JMIR Publications

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JMIR Mental Health

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


Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959) is a PubMed-indexed, peer-reviewed sister journal of JMIR, the leading eHealth journal by Impact Factor. (The projected inofficial impact factor for JMIR Mental Health is about 3.0)

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

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

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

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


Recent Articles:

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

    Influencing the Conversation About Masculinity and Suicide: Evaluation of the Man Up Multimedia Campaign Using Twitter Data


    Background: It has been suggested that some dominant aspects of traditional masculinity are contributing to the high suicide rates among Australian men. We developed a three-episode documentary called Man Up, which explores the complex relationship between masculinity and suicide and encourages men to question socially imposed rules about what it means to be a man and asks them to open up, express difficult emotions, and seek help if and when needed. We ran a three-phase social media campaign alongside the documentary using 5 channels (Twitter, Facebook, Instagram, YouTube, and Tumblr). Objective: This study aimed to examine the extent to which the Man Up Twitter campaign influenced the social media conversation about masculinity and suicide. Methods: We used Twitter insights data to assess the reach of and engagement with the campaign (using metrics on followers, likes, retweets, and impressions) and to determine the highest and lowest performing tweets in the campaign (using an aggregated performance measure of reactions). We used original content tweets to determine whether the campaign increased the volume of relevant Twitter conversations (aggregating the number of tweets for selected campaign hashtags over time), and we used a subset of these data to gain insight into the main content themes with respect to audience engagement. Results: The campaign generated a strong following that was engaged with the content of the campaign; over its whole duration, the campaign earned approximately 5000 likes and 2500 retweets and gained around 1,022,000 impressions. The highest performing tweets posted by the host included video footage and occurred during the most active period of the campaign (around the screening of the documentary). The volume of conversations in relation to commonly used hashtags (#MANUP, #ABCMANUP, #LISTENUP, and #SPEAKUP) grew in direct relation to the campaign activities, achieving strongest growth during the 3 weeks when the documentary was aired. Strongest engagement was found with content related to help-seeking, masculinity, and expressing emotions. A number of followers tweeted personal stories that revealed overwhelmingly positive perceptions of the content of the documentary and strongly endorsed its messages. Conclusions: The Man Up Twitter campaign triggered conversations about masculinity and suicide that otherwise may not have happened. For some, this may have been game-changing in terms of shifting attitudes toward expressing emotions and reaching out to others for help. The campaign was particularly effective in disseminating information and promoting conversations in real time, an advantage that it had over more traditional health promotion campaigns. This sort of approach could well be adapted to other areas of mental (and physical) health promotion campaigns to increase their reach and effectiveness.

  • Young person using MoodHwb (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Licensed by the authors.

    A Web-Based Psychoeducational Intervention for Adolescent Depression: Design and Development of MoodHwb


    Background: Depression is common in adolescence and leads to distress and impairment in individuals, families and carers. Treatment and prevention guidelines highlight the key role of information and evidence-based psychosocial interventions not only for individuals but also for their families and carers. Engaging young people in prevention and early intervention programs is a challenge, and early treatment and prevention of adolescent depression is a major public health concern. There has been growing interest in psychoeducational interventions to provide accurate information about health issues and to enhance and develop self-management skills. However, for adolescents with, or at high risk of depression, there is a lack of engaging Web-based psychoeducation programs that have been developed with user input and in line with research guidelines and targeted at both the individual and their family or carer. There are also few studies published on the process of development of Web-based psychoeducational interventions. Objective: The aim of this study was to describe the process underlying the design and development of MoodHwb (HwbHwyliau in Welsh): a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families, carers, friends, and professionals. Methods: The initial prototype was informed by (1) a systematic review of psychoeducational interventions for adolescent depression; (2) findings from semistructured interviews and focus groups conducted with adolescents (with depressive symptoms or at high risk), parents or carers, and professionals working with young people; and (3) workshops and discussions with a multimedia company and experts (in clinical, research, and multimedia work). Twelve interviews were completed (four each with young people, parents or carers, and professionals) and six focus groups (three with young people, one with parents and carers, one with professionals, and one with academics). Results: Key themes from the interviews and focus groups were: aims of the program, design and content issues, and integration and context of the program. The prototype was designed to be person-centered, multiplatform, engaging, interactive, and bilingual. It included mood-monitoring and goal-setting components and was available as a Web-based program and an app for mobile technologies. Conclusions: MoodHwb is a Web-based psychoeducational intervention developed for young people with, or at high risk of, depression and their families and carers. It was developed with user input using qualitative methods as well as user-centered design and educational and psychological theory. Further research is needed to evaluate the effectiveness of the program in a randomized controlled trial. If found to be effective, it could be implemented in health, education, youth and social services, and charities, to not only help young people but also families, carers, friends, and professionals involved in their care.

