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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:

  • MindMax app. Source: AFL Players' Association; Copyright: AFL Players' Association; URL:; License: Licensed by JMIR.

    An App That Incorporates Gamification, Mini-Games, and Social Connection to Improve Men's Mental Health and Well-Being (MindMax): Participatory Design Process


    Background: Men have different mental health needs as compared with women, and women make up the primary audience of most digital mental health interventions. An Australian football-themed (specifically Australian Football League, AFL) app named MindMax incorporating psychoeducation, gamification, mini-games, and social connection was developed in an effort to address this issue. Objective: The aim of this study was to identify the best way to structure and present MindMax, an app that aims to deliver psychoeducational modules, and create a Web-based community centering on well-being, AFL, and video games for men aged 16 to 35 years who are interested in AFL or video games. Methods: We conducted 6 participatory design (PD) workshops with people aged 16 to 35 years in 3 cities in Australia, to identify the best way to present MindMax, and contracted a digital development agency to develop MindMax. We then iteratively tested MindMax prototypes with 15 user experience testing interviews across 3 separate time points: 2 before app launch and 1 after app launch. Results: A total of 40 individuals (25 male and 15 female) participated in the PD workshops, and a total of 15 individuals (10 male and 5 female) participated in user experience interviews. Broadly, participants expressed a preference for activities requiring active engagement that practiced useful skills. They were also sensitive to how content was presented and wanted the ability to customize their own app experience. Although participants agreed that social motivations were important for engagement with an app, they recommended not to mimic existing social networks. Conclusions: In basing itself strongly within the AFL subculture and by incorporating gamification as well as mini-games, MindMax aimed to tackle mental health help-seeking barriers for people who enjoy AFL or video games, with a particular emphasis on men, and to provide psychoeducation on strategies to increase mental health and well-being. If MindMax is successful, this would indicate that generalizing this approach to other traditional sporting codes and even competitive video gaming leagues (esports) would be fruitful.

  • Patient using a mental health app (montage). Source: Mokriya LLC / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Mental Health Mobile Phone App Usage, Concerns, and Benefits Among Psychiatric Outpatients: Comparative Survey Study


    Background: Despite the popularity of mental health apps, it is unknown if they are actually used by those with mental illness. This study assessed whether differences in clinic setting may influence the use of mental health apps and which factors influence patient perception of apps. Objective: The objective of this study was to gain an understanding of how individuals with mental illness use their mobile phones by exploring their access to mobile phones and their use of mental health apps. Methods: A single time point survey study was conducted over a 2-week period in February 2018 at two nearby outpatient psychiatry clinics: one serving largely mood and anxiety disorder patients with private insurance staffed by both faculty and residents and the other serving largely psychotic disorder patients in a state Department of Mental Health (DMH) setting. A total of 25 patients at the state DMH clinic also consented for a single time point observation of apps currently installed on their personal mobile phone. Results: A total of 113 patients at the private insurance clinic and 73 at the state DMH clinic completed the survey. Those in the private insurance clinic were more likely to download a mental health app compared to the state DMH clinic, but actual rates of reported current app usage were comparable at each clinic, approximately 10%. Verifying current apps on patients’ mobile phones at the state DMH clinic confirmed that approximately 10% had mental health apps installed. Patients at both clinics were most concerned about privacy of mental health apps, although those at the state DMH clinic viewed cost savings as the greatest benefit while those at the private clinic reported time as the greatest benefit. Conclusions: High interest in mental health apps does not automatically translate into high use. Our results of low but similar rates of mental health app use at diverse clinics suggests DMH patients with largely psychotic disorders are as interested and engaged with apps as those in a private insurance clinic treating largely mood and anxiety disorders. Results from our study also highlight the importance of understanding how actual patients are using apps instead of relying on internet-based samples, which often yield higher results due to their likelihood of being selected.

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

    The Mediating Role of Perceived Social Support Between Physical Activity Habit Strength and Depressive Symptoms in People Seeking to Decrease Their...


