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Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959, Editor-in-Chief: John Torous MD MBI) is a PubMed-indexed, peer-reviewed journal which has a unique focus on digital health and Internet/mobile interventions, technologies and electronic innovations (software and hardware) for mental health, addictions, online counselling and behaviour change. This includes formative evaluation and system descriptions, theoretical papers, review papers, viewpoint/vision papers, and rigorous evaluations related to digital psychiatry, e-mental health, and clinical informatics in psychiatry/psychology. The main themes/topics covered by this journal can be found here.

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

JMIR Mental Health features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

The journal is indexed in PubMed, PubMed Central, and ESCI (Emerging Sources Citation Index).

 

Recent Articles:

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/woman-light-typing-laptop-keyboard_3858325.htm#page=2&query=person+on+computer&position=44; License: Licensed by JMIR.

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

    Abstract:

    Background: Cognitive behavioral therapy (CBT) is frequently used to treat depressive symptoms in people living with HIV. We developed an internet-based cognitive behavioral intervention for people with HIV and depressive symptoms, which was based on an effective self-help booklet. The Web-based intervention was previously found to be effective. Objective: The objective of this study was to investigate potential mediators of the Web-based intervention. Methods: This study was part of a randomized controlled trial, in which the intervention was compared with an attention-only waiting list control condition. Participants were 188 (97 in intervention group and 91 in control group) people with HIV and mild to moderate depressive symptoms recruited in HIV treatment centers in the Netherlands. A total of 22 participants (22/188, 11.7%) in the study were female and 166 (166/188, 88.3%) were male. The average age of the participants was 46.30 years (SD 10.63). The intervention comprised Web-based self-help CBT for 8 weeks, 1 to 2 hours a week, including minimal telephone support from a coach. The participants received Web-based questionnaires at pretest, 3 times during the intervention/or waiting period, and post intervention. The outcome was depressive symptoms. Factors tested as potential mediators were changes in behavioral activation, relaxation, the cognitive coping strategies catastrophizing and positive refocusing, goal re-engagement, and coping self-efficacy. Results: Using multilevel structural equation modeling, changes in behavioral activation (P=.006) and goal re-engagement (P=.009) were found to be significant mediators of the intervention effect. The mediation effect seemed to occur between weeks 3 and 5 for behavioral activation and weeks 1 and 3 for goal re-engagement. Using (bivariate) autoregressive latent trajectory analysis, we found a return effect (from the dependent variable to the mediator) for goal re-engagement but not for behavioral activation, which suggested that the mediation effect of changes in behavioral activation was stronger than that in goal re-engagement. Conclusions: The results suggest that changes in behavioral activation and goal re-engagement may mediate the effect of the Web-based intervention for people with HIV and depressive symptoms. The results may lead to possible mechanisms of change of the intervention and improvement of therapy outcomes. Trial Registration: Netherlands Trial Register NTR5407; https://www.trialregister.nl/trial/5298

  • Source: Jonathan Nash; Copyright: Jonathan Nash; URL: https://mental.jmir.org/2019/8/e12820/; License: Licensed by JMIR.

    Mindful Eating Mobile Health Apps: Review and Appraisal

    Abstract:

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

  • Source: Pexels.com; Copyright: Rawpixel.com; URL: https://www.pexels.com/photo/selective-focus-photography-of-woman-using-smartphone-beside-bookshelf-1061580/; License: Licensed by JMIR.

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

    Abstract:

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

  • Source: Freepik; Copyright: jannoon028; URL: https://www.freepik.com/free-photo/hands-holding-credit-card-using-laptop-computer-mobile-phone-online-shopping_1254914.htm; License: Licensed by JMIR.

    Reimbursement of Apps for Mental Health: Findings From Interviews

    Abstract:

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

  • Source: Image created by the Authors; Copyright: The Authors; URL: https://mental.jmir.org/2019/8/e14029; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • Source: Freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/portrait-smiling-female-psychologist-sitting-white-chair-with-clipboard-pencil-her-office_3706756.htm; License: Licensed by JMIR.

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

    Abstract:

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

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/african-young-businessman-with-his-hands-his-pocket-using-mobile-phone_4765057.htm; License: Licensed by JMIR.

    Predicting Posttraumatic Stress Disorder Risk: A Machine Learning Approach

    Abstract:

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

  • Source: pixabay; Copyright: Pexels; URL: https://pixabay.com/photos/man-mobile-phone-person-smartphone-1868730/; License: Licensed by JMIR.

