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There is a growing body of evidence relating to how information and communication technology (ICT) can be used to support people with physical health conditions. Less is known regarding mental health, and in particular, mood disorder.
To conduct a metasynthesis of all qualitative studies exploring the use of ICTs by people with mood disorder.
Searches were run in eight electronic databases using a systematic search strategy. Qualitative and mixed-method studies published in English between 2007 and 2014 were included. Thematic synthesis was used to interpret and synthesis the results of the included studies.
Thirty-four studies were included in the synthesis. The methodological design of the studies was qualitative or mixed-methods. A global assessment of study quality identified 22 studies as strong and 12 weak with most having a typology of findings either at topical or thematic survey levels of data transformation. A typology of ICT use by people with mood disorder was created as a result of synthesis.
The systematic review and metasynthesis clearly identified a gap in the research literature as no studies were identified, which specifically researched how people with mood disorder use mobile ICT. Further qualitative research is recommended to understand the meaning this type of technology holds for people. Such research might provide valuable information on how people use mobile technology in their lives in general and also, more specifically, how they are being used to help with their mood disorders.
Mood disorder is a diagnostic category containing, among others, diagnoses such as major depression and bipolar depression [
In mental health care systems designed primarily to treat acute episodes of care, the rise in long-term conditions has threatened the sustainability of services and ultimately failed to meet the needs of patients with ongoing care management and the delivery of psychosocial interventions [
ICTs are increasingly being used for direct patient care [
In mental health care, eHealth technologies can facilitate the delivery of a wide range of effective treatments for a variety of clinical problems. They have widened the choices available to patients for selecting an approach best suited to manage their long-term condition [
More recently, a shift has occurred toward making technologies more portable or mobile, evidenced by the recent rise in smartphone and tablet ownership and usage [
Evidence suggests that mHealth can facilitate the provision of effective interventions and support the self-management of long-term conditions [
However, despite its growing popularity over the last decade, systematic research on the use of mHealth as a means of improving health outcomes remains scarce [
With the fast accumulation of qualitative studies in practice disciplines that specifically reflect experiences and subjective perspectives there is a need to bring together evidence from these studies [
1. Why do people with mood disorders use (m)ICTs?
2. What are (m)ICTs being used for by people with mood disorders?
3. What are the perceived benefits and challenges of using (m)ICTs by people with mood disorders?
4. In what ways are (m)ICTs being used for self-management by people with mood disorders?
5. What role, if any, do (m)ICTs play in terms of social relationships for people with mood disorders?
A protocol for the review was published in PROSPERO (ID=CRD42014008841). The systematic review and metasynthesis drew on methods proposed by Sandelowski and Barroso [
Due to potential difficulties in finding qualitative research [
1. (MH “World Wide Web Applications+”) (MH “Computers, Hand-Held”) (MH “Macintosh Microcomputers”) (MH “Multimedia”) OR (MH “Social Media”) (MH “Telemedicine+”) OR (MH “Telepsychiatry”) OR (MH “Telehealth+”) (MH “Computers, Portable+”) (MH “Computer Input Devices+”)OR TI App OR TX Mobile phone*OR TX Mobile Internet OR TX Sony OR TX HTC OR TX Nokia OR TX Samsung OR TX Wireless OR TI 5G OR TI 4G OR TI 3G OR TX Touch screen OR TX Context-aware system* OR TX Cel* Phone* OR TX User-centered design OR TX Mobile app* OR TX Internet treatment OR TX Virtual realit* OR TX Internet delivered OR TX Mobile technolog* OR TX Electronic health OR TX Mobile health OR TX iPad* OR TI Apple OR TX mHealth OR TX eHealth OR TX Android OR TX Blackberry OR TX Windows mobile* OR TX Windows phone* OR TX Smartphone* OR TX iPhone* OR TI Mobile*
2. (MH “Phenomenological Research”) OR (MH “Observational Methods+”) OR (MH “Patient Attitudes”) OR (MH “Ethnographic Research”) OR (MH “Constant Comparative Method”) OR (MH “Purposive Sample”) OR (MH “Qualitative Studies+”) OR (MH “Focus Groups”) OR TX Theoretical sample OR TX Qualitative research OR TX Theoretical saturation OR TX Mixed methodolog*
3. 1 AND 2
4. Limit 3 to published 2007-2014
Searches were run in eight electronic databases: Medline, Embase, Cumulative Index to Nursing and Allied Health, the psychological literature database, Applied Social Sciences Index and Abstracts, British Nursing Index, Social Sciences Citation Index, and Cochrane Library. The results from each database were exported into Endnote X7 where duplicates were removed electronically and manually. The title and abstracts of the remaining articles were exported into a Microsoft Word document and numbered ready for screening.