  • Work Addiction. Source: iStock by Getty Images; Copyright: Geber86; URL:; License: Licensed by the authors.

    Work Addiction Test Questionnaire to Assess Workaholism: Validation of French Version


    Background: Work addiction is a significant public health problem with a growing prevalence. The Work Addiction Risk Test (WART) is the gold standard questionnaire to detect workaholism. Objective: The main objective of this study was to validate the French version of the WART. Methods: Questionnaires were proposed to voluntary French workers using the WittyFit software. There were no exclusion criteria. The questionnaire was administered anonymously for initial validity testing and readministered one week later for test-retest reliability. We also assessed the workers’ sociodemographic characteristics, as well as other measurements for external validity, such as stress, well-being, and coaddictions to tobacco, alcohol, and cannabis. Several psychometric properties of the French-WART were explored: acceptability, reliability (internal consistency [Cronbach alpha coefficient] and reproducibility [Lin concordance coefficient]), construct validity (correlation coefficients and principal component analysis), and external validity (correlation coefficients). Results: Among the 1580 workers using WittyFit, 187 (11.83%) agreed to complete the WART questionnaire. Of those, 128 completed the test-retest survey (68.4%). Acceptability found that all respondents had fully completed the questionnaire, with few floor or ceiling effects. Reliability was very good with a Cronbach alpha coefficient at .90 (internal consistency) and Lin concordance coefficient at .90 (95% CI .87-.94] with a difference on the retest of .04 (SD 4.9) (95% CI −9.6 to 9.7) (reproducibility). We identified three main dimensions (construct validity). Relationships between WART and stress and well-being confirmed its external validity. Conclusions: The French version of the WART is a valid and reliable instrument to assess work addiction with satisfactory psychometric properties. Used in occupational medicine, this tool would allow the diagnosis of work addiction and can be easily implemented in current practice.

  • Source: Wikimedia Commons; Copyright: MC4 Army; URL:; License: Creative Commons Attribution (CC-BY).

    Open Notes in Swedish Psychiatric Care (Part 1): Survey Among Psychiatric Care Professionals


    Background: When the Swedish version of Open Notes, an electronic health record (EHR) service that allows patients online access, was introduced in hospitals, primary care, and specialized care in 2012, psychiatric care was exempt. This was because psychiatric notes were considered too sensitive for patient access. However, as the first region in Sweden, Region Skåne added adult psychiatry to its Open Notes service in 2015. This made it possible to carry out a unique baseline study to investigate how different health care professionals (HCPs) in adult psychiatric care in the region expect Open Notes to impact their patients and their practice. This is the first of two papers about the implementation of Open Notes in adult psychiatric care in Region Skåne. Objective: The objective of this study was to describe, compare, and discuss how different HCPs in adult psychiatric care in Region Skåne expect Open Notes to impact their patients and their own practice. Methods: A full population Web-based questionnaire was distributed to psychiatric care professionals in Region Skåne in late 2015. The response rate was 28.86% (871/3017). Analyses show that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between different professionals and attitudes to the Open Notes service. Results: The results show that the psychiatric HCPs are generally of the opinion that the service would affect their own practice and their patients negatively. The most striking result was that more than 60% of both doctors (80/132, 60.6%) and psychologists (55/90, 61%) were concerned that they would be less candid in their documentation in the future. Conclusions: Open Notes can increase the transparency between patients and psychiatric HCPs because patients are able to access their EHRs online without delay and thus, can read notes that have not yet been approved by the responsible HCP. This may be one explanation as to why HCPs are concerned that the service will affect both their own work and their patients.