    Background: Regular physical activity treatment has been advocated for the prevention and rehabilitation of patients at risk of cardiovascular diseases and depressive symptoms. How physical activity is related to depressive symptoms is widely discussed. Objective: The aim of this internet-based study was to investigate the role of perceived social support in the relationship between physical activity habit strength and depressive symptoms. Methods: In total, 790 participants (mean 50.9 years, SD 12.2, range 20-84 years) who were interested in reducing their cardiovascular risk were recruited in Germany and the Netherlands. Data collection was conducted via an internet-based questionnaire addressing physical activity habit strength, depressive symptoms, and perceived social support. Cross-sectional data analysis was done with SPSS version 24 using the Macro PROCESS version 2 16.3 by Hayes with bootstrapping (10,000 samples), providing 95% CIs. Results: Physical activity habit strength was negatively related to depressive symptoms (r=–.13, P=.006), but this interrelation disappeared when controlling for perceived social support (beta=–.14, SE 0.09, P=.11). However, there was an indirect relationship between physical activity habit strength and depressive symptoms, which was mediated via perceived social support (beta=–.13; SE 0.04, 95% CI –0.21 to 0.06). The negative relationship between physical activity habit strength and depressive symptoms was fully mediated by perceived social support. Conclusions: We suggest that physical activity treatment in people interested in reducing their cardiovascular risk should also embed social support to target depressive symptoms. Internet-based interventions and electronic health may provide a good option for doing so. Trial Registration: NCT01909349; (Archived by WebCite at

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

    Identifying and Understanding Communities Using Twitter to Connect About Depression: Cross-Sectional Study


    Background: Depression is the leading cause of diseases globally and is often characterized by a lack of social connection. With the rise of social media, it is seen that Twitter users are seeking Web-based connections for depression. Objective: This study aimed to identify communities where Twitter users tweeted using the hashtag #MyDepressionLooksLike to connect about depression. Once identified, we wanted to understand which community characteristics correlated to Twitter users turning to a Web-based community to connect about depression. Methods: Tweets were collected using NCapture software from May 25 to June 1, 2016 during the Mental Health Month (n=104) in the northeastern United States and Washington DC. After mapping tweets, we used a Poisson multilevel regression model to predict tweets per community (county) offset by the population and adjusted for percent female, percent population aged 15-44 years, percent white, percent below poverty, and percent single-person households. We then compared predicted versus observed counts and calculated tweeting index values (TIVs) to represent undertweeting and overtweeting. Last, we examined trends in community characteristics by TIV using Pearson correlation. Results: We found significant associations between tweet counts and area-level proportions of females, single-person households, and population aged 15-44 years. TIVs were lower than expected (TIV 1) in eastern, seaboard areas of the study region. There were communities tweeting as expected in the western, inland areas (TIV 2). Counties tweeting more than expected were generally scattered throughout the study region with a small cluster at the base of Maine. When examining community characteristics and overtweeting and undertweeting by county, we observed a clear upward gradient in several types of nonprofits and TIV values. However, we also observed U-shaped relationships for many community factors, suggesting that the same characteristics were correlated with both overtweeting and undertweeting. Conclusions: Our findings suggest that Web-based communities, rather than replacing physical connection, may complement or serve as proxies for offline social communities, as seen through the consistent correlations between higher levels of tweeting and abundant nonprofits. Future research could expand the spatiotemporal scope to confirm these findings.

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

    Early Psychosis Service User Views on Digital Technology: Qualitative Analysis


    Background: Digital technology has the potential to improve outcomes for people with psychosis. However, to date, research has largely ignored service user views on digital health interventions (DHIs). Objective: The objective of our study was to explore early psychosis service users’ subjective views on DHIs. Methods: Framework analysis was undertaken with data obtained from 21 semistructured interviews with people registered with early intervention for psychosis services. Robust measures were used to develop a stable framework, including member checking, triangulation, independent verification of themes, and consensus meetings. Results: The following 4 themes were established a priori: acceptability of technology in psychosis and mental health; technology increasing access to and augmenting mental health support; barriers to adopting DHIs; and concerns about management of data protection, privacy, risk, and security of information. The following 2 themes were generated a posteriori: blending DHIs with face-to-face treatment and empowerment, control, and choice. DHIs were also viewed as potentially destigmatizing, overcoming barriers faced in traditional service settings, facilitating communication, and empowering service users to take active control of their health care. Conclusions: In the first study of its kind, early psychosis service users’ were largely positive about the potential use of DHIs supporting and managing mental health. Overall, service users felt that DHIs were a progressive, modern, and relevant platform for health care delivery. Concerns were expressed around privacy and data security and practical barriers inherent within DHIs, all of which require further attention. Future research should explore whether findings transfer to other service user groups, other technology delivery formats, and across a range of treatment modalities.

