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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.

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

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

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

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


Recent Articles:

  • Source: Shutterstock; Copyright: George Rudy; URL:; License: Licensed by the authors.

    Supported Internet-Delivered Cognitive Behavioral Therapy Programs for Depression, Anxiety, and Stress in University Students: Open, Non-Randomised Trial of...


    Background: Many university campuses have limited mental health services that cannot cope with the high demand. One alternative is to use internet-delivered cognitive behavioral therapy (iCBT) as a way of tackling barriers such as lack of availability and scheduling issues. Objective: This study aimed to assess feasibility, acceptability, effectiveness, and satisfaction of a supported iCBT intervention offering 3 programs on depression, anxiety, and stress to university students. The design was an open or nonrandomized feasibility trial. Methods: Participants were recruited from 3 counseling centers at a large midwestern University in the United States. Those agreeing to take part chose 1 of 3 iCBT programs—Space from Depression, Space from Anxiety, or Space from Stress —all comprised 8 modules of media-rich interactive content. Participants were supported throughout the trial by a trained professional. The Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) questionnaire, and stress subscale of the Depression Anxiety and Stress Scale (DASS-21) were completed at baseline, 8 weeks, and 3-month follow-up. A Satisfaction With Treatment (SAT) questionnaire was completed at 8 weeks, and qualitative interviews were completed by a subsample of participants at 3 months. Results: A total of 102 participants were recruited, with 52 choosing Space from Anxiety, 31 choosing Space from Depression, and 19 choosing Space from Stress. Mixed-effects models showed a significant decrease in symptoms of depression (F4=6.36, P<.001), anxiety (F4=7.97, P<.001), and stress (F4=8.50, P<.001) over time across all 3 programs. The largest decreases in PHQ-9 scores at 8 weeks were among participants who chose the Space from Depression program (d=0.84); at 3 months, the largest decreases in PHQ-9 scores were among those who chose the Space from Stress program (d=0.74). The largest decreases in GAD-7 scores were among those who chose the Space from Anxiety program (d=0.74 at 8 weeks and d=0.94 at 3 months). The largest decrease in DASS-21 stress subscale scores was among those who chose the Space from Stress program (d=0.49 at 8 weeks and d=1.16 at 3 months). The mean time spent using the platform per session was 27.4 min (SD 33.8), and participants completed 53% (SD 37.6) of the total program content on average. Most (37/53, 69%) participants found the programs helpful or very helpful and liked the convenience and flexibility of the intervention. Qualitative interviews (n=14) indicated the intervention met students’ expectations, and they saw it as a valuable complement to face-to-face treatment. Conclusions: The iCBT programs tested in our study appear to be feasible, acceptable, and effective in a university environment. Participants described the benefits of having a flexible, supported Web-based intervention available on campus. Larger trials should be conducted to further test the effectiveness of supported Web-based interventions that give students a choice of program depending on their symptom profile.

  • Source: The Authors / Pixabay; Copyright: The Authors; URL:; License: Public Domain (CC0).

    Psychiatrists' Attitudes Toward Disruptive New Technologies: Mixed-Methods Study


    Background: Recent discoveries in the fields of machine learning (ML), Ecological Momentary Assessment (EMA), computerized adaptive testing (CAT), digital phenotype, imaging, and biomarkers have brought about a new paradigm shift in medicine. Objective: The aim of this study was to explore psychiatrists’ perspectives on this paradigm through the prism of new clinical decision support systems (CDSSs). Our primary objective was to assess the acceptability of these new technologies. Our secondary objective was to characterize the factors affecting their acceptability. Methods: A sample of psychiatrists was recruited through a mailing list. Respondents completed a Web-based survey. A quantitative study with an original form of assessment involving the screenplay method was implemented involving 3 scenarios, each featuring 1 of the 3 support systems, namely, EMA and CAT, biosensors comprising a connected wristband-based digital phenotype, and an ML-based blood test or magnetic resonance imaging (MRI). We investigated 4 acceptability domains based on International Organization for Standardization and Nielsen models (usefulness, usability, reliability, and risk). Results: We recorded 515 observations. Regarding our primary objective, overall acceptability was moderate. MRI coupled with ML was considered to be the most useful system, and the connected wristband was considered the least. All the systems were described as risky (410/515, 79.6%). Regarding our secondary objective, acceptability was strongly influenced by socioepidemiological variables (professional culture), such as gender, age, and theoretical approach. Conclusions: This is the first study to assess psychiatrists’ views on new CDSSs. Data revealed moderate acceptability, but our analysis shows that this is more the result of the lack of knowledge about these new technologies rather than a strong rejection. Furthermore, we found strong correspondences between acceptability profiles and professional culture profiles. Many medical, forensics, and ethical issues were raised, including therapeutic relationship, data security, data storage, and privacy risk. It is essential for psychiatrists to receive training and become involved in the development of new technologies.