Additionally, to optimize qualitative article retrieval the following methods were used: footnote searching; citation searching; journal run; area scanning; and author searching. In addition, experts and key authors were contacted to identify unpublished and ongoing studies. Due to research on the mobile aspect of ICTs being an emerging field, it was envisaged that grey literature might be a valuable source of primary data. Grey literature covers a wide range of material including: reports, government publications, fact sheets, newsletters, conference proceedings, policy documents, and protocols. We therefore searched the following sources for grey literature: The New York Academy of Medicine’s Grey Literature report and Open Grey and Grey Source Index. The Journal of Medical Internet Research and Biomedcentral Psychiatry were hand searched from 2007 to present day.
One reviewer screened all of the titles and abstracts for inclusion in accordance with the following inclusion criteria: study used widely accepted qualitative methods to elicit in-depth experiences with findings appearing well supported by raw data (eg, participant quotes); study sample included people with mood disorders; study sample included the use of (m)ICTs; time period of 2007 to 2014 (2007 saw the release of the first ‘smartphone’, ie, Apple’s iPhone); and English language.
To optimize the validity of the search a systematic sampling strategy was adopted, whereby 10% of results were coscreened (HF & SM/LM) to facilitate consistency of approach [
There is a lack of agreement about the approach to quality appraisal in qualitative research [
The synthesis stage used thematic synthesis, an approach that combines elements of meta-ethnography and grounded theory providing the opportunity to synthesis methodologically heterogeneous studies [
Step 1
Free sentence-by-sentence coding: the verbatim findings of each selected study were entered into NVivo 10. Codes were developed initially free from hierarchical structure but as the translation of concepts developed from one study to another new codes were either added to existing ones or new codes created.
Step2
Organization of free codes in hierarchical order under a range of descriptive themes: free codes were organized into related areas to create descriptive themes; then similarities and differences between codes were studied, facilitating the organization of the codes into related groups and the formation of a hierarchical tree structure of descriptive themes.
Step 3
Development of analytical themes: descriptive themes were analyzed and then organized into more abstract analytical themes, producing a synthesis that went beyond the data in the original studies and addressed the research questions.
In order to keep the synthesis as close to the data as possible the research questions were initially set to one side facilitating an inductive process. Codes were applied as part of an iterative process with constant comparison with other codes (Step 1). This process was repeated for all the codes until higher order categories were constructed and all codes accounted for (Step 2). The review questions were then brought to the fore and used as a framework to guide the analytical process, which focused and transformed the descriptive themes into the final synthesis (Step 3). The categorization process was examined by the reviewing team where, through discussion, changes, and adaptions were made where necessary until consensus was reached and no further changes were required. The reviewing team scrutinized the synthesis at an analytical level through a cyclical process until a final synthesis was achieved.
The search identified 12,926 titles; 67 publications were retrieved in full (
Only one paper was identified from the systematic review of qualitative papers and therefore, synthesis of mICTs and mood disorders was not possible due to lack of data. However, the review mapped and categorized all qualitative papers in the domain of health and ICT research. This facilitated methodological development in order to find a solution regarding how to use imperfect data. Rather than lose the potentially valuable qualitative data of relevance to the project, the 67 full-text papers were rescreened. The aggregative and sensitive systematic search strategy offered a flexible approach toward the data. This provided the researchers with the ability to use the existing data to explore how people with mood disorders used ICTs ‘of relevance’ to mobile technology. This would include, but not be limited to, ICTs such as websites, online therapy, online support groups, forums, blogs, and so on, essentially, ICTs that could be accessed from mICTs but were not necessarily made explicit within the text. Thirty-four studies were included in the synthesis after the full-text articles had been rescreened; a summary of their results can be found in
The results of the appraisal process are shown in
The synthesis created three analytical themes and a number of respective analytical subthemes to describe people’s use of ICTs. This is presented as a typology of findings (
The research questions were then used as a template, explicating the typology of findings to understand how the descriptive themes interrelated with their analytical themes, thus helping to answer the questions asked of the data. The results are presented below.
Appraisal of qualitative papers in metasynthesis.