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

    Gamified Cognitive Bias Modification Interventions for Psychiatric Disorders: Review


    Background: Automatic biases, such as attentional biases and avoidance and interpretative biases, have been purported to be responsible for several psychiatric disorders. Gamification has been considered for cognitive bias modification, mainly to address the core issues of diminishing motivation to train over time, as bias modification intervention tasks tend to be highly repetitive. While a prior review has suggested how gamification strategies could be applied to such tasks, there remains a lack of systematic evaluation of gamified cognitive bias modification interventions in the literature. Objective: The objective of this review is to understand the overall effectiveness of a gamified approach for cognitive bias modification and inform future research that seeks to integrate gamification technologies into existing conventional bias modification interventions. Methods: To identify the relevant articles for our review, the following search terminologies were used: (“cognitive bias” OR “attention bias” OR “interpret* bias” OR “approach bias” OR “avoidance bias”) AND (“training” OR “modification” OR “practice” OR “therapy”) AND (“gamification” OR “game elements” OR “game” OR “gaming” OR “game mechanics”). PubMed, MEDLINE, PsycINFO, and Scopus databases were searched systematically for articles published after 2000. Articles were included if they described a gamified cognitive bias modification task and included participants with underlying psychopathological symptoms. Data were systematically extracted from the identified articles, and a qualitative synthesis was performed. Results: Four studies evaluated gamified cognitive bias modification interventions. Two studies included participants with anxiety symptoms, one with affective symptoms, and one with alcohol problems. The conventional visual probe task paradigm was used in 3 studies, and the attentional visual search task paradigm was used in the last study. We found gaming elements incorporated to include that of animations, sounds, feedback, and a point-scoring system for response time and difficulty. Of the 4 identified studies, only 2 reported their gamified interventions to be effective. Conclusions: Our review is the first to systematically synthesize the evidence for gamified cognitive bias modification interventions. The results arising from our review should be considered in the future design and conceptualization of gamified cognitive bias modification interventions. International Registered Report Identifier (IRRID): RR2-10.2196/10154

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

    The WorkingWell Mobile Phone App for Individuals With Serious Mental Illnesses: Proof-of-Concept, Mixed-Methods Feasibility Study


    Background: The disparities in employment for individuals with serious mental illnesses have been well documented, as have the benefits of work. Mobile technology can provide accessible in-the-moment support for these individuals. The WorkingWell mobile app was developed to meet the need for accessible follow-along supports for individuals with serious mental illnesses in the workplace. Objective: We explore the usability, usage, usefulness, and overall feasibility of the WorkingWell mobile app with individuals with serious mental illnesses who are actively employed and receiving community-based services. Methods: In this proof-of-concept, mixed-methods, 2-month feasibility study (N=40), employed individuals with serious mental illnesses were recruited in mental health agencies. Participants completed surveys regarding background characteristics and cellphone use at enrollment and responded to interview items regarding app usability, usage, and usefulness in technical assistance calls at 1, 2, 4, and 6 weeks of participation and in the exit interview at 8 weeks. Data on the frequency of app usage were downloaded on a daily basis. A version of the System Usability Scale (SUS) was administered in the exit interview. Overall feasibility was determined by the percent of users completing the study, responses to an interview item regarding continued use, and findings on usability, usage, and usefulness. General impressions were obtained from users regarding user support materials, technical assistance, and study procedures. Results: Most participants were male (60%, 24/40), aged 55 or younger (70%, 28/40), white (80%, 32/40), had less than a 4-year college education (78%, 31/40), were employed part-time (98%, 39/40), had been working more than 6 months (60%, 24/40), and indicated a diagnosis of bipolar, schizoaffective, or depressive disorder (84%, 16/25). The majority of participants owned cellphones (95%, 38/40) and used them multiple times per day (83%, 33/40). Their average rating on SUS usability items was 3.93 (SD 0.77, range 1.57-5.00), reflecting positive responses. In general, participants indicated WorkingWell was “very easy,” “straightforward,” “simple,” and “user friendly.” Usability challenges were related to personal issues (eg, memory) or to difficulties with the phone or app. Data on app usage varied considerably. The most frequent navigations were to the home screen, followed by Rate My Day and My Progress, and then by Manage the Moment and Remind Me. The app was described as useful by most participants; 86% (30/35) agreed the app would help them manage better on the job. Of the 40 original participants, 35 (87%) completed the study. Conclusions: The WorkingWell app is a feasible approach to providing accessible, as-needed employment support for individuals with serious mental illnesses. The app would benefit from modifications to address recommendations from feasibility testing. Controlled research with larger samples, more diverse in individual characteristics and workplace settings, is essential to demonstrating the effectiveness of the app.

