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  Anxiety and Stress Disorders

  May 15, 2019

  Economic Evaluation of an Internet-Based Stress Management Intervention Alongside a Randomized Controlled Trial

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  Authors List:

  • Fanny Kählke  
  • Claudia Buntrock  
  • Filip Smit  
  • Matthias Berking  
  • Dirk Lehr  
  • Elena Heber  
  • Burkhardt Funk  
  • Heleen Riper  
  • David Daniel Ebert  

  Abstract:

  Background: Work-related stress is widespread among employees and associated with high costs for German society. Internet-based stress management interventions (iSMIs) are effective in reducing such stress. However, evidence for their cost-effectiveness is scant. Objective: The aim of this study was to assess the cost-effectiveness of a guided iSMI for employees. Methods: A sample of 264 employees with elevated symptoms of perceived stress (Perceived Stress Scale≥22) was assigned to either the iSMI or a waitlist control condition (WLC) with unrestricted access to treatment as usual. Participants were recruited in Germany in 2013 and followed through 2014, and data were analyzed in 2017. The iSMI consisted of 7 sessions plus 1 booster session. It was based on problem-solving therapy and emotion regulation techniques. Costs were measured from the societal perspective, including all direct and indirect medical costs. We performed a cost-effectiveness analysis and a cost-utility analysis relating costs to a symptom-free person and quality-adjusted life years (QALYs) gained, respectively. Sampling uncertainty was handled using nonparametric bootstrapping (N=5000). Results: When the society is not willing to pay anything to get an additional symptom-free person (eg, willingness-to-pay [WTP]=€0), there was a 70% probability that the intervention is more cost-effective than WLC. This probability rose to 85% and 93% when the society is willing to pay €1000 and €2000, respectively, for achieving an additional symptom-free person. The cost-utility analysis yielded a 76% probability that the intervention is more cost-effective than WLC at a conservative WTP threshold of €20,000 (US $25,800) per QALY gained. Conclusions: Offering an iSMI to stressed employees has an acceptable likelihood of being cost-effective compared with WLC. Trial Registration: German Clinical Trials Register DRKS00004749; https://www.drks.de/DRKS00004749 International Registered Report Identifier (IRRID): RR2-10.1186/1471-2458-13-655

  • JMIR Ment Health 2019;6(5):e10866

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  Anxiety and Stress Disorders

  May 13, 2019

  Influence of Personality and Differences in Stress Processing Among Finnish Students on Interest to Use a Mobile Stress Management App: Survey Study

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  Authors List:

  • Mari Ervasti  
  • Johanna Kallio  
  • Ilmari Määttänen  
  • Jani Mäntyjärvi  
  • Markus Jokela  

  Abstract:

  Background: Excessive stress has a negative impact on many aspects of life for both individuals and societies, from studying and working to health and well-being. Each individual has their unique level of stress-proneness, and positive or negative outcomes of stress may be affected by it. Technology-aided interventions have potential efficacy in the self-management of stress. However, current Web-based or mobile stress management solutions may not reach the individuals that would need them the most, that is, stress-sensitive people. Objective: The aim of this study was to examine how personality is associated with stress among Finnish university students and their interest to use apps that help in managing stress. Methods: We used 2 structured online questionnaires (combined, n=1001) that were advertised in the University of Helsinki’s mailing lists. The first questionnaire (n=635) was used to investigate intercorrelations between the Big Five personality variables (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and other stress-related background variables. The second questionnaire (n=366) was used to study intercorrelations between the above-mentioned study variables and interest in using stress management apps. Results: The quantitative findings of the first questionnaire showed that higher levels of extraversion, agreeableness, and conscientiousness were associated with lower self-reported stress. Neuroticism, in turn, was found to be strongly associated with rumination, anxiety, and depression. The findings of the second questionnaire indicated that individuals characterized by the Big Five personality traits of neuroticism and agreeableness were particularly interested to use stress management apps (r=.27, P<.001 and r=.11, P=.032, respectively). Moreover, the binary logistic regression analysis revealed that when a person’s neuroticism is one SD above average (ie, it is higher than among 84% of people), the person has roughly 2 times higher odds of being interested in using a stress management app. Respectively, when a person’s agreeableness is one SD above average, the person has almost 1.4 times higher odds of being interested in using a stress management app. Conclusions: Our results indicated that personality traits may have an influence on the adoption interest of stress management apps. Individuals with high neuroticism are, according to our results, adaptive in the sense that they are interested in using stress management apps that may benefit them. On the contrary, low agreeableness may lead to lower interest to use the mobile stress management apps. The practical implication is that future mobile stress interventions should meaningfully be adjusted to improve user engagement and support health even among less-motivated users, for instance, to successfully engage individuals with low agreeableness.

