%0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e19168 %T Mental Health Professional Consultations and the Prevalence of Mood and Anxiety Disorders Among Immigrants: Multilevel Analysis of the Canadian Community Health Survey %A Nwoke,Chinenye Nmanma %A Okpalauwaekwe,Udoka %A Bwala,Hauwa %+ Faculty of Health Sciences, University of Lethbridge, 4401 University Drive, Lethbridge, AB, T1K 3M4, Canada, 1 403 561 7125, chinenye.nwoke@uleth.ca %K immigrants %K immigrant mental health %K mental health consultations %K mood disorders %K anxiety disorders %K mental health visits %K Canadian Community Health Survey %D 2020 %7 16.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a significant body of evidence on the link between migration and mental health stressors. However, there has been very little research on the use of mental health services by immigrants in Canada. The prevalence of mental health professional consultations among immigrants, as well as its correlations, are not well understood and remain largely unknown. Objective: This study aims to examine how specialist mental health visits (to a psychiatrist) differ from general mental health visits (to a family doctor or general practitioner) from immigrants, when compared to visits from those born in Canada, in a nationally representative sample of Canadian adults. This study also examines which group—immigrant or Canadian-born—suffers more from depression or anxiety, 2 of the more common mental health conditions. Methods: We used data from the Canadian Community Health Survey (CCHS) between the years 2015 and 2016. The outcome variables included consultation with any mental health professional, consultation with a specialist (psychiatrist), and the prevalence of mood and anxiety disorders. The independent variable was immigrant status. Other variables of interest were adjusted for in the analyses. Multilevel regression models were developed, and all analyses were performed with Stata IC statistical software (version 13.0, StataCorp). Results: The prevalence of mood and anxiety disorders was significantly lower among immigrants compared with individuals born in Canada; the prevalence of mood disorders was 5.24% (389,164/7,422,773) for immigrants vs. 9.15% (2,001,829/21,885,625) for individuals born in Canada, and the prevalence of anxiety disorders was 4.47% (330,937/7,410,437) for immigrants vs. 9.51% (2,083,155/21,898,839) for individuals born in Canada. It is expected that individuals with a lower prevalence of mood or anxiety disorders would use mental health services less frequently. However, results show that immigrants, while less likely to consult with any mental health professional (OR=0.80, 95% CI 0.72-0.88, P<.001), were more likely to consult with a psychiatrist (OR=1.24, 95% CI 1.04-1.48, P=.02) for their mental health visits when compared to individuals born in Canada. Conclusions: The results of this study reveal an unusual discord between the likelihood of mental health professional consultations with any mental health professional and mental health visits with psychiatrists among immigrants compared to nonimmigrants in Canada. Mental health initiatives need to be cognizant of the differences in the associated characteristics of consultations for immigrants to better tailor mental health services to be responsive to the unique needs of immigrant populations in Canada. %M 32801115 %R 10.2196/19168 %U http://mental.jmir.org/2020/9/e19168/ %U https://doi.org/10.2196/19168 %U http://www.ncbi.nlm.nih.gov/pubmed/32801115 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e18383 %T Suicidal Thoughts and Behaviors and Their Associations With Transitional Life Events in Men and Women: Findings From an International Web-Based Sample %A Milton,Alyssa Clare %A Davenport,Tracey A %A Iorfino,Frank %A Flego,Anna %A Burns,Jane M %A Hickie,Ian B %+ Brain and Mind Centre, University of Sydney, 88 Mallet St, Camperdown, 2050, Australia, 61 2 86276947, alyssa.milton@sydney.edu.au %K suicidal ideation %K suicide %K suicide, attempted %K men %K women %K sex differences %K life change events %K adaptation, psychological %K health surveys %D 2020 %7 11.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although numerous studies have demonstrated sex differences in the prevalence of suicidal thoughts and behaviors (STB), there is a clear lack of research examining the similarities and differences between men and women in terms of the relationship between STB, transitional life events, and the coping strategies employed after experiencing such events when they are perceived as stressful. Objective: This study aims to examine the differences between men’s and women’s experiences of STB, sociodemographic predictors of STB, and how coping responses after experiencing a stressful transitional life event predict STB. Methods: A web-based self-report survey was used to assess the health and well-being of a voluntary community-based sample of men and women aged 16 years and older, living in Australia, Canada, New Zealand, the United Kingdom, and the United States, who were recruited using web-based social media promotion and snowballing. Results: In total, 10,765 eligible web-based respondents participated. Compared with men, a significantly greater proportion of women reported STB (P<.001) and endorsed experiencing a transitional life event as stressful (P<.001). However, there were no gender differences in reporting that the transitional life event or events was stressful for those who also reported STB. Significant sociodemographic adjusted risk factors of STB included younger age; identifying as a sexual minority; lower subjective social connectedness; lower subjective intimate bonds; experiencing a stressful transitional life event in the past 12 months; living alone (women only); not being in employment, education, or training (women only); suddenly or unexpectedly losing a job (men only); and experiencing a relationship breakdown (men only). Protective factors included starting a new job, retiring, having a language background other than English, and becoming a parent for the first time (men only). The results relating to coping after experiencing a self-reported stressful transitional life event in the past 12 months found that regardless of sex, respondents who reported STB compared with those who did not were less likely to engage in activities that promote social connections, such as talking about their feelings (P<.001). Coping strategies significantly explained 19.0% of the STB variance for men (F16,1027=14.64; P<.001) and 22.0% for women (F16,1977=36.45; P<.001). Conclusions: This research highlights multiple risk factors for STB, one of which includes experiencing at least one stressful transitional life event in the past 12 months. When individuals are experiencing such events, support from services and the community alike should consider using sex-specific or targeted strategies, as this research indicates that compared with women, more men do nothing when experiencing stress after a transitional life event and may be waiting until they experience STB to engage with their social networks for support. %M 32915160 %R 10.2196/18383 %U http://mental.jmir.org/2020/9/e18383/ %U https://doi.org/10.2196/18383 %U http://www.ncbi.nlm.nih.gov/pubmed/32915160 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22227 %T Depression and Psychological-Behavioral Responses Among the General Public in China During the Early Stages of the COVID-19 Pandemic: Survey Study %A Zhang,Weiyu %A Yang,Xiaoting %A Zhao,Jinfeng %A Yang,Fengzhi %A Jia,Yajing %A Cui,Can %A Yang,Xiaoshi %+ Department of Social Medicine, School of Public Health, China Medical University, No 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China, 86 18900910796, xsyang@cmu.edu.cn %K depression %K COVID-19 %K social support %K the general public %D 2020 %7 4.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has recently spread dramatically worldwide, raising considerable concerns and resulting in detrimental effects on the psychological health of people who are vulnerable to the disease. Therefore, assessment of depression in members of the general public and their psychological and behavioral responses is essential for the maintenance of health. Objective: This study aimed to assess the prevalence of depression and the associated factors among the general public during the early stages of the COVID-19 pandemic in China. Methods: A cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression.aA cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression. Results: The prevalence of depression (PHQ-9 score ≥10) among the general public during the COVID-19 pandemic was 182/1342 (13.6%). Regression analysis indicated that feeling stressed, feeling helpless, persistently being worried even with support, never feeling clean after disinfecting, scrubbing hands and items repeatedly, hoarding food, medicine, or daily supplies, and being distracted from work or study were positively associated with depression, while social support and being calm were negatively associated with depression. Conclusions: The general public suffered from high levels of depression during the early stages of the COVID-19 pandemic. Thus, COVID-19–related mood management and social support should be provided to attenuate depression in the general public. %M 32886066 %R 10.2196/22227 %U https://www.jmir.org/2020/9/e22227 %U https://doi.org/10.2196/22227 %U http://www.ncbi.nlm.nih.gov/pubmed/32886066 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e15972 %T Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study %A Stawarz,Katarzyna %A Preist,Chris %A Tallon,Debbie %A Wiles,Nicola %A Kessler,David %A Turner,Katrina %A Shafran,Roz %A Coyle,David %+ School of Computer Science and Informatics, Cardiff University, Queen's Buildings, 5 The Parade, Cardiff, 3AA, United Kingdom, 44 29 2251 0037, stawarzk@cardiff.ac.uk %K cognitive behavioral therapy %K depression %K mental health %K blended therapy %K integrated therapy %K user-centered design %K qualitative research %D 2020 %7 3.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists’ workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. Objective: The research aimed to explore patients’ and therapists’ views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. Methods: We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. Results: Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists’ workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. Conclusions: To meet clients’ and therapists’ needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists’ workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context. %M 32880580 %R 10.2196/15972 %U https://mental.jmir.org/2020/9/e15972 %U https://doi.org/10.2196/15972 %U http://www.ncbi.nlm.nih.gov/pubmed/32880580 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20581 %T Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis %A Sin,Jacqueline %A Galeazzi,Gian %A McGregor,Elicia %A Collom,Jennifer %A Taylor,Anna %A Barrett,Barbara %A Lawrence,Vanessa %A Henderson,Claire %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, Reading, RG6 6AL, United Kingdom, 44 7817027035, jacqueline.sin@reading.ac.uk %K eHealth %K mHealth %K psychiatric illness %K mental disorders %K common mental illness %K depression %K anxiety %K self-care %D 2020 %7 2.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Digital interventions targeting common mental disorders (CMDs) or symptoms of CMDs are growing rapidly and gaining popularity, probably in response to the increased prevalence of CMDs and better awareness of early help-seeking and self-care. However, no previous systematic reviews that focus on these novel interventions were found. Objective: This systematic review aims to scope entirely web-based interventions that provided screening and signposting for treatment, including self-management strategies, for people with CMDs or subthreshold symptoms. In addition, a meta-analysis was conducted to evaluate the effectiveness of these interventions for mental well-being and mental health outcomes. Methods: Ten electronic databases including MEDLINE, PsycINFO, and EMBASE were searched from January 1, 1999, to early April 2020. We included randomized controlled trials (RCTs) that evaluated a digital intervention (1) targeting adults with symptoms of CMDs, (2) providing both screening and signposting to other resources including self-care, and (3) delivered entirely through the internet. Intervention characteristics including target population, platform used, key design features, and outcome measure results were extracted and compared. Trial outcome results were included in a meta-analysis on the effectiveness of users’ well-being and mental health outcomes. We also rated the meta-analysis results with the Grading of Recommendations, Assessment, Development, and Evaluations approach to establish the quality of the evidence. Results: The electronic searches yielded 21 papers describing 16 discrete digital interventions. These interventions were investigated in 19 unique trials including 1 (5%) health economic study. Most studies were conducted in Australia and North America. The targeted populations varied from the general population to allied health professionals. All interventions offered algorithm-driven screening with measures to assess symptom levels and to assign treatment options including automatic web-based psychoeducation, self-care strategies, and signposting to existing services. A meta-analysis of usable trial data showed that digital interventions improved well-being (3 randomized controlled trials [RCTs]; n=1307; standardized mean difference [SMD] 0.40; 95% CI 0.29 to 0.51; I2=28%; fixed effect), symptoms of mental illness (6 RCTs; n=992; SMD −0.29; 95% CI −0.49 to −0.09; I2=51%; random effects), and work and social functioning (3 RCTs; n=795; SMD −0.16; 95% CI −0.30 to −0.02; I2=0%; fixed effect) compared with waitlist or attention control. However, some follow-up data failed to show any sustained effects beyond the post intervention time point. Data on mechanisms of change and cost-effectiveness were also lacking, precluding further analysis. Conclusions: Digital mental health interventions to assess and signpost people experiencing symptoms of CMDs appear to be acceptable to a sufficient number of people and appear to have enough evidence for effectiveness to warrant further study. We recommend that future studies incorporate economic analysis and process evaluation to assess the mechanisms of action and cost-effectiveness to aid scaling of the implementation. %M 32876577 %R 10.2196/20581 %U https://www.jmir.org/2020/9/e20581 %U https://doi.org/10.2196/20581 %U http://www.ncbi.nlm.nih.gov/pubmed/32876577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18458 %T Compensatory Social Networking Site Use, Family Support, and Depression Among College Freshman: Three-Wave Panel Study %A Zhou,Mingjie %A Li,Fugui %A Wang,Yanhong %A Chen,Shuang %A Wang,Kexin %+ College of Media and International Culture, Zhejiang University, Main Teaching Building, 4th Fl., Hangzhou, 310007, China, 86 18611897400, wangkexin0809@zju.edu.cn %K freshmen %K introversion %K compensatory use of SNS %K depression %K family support %K social media %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Freshmen were found to use social networking sites (SNS) as a useful medium to effectively adjust to college life, which hints at a tendency to resort to SNS for social compensation. However, the compensatory use of SNS is usually problematic. Objective: This study explores why a subgroup of freshmen developed depressive symptoms while socially adjusting to college by investigating the antecedent role of introversion, the explanatory role of compensatory use of SNS, and the protective role of perceived family support. The study is among the first to point out the relevance of the compensatory use of SNS in explaining the indirect association between introversion and depression with a longitudinal design. Methods: A 3-wave panel sample of freshmen (N=1137) is used to examine the moderated mediation model. Results: We found that introversion at Wave 1 positively predicted compensatory use of SNS at Wave 2 and subsequently increased depression at Wave 3 (unstandardized B=0.07, SE 0.02, P<.001, 95% CI 0.04-0.10; unstandardized B=0.09, SE 0.01, P<.001, 95% CI 0.06-0.12). The moderated mediation model further examined the buffering role of perceived family support within the link between introversion and compensatory SNS use (index=0.0031, SE 0.0015, 95% CI 0.0003-0.0062). Unexpectedly, we found that family support in Wave 1 decreased compensatory SNS use for less introverted freshmen in Wave 2 and further decreased depression in Wave 3. Conclusions: Unexpectedly, our findings uncover an enhancing effect, rather than a buffering effect, of family support by embedding its effect within the relationship between introversion and compensatory SNS use. Appreciating the differences in the casual pathways for freshmen with different levels of introversion clarifies how SNS affect young adults' lives. %M 32795999 %R 10.2196/18458 %U https://www.jmir.org/2020/9/e18458 %U https://doi.org/10.2196/18458 %U http://www.ncbi.nlm.nih.gov/pubmed/32795999 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18100 %T Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis %A Etzelmueller,Anne %A Vis,Christiaan %A Karyotaki,Eirini %A Baumeister,Harald %A Titov,Nickolai %A Berking,Matthias %A Cuijpers,Pim %A Riper,Heleen %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Nägelsbachstr 25a, Erlangen, 91052, Germany, 49 9131 85 67575, anne.etzelmueller@fau.de %K internet-based interventions %K depression %K anxiety %K effectiveness %K acceptability %K routine care %D 2020 %7 31.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited. Objective: This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety. Methods: The acceptability (uptake, participants’ characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches. Results: A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges’ g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants’ characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%. Conclusions: This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts. %M 32865497 %R 10.2196/18100 %U http://www.jmir.org/2020/8/e18100/ %U https://doi.org/10.2196/18100 %U http://www.ncbi.nlm.nih.gov/pubmed/32865497 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e21304 %T Digital Cognitive Behavior Therapy Intervention for Depression and Anxiety: Retrospective Study %A Venkatesan,Aarathi %A Rahimi,Lily %A Kaur,Manpreet %A Mosunic,Christopher %+ Vida Health, 100 Montgomery St, Ste 750, San Francisco, CA, 94104, United States, 1 (415) 989 1017, aarathi.venkatesan@vida.com %K depression %K anxiety %K CBT %K digital mental health intervention %K digital therapeutics %K cognitive behavioral therapy %K therapy %K digital health %K intervention %K mental health %D 2020 %7 26.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital mental health interventions offer a scalable solution that reduces barriers to seeking care for clinical depression and anxiety. Objective: We aimed to examine the effectiveness of a 12-week therapist supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety within 9 months. Methods: A total of 323 participants with mild to moderately severe depression or anxiety were enrolled in a 12-week digital cognitive behavior therapy program. The analysis was restricted to participants who provided at least one follow-up assessment after baseline. As a result, 146 participants (45.2%) were included in the analysis—74 (50.7%) participants completed assessments at 3 months, 31 participants (21.2%) completed assessments at 6 months, and 21 participants (14.4%) completed assessments at 9 months. The program included structured lessons and tools (ie, exercises and practices) as well as one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly check-in sessions for 1 year. The clinically validated Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder Scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Results: We observed a significant positive effect of program time on improvement in depression (β=–0.12, P<.001) and anxiety scores (β=–0.10, P<.001). At the end of the 12-week intervention, we observed an average reduction of 3.76 points (95% CI –4.76 to –2.76) in PHQ-8 scores. Further reductions in depression were seen at program month 6 (4.75-point reduction, 95% CI –6.61 to –2.88) and program month 9 (6.42-point reduction, 95% CI –8.66 to –6.55, P<.001). A similar pattern of improvement emerged for anxiety, with a 3.17-point reduction at the end of the 12-week intervention (95% CI –4.21 to –2.13). These improvements were maintained at program month 6 (4.87-point reduction, 95% CI –6.85 to –2.87) and program month 9 (5.19-point, 95% –6.85 to 4.81). In addition, greater program engagement during the first 12 weeks predicted a greater reduction in depression (β=–0.29, P<.001) Conclusions: The results suggest that digital interventions can support sustained and clinically meaningful improvements in depression and anxiety. Furthermore, it appears that strong initial digital mental health intervention engagement may facilitate this effect. However, the study was limited by postintervention participant attrition as well as the retrospective observational study design. %M 32845246 %R 10.2196/21304 %U http://mental.jmir.org/2020/8/e21304/ %U https://doi.org/10.2196/21304 %U http://www.ncbi.nlm.nih.gov/pubmed/32845246 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16388 %T Relationship Between Depression and the Use of Mobile Technologies and Social Media Among Adolescents: Umbrella Review %A Arias-de la Torre,Jorge %A Puigdomenech,Elisa %A García,Xavier %A Valderas,Jose M %A Eiroa-Orosa,Francisco Jose %A Fernández-Villa,Tania %A Molina,Antonio J %A Martín,Vicente %A Serrano-Blanco,Antoni %A Alonso,Jordi %A Espallargues,Mireia %+ Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill campus, London, SE5 8AF, United Kingdom, 44 634722677, jorgeariasdelatorre@gmail.com %K mobile technologies and social media %K depression %K adolescents %K review %D 2020 %7 26.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Despite the relevance of mobile technologies and social media (MTSM) for adolescents, their association with depressive disorders in this population remains unclear. While there are previous reviews that have identified the use of MTSM as a risk factor for developing depression, other reviews have indicated their possible preventive effect. Objective: The aim of this review was to synthesize the current evidence on the association between MTSM use and the development or prevention of depressive disorders in adolescents. Methods: An umbrella review was conducted using information published up to June 2019 from PubMed/MEDLINE, PsycINFO, Web of Science, and The Cochrane Library. Systematic reviews focusing on the adolescent population (up to 20 years old) and depression and its potential relationship with MTSM use were included. Screening of titles, abstracts, and full texts was performed. After selecting the reviews and given the heterogeneity of the outcome variables and exposures, a narrative synthesis of the results was carried out. Results: The search retrieved 338 documents, from which 7 systematic reviews (3 meta-analyses) were selected for data extraction. There were 11-70 studies and 5582-46,015 participants included in the 7 reviews. All reviews included quantitative research, and 2 reviews also included qualitative studies. A statistically significant association between social media and developing depressive symptoms was reported in 2 reviews, while 5 reviews reported mixed results. Conclusions: Excessive social comparison and personal involvement when using MTSM could be associated with the development of depressive symptomatology. Nevertheless, MTSM might promote social support and even become a point of assistance for people with depression. Due to the mixed results, prospective research could be valuable for providing stronger evidence. %M 32663157 %R 10.2196/16388 %U http://www.jmir.org/2020/8/e16388/ %U https://doi.org/10.2196/16388 %U http://www.ncbi.nlm.nih.gov/pubmed/32663157 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e19706 %T Digital Tools to Ameliorate Psychological Symptoms Associated With COVID-19: Scoping Review %A Zhang,Melvyn %A Smith,Helen Elizabeth %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 11, Family Medicine and Primary Care, 308322, Singapore, 65 98556631, melvynzhangweibin@gmail.com %K COVID-19 %K digital tool %K psychiatry %K mental health %K digital health %K psychology %K distress %K stress %K anxiety %K depression %D 2020 %7 21.8.2020 %9 Review %J J Med Internet Res %G English %X Background: In the four months after the discovery of the index case of coronavirus disease (COVID-19), several studies highlighted the psychological impact of COVID-19 on frontline health care workers and on members of the general public. It is evident from these studies that individuals experienced elevated levels of anxiety and depression in the acute phase, when they first became aware of the pandemic, and that the psychological distress persisted into subsequent weeks. It is becoming apparent that technological tools such as SMS text messages, web-based interventions, mobile interventions, and conversational agents can help ameliorate psychological distress in the workplace and in society. To our knowledge, there are few publications describing how digital tools have been used to ameliorate psychological symptoms among individuals. Objective: The aim of this review was to identify existing SMS text message, web-based, mobile, and conversational agents that the general public can access to ameliorate the psychological symptoms they are experiencing during the COVID-19 pandemic. Methods: To identify digital tools that were published specifically for COVID-19, a search was performed in the PubMed and MEDLINE databases from the inception of the databases through June 17, 2020. The following search strings were used: “NCOV OR 2019-nCoV OR SARS-CoV-2 OR Coronavirus OR COVID19 OR COVID” and “mHealth OR eHealth OR text”. Another search was conducted in PubMed and MEDLINE to identify existing digital tools for depression and anxiety disorders. A web-based search engine (Google) was used to identify if the cited web-based interventions could be accessed. A mobile app search engine, App Annie, was used to determine if the identified mobile apps were commercially available. Results: A total of 6 studies were identified. Of the 6 identified web-based interventions, 5 websites (83%) could be accessed. Of the 32 identified mobile interventions, 7 apps (22%) could be accessed. Of the 7 identified conversational agents, only 2 (29%) could be accessed. Results: A total of 6 studies were identified. Of the 6 identified web-based interventions, 5 websites (83%) could be accessed. Of the 32 identified mobile interventions, 7 apps (22%) could be accessed. Of the 7 identified conversational agents, only 2 (29%) could be accessed. Conclusions: The COVID-19 pandemic has caused significant psychological distress. Digital tools that are commercially available may be useful for at-risk individuals or individuals with pre-existing psychiatric symptoms. %M 32721922 %R 10.2196/19706 %U http://www.jmir.org/2020/8/e19706/ %U https://doi.org/10.2196/19706 %U http://www.ncbi.nlm.nih.gov/pubmed/32721922 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e18642 %T Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views %A Titzler,Ingrid %A Berking,Matthias %A Schlicker,Sandra %A Riper,Heleen %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, University of Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen, 91052, Germany, 49 91318567567, ingrid.titzler@fau.de %K barriers and facilitators %K general practitioners %K depression %K referral %K blended therapy %K internet-based intervention %K mobile phone %K psychotherapy %K qualitative research %D 2020 %7 18.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users’ perspectives and behavior. Objective: This study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined. Methods: Semistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted. Results: GPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs’ referrals and their self-rated pharmacotherapeutic competence, r(73)=−0.31, P<.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included “little knowledge about internet-based interventions” and “patients’ lack of familiarity with technology/internet/media” (number of statements, each k=22). Key facilitators were “perceived patient suitability, e.g. well-educated, young” (k=22) and “no conflict with GP’s role” (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned. Conclusions: This study provides insights into factors influencing GPs’ referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates. %M 32673213 %R 10.2196/18642 %U http://mental.jmir.org/2020/8/e18642/ %U https://doi.org/10.2196/18642 %U http://www.ncbi.nlm.nih.gov/pubmed/32673213 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e18751 %T The Relationship Between Smartphone-Recorded Environmental Audio and Symptomatology of Anxiety and Depression: Exploratory Study %A Di Matteo,Daniel %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Yu,Julia %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Centre for Automation of Medicine, The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, DL Pratt Building, 6 King's College Road, Toronto, ON, M5S 3H5, Canada, 1 416 978 6992, dandm@ece.utoronto.ca %K depression %K anxiety %K mobile phone %K ecological momentary assessment %K mobile apps %K mobile health %K digital signal processing %K acoustics %K speech recognition software %D 2020 %7 13.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Objective and continuous severity measures of anxiety and depression are highly valuable and would have many applications in psychiatry and psychology. A collective source of data for objective measures are the sensors in a person’s smartphone, and a particularly rich source is the microphone that can be used to sample the audio environment. This may give broad insight into activity, sleep, and social interaction, which may be associated with quality of life and severity of anxiety and depression. Objective: This study aimed to explore the properties of passively recorded environmental audio from a subject’s smartphone to find potential correlates of symptom severity of social anxiety disorder, generalized anxiety disorder, depression, and general impairment. Methods: An Android app was designed, together with a centralized server system, to collect periodic measurements of the volume of sounds in the environment and to detect the presence or absence of English-speaking voices. Subjects were recruited into a 2-week observational study during which the app was run on their personal smartphone to collect audio data. Subjects also completed self-report severity measures of social anxiety disorder, generalized anxiety disorder, depression, and functional impairment. Participants were 112 Canadian adults from a nonclinical population. High-level features were extracted from the environmental audio of 84 participants with sufficient data, and correlations were measured between the 4 audio features and the 4 self-report measures. Results: The regularity in daily patterns of activity and inactivity inferred from the environmental audio volume was correlated with the severity of depression (r=−0.37; P<.001). A measure of sleep disturbance inferred from the environmental audio volume was also correlated with the severity of depression (r=0.23; P=.03). A proxy measure of social interaction based on the detection of speaking voices in the environmental audio was correlated with depression (r=−0.37; P<.001) and functional impairment (r=−0.29; P=.01). None of the 4 environmental audio-based features tested showed significant correlations with the measures of generalized anxiety or social anxiety. Conclusions: In this study group, the environmental audio was shown to contain signals that were associated with the severity of depression and functional impairment. Associations with the severity of social anxiety disorder and generalized anxiety disorder were much weaker in comparison and not statistically significant at the 5% significance level. This work also confirmed previous work showing that the presence of voices is associated with depression. Furthermore, this study suggests that sparsely sampled audio volume could provide potentially relevant insight into subjects’ mental health. %M 32788153 %R 10.2196/18751 %U https://formative.jmir.org/2020/8/e18751 %U https://doi.org/10.2196/18751 %U http://www.ncbi.nlm.nih.gov/pubmed/32788153 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18033 %T Views of Implementers and Nonimplementers of Internet-Administered Cognitive Behavioral Therapy for Depression and Anxiety: Survey of Primary Care Decision Makers in Sweden %A Brantnell,Anders %A Woodford,Joanne %A Baraldi,Enrico %A van Achterberg,Theo %A von Essen,Louise %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds Väg 14B, Uppsala, Sweden, 46 18 471 70 55, anders.brantnell@angstrom.uu.se %K mental health %K internet-administered CBT %K self-management %K implementation %K barriers and facilitators %K decision-making %K eHealth %K primary care %D 2020 %7 12.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-administered cognitive behavioral therapy (ICBT) has been demonstrated to be an effective intervention for adults with depression and/or anxiety and is recommended in national guidelines for provision within Swedish primary care. However, the number and type of organizations that have implemented ICBT within primary care in Sweden is currently unclear. Further, there is a lack of knowledge concerning barriers and facilitators to ICBT implementation. Objective: The two primary objectives were to identify and describe primary care organizations providing ICBT in Sweden and compare decision makers’ (ie, directors of primary care organizations) views on barriers and facilitators to implementation of ICBT among ICBT implementers (ie, organizations that offered ICBT) and nonimplementers (ie, organizations that did not offer ICBT). Methods: An online survey based on a checklist for identifying barriers and facilitators to implementation was developed and made accessible to decision makers from all primary care organizations in Sweden. The survey consisted of background questions (eg, provision of ICBT and number of persons working with ICBT) and barriers and facilitators relating to the following categories: users, therapists, ICBT programs, organizations, and wider society. Results: The participation rate was 35.75% (404/1130). The majority (250/404, 61.8%) of participants were health care center directors and had backgrounds in nursing. Altogether, 89.8% (363/404) of the participating organizations provided CBT. A minority (83/404, 20.5%) of organizations offered ICBT. Most professionals delivering ICBT were psychologists (67/83, 80%) and social workers (31/83, 37%). The majority (61/83, 73%) of organizations had 1 to 2 persons delivering ICBT interventions. The number of patients treated with ICBT during the last 12 months was 1 to 10 in 65% (54/83) of the organizations, ranging between 1 and 400 treated patients across the whole sample. There were 9 significant (P<.05) differences out of 37 possible between implementers and nonimplementers. For example, more implementers (48/51, 94%) than nonimplementers (107/139, 76.9%) perceived few technical problems (P<.001), and more implementers (53/77, 68%) than nonimplementers (103/215, 47.9%) considered that their organization has resources to offer ICBT programs (P<.001). Conclusions: Despite research demonstrating the effectiveness of ICBT for depression and anxiety and national guidelines recommending its use, ICBT is implemented in few primary care organizations in Sweden. Several interesting differences between implementers and nonimplementers were identified, which may help inform interventions focusing on facilitating the implementation of ICBT. %M 32784186 %R 10.2196/18033 %U https://www.jmir.org/2020/8/e18033 %U https://doi.org/10.2196/18033 %U http://www.ncbi.nlm.nih.gov/pubmed/32784186 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e16969 %T Designing a Clinician-Facing Tool for Using Insights From Patients’ Social Media Activity: Iterative Co-Design Approach %A Yoo,Dong Whi %A Birnbaum,Michael L %A Van Meter,Anna R %A Ali,Asra F %A Arenare,Elizabeth %A Abowd,Gregory D %A De Choudhury,Munmun %+ School of Interactive Computing, Georgia Institute of Technology, 756 W Peachtree St NW, Atlanta, GA, 30308, United States, 1 4043858603, yoo@gatech.edu %K social media %K psychotic disorders %K information technology %D 2020 %7 12.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Recent research has emphasized the need for accessing information about patients to augment mental health patients’ verbal reports in clinical settings. Although it has not been introduced in clinical settings, computational linguistic analysis on social media has proved it can infer mental health attributes, implying a potential use as collateral information at the point of care. To realize this potential and make social media insights actionable to clinical decision making, the gaps between computational linguistic analysis on social media and the current work practices of mental health clinicians must be bridged. Objective: This study aimed to identify information derived from patients’ social media data that can benefit clinicians and to develop a set of design implications, via a series of low-fidelity (lo-fi) prototypes, on how to deliver the information at the point of care. Methods: A team of clinical researchers and human-computer interaction (HCI) researchers conducted a long-term co-design activity for over 6 months. The needs-affordances analysis framework was used to refine the clinicians’ potential needs, which can be supported by patients’ social media data. On the basis of those identified needs, the HCI researchers iteratively created 3 different lo-fi prototypes. The prototypes were shared with both groups of researchers via a videoconferencing software for discussion and feedback. During the remote meetings, potential clinical utility, potential use of the different prototypes in a treatment setting, and areas of improvement were discussed. Results: Our first prototype was a card-type interface that supported treatment goal tracking. Each card included attribute levels: depression, anxiety, social activities, alcohol, and drug use. This version confirmed what types of information are helpful but revealed the need for a glanceable dashboard that highlights the trends of these information. As a result, we then developed the second prototype, an interface that shows the clinical state and trend. We found that focusing more on the changes since the last visit without visual representation can be more compatible with clinicians’ work practices. In addition, the second phase of needs-affordances analysis identified 3 categories of information relevant to patients with schizophrenia: symptoms related to psychosis, symptoms related to mood and anxiety, and social functioning. Finally, we developed the third prototype, a clinical summary dashboard that showed changes from the last visit in plain texts and contrasting colors. Conclusions: This exploratory co-design research confirmed that mental health attributes inferred from patients’ social media data can be useful for clinicians, although it also revealed a gap between computational social media analyses and clinicians’ expectations and conceptualizations of patients’ mental health states. In summary, the iterative co-design process crystallized design directions for the future interface, including how we can organize and provide symptom-related information in a way that minimizes the clinicians’ workloads. %M 32784180 %R 10.2196/16969 %U http://mental.jmir.org/2020/8/e16969/ %U https://doi.org/10.2196/16969 %U http://www.ncbi.nlm.nih.gov/pubmed/32784180 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17593 %T Effects of a Brief Electronic Mindfulness-Based Intervention on Relieving Prenatal Depression and Anxiety in Hospitalized High-Risk Pregnant Women: Exploratory Pilot Study %A Goetz,Maren %A Schiele,Claudia %A Müller,Mitho %A Matthies,Lina M %A Deutsch,Thomas M %A Spano,Claudio %A Graf,Johanna %A Zipfel,Stephan %A Bauer,Armin %A Brucker,Sara Y %A Wallwiener,Markus %A Wallwiener,Stephanie %+ Department of Obstetrics and Gynecology, University of Heidelberg, Im Neuenheimer Feld 440, Heidelberg, 69120, Germany, 49 6221 5636956, stephanie.wallwiener@googlemail.com %K pregnancy %K high-risk pregnancy %K hospitalization %K preterm labor %K anxiety %K depression %K psychological stress %K mindfulness %K stress reduction %K mobile app %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Peripartum depression and anxiety disorders are highly prevalent and are correlated with adverse maternal and neonatal outcomes. Antenatal care in Germany does not yet include structured screening and effective low-threshold treatment options for women facing peripartum depression and anxiety disorders. Mindfulness-based interventions (MBIs) are increasingly becoming a focus of interest for the management of such patients. Studies have shown a decrease in pregnancy-related stress and anxiety in expectant mothers following mindfulness programs. Objective: The aim of this study was to explore the clinical effectiveness of a 1-week electronic course of mindfulness on prenatal depression and anxiety in hospitalized, high-risk pregnant women. We hypothesized that participating in a 1-week electronic MBI (eMBI) could alleviate symptoms of depression and anxiety during the hospital stay. Methods: A prospective pilot study with an explorative study design was conducted from January to May 2019 in a sample of 68 women hospitalized due to high-risk pregnancies. After enrolling into the study, the participants were given access to an eMBI app on how to deal with stress, anxiety, and symptoms of depression. Psychometric parameters were assessed via electronic questionnaires comprising the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI-S), and abridged version of the Pregnancy-Related Anxiety Questionnaire (PRAQ-R). Results: We observed a high prevalence of peripartum depression and anxiety among hospitalized high-risk pregnant women: 39% (26/67) of the study participants in the first assessment and 41% (16/39) of the participants in the second assessment achieved EPDS scores above the cutoff value for minor/major depression. The number of participants with anxiety levels above the cutoff value (66% [45/68] of the participants in the first assessment and 67% [26/39] of the participants in the second assessment) was significantly more than that of the participants with anxiety levels below the cutoff value, as measured with the STAI-S. After completing the 1-week electronic course on mindfulness, the participants showed a significant reduction in the mean state anxiety levels (P<.03). Regarding pregnancy-related anxiety, participants who completed more than 50% of the 1-week course showed lower scores in PRAQ-R in the second assessment (P<.05). No significant changes in the EPDS scores were found after completing the intervention. Conclusions: Peripartum anxiety and depression represent a relevant health issue in hospitalized pregnant patients. Short-term eMBIs could have the potential to reduce anxiety levels and pregnancy-related anxiety. However, we observed that compliance to eMBI seems to be related to lower symptoms of pregnancy-related stress among high-risk patients. eMBIs represent accessible mental health resources at reduced costs and can be adapted for hospitalized patients during pregnancy. %M 32780023 %R 10.2196/17593 %U https://www.jmir.org/2020/8/e17593 %U https://doi.org/10.2196/17593 %U http://www.ncbi.nlm.nih.gov/pubmed/32780023 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e15506 %T Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study %A Betthauser,Lisa M %A Stearns-Yoder,Kelly A %A McGarity,Suzanne %A Smith,Victoria %A Place,Skyler %A Brenner,Lisa A %+ Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N Wheeling St, Aurora, CO, 80045, United States, 1 720 723 4867, lisa.betthauser@va.gov %K veterans %K mobile app %K smartphone %K mental health %K acceptability %K feasibility %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. Objective: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. Methods: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. Results: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire–8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. Conclusions: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide. %M 32779572 %R 10.2196/15506 %U https://www.jmir.org/2020/8/e15506 %U https://doi.org/10.2196/15506 %U http://www.ncbi.nlm.nih.gov/pubmed/32779572 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e18453 %T A Combined Digital and Biomarker Diagnostic Aid for Mood Disorders (the Delta Trial): Protocol for an Observational Study %A Olmert,Tony %A Cooper,Jason D %A Han,Sung Yeon Sarah %A Barton-Owen,Giles %A Farrag,Lynn %A Bell,Emily %A Friend,Lauren V %A Ozcan,Sureyya %A Rustogi,Nitin %A Preece,Rhian L %A Eljasz,Pawel %A Tomasik,Jakub %A Cowell,Daniel %A Bahn,Sabine %+ Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Dr, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K proteomics %K early diagnosis %K mood disorders %K bipolar disorder %K major depressive disorders %D 2020 %7 10.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mood disorders affect hundreds of millions of people worldwide, imposing a substantial medical and economic burden. Existing diagnostic methods for mood disorders often result in a delay until accurate diagnosis, exacerbating the challenges of these disorders. Advances in digital tools for psychiatry and understanding the biological basis of mood disorders offer the potential for novel diagnostic methods that facilitate early and accurate diagnosis of patients. Objective: The Delta Trial was launched to develop an algorithm-based diagnostic aid combining symptom data and proteomic biomarkers to reduce the misdiagnosis of bipolar disorder (BD) as a major depressive disorder (MDD) and achieve more accurate and earlier MDD diagnosis. Methods: Participants for this ethically approved trial were recruited through the internet, mainly through Facebook advertising. Participants were then screened for eligibility, consented to participate, and completed an adaptive digital questionnaire that was designed and created for the trial on a purpose-built digital platform. A subset of these participants was selected to provide dried blood spot (DBS) samples and undertake a World Health Organization World Mental Health Composite International Diagnostic Interview (CIDI). Inclusion and exclusion criteria were chosen to maximize the safety of a trial population that was both relevant to the trial objectives and generalizable. To provide statistical power and validation sets for the primary and secondary objectives, 840 participants were required to complete the digital questionnaire, submit DBS samples, and undertake a CIDI. Results: The Delta Trial is now complete. More than 3200 participants completed the digital questionnaire, 924 of whom also submitted DBS samples and a CIDI, whereas a total of 1780 participants completed a 6-month follow-up questionnaire and 1542 completed a 12-month follow-up questionnaire. The analysis of the trial data is now underway. Conclusions: If a diagnostic aid is able to improve the diagnosis of BD and MDD, it may enable earlier treatment for patients with mood disorders. International Registered Report Identifier (IRRID): DERR1-10.2196/18453 %M 32773373 %R 10.2196/18453 %U https://www.researchprotocols.org/2020/8/e18453 %U https://doi.org/10.2196/18453 %U http://www.ncbi.nlm.nih.gov/pubmed/32773373 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e21283 %T Effectiveness of a Smartphone App With a Wearable Activity Tracker in Preventing the Recurrence of Mood Disorders: Prospective Case-Control Study %A Cho,Chul-Hyun %A Lee,Taek %A Lee,Jung-Been %A Seo,Ju Yeon %A Jee,Hee-Jung %A Son,Serhim %A An,Hyonggin %A Kim,Leen %A Lee,Heon-Jeong %+ Department of Psychiatry, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, Republic of Korea, 82 29206721, leehjeong@korea.ac.kr %K circadian rhythm %K digital therapeutics %K mood disorder %K recurrence prevention %K smartphone app %K wearable activity tracker %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphones and wearable devices can be used to obtain diverse daily log data related to circadian rhythms. For patients with mood disorders, giving feedback via a smartphone app with appropriate behavioral correction guides could play an important therapeutic role in the real world. Objective: We aimed to evaluate the effectiveness of a smartphone app named Circadian Rhythm for Mood (CRM), which was developed to prevent mood episodes based on a machine learning algorithm that uses passive digital phenotype data of circadian rhythm behaviors obtained with a wearable activity tracker. The feedback intervention for the CRM app consisted of a trend report of mood prediction, H-score feedback with behavioral guidance, and an alert system triggered when trending toward a high-risk state. Methods: In total, 73 patients with a major mood disorder were recruited and allocated in a nonrandomized fashion into 2 groups: the CRM group (14 patients) and the non-CRM group (59 patients). After the data qualification process, 10 subjects in the CRM group and 33 subjects in the non-CRM group were evaluated over 12 months. Both groups were treated in a similar manner. Patients took their usual medications, wore a wrist-worn activity tracker, and checked their eMoodChart daily. Patients in the CRM group were provided with daily feedback on their mood prediction and health scores based on the algorithm. For the CRM group, warning alerts were given when irregular life patterns were observed. However, these alerts were not given to patients in the non-CRM group. Every 3 months, mood episodes that had occurred in the previous 3 months were assessed based on the completed daily eMoodChart for both groups. The clinical course and prognosis, including mood episodes, were evaluated via face-to-face interviews based on the completed daily eMoodChart. For a 1-year prospective period, the number and duration of mood episodes were compared between the CRM and non-CRM groups using a generalized linear model. Results: The CRM group had 96.7% fewer total depressive episodes (n/year; exp β=0.033, P=.03), 99.5% shorter depressive episodes (total; exp β=0.005, P<.001), 96.1% shorter manic or hypomanic episodes (exp β=0.039, P<.001), 97.4% fewer total mood episodes (exp β=0.026, P=.008), and 98.9% shorter mood episodes (total; exp β=0.011, P<.001) than the non-CRM group. Positive changes in health behaviors due to the alerts and in wearable device adherence rates were observed in the CRM group. Conclusions: The CRM app with a wearable activity tracker was found to be effective in preventing and reducing the recurrence of mood disorders, improving prognosis, and promoting better health behaviors. Patients appeared to develop a regular habit of using the CRM app. Trial Registration: ClinicalTrials.gov NCT03088657; https://clinicaltrials.gov/ct2/show/NCT03088657 %M 32755884 %R 10.2196/21283 %U http://mental.jmir.org/2020/8/e21283/ %U https://doi.org/10.2196/21283 %U http://www.ncbi.nlm.nih.gov/pubmed/32755884 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e18392 %T The Association Between App-Administered Depression Assessments and Suicidal Ideation in User Comments: Retrospective Observational Study %A DeForte,Shelly %A Huang,Yungui %A Bourgeois,Tran %A Hussain,Syed-Amad %A Lin,Simon %+ Abigail Wexner Research Institute, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43215, United States, 1 202 318 1627, simon.lin@nationwidechildrens.org %K mobile health %K mHealth %K depression %K qualitative research %K mental health %D 2020 %7 4.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many people use apps to help understand and manage their depression symptoms. App-administered questionnaires for the symptoms of depression, such as the Patient Health Questionnaire-9, are easy to score and implement in an app, but may not be accompanied by essential resources and access needed to provide proper support and avoid potential harm. Objective: Our primary goal was to evaluate the differences in risks and helpfulness associated with using an app to self-diagnose depression, comparing assessment-only apps with multifeatured apps. We also investigated whether, what, and how additional app features may mitigate potential risks. Methods: In this retrospective observational study, we identified apps in the Google Play store that provided a depression assessment as a feature and had at least five user comments. We separated apps into two categories based on those having only a depression assessment versus those that offered additional supportive features. We conducted theoretical thematic analyses over the user reviews, with thematic coding indicating the helpfulness of the app, the presence of suicidal ideation, and how and why the apps were used. We compared the results across the two categories of apps and analyzed the differences using chi-square statistical tests. Results: We evaluated 6 apps; 3 provided only a depression assessment (assessment only), and 3 provided features in addition to self-assessment (multifeatured). User comments for assessment-only apps indicated significantly more suicidal ideation or self-harm (n=31, 9.4%) compared to comments for multifeatured apps (n=48, 2.3%; X21=43.88, P<.001). Users of multifeatured apps were over three times more likely than assessment-only app users to comment in favor of the app’s helpfulness, likely due to features like mood tracking, journaling, and informational resources (n=56, 17% vs n=1223, 59% respectively; X21=200.36, P<.001). The number of users under the age of 18 years was significantly higher among assessment-only app users (n=40, 12%) than multifeatured app users (n=9, 0.04%; X21=189.09, P<.001). Conclusions: Apps that diagnose depression by self-assessment without context or other supportive features are more likely to be used by those under 18 years of age and more likely to be associated with increased user distress and potential harm. Depression self-assessments in apps should be implemented with caution and accompanied by evidence-based capabilities that establish proper context, increase self-empowerment, and encourage users to seek clinical diagnostics and outside help. %M 32663158 %R 10.2196/18392 %U https://mhealth.jmir.org/2020/8/e18392 %U https://doi.org/10.2196/18392 %U http://www.ncbi.nlm.nih.gov/pubmed/32663158 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e16180 %T Characteristics of Neuropsychiatric Mobile Health Trials: Cross-Sectional Analysis of Studies Registered on ClinicalTrials.gov %A Minen,Mia Tova %A Reichel,Julia Frederica %A Pemmireddy,Pallavi %A Loder,Elizabeth %A Torous,John %+ NYU Langone Health, 222 E 41st Street,, New York, NY, 10017, United States, 1 2122637744, minenmd@gmail.com %K smartphones %K mobile phones %K apps %K mental health %K regulation %K stroke %K migraine %K major depressive disorder %K Alzheimer disease %K anxiety disorders %K alcohol use disorders %K opioid use disorders %K epilepsy %K schizophrenia %D 2020 %7 4.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The development of mobile health (mHealth) technologies is progressing at a faster pace than that of the science to evaluate their validity and efficacy. Under the International Committee of Journal Medical Editors (ICMJE) guidelines, clinical trials that prospectively assign people to interventions should be registered with a database before the initiation of the study. Objective: The aim of this study was to better understand the smartphone mHealth trials for high-burden neuropsychiatric conditions registered on ClinicalTrials.gov through November 2018, including the number, types, and characteristics of the studies being conducted; the frequency and timing of any outcome changes; and the reporting of results. Methods: We conducted a systematic search of ClinicalTrials.gov for the top 10 most disabling neuropsychiatric conditions and prespecified terms related to mHealth. According to the 2016 World Health Organization Global Burden of Disease Study, the top 10 most disabling neuropsychiatric conditions are (1) stroke, (2) migraine, (3) major depressive disorder, (4) Alzheimer disease and other dementias, (5) anxiety disorders, (6) alcohol use disorders, (7) opioid use disorders, (8) epilepsy, (9) schizophrenia, and (10) other mental and substance use disorders. There were no date, location, or status restrictions. Results: Our search identified 135 studies. A total of 28.9% (39/135) of studies evaluated interventions for major depressive disorder, 14.1% (19/135) of studies evaluated interventions for alcohol use disorders, 12.6% (17/135) of studies evaluated interventions for stroke, 11.1% (15/135) of studies evaluated interventions for schizophrenia, 8.1% (11/135) of studies evaluated interventions for anxiety disorders, 8.1% (11/135) of studies evaluated interventions for other mental and substance use disorders, 7.4% (10/135) of studies evaluated interventions for opioid use disorders, 3.7% (5/135) of studies evaluated interventions for Alzheimer disease or other dementias, 3.0% (4/135) of studies evaluated interventions for epilepsy, and 3.0% (4/135) of studies evaluated interventions for migraine. The studies were first registered in 2008; more than half of the studies were registered from 2016 to 2018. A total of 18.5% (25/135) of trials had results reported in some publicly accessible location. Across all the studies, the mean estimated enrollment (reported by the study) was 1078, although the median was only 100. In addition, across all the studies, the actual reported enrollment was lower, with a mean of 249 and a median of 80. Only about a quarter of the studies (35/135, 25.9%) were funded by the National Institutes of Health. Conclusions: Despite the increasing use of health-based technologies, this analysis of ClinicalTrials.gov suggests that only a few apps for high-burden neuropsychiatric conditions are being clinically evaluated in trials. %M 32749230 %R 10.2196/16180 %U https://mhealth.jmir.org/2020/8/e16180 %U https://doi.org/10.2196/16180 %U http://www.ncbi.nlm.nih.gov/pubmed/32749230 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e18578 %T Immediate and Long-Term Effects of an 8-Week Digital Mental Health Intervention on Adults With Poorly Managed Type 2 Diabetes: Protocol for a Randomized Controlled Trial %A Boucher,Eliane %A Moskowitz,Judith T %A Kackloudis,Gina M %A Stafford,Julia L %A Kwok,Ian %A Parks,Acacia C %+ Happify Health, 51 East 12th Street, 5th Floor, New York, NY, 10003, United States, 1 4322585233, eliane@happify.com %K online intervention %K diabetes mellitus %K type 2 %K mental health %K randomized clinical trial %K positive psychology %K HbA1c %D 2020 %7 4.