JMIR Publications

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  Guest Editorial

  Jun 2, 2020

  Digital Mental Health: The Answer to the Global Mental Health Crisis?

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  Authors List:

  • Brittany N Rudd  
  • Rinad S Beidas  

  Abstract:

  Digital mental health interventions are often touted as the solution to the global mental health crisis. However, moving mental health care from the hands of professionals and into digital apps may further isolate individuals who need human connection the most. In this commentary, we argue that people, our society’s greatest resource, are as ubiquitous as technology. Thus, we argue that research focused on using technology to support all people in delivering mental health prevention and intervention deserves greater attention in the coming decade.

  • JMIR Ment Health 2020;7(6):e18472

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  Depression and Mood Disorders;...

  Jun 2, 2020

  Possible Application of Ecological Momentary Assessment to Older Adults’ Daily Depressive Mood: Integrative Literature Review

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  Authors List:

  • Heejung Kim  
  • Sunah Kim  
  • Seong Sook Kong  
  • Yi-Rang Jeong  
  • Hyein Kim  
  • Namhee Kim  

  Abstract:

  Background: Ecological momentary assessment is a method of investigating individuals’ real-time experiences, behaviors, and moods in their natural environment over time. Despite its general usability and clinical value for evaluating daily depressive mood, there are several methodological challenges when applying ecological momentary assessment to older adults. Objective: The aims of this integrative literature review were to examine possible uses of the ecological momentary assessment methodology with older adults and to suggest strategies to increase the feasibility of its application in geriatric depression research and practice. Methods: We searched 4 electronic databases (MEDLINE, CINAHL, PsycINFO, and EMBASE) and gray literature; we also hand searched the retrieved articles’ references. We limited all database searches to articles published in peer-reviewed journals from 2009 to 2019. Search terms were “ecological momentary assessment,” “smartphone assessment,” “real time assessment,” “electronic daily diary,” “mHealth momentary assessment,” “mobile-based app,” and “experience sampling method,” combined with the relevant terms of depression. We included any studies that enrolled older adults even as a subgroup and that reported depressive mood at least once a day for more than 2 days. Results: Of the 38 studies that met the inclusion criteria, only 1 study enrolled adults aged 65 years or older as the entire sample; the remainder of the reviewed studies used mixed samples of both younger and older adults. Most of the analyzed studies (18/38, 47%) were quantitative, exploratory (descriptive, correlational, and predictive), and cohort in design. Ecological momentary assessment was used to describe the fluctuating pattern of participants’ depressive moods primarily and to examine the correlation between mood patterns and other health outcomes as a concurrent symptom. We found 3 key methodological issues: (1) heterogeneity in study design and protocol, (2) issues with definitions of dropout and adherence, and (3) variation in how depressive symptoms were measured with ecological momentary assessment. Some studies (8/38, 21%) examined the age difference of participants with respect to dropout or poor compliance rate. Detailed participant burden was reported, such as technical problems, aging-related health problems, or discomfort while using the device. Conclusions: Ecological momentary assessment has been used for comprehensive assessment of multiple mental health indicators in relation to depressive mood. Our findings provide methodological considerations for further studies that may be implemented using ecological momentary assessment to assess daily depressive mood in older adults. Conducting more feasibility studies focusing on older adults with standardized data collection protocols and mixed-methods research is required to reflect users’ experiences. Further telepsychiatric evaluation and diagnosis based on ecological momentary assessment data should involve standardized and sophisticated strategies to maximize the potential of ecological momentary assessment for older adults with depression in the community setting.

  • JMIR Ment Health 2020;7(6):e13247

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  JMH Theme Issue 2020: COVID-19 and...

