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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:

  • A screen from the e-mental health app described in the paper. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Worker Preferences for a Mental Health App Within Male-Dominated Industries: Participatory Study


    Background: Men are less likely to seek help for mental health problems, possibly because of stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of mental health technologies men would be willing to engage with, and no app can be effective if the intended users do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations took part in an exploratory qualitative study involving participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged between 26 and 65 years, 92% (55/60) male, from male-dominated workplaces in rural (16/60, 27%), suburban (14/60, 23%), and urban (30/60, 50%) locations participated in one of the 6 workshops, resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment, and mood-fix tool were highly valued, and app characteristics such as brevity of interactions, minimal on-screen text, and a solutions-oriented approach were considered essential by participants. Some implementation strategies based on these findings are included in the discussion. Conclusions: Future mental health mobile phone apps targeting workers in male-dominated workplaces need to consider language use and preferred features, as well as balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights for mental health technologies, for men in general, and for others in high-stigma environments.

  • Source: Pxhere; Copyright: Pxhere; URL:; License: Licensed by JMIR.

    Ethical Issues for Direct-to-Consumer Digital Psychotherapy Apps: Addressing Accountability, Data Protection, and Consent


    This paper focuses on the ethical challenges presented by direct-to-consumer (DTC) digital psychotherapy services that do not involve oversight by a professional mental health provider. DTC digital psychotherapy services can potentially assist in improving access to mental health care for the many people who would otherwise not have the resources or ability to connect with a therapist. However, the lack of adequate regulation in this area exacerbates concerns over how safety, privacy, accountability, and other ethical obligations to protect an individual in therapy are addressed within these services. In the traditional therapeutic relationship, there are ethical obligations that serve to protect the interests of the client and provide warnings. In contrast, in a DTC therapy app, there are no clear lines of accountability or associated ethical obligations to protect the user seeking mental health services. The types of DTC services that present ethical challenges include apps that use a digital platform to connect users to minimally trained nonprofessional counselors, as well as services that provide counseling steered by artificial intelligence and conversational agents. There is a need for adequate oversight of DTC nonprofessional psychotherapy services and additional empirical research to inform policy that will provide protection to the consumer.

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

    Feasibility and Acceptability of a Web-Based Treatment with Telephone Support for Postpartum Women With Anxiety: Randomized Controlled Trial


    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 a self-guided treatment based on cognitive-behavioral and mindfulness principles for women experiencing postpartum anxiety. WaWa was developed in Australia and consists of 9 modules with optional weekly telephone support. WaWa was adapted to a Web-based version for use in England (Internet-based What Am I Worried About, iWaWa). Objective: This study aimed to investigate the feasibility (engagement and usability) and acceptability (usefulness, satisfaction, and helpfulness) 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 group. Treatment and study feasibility and acceptability were assessed after the treatment, and anxiety symptoms were assessed at baseline, 8 weeks postrandomization, and 12 weeks postrandomization (treatment group only) using Web-based questionnaires. Semistructured telephone interviews were carried out after the treatment period for a more in-depth exploration of treatment acceptability and feasibility. Results: A total of 89 eligible women were recruited through social media and randomized into the treatment (n=46) or wait-list control group (n=43). Women were predominantly Caucasian, well-educated, married, on maternity leave, first-time mothers and reported moderate levels of anxiety. Dropout rates were high, especially in the treatment group (treatment: 82%, 38/46; wait-list control: 51%, 22/43). A total of 26 women started iWaWa with only 2 women completing all 9 modules. 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-behavioral therapy (CBT) and mindfulness. However, iWaWa was also experienced as not user-friendly enough, too 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 that can inform iWaWa’s future development, as well as research and development of Web-based postpartum anxiety treatments, in general, to optimize adherence. Trial Registration: NCT02434406; (Archived by WebCite at

  • Source: Freepik; Copyright: yanalya; URL:; License: Licensed by JMIR.