  • Participant using the "My Self-Help Tool" decision aid. Source: Pixabay; Copyright: Kathy Bugajsky; URL:;

    Web-Based Decision Aid to Assist Help-Seeking Choices for Young People Who Self-Harm: Outcomes From a Randomized Controlled Feasibility Trial


    Background: Adolescents who self-harm are often unsure how or where to get help. We developed a Web-based personalized decision aid (DA) designed to support young people in decision making about seeking help for their self-harm. Objective: The aim of this study was to evaluate the feasibility and acceptability of the DA intervention and the randomized controlled trial (RCT) in a school setting. Methods: We conducted a two-group, single blind, randomized controlled feasibility trial in a school setting. Participants aged 12 to 18 years who reported self-harm in the past 12 months were randomized to either a Web-based DA or to general information about mood and feelings. Feasibility of recruitment, randomization, and follow-up rates were assessed, as was acceptability of the intervention and study procedures. Descriptive data were collected on outcome measures examining decision making and help-seeking behavior. Qualitative interviews were conducted with young people, parents or carers, and staff and subjected to thematic analysis to explore their views of the DA and study processes. Results: Parental consent was a significant barrier to young people participating in the trial, with only 17.87% (208/1164) of parents or guardians who were contacted for consent responding to study invitations. Where parental consent was obtained, we were able to recruit 81.7% (170/208) of young people into the study. Of those young people screened, 13.5% (23/170) had self-harmed in the past year. Ten participants were randomized to receiving the DA, and 13 were randomized to the control group. Four-week follow-up assessments were completed with all participants. The DA had good acceptability, but qualitative interviews suggested that a DA that addressed broader mental health problems such as depression, anxiety, and self-harm may be more beneficial. Conclusions: A broad-based mental health DA addressing a wide range of psychosocial problems may be useful for young people. The requirement for parental consent is a key barrier to intervention research on self-harm in the school setting. Adaptations to the research design and the intervention are needed before generalizable research about DAs can be successfully conducted in a school setting. Trial Registration: International Standard Randomized Controlled Trial registry: ISRCTN11230559; (Archived by WebCite at

  • Source: Pixabay; Copyright: rebcenter-moscow; URL:; License: Public Domain (CC0).

    Facilitating Factors and Barriers to the Use of Emerging Technologies for Suicide Prevention in Europe: Multicountry Exploratory Study


    Background: This study provides an analysis on the use of emerging technologies for the prevention of suicide in 8 different European countries. Objective: The objective of this study was to analyze the potentiality of using emerging technologies in the area of suicide prevention based on the opinion of different professionals involved in suicide prevention. Methods: Opinions of 3 groups of stakeholders (ie, relevant professionals in suicide field) were gathered using a specifically designed questionnaire to explore dimensions underlying perceptions of facilitating factors and barriers in relation to the use of emerging technologies for suicide prevention. Results: Goal 1 involved facilitating factors for the use of emerging technologies in suicide prevention. Northern European countries, except for Belgium, attach greater relevance to those that optimize implementation and benefits. On the other hand, Southern European countries attach greater importance to professionally oriented and user-centered facilitating factors. According to different stakeholders, the analysis of these facilitating factors suggest that professionals in the field of social work attach greater relevance to those that optimize implementation and benefits. However, professionals involved in the area of mental health, policy makers, and political decision makers give greater importance to professionally oriented and user-centered facilitating factors. Goal 2 was related to barriers to the usability of emerging technologies for suicide prevention. Both countries and stakeholders attach greater importance to barriers associated with resource constraints than to those centered on personal limitations. There are no differences between countries or between stakeholders. Nevertheless, there is a certain stakeholders-countries interaction that indicates that the opinions on resource constraints expressed by different stakeholders do not follow a uniform pattern in different countries, but they differ depending on the country. Conclusions: Although all countries and stakeholders agree in identifying resource constraints as the main barrier to the use of emerging technologies, factors facilitating their use in suicide prevention differ among countries and among stakeholders.

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

    Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation,...


    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: The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning 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 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign 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 customization, and was named a “well-being tracker” in response to the need for a positive approach to this function. Brief personalized 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 (ie, responding in a timely manner) and will need to be addressed during 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 increasing 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 and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

  • Source: Flickr; Copyright: Image Catalog; URL:; License: Public Domain (CC0).

    Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial


    Background: The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy. Objective: This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks. Methods: We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers. Results: We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t41=1.05, P=.30; mean difference=2.3, 95% CI −2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t45=−0.80, P=.43; mean difference=1.3, 95% CI −4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions. Conclusions: The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12613000015741; (Archived by WebCite at

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

    Evaluation of an mHealth App (DeStressify) on University Students’ Mental Health: Pilot Trial


    Background: One in five Canadians experience mental health issues with those in the age range of 15 to 24 years being most at risk of a mood disorder. University students have shown significantly higher rates of mental health problems than the general public. Current university support services are limited by factors such as available staff and finances, and social stigma has frequently been identified as an additional barrier that prevents students from accessing these resources. Mobile health (mHealth) apps are one form of alternative health support that is discrete and accessible to students, and although they are recognized as a promising alternative, there is limited research demonstrating their efficacy. Objective: The aim of this study was to evaluate a mindfulness-based app’s (“DeStressify”) efficacy on stress, anxiety, depressive symptomology, sleep behavior, work or class absenteeism, work or school productivity, and quality of life (QoL) among university students. Methods: Full-time undergraduate students at a Canadian university with smartphones and Internet access were recruited through in-class announcements and on-campus posters. Participants randomized into an experimental condition were given and instructed to use the DeStressify app 5 days a week for 4 weeks. Control condition participants were wait-listed. All participants completed pre- and postintervention Web-based surveys to self-assess stress, anxiety, depressive symptomatology, sleep quality, and health-related QoL. Results: A total of 206 responses were collected at baseline, with 163 participants completing the study (86 control, 77 experimental). Using DeStressify was shown to reduce trait anxiety (P=.01) and improve general health (P=.001), energy (P=.01), and emotional well-being (P=.01) in university students, and more participants in the experimental condition believed their productivity improved between baseline and postintervention measurements than the number of participants expected to believe so randomly by chance (P=.01). The app did not significantly improve stress, state anxiety, physical and social functioning, and role limitations because of physical or emotional health problems or pain (P>.05). Conclusions: Mindfulness-based apps may provide an effective alternative support for university students’ mental health. Universities and other institutions may benefit from promoting the use of DeStressify or other mindfulness-based mHealth apps among students who are interested in methods of anxiety management or mindfulness-based self-driven health support. Future steps include examining DeStressify and similar mHealth apps over a longer period and in university staff and faculty.

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

    Employees’ Perspectives on the Facilitators and Barriers to Engaging With Digital Mental Health Interventions in the Workplace: Qualitative Study


    Background: Prevalence rates of work-related stress, depression, and anxiety are high, resulting in reduced productivity and increased absenteeism. There is evidence that these conditions can be successfully treated in the workplace, but take-up of psychological treatments among workers is low. Digital mental health interventions delivered in the workplace may be one way to address this imbalance, but although there is evidence that digital mental health is effective at treating stress, depression, and anxiety in the workplace, uptake of and engagement with these interventions remains a concern. Additionally, there is little research on the appropriateness of the workplace for delivering these interventions or on what the facilitators and barriers to engagement with digital mental health interventions in an occupational setting might be. Objective: The aim of this research was to get a better understanding of the facilitators and barriers to engaging with digital mental health interventions in the workplace. Methods: Semistructured interviews were held with 18 participants who had access to an occupational digital mental health intervention as part of a randomized controlled trial. The interviews were transcribed, and thematic analysis was used to develop an understanding of the data. Results: Digital mental health interventions were described by interviewees as convenient, flexible, and anonymous; these attributes were seen as being both facilitators and barriers to engagement in a workplace setting. Convenience and flexibility could increase the opportunities to engage with digital mental health, but in a workplace setting they could also result in difficulty in prioritizing time and ensuring a temporal and spatial separation between work and therapy. The anonymity of the Internet could encourage use, but that benefit may be lost for people who work in open-plan offices. Other facilitators to engagement included interactive and interesting content and design features such as progress trackers and reminders to log in. The main barrier to engagement was the lack of time. The perfect digital mental health intervention was described as a website that combined a short interactive course that was accessed alongside time-unlimited information and advice that was regularly updated and could be dipped in and out of. Participants also wanted access to e-coaching support. Conclusions: Occupational digital mental health interventions may have an important role in delivering health care support to employees. Although the advantages of digital mental health interventions are clear, they do not always fully translate to interventions delivered in an occupational setting and further work is required to identify ways of minimizing potential barriers to access and engagement. Trial Registration: NCT02729987; rank=1 (Archived at WebCite at

  • How patients with major depression use and benefit from smartphone CBT (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a...


    Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as “test-drive a new car,” “go to a coffee shop after lunch,” or “call up an old friend” were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; ctr_view.cgi?recptno=R000015984 (Archived by WebCite at

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

    Technology-Assisted Behavioral Intervention to Extend Sleep Duration: Development and Design of the Sleep Bunny Mobile App


    Background: Despite the high prevalence of short sleep duration (29.2% of adults sleep <6 hours on weekdays), there are no existing theory-based behavioral interventions to extend sleep duration. The popularity of wearable sleep trackers provides an opportunity to engage users in interventions. Objective: The objective of this study was to outline the theoretical foundation and iterative process of designing the “Sleep Bunny,” a technology-assisted sleep extension intervention including a mobile phone app, wearable sleep tracker, and brief telephone coaching. We conducted a two-step process in the development of this intervention, which was as follows: (1) user testing of the app and (2) a field trial that was completed by 2 participants with short sleep duration and a cardiovascular disease risk factor linked to short sleep duration (body mass index [BMI] >25). Methods: All participants had habitual sleep duration <6.5 hours verified by 7 days of actigraphy. A total of 6 individuals completed initial user testing in the development phase, and 2 participants completed field testing. Participants in the user testing and field testing responded to open-ended surveys about the design and utility of the app. Participants in the field testing completed the Epworth Sleepiness Scale and also wore an actigraph for a 1-week baseline period and during the 4-week intervention period. Results: The feedback suggests that users enjoyed the wearable sleep tracker and found the app visually pleasing, but they suggested improvements to the notification and reminder features of the app. The 2 participants who completed the field test demonstrated significant improvements in sleep duration and daytime sleepiness. Conclusions: Further testing is needed to determine effects of this intervention in populations at risk for the mental and physical consequences of sleep loss.

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  • Smartwatch Applications for Mental Health: A Qualitative Analysis of the Users’ Perspectives

    Date Submitted: Feb 15, 2018

    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Lifestyle diseases continuously rise, with aging, epidemics, and life stressors altogether contributing to a growing need for solutions in mental health care. Mobile and wearable solutions...

    Background: Lifestyle diseases continuously rise, with aging, epidemics, and life stressors altogether contributing to a growing need for solutions in mental health care. Mobile and wearable solutions have a large potential in this domain. Despite a significant growth in the availability of mobile apps in the past years, little is known about the characteristics of these applications and the end users’ perspectives about them, especially considering novel smart watch applications dedicated to promote mental health. Objective: To understand the current state-of-the-art smartwatch solutions for mental health, characterizing them in terms of features, benefits and drawbacks focusing on the end users’ perspectives, to identify opportunities to improve next-generation solutions. Methods: A comprehensive analysis of the existing applications for Apple Watch dedicated to mental health care, to characterize their state-of-the-art and provide a unified view of existing solutions, an analysis of their purposes, features, and users’ perspectives from online reviews and discussion boards to identify the main benefits and drawbacks with existing solutions Results: The smart watch applications analyzed focus mainly on intervention, rather than monitoring and tracking users’ affective states; they also focus on wellness and wellbeing and the sources tend to be non-medical; multimodal contents are explored to provide interventions, including audio, images and vibration; users enjoy the customization options and tend to use the applications in a regular basis, mainly to improve sleep quality, to focus, relax, meditate and distract themselves in adverse situations. Conclusions: There is a vast potential for wrist-worn applications for solutions in mental health, but the domain is still underexplored. Existing applications focus on interventions, and further development and research efforts are needed to advance on monitoring and personalized interventions. Privacy-enhanced solutions for access control and protection of human subjects and their data are essential in the development of mobile applications for mental health, still those remain as open questions to be addressed in the future.

  • Using Smartphone Apps to Promote Psychiatric Rehabilitation in a Peer-led Community Support Program

    Date Submitted: Feb 11, 2018

    Open Peer Review Period: Feb 12, 2018 - Apr 9, 2018

    Background: Management of severe and persistent mental illness is a complex, resource-intensive challenge for individuals, their families, their treaters, and the healthcare system at large. Community...