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

    Monitoring Online Discussions About Suicide Among Twitter Users With Schizophrenia: Exploratory Study


    Background: People with schizophrenia experience elevated risk of suicide. Mental health symptoms, including depression and anxiety, contribute to increased risk of suicide. Digital technology could support efforts to detect suicide risk and inform suicide prevention efforts. Objective: This exploratory study examined the feasibility of monitoring online discussions about suicide among Twitter users who self-identify as having schizophrenia. Methods: Posts containing the terms suicide or suicidal were collected from a sample of Twitter users who self-identify as having schizophrenia (N=203) and a random sample of control users (N=173) over a 200-day period. Frequency and timing of posts about suicide were compared between groups. The associations between posting about suicide and common mental health symptoms were examined. Results: Twitter users who self-identify as having schizophrenia posted more tweets about suicide (mean 7.10, SD 15.98) compared to control users (mean 1.89, SD 4.79; t374=-4.13, P<.001). Twitter users who self-identify as having schizophrenia showed greater odds of tweeting about suicide compared to control users (odds ratio 2.15, 95% CI 1.42-3.28). Among all users, tweets about suicide were associated with tweets about depression (r=0.62, P<.001) and anxiety (r=0.45, P<.001). Conclusions: Twitter users who self-identify as having schizophrenia appear to commonly discuss suicide on social media, which is associated with greater discussion about other mental health symptoms. These findings should be interpreted cautiously, as it is not possible to determine whether online discussions about suicide correlate with suicide risk. However, these patterns of online discussion may be indicative of elevated risk of suicide observed in this patient group. There may be opportunities to leverage social media for supporting suicide prevention among individuals with schizophrenia.

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

    Website Analytics of a Google Ads Campaign for a Men’s Mental Health Website: Comparative Analysis


    Background: Men with mental health and addictions problems seek information and help from health service providers and community support less often than women with such problems. Online health resources offer men rapid access to self-care recommendations and resources and anonymity; however, only a few websites are specifically developed for men. Headstrong - Taking Things Head-On was a community pharmacy and online health promotion initiative for men living with mental health and addictions problems. The Headstrong website was developed to offer a curated collection of print and online recommended resources (primarily self-help oriented) for depression, anxiety, insomnia, tobacco and alcohol use problems, and suicide. To increase awareness of the initiative and use of the website’s content and resource recommendations, a Google Ads campaign was developed. Objective: This study aimed to compare user acquisition and behavior on the Headstrong website during and after a Google Ads campaign. Methods: The Google Ads campaign was launched on December 21, 2017, and run until February 28, 2018. Website analytics (acquisition of new users, behavior in terms of at-website actions and duration, devices used, and conversions [link-outs to recommended resources]) in a 30-day period during the campaign (January 26, 2018 to February 24, 2018) were compared to a similar 30-day period after the campaign (March 23, 2018 to April 21, 2018). A cost analysis of the ad campaign was also performed. Results: The ad campaign generated 3011 clicks and 4.5 million impressions in total. In addition, the campaign received 1311 website users during the 30-day period of the ad campaign as compared to 241 users during the 30-day period after the ad campaign (P<.001). Return visitor (17.7% vs 27.8%) and nonbounce (19.5% vs 39.8%) user rates as well as session duration (42 vs 102 seconds) and page views per session (1.4 vs 2.1) were lower during the ad campaign than after the campaign (P<.01 for all). The 30-day period of the ad campaign included 9 sessions with conversions initiated by an ad click. Paid and display ads accounted for 63% of the site traffic during the ad campaign, most of which came from mobile phone users. Desktops were the most-common device used after the ad campaign acquired the website via direct and organic searches primarily (92%). The estimated cost per session with one or more conversions was Can $54.69 and cost per conversion was Can $32.81. Conclusions: A Google Ads campaign designed to direct men to the Headstrong website increased the number of user visits by more than five-fold. However, engagement by users responding to the ad campaign was substantially lower than that by users who visited the website via other acquisition methods, possibly reflecting the nonspecific online targeting of men by the ad campaign. General targeting of men online to promote men’s mental health appears to have limited value.

