JMIR Publications

JMIR Mental Health

Internet interventions, technologies and digital innovations for mental health and behaviour change


Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959) is a PubMed-indexed, peer-reviewed sister journal of JMIR, the leading eHealth journal (Impact Factor 2016: 5.175). 

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.

Editorial Board members are currently being recruited, please contact us if you are interested ( at


Recent Articles:

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

    Pregnant Women’s Perceptions of the Risks and Benefits of Disclosure During Web-Based Mental Health E-Screening Versus Paper-Based Screening: Randomized...


    Background: Pregnant women’s perceptions of the risks and benefits during mental health screening impact their willingness to disclose concerns. Early research in violence screening suggests that such perceptions may vary by mode of screening, whereby women view the anonymity of e-screening as less risky than other approaches. Understanding whether mode of screening influences perceptions of risk and benefit of disclosure is important in screening implementation. Objective: The objective of this randomized controlled trial was to compare the perceptions of pregnant women randomized to a Web-based screening intervention group and a paper-based screening control group on the level of risk and benefit they perceive in disclosing mental health concerns to their prenatal care provider. A secondary objective was to identify factors associated with women’s perceptions of risk and benefit of disclosure. Methods: Pregnant women recruited from maternity clinics, hospitals, and prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a computer tablet, whereas the control group completed them on paper. The primary outcome was women’s perceptions of the risk and benefits of mental health screening using the Disclosure Expectations Scale (DES). A completer analysis was conducted. Statistical significance was set at P<.05. We used t tests to compare the means of the risk and benefit subscales between groups. Results: Of the 675 eligible women approached, 636 (94.2%) agreed to participate and were randomized to the intervention (n=305) and control (n=331) groups. There were no significant baseline differences between groups. The mode of screening was not associated with either perceived risk or benefit of screening. There were no differences in groups in the mean scores of the risk and benefit of disclosure subscales. Over three-quarters of women in both intervention and control groups perceived that mental health screening was beneficial. However, 43.1% (272/631) of women in both groups reported feeling very, moderately, or somewhat vulnerable during mental health screening. We found that women of low income, those treated previously for depression or anxiety, and those pregnant with their first child were more likely to perceive greater risk. However, these associations were very small. Conclusions: Pregnant women in both the e-screening and paper-based screening groups perceived benefit and risk of disclosure similarly, suggesting that providers can implement the mode of screening that is most ideal for their clinical setting. Regardless of the mode of screening, a substantial number of women reported feeling vulnerable during mental health screening, highlighting the importance of the need to reduce women’s vulnerability throughout the screening process with strategies such as addressing women’s concerns, explaining the rationale for screening, and discussing how results will be used. Trial Registration: NCT01899534; (Archived by WebCite at

  • Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Transmedia Storytelling Intervention With Interactive Elements to Benefit Latinas’ Mental Health: Feasibility, Acceptability, and Efficacy


    Background: Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs. Objective: The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both. Methods: A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression. Results: All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (F2,54=9.0, P<.001) and anxiety (F2,54=18.7, P<.001) significantly reduced across time. Higher levels of confidence were significantly associated with actions taken at 1 (P=.005) and 6 weeks (P=.04), and higher levels of importance were significantly associated with actions taken at 1 (P=.009) and 6 weeks (P=.003). Higher levels of confidence were associated with lower levels of depression (P=.04) and anxiety (P=.01) at 6 weeks. Conclusions: Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression.

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

    #MyDepressionLooksLike: Examining Public Discourse About Depression on Twitter


    Background: Social media provides a context for billions of users to connect, express sentiments, and provide in-the-moment status updates. Because Twitter users tend to tweet emotional updates from daily life, the platform provides unique insights into experiences of mental health problems. Depression is not only one of the most prevalent health conditions but also carries a social stigma. Yet, opening up about one’s depression and seeking social support may provide relief from symptoms. Objective: The aim of this study was to examine the public discourse of the trending hashtag #MyDepressionLooksLike to look more closely at how users talk about their depressive symptoms on Twitter. Methods: We captured 3225 original content tweets for the hashtag #MyDepressionLooksLike that circulated in May of 2016. Eliminating public service announcements, spam, and tweets with links to pictures or videos resulted in a total of 1978 tweets. Using qualitative content analysis, we coded the tweets to detect themes. Results: The content analysis revealed seven themes: dysfunctional thoughts, lifestyle challenges, social struggles, hiding behind a mask, apathy and sadness, suicidal thoughts and behaviors, and seeking relief. Conclusions: The themes revealed important information about the content of the public messages that people share about depression on Twitter. More research is needed to understand the effects of the hashtag on increasing social support for users and reducing social stigma related to depression.