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

    Patient's Perspective on Using Mobile Technology as an Aid to Psychotherapy

    Authors List:


    This piece draws from a patient’s perspective on his treatment using mobile health technology in conjunction with weekly group and individual psychotherapy. Research has demonstrated that using telepsychology as part of mental health treatment shows great promise to help advance the field of psychotherapy. Using mobile health technology such as mobile phone apps allows for collaboration with patients and their providers. This was written after several consultations with an individual diagnosed with borderline personality disorder who prefers to remain anonymous but was forthcoming with information regarding his use of mobile health technology in order to benefit the field of mental telepsychology.

  • A college student feeling overwhelmed during her studies. Source: Flickr; Copyright: UBC Learning Commons; URL:; License: Creative Commons Attribution (CC-BY).

    Text Mining Mental Health Reports for Issues Impacting Today’s College Students: Qualitative Study


    Background: A growing number of college students are experiencing personal circumstances or encountering situations that feel overwhelming and negatively affect their academic studies and other aspects of life on campus. To meet this growing demand for counseling services, US colleges and universities are offering a growing variety of mental health services that provide support and services to students in distress. Objective: In this study, we explore mental health issues impacting college students using a corpus of news articles, foundation reports, and media stories. Mental health concerns within this population have been on the rise. Uncovering the most salient themes articulated in current news and literature reports can better enable higher education institutions to provide health services to its students. Methods: We used SAS Text Miner to analyze 165 references that were published from 2010 to 2015 and focused on mental health among college students. Key clusters were identified to reveal the themes that were most significant to the topic. Results: The final cluster analysis yielded six themes in students’ mental health experiences in higher education (ie, age, race, crime, student services, aftermath, victim). Two themes, increasing demand for student services provided by campus counseling centers (113/165, 68.5%) and the increased mental health risks faced by racial and ethnic minorities (30/165, 18.2%), dominated the discourse. Conclusions: Higher education institutions are actively engaged in extending mental health services and offering targeted outreach to students of color. Cluster analysis identified that institutions are devoting more and innovative resources in response to the growing number students who experience mental health concerns. However, there is a need to focus on proactive approaches to mitigate the causes of mental health and the aftermath of a negative experience, particularly violence and sexual assault. Such strategies can potentially influence how students navigate their health information seeking and how information and communication technologies, including mobile apps, can partially address the needs of college students.

  • 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

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  • Online survey of treatment preferences for internet cognitive behavioral therapy for insomnia

    Date Submitted: Nov 4, 2018

    Open Peer Review Period: Nov 4, 2018 - Dec 30, 2018

    Background: The use of the internet has the potential to increase individuals' access to cognitive behavioral therapy (CBT) for insomnia at low cost. However, treatment preferences regarding internet-...

    Background: The use of the internet has the potential to increase individuals' access to cognitive behavioral therapy (CBT) for insomnia at low cost. However, treatment preferences regarding internet-based computerized CBT for insomnia have not been fully examined. Objective: We conducted an anonymous online survey to evaluate treatment preferences for insomnia among patients with insomnia and individuals without insomnia. Methods: We developed an online survey to recruit a total of 600 participants living in the Kanto district in Japan. There were three subgroups: 200 medicated individuals with insomnia, 200 un-medicated individuals with insomnia, and 200 individuals without insomnia. The survey asked questions about the severity of the respondent's insomnia (using the Athens Insomnia Scale), the frequency of sleep medication use and the level of satisfaction with sleep medication use, the respondent's knowledge of cognitive behavior therapy (CBT), his or her preference for CBT for insomnia before drug therapy, preference for CBT versus drug therapy, and preference for internet CBT versus face-to-face CBT. Results: Of the 600 respondents, 47.7% indicated that they received CBT before drug therapy, and 57.2% preferred CBT for insomnia to drug therapy. In addition, 47% preferred internet CBT for insomnia to face-to-face CBT. Although the respondents with insomnia who were taking an insomnia medication had a relatively lower preference for internet CBT (40.5%), the respondents with insomnia who were not taking an insomnia medication had a relatively higher preference for internet CBT (55.5%). Conclusions: The results of our online survey suggest that approximately half of the people queried preferred CBT for insomnia to drug therapy, and half of the respondents preferred internet CBT for insomnia to face-to-face CBT.