  • JMIR Ment Health 2019;6(5):e10039

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  Special Issue on Video Games for...

  May 9, 2019

  Using Computer Games to Support Mental Health Interventions: Naturalistic Deployment Study

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  Authors List:

  • Hidde van der Meulen  
  • Darragh McCashin  
  • Gary O'Reilly  
  • David Coyle  

  Abstract:

  Background: Recent research has highlighted naturalistic uptake as a key barrier to maximizing the impact of mental health technologies. Although there is increasing evidence regarding the efficacy of digital interventions for mental health, as demonstrated through randomized controlled trials, there is also evidence that technologies do not succeed as expected when deployed in real-world settings. Objective: This paper describes the naturalistic deployment of Pesky gNATs, a computer game designed to support cognitive behavioral therapy (CBT) for children experiencing anxiety or low mood. The objective of this deployment study was to identify how therapists use Pesky gNATs in real-world settings and to discover positive and negative factors. On the basis of this, we aimed to derive generalizable recommendations for the development of mental health technologies that can have greater impact in real-world settings. Methods: Pesky gNATs has been made available through a not-for-profit organization. After 18 months of use, we collected usage and user experience data from therapists who used the game. Data were collected through an online survey and semistructured interviews addressing the expectations and experiences of both therapists and young people. Thematic analysis was used to identify key themes in the interview and survey data. Results: A total of 21 therapists, who used Pesky gNATs with 95 young people, completed the online survey. Furthermore, 5 therapists participated in the follow-up interview. Confirming previous assessments, data suggest that the game can be helpful in delivering therapy and that young people generally liked the approach. Therapists shared diverse opinions regarding the young people for whom they deemed the game appropriate. The following 3 themes were identified: (1) stages of use, (2) impact on the delivery of therapy, and (3) customization. We discuss therapists’ reflections on the game with regard to their work practices and consider the question of customization, including the delicate balance of adaptable interaction versus the need for fidelity to a therapeutic model. Conclusions: This study provides further evidence that therapeutic games can support the delivery of CBT for young people in real-world settings. It also shows that deployment studies can provide a valuable means of understanding how technologies integrate with the overall mental health ecosystem and become a part of therapists' toolbox. Variability in use should be expected in real-world settings. Effective training, support for therapist autonomy, careful consideration of different approaches to customization, the reporting of deployment data, and support for communities of practice can play an important role in supporting variable, but effective, use.

  • JMIR Ment Health 2019;6(5):e12430

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  Mental Health Games

  May 8, 2019

  The Importance of User Segmentation for Designing Digital Therapy for Adolescent Mental Health: Findings From Scoping Processes

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  Authors List:

  • Theresa Fleming  
  • Sally Merry  
  • Karolina Stasiak  
  • Sarah Hopkins  
  • Tony Patolo  
  • Stacey Ruru  
  • Manusiu Latu  
  • Matthew Shepherd  
  • Grant Christie  
  • Felicity Goodyear-Smith  

  Abstract:

  Background: New Zealand youth, especially those of Māori and Pacific descent, have high rates of depression, anxiety, and self-harm, but have low rates of help-seeking from mental health professionals. Apps, computerized therapy, and other digital tools can be effective, highly scalable treatments for anxiety and depression. Co-design processes are often used to foster engagement with end users, but this does not always lead to high levels of engagement. Objective: We aimed to carry out preliminary scoping to understand adolescents’ current internet use and diversity of preferences to inform a planned co-design process for creating digital mental health tools for teenagers. Methods: Interactive workshops and focus groups were held with young people. Data were analyzed using a general inductive approach. Results: Participants (N=58) engaged in 2 whānau (extended family) focus groups (n=4 and n=5), 2 school- or community-based focus groups (n=9 each), and 2 workshops (n=11 and n=20). The authors identified 3 overarching themes: (1) Digital mental health tools are unlikely to be successful if they rely solely on youth help-seeking. (2) A single approach is unlikely to appeal to all. Participants had diverse, noncompatible preferences in terms of look or feel of an app or digital tool. The authors identified 4 user groups players or gamers, engagers, sceptics, and straight-talkers. These groups differed by age and degree of current mental health need and preferred gamified or fun approaches, were open to a range of approaches, were generally disinterested, or preferred direct-to-the-point, serious approaches, respectively. (3) Digital mental health tools should provide an immediate response to a range of different issues and challenges that a young person may face. Conclusions: Defining the preferences of different groups of users may be important for increasing engagement with digital therapies even within specific population and mental health–need groups. This study demonstrates the importance of scoping possible user needs to inform design processes.

  • JMIR Ment Health 2019;6(5):e12656

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  Mindfulness

  May 8, 2019

  Association Between Improvement in Baseline Mood and Long-Term Use of a Mindfulness and Meditation App: Observational Study

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  Authors List:

  • Argus J Athanas  
  • Jamison M McCorrison  
  • Susan Smalley  
  • Jamie Price  
  • Jim Grady  
  • Julie Campistron  
  • Nicholas J Schork  

  Abstract:

  Background: The use of smartphone apps to monitor and deliver health care guidance and interventions has received considerable attention recently, particularly with regard to behavioral disorders, stress relief, negative emotional state, and poor mood in general. Unfortunately, there is little research investigating the long-term and repeated effects of apps meant to impact mood and emotional state. Objective: We aimed to investigate the effects of both immediate point-of-intervention and long-term use (ie, at least 10 engagements) of a guided meditation and mindfulness smartphone app on users’ emotional states. Data were collected from users of a mobile phone app developed by the company Stop, Breathe & Think (SBT) for achieving emotional wellness. To explore the long-term effects, we assessed changes in the users’ basal emotional state before they completed an activity (eg, a guided meditation). We also assessed the immediate effects of the app on users’ emotional states from preactivity to postactivity. Methods: The SBT app collects information on the emotional state of the user before and after engagement in one or several mediation and mindfulness activities. These activities are recommended and provided by the app based on user input. We considered data on over 120,000 users of the app who collectively engaged in over 5.5 million sessions with the app during an approximate 2-year period. We focused our analysis on users who had at least 10 engagements with the app over an average of 6 months. We explored the changes in the emotional well-being of individuals with different emotional states at the time of their initial engagement with the app using mixed-effects models. In the process, we compared 2 different methods of classifying emotional states: (1) an expert-defined a priori mood classification and (2) an empirically driven cluster-based classification. Results: We found that among long-term users of the app, there was an association between the length of use and a positive change in basal emotional state (4% positive mood increase on a 2-point scale every 10 sessions). We also found that individuals who were anxious or depressed tended to have a favorable long-term emotional transition (eg, from a sad emotional state to a happier emotional state) after using the app for an extended period (the odds ratio for achieving a positive emotional state was 3.2 and 6.2 for anxious and depressed individuals, respectively, compared with users with fewer sessions). Conclusions: Our analyses provide evidence for an association between both immediate and long-term use of an app providing guided meditations and improvements in the emotional state.

  • JMIR Ment Health 2019;6(5):e12617

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  Special Issue on Video Games for...

  May 8, 2019

  Gaming With Stigma: Analysis of Messages About Mental Illnesses in Video Games

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  Authors List:

  • Manuela Ferrari  
  • Sarah V McIlwaine  
  • Gerald Jordan  
  • Jai L Shah  
  • Shalini Lal  
  • Srividya N Iyer  

  Abstract:

  Background: Video game playing is a daily activity for many youths that replaces other media forms (eg, television); it serves as an important source of knowledge and can potentially impact their attitudes and behaviors. Researchers are, thus, concerned with the impact of video gaming on youth (eg, for promoting prosocial or antisocial behavior). Studies have also begun to explore players’ experience of gameplay and video game messages about violence, sexism, and racism; however, little is known about the impact of commercial video games in the sharing and shaping of knowledge, and messages about mental illness. Objective: The aim of this review was to identify how mental illness, especially psychosis, is portrayed in commercial video games. Methods: We performed keyword searches on games made available between January 2016 and June 2017 on Steam (a popular personal computer gaming platform). A total of 789 games were identified and reviewed to assess whether their game content was related to mental illness. At the end of the screening phase, a total of 100 games were retained. Results: We used a game elements framework (characters, game environment/atmosphere, goals, etc) to describe and unpack messages about mental health and illness in video games. The majority of the games we reviewed (97%, 97/100) portrayed mental illness in negative, misleading, and problematic ways (associating it with violence, fear, insanity, hopelessness, etc). Furthermore, some games portrayed mental illness as manifestations or consequences of supernatural phenomena or paranormal experiences. Mental illness was associated with mystery, the unpredictable, and as an obscure illness; its treatment was also associated with uncertainties, as game characters with mental illness had to undergo experimental treatment to get better. Unfortunately, little or no hope for recovery was present in the identified video games, where mental illness was often presented as an ongoing struggle and an endless battle with the mind and oneself. Conclusions: The game elements of the identified commercial video games included mental illness, about which many perpetuated well-known stereotypes and prejudices. We discuss the key findings in relation to current evidence on the impact of media portrayals of mental illness and stigma. Furthermore, we reflect on the ability of serious video games to promote alternative messages about mental illness and clinical practices. Future research is needed to investigate the impact that such messages have on players and to explore the role that video games can play in fostering alternative messages to reduce the stigma associated with mental illness.

  • JMIR Ment Health 2019;6(5):e12418

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  Depression and Mood Disorders;...

  May 7, 2019

  An Approach for Data Mining of Electronic Health Record Data for Suicide Risk Management: Database Analysis for Clinical Decision Support

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  Authors List:

  • Sofian Berrouiguet  
  • Romain Billot  
  • Mark Erik Larsen  
  • Jorge Lopez-Castroman  
  • Isabelle Jaussent  
  • Michel Walter  
  • Philippe Lenca  
  • Enrique Baca-García  
  • Philippe Courtet  

  Abstract:

  Background: In an electronic health context, combining traditional structured clinical assessment methods and routine electronic health–based data capture may be a reliable method to build a dynamic clinical decision-support system (CDSS) for suicide prevention. Objective: The aim of this study was to describe the data mining module of a Web-based CDSS and to identify suicide repetition risk in a sample of suicide attempters. Methods: We analyzed a database of 2802 suicide attempters. Clustering methods were used to identify groups of similar patients, and regression trees were applied to estimate the number of suicide attempts among these patients. Results: We identified 3 groups of patients using clustering methods. In addition, relevant risk factors explaining the number of suicide attempts were highlighted by regression trees. Conclusions: Data mining techniques can help to identify different groups of patients at risk of suicide reattempt. The findings of this study can be combined with Web-based and smartphone-based data to improve dynamic decision making for clinicians.

  • JMIR Ment Health 2019;6(5):e9766

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  Methods and New Tools in Mental...

  May 3, 2019

  When All Else Fails, Listen to the Patient: A Viewpoint on the Use of Ecological Momentary Assessment in Clinical Trials

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  Authors List:

  • Aaron M Mofsen  
  • Thomas L Rodebaugh  
  • Ginger E Nicol  
  • Colin A Depp  
  • J Philip Miller  
  • Eric J Lenze  

  Abstract:

  A major problem in mental health clinical trials, such as depression, is low assay sensitivity in primary outcome measures. This has contributed to clinical trial failures, resulting in the exodus of the pharmaceutical industry from the Central Nervous System space. This reduced assay sensitivity in psychiatry outcome measures stems from inappropriately broad measures, recall bias, and poor interrater reliability. Limitations in the ability of traditional measures to differentiate between the trait versus state-like nature of individual depressive symptoms also contributes to measurement error in clinical trials. In this viewpoint, we argue that ecological momentary assessment (EMA)—frequent, real time, in-the-moment assessments of outcomes, delivered via smartphone—can both overcome these psychometric challenges and reduce clinical trial failures by increasing assay sensitivity and minimizing recall and rater bias. Used in this manner, EMA has the potential to further our understanding of treatment response by allowing for the assessment of dynamic interactions between treatment and distinct symptom response.