  • An integrative psychological AI, Tess (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Using Psychological Artificial Intelligence (Tess) to Relieve Symptoms of Depression and Anxiety: Randomized Controlled Trial


    Background: Students in need of mental health care face many barriers including cost, location, availability, and stigma. Studies show that computer-assisted therapy and 1 conversational chatbot delivering cognitive behavioral therapy (CBT) offer a less-intensive and more cost-effective alternative for treating depression and anxiety. Although CBT is one of the most effective treatment methods, applying an integrative approach has been linked to equally effective posttreatment improvement. Integrative psychological artificial intelligence (AI) offers a scalable solution as the demand for affordable, convenient, lasting, and secure support grows. Objective: This study aimed to assess the feasibility and efficacy of using an integrative psychological AI, Tess, to reduce self-identified symptoms of depression and anxiety in college students. Methods: In this randomized controlled trial, 75 participants were recruited from 15 universities across the United States. All participants completed Web-based surveys, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Positive and Negative Affect Scale (PANAS) at baseline and 2 to 4 weeks later (T2). The 2 test groups consisted of 50 participants in total and were randomized to receive unlimited access to Tess for either 2 weeks (n=24) or 4 weeks (n=26). The information-only control group participants (n=24) received an electronic link to the National Institute of Mental Health’s (NIMH) eBook on depression among college students and were only granted access to Tess after completion of the study. Results: A sample of 74 participants completed this study with 0% attrition from the test group and less than 1% attrition from the control group (1/24). The average age of participants was 22.9 years, with 70% of participants being female (52/74), mostly Asian (37/74, 51%), and white (32/74, 41%). Group 1 received unlimited access to Tess, with daily check-ins for 2 weeks. Group 2 received unlimited access to Tess with biweekly check-ins for 4 weeks. The information-only control group was provided with an electronic link to the NIMH’s eBook. Multivariate analysis of covariance was conducted. We used an alpha level of .05 for all statistical tests. Results revealed a statistically significant difference between the control group and group 1, such that group 1 reported a significant reduction in symptoms of depression as measured by the PHQ-9 (P=.03), whereas those in the control group did not. A statistically significant difference was found between the control group and both test groups 1 and 2 for symptoms of anxiety as measured by the GAD-7. Group 1 (P=.045) and group 2 (P=.02) reported a significant reduction in symptoms of anxiety, whereas the control group did not. A statistically significant difference was found on the PANAS between the control group and group 1 (P=.03) and suggests that Tess did impact scores. Conclusions: This study offers evidence that AI can serve as a cost-effective and accessible therapeutic agent. Although not designed to appropriate the role of a trained therapist, integrative psychological AI emerges as a feasible option for delivering support. Trial Registration: International Standard Randomized Controlled Trial Number: ISRCTN61214172;

  • A neurofeedback training game (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Effects of a Theta/Sensorimotor Rhythm Neurofeedback Training Protocol on Measures of Impulsivity, Drug Craving, and Substance Abuse in Forensic Psychiatric...


    Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination of psychiatric disorders and SUD increases the risk of future violence. Chronic substance abuse can lead to a structural state of disinhibition, resulting in more drug taking and eventually loss of control over drug intake. When treating SUD, it is crucial to address high levels of impulsivity and lack of inhibitory control. Objective: This study set out to investigate the effects of a theta/sensorimotor rhythm (SMR) neurofeedback training protocol on levels of impulsivity, levels of drug craving, and actual drug intake in a population of forensic psychiatric patients with a diagnosis of SUD. Methods: A total of 21 participants received 20 sessions of theta/SMR neurofeedback training in combination with treatment-as-usual (TAU). Results of the intervention were compared with results from 21 participants who received TAU only. Results: SMR magnitude showed a significant (P=.02) increase post training for patients in the neurofeedback training group, whereas theta magnitude did not change (P=.71). Levels of drug craving as well as scores on the motor subscale of the Barratt Impulsivity Scale-11 decreased equally for patients in the neurofeedback training group and the TAU group. Other measures of impulsivity as well as drug intake did not change posttreatment (P>.05). Therefore, neurofeedback+TAU was not more effective than TAU only. Conclusions: This study demonstrated evidence that forensic psychiatric patients are able to increase SMR magnitude over the course of neurofeedback training. However, at the group level, the increase in SMR activity was not related to any of the included impulsivity or drug craving measures. Further research should focus on which patients will be able to benefit from neurofeedback training at an early stage of the employed training sessions. Trial Registration: Dutch National Trial Register: NTR5386; (Archived by WebCite at

  • Family using video chat. Source: Flickr; Copyright: anabananasplit; URL:; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    Video-Delivered Family Therapy for Home Visited Young Mothers With Perinatal Depressive Symptoms: Quasi-Experimental Implementation-Effectiveness Hybrid Trial


    Background: The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas. Objective: This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation. Methods: A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act–compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes. Results: No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms (P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004). Conclusions: This pilot study yielded preliminary findings that support the feasibility, acceptability, and effectiveness of the video-delivered family therapy intervention for underserved home visited families in rural areas. Our findings are very promising, but more research is needed to ultimately influence mental health practices and policies that pertain to video-delivered mental health interventions in unsupervised settings (eg, homes).

  • A mental health technician providing telephone support to a patient. Source: Public Affairs Department, Centre for Addiction and Mental Health; Copyright: Centre for Addiction and Mental Health; URL:; License: Licensed by JMIR.

    Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions: Randomized Controlled Trial


    Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone. Objective: This analysis assesses patient’s acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. Methods: The Primary care Assessment and Research of a Telephone intervention for Neuropsychiatric conditions with Education and Resources study is a randomized controlled trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for the treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion. Results: During the consent process, 17.1% (114/667) patients referred to the study declined to participate and 57.0% of them (65/114) attributed their refusal to research-related factors (ie, randomization and time commitment); a further 16.7% (19/114) declined owing to the telephone delivery of the intervention. Among the 377 participants who were randomized to the 1-year intervention, the overall retention rate was 82.8% (312/377). Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97% (38/39) of comments related to the telephone components were positive with key reported positive attributes being accessibility, convenience, and privacy. Conclusions: Our results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy. Trial Registration: NCT02345122; (Archived by WebCite at

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

    Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A...


    Background: Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for Web-based dissemination to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical conditions. Objective: This study aimed to examine the impact of a 12-week Web-based PAJ intervention on psychological distress and quality of life in general medical patients. Methods: A total of 70 adults with various medical conditions and elevated anxiety symptoms were recruited from local clinics and randomly assigned to a Web-based PAJ intervention (n=35) or usual care (n=35). The intervention group completed 15-min Web-based PAJ sessions on 3 days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed. Results: Patients evidenced moderate sustained adherence to Web-based intervention. PAJ was associated with decreased mental distress and increased well-being relative to baseline. PAJ was also associated with less depressive symptoms and anxiety after 1 month and greater resilience after the first and second month, relative to usual care. Conclusions: Web-based PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical care to improve quality of life. Trial Registration: NCT01873599; (Archived by WebCite at