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Diabetes is a leading cause of years of life lost and accounts for approximately one-fourth of health care dollars spent in the United States. Many of these costs are related to poor medication adherence and lack of self-care behaviors and are thus preventable. Depression, which is more prevalent among people with diabetes than in the general population, predicts poorer management of one’s diabetes, whereas positive affect predicts engaging in more positive health behaviors. Consequently, interventions that improve depression and positive affect may also improve diabetes-related outcomes among people with diabetes. Although preliminary research on the impact of such interventions among people with diabetes is promising, these studies focused primarily on in-person interventions, have had small samples, and lack long-term follow-up. Objective: This study aims to examine the short- and long-term effects of a digital therapeutic platform focused on mental health among adults with poorly managed type 2 diabetes and elevated levels of depression. Methods: This is a randomized controlled trial in which adults with a type 2 diabetes diagnosis, elevated hemoglobin A1c (HbA1c) levels (≧7), and moderate to severe depressive symptoms will be randomly assigned to a positive emotion regulation skills intervention group or a sham digital intervention with only psychoeducational content. The study will take place over 14 months, including the 8-week intervention (or control) delivered via a digital therapeutic platform (Happify Health) and follow-up assessments at 3, 6, and 12 months postintervention. Throughout the intervention and for 1 week at each postintervention follow-up, participants will complete daily assessments of diabetes-related distress, diabetes regimen adherence, and mood. Our primary outcome, HbA1c, will be self-reported every 3 months throughout the study. Secondary and exploratory outcomes will be assessed at baseline; at 8 weeks; and at 3, 6, and 12 months postintervention. Results: Recruitment is expected to begin in June 2020. Participants will begin the study as they are recruited and will finish in waves. The final wave of data collection from the 8-week intervention is expected for winter 2020, with the completion of the 12-month follow-up in winter 2021. Conclusions: Although previous research suggests that in-person psychological interventions have promising effects on both psychological and physical outcomes among adults with diabetes, digital interventions can be advantageous because they are easily scalable and reduce many barriers that prevent people from seeking treatment. This trial will provide important information about the effects of a digital mental health intervention among adults with type 2 diabetes, assessing both short- and long-term effects of this intervention on HbA1c, depressive symptoms, and other diabetes-specific outcomes. If successful, this may introduce a scalable intervention that would help reduce some of the preventable costs associated with diabetes. Trial Registration: ClinicalTrials.gov NCT04068805; https://clinicaltrials.gov/ct2/show/NCT04068805. International Registered Report Identifier (IRRID): PRR1-10.2196/18578 %M 32749998 %R 10.2196/18578 %U https://www.researchprotocols.org/2020/8/e18578 %U https://doi.org/10.2196/18578 %U http://www.ncbi.nlm.nih.gov/pubmed/32749998 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15418 %T Effectiveness of a Mobile App Intervention for Anxiety and Depression Symptoms in University Students: Randomized Controlled Trial %A McCloud,Tayla %A Jones,Rebecca %A Lewis,Gemma %A Bell,Vaughan %A Tsakanikos,Elias %+ Division of Psychiatry, University College London, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom, 44 2031087765, t.mccloud@ucl.ac.uk %K anxiety %K depression %K cognitive behavioral therapy %K eHealth %K online intervention %K mobile apps %K randomized controlled trial %K mobile phone %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression and anxiety symptoms are common among university students, but many do not receive treatment. This is often because of lack of availability, reluctance to seek help, and not meeting the diagnostic criteria required to access services. Internet-based interventions, including smartphone apps, can overcome these issues. However, a large number of apps are available, each with little evidence of their effectiveness. Objective: This study aims to evaluate for the first time the effectiveness of a self-guided mobile app, Feel Stress Free, for the treatment of depression and anxiety symptoms in students. Methods: A web-based randomized controlled trial compared a cognitive behavioral therapy (CBT)–based mobile app Feel Stress Free with a wait-list control. University students self-identified as experiencing symptoms of anxiety or depression and were randomized to 6 weeks of intervention (n=84) or control (n=84), unblinded. The app is self-guided and incorporates behavioral relaxation activities, mood tracking and thought challenging, and minigames. Participants completed the Hospital Anxiety and Depression Scale online at baseline and every fortnight. Results: At week 6, the primary end point, there was evidence that the Feel Stress Free app reduced depression symptoms (mean difference −1.56; 95% CI −2.67 to −0.44; P=.006) but only very weak evidence that it reduced anxiety symptoms (mean difference −1.36; 95% CI −2.93 to 0.21; P=.09). At week 4, there was evidence to support the effectiveness of the intervention for anxiety symptoms (mean difference −1.94; 95% CI −3.11 to −0.77; P=.001) and, though weaker, depression symptoms (mean difference −1.08; 95% CI −2.12 to −0.04; P=.04). At week 6, 83% (34/41) of participants indicated that they were using the app weekly or more frequently. Conclusions: The Feel Stress Free app is a promising mobile intervention for treating symptoms of anxiety and depression in students and overcomes many of the barriers to traditional CBT. Further research is needed to establish its effectiveness at and beyond 6 weeks. Trial Registration: ClinicalTrials.gov NCT03032952; https://clinicaltrials.gov/ct2/show/NCT03032952 %M 32735221 %R 10.2196/15418 %U http://mhealth.jmir.org/2020/7/e15418/ %U https://doi.org/10.2196/15418 %U http://www.ncbi.nlm.nih.gov/pubmed/32735221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16961 %T Perceived Effectiveness and Motivations for the Use of Web-Based Mental Health Programs: Qualitative Study %A Eccles,Heidi %A Nannarone,Molly %A Lashewicz,Bonnie %A Attridge,Mark %A Marchand,Alain %A Aiken,Alice %A Ho,Kendall %A Wang,Jianli %+ Work & Mental Health Research Unit, The Institute of Mental Health Research, University of Ottawa, Room 5404, 1145 Carling Ave, Ottawa, ON, K1Z7K4, Canada, 1 6137226521, jianli.wang@theroyal.ca %K prevention %K mental health %K depression %K cognitive behavioral therapy %K motivators %K perceived effectiveness %K internet-based intervention %K interview %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of depression is high and has been stable despite increased treatment, research, and dissemination. People encounter barriers to seeking traditional mental health services, which could be mitigated by using web-based prevention methods. Objective: This study aims to understand what people at high risk for depression perceive as effective aspects of web-based mental health programs and what motivates people at high risk for depression to use web-based mental health programs. Methods: We conducted an inductive content analysis using telephone interview data from 77 participants at high risk for depression who were recruited from 2 randomized controlled trials (RCTs). Participants from the first RCT were working men who had been randomly assigned to 1 of the following 3 groups: control group, who had access to general depression information from a website called BroMatters; intervention group 1, who had access to the BroMatters website along with the associated BroHealth web-based mental health program; and intervention group 2, who had access to the BroMatters website, the BroHealth web-based mental health program, and telephone sessions with a life coach. Participants from the second RCT were men and women who had been assigned to the intervention group, who received access to the HardHat web-based mental health program, or the control group, who only received access to the HardHat web-based mental health program following completion of the RCT. Participants for this inductive content analysis study were recruited from the intervention groups in both RCTs. Two groups of participants (n=41 and n=20) were recruited from the BroHealth RCT, and a third group comprised 16 participants that were recruited from the HardHat RCT. Results: We generated four categories regarding the perceived effectiveness of web-based programs and five categories related to what motivates the use of web-based programs. Participants identified awareness, program medium and functionality, program content, and coaches as categories related to the effectiveness of the programs. Categories of motivators to use web-based programs included providing reminders or incentives, promotion of the programs, providing appropriate medium and functionality, appropriate content, and perceived need. The final category related to motivators reflects perceptions of participants who were either unsure about what motivates them or believed that there is no way to motivate use. Conclusions: Conflicting evidence was obtained regarding the perceived effectiveness of aspects of the content and functionality of web-based programs. In general, web-based mental health programs were perceived to help increase mental health awareness, especially when it includes live access to a coach. However, the results also revealed that it is difficult to motivate people to begin using web-based mental health programs. Strategies that may motivate the use of such programs include perceived personal need, effective promotion, providing incentives and reminders, and improving functionality. %M 32735216 %R 10.2196/16961 %U http://www.jmir.org/2020/7/e16961/ %U https://doi.org/10.2196/16961 %U http://www.ncbi.nlm.nih.gov/pubmed/32735216 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17481 %T A Mobile Health Approach for Improving Outcomes in Suicide Prevention (SafePlan) %A O'Grady,Conor %A Melia,Ruth %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Duggan,Jim %+ School of Computer Science, National University of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91493336, james.duggan@nuigalway.ie %K mobile apps %K suicide %K mHealth %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a prominent cause of death worldwide, particularly among young people. It was the second leading cause of death among those aged 15-29 years globally in 2016. Treatment for patients with suicidal thoughts or behaviors often includes face-to-face psychological therapy with a mental health professional. These forms of interventions may involve maintaining and updating paper-based reports or worksheets in between sessions. Mobile technology can offer a way to support the implementation of evidence-based psychological techniques and the acquisition of protective coping skills. Objective: This study aims to develop a mobile app to facilitate service users’ access to mental health support and safety planning. This process involved eliciting expert input from clinicians who are actively engaged in the provision of mental health care. Methods: A survey was distributed to targeted health care professionals to determine what features should be prioritized in a new mobile app relating to suicide prevention. On the basis of the survey results, a clinical design group, comprising 6 members with experience in fields such as mobile health (mHealth), clinical psychology, and suicide prevention, was established. This group was supplemented with further input from additional clinicians who provided feedback over three focus group sessions. The sessions were centered on refining existing app components and evaluating new feature requests. This process was iterated through regular feedback until agreement was reached on the overall app design and functionality. Results: A fully functional mobile app, known as the SafePlan app, was developed and tested with the input of clinicians through an iterative design process. The app’s core function is to provide an interactive safety plan to support users with suicidal thoughts or behaviors as an adjunct to face-to-face therapy. A diary component that facilitates the generalization of skills learned through dialectical behavior therapy was also implemented. Usability testing was carried out on the final prototype by students from a local secondary school, who are representative of the target user population in both age and technology experience. The students were asked to complete a system usability survey (SUS) at the end of this session. The mean overall SUS rating was 71.85 (SD 1.38). Conclusions: The participatory process involving key stakeholders (clinicians, psychologists, and information technology specialists) has resulted in the creation of an mHealth intervention technology that has the potential to increase accessibility to this type of mental health service for the target population. The app has gone through the initial testing phase, and the relevant recommendations have been implemented, and it is now ready for trialing with both clinicians and their patients. %M 32729845 %R 10.2196/17481 %U http://www.jmir.org/2020/7/e17481/ %U https://doi.org/10.2196/17481 %U http://www.ncbi.nlm.nih.gov/pubmed/32729845 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e17784 %T Identifying and Predicting Intentional Self-Harm in Electronic Health Record Clinical Notes: Deep Learning Approach %A Obeid,Jihad S %A Dahne,Jennifer %A Christensen,Sean %A Howard,Samuel %A Crawford,Tami %A Frey,Lewis J %A Stecker,Tracy %A Bunnell,Brian E %+ Medical University of South Carolina, 135 Cannon St. Suite 405 MSC200, Charleston, SC, 29425, United States, 1 8437920272, jobeid@musc.edu %K machine learning %K deep learning %K suicide %K suicide, attempted %K electronic health records %K natural language processing %D 2020 %7 30.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide is an important public health concern in the United States and around the world. There has been significant work examining machine learning approaches to identify and predict intentional self-harm and suicide using existing data sets. With recent advances in computing, deep learning applications in health care are gaining momentum. Objective: This study aimed to leverage the information in clinical notes using deep neural networks (DNNs) to (1) improve the identification of patients treated for intentional self-harm and (2) predict future self-harm events. Methods: We extracted clinical text notes from electronic health records (EHRs) of 835 patients with International Classification of Diseases (ICD) codes for intentional self-harm and 1670 matched controls who never had any intentional self-harm ICD codes. The data were divided into training and holdout test sets. We tested a number of algorithms on clinical notes associated with the intentional self-harm codes using the training set, including several traditional bag-of-words–based models and 2 DNN models: a convolutional neural network (CNN) and a long short-term memory model. We also evaluated the predictive performance of the DNNs on a subset of patients who had clinical notes 1 to 6 months before the first intentional self-harm event. Finally, we evaluated the impact of a pretrained model using Word2vec (W2V) on performance. Results: The area under the receiver operating characteristic curve (AUC) for the CNN on the phenotyping task, that is, the detection of intentional self-harm in clinical notes concurrent with the events was 0.999, with an F1 score of 0.985. In the predictive task, the CNN achieved the highest performance with an AUC of 0.882 and an F1 score of 0.769. Although pretraining with W2V shortened the DNN training time, it did not improve performance. Conclusions: The strong performance on the first task, namely, phenotyping based on clinical notes, suggests that such models could be used effectively for surveillance of intentional self-harm in clinical text in an EHR. The modest performance on the predictive task notwithstanding, the results using DNN models on clinical text alone are competitive with other reports in the literature using risk factors from structured EHR data. %M 32729840 %R 10.2196/17784 %U https://medinform.jmir.org/2020/7/e17784 %U https://doi.org/10.2196/17784 %U http://www.ncbi.nlm.nih.gov/pubmed/32729840 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e17958 %T Depression Risk Prediction for Chinese Microblogs via Deep-Learning Methods: Content Analysis %A Wang,Xiaofeng %A Chen,Shuai %A Li,Tao %A Li,Wanting %A Zhou,Yejie %A Zheng,Jie %A Chen,Qingcai %A Yan,Jun %A Tang,Buzhou %+ Department of Computer Science, Harbin Institute of Technology Shenzhen Graduate School, L1407, Shenzhen, China, 86 13725525983, tangbuzhou@gmail.com %K depression risk prediction %K deep learning %K pretrained language model %K Chinese microblogs %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Depression is a serious personal and public mental health problem. Self-reporting is the main method used to diagnose depression and to determine the severity of depression. However, it is not easy to discover patients with depression owing to feelings of shame in disclosing or discussing their mental health conditions with others. Moreover, self-reporting is time-consuming, and usually leads to missing a certain number of cases. Therefore, automatic discovery of patients with depression from other sources such as social media has been attracting increasing attention. Social media, as one of the most important daily communication systems, connects large quantities of people, including individuals with depression, and provides a channel to discover patients with depression. In this study, we investigated deep-learning methods for depression risk prediction using data from Chinese microblogs, which have potential to discover more patients with depression and to trace their mental health conditions. Objective: The aim of this study was to explore the potential of state-of-the-art deep-learning methods on depression risk prediction from Chinese microblogs. Methods: Deep-learning methods with pretrained language representation models, including bidirectional encoder representations from transformers (BERT), robustly optimized BERT pretraining approach (RoBERTa), and generalized autoregressive pretraining for language understanding (XLNET), were investigated for depression risk prediction, and were compared with previous methods on a manually annotated benchmark dataset. Depression risk was assessed at four levels from 0 to 3, where 0, 1, 2, and 3 denote no inclination, and mild, moderate, and severe depression risk, respectively. The dataset was collected from the Chinese microblog Weibo. We also compared different deep-learning methods with pretrained language representation models in two settings: (1) publicly released pretrained language representation models, and (2) language representation models further pretrained on a large-scale unlabeled dataset collected from Weibo. Precision, recall, and F1 scores were used as performance evaluation measures. Results: Among the three deep-learning methods, BERT achieved the best performance with a microaveraged F1 score of 0.856. RoBERTa achieved the best performance with a macroaveraged F1 score of 0.424 on depression risk at levels 1, 2, and 3, which represents a new benchmark result on the dataset. The further pretrained language representation models demonstrated improvement over publicly released prediction models. Conclusions: We applied deep-learning methods with pretrained language representation models to automatically predict depression risk using data from Chinese microblogs. The experimental results showed that the deep-learning methods performed better than previous methods, and have greater potential to discover patients with depression and to trace their mental health conditions. %M 32723719 %R 10.2196/17958 %U http://medinform.jmir.org/2020/7/e17958/ %U https://doi.org/10.2196/17958 %U http://www.ncbi.nlm.nih.gov/pubmed/32723719 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e19008 %T Assessing Digital Risk in Psychiatric Patients: Mixed Methods Study of Psychiatry Trainees’ Experiences, Views, and Understanding %A Aref-Adib,Golnar %A Landy,Gabriella %A Eskinazi,Michelle %A Sommerlad,Andrew %A Morant,Nicola %A Johnson,Sonia %A Graham,Richard %A Osborn,David %A Pitman,Alexandra %+ Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom, 44 7968035509, a.pitman@ucl.ac.uk %K risk assessment %K internet %K suicide %K self-injurious behavior %K mental health %K psychiatrists %K mixed methods %K mobile phone %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The use of digital technology can help people access information and provide support for their mental health problems, but it can also expose them to risk, such as bullying or prosuicide websites. It may be important to consider internet-related risk behavior (digital risk) within a generic psychiatric risk assessment, but no studies have explored the practice or acceptability of this among psychiatrists. Objective: This study aimed to explore psychiatry trainees’ experiences, views, and understanding of digital risk in psychiatry. We predicted that clinician awareness would be highest among trainees who work in child and adolescent mental health services. Methods: We conducted a cross-sectional survey of psychiatry trainees attending a UK regional trainees’ conference to investigate how they routinely assess patients’ internet use and related risk of harm and their experience and confidence in assessing these risks. We conducted focus groups to further explore trainees’ understandings and experiences of digital risk assessment. Descriptive statistics and chi-squared tests were used to present the quantitative data. A thematic analysis was used to identify the key themes in the qualitative data set. Results: The cross-sectional survey was completed by 113 out of 312 psychiatry trainees (response rate 36.2%), from a range of subspecialties and experience levels. Half of the trainees (57/113, 50.4%) reported treating patients exposed to digital risk, particularly trainees subspecializing in child and adolescent psychiatry (17/22, 77% vs 40/91, 44%;P=.02). However, 67.3% (76/113) reported not feeling competent to assess digital risk. Child and adolescent psychiatrists were more likely than others to ask patients routinely about specific digital risk domains, including reckless web-based behavior (18/20, 90% vs 54/82, 66%; P=.03), prosuicide websites (20/21, 95% vs 57/81, 70%; P=.01), and online sexual behavior (17/21, 81% vs 44/81, 54%; P=.02). Although 84.1% (95/113) of the participants reported using a proforma to record general risk assessment, only 5% (5/95) of these participants prompted an assessment of internet use. Only 9.7% (11/113) of the trainees had received digital risk training, and 73.5% (83/113) reported that they would value this. Our thematic analysis of transcripts from 3 focus groups (comprising 11 trainees) identified 2 main themes: barriers to assessment and management of digital risk, and the double-edged sword of web use. Barriers reported included the novelty and complexity of the internet, a lack of confidence and guidance in addressing internet use directly, and ongoing tension between assessment and privacy. Conclusions: Although it is common for psychiatrists to encounter patients subject to digital risk, trainee psychiatrists lack competence and confidence in their assessment. Training in digital risk and the inclusion of prompts in standardized risk proformas would promote good clinical practice and prevent a potential blind spot in general risk assessment. %M 32726288 %R 10.2196/19008 %U http://mental.jmir.org/2020/7/e19008/ %U https://doi.org/10.2196/19008 %U http://www.ncbi.nlm.nih.gov/pubmed/32726288 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15683 %T Exploring the Relationship Between Internet Use and Mental Health Among Older Adults in England: Longitudinal Observational Study %A Lam,Sabrina Sze Man %A Jivraj,Stephen %A Scholes,Shaun %+ University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 20 7679 1721, stephen.jivraj@gmail.com %K internet %K socioeconomic factors %K mental health %K life satisfaction %K depression %K effect modifier %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is uncertainty about the impact of internet use on mental health in older adults. Moreover, there is very little known specifically about the impact of particular purposes of internet use. Objective: This study aims to investigate the longitudinal relationship between two distinct concepts of mental health with the frequency of internet use among older adults: the moderating role of socioeconomic position (SEP) and the association between specific purposes of internet use. Methods: Longitudinal fixed and random effects (27,507 person-years) models were fitted using waves 6-8 of the English Longitudinal Study of Ageing to examine the relationship between different aspects of internet use (frequency and purpose) and two mental health outcomes (depression and life satisfaction). The potential moderating effect of SEP on these associations was tested using interaction terms. Results: Infrequent internet use (monthly or less vs daily) was predictive of deteriorating life satisfaction (β=−0.512; P=.02) but not depression. Education and occupational class had a moderating effect on the association between frequency of internet use and mental health. The associations were stronger in the highest educational group in both depression (P=.09) and life satisfaction (P=.02), and in the highest occupational group in life satisfaction (P=.05) only. Using the internet for communication was associated with lower depression (β=−0.24; P=.002) and better life satisfaction (β=.97; P<.001), whereas those using the internet for information access had worse life satisfaction (β=−0.86; P<.001) compared with those who did not. Conclusions: Policies to improve mental health in older adults should encourage internet use, especially as a tool to aid communication. %M 32718913 %R 10.2196/15683 %U https://www.jmir.org/2020/7/e15683 %U https://doi.org/10.2196/15683 %U http://www.ncbi.nlm.nih.gov/pubmed/32718913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15732 %T Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial %A Pihlaja,Satu %A Lahti,Jari %A Lipsanen,Jari Olavi %A Ritola,Ville %A Gummerus,Eero-Matti %A Stenberg,Jan-Henry %A Joffe,Grigori %+ Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, PO Box 590, Helsinki, 00029 HUS, Finland, 358 40 513 6500, Grigori.joffe@hus.fi %K internet CBT %K depression %K scheduled telephone support %K adherence %K routine clinical practice %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment. Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131. %M 32706658 %R 10.2196/15732 %U http://www.jmir.org/2020/7/e15732/ %U https://doi.org/10.2196/15732 %U http://www.ncbi.nlm.nih.gov/pubmed/32706658 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e17075 %T Design, Recruitment, and Baseline Characteristics of a Virtual 1-Year Mental Health Study on Behavioral Data and Health Outcomes: Observational Study %A Kumar,Shefali %A Tran,Jennifer L A %A Ramirez,Ernesto %A Lee,Wei-Nchih %A Foschini,Luca %A Juusola,Jessie L %+ Evidation Health, 167 2nd Ave, San Mateo, CA, 94401, United States, 1 650 279 8855, jjuusola@evidation.com %K mental health %K anxiety %K depression %K behavioral data %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety greatly impact daily behaviors, such as sleep and activity levels. With the increasing use of activity tracking wearables among the general population, there has been a growing interest in how data collected from these devices can be used to further understand the severity and progression of mental health conditions. Objective: This virtual 1-year observational study was designed with the objective of creating a longitudinal data set combining self-reported health outcomes, health care utilization, and quality of life data with activity tracker and app-based behavioral data for individuals with depression and anxiety. We provide an overview of the study design, report on baseline health and behavioral characteristics of the study population, and provide initial insights into how behavioral characteristics differ between groups of individuals with varying levels of disease severity. Methods: Individuals who were existing members of an online health community (Achievement, Evidation Health Inc) and were 18 years or older who had self-reported a diagnosis of depression or anxiety were eligible to enroll in this virtual 1-year study. Participants agreed to connect wearable activity trackers that captured data related to physical activity and sleep behavior. Mental health outcomes such as the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), mental health hospitalizations, and medication use were captured with surveys completed at baseline and months 3, 6, 9, and 12. In this analysis, we report on baseline characteristics of the sample, including mental health disease severity and health care utilization. Additionally, we explore the relationship between passively collected behavioral data and baseline mental health status and health care utilization. Results: Of the 1304 participants enrolled in the study, 1277 individuals completed the baseline survey and 1068 individuals had sufficient activity tracker data. Mean age was 33 (SD 9) years, and the majority of the study population was female (77.2%, 994/1288) and identified as Caucasian (88.3%, 1137/1288). At baseline, 94.8% (1211/1277) of study participants reported experiencing depression or anxiety symptoms in the last year. This baseline analysis found that some passively tracked behavioral traits are associated with more severe forms of anxiety or depression. Individuals with depressive symptoms were less active than those with minimal depressive symptoms. Severe forms of depression were also significantly associated with inconsistent sleep patterns and more disordered sleep. Conclusions: These initial findings suggest that longitudinal behavioral and health outcomes data may be useful for developing digital measures of health for mental health symptom severity and progression. %M 32706712 %R 10.2196/17075 %U http://mental.jmir.org/2020/7/e17075/ %U https://doi.org/10.2196/17075 %U http://www.ncbi.nlm.nih.gov/pubmed/32706712 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17712 %T Internet-Based Cognitive-Behavioral Therapy for College Students With Anxiety, Depression, Social Anxiety, or Insomnia: Four Single-Group Longitudinal Studies of Archival Commercial Data and Replication of Employee User Study %A Attridge,Mark D %A Morfitt,Russell C %A Roseborough,David J %A Jones,Edward R %+ Attridge Consulting, Inc, 1129 Cedar Lake Rd S, Minneapolis, MN, United States, 1 612 889 2398, mark@attridgeconsulting.com %K anxiety %K cognitive behavioral %K college %K depression %K insomnia %K mental health %K social phobia %K stress %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The growing behavioral health needs of college students have resulted in counseling centers reporting difficulties in meeting student demand. Objective: This study aims to test the real-world voluntary use by college students of 4 digital, self-directed mental health modules based on a cognitive behavioral therapy clinical model. The findings were also compared with those of employee users. Methods: Archival operational data from Learn to Live were extracted for student users at 4 colleges and universities in the Midwest region of the United States (N=951). The inclusion criteria were having clinical symptoms at established levels of moderate or higher severity and the use of 2 or more of the 8 lessons of a program within a 6-month period. Unique users in each program included 347 for depression; 325 for stress, anxiety, and worry; 203 for social anxiety; and 76 for insomnia. Paired t tests (two-tailed) compared the average level of change over time on a standardized measure of clinical symptoms appropriate to each program. Cohen d statistical effect sizes were calculated for each program. Potential moderator factors (age, gender, preliminary comprehensive assessment, number of lessons, duration, live coach support, and live teammate support) were tested together in repeated measures analysis of variance models with covariates in the full sample. Follow-up survey data (n=136) were also collected to explore user satisfaction and outcomes. Select data from another study of the same 4 programs by employee users meeting the same criteria (N=707) were examined for comparison. Results: The percentage of users who improved to a clinical status of no longer being at risk after program use was as follows: stress, anxiety, and worry program (149/325, 45.8%); insomnia program (33/76, 43.4%), depression program (124/347, 35.7%); and social anxiety program (45/203, 22.2%). Significant improvements (all P<.001) over time were found in the mean scores for the clinical measures for each program: stress, anxiety, and worry (t324=16.21; d=1.25); insomnia (t75=6.85; d=1.10); depression (t346=12.71; d=0.91); and social anxiety (t202=8.33; d=0.80). Tests of the moderating factors across programs indicated that greater improvement was strongly associated with the use of more lessons and it also differed by program, by gender (males demonstrated more improvement than females), and by the use of live support (particularly coaching). Analyses of survey data found high satisfaction, improved academic outcomes, and successful integration into the university counseling ecosystem. The operational profile and outcomes of the college students were also similar to those of employee users of the same programs from our other study of employee users. Thus, this study provides a replication. Conclusions: Self-directed internet-based cognitive behavioral therapy mental health modules are promising as a supplement to traditional in-person counseling services provided by college counseling centers. %M 32706662 %R 10.2196/17712 %U http://formative.jmir.org/2020/7/e17712/ %U https://doi.org/10.2196/17712 %U http://www.ncbi.nlm.nih.gov/pubmed/32706662 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17926 %T Psychometric Properties of the Korean Version of the PsyMate Scale Using a Smartphone App: Ecological Momentary Assessment Study %A Yang,Yong Sook %A Ryu,Gi Wook %A Delespaul,Philippe A E G %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K psychometrics %K reliability %K validity %K PsyMate scale %K ecological momentary assessment %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Ecological momentary assessment (EMA) is a method for capturing the changes in the variables in daily life with increased accuracy and decreased recall bias. The PsyMate scale assesses momentary moods in daily life and can be used in various settings. Objective: The aim of this study was to develop a Korean version of the PsyMate (K-PsyMate) scale and evaluate its psychometric properties by using the EMA method in patients with moyamoya disease (MMD) in South Korea. Methods: Patients with MMD aged over 18 years were recruited from July 2018 to January 2019 at the inpatient and outpatient departments of a university hospital in South Korea. The K-PsyMate scale comprising 13 items was developed following a translation/back translation approach of the English version and loaded onto a mobile app. Participants were instructed to enter their moods 4 times a day for 7 consecutive days. Content validity index, factor analysis, and Pearson’s correlation were performed for validity analysis. For reliability, intraclass correlation coefficients between the first and last measurements were estimated by mean rating, absolute agreement, and a 2-way mixed-effects model. Usability was analyzed through a descriptive analysis, 2-tailed t test, and analysis of variance, and the results were confirmed by Mann-Whitney U test and the Kruskal-Wallis test, as the dependent variable was not normally distributed. Results: In total, 1929 assessments from 93 patients were analyzed. The mean age of the participants was 40.59 (SD 10.06) years, and 66 (71%) of the 93 participants were women. Content validity was excellent as content validity index was 0.99, and 2 factors, negative affect and positive affect, were derived by an exploratory factor analysis. The correlations between the subdomains of the K-PsyMate scale and Hospital Anxiety and Depression Scale were significant (P<.001). The agreement between the first and last measurements was poor to moderate according to the obtained intraclass correlation coefficient values. Usability was evaluated by 67 (72%) out of the 93 participants. The participants rated the accuracy of assessing their momentary moods on the app at 4.13 (SD 0.97), easiness in understanding questions, operating, and inputting answers at 4.12 (SD 0.88), and interruption by the survey alarms at 2.48 (SD 1.02) out of 5. Conclusions: The K-PsyMate scale has good validity but poor to moderate agreement, which reflects the characteristics of the EMA data collected in real and natural living environments without control. The findings of our study show that the K-PsyMate scale uploaded in a mobile app can be a valid and reliable tool for evaluating the momentary mood of patients with MMD because using a mobile app is convenient and patients are familiar with their own smartphones, which they use in their daily lives. %M 32706707 %R 10.2196/17926 %U http://mhealth.jmir.org/2020/7/e17926/ %U https://doi.org/10.2196/17926 %U http://www.ncbi.nlm.nih.gov/pubmed/32706707 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e16455 %T Effectiveness of a Voice-Based Mental Health Evaluation System for Mobile Devices: Prospective Study %A Higuchi,Masakazu %A Nakamura,Mitsuteru %A Shinohara,Shuji %A Omiya,Yasuhiro %A Takano,Takeshi %A Mitsuyoshi,Shunji %A Tokuno,Shinichi %+ Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, , Japan, 81 3 5841 3432, higuchi@bioeng.t.u-tokyo.ac.jp %K mental health %K monitoring system %K stress evaluation %K voice analysis %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: We developed a system for monitoring mental health using voice data from daily phone calls, termed Mind Monitoring System (MIMOSYS), by implementing a method for estimating mental health status from voice data. Objective: The objective of this study was to evaluate the potential of this system for detecting depressive states and monitoring stress-induced mental changes. Methods: We opened our system to the public in the form of a prospective study in which data were collected over 2 years from a large, unspecified sample of users. We used these data to analyze the relationships between the rate of continued use, the men-to-women ratio, and existing psychological tests for this system over the study duration. Moreover, we analyzed changes in mental data over time under stress from particular life events. Results: The system had a high rate of continued use. Voice indicators showed that women have more depressive tendencies than men, matching the rate of depression in Japan. The system’s voice indicators and the scores on classical psychological tests were correlated. We confirmed deteriorating mental health for users in areas affected by major earthquakes in Japan around the time of the earthquakes. Conclusions: The results suggest that although this system is insufficient for detecting depression, it may be effective for monitoring changes in mental health due to stress. The greatest feature of our system is mental health monitoring, which is most effectively accomplished by performing long-term time-series analysis of the acquired data considering the user’s life events. Such a system can improve the implementation of patient interventions by evaluating objective data along with life events. %M 32554367 %R 10.2196/16455 %U http://formative.jmir.org/2020/7/e16455/ %U https://doi.org/10.2196/16455 %U http://www.ncbi.nlm.nih.gov/pubmed/32554367 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e16338 %T Implementation Determinants and Outcomes of a Technology-Enabled Service Targeting Suicide Risk in High Schools: Mixed Methods Study %A Adrian,Molly %A Coifman,Jessica %A Pullmann,Michael D %A Blossom,Jennifer B %A Chandler,Casey %A Coppersmith,Glen %A Thompson,Paul %A Lyon,Aaron R %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 6200 NE 74th St, Suite 110, Seattle, WA, 98115, United States, 1 206 221 1689, adriam@uw.edu %K technology-enabled services %K suicide prevention %K school-based mental health %K user-centered design %K mobile phone %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology-enabled services (TESs), which integrate human service and digital components, are popular strategies to increase the reach and impact of mental health interventions, but large-scale implementation of TESs has lagged behind their potential. Objective: This study applied a mixed qualitative and quantitative approach to gather input from multiple key user groups (students and educators) and to understand the factors that support successful implementation (implementation determinants) and implementation outcomes of a TES for universal screening, ongoing monitoring, and support for suicide risk management in the school setting. Methods: A total of 111 students in the 9th to 12th grade completed measures regarding implementation outcomes (acceptability, feasibility, and appropriateness) via an open-ended survey. A total of 9 school personnel (school-based mental health clinicians, nurses, and administrators) completed laboratory-based usability testing of a dashboard tracking the suicide risk of students, quantitative measures, and qualitative interviews to understand key implementation outcomes and determinants. School personnel were presented with a series of scenarios and common tasks focused on the basic features and functions of the dashboard. Directed content analysis based on the Consolidated Framework for Implementation Research was used to extract multilevel determinants (ie, the barriers or facilitators at the levels of the outer setting, inner setting, individuals, intervention, and implementation process) related to positive implementation outcomes of the TES. Results: Overarching themes related to implementation determinants and outcomes suggest that both student and school personnel users view TESs for suicide prevention as moderately feasible and acceptable based on the Acceptability of Intervention Measure and Feasibility of Intervention Measure and as needing improvements in usability based on the System Usability Scale. Qualitative results suggest that students and school personnel view passive data collection based on social media data as a relative advantage to the current system; however, the findings indicate that the TES and the school setting need to address issues of privacy, integration into existing workflows and communication patterns, and options for individualization for student-centered care. Conclusions: Innovative suicide prevention strategies that rely on passive data collection in the school context are a promising and appealing idea. Usability testing identified key issues for revision to facilitate widespread implementation. %M 32706691 %R 10.2196/16338 %U https://mental.jmir.org/2020/7/e16338 %U https://doi.org/10.2196/16338 %U http://www.ncbi.nlm.nih.gov/pubmed/32706691 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e14536 %T A Digital Intervention for Adolescent Depression (MoodHwb): Mixed Methods Feasibility Evaluation %A Bevan Jones,Rhys %A Thapar,Anita %A Rice,Frances %A Mars,Becky %A Agha,Sharifah Shameem %A Smith,Daniel %A Merry,Sally %A Stallard,Paul %A Thapar,Ajay K %A Jones,Ian %A Simpson,Sharon A %+ Division of Psychological Medicine and Clinical Neurosciences, Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, Cardiff, Wales, CF24 4HQ, United Kingdom, 44 02920688451, bevanjonesr1@cardiff.ac.uk %K adolescent %K depression %K internet %K education %K early medical intervention %K feasibility study %D 2020 %7 17.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Treatment and prevention guidelines highlight the key role of health information and evidence-based psychosocial interventions for adolescent depression. Digital health technologies and psychoeducational interventions have been recommended to help engage young people and to provide accurate health information, enhance self-management skills, and promote social support. However, few digital psychoeducational interventions for adolescent depression have been robustly developed and evaluated in line with research guidance. Objective: We aimed to evaluate the feasibility, acceptability, and potential impact of a theory-informed, co-designed digital intervention program, MoodHwb. Methods: We used a mixed methods (quantitative and qualitative) approach to evaluate the program and the assessment process. Adolescents with or at elevated risk of depression and their parents and carers were recruited from mental health services, school counselors and nurses, and participants from a previous study. They completed a range of questionnaires before and after the program (related to the feasibility and acceptability of the program and evaluation process, and changes in mood, knowledge, attitudes, and behavior), and their Web usage was monitored. A subsample was also interviewed. A focus group was conducted with professionals from health, education, social, and youth services and charities. Interview and focus group transcripts were analyzed using thematic analysis with NVivo 10 (QSR International Pty Ltd). Results: A total of 44 young people and 31 parents or carers were recruited, of which 36 (82%) young people and 21 (68%) parents or carers completed follow-up questionnaires. In all, 19 young people and 12 parents or carers were interviewed. Overall, 13 professionals from a range of disciplines participated in the focus group. The key themes from the interviews and groups related to the design features, sections and content, and integration and context of the program in the young person’s life. Overall, the participants found the intervention engaging, clear, user-friendly, and comprehensive, and stated that it could be integrated into existing services. Young people found the “Self help” section and “Mood monitor” particularly helpful. The findings provided initial support for the intervention program theory, for example, depression literacy improved after using the intervention (difference in mean literacy score: 1.7, 95% CI 0.8 to 2.6; P<.001 for young people; 1.3, 95% CI 0.4 to 2.2; P=.006 for parents and carers). Conclusions: Findings from this early stage evaluation suggest that MoodHwb and the assessment process were feasible and acceptable, and that the intervention has the potential to be helpful for young people, families and carers as an early intervention program in health, education, social, and youth services and charities. A randomized controlled trial is needed to further evaluate the digital program. %M 32384053 %R 10.2196/14536 %U https://mental.jmir.org/2020/7/e14536 %U https://doi.org/10.2196/14536 %U http://www.ncbi.nlm.nih.gov/pubmed/32384053 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e13650 %T What College Students Post About Depression on Facebook and the Support They Perceive: Content Analysis %A Cash,Scottye %A Schwab-Reese,Laura Marie %A Zipfel,Erin %A Wilt,Megan %A Moreno,Megan %+ College of Social Work, The Ohio State University, 1947 College Rd, Columbus, OH, 43210, United States, 1 614 292 3690, cash.33@osu.edu %K social media %K depression %K college students %K qualitative %D 2020 %7 17.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: College students frequently use social media sites to connect with friends. Increasingly, research suggests college students and other young adults seek mental health-related support on social media, which may present a unique venue for intervention. Objective: The purpose of this study was to examine college students’ perceptions about displaying feelings of depression on Facebook and, in turn, how their social media friends responded. Methods: A primarily quantitative online survey with open response questions was distributed to students at four US universities. Qualitative responses were analyzed using content analysis. Results: A total of 34 students provided qualitative responses for analysis, these students were 85.3% female, mean age 20.2 (SD=1.4) and 20.6% racial/ethnic minority. Students who reported posting about depression often expressed an emotion or feeling but did not use the word “depression” in the post. Approximately 20% posted language about a bad day, and 15% posted a song or music video. Only one person reported posting a statement that directly asked for help. When friends responded to the posts, students generally perceived the responses as supportive or motivating gestures. Nearly 15% of friends contacted the individual outside of Facebook. One individual received a negative response and no responses suggested that the individual seek help. Conclusions: This study found that college students who post about depression often do so without directly referencing depression and that friends were generally supportive. However, no participants reported their social network suggested they seek help, which may suggest increasing mental health literacy, for both support seekers and responders, would be an opportunity to improve online mental health-related support. %M 32706687 %R 10.2196/13650 %U https://formative.jmir.org/2020/7/e13650 %U https://doi.org/10.2196/13650 %U http://www.ncbi.nlm.nih.gov/pubmed/32706687 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16136 %T Adherence to Established Treatment Guidelines Among Unguided Digital Interventions for Depression: Quality Evaluation of 28 Web-Based Programs and Mobile Apps %A Bubolz,Stefan %A Mayer,Gwendolyn %A Gronewold,Nadine %A Hilbel,Thomas %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 6221 56 38176, nadine.gronewold@med.uni-heidelberg.de %K web-based interventions %K depression %K mHealth %K mental health %K telemedicine %K mobile phone %K eHealth %K electronic mental health %K online therapy %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions for depression have been widely tested for usability and functioning. However, the few studies that have addressed the therapeutic quality of these interventions have mainly focused on general aspects without consideration of specific quality factors related to particular treatment components. Clinicians and scientists are calling for standardized assessment criteria for web-based interventions to enable effective and trustworthy patient care. Therefore, an extensive evaluation of web-based interventions at the level of individual treatment components based on therapeutic guidelines and manuals is needed. Objective: The objective of this study was to evaluate the quality of unguided web-based interventions for depression at the level of individual treatment components based on their adherence to current gold-standard treatment guidelines and manuals. Methods: A comprehensive online search of popular app stores and search engines in January 2018 revealed 11 desktop programs and 17 smartphone apps that met the inclusion criteria. Programs and apps were included if they were available for German users, interactive, unguided, and targeted toward depression. All programs and apps were tested by three independent researchers following a standardized procedure with a predefined symptom trajectory. During the testing, all web-based interventions were rated with a standardized list of criteria based on treatment guidelines and manuals for depression. Results: Overall interrater reliability for all raters was substantial with an intraclass correlation coefficient of 0.73 and Gwet AC1 value of 0.80. The main features of web-based interventions included mood tracking (24/28, 86%), psychoeducation (21/28, 75%), cognitive restructuring (21/28, 75%), crisis management (20/28, 71%), behavioral activation (19/29, 68%), and relaxation training (18/28, 64%). Overall, therapeutic meaningfulness was rated higher for desktop programs (mean 4.13, SD 1.17) than for smartphone apps (mean 2.92, SD 1.46). Conclusions: Although many exercises from manuals are included in web-based interventions, the necessary therapeutic depth of the interventions is often not reached, and risk management is frequently lacking. There is a need for further research targeting general principles for the development and evaluation of therapeutically sound web-based interventions for depression. %M 32673221 %R 10.2196/16136 %U https://www.jmir.org/2020/7/e16136 %U https://doi.org/10.2196/16136 %U http://www.ncbi.nlm.nih.gov/pubmed/32673221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16021 %T Effectiveness and Safety of Using Chatbots to Improve Mental Health: Systematic Review and Meta-Analysis %A Abd-Alrazaq,Alaa Ali %A Rababeh,Asma %A Alajlani,Mohannad %A Bewick,Bridgette M %A Househ,Mowafa %+ College of Science and Engineering, Hamad Bin Khalifa University, Liberal Arts and Sciences Building, Education City, Ar Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K chatbots %K conversational agents %K mental health %K mental disorders %K depression %K anxiety %K effectiveness %K safety %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The global shortage of mental health workers has prompted the utilization of technological advancements, such as chatbots, to meet the needs of people with mental health conditions. Chatbots are systems that are able to converse and interact with human users using spoken, written, and visual language. While numerous studies have assessed the effectiveness and safety of using chatbots in mental health, no reviews have pooled the results of those studies. Objective: This study aimed to assess the effectiveness and safety of using chatbots to improve mental health through summarizing and pooling the results of previous studies. Methods: A systematic review was carried out to achieve this objective. The search sources were 7 bibliographic databases (eg, MEDLINE, EMBASE, PsycINFO), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently selected the studies, extracted data from the included studies, and assessed the risk of bias. Data extracted from studies were synthesized using narrative and statistical methods, as appropriate. Results: Of 1048 citations retrieved, we identified 12 studies examining the effect of using chatbots on 8 outcomes. Weak evidence demonstrated that chatbots were effective in improving depression, distress, stress, and acrophobia. In contrast, according to similar evidence, there was no statistically significant effect of using chatbots on subjective psychological wellbeing. Results were conflicting regarding the effect of chatbots on the severity of anxiety and positive and negative affect. Only two studies assessed the safety of chatbots and concluded that they are safe in mental health, as no adverse events or harms were reported. Conclusions: Chatbots have the potential to improve mental health. However, the evidence in this review was not sufficient to definitely conclude this due to lack of evidence that their effect is clinically important, a lack of studies assessing each outcome, high risk of bias in those studies, and conflicting results for some outcomes. Further studies are required to draw solid conclusions about the effectiveness and safety of chatbots. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019141219; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141219 %M 32673216 %R 10.2196/16021 %U http://www.jmir.org/2020/7/e16021/ %U https://doi.org/10.2196/16021 %U http://www.ncbi.nlm.nih.gov/pubmed/32673216 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e14500 %T Identifying the Medical Lethality of Suicide Attempts Using Network Analysis and Deep Learning: Nationwide Study %A Kim,Bora %A Kim,Younghoon %A Park,C Hyung Keun %A Rhee,Sang Jin %A Kim,Young Shin %A Leventhal,Bennett L %A Ahn,Yong Min %A Paik,Hyojung %+ Center for Supercomputing Applications, Division of Supercomputing, Korea Institute of Science and Technology Information (KISTI), 245 Daehak-ro, Yuseong-gu, Daejeon, 305-806, Republic of Korea, 1 82 42 869 1004, hyojungpaik@kisti.re.kr %K suicide %K deep learning %K network %K antecedent behaviors %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide is one of the leading causes of death among young and middle-aged people. However, little is understood about the behaviors leading up to actual suicide attempts and whether these behaviors are specific to the nature of suicide attempts. Objective: The goal of this study was to examine the clusters of behaviors antecedent to suicide attempts to determine if they could be used to assess the potential lethality of the attempt. To accomplish this goal, we developed a deep learning model using the relationships among behaviors antecedent to suicide attempts and the attempts themselves. Methods: This study used data from the Korea National Suicide Survey. We identified 1112 individuals who attempted suicide and completed a psychiatric evaluation in the emergency room. The 15-item Beck Suicide Intent Scale (SIS) was used for assessing antecedent behaviors, and the medical outcomes of the suicide attempts were measured by assessing lethality with the Columbia Suicide Severity Rating Scale (C-SSRS; lethal suicide attempt >3 and nonlethal attempt ≤3). Results: Using scores from the SIS, individuals who had lethal and nonlethal attempts comprised two different network nodes with the edges representing the relationships among nodes. Among the antecedent behaviors, the conception of a method’s lethality predicted suicidal behaviors with severe medical outcomes. The vectorized relationship values among the elements of antecedent behaviors in our deep learning model (E-GONet) increased performances, such as F1 and area under the precision-recall gain curve (AUPRG), for identifying lethal attempts (up to 3% for F1 and 32% for AUPRG), as compared with other models (mean F1: 0.81 for E-GONet, 0.78 for linear regression, and 0.80 for random forest; mean AUPRG: 0.73 for E-GONet, 0.41 for linear regression, and 0.69 for random forest). Conclusions: The relationships among behaviors antecedent to suicide attempts can be used to understand the suicidal intent of individuals and help identify the lethality of potential suicide attempts. Such a model may be useful in prioritizing cases for preventive intervention. %M 32673253 %R 10.2196/14500 %U http://medinform.jmir.org/2020/7/e14500/ %U https://doi.org/10.2196/14500 %U http://www.ncbi.nlm.nih.gov/pubmed/32673253 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e16341 %T Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies %A Orr,L Casey %A Graham,Andrea K %A Mohr,David C %A Greene,Carolyn J %+ Center for Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 W Markham #554, Little Rock, AR, 72205, United States, 1 5015512880, lcorr@ualr.edu %K mobile health %K older adults %K depression %K anxiety %K primary care %K smartphone %K mobile phone %K text messaging %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use. Objective: The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period. Methods: The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention. Results: The 3 participants’ unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves. Conclusions: These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages. %M 32673236 %R 10.2196/16341 %U https://mental.jmir.org/2020/7/e16341 %U https://doi.org/10.2196/16341 %U http://www.ncbi.nlm.nih.gov/pubmed/32673236 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18220 %T Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial %A González-Robles,Alberto %A Díaz-García,Amanda %A García-Palacios,Azucena %A Roca,Pablo %A Ramos-Quiroga,Josep Antoni %A Botella,Cristina %+ Department of Basic and Clinical Psychology, and Psychobiology, Universitat Jaume I, Sos Baynat Avenue, Campus del Riu Sec, Research II Building, Labpsitec, Castellón de la Plana, 12071, Spain, 34 964387646 ext 7646, vrobles@uji.es %K transdiagnostic %K internet %K cognitive behavioral therapy %K emotional disorders %K depression %K anxiety %K specialized care %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT. Objective: This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings. Methods: A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up. Results: The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants. Conclusions: EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed. Trial Registration: ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668 %M 32673226 %R 10.2196/18220 %U https://www.jmir.org/2020/7/e18220 %U https://doi.org/10.2196/18220 %U http://www.ncbi.nlm.nih.gov/pubmed/32673226 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17758 %T Detection of Suicidal Ideation on Social Media: Multimodal, Relational, and Behavioral Analysis %A Ramírez-Cifuentes,Diana %A Freire,Ana %A Baeza-Yates,Ricardo %A Puntí,Joaquim %A Medina-Bravo,Pilar %A Velazquez,Diego Alejandro %A Gonfaus,Josep Maria %A Gonzàlez,Jordi %+ Department of Information and Communication Technologies, Universitat Pompeu Fabra, Carrer de Tànger, 122-140, Barcelona, 08018, Spain, 34 643294184, diana.ramirez@upf.edu %K social media %K mental health %K suicidal ideation %K risk assessment %K machine learning %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide risk assessment usually involves an interaction between doctors and patients. However, a significant number of people with mental disorders receive no treatment for their condition due to the limited access to mental health care facilities; the reduced availability of clinicians; the lack of awareness; and stigma, neglect, and discrimination surrounding mental disorders. In contrast, internet access and social media usage have increased significantly, providing experts and patients with a means of communication that may contribute to the development of methods to detect mental health issues among social media users. Objective: This paper aimed to describe an approach for the suicide risk assessment of Spanish-speaking users on social media. We aimed to explore behavioral, relational, and multimodal data extracted from multiple social platforms and develop machine learning models to detect users at risk. Methods: We characterized users based on their writings, posting patterns, relations with other users, and images posted. We also evaluated statistical and deep learning approaches to handle multimodal data for the detection of users with signs of suicidal ideation (suicidal ideation risk group). Our methods were evaluated over a dataset of 252 users annotated by clinicians. To evaluate the performance of our models, we distinguished 2 control groups: users who make use of suicide-related vocabulary (focused control group) and generic random users (generic control group). Results: We identified significant statistical differences between the textual and behavioral attributes of each of the control groups compared with the suicidal ideation risk group. At a 95% CI, when comparing the suicidal ideation risk group and the focused control group, the number of friends (P=.04) and median tweet length (P=.04) were significantly different. The median number of friends for a focused control user (median 578.5) was higher than that for a user at risk (median 372.0). Similarly, the median tweet length was higher for focused control users, with 16 words against 13 words of suicidal ideation risk users. Our findings also show that the combination of textual, visual, relational, and behavioral data outperforms the accuracy of using each modality separately. We defined text-based baseline models based on bag of words and word embeddings, which were outperformed by our models, obtaining an increase in accuracy of up to 8% when distinguishing users at risk from both types of control users. Conclusions: The types of attributes analyzed are significant for detecting users at risk, and their combination outperforms the results provided by generic, exclusively text-based baseline models. After evaluating the contribution of image-based predictive models, we believe that our results can be improved by enhancing the models based on textual and relational features. These methods can be extended and applied to different use cases related to other mental disorders. %M 32673256 %R 10.2196/17758 %U https://www.jmir.org/2020/7/e17758 %U https://doi.org/10.2196/17758 %U http://www.ncbi.nlm.nih.gov/pubmed/32673256 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18723 %T Blended Care-Cognitive Behavioral Therapy for Depression and Anxiety in Real-World Settings: Pragmatic Retrospective Study %A Lungu,Anita %A Jun,Janie Jihee %A Azarmanesh,Okhtay %A Leykin,Yan %A Chen,Connie E-Jean %+ Lyra Health, 287 Lorton Avenue, Burlingame, CA, 94010, United States, 1 6505673136, anita@lyrahealth.com %K cognitive behavior therapy %K blended psychotherapy %K dissemination %K implementation %K depression %K anxiety/anxiety disorders %K internet %K web based %K video psychotherapy %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The past few decades saw considerable advances in research and dissemination of evidence-based psychotherapies, yet available treatment resources are not able to meet the high need for care for individuals suffering from depression or anxiety. Blended care psychotherapy, which combines the strengths of therapist-led and internet interventions, can narrow this gap and be clinically effective and efficient, but has rarely been evaluated outside of controlled research settings. Objective: This study evaluated the effectiveness of a blended care intervention (video-based cognitive behavior therapy and internet intervention) under real-world conditions. Methods: This is a pragmatic retrospective cohort analysis of 385 participants with clinical range depression and/or anxiety symptoms at baseline, measured using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), who enrolled in blended care psychotherapy treatment. Participants resided in the United States and had access to the blended care intervention as a mental health benefit offered through their employers. Levels of depression and anxiety were tracked throughout treatment. Hierarchical linear modeling was used to examine the change in symptoms over time. The effects of age, gender, and providers on participants’ symptom change trajectories were also evaluated. Paired sample t-tests were also conducted, and rates of positive clinical change and clinically significant improvement were calculated. Results: The average depression and anxiety symptoms at 6 weeks after the start of treatment were 5.94 and 6.57, respectively. There were significant linear effects of time on both symptoms of depression and anxiety (β=–.49, P<.001 and β=–.64, P<.001). The quadratic effect was also significant for both symptoms of depression and anxiety (β=.04, P<.001 for both), suggesting a decelerated decrease in symptoms over time. Approximately 73% (n=283) of all 385 participants demonstrated reliable improvement, and 83% (n=319) recovered on either the PHQ-9 or GAD-7 measures. Large effect sizes were observed on both symptoms of depression (Cohen d=1.08) and of anxiety (d=1.33). Conclusions: Video blended care cognitive behavioral therapy interventions can be effective and efficient in treating symptoms of depression and anxiety in real-world conditions. Future research should investigate the differential and interactive contribution of the therapist-led and digital components of care to patient outcomes to optimize care. %M 32628120 %R 10.2196/18723 %U https://www.jmir.org/2020/7/e18723 %U https://doi.org/10.2196/18723 %U http://www.ncbi.nlm.nih.gov/pubmed/32628120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16228 %T The Acceptability and Usability of Digital Health Interventions for Adults With Depression, Anxiety, and Somatoform Disorders: Qualitative Systematic Review and Meta-Synthesis %A Patel,Shireen %A Akhtar,Athfah %A Malins,Sam %A Wright,Nicola %A Rowley,Emma %A Young,Emma %A Sampson,Stephanie %A Morriss,Richard %+ Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Institute of Mental Health Building, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231434, shireen.patel@nottingham.ac.uk %K digital health interventions %K depression %K anxiety %K somatoform disorders %K smartphone %K mobile phone %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: The prevalence of mental health disorders continues to rise, with almost 4% of the world population having an anxiety disorder and almost 3.5% having depression in 2017. Despite the high prevalence, only one-third of people with depression or anxiety receive treatment. Over the last decade, the use of digital health interventions (DHIs) has risen rapidly as a means of accessing mental health care and continues to increase. Although there is evidence supporting the effectiveness of DHIs for the treatment of mental health conditions, little is known about what aspects are valued by users and how they might be improved. Objective: This systematic review aimed to identify, appraise, and synthesize the qualitative literature available on service users’ views and experiences regarding the acceptability and usability of DHIs for depression, anxiety, and somatoform disorders. Methods: A systematic search strategy was developed, and searches were run in 7 electronic databases. Qualitative and mixed methods studies published in English were included. A meta-synthesis was used to interpret and synthesize the findings from the included studies. Results: A total of 24 studies were included in the meta-synthesis, and 3 key themes emerged with descriptive subthemes. The 3 key themes were initial motivations and approaches to DHIs, personalization of treatment, and the value of receiving personal support in DHIs. The meta-synthesis suggests that participants’ initial beliefs about DHIs can have an important effect on their engagement with these types of interventions. Personal support was valued very highly as a major component of the success of DHIs. The main reason for this was the way it enabled individual personalization of care. Conclusions: Findings from the systematic review have implications for the design of future DHIs to improve uptake, retention, and outcomes in DHIs for depression, anxiety, and somatoform disorders. DHIs need to be personalized to the specific needs of the individual. Future research should explore whether the findings could be generalized to other health conditions. %M 32628116 %R 10.2196/16228 %U https://www.jmir.org/2020/7/e16228 %U https://doi.org/10.2196/16228 %U http://www.ncbi.nlm.nih.gov/pubmed/32628116 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 7 %P e17159 %T Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design %A Marshall,Jamie M %A Dunstan,Debra A %A Bartik,Warren %+ School of Psychology, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia, 61 2 6773 3012, jmarsh21@une.edu.au %K mHealth %K eHealth %K mobile apps %K mobile phone %K anxiety %K depression %K single-case study %D 2020 %7 5.7.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located. Objective: The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy. Methods: A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention. Results: Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021. Conclusions: If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment. International Registered Report Identifier (IRRID): PRR1-10.2196/17159 %M 32623368 %R 10.2196/17159 %U https://www.researchprotocols.org/2020/7/e17159 %U https://doi.org/10.2196/17159 %U http://www.ncbi.nlm.nih.gov/pubmed/32623368 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17722 %T Use of a Mobile App to Augment Psychotherapy in a Community Psychiatric Clinic: Feasibility and Fidelity Trial %A Adam,Atif %A Jain,Ameena %A Pletnikova,Alexandra %A Bagga,Rishi %A Vita,Allison %A N Richey,Lisa %A Gould,Neda %A Munshaw,Supriya %A Misrilall,Kavi %A Peters,Matthew E %+ Rose: Smarter Mental Health, 3400 Prospect St NW, Washington, DC, 20007, United States, 1 4103363626, dratif@askrose.com %K mobile app %K mental health %K depression %K anxiety %D 2020 %7 3.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Even though 1 in 5 Americans experience some form of mental illness each year, 80% have been shown to discontinue psychotherapy prematurely. The traditional psychotherapy service delivery model, consisting of isolated clinical sessions, lacks the ability to keep patients engaged outside clinical sessions. Newer digital mental health platforms can address the clinical need for a robust tool that tracks mental well-being and improves engagement in patients with depressive symptoms. Objective: The primary goals of this feasibility study were to (1) assess compliance among providers and their patients with a digital mental health platform protocol, and (2) examine the usability and fidelity of a mobile app through structured participant feedback. Methods: A sample of 30 participants was recruited for a 5-week study from a community-based mental health clinic in Baltimore, Maryland, USA. Inclusion criteria were: aged 18 years or older, having access to a smartphone, and having at least mild-to-moderate depression and/or anxiety as measured by the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales, respectively. Eligible participants were randomized into one of two study arms: (1) the intervention arm or (2) the waitlist control arm. Participants in the intervention arm were asked to download the Rose app and were prompted to complete clinical assessments (PHQ-9 and GAD-7) every other week, daily mood and anxiety Likert scales, and daily journal entries. The participants in the waitlist arm served as controls for the study and completed the clinical assessments only. Both arms engaged in weekly psychotherapy sessions, with participant in-app input informing the psychotherapy process of the intervention arm, while those in the waitlist control arm continued their standard care. Outcomes of interest included adherence to completion of in-app assessments and usability of the Rose mobile app assessed through the modified Mobile Application Rating Scale. Results: Over the study period, a sample of 30 participants used the Rose app 2834 times to complete clinical assessments. On average, 70% (21; 95% CI 61.14%-77.41%) of participants completed mood and anxiety daily check-ins and journal entries 5 days per week. Nearly all participants (29/30, 97%) completed all PHQ-9 and GAD-7 in-app scales during the study. Subjective impressions showed that 73% (22/30) of participants found the mobile app to be engaging and in line with their needs, and approximately 70% (21/30) of participants reported the app functionality and quality of information to be excellent. Additionally, more than two-thirds of the participants felt that their knowledge and awareness of depression and anxiety management improved through using the app. Conclusions: Steady compliance and high app ratings showcase the utility of the Rose mobile mental health app in augmenting the psychotherapy process for patients with mood disorders and improving mental health knowledge. Future studies are needed to further examine the impact of Rose on treatment outcomes. Trial Registration: ClinicalTrials.gov NCT04200170; https://clinicaltrials.gov/ct2/show/NCT04200170 %M 32618572 %R 10.2196/17722 %U https://formative.jmir.org/2020/7/e17722 %U https://doi.org/10.2196/17722 %U http://www.ncbi.nlm.nih.gov/pubmed/32618572 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e15901 %T Testing Suicide Risk Prediction Algorithms Using Phone Measurements With Patients in Acute Mental Health Settings: Feasibility Study %A Haines-Delmont,Alina %A Chahal,Gurdit %A Bruen,Ashley Jane %A Wall,Abbie %A Khan,Christina Tara %A Sadashiv,Ramesh %A Fearnley,David %+ Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Brooks Building, Nursing Department, 53 Bonsall Street, Manchester, M15 6GX, United Kingdom, 44 01612472461 ext 2461, a.haines@mmu.ac.uk %K suicide %K suicidal ideation %K smartphone %K cell phone %K machine learning %K nearest neighbor algorithm %K digital phenotyping %D 2020 %7 26.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Digital phenotyping and machine learning are currently being used to augment or even replace traditional analytic procedures in many domains, including health care. Given the heavy reliance on smartphones and mobile devices around the world, this readily available source of data is an important and highly underutilized source that has the potential to improve mental health risk prediction and prevention and advance mental health globally. Objective: This study aimed to apply machine learning in an acute mental health setting for suicide risk prediction. This study uses a nascent approach, adding to existing knowledge by using data collected through a smartphone in place of clinical data, which have typically been collected from health care records. Methods: We created a smartphone app called Strength Within Me, which was linked to Fitbit, Apple Health kit, and Facebook, to collect salient clinical information such as sleep behavior and mood, step frequency and count, and engagement patterns with the phone from a cohort of inpatients with acute mental health (n=66). In addition, clinical research interviews were used to assess mood, sleep, and suicide risk. Multiple machine learning algorithms were tested to determine the best fit. Results: K-nearest neighbors (KNN; k=2) with uniform weighting and the Euclidean distance metric emerged as the most promising algorithm, with 68% mean accuracy (averaged over 10,000 simulations of splitting the training and testing data via 10-fold cross-validation) and an average area under the curve of 0.65. We applied a combined 5×2 F test to test the model performance of KNN against the baseline classifier that guesses training majority, random forest, support vector machine and logistic regression, and achieved F statistics of 10.7 (P=.009) and 17.6 (P=.003) for training majority and random forest, respectively, rejecting the null of performance being the same. Therefore, we have taken the first steps in prototyping a system that could continuously and accurately assess the risk of suicide via mobile devices. Conclusions: Predicting for suicidality is an underaddressed area of research to which this paper makes a useful contribution. This is part of the first generation of studies to suggest that it is feasible to utilize smartphone-generated user input and passive sensor data to generate a risk algorithm among inpatients at suicide risk. The model reveals fair concordance between phone-derived and research-generated clinical data, and with iterative development, it has the potential for accurate discriminant risk prediction. However, although full automation and independence of clinical judgment or input would be a worthy development for those individuals who are less likely to access specialist mental health services, and for providing a timely response in a crisis situation, the ethical and legal implications of such advances in the field of psychiatry need to be acknowledged. %M 32442152 %R 10.2196/15901 %U https://mhealth.jmir.org/2020/6/e15901 %U https://doi.org/10.2196/15901 %U http://www.ncbi.nlm.nih.gov/pubmed/32442152 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17365 %T Examining Social Capital, Social Support, and Language Use in an Online Depression Forum: Social Network and Content Analysis %A Pan,Wenjing %A Feng,Bo %A Shen,Cuihua %+ School of Journalism and Communication, Renmin University of China, 507, School of Journalism and Communication, Renmin University of China, 59 Zhongguancun St, Haidian District, Beijing, 100872, China, 86 010 82500855, wenjingpan@ruc.edu.cn %K social capital %K social support %K social network analysis %K computerized text analysis %K communication accommodation %K language style matching %K online support forums %K depression %K mental health %D 2020 %7 24.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of peer-to-peer online support groups and communities has grown into a social phenomenon. Many people use online support groups and communities to seek and provide social support. It is essential to examine how users’ participation behaviors may contribute to different outcomes. Objective: This study aimed to (1) use the structural positions of online depression forum users in their reply network to predict received support and (2) examine their language use reflecting their health conditions. Methods: A total of 2061 users and their 62,274 replies posted on a depression forum from July 2004 to July 2014 were extracted using a web crawler written in Python. The content of the forum users’ posts and replies and their reply patterns were examined. A social network analysis method was used to build the reply networks of users. The computerized text analysis method was used to measure features of the forum users’ language styles. Results: Forum users’ bridging social capital (operationalized as network betweenness) was positively associated with the level of communication accommodation in their received replies (P=.04). Forum users’ bonding social capital (operationalized as network constraint) was negatively associated with the level of communication accommodation in their received replies (P<.001). The forum users’ change in their use of self-referent words and words expressing negative emotions were examined as linguistic proxies for their health conditions and mental states. The results revealed a general negative association between the number of received replies and the degree of decrease in the use of words expressing negative emotion (P=.007). Conclusions: The structural positions of online depression forum users in the reply network are associated with different participation outcomes in the users. Thus, receiving replies can be beneficial to online depression forum users. %M 32579125 %R 10.2196/17365 %U https://www.jmir.org/2020/6/e17365 %U https://doi.org/10.2196/17365 %U http://www.ncbi.nlm.nih.gov/pubmed/32579125 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e16525 %T Apps With Maps—Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores %A Marshall,Jamie M %A Dunstan,Debra A %A Bartik,Warren %+ School of Psychology, Faculty of Medicine and Health, University of New England, Elm Ave, Armidale, 2351, Australia, 61 2 6773 3012, jmarsh21@myune.edu.au %K mHealth %K apps %K app store %K depression %K anxiety %K e-mental health %K smartphone %K mobile mental health %K digital mental health %K mobile phone %D 2020 %7 24.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy. Objective: This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area. Methods: A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach. Results: Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy. Conclusions: The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps. %M 32579127 %R 10.2196/16525 %U http://mental.jmir.org/2020/6/e16525/ %U https://doi.org/10.2196/16525 %U http://www.ncbi.nlm.nih.gov/pubmed/32579127 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 6 %P e17650 %T Automatic Construction of a Depression-Domain Lexicon Based on Microblogs: Text Mining Study %A Li,Genghao %A Li,Bing %A Huang,Langlin %A Hou,Sibing %+ School of Information Technology & Management, University of International Business and Economics, Chaoyang District, Huixin East Street, Beijing, 100029, China, 86 1 343 978 8086, 01630@uibe.edu.cn %K depression detection %K depression diagnosis %K social media %K automatic construction %K domain-specific lexicon %K depression lexicon %K label propagation %D 2020 %7 23.6.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: According to a World Health Organization report in 2017, there was almost one patient with depression among every 20 people in China. However, the diagnosis of depression is usually difficult in terms of clinical detection owing to slow observation, high cost, and patient resistance. Meanwhile, with the rapid emergence of social networking sites, people tend to share their daily life and disclose inner feelings online frequently, making it possible to effectively identify mental conditions using the rich text information. There are many achievements regarding an English web-based corpus, but for research in China so far, the extraction of language features from web-related depression signals is still in a relatively primary stage. Objective: The purpose of this study was to propose an effective approach for constructing a depression-domain lexicon. This lexicon will contain language features that could help identify social media users who potentially have depression. Our study also compared the performance of detection with and without our lexicon. Methods: We autoconstructed a depression-domain lexicon using Word2Vec, a semantic relationship graph, and the label propagation algorithm. These two methods combined performed well in a specific corpus during construction. The lexicon was obtained based on 111,052 Weibo microblogs from 1868 users who were depressed or nondepressed. During depression detection, we considered six features, and we used five classification methods to test the detection performance. Results: The experiment results showed that in terms of the F1 value, our autoconstruction method performed 1% to 6% better than baseline approaches and was more effective and steadier. When applied to detection models like logistic regression and support vector machine, our lexicon helped the models outperform by 2% to 9% and was able to improve the final accuracy of potential depression detection. Conclusions: Our depression-domain lexicon was proven to be a meaningful input for classification algorithms, providing linguistic insights on the depressive status of test subjects. We believe that this lexicon will enhance early depression detection in people on social media. Future work will need to be carried out on a larger corpus and with more complex methods. %M 32574151 %R 10.2196/17650 %U http://medinform.jmir.org/2020/6/e17650/ %U https://doi.org/10.2196/17650 %U http://www.ncbi.nlm.nih.gov/pubmed/32574151 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17902 %T Evaluation of an On-Demand Mental Health System for Depression Symptoms: Retrospective Observational Study %A Kunkle,Sarah %A Yip,Manny %A Ξ,Watson %A Hunt,Justin %+ Ginger, 116 New Montgomery St Suite 500, San Francisco, CA, 94105, United States, 1 7175197355, sarah@ginger.io %K mental health %K depression %K digital health %K therapy %K coaching %K behavioral health %K virtual care %D 2020 %7 18.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is an extremely prevalent issue in the United States, with an estimated 7% of adults experiencing at least one major depressive episode in 2017. Although psychotherapy and medication management are effective treatments for depression, significant barriers in accessing care persist. Virtual care can potentially address some of these obstacles. Objective: We conducted a preliminary investigation of utilization characteristics and effectiveness of an on-demand health system for reducing depression symptoms. Methods: Data were analyzed from 1662 users of an on-demand mental health system that includes behavioral health coaching, clinical services (therapy and psychiatry), and self-guided content and assessments primarily via a mobile app platform. Measures included engagement characterized by mobile app data, member satisfaction scores collected via in-app surveys, and depression symptoms via the Patient Health Questionnaire-2 (PHQ-2) at baseline and 8-12 week follow-up. Descriptive statistics are reported for measures, and pre/post-PHQ-2 data were analyzed using the McNemar test. A chi-square test was used to test the association between the proportion of individuals with an improvement in PHQ-2 result and care modality (coaching, therapy, and psychiatry, or hybrid). Results: During the study period, 65.5% of individuals (1089/1662) engaged only in coaching services, 27.6% of individuals (459/1662) were engaged in both coaching and clinical services, 3.3% of individuals (54/1662) engaged only in clinical services, and 3.7% of individuals (61/1662) only used the app. Of the 1662 individuals who completed the PHQ-2 survey, 772 (46.5%) were considered a positive screen at intake, and 890 (53.6%) were considered a negative screen at intake. At follow-up, 477 (28.7%) of individuals screened positive, and 1185 (71.3%) screened negative. A McNemar test showed that there was a statistically significant decrease in the proportion of users experiencing depressed mood and anhedonia more than half the time at follow-up (P<.001). A chi-square test showed there was no significant association between care modality and the proportion of individuals with an improvement in PHQ-2 score. Conclusions: This study provides preliminary insights into which aspects of an on-demand mental health system members are utilizing and levels of engagement and satisfaction over an 8-12 week window. Additionally, there is some signal that this system may be useful for reducing depression symptoms in users over this period. Additional research is required, given the study limitations, and future research directions are discussed. %M 32554387 %R 10.2196/17902 %U http://www.jmir.org/2020/6/e17902/ %U https://doi.org/10.2196/17902 %U http://www.ncbi.nlm.nih.gov/pubmed/32554387 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16350 %T Optimizing Smartphone-Delivered Cognitive Behavioral Therapy for Body Dysmorphic Disorder Using Passive Smartphone Data: Initial Insights From an Open Pilot Trial %A Weingarden,Hilary %A Matic,Aleksandar %A Calleja,Roger Garriga %A Greenberg,Jennifer L %A Harrison,Oliver %A Wilhelm,Sabine %+ Massachusetts General Hospital/Harvard Medical School, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States, 1 6176436206, hilary_weingarden@mgh.harvard.edu %K body dysmorphic disorder %K cognitive behavioral therapy %K mobile health %K mobile phone %K patient engagement %D 2020 %7 18.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-delivered cognitive behavioral therapy (CBT) is becoming more common, but research on the topic remains in its infancy. Little is known about how people typically engage with smartphone CBT or which engagement and mobility patterns may optimize treatment. Passive smartphone data offer a unique opportunity to gain insight into these knowledge gaps. Objective: This study aimed to examine passive smartphone data across a pilot course of smartphone CBT for body dysmorphic disorder (BDD), a psychiatric illness characterized by a preoccupation with a perceived defect in physical appearance, to inform hypothesis generation and the design of subsequent, larger trials. Methods: A total of 10 adults with primary diagnoses of BDD were recruited nationally and completed telehealth clinician assessments with a reliable evaluator. In a 12-week open pilot trial of smartphone CBT, we initially characterized natural patterns of engagement with the treatment and tested how engagement and mobility patterns across treatment corresponded with treatment response. Results: Most participants interacted briefly and frequently with smartphone-delivered treatment. More frequent app usage (r=–0.57), as opposed to greater usage duration (r=–0.084), correlated strongly with response. GPS-detected time at home, a potential digital marker of avoidance, decreased across treatment and correlated moderately with BDD severity (r=0.49). Conclusions: The sample was small in this pilot study; thus, results should be used to inform the hypotheses and design of subsequent trials. The results provide initial evidence that frequent (even if brief) practice of CBT skills may optimize response to smartphone CBT and that mobility patterns may serve as useful passive markers of symptom severity. This is one of the first studies to examine the value that passively collected sensor data may contribute to understanding and optimizing users’ response to smartphone CBT. With further validation, the results can inform how to enhance smartphone CBT design. %M 32554382 %R 10.2196/16350 %U http://mhealth.jmir.org/2020/6/e16350/ %U https://doi.org/10.2196/16350 %U http://www.ncbi.nlm.nih.gov/pubmed/32554382 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 6 %P e16372 %T Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation %A Faruqui,Syed Hasib Akhter %A Alaeddini,Adel %A Chang,Mike C %A Shirinkam,Sara %A Jaramillo,Carlos %A NajafiRad,Peyman %A Wang,Jing %A Pugh,Mary Jo %+ Department of Mechanical Engineering, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, United States, 1 210 458 8747, adel.alaeddini@utsa.edu %K graphical models %K graph summarization %K graph Laplacian %K disease network %K multiple chronic conditions %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective: This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods: We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results: The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows—year 2: 79.91%, 84.04%, 78.83%, 82.50%, and 81.47%; year 3: 76.23%, 80.61%, 73.51%, 79.84%, and 77.13%; year 4: 72.38%, 78.22%, 72.96%, 77.92%, and 72.65%; and year 5: 69.51%, 76.15%, 73.04%, 76.72%, and 69.99%, respectively. This demonstrates an overall 12.07% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions: Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC. %M 32554376 %R 10.2196/16372 %U http://medinform.jmir.org/2020/6/e16372/ %U https://doi.org/10.2196/16372 %U http://www.ncbi.nlm.nih.gov/pubmed/32554376 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 6 %P e18890 %T Adherence of the #Here4U App – Military Version to Criteria for the Development of Rigorous Mental Health Apps %A Linden,Brooke %A Tam-Seto,Linna %A Stuart,Heather %+ Health Services and Policy Research Institute, Queen's University, 21 Arch Street, Kingston, ON, K7L 3L3, Canada, 1 613 533 6387, brooke.linden@queensu.ca %K mental health services %K telemedicine %K mHealth %K chatbot %K e-solutions %K Canadian Armed Forces %K military health %K mobile phone %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Over the past several years, the emergence of mobile mental health apps has increased as a potential solution for populations who may face logistical and social barriers to traditional service delivery, including individuals connected to the military. Objective: The goal of the #Here4U App – Military Version is to provide evidence-informed mental health support to members of Canada’s military community, leveraging artificial intelligence in the form of IBM Canada’s Watson Assistant to carry on unique text-based conversations with users, identify presenting mental health concerns, and refer users to self-help resources or recommend professional health care where appropriate. Methods: As the availability and use of mental health apps has increased, so too has the list of recommendations and guidelines for efficacious development. We describe the development and testing conducted between 2018 and 2020 and assess the quality of the #Here4U App against 16 criteria for rigorous mental health app development, as identified by Bakker and colleagues in 2016. Results: The #Here4U App – Military Version met the majority of Bakker and colleagues’ criteria, with those unmet considered not applicable to this particular product or out of scope for research conducted to date. Notably, a formal evaluation of the efficacy of the app is a major priority moving forward. Conclusions: The #Here4U App – Military Version is a promising new mental health e-solution for members of the Canadian Armed Forces community, filling many of the gaps left by traditional service delivery. %M 32554374 %R 10.2196/18890 %U https://formative.jmir.org/2020/6/e18890 %U https://doi.org/10.2196/18890 %U http://www.ncbi.nlm.nih.gov/pubmed/32554374 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17586 %T Challenges and Benefits of an Internet-Based Intervention With a Peer Support Component for Older Adults With Depression: Qualitative Analysis of Textual Data %A Chen,Annie T %A Slattery,Krystal %A Tomasino,Kathryn N %A Rubanovich,Caryn Kseniya %A Bardsley,Leland R %A Mohr,David C %+ Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, 850 Republican Street, Box 358047, UW Medicine South Lake Union, Seattle, WA, 98109, United States, 1 2062219218, atchen@uw.edu %K aged %K depression %K internet %K peer group %K social support %K qualitative research %D 2020 %7 16.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated. Objective: This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants’ experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions. Methods: We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention. Results: We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants’ comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating. Conclusions: This paper offers several contributions concerning study participants’ experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults. %M 32543448 %R 10.2196/17586 %U https://www.jmir.org/2020/6/e17586 %U https://doi.org/10.2196/17586 %U http://www.ncbi.nlm.nih.gov/pubmed/32543448 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e18236 %T Prospective Associations Between Working Time Arrangements and Psychiatric Treatment in Denmark: Protocol for a Cohort Study %A Hannerz,Harald %A Albertsen,Karen %A Nielsen,Martin Lindhardt %A Garde,Anne Helene %+ The National Research Center for the Working Environment, Lersø Parkallé 105, Copenhagen, 2100, Denmark, 45 39165460, hha@nrcwe.dk %K occupational health %K long working hours %K night shift work %K mood disorders %K anxiety %K stress-related disorders %K psychiatric hospital treatment %K prescription drugs %K psychotropic medicine %D 2020 %7 15.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The burden of mental ill health in working-age populations has prompted research on possible links between work-related factors and mental ill health. Long working hours and night shift work are some of the factors that have been studied in relation to the risk of developing mental ill health. Yet, previous studies have not generated conclusive evidence, and further studies of high quality are needed. Objective: This study aims to investigate the prospective association between working time arrangements and mental health in terms of psychotropic drug usage or psychiatric hospital treatment in the general working population of Denmark. Methods: Data on total weekly working hours in any job and night shift work from the Danish Labor Force Survey 2000–2013 will be linked to data from the Psychiatric Central Research Register (expected 2400 cases during 700,000 person years at risk) and National Prescription Registry (expected 17,400 cases during 600,000 person years at risk). Participants will be followed for up to 5 years. We will use Poisson regression to separately analyze incidence rates of redeemed prescriptions for psychotropic medicine and incidence rates of psychiatric hospital treatment due to mood disorders, anxiety disorders, or stress-related disorders as a function of weekly working hours and night shift work. The analyses will be controlled for sex, age, calendar time of the interview, and socioeconomic status. Results: This is a study protocol. Power calculations indicate that the study has sufficient statistical power to detect relatively small differences in risks and minor interactions (eg, ~90% power to detect a rate ratio of 1.1 for psychoactive medication use). We expect the analyses to be completed by the end of 2020 and the results to be published in 2021. Conclusions: In this study protocol, all hypotheses and statistical models of the project have been completely defined before we link the exposure data to the outcome data. The results of the project will indicate to what extent and in what direction the national burden of mental ill health in Denmark has been influenced by long working hours and night shift work. International Registered Report Identifier (IRRID): DERR1-10.2196/18236 %M 32442158 %R 10.2196/18236 %U https://www.researchprotocols.org/2020/6/e18236 %U https://doi.org/10.2196/18236 %U http://www.ncbi.nlm.nih.gov/pubmed/32442158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17195 %T Therapeutic Alliance in Technology-Based Interventions for the Treatment of Depression: Systematic Review %A Wehmann,Eileen %A Köhnen,Moritz %A Härter,Martin %A Liebherz,Sarah %+ Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany, 49 40 7410 57969, s.liebherz@uke.de %K therapeutic alliance %K depression %K technology-based intervention %K treatment %D 2020 %7 11.6.2020 %9 Review %J J Med Internet Res %G English %X Background: There is growing evidence that technology-based interventions (TBIs) are effective for the treatment of depression. As TBIs are gaining acceptance, a question arises whether good therapeutic alliance, considered a key aspect of psychotherapy, can be established without or with minimal face-to-face contact or rather changes if blended concepts are applied. While therapeutic alliance has been studied extensively in the context of face-to-face therapy, only few studies have reviewed evidence on alliance ratings in TBIs. Objective: The purpose of this study was to examine therapeutic alliance in technology-based psychological interventions for the treatment of depression. Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PSYNDEX, CINAHL, clinical trial registers, and sources of grey literature for randomized controlled trials on TBIs in the treatment of adults with unipolar depression. All publications were selected according to prespecified criteria. Data were extracted by two independent reviewers. Results: A total of eight out of 98 studies (9.5%) included in the review on TBIs for depression considered therapeutic alliance as part of their evaluation. The available data covered eight different treatment conditions, including four stand-alone treatments (face-to-face psychotherapy, email, telephone, and internet program) and four combined treatments (face-to-face psychotherapy plus a smartphone app and an internet program combined with face-to-face psychotherapy, treatment as usual, or email/telephone). On average, patients rated the alliance positively across all groups. Importantly, no relevant group differences regarding therapeutic alliance sum scores were found in any of the studies. Five studies investigated the relationship between patients’ alliance ratings and treatment outcome, revealing mixed results. Conclusions: Our results suggest that it is possible to establish a positive therapeutic alliance across a variety of different TBIs for depression, but this is based on a small number of studies. Future research needs to determine on what basis therapeutic alliance is formed in settings that do not allow for additional nonverbal cues, perhaps with adapted instruments to measure therapeutic alliance. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413) International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-028042 %M 32525484 %R 10.2196/17195 %U http://www.jmir.org/2020/6/e17195/ %U https://doi.org/10.2196/17195 %U http://www.ncbi.nlm.nih.gov/pubmed/32525484 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e16684 %T Causal Factors of Anxiety and Depression in College Students: Longitudinal Ecological Momentary Assessment and Causal Analysis Using Peter and Clark Momentary Conditional Independence %A Huckins,Jeremy F %A DaSilva,Alex W %A Hedlund,Elin L %A Murphy,Eilis I %A Rogers,Courtney %A Wang,Weichen %A Obuchi,Mikio %A Holtzheimer,Paul E %A Wagner,Dylan D %A Campbell,Andrew T %+ Department of Psychological and Brain Sciences, Dartmouth College, HB6207, Hanover, NH, 03755, United States, 1 5086574825, jeremy.f.huckins@dartmouth.edu %K depression %K anxiety %K self-esteem %K stress %K causality %K ecological momentary assessments %K mental health %K network %K college %D 2020 %7 10.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Across college campuses, the prevalence of clinically relevant depression or anxiety is affecting more than 27% of the college population at some point between entry to college and graduation. Stress and self-esteem have both been hypothesized to contribute to depression and anxiety levels. Although contemporaneous relationships between these variables have been well-defined, the causal relationship between these mental health factors is not well understood, as frequent sampling can be invasive, and many of the current causal techniques are not well suited to investigate correlated variables. Objective: This study aims to characterize the causal and contemporaneous networks between these critical mental health factors in a cohort of first-year college students and then determine if observed results replicate in a second, distinct cohort. Methods: Ecological momentary assessments of depression, anxiety, stress, and self-esteem were obtained weekly from two cohorts of first-year college students for 40 weeks (1 academic year). We used the Peter and Clark Momentary Conditional Independence algorithm to identify the contemporaneous (t) and causal (t-1) network structures between these mental health metrics. Results: All reported results are significant at P<.001 unless otherwise stated. Depression was causally influenced by self-esteem (t-1 rp, cohort 1 [C1]=–0.082, cohort 2 [C2]=–0.095) and itself (t-1 rp, C1=0.388, C2=0.382) in both cohorts. Anxiety was causally influenced by stress (t-1 rp, C1=0.095, C2=0.104), self-esteem (t-1 rp, C1=–0.067, C2=–0.064, P=.002), and itself (t-1 rp, of C1=0.293, C2=0.339) in both cohorts. A causal link between anxiety and depression was observed in the first cohort (t-1 rp, C1=0.109) and only observed in the second cohort with a more liberal threshold (t-1 rp, C2=0.044, P=.03). Self-esteem was only causally influenced by itself (t-1 rp, C1=0.389, C2=0.393). Stress was only causally influenced by itself (t-1 rp, C1=0.248, C2=0.273). Anxiety had positive contemporaneous links to depression (t rp, C1=0.462, C2=0.444) and stress (t rp, C1=0.354, C2=0.358). Self-esteem had negative contemporaneous links to each of the other three mental health metrics, with the strongest negative relationship being stress (t rp, C1=–0.334, C2=–0.340), followed by depression (t rp, C1=–0.302, C2=–0.274) and anxiety (t rp, C1=–0.256, C2=–0.208). Depression had positive contemporaneous links to anxiety (previously mentioned) and stress (t rp, C1=0.250, C2=0.231). Conclusions: This paper is an initial attempt to describe the contemporaneous and causal relationships among these four mental health metrics in college students. We replicated previous research identifying concurrent relationships between these variables and extended them by identifying causal links among these metrics. These results provide support for the vulnerability model of depression and anxiety. Understanding how causal factors impact the evolution of these mental states over time may provide key information for targeted treatment or, perhaps more importantly, preventative interventions for individuals at risk for depression and anxiety. %M 32519971 %R 10.2196/16684 %U https://mental.jmir.org/2020/6/e16684 %U https://doi.org/10.2196/16684 %U http://www.ncbi.nlm.nih.gov/pubmed/32519971 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15001 %T Coach-Facilitated Web-Based Therapy Compared With Information About Web-Based Resources in Patients Referred to Secondary Mental Health Care for Depression: Randomized Controlled Trial %A MacLean,Sarah %A Corsi,Daniel J %A Litchfield,Sadie %A Kucharski,Julia %A Genise,Kira %A Selaman,Zeynep %A Testa,Valerie %A Hatcher,Simon %+ Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1919 Riverside Drive, Suite 406, Ottawa, ON, K1H 7W9, Canada, 1 613 737 8899, shatcher@toh.ca %K major depressive disorder %K secondary care %K randomized controlled trial %K telemedicine %K digital health technologies %K Canada %D 2020 %7 9.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common mental disorder with a high social burden and significant impact on suicidality and quality of life. Treatment is often limited to drug therapies because of long waiting times to see psychological therapists face to face, despite several guidelines recommending that psychological treatments should be first-line interventions for mild to moderate depression. Objective: We aimed to evaluate, among patients on a waitlist to receive secondary mental health care services for depression, how effective coach-guided web-based therapy (The Journal) is, compared with an information-only waitlist control group, in reducing depression symptoms after 12 weeks. Methods: We conducted a randomized controlled trial with 2 parallel arms and a process evaluation, which included interviews with study participants. Participants assigned to the intervention group received 12 weeks of web-based therapy guided by a coach who had a background in social work. Patients in the control group receive a leaflet of mental health resources they could access. The primary outcome measure was a change in depression scores, as measured by the Patient-Health Questionnaire (PHQ-9). Results: A total of 95 participants were enrolled (intervention, n=47; control, n=48). The mean change in PHQ-9 scores from baseline to week 12 was −3.6 (SD 6.6) in the intervention group and −3.1 (SD 6.2) in the control group, which was not a statistically significant difference with a two-sided alpha of .05 (t91=−0.37; P=.72, 95% CI −3.1 to 2.2). At 12 weeks, participants in the intervention group reported higher health-related quality of life (mean EuroQol 5 dimensions visual analogue scale [EQ-5D-VAS] score 66.8, SD 18.0) compared with the control group (mean EQ-5D VAS score 55.9, SD 19.2; t84=−2.73; P=.01). There were no statistically significant differences between the two groups in health service use following their initial consultation with a psychiatrist. The process evaluation showed that participants in the intervention group completed a mean of 5.0 (SD 2.3) lessons in The Journal and 8.8 (SD 3.1) sessions with the coach. Most participants (29/47, 62%) in the intervention group who completed the full dose of the intervention, by finishing 6 or more lessons in The Journal, were more likely to have a clinically important reduction in depressive symptoms at 12 weeks compared with the control group (Χ21=6.3; P=.01, Φ=0.37). Participants who completed the interviews reported that the role played by the coach was a major factor in adherence to the study intervention. Conclusions: The results demonstrate that the use of guided web-based therapy for the treatment of depression is not more effective than information-only waitlist control. However, it showed that the coach has the potential to increase adherence and engagement with web-based depression treatment protocols. Further research is needed on what makes the coach effective. Trial Registration: ClinicalTrials.gov: NCT02423733; https://clinicaltrials.gov/ct2/show/NCT02423733 %M 32515740 %R 10.2196/15001 %U https://www.jmir.org/2020/6/e15001 %U https://doi.org/10.2196/15001 %U http://www.ncbi.nlm.nih.gov/pubmed/32515740 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e15973 %T Examining the Self-Harm and Suicide Contagion Effects of the Blue Whale Challenge on YouTube and Twitter: Qualitative Study %A Khasawneh,Amro %A Chalil Madathil,Kapil %A Dixon,Emma %A Wiśniewski,Pamela %A Zinzow,Heidi %A Roth,Rebecca %+ Department of Anesthesiology and Critical Care, Johns Hopkins University, 750 E Pratt St, 15th Fl, Baltimore, MD, 21202, United States, 1 410 637 4365, akhasaw1@jhmi.edu %K suicide %K suicidal ideation %K self-mutilation %K mental health %K self-injurious behavior %K behavioral symptoms %D 2020 %7 5.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research suggests that direct exposure to suicidal behaviors and acts of self-harm through social media may increase suicidality through imitation and modeling, particularly in more vulnerable populations. One example of a social media phenomenon that demonstrates how self-harming behavior could potentially be propagated is the blue whale challenge. In this challenge, adolescents and young adults are encouraged to engage in self-harm and eventually kill themselves. Objective: This paper aimed to investigate the way individuals portray the blue whale challenge on social media, with an emphasis on factors that could pose a risk to vulnerable populations. Methods: We first used a thematic analysis approach to code 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced the blue whale challenge. We then deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) safe messaging guidelines as a metric for the contagion risk associated with each video. Results: The thematic analysis revealed that social media users post about the blue whale challenge to raise awareness and discourage participation, express sorrow for the participants, criticize the participants, or describe a relevant experience. The deductive coding of the YouTube videos showed that most of the videos violated at least 50% of the SPRC safe and effective messaging guidelines. Conclusions: These posts might have the problematic effect of normalizing the blue whale challenge through repeated exposure, modeling, and reinforcement of self-harming and suicidal behaviors, especially among vulnerable populations such as adolescents. More effort is needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects. %M 32515741 %R 10.2196/15973 %U https://mental.jmir.org/2020/6/e15973 %U https://doi.org/10.2196/15973 %U http://www.ncbi.nlm.nih.gov/pubmed/32515741 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e17223 %T The Safety, Efficacy, and Tolerability of Microbial Ecosystem Therapeutic-2 in People With Major Depression and/or Generalized Anxiety Disorder: Protocol for a Phase 1, Open-Label Study %A Chinna Meyyappan,Arthi %A Milev,Roumen %+ Providence Care Hospital, 752 King St West, Kingston, ON, K7L 4X3, Canada, 1 6135444900 ext 53326, 14acm@queensu.ca %K depression %K anxiety %K microbial ecosystem therapy %K gut-brain axis %K microbiome %K clinical trial %K protocol %D 2020 %7 4.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The bidirectional signaling between the gut microbiota and the brain, known as the gut-brain axis, is being heavily explored in current neuropsychiatric research. Analyses of the human gut microbiota have shown considerable individual variability in bacterial content, which is hypothesized to influence brain function, and potentially mood and anxiety symptoms, through gut-brain axis communication. Preclinical and clinical research examining these effects suggests that fecal microbiota transplant (FMT) may aid in improving the severity of depression and anxiety symptoms by recolonizing the gastrointestinal (GI) tract with healthy bacteria. The microbial ecosystem therapeutic (ie, microbial ecosystem therapeutic-2 [MET-2]) used in this study is an alternative treatment to FMT, which comprises 40 different strains of gut bacteria from a healthy donor. Objective: The primary objective of this study is to assess subjective changes in mood and anxiety symptoms before, during, and after administration of MET-2. The secondary objectives of this study are to assess the changes in metabolic functioning and the level of repopulation of healthy gut bacteria, the safety and tolerability of MET-2, and the effects of early stress on biomarkers of depression/anxiety and the response to treatment. Methods: Adults experiencing depressive or anxiety symptoms will be recruited from the Kingston area. These participants will orally consume an encapsulated MET-2 once daily—containing 40 strains of purified and laboratory-grown bacteria from a single healthy donor—for 8 weeks, followed by a 2-week treatment-free follow-up period. Participants will undergo a series of clinical assessments measuring mood, anxiety, and GI symptoms using validated clinical scales and questionnaires. Molecular data will be collected from blood and fecal samples to assess metabolic changes, neurotransmitter levels, inflammatory markers, and the level of engraftment of the fecal samples that may predict outcomes in depression or anxiety. Results: Given the association between the gut bacteria and the risk factors of depression, we expect to observe an improvement in the severity of depressive and anxiety symptoms following treatment, and we expect that this improvement is mediated by the recolonization of the GI tract with healthy bacteria. The recruitment for this study has been completed, and the data obtained are currently being analyzed. Conclusions: This is the first time MET-2 is being tested in psychiatric indications, specifically depression and anxiety. As such, this may be the first study to show the potential effects of microbial therapy in alleviating psychiatric symptoms as well as its safety and tolerability. International Registered Report Identifier (IRRID): DERR1-10.2196/17223 %M 32495743 %R 10.2196/17223 %U https://www.researchprotocols.org/2020/6/e17223 %U https://doi.org/10.2196/17223 %U http://www.ncbi.nlm.nih.gov/pubmed/32495743 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e13247 %T Possible Application of Ecological Momentary Assessment to Older Adults’ Daily Depressive Mood: Integrative Literature Review %A Kim,Heejung %A Kim,Sunah %A Kong,Seong Sook %A Jeong,Yi-Rang %A Kim,Hyein %A Kim,Namhee %+ College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 10 9267 3611, namheekim0316@gmail.com %K ecological momentary assessment %K depression %K aged %K review %D 2020 %7 2.6.2020 %9 Review %J JMIR Ment Health %G English %X Background: Ecological momentary assessment is a method of investigating individuals’ real-time experiences, behaviors, and moods in their natural environment over time. Despite its general usability and clinical value for evaluating daily depressive mood, there are several methodological challenges when applying ecological momentary assessment to older adults. Objective: The aims of this integrative literature review were to examine possible uses of the ecological momentary assessment methodology with older adults and to suggest strategies to increase the feasibility of its application in geriatric depression research and practice. Methods: We searched 4 electronic databases (MEDLINE, CINAHL, PsycINFO, and EMBASE) and gray literature; we also hand searched the retrieved articles’ references. We limited all database searches to articles published in peer-reviewed journals from 2009 to 2019. Search terms were “ecological momentary assessment,” “smartphone assessment,” “real time assessment,” “electronic daily diary,” “mHealth momentary assessment,” “mobile-based app,” and “experience sampling method,” combined with the relevant terms of depression. We included any studies that enrolled older adults even as a subgroup and that reported depressive mood at least once a day for more than 2 days. Results: Of the 38 studies that met the inclusion criteria, only 1 study enrolled adults aged 65 years or older as the entire sample; the remainder of the reviewed studies used mixed samples of both younger and older adults. Most of the analyzed studies (18/38, 47%) were quantitative, exploratory (descriptive, correlational, and predictive), and cohort in design. Ecological momentary assessment was used to describe the fluctuating pattern of participants’ depressive moods primarily and to examine the correlation between mood patterns and other health outcomes as a concurrent symptom. We found 3 key methodological issues: (1) heterogeneity in study design and protocol, (2) issues with definitions of dropout and adherence, and (3) variation in how depressive symptoms were measured with ecological momentary assessment. Some studies (8/38, 21%) examined the age difference of participants with respect to dropout or poor compliance rate. Detailed participant burden was reported, such as technical problems, aging-related health problems, or discomfort while using the device. Conclusions: Ecological momentary assessment has been used for comprehensive assessment of multiple mental health indicators in relation to depressive mood. Our findings provide methodological considerations for further studies that may be implemented using ecological momentary assessment to assess daily depressive mood in older adults. Conducting more feasibility studies focusing on older adults with standardized data collection protocols and mixed-methods research is required to reflect users’ experiences. Further telepsychiatric evaluation and diagnosis based on ecological momentary assessment data should involve standardized and sophisticated strategies to maximize the potential of ecological momentary assessment for older adults with depression in the community setting. %M 32484442 %R 10.2196/13247 %U https://mental.jmir.org/2020/6/e13247 %U https://doi.org/10.2196/13247 %U http://www.ncbi.nlm.nih.gov/pubmed/32484442 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e19347 %T Flattening the Mental Health Curve: COVID-19 Stay-at-Home Orders Are Associated With Alterations in Mental Health Search Behavior in the United States %A Jacobson,Nicholas C %A Lekkas,Damien %A Price,George %A Heinz,Michael V %A Song,Minkeun %A O’Malley,A James %A Barr,Paul J %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Parkway, Suite 300, Office #333S, Lebanon, NH, 03766, United States, 1 6036467037, Nicholas.C.Jacobson@dartmouth.edu %K COVID-19 %K coronavirus %K stay-at-home orders %K mental health %K suicide %K anxiety %K infodemiology %K infoveillance %K search trends %K health information needs %D 2020 %7 1.