  • JMIR Ment Health 2019;6(5):e11845

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  Technology in Psychiatry/Clinical...

  Apr 29, 2019

  Applicability of Motivational Interviewing for Chronic Disease Management in Primary Care Following a Web-Based E-Learning Course: Cross-Sectional Study

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  Authors List:

  • Karoline Lukaschek  
  • Nico Schneider  
  • Mercedes Schelle  
  • Ulrik Bak Kirk  
  • Tina Eriksson  
  • Ilkka Kunnamo  
  • Andrée Rochfort  
  • Claire Collins  
  • Jochen Gensichen  

  Abstract:

  Background: Motivational interviewing (MI) is an established communication method for enhancing intrinsic motivation for changing health behavior. E-learning can reduce the cost and time involved in providing continuing education and can be easily integrated into individual working arrangements and the daily routines of medical professionals. Thus, a Web-based course was devised to familiarize health professionals with different levels of education and expertise with MI techniques for patients with chronic conditions. Objective: The aim of this study was to report participants’ opinion on the practicality of MI (as learned in the course) in daily practice, stratified by the level of education. Methods: Participants (N=607) of the MI Web-based training course evaluated the course over 18 months, using a self-administered questionnaire. The evaluation was analyzed descriptively and stratified for the level of education (medical students, physicians in specialist training [PSTs], and general practitioners [GPs]). Results: Participants rated the applicability of the skills and knowledge gained by the course as positive (medical students: 94% [79/84] good; PSTs: 88.6% [109/123] excellent; and GPs: 51.3% [182/355] excellent). When asked whether they envisage the use of MI in the future, 79% (67/84) of the students stated to a certain extent, 88.6% (109/123) of the PSTs stated to a great extent, and 38.6% (137/355) of GPs stated to a great extent. Participants acknowledged an improvement of communication skills such as inviting (medical students: 85% [72/84]; PSTs: 90.2% [111/123]; GPs: 37.2% [132/355]) and encouraging (medical students: 81% [68/84]; PSTs: 45.5% [56/123]; GPs: 36.3% [129/355]) patients to talk about behavior change and conveying respect for patient’s choices (medical students: 72% [61/84]; PSTs: 50.0% [61/123]; GPs: 23.4% [83/355]). Conclusions: Participants confirmed the practicality of MI. However, the extent to which the practicality of MI was acknowledged as well as its expected benefits depended on the individual’s level of education/expertise.

  • JMIR Ment Health 2019;6(4):e12540

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  Depression and Mood Disorders;...

  Apr 26, 2019

  Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru

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  Authors List:

  • Paulo Menezes  
  • Julieta Quayle  
  • Heloísa Garcia Claro  
  • Simone da Silva  
  • Lena R Brandt  
  • Francisco Diez-Canseco  
  • J Jaime Miranda  
  • LeShawndra N Price  
  • David C Mohr  
  • Ricardo Araya  

  Abstract:

  Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.

  • JMIR Ment Health 2019;6(4):e11698

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  Depression and Mood Disorders;...

  Apr 26, 2019

  Evaluating the Feasibility of an Innovative Self-Confidence Webinar Intervention for Depression in the Workplace: A Proof-of-Concept Study

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  Authors List:

  • Wan Mohd Azam Wan Mohd Yunus  
  • Peter Musiat  
  • June SL Brown  

  Abstract:

  Background: Depression in the workplace is a very common problem that exacerbates employees’ functioning and consequently influences the productivity of organizations. Despite the commonness of the problem and the currently available interventions, a high proportion of employees do not seek help. A new intervention, a webinar (Web-based seminar), was developed, which integrated the use of technology and the traditional guided therapist support to provide accessible help for the problem of depression in the workplace. Objective: The aim of this study was to explore the feasibility, preliminary outcome, and acceptability of the webinar intervention conducted in organizations. Methods: In total, 2 organizations were invited to participate, and 33 employees participated in this proof-of-concept study. The webinar intervention consisted of 6 1-hour sessions conducted via the Adobe Connect platform, developed by Adobe Inc. The intervention was developed based on a systematic review, focus group studies, and face-to-face self-confidence workshops that utilized cognitive behavior therapy (CBT). The final webinar intervention used CBT and the coping flexibility approach. The structure of the intervention included PowerPoint presentations, animation videos, utilization of chat panels, and whiteboard features. The intervention was conducted live and guided by a consultant psychologist assisted by a moderator. Study outcomes were self-assessed using self-reported Web surveys. The acceptability of the intervention was assessed using self-reported user experience Web surveys and open-ended questions. Results: The findings showed: (1) evidence of feasibility of the intervention: the webinar intervention was successfully conducted in 3 groups, with 6 1-hour sessions for each group, with 82% (23/28) participants completing all 6 sessions; (2) positive improvements in depression: the linear mixed effects modeling analysis recorded a significant overall effect of time primarily for depression (F2, 48.813=31.524; P<.001) with a Hedge g effect size of 0.522 at 1-month follow-up. Individually, 8 subjects showed significant reliable and clinically significant changes, with 3 subjects showing clinically significant change only; and (3) encouraging evidence regarding the acceptability of the webinar intervention among the employees: the user experience score was above average for 4 out of 6 domains measured (perspicuity mean 1.198 [95% CI 0.832-1.564], efficiency mean 1.000 [95% CI 0.571-1.429], dependability mean 1.208 [95% CI 0.899-1.517], and stimulation mean 1.323 [95% CI 0.987-1.659]). The open-ended questions also yielded 52% (47/91) of the responses that reported facilitators, whereas only 12% (11/91) of the responses reported barriers. Conclusions: The self-confidence webinar intervention appears to be a potentially feasible, effective, and acceptable intervention for depression in the workplace that merits further investigation.

  • JMIR Ment Health 2019;6(4):e11401

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  Substance Abuse

  Apr 25, 2019

  Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study

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  Authors List:

  • Eleanor Lee  
  • Richard J Cooper  

  Abstract:

  Background: The use of codeine as an analgesic is well-recognized, but there are increasing concerns that for some individuals continued use may lead to misuse, dependence, and fatalities. Research suggests that those affected may represent a hard-to-reach group who do not engage with formal treatment services. Objective: This study sought to explore the experiences of people with self-reported addiction to codeine and, specifically, how a social media forum is used to communicate with others about this issue. Methods: Using a qualitative netnographic methodology, the social media forum Mumsnet was used, with permission, and searches were undertaken in 2016 of any posts that related to codeine and addiction. A total of 95 relevant posts were identified; a purposive sample of 25 posts was selected to undertake subsequent six-stage thematic analysis and development of emerging themes. These 25 posts were posted between 2003 and 2016 and comprised 757 individual posts. Results: Individuals created posts to actively request help in relation to usually their own, but occasionally their partner’s or relative’s, problems relating to codeine use and self-reported “addiction.” Varying levels of detail were provided in narratives of problematic codeine use. There were both positive and negative descriptions of side effects emerging, problems experiencing withdrawal, and failed attempts to discontinue codeine use. Mainly positive and supportive responses to posts were identified from those with either self-reported health profession experience or lay respondents, who often drew on their own experiences of similar problems. Treatment advice emerged in two main ways, either as signposting to formal health services or to informal approaches and often anecdotal advice about how to taper or use cold turkey techniques. Some posts were more critical of the original poster, and arguments and challenges to advice were not uncommon. Shame and stigma were often associated with users’ posts and, while there was a desire to receive support and treatment advice in this forum, users often wanted to keep their codeine use hidden in other aspects of their lives. Distinctly different views emerged as to whether responsibility lay with prescribers or patients. Some users expressed anger toward doctors and their prescribing practices. Conclusions: This study provides a unique insight into how a public internet forum is used by individuals to confirm and seek support about problematic codeine use and of the ways others respond. The pseudonymous use of internet forums for such information and variation in treatment options suggested by often lay respondents suggest that increased formal support and awareness about codeine addiction are needed. There may be opportunities for providing further support directly on such online forums. Improvements in prescribing codeine and in the over-the-counter supply of codeine are required to prevent problematic use from occurring.

  • JMIR Ment Health 2019;6(4):e12354

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