  • Long-Term Use of a Mindfulness & Meditation App Improves Baseline Mood

    Date Submitted: Oct 26, 2018

    Open Peer Review Period: Oct 30, 2018 - Dec 25, 2018

    Background: The use of mobile phone apps to monitor and deliver health-care guidance and interventions has received considerable recent attention, particularly with respect to behavioral disorders, st...

    Background: The use of mobile phone apps to monitor and deliver health-care guidance and interventions has received considerable recent attention, particularly with respect to behavioral disorders, stress relief, negative emotional state, and poor mood. Unfortunately, there is little experience with the long-term effects of apps meant to impact mood. Objective: We aim to determine the effects of immediate and long term use of a guided meditation and mindfulness application on user’s long term emotional state. We describe an analysis of data obtained from a mobile phone app developed by Stop, Breathe & Think, Inc. (SBT) for achieving emotional wellness. Methods: The SBT app collects information on the emotional state of the user prior to and after engagement in one or several mediation and mindfulness activities provided by the app. We considered data on over 120,000 users of the app who collectively engaged in over 5.5 million activities during an approximate two-year time period. We focused our analysis on users who had at least 10 uses of the app over an average 6 months. We compared the long-term emotional-wellbeing of individuals with different emotional states at the time of their initial use of the app using mixed effects models. We also compared two different methods of classifying emotional state 1) expert defined classification and 2) empirically driven clustering. Results: We found that the long-term use of the app has a positive effect on baseline emotional state (2% increase per 10x sessions). We also found that individuals who are anxious or depressed, tend to have a more favorable long-term emotional transition after using the app for an extended period (odds ratio 3.2 and 6.2). Conclusions: Our analyses suggest that there is great potential for the delivery of stress reduction and emotional wellness maintenance through mobile devices. We consider future analyses and further development of meditation and mindfulness-based stress reduction apps in light of our findings.

  • Relationship between sleep quality and mood in ecological momentary assessments

    Date Submitted: Oct 26, 2018

    Open Peer Review Period: Oct 26, 2018 - Dec 21, 2018

    Background: Sleep disturbances play an important role in everyday affect and vice versa. However, the causal day-to-day interaction between sleep and mood has not been thoroughly explored, partly due...

    Background: Sleep disturbances play an important role in everyday affect and vice versa. However, the causal day-to-day interaction between sleep and mood has not been thoroughly explored, partly due to lack of daily assessment data. Mobile phones enable us to collect ecological momentary assessment data on a daily basis in a non-invasive manner. Objective: We investigate the relationship between self-reported daily mood and sleep quality. Methods: 208 adult participants were recruited to report mood and sleep patterns daily via their mobile phones for 6 consecutive weeks. Participants were recruited in four roughly equal groups: depressed and anxious, depressed only, anxious only, and healthy controls. The effect of daily mood on sleep quality and vice versa were assessed using mixed effects models, and propensity score matching Results: All methods showed a significant effect of sleep quality on mood and vice versa. However, within individuals, the effect of sleep quality on next-day mood was much larger than the effect of previous-day mood on sleep quality. We did not find these effects to be confounded by the participants’ past mood and sleep quality, or other variables such as stress, physical activity, and weather conditions. Conclusions: We found that daily sleep quality and mood are related, with the effect of sleep quality on mood being significantly larger than the reverse. Correcting for participant fixed effects dramatically affected results. Causal analysis suggests that environmental factors included in the study, and sleep and mood history do not mediate the relationship.

  • 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.

  • 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.