  • REACT Web-based intervention (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Web-Based Intervention for Relatives of People Experiencing Psychosis or Bipolar Disorder: Design Study Using a User-Centered Approach


    Background: Relatives of people experiencing bipolar mood episodes or psychosis face a multitude of challenges (eg, social isolation, limited coping strategies, and issues with maintaining relationships). Despite this, there is limited informational and emotional support for people who find themselves in supporting or caring roles. Digital technologies provide us with an opportunity to offer accessible tools, which can be used flexibly to provide evidence-based information and support, allowing relatives to build their understanding of mental health problems and learn from others who have similar experiences. However, to design tools that are useful to relatives, we first need to understand their needs. Objective: The aim of this study was to use a user-centered design approach to develop an accessible Web-based intervention, based on the Relatives Education And Coping Toolkit (REACT) booklet, to support the informational and emotional needs of relatives of people experiencing psychosis or bipolar disorder. Methods: We engaged relatives of people with experiences of bipolar disorder or psychosis in workshops to identify their needs and design requirements for developing a Web-based version of a paper-based toolkit. We used a 2-phase qualitative approach to explore relatives’ views on content, design, and functionalities, which are considered to be engaging and useful in a Web-based intervention. In phase 1, we consulted 24 relatives in 2 workshops to better understand their existing support infrastructure, their barriers for accessing support, unmet needs, and relatives’ views on online support. On the basis of the results of these workshops, we developed a set of design considerations to be explored in a smaller workshop. Workshop 3 then involved working with 2 digitally literate relatives to design a usable and acceptable interface for our Web-based toolkit. Finally, in phase 2, we conducted a heuristic evaluation to assess the usability of the toolkit. Results: Our findings indicated that relatives require technologies that (1) they can place their trust in, particularly when discussing a highly sensitive topic, (2) enable learning from the lived experiences of others while retaining confidentiality, and (3) they can work through at their own pace in a personalized manner. Conclusions: Our study highlights the need for providing a trustworthy, supportive tool where relatives can engage with people who have similar experiences to their own. Our heuristic evaluation showed promise in terms of perceived usability of the REACT Web-based intervention. Through this work, we emphasize the need to involve stakeholders with various characteristics, including users with limited computer literacy or experience in online support.

  • A woman using the computer tool for integrated care eHealth-Interop Admin. Source: The Authors / Flickr; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An eHealth Platform for the Support of a Brazilian Regional Network of Mental Health Care (eHealth-Interop): Development of an Interoperability Platform for...


    Background: The electronic exchange of health-related data can support different professionals and services to act in a more coordinated and transparent manner and make the management of health service networks more efficient. Although mental health care is one of the areas that can benefit from a secure health information exchange (HIE), as it usually involves long-term and multiprofessional care, there are few published studies on this topic, particularly in low- and middle-income countries. Objective: The aim of this study was to design, implement, and evaluate an electronic health (eHealth) platform that allows the technical and informational support of a Brazilian regional network of mental health care. This solution was to enable HIE, improve data quality, and identify and monitor patients over time and in different services. Methods: The proposed platform is based on client-server architecture to be deployed on the Web following a Web services communication model. The interoperability information model was based on international and Brazilian health standards. To test platform usage, we have utilized the case of the mental health care network of the XIII Regional Health Department of the São Paulo state, Brazil. Data were extracted from 5 different sources, involving 26 municipalities, and included national demographic data, data from primary health care, data from requests for psychiatric hospitalizations performed by community services, and data obtained from 2 psychiatric hospitals about hospitalizations. Data quality metrics such as accuracy and completeness were evaluated to test the proposed solution. Results: The eHealth-Interop integration platform was designed, developed, and tested. It contains a built-in terminology server and a record linkage module to support patients’ identification and deduplication. The proposed interoperability environment was able to integrate information in the mental health care network case with the support of 5 international and national terminologies. In total, 27,353 records containing demographic and clinical data were integrated into eHealth-Interop. Of these records, 34.91% (9548/27,353) were identified as patients who were present in more than 1 data source with different levels of accuracy and completeness. The data quality analysis was performed on 26 demographic attributes for each integrable patient record, totaling 248,248 comparisons. In general, it was possible to achieve an improvement of 18.40% (45,678/248,248) in completeness and 1.10% (2731/248,248) in syntactic accuracy over the test dataset after integration and deduplication. Conclusions: The proposed platform established an eHealth solution to fill the gap in the availability and quality of information within a network of health services to improve the continuity of care and the health services management. It has been successfully applied in the context of mental health care and is flexible to be tested in other areas of care.