Global assessment of study quality | n (%) | ||
Weak | 12 (35) | ||
Strong | 22 (65) | ||
No findings | 4 (12) | ||
Topical survey | 11 (32) | ||
Thematic survey | 14 (41) | ||
Conceptual thematic description | 5 (15) | ||
Interpretive explanation | 0 (0) | ||
34 (100) |
Movement and change
Change processes
Engagement
Motivational aspects of use
Recovery
Taking action
Values
Providing a source of community
Communication
Intrapersonal effects
Safe places
Sharing
Social aspects
The person and technology
Acceptance of technology
Design features
Functionality
Personal time
Safety
Technical mastery
Technical issues
Usability
PRISMA diagram of screened articles of relevance to mood disorders and mICT .
Considerable overlap was found in terms of why people used ICTs and the perceived benefits this technology gave them. Two studies [
Three studies showed how users of ICTs liked the option of being able to choose where to use technology (ie, at work or in the convenience of their own homes) [
The use of websites to support relatives of people with depression appeared to decrease feelings of stigma in both by enabling people to draw strength from talking more openly about their situation [
ICTs appeared to provide people with options regarding how they used technology with choice over temporal, location, treatment, privacy, and disclosure aspects of their care needs [
The use and view of ICTs as a resource appeared to be an important factor in people’s lives. ICTs could open up access to information, support, and treatment in a highly accessible, interactive, and instant way [
There was significant overlap in terms of why people use ICTs and the benefits provided. As these benefits have already been identified and discussed in the previous two sections, this section focuses on the challenges of using technology. Certain forms of technology and their functionalities produced usage difficulties [
Some people made a conscious decision not to use ICTs. Reasons included having no interest in certain forms of technology, not being technologically savvy, and being too unwell to use technology (for example, reduced energy and motivation due to an acute depressive phase) [
The use of ICTs appeared to support people to acquire relevant knowledge in regards to their mood problems providing a sense of recognition in situations that might be difficult to accept or unfamiliar, thus helping them feel supported [
ICTs appeared to help provide a sense of control in people’s lives by providing them with the opportunity to find information about where to find help, assisted them with understanding when to seek help, and what support was available to them [
Receiving support through ICTs appeared to be of benefit by people with mood disorders [
Learning time management techniques facilitated people to organize their time better helping them meet deadlines and prepare for exams [
People’s awareness sometimes appeared to change when using ICTs. For instance, becoming aware of holding high expectations toward technology and feeling disappointment if programs did not meet all their needs fostered a sense of consideration to revisit and work with material to see if it would be of benefit [
Using ICTs for social support appeared to be of benefit to people and one of the predominant reasons for using the technology on a daily basis [
ICTs provided people with the capacity to use online social networks in order to communicate with people experiencing similar issues, to ask advice or discuss certain topics in a convenient and accessible manner [
The aim of the study was to conduct a metasynthesis of all qualitative studies exploring the use of ICTs by people with mood disorder. The resultant metasynthesis created an analytical typology of findings and a descriptively themed framework, which conceptualized how people with mood disorder use and relate to their ICTs, and in so doing, answered the specific review questions. The metasynthesis identified that people with mood disorders use ICTs in similar ways and face similar technological paradoxes as other users [
Our metasynthesis identified the factors influencing why people with mood disorders chose to use ICTs such as affordability, accessibility, and versatility. These factors align closely with previous studies on the delivery of health-related products evidenced through increasing Web-based self-help resources [
People who took responsibility for their treatment, had a sense of determination, curiosity, and attributed success to their own endeavors appeared to benefit more from treatment delivered through ICTs [
When designing ICTs and Web-based interventions importance was placed upon managing depressive symptoms in order to support people, through evidence-based interventions, with their practical and interpersonal issues caused by their conditions. [
The findings of our metasynthesis indicate that usage difficulties were a key factor in reducing people’s motivation to use ICTs. This aligns well with the findings of others, including Bessel et al [
There are many advantages for patients when using ICTs, such as being able to get in contact with health professionals quickly and easily, a reduction in travel and waiting times for face-to-face appointments, convenience, and affordability. The technology provides a medium for communication between health professionals and patients where information about the patients’ disease, treatment, and therapeutic interventions can be discussed [
Our metasynthesis identified that people used ICTs to acquire relevant knowledge in regards to their mental health issues. This can be linked to an increasing trend in society to adopt self-service models of interaction. There have been promising results for using computers to deliver self-management programs to patients with long-term conditions in health-supported settings showing potential for changing health behavior and improving clinical outcomes [
Outcome data from RCTs and meta-analyses have identified the cost-effectiveness and clinical efficacy of mental health programs delivered via ICTs with comparable effect sizes to face-to-face treatment [
Our metasynthesis identified that people with mood disorder were using ICTs to give and receive social support. This corresponds with evidence from SNS use and associated indices of psychological well-being relating to a persons’ sense of self-worth, self-esteem, satisfaction with life, and other psychological development measures [
Of particular importance was the lack of qualitative research being undertaken in this field as evidenced by only one paper retrieved specifically reporting on mICTs. To date, patients or end uses have not been sufficiently included in the design of software applications. The same applies to the selection of relevant and appropriate outcome measures in effectiveness studies such as RCTs. These omissions have contributed to redundancy and the abandonment of technology. n fact, there has been a presumption that those designing technology and undertaking research already know what the user wants in terms of software and hardware. Designers have, jumped ahead, and designed apps and websites, without first talking to end users about how they use and fit technology into both their existing lives and what would help them manage their lives. Qualitative research, which provides a more in-depth understanding of users’ views and experiences is of vital importance if we are to understand how people use or benefit from technology and what drives them to engage, or not, with these technologies.
