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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).

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 world's leading medical journal in health sciences / health services research and health informatics.


Recent Articles:

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

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


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

  • A person using a mental health app while browsing a social media site. Source: Image created by the Authors; Copyright: The Authors; URL:; 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


    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:; License: Licensed by JMIR.

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


    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:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

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


    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:; License: Licensed by JMIR.

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


    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.

  • Source: Flickr; Copyright: verkeorg; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Teens Using Screens for Help: Impact of Suicidal Ideation, Anxiety, and Depression Levels on Youth Preferences for Telemental Health Resources


    Background: High rates of mental illness, stress, and suicidality among teens constitute a major public health concern in the United States. However, treatment rates remain low, partially because of barriers that could be mitigated with tech-based telemental health (TMH) resources, separate from or in addition to traditional care. Objective: This study aimed to analyze TMH resource usage by high school students to establish current user characteristics and provide a framework for future development. Methods: A total of 2789 students were surveyed regarding demographics, recent anxiety and depression symptoms, suicidality, and stress; people with whom they could openly and honestly discuss stress or problems, and prior TMH use. Logistic regression models and a general linear model were used to test relationships between variables. Results: Overall, 30.58% (853/2789) and 22.91% (639/2789) of students reported moderate to severe anxiety and depression symptoms, respectively, in the past 2 weeks; 16.24% (414/2550) had seriously considered suicide in the past year, consistent with national averages. Meanwhile, 16.03% (447/2789) of students had previously used at least 1 of 4 types of TMH resources (ie, self-help, anonymous chat, online counselor, or crisis text line). Teens reporting depression symptoms, higher stress, or suicidality were less likely to talk to a parent about stress or problems and more likely to tell no one. Suicidality was related to the use of all 4 types of TMH resources. Depression symptoms were related to the use of anonymous chat and crisis text line, and those with higher stress were more likely to have used an online counselor. Those reporting anxiety symptoms were less likely to have no one to talk to and more likely to have used a self-help resource. Conclusions: Youth struggling with mental health symptoms, some of whom lack real-life confidants, are using existing TMH support, with resource preferences related to symptoms. Future research should consider these preferences and assist in the creation of specialized, evidence-based TMH resources.

  • The smartphone application CONEMO. Source: Image created by authors; Copyright: The authors; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported...


    Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression.

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

    Sexting, Web-Based Risks, and Safety in Two Representative National Samples of Young Australians: Prevalence, Perspectives, and Predictors


    Background: The rapid uptake of information and communication technology (ICT) over the past decade—particularly the smartphone—has coincided with large increases in sexting. All previous Australian studies examining the prevalence of sexting activities in young people have relied on convenience or self-selected samples. Concurrently, there have been recent calls to undertake more in-depth research on the relationship between mental health problems, suicidal thoughts and behaviors, and sexting. How sexters (including those who receive, send, and two-way sext) and nonsexters apply ICT safety skills warrants further research. Objective: This study aimed to extend the Australian sexting literature by measuring (1) changes in the frequency of young people’s sexting activities from 2012 to 2014; (2) young people’s beliefs about sexting; (3) association of demographics, mental health and well-being items, and internet use with sexting; and (4) the relationship between sexting and ICT safety skills. Methods: Computer-assisted telephone interviewing using random digit dialing was used in two Young and Well National Surveys conducted in 2012 and 2014. The participants included representative and random samples of 1400 young people aged 16 to 25 years. Results: From 2012 to 2014, two-way sexting (2012: 521/1369, 38.06%; 2014: 591/1400, 42.21%; P=.03) and receiving sexts (2012: 375/1369, 27.39%; 2014: 433/1400, 30.93%; P<.001) increased significantly, not sexting (2012: 438/1369, 31.99%; 2014: 356/1400, 25.43%; P<.001) reduced significantly, whereas sending sexts (2012: n=35/1369, 2.56%; 2014: n=20/1400, 1.43%; P>.05) did not significantly change. In addition, two-way sexting and sending sexts were found to be associated with demographics (male, second language, and being in a relationship), mental health and well-being items (suicidal thoughts and behaviors and body image concerns), and ICT risks (cyberbullying others and late-night internet use). Receiving sexts was significantly associated with demographics (being male and not living with parents or guardians) and ICT risks (being cyberbullied and late-night internet use). Contrary to nonsexters, Pearson correlations demonstrated that all sexting groups (two-way, sending, and receiving) had a negative relationship with endorsing the ICT safety items relating to being careful when using the Web and not giving out personal details. Conclusions: Our research demonstrates that most young Australians are sexting or exposed to sexting in some capacity. Sexting is associated with some negative health and well-being outcomes—specifically, sending sexts is linked to suicidal thoughts and behaviors, body image issues, and ICT safety risks, including cyberbullying and late-night internet use. Those who do sext are less likely to engage in many preventative ICT safety behaviors. How the community works in partnership with young people to address this needs to be a multifaceted approach, where sexting is positioned within a wider proactive conversation about gender, culture, psychosocial health, and respecting and caring for each other when on the Web.