  • Source: Pexels; Copyright: MOHI SYED; URL:; License: Public Domain (CC0).

    Mental and Emotional Self-Help Technology Apps: Cross-Sectional Study of Theory, Technology, and Mental Health Behaviors


    Background: Mental and emotional self-help apps have emerged as potential mental illness prevention and treatment tools. The health behavior theory mechanisms by which these apps influence mental health–related behavior change have not been thoroughly examined. Objective: The objective of this study was to examine the association between theoretical behavior change mechanisms and use of mental and emotional self-help apps and whether the use of such apps is associated with mental health behaviors. Methods: This study utilized a cross-sectional survey of 150 users of mental or emotional health apps in the past 6 months. Survey questions included theory-based items, app engagement and likeability items, and behavior change items. Stata version 14 was used to calculate all statistics. Descriptive statistics were calculated for each of the demographic, theory, engagement, and behavior variables. Multiple regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior after controlling for potentially confounding variables. Results: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. Engagement (P<.001) was positively associated with the reported changes in theory items, whereas perceived behavior change was positively associated with theory (P<.001), engagement (P=.004), frequency of use of apps (P=.01), and income (P=.049). Conclusions: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. This increase in perceptions, beliefs, and attitudes surrounding their mental and emotional health was considerably associated with perceived change in behavior. There was a positive association between the level of engagement with the app and the impact on theory items. Future efforts should consider the value of impacting key theoretical constructs when designing mental and emotional health apps. As apps are evaluated and additional theory-based apps are created, cost-effective self-help apps may become common preventative and treatment tools in the mental health field.

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

    Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled...


    Background: Mental disorders have become a major health issue, and a substantial number of afflicted individuals do not get appropriate treatment. Web-based interventions are promising supplementary tools for improving health care for patients with mental disorders, as they can be delivered at low costs and used independently of time and location. Although psychodynamic treatments are used frequently in the face-to-face setting, there has been a paucity of studies on psychodynamic Web-based self-help interventions. Objective: The objective of this study was to determine the feasibility and preliminary efficacy of a transdiagnostic affect-focused psychodynamic Web-based self-help intervention designed to increase emotional competence of patients with mental disorders. Methods: A total of 82 psychotherapy inpatients with mixed diagnoses were randomized into two groups. Following discharge, the intervention group (IG) got access to a guided version of the intervention for 10 weeks. After a waiting period of 10 weeks, the wait-list control group (WLCG) got access to an unguided version of the intervention. We reported the assessments at the beginning (T0) and at the end of the intervention, resp. the waiting period (T1). The primary outcome was satisfaction with the treatment at T1. Secondary outcome measures included emotional competence, depression, anxiety, and quality of life. Statistical analyses were performed with descriptive statistics (primary outcome) and analysis of covariance; a repeated measurement analysis of variance was used for the secondary outcomes. Effect sizes were calculated using Cohen d and data were analyzed as per protocol, as well as intention-to-treat (ITT). Results: Patients were chronically ill, diagnosed with multiple diagnoses, most frequently with depression (84%, 58/69), anxiety (68%, 47/69), personality disorder (38%, 26/69), and depersonalization-derealization disorder (22%, 15/69). A majority of the patients (86%, 36/42) logged into the program, of which 86% (31/36) completed the first unit. Satisfaction with the units mastered was rated as good (52%, 16/31) and very good (26%, 9/31). However, there was a steady decline of participation over the course of the program; only 36% of the participants (13/36) participated throughout the trial completing at least 50% of the sessions. According to the ITT analysis, participants improved statistically significantly and with moderate effect sizes (Cohen d) compared with the WLCG regarding depression (d=0.60), quality of life (d=0.53), and emotional competence (d=0.49). Effects were considerably stronger for the completers with respect to depression (d=1.33), quality of life (d=0.83), emotional competence (d=0.68), and general anxiety (d=0.62). Conclusions: Although overall program satisfaction and benefit of the program were favorable with respect to the indicators of emotional disorders, the rate of completion was low. Our findings point to the need to target the intervention more specifically to the needs and capabilities of participants and to the context of the intervention. Trial Registration: NCT02671929; (Archived by WebCite at

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

    Exploring the Therapeutic Affordances of Self-Harm Online Support Communities: An Online Survey of Members