    Background: Management of severe and persistent mental illness is a complex, resource-intensive challenge for individuals, their families, their treaters, and the healthcare system at large. Community based rehabilitation, in which peer specialists provide support for individuals managing their own condition, has demonstrated effectiveness, but has only been implemented in specialty centers. It remains unclear how the peer based community rehabilitation model could be expanded, given that it requires significant resources to both establish and maintain. Objective: Here, we describe the results from a study of one such program implemented within Waverley Place, a community support program at McLean Hospital emphasizing psychiatric rehabilitation for individuals with severe and persistent mental illness. Key questions were whether the patients could and would successfully use the app. Methods: The smartphone app offered multiple features relevant to psychiatric rehabilitation, including daily task lists and text messaging with peer specialists. Thirteen patients downloaded the app and used it for up to 90 days. Results: Only two patients were not able to complete app installation. Five patients were able to use the app regularly as part of their daily lives. No demographic or clinical features predicted ability to use the app in this way, but receiving a message from the certified peer specialist on the first day after installing the app did. Reasons for success or failure were highly individualistic. Conclusions: Smartphone apps may become a useful tool for psychiatric rehabilitation, addressing both psychiatric and co-occurring medical problems. Individualizing functions to each patient and facilitating connection with a certified peer specialist may be an important feature of useful apps.

  • Usability of a psychotherapeutic interactive gaming tool used in Facial Emotion Recognition for people with Schizophrenia

    Date Submitted: Feb 12, 2018

    Open Peer Review Period: Feb 12, 2018 - Apr 9, 2018

    The interactive software “Feeling Master” (a Cartoon Facial Recognition Tool) was developed to investigate the deficit in facial emotion recognition (FER) with a sample of patients with schizophre...

    The interactive software “Feeling Master” (a Cartoon Facial Recognition Tool) was developed to investigate the deficit in facial emotion recognition (FER) with a sample of patients with schizophrenia in a pilot project framework. 24 persons with schizophrenia and 17 healthy control (HC) subjects completed the “Feeling Master” including five emotions (happiness, sadness, anger, fear and surprise). Regarding the group with schizophrenia they were evaluated with the Personal and Situational Attribution Questionnaire (IPSAQ) and the Hinting Task (Theory of Mind) to evaluate social cognition. Descriptive data showed suitable usability, adaptability, effectiveness and efficiency of “feeling master”. Patients with schizophrenia showed impairments in emotion recognition. The individuals with schizophrenia remained slower than the HC in the recognition of each emotion. Regarding the impairment in the recognition of each emotion we only have found significant error rates on fear discrimination (P=.07). And the correlations between correct response on the “Feeling Master” and the Hinting Task showed significant values in the correlation of surprise and Theory of Mind (P=.46). In conclusion, the study puts forward the usability of the “feeling master” in FER for people with schizophrenia. These findings lend support to the notion that difficulties in emotion recognition are more prevalent in people with schizophrenia, and those are associated with an imparment in ToM, suggesting the potential utility of the FER in the rehabilitation of people with schizophrenia.

  • Technology as an Aid to Current Treatment

    Date Submitted: Feb 2, 2018

    Open Peer Review Period: Feb 3, 2018 - Mar 31, 2018

    This piece draws from a patient’s perspective on their treatment using mobile health technology in conjunction with weekly group and individual psychotherapy. Research has demonstrated that utilizin...

    This piece draws from a patient’s perspective on their treatment using mobile health technology in conjunction with weekly group and individual psychotherapy. Research has demonstrated that utilizing telepsychology as part of mental health treatment shows great promise to help advance the field of psychotherapy. Utilizing mobile health technology, such as cell phone applications, allows for collaboration with patients and their providers. This was written after several consultations with individual with borderline personality disorder, who would prefer to remain anonymous but was forthcoming with information regarding his use of mobile health technology in order to benefit the field of mental telepsychology.

  • e-Health: Suitable for every patient with psychosis?

    Date Submitted: Jan 26, 2018

    Open Peer Review Period: Jan 26, 2018 - Mar 23, 2018

    Background: Despite a growing interest in the use of technology in order to support the treatment of psychotic disorders, limited knowledge exists about the viability and acceptability of these electr...