  Jun 1, 2020

  Flattening the Mental Health Curve: COVID-19 Stay-at-Home Orders Are Associated With Alterations in Mental Health Search Behavior in the United States

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  Authors List:

  • Nicholas C Jacobson  
  • Damien Lekkas  
  • George Price  
  • Michael V Heinz  
  • Minkeun Song  
  • A James O’Malley  
  • Paul J Barr  

  Abstract:

  Background: The coronavirus disease (COVID-19) has led to dramatic changes worldwide in people’s everyday lives. To combat the pandemic, many governments have implemented social distancing, quarantine, and stay-at-home orders. There is limited research on the impact of such extreme measures on mental health. Objective: The goal of this study was to examine whether stay-at-home orders produced differential changes in mental health symptoms using internet search queries on a national scale. Methods: In the United States, individual states vary in their adoption of measures to reduce the spread of COVID-19; as of March 23, 2020, 11 of the 50 states had issued stay-at-home orders. The staggered rollout of stay-at-home measures across the United States allows us to investigate whether these measures impact mental health by exploring variations in mental health search queries across the states. This paper examines the changes in mental health search queries on Google between March 16-23, 2020, across each state and Washington, DC. Specifically, this paper examines differential changes in mental health searches based on patterns of search activity following issuance of stay-at-home orders in these states compared to all other states. The participants were all the people who searched mental health terms in Google between March 16-23. Between March 16-23, 11 states underwent stay-at-home orders to prevent the transmission of COVID-19. Outcomes included search terms measuring anxiety, depression, obsessive-compulsive, negative thoughts, irritability, fatigue, anhedonia, concentration, insomnia, and suicidal ideation. Results: Analyzing over 10 million search queries using generalized additive mixed models, the results suggested that the implementation of stay-at-home orders are associated with a significant flattening of the curve for searches for suicidal ideation, anxiety, negative thoughts, and sleep disturbances, with the most prominent flattening associated with suicidal ideation and anxiety. Conclusions: These results suggest that, despite decreased social contact, mental health search queries increased rapidly prior to the issuance of stay-at-home orders, and these changes dissipated following the announcement and enactment of these orders. Although more research is needed to examine sustained effects, these results suggest mental health symptoms were associated with an immediate leveling off following the issuance of stay-at-home orders.

  • JMIR Ment Health 2020;7(6):e19347

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  Innovations in Mental Health Systems

  May 26, 2020

  Evaluation of Electronic Mental Health Implementation in Northern Territory Services Using the Integrated “Promoting Action on Research Implementation in...

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  • Buaphrao Raphiphatthana  
  • Michelle Sweet  
  • Stefanie Puszka  
  • Megan Whitty  
  • Kylie Dingwall  
  • Tricia Nagel  

  Abstract:

  Background: Electronic mental health is a promising strategy to bridge the treatment gap in mental health care. Training workshops have been delivered to service providers working with Aboriginal and Torres Strait Islander people at a primary health care level to raise awareness and knowledge of electronic mental health approaches. Objective: This study aimed to understand service providers’ perspectives and experiences of electronic mental health adoption. More specifically, it aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to further identify and understand how different factors facilitate or impede electronic mental health uptake within primary health care settings providing services to Aboriginal and Torres Strait Islander people. Methods: Qualitative interviews were conducted with 57 service providers working with Aboriginal and Torres Strait Islander people, who had undergone electronic mental health training workshops. Results: Several factors related to innovation (electronic mental health approach), recipients (service providers as an individual and as a team), and context (local, organizational, and external contexts) were found to influence electronic mental health uptake. Particularly, organizational readiness, in terms of information technology resources and infrastructure, policies, workforce and culture, and processes to mandate electronic mental health use, were found to be significant impediments to electronic mental health utilization. These findings led to the development of a three-phase implementation strategy that aims to enhance electronic mental health adoption by addressing organizational readiness before and post electronic mental health training. Conclusions: The i-PARIHS provides a useful determinant framework that deepens our understanding of how different factors impede or facilitate electronic mental health adoption in this setting. This insight was used to develop a practical and comprehensive implementation strategy to enhance the utilization of electronic mental health approaches within primary health care settings, involving three phases: pretraining consultations, training workshops, and post-training follow-up support.

  • JMIR Ment Health 2020;7(5):e14835

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  Depression and Mood Disorders;...