    Background: A growing number of online communities have been established to support those who self-harm. However, little is known about the therapeutic affordances arising from engagement with these communities and resulting outcomes. Objective: The aim of this study was to explore the presence of therapeutic affordances as reported by members of self-harm online support communities. Methods: In total, 94 respondents (aged 13-63 years, mean=23.5 years; 94% female) completed an online survey exploring their experiences of engaging with a self-harm online support community. Respondents varied in terms of how long they had been accessing an online community, with 22% (21/94) accessing less than 1 year, 39% (37/94) 1 to 2 years, 14% (13/94) 2 to 3 years, and 24.5% (23/94) more than 3 years. Responses were analyzed using deductive thematic analysis. Results: The results of our analysis describe each of the five therapeutic affordances that were present in the data, namely (1) connection, the ability to make contact with others who self-harm for the purposes of mutual support and in so doing reduce feelings of loneliness and isolation; (2) adaptation, that is, how use of online support varies in relation to the personal circumstances of the individual user; (3) exploration, that is, the ability to learn about self-harm and learn about strategies to reduce or stop self-harming behavior; (4) narration, that is, the ability to share experiences, as well as read about the experiences of others; and (5) self-presentation, that is, how and what users present about themselves to others in the online community. Conclusions: Our findings suggest that engagement with self-harm online support communities may confer a range of therapeutic benefits for some users, which may serve to minimize the psychosocial burden of self-harm and promote positive coping strategies. In addition, the online nature of the support available may be helpful to those who are unable to access face-to-face support.

  • The Safe Conversations project. Source: YouTube; Copyright: Orygen, The National Centre of Excellence in Youth Mental Health; URL:; License: Fair use/fair dealings.

    Developing Social Media-Based Suicide Prevention Messages in Partnership With Young People: Exploratory Study


    Background: Social media is increasingly being used by young people for health-related issues, including communicating about suicide. Due to the concerns about causing distress or inducing suicidal thoughts or behaviors, to date young people neither have been engaged in the development of social media–based suicide prevention interventions nor have interventions focused on educating young people about safe ways to communicate about suicide online. Given the potential that social media holds to deliver messages to vast numbers of people across space and time and the fact that young people often prefer to seek help from their friends and peers, safely educating and engaging young people to develop suicide prevention messages that can be delivered via social media is an obvious next step. Objectives: The objectives of this study were to (1) provide education to a small number of secondary school students about safe ways to communicate about suicide via social media; (2) engage the same young people in the development of a suite of social media–based suicide prevention multimedia messages; (3) assess the impact of this on participants; and (4) assess the acceptability and safety of the messages developed. Methods: This study involved two phases. In phase 1, 20 participants recruited from two schools took part in an 8- to 10-week program during which they were provided with psychoeducation about mental health and suicide, including how to talk safely about suicide online, and they were then supported to design and develop their own media messages. These participants completed an evaluation questionnaire at the conclusion of the program. In phase 2, a larger group of participants (n=69), recruited via an opt-in process, viewed the media messages and completed a short questionnaire about each one. Results: Participants in phase 1 enjoyed the program and reported that they learned new skills, such as how to talk safely about suicide online, and felt more able to provide emotional support to others (16/20, 80%). No participants reported that the program made them feel suicidal. Participants in phase 2 generally rated the media messages as safe and acceptable, although some messages were rated more highly than others. Conclusions: This study suggests that young people can be safely engaged in developing suicide prevention messages, which can be disseminated via social media. Engaging young people in this process may improve the traction that such campaigns will have with other young people. The study also suggests that educating young people regarding how to talk safely about suicide online has multiple benefits and is not associated with distress. Overall, these findings pave the way for new approaches to prevent suicide among young people.

  • Telemedical treatment in psychiatry and psychotherapy. Source: Unsplash; Copyright: Thought Catalog; URL:; License: Licensed by the authors.