    Background: Despite a growing interest in the use of technology in order to support the treatment of psychotic disorders, limited knowledge exists about the viability and acceptability of these electronic health (e-Health) interventions in relation to the clinical characteristics of patients. Objective: The aim of this study was to assess the access, use, experiences and interest in new technologies using a survey of patients diagnosed with first-episode psychosis (FEP) compared to a survey of patients diagnosed with chronic psychotic disorders (CP). Methods: A structured questionnaire was designed. This questionnaire was divided into five parts: 1) clinical and demographic information, 2) access and use of the internet, 3) use of the internet in relation to mental health, 4) experiences with technology, and 5) patient’s interest in e-Health services. In total, 105 patients were recruited from FEP units and recovery units. Depending on the length of the illness, the patients were assigned to either the FEP group (n=65, mean= 28.8 months) or to the CP group (n=40, mean= 253.3 months). Results: The mean age of the patients was 38.1 years (SD=13), and 72.4% (76/105) of them were male. The patients were mainly single (84.8%, 89/105) and had achieved a medium level of education (compulsory or secondary schooling) (61.9%, 65/105). The patients in the FEP group were younger than those in the CP group (t=-6.09, P<.001) and had more functional employment statuses (employed or student, 52.3% 34/65) than the CP group (12.5%, 5/40). Of the patients, 84.8% (89/105) had access to the internet, and 88.6% (93/105) owned an electronic internet device. In total, 71.3% (57/80) of patients who owned a smartphone were interested in e-Health systems; however, 28.7% (23/80) were not interested, and 38.2% (37/97) reported negative experiences related to internet usage. Differences between the groups were found in terms of device ownership (X2=13.77, P=.02), the frequency of internet access (X2=31.84, P<.001), the use of social media (X2=13.89, P=.01) and in seeking health information (X2=11.49, P=.04) and were found to be higher in the FEP group. No differences between the groups were found in terms of the use of internet in relation to mental health, experiences and opinions about the internet or in terms of interest in e-Health interventions (X2=3.85, P=.43). Conclusions: The availability and use of technology for the participants in our survey were equivalent to those for the general population. The differences found between the groups in relation to the access or use of technology seemed to be age-related factors. The use of technology involving mental health and the interest in e-Health interventions were mainly positive and equivalent between the groups. Accordingly, this group of patients is a suitable target for the emerging e-Health interventions, regardless of the clinical status of these patients. However, between 20-30% of the patients studied rejected the use of the internet or had unpleasant experiences related to its usage, so more in-depth studies are needed to better define the profile of psychotic patients who may benefit from e-Health treatments.

  • Adolescent personality profile and internet addiction

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Previous research into effects of personality on internet addiction in adolescents has produced inconclusive results. Adolescents are considered to be at risk of Internet addiction because...

    Background: Previous research into effects of personality on internet addiction in adolescents has produced inconclusive results. Adolescents are considered to be at risk of Internet addiction because of their physical and psychological immaturity and negative effects of Internet use are more obvious in this age group. Objective: To determine the characteristics of adolescent personality that are most often associated with normal, moderate or serious Internet addiction and how these characteristics reflect on the six dimensions of Internet addiction. Methods: The study included 1078 male and female adolescents aged 11-18 years from Croatia, Poland, and Finland. The Internet addiction was assessed using Young's Internet Addition Test. A 30-item five-factor personality inventory, i.e., a Croatian version of the Goldberg's International Personality Item Pool, was used for personality assessment. Data were analyzed using a correlation analysis. Results: The level of Internet addiction did not significantly vary across different levels of neuroticism (P<.001); extraversion (P=.053); openness to experience (P<.001), and conscientiousness (P=.022). High and very high levels of openness were found in (46/241, 19%) of adolescents without Internet addiction and (92/241, 38%) adolescents with moderate and serious Internet addiction. Thus, openness was more pronounced in those more addicted to the Internet. Adolescents with moderate and serious Internet addiction showed higher levels of neuroticism, openness to new experience, and conscientiousness in comparison with adolescents evaluated as normal Internet users, whereas no difference was found for extraversion and agreeableness (P>.05). Conclusions: Analysis of correlation between five big personality traits and Internet addiction indicated that neuroticism, extraversion, and openness to new experience were more common among adolescents with moderate and serious Internet addictio