    “Wish You Were Here”: Examining Characteristics, Outcomes, and Statistical Solutions for Missing Cases in Web-Based Psychotherapeutic Trials


    Background: Missing cases following treatment are common in Web-based psychotherapy trials. Without the ability to directly measure and evaluate the outcomes for missing cases, the ability to measure and evaluate the effects of treatment is challenging. Although common, little is known about the characteristics of Web-based psychotherapy participants who present as missing cases, their likely clinical outcomes, or the suitability of different statistical assumptions that can characterize missing cases. Objective: Using a large sample of individuals who underwent Web-based psychotherapy for depressive symptoms (n=820), the aim of this study was to explore the characteristics of cases who present as missing cases at posttreatment (n=138), their likely treatment outcomes, and compare between statistical methods for replacing their missing data. Methods: First, common participant and treatment features were tested through binary logistic regression models, evaluating the ability to predict missing cases. Second, the same variables were screened for their ability to increase or impede the rate symptom change that was observed following treatment. Third, using recontacted cases at 3-month follow-up to proximally represent missing cases outcomes following treatment, various simulated replacement scores were compared and evaluated against observed clinical follow-up scores. Results: Missing cases were dominantly predicted by lower treatment adherence and increased symptoms at pretreatment. Statistical methods that ignored these characteristics can overlook an important clinical phenomenon and consequently produce inaccurate replacement outcomes, with symptoms estimates that can swing from −32% to 70% from the observed outcomes of recontacted cases. In contrast, longitudinal statistical methods that adjusted their estimates for missing cases outcomes by treatment adherence rates and baseline symptoms scores resulted in minimal measurement bias (<8%). Conclusions: Certain variables can characterize and predict missing cases likelihood and jointly predict lesser clinical improvement. Under such circumstances, individuals with potentially worst off treatment outcomes can become concealed, and failure to adjust for this can lead to substantial clinical measurement bias. Together, this preliminary research suggests that missing cases in Web-based psychotherapeutic interventions may not occur as random events and can be systematically predicted. Critically, at the same time, missing cases may experience outcomes that are distinct and important for a complete understanding of the treatment effect.

  • Source: US Army; Copyright: US Army (AFN Wiesbaden); URL:; License: Public Domain (CC0).

    Engagement With a Trauma Recovery Internet Intervention Explained With the Health Action Process Approach (HAPA): Longitudinal Study


    Background: There has been a growing trend in the delivery of mental health treatment via technology (ie, electronic health, eHealth). However, engagement with eHealth interventions is a concern, and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress. Objective: The aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pretreatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning, which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy. Methods: Trauma survivors from around the United States used the eHealth intervention for 2 weeks. We collected baseline demographic, social cognitive predictors, and distress symptoms and measured engagement subjectively and objectively throughout the intervention. Results: The motivational phase model explained 48% of the variance, and outcome expectations (beta=.36), perceived need (beta=.32), pretreatment self-efficacy (beta=.13), and trauma symptoms (beta=.21) were significant predictors of intention (N=440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement (B=0.89, 95% CI 0.143-2.605; N=115). Conclusions: Though many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy, and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work.

  • Health anxiety. Source: Place it - Digital Mockups/Ditte Hoffmann; Copyright: Ditte Hoffmann; URL:; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    Development and Feasibility Testing of Internet-Delivered Acceptance and Commitment Therapy for Severe Health Anxiety: Pilot Study


    Background: Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, is characterized by preoccupation with fear of suffering from a serious illness in spite of medical reassurance. It is a debilitating, prevalent disorder associated with increased health care utilization. Still, there is a lack of easily accessible specialized treatment for severe health anxiety. Objective: The aims of this paper were to (1) describe the development and setup of a new internet-delivered acceptance and commitment therapy (iACT) program for patients with severe health anxiety using self-referral and a video-based assessment; and (2) examine the feasibility and potential clinical efficacy of iACT for severe health anxiety. Methods: Self-referred patients (N=15) with severe health anxiety were diagnostically assessed by a video-based interview. They received 7 sessions of clinician-supported iACT comprising self-help texts, video clips, audio files, and worksheets over 12 weeks. Self-report questionnaires were obtained at baseline, post-treatment, and at 3-month follow-up. The primary outcome was Whiteley-7 Index (WI-7) measuring health anxiety severity. Depressive symptoms, health-related quality of life (HRQoL), life satisfaction, and psychological flexibility were also assessed. A within-group design was employed. Means, standard deviations, and effect sizes using the standardized response mean (SRM) were estimated. Post-treatment interviews were conducted to evaluate the patient experience of the usability and acceptability of the treatment setup and program. Results: The self-referral and video-based assessments were well received. Most patients (12/15, 80%) completed the treatment, and only 1 (1/15, 7%) dropped out. Post-treatment (14/15, 93%) and 3-month follow-up (12/15, 80%) data were available for almost all patients. Paired t tests showed significant improvements on all outcome measures both at post-treatment and 3-month follow-up, except on one physical component subscale of HRQoL. Health anxiety symptoms decreased with 33.9 points at 3-month follow-up (95% CI 13.6-54.3, t11= 3.66, P=.004) with a large within-group effect size of 1.06 as measured by the SRM. Conclusions: Treatment adherence and potential efficacy suggest that iACT may be a feasible treatment for health anxiety. The uncontrolled design and small sample size of the study limited the robustness of the findings. Therefore, the findings should be replicated in a randomized controlled trial. Potentially, iACT may increase availability and accessibility of specialized treatment for health anxiety. Trial Registration: Danish Data Protection Agency, Central Denmark Region: 1-16-02-427-14; (Archived by Webcite at