    Development of a Questionnaire to Measure the Attitudes of Laypeople, Physicians, and Psychotherapists Toward Telemedicine in Mental Health


    Background: In the field of psychiatry and psychotherapy, there are now a growing number of Web-based interventions, mobile phone apps, or treatments that are available via remote transmission screen worldwide. Many of these interventions have been shown to be effective in studies but still find little use in everyday therapeutic work. However, it is important that attitude and expectation toward this treatment are generally examined, because these factors have an important effect on the efficacy of the treatment. To measure the general attitude of the users and prescribers toward telemedicine, which may include, for instance, Web-based interventions or interventions through mobile phone apps, there are a small number of extensive tests. The results of studies based on small groups of patients have been published too, but there is no useful short screening tool to give an insight into the general population’s attitude. We have developed a screening instrument that examines such attitude through a few graded questions. Objective: This study aimed to explore the Attitude toward Telemedicine in Psychiatry and Psychotherapy (ATiPP) and to evaluate the results of general population and some subgroups. Methods: In a three-step process, the questionnaire, which is available in three versions (laypeople, physicians, and psychologists), was developed. Afterwards, it was evaluated by four groups: population-representative laypeople, outpatients in different faculties, physicians, and psychotherapists. Results: The results were evaluated from a total of 1554 questionnaires. The sample population included 1000 laypeople, 455 outpatients, 62 physicians, and 37 psychotherapists. The reliability of all three versions of the questionnaire seemed good, as indicated by the Cronbach alpha values of .849 (the laypeople group), .80 (the outpatients’ group), .827 (the physicians’ group), and .855 (the psychotherapists’ group). Conclusions: The ATiPP was found to be useful and reliable for measuring the attitudes toward the Web-based interventions in psychiatry and psychotherapy and should be used in different studies in this field in the future to evaluate and reflect the attitude of the participants.

  • Videoconferencing-based alcohol treatment. Source: Image created by the Authors and Colleagues; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial


    Background: Treatment of alcohol use disorders (AUDs) is characterized by an adherence rate below 50%. Clinical research has found that patient adherence enhances treatment effect; hence, health authorities, clinicians, and researchers strive to explore initiatives contributing to patients receiving treatment. Concurrently, videoconferencing-based treatment is gaining ground within other addiction and psychiatric areas. Objective: The aim of this study was to test whether optional videoconferencing increases adherence to and effectiveness of AUD treatment in a randomized controlled trial (RCT). We hypothesized that the intervention would decrease premature dropout (the primary outcome), as well as increase successful treatment termination, treatment duration, and treatment outcome (secondary outcomes). Methods: We conducted this study in the public outpatient alcohol clinic in Odense, Denmark, between September 2012 and April 2013. It was an RCT with 2 groups: treatment as usual (TAU) and treatment as usual with add-on intervention (TAU+I). The TAU+I group had the option, from session to session, to choose to receive treatment as usual via videoconferencing. Data consisted of self-reported responses to the European version of the Addiction Severity Index (EuropASI). We collected data at baseline, at follow-up at 3, 6, and 12 months, and at discharge. Results: Among consecutive patients attending the clinic, 128 met the inclusion criteria, and 71 of them were included at baseline. For the primary outcome, after 180 days, 2 of 32 patients (6%) in the TAU+I group and 12 of 39 patients (31%) in the TAU group had dropped out prematurely. The difference is significant (P=.008). After 365 days, 8 patients (25%) in the TAU+I group and 17 patients (44%) in the TAU group had dropped out prematurely. The difference is significant (P=.02). For the secondary outcomes, significantly more patients in the TAU+I group were still attending treatment after 1 year (P=.03). We found no significant differences between the 2 groups with regard to successful treatment termination and treatment outcome. Conclusions: The results indicate that offering patients optional videoconferencing may prevent premature dropouts from treatment and prolong treatment courses. However, the small sample size precludes conclusions regarding the effect of the intervention, which was not detectable in the patients’ use of alcohol and severity of problems. Trial Registration: The Regional Health Research Ethics Committee System in Denmark: S-20110052; (Archived by WebCite at

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

    Comparison of Self-Reported Telephone Interviewing and Web-Based Survey Responses: Findings From the Second Australian Young and Well National Survey


