.67% of the YouTube videos, comments, and Twitter posts were trying to raise awareness and discourage participation in BWC. Yet, about 37% of the videos violated six or more of the SPRC messaging guidelines. Conclusions: These posts might have the problematic effect of normalizing BWC through repeated exposure, modeling, and reinforcement of self-harming and suicidal behavior, especially among vulnerable adolescents. Greater efforts are needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects.

  • A Virtual Reality Video to Improve Information Provision and to Reduce Anxiety before a Cesarean Delivery: a Randomized Controlled Trial

    Date Submitted: Aug 14, 2019

    Open Peer Review Period: Aug 14, 2019 - Oct 9, 2019

    Background: Anxiety levels before cesarean delivery (CD) can lead to a negative birth experience, which may influence several aspects of the woman’s life in the long term. Improving preoperative inf...

    Background: Anxiety levels before cesarean delivery (CD) can lead to a negative birth experience, which may influence several aspects of the woman’s life in the long term. Improving preoperative information may lower preoperative anxiety and lead to a more positive birth experience and to greater patient satisfaction. Objective: To determine whether a virtual reality (VR) video in addition to standard preoperative information decreases anxiety levels before a planned CD. Methods: Women planned for term elective CD were included at the outpatient clinic. They were randomized and stratified based on history of emergency CD (yes/no). All participants received standard preoperative information (folder leaflets and counseling by the obstetrician), while the VR-group additionally watched the VR video showing all aspects of CD like the ward admission, operating theatre, spinal analgesia and moment of birth. Primary outcome measure was a change in score on the Visual Analogue Scale for Anxiety (VAS-A) measured at admittance for CD, compared to the baseline VAS-A score. Results: 97 women were included for analysis. Baseline characteristics were similar in both groups, except for a significant higher level of education in the control group. There was no significant decrease in VAS-A score in the VR-group (N = 49) compared to the control group (N = 48). Subgroup analysis for the group of women with a history of an emergency CD showed a trend towards decreased preoperative anxiety, despite the small sample size of this subgroup (N = 17, p = .06). Participants in the VR-group (85%) reported to feel more prepared after seeing the VR video, and 79% of their partners agreed. No discomfort or motion sickness was reported. Conclusions: A VR video may help patients and their partners to feel better prepared for a planned CD. This study showed that VR does not lead to a decrease in preoperative anxiety. However, subgroups may benefit, such as women with a history of emergency CD. Clinical Trial: MMC N17.017

  • Exploring Mental Health Professionals’ perspectives of Text-Based Online Counselling effectiveness with Young People: Mixed Methods Pilot Study

    Date Submitted: Jul 22, 2019

    Open Peer Review Period: Jul 23, 2019 - Sep 17, 2019

    Background: Population-based studies show that the risk of mental ill health is highest among young people aged 10-24 years, who are also the least likely to seek professional treatment due to a numbe...

    Background: Population-based studies show that the risk of mental ill health is highest among young people aged 10-24 years, who are also the least likely to seek professional treatment due to a number of barriers. Electronic-mental (e-mental) health services have been advocated as a method for decreasing these barriers for young people, among which, Text-Based Online Counselling (TBOC) is a primary intervention used at many youth-oriented services. Yet, while TBOC has shown promising results, its outcome variance is greater in comparison to other e-interventions and adult user groups. Objective: This pilot study aimed to explore and confirm e-Mental Health professional’s perspectives about various domains and themes related to Young Service Users’ (YSUs) motivations for accessing TBOC services; as well as factors related to higher and lower effectiveness on these modalities. Methods: Participants were nine e-Mental Health professionals that were interviewed in focus groups using a semi-structured interview. Thematic analysis of qualitative themes from interview transcripts were examined across the areas of: YSU motivations for access; and factors that increase and decrease TBOC effectiveness. Results: Four domains, and various sub/themes, were confirmed and identified to be related to YSUs’ characteristics, motivations for accessing TBOC, and moderators of service effectiveness: user characteristics (i.e., prior negative help-seeking experience, mental health syndrome, perceived low social support, perceived social difficulties); selection factors (i.e., safety, avoidance motivation, accessibility, expectation); and factors perceived to increase effectiveness (i.e. general therapeutic benefits, positive service-modality factors, persisting with counselling despite substantial benefit) and decrease effectiveness (i.e., negative service- modality factors). Conclusions: Participants perceived YSUs to have polarized expectations of TBOC effectiveness and be motivated by service accessibility and safety, in response to several help-seeking concerns. Factors increasing TBOC effectiveness were using text-based communication; the online counsellor’s interpersonal skills and use of self-management and crisis-support strategies; and working with less complex presenting problems or facilitating access to more intensive support. Factors decreasing TBOC effectiveness were working with more complex problems owing to challenges with assessment, the slow pace of text-communication, lack of non-verbal conversational cues, and environmental and connectivity issues. Other factors were using ineffective techniques (eg, poor goal-setting, focusing, postcounselling direction) that produced only short-term outcomes, poor timeliness in responding to service requests, rupture in rapport from managing service boundaries, and low YSU readiness and motivation.