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

    How Inclusive, User-Centered Design Research Can Improve Psychological Therapies for Psychosis: Development of SlowMo


    Background: Real-world implementation of psychological interventions for psychosis is poor. Barriers include therapy being insufficiently usable and useful for a diverse range of people. User-centered, inclusive design approaches could improve the usability of therapy, which may increase uptake, adherence, and effectiveness. Objective: This study aimed to optimize the usability of an existing psychological intervention, Thinking Well, which targets reasoning processes in paranoia using a basic digital interface. Methods: We conducted inclusive, user-centered design research characterized by purposive sampling of extreme users from the margins of groups, ethnographic investigation of the problem context, and iterative prototyping of solutions. The UK Design Council’s double diamond method was used. This consisted of 4 phases: discover, including a case series of Thinking Well, stakeholder interviews, desk research, user profiling, system mapping, and a mood board; define, consisting of workshops to synthesize findings and generate the design brief; develop, involving concept workshops and prototype testing; and deliver, in which the final minimal viable product was storyboarded and iteratively coded. Results: Consistent with our previous work, the Thinking Well case series showed medium to large effects on paranoia and well-being and small effects on reasoning. These were maintained at follow-up despite some participants reporting difficulties with the therapy interface. Insights from the discover phase confirmed that usability was challenged by information complexity and poor accessibility. Participants were generally positive about the potential of technology to be enjoyable, help manage paranoia, and provide tailored interpersonal support from therapists and peers, although they reported privacy and security concerns. The define phase highlighted that the therapy redesign should support monitoring, simplify information processing, enhance enjoyment and trust, promote personalization and normalization, and offer flexible interpersonal support. During the develop phase over 60 concepts were created, with 2 key concepts of thoughts visualized as bubbles and therapy as a journey selected for storyboarding. The output of the deliver phase was a minimal viable product of an innovative digital therapy, SlowMo. SlowMo works by helping people to notice their worries and fast thinking habits, and encourages them to slow down for a moment to find ways of feeling safer. A Web app supports the delivery of 8 face-to-face sessions, which are synchronized to a native mobile app. Conclusions: SlowMo makes use of personalization, ambient information, and visual metaphors to tailor the appeal, engagement, and memorability of therapy to a diversity of needs. Feasibility testing has been promising, and the efficacy of SlowMo therapy is now being tested in a multicentered randomized controlled trial. The study demonstrates that developments in psychological theory and techniques can be enhanced by improving the usability of the therapy interface to optimize its impact in daily life.

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  • Modeling Smart Wristband Sleep Data to Classify Undergraduates’ Sleep Deprived Tweets

    Date Submitted: Dec 10, 2018

    Open Peer Review Period: Dec 13, 2018 - Feb 7, 2019

    Background: Social media data can be explored as a tool to detect sleep deprivation. First-year undergraduate students in their first quarter were invited to wear sleep tracking devices (Basis/Intel),...