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The coronavirus disease (COVID-19) has led to dramatic changes worldwide in people’s everyday lives. To combat the pandemic, many governments have implemented social distancing, quarantine, and stay-at-home orders. There is limited research on the impact of such extreme measures on mental health. Objective: The goal of this study was to examine whether stay-at-home orders produced differential changes in mental health symptoms using internet search queries on a national scale. Methods: In the United States, individual states vary in their adoption of measures to reduce the spread of COVID-19; as of March 23, 2020, 11 of the 50 states had issued stay-at-home orders. The staggered rollout of stay-at-home measures across the United States allows us to investigate whether these measures impact mental health by exploring variations in mental health search queries across the states. This paper examines the changes in mental health search queries on Google between March 16-23, 2020, across each state and Washington, DC. Specifically, this paper examines differential changes in mental health searches based on patterns of search activity following issuance of stay-at-home orders in these states compared to all other states. The participants were all the people who searched mental health terms in Google between March 16-23. Between March 16-23, 11 states underwent stay-at-home orders to prevent the transmission of COVID-19. Outcomes included search terms measuring anxiety, depression, obsessive-compulsive, negative thoughts, irritability, fatigue, anhedonia, concentration, insomnia, and suicidal ideation. Results: Analyzing over 10 million search queries using generalized additive mixed models, the results suggested that the implementation of stay-at-home orders are associated with a significant flattening of the curve for searches for suicidal ideation, anxiety, negative thoughts, and sleep disturbances, with the most prominent flattening associated with suicidal ideation and anxiety. Conclusions: These results suggest that, despite decreased social contact, mental health search queries increased rapidly prior to the issuance of stay-at-home orders, and these changes dissipated following the announcement and enactment of these orders. Although more research is needed to examine sustained effects, these results suggest mental health symptoms were associated with an immediate leveling off following the issuance of stay-at-home orders. %M 32459186 %R 10.2196/19347 %U https://mental.jmir.org/2020/6/e19347 %U https://doi.org/10.2196/19347 %U http://www.ncbi.nlm.nih.gov/pubmed/32459186 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17458 %T Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses %A Lecomte,Tania %A Potvin,Stéphane %A Corbière,Marc %A Guay,Stéphane %A Samson,Crystal %A Cloutier,Briana %A Francoeur,Audrey %A Pennou,Antoine %A Khazaal,Yasser %+ Department of Psychology, University of Montreal, 90 rue Vincent d'Indy, Bur C-358, CP 6128, Succ Centre-Ville, Montreal, QC, H3C 3J7, Canada, 1 343 6274, tania.lecomte@umontreal.ca %K apps %K mental health %K depression %K anxiety %K review %K meta %D 2020 %7 29.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied. Objective: This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far. Methods: Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up. Conclusions: This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations. %M 32348289 %R 10.2196/17458 %U https://mhealth.jmir.org/2020/5/e17458 %U https://doi.org/10.2196/17458 %U http://www.ncbi.nlm.nih.gov/pubmed/32348289 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 1 %P e18043 %T Association of Social Media Use and High-Risk Behaviors in Adolescents: Cross-Sectional Study %A Vente,Teresa %A Daley,Mary %A Killmeyer,Elizabeth %A Grubb,Laura K %+ Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 16, Chicago, IL, United States, 1 518 339 5440, tvente@luriechildrens.org %K self-harm %K social media %K nonsuicidal self-injury %K sexting %D 2020 %7 26.5.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Previous studies have demonstrated the prevalence of social media use and identified the presence of high-risk behaviors among adolescents, including self-harm and sharing of sexually explicit messages. Objective: This study aimed to identify patterns in the amount of time spent on social media by adolescents who engage in high-risk behavior and the extent to which they use social media as a platform for sharing such behaviors. Methods: This was a descriptive cross-sectional study of 179 adolescents seen in a pediatric clinic at an urban medical center. We used an anonymous self-report survey to obtain demographic characteristics, rates of self-harm thoughts and behaviors, sharing of sexually explicit messages, and social media use as determined by total hours spent on social media per day and the number of applications used. Results: Most adolescents reported spending 3 to 5 hours on social media each day and using 3 or more social media applications. Almost 1 in 8 (22/179, 12.3%) adolescents self-reported having ever engaged in self-injury with a mean age of onset of 11.8 years. Over a quarter (49/179, 27.4%) of adolescents reported sharing sexually explicit messages. Relative risk of engaging in self-injury and or sharing sexually explicit messages increased with the use of 4 or more social media applications (1.66; CI 1.11-2.48). Conclusions: Results show a relationship between the number of social media applications used and increased rates of high-risk behaviors. We identified relevant risk factors that clinicians can use to screen for high-risk behavior and parents can monitor to encourage education about healthy online practices. %M 32452820 %R 10.2196/18043 %U http://pediatrics.jmir.org/2020/1/e18043/ %U https://doi.org/10.2196/18043 %U http://www.ncbi.nlm.nih.gov/pubmed/32452820 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e17345 %T Augmenting Safety Planning With Text Messaging Support for Adolescents at Elevated Suicide Risk: Development and Acceptability Study %A Czyz,Ewa K %A Arango,Alejandra %A Healy,Nathaniel %A King,Cheryl A %A Walton,Maureen %+ Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI, 48109, United States, 1 7346476727, ewac@umich.edu %K adolescents %K suicide %K text messaging %K safety planning %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is the second leading cause of death among adolescents. A critical need exists for developing promising interventions for adolescents after psychiatric hospitalization who are at a high risk of experiencing repeated suicidal behaviors and related crises. The high-risk period following psychiatric hospitalization calls for cost-effective and scalable continuity of care approaches to support adolescents’ transition from inpatient care. Text messages have been used to improve a wide range of behavioral and health outcomes and may hold promise as an accessible continuity of care strategy for youth at risk of suicide. Objective: In this study of 40 adolescents at elevated suicide risk, we report on the iterative development and acceptability of a text-based intervention designed to encourage adaptive coping and safety plan adherence in the high-risk period following psychiatric hospitalization. Methods: Adolescents (aged 13-17 years) who were hospitalized because of last-month suicide attempts or last-week suicidal ideation took part in either study phase 1 (n=25; 19/25, 76% female), wherein message content was developed and revised on the basis of feedback obtained during hospitalization, or study phase 2 (n=15; 11/15, 73% female), wherein text messages informed by phase 1 were further tested and refined based on feedback obtained daily over the course of a month after discharge (n=256 observations) and during an end-of-study phone interview. Results: Quantitative and qualitative feedback across the 2 study phases pointed to the acceptability of text-based support. Messages were seen as having the potential to be helpful with the transition after hospitalization, with adolescents indicating that texts may serve as reminders to use coping strategies, contribute to improvement in mood, and provide them with a sense of encouragement and hope. At the same time, some adolescents expressed concerns that messages may be insufficient for all teens or circumstances. In phase 2, the passage of time did not influence adolescents’ perception of messages in the month after discharge (P=.74); however, there were notable daily level associations between the perception of messages and adolescents’ affect. Specifically, higher within-person (relative to adolescents’ own average) anger was negatively related to liking text messages (P=.005), whereas within-person positive affect was associated with the perception of messages as more helpful (P=.04). Conclusions: Text-based support appears to be an acceptable continuity of care strategy to support adolescents’ transition after hospitalization. The implications of study findings are discussed. Future work is needed to evaluate the impact of text-based interventions on suicide-related outcomes. %M 32160150 %R 10.2196/17345 %U http://mental.jmir.org/2020/5/e17345/ %U https://doi.org/10.2196/17345 %U http://www.ncbi.nlm.nih.gov/pubmed/32160150 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17034 %T Mood and Stress Evaluation of Adult Patients With Moyamoya Disease in Korea: Ecological Momentary Assessment Method Using a Mobile Phone App %A Yang,Yong Sook %A Ryu,Gi Wook %A Park,Chang Gi %A Yeom,Insun %A Shim,Kyu Won %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 222283341, monachoi@yuhs.ac %K affect %K ecological momentary assessment %K mood %K Moyamoya disease %K psychological stress %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Moyamoya disease (MMD) is a known progressive obstructive cerebrovascular disorder. Monitoring and managing mood and stress are critical for patients with MMD, as they affect clinical outcomes. The ecological momentary assessment (EMA) method is a longitudinal study design by which multiple variable assessments can be performed over time to detect momentary fluctuations and changes in psychological dimensions such as mood and stress over time. Objective: This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app. Methods: Participants aged older than 18 years were recruited from a tertiary hospital in Seoul, Korea, between July 2018 and January 2019. The PsyMate scale for negative affect (NA) and positive affect (PA) and the Trier Inventory for Chronic Stress Scale were uploaded on patient mobile phones. Using a mobile app, data were collected four times a day for 7 days. Pearson correlations and mixed modeling were used to predict relationships between repeatedly measured variables at both the between-person and within-person levels. Results: The mean age of the 93 participants was 40.59 (SD 10.06) years, 66 (71%) were female, and 71 (76%) were married. Participants provided 1929 responses out of a possible 2604 responses (1929/2604, 74.08%). The mean momentary NA and PA values were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The momentary stress value was 2.03 (SD 0.98) out of 5. Momentary NA, PA, and stress were correlated (P<.001) and varied over time in relation to momentary variables. Common momentary variables associated with momentary mood and stress at both the within-person (level 1) and between-person (level 2) levels were identified. Momentary NA increased when being alone and being at the hospital at both levels, whereas momentary PA increased when eating or drinking, resting, being at a café, restaurant or a public place but decreased when being alone at both levels. Momentary stress increased when being at the office, at a public place, or as the time of the day went by but decreased when resting or during the weekend. Different factors affecting mood and stress at different levels were identified. Fluctuations in individual momentary mood over time at the within-person level were captured. Conclusions: The EMA method using a mobile phone app demonstrated its ability to capture changes in mood and stress in various environmental contexts in patients with MMD. The results could provide baseline information for developing interventions to manage negative mood and stress of patients with MMD based on the identified predictors affecting mood and stress at two different levels. %M 32449687 %R 10.2196/17034 %U http://mhealth.jmir.org/2020/5/e17034/ %U https://doi.org/10.2196/17034 %U http://www.ncbi.nlm.nih.gov/pubmed/32449687 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 5 %P e14309 %T Effectiveness of Group Cognitive Behavioral Therapy and Exercise in the Management of Major Depressive Disorder: Protocol for a Pilot Randomized Controlled Trial %A Yekrang Safakar,Mojtaba %A Hrabok,Marianne %A Urichuk,Liana %A Juhas,Michal %A Shalaby,Reham %A Parmar,Devashree %A Chue,Pierre %A Snaterse,Mark %A Mason,Judith %A Tchida,Donna %A Kelland,Jill %A Coulson,Pamela %A Sosdjan,Daniella %A Brown,Jason %A Hay,Katherine %A Lesage,Deanna %A Paulsen,Lacey %A Delday,Amy %A Duiker,Sherianna %A Surood,Shireen %A Abba-Aji,Adam %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7802157771, agyapong@ualberta.ca %K depression %K major depressive disorder %K cognitive behavioral therapy %K group CBT %K exercise %D 2020 %7 25.5.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite evidence in scientific literature indicating the effectiveness of both cognitive behavioral therapy (CBT) and physical exercise in the management of major depressive disorder (MDD), few studies have directly compared them. Objective: This study aims to evaluate and compare the effectiveness of group CBT, physical exercise, and only wait-listing to receive treatment-as-usual (TAU) in the management of MDD. The investigators hypothesize that participants with MDD assigned to the group CBT or exercise arms of the study will achieve superior outcomes compared with participants wait-listed to receive TAU only. Methods: This prospective rater-blinded randomized controlled trial assesses the benefits of group CBT and exercise for participants with MDD. A total of 120 patients with MDD referred to addiction and mental health clinics in Edmonton, Canada, will be randomly assigned to one of the three equal-sized arms of the study to receive either weekly sessions of group CBT plus TAU, group exercise three times a week plus TAU, or only TAU for 14 weeks. Participants will be assessed at enrollment, 3 and 6 months post enrollment, midtreatment, and upon treatment completion for primary (functional and symptom variables) and secondary outcomes (service variables and health care utilization). In addition, participants in the intervention groups would be evaluated weekly with one functional measure. The data will be analyzed using repeated measures and effect size analyses, and correlational analyses will be completed between measures at each time point. Results: The study will be conducted in accordance with the Declaration of Helsinki (Hong Kong amendment) and Good Clinical Practice (Canadian guidelines). Written informed consent will be obtained from each subject. The study received ethical clearance from the Health Ethics Research Board of the University of Alberta on September 7, 2018 (Pro 00080975) and operational approval from the provincial health authority (Alberta Health Services 43638). As of October 13, 2019, we have enrolled 32 participants. The results will be disseminated at several levels, including patients, practitioners, academics, researchers, and health care organizations. Conclusions: The results of the pilot trial may inform the implementation of a multicenter clinical trial and provide useful information for administrators and clinicians who are interested in incorporating group CBT and group exercise interventions into existing care. Trial Registration: ClinicalTrials.gov NCT03731728; https://clinicaltrials.gov/ct2/show/NCT03731728 International Registered Report Identifier (IRRID): PRR1-10.2196/14309 %M 32449684 %R 10.2196/14309 %U https://www.researchprotocols.org/2020/5/e14309 %U https://doi.org/10.2196/14309 %U http://www.ncbi.nlm.nih.gov/pubmed/32449684 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e16237 %T An Automated Mobile Mood Tracking Technology (Mood 24/7): Validation Study %A Kumar,Anupama %A Wang,Michael %A Riehm,Alison %A Yu,Eileen %A Smith,Ted %A Kaplin,Adam %+ Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Room 121, 600 N Wolfe Street, Meyer Building, Baltimore, MD, 21287-0005, United States, 1 4106143307, akaplin@jhmi.edu %K depression %K text messaging %K patient monitoring %K mobile phone %K short message service %K ecological momentary assessment %K digital health %D 2020 %7 20.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Electronic tracking has been utilized for a variety of health conditions. Previous studies have shown that there is higher adherence to electronic methods vs paper-and-pencil tracking modalities. Electronic tracking also ensures that there are no back-filled entries, where patients have—to appear compliant—entered their responses retrospectively just before their visits with their health care provider. On the basis of the recognition of an unmet need for a Web-based automated platform to track psychiatric outcomes, Johns Hopkins University partnered with Health Central (a subsidiary of Remedy Health Media LLC) to develop Mood 24/7, an electronic, mobile, automated, SMS-based mood tracker. This is a pilot study to validate the use of Mood 24/7 in anticipation of clinical trials to demonstrate the therapeutic benefit on patients’ health outcomes of utilizing digital mood-tracking technology. Objective: Mood 24/7 is an electronic mood-monitoring platform developed to accurately and efficiently track mood over time through automated daily SMS texts or emails. This study was designed to assess the accuracy and validity of Mood 24/7 in an outpatient psychiatric setting. Methods: This pilot study involved a retrospective chart review for depressed outpatients (N=9) to compare their self-reported Mood 24/7 daily mood ratings with their psychiatrist’s independent clinical mood assessment at the time of the patient’s visit. Their mood ratings via Mood 24/7 were collected over 36 weeks. In addition, a mixed model analysis was applied to compare the weekly Montgomery-Åsberg Depression Rating Scale (MADRS) scores with Mood 24/7 scores over an average of 3 months. Results: A 97.2% (315/324) digital mood reporting adherence was found over 36 weeks, and a significant correlation (r=0.86, P<.001) was observed between patients’ Mood 24/7 scores and their psychiatrist’s blinded clinical assessment of the patient’s mood when seen in the clinic. In addition, a significant concordance (intraclass correlation of 0.69, 95% CI 0.33-0.91, P<.001) was observed in the mixed model analysis of the clinician-administered MADRS vs Mood 24/7 scores over time. Conclusions: Our chart review and mixed model analyses demonstrate that Mood 24/7 is a valid instrument for convenient, simple, noninvasive, and accurate longitudinal mood assessment in the outpatient clinical setting. %M 32432558 %R 10.2196/16237 %U https://mental.jmir.org/2020/5/e16237 %U https://doi.org/10.2196/16237 %U http://www.ncbi.nlm.nih.gov/pubmed/32432558 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e16604 %T User Experiences of an Internet-Based Stepped-Care Intervention for Individuals With Cancer and Concurrent Symptoms of Anxiety or Depression (the U-CARE AdultCan Trial): Qualitative Study %A Igelström,Helena %A Hauffman,Anna %A Alfonsson,Sven %A Sjöström,Jonas %A Cajander,Åsa %A Johansson,Birgitta %+ Department of Neuroscience, Uppsala University, BMC, Box 593, Uppsala, 75124, Sweden, 46 184714761, helena.igelstrom@neuro.uu.se %K interactive web portal %K stepped care %K user experience %K cancer %K interviews %D 2020 %7 19.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet-based stepped-care intervention iCAN-DO, used in the multicenter randomized controlled trial AdultCan, was developed for adult patients undergoing treatment for cancer and concurrently experiencing anxiety or depressive symptoms. iCAN-DO aimed to decrease symptoms of anxiety or depression. Step 1 comprises access to a library with psychoeducational material and a peer-support section, as well as the possibility to pose questions to a nurse. Step 2 of the intervention offers treatment consisting of internet-based cognitive behavioral therapy (iCBT) to participants still experiencing anxiety or depression at 1, 4, or 7 months after inclusion. Objective: The study aimed to explore user experiences of delivery, design, and structure of iCAN-DO from the perspective of people with cancer. Methods: We studied user experiences by interviewing 15 informants individually: 10 women with breast cancer (67%), 4 men with prostate cancer (27%), and 1 man with colorectal cancer (7%) with a mean age 58.9 years (SD 8.9). The interviews focused on informants' perceptions of ease of use and of system design and structure. Informants had been included in iCAN-DO for at least 7 months. They were purposefully selected based on activity in Step 1, participation in iCBT (ie, Step 2), gender, and diagnosis. Results: Of the 15 informants, 6 had been offered iCBT (40%). All informants used the internet on a daily basis, but 2 (13%) described themselves as very inexperienced computer users. The analysis revealed three subthemes, concerning how user experiences were affected by disease-specific factors and side effects (User experience in the context of cancer), technical problems (Technical struggles require patience and troubleshooting), and the structure and design of iCAN-DO (Appealing and usable, but rather simple). Conclusions: The results indicate that user experiences were affected by informants’ life situations, the technical aspects and the design of iCAN-DO, and informants’ preferences. The results have generated some developments feasible to launch during the ongoing study, but if iCAN-DO is to be used beyond research interest, a greater level of tailoring of information, features, and design may be needed to improve user experiences. The use of recurrent questionnaires during the treatment period may highlight an individual’s health, but also function as a motivator showing improvements over time. %M 32427108 %R 10.2196/16604 %U http://www.jmir.org/2020/5/e16604/ %U https://doi.org/10.2196/16604 %U http://www.ncbi.nlm.nih.gov/pubmed/32427108 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e17520 %T Developing a Suicide Prevention Social Media Campaign With Young People (The #Chatsafe Project): Co-Design Approach %A Thorn,Pinar %A Hill,Nicole TM %A Lamblin,Michelle %A Teh,Zoe %A Battersby-Coulter,Rikki %A Rice,Simon %A Bendall,Sarah %A Gibson,Kerry L %A Finlay,Summer May %A Blandon,Ryan %A de Souza,Libby %A West,Ashlee %A Cooksey,Anita %A Sciglitano,Joe %A Goodrich,Simon %A Robinson,Jo %+ Orygen, 35 Poplar Road, Parkville, VIC, Australia, 61 412 999 140, jo.robinson@orygen.org.au %K suicide %K social media %K health promotion %K co-design %K adolescent %K young adult %K #chatsafe %D 2020 %7 11.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Young people commonly use social media platforms to communicate about suicide. Although research indicates that this communication may be helpful, the potential for harm still exists. To facilitate safe communication about suicide on social media, we developed the #chatsafe guidelines, which we sought to implement via a national social media campaign in Australia. Population-wide suicide prevention campaigns have been shown to improve knowledge, awareness, and attitudes toward suicide. However, suicide prevention campaigns will be ineffective if they do not reach and resonate with their target audience. Co-designing suicide prevention campaigns with young people can increase the engagement and usefulness of these youth interventions. Objective: This study aimed to document key elements of the co-design process; to evaluate young people’s experiences of the co-design process; and to capture young people’s recommendations for the #chatsafe suicide prevention social media campaign. Methods: In total, 11 co-design workshops were conducted, with a total of 134 young people aged between 17 and 25 years. The workshops employed commonly used co-design strategies; however, modifications were made to create a safe and comfortable environment, given the population and complexity and sensitivity of the subject matter. Young people’s experiences of the workshops were evaluated through a short survey at the end of each workshop. Recommendations for the campaign strategy were captured through a thematic analysis of the postworkshop discussions with facilitators. Results: The majority of young people reported that the workshops were both safe (116/131, 88.5%) and enjoyable (126/131, 96.2%). They reported feeling better equipped to communicate safely about suicide on the web and feeling better able to identify and support others who may be at risk of suicide. Key recommendations for the campaign strategy were that young people wanted to see bite-sized sections of the guidelines come to life via shareable content such as short videos, animations, photographs, and images. They wanted to feel visible in campaign materials and wanted all materials to be fully inclusive and linked to resources and support services. Conclusions: This is the first study internationally to co-design a suicide prevention social media campaign in partnership with young people. The study demonstrates that it is feasible to safely engage young people in co-designing a suicide prevention intervention and that this process produces recommendations, which can usefully inform suicide prevention campaigns aimed at youth. The fact that young people felt better able to safely communicate about suicide on the web as a result of participation in the study augurs well for youth engagement with the national campaign, which was rolled out across Australia. If effective, the campaign has the potential to better prepare many young people to communicate safely about suicide on the web. %M 32391800 %R 10.2196/17520 %U https://mental.jmir.org/2020/5/e17520 %U https://doi.org/10.2196/17520 %U http://www.ncbi.nlm.nih.gov/pubmed/32391800 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 4 %P e15516 %T Machine Learning Models for the Prediction of Postpartum Depression: Application and Comparison Based on a Cohort Study %A Zhang,Weina %A Liu,Han %A Silenzio,Vincent Michael Bernard %A Qiu,Peiyuan %A Gong,Wenjie %+ XiangYa School of Public Health, Central South University, 238 Shangmayuanling Lane Xiangya Road, Kaifu District, Changsha, 410005, China, 86 13607445252, gongwenjie@csu.edu.cn %K depression %K postpartum %K machine learning %K support vector machine %K random forest %K prediction model %D 2020 %7 30.4.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Postpartum depression (PPD) is a serious public health problem. Building a predictive model for PPD using data during pregnancy can facilitate earlier identification and intervention. Objective: The aims of this study are to compare the effects of four different machine learning models using data during pregnancy to predict PPD and explore which factors in the model are the most important for PPD prediction. Methods: Information on the pregnancy period from a cohort of 508 women, including demographics, social environmental factors, and mental health, was used as predictors in the models. The Edinburgh Postnatal Depression Scale score within 42 days after delivery was used as the outcome indicator. Using two feature selection methods (expert consultation and random forest-based filter feature selection [FFS-RF]) and two algorithms (support vector machine [SVM] and random forest [RF]), we developed four different machine learning PPD prediction models and compared their prediction effects. Results: There was no significant difference in the effectiveness of the two feature selection methods in terms of model prediction performance, but 10 fewer factors were selected with the FFS-RF than with the expert consultation method. The model based on SVM and FFS-RF had the best prediction effects (sensitivity=0.69, area under the curve=0.78). In the feature importance ranking output by the RF algorithm, psychological elasticity, depression during the third trimester, and income level were the most important predictors. Conclusions: In contrast to the expert consultation method, FFS-RF was important in dimension reduction. When the sample size is small, the SVM algorithm is suitable for predicting PPD. In the prevention of PPD, more attention should be paid to the psychological resilience of mothers. %M 32352387 %R 10.2196/15516 %U http://medinform.jmir.org/2020/4/e15516/ %U https://doi.org/10.2196/15516 %U http://www.ncbi.nlm.nih.gov/pubmed/32352387 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e14940 %T Mediation Effect of Suicide-Related Social Media Use Behaviors on the Association Between Suicidal Ideation and Suicide Attempt: Cross-Sectional Questionnaire Study %A Liu,Xingyun %A Huang,Jiasheng %A Yu,Nancy Xiaonan %A Li,Qing %A Zhu,Tingshao %+ Institute of Psychology, Chinese Academy of Sciences, No 16, Lincui Road, Beijing, , China, 86 15010965509, tszhu@psych.ac.cn %K suicidal ideation %K suicide %K attempted %K social media %K suicide-related social media use behaviors %D 2020 %7 28.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A limited number of studies have examined the differences in suicide-related social media use behaviors between suicide ideators and suicide attempters or have sought to elucidate how these social media usage behaviors contributed to the transition from suicidal ideation to suicide attempt. Objective: Suicide attempts can be acquired through suicide-related social media use behaviors. This study aimed to propose 3 suicide-related social media use behaviors (ie, attending to suicide information, commenting on or reposting suicide information, or talking about suicide) based on social cognitive theory, which proposes that successive processes governing behavior transition include attentional, retention, production, and motivational processes. Methods: We aimed to examine the mediating role of suicide-related social media use behaviors in Chinese social media users with suicidal risks. A sample of 569 Chinese social media users with suicidal ideation completed measures on suicidal ideation, suicide attempt, and suicide-related social media use behaviors. Results: The results demonstrated that suicide attempters showed a significantly higher level of suicidal ideation (t563.64=5.04; P<.001; two-tailed) and more suicide-related social media use behaviors, which included attending to suicide information (t567=1.94; P=.05; two-tailed), commenting on or reposting suicide information (t567=2.12; P=.03; two-tailed), or talking about suicide (t542.22=5.12; P<.001; two-tailed). Suicidal ideation also affected suicide attempts through the mediational chains. Conclusions: Our findings thus support the social cognitive theory, and there are implications for population-based suicide prevention that can be achieved by identifying behavioral signals. %M 32343249 %R 10.2196/14940 %U http://www.jmir.org/2020/4/e14940/ %U https://doi.org/10.2196/14940 %U http://www.ncbi.nlm.nih.gov/pubmed/32343249 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 4 %P e17071 %T Temporal Associations of Daily Changes in Sleep and Depression Core Symptoms in Patients Suffering From Major Depressive Disorder: Idiographic Time-Series Analysis %A Lorenz,Noah %A Sander,Christian %A Ivanova,Galina %A Hegerl,Ulrich %+ Research Centre of the German Depression Foundation, Goerdelerring 9, Leipzig, 04109, Germany, 49 341 2238740, noah.lorenz@medizin.uni-leipzig.de %K depression %K sleep %K time series %K idiographic %K self-management %D 2020 %7 23.4.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a strong link between sleep and major depression; however, the causal relationship remains unclear. In particular, it is unknown whether changes in depression core symptoms precede or follow changes in sleep, and whether a longer or shorter sleep duration is related to improvements of depression core symptoms. Objective: The aim of this study was to investigate temporal associations between sleep and depression in patients suffering from major depressive disorder using an idiographic research approach. Methods: Time-series data of daily sleep assessments (time in bed and total sleep time) and self-rated depression core symptoms for an average of 173 days per patient were analyzed in 22 patients diagnosed with recurrent major depressive disorder using a vector autoregression model. Granger causality tests were conducted to test for possible causality. Impulse response analysis and forecast error variance decomposition were performed to quantify the temporal mutual impact of sleep and depression. Results: Overall, 11 positive and 5 negative associations were identified between time in bed/total sleep time and depression core symptoms. Granger analysis showed that time in bed/total sleep time caused depression core symptoms in 9 associations, whereas this temporal order was reversed for the other 7 associations. Most of the variance (10%) concerning depression core symptoms could be explained by time in bed. Changes in sleep or depressive symptoms of 1 SD had the greatest impact on the other variable in the following 2 to 4 days. Conclusions: Longer rather than shorter bedtimes were associated with more depression core symptoms. However, the temporal orders of the associations were heterogeneous. %M 32324147 %R 10.2196/17071 %U http://mental.jmir.org/2020/4/e17071/ %U https://doi.org/10.2196/17071 %U http://www.ncbi.nlm.nih.gov/pubmed/32324147 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17330 %T Patients’ Perspective on Mental Health Specialist Video Consultations in Primary Care: Qualitative Preimplementation Study of Anticipated Benefits and Barriers %A Bleyel,Caroline %A Hoffmann,Mariell %A Wensing,Michel %A Hartmann,Mechthild %A Friederich,Hans-Christoph %A Haun,Markus W %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, Heidelberg, D-69120, Germany, 49 622156 ext 38396, markus.haun@med.uni-heidelberg.de %K telemedicine %K remote consultation %K implementation %K primary health care %K mental health services %K thematic analysis %K integrated behavioral health %K health services research %D 2020 %7 20.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Due to limited access to specialist services, most patients with common mental disorders (depression or anxiety, or both) usually receive treatment in primary care. More recently, innovative technology-based care models (eg, video consultations) have been proposed to facilitate access to specialist services. Against this background, the PROVIDE (Improving Cross-Sectoral Collaboration Between Primary and Psychosocial Care: An Implementation Study on Video Consultations) project aims to improve the provision of psychosocial care through implementing video consultations integrated into routine primary care. Objective: From the patients’ perspective, this qualitative preimplementation study explored (1) anticipated benefits from and (2) barriers to implementing mental health specialist video consultations embedded in primary care services and (3) prerequisites for interacting with therapists via video consultations. Methods: Using a purposive (ie, stratified) sampling strategy, we recruited 13 patients from primary care practices and a tertiary care hospital (psychosomatic outpatient clinic) for one-off semistructured interviews. In a computer-assisted thematic analysis, we inductively (bottom-up) derived key themes concerning the practicability of mental health specialist video consultations. To validate our results, we discussed our findings with the interviewees as part of a systematic member checking. Results: Overall, we derived 3 key themes and 10 subthemes. Participants identified specific benefits in 2 areas: the accessibility of mental health specialist care (shorter waiting times: 11/13, 85%; lower threshold for seeking specialist mental health care: 6/13, 46%; shorter travel distances: 3/13, 23%); and the environment in primary care (familiar travel modalities, premises, and employees: 5/13, 38%). The main barriers to the implementation of mental health video consultations from the patients’ perspective were the lack of face-to-face contact (13/13, 100%) and technical challenges (12/13, 92%). Notably, participants’ prerequisites for interacting with therapists (12/13, 92%) did not seem to differ much from those concerning face-to-face contacts. Conclusions: Mental health service users mostly welcomed mental health specialist video consultations in primary care. Taking a pragmatic stance, service users, who are often frustrated about uncoordinated care, particularly valued the embedment of the consultations in the familiar environment of the primary care practice. With respect to interventional studies and implementation, our findings underscore the need to minimize technical disruptions during video consultations and to ensure optimal resemblance to face-to-face settings (eg, by training therapists in consistently reacting to nonverbal cues). Trial Registration: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one %M 32310139 %R 10.2196/17330 %U http://www.jmir.org/2020/4/e17330/ %U https://doi.org/10.2196/17330 %U http://www.ncbi.nlm.nih.gov/pubmed/32310139 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 4 %P e16398 %T A Web- and Mobile-Based Intervention for Comorbid, Recurrent Depression in Patients With Chronic Back Pain on Sick Leave (Get.Back): Pilot Randomized Controlled Trial on Feasibility, User Satisfaction, and Effectiveness %A Schlicker,Sandra %A Baumeister,Harald %A Buntrock,Claudia %A Sander,Lasse %A Paganini,Sarah %A Lin,Jiaxi %A Berking,Matthias %A Lehr,Dirk %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen, 91052, Germany, 49 91318567564, Sandra.Schlicker@fau.de %K pilot project %K low back pain %K depressive disorder %K mental health %K sick leave %D 2020 %7 15.4.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Chronic back pain (CBP) is linked to a higher prevalence and higher occurrence of major depressive disorder (MDD) and can lead to reduced quality of life. Unfortunately, individuals with both CBP and recurrent MDD are underidentified. Utilizing health care insurance data may provide a possibility to better identify this complex population. In addition, internet- and mobile-based interventions might enhance the availability of existing treatments and provide help to those highly burdened individuals. Objective: This pilot randomized controlled trial investigated the feasibility of recruitment via the health records of a German health insurance company. The study also examined user satisfaction and effectiveness of a 9-week cognitive behavioral therapy and Web- and mobile-based guided self-help intervention Get.Back in CBP patients with recurrent MDD on sick leave compared with a waitlist control condition. Methods: Health records from a German health insurance company were used to identify and recruit participants (N=76) via invitation letters. Study outcomes were measured using Web-based self-report assessments at baseline, posttreatment (9 weeks), and a 6-month follow-up. The primary outcome was depressive symptom severity (Center for Epidemiological Studies–Depression); secondary outcomes included anxiety (Hamilton Anxiety and Depression Scale), quality of life (Assessment of Quality of Life), pain-related variables (Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and pain intensity), and negative effects (Inventory for the Assessment of Negative Effects of Psychotherapy). Results: The total enrollment rate with the recruitment strategy used was 1.26% (76/6000). Participants completed 4.8 modules (SD 2.6, range 0-7) of Get.Back. The overall user satisfaction was favorable (mean Client Satisfaction Questionnaire score=24.5, SD 5.2). Covariance analyses showed a small but statistically significant reduction in depressive symptom severity in the intervention group (n=40) at posttreatment compared with the waitlist control group (n=36; F1,76=3.62, P=.03; d=0.28, 95% CI −0.17 to 0.74). Similar findings were noted for the reduction of anxiety symptoms (F1,76=10.45; P=.001; d=0.14, 95% CI −0.31 to 0.60) at posttreatment. Other secondary outcomes were nonsignificant (.06≤P≤.44). At the 6-month follow-up, the difference between the groups with regard to reduction in depressive symptom severity was no longer statistically significant (F1,76=1.50, P=.11; d=0.10, 95% CI −0.34 to 0.46). The between-group difference in anxiety at posttreatment was maintained to follow-up (F1,76=2.94, P=.04; d=0.38, 95% CI −0.07 to 0.83). There were no statistically significant differences across groups regarding other secondary outcomes at the 6-month follow-up (.08≤P≤.42). Conclusions: These results suggest that participants with comorbid depression and CBP on sick leave may benefit from internet- and mobile-based interventions, as exemplified with the positive user satisfaction ratings. The recruitment strategy via health insurance letter invitations appeared feasible, but more research is needed to understand how response rates in untreated individuals with CBP and comorbid depression can be increased. Trial Registration: German Clinical Trials Register DRKS00010820; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010820. %M 32293577 %R 10.2196/16398 %U http://mental.jmir.org/2020/4/e16398/ %U https://doi.org/10.2196/16398 %U http://www.ncbi.nlm.nih.gov/pubmed/32293577 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 6 %N 1 %P e16476 %T Use of Mental Health Apps by Patients With Breast Cancer in the United States: Pilot Pre-Post Study %A Chow,Philip I %A Showalter,Shayna L %A Gerber,Matthew %A Kennedy,Erin M %A Brenin,David %A Mohr,David C %A Lattie,Emily G %A Gupta,Alisha %A Ocker,Gabrielle %A Cohn,Wendy F %+ Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA, United States, 1 4349245401, philip.i.chow@gmail.com %K breast cancer %K mental health %K mHealth %D 2020 %7 15.4.2020 %9 Original Paper %J JMIR Cancer %G English %X Background: Nearly half of the patients with breast cancer experience clinically significant mental distress within the first year of receiving their cancer diagnosis. There is an urgent need to identify scalable and cost-efficient ways of delivering empirically supported mental health interventions to patients with breast cancer. Objective: The aim of this study was to evaluate the feasibility of in-clinic recruitment for a mobile phone app study and to evaluate the usability and preliminary impact of a suite of mental health apps (IntelliCare) with phone coaching on psychosocial distress symptoms in patients recently diagnosed with breast cancer. Methods: This pilot study adopted a within-subject, 7-week pre-post study design. A total of 40 patients with breast cancer were recruited at a US National Cancer Institute–designated clinical cancer center. Self-reported distress (Patient Health Questionnaire-4) and mood symptoms (Patient-Reported Outcomes Measurement Information System depression and anxiety scales) were assessed at baseline and postintervention. App usability was assessed at postintervention. Results: The minimum recruitment threshold was met. There was a significant decrease in general distress symptoms, as well as symptoms of depression and anxiety, from baseline to postintervention. Overall, participants reported high levels of ease of app use and learning. Scores for app usefulness and satisfaction were reinforced by some qualitative feedback suggesting that tailoring the apps more for patients with breast cancer could enhance engagement. Conclusions: There is a dire need for scalable, supportive interventions in cancer. The results from this study inform how scalable mobile phone–delivered programs with additional phone support can be used to support patients with breast cancer. International Registered Report Identifier (IRRID): RR2-10.2196/11452 %M 32293570 %R 10.2196/16476 %U http://cancer.jmir.org/2020/1/e16476/ %U https://doi.org/10.2196/16476 %U http://www.ncbi.nlm.nih.gov/pubmed/32293570 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17011 %T Mobile Health for Perinatal Depression and Anxiety: Scoping Review %A Hussain-Shamsy,Neesha %A Shah,Amika %A Vigod,Simone N %A Zaheer,Juveria %A Seto,Emily %+ Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 416 978 4326, neesha.hussainshamsy@mail.utoronto.ca %K mental health %K depression %K anxiety %K pregnancy %K postpartum %K smartphone %K mobile phone %K text message %K mHealth %D 2020 %7 13.4.2020 %9 Review %J J Med Internet Res %G English %X Background: The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers. Objective: This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work. Methods: Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded. Results: A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies. Conclusions: Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth. %M 32281939 %R 10.2196/17011 %U http://www.jmir.org/2020/4/e17011/ %U https://doi.org/10.2196/17011 %U http://www.ncbi.nlm.nih.gov/pubmed/32281939 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e15164 %T Gamified Mobile Computerized Cognitive Behavioral Therapy for Japanese University Students With Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Yokomitsu,Kengo %A Irie,Tomonari %A Sekiguchi,Mayu %A Shimizu,Ayako %A Matsuoka,Hirofumi %A Merry,Sally Nicola %A Stasiak,Karolina %+ College of Comprehensive Psychology, Ritsumeikan University, 2-150 Iwakura-cho, Ibaraki, Osaka, 567-8570, Japan, 81 72 665 2490, k-yoko@fc.ritsumei.ac.jp %K SPARX %K Japan %K university students %K depressive symptoms %D 2020 %7 7.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence shows that computerized self-help interventions are effective for reducing symptoms of depression. One such intervention, SPARX, is a gamified mobile computerized cognitive behavioral therapy (cCBT) developed for adolescents in New Zealand, which was shown to be as effective as usual care for young people with mild-to-moderate symptoms of depression. However, gamified cCBT has not yet been tested in Japan. Objective: This trial is designed to investigate whether a Japanese-adapted version of SPARX improves depressive symptoms in Japanese university students with mild-to-moderate depressive symptoms. Methods: In this 7-week, multicenter, stratified, parallel-group, superiority randomized trial, participants will be allocated to either a treatment condition (SPARX) or a wait-list control condition. SPARX is a fully automated program, which will be delivered to the mobile phone or tablet device of the participants. SPARX is designed as an interactive fantasy game to guide the user through seven modules that teach key CBT strategies. All participants will be recruited from universities via advertisements on online bulletin boards, the campus newspaper, and posters. Participants in the treatment condition will use the SPARX program weekly. The primary outcome is the reduction of depressive symptoms (using Patient Health Questionnaires-9) measured at baseline and weekly: once after the 7-week intervention and once at a 1-month follow-up. Secondary outcomes include satisfaction with the program and satisfaction with life, measured by the Satisfaction With Life Scale; positive and negative moods, measured by the Profile of Mood States Second Edition; social functioning, measured by the EuroQol Instrument; rumination, measured by the Ruminative Responses Scale; and coping, measured by the Brief Coping Orientation to Problem Experienced Inventory. Results: This study received funding from The Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, and obtained institutional review board approval in September 2019. Data collection began in April 2019. Conclusions: Results of this trial may provide further evidence for the efficacy of gamified cCBT for the treatment of depression and, specifically, provide support for using SPARX with Japanese university students. Trial Registration: Japan Primary Registries Network UMIN000034354; https://tinyurl.com/uu7xd77 International Registered Report Identifier (IRRID): DERR1-10.2196/15164 %M 32254045 %R 10.2196/15164 %U https://www.researchprotocols.org/2020/4/e15164 %U https://doi.org/10.2196/15164 %U http://www.ncbi.nlm.nih.gov/pubmed/32254045 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e17767 %T Efficacy of the Digital Therapeutic Mobile App BioBase to Reduce Stress and Improve Mental Well-Being Among University Students: Randomized Controlled Trial %A Ponzo,Sonia %A Morelli,Davide %A Kawadler,Jamie M %A Hemmings,Nicola Rose %A Bird,Geoffrey %A Plans,David %+ Initiative in the Digital Economy, Department of Science, Innovation, Technology, and Entrepreneurship, University of Exeter, Stocker Road, Exeter, EX4 4PY, United Kingdom, 44 7527016574, D.Plans@exeter.ac.uk %K anxiety %K depression %K mobile apps %K biofeedback %K mental health %K mobile phones %K technology %D 2020 %7 6.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: University students in the United Kingdom are experiencing increasing levels of anxiety. A program designed to increase awareness of one’s present levels of well-being and suggest personalized health behaviors may reduce anxiety and improve mental well-being in students. The efficacy of a digital version of such a program, providing biofeedback and therapeutic content based on personalized well-being metrics, is reported here. Objective: The aim of this study was to test the efficacy and sustained effects of using a mobile app (BioBase) and paired wearable device (BioBeam), compared with a waitlist control group, on anxiety and well-being in university students with elevated levels of anxiety and stress. Methods: The study employed a randomized, waitlist-controlled trial with assessments at baseline, 2 weeks, postintervention (4 weeks), and follow-up (6 weeks). Participants were eligible if they were current full-time undergraduate students and (1) at least 18 years of age, (2) scored >14 points on the Depression, Anxiety, and Stress Scale-21 items (DASS-21) stress subscale or >7 points on the DASS-21 anxiety subscale, (3) owned an iOS mobile phone, (4) did not have any previous psychiatric or neurological conditions, (6) were not pregnant at the time of testing, and (7) were able to read and understand English. Participants were encouraged to use BioBase daily and complete at least one course of therapeutic content. A P value ≤.05 was considered statistically significant. Results: We found that a 4-week intervention with the BioBase program significantly reduced anxiety and increased perceived well-being, with sustained effects at a 2-week follow-up. Furthermore, a significant reduction in depression levels was found following the 4-week usage of BioBase. Conclusions: This study shows the efficacy of a biofeedback digital intervention in reducing self-reported anxiety and increasing perceived well-being in UK university students. Results suggest that digital mental health interventions could constitute a novel approach to treat stress and anxiety in students, which could be combined or integrated with existing therapeutic pathways. Trial Registration: Open Science Framework (OSF.io) 2zd45; https://osf.io/2zd45/ %M 31926063 %R 10.2196/17767 %U https://mhealth.jmir.org/2020/4/e17767 %U https://doi.org/10.2196/17767 %U http://www.ncbi.nlm.nih.gov/pubmed/31926063 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 4 %P e14278 %T Critical Predictors for the Early Detection of Conversion From Unipolar Major Depressive Disorder to Bipolar Disorder: Nationwide Population-Based Retrospective Cohort Study %A Hu,Ya-Han %A Chen,Kuanchin %A Chang,I-Chiu %A Shen,Cheng-Che %+ Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, No. 600, Sec 2, Shixian Road, West District, Chiayi City, 60090, Taiwan, 886 52359630, pures1000@yahoo.com.tw %K major depressive disorder %K bipolar disorder %K National Health Insurance Database %K data mining %K classification and regression tree %D 2020 %7 3.4.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD in the initial stage, which may later contribute to treatment failure. Previous studies indicated that a high proportion of patients diagnosed with MDD will develop bipolar disorder over time. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in patients with MDD. Objective: In this population-based study, our aim was to investigate the rate and risk factors of a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow-up. Furthermore, a risk stratification model was developed for MDD-to-bipolar disorder conversion. Methods: We conducted a retrospective cohort study involving patients who were newly diagnosed with MDD between January 1, 2000, and December 31, 2004, by using the Taiwan National Health Insurance Research Database. All patients with depression were observed until (1) diagnosis of bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All patients with depression were divided into the following two groups, according to whether bipolar disorder was diagnosed during the follow-up period: converted group and nonconverted group. Six groups of variables within the first 6 months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, disorder severity, and psychotropic use, were extracted and were included in a classification and regression tree (CART) analysis to generate a risk stratification model for MDD-to-bipolar disorder conversion. Results: Our study enrolled 2820 patients with MDD. During the follow-up period, 536 patients were diagnosed with bipolar disorder (conversion rate=19.0%). The CART method identified five variables (kinds of antipsychotics used within the first 6 months of enrollment, kinds of antidepressants used within the first 6 months of enrollment, total psychiatric outpatient visits, kinds of benzodiazepines used within one visit, and use of mood stabilizers) as significant predictors of the risk of bipolar disorder conversion. This risk CART was able to stratify patients into high-, medium-, and low-risk groups with regard to bipolar disorder conversion. In the high-risk group, 61.5%-100% of patients with depression eventually developed bipolar disorder. On the other hand, in the low-risk group, only 6.4%-14.3% of patients with depression developed bipolar disorder. Conclusions: The CART method identified five variables as significant predictors of bipolar disorder conversion. In a simple two- to four-step process, these variables permit the identification of patients with low, intermediate, or high risk of bipolar disorder conversion. The developed model can be applied to routine clinical practice for the early diagnosis of bipolar disorder. %M 32242821 %R 10.2196/14278 %U https://medinform.jmir.org/2020/4/e14278 %U https://doi.org/10.2196/14278 %U http://www.ncbi.nlm.nih.gov/pubmed/32242821 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15033 %T Assessing Real-Time Moderation for Developing Adaptive Mobile Health Interventions for Medical Interns: Micro-Randomized Trial %A NeCamp,Timothy %A Sen,Srijan %A Frank,Elena %A Walton,Maureen A %A Ionides,Edward L %A Fang,Yu %A Tewari,Ambuj %A Wu,Zhenke %+ Department of Statistics, University of Michigan, 1085 South University Ave, Ann Arbor, MI, 48109, United States, 1 7346474820, tnecamp@umich.edu %K mobile health %K digital health %K smartphone %K mobile phone %K wearable devices %K ecological momentary assessment %K depression %K mood %K physical activity %K sleep %K moderator variables %D 2020 %7 31.