  May 25, 2020

  Augmenting Safety Planning With Text Messaging Support for Adolescents at Elevated Suicide Risk: Development and Acceptability Study

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  Authors List:

  • Ewa K Czyz  
  • Alejandra Arango  
  • Nathaniel Healy  
  • Cheryl A King  
  • Maureen Walton  

  Abstract:

  Background: Suicide is the second leading cause of death among adolescents. A critical need exists for developing promising interventions for adolescents after psychiatric hospitalization who are at a high risk of experiencing repeated suicidal behaviors and related crises. The high-risk period following psychiatric hospitalization calls for cost-effective and scalable continuity of care approaches to support adolescents’ transition from inpatient care. Text messages have been used to improve a wide range of behavioral and health outcomes and may hold promise as an accessible continuity of care strategy for youth at risk of suicide. Objective: In this study of 40 adolescents at elevated suicide risk, we report on the iterative development and acceptability of a text-based intervention designed to encourage adaptive coping and safety plan adherence in the high-risk period following psychiatric hospitalization. Methods: Adolescents (aged 13-17 years) who were hospitalized because of last-month suicide attempts or last-week suicidal ideation took part in either study phase 1 (n=25; 19/25, 76% female), wherein message content was developed and revised on the basis of feedback obtained during hospitalization, or study phase 2 (n=15; 11/15, 73% female), wherein text messages informed by phase 1 were further tested and refined based on feedback obtained daily over the course of a month after discharge (n=256 observations) and during an end-of-study phone interview. Results: Quantitative and qualitative feedback across the 2 study phases pointed to the acceptability of text-based support. Messages were seen as having the potential to be helpful with the transition after hospitalization, with adolescents indicating that texts may serve as reminders to use coping strategies, contribute to improvement in mood, and provide them with a sense of encouragement and hope. At the same time, some adolescents expressed concerns that messages may be insufficient for all teens or circumstances. In phase 2, the passage of time did not influence adolescents’ perception of messages in the month after discharge (P=.74); however, there were notable daily level associations between the perception of messages and adolescents’ affect. Specifically, higher within-person (relative to adolescents’ own average) anger was negatively related to liking text messages (P=.005), whereas within-person positive affect was associated with the perception of messages as more helpful (P=.04). Conclusions: Text-based support appears to be an acceptable continuity of care strategy to support adolescents’ transition after hospitalization. The implications of study findings are discussed. Future work is needed to evaluate the impact of text-based interventions on suicide-related outcomes.

  • JMIR Ment Health 2020;7(5):e17345

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  Letters to the editor (and replies...

  May 21, 2020

  Author’s Reply to: Comment on “Web-Based Measure of Life Events Using Computerized Life Events and Assessment Record (CLEAR): Preliminary Cross-Sectional...

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  • Antonia Bifulco  

  Abstract:

  • JMIR Ment Health 2020;7(5):e15434

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  Letters to the editor (and replies...

  May 21, 2020

  Comment on “Web-Based Measure of Life Events Using Computerized Life Events and Assessment Record (CLEAR): Preliminary Cross-Sectional Study of...

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  Authors List:

  • Jamal Rahmani  
  • Roya Karimi  
  • Farideh Mohtasham  
  • Siamak Sabour  

  Abstract:

  • JMIR Ment Health 2020;7(5):e14505

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  Diagnostic Tools in Mental Health

  May 20, 2020

  An Automated Mobile Mood Tracking Technology (Mood 24/7): Validation Study

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  Authors List:

  • Anupama Kumar  
  • Michael Wang  
  • Alison Riehm  
  • Eileen Yu  
  • Ted Smith  
  • Adam Kaplin  

  Abstract:

  Background: Electronic tracking has been utilized for a variety of health conditions. Previous studies have shown that there is higher adherence to electronic methods vs paper-and-pencil tracking modalities. Electronic tracking also ensures that there are no back-filled entries, where patients have—to appear compliant—entered their responses retrospectively just before their visits with their health care provider. On the basis of the recognition of an unmet need for a Web-based automated platform to track psychiatric outcomes, Johns Hopkins University partnered with Health Central (a subsidiary of Remedy Health Media LLC) to develop Mood 24/7, an electronic, mobile, automated, SMS-based mood tracker. This is a pilot study to validate the use of Mood 24/7 in anticipation of clinical trials to demonstrate the therapeutic benefit on patients’ health outcomes of utilizing digital mood-tracking technology. Objective: Mood 24/7 is an electronic mood-monitoring platform developed to accurately and efficiently track mood over time through automated daily SMS texts or emails. This study was designed to assess the accuracy and validity of Mood 24/7 in an outpatient psychiatric setting. Methods: This pilot study involved a retrospective chart review for depressed outpatients (N=9) to compare their self-reported Mood 24/7 daily mood ratings with their psychiatrist’s independent clinical mood assessment at the time of the patient’s visit. Their mood ratings via Mood 24/7 were collected over 36 weeks. In addition, a mixed model analysis was applied to compare the weekly Montgomery-Åsberg Depression Rating Scale (MADRS) scores with Mood 24/7 scores over an average of 3 months. Results: A 97.2% (315/324) digital mood reporting adherence was found over 36 weeks, and a significant correlation (r=0.86, P<.001) was observed between patients’ Mood 24/7 scores and their psychiatrist’s blinded clinical assessment of the patient’s mood when seen in the clinic. In addition, a significant concordance (intraclass correlation of 0.69, 95% CI 0.33-0.91, P<.001) was observed in the mixed model analysis of the clinician-administered MADRS vs Mood 24/7 scores over time. Conclusions: Our chart review and mixed model analyses demonstrate that Mood 24/7 is a valid instrument for convenient, simple, noninvasive, and accurate longitudinal mood assessment in the outpatient clinical setting.

  • JMIR Ment Health 2020;7(5):e16237

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  Innovations in Mental Health Systems

  May 15, 2020

  Mental Health Problems and Internet Access: Results From an Australian National Household Survey

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  Authors List:

  • Lay San Too  
  • Liana Leach  
  • Peter Butterworth  

  Abstract:

  Background: Mental health support and interventions are increasingly delivered on the web, and stepped care systems of mental health services are embracing the notion of a digital gateway through which individuals can have access to information, assessment, and services and can be connected with more intensive services if needed. Although concerns have been raised over whether people with mental health problems are disadvantaged in terms of their access to the internet, there is a lack of representative data on this topic. Objective: This study aimed to examine the relationship between mental health and internet access, particularly lack of access because of affordability issues. Methods: Data from wave 14 of the Household, Income, and Labour Dynamics in Australia survey were used (n=15,596) in the analyses. Sample weights available in the survey were used to calculate the proportion of those with or without internet access for those with and without mental health problems and more severe long-term mental health conditions. These proportions were also calculated for those with and without internet access due, specifically, to affordability issues. Multinomial logistic regression analyses assessed the relationship between mental health status and internet access/affordability issues, adjusting for a range of covariates. Results: Access to the internet was poorer for those with mental health problems (87.8%) than those without mental health problems (92.2%), and the difference was greater when a measure of more severe mental health conditions was used (81.3% vs 92.2%). The regression models showed that even after adjusting for a broad range of covariates, people with mental ill health were significantly more likely to have no internet access because of unaffordability than those without mental ill health (mental health problems: relative risk ratio [RRR] 1.68; 95% CI 1.11-2.53 and severe mental health conditions: RRR 1.92; 95% CI 1.16-3.19). Conclusions: As Australia and other nations increasingly deliver mental health services on the web, issues of equity and affordability need to be considered to ensure that those who most need support and assistance are not further disadvantaged.

  • JMIR Ment Health 2020;7(5):e14825

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  JMH Theme Issue 2020: COVID-19 and...

  May 12, 2020

  Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan,...