  • Personalized arousal feedback–based exposure therapy. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Exposure Therapy With Personalized Real-Time Arousal Detection and Feedback to Alleviate Social Anxiety Symptoms in an Analogue Adult Sample: Pilot...


    Background: Exposure therapy is highly effective for social anxiety disorder. However, there is room for improvement. Objective: This is a first attempt to examine the feasibility of an arousal feedback–based exposure therapy to alleviate social anxiety symptoms in an analogue adult sample. Methods: A randomized, pilot, proof-of-concept trial was conducted to evaluate the acceptability, safety, and preliminary efficacy of our treatment program. Sessions were administered once a week for 4 weeks (1 hour each) to an analogue sample of 50 young adults who reported at least minimal social anxiety symptoms. Participants in both intervention and waitlist control groups completed assessments for social anxiety symptoms at the baseline, week 5, and week 10. Results: Most participants found the intervention acceptable (82.0%, 95% CI 69.0%-91.0%). Seven (14.9%, 95% CI 7.0%-28.0%) participants reported at least one mild adverse event over the course of study. No moderate or serious adverse events were reported. Participants in the intervention group demonstrated greater improvements on all outcome measures of public speaking anxiety from baseline to week 5 as compared to the waitlist control group (Cohen d=0.61-1.39). Effect size of the difference in mean change on the overall Liebowitz Social Anxiety Scale was small (Cohen d=0.13). Conclusions: Our results indicated that it is worthwhile to proceed to a larger trial for our treatment program. This new medium of administration for exposure therapy may be feasible for treating a subset of social anxiety symptoms. Additional studies are warranted to explore its therapeutic mechanisms. Trial Registration: NCT02493010;

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

    How Is the Caregiver Doing? Capturing Caregivers’ Experiences With a Reflective Toolkit


    Background: This paper describes the Co-Care-KIT, a reflective toolkit designed to provide insights into the diverse experiences of home-based informal caregivers during the delivery of care to a relative or loved one. Objective: The aim of this study was to evaluate the toolkit, including a custom-designed journal, tools for photography-based experience sampling, and heart rate tracking, which enables caregivers to collect and reflect on their positive and negative daily experiences in situ. Methods: A 2-week field study with informal caregivers (N=7) was conducted to evaluate the Co-Care-KIT and to capture their daily personal emotional experiences. The collected data samples were analyzed and used for collaborative dialogue between the researcher and caregiver. Results: The results suggest that the toolkit (1) increased caregivers’ awareness of their own well-being through in situ reflection on their experiences; (2) empowered caregivers to share their identities and experiences as a caregiver within their social networks; (3) enabled the capturing of particularly positive experiences; and (4) provided caregivers reassurance with regards to their own mental health. Conclusion: By enabling capturing and collaborative reflection, the kit helped to gain a new understanding of caregivers’ day-to-day needs and emotional experiences.

  • Source: Flickr; Copyright: Tom Woodward; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial


    Background: Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objectives: This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes. Methods: User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum. Results: A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent. Trial Registration: NCT02121015; (archived by WebCite at

  • Source: Shutterstock Inc; Copyright: LDprod; URL:; License: Licensed by the authors.