    Background: Web-based self-report surveying has increased in popularity, as it can rapidly yield large samples at a low cost. Despite this increase in popularity, in the area of youth mental health, there is a distinct lack of research comparing the results of Web-based self-report surveys with the more traditional and widely accepted computer-assisted telephone interviewing (CATI). Objective: The Second Australian Young and Well National Survey 2014 sought to compare differences in respondent response patterns using matched items on CATI versus a Web-based self-report survey. The aim of this study was to examine whether responses varied as a result of item sensitivity, that is, the item’s susceptibility to exaggeration on underreporting and to assess whether certain subgroups demonstrated this effect to a greater extent. Methods: A subsample of young people aged 16 to 25 years (N=101), recruited through the Second Australian Young and Well National Survey 2014, completed the identical items on two occasions: via CATI and via Web-based self-report survey. Respondents also rated perceived item sensitivity. Results: When comparing CATI with the Web-based self-report survey, a Wilcoxon signed-rank analysis showed that respondents answered 14 of the 42 matched items in a significantly different way. Significant variation in responses (CATI vs Web-based) was more frequent if the item was also rated by the respondents as highly sensitive in nature. Specifically, 63% (5/8) of the high sensitivity items, 43% (3/7) of the neutral sensitivity items, and 0% (0/4) of the low sensitivity items were answered in a significantly different manner by respondents when comparing their matched CATI and Web-based question responses. The items that were perceived as highly sensitive by respondents and demonstrated response variability included the following: sexting activities, body image concerns, experience of diagnosis, and suicidal ideation. For high sensitivity items, a regression analysis showed respondents who were male (beta=−.19, P=.048) or who were not in employment, education, or training (NEET; beta=−.32, P=.001) were significantly more likely to provide different responses on matched items when responding in the CATI as compared with the Web-based self-report survey. The Web-based self-report survey, however, demonstrated some evidence of avidity and attrition bias. Conclusions: Compared with CATI, Web-based self-report surveys are highly cost-effective and had higher rates of self-disclosure on sensitive items, particularly for respondents who identify as male and NEET. A drawback to Web-based surveying methodologies, however, includes the limited control over avidity bias and the greater incidence of attrition bias. These findings have important implications for further development of survey methods in the area of health and well-being, especially when considering research topics (in this case diagnosis, suicidal ideation, sexting, and body image) and groups that are being recruited (young people, males, and NEET).

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

    Web-Based Cognitive Remediation Improves Supported Employment Outcomes in Severe Mental Illness: Randomized Controlled Trial


    Background: Finding work is a top priority for most people; however, this goal remains out of reach for the majority of individuals with a severe mental illness (SMI) who remain on benefits or are unemployed. Supported employment (SE) programs aimed at returning people with a severe mental illness to work are successful; however, they still leave a significant number of people with severe mental illness unemployed. Cognitive deficits are commonly found in SMI and are a powerful predictor of poor outcome. Fortunately, these deficits are amenable to treatment with cognitive remediation therapy (CRT) that significantly improves cognition in SMI. CRT combined with SE significantly increases the likelihood of individuals with severe mental illness obtaining and staying in work. However, the availability of CRT is limited in many settings. Objective: The aim of this study was to examine whether Web-based CRT combined with a SE program can improve the rate return to work of people with severe mental illness. Methods: A total of 86 people with severe mental illness (mean age 39.6 years; male: n=55) who were unemployed and who had joined a SE program were randomized to either a Web-based CRT program (CogRem) or an Internet-based control condition (WebInfo). Primary outcome measured was hours worked over 6 months post treatment. Results: At 6 months, those participants randomized to CogRem had worked significantly more hours (P=.01) and had earned significantly more money (P=.03) than those participants randomized to the WebInfo control condition. No change was observed in cognition. Conclusions: This study corroborates other work that has found a synergistic effect of combining CRT with a SE program and extends this to the use of Web-based CRT. The lack of any improvement in cognition obscures the mechanism by which an improved wage outcome for participants randomized to the active treatment was achieved. However, the study substantially lowers the barrier to the deployment of CRT with other psychosocial interventions for severe mental illness. Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR) 12611000849998; (Archived by WebCite at

  • A comparison between survey administration on paper, tablet, and mobile phone. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by the authors.

    Assessing the Equivalence of Paper, Mobile Phone, and Tablet Survey Responses at a Community Mental Health Center Using Equivalent Halves of a...