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

    Abstract:

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

  • A person using a mental health app while browsing a social media site. Source: Image created by the Authors; Copyright: The Authors; URL: https://mental.jmir.org/2019/7/e12546; License: Creative Commons Attribution (CC-BY).

    Use of Smartphone Apps, Social Media, and Web-Based Resources to Support Mental Health and Well-Being: Online Survey

    Abstract:

    Background: Technology can play an important role in supporting mental health. Many studies have explored the effectiveness, acceptability, or context of use of different types of mental health technologies. However, existing research has tended to investigate single types of technology at a time rather than exploring a wider ecosystem that people may use. This narrow focus can limit our understanding of how we could best design mental health technologies. Objective: The aim of this study was to investigate which technologies (smartphone apps, discussion forums and social media, and websites and Web-based programs) people use to support their mental health and why, whether they combine and use more than one technology, what purpose each technology serves, and which features people find the most valuable. Methods: We conducted an online survey to gather responses from members of the public who use technology to support their mental health and well-being. The survey was advertised on social media and via posters at a university. It explored usage patterns, frequently used features, and engagement with technology. To gain deeper insights into users’ preferences, we also thematically analyzed open-ended comments about each technology type and suggestions for improvements provided by the respondents. Results: In total, 81 eligible participants completed the survey. Smartphone apps were the most commonly used technology, with 78% of the participants (63/81) using them, either alone (40%) or in combination with other technologies (38%). Each type of technology was used for specific purposes: apps provided guided activities, relaxation, and enabled tracking; social media and discussion forums allowed participants to learn from the experiences of others and use that knowledge to understand their own situation; and Web-based programs and websites helped to find out how to deal on a day-to-day basis with stress and anxiety. The analysis of open-ended responses showed that although many people valued technology and felt it could support targeted activities, it was not seen as a substitute for traditional face-to-face therapy. Participants wanted technology to be more sophisticated and nuanced, supporting personalized and actionable recommendations. There was evidence that participants mistrusted technology, irrespective of the type, and had broader concerns regarding the impact of overuse of technology. Conclusions: People use different types of technology to support their mental health. Each can serve a specific purpose. Although apps are the most widely used technology, mixing and matching different types of technology is also common. Technology should not be seen as a replacement for traditional psychotherapy, rather it offers new opportunities to support mental health as part of an overall ecosystem. People want technology to be more nuanced and personalized to help them plan informed actions. Future interventions should explore the use of multiple technologies and their combined effects on mental health support.

  • Source: Pexels; Copyright: Pixabay; URL: https://www.pexels.com/photo/adult-architecture-casual-fashion-264637/; License: Licensed by JMIR.

    Exploring Young People’s Perceptions of the Effectiveness of Text-Based Online Counseling: Mixed Methods Pilot Study

    Abstract:

    Background: Young people aged 10-24 years are at the highest risk for mental health problems and are the least likely to seek professional treatment. Owing to this population’s high consumption of internet content, electronic mental (e-mental) health services have increased globally, with an aim to address barriers to treatment. Many of these services use text-based online counseling (TBOC), which shows promising results in supporting young people but also greater variance in outcomes compared with adult comparators. Objective: This pilot study qualitatively explored the characteristics of users aged 15-25 years accessing TBOC services, their motivations for access, and their perceptions about factors believed to influence the effectiveness of these modalities. Methods: E-surveys were administered naturalistically to 100 young service users aged 15-25 years who accessed webchat and email counseling services via an Australian e-mental health service. Thematic analysis of qualitative themes and quantitative descriptive and proportional data presented in electronic surveys were examined across the areas of user characteristics, motivations for selecting TBOC modalities, and their perceptions of TBOC effectiveness. Results: Participants were predominately female high school students of Caucasian or European descent from middle socioeconomic status, living with their parents in major cities. Four domains and various themes and subthemes were related to participants’ reasons for accessing TBOC and perceptions of its effectiveness: user characteristics (ie, physical and mental health syndrome and perceived social difficulties), selection factors (ie, safety, avoidance motivation, accessibility, and expectation), factors perceived to increase effectiveness (ie, general therapeutic benefits, positive modality and service factors, and persisting with counseling to increase benefit), and factors perceived to decrease effectiveness (ie, negative modality and service factors, and persisting with counseling despite benefit). Conclusions: Participants were motivated to use TBOC to increase their sense of safety in response to negative perceptions of their social skills and the response of the online counsellor to their presenting problem. By using TBOC services, they also sought to improve their access to mental health services that better met their expectations. Factors that increased effectiveness of TBOC were the counsellor’s interpersonal skills, use of text-based communication, and persisting with beneficial counseling sessions. Factors that reduced TBOC effectiveness were poor timeliness in response to service requests, experiencing no change in their presenting problem, not knowing what postcounseling action to take, and persisting with ineffective counseling sessions.