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  Authors List:

  • Michael Y Ni  
  • Lin Yang  
  • Candi M C Leung  
  • Na Li  
  • Xiaoxin I Yao  
  • Yishan Wang  
  • Gabriel M Leung  
  • Benjamin J Cowling  
  • Qiuyan Liao  

  Abstract:

  Background: The mental health consequences of the coronavirus disease (COVID-19) pandemic, community-wide interventions, and social media use during a pandemic are unclear. The first and most draconian interventions have been implemented in Wuhan, China, and these countermeasures have been increasingly deployed by countries around the world. Objective: The aim of this study was to examine risk factors, including the use of social media, for probable anxiety and depression in the community and among health professionals in the epicenter, Wuhan, China. Methods: We conducted an online survey via WeChat, the most widely used social media platform in China, which was administered to 1577 community-based adults and 214 health professionals in Wuhan. Probable anxiety and probable depression were assessed by the validated Generalized Anxiety Disorder-2 (cutoff ≥3) and Patient Health Questionnaire-2 (cutoff ≥3), respectively. A multivariable logistic regression analysis was used to examine factors associated with probable anxiety and probable depression. Results: Of the 1577 community-based adults, about one-fifth of respondents reported probable anxiety (n=376, 23.84%, 95% CI 21.8-26.0) and probable depression (n=303, 19.21%, 95% CI 17.3-21.2). Similarly, of the 214 health professionals, about one-fifth of surveyed health professionals reported probable anxiety (n=47, 22.0%, 95% CI 16.6-28.1) or probable depression (n=41, 19.2%, 95% CI 14.1-25.1). Around one-third of community-based adults and health professionals spent ≥2 hours daily on COVID-19 news via social media. Close contact with individuals with COVID-19 and spending ≥2 hours daily on COVID-19 news via social media were associated with probable anxiety and depression in community-based adults. Social support was associated with less probable anxiety and depression in both health professionals and community-based adults. Conclusions: The internet could be harnessed for telemedicine and restoring daily routines, yet caution is warranted toward spending excessive time searching for COVID-19 news on social media given the infodemic and emotional contagion through online social networks. Online platforms may be used to monitor the toll of the pandemic on mental health.

  • JMIR Ment Health 2020;7(5):e19009

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  Depression and Mood Disorders;...

  May 11, 2020

  Developing a Suicide Prevention Social Media Campaign With Young People (The #Chatsafe Project): Co-Design Approach

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  Authors List:

  • Pinar Thorn  
  • Nicole TM Hill  
  • Michelle Lamblin  
  • Zoe Teh  
  • Rikki Battersby-Coulter  
  • Simon Rice  
  • Sarah Bendall  
  • Kerry L Gibson  
  • Summer May Finlay  
  • Ryan Blandon  
  • Libby de Souza  
  • Ashlee West  
  • Anita Cooksey  
  • Joe Sciglitano  
  • Simon Goodrich  
  • Jo Robinson  

  Abstract:

  Background: Young people commonly use social media platforms to communicate about suicide. Although research indicates that this communication may be helpful, the potential for harm still exists. To facilitate safe communication about suicide on social media, we developed the #chatsafe guidelines, which we sought to implement via a national social media campaign in Australia. Population-wide suicide prevention campaigns have been shown to improve knowledge, awareness, and attitudes toward suicide. However, suicide prevention campaigns will be ineffective if they do not reach and resonate with their target audience. Co-designing suicide prevention campaigns with young people can increase the engagement and usefulness of these youth interventions. Objective: This study aimed to document key elements of the co-design process; to evaluate young people’s experiences of the co-design process; and to capture young people’s recommendations for the #chatsafe suicide prevention social media campaign. Methods: In total, 11 co-design workshops were conducted, with a total of 134 young people aged between 17 and 25 years. The workshops employed commonly used co-design strategies; however, modifications were made to create a safe and comfortable environment, given the population and complexity and sensitivity of the subject matter. Young people’s experiences of the workshops were evaluated through a short survey at the end of each workshop. Recommendations for the campaign strategy were captured through a thematic analysis of the postworkshop discussions with facilitators. Results: The majority of young people reported that the workshops were both safe (116/131, 88.5%) and enjoyable (126/131, 96.2%). They reported feeling better equipped to communicate safely about suicide on the web and feeling better able to identify and support others who may be at risk of suicide. Key recommendations for the campaign strategy were that young people wanted to see bite-sized sections of the guidelines come to life via shareable content such as short videos, animations, photographs, and images. They wanted to feel visible in campaign materials and wanted all materials to be fully inclusive and linked to resources and support services. Conclusions: This is the first study internationally to co-design a suicide prevention social media campaign in partnership with young people. The study demonstrates that it is feasible to safely engage young people in co-designing a suicide prevention intervention and that this process produces recommendations, which can usefully inform suicide prevention campaigns aimed at youth. The fact that young people felt better able to safely communicate about suicide on the web as a result of participation in the study augurs well for youth engagement with the national campaign, which was rolled out across Australia. If effective, the campaign has the potential to better prepare many young people to communicate safely about suicide on the web.