    Background: The computerized administration of self-report psychiatric diagnostic and outcomes assessments has risen in popularity. If results are similar enough across different administration modalities, then new administration technologies can be used interchangeably and the choice of technology can be based on other factors, such as convenience in the study design. An assessment based on item response theory (IRT), such as the Patient-Reported Outcomes Measurement Information System (PROMIS) depression item bank, offers new possibilities for assessing the effect of technology choice upon results. Objective: To create equivalent halves of the PROMIS depression item bank and to use these halves to compare survey responses and user satisfaction among administration modalities—paper, mobile phone, or tablet—with a community mental health care population. Methods: The 28 PROMIS depression items were divided into 2 halves based on content and simulations with an established PROMIS response data set. A total of 129 participants were recruited from an outpatient public sector mental health clinic based in Memphis. All participants took both nonoverlapping halves of the PROMIS IRT-based depression items (Part A and Part B): once using paper and pencil, and once using either a mobile phone or tablet. An 8-cell randomization was done on technology used, order of technologies used, and order of PROMIS Parts A and B. Both Parts A and B were administered as fixed-length assessments and both were scored using published PROMIS IRT parameters and algorithms. Results: All 129 participants received either Part A or B via paper assessment. Participants were also administered the opposite assessment, 63 using a mobile phone and 66 using a tablet. There was no significant difference in item response scores for Part A versus B. All 3 of the technologies yielded essentially identical assessment results and equivalent satisfaction levels. Conclusions: Our findings show that the PROMIS depression assessment can be divided into 2 equivalent halves, with the potential to simplify future experimental methodologies. Among community mental health care recipients, the PROMIS items function similarly whether administered via paper, tablet, or mobile phone. User satisfaction across modalities was also similar. Because paper, tablet, and mobile phone administrations yielded similar results, the choice of technology should be based on factors such as convenience and can even be changed during a study without adversely affecting the comparability of results.

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  • Analysis of hourly variations in search engine query volumes for depression-related health information

    Date Submitted: Oct 10, 2017

    Open Peer Review Period: Oct 10, 2017 - Dec 5, 2017

    Background: Depression is one of the most burdensome noncommunicable diseases in the world. One of the characteristics of depression is diurnal mood variation (DMV), which refers to noticeable daily c...

    Background: Depression is one of the most burdensome noncommunicable diseases in the world. One of the characteristics of depression is diurnal mood variation (DMV), which refers to noticeable daily changes in the overall mood state in individuals suffering from depression. Studying search engine data for depression-related health information seeking behaviour has the potential to provide new meaningful insights into DMVs, as individuals suffering from mental health issues are more likely to seek information about their problems online. This kind of infodemiological research is promising, and has been shown to be reliable for predicting patterns of both communicable and noncommunicable diseases. Objective: The objective of this study is to analyse hourly search engine query data to find evidence for diurnal mood variation in Finland. Methods: Query volume data in the form of relative search volume (RSV) for six depression-related queries in Finland was downloaded from the Google Trends database. Data was downloaded every week to obtain data for every hour during the month of March 2017. This resulted in a relative search volume value for 744 hours for the six query terms (n=4464). Arithmetical means for the RSVs of the search queries for the different hours of the day were calculated. The hourly data was also trichotomized and analysed in three time blocks: 0.00 a.m. - 7.59 a.m, 8.00 a.m. - 3.59 p.m. and 4.00 p.m. - 11.59 p.m. to make comparisons between different time periods during the 24 hours of the day. Results: All query term volumes showed a unimodal regular pattern during the 24 hours of the day, with increasing search volumes from the evening towards midnight and decreasing interest from 3.00 a.m. towards morning. Analysis of mean search activity of the three time blocks showed peaks in the first time block (00.00 a.m. – 7.59 a.m.) for all six terms. The search volumes decreased significantly during the second time block (8.00 a.m. - 3.59 p.m), and rose again between the third (4.00 p.m. - 11.59 p.m) and the first time block. Conclusions: Search engine query data support the notion of the evening-worse pattern in depression. Symptoms of diurnal mood variation may be tracked by monitoring changes in Google search engine query volume during the different hours of the day. Information on the timely nature of depression on an hourly level could improve the chances for early intervention.

  • Feasibility and acceptability of a web-based treatment with telephone support for postpartum women with anxiety: A randomized controlled trial

    Date Submitted: Oct 6, 2017

    Open Peer Review Period: Oct 8, 2017 - Dec 3, 2017

    Background: Postpartum anxiety can have adverse effects on the mother and child if left untreated. Time constraints and stigma are common barriers to postpartum treatment. Web-based treatments offer p...