  • Source: Flickr; Copyright: Michael Nugent; URL: https://www.flickr.com/photos/michaelnugent/5657757571/; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

    Abstract:

    Background: There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators. Objective: This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions. Methods: We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3. Results: The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers’ justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention’s intended effects. Conclusions: Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/from-man-using-laptop-floor_2221704.htm; License: Licensed by JMIR.

    Preferences of Information Dissemination on Treatment for Bipolar Disorder: Patient-Centered Focus Group Study

    Abstract:

    Background: Patient education has taken center stage in successfully shared decision making between patients and health care providers. However, little is known about how patients with bipolar disorder typically obtain information on their illness and the treatment options available to them. Objective: This study aimed to obtain the perspectives of patients with bipolar disorder and their family members on the preferred and most effectively used information channels on bipolar disorder and the available treatment options. Methods: We conducted nine focus groups in Montana, New Mexico, and California, in which we surveyed 84 individuals including patients with bipolar disorder and family members of patients with bipolar disorder. The participants were recruited using National Alliance on Mental Illness mailing lists and websites. Written verbatim responses to semistructured questionnaires were analyzed using summative content analysis based on grounded theory. Two annotators coded and analyzed the data on the sentence or phrase level to create themes. Relationships between demographics and information channel were also examined using the Chi-square and Fisher exact tests. Results: The focus group participants mentioned a broad range of information channels that were successfully used in the past and could be recommended for future information dissemination. The majority of participants used providers (74%) and internet-based resources (75%) as their main information sources. There was no association between internet use and basic demographics such as age or geographical region of the focus groups. Patients considered time constraints and the fast pace in which an overwhelming amount of information is often presented by the provider as major barriers to successful provider-patient interactions. If Web-based channels were used, the participants perceived information obtained through Web-based channels as more helpful than information received in the provider’s office (P<.05). Conclusions: Web-based resources are increasingly used by patients with bipolar disorder and their family members to educate themselves about the disease and its treatment. Although provider-patient interactions are frequently perceived to be burdened with time constraints, Web-based information sources are considered reliable and helpful. Future research should explore how high-quality websites could be used to empower patients and improve provider-patient interactions with the goal of enhancing shared decision making between patients and providers.

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

    Date Submitted: Aug 14, 2019

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

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

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

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

    Date Submitted: Jul 22, 2019

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

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

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

  • How contextual constraints shape mid-career high school teachers’ stress management and use of digital support tools: A qualitative study.

    Date Submitted: Jul 9, 2019

    Open Peer Review Period: Jul 10, 2019 - Sep 4, 2019

    Background: Persistent psychosocial stress is endemic in the modern workplace, including amongst mid-career high school (secondary comprehensive) teachers in England. Understanding contextual influenc...

    Background: Persistent psychosocial stress is endemic in the modern workplace, including amongst mid-career high school (secondary comprehensive) teachers in England. Understanding contextual influences on teachers’ self-management of stress along with their use of digital health technologies could give important insight into creating more usable and accessible stress support interventions. Objective: The aim of the study was to investigate constraints on stress management and prevention among teachers in the school environment and how this shapes use of digitally enabled stress management tools. Methods: Semi-structured interviews were conducted with 14 teachers from southern England. Interviews were analysed using thematic analysis. Results: Teachers were unanimous in their recognition of workplace stress, describing physical (such as isolation and scheduling) and cultural (such as stigma and individualism) aspects of the workplace context which influence their ability to manage stress. Twelve of the participants engaged with technology to self-manage their physical or psychological wellbeing, with consumer wearables used by more than half, but online or smartphone apps were rarely accessed in school. Digital wellbeing interventions recommended by school leaders could potentially be trusted and adopted. Conclusions: Findings from this study bring together both important cultural and physical contextual constraints for mid-career high school teachers’ ability to manage workplace stress. It highlights correlates of stress and offers original insight into how digital health interventions are currently being used to help with stress, both within and outside high schools. The findings add another step towards designing tailored digital stress support for teachers.

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