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Individuals in stressful work environments often experience mental health issues, such as depression. Reducing depression rates is difficult because of persistently stressful work environments and inadequate time or resources to access traditional mental health care services. Mobile health (mHealth) interventions provide an opportunity to deliver real-time interventions in the real world. In addition, the delivery times of interventions can be based on real-time data collected with a mobile device. To date, data and analyses informing the timing of delivery of mHealth interventions are generally lacking. Objective: This study aimed to investigate when to provide mHealth interventions to individuals in stressful work environments to improve their behavior and mental health. The mHealth interventions targeted 3 categories of behavior: mood, activity, and sleep. The interventions aimed to improve 3 different outcomes: weekly mood (assessed through a daily survey), weekly step count, and weekly sleep time. We explored when these interventions were most effective, based on previous mood, step, and sleep scores. Methods: We conducted a 6-month micro-randomized trial on 1565 medical interns. Medical internship, during the first year of physician residency training, is highly stressful, resulting in depression rates several folds higher than those of the general population. Every week, interns were randomly assigned to receive push notifications related to a particular category (mood, activity, sleep, or no notifications). Every day, we collected interns’ daily mood valence, sleep, and step data. We assessed the causal effect moderation by the previous week’s mood, steps, and sleep. Specifically, we examined changes in the effect of notifications containing mood, activity, and sleep messages based on the previous week’s mood, step, and sleep scores. Moderation was assessed with a weighted and centered least-squares estimator. Results: We found that the previous week’s mood negatively moderated the effect of notifications on the current week’s mood with an estimated moderation of −0.052 (P=.001). That is, notifications had a better impact on mood when the studied interns had a low mood in the previous week. Similarly, we found that the previous week’s step count negatively moderated the effect of activity notifications on the current week’s step count, with an estimated moderation of −0.039 (P=.01) and that the previous week’s sleep negatively moderated the effect of sleep notifications on the current week’s sleep with an estimated moderation of −0.075 (P<.001). For all three of these moderators, we estimated that the treatment effect was positive (beneficial) when the moderator was low, and negative (harmful) when the moderator was high. Conclusions: These findings suggest that an individual’s current state meaningfully influences their receptivity to mHealth interventions for mental health. Timing interventions to match an individual’s state may be critical to maximizing the efficacy of interventions. Trial Registration: ClinicalTrials.gov NCT03972293; http://clinicaltrials.gov/ct2/show/NCT03972293 %M 32229469 %R 10.2196/15033 %U http://www.jmir.org/2020/3/e15033/ %U https://doi.org/10.2196/15033 %U http://www.ncbi.nlm.nih.gov/pubmed/32229469 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e18047 %T Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial %A Lindqvist,Karin %A Mechler,Jakob %A Carlbring,Per %A Lilliengren,Peter %A Falkenström,Fredrik %A Andersson,Gerhard %A Johansson,Robert %A Edbrooke-Childs,Julian %A Dahl,Hanne-Sofie J %A Lindert Bergsten,Katja %A Midgley,Nick %A Sandell,Rolf %A Thorén,Agneta %A Topooco,Naira %A Ulberg,Randi %A Philips,Björn %+ Department of Psychology, Stockholm University, SE-106 91, Stockholm, Sweden, 46 (0)8 16 20 10, bjorn.philips@psychology.su.se %K depressive disorder %K adolescents %K psychodynamic %K internet-based treatment %K treatment outcome %K mobile phone %D 2020 %7 30.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments. Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents. Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment. Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules. Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254 %M 32224489 %R 10.2196/18047 %U http://www.jmir.org/2020/3/e18047/ %U https://doi.org/10.2196/18047 %U http://www.ncbi.nlm.nih.gov/pubmed/32224489 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16547 %T Experiences of Internet-Based Stepped Care in Individuals With Cancer and Concurrent Symptoms of Anxiety and Depression: Qualitative Exploration Conducted Alongside the U-CARE AdultCan Randomized Controlled Trial %A Hauffman,Anna %A Alfonsson,Sven %A Igelström,Helena %A Johansson,Birgitta %+ Department of Immunology, Genetics and Pathology, Section of Experimental and Clinical Oncology, Uppsala University, Akademiska University Hospital ing 100 D, Uppsala, SE-751 85, Sweden, 46 18 611 00 00, anna.hauffman@igp.uu.se %K internet-based stepped care %K internet-based interactive health communication application %K internet-based intervention %K telemedicine %K patient portals %K oncology nursing %K self care %K psychoeducation %D 2020 %7 30.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Individuals with newly diagnosed cancer may experience impaired health in several aspects and often have a large need for information and support. About 30% will experience symptoms of anxiety and depression, with varying needs of knowledge and support. Despite this, many of these patients lack appropriate support. Internet-based support programs may offer a supplement to standard care services, but must be carefully explored from a user perspective. Objective: The purpose of this study was to explore the participants’ perceptions of the relevance and benefits of an internet-based stepped care program (iCAN-DO) targeting individuals with cancer and concurrent symptoms of anxiety and depression. Methods: We performed a qualitative study with an inductive approach, in which we used semistructured questions to interview 15 individuals using iCAN-DO. We analyzed the interviews using content analysis. Results: The analysis found 17 subcategories regarding the stepped care intervention, resulting in 4 categories. Participants described the need for information as large and looked upon finding information almost as a survival strategy when receiving the cancer diagnosis. iCAN-DO was seen as a useful, reliable source of information and support. It was used as a complement to standard care and as a means to inform next of kin. Increased knowledge was a foundation for continued processing of participants’ own feelings. The optimal time to gain access to iCAN-DO would have been when being informed of the diagnosis. The most common denominator was feeling acknowledged and supported, but with a desire for further adaptation of the system to each individual’s own situation and needs. Conclusions: Users saw the internet-based stepped care program as safe and reliable and used it as a complement to standard care. Similar interventions may gain from more personalized contents, being integrated into standard care, or using symptom tracking to adjust the contents. Offering this type of program close to diagnosis may provide benefits to users. Trial Registration: ClincalTrials.gov NCT-01630681; https://clinicaltrials.gov/ct2/show/NCT01630681 %M 32224483 %R 10.2196/16547 %U http://www.jmir.org/2020/3/e16547/ %U https://doi.org/10.2196/16547 %U http://www.ncbi.nlm.nih.gov/pubmed/32224483 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17282 %T Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study %A Jin,Haomiao %A Wu,Shinyi %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 2138216441, haomiaoj@usc.edu %K depression %K diabetes mellitus %K comorbidity %K screening %K primary care %K health information technology %K mobile health %K text messaging %K patient reported outcome measures %D 2020 %7 26.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: SMS text messaging is an inexpensive, private, and scalable technology-mediated assessment mode that can alleviate many barriers faced by the safety net population to receive depression screening. Some existing studies suggest that technology-mediated assessment encourages self-disclosure of sensitive health information such as depressive symptoms while other studies show the opposite effect. Objective: This study aimed to evaluate the validity of using SMS text messaging to screen depression and related conditions, including anxiety and functional disability, in a low-income, culturally diverse safety net primary care population. Methods: This study used a randomized design with 4 study groups that permuted the order of SMS text messaging and the gold standard interview (INTW) assessment. The participants for this study were recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial (DCAT). Depression was screened by using the 2-item and 8-item Patient Health Questionnaire (PHQ-2 and PHQ-8, respectively). Anxiety was screened by using the 2-item Generalized Anxiety Disorder scale (GAD-2), and functional disability was assessed by using the Sheehan Disability Scale (SDS). Participants chose to take up the assessment in English or Spanish. Internal consistency and test-retest reliability were evaluated by using Cronbach alpha and intraclass correlation coefficient (ICC), respectively. Concordance was evaluated by using an ICC, a kappa statistic, an area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. A regression analysis was conducted to examine the association between the participant characteristics and the differences in the scores between the SMS text messaging and INTW assessment modes. Results: Overall, 206 participants (average age 57.1 [SD 9.18] years; females: 119/206, 57.8%) were enrolled. All measurements except the SMS text messaging–assessed PHQ-2 showed Cronbach alpha values ≥.70, indicating acceptable to good internal consistency. All measurements except the INTW-assessed SDS had ICC values ≥0.75, indicating good to excellent test-retest reliability. For concordance, the PHQ-8 had an ICC of 0.73 and AUROC of 0.93, indicating good concordance. The kappa statistic, sensitivity, and specificity for major depression (PHQ-8 ≥8) were 0.43, 0.60, and 0.86, respectively. The concordance of the shorter PHQ-2, GAD-2, and SDS scales was poor to fair. The regression analysis revealed that a higher level of personal depression stigma was associated with reporting higher SMS text messaging–assessed PHQ-8 and GAD-2 scores than the INTW-assessed scores. The analysis also determined that the differences in the scores were associated with marital status and personality traits. Conclusions: Depression screening conducted using the longer PHQ-8 scale via SMS text messaging demonstrated good internal consistency, test-retest reliability, and concordance with the gold standard INTW assessment mode. However, care must be taken when deploying shorter scales via SMS text messaging. Further regression analysis supported that a technology-mediated assessment, such as SMS text messaging, may create a private space with less pressure from the personal depression stigma and therefore encourage self-disclosure of depressive symptoms. Trial Registration: ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 International Registered Report Identifier (IRRID): RR2-10.2196/12392 %M 32213473 %R 10.2196/17282 %U http://www.jmir.org/2020/3/e17282/ %U https://doi.org/10.2196/17282 %U http://www.ncbi.nlm.nih.gov/pubmed/32213473 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15312 %T Brief Web-Based Intervention for Depression: Randomized Controlled Trial on Behavioral Activation %A Jelinek,Lena %A Arlt,Sönke %A Moritz,Steffen %A Schröder,Johanna %A Westermann,Stefan %A Cludius,Barbara %+ Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany, 49 407410 ext 58087, ljelinek@uke.de %K affective disorders %K depressive symptoms %K brief psychotherapy %K internet %K world wide web %D 2020 %7 26.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions have been shown to be effective for the treatment of depression. However, interventions are often complex and include a variety of elements, making it difficult to identify the most effective component(s). Objective: The aim of this pilot study was to shed light on mechanisms in the online treatment of depression by comparing a single-module, fully automated intervention for depression (internet-based behavioral activation [iBA]) to a nonoverlapping active control intervention and a nonactive control group. Methods: We assessed 104 people with at least mild depressive symptoms (Patient Health Questionnaire-9, >4) via the internet at baseline (t0) and 2 weeks (t1) and 4 weeks (t2) later. After the t0 assessment, participants were randomly allocated to one of three groups: (1) iBA (n=37), (2) active control using a brief internet-based mindfulness intervention (iMBI, n=32), or (3) care as usual (CAU, n=35). The primary outcome was improvement in depressive symptoms, as measured using the Patient Health Questionnaire-9. Secondary parameters included changes in activity, dysfunctional attitudes, and quality of life Results: While groups did not differ regarding the change in depression from t0 to t1 (ηp2=.007, P=.746) or t0 to t2 (ηp2=.008, P=.735), iBA was associated with a larger decrease in dysfunctional attitudes from t0 to t2 in comparison to CAU (ηp2=.053, P=.04) and a larger increase in activity from t0 to t1 than the pooled control groups (ηp2=.060, P=.02). A change in depression from t0 to t2 was mediated by a change in activity from t0 to t1. At t1, 22% (6/27) of the participants in the iBA group and 12% (3/25) of the participants in the iMBI group indicated that they did not use the intervention. Conclusions: Although we did not find support for the short-term efficacy of the single-module iBA regarding depression, long-term effects are still conceivable, potentially initiated by changes in secondary outcomes. Future studies should use a longer intervention and follow-up interval. Trial Registration: DKRS (#DRKS00011562) %M 32213470 %R 10.2196/15312 %U http://www.jmir.org/2020/3/e15312/ %U https://doi.org/10.2196/15312 %U http://www.ncbi.nlm.nih.gov/pubmed/32213470 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15824 %T The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial %A Gómez Penedo,Juan Martín %A Babl,Anna Margarete %A grosse Holtforth,Martin %A Hohagen,Fritz %A Krieger,Tobias %A Lutz,Wolfgang %A Meyer,Björn %A Moritz,Steffen %A Klein,Jan Philipp %A Berger,Thomas %+ Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, Bern, 3012, Switzerland, 41 31 631 5424, jmgomezpenedo@gmail.com %K internet interventions %K guidance %K alliance %K Working Alliance Inventory for Guided Internet Intervention %K only interventions %K tasks and goals %K bond %D 2020 %7 24.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. Objective: The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. Methods: A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. Results: We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). Conclusions: The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats. %M 32207689 %R 10.2196/15824 %U https://www.jmir.org/2020/3/e15824 %U https://doi.org/10.2196/15824 %U http://www.ncbi.nlm.nih.gov/pubmed/32207689 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 3 %P e14860 %T Three Decades of Internet- and Computer-Based Interventions for the Treatment of Depression: Protocol for a Systematic Review and Meta-Analysis %A Moshe,Isaac %A Terhorst,Yannik %A Cuijpers,Pim %A Cristea,Ioana %A Pulkki-Råback,Laura %A Sander,Lasse %+ Department of Rehabilitation Psychology and Psychotherapy, University of Freiburg, Engelbergerstrasse 41, Freiburg, 79085, Germany, 49 761 203 3049, lasse.sander@psychologie.uni-freiburg.de %K depression %K internet-based interventions %K meta-analysis %K review %D 2020 %7 24.3.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is one of the leading causes of disability worldwide. Internet- and computer-based interventions (IBIs) have been shown to provide effective, scalable forms of treatment. More than 100 controlled trials and a growing number of meta-analyses published over the past 30 years have demonstrated the efficacy of IBIs in reducing symptoms in the short and long term. Despite the large body of research, no comprehensive review or meta-analysis has been conducted to date that evaluates how the effectiveness of IBIs has evolved over time. Objective: This systematic review and meta-analysis aims to evaluate whether there has been a change in the effectiveness of IBIs on the treatment of depression over the past 30 years and to identify potential variables moderating the effect size. Methods: A sensitive search strategy will be executed across the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO. Data extraction and evaluation will be conducted by two independent researchers. Risk of bias will be assessed. A multilevel meta-regression model will be used to analyze the data and estimate effect size. Results: The search was completed in mid-2019. We expect the results to be submitted for publication in early 2020. Conclusions: The year 2020 will mark 30 years since the first paper was published on the use of IBIs for the treatment of depression. Despite the large and rapidly growing body of research in the field, evaluations of effectiveness to date are missing the temporal dimension. This review will address that gap and provide valuable analysis of how the effectiveness of interventions has evolved over the past three decades; which participant-, intervention-, and study-related variables moderate changes in effectiveness; and where research in the field may benefit from increased focus. Trial Registration: PROSPERO CRD42019136554; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=136554 International Registered Report Identifier (IRRID): PRR1-10.2196/14860 %M 32207695 %R 10.2196/14860 %U http://www.researchprotocols.org/2020/3/e14860/ %U https://doi.org/10.2196/14860 %U http://www.ncbi.nlm.nih.gov/pubmed/32207695 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15172 %T The Effectiveness of a Guided Internet-Based Tool for the Treatment of Depression and Anxiety in Pregnancy (MamaKits Online): Randomized Controlled Trial %A Heller,Hanna M %A Hoogendoorn,Adriaan W %A Honig,Adriaan %A Broekman,Birit F P %A van Straten,Annemieke %+ Department of Psychiatry, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, 1081 HV, Netherlands, 31 204440196, hm.heller@amsterdamumc.nl %K pregnancy %K depression %K anxiety %K internet %K pregnancy outcome %K treatment %D 2020 %7 23.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Pregnant women with symptoms of depression or anxiety often do not receive adequate treatment. In view of the high incidence of these symptoms in pregnancy and their impact on pregnancy outcomes, getting treatment is of the utmost importance. A guided internet self-help intervention may help to provide more women with appropriate treatment. Objective: This study aimed to examine the effectiveness of a guided internet intervention (MamaKits online) for pregnant women with moderate to severe symptoms of anxiety or depression. Assessments took place before randomization (T0), post intervention (T1), at 36 weeks of pregnancy (T2), and 6 weeks postpartum (T3). We also explored effects on perinatal child outcomes 6 weeks postpartum. Methods: This randomized controlled trial included pregnant women (<30 weeks) with depressive symptoms above threshold (ie, Center for Epidemiological Studies Depression scale [CES-D] >16) or anxiety above threshold (ie, Hospital Anxiety and Depression Scale-Anxiety subscale [HADS-A] >8) or both of them. Participants were recruited via general media and flyers in prenatal care waiting rooms or via obstetricians and midwives. After initial assessment, women were randomized to (1) MamaKits online in addition to treatment as usual or (2) treatment as usual (control condition). MamaKits online is a 5-week guided internet intervention based on problem solving treatment. Guidance was was provided by trained students pursuing a Master's in Psychology. Outcomes were based on a Web-based self-report. Women in the control condition were allowed to receive the intervention after the last assessment (6 weeks postpartum). Results: Of the 159 included women, 79 were randomized to MamaKits online, 47% (79/37) of whom completed the intervention. Both groups showed a substantial decrease in affective symptoms on the CES-D, HADS-A, and Edinburgh Postnatal Depression Scale over time. In the intervention group, affective symptoms decreased more than that in the control group, but between-group effect sizes were small to medium (Cohen d at T3=0.45, 0.21, and 0.23 for the 3 questionnaires, respectively) and statistically not significant. Negative perinatal child outcomes did not differ between the 2 groups (χ21=0.1; P=.78). Completer analysis revealed no differences in outcome between the treatment completers and the control group. The trial was terminated early for reasons of futility based on the results of an interim analysis, which we performed because of inclusion problems. Conclusions: Our study did show a significant reduction in affective symptoms in both groups, but the differences in reduction of affective symptoms between the intervention and control groups were not significant. There were also no differences in perinatal child outcomes. Future research should examine for which women these interventions might be effective or if changes in the internet intervention might make the intervention more effective. Trial Registration: Netherlands Trial Register NL4162; https://tinyurl.com/sdckjek %M 32202505 %R 10.2196/15172 %U http://www.jmir.org/2020/3/e15172/ %U https://doi.org/10.2196/15172 %U http://www.ncbi.nlm.nih.gov/pubmed/32202505 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e14842 %T Digital Cognitive Behavioral Therapy for Insomnia for Adolescents With Mental Health Problems: Feasibility Open Trial %A Cliffe,Bethany %A Croker,Abigail %A Denne,Megan %A Smith,Jacqueline %A Stallard,Paul %+ Department of Health, University of Bath, 1 West, Claverton Down, Bath, BA2 7AY, United Kingdom, 44 01225 388388, p.stallard@bath.ac.uk %K insomnia %K internet-based intervention %K cognitive therapy %K mental health %D 2020 %7 3.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown. Objective: This open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS). Methods: A total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi. Results: Average baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005). Conclusions: Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health. International Registered Report Identifier (IRRID): RR2-10.2196/11324 %M 32134720 %R 10.2196/14842 %U https://mental.jmir.org/2020/3/e14842 %U https://doi.org/10.2196/14842 %U http://www.ncbi.nlm.nih.gov/pubmed/32134720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e16105 %T Evaluating the Effect of Daily Diary Instructional Phrases on Respondents’ Recall Time Frames: Survey Experiment %A Stone,Arthur A %A Wen,Cheng K Fred %A Schneider,Stefan %A Junghaenel,Doerte U %+ Center for Self-Report Science and Center for Economic and Social Research, University of Southern California, 635 Downey Way 405H, Los Angeles, CA, 90089, United States, 1 2138212894, chengkuw@usc.edu %K end-of-day dairy %K daily diary study %K recall time frame %D 2020 %7 21.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Daily diaries are extensively used for examining participants’ daily experience in behavioral and medical science. However, little attention is paid to whether participants recall their experiences within the time frames prescribed by the task. Objective: This study aimed to describe survey respondents’ self-reported recall time frames and to evaluate the impact of different daily diary items on respondents’ reported affective states. Methods: In this study, 577 participants completed a mood survey with one of the following 4 time frame instructions: (1) today, (2) since waking up today, (3) during the last 24 hours, or (4) in the last day. They were also asked to indicate the periods they considered when answering these items and to recall the instructional phrases associated with the items. Results: Almost all participants in the today (141/146, 96.6%) and since waking up today (136/145, 93.8%) conditions reported using periods consistent with our expectations, whereas a lower proportion was observed in the during the last 24 hours (100/145, 69.0%) condition. A diverse range of responses was observed in the in the last day condition. Furthermore, the instructions influenced the levels of some self-reported affects, although exploratory analyses were not able to identify the mechanism underlying this finding. Conclusions: Overall, these results indicate that today and since waking up today are the most effective instructional phrases for inquiring about daily experience and that investigators should use caution when using the other 2 instructional phrases. %M 32130129 %R 10.2196/16105 %U http://www.jmir.org/2020/2/e16105/ %U https://doi.org/10.2196/16105 %U http://www.ncbi.nlm.nih.gov/pubmed/32130129 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e15520 %T An Eight-Week, Web-Based Mindfulness Virtual Community Intervention for Students’ Mental Health: Randomized Controlled Trial %A Ahmad,Farah %A El Morr,Christo %A Ritvo,Paul %A Othman,Nasih %A Moineddin,Rahim %A , %+ School of Health Policy and Management, York University, Stong 350, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 4167362100 ext 22053, Elmorr@yorku.ca %K mindfulness %K CBT %K depression %K anxiety %K students %K universities %K randomized controlled trial %K Canada %D 2020 %7 18.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Innovative interventions are needed to address the increasing mental health needs of university students. Given the demonstrated anxiolytic and antidepressant benefits of mindfulness training, we developed an 8-week, Web-based Mindfulness Virtual Community (MVC) intervention informed by cognitive behavioral therapy (CBT) constructs. Objective: This study investigated the efficacy of the MVC intervention in reducing symptoms of depression, anxiety, and stress among undergraduate students in Toronto, Canada. The secondary outcomes included quality of life, life satisfaction, and mindfulness. Methods: The first 4 weeks of the full MVC intervention (F-MVC) comprised: (1) 12 video-based modules with psycho-education on students’ preidentified stressful topics and topically applied mindfulness practice; (2) anonymous peer-to-peer discussion forums; and (3) anonymous, group-based, professionally guided, 20-min live videoconferences. The second 4 weeks of F-MVC involved access only to video-based modules. The 8-week partial MVC (P-MVC) comprised 12 video-based modules. A randomized controlled trial was conducted with 4 parallel arms: F-MVC, P-MVC, waitlist control (WLC), and group-based face-to-face CBT; results for the latter group are presented elsewhere. Students recruited through multiple strategies consented and were randomized: WLC=40; F-MVC=40, P-MVC=39; all learned about allocation after consenting. The online surveys at baseline (T1), 4 weeks (T2), and 8 weeks (T3) included the Patient Health Questionnaire-9 item, Beck Anxiety Inventory, Perceived Stress Scale, Quality of Life Scale, Brief Multi-Dimensional Students Life Satisfaction Scale, and Five-Facet Mindfulness Questionnaire. Analyses employed generalized estimation equation methods with AR(1) covariance structures and were adjusted for possible confounders (gender, age, birth country, paid work, unpaid work, physical activities, self-rated health, and mental health counseling access). Results: Of the 113 students who provided T1 data, 28 were males and 85 were females with a mean age of 24.8 years. Participants in F-MVC (n=39), P-MVC (n=35), and WLC (n=39) groups were similar in sociodemographic characteristics at T1. At T3 follow-up, per adjusted comparisons, there were statistically significant reductions in depression scores for F-MVC (score change −4.03; P<.001) and P-MVC (score change −4.82; P<.001) when compared with WLC. At T3, there was a statistically significant reduction in anxiety scores only for P-MVC (score change −7.35; P=.01) when compared with WLC. There was a statistically significant reduction in scores for perceived stress for both F-MVC (score change −5.32; P<.001) and P-MVC (score change −5.61; P=.005) compared with WLC. There were statistically significant changes at T3 for quality of life and mindfulness for F-MVC and P-MVC vs WLC but not for life satisfaction. Conclusions: Internet-based mindfulness CBT–based interventions, such as F-MVC and P-MVC, can result in significant reductions in symptoms of depression, anxiety, and stress in a student population. Future research with a larger sample from multiple universities would more precisely test generalizability. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN92827275; https://www.isrctn.com/ISRCTN92827275 %M 32074061 %R 10.2196/15520 %U https://mental.jmir.org/2020/2/e15520 %U https://doi.org/10.2196/15520 %U http://www.ncbi.nlm.nih.gov/pubmed/32074061 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e16715 %T Effect of a WeChat-Based Intervention (Run4Love) on Depressive Symptoms Among People Living With HIV in China: Randomized Controlled Trial %A Guo,Yan %A Hong,Y Alicia %A Cai,Weiping %A Li,Linghua %A Hao,Yuantao %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Chengbo %A Liu,Cong %A Li,Yiran %A Zhu,Mengting %A Zeng,Yu %A Penedo,Frank J %+ Department of Health Administration and Policy, College of Health and Human Services, George Mason University, 4400 University Dr MS 1J3, Fairfax, VA, United States, 1 7039931929, yhong22@gmu.edu %K HIV %K depression %K mHealth %K WeChat %K randomized controlled trial %D 2020 %7 11.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: People living with HIV (PLWH) have high rates of depressive symptoms. However, only a few effective mental health interventions exist for this vulnerable population. Objective: The aim of this study was to assess the efficacy of a WeChat-based intervention, Run4Love, with a randomized controlled trial among 300 people living with HIV and depression (PLWHD) in China. Methods: We recruited PLWH from the HIV outpatient clinic in South China. Participants were screened based on the Center for Epidemiologic Studies-Depression (CES-D) scale. Those who scored 16 or higher were eligible to participate. A total of 300 eligible patients were enrolled. After obtaining informed consent from the participants, completion of a baseline survey, and collection of participants’ hair samples for measuring cortisol, the participants were randomly assigned to an intervention or a control group in a 1:1 ratio. The intervention group received the Run4Love program, delivered via the popular social media app WeChat. Cognitive behavioral stress management courses and weekly reminders of exercise were delivered in a multimedia format. Participants’ progress was monitored with timely and tailored feedback. The control group received usual care and a brochure on nutrition for PLWH. Data were collected at 3, 6, and 9 months. The primary outcome was depression, which was measured by a validated instrument. Results: Participants in the intervention and control groups were comparable at baseline; about 91.3% (139/150), 88.3% (132/150), and 86.7% (130/150) participants completed the 3-, 6-, and 9-month follow-ups, respectively. At the 3-month follow-up, a significant reduction in CES-D score was observed in the intervention group (from 23.9 to 17.7 vs from 24.3 to 23.8; mean difference=−5.77, 95% CI −7.82 to −3.71; P<.001; standard effect size d=0.66). The mean changes in CES-D score from baseline to the 6- and 9-month follow-ups between the two groups remained statistically significant. No adverse events were reported. Conclusions: The WeChat-based mobile health (mHealth) intervention Run4Love significantly reduced depressive symptoms among PLWHD, and the effect was sustained. An app-based mHealth intervention could provide a feasible therapeutic option for many PLWHD in resource-limited settings. Further research is needed to assess generalizability and cost-effectiveness of this intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; http://www.chictr.org.cn/showproj.aspx?proj=21019 (Archived by WebCite at https://www.webcitation.org/78Bw2vouF) %R 10.2196/16715 %U https://www.jmir.org/2020/2/e16715 %U https://doi.org/10.2196/16715 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 2 %P e16267 %T Willingness to Seek Help for Depression in Young African American Adults: Protocol for a Mixed Methods Study %A Bamgbade,Benita A %A Barner,Jamie C %A Ford,Kentya H %A Brown,Carolyn M %A Lawson,William B %A Burdine,Kimberly %+ Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 140 The Fenway, Room R218X, 360 Huntington Avenue, Boston, MA, 02115, United States, 1 6173737973, b.bamgbade@northeastern.edu %K African American young adults %K depression %K willingness to seek help %K Theory of Planned Behavior %D 2020 %7 11.2.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: In the United States, among those living with mental illness, 81% of African American (AA) young adults do not seek treatment compared with 66% of their white counterparts. Although the literature has identified unique culturally related factors that impact help seeking among AAs, limited information exists regarding the development and evaluation of interventions that incorporate these unique factors. Objective: This study aims to describe a study protocol designed to develop a culturally relevant, theory-based, psychoeducational intervention for AA young adults; to determine if exposure to the intervention impacts AA young adults’ willingness to seek help; and to determine whether cultural factors and stigma add to the prediction of willingness to seek help. Methods: The Theory of Planned Behavior (TPB) and Barrera and Castro’s framework for cultural adaptation of interventions were used as guiding frameworks. In stage 1 (information gathering), a literature review and three focus groups were conducted to identify salient cultural beliefs. Using stage 1 results, the intervention was designed in stage 2 (preliminary adaptation design), and in stage 3 (preliminary adaptation tests), the intervention was tested using pretest, posttest, and 3-month follow-up surveys. An experimental, mixed methods, prospective one-group intervention design was employed, and the primary outcomes were participants’ willingness and intention to seek help for depression and actual help-seeking behavior. Results: This study was funded in May 2016 and approved by the University of Texas at Austin institutional review board. Data were collected from November 2016 to March 2016. Of the 103 students who signed up to participate in the study, 70 (67.9%) completed the pre- and posttest surveys. The findings are expected to be submitted for publication in 2020. Conclusions: The findings from this research are expected to improve clinical practice by providing empirical evidence as to whether a culturally relevant psychoeducational intervention is useful for improving help seeking among young AAs. It will also inform future research and intervention development involving the TPB and willingness to seek help by identifying the important factors related to willingness to seek help. Advancing this field of research may facilitate improvements in help-seeking behavior among AA young people and reduce the associated mental health disparities that apparently manifest early on. International Registered Report Identifier (IRRID): DERR1-10.2196/16267 %R 10.2196/16267 %U https://www.researchprotocols.org/2020/2/e16267 %U https://doi.org/10.2196/16267 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 6 %N 1 %P e15750 %T A Novel Mobile Phone App Intervention With Phone Coaching to Reduce Symptoms of Depression in Survivors of Women’s Cancer: Pre-Post Pilot Study %A Chow,Philip I %A Drago,Fabrizio %A Kennedy,Erin M %A Cohn,Wendy F %+ University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA, 22903, United States, 1 9244345401, philip.i.chow@gmail.com %K mobile apps %K mental health %K mHealth %K women %K cancer survivors %D 2020 %7 6.2.2020 %9 Original Paper %J JMIR Cancer %G English %X Background: Psychological distress is a major issue among survivors of women’s cancer who face numerous barriers to accessing in-person mental health treatments. Mobile phone app–based interventions are scalable and have the potential to increase access to mental health care among survivors of women’s cancer worldwide. Objective: This study aimed to evaluate the acceptability and preliminary efficacy of a novel app-based intervention with phone coaching in a sample of survivors of women’s cancer. Methods: In a single-group, pre-post, 6-week pilot study in the United States, 28 survivors of women’s cancer used iCanThrive, a novel app intervention that teaches skills for coping with stress and enhancing well-being, with added phone coaching. The primary outcome was self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale). Emotional self-efficacy and sleep disruption were also assessed at baseline, 6-week postintervention, and 4 weeks after the intervention period. Feedback obtained at the end of the study focused on user experience of the intervention. Results: There were significant decreases in symptoms of depression and sleep disruption from baseline to postintervention. Sleep disruption remained significantly lower at 4-week postintervention compared with baseline. The iCanThrive app was launched a median of 20.5 times over the intervention period. The median length of use was 2.1 min. Of the individuals who initiated the intervention, 87% (20/23) completed the 6-week intervention. Conclusions: This pilot study provides support for the acceptability and preliminary efficacy of the iCanThrive intervention. Future work should validate the intervention in a larger randomized controlled study. It is important to develop scalable interventions that meet the psychosocial needs of different cancer populations. The modular structure of the iCanThrive app and phone coaching could impact a large population of survivors of women’s cancer. %R 10.2196/15750 %U http://cancer.jmir.org/2020/1/e15750/ %U https://doi.org/10.2196/15750 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e16005 %T An Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Clients Referred and Funded by Insurance Companies Compared With Those Who Are Publicly Funded: Longitudinal Observational Study %A Hadjistavropoulos,Heather D %A Peynenburg,Vanessa %A Mehta,Swati %A Adlam,Kelly %A Nugent,Marcie %A Gullickson,Kirsten M %A Titov,Nickolai %A Dear,Blake %+ Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK, , Canada, 1 3065855133, heather.hadjistavropoulos@uregina.ca %K internet %K disability %K depression %K anxiety %K insurance %K cognitive behavior therapy %D 2020 %7 4.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anxiety and depression are leading causes of disability but are often undertreated. Internet-delivered cognitive behavioral therapy (ICBT) improves access to treatment by overcoming barriers to obtaining care. ICBT has been found to be efficacious in research trials and routine care, but there is limited research of ICBT when it is recommended and funded by insurance companies for clients on or recently in receipt of disability benefits or accommodations. Objective: The aim of this study was to examine ICBT engagement, treatment satisfaction, and effectiveness among individuals involved with 2 insurance companies. The 2 samples were benchmarked against published outcomes from a publicly funded (PF) ICBT clinic. Methods: Individuals who were on or recently in receipt of disability benefits and were either insurance company (IC) employees (n=21) or IC plan members (n=19) were referred to ICBT funded by the respective insurance companies. Outcomes were benchmarked against outcomes of ICBT obtained in a PF ICBT clinic, with clients in the clinic divided into those who reported no involvement with insurance companies (n=414) and those who were on short-term disability (n=44). All clients received the same 8-week, therapist-assisted, transdiagnostic ICBT course targeting anxiety and depression. Engagement was assessed using completion rates, log-ins, and emails exchanged. Treatment satisfaction was assessed posttreatment. Depression, anxiety, and disability measures were administered pretreatment, posttreatment, and at 3 months. Results: All samples showed high levels of ICBT engagement and treatment satisfaction. IC employees experienced significant improvement at posttreatment (depression d=0.77; anxiety d=1.13; and disability d=0.91) with outcomes maintained at 3 months. IC plan members, who notably had greater pretreatment disability than the other samples, experienced significant moderate effects at posttreatment (depression d=0.58; anxiety d=0.54; and disability d=0.60), but gains were not maintained at 3 months. Effect sizes at posttreatment in both IC samples were significantly smaller than in the PF sample who reported no insurance benefits (depression d=1.14 and anxiety d=1.30) and the PF sample who reported having short-term disability benefits (depression d=0.95 and anxiety d=1.07). No difference was seen in effect sizes among IC employees and the PF samples on disability. However, IC plan members experienced significantly smaller effects on disability d=0.60) compared with the PF sample with no disability benefits d=0.90) and those on short-term disability benefits d=0.94). Conclusions: Many clients referred and funded by insurance companies were engaged with ICBT and found it acceptable and effective. Results, however, were not maintained among those with very high levels of pretreatment disability. Small sample sizes in the IC groups are a limitation. Directions for research related to ICBT funded by insurance companies have been described. %M 32014840 %R 10.2196/16005 %U https://mental.jmir.org/2020/2/e16005 %U https://doi.org/10.2196/16005 %U http://www.ncbi.nlm.nih.gov/pubmed/32014840 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e15801 %T The Acceptability of Text Messaging to Help African American Women Manage Anxiety and Depression: Cross-Sectional Survey Study %A McCall,Terika %A Schwartz,Todd A %A Khairat,Saif %+ School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC, 27599-7460, United States, 1 9198435413, saif@unc.edu %K African Americans %K women %K anxiety %K depression %K mHealth %K text messaging %D 2020 %7 3.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The rates of mental illness among African American women are comparable with the general population; however, they significantly underutilize mental health services compared with their white counterparts. Previous studies revealed that interventions delivered via text messaging are effective and can be used to increase access to services and resources. More insight into whether or not this modality is acceptable for use to deliver mental health care to help African American women manage anxiety and depression is needed. Objective: This exploratory study aimed to gain insight into the acceptability of using text messaging to help African American women manage anxiety and depression. Methods: A self-administered Web-based survey was launched in June 2018 and closed in August 2018. Eligible participants were African American women (18 years or older) who reside in the United States. Participants were recruited through convenience sampling (eg, email sent via listservs and social media posts). Respondents were provided an anonymous link to the questionnaire. The survey consisted of 53 questions on the following subjects: sociodemographic characteristics, attitudes toward seeking professional psychological help, mobile phone use, and acceptability of using a mobile phone to receive mental health care. Results: The results of this exploratory study (N=101) showed that fewer than half of respondents endorsed the use of text messaging to communicate with a professional to receive help to manage anxiety (49/101, 48.5%) and depression (43/101, 42.6%). Approximately 51.4% (52/101) agreed that having the option to use text messaging to communicate with a professional if they are dealing with anxiety would be helpful. Similarly, 48.5% (49/101) agreed that having the option to use text messaging to communicate with a professional if they are dealing with depression would be helpful. Among participants who agreed that text messaging would be helpful, more than 80% noted being comfortable with its use to receive help for managing anxiety (approximately 86%, 45/52) and depression (approximately 82%, 40/49; highly significant positive association, all P<.001). More than 50% of respondents (56/101, 55.4%) indicated having concerns about using text messaging. No statistically significant associations were found between age and agreement with the use of text messaging to communicate with a professional to receive help for managing anxiety (P=.26) or depression (P=.27). Conclusions: The use of text messaging was not highly endorsed by African American women as an acceptable mode of communication with a professional to help them manage anxiety or depression. Concerns around privacy, confidentiality, and the impersonal feel of communicating about sensitive issues via text messages must be addressed for this modality to be a viable option. The findings of this study demonstrated the need for further research into the use of mobile technology to provide this population with more accessible and convenient options for mental health care. %M 31909720 %R 10.2196/15801 %U https://mental.jmir.org/2020/2/e15801 %U https://doi.org/10.2196/15801 %U http://www.ncbi.nlm.nih.gov/pubmed/31909720 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 7 %N 1 %P e14146 %T Engagement and Usability of a Cognitive Behavioral Therapy Mobile App Compared With Web-Based Cognitive Behavioral Therapy Among College Students: Randomized Heuristic Trial %A Purkayastha,Saptarshi %A Addepally,Siva Abhishek %A Bucher,Sherri %+ Indiana University - Purdue University Indianapolis, 719 Indiana Avenue, WK 119, Indianapolis, IN, , United States, 1 3172740439, saptpurk@iupui.edu %K cognitive behavioral therapy %K mHealth %K mental health %K heuristics %K usability %D 2020 %7 3.2.2020 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Recent evidence in mobile health has demonstrated that, in some cases, apps are an effective way to improve health care delivery. Health care interventions delivered via mobile technology have demonstrated both practicality and affordability. Lately, cognitive behavioral therapy (CBT) interventions delivered over the internet have also shown a meaningful impact on patients with anxiety and depression. Objective: Given the growing proliferation of smartphones and the trust in apps to support improved health behaviors and outcomes, we were interested in comparing a mobile app with Web-based methods for the delivery of CBT. This study aimed to compare the usability of a CBT mobile app called MoodTrainer with an evidence-based website called MoodGYM. Methods: We used convenience sampling to recruit 30 students from a large Midwestern university and randomly assigned them to either the MoodGYM or MoodTrainer user group. The trial period ran for 2 weeks, after which the students completed a self-assessment survey based on Nielsen heuristics. Statistical analysis was performed to compare the survey results from the 2 groups. We also compared the number of modules attempted or completed and the time spent on CBT strategies. Results: The results indicate that the MoodTrainer app received a higher usability score when compared with MoodGYM. Overall, 87% (13/15) of the participants felt that it was easy to navigate through the MoodTrainer app compared with 80% (12/15) of the MoodGYM participants. All MoodTrainer participants agreed that the app was easy to use and did not require any external assistance, whereas only 67% (10/15) had the same opinion for MoodGYM. Furthermore, 67% (10/15) of the MoodTrainer participants found that the navigation controls were easy to locate compared with 80% (12/15) of the MoodGYM participants. MoodTrainer users, on average, completed 2.5 modules compared with 1 module completed by MoodGYM users. Conclusions: As among the first studies to directly compare the usability of a mobile app–based CBT with smartphone-specific features against a Web-based CBT, there is an opportunity for app-based CBT as, at least in our limited trial, it was more usable and engaging. The study was limited to evaluate usability only and not the clinical effectiveness of the app. %M 32012043 %R 10.2196/14146 %U http://humanfactors.jmir.org/2020/1/e14146/ %U https://doi.org/10.2196/14146 %U http://www.ncbi.nlm.nih.gov/pubmed/32012043 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 2 %P e14200 %T Nurse-Delivered Cognitive Behavioral Therapy for Adherence and Depression Among People Living With HIV (the Ziphamandla Study): Protocol for a Randomized Controlled Trial %A Joska,John A %A Andersen,Lena S %A Smith-Alvarez,Rosana %A Magidson,Jessica %A Lee,Jasper S %A O’Cleirigh,Conall %A Safren,Steven A %+ HIV Mental Health Research Unit, Neuroscience Institute, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital, OPD Building, H-Floor, Rm 30, Groote Schuur Drive, Observatory, Cape Town, 7925, South Africa, 27 21 404 2164, John.Joska@uct.ac.za %K major depressive disorder %K cognitive behavioral therapy %K HIV %K medication adherence %K integrated treatment %K task shifting %D 2020 %7 3.2.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is an unmet need to develop effective, feasible, and scalable interventions for poor adherence and depression in persons living with HIV in low- and middle-income countries (LMIC). Objective: This study aims to investigate the effectiveness of a nurse-delivered cognitive behavioral therapy (CBT) intervention for adherence and depression (CBT-AD) among persons living with HIV who are failing first-line antiretroviral therapy (ART) in Cape Town, South Africa. Methods: This study is a 2-arm randomized controlled trial of CBT-AD integrated into the HIV primary care setting in South Africa. A total of 160 participants who did not achieve viral suppression from their first-line ART and have a unipolar depressive mood disorder will be randomized to receive either 8 sessions of CBT-AD or enhanced treatment as usual. Participants will be assessed for major depressive disorder using the Mini International Neuropsychiatric Interview at baseline and 4, 8, and 12 months. The primary outcomes are depression on the Hamilton Depression Scale (HAM-D; as assessed by a blinded assessor) at the 4-month assessment and changes in ART adherence (assessed via real-time, electronic monitoring with Wisepill) between baseline and the 4-month assessment. Secondary outcomes are HIV viral load and CD4 cell count at the 12-month assessment as well as ART adherence (Wisepill) and depression (HAM-D) over follow-up (4-, 8-, and 12-month assessments). Results: The trial commenced in August 2015 and recruitment began in July 2016. Enrollment was completed in June 2019. Conclusions: Results of this study will inform whether an existing intervention (CBT-AD) can be effectively administered in LMIC by nurses with training and ongoing supervision. This will present unique opportunities to further explore the scale-up of a behavioral intervention to enhance ART adherence among persons living with HIV with major depression in a high-prevalence setting, to move toward achieving The Joint United Nations Programme on HIV/AIDS 90-90-90 goals. Trial Registration: ClincialTrials.gov NCT02696824; https://clinicaltrials.gov/ct2/show/NCT02696824 International Registered Report Identifier (IRRID): DERR1-10.2196/14200 %M 32012114 %R 10.2196/14200 %U https://www.researchprotocols.org/2020/2/e14200 %U https://doi.org/10.2196/14200 %U http://www.ncbi.nlm.nih.gov/pubmed/32012114 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e13392 %T A Culturally Adapted Cognitive Behavioral Internet-Delivered Intervention for Depressive Symptoms: Randomized Controlled Trial %A Salamanca-Sanabria,Alicia %A Richards,Derek %A Timulak,Ladislav %A Connell,Sarah %A Mojica Perilla,Monica %A Parra-Villa,Yamilena %A Castro-Camacho,Leonidas %+ SilverCloud Health, Clinical Research & Innovation, 1 Stephen St Upper, Dublin 8, DR9P, Ireland, 353 87 9343678, drichard@tcd.ie %K culture %K internet %K cognitive behavioral therapy %K depressive symptoms %K students %K South America %D 2020 %7 31.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-delivered treatments for depressive symptoms have proved to be successful in high-income Western countries. There may be potential for implementing such treatments in low- and middle-income countries such as Colombia, where access to mental health services is limited. Objective: The objective of this study was to assess the efficacy of a culturally adapted cognitive behavioral internet-delivered treatment for college students with depressive symptoms in Colombia. Methods: This was a randomized controlled trial with a 3-month follow-up. The program comprised seven modules. A total of 214 Colombian college students were recruited. They were assessed and randomly assigned to either the treatment group (n=107) or a waiting list (WL) control group (n=107). Participants received weekly support from a trained supporter. The primary outcome was symptoms of depression, as measured by the Patient Health Questionnaire - 9, and the secondary outcomes were anxiety symptoms assessed by the Generalized Anxiety Disorder questionnaire - 7. Other measures, including satisfaction with treatment, were evaluated after 7 weeks. Results: Research attrition and treatment dropouts were high in this study. On average, 7.6 sessions were completed per user. The mean time spent on the program was 3 hours and 18 min. The linear mixed model (LMM) showed significant effects after treatment (t197.54=−5.189; P<.001) for the treatment group, and these effects were maintained at the 3-month follow-up (t39.62=4.668; P<.001). Within-group results for the treatment group yielded a large effect size post treatment (d=1.44; P<.001), and this was maintained at the 3-month follow-up (d=1.81; P<.001). In addition, the LMM showed significant differences between the groups (t197.54=−5.189; P<.001). The results showed a large effect size between the groups (d=0.91; P<.001). In the treatment group, 76.0% (16/107) achieved a reliable change, compared with 32.0% (17/107) in the WL control group. The difference between groups was statistically significant (X22=10.5; P=.001). Conclusions: This study was the first contribution to investigating the potential impact of a culturally adapted internet-delivered treatment on depressive symptoms for college students as compared with a WL control group in South America. Future research should focus on identifying variables associated both with premature dropout and treatment withdrawal at follow-up. Trial Registration: ClinicalTrials.gov NCT03062215; https://clinicaltrials.gov/ct2/show/NCT03062215 %M 32003749 %R 10.2196/13392 %U https://mental.jmir.org/2020/1/e13392 %U https://doi.org/10.2196/13392 %U http://www.ncbi.nlm.nih.gov/pubmed/32003749 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e16919 %T Web-Based Graphic Representation of the Life Course of Mental Health: Cross-Sectional Study Across the Spectrum of Mood, Anxiety, Eating, and Substance Use Disorders %A Aupperle,Robin Leora %A Paulus,Martin P %A Kuplicki,Rayus %A Touthang,James %A Victor,Teresa %A Yeh,Hung-Wen %A , %A Khalsa,Sahib S %+ Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK, 74136, United States, 1 9137084766, raupperle@laureateinstitute.org %K mental health %K life history %K psychosocial factors %K depression %K anxiety %K substance use disorders %K eating disorders %D 2020 %7 28.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although patient history is essential for informing mental health assessment, diagnosis, and prognosis, there is a dearth of standardized instruments measuring time-dependent factors relevant to psychiatric disorders. Previous research has demonstrated the potential utility of graphical representations, termed life charts, for depicting the complexity of the course of mental illness. However, the implementation of these assessments is limited by the exclusive focus on specific mental illnesses (ie, bipolar disorder) and the lack of intuitive graphical interfaces for data collection and visualization. Objective: This study aimed to develop and test the utility of the Tulsa Life Chart (TLC) as a Web-based, structured approach for obtaining and graphically representing historical information on psychosocial and mental health events relevant across a spectrum of psychiatric disorders. Methods: The TLC interview was completed at baseline by 499 participants of the Tulsa 1000, a longitudinal study of individuals with depressive, anxiety, substance use, or eating disorders and healthy comparisons (HCs). All data were entered electronically, and a 1-page electronic and interactive graphical representation was developed using the Google Visualization Application Programming Interface. For 8 distinct life epochs (periods of approximately 5-10 years), the TLC assessed the following factors: school attendance, hobbies, jobs, social support, substance use, mental health treatment, family structure changes, negative and positive events, and epoch and event-related mood ratings. We used generalized linear mixed models (GLMMs) to evaluate trajectories of each domain over time and by sex, age, and diagnosis, using case examples and Web-based interactive graphs to visualize data. Results: GLMM analyses revealed main or interaction effects of epoch and diagnosis for all domains. Epoch by diagnosis interactions were identified for mood ratings and the number of negative-versus-positive events (all P values <.001), with all psychiatric groups reporting worse mood and greater negative-versus-positive events than HCs. These differences were most robust at different epochs, depending on diagnosis. There were also diagnosis and epoch main effects for substance use, mental health treatment received, social support, and hobbies (P<.001). User experience ratings (each on a 1-5 scale) revealed that participants found the TLC pleasant to complete (mean 3.07, SD 1.26) and useful for understanding their mental health (mean 3.07, SD 1.26), and that they were likely to recommend it to others (mean 3.42, SD 0.85). Conclusions: The TLC provides a structured, Web-based transdiagnostic assessment of psychosocial history relevant for the diagnosis and treatment of psychiatric disorders. Interactive, 1-page graphical representations of the TLC allow for the efficient communication of historical life information that would be useful for clinicians, patients, and family members. %M 32012081 %R 10.2196/16919 %U http://mental.jmir.org/2020/1/e16919/ %U https://doi.org/10.2196/16919 %U http://www.ncbi.nlm.nih.gov/pubmed/32012081 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e12503 %T The Role of Campus Data in Representing Depression Among College Students: Exploratory Research %A Mei,Guang %A Xu,Weisheng %A Li,Li %A Zhao,Zhen %A Li,Hao %A Liu,Wenqing %A Jiao,Yueming %+ Department of Control Science and Engineering, College of Electronic and Information Engineering, Tongji University, Zhixin Bldg, 6th Fl, 4800 Caoan Rd, Shanghai, China, 86 18916087269, lili@tongji.edu.cn %K depression %K mental health %K behavior analysis %D 2020 %7 27.