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

    Youth Mental Health Services Utilization Rates After a Large-Scale Social Media Campaign: Population-Based Interrupted Time-Series Analysis


    Background: Despite the uptake of mass media campaigns, their overall impact remains unclear. Since 2011, a Canadian telecommunications company has operated an annual, large-scale mental health advocacy campaign (Bell Let’s Talk) focused on mental health awareness and stigma reduction. In February 2012, the campaign began to explicitly leverage the social media platform Twitter and incented participation from the public by promising donations of Can $0.05 for each interaction with a campaign-specific username (@Bell_LetsTalk). Objective: The intent of the study was to examine the impact of this 2012 campaign on youth outpatient mental health services in the province of Ontario, Canada. Methods: Monthly outpatient mental health visits (primary health care and psychiatric services) were obtained for the Ontario youth aged 10 to 24 years (approximately 5.66 million visits) from January 1, 2006 to December 31, 2015. Interrupted time series, autoregressive integrated moving average modeling was implemented to evaluate the impact of the campaign on rates of monthly outpatient mental health visits. A lagged intervention date of April 1, 2012 was selected to account for the delay required for a patient to schedule and attend a mental health–related physician visit. Results: The inclusion of Twitter into the 2012 Bell Let’s Talk campaign was temporally associated with an increase in outpatient mental health utilization for both males and females. Within primary health care environments, female adolescents aged 10 to 17 years experienced a monthly increase in the mental health visit rate from 10.2/1000 in April 2006 to 14.1/1000 in April 2015 (slope change of 0.094 following campaign, P<.001), whereas males of the same age cohort experienced a monthly increase from 9.7/1000 to 9.8/1000 (slope change of 0.052 following campaign, P<.001). Outpatient psychiatric services visit rates also increased for both male and female adolescents aged 10 to 17 years post campaign (slope change of 0.005, P=.02; slope change of 0.003, P=.005, respectively). For young adults aged 18 to 24 years, females who used primary health care experienced the most significant increases in mental health visit rates from 26.5/1000 in April 2006 to 29.2/1000 in April 2015 (slope change of 0.17 following campaign, P<.001). Conclusions: The 2012 Bell Let’s Talk campaign was temporally associated with an increase in the rate of mental health visits among Ontarian youth. Furthermore, there appears to be an upward trend of youth mental health utilization in the province of Ontario, especially noticeable in females who accessed primary health care services.

  • The Mindgauge App (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Impact of Mental Health Screening on Promoting Immediate Online Help-Seeking: Randomized Trial Comparing Normative Versus Humor-Driven Feedback


    Background: Given the widespread availability of mental health screening apps, providing personalized feedback may encourage people at high risk to seek help to manage their symptoms. While apps typically provide personal score feedback only, feedback types that are user-friendly and increase personal relevance may encourage further help-seeking. Objective: The aim of this study was to compare the effects of providing normative and humor-driven feedback on immediate online help-seeking, defined as clicking on a link to an external resource, and to explore demographic predictors that encourage help-seeking. Methods: An online sample of 549 adults were recruited using social media advertisements. Participants downloaded a smartphone app known as “Mindgauge” which allowed them to screen their mental wellbeing by completing standardized measures on Symptoms (Kessler 6-item Scale), Wellbeing (World Health Organization [Five] Wellbeing Index), and Resilience (Brief Resilience Scale). Participants were randomized to receive normative feedback that compared their scores to a reference group or humor-driven feedback that presented their scores in a relaxed manner. Those who scored in the moderate or poor ranges in any measure were encouraged to seek help by clicking on a link to an external online resource. Results: A total of 318 participants scored poorly on one or more measures and were provided with an external link after being randomized to receive normative or humor-driven feedback. There was no significant difference of feedback type on clicking on the external link across all measures. A larger proportion of participants from the Wellbeing measure (170/274, 62.0%) clicked on the links than the Resilience (47/179, 26.3%) or Symptoms (26/75, 34.7%) measures (χ2=60.35, P<.001). There were no significant demographic factors associated with help-seeking for the Resilience or Wellbeing measures. Participants with a previous episode of poor mental health were less likely than those without such history to click on the external link in the Symptoms measure (P=.003, odds ratio [OR] 0.83, 95% CI 0.02-0.44), and younger adults were less likely to click on the link compared to older adults across all measures (P=.005, OR 0.44, 95% CI 0.25-0.78). Conclusions: This pilot study found that there was no difference between normative and humor-driven feedback on promoting immediate clicks to an external resource, suggesting no impact on online help-seeking. Limitations included: lack of personal score control group, limited measures of predictors and potential confounders, and the fact that other forms of professional help-seeking were not assessed. Further investigation into other predictors and factors that impact on help-seeking is needed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000707460; Trial/Registration/TrialReview.aspx?id=370187 (Archived by WebCite at