    Background: Postpartum anxiety can have adverse effects on the mother and child if left untreated. Time constraints and stigma are common barriers to postpartum treatment. Web-based treatments offer potential flexibility and anonymity. “What Am I Worried About” (WaWa) is self-guided treatment based on cognitive behavioral and mindfulness principles for women experiencing postpartum anxiety. WaWa was developed in Australia and consists of nine modules with optional weekly telephone support. WaWa was adapted to a web-based version for the use in England (iWaWa). Objective: This study aimed to investigate the feasibility (engagement and usability), acceptability (usefulness, satisfaction, and helpfulness), and potential efficacy of iWaWa among English postpartum women with anxiety. Methods: Postpartum (<12 months) women with mild to severe anxiety were recruited anonymously via social media during an 8-week period. Participants were randomized to the iWaWa treatment (8 weeks) or wait-list control conditions. Treatment and study feasibility and acceptability were assessed post-treatment and anxiety symptoms were assessed before treatment, immediately after treatment and 1-month later using online questionnaires. Semi-structured telephone interviews were carried out after the treatment period for a more in-depth exploration of treatment acceptability and feasibility. Results: Eighty-nine eligible women were recruited through social media and randomized into the treatment (n=46) or wait-list control condition (n=43). Women were predominantly White/Caucasian, well-educated, married, on maternity leave, first-time mothers and reported moderate levels of anxiety. Drop-out rates were high, especially in the treatment group (treatment: 82.60%, n=38; waitlist-control: 51.16%, n=22). Twenty-six women started iWaWa with only two women completing all nine modules. Anxiety levels decreased significantly for both groups from baseline to the 8-week follow-up, but there was no difference between the groups. Quantitative and qualitative data suggest iWaWa was experienced as generally useful and helpful. Participants enjoyed iWaWa’s accessibility, anonymity and weekly reminders, as well as the introduction to the principles of cognitive-behavioural therapy and mindfulness. However, iWaWa was also experienced as not user-friendly enough, too wordy and long and not smartphone-friendly. Parts of the content were experienced as not always relevant and appropriate. Participants felt that iWaWa could be improved by having it in a smartphone app format and by making the content more concise and inclusive of different parenting styles. Conclusions: Despite interest in iWaWa, the results suggest that both the study and iWaWa were not feasible in the current format. However, this first trial provides useful evidence about treatment format and content preferences which can inform research and development of web-based postpartum anxiety treatments to optimize adherence. Clinical Trial: NCT02434406

  • Digital access in working age and older adults and their carers attending psychiatry outpatient clinics

    Date Submitted: Oct 6, 2017

    Open Peer Review Period: Oct 8, 2017 - Dec 3, 2017

    Background: Background: It has been suggested that improving access to mental health services, supporting self-management and increasing clinical productivity can be achieved through the delivery of...

    Background: Background: It has been suggested that improving access to mental health services, supporting self-management and increasing clinical productivity can be achieved through the delivery of technology-enabled care via personal mobile and internet-based services, but there is little evidence available about whether working age and older adults with mental health problems or their carers have access to these technologies, or their confidence with these technologies. Objective: To ascertain the prevalence and range of devices used to access the internet in patients and carers attending general and older adult psychiatry outpatient services, and their confidence in using these technologies. Methods: We conducted an anonymous survey of 77 patients and carers from a general psychiatry and old age psychiatry clinic to determine rates of internet access and device ownership, and attitudes to technology enabled care. Results: We found high levels of internet access and confidence in using the internet in working age adults, their carers, and older adult carers but not in older adult patients. Smartphone usage predominated in working age adults and their carers. Older adult carers were more likely to use desktop or laptop computers. In our sample, tablets were the least popular form factor. Conclusions: Access rates and uptake of internet based services have the potential to be high in working age adults and their carers, but are likely to be significantly lower among older adult patients attending psychiatry clinics. Applications designed for tablets are likely to have low uptake. All groups identified appointment reminders as likely to be beneficial.

  • Youth Co-design Of A Mobile Phone app to facilitate self-monitoring and management of mood symptoms in young people with major depression, suicidal ideation and self-harm

    Date Submitted: Sep 26, 2017

    Open Peer Review Period: Sep 26, 2017 - Nov 21, 2017

    Background: Effective treatment of depression in young people is critical given its prevalence, impacts and link to suicide. Clinical practice guidelines point to the need for regular monitoring of de...

    Background: Effective treatment of depression in young people is critical given its prevalence, impacts and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation, to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice. Objective: We aimed to address the gap between guidelines about monitoring and real-world practice by co-designing an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician. Methods: We engaged young people aged 18 to 25 who had experienced depression, suicidal ideation and/or self-harm, as well as clinicians in a co-design process. We used a human centred co-design “design studio” methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low fidelity hand drawn wireframes. Clinicians were engaged throughout the process via focus groups. Results: The app incorporated a mood monitoring feature with innovative design aspects that allowed customisation, and was named a ‘well-being tracker’ in response to the need for a positive approach to this function. Brief personalised interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (i.e., responding in a timely manner) and will need to be addressed in the full implementation of the app into clinical services. Conclusions: The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress, and increase access to timely and evidence based interventions are desirable outcomes. To achieve positive outcomes for young people using technology (app) based interventions, it is critical to understand an incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

  • Lamotrigine therapy for bipolar depression: Analysis of self-reported patient data

    Date Submitted: Sep 23, 2017

    Open Peer Review Period: Sep 24, 2017 - Nov 19, 2017

    Lamotrigine is an anticonvulsant used for the treatment of bipolar disorder, especially for depressive episodes. A randomized placebo controlled trial was conducted and self-reported mood scores were...