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a predominant feature of many psychological problems leading to extreme behaviors and, in some cases, suicide. Campus information systems keep detailed and reliable student behavioral data; however, whether these data can reflect depression and we know the differences in behavior between depressive and nondepressive students are still research problems. Objective: The purpose of this paper is to investigate the behavioral patterns of depressed students by using multisource campus data and exploring the link between behavioral preferences and depressive symptoms. The campus data described in this paper include basic personal information, academic performance, poverty subsidy, consumption habit, daily routine, library behavior, and meal habit, totaling 121 features. Methods: To identify potentially depressive students, we developed an online questionnaire system based on a standard psychometric instrument, the Zung Self-Rating Depression Scale (SDS). To explore the differences in behavior of depressive and nondepressive students, the Mann-Whitney U test was applied. In order to investigate the behavioral features of different depressive symptoms, factor analysis was used to divide the questionnaire items into different symptom groups and then correlation analysis was employed to study the extrinsic characteristics of each depressive symptom. Results: The correlation between these factors and the features were computed. The results indicated that there were 25 features correlated with either 4 factors or SDS score. The statistical results indicated that depressive students were more likely to fail exams, have poor meal habits, have increased night activities and decreased morning activities, and engage less in social activities (eg, avoiding meal times with friends). Correlation analysis showed that the somatic factor 2 (F4) was negatively correlated with the number of library visits (r=–.179, P<.001), and, compared with other factors, had the greatest impact on students’ daily schedule, eating and social habits. The biggest influencing factor to poor academic performance was cognitive factor F1, and its score was found to be significantly positively correlated with fail rate (r=.185, P=.02). Conclusions: The results presented in this study indicate that campus data can reflect depression and its symptoms. By collecting a large amount of questionnaire data and combining machine learning algorithms, it is possible to realize an identification method of depression and depressive symptoms based on campus data. %M 32012070 %R 10.2196/12503 %U http://mental.jmir.org/2020/1/e12503/ %U https://doi.org/10.2196/12503 %U http://www.ncbi.nlm.nih.gov/pubmed/32012070 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e15321 %T Functionality of Top-Rated Mobile Apps for Depression: Systematic Search and Evaluation %A Qu,Chengcheng %A Sas,Corina %A Daudén Roquet,Claudia %A Doherty,Gavin %+ School of Computing and Communications, Lancaster University, Bailrigg, Lancaster, LA1 4YW, United Kingdom, 44 01524510321, c.qu3@lancaster.ac.uk %K mobile apps %K depression %K review %K ethics %K mHealth %D 2020 %7 24.1.2020 %9 Review %J JMIR Ment Health %G English %X Background: In the last decade, there has been a proliferation of mobile apps claiming to support the needs of people living with depression. However, it is unclear what functionality is actually provided by apps for depression, or for whom they are intended. Objective: This paper aimed to explore the key features of top-rated apps for depression, including descriptive characteristics, functionality, and ethical concerns, to better inform the design of apps for depression. Methods: We reviewed top-rated iPhone OS (iOS) and Android mobile apps for depression retrieved from app marketplaces in spring 2019. We applied a systematic analysis to review the selected apps, for which data were gathered from the 2 marketplaces and through direct use of the apps. We report an in-depth analysis of app functionality, namely, screening, tracking, and provision of interventions. Of the initially identified 482 apps, 29 apps met the criteria for inclusion in this review. Apps were included if they remained accessible at the moment of evaluation, were offered in mental health–relevant categories, received a review score greater than 4.0 out of 5.0 by more than 100 reviewers, and had depression as a primary target. Results: The analysis revealed that a majority of apps specify the evidence base for their intervention (18/29, 62%), whereas a smaller proportion describes receiving clinical input into their design (12/29, 41%). All the selected apps are rated as suitable for children and adolescents on the marketplace, but 83% (24/29) do not provide a privacy policy consistent with their rating. The findings also show that most apps provide multiple functions. The most commonly implemented functions include provision of interventions (24/29, 83%) either as a digitalized therapeutic intervention or as support for mood expression; tracking (19/29, 66%) of moods, thoughts, or behaviors for supporting the intervention; and screening (9/29, 31%) to inform the decision to use the app and its intervention. Some apps include overtly negative content. Conclusions: Currently available top-ranked apps for depression on the major marketplaces provide diverse functionality to benefit users across a range of age groups; however, guidelines and frameworks are still needed to ensure users’ privacy and safety while using them. Suggestions include clearly defining the age of the target population and explicit disclosure of the sharing of users’ sensitive data with third parties. In addition, we found an opportunity for apps to better leverage digital affordances for mitigating harm, for personalizing interventions, and for tracking multimodal content. The study further demonstrated the need to consider potential risks while using depression apps, including the use of nonvalidated screening tools, tracking negative moods or thinking patterns, and exposing users to negative emotional expression content. %M 32012079 %R 10.2196/15321 %U https://mental.jmir.org/2020/1/e15321 %U https://doi.org/10.2196/15321 %U http://www.ncbi.nlm.nih.gov/pubmed/32012079 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14045 %T Tracking and Predicting Depressive Symptoms of Adolescents Using Smartphone-Based Self-Reports, Parental Evaluations, and Passive Phone Sensor Data: Development and Usability Study %A Cao,Jian %A Truong,Anh Lan %A Banu,Sophia %A Shah,Asim A %A Sabharwal,Ashutosh %A Moukaddam,Nidal %+ Menninger Department of Psychiatry, Baylor College of Medicine, 1504 Taub Loop, NPC Bldg, Houston, TX, 77030, United States, 1 7138735270, nidalm@bcm.edu %K SOLVD-Teen and SOLVD-Parent App %K adolescent depression %K smartphone monitoring %K self-evaluation %K parental input %K sensory data %D 2020 %7 24.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression carries significant financial, medical, and emotional burden on modern society. Various proof-of-concept studies have highlighted how apps can link dynamic mental health status changes to fluctuations in smartphone usage in adult patients with major depressive disorder (MDD). However, the use of such apps to monitor adolescents remains a challenge. Objective: This study aimed to investigate whether smartphone apps are useful in evaluating and monitoring depression symptoms in a clinically depressed adolescent population compared with the following gold-standard clinical psychometric instruments: Patient Health Questionnaire (PHQ-9), Hamilton Rating Scale for Depression (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A). Methods: We recruited 13 families with adolescent patients diagnosed with MDD with or without comorbid anxiety disorder. Over an 8-week period, daily self-reported moods and smartphone sensor data were collected by using the Smartphone- and OnLine usage–based eValuation for Depression (SOLVD) app. The evaluations from teens’ parents were also collected. Baseline depression and anxiety symptoms were measured biweekly using PHQ-9, HAM-D, and HAM-A. Results: We observed a significant correlation between the self-evaluated mood averaged over a 2-week period and the biweekly psychometric scores from PHQ-9, HAM-D, and HAM-A (0.45≤|r|≤0.63; P=.009, P=.01, and P=.003, respectively). The daily steps taken, SMS frequency, and average call duration were also highly correlated with clinical scores (0.44≤|r|≤0.72; all P<.05). By combining self-evaluations and smartphone sensor data of the teens, we could predict the PHQ-9 score with an accuracy of 88% (23.77/27). When adding the evaluations from the teens’ parents, the prediction accuracy was further increased to 90% (24.35/27). Conclusions: Smartphone apps such as SOLVD represent a useful way to monitor depressive symptoms in clinically depressed adolescents, and these apps correlate well with current gold-standard psychometric instruments. This is a first study of its kind that was conducted on the adolescent population, and it included inputs from both teens and their parents as observers. The results are preliminary because of the small sample size, and we plan to expand the study to a larger population. %M 32012072 %R 10.2196/14045 %U http://mental.jmir.org/2020/1/e14045/ %U https://doi.org/10.2196/14045 %U http://www.ncbi.nlm.nih.gov/pubmed/32012072 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14623 %T E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial %A Kullberg,Marie-Louise J %A Mouthaan,Joanne %A Schoorl,Maartje %A de Beurs,Derek %A Kenter,Robin Maria Francisca %A Kerkhof,Ad JFM %+ Department of Clinical Psychology, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, Netherlands, 31 715276676, m.j.kullberg@fsw.leidenuniv.nl %K e-learning %K suicide prevention %K digital learning %K skills training %K randomized controlled trial %K undergraduate students %D 2020 %7 22.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied. Objective: This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider’s confidence to have a conversation about suicidal behavior with undergraduate psychology students. Methods: The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program’s effects on guideline adherence, self-evaluated knowledge, and provider’s confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1. Results: Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider’s confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05). Conclusions: An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs. %M 32012076 %R 10.2196/14623 %U http://mental.jmir.org/2020/1/e14623/ %U https://doi.org/10.2196/14623 %U http://www.ncbi.nlm.nih.gov/pubmed/32012076 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14949 %T Assessing the Usability, Appeal, and Impact of a Web-Based Training for Adults Responding to Concerning Posts on Social Media: Pilot Suicide Prevention Study %A Kerr,Bradley %A Stephens,David %A Pham,Daniel %A Ghost Dog,Thomas %A McCray,Celena %A Caughlan,Colbie %A Gaston,Amanda %A Gritton,Jesse %A Jenkins,Marina %A Craig Rushing,Stephanie %A Moreno,Megan A %+ Department of Pediatrics, University of Wisconsin-Madison, 2870 University Avenue, Suite 200, Madison, WI, 53705, United States, 1 6082624440, bkerr@wisc.edu %K community health education %K mental health %K social networking %D 2020 %7 20.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation. Nearly one-third of American Indian and Alaska Native (AI and AN, tribal, or native) youth see concerning messages on social media at least weekly. Objective: To prepare adults to support AI and AN youth who post or view concerning messages, our team designed an hour-long training: Responding to Concerning Posts on Social Media. This study tested the usability, appeal, and impact of the training. Methods: A purposive sample of 70 adults was recruited to participate in the pilot, which included 2 study arms. Arm 1 participants completed a 30-min training video and reviewed accompanying handouts, including the Viewer Care Plan (VCP). The VCP provided a 3-step planning and response tool: (1) Start the Conversation, (2) Listen, Gather Information, and Assess Viewer Experience, and (3) Plan and Act. The intent of the VCP was to support and connect AI and AN youth who either view or post concerning messages on social media to life-saving resources. Those enrolled in arm 2 participated in an additional interactive role-play scenario with a coach that took place after the training, via text message. Participants provided qualitative and quantitative feedback on the training’s relevance, appeal, and utility. Paired t tests were used to assess confidence in addressing concerning posts between pre- and postsurveys. Content analysis of the role-play transcripts was used to assess the quality and completion of the coached role-plays, in relation to the recommended VCP. Results: Altogether, 35 participants finished the training and completed pre- and postsurveys; 22 participants completed the 6-month follow-up survey. Pre-post analyses of differences in means found significant improvement across several efficacy measures, including confidence starting a conversation about social media (P=.003), confidence contacting the person who posted something concerning (P<.001), and confidence recommending support services to youth who view (P=.001) or youth who post concerning messages (P<.001). Similarly, pre- to 6-month analyses found significant positive improvement across multiple measures, including confidence contacting the youth who posted (P<.001), confidence starting a conversation about social media with youth (P=.003), and an increase in the number of experiences recommending resources for youth who viewed concerning social media posts (P=.02). Of the 3 steps of the VCP, the least followed step in coached role-plays was sharing tools and resources, which is a part of the third Plan and Act step. Conclusions: Findings indicate that the Responding to Concerning Posts on Social Media training is a promising tool to prepare adults to intervene and complete the VCP. Additional evaluation with a larger cohort of participants is needed to determine the unique impact of the role-play scenario and changes in mental health referral rates, behaviors, and skills. %M 31958066 %R 10.2196/14949 %U https://mental.jmir.org/2020/1/e14949 %U https://doi.org/10.2196/14949 %U http://www.ncbi.nlm.nih.gov/pubmed/31958066 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e12599 %T Technological State of the Art of Electronic Mental Health Interventions for Major Depressive Disorder: Systematic Literature Review %A Burger,Franziska %A Neerincx,Mark A %A Brinkman,Willem-Paul %+ Delft University of Technology, van Mourik Broekmanweg 6, Delft, 2628XE, Netherlands, 31 0645340352, f.v.burger@tudelft.nl %K eHealth %K major depressive disorder %K technology %K systematic review %D 2020 %7 20.1.2020 %9 Review %J J Med Internet Res %G English %X Background: Electronic mental (e-mental) health care for depression aims to overcome barriers to and limitations of face-to-face treatment. Owing to the high and growing demand for mental health care, a large number of such information and communication technology systems have been developed in recent years. Consequently, a diverse system landscape formed. Objective: This literature review aims to give an overview of this landscape of e-mental health systems for the prevention and treatment of major depressive disorder, focusing on three main research questions: (1) What types of systems exist? (2) How technologically advanced are these systems? (3) How has the system landscape evolved between 2000 and 2017? Methods: Publications eligible for inclusion described e-mental health software for the prevention or treatment of major depressive disorder. Additionally, the software had to have been evaluated with end users and developed since 2000. After screening, 270 records remained for inclusion. We constructed a taxonomy concerning software systems, their functions, how technologized these were in their realization, and how systems were evaluated, and then, we extracted this information from the included records. We define here as functions any component of the system that delivers either treatment or adherence support to the user. For this coding process, an elaborate classification hierarchy for functions was developed yielding a total of 133 systems with 2163 functions. The systems and their functions were analyzed quantitatively, with a focus on technological realization. Results: There are various types of systems. However, most are delivered on the World Wide Web (76%), and most implement cognitive behavioral therapy techniques (85%). In terms of content, systems contain twice as many treatment functions as adherence support functions, on average. Furthermore, autonomous systems, those not including human guidance, are equally as technologized and have one-third less functions than guided ones. Therefore, lack of guidance is neither compensated with additional functions nor compensated by technologizing functions to a greater degree. Although several high-tech solutions could be found, the average system falls between a purely informational system and one that allows for data entry but without automatically processing these data. Moreover, no clear increase in the technological capabilities of systems showed in the field, between 2000 and 2017, despite a marked growth in system quantity. Finally, more sophisticated systems were evaluated less often in comparative trials than less sophisticated ones (OR 0.59). Conclusions: The findings indicate that when developers create systems, there is a greater focus on implementing therapeutic treatment than adherence support. Although the field is very active, as evidenced by the growing number of systems developed per year, the technological possibilities explored are limited. In addition to allowing developers to compare their system with others, we anticipate that this review will help researchers identify opportunities in the field. %M 31958063 %R 10.2196/12599 %U https://www.jmir.org/2020/1/e12599 %U https://doi.org/10.2196/12599 %U http://www.ncbi.nlm.nih.gov/pubmed/31958063 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15188 %T The True Colours Remote Symptom Monitoring System: A Decade of Evolution %A Goodday,Sarah M %A Atkinson,Lauren %A Goodwin,Guy %A Saunders,Kate %A South,Matthew %A Mackay,Clare %A Denis,Mike %A Hinds,Chris %A Attenburrow,Mary-Jane %A Davies,Jim %A Welch,James %A Stevens,William %A Mansfield,Karen %A Suvilehto,Juulia %A Geddes,John %+ Department of Psychiatry, University of Oxford, Warneford Lane, Oxford, OX3 7JX, United Kingdom, 44 (0)1865 618200, sarah.goodday@psych.ox.ac.uk %K symptom assessment %K signs and symptoms %K digital health %K ecological momentary assessment %K mood disorders %D 2020 %7 15.1.2020 %9 Viewpoint %J J Med Internet Res %G English %X The True Colours remote mood monitoring system was developed over a decade ago by researchers, psychiatrists, and software engineers at the University of Oxford to allow patients to report on a range of symptoms via text messages, Web interfaces, or mobile phone apps. The system has evolved to encompass a wide range of measures, including psychiatric symptoms, quality of life, and medication. Patients are prompted to provide data according to an agreed personal schedule: weekly, daily, or at specific times during the day. The system has been applied across a number of different populations, for the reporting of mood, anxiety, substance use, eating and personality disorders, psychosis, self-harm, and inflammatory bowel disease, and it has shown good compliance. Over the past decade, there have been over 36,000 registered True Colours patients and participants in the United Kingdom, with more than 20 deployments of the system supporting clinical service and research delivery. The system has been adopted for routine clinical care in mental health services, supporting more than 3000 adult patients in secondary care, and 27,263 adolescent patients are currently registered within Oxfordshire and Buckinghamshire. The system has also proven to be an invaluable scientific resource as a platform for research into mood instability and as an electronic outcome measure in randomized controlled trials. This paper aimed to report on the existing applications of the system, setting out lessons learned, and to discuss the implications for tailored symptom monitoring, as well as the barriers to implementation at a larger scale. %M 31939746 %R 10.2196/15188 %U https://www.jmir.org/2020/1/e15188 %U https://doi.org/10.2196/15188 %U http://www.ncbi.nlm.nih.gov/pubmed/31939746 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e12516 %T Mobile Health Technology Interventions for Suicide Prevention: Systematic Review %A Melia,Ruth %A Francis,Kady %A Hickey,Emma %A Bogue,John %A Duggan,Jim %A O'Sullivan,Mary %A Young,Karen %+ School of Psychology, National University of Ireland Galway, Arts Millennium Building, Galway, H91 TK33, Ireland, 353 877710431, ruth.melia@hse.ie %K mHealth %K systematic review %D 2020 %7 15.1.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Digital interventions are proposed as one way by which effective treatments for self-harm and suicidal ideation may be improved and their scalability enhanced. Mobile devices offer a potentially powerful medium to deliver evidence-based interventions with greater specificity to the individual when the intervention is needed. The recent proliferation of publicly available mobile apps designed for suicide prevention underlines the need for robust evidence to promote safe practice. Objective: This review aimed to examine the effectiveness of currently available mobile health (mHealth) technology tools in reducing suicide-specific outcomes. Methods: The following databases were searched: Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and relevant sources of gray literature. All published and unpublished randomized controlled trials (RCTs), pseudo-RCTs, and pre-post observational studies that evaluated the effectiveness of mHealth technology in suicide prevention delivered via mobile computing and communication technology were included. Studies were included if they measured at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, and suicidal behavior). A total of 2 review authors independently extracted data and assessed study suitability, in accordance with the Cochrane Collaboration Risk of Bias Tool, on July 31, 2018. Owing to the heterogeneity of outcomes found across studies, results were not amenable for pooled synthesis, and a meta-analysis was not performed. A narrative synthesis of the available research is presented here. Results: A total of 7 studies met criteria for inclusion . Four published articles that reported on the effectiveness of the following mobile phone apps were included: iBobbly, Virtual Hope Box, BlueIce, and Therapeutic Evaluative Conditioning. Results demonstrated some positive impacts for individuals at elevated risk of suicide or self-harm, including reductions in depression, psychological distress, and self-harm and increases in coping self-efficacy. None of the apps evaluated demonstrated the ability to significantly decrease suicidal ideation compared with a control condition. In addition, 3 unpublished and recently completed trials also met criteria for inclusion in the review. Conclusions: Further research is needed to evaluate the efficacy of stand-alone mHealth technology–based interventions in suicide prevention. The small number of studies reported in this review tentatively indicate that such tools may have a positive impact on suicide-specific outcomes. Future mHealth intervention evaluations would benefit from addressing the following 3 main methodological limitations : (1) heterogeneity of outcomes: a lack of standardized measurement of suicide outcomes across studies; (2) ecological validity: the tendency to exclude potential participants because of the elevated suicide risk may reduce generalizability within clinical settings; and (3) app regulation and definition: the lack of a standardized classification system for mHealth intervention type points to the need for better definition of the scope of such technologies to promote safe practice. Trial Registration: PROSPERO CRD42017072899; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72899 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8635 %M 31939744 %R 10.2196/12516 %U https://mhealth.jmir.org/2020/1/e12516 %U https://doi.org/10.2196/12516 %U http://www.ncbi.nlm.nih.gov/pubmed/31939744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e15644 %T Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: Mixed Methods Study %A Zhang,Renwen %A Nicholas,Jennifer %A Knapp,Ashley A %A Graham,Andrea K %A Gray,Elizabeth %A Kwasny,Mary J %A Reddy,Madhu %A Mohr,David C %+ Department of Communication Studies, Northwestern University, 2240 Campus Dr, MTS Program, Evanston, IL, 60208, United States, 1 8479976596, alicezhang@u.northwestern.edu %K mHealth %K mobile apps %K mental health %K engagement %D 2019 %7 20.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: User engagement is key to the effectiveness of digital mental health interventions. Considerable research has examined the clinical outcomes of overall engagement with mental health apps (eg, frequency and duration of app use). However, few studies have examined how specific app use behaviors can drive change in outcomes. Understanding the clinical outcomes of more nuanced app use could inform the design of mental health apps that are more clinically effective to users. Objective: This study aimed to classify user behaviors in a suite of mental health apps and examine how different types of app use are related to depression and anxiety outcomes. We also compare the clinical outcomes of specific types of app use with those of generic app use (ie, intensity and duration of app use) to understand what aspects of app use may drive symptom improvement. Methods: We conducted a secondary analysis of system use data from an 8-week randomized trial of a suite of 13 mental health apps. We categorized app use behaviors through a mixed methods analysis combining qualitative content analysis and principal component analysis. Regression analyses were used to assess the association between app use and levels of depression and anxiety at the end of treatment. Results: A total of 3 distinct clusters of app use behaviors were identified: learning, goal setting, and self-tracking. Each specific behavior had varied effects on outcomes. Participants who engaged in self-tracking experienced reduced depression symptoms, and those who engaged with learning and goal setting at a moderate level (ie, not too much or not too little) also had an improvement in depression. Notably, the combination of these 3 types of behaviors, what we termed “clinically meaningful use,” accounted for roughly the same amount of variance as explained by the overall intensity of app use (ie, total number of app use sessions). This suggests that our categorization of app use behaviors succeeded in capturing app use associated with better outcomes. However, anxiety outcomes were neither associated with specific behaviors nor generic app use. Conclusions: This study presents the first granular examination of user interactions with mental health apps and their effects on mental health outcomes. It has important implications for the design of mobile health interventions that aim to achieve greater user engagement and improved clinical efficacy. %M 31859682 %R 10.2196/15644 %U http://www.jmir.org/2019/12/e15644/ %U https://doi.org/10.2196/15644 %U http://www.ncbi.nlm.nih.gov/pubmed/31859682 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e13911 %T Comparison of YouthCHAT, an Electronic Composite Psychosocial Screener, With a Clinician Interview Assessment for Young People: Randomized Trial %A Thabrew,Hiran %A D'Silva,Simona %A Darragh,Margot %A Goldfinch,Mary %A Meads,Jake %A Goodyear-Smith,Felicity %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Department of Psychological Medicine, University of Auckland, Level 12, Support Block, Auckland Hospital, 2 Park Road, Grafton, Auckland, 1142, New Zealand, 64 21402055, h.thabrew@auckland.ac.nz %K mass screening %K adolescents %K anxiety %K depression %K substance-related disorders %K primary health care %K school health services %K eHealth %D 2019 %7 3.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychosocial problems such as depression, anxiety, and substance abuse are common and burdensome in young people. In New Zealand, screening for such problems is undertaken routinely only with year 9 students in low-decile schools and opportunistically in pediatric settings using a nonvalidated and time-consuming clinician-administered Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety (HEEADSSS) interview. The Youth version, Case-finding and Help Assessment Tool (YouthCHAT) is a relatively new, locally developed, electronic tablet–based composite screener for identifying similar psychosocial issues to HEEADSSS Objective: This study aimed to compare the performance and acceptability of YouthCHAT with face-to-face HEEADSSS assessment among 13-year-old high school students. Methods: A counterbalanced randomized trial of YouthCHAT screening either before or after face-to-face HEEADSSS assessment was undertaken with 129 13-year-old New Zealand high school students of predominantly Māori and Pacific Island ethnicity. Main outcome measures were comparability of YouthCHAT and HEEADSSS completion times, detection rates, and acceptability to students and school nurses. Results: YouthCHAT screening was more than twice as fast as HEEADSSS assessment (mean 8.57 min vs mean 17.22 min; mean difference 8 min 25 seconds [range 6 min 20 seconds to 11 min 10 seconds]; P<.01) and detected more issues overall on comparable domains. For substance misuse and problems at home, both instruments were roughly comparable. YouthCHAT detected significantly more problems with eating or body image perception (70/110, 63.6% vs 25/110, 22.7%; P<.01), sexual health (24/110, 21.8% vs 10/110, 9.1%; P=.01), safety (65/110, 59.1% vs 17/110, 15.5%; P<.01), and physical inactivity (43/110, 39.1% vs 21/110, 19.1%; P<.01). HEEADSSS had a greater rate of detection for a broader set of mental health issues (30/110, 27%) than YouthCHAT (11/110, 10%; P=.001), which only assessed clinically relevant anxiety and depression. Assessment order made no significant difference to the duration of assessment or to the rates of YouthCHAT-detected positive screens for anxiety and depression. There were no significant differences in student acceptability survey results between the two assessments. Nurses identified that students found YouthCHAT easy to answer and that it helped students answer face-to-face questions, especially those of a sensitive nature. Difficulties encountered with YouthCHAT included occasional Wi-Fi connectivity and student literacy issues. Conclusions: This study provides preliminary evidence regarding the shorter administration time, detection rates, and acceptability of YouthCHAT as a school-based psychosocial screener for young people. Although further research is needed to confirm its effectiveness in other age and ethnic groups, YouthCHAT shows promise for aiding earlier identification and treatment of common psychosocial problems in young people, including possible use as part of an annual, school-based, holistic health check. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ACTRN) ACTRN12616001243404p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371422. %M 31793890 %R 10.2196/13911 %U https://www.jmir.org/2019/12/e13911 %U https://doi.org/10.2196/13911 %U http://www.ncbi.nlm.nih.gov/pubmed/31793890 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 12 %P e14119 %T Effects of a 12-Minute Smartphone-Based Mindful Breathing Task on Heart Rate Variability for Students With Clinically Relevant Chronic Pain, Depression, and Anxiety: Protocol for a Randomized Controlled Trial %A Azam,Muhammad Abid %A Latman,Vered Valeria %A Katz,Joel %+ York University, 4700 Keele Street, Toronto, ON, MJ3 1P3, Canada, 1 4163129252, abid.azam1@gmail.com %K mindfulness %K mobile apps %K heart rate variability %K chronic pain %K depression %K anxiety %D 2019 %7 2.12.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mindfulness meditation (MM) is a commonly used psychological intervention for pain, mood, and anxiety conditions, but can be challenging to practice with severe symptoms without proper training. The Mindfulness Meditation app (MMA) is a supportive training tool specifically developed for this study to aid in the practice of mindful breathing using a smartphone. Objective: This study aims to evaluate the psychophysiological effects of the MMA. Specifically, the study will assess parasympathetic functioning using heart rate variability (HRV; primary outcome), pain and mood symptoms, mind-wandering and present moment awareness, and breath focus in groups of undergraduate participants who self-report clinically-relevant symptoms of chronic pain (CP) and depression or anxiety (DA) and condition-free (CF) participants who do not meet either criteria. We hypothesize that use of the MMA by study groups will lead to improved HRV, pain, and mood symptoms compared with groups who do not use the app. Methods: This study is a two-arm randomized controlled trial (RCT) recruiting through a Web-based research participation pool at York University in Toronto, Canada. We are aiming for minimum 60 participants in each of CP, DA, and CF groups. Upon arriving to the laboratory, participants will be prescreened for classification into groups of CP, DA, or CF. Groups will be randomly assigned by a 1:1 ratio to an MMA (MMA+) condition or MM condition without the app (MMA−) after a brief stress induction procedure. In MMA+, participants will practice mindful breathing with a smartphone and press breath or other buttons at the sound of audio tones if their awareness was on breathing or another experience, respectively. HRV and respiration data will be obtained during rest (5 min), stress induction (5 min), and meditation conditions (12 min). Participants will complete psychological self-report inventories before and after the stress induction and after the meditation condition. Separate linear mixed models will be used to examine HRV and self-report inventories comparing groups and treatment conditions. Results: Recruitment for the study began in November 2017 and is expected to be completed in winter of 2019-2020. As of July 2019, 189 participants have been recruited. The study’s main findings are expected to reveal a positive pattern of HRV responses in the CP, DA, and CF groups, such that a significant increase in HRV (P<.05) is detected in those randomized to the MMA+ condition in comparison with those randomized to the MMA− condition. Conclusions: This RCT will contribute to the burgeoning health psychology literature regarding the clinical relevance of HRV in assessment and treatment of psychological and medical conditions. Furthermore, possible ways to inform designs of MM training tools delivered by apps and Web platforms for CP, depression, and anxiety conditions’ treatment will be discussed. Trial Registration: Clinicaltrials.gov NCT03296007; https://clinicaltrials.gov/ct2/show/NCT03296007. International Registered Report Identifier (IRRID): DERR1-10.2196/14119 %M 31789601 %R 10.2196/14119 %U https://www.researchprotocols.org/2019/12/e14119 %U https://doi.org/10.2196/14119 %U http://www.ncbi.nlm.nih.gov/pubmed/31789601 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14728 %T Using Cluster Analysis to Explore Engagement and e-Attainment as Emergent Behavior in Electronic Mental Health %A Sanatkar,Samineh %A Baldwin,Peter Andrew %A Huckvale,Kit %A Clarke,Janine %A Christensen,Helen %A Harvey,Samuel %A Proudfoot,Judy %+ Black Dog Institute, School of Psychiatry, University of New South Wales, Hospital Road, Sydney 2031, , Australia, 61 2 9382 ext 4368, s.sanatkar@unsw.edu.au %K eHealth %K engagement %K adherence %K Web-based intervention %K depression %K anxiety %D 2019 %7 28.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In most e-mental health (eMH) research to date, adherence is defined according to a trial protocol. However, adherence to a study protocol may not completely capture a key aspect of why participants engage with eMH tools, namely, to achieve personal mental health goals. As a consequence, trial attrition reported as non-adherence or dropout may reflect e-attainment, the discontinuation of eMH engagement after personal goals have been met. Clarifying engagement patterns, such as e-attainment, and how these align with mental health trajectories, may help optimize eMH design and implementation science. Objective: This study aimed to use clustering techniques to identify real-world engagement profiles in a community of eMH users and examine if such engagement profiles are associated with different mental health outcomes. The novelty of this approach was our attempt to identify actual user engagement behaviors, as opposed to employing engagement benchmarks derived from a trial protocol. The potential of this approach is to link naturalistic behaviors to beneficial mental health outcomes, which would be especially informative when designing eMH programs for the general public. Methods: Between May 2013 and June 2018, Australian adults (N=43,631) signed up to myCompass, a self-guided eMH program designed to help alleviate mild to moderate symptoms of depression, anxiety, and stress. Recorded usage data included number of logins, frequency of mood tracking, number of started and completed learning activities, and number of tracking reminders set. A subset of users (n=168) completed optional self-assessment mental health questionnaires (Patient Health Questionnaire-9 item, PHQ-9; Generalized Anxiety Disorder Questionnaire-7 item, GAD-7) at registration and at 28 and 56 days after sign-up. Another subset of users (n=861) completed the PHQ-9 and GAD-7 at registration and at 28 days. Results: Two-step cluster analyses revealed 3 distinct usage patterns across both subsamples: moderates, trackers, and super users, signifying differences both in the frequency of use as well as differences in preferences for program functionalities. For both subsamples, repeated measures analysis of variances showed significant decreases over time in PHQ-9 and GAD-7 scores. Time-by-cluster interactions, however, did not yield statistical significance in both subsamples, indicating that clusters did not predict symptom reduction over time. Interestingly, users who completed the self-assessment questionnaires twice had slightly but significantly lower depression and anxiety levels at sign-up compared with users who completed the questionnaires a third time at 56 days. Conclusions: Findings suggested that although users engaged with myCompass in different but measurable ways, those different usage patterns evoked equivalent mental health benefits. Furthermore, the randomized controlled trial paradigm may unintentionally limit the scope of eMH engagement research by mislabeling early mental health goal achievers as dropouts. More detailed and naturalistic approaches to study engagement with eMH technologies may improve program design and, ultimately, program effectiveness. %M 31778115 %R 10.2196/14728 %U http://www.jmir.org/2019/11/e14728/ %U https://doi.org/10.2196/14728 %U http://www.ncbi.nlm.nih.gov/pubmed/31778115 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14729 %T Mechanisms and Effects of a WeChat-Based Intervention on Suicide Among People Living With HIV and Depression: Path Model Analysis of a Randomized Controlled Trial %A Li,Yiran %A Guo,Yan %A Hong,Y Alicia %A Zhu,Mengting %A Zeng,Chengbo %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Yu %A Cai,Weiping %A Li,Linghua %A Liu,Cong %+ Department of Epidemiology and Biostatistics, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, , China, 86 020 87334202, guoy8@mail.sysu.edu.cn %K HIV %K mHealth %K depression %K suicide %D 2019 %7 27.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: People living with HIV and depression have high rates of suicide. Studies of mobile health (mHealth) interventions have shown feasibility, acceptability, and efficacy in improving mental health in people living with HIV and depression. However, few studies have examined the mechanisms and effects of mHealth interventions on suicide. Objective: This study was designed to examine the mechanisms and effects of a WeChat-based intervention, Run4Love, on suicide among people living with HIV and depression in China, while considering perceived stress and depressive symptoms as mediators. Methods: A sample of 300 People living with HIV and depression was recruited from the outpatient clinic of a large HIV or AIDS treatment hospital and was randomized to the Run4Love group or a control group. Data were collected at baseline, 3-, 6-, and 9-month follow-ups. Path analysis modeling, with longitudinal data, was used in data analyses. Results: The Run4Love mHealth intervention had a direct effect on reducing suicide rate at the 6-month follow-up (beta=−.18, P=.02) and indirect effect through reducing perceived stress and depressive symptoms at the 3-month follow-up (beta=−.09, P=.001). A partial mediating effect between perceived stress and depressive symptoms accounted for 33% (–0.09/–0.27) of the total effect. Conclusions: Through path analyses, we understood the mechanisms and effects of an mHealth intervention on suicide prevention. The findings underscored the importance of stress reduction and depression treatment in such a program. We call for more effective suicide prevention, especially mHealth interventions targeting the vulnerable population of people living with HIV and depression. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; http://www.chictr.org.cn/showprojen.aspx?proj=21019 %M 31774411 %R 10.2196/14729 %U https://www.jmir.org/2019/11/e14729 %U https://doi.org/10.2196/14729 %U http://www.ncbi.nlm.nih.gov/pubmed/31774411 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14946 %T Mood Monitoring Over One Year for People With Chronic Obstructive Pulmonary Disease Using a Mobile Health System: Retrospective Analysis of a Randomized Controlled Trial %A Whelan,Maxine E %A Velardo,Carmelo %A Rutter,Heather %A Tarassenko,Lionel %A Farmer,Andrew J %+ Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom, 44 7435330992, maxine.whelan@phc.ox.ac.uk %K pulmonary disease, chronic obstructive %K self-management %K telemedicine %K computers %K handheld %K anxiety %K depression %D 2019 %7 22.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Comorbid anxiety and depression can add to the complexity of managing treatment for people living with chronic obstructive pulmonary disease (COPD). Monitoring mood has the potential to identify individuals who might benefit from additional support and treatment. Objective: We used data from the sElf-management anD support proGrammE (EDGE) trial to examine: (1) the extent to which the mood-monitoring components of a mobile health system for patients with COPD were used by participants; (2) the levels of anxiety and depression symptoms among study participants; (3) the extent to which videos providing advice about coping with low mood were viewed; and (4) the characteristics of participants with differing levels of mood and utilization of mood monitoring. Methods: A total of 107 men and women with a clinical diagnosis of COPD, aged ≥40 years old, were recruited to the intervention arm of the EDGE trial. Participants were invited to complete the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 test every four weeks using a tablet computer. Mood disturbance based on these measures was defined as a score ≥5 on either scale. Participants reporting a mood disturbance were automatically directed (signposted) to a stress or mood management video. Study outcomes included measures of health status, respiratory quality of life, and symptoms of anxiety and depression. Results: Overall, 94 (87.9%) participants completed the 12-month study. A total of 80 participants entered at least one response each month for at least ten months. On average, 16 participants (range 8-38 participants) entered ≥2 responses each month. Of all the participants, 47 (50%) gave responses indicating a mood disturbance. Participants with a mood disturbance score for both scales (n=47) compared with those without (n=20) had lower health status (P=.008), lower quality of life (P=.009), and greater anxiety (P<.001) and increased depression symptoms (P<.001). Videos were viewed by 64 (68%) people over 12 months. Of the 220 viewing visualizations, 70 (34.7%) began after being signposted. Participants signposted to the stress management video (100%; IQR 23.3-100%) watched a greater proportion of it compared to those not signposted (38.4%; IQR 16.0-68.1%; P=.03), whereas duration of viewing was not significantly different for the mood management video. Conclusions: Monitoring of anxiety and depression symptoms for people with COPD is feasible. More than half of trial participants reported scores indicating a mood disturbance during the study. Signposting participants to an advisory video when reporting increased symptoms of a mood disturbance resulted in a longer view-time for the stress management video. The opportunity to elicit measures of mood regularly as part of a health monitoring system could contribute to better care for people with COPD. %M 31755872 %R 10.2196/14946 %U http://mhealth.jmir.org/2019/11/e14946/ %U https://doi.org/10.2196/14946 %U http://www.ncbi.nlm.nih.gov/pubmed/31755872 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14754 %T Use of a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention in a Community Population of Adults With Depression Symptoms: Randomized Controlled Trial %A Schure,Mark B %A Lindow,Janet C %A Greist,John H %A Nakonezny,Paul A %A Bailey,Sandra J %A Bryan,William L %A Byerly,Matthew J %+ Department of Health & Human Development, Montana State University, 305 Herrick Hall, Bozeman, MT, United States, 1 406 994 3248, mark.schure@montana.edu %K internet-based cognitive behavior therapy %K iCBT %K depression symptoms %K rural populations %K RCT %K randomized controlled trial %K CBT %D 2019 %7 18.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms, large differences in their effectiveness exist. Objective: The aim of this study was to evaluate the effectiveness of an iCBT intervention called Thrive, which was designed to enhance engagement when delivered as a fully automated, stand-alone intervention to a rural community population of adults with depression symptoms. Methods: Using no diagnostic or treatment exclusions, 343 adults with depression symptoms were recruited from communities using an open-access website and randomized 1:1 to the Thrive intervention group or the control group. Using self-reports, participants were evaluated at baseline and 4 and 8 weeks for the primary outcome of depression symptom severity and secondary outcome measures of anxiety symptoms, work and social adjustment, psychological resilience, and suicidal ideation. Results: Over the 8-week follow-up period, the intervention group (n=181) had significantly lower depression symptom severity than the control group (n=162; P<.001), with a moderate treatment effect size (d=0.63). Moderate to near-moderate effect sizes favoring the intervention group were observed for anxiety symptoms (P<.001; d=0.47), work/social functioning (P<.001; d=0.39), and resilience (P<.001; d=0.55). Although not significant, the intervention group was 45% less likely than the control group to experience increased suicidal ideation (odds ratio 0.55). Conclusions: These findings suggest that the Thrive intervention was effective in reducing depression and anxiety symptom severity and improving functioning and resilience among a mostly rural community population of US adults. The effect sizes associated with Thrive were generally larger than those of other iCBT interventions delivered as a fully automated, stand-alone intervention. Trial Registration: ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878 %M 31738173 %R 10.2196/14754 %U http://www.jmir.org/2019/11/e14754/ %U https://doi.org/10.2196/14754 %U http://www.ncbi.nlm.nih.gov/pubmed/31738173 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e12814 %T Wearable Technology for High-Frequency Cognitive and Mood Assessment in Major Depressive Disorder: Longitudinal Observational Study %A Cormack,Francesca %A McCue,Maggie %A Taptiklis,Nick %A Skirrow,Caroline %A Glazer,Emilie %A Panagopoulos,Elli %A van Schaik,Tempest A %A Fehnert,Ben %A King,James %A Barnett,Jennifer H %+ Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge, CB25 9TU, United Kingdom, 44 1223 810700 ext 686, Francesca.Cormack@camcog.com %K depression %K cognition %K mood %K mobile health %K mHealth %K mobile apps %K ecological momentary assessment %K digital phenotyping %K digital biomarkers %D 2019 %7 18.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive symptoms are common in major depressive disorder and may help to identify patients who need treatment or who are not experiencing adequate treatment response. Digital tools providing real-time data assessing cognitive function could help support patient treatment and remediation of cognitive and mood symptoms. Objective: The aim of this study was to examine feasibility and validity of a wearable high-frequency cognitive and mood assessment app over 6 weeks, corresponding to when antidepressant pharmacotherapy begins to show efficacy. Methods: A total of 30 patients (aged 19-63 years; 19 women) with mild-to-moderate depression participated in the study. The new Cognition Kit app was delivered via the Apple Watch, providing a high-resolution touch screen display for task presentation and logging responses. Cognition was assessed by the n-back task up to 3 times daily and depressed mood by 3 short questions once daily. Adherence was defined as participants completing at least 1 assessment daily. Selected tests sensitive to depression from the Cambridge Neuropsychological Test Automated Battery and validated questionnaires of depression symptom severity were administered on 3 occasions (weeks 1, 3, and 6). Exploratory analyses examined the relationship between mood and cognitive measures acquired in low- and high-frequency assessment. Results: Adherence was excellent for mood and cognitive assessments (95% and 96%, respectively), did not deteriorate over time, and was not influenced by depression symptom severity or cognitive function at study onset. Analyses examining the relationship between high-frequency cognitive and mood assessment and validated measures showed good correspondence. Daily mood assessments correlated moderately with validated depression questionnaires (r=0.45-0.69 for total daily mood score), and daily cognitive assessments correlated moderately with validated cognitive tests sensitive to depression (r=0.37-0.50 for mean n-back). Conclusions: This study supports the feasibility and validity of high-frequency assessment of cognition and mood using wearable devices over an extended period in patients with major depressive disorder. %M 31738172 %R 10.2196/12814 %U https://mental.jmir.org/2019/11/e12814 %U https://doi.org/10.2196/12814 %U http://www.ncbi.nlm.nih.gov/pubmed/31738172 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e15489 %T Mediators of Intervention Effects on Depressive Symptoms Among People Living With HIV: Secondary Analysis of a Mobile Health Randomized Controlled Trial Using Latent Growth Curve Modeling %A Zhu,Mengting %A Cai,Weiping %A Li,Linghua %A Guo,Yan %A Monroe-Wise,Aliza %A Li,Yiran %A Zeng,Chengbo %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Yu %A Liu,Cong %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhong Shan 2nd Road, Guangzhou, China, 86 1 350 150 2582, guoy8@mail.sysu.edu.cn %K mobile health %K depression %K HIV %K randomized controlled trial %K longitudinal studies %D 2019 %7 15.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although several studies have investigated the effects of mobile health (mHealth) interventions on depression among people living with HIV, few studies have explored mediators of mHealth-based interventions to improve mental health in people living with HIV. Identifying influential mediators may enhance and refine effective components of mHealth interventions to improve mental health of people living with HIV. Objective: This study aimed to examine mediating factors of the effects of a mHealth intervention, Run4Love, designed to reduce depression among people living with HIV using 4 time-point measurement data. Methods: This study used data from a randomized controlled trial of a mHealth intervention among people living with HIV with elevated depressive symptoms in Guangzhou, China. A total of 300 patients were assigned to receive either the mHealth intervention (n=150) or a waitlist control group (n=150) through computer-generated block randomization. Depressive symptoms, coping, and HIV-related stigma were measured at baseline, 3-, 6-, and 9-month follow-ups. The latent growth curve model was used to examine the effects of the intervention on depressive symptoms via potential mediators. Mediating effects were estimated using bias-corrected 95% bootstrapped CIs (BCIs) with resampling of 5000. Results: Enhanced positive coping and reduced HIV-related stigma served as effective treatment mediators in the mHealth intervention. Specially, there was a significant indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of positive coping (beta=–2.86; 95% BCI –4.78 to –0.94). The indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of HIV-related stigma was also statistically significant (beta=–1.71; 95% BCI –3.03 to –0.40). These findings indicated that enhancement of positive coping and reduction of HIV-related stigma were important mediating factors of the mHealth intervention in reducing depression among people living with HIV. Conclusions: This study revealed the underlying mediators of a mHealth intervention to reduce depression among people living with HIV using latent growth curve model and 4 time-point longitudinal measurement data. The study results underscored the importance of improving positive coping skills and mitigating HIV-related stigma in mHealth interventions to reduce depression among people living with HIV. %M 31730042 %R 10.2196/15489 %U http://mhealth.jmir.org/2019/11/e15489/ %U https://doi.org/10.2196/15489 %U http://www.ncbi.nlm.nih.gov/pubmed/31730042 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e12942 %T Public Opinions on Using Social Media Content to Identify Users With Depression and Target Mental Health Care Advertising: Mixed Methods Survey %A Ford,Elizabeth %A Curlewis,Keegan %A Wongkoblap,Akkapon %A Curcin,Vasa %+ Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, United Kingdom, 44 +441273641974, e.m.ford@bsms.ac.uk %K social media %K depression %K mental health %K machine learning %K public opinion %K social license %K survey %D 2019 %7 13.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a common disorder that still remains underdiagnosed and undertreated in the UK National Health Service. Charities and voluntary organizations offer mental health services, but they are still struggling to promote these services to the individuals who need them. By analyzing social media (SM) content using machine learning techniques, it may be possible to identify which SM users are currently experiencing low mood, thus enabling the targeted advertising of mental health services to the individuals who would benefit from them. Objective: This study aimed to understand SM users’ opinions of analysis of SM content for depression and targeted advertising on SM for mental health services. Methods: A Web-based, mixed methods, cross-sectional survey was administered to SM users aged 16 years or older within the United Kingdom. It asked participants about their demographics, their usage of SM, and their history of depression and presented structured and open-ended questions on views of SM content being analyzed for depression and views on receiving targeted advertising for mental health services. Results: A total of 183 participants completed the survey, and 114 (62.3%) of them had previously experienced depression. Participants indicated that they posted less during low moods, and they believed that their SM content would not reflect their depression. They could see the possible benefits of identifying depression from SM content but did not believe that the risks to privacy outweighed these benefits. A majority of the participants would not provide consent for such analysis to be conducted on their data and considered it to be intrusive and exposing. Conclusions: In a climate of distrust of SM platforms’ usage of personal data, participants in this survey did not perceive that the benefits of targeting advertisements for mental health services to individuals analyzed as having depression would outweigh the risks to privacy. Future work in this area should proceed with caution and should engage stakeholders at all stages to maximize the transparency and trustworthiness of such research endeavors. %M 31719022 %R 10.2196/12942 %U http://mental.jmir.org/2019/11/e12942/ %U https://doi.org/10.2196/12942 %U http://www.ncbi.nlm.nih.gov/pubmed/31719022 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e13393 %T Evaluating the Efficacy of Internet-Delivered Cognitive Behavioral Therapy Blended With Synchronous Chat Sessions to Treat Adolescent Depression: Randomized Controlled Trial %A Topooco,Naira %A Byléhn,Sandra %A Dahlström Nysäter,Ellen %A Holmlund,Jenny %A Lindegaard,Johanna %A Johansson,Sanna %A Åberg,Linnea %A Bergman Nordgren,Lise %A Zetterqvist,Maria %A Andersson,Gerhard %+ Department of Behavioural Sciences and Learning, Linköping University, Campus Valla, Linköping, SE-581 83, Sweden, 46 13281000, naira.topooco@liu.se %K adolescent %K depression %K cognitive behavioral therapy %K randomized controlled trial %K internet %K digital health %K technology %K mental health %K text messaging %K instant messaging %D 2019 %7 1.