  • Empowered Brain. Source: Brain Power LLC; Copyright: Brain Power LLC; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Improvement of Attention-Deficit/Hyperactivity Disorder Symptoms in School-Aged Children, Adolescents, and Young Adults With Autism via a Digital...


    Background: People with autism spectrum disorder (ASD) commonly experience symptoms related to attention-deficit/hyperactivity disorder (ADHD), including hyperactivity, inattention, and impulsivity. One-third of ASD cases may be complicated by the presence of ADHD. Individuals with dual diagnoses face greater barriers to accessing treatment for ADHD and respond less positively to primary pharmacologic interventions. Nonpharmacologic technology-aided tools for hyperactivity and inattention in people with ASD are being developed, although research into their efficacy and safety remains limited. Objective: The objective of this preliminary study was to describe the changes in ADHD-related symptoms in children, adolescents, and young adults with ASD immediately after use of the Empowered Brain system, a behavioral and social communication aid for ASD running on augmented reality smartglasses. Methods: We recruited 8 children, adolescents, and young adults with ASD (male to female ratio of 7:1, mean age 15 years, range 11.7-20.5 years) through a Web-based research signup form. The baseline score on the hyperactivity subscale of the Aberrant Behavioral Checklist (ABC-H), a measure of hyperactivity, inattention, and impulsivity, determined their classification into a high ADHD-related symptom group (n=4, ABC-H≥13) and a low ADHD-related symptom group (n=4, ABC-H<13). All participants received an intervention with Empowered Brain, where they used smartglasses-based social communication and behavioral modules while interacting with their caregiver. We then calculated caregiver-reported ABC-H scores at 24 and 48 hours after the session. Results: All 8 participants were able to complete the intervention session. Postintervention ABC-H scores were lower for most participants at 24 hours (n=6, 75%) and for all participants at 48 hours (n=8, 100%). At 24 hours after the session, average participant ABC-H scores decreased by 54.9% in the high ADHD symptom group and by 20% in the low ADHD symptom group. At 48 hours after the session, ABC-H scores compared with baseline decreased by 56.4% in the high ADHD symptom group and by 66.3% in the low ADHD symptom group. Conclusions: This study provides initial evidence for the possible potential of the Empowered Brain system to reduce ADHD-related symptoms, such as hyperactivity, inattention, and impulsivity, in school-aged children, adolescents, and young adults with ASD. This digital smartglasses intervention can potentially be targeted at a broader array of mental health conditions that exhibit transdiagnostic attentional and social communication deficits, including schizophrenia and bipolar disorder. Further research is required to understand the clinical importance of these observed changes and to conduct longitudinal studies on this intervention with control groups and larger sample sizes.

  • The home screen of the Self-Record app. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Standalone Effects of a Cognitive Behavioral Intervention Using a Mobile Phone App on Psychological Distress and Alcohol Consumption Among Japanese Workers:...