    Exploring User Needs and Preferences for Mobile Apps for Sleep Disturbance: Mixed Methods Study


    Background: Mobile health (mHealth) apps demonstrate promise for improving sleep at scale. End-user engagement is a prerequisite for sustained use and effectiveness. Objective: We assessed the needs and preferences of those with poor sleep and insomnia to inform the development of an engaging sleep app. Methods: We triangulated results from qualitative (focus groups and app reviews) and quantitative (online survey) approaches. A total of 2 focus groups were conducted (N=9). An online survey tested themes identified from the focus groups against a larger population (N=167). In addition, we analyzed 434 user reviews of 6 mobile apps available on app stores. Results: Common focus group themes included the need to account for diverse sleep phenotypes with an adaptive and tailored program, key app features (alarms and sleep diaries), the complex yet condescending nature of existing resources, providing rationale for information requested, and cost as a motivator. Most survey participants (156/167, 93%) would try an evidence-based sleep app. The most important app features reported were sleep diaries (148/167, 88%), sharing sleep data with a doctor (116/167, 70%), and lifestyle tracking (107/167, 64%). App reviews highlighted the alarm as the most salient app feature (43/122, 35%) and data synchronization with a wearable device (WD) as the most commonly mentioned functionality (40/135, 30%). Conclusions: This co-design process involving end users through 3 methods consistently highlighted sleep tracking (through a diary and WD), alarms, and personalization as vital for engagement, although their implementation was commonly criticized in review. Engagement is negatively affected by poorly designed features, bugs, and didactic information which must be addressed. Other needs depend upon the type of user, for example, those with severe insomnia.

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  • Characterizing Anxiety Disorders with Online Social and Interactional Networks

    Date Submitted: Jul 8, 2019

    Open Peer Review Period: Jul 11, 2019 - Sep 5, 2019

    Background: Anxiety disorders constitute one of the leading mental health concerns in the United States. These disorders are closely associated with an individual’s interactions, manifested in the w...

    Background: Anxiety disorders constitute one of the leading mental health concerns in the United States. These disorders are closely associated with an individual’s interactions, manifested in the way an individual expresses themselves and interacts with others in their social environment. However, little is explored empirically about the association of social network structure and the interactions of an individual with aspects of mental health functioning, such as anxiety. Objective: In recent years, individuals have begun to appropriate social media to self-disclose about their mental illnesses, seek support, and derive therapeutic benefits. The study examines the online social network and interaction characteristics of Twitter users who self-disclose about their anxiety disorders. Methods: The study analyses a sample of N=200 Twitter users and their over 200,000 posts shared on the platform, who were expert-validated to have self-disclosed about suffering from an anxiety disorder. On their data, a variety of attributes of the users’ online social networks, interactions, and social behaviors using natural language and network analysis approaches were modeled using state-of-the-art network science measures. A number of state-of-the-art supervised learning classification frameworks are built using these attributes, to identify whether an individual’s anxiety disorder status could be automatically inferred. Results: Results show that these social network, behavior, and interaction attributes, when incorporated in a support vector machine classifier, signal an individual’s self-reported anxiety disorder status, in contrast to a control group, with 79% accuracy and 84% area under the receiver-operating characteristic curve. Conclusions: The work provides the first insights into the role that the social interactions and social network structure on online platforms play in characterizing an individual’s mental health experience, such as anxiety. We discuss the implications of our work in instrumenting online social platforms in ways that yield positive affordances and outcomes for individuals vulnerable to mental illnesses.

  • 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.

  • Smartphone-based interventions in German language in affective disorders – a review about currently available products

    Date Submitted: Jun 19, 2019

    Open Peer Review Period: Jun 20, 2019 - Aug 15, 2019

    Background: Currently, numerous new products such as applications (apps) for smartphones are being marketed in the electronic (e)-health sector. Mood-graphs, diagnostic questions, mindfulness exercise...

    Background: Currently, numerous new products such as applications (apps) for smartphones are being marketed in the electronic (e)-health sector. Mood-graphs, diagnostic questions, mindfulness exercises and chat-therapy affect psychiatric treatment of affective disorders (ADs) positively. The products are easily available and allow for little control over efficacy and adverse effects. Objective: A systemic review was performed in order to examine the currently available apps that advertise for supporting people with AD and anxiety disorders. Methods: The keywords “psychiatry”, “depression”, “bipolar”, “anxiety”, “mood” in German language were entered in Google Play Store and IOS iTunes and all available products were examined. Furthermore, the current research on these apps should be listed transparently at and PubMed. Results: Depending on keywords and app store, respectively, 98 to 250 products were spotted. 56 of the apps were included in this paper as they are related to AD. However, only nine of them are supported by scientific research or federal authorities. Five products are currently study subjects in clinical trials, but no publication was available at the time of research. Moreover, five publications of study protocols of other German-language apps, as well as five publications about evaluated products in PubMed were found. Conclusions: Diverse free apps with potentially favorable effects on mood stabilization are available for people suffering from ADs. As currently only a very small number of them have been scientifically evaluated, there is an urgent need for research in the mobile e-health sector. In addition, physicians and psychotherapists should talk to their patients about the advantages and disadvantages of apps and inform them about the lack of evidence.