    Lamotrigine is an anticonvulsant used for the treatment of bipolar disorder, especially for depressive episodes. A randomized placebo controlled trial was conducted and self-reported mood scores were collected over a period of 52 weeks. Different features were computed from the weekly time series produced by each subject. The coefficient of variation (σ/μ) and detrended fluctuation analysis scaling exponent (α), a measure of scaling and long-range persistence (long memory) in time series, were selected as having the most explanatory power. Data from patients taking lamotrigine show a general decrease in depression score in comparison to the patients taking placebo. The time series of lamotrigine patients tend to be rougher than the placebo group. A classifier was built and, based on the two chosen metrics, we are able to achieve a classification accuracy of more than 60% in predicting the treatment mode.

  • Psychosocial assessment using telehealth in adolescent and young adults with cancer: A randomised pilot study

    Date Submitted: Sep 1, 2017

    Open Peer Review Period: Sep 3, 2017 - Oct 29, 2017

    Background: Adolescent and young adults (AYAs) with cancer are at increased risk of psychosocial difficulties relative to their healthy peers. Current models of in-patient face-to-face psychosocial ca...

    Background: Adolescent and young adults (AYAs) with cancer are at increased risk of psychosocial difficulties relative to their healthy peers. Current models of in-patient face-to-face psychosocial care, whilst essential, may limit the capacity for clinicians to provide timely and personalised assessment and intervention to AYAs who are unable to attend due to barriers such as time, logistics, distance to travel and stigma. Telehealth offers a promising alternative towards increasing access to the provision of evidence-based psychosocial assessment and treatment for AYAs with cancer. Objective: This partially-randomised patient-preference pilot study aimed to examine the feasibility and acceptability of providing psychosocial assessment via telehealth to AYAs currently receiving treatment for cancer, relative to face-to-face delivery. Methods: Patients were eligible if they were: between the ages of 15-25; currently receiving treatment; had sufficient English; and were medically stable. Patients were recruited from oncology clinics/wards, and allocated to receive a psychosocial assessment (AYA Oncology Psychosocial Assessment Measure) with a clinical psychologist or social worker via face-to-face or telehealth modalities using a partially-randomised patient preference model. Patients completed a pre- and post-assessment questionnaire including validated and purposely designed feasibility and acceptability indices (YSQ, Treatment Credibility and Expectations Questionnaire, WAI) and measures of psychosocial wellbeing (K10, Peds-QL-AYA, AYA Oncology Screening Tool). Clinicians also completed a post-assessment questionnaire rating their impressions of the acceptability and feasibility of the intervention delivery via each modality. Results: Patients were recruited from three hospitals in Australia. Of 29 patients approached, 23 consented to participate (response rate = 79%). Participants were randomised to either the telehealth (n=8; 35%; mean age=16.50 years [range=15-23]; females=4 [50%]) or face-to-face (n=11; 62%; mean age=17 years [range=15-22]; females=8 [72.70%]) conditions. Four participants were withdrawn due to logistical/medical complications (attrition rate = 17.4%). The majority 6/8 (75%) of participants in the telehealth group used their own computer/iPad with minor technical difficulties occurring in 3/8 (37.5%) of assessments. Participants from both groups rated high working alliance (WAI: median patient response in the telehealth group = 74 [range: 59-84] and face to face group = 63 [range: 51-84]) and reported positive beliefs regarding the credibility and expectations of their treatment group. Post-assessment preferences between face-to-face or online modalities varied. The majority of patients in the telehealth group (5/8, 63%) reported no preference, whilst 6/11 (55%) in the face-to-face group reported a preference for the face-to-face modality. Conclusions: This study demonstrated that telehealth was acceptable, patient comfort was comparable across modalities, and no significant technological barriers were experienced. Despite this, patients varied in their preferred interview modality, highlighting the need to tailor treatment to patient preference and circumstance. Clinical Trial: ACTRN12614001142628,