    Background: Research that investigates standalone effects of a mobile phone-based cognitive behavioral therapy without any human contact for reducing both psychological distress and risky drinking has been advancing; however, the number of studies is still limited. A mobile phone app called Self Record that facilitates cognitive restructuring through self-monitoring of daily thoughts and activities was developed in Japan. Objective: This study conducted a nonrandomized controlled pilot trial of the Self Record app to investigate standalone effects of the intervention on psychological distress and alcohol consumption among Japanese workers. Additionally, we examined moderating effects of negative mood regulation expectancies, which are beliefs about one’s ability to control one’s negative mood. Methods: A quasi-experimental design with a 1-month follow-up was conducted online in Japan from February 2016 to March 2016. A research marketing company recruited participants. The selection criteria were being a Japanese full-time worker (age 20-59 years), experiencing mild to moderate psychological distress, and having some interest in self-record apps. Assignment to group was based on participants’ willingness to use the app in the study. All participants completed outcome measures of negative mood regulation expectancies, positive well-being, general distress, depression, anxiety, and typical/most weekly alcohol consumption. Results: From the recruitment, 15.65% (1083/6921) of participants met the inclusion criteria. Of these, 51.43% (557/1083) enrolled in the study: 54.9% (306/557) in the intervention group and 45.1% (251/557) in the control group. At the 1-month follow-up, 15.3% (85/557) of participants had dropped out. Intention-to-treat analyses revealed that participants in the intervention group reported increased typical drinking (η2=.009) and heavy drinking (η2=.001). Adherence to using the app was low; 64.8% (199/306) of participants in the intervention group discontinued using the app on the first day. Additionally, 65.7% (366/557) of the total sample did not correctly answer the validity checks in the outcome measures (eg, “Please select ‘mildly agree’ for this item”). Therefore, per-protocol analyses were conducted after removing these participants. Results showed that continuing app users (42/127) in the intervention group reported increases in anxiety (η2=.006), typical drinking (η2=.005), and heavy drinking (η2=.007) compared to those in the control group (85/127). Negative mood regulation expectancies moderated the effects of the intervention for general distress (beta=.39). Conclusions: Results were contrary to our hypotheses. Self-recording methods of standalone mobile phone interventions may heighten individuals’ awareness of their pathological thought and drinking behavior, but may be insufficient to decrease them unless combined with a more intense or face-to-face intervention. Limitations include high attrition in this study; measures to improve the response rate are discussed.

  • User viewing the Cracks in the Ice Community Toolkit home page (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Web-Based Toolkit to Provide Evidence-Based Resources About Crystal Methamphetamine for the Australian Community: Collaborative Development of Cracks in...


    Background: The use of crystal methamphetamine (ice) and the associated harms for individuals, families, and communities across Australia has been the subject of growing concern in recent years. The provision of easily accessible, evidence-based, and up-to-date information and resources about crystal methamphetamine for the community is a critical component of an effective public health response. Objective: This paper aims to describe the codevelopment process of the Web-based Cracks in the Ice Community Toolkit, which was developed to improve access to evidence-based information and resources about crystal methamphetamine for the Australian community. Methods: Development of the Cracks in the Ice Community Toolkit was conducted in collaboration with community members across Australia and with experts working in the addiction field. The iterative process involved the following: (1) consultation with end users, including community members, crystal methamphetamine users, families and friends of someone using crystal methamphetamine, health professionals, and teachers (n=451) via a cross-sectional Web-based survey to understand information needs; (2) content and Web development; and (3) user testing of a beta version of the Web-based toolkit among end users (n=41) and experts (n=10) to evaluate the toolkit’s acceptability, relevance, and appeal. Results: Initial end user consultation indicated that the most commonly endorsed reasons for visiting a website about crystal methamphetamine were “to get information for myself” (185/451, 41.0%) and “to find out how to help a friend or a family member” (136/451, 30.2%). Community consultation also revealed the need for simple information about crystal methamphetamine, including what it is, its effects, and when and where to seek help or support. Feedback on a beta version of the toolkit was positive in terms of content, readability, layout, look, and feel. Commonly identified areas for improvement related to increasing the level of engagement and personal connection, improving the ease of navigation, and balancing a “low prevalence of use, yet high impact” message. A total of 9138 users visited the website in the 3 months immediately post launch, and over 25,000 hard-copy Cracks in the Ice booklets and flyers were distributed across Australia. Of these resources, 60.93% (15,525/25,480) were distributed to relevant organizations and mailing list subscribers, and 39.07% (9955/25,480) were ordered directly by individuals, services, and community groups via the Cracks in the Ice website. Conclusions: The codevelopment process resulted in an engaging Web-based resource for the Australian community to access up-to-date and evidence-based resources about crystal methamphetamine. The Cracks in the Ice Community Toolkit provides much-needed information and support for individuals, families, and communities.