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common and serious problem among adolescents, but few seek or have access to therapy. Internet-delivered cognitive behavioral therapies (ICBTs), developed to increase treatment access, show promise in reducing depression. The inclusion of coach support in treatment is desired and may be needed. Objective: The aim of this study was to determine the efficacy of an ICBT protocol blended with weekly real-time therapist sessions via chat; blended treatment, for adolescent depression, including major depressive episode (MDE). The protocol has previously been evaluated in a controlled study. Methods: In a two-arm randomized controlled trial, adolescents 15 to 19 years of age were recruited through a community setting at the national level in Sweden (n=70) and allocated to either 8 weeks of treatment or to minimal attention control. Depression was assessed at baseline, at posttreatment, and at 12 months following treatment (in the intervention group). The primary outcome was self-reported depression level as measured with the Beck Depression Inventory II at posttreatment. The intervention was offered without the need for parental consent. Results: Over two weeks, 162 adolescents registered and completed the baseline screening. Eligible participants (n=70) were on average 17.5 years of age (SD 1.15), female (96%, 67/70), suffered from MDE (76%, 53/70), had no previous treatment experience (64%, 45/70), and reported guardian(s) to be aware about their depression state (71%, 50/70). The average intervention completion was 74% (11.8 of 16 modules and sessions). Following the treatment, ICBT participants demonstrated a significant decrease in depression symptoms compared with controls (P<.001), corresponding to a large between-group effect (intention-to-treat analysis: d=0.86, 95% CI 0.37-1.35; of completer analysis: d=0.99, 95% CI 0.48-1.51). A significant between-group effect was observed in the secondary depression outcome (P=.003); clinically significant improvement was found in 46% (16/35) of ICBT participants compared with 11% (4/35) in the control group (P=.001). Conclusions: The results are in line with our previous study, further demonstrating that adolescents with depression can successfully be engaged in and experience significant improvement following ICBT blended with therapist chat sessions. Findings on participants’ age and baseline depression severity are of interest in relation to used study methods. Trial Registration: ClinicalTrials.gov NCT02363205; https://clinicaltrials.gov/ct2/show/NCT02363205 %M 31682572 %R 10.2196/13393 %U https://www.jmir.org/2019/11/e13393 %U https://doi.org/10.2196/13393 %U http://www.ncbi.nlm.nih.gov/pubmed/31682572 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e12514 %T Difficulties Encountered by People With Depression and Anxiety on the Web: Qualitative Study and Web-Based Expert Survey %A Bernard,Renaldo %A Sabariego,Carla %A Cieza,Alarcos %+ Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, Department of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, Munich, 81377, Germany, 49 49 89 2180 7822, renaldo.bernard@med.lmu.de %K World Wide Web %K depression %K anxiety %K accessibility %K interview %K persona %K expert study %K eHealth %K usability %K user experience %K facilitators %K barriers %K mental disorders %D 2019 %7 31.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety are the most common mental health conditions, and they were identified as leading contributors to global disability in 2016. People with these conditions rely on Web-based resources as a source of accurate health information, convenient and effective treatment, and essential social support. However, a recent systematic review revealed several potentially limiting difficulties that this group experiences online and also suggested that there is a partial understanding of these difficulties as only difficulties associated with neurocognitive, but not sociocognitive, deficits were identified. Therefore, this study fills this knowledge gap and contributes to a more robust and fuller understanding of the difficulties this group experiences online. Objective: The objective of this study was to identify the difficulties people with depression and anxiety experience when using the Web and the Web activities that are most associated with the experience of difficulties. Methods: The study employed data triangulation using face-to-face semistructured interviews with 21 participants affected by depression and anxiety and a comparison group (7 participants) without mental disorders (study 1) as well as a persona-based expert online survey with 21 mental health practitioners (MHPs) who treated people with depression and anxiety (study 2). Framework analysis for both studies proceeded through 5 stages: (1) familiarization, (2) identifying a thematic framework, (3) indexing, (4) charting, and (5) mapping and interpretation. Results: In study 1, 167 difficulties were identified from the experiences of participants in the depression and anxiety group were discussed within the context of 81 Web activities, services, and features. From these, 4 themes and 12 subthemes describing the difficulties people with depression and anxiety experienced online were identified. Difficulties relating to the subtheme lack of control over access and usage were the most common difficulties experienced by participants in the depression and anxiety group (19/21). Sixteen difficulties identified from the experiences of participants in the comparison group were discussed within the context of 11 Web activities, services, and features. Most participants in the comparison group (6/7) contributed to the subtheme describing difficulties with unexpected and irrelevant content. In study 2, researchers identified 3 themes and 10 subthemes that described the perceived difficulties people with depression and anxiety might experience online as reported by MHPs. Practitioners linked these difficulties with 22 common impairments, limitations in activities of daily life, and diagnostic criteria associated with depression and anxiety. Conclusions: People with depression and anxiety also experience difficulties when using the Web that are related to the sociocognitive deficits associated with their conditions. MHPs have a good awareness of the difficulties that people with depression and anxiety are likely to experience when using the Web. This investigation has contributed to a fuller understanding of these difficulties and provides innovative guidance on how to remove and reduce them for people with depression and anxiety when using the Web. International Registered Report Identifier (IRRID): RR2-10.1007/978-3-319-21006-3_3 %M 31674915 %R 10.2196/12514 %U http://www.jmir.org/2019/10/e12514/ %U https://doi.org/10.2196/12514 %U http://www.ncbi.nlm.nih.gov/pubmed/31674915 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14261 %T Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial %A Kooistra,Lisa Catharine %A Wiersma,Jenneke Elize %A Ruwaard,Jeroen %A Neijenhuijs,Koen %A Lokkerbol,Joran %A van Oppen,Patricia %A Smit,Filip %A Riper,Heleen %+ Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical Center, VU University Medical Center, Postbus 74077, Amsterdam, 1070 BB, Netherlands, 31 204448180, l.kooistra@ggzingeest.nl %K depression %K blended cognitive behavioral therapy %K specialized mental health care %K cost-effectiveness %K randomized controlled trial %D 2019 %7 29.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI −0.05 to 0.19), response to treatment (RD 0.03, 95% CI −0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI −0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI −399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI −659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial Registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-014-0290-z %M 31663855 %R 10.2196/14261 %U http://www.jmir.org/2019/10/e14261/ %U https://doi.org/10.2196/14261 %U http://www.ncbi.nlm.nih.gov/pubmed/31663855 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e13655 %T Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial %A Zwerenz,Rüdiger %A Baumgarten,Carlotta %A Becker,Jan %A Tibubos,Ana %A Siepmann,Martin %A Knickenberg,Rudolf J %A Beutel,Manfred E %+ Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Johannes Gutenberg-University, Untere Zahlbacher Str 8, Mainz, 55131, Germany, 49 61311 75981, ruediger.zwerenz@unimedizin-mainz.de %K depression %K mental health %K internet %K aftercare %K psychotherapy %K psychology, clinical %K inpatients %D 2019 %7 24.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression. Objective: The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up. Methods: Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3). Results: At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (d=0.58) and anxiety (d=0.46) as well as a better quality of life (d=0.43) and self-esteem (d=0.31) than participants of the control group. Nearly 3 times as many participants of the intervention group compared with the control group achieved remission in accordance with less deterioration. The number needed to treat based on the Beck Depression Inventory-II (BDI-II) improved over time (T1: 7.84, T2: 7.09, and T3: 5.12). Significant outcome predictors were BDI at discharge and treatment group. Conclusions: Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists’ concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed. Trial Registration: ClinicalTrials.gov NCT02196896; https://clinicaltrials.gov/ct2/show/NCT02196896. %M 31651403 %R 10.2196/13655 %U https://www.jmir.org/2019/10/e13655 %U https://doi.org/10.2196/13655 %U http://www.ncbi.nlm.nih.gov/pubmed/31651403 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14065 %T Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial %A Bisseling,Else %A Cillessen,Linda %A Spinhoven,Philip %A Schellekens,Melanie %A Compen,Félix %A van der Lee,Marije %A Speckens,Anne %+ Radboudumc for Mindfulness, Department of Psychiatry, Radboud University Medical Center, 966/CvM, Postbus 9101, Nijmegen, 6500HB, Netherlands, 31 243615445, else.bisseling@radboudumc.nl %K therapeutic alliance %K telemedicine %K mindfulness %K cancer %K patient dropouts %D 2019 %7 18.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs. Objective: This study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions. Methods: This study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form. Results: The strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t114=−2.656; P=.01) and an increase in mental well-being (B=.23; t113=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t113=2.261; P=.03). Conclusions: A therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT. Trial Registration: ClinicalTrials.gov NCT02138513; https://clinicaltrials.gov/ct2/show/NCT02138513 %M 31628791 %R 10.2196/14065 %U https://www.jmir.org/2019/10/e14065 %U https://doi.org/10.2196/14065 %U http://www.ncbi.nlm.nih.gov/pubmed/31628791 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e13440 %T A Protocol-Driven, Bedside Digital Conversational Agent to Support Nurse Teams and Mitigate Risks of Hospitalization in Older Adults: Case Control Pre-Post Study %A Bott,Nicholas %A Wexler,Sharon %A Drury,Lin %A Pollak,Chava %A Wang,Victor %A Scher,Kathleen %A Narducci,Sharon %+ Clinical Excellence Research Center, Department of Medicine, Stanford University School of Medicine, 75 Alta Road, Stanford, CA, 94305, United States, 1 650 814 9383, nbott@stanford.edu %K digital health %K older adults %K loneliness %K delirium %K falls %K embodied conversational agent %K chatbot %K relational agent %K information and communication technology %D 2019 %7 17.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Hospitalized older adults often experience isolation and disorientation while receiving care, placing them at risk for many inpatient complications, including loneliness, depression, delirium, and falls. Embodied conversational agents (ECAs) are technological entities that can interact with people through spoken conversation. Some ECAs are also relational agents, which build and maintain socioemotional relationships with people across multiple interactions. This study utilized a novel form of relational ECA, provided by Care Coach (care.coach, inc): an animated animal avatar on a tablet device, monitored and controlled by live health advocates. The ECA implemented algorithm-based clinical protocols for hospitalized older adults, such as reorienting patients to mitigate delirium risk, eliciting toileting needs to prevent falls, and engaging patients in social interaction to facilitate social engagement. Previous pilot studies of the Care Coach avatar have demonstrated the ECA’s usability and efficacy in home-dwelling older adults. Further study among hospitalized older adults in a larger experimental trial is needed to demonstrate its effectiveness. Objective: The aim of the study was to examine the effect of a human-in-the-loop, protocol-driven relational ECA on loneliness, depression, delirium, and falls among diverse hospitalized older adults. Methods: This was a clinical trial of 95 adults over the age of 65 years, hospitalized at an inner-city community hospital. Intervention participants received an avatar for the duration of their hospital stay; participants on a control unit received a daily 15-min visit from a nursing student. Measures of loneliness (3-item University of California, Los Angeles Loneliness Scale), depression (15-item Geriatric Depression Scale), and delirium (confusion assessment method) were administered upon study enrollment and before discharge. Results: Participants who received the avatar during hospitalization had lower frequency of delirium at discharge (P<.001), reported fewer symptoms of loneliness (P=.01), and experienced fewer falls than control participants. There were no significant differences in self-reported depressive symptoms. Conclusions: The study findings validate the use of human-in-the-loop, relational ECAs among diverse hospitalized older adults. %M 31625949 %R 10.2196/13440 %U http://www.jmir.org/2019/10/e13440/ %U https://doi.org/10.2196/13440 %U http://www.ncbi.nlm.nih.gov/pubmed/31625949 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e14149 %T Depression Prediction by Using Ecological Momentary Assessment, Actiwatch Data, and Machine Learning: Observational Study on Older Adults Living Alone %A Kim,Heejung %A Lee,SungHee %A Lee,SangEun %A Hong,Soyun %A Kang,HeeJae %A Kim,Namhee %+ College of Nursing, Yonsei University, Room #603, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3273, hkim80@yuhs.ac %K elderly %K one-person household %K depression %K ecological momentary assessment %K actigraphy %K machine learning %D 2019 %7 16.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although geriatric depression is prevalent, diagnosis using self-reporting instruments has limitations when measuring the depressed mood of older adults in a community setting. Ecological momentary assessment (EMA) by using wearable devices could be used to collect data to classify older adults into depression groups. Objective: The objective of this study was to develop a machine learning algorithm to predict the classification of depression groups among older adults living alone. We focused on utilizing diverse data collected through a survey, an Actiwatch, and an EMA report related to depression. Methods: The prediction model using machine learning was developed in 4 steps: (1) data collection, (2) data processing and representation, (3) data modeling (feature engineering and selection), and (4) training and validation to test the prediction model. Older adults (N=47), living alone in community settings, completed an EMA to report depressed moods 4 times a day for 2 weeks between May 2017 and January 2018. Participants wore an Actiwatch that measured their activity and ambient light exposure every 30 seconds for 2 weeks. At baseline and the end of the 2-week observation, depressive symptoms were assessed using the Korean versions of the Short Geriatric Depression Scale (SGDS-K) and the Hamilton Depression Rating Scale (K-HDRS). Conventional classification based on binary logistic regression was built and compared with 4 machine learning models (the logit, decision tree, boosted trees, and random forest models). Results: On the basis of the SGDS-K and K-HDRS, 38% (18/47) of the participants were classified into the probable depression group. They reported significantly lower scores of normal mood and physical activity and higher levels of white and red, green, and blue (RGB) light exposures at different degrees of various 4-hour time frames (all P<.05). Sleep efficiency was chosen for modeling through feature selection. Comparing diverse combinations of the selected variables, daily mean EMA score, daily mean activity level, white and RGB light at 4:00 pm to 8:00 pm exposure, and daily sleep efficiency were selected for modeling. Conventional classification based on binary logistic regression had a good model fit (accuracy: 0.705; precision: 0.770; specificity: 0.859; and area under receiver operating characteristic curve or AUC: 0.754). Among the 4 machine learning models, the logit model had the best fit compared with the others (accuracy: 0.910; precision: 0.929; specificity: 0.940; and AUC: 0.960). Conclusions: This study provides preliminary evidence for developing a machine learning program to predict the classification of depression groups in older adults living alone. Clinicians should consider using this method to identify underdiagnosed subgroups and monitor daily progression regarding treatment or therapeutic intervention in the community setting. Furthermore, more efforts are needed for researchers and clinicians to diversify data collection methods by using a survey, EMA, and a sensor. %M 31621642 %R 10.2196/14149 %U http://mhealth.jmir.org/2019/10/e14149/ %U https://doi.org/10.2196/14149 %U http://www.ncbi.nlm.nih.gov/pubmed/31621642 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 10 %P e13434 %T Effectiveness and Cost-Effectiveness of Blended Cognitive Behavioral Therapy in Clinically Depressed Adolescents: Protocol for a Pragmatic Quasi-Experimental Controlled Trial %A Rasing,Sanne P A %A Stikkelbroek,Yvonne A J %A Riper,Heleen %A Dekovic,Maja %A Nauta,Maaike H %A Dirksen,Carmen D %A Creemers,Daan H M %A Bodden,Denise H M %+ Child and Adolescent Studies, Utrecht University, PO Box 80140, Utrecht, 3508 TC, Netherlands, 31 30 253 47 00, s.p.a.rasing1@uu.nl %K depression %K major depressive disorder %K cognitive behavioral therapy %K blended %K eHealth %K online %K adolescents %K effectiveness %K cost-effectiveness %D 2019 %7 7.10.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cognitive behavioral therapy (CBT) is an effective intervention to treat depressive disorders in youth. However, 50% of adolescents still have depressive symptoms after treatment, and 57% drop out during treatment. Online CBT interventions have proven to be effective in reducing depressive symptoms and seem promising as a treatment for depressed adolescents. However, combining online programs with face-to-face sessions seems necessary to increase their effectiveness and monitor for suicide risk. Objective: In this study, we examine the effectiveness and cost-effectiveness of a blended CBT treatment protocol, a mixture of online and face-to-face CBT, as a treatment for clinically depressed adolescents. Methods: A pragmatic quasi-experimental controlled trial will be conducted to study the effectiveness of a blended CBT treatment protocol, in which blended CBT is compared with face-to-face CBT (n=44) and treatment as usual (n=44); the latter two were collected in a previous randomized controlled trial. The same inclusion and exclusion criteria will be used: adolescents aged between 12 and 21 years, with a clinical diagnosis of a depressive disorder, and referred to one of the participating mental health institutions. Assessments will be conducted at the same time points: before the start of the intervention, during the intervention (after 5 and 10 weeks), postintervention, and at 6- and 12-month follow-ups. Results: The primary outcome is the presence of a depression diagnosis at 12-month follow-up. Several secondary outcomes will be measured, such as depressive symptoms, quality of life, and suicide risk. Costs and effects in both conditions will be compared to analyze cost-effectiveness. Further, moderating (age, gender, alcohol and drug use, parental depression, and other psychopathology) and mediating effects (negative automatic thoughts, cognitive emotion regulation, attributional style) will be analyzed. Also, treatment characteristics will be studied, such as characteristics of the therapists, treatment expectancy, and therapeutic alliance. Dropout rates and treatment characteristics will be measured to study the feasibility of blended CBT. Conclusions: This study will examine the effectiveness and cost-effectiveness of a blended CBT program in which depressed adolescents are treated in mental health care. Results of blended CBT will be compared with face-to-face CBT and treatment as usual, and implications for implementation will be reviewed. Trial Registration: Dutch Trial Register (NTR6759); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6759 International Registered Report Identifier (IRRID): DERR1-10.2196/13434 RR1-10.2196/12654 %M 31593538 %R 10.2196/13434 %U https://www.researchprotocols.org/2019/10/e13434 %U https://doi.org/10.2196/13434 %U http://www.ncbi.nlm.nih.gov/pubmed/31593538 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 10 %P e14648 %T An Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial %A Johansson,Peter %A Westas,Mats %A Andersson,Gerhard %A Alehagen,Urban %A Broström,Anders %A Jaarsma,Tiny %A Mourad,Ghassan %A Lundgren,Johan %+ Department of Social and Welfare Studies, Linköping University, 601 74, Norrköping, Sweden, 46 11 36 31 85, peter.b.johansson@liu.se %K cardiovascular disease %K depression %K cognitive behavior therapy %K internet %K randomized controlled trial %D 2019 %7 3.10.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression. Objective: The study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD. Methods: A randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire–9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale–self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models. Results: Compared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=−2.34 [95% CI −3.58 to −1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression. Conclusions: Nurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time. Trial Registration: ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074 %M 31584000 %R 10.2196/14648 %U https://mental.jmir.org/2019/10/e14648 %U https://doi.org/10.2196/14648 %U http://www.ncbi.nlm.nih.gov/pubmed/31584000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14240 %T Diminishing Effects After Recurrent Use of Self-Guided Internet-Based Interventions in Depression: Randomized Controlled Trial %A Bücker,Lara %A Schnakenberg,Patricia %A Karyotaki,Eirini %A Moritz,Steffen %A Westermann,Stefan %+ Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg, 20246, Germany, 49 40 7410 55868, l.buecker@uke.de %K eHealth %K self-management %K depressive symptoms %K randomized controlled trial %D 2019 %7 2.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Self-guided internet-based interventions have several advantages over guided interventions and are generally effective in treating psychiatric symptoms. Objective: We aimed to investigate whether the use of a new self-guided internet-based intervention (MOOD) would lead to a significant reduction in depressive symptoms compared with a care-as-usual (CAU) control group in a sample of individuals with depressive symptoms, most of whom had already used a different self-guided internet-based intervention in a previous trial. Methods: A total of 125 individuals were randomized to the intervention condition (MOOD) and received access to the intervention for a period of six weeks or a CAU group. After six weeks, all participants were invited to take part in the post assessment. The Beck Depression Inventory-II served as the primary outcome. Results: Both intention-to-treat as well as per-protocol analyses indicated that the depressive symptomatology decreased in both conditions but showed no advantage for those who had used MOOD. Subsequent moderation analyses suggested that those individuals who had less experience with psychotherapy benefitted to a greater extent compared with those with more experience. Conclusions: Self-guided internet-based interventions are deemed a suitable first-step approach to the treatment of depression. However, our results indicate that they are more efficacious in those with less psychotherapy experience. Trial Registration: ClinicalTrials.gov NCT03795480; http://clinicaltrials.gov/ct2/show/NCT03795480 %M 31579014 %R 10.2196/14240 %U https://www.jmir.org/2019/10/e14240 %U https://doi.org/10.2196/14240 %U http://www.ncbi.nlm.nih.gov/pubmed/31579014 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 4 %P e13610 %T Use of Patient-Reported Data to Match Depression Screening Intervals With Depression Risk Profiles in Primary Care Patients With Diabetes: Development and Validation of Prediction Models for Major Depression %A Jin,Haomiao %A Wu,Shinyi %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive St, Suite 1400, Los Angeles, CA, 90015, United States, 1 213 821 6441, haomiaoj@usc.edu %K patient-reported data %K patient-centered decision making %K depression screening %K depression %K diabetes %K health information technology %K data analytics %K predictive modeling %K machine learning %K data mining %D 2019 %7 1.10.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Clinical guidelines recommend screening for depression in the general adult population but recognizes that the optimum interval for screening is unknown. Ideal screening intervals should match the patient risk profiles. Objective: This study describes a predictive analytics approach for mining clinical and patient-reported data from a large clinical study for the identification of primary care patients at high risk for depression to match depression screening intervals with patient risk profiles. Methods: This paper analyzed data from a large safety-net primary care study for diabetes and depression. A regression-based data mining technique was used to examine 53 demographics, clinical variables, and patient-reported variables to develop three prediction models for major depression at 6, 12, and 18 months from baseline. Predictors with the strongest predictive power that require low information collection efforts were selected to develop the prediction models. Predictive accuracy was measured by the area under the receiver operating curve (AUROC) and was evaluated by 10-fold cross-validation. The effectiveness of the prediction algorithms in supporting clinical decision making for six “typical” types of patients was demonstrated. Results: The analysis included 923 patients who were nondepressed at the study baseline. Five patient-reported variables were selected in the prediction models to predict major depression at 6, 12, and 18 months: (1) Patient Health Questionnaire 2-item score; (2) the Sheehan Disability Scale; (3) previous problems with depression; (4) the diabetes symptoms scale; and (5) emotional burden of diabetes. All three depression prediction models had an AUROC>0.80, comparable with published depression prediction studies. Among the 6 “typical” types of patients, the algorithms suggest that patients who reported impaired daily functioning by health status are at an elevated risk for depression in all three periods. Conclusions: This study demonstrated that leveraging patient-reported data and prediction models can help improve identification of high-risk patients and clinical decisions about the depression screening interval for diabetes patients. Implementation of this approach can be coupled with application of modern technologies such as telehealth and mobile health assessment for collecting patient-reported data to improve privacy, reducing stigma and costs, and promoting a personalized depression screening that matches screening intervals with patient risk profiles. %M 31573900 %R 10.2196/13610 %U https://formative.jmir.org/2019/4/e13610 %U https://doi.org/10.2196/13610 %U http://www.ncbi.nlm.nih.gov/pubmed/31573900 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 9 %P e13467 %T Role of Moderators on Engagement of Adolescents With Depression or Anxiety in a Social Media Intervention: Content Analysis of Web-Based Interactions %A Windler,Carolyn %A Clair,Maeve %A Long,Cassandra %A Boyle,Leah %A Radovic,Ana %+ University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15261, United States, 1 310 699 2025, cmw185@pitt.edu %K moderator %K social media %K engagement %K adolescents %K mental health %D 2019 %7 26.9.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Supporting Our Valued Adolescents (SOVA) intervention aims to use a moderated social media website to encourage peer discussion about negative health beliefs, which may prevent treatment uptake. Web moderators with a background in behavioral health are used to facilitate peer conversation to promote a sense of community, provide social support, and ensure safety. Objective: Although moderation is a core component of this intervention, little is known on best practices for moderators to ensure safety while encouraging engagement. This study sought to describe interactions between moderators and peer users and understand moderator experiences through individual interviews. Methods: Adolescents and young adults aged 14 to 26 years with depression or anxiety history were recruited for a usability study of the SOVA intervention. During this study, 14 moderators were trained to regularly review comments to blog posts for safety, facilitate conversation, and correct misinformation. A total of 110 blog posts and their associated comments were extracted and coded using a codebook based on items from the supportive accountability model and a peer social support analysis. Closing interviews with 12 moderators assessing their experience of moderating were conducted, recorded, and transcribed. Blog post text and comments as well as transcripts of moderator interviews were assessed using a thematic analysis approach, and blog posts were examined for trends in content of moderator comments comparing blog posts with differences in comment contributor order. Results: There were no safety concerns during the study, and moderators only intervened to remove identifiable information. Web moderators exhibited elements of supportive accountability (such as being perceived as experts and using verbal rewards as well as offering informational and emotional support). When the moderators provided the last comment under a blog post, thereby potentially ending contribution by users, they were at times found to be commenting about their own experiences. Moderators interviewed after completing their role expressed challenges in engaging users. A cohort of moderators who received more extensive training on supportive accountability and peer social support felt their ability to engage users improved because of the training. Conclusions: Moderators of a Web-based support site for adolescents with depression or anxiety were able to ensure safety while promoting user engagement. Moderators can elicit user engagement by offering gratitude and encouragement to users, asking users follow-up questions, and limiting their own opinions and experiences when responding to comments. %M 31573923 %R 10.2196/13467 %U http://mental.jmir.org/2019/9/e13467/ %U https://doi.org/10.2196/13467 %U http://www.ncbi.nlm.nih.gov/pubmed/31573923 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 0 %N 0 %P e0 %T Using Wearable Physiological Monitors With Suicidal Adolescent Inpatients: Feasibility and Acceptability Study %A Kleiman,Evan %A Millner,Alexander J %A Joyce,Victoria W %A Nash,Carol C %A Buonopane,Ralph J %A Nock,Matthew K %+ Rutgers, The State University of New Jersey, Department of Psychology, 53 Avenue E, Room 627, Piscataway, NJ, 08854, United States, 1 8484452345, evan.kleiman@rutgers.edu %K feasibility studies %K wearable electronic devices %K adolescent, hospitalized %K self-injurious behavior %K qualitative research %D 2019 %7 24.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such monitors are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress. Objective: This study aimed to evaluate the feasibility and acceptability of using a wearable behavioral and physiological monitor, the Empatica E4, to continuously assess a group of suicidal adolescent inpatients. Methods: Participants (n=50 adolescent inpatients) were asked to wear an Empatica E4 on their wrist for the duration of their inpatient stay. In addition to assessing behavioral metadata (eg, hours worn per day), we also used qualitative interviews and self-report measures to assess participants’ experience of wearing the monitor. Results: Results supported the feasibility and acceptability of this approach. Participants wore the monitor for an average of 18 hours a day and reported that despite sometimes finding the monitor uncomfortable, they did not mind wearing it. Many of the participants noted that the part of the study they enjoyed most was contributing to scientific understanding, especially if it could help people similar to them in the future. Conclusions: These findings provide promising support for using wearable monitors in clinical samples in future studies, especially if participants are invested in being part of a research study. %M 31586364 %R 10.2196/13725 %U http://mhealth.jmir.org/2019/0/e0/ %U https://doi.org/10.2196/13725 %U http://www.ncbi.nlm.nih.gov/pubmed/31586364 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e12051 %T Validation of an mHealth App for Depression Screening and Monitoring (Psychologist in a Pocket): Correlational Study and Concurrence Analysis %A Ramos,Roann Munoz %A Cheng,Paula Glenda Ferrer %A Jonas,Stephan Michael %+ Department of Medical Informatics, RWTH Aachen University Hospital, Pauwelstrasse 30, Aachen, 52074, Germany, 49 2418080352, rramos@mi.rwth-aachen.de %K mobile health %K depression %K validation %K Psychologist in a Pocket %K PiaP %D 2019 %7 16.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) is a fast-growing professional sector. As of 2016, there were more than 259,000 mHealth apps available internationally. Although mHealth apps are growing in acceptance, relatively little attention and limited efforts have been invested to establish their scientific integrity through statistical validation. This paper presents the external validation of Psychologist in a Pocket (PiaP), an Android-based mental mHealth app which supports traditional approaches in depression screening and monitoring through the analysis of electronic text inputs in communication apps. Objective: The main objectives of the study were (1) to externally validate the construct of the depression lexicon of PiaP with standardized psychological paper-and-pencil tools and (2) to determine the comparability of PiaP, a new depression measure, with a psychological gold standard in identifying depression. Methods: College participants downloaded PiaP for a 2-week administration. Afterward, they were asked to complete 4 psychological depression instruments. Furthermore, 1-week and 2-week PiaP total scores (PTS) were correlated with (1) Beck Depression Index (BDI)-II and Center for Epidemiological Studies–Depression (CES-D) Scale for congruent construct validation, (2) Affect Balance Scale (ABS)–Negative Affect for convergent construct validation, and (3) Satisfaction With Life Scale (SWLS) and ABS–Positive Affect for divergent construct validation. In addition, concordance analysis between PiaP and BDI-II was performed. Results: On the basis of the Pearson product-moment correlation, significant positive correlations exist between (1) 1-week PTS and CES-D Scale, (2) 2-week PTS and BDI-II, and (3) PiaP 2-week PTS and SWLS. Concordance analysis (Bland-Altman plot and analysis) suggested that PiaP’s approach to depression screening is comparable with the gold standard (BDI-II). Conclusions: The evaluation of mental health has historically relied on subjective measurements. With the integration of novel approaches using mobile technology (and, by extension, mHealth apps) in mental health care, the validation process becomes more compelling to ensure their accuracy and credibility. This study suggests that PiaP’s approach to depression screening by analyzing electronic data is comparable with traditional and well-established depression instruments and can be used to augment the process of measuring depression symptoms. %M 31538946 %R 10.2196/12051 %U https://mhealth.jmir.org/2019/9/e12051/ %U https://doi.org/10.2196/12051 %U http://www.ncbi.nlm.nih.gov/pubmed/31538946 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e14657 %T Response Time as an Implicit Self-Schema Indicator for Depression Among Undergraduate Students: Preliminary Findings From a Mobile App–Based Depression Assessment %A Chung,Kyungmi %A Park,Jin Young %A Joung,DaYoung %A Jhung,Kyungun %+ Department of Psychiatry, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Simgokro 100gil 25 Seo-gu, Incheon, 22711, Republic of Korea, 82 32 290 3878, kyungun12@gmail.com %K depressive symptoms %K response time %K self-concept %K mobile phone %K mobile apps %K diagnostic screening programs %K self-assessment %K treatment adherence %K compliance %D 2019 %7 13.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Response times to depressive symptom items in a mobile-based depression screening instrument has potential as an implicit self-schema indicator for depression but has yet to be determined; the instrument was designed to readily record depressive symptoms experienced on a daily basis. In this study, the well-validated Korean version of the Center for Epidemiologic Studies Depression Scale-Revised (K-CESD-R) was adopted. Objective: The purpose of this study was to investigate the relationship between depression severity (ie, explicit measure: total K-CESD-R Mobile scores) and the latent trait of interest in schematic self-referent processing of depressive symptom items (ie, implicit measure: response times to items in the K-CESD-R Mobile scale). The purpose was to investigate this relationship among undergraduate students who had never been diagnosed with, but were at risk for, major depressive disorder (MDD) or comorbid MDD with other neurological or psychiatric disorders. Methods: A total of 70 participants—36 males (51%) and 34 females (49%)—aged 19-29 years (mean 22.66, SD 2.11), were asked to complete both mobile and standard K-CESD-R assessments via their own mobile phones. The mobile K-CESD-R sessions (binary scale: yes or no) were administered on a daily basis for 2 weeks. The standard K-CESD-R assessment (5-point scale) was administered on the final day of the 2-week study period; the assessment was delivered via text message, including a link to the survey, directly to participants’ mobile phones. Results: A total of 5 participants were excluded from data analysis. The result of polynomial regression analysis showed that the relationship between total K-CESD-R Mobile scores and the reaction times to the depressive symptom items was better explained by a quadratic trend—F (2, 62)=21.16, P<.001, R2=.41—than by a linear trend—F (1, 63)=25.43, P<.001, R2=.29. It was further revealed that the K-CESD-R Mobile app had excellent internal consistency (Cronbach alpha=.94); at least moderate concurrent validity with other depression scales, such as the Korean version of the Quick Inventory for Depressive Symptomatology-Self Report (ρ=.38, P=.002) and the Patient Health Questionnaire-9 (ρ=.48, P<.001); a high adherence rate for all participants (65/70, 93%); and a high follow-up rate for 10 participants whose mobile or standard K-CESD-R score was 13 or greater (8/10, 80%). Conclusions: As hypothesized, based on a self-schema model for depression that represented both item and person characteristics, the inverted U-shaped relationship between the explicit and implicit self-schema measures for depression showed the potential of an organizational breakdown; this also showed the potential for a subsequent return to efficient processing of schema-consistent information along a continuum, ranging from nondepression through mild depression to severe depression. Further, it is expected that the updated K-CESD-R Mobile app can play an important role in encouraging people at risk for depression to seek professional follow-up for mental health care. %M 31586362 %R 10.2196/14657 %U https://mhealth.jmir.org/2019/9/e14657/ %U https://doi.org/10.2196/14657 %U http://www.ncbi.nlm.nih.gov/pubmed/31586362 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e14734 %T Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal %A Poudyal,Anubhuti %A van Heerden,Alastair %A Hagaman,Ashley %A Maharjan,Sujen Man %A Byanjankar,Prabin %A Subba,Prasansa %A Kohrt,Brandon A %+ Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, 2120 L Street, Suite 600, Washington, DC, 20037, United States, 1 (202) 741 2888, bkohrt@gwu.edu %K developing countries %K feasibility studies %K mobile health %K mother-child interaction %K postpartum depression %K psychotherapy %D 2019 %7 11.09.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. Objective: This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. Methods: This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. Results: To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. Conclusions: Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/14734 %M 31512581 %R 10.2196/14734 %U http://www.researchprotocols.org/2019/8/e14734/ %U https://doi.org/10.2196/14734 %U http://www.ncbi.nlm.nih.gov/pubmed/31512581 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12915 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 2): Qualitative Study %A Shorey,Shefaly %A Ng,Esperanza Debby %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K depression %K mothers %K postpartum %K qualitative %K social support %K telecommunication %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Social support is known to reduce risks of postnatal depression (PND) and improve maternal emotional well-being. However, the Asian cultural context is often neglected when appraising maternal needs and mothers’ preferences for social support. While many preventive efforts have experimented with technology, professionals, and paraprofessionals in providing social support to mothers in need, most studies determined the effectiveness of their interventions through quantitative measurements of maternal outcomes. Experiences and feedback from both participants and administrators are rarely discussed, especially in an Asian setting. Objective: The goal of the research was to evaluate the postnatal experiences of Asian mothers at risk of PND and the perceptions of peer volunteers regarding a technology-based peer-support intervention program (PIP). Methods: A qualitative semistructured interview was conducted with 20 Asian mothers at risk of depression (10 from the control group and 10 from the intervention group) and 19 peer volunteers from a randomized controlled trial. The PIP included weekly correspondence between peer volunteers and mothers through any telecommunication means over 4 weeks. All interviews were approximately 30 to 60 minutes long, audiotaped, transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Standards of Reporting Trials checklist. Results: Two overarching themes comprising five subthemes were generated: postnatal experience (a bouncy ride, a way forward) and evaluation of the PIP (valuable, flexible, and supportive program; building blocks of a good relationship; and lessons learned and the road ahead). Mothers from both the control and interventions groups were generally satisfied with hospital care and the support received from family. They also shared similar breastfeeding challenges and needs for more informed decisions and follow-up support from the hospital. However, mothers who received the PIP tended to have more positive outlooks of their birth experiences. Overall, peer volunteers and mothers involved in the PIP found the PIP useful and expressed satisfaction with the program’s flexibility. They also shared their personal takeaways, the qualities of their friendships, and the need for extended correspondence time and recommended outreach to non–at-risk mothers. Conclusions: The positive endorsement of the PIP by peer volunteers and mothers suggests the success of the PIP in maintaining positive maternal emotional well-being during the postpartum period. With the help of technology, hospitals can easily provide additional peer support to at-risk mothers in addition to existing standard care offered to these mothers. Trial Registration: ISRCTN Registry ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469080 %R 10.2196/12915 %U http://www.jmir.org/2019/8/e12915/ %U https://doi.org/10.2196/12915 %U http://www.ncbi.nlm.nih.gov/pubmed/31469080 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12410 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 1): Randomized Controlled Trial %A Shorey,Shefaly %A Chee,Cornelia Yin Ing %A Ng,Esperanza Debby %A Lau,Ying %A Dennis,Cindy-Lee %A Chan,Yiong Huak %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School Of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K anxiety %K loneliness %K postpartum depression %K social support %K technology %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The frenzy of postbirth events often takes a toll on mothers’ mental well-being, leaving them susceptible to postpartum psychological disorders such as postnatal depression (PND). Social support has been found to be effective in restoring the emotional well-being of new mothers. Therefore, mothers need to be supported during the crucial postpartum period to buffer the negative after effects of childbirth and to promote healthier maternal well-being. Objective: This study aimed to evaluate the effectiveness of a technology-based peer-support intervention program (PIP) on maternal outcomes during the early postpartum period. Methods: A randomized, parallel-armed controlled trial was conducted. The study recruited 138 mothers (69 in intervention group, 69 in control group) at risk of PND from a tertiary hospital in Singapore. To support these mothers, 20 peer volunteers were recruited by word of mouth and trained by a psychiatrist in social support skills before the intervention commenced. The 4-week–long intervention included a weekly follow-up with a peer volunteer through phone calls or text messages. The intervention group received peer support in addition to the standard care offered by the hospital. The control group only received postnatal standard care. Maternal outcomes (PND, postnatal anxiety [PNA], loneliness, and perceived social support) were measured with reliable and valid instruments. Data were collected immediately postpartum, at 1 month postpartum and at 3 months postpartum. The general linear model was used to compare the groups for postpartum percentage changes in the outcome variables at first and third months, and the linear mixed model was used to compare the trend over the study period. Results: There was a statistically significant difference in Edinburgh Postnatal Depression Scale scores (d=–2.11; 95% CI −4.0 to −0.3; P=.03) between the intervention and control groups at 3 months postpartum after adjusting for covariates. The intervention group had a significant change over time compared with the control group. Conclusions: The technology-based PIP was found to be effective in reducing the risk of PND among new mothers and showed a generally positive trend in reducing PNA and loneliness and increasing perceived social support. This study highlights the importance of training paraprofessionals to provide needed support for new mothers postpartum. A further long-term evaluation of the PIP on maternal and family outcomes and its cost-effectiveness is needed to inform clinical practices. Trial Registration: ISRCTN Registry ISRCTN14864807; https://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469084 %R 10.2196/12410 %U http://www.jmir.org/2019/8/e12410/ %U https://doi.org/10.2196/12410 %U http://www.ncbi.nlm.nih.gov/pubmed/31469084 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e13609 %T Comparison of the Effects of Coaching and Receipt of App Recommendations on Depression, Anxiety, and Engagement in the IntelliCare Platform: Factorial Randomized Controlled Trial %A Mohr,David C %A Schueller,Stephen M %A Tomasino,Kathryn Noth %A Kaiser,Susan M %A Alam,Nameyeh %A Karr,Chris %A Vergara,Jessica L %A Gray,Elizabeth L %A Kwasny,Mary J %A Lattie,Emily G %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lakeshore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K depression %K anxiety %K mHealth %K clinical trial %D 2019 %7 28.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: IntelliCare is a modular platform that includes 12 simple apps targeting specific psychological strategies for common mental health problems. Objective: This study aimed to examine the effect of 2 methods of maintaining engagement with the IntelliCare platform, coaching, and receipt of weekly recommendations to try different apps on depression, anxiety, and app use. Methods: A total of 301 participants with depression or anxiety were randomized to 1 of 4 treatments lasting 8 weeks and were followed for 6 months posttreatment. The trial used a 2X2 factorial design (coached vs self-guided treatment and weekly app recommendations vs no recommendations) to compare engagement metrics. Results: The median time to last use of any app during treatment was 56 days (interquartile range 54-57), with 253 participants (84.0%, 253/301) continuing to use the apps over a median of 92 days posttreatment. Receipt of weekly recommendations resulted in a significantly higher number of app use sessions during treatment (overall median=216; P=.04) but only marginal effects for time to last use (P=.06) and number of app downloads (P=.08). Coaching resulted in significantly more app downloads (P<.001), but there were no significant effects for time to last download or number of app sessions (P=.36) or time to last download (P=.08). Participants showed significant reductions in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) across all treatment arms (P s<.001). Coached treatment led to larger GAD-7 reductions than those observed for self-guided treatment (P=.03), but the effects for the PHQ-9 did not reach significance (P=.06). Significant interaction was observed between receiving recommendations and time for the PHQ-9 (P=.04), but there were no significant effects for GAD-7 (P=.58). Conclusions: IntelliCare produced strong engagement with apps across all treatment arms. Coaching was associated with stronger anxiety outcomes, and receipt of recommendations enhanced depression outcomes. Trial Registration: ClinicalTrials.gov NCT02801877; https://clinicaltrials.gov/ct2/show/NCT02801877 %M 31464192 %R 10.2196/13609 %U http://www.jmir.org/2019/8/e13609/ %U https://doi.org/10.2196/13609 %U http://www.ncbi.nlm.nih.gov/pubmed/31464192 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14284 %T Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study %A Economides,Marcos %A Ranta,Kristian %A Nazander,Albert %A Hilgert,Outi %A Goldin,Philippe R %A Raevuori,Anu %A Forman-Hoffman,Valerie %+ Meru Health Inc, 470 Ramona Street, Palo Alto, CA, 94301, United States, 1 (650) 740 9404, marcos@mhealthoutcomes.com %K digital health %K depression %K anxiety %K mindfulness %K CBT %K online intervention %K smartphone intervention %D 2019 %7 26.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is one of the most common mental health disorders and severely impacts one’s physical, psychological, and social functioning. To address access barriers to care, we developed Ascend—a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. A previous feasibility study with 102 adults with elevated depression reported that Ascend is associated with a postintervention reduction in depression symptoms. Objective: We aimed to examine whether Ascend is associated with a reduction in symptoms of anxiety, and importantly, whether reductions in symptoms of depression and anxiety are maintained up to 12-months postintervention. Methods: We assessed whether the previously reported, end-of-treatment improvements seen in the 102 adults with elevated symptoms of depression extended up to 12 months posttreatment for depression symptoms (measured by the Patient Health Questionnaire-9 [PHQ-9]) and up to 6 months posttreatment for anxiety symptoms (added to the intervention later and measured using the Generalized Anxiety Disorder-7 [GAD-7] scale). We used linear mixed effects models with Tukey contrasts to compare time points and reported intention-to-treat statistics with a sensitivity analysis. Results: The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67-point reduction in PHQ-9 score, 95% CI 5.59-7.75; P<.001; Hedges g=1.14, 95% CI 0.78-1.49). A total of 60% of the participants with PHQ-9 scores above the cutoff for major depression at baseline (PHQ≥10) reported clinically significant improvement at the 12-month follow-up (at least 50% reduction in PHQ-9 score and postprogram score <10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26-point reduction in GAD-7 score, 95% CI 3.14-5.38; P<.001; Hedges g=0.91, 95% CI 0.54-1.28). Conclusions: There is limited evidence on whether outcomes associated with smartphone-based interventions for common mental health problems are maintained posttreatment. Participants who enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to 1 year and 6 months after the intervention, respectively. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and anxiety. %M 31452521 %R 10.2196/14284 %U http://mhealth.jmir.org/2019/8/e14284/ %U https://doi.org/10.2196/14284 %U http://www.ncbi.nlm.nih.gov/pubmed/31452521 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 8 %P e12711 %T Exploring Mediators of a Guided Web-Based Self-Help Intervention for People With HIV and Depressive Symptoms: Randomized Controlled Trial %A van Luenen,Sanne %A Kraaij,Vivian %A Spinhoven,Philip %A Wilderjans,Tom F %A Garnefski,Nadia %+ Section of Clinical Psychology, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, Netherlands, 31 715277957, s.van.luenen@fsw.leidenuniv.nl %K HIV %K depression %K internet %K cognitive behavioral therapy %K coaching %K randomized controlled trial %K mediators %D 2019 %7 23.08.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive behavioral therapy (CBT) is frequently used to treat depressive symptoms in people living with HIV. We developed an internet-based cognitive behavioral intervention for people with HIV and depressive symptoms, which was based on an effective self-help booklet. The Web-based intervention was previously found to be effective. Objective: The objective of this study was to investigate potential mediators of the Web-based intervention. Methods: This study was part of a randomized controlled trial, in which the intervention was compared with an attention-only waiting list control condition. Participants were 188 (97 in intervention group and 91 in control group) people with HIV and mild to moderate depressive symptoms recruited in HIV treatment centers in the Netherlands. A total of 22 participants (22/188, 11.7%) in the study were female and 166 (166/188, 88.3%) were male. The average age of the participants was 46.30 years (SD 10.63). The intervention comprised Web-based self-help CBT for 8 weeks, 1 to 2 hours a week, including minimal telephone support from a coach. The participants received Web-based questionnaires at pretest, 3 times during the intervention/or waiting period, and post intervention. The outcome was depressive symptoms. Factors tested as potential mediators were changes in behavioral activation, relaxation, the cognitive coping strategies catastrophizing and positive refocusing, goal re-engagement, and coping self-efficacy. Results: Using multilevel structural equation modeling, changes in behavioral activation (P=.006) and goal re-engagement (P=.009) were found to be significant mediators of the intervention effect. The mediation effect seemed to occur between weeks 3 and 5 for behavioral activation and weeks 1 and 3 for goal re-engagement. Using (bivariate) autoregressive latent trajectory analysis, we found a return effect (from the dependent variable to the mediator) for goal re-engagement but not for behavioral activation, which suggested that the mediation effect of changes in behavioral activation was stronger than that in goal re-engagement. Conclusions: The results suggest that changes in behavioral activation and goal re-engagement may mediate the effect of the Web-based intervention for people with HIV and depressive symptoms. The results may lead to possible mechanisms of change of the intervention and improvement of therapy outcomes. Clinical Trial: Netherlands Trial Register NTR5407; https://www.trialregister.nl/trial/5298 %M 31444873 %R 10.2196/12711 %U http://mental.jmir.org/2019/8/e12711/ %U https://doi.org/10.2196/12711 %U http://www.ncbi.nlm.nih.gov/pubmed/31444873 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e13271 %T Improving Mental Health in Pregnancy for Refugee Women: Protocol for the Implementation and Evaluation of a Screening Program in Melbourne, Australia %A Boyle,Jacqueline Anne %A Willey,Suzanne %A Blackmore,Rebecca %A East,Christine %A McBride,Jacqueline %A Gray,Kylie %A Melvin,Glenn %A Fradkin,Rebecca %A Ball,Natahl %A Highet,Nicole %A Gibson-Helm,Melanie %+ Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, 43-51 Kanooka Gve, Clayton, Melbourne, 3168, Australia, 61 (613) 85722670, jacqueline.boyle@monash.edu %K mental health %K refugees %K transients and migrants %K pregnancy %K prenatal care %K mass screening %D 2019 %7 19.08.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Identifying mental health disorders in migrant and refugee women during pregnancy provides an opportunity for interventions that may benefit women and their families. Evidence suggests that perinatal mental health disorders impact mother-infant attachment at critical times, which can affect child development. Postnatal depression resulting in suicide is one of the leading causes of maternal mortality postpartum. Routine screening of perinatal mental health is recommended to improve the identification of depression and anxiety and to facilitate early management. However, screening is poorly implemented into routine practice. This study is the first to investigate routine screening for perinatal mental health in a maternity setting designed for refugee women. This study will determine whether symptoms of depression and anxiety are more likely to be detected by the screening program compared with routine care and will evaluate the screening program’s feasibility and acceptability to women and health care providers (HCPs). Objective: The objectives of this study are (1) to assess if refugee women are more likely to screen risk-positive for depression and anxiety than nonrefugee women, using the Edinburgh Postnatal Depression Scale (EPDS); (2) to assess if screening in pregnancy using the EPDS enables better detection of symptoms of depression and anxiety in refugee women than current routine care; (3) to determine if a screening program for perinatal mental health in a maternity setting designed for refugee women is acceptable to women; and (4) to evaluate the feasibility and acceptability of the perinatal mental health screening program from the perspective of HCPs (including the barriers and enablers to implementation). Methods: This study uses an internationally recommended screening measure, the EPDS, and a locally developed psychosocial questionnaire, both administered in early pregnancy and again in the third trimester. These measures have been translated into the most common languages used by the women attending the clinic and are administered via an electronic platform (iCOPE). This platform automatically calculates the EPDS score and generates reports for the HCP and woman. A total of 119 refugee women and 155 nonrefugee women have been recruited to evaluate the screening program’s ability to detect depression and anxiety symptoms and will be compared with 34 refugee women receiving routine care. A subsample of women will participate in a qualitative assessment of the screening program’s acceptability and feasibility. Health service staff have been recruited to evaluate the integration of screening into maternity care. Results: The recruitment is complete, and data collection and analysis are underway. Conclusions: It is anticipated that screening will increase the identification and management of depression and anxiety symptoms in pregnancy. New information will be generated on how to implement such a program in feasible and acceptable ways that will improve health outcomes for refugee women. International Registered Report Identifier (IRRID): DERR1-10.2196/13271 %M 31429411 %R 10.2196/13271 %U http://www.researchprotocols.org/2019/8/e13271/ %U https://doi.org/10.2196/13271 %U http://www.ncbi.nlm.nih.gov/pubmed/31429411 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14318 %T Counseling With Guided Use of a Mobile Well-Being App for Students Experiencing Anxiety or Depression: Clinical Outcomes of a Feasibility Trial Embedded in a Student Counseling Service %A Broglia,Emma %A Millings,Abigail %A Barkham,Michael %+ Research Department, British Association for Counselling and Psychotherapy, 15 St John's Business Park, Lutterworth, Leicestershire,, United Kingdom, 44 1455 883318, emma.broglia@bacp.co.uk %K counseling %K students %K mental health %K mobile app %K feasibility studies %K outcome measures %K depressive symptoms %K generalized anxiety %K universities %D 2019 %7 15.