  • JMIR Ment Health 2020;7(5):e17520

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  Smoking Cessation

  May 8, 2020

  Combining Web-Based Attentional Bias Modification and Approach Bias Modification as a Self-Help Smoking Intervention for Adult Smokers Seeking Online Help:...

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  Authors List:

  • Si Wen  
  • Helle Larsen  
  • Marilisa Boffo  
  • Raoul P P P Grasman  
  • Thomas Pronk  
  • Joeri B G van Wijngaarden  
  • Reinout W Wiers  

  Abstract:

  Background: Automatically activated cognitive motivational processes such as the tendency to attend to or approach smoking-related stimuli (ie, attentional and approach bias) have been related to smoking behaviors. Therefore, these cognitive biases are thought to play a role in maintaining smoking behaviors. Cognitive biases can be modified with cognitive bias modification (CBM), which holds promise as an easy-access and low-cost online intervention. However, little is known about the effectiveness of online interventions combining two varieties of CBM. Targeting multiple cognitive biases may improve treatment outcomes because these biases have been shown to be relatively independent. Objective: This study aimed to test the individual and combined effects of two web-based CBM varieties—attentional bias modification (AtBM) and approach bias modification (ApBM)—in a double-blind randomized controlled trial (RCT) with a 2 (AtBM: active versus sham) × 2 (ApBM: active versus sham) factorial design. Methods: A total of 504 adult smokers seeking online help to quit smoking were randomly assigned to 1 of 4 experimental conditions to receive 11 fully automated CBM training sessions. To increase participants’ intrinsic motivation to change their smoking behaviors, all participants first received brief, automated, tailored feedback. The primary outcome was point prevalence abstinence during the study period. Secondary outcomes included daily cigarette use and attentional and approach bias. All outcomes were repeatedly self-assessed online from baseline to the 3-month follow-up. For the examination of training effects on outcome changes, an intention-to-treat analysis with a multilevel modeling (MLM) approach was adopted. Results: Only 10.7% (54/504) of the participants completed all 11 training sessions, and 8.3% (42/504) of the participants reached the 3-month follow-up assessment. MLM showed that over time, neither AtBM or ApBM nor a combination of both differed from their respective sham training in point prevalence abstinence rates (P=.17, P=.56, and P=.14, respectively), and in changes in daily cigarette use (P=.26, P=.08, and P=.13, respectively), attentional bias (P=.07, P=.81, and P=.15, respectively), and approach bias (P=.57, P=.22, and P=.40, respectively), while daily cigarette use decreased over time across conditions for all participants (P<.001). Conclusions: This RCT provides no support for the effectiveness of combining AtBM and ApBM in a self-help web-based smoking cessation intervention. However, this study had a very high dropout rate and a very low frequency of training usage, indicating an overall low acceptability of the intervention, which precludes any definite conclusion on its efficacy. We discuss how this study can inform future designs and settings of online CBM interventions. Trial Registration: Netherlands Trial Register NTR4678; https://www.trialregister.nl/trial/4678

  • JMIR Ment Health 2020;7(5):e16342

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