  • Wearable heart rate monitor. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Acute Effect of Alcohol Intake on Cardiovascular Autonomic Regulation During the First Hours of Sleep in a Large Real-World Sample of Finnish Employees:...


    Background: Sleep is fundamental for good health, and poor sleep has been associated with negative health outcomes. Alcohol consumption is a universal health behavior associated with poor sleep. In controlled laboratory studies, alcohol intake has been shown to alter physiology and disturb sleep homeostasis and architecture. The association between acute alcohol intake and physiological changes has not yet been studied in noncontrolled real-world settings. Objective: The aim of this study was to assess the effects of alcohol intake on the autonomic nervous system (ANS) during sleep in a large noncontrolled sample of Finnish employees. Methods: From a larger cohort, this study included 4098 subjects (55.81%, 2287/4098 females; mean age 45.1 years) who had continuous beat-to-beat R-R interval recordings of good quality for at least 1 day with and for at least 1 day without alcohol intake. The participants underwent continuous beat-to-beat R-R interval recording during their normal everyday life and self-reported their alcohol intake as doses for each day. Heart rate (HR), HR variability (HRV), and HRV-derived indices of physiological state from the first 3 hours of sleep were used as outcomes. Within-subject analyses were conducted in a repeated measures manner by studying the differences in the outcomes between each participant’s days with and without alcohol intake. For repeated measures two-way analysis of variance, the participants were divided into three groups: low (≤0.25 g/kg), moderate (>0.25-0.75 g/kg), and high (>0.75 g/kg) intake of pure alcohol. Moreover, linear models studied the differences in outcomes with respect to the amount of alcohol intake and the participant’s background parameters (age; gender; body mass index, BMI; physical activity, PA; and baseline sleep HR). Results: Alcohol intake was dose-dependently associated with increased sympathetic regulation, decreased parasympathetic regulation, and insufficient recovery. In addition to moderate and high alcohol doses, the intraindividual effects of alcohol intake on the ANS regulation were observed also with low alcohol intake (all P<.001). For example, HRV-derived physiological recovery state decreased on average by 9.3, 24.0, and 39.2 percentage units with low, moderate, and high alcohol intake, respectively. The effects of alcohol in suppressing recovery were similar for both genders and for physically active and sedentary subjects but stronger among young than older subjects and for participants with lower baseline sleep HR than with higher baseline sleep HR. Conclusions: Alcohol intake disturbs cardiovascular relaxation during sleep in a dose-dependent manner in both genders. Regular PA or young age do not protect from these effects of alcohol. In health promotion, wearable HR monitoring and HRV-based analysis of recovery might be used to demonstrate the effects of alcohol on sleep on an individual level.

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  • Effects of a theta/SMR neurofeedback training protocol on measures of impulsivity, drug craving and substance abuse in forensic psychiatric patients with substance abuse: a randomized controlled trial

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination...

    Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination of psychiatric disorders and SUD increases the risk of future violence. Chronic substance abuse can lead to a structural state of disinhibition, resulting in more drug taking and eventually loss of control over drug intake. When treating SUD, it is crucial to address high levels of impulsivity and lack of inhibitory control. Objective: The current study set out to investigate the effects of a theta/Sensorimotor rhythm (SMR) neurofeedback training protocol on levels of impulsivity, levels of drug craving and actual drug intake in a population of forensic psychiatric patients with a diagnosis of SUD. Methods: 21 participants received 20 sessions of SMR/theta neurofeedback training in combination with treatment as usual (TAU). Results were compared to 21 participants who received TAU only. Results: SMR magnitude showed a significant (P = .02) increase post-training for patients in the neurofeedback training group, whereas theta magnitude did not change (P >.05). Levels of drug craving as well as scores on the ‘motor’ subscale of the BIS-11 decreased equally for patients in the neurofeedback training group and the TAU group. Other measures of impulsivity, as well as drug intake, did not change post-treatment (P > .05). Therefore, neurofeedback + TAU was not more effective than TAU only. Conclusions: The current study demonstrated evidence that forensic psychiatric patients are able to increase SMR magnitude over the course of neurofeedback training. However, at the group level, the increase in SMR activity was not related to any of the included impulsivity or drug craving measures. Further research should focus on which patients will be able to benefit from neurofeedback training at an early stage of the employed training sessions. Clinical Trial: Dutch National Trial Register NTR5386; (Archived by WebCite at

  • Acceptability of Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions

    Date Submitted: Feb 26, 2018

    Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

    Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitat...

    Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone. Objective: This analysis assesses patient’s acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. Methods: PARTNERs is a research trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion. Results: During the consent process, 53.7% of 667 patients referred to the study declined to participate, and attributed their refusal to research-related factors (i.e., randomization and time commitment); a further 16.8% declined due to the telephone delivery of the intervention. Among 377 participants who were randomized to the one-year intervention, the overall retention rate was 81.8%. Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97.4% of comments related to the telephone components were positive, with key reported positive attributes being accessibility, convenience, and privacy. Conclusions: Our results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy. Clinical Trial: Trial registration: Identifier: NCT02345122

  • The Computerised Life Events and Assessment Record (CLEAR) online measure of life events: reliability, validity and association with depression.

    Date Submitted: Apr 3, 2018

    Open Peer Review Period: Apr 6, 2018 - Jun 1, 2018

    Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Th...

    Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Therefore, the Computerised Life Events and Assessment Record (CLEAR), based on the Life Events and Difficulties Schedule (LEDS), was developed. Objective: To test CLEAR’s reliability, validity, and association with depression. Methods: CLEAR, the General Health Questionnaire, and the List of Threatening Experiences Questionnaire (LTE-Q) was completed by 328 participants (126 students; 202 matched midlife sample: 127 controls, 75 recurrent depression cases). Test-retest reliability over 3-4 weeks was examined, and validity determined by comparing CLEAR with LEDs and LTE-Q. Both CLEAR and LTE-Q were examined in relation to depression. Results: CLEAR demonstrated good test-retest reliability for overall number of events (.89) but only fair reliability for overall agreement of events at both points (.21). Event characteristics for those that agreed had good reliability. Long-term problems (LTPs) showed similar findings. For validity, CLEAR had moderate sensitivity of 59% and specificity of 65% when compared to LEDS on matched events. Associations by category were good e.g. education (.81), work (.70) and health (.59), with high levels of specificity in these domains. CLEAR demonstrated moderate sensitivity (43.1%) and specificity (78.6%) when compared to LTE-Q. CLEAR severe LEs and LTPs were significantly associated with depression (OR = 3.50, 95% CI: 2.10-5.85, P < .001; OR = 3.38, 95% CI: 2.02-5.67, P < .001) whereas LTE-Q events were not (OR=1.06, 95% CI: .43-2.60, P =.90). Conclusions: CLEAR has acceptable reliability and validity and predicts depression. It therefore has great potential for effective use in research and clinical practice identifying stress factors in depression and related disorders.

  • Mining Social Media Data to Study the Consequences of Dementia Diagnosis on Caregivers and Relatives

    Date Submitted: Mar 26, 2018

    Open Peer Review Period: Mar 31, 2018 - May 26, 2018

    Background: Dementia is a growing public health concern with approximately 50 million people affected worldwide in 2017 and this number is expected to reach more than 131 million by 2050. The toll on...

    Background: Dementia is a growing public health concern with approximately 50 million people affected worldwide in 2017 and this number is expected to reach more than 131 million by 2050. The toll on caregivers and relatives cannot be underestimated as dementia changes family relationships, leaves people socially isolated, and affects the finances of all those involved. Objective: The aim of this study was to explore using automated analysis (i) the age and gender of people who post to the social media forum Reddit about dementia diagnoses, (ii) the affected person and their diagnosis, (iii) relevant subreddits authors are posting to, (iv) the types of messages posted and (v) the content of these posts. Methods: We analysed Reddit posts concerning dementia diagnoses. We used a previously developed text analysis pipeline to determine attributes of the posts as well as their authors to characterise online communications about dementia diagnoses. The posts were also examined by manual curation for the diagnosis provided and the person affected. Furthermore, we investigated the communities these people engage in and assessed the contents of the posts with an automated topic gathering technique. Results: Our results indicate that the majority of posters in our data set are women, and it is mostly close relatives such as parents and grandparents that are mentioned. Both the communities frequented and topics gathered reflect not only the sufferer's diagnosis but also potential outcomes, e.g. hardships experienced by the caregiver. The trends observed from this dataset are consistent with findings based on qualitative review, validating the robustness of social media automated text processing. Conclusions: This work demonstrates the value of social media data sources as a resource for in-depth studies of those affected by a dementia diagnosis and the potential to develop novel support systems based on their real time processing in line with the increasing digitalisation of medical care.