  • Assessing the Feasibility, Usability, and Effectiveness of an Online Training for Adults Responding to Concerning Posts on Social Media

    Date Submitted: Jun 14, 2019

    Open Peer Review Period: Jun 15, 2019 - Aug 10, 2019

    Background: Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation to others before attempting suicide. However, a recent national survey suggests that nearly on...

    Background: Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation to others before attempting suicide. However, a recent national survey suggests that nearly one-third of American Indian and Alaska Native (AI/AN) youth see concerning messages on social media on a daily or weekly basis. Objective: To prepare adults who work with Native youth to better support teens who post or view concerning messages, our team designed an hour-long training: Responding to Concerning Posts on Social Media. In 2017, AI/AN adults who work with Native youth were recruited to test the training and provide feedback on its usability, appeal, and impact. Methods: A purposive sample of 70 adults were recruited to participate in the pilot, which included two study arms. Arm 1 watched a 30-minute training video and reviewed accompanying handouts, including the Viewer Care Plan. Those enrolled in Arm 2 participated in an additional interactive roleplay scenario with a coach that took place after the training, via text message. Participants provided qualitative and quantitative feedback on the training’s relevance, appeal, and utility. Paired t-tests were used to assess confidence in addressing concerning posts between pre- and post-surveys. Qualitative analysis of the roleplay transcripts were used to assess the quality and completion of the coached roleplays, in relation to a recommended Viewer Care Plan. Results: Altogether, 35 participants finished the training over a 3-month period and completed pre- and post-surveys; 22 participants completed the 6-month follow-up survey. Pre-post analyses of differences in means found significant improvement across several efficacy measures, including confidence starting a conversation about social media (P = .003), confidence contacting the person who posted something concerning (P < .001), and confidence recommending support services to youth who witness (P = .001) or youth who post concerning messages (P < .001). Similarly, pre- to 6-month analyses found significant positive improvement across multiple measures, including confidence contacting the youth who posted (P < .001), confidence starting a conversation about social media with youth (P = .003), and an increase in the number of experiences recommending resources for youth who witnessed concerning social media posts (P = .02). The least followed Viewer Care Plan Step was sharing Tools and Resources. Conclusions: Preliminary findings indicate that the Responding to Concerning Posts on Social Media training is a promising tool to prepare adults to intervene and complete the Viewer Care Plan. Additional evaluation with a larger cohort of participants is needed to determine the unique impact of the roleplay scenario and changes in mental health referral rates, behaviors, and skills. Clinical Trial: NA

  • The Ethics and Design Principles of an Online Social Therapy System

    Date Submitted: May 30, 2019

    Open Peer Review Period: May 31, 2019 - Jul 26, 2019

    The modern omnipresence of social media and social networking sites (SNS) brings with it a range of important research questions. One of these concerns the impact of SNS use on mental health and wellb...

    The modern omnipresence of social media and social networking sites (SNS) brings with it a range of important research questions. One of these concerns the impact of SNS use on mental health and wellbeing; a question that has been pursued in depth by scholars in the psychological sciences and the field of human-computer interaction. Despite this attention, the design choices made in the development of SNS and the notion of wellbeing employed to evaluate such systems require further scrutiny. In this paper we examine the strategic design choices made in developing an enclosed SNS for young people experiencing mental ill-health; in terms of ethical, persuasive design and in terms of how it fosters wellbeing. In doing so, we come to critique the understanding of wellbeing that is used in much of the existing literature to make claims about the impact of a given technology on wellbeing. We also demonstrate how the holistic concept of eudaimonic wellbeing and ethical design of SNS can complement one another.