    Background: Social media data can be explored as a tool to detect sleep deprivation. First-year undergraduate students in their first quarter were invited to wear sleep tracking devices (Basis/Intel), allow us to follow them on Twitter, and complete weekly surveys regarding their sleep. Objective: To determine whether social media data can be used to monitor sleep deprivation. Methods: The device sleep data were used to label the tweets as sleep deprived or not at the time of Twitter post. These labeled data were used to train and test a Gated Recurrent Unit (GRU) neural network as to whether the participants were sleep deprived at the time of the post or not. Results: Results from a GRU neural network suggest it is possible to classify the sleep deprivation status of a tweet’s author with an average area under the curve (AUC) of 0.68. Conclusions: It is feasible to use social media data to identify students’ sleep deprivation. Results add to the body of research suggesting that social media data should be further explored for a potential source for monitoring mental and behavioral health. Clinical Trial: N/A

  • Seasonality Patterns of Internet Searches on Mental Health in Ontario

    Date Submitted: Nov 28, 2018

    Open Peer Review Period: Nov 30, 2018 - Jan 25, 2019

    Background: The study of seasonal patterns of public interest in psychiatric disorders has important theoretical and practical implications for service planning and delivery. The recent explosion of I...

    Background: The study of seasonal patterns of public interest in psychiatric disorders has important theoretical and practical implications for service planning and delivery. The recent explosion of Internet searches suggests that mining search databases yields unique information on public interest in mental health disorders—a significantly more affordable approach compared to population health studies. Objective: The present study aims to investigate seasonal patterns of Internet mental health queries in Ontario. Methods: Weekly data on health queries in Ontario from Google Trends were downloaded for a five-year period (2012-2017) for the terms “schizophrenia,” “autism,” “bipolar,” “depression,” “anxiety,” “OCD,” and “suicide.” Control terms were overall search results for the term “health” and the term “how.” Time series analyses using a continuous wavelet transform were performed to isolate seasonal components in the search volume for each term. Results: All mental health queries showed significant seasonal patterns with peak periodicity occurring over the winter months and troughs occurring during summer, except for “suicide.” The comparison term “health” also exhibited seasonal periodicity while the term “how” did not, indicating that general information seeking may not follow a seasonal trend in the way that mental health information seeking does. Conclusions: Seasonal patterns of Internet search volume in a wide range of mental health terms was observed, with the exception of “suicide.” Our study demonstrates that monitoring Internet search trends is an affordable, instantaneous and naturalistic method to sample public interest in large populations and inform health policy planners.

  • Information dissemination preferences on treatment in bipolar disorder; a patient-centered mixed methods study

    Date Submitted: Nov 18, 2018

    Open Peer Review Period: Nov 26, 2018 - Jan 21, 2019

    Background: Patient education has taken center stage in successfully shared decision-making between patients and health care providers; however, very little is known about how patients typically obtai...

    Background: Patient education has taken center stage in successfully shared decision-making between patients and health care providers; however, very little is known about how patients typically obtain information on their illness, especially as it relates to the treatment of bipolar disorder and what methods of information sharing are preferred. Objective: To obtain patients’ perspectives on the most effective information channels through which they educate themselves about the treatment of bipolar disorder. Methods: We conducted three focus groups in Montana, New Mexico, and California in which we enrolled 36 individuals with bipolar disorder and family members of patients with bipolar disorder. A mixed methods approach was utilized to analyze data collected through semi-structured questionnaires based on grounded theory and summative content analysis. Results: Participants preferred to receive information through a broad range of channels, with health care professionals, peers, and patient advocacy groups leading the list. The preferences of the participants mostly reflected information sources successfully used by them in the past, but problems with traditional approaches were also pointed out. Internet-based resources surpassed doctors as a successfully used source of information, while failed communication between patient and doctor was perceived as a leading barrier to successful outcomes. Regional differences in resources and culture strongly influenced the utilization of information channels. Most participants emphasized the importance of non-traditional ways of providing information on disease and disease management to support informed health care decision-making. Conclusions: Patients use a variety of channels to educate themselves about their disease. While regional and social differences in resource use were apparent, failed doctor-patient communication was universally perceived as a barrier to successful treatment outcomes. It should be further explored how improving patient education and patient-doctor communication might increase patient engagement and could lead to better outcomes in care. Clinical Trial: identifier: NCT02893371

  • High-frequency cognitive and mood assessment in major depressive disorder with wearable technology

    Date Submitted: Nov 20, 2018

    Open Peer Review Period: Nov 22, 2018 - Jan 17, 2019

    Background: Cognitive symptoms are common in major depressive disorder, and may help to identify patients that need treatment or who are not experiencing adequate treatment response. Digital tools to...