Research: research relating to how people with mood disorder used ICTs was lacking and in particular, their use of mICTs, not as participants in research studies, but as ubiquitous technology in their everyday lives. Qualitative research is required to help understand how mICTs fit into people’s lives both in general but also more specifically in relation to their mood disorders.
Practice: clinical practice could be supported through understanding how people with mood disorder use mICTs to look after themselves providing clinicians with valuable information to help harness peoples’ mICTs for use in their recovery and inform the future design of technology.
The review relied exclusively upon English language publications, which may not adequately reflect the user experiences and perceptions that were gathered in non-English speaking contexts. Another issue may relate to the quality of primary data sources and the quality of existing quality appraisal tools for metasyntheses. The researcher’s stance was clearly set out in the study providing rationales for the choice of methodology and methods used. Transparency was achieved by clearly detailing the synthesis process and checks and balances were used to ensure rigor throughout. The study originally set out to synthesis all qualitative articles regarding people with mood disorder and mICT. Unfortunately, as only one article met the original inclusion criteria for mobile technology a synthesis of this material was not possible. However, our novel approach toward the search and retrieval of data allowed us to catalogue all qualitative data related to health and ICTs including data of relevance to mICTs. This process provided us with the opportunity to restructure our inclusion criteria and make use of the data that would have otherwise been neglected in other systematic reviews and metasyntheses.
The metasynthesis of people with mood disorders and their use of ICTs has provided a tentative understanding into their uses, challenges, and gratifications spanning the intrapersonal, interpersonal, and through into wider society. The typology of findings and analytical framework highlights the connections and interrelationships between analytical themes and subcategories; the intrinsic and extrinsic nature of use and the embedded characteristics of the technology. Our metasynthesis has identified that people can use ICTs in novel ways to help them manage their lives and health. People use ICTs to support motivation, for their convenience, to help decrease feelings of stigma, their facilitative capabilities, enhance privacy, credibility, and cost effectiveness. ICTs support people to access the Internet to get what they need in a way that fits into their lives. ICTs are a resource for communication and promote user engagement. However, they are not without issue, with particular challenges of trust and confidentially requiring to be negotiated. That being said, when the challenges are navigated successfully, people are able access opportunities to manage their mood disorder by acquiring relevant knowledge, engage in help-seeking behavior, receive support, gain a sense of control, learn time management techniques, take responsibility, and increase their awareness. ICTs also allow access to Web-based social networks where sharing with others can facilitate social support. Our typology of findings creates an empirical basis to help guide and harness the potential of (m)ICTs to support self-management, facilitate collaborative, person-centered care, and support the person actively recover from their mood disorder. Importantly, our metasynthesis has highlighted a gap in the evidence base, as no research has focused specifically on mICT use by people with mood disorder.
Summary of results
computerized cognitive behavioral therapy
bipolar disorder
general practitioner
mobile information and communication technologies
information and communication technologies
randomized control trials
social networking site
H. Fulford undertook the metasynthesis and manuscript preparation with principal supervision from S. MacGillivray and additional supervision from L. McSwiggan and T. Kroll.
None declared.