  • Real-World Technology Use among People with Mental Illnesses: A Qualitative Study

    Date Submitted: Mar 30, 2018

    Open Peer Review Period: Mar 31, 2018 - May 26, 2018

    Background: There is growing interest in using technology-based tools to support mental health recovery. Yet, despite evidence suggesting widespread access to technology among people with mental illne...

    Background: There is growing interest in using technology-based tools to support mental health recovery. Yet, despite evidence suggesting widespread access to technology among people with mental illnesses, interest in using technology to support mental health, and effectiveness of technology-based tools developed by researchers, such tools have not been widely adopted within mental health settings. Little is currently known about how mental health consumers are using technology to address mental health needs in real-world settings outside of controlled research studies. Objective: This qualitative study examined current practices and orientations toward technology among consumers in three mental health settings in the U.S. Methods: Ethnographic observations and semi-structured interviews were conducted. Observations focused on if and how technology was salient within the setting and documented relevant behaviors, interactions, and dialogue in fieldnotes. Ethnographic data informed the development of a semi-structured interview that inquired into technology use and interest among consumers (n=15) in a community mental health setting. Fieldnotes and interview transcripts were reviewed and coded by multiple researchers. Key concepts and patterns identified were refined by the research team to develop the main findings. Results: Ownership of technology, although common, was not ubiquitous and was varied across the sites. Participants had varying levels of awareness regarding the key capabilities of modern technologies. Participants used technology for many purposes, but there was limited evidence of technology use to support mental health. Technology-based tools specific to mental health were not routinely used although some participants found widely available mobile apps to be helpful in recovery. Conclusions: Qualitative findings suggest that most but not all clients will be interested in using technology to support mental health needs. The variability in type and quality of technology owned by participants suggests the need to design for a range of functionality in the development of mental health tools. Findings also suggest thinking broadly about using existing platforms and widely available tools to support consumers in mental health recovery.

  • For Better or for Worse? A Systematic Review of the Evidence on Social Media Use and Depression among Lesbian, Gay, and Bisexual Minorities

    Date Submitted: Mar 23, 2018

    Open Peer Review Period: Mar 24, 2018 - May 19, 2018

    Background: Over 90% of adults in the U.S. have at least one social media (SM) account and lesbian, gay, and bisexual (LGB) persons are more socially active on SM than heterosexuals. Rates of depressi...

    Background: Over 90% of adults in the U.S. have at least one social media (SM) account and lesbian, gay, and bisexual (LGB) persons are more socially active on SM than heterosexuals. Rates of depression among LGB persons are between 1.5- and 2-fold higher than those of heterosexual counterparts. SM allows users to connect, interact, express ideas, emotions, feelings, and thoughts. Thus, social media use (SMU) might represent both a protective and risk factor for depression among LGB persons. Studying the nature of the relationship between SMU and depression among LGB individuals is a necessary step to inform public health interventions for this population. Objective: We conducted a systematic review to synthesize and critique the evidence on SMU and depression among LGB populations. Methods: We conducted a literature search for quantitative and qualitative studies published between January 2003 and June 2017 using 3 electronic databases. Articles were included if they were peer-reviewed, in English language, assessed SMU either quantitatively or qualitatively, measured depression, and focused on LGB populations. A minimum of 2 authors independently extracted data from each study using an a priori developed abstraction form. We assessed appropriate reporting of studies using the Strengthening the Reporting of Observational Studies in Epidemiology and the Consolidated Criteria for Reporting Qualitative Research for quantitative and qualitative studies, respectively. Results: Eleven articles were included in the review. Nine studies were quantitative and cross-sectional, two were qualitative. Appropriate reporting of results varied greatly. Across quantitative studies, we found heterogeneity in how SMU was defined and measured. Cyberbullying was the most studied SM experience, and was associated with depression and suicidality. Qualitative studies found that while SM provides a space to disclose minority experiences and share ways to cope and get support, constant surveillance of one’s SM profile can become a stressor, potentially leading to depression. In most studies, sexual minority participants were identified inconsistently. Conclusions: This review supports the need for research on the role of SMU on depression outcomes among LBG persons. SMU may be both a protective and risk factor for depression among LGB individuals. Support gained via SM may buffer the impact of geographic isolation and loneliness. Negative SM experiences such as cyberbullying and other patters of SMU may be associated with depression. Future research would benefit from more consistent definitions of both SMU and study populations. Moreover, use of larger samples and accounting for patterns of SMU and individuals’ experiences on SM may help to better understand the factors that impact LGB mental health disparities.