    Background: Cognitive symptoms are common in major depressive disorder, and may help to identify patients that need treatment or who are not experiencing adequate treatment response. Digital tools to provide real time data assessing cognitive function could help to support patients treatment and remediation of cognitive and mood symptoms. Objective: This study examined adherence, feasibility, and validity of a wearable high-frequency cognitive and mood assessment app over 6 weeks, corresponding to when antidepressant pharmacotherapy begins to show efficacy. Methods: Thirty patients (aged 19−63; 19 women) with mild-moderate depression participated. The new Cognition Kit application was delivered via the Apple Watch, providing a high-resolution touch screen display for task presentation and logging responses. Cognition was assessed by the n-back task up to 3 times daily and depressed mood by 3 short questions once daily. Selected tests sensitive to depression from the Cambridge Neuropsychological Test Automated Battery and validated questionnaires of depression symptom severity were administered on 4 occasions (baseline, weeks 1, 3, and 6). Adherence was defined as participants completing at least one assessment daily. Results: Adherence was excellent for mood and cognitive assessments (95% and 96%, respectively), did not deteriorate over time, and was not influenced by depression symptom severity or cognitive function at study onset. Daily mood assessments showed good correspondence with validated depression questionnaires (correlations range from .45 to .69 for total daily mood score) and daily cognitive assessments showed good correspondence with cognitive tests sensitive to depression (correlations ranged from .37 to .50 for mean n-back). Conclusions: The study supports the feasibility and validity of high-frequency assessment of cognitive function and mood function using wearable devices over an extended period in patients with major depressive disorder. Clinical Trial: NCT03067506

  • Digital Games vs Mindfulness Apps: Which is More Effective for Post-Work Recovery?

    Date Submitted: Nov 18, 2018

    Open Peer Review Period: Nov 22, 2018 - Jan 17, 2019

    Background: Engagement in activities that promote the dissipation of work stress are essential for post-work recovery and consequently wellbeing. Previous work suggests that activities that are immers...

    Background: Engagement in activities that promote the dissipation of work stress are essential for post-work recovery and consequently wellbeing. Previous work suggests that activities that are immersive, active and engaging are especially effective at promoting recovery. Digital games may therefore be able to promote recovery, but little is known about how they compare to other popular mobile activities, such as mindfulness apps which are specifically designed to support wellbeing. Objective: This research aimed to investigate and compare the effectiveness of a digital game and a mindfulness app in promoting post-work recovery, first in a lab setting and then in a field study. Methods: Study 1 was a lab experiment (n=45) in which participants’ need for recovery was induced by a work task, before undertaking one of three interventions: a digital game (Block! Hexa Puzzle), a mindfulness app (Headspace) or a non-media 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 arriving home from work over a period of five working days. Measures of energetic arousal were taken before and after the intervention, and recovery experience was measured after the intervention, along with measures of enjoyment and job strain. Results: A 3x2 mixed ANOVA identified that, in study 1, the digital game condition increased energetic arousal (indicative of improved recovery) whereas the other two conditions decreased energetic arousal (F2,42=3.76, p<.05). However, there were no differences between the conditions in Recovery Experience (F2,42=.01, P=.99). In Study 2, multi-level model comparisons identified that neither 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 (F1,20=2.1489, p<0.01). Follow up interviews with participants identified three core themes: Detachment and Restoration, Fluctuations and Differences, and finally, Routine and Scheduling. Conclusions: This work suggests that digital games may be effective in promoting post-work recovery in lab contexts (Study 1) and in the real world, although the effect in this case may be cumulative rather than instant (Study 2). Clinical Trial: N/A

  • 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.