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue to offer quality support with fewer resources to a growing student population. The convenience and availability of mobile phone apps offer innovative solutions to address therapeutic challenges and expand the reach of traditional support. Objective: The primary aim of this study was to establish the feasibility of a trial in which guided use of a mobile phone well-being app was introduced into a student counseling service and offered as an adjunct to face-to-face counseling. Methods: The feasibility trial used a two-arm, parallel nonrandomized design comparing counseling alone (treatment as usual, or TAU) versus counseling supplemented with guided use of a mobile phone well-being app (intervention) for 38 university students experiencing moderate anxiety or depression. Students in both conditions received up to 6 sessions of face-to-face counseling within a 3-month period. Students who approached the counseling service and were accepted for counseling were invited to join the trial. Feasibility factors evaluated include recruitment duration, treatment preference, randomization acceptability, and intervention fidelity. Clinical outcomes and clinical change were assessed with routine clinical outcome measures administered every counseling session and follow-up phases at 3 and 6 months after recruitment. Results: Both groups demonstrated reduced clinical severity by the end of counseling. This was particularly noticeable for depression, social anxiety, and hostility, whereby clients moved from elevated clinical to low clinical or from low clinical to nonclinical by the end of the intervention. By the 6-month follow-up, TAU clients’ (n=18) anxiety had increased whereas intervention clients’ (n=20) anxiety continued to decrease, and this group difference was significant (Generalized Anxiety Disorder–7: t22=3.46, P=.002). This group difference was not replicated for levels of depression: students in both groups continued to decrease their levels of depression by a similar amount at the 6-month follow-up (Physical Health Questionnaire–9: t22=1.30, P=.21). Conclusion: Supplementing face-to-face counseling with guided use of a well-being app is a feasible and acceptable treatment option for university students experiencing moderate anxiety or depression. The feasibility trial was successfully embedded into a university counseling service without denying access to treatment and with minimal disruption to the service. This study provides preliminary evidence for using a well-being app to maintain clinical improvements for anxiety following the completion of counseling. The design of the feasibility trial provides the groundwork for the development of future pilot trials and definitive trials embedded in a student counseling service. Trial registration: ISRCTN registry ISRCTN55102899; http://www.isrctn.com/ISRCTN55102899 %M 31418424 %R 10.2196/14318 %U http://mhealth.jmir.org/2019/8/e14318/ %U https://doi.org/10.2196/14318 %U http://www.ncbi.nlm.nih.gov/pubmed/31418424 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e13885 %T Suicide Prevention Mobile Apps: Descriptive Analysis of Apps from the Most Popular Virtual Stores %A Castillo-Sánchez,Gema %A Camargo-Henríquez,Ismael %A Muñoz-Sánchez,Juan Luis %A Franco-Martín,Manuel %A de la Torre-Díez,Isabel %+ Department of Signal Theory and Communications, and Telematics Engineering, University of Valladolid, Paseo de Belén 15, Valladolid, 47011, Spain, 34 983423000 ext 3703, isator@tel.uva.es %K apps %K prevention %K suicide %K virtual store %K analysis %D 2019 %7 13.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Provision of follow-up and care during treatment of people with suicidal intentions is a challenge for health professionals and experts in information and communications technology (ICT). Therefore, health professionals and ICT experts are making efforts to carry out these activities in collaboration by using mobile apps as a technological resource. Objective: This study aimed to descriptively analyze mobile apps aimed at suicide prevention and to determine relevant factors in their design and development. In addition, it sought to analyze their impact on the support of treatment for patients at risk for suicide. Methods: We considered 20 apps previously listed in the article “Mobile Apps for Suicide Prevention: Review of Virtual Stores and Literature” (de la Torre et al, JMIR mHealth uHealth 2017;5[10]:e130). To find the apps in this list, the most popular app stores (Android and iOS) were searched using the keyword “suicide prevention.” The research focused on publicly available app information: language, platform, and user ratings. The results obtained were statistically evaluated using 16 parameters that establish various factors that may affect the choice of the user, and the consequent support that the app can offer to a person at risk for suicide. Results: Of the 20 mobile apps, 4 no longer appeared in the app stores and were therefore excluded. Analysis of the remaining 16 apps sampled showed the following: (1) a high percentage of the apps analyzed in the study (n=13, 82%) are provided in English language; (2) the sampled apps were last updated in 2017, when only 45% of them were updated, but the constant and progressive update of treatments should be reflected in the apps; and (3) the technical quality of these apps cannot be determined on the basis of the distribution of scores, because their popularity indices can be subjective (according to the users). User preference for a particular operating system would require further, more specific research, including study of the differences in the technical and usability aspects between both platforms and the design of medical apps. Conclusions: Although there are positive approaches to the use of apps for suicide prevention and follow-up, the technical and human aspects are yet to be explored and defined. For example, the design and development of apps that support suicide prevention should be strongly supported by health personnel to humanize these apps, so that the effectiveness of the treatments supported by them can be improved. %M 31411144 %R 10.2196/13885 %U http://mhealth.jmir.org/2019/8/e13885/ %U https://doi.org/10.2196/13885 %U http://www.ncbi.nlm.nih.gov/pubmed/31411144 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e13797 %T Family Members’ Perspectives of Health Care System Interactions With Suicidal Patients and Responses to Suicides: Protocol for a Qualitative Research Study %A Bryksa,Erin %A Shalaby,Reham %A Friesen,Laura %A Klingle,Kirsten %A Gaine,Graham %A Urichuk,Liana %A Surood,Shireen %A Agyapong,Vincent %+ Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 (780) 407 6504, agyapong@ualberta.ca %K suicide %K family members %K public health systems research %D 2019 %7 09.08.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a major cause of preventable death globally and a leading cause of death by injury in Canada. To support people who experience suicidal thoughts and behaviors and ultimately prevent people from dying by suicide, it is important to understand the individual and familial experiences with the health care system. Objective: This study aims to explore how suicide victims, and their family members, interacted with the health care system. Methods: We will invite family members of 6 to 8 suicide victims to participate in the study by sharing their perspectives on both their relative’s as well as their own interactions with the health care system. Interviews will take place in-person and will be audio recorded, transcribed, and analyzed thematically. Results: The results of the study are expected to be available in 12 months. We expect the results to shed light on the experiences of suicide victims and their family members with the health care system. Conclusions: Our study results may inform practice, policy, and further research. They may shape how members of the health care system respond to people who are at risk of suicide and their families. International Registered Report Identifier (IRRID): PRR1-10.2196/13797 %M 31400108 %R 10.2196/13797 %U https://www.researchprotocols.org/2019/8/e13797/ %U https://doi.org/10.2196/13797 %U http://www.ncbi.nlm.nih.gov/pubmed/31400108 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12775 %T Exploring the Relationship Between Usage and Outcomes of an Internet-Based Intervention for Individuals With Depressive Symptoms: Secondary Analysis of Data From a Randomized Controlled Trial %A Enrique,Angel %A Palacios,Jorge E %A Ryan,Holly %A Richards,Derek %+ E-mental Health Research Group, School of Psychology, University of Dublin Trinity College, Dublin, 2, Ireland, 353 1 554 9771, enriquea@tcd.ie %K Web-based intervention %K depression %K adherence %K engagement %K eHealth %K internet %D 2019 %7 01.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change. Objective: This study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression. Methods: This is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not. Results: Data from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC. Conclusions: Overall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes. Trial Registration: ISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676 International Registered Report Identifier (IRRID): RR2-10.1186/1471-244X-14-147 %M 31373272 %R 10.2196/12775 %U https://www.jmir.org/2019/8/e12775/ %U https://doi.org/10.2196/12775 %U http://www.ncbi.nlm.nih.gov/pubmed/31373272 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e14174 %T The Effectiveness of Internet-Based Self-Help Interventions to Reduce Suicidal Ideation: Protocol for a Systematic Review and Meta-Analysis %A Büscher,Rebekka %A Torok,Michelle %A Sander,Lasse %+ Department of Rehabilitation Psychology and Psychotherapy, University of Freiburg, Engelbergerstraße 41, Freiburg, 79085, Germany, 49 761 203 3049, lasse.sander@psychologie.uni-freiburg.de %K suicide %K suicidal ideation %K internet %K computer-assisted therapy %K randomized controlled trial %K systematic review %K meta-analysis %D 2019 %7 29.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicidal ideation is a highly prevalent condition. There are several barriers for individuals to seek treatment that may be addressed by providing internet-based self-help interventions (ISIs). Current evidence suggests that ISIs for mental disorders may only be effective in reducing suicidal ideation if they specifically target suicidal thoughts or behaviors. Objective: The aim of this systematic review and meta-analysis is to investigate the effectiveness of ISIs that directly target suicidal thoughts or behaviors. Methods: We will conduct a sensitive systematic literature search in PsycINFO, MEDLINE, the Cochrane Central Register of Controlled Trials, and the Centre for Research Excellence of Suicide Prevention databases. Only randomized controlled trials evaluating the effectiveness of ISIs for suicide prevention will be included. Interventions must be delivered primarily in a Web-based setting; mobile-based interventions and interventions targeting gatekeepers will be excluded. Suicide ideation will be the primary outcome; secondary outcomes will be completed suicides, suicide attempts, depressiveness, anxiety, and hopelessness. Study quality will be assessed using the Cochrane Risk of Bias tool. We will provide a narrative synthesis of included studies. If studies are sufficiently homogenous, we will conduct a meta-analysis of the effectiveness on suicide ideation and, if possible, we will evaluate publication bias using funnel plots. We will evaluate the cumulative evidence in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. Results: This review is in progress, with findings expected by August 2019. Conclusions: This systematic review and meta-analysis focuses on the effectiveness of ISIs for suicidal thoughts and behaviors. It will provide guidance to clinical practice and encourage further research by synthesizing the best available evidence. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019130253; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130253 International Registered Report Identifier (IRRID): PRR1-10.2196/14174 %M 31359868 %R 10.2196/14174 %U https://www.researchprotocols.org/2019/7/e14174/ %U https://doi.org/10.2196/14174 %U http://www.ncbi.nlm.nih.gov/pubmed/31359868 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e11591 %T An Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth Diagnosed With Major Depressive Disorders: Protocol for a Randomized Controlled Trial %A Ritvo,Paul %A Daskalakis,Zafiris J %A Tomlinson,George %A Ravindran,Arun %A Linklater,Renee %A Kirk Chang,Megan %A Knyahnytska,Yuliya %A Lee,Jonathan %A Alavi,Nazanin %A Bai,Shari %A Harber,Lillian %A Jain,Tania %A Katz,Joel %+ School of Kinesiology and Health Science, York University, Bethune Building, 4700 Keele St, Toronto, ON, M3J 1P3, Canada, 1 4165808021, pritvo@yorku.ca %K intervention study %K telemedicine %K mobile phone %K mhealth %K fitbit %K depression %K cognitive behavioral therapy %D 2019 %7 29.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: About 70% of all mental health disorders appear before the age of 25 years. When untreated, these disorders can become long-standing and impair multiple life domains. When compared with all Canadian youth (of different ages), individuals aged between 15 and 25 years are significantly more likely to experience mental health disorders, substance dependencies, and risks for suicidal ideation and death by suicide. Progress in the treatment of youth, capitalizing on their online responsivity, can strategically address depressive disorders. Objective: We will conduct a randomized controlled trial to compare online mindfulness-oriented cognitive behavioral therapy (CBT-M) combined with standard psychiatric care versus psychiatric care alone in youth diagnosed with major depressive disorder. We will enroll 168 subjects in the age range of 18 to 30 years; 50% of subjects will be from First Nations (FN) backgrounds, whereas the other 50% will be from all other ethnic backgrounds. There will be equal stratification into 2 intervention groups (INT1 and INT2) and 2 wait-list control groups (CTL1 and CTL2) with 42 subjects per group, resulting in an equal number of INT1 and CTL1 of FN background and INT2 and CTL2 of non-FN background. Methods: The inclusion criteria are: (1) age 18 to 30 years, FN background or other ethnicity; (2) Beck Depression Inventory (BDI)-II of at least mild severity (BDI-II score ≥14) and no upper limit; (3) Mini-International Neuropsychiatric Interview (MINI)–confirmed psychiatric diagnosis of major depressive disorder; and (4) fluent in English. All patients are diagnosed by a Centre for Addiction and Mental Health psychiatrist, with diagnoses confirmed using the MINI interview. The exclusion criteria are: (1) individuals receiving weekly structured psychotherapy; (2) individuals who meet the Diagnostic and Statistical Manual of Mental Disorders criteria for severe alcohol/substance use disorder in the past 3 months, or who demonstrate clinically significant suicidal ideation defined as imminent intent, or who have attempted suicide in the past 6 months; and (3) individuals with comorbid diagnoses of borderline personality, schizophrenia, bipolar disorder, and/or obsessive compulsive disorder. All subjects are provided standard psychiatric care defined as 1 monthly session that focuses on appropriate medication, with session durations of 15 to 30 min. Experimental subjects receive an additional intervention consisting of the CBT-M online software program (in collaboration with Nex J Health, Inc). Exposure to and interaction with the online workbooks are combined with navigation-coaching delivered by phone and secure text message interactions. Results: The outcomes selected, combined with measurement blinding, are key features in assessing whether significant benefits regarding depression and anxiety symptoms occur. Conclusions: If results confirm the hypothesis that youth can be effectively treated with online CBT-M, effective services may be widely delivered with less geographic restriction. International Registered Report Identifier (IRRID): PRR1-10.2196/11591 %M 31359869 %R 10.2196/11591 %U http://www.researchprotocols.org/2019/7/e11591/ %U https://doi.org/10.2196/11591 %U http://www.ncbi.nlm.nih.gov/pubmed/31359869 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 7 %P e12707 %T Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study %A Kemmeren,Lise L %A van Schaik,Anneke %A Smit,Johannes H %A Ruwaard,Jeroen %A Rocha,Artur %A Henriques,Mário %A Ebert,David Daniel %A Titzler,Ingrid %A Hazo,Jean-Baptiste %A Dorsey,Maya %A Zukowska,Katarzyna %A Riper,Heleen %+ Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, Amsterdam, 1081 HJ, Netherlands, 31 207884527, l.kemmeren@ggzingeest.nl %K cognitive behavior therapy %K internet %K combined modality therapy %K depression %K routine mental healthcare %K treatment compliance %K logfile analysis %D 2019 %7 25.07.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care. Objective: The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns. Methods: Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years). Results: Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement. Conclusions: Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care. %M 31344670 %R 10.2196/12707 %U http://mental.jmir.org/2019/7/e12707/ %U https://doi.org/10.2196/12707 %U http://www.ncbi.nlm.nih.gov/pubmed/31344670 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e13809 %T Identification of Patients in Need of Advanced Care for Depression Using Data Extracted From a Statewide Health Information Exchange: A Machine Learning Approach %A Kasthurirathne,Suranga N %A Biondich,Paul G %A Grannis,Shaun J %A Purkayastha,Saptarshi %A Vest,Joshua R %A Jones,Josette F %+ Center for Biomedical Informatics, Regenstrief Institute, 1101 W 10th St, Indianapolis, IN, 46202, United States, 1 3173323480, snkasthu@iupui.edu %K depression %K supervised machine learning %K delivery of health care %D 2019 %7 22.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: As the most commonly occurring form of mental illness worldwide, depression poses significant health and economic burdens to both the individual and community. Different types of depression pose different levels of risk. Individuals who suffer from mild forms of depression may recover without any assistance or be effectively managed by primary care or family practitioners. However, other forms of depression are far more severe and require advanced care by certified mental health providers. However, identifying cases of depression that require advanced care may be challenging to primary care providers and health care team members whose skill sets run broad rather than deep. Objective: This study aimed to leverage a comprehensive range of patient-level diagnostic, behavioral, and demographic data, as well as past visit history data from a statewide health information exchange to build decision models capable of predicting the need of advanced care for depression across patients presenting at Eskenazi Health, the public safety net health system for Marion County, Indianapolis, Indiana. Methods: Patient-level diagnostic, behavioral, demographic, and past visit history data extracted from structured datasets were merged with outcome variables extracted from unstructured free-text datasets and were used to train random forest decision models that predicted the need of advanced care for depression across (1) the overall patient population and (2) various subsets of patients at higher risk for depression-related adverse events; patients with a past diagnosis of depression; patients with a Charlson comorbidity index of ≥1; patients with a Charlson comorbidity index of ≥2; and all unique patients identified across the 3 above-mentioned high-risk groups. Results: The overall patient population consisted of 84,317 adult (aged ≥18 years) patients. A total of 6992 (8.29%) of these patients were in need of advanced care for depression. Decision models for high-risk patient groups yielded area under the curve (AUC) scores between 86.31% and 94.43%. The decision model for the overall patient population yielded a comparatively lower AUC score of 78.87%. The variance of optimal sensitivity and specificity for all decision models, as identified using Youden J Index, is as follows: sensitivity=68.79% to 83.91% and specificity=76.03% to 92.18%. Conclusions: This study demonstrates the ability to automate screening for patients in need of advanced care for depression across (1) an overall patient population or (2) various high-risk patient groups using structured datasets covering acute and chronic conditions, patient demographics, behaviors, and past visit history. Furthermore, these results show considerable potential to enable preventative care and can be easily integrated into existing clinical workflows to improve access to wraparound health care services. %M 31333196 %R 10.2196/13809 %U http://www.jmir.org/2019/7/e13809/ %U https://doi.org/10.2196/13809 %U http://www.ncbi.nlm.nih.gov/pubmed/31333196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e12869 %T Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: Systematic Review %A Lattie,Emily G %A Adkins,Elizabeth C %A Winquist,Nathan %A Stiles-Shields,Colleen %A Wafford,Q Eileen %A Graham,Andrea K %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 3125033741, emily.lattie@northwestern.edu %K eHealth %K mHealth %K mental health %K students %K universities %D 2019 %7 22.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: College students are increasingly reporting common mental health problems, such as depression and anxiety, and they frequently encounter barriers to seeking traditional mental health treatments. Digital mental health interventions, such as those delivered via the Web and apps, offer the potential to improve access to mental health treatment. Objective: This study aimed to review the literature on digital mental health interventions focused on depression, anxiety, and enhancement of psychological well-being among samples of college students to identify the effectiveness, usability, acceptability, uptake, and adoption of such programs. Methods: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092800), and the search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) from the date of inception to April 2019. Data were synthesized using a systematic narrative synthesis framework, and formal quality assessments were conducted to address the risk of bias. Results: A total of 89 studies met the inclusion criteria. The majority of interventions (71/89, 80%) were delivered via a website, and the most common intervention was internet-based cognitive behavioral therapy (28, 31%). Many programs (33, 37%) featured human support in the form of coaching. The majority of programs were either effective (42, 47%) or partially effective (30, 34%) in producing beneficial changes in the main psychological outcome variables. Approximately half of the studies (45, 51%) did not present any usability or acceptability outcomes, and few studies (4, 4%) examined a broad implementation of digital mental health interventions on college campuses. Quality assessments revealed a moderate-to-severe risk of bias in many of the studies. Conclusions: Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psychological well-being among college students, but more rigorous studies are needed to ascertain the effective elements of these interventions. Continued research on improving the user experience of, and thus user engagement with, these programs appears vital for the sustainable implementation of digital mental health interventions on college campuses. %M 31333198 %R 10.2196/12869 %U http://www.jmir.org/2019/7/e12869/ %U https://doi.org/10.2196/12869 %U http://www.ncbi.nlm.nih.gov/pubmed/31333198 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e10876 %T Internet-Based Interventions for Carers of Individuals With Psychiatric Disorders, Neurological Disorders, or Brain Injuries: Systematic Review %A Spencer,Lucy %A Potterton,Rachel %A Allen,Karina %A Musiat,Peter %A Schmidt,Ulrike %+ Section of Eating Disorders, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 2078485608, lucy.spencer@kcl.ac.uk %K internet %K carers %K mental health %K technology %K review %D 2019 %7 09.07.2019 %9 Review %J J Med Internet Res %G English %X Background: Nonprofessional carers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, or low mood, and they perceive that they receive little support. Internet-based interventions have previously been found to be effective in the prevention and treatment of a range of mental health difficulties in carers. Objective: This review seeks to establish the status of internet-based interventions for informal (nonprofessional) carers of people with psychiatric or neurological disorders by investigating (1) the number and quality of studies evaluating the efficacy or effectiveness of internet-based carer interventions and (2) the impact that such interventions have on carer mental health, as well as (3) how internet-based interventions compare with other intervention types (eg, face-to-face treatment). Methods: A systematic literature search was conducted in January 2019 using the EMBASE (1974-present), Ovid MEDLINE (1946-present), PsychARTICLES, PsychINFO (1806-present), and Global Health (1973-present) databases, via the Ovid Technologies database. Search terms included carer, caregiver, online, technology, internet-based, internet, interactive, intervention, and evaluation. Studies selected for inclusion in this review met the following predetermined criteria: (1) delivering an intervention aimed primarily at informal carers, (2) carers supporting individuals with psychiatric disorders, stroke, dementia, or brain injury, (3) the intervention delivered to the carers was primarily internet based, (4) the study reported a pre- and postquantitative measure of carer depression, anxiety, stress, burden, or quality of life, (5) appeared in a peer-reviewed journal, and (6) was accessible in English. Results: A total of 46 studies were identified for inclusion through the detailed search strategy. The search was conducted, and data were extracted independently by 2 researchers. The majority of studies reported that 1 or more measures relating to carer mental health improved following receipt of a relevant intervention, with interventions for carers of people with traumatic brain injury showing a consistent link with improved outcomes. Conclusions: Studies investigating internet-based interventions for carers of individuals with diverse psychiatric or neurological difficulties show some evidence in support of the effectiveness of these interventions. In addition, such interventions are acceptable to carers. Available evidence is of varying quality, and more high-quality trials are needed. Further research should also establish how specific intervention components, such as structure or interactivity, contribute to their overall efficacy with regard to carer mental health. %M 31290399 %R 10.2196/10876 %U https://www.jmir.org/2019/7/e10876/ %U https://doi.org/10.2196/10876 %U http://www.ncbi.nlm.nih.gov/pubmed/31290399 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e13368 %T Virtual Reality and Web-Based Growth Mindset Interventions for Adolescent Depression: Protocol for a Three-Arm Randomized Trial %A Schleider,Jessica Lee %A Mullarkey,Michael C %A Weisz,John R %+ Department of Psychology, Stony Brook University, Psychology B 340, Stony Brook, NY,, United States, 1 631 632 4131, jessica.schleider@stonybrook.edu %K mental health %K depression %K virtual reality %K adolescence %K ehealth %D 2019 %7 09.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is the leading cause of disability in youth, with a global economic burden of US >$210 billion annually. However, up to 70% of youth with depression do not receive services. Even among those who do access treatment, 30% to 65% fail to respond and many dropout prematurely, demonstrating a need for more potent, accessible interventions. In a previous trial, a single-session Web-based growth mindset (GM) intervention significantly reduced depressive symptoms in high-symptom adolescents; however, this intervention did not benefit adolescents uniformly. For instance, the intervention reduced depression in adolescents who reported post intervention increases in perceived control, but it did not lead to significant depression reductions in adolescents who reported no significant post intervention increases in perceived control. Objective: The goal of this project is to test the acceptability and efficacy of a novel, single-session, virtual reality (VR) depression intervention—the VR Personality Project—teaching GM, the belief that personal attributes are malleable rather than fixed. The VR Personality Project was designed to systematically target and increase adolescents’ perceived control by offering a more immersive, engaging, user-directed intervention experience than the Web-based intervention can provide. By targeting an identified predictor of intervention response, the VR Personality Project may lead to larger reductions in depressive symptoms than existing Web-based mindset interventions. Methods: Adolescents with elevated depressive symptoms or a recent history of depression (N=159; ages 12 to 16 years) will be randomized to one of 3 intervention conditions: the VR Personality Project; the Web-based GM intervention tested previously; or an active, Web-based control. Adolescents and their parents will report on the adolescents’ depression symptoms, perceived control, and related domains of functioning at preintervention, postintervention, and at 3- and 9-month follow-up assessments. Results: We predict that the VR and Web-based mindset interventions will both lead to larger reductions in adolescent symptoms than the control intervention. Additionally, we predict that the VR-based single session intervention will lead to larger reductions in depression than the online mindset intervention and that these symptom reductions will be mediated by increases in adolescents’ perceived control from pre- to postintervention. Conclusions: The results may suggest an efficient strategy for reducing adolescent depressive symptoms: One that is mechanism-targeted, relatively affordable (less than US $200 for a commercially available VR headset, a fraction of the cost of long-term psychotherapy) and potentially engaging to adolescents experiencing mood-related distress. Trial Registration: ClinicalTrials.gov NCT0385881; https://clinicaltrials.gov/ct2/show/NCT03858881 (Archived by WebCite at http://www.webcitation.org/78C3roDgA). International Registered Report Identifier (IRRID): DERR1-10.2196/13368 %M 31290406 %R 10.2196/13368 %U https://www.researchprotocols.org/2019/7/e13368/ %U https://doi.org/10.2196/13368 %U http://www.ncbi.nlm.nih.gov/pubmed/31290406 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e13664 %T Reducing Patient Loneliness With Artificial Agents: Design Insights From Evolutionary Neuropsychiatry %A Loveys,Kate %A Fricchione,Gregory %A Kolappa,Kavitha %A Sagar,Mark %A Broadbent,Elizabeth %+ Department of Psychological Medicine, The University of Auckland, Auckland City Hospital, Level 12 Support Building, 85 Park Road, Grafton, Auckland, 1023, New Zealand, 64 9 373 7599 ext 84340, k.loveys@auckland.ac.nz %K loneliness %K neuropsychiatry %K biological evolution %K psychological bonding %K interpersonal relations %K artificial intelligence %K social support %K eHealth %D 2019 %7 08.07.2019 %9 Viewpoint %J J Med Internet Res %G English %X Loneliness is a growing public health issue that substantially increases the risk of morbidity and mortality. Artificial agents, such as robots, embodied conversational agents, and chatbots, present an innovation in care delivery and have been shown to reduce patient loneliness by providing social support. However, similar to doctor and patient relationships, the quality of a patient’s relationship with an artificial agent can impact support effectiveness as well as care engagement. Incorporating mammalian attachment-building behavior in neural network processing as part of an agent’s capabilities may improve relationship quality and engagement between patients and artificial agents. We encourage developers of artificial agents intended to relieve patient loneliness to incorporate design insights from evolutionary neuropsychiatry. %M 31287067 %R 10.2196/13664 %U https://www.jmir.org/2019/7/e13664/ %U https://doi.org/10.2196/13664 %U http://www.ncbi.nlm.nih.gov/pubmed/31287067 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e14199 %T Detecting Signs of Depression in Tweets in Spanish: Behavioral and Linguistic Analysis %A Leis,Angela %A Ronzano,Francesco %A Mayer,Miguel A %A Furlong,Laura I %A Sanz,Ferran %+ Research Programme on Biomedical Informatics, Hospital del Mar Medical Research Institute, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Carrer Dr Aiguader 88, Barcelona, 08003, Spain, 34 933 160 540, ferran.sanz@upf.edu %K depression %K social media %K mental health %K text mining %D 2019 %7 27.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental disorders have become a major concern in public health, and they are one of the main causes of the overall disease burden worldwide. Social media platforms allow us to observe the activities, thoughts, and feelings of people’s daily lives, including those of patients suffering from mental disorders. There are studies that have analyzed the influence of mental disorders, including depression, in the behavior of social media users, but they have been usually focused on messages written in English. Objective: The study aimed to identify the linguistic features of tweets in Spanish and the behavioral patterns of Twitter users who generate them, which could suggest signs of depression. Methods: This study was developed in 2 steps. In the first step, the selection of users and the compilation of tweets were performed. A total of 3 datasets of tweets were created, a depressive users dataset (made up of the timeline of 90 users who explicitly mentioned that they suffer from depression), a depressive tweets dataset (a manual selection of tweets from the previous users, which included expressions indicative of depression), and a control dataset (made up of the timeline of 450 randomly selected users). In the second step, the comparison and analysis of the 3 datasets of tweets were carried out. Results: In comparison with the control dataset, the depressive users are less active in posting tweets, doing it more frequently between 23:00 and 6:00 (P<.001). The percentage of nouns used by the control dataset almost doubles that of the depressive users (P<.001). By contrast, the use of verbs is more common in the depressive users dataset (P<.001). The first-person singular pronoun was by far the most used in the depressive users dataset (80%), and the first- and the second-person plural pronouns were the least frequent (0.4% in both cases), this distribution being different from that of the control dataset (P<.001). Emotions related to sadness, anger, and disgust were more common in the depressive users and depressive tweets datasets, with significant differences when comparing these datasets with the control dataset (P<.001). As for negation words, they were detected in 34% and 46% of tweets in among depressive users and in depressive tweets, respectively, which are significantly different from the control dataset (P<.001). Negative polarity was more frequent in the depressive users (54%) and depressive tweets (65%) datasets than in the control dataset (43.5%; P<.001). Conclusions: Twitter users who are potentially suffering from depression modify the general characteristics of their language and the way they interact on social media. On the basis of these changes, these users can be monitored and supported, thus introducing new opportunities for studying depression and providing additional health care services to people with this disorder. %M 31250832 %R 10.2196/14199 %U http://www.jmir.org/2019/6/e14199/ %U https://doi.org/10.2196/14199 %U http://www.ncbi.nlm.nih.gov/pubmed/31250832 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e13230 %T Teens Using Screens for Help: Impact of Suicidal Ideation, Anxiety, and Depression Levels on Youth Preferences for Telemental Health Resources %A Toscos,Tammy %A Coupe,Amanda %A Flanagan,Mindy %A Drouin,Michelle %A Carpenter,Maria %A Reining,Lauren %A Roebuck,Amelia %A Mirro,Michael J %+ Parkview Research Center, Parkview Health, 10622 Parkview Plaza Drive, Fort Wayne, IN, 46845, United States, 1 260 266 5586, tammy.toscos@parkview.com %K adolescent %K students %K telemedicine %K mental health %K suicidal ideation %K depression %K anxiety %K health resources %K online social networking %K mental health services %K help-seeking behavior %D 2019 %7 21.6.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: High rates of mental illness, stress, and suicidality among teens constitute a major public health concern in the United States. However, treatment rates remain low, partially because of barriers that could be mitigated with tech-based telemental health (TMH) resources, separate from or in addition to traditional care. Objective: This study aimed to analyze TMH resource usage by high school students to establish current user characteristics and provide a framework for future development. Methods: A total of 2789 students were surveyed regarding demographics, recent anxiety and depression symptoms, suicidality, and stress; people with whom they could openly and honestly discuss stress or problems, and prior TMH use. Logistic regression models and a general linear model were used to test relationships between variables. Results: Overall, 30.58% (853/2789) and 22.91% (639/2789) of students reported moderate to severe anxiety and depression symptoms, respectively, in the past 2 weeks; 16.24% (414/2550) had seriously considered suicide in the past year, consistent with national averages. Meanwhile, 16.03% (447/2789) of students had previously used at least 1 of 4 types of TMH resources (ie, self-help, anonymous chat, online counselor, or crisis text line). Teens reporting depression symptoms, higher stress, or suicidality were less likely to talk to a parent about stress or problems and more likely to tell no one. Suicidality was related to the use of all 4 types of TMH resources. Depression symptoms were related to the use of anonymous chat and crisis text line, and those with higher stress were more likely to have used an online counselor. Those reporting anxiety symptoms were less likely to have no one to talk to and more likely to have used a self-help resource. Conclusions: Youth struggling with mental health symptoms, some of whom lack real-life confidants, are using existing TMH support, with resource preferences related to symptoms. Future research should consider these preferences and assist in the creation of specialized, evidence-based TMH resources. %M 31228179 %R 10.2196/13230 %U http://mental.jmir.org/2019/6/e13230/ %U https://doi.org/10.2196/13230 %U http://www.ncbi.nlm.nih.gov/pubmed/31228179 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13500 %T Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive for Affective Disorders: Secondary Analysis %A Watson,Noreen L %A Heffner,Jaimee L %A Mull,Kristin E %A McClure,Jennifer B %A Bricker,Jonathan B %+ Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-B232, Seattle, WA,, United States, 1 206 667 2942, nlwatson@fredhutch.org %K smoking %K smoking cessation %K affective disorders %K anxiety %K depression %K eHealth %K Web intervention %K co-occurring disorders %D 2019 %7 19.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required. Objective: The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS. Methods: Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS—either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records. Results: Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates. Conclusions: Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS. Trial registration: Clinical Trials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/78L9cNdG4) %M 31219052 %R 10.2196/13500 %U https://www.jmir.org/2019/6/e13500/ %U https://doi.org/10.2196/13500 %U http://www.ncbi.nlm.nih.gov/pubmed/31219052 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e11701 %T Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru %A Brandt,Lena R %A Hidalgo,Liliana %A Diez-Canseco,Francisco %A Araya,Ricardo %A Mohr,David C %A Menezes,Paulo R %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Avenida Armendariz 497, Miraflores, Lima, Peru, 51 12416978, fdiezcanseco@gmail.com %K mental health %K depression %K noncommunicable diseases %K mHealth %K smartphone %K developing countries %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression. %M 31215511 %R 10.2196/11701 %U https://mental.jmir.org/2019/6/e11701/ %U https://doi.org/10.2196/11701 %U http://www.ncbi.nlm.nih.gov/pubmed/31215511 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e12554 %T Early Detection of Depression: Social Network Analysis and Random Forest Techniques %A Cacheda,Fidel %A Fernandez,Diego %A Novoa,Francisco J %A Carneiro,Victor %+ Department of Computer Science, Faculty of Computer Science, University of A Coruna, Campus de Elvina, A Coruna, 15071, Spain, 34 881011213, diego.fernandez@udc.es %K depression %K major depressive disorder %K social media %K artificial intelligence %K machine learning %D 2019 %7 10.6.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder (MDD) or depression is among the most prevalent psychiatric disorders, affecting more than 300 million people globally. Early detection is critical for rapid intervention, which can potentially reduce the escalation of the disorder. Objective: This study used data from social media networks to explore various methods of early detection of MDDs based on machine learning. We performed a thorough analysis of the dataset to characterize the subjects’ behavior based on different aspects of their writings: textual spreading, time gap, and time span. Methods: We proposed 2 different approaches based on machine learning singleton and dual. The former uses 1 random forest (RF) classifier with 2 threshold functions, whereas the latter uses 2 independent RF classifiers, one to detect depressed subjects and another to identify nondepressed individuals. In both cases, features are defined from textual, semantic, and writing similarities. Results: The evaluation follows a time-aware approach that rewards early detections and penalizes late detections. The results show how a dual model performs significantly better than the singleton model and is able to improve current state-of-the-art detection models by more than 10%. Conclusions: Given the results, we consider that this study can help in the development of new solutions to deal with the early detection of depression on social networks. %M 31199323 %R 10.2196/12554 %U http://www.jmir.org/2019/6/e12554/ %U https://doi.org/10.2196/12554 %U http://www.ncbi.nlm.nih.gov/pubmed/31199323 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e12556 %T Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression %A Moberg,Christine %A Niles,Andrea %A Beermann,Dale %+ Pacifica Labs, Inc, 150 S 5th Street, Suite 825, Minneapolis, MN, 55402, United States, 1 6083470325, christine.moberg@gmail.com %K mHealth %K anxiety %K depression %K stress %K cognitive behavioral therapy %K smartphone app %D 2019 %7 8.6.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite substantial improvements in technology and the increased demand for technology-enabled behavioral health tools among consumers, little progress has been made in easing the burden of mental illness. This may be because of the inherent challenges of conducting traditional clinical trials in a rapidly evolving technology landscape. Objective: This study sought to validate the effectiveness of Pacifica, a popular commercially available app for the self-management of mild-to-moderate stress, anxiety, and depression. Methods: A total of 500 adults with mild-to-moderate anxiety or depression were recruited from in-app onboarding to participate in a randomized waitlist controlled trial of Pacifica. We conducted an all-virtual study, recruiting, screening, and randomizing participants through a Web-based participant portal. Study participants used the app for 1 month, with no level of use required, closely mimicking real-world app usage. Participants in the waitlist group were given access to the app after 1 month. Measurements included self-reported symptoms of stress, anxiety, depression, and self-efficacy. We performed an intent-to-treat analysis to examine the interactive effects of time and condition. Results: We found significant interactions between time and group. Participants in the active condition demonstrated significantly greater decreases in depression, anxiety, and stress and increases in self-efficacy. Although we did not find a relationship between overall engagement with the app and symptom improvement, participants who completed relatively more thought record exercises sustained improvements in their symptoms through the 2-month follow-up to a greater degree than those who completed fewer. In addition, we found that participants who reported concomitantly taking psychiatric medications during the trial benefitted less from the app, as measured by the symptoms of anxiety and stress. Conclusions: This study provides evidence that Pacifica, a popular commercially available self-help app, is effective in reducing self-reported symptoms of depression, anxiety, and stress, particularly among individuals who utilize thought records and are not taking psychiatric medication. Trial Registration: ClinicalTrials.gov NCT03333707; https://clinicaltrials.gov/ct2/show/NCT03333707 (Archived by WebCite at http://www.webcitation.org/78YE07ADB) %M 31199319 %R 10.2196/12556 %U https://www.jmir.org/2019/6/e12556/ %U https://doi.org/10.2196/12556 %U http://www.ncbi.nlm.nih.gov/pubmed/31199319 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13172 %T Optional Web-Based Videoconferencing Added to Office-Based Care for Women Receiving Psychotherapy During the Postpartum Period: Pilot Randomized Controlled Trial %A Yang,Rebecca %A Vigod,Simone N %A Hensel,Jennifer M %+ Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville Street, 6th Floor, Toronto, ON, M5S 1B2, Canada, 1 416 323 6400 ext 5989, rebecca.yang@wchospital.ca %K mental health %K psychotherapy %K postpartum period %K videoconferencing %D 2019 %7 20.5.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care. Objective: The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period. Methods: We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score. Results: We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms. Conclusions: The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive. %M 31199291 %R 10.2196/13172 %U https://www.jmir.org/2019/6/e13172/ %U https://doi.org/10.2196/13172 %U http://www.ncbi.nlm.nih.gov/pubmed/31199291 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e10838 %T A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial %A Hensel,Jennifer M %A Shaw,James %A Ivers,Noah M %A Desveaux,Laura %A Vigod,Simone N %A Cohen,Ashley %A Onabajo,Nike %A Agarwal,Payal %A Mukerji,Geetha %A Yang,Rebecca %A Nguyen,Megan %A Bouck,Zachary %A Wong,Ivy %A Jeffs,Lianne %A Jamieson,Trevor %A Bhatia,R Sacha %+ Women's College Institute for Health Systems Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 416 323 6400 ext 5126, jennifer.hensel@wchospital.ca %K internet %K mental health %K anxiety %K depression %D 2019 %7 04.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support. Objective: The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. Methods: A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. Results: Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (−1.83 points, 95% CI −2.85 to −0.82) and GAD-7 score (−1.55 points, 95% CI −2.42 to −0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. Conclusions: The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions. Trial Registration: ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO) %M 31165710 %R 10.2196/10838 %U https://www.jmir.org/2019/6/e10838/ %U https://doi.org/10.2196/10838 %U http://www.ncbi.nlm.nih.gov/pubmed/31165710 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13689 %T The Effectiveness of an App-Based Nurse-Moderated Program for New Mothers With Depression and Parenting Problems (eMums Plus): Pragmatic Randomized Controlled Trial %A Sawyer,Alyssa %A Kaim,Amy %A Le,Huynh-Nhu %A McDonald,Denise %A Mittinty,Murthy %A Lynch,John %A Sawyer,Michael %+ School of Public Health, University of Adelaide, Adelaide Health & Medical Sciences Building, 57 North Terrace, Mail Drop DX 650 550, Adelaide, 5005, Australia, 61 8 81617207, alyssa.sawyer@adelaide.edu.au %K mobile phone %K infant %K mother-child relations %K postnatal depression %K randomized controlled trial %D 2019 %7 04.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Postnatal depression and caregiving difficulties adversely affect mothers, infants, and later childhood development. In many countries, resources to help mothers and infants are limited. Online group–based nurse-led interventions have the potential to help address this problem by providing large numbers of mothers with access to professional and peer support during the postnatal period. Objective: This study tested the effectiveness of a 4-month online group–based nurse-led intervention delivered when infants were aged 2 to 6 months as compared with standard care outcomes. Methods: The study was a block randomized control trial. Mothers were recruited at the time they were contacted for the postnatal health check offered to all mothers in South Australia. Those who agreed to participate were randomly assigned to the intervention or standard care. The overall response rate was 63.3% (133/210). Primary outcomes were the level of maternal depressive symptoms assessed with the Edinburgh Postnatal Depression Scale (EPDS) and quality of maternal caregiving assessed using the Parenting Stress Index (PSI; competence and attachment subscales), the Parenting Sense of Competence Scale (PSCS), and the Nursing Child Assessment Satellite Training Scale. Assessments were completed at baseline (mean child age 4.9 weeks [SD 1.4]) and again when infants were aged 8 and 12 months. Results: Outcomes were evaluated using linear generalized estimating equations adjusting for postrandomization group differences in demographic characteristics and the outcome score at baseline. There were no significant differences in the intervention and standard care groups in scores on the PSI competence subscale (P=.69) nor in the PSCS (P=.11). Although the group by time interaction suggested there were differences over time between the EPDS and PSI attachment subscale scores in the intervention and standard care groups (P=.001 and P=.04, respectively), these arose largely because the intervention group had stable scores over time whereas the standard care group showed some improvements between baseline and 12 months. Mothers engaged well with the intervention with at least 60% (43/72) of mothers logging-in once per week during the first 11 weeks of the intervention. The majority of mothers also rated the intervention as helpful and user-friendly. Conclusions: Mothers reported that the intervention was helpful, and the app was described as easy to use. As such, it appears that support for mothers during the postnatal period, provided using mobile phone technology, has the potential to be an important addition to existing services. Possible explanations for the lack of differences in outcomes for the 2 groups in this study are the failure of many mothers to use key components of the intervention and residual differences between the intervention and standard care groups post randomization. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616001732471; http://www.ANZCTR.org.au/ACTRN12616001732471.aspx (archived on WebCite as http://www.webcitation.org/77zo30GDw) %M 31165715 %R 10.2196/13689 %U https://www.jmir.org/2019/6/e13689/ %U https://doi.org/10.2196/13689 %U http://www.ncbi.nlm.nih.gov/pubmed/31165715 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e10778 %T A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial %A Duffecy,Jennifer %A Grekin,Rebecca %A Hinkel,Hannah %A Gallivan,Nicholas %A Nelson,Graham %A O'Hara,Michael W %+ Department of Psychiatry, College of Medicine, University of Illinois at Chicago, 912 S Wood, Chicago, IL, 60612, United States, 1 3124131225, jduffecy@gmail.com %K postpartum depression %K cognitive behavioral therapy %K internet %K social support %D 2019 %7 28.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objectives: This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes. Methods: User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum. Results: A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent. Trial Registration: ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy) %M 31140443 %R 10.2196/10778 %U http://mental.jmir.org/2019/5/e10778/ %U https://doi.org/10.2196/10778 %U http://www.ncbi.nlm.nih.gov/pubmed/31140443 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12793 %T Recruiting to a Randomized Controlled Trial of a Web-Based Program for People With Type 2 Diabetes and Depression: Lessons Learned at the Intersection of e-Mental Health and Primary Care %A Fletcher,Susan %A Clarke,Janine %A Sanatkar,Samineh %A Baldwin,Peter %A Gunn,Jane %A Zwar,Nick %A Campbell,Lesley %A Wilhelm,Kay %A Harris,Mark %A Lapsley,Helen %A Hadzi-Pavlovic,Dusan %A Proudfoot,Judy %+ Department of General Practice, University of Melbourne, Ground Floor, 200 Berkeley Street, Carlton, 3052, Australia, 61 390354872, susanlf@unimelb.edu.au %K e-mental health %K primary care %K patient recruitment %K depression %K type 2 diabetes %K learning %D 2019 %7 24.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: E-mental health (eMH) interventions are now widely available and they have the potential to revolutionize the way that health care is delivered. As most health care is currently delivered by primary care, there is enormous potential for eMH interventions to support, or in some cases substitute, services currently delivered face to face in the community setting. However, randomized trials of eMH interventions have tended to recruit participants using online recruitment methods. Consequently, it is difficult to know whether participants who are recruited online differ from those who attend primary care. Objective: This paper aimed to document the experience of recruiting to an eMH trial through primary care and compare the characteristics of participants recruited through this and other recruitment methods. Methods: Recruitment to the SpringboarD randomized controlled trial was initially focused on general practices in 2 states of Australia. Over 15 months, we employed a comprehensive approach to engaging practice staff and supporting them to recruit patients, including face-to-face site visits, regular contact via telephone and trial newsletters, and development of a Web-based patient registration portal. Nevertheless, it became apparent that these efforts would not yield the required sample size, and we therefore supplemented recruitment through national online advertising and promoted the study through existing networks. Baseline characteristics of participants recruited to the trial through general practice, online, or other sources were compared using the analysis of variance and chi square tests. Results: Between November 2015 and October 2017, 780 people enrolled in SpringboarD, of whom 740 provided information on the recruitment source. Of these, only 24 were recruited through general practice, whereas 520 were recruited online and 196 through existing networks. Key barriers to general practice recruitment included perceived mismatch between trial design and diabetes population, prioritization of acute health issues, and disruptions posed by events at the practice and community level. Participants recruited through the 3 different approaches differed in age, gender, employment status, depressive symptoms, and diabetes distress, with online participants being distinguished from those recruited through general practice or other sources. However, most differences reached only a small effect size and are unlikely to be of clinical importance. Conclusions: Time, labor, and cost-intensive efforts did not translate into successful recruitment through general practice in this instance, with barriers identified at several different levels. Online recruitment yielded more participants, who were broadly similar to those recruited via general practice. %M 31127718 %R 10.2196/12793 %U https://www.jmir.org/2019/5/e12793/ %U https://doi.org/10.2196/12793 %U http://www.ncbi.nlm.nih.gov/pubmed/31127718 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12246 %T A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial %A Clarke,Janine %A Sanatkar,Samineh %A Baldwin,Peter Andrew %A Fletcher,Susan %A Gunn,Jane %A Wilhelm,Kay %A Campbell,Lesley %A Zwar,Nicholas %A Harris,Mark %A Lapsley,Helen %A Hadzi-Pavlovic,Dusan %A Christensen,Helen %A Proudfoot,Judy %+ Black Dog Institute, Hospital Road, Randwick, Sydney,, Australia, 61 0293824521, p.baldwin@unsw.edu.au %K type 2 diabetes %K depression %K internet %D 2019 %7 21.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression. Objective: The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined. Methods: Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Results: myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement. Conclusions: Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi) %M 31115345 %R 10.2196/12246 %U http://www.jmir.org/2019/5/e12246/ %U https://doi.org/10.2196/12246 %U http://www.ncbi.nlm.nih.gov/pubmed/31115345 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 11 %N 2 %P e11167 %T Patient Perspective of Cognitive Symptoms in Major Depressive Disorder: Retrospective Database and Prospective Survey Analyses %A Chiauzzi,Emil %A Drahos,Jennifer %A Sarkey,Sara %A Curran,Christopher %A Wang,Victor %A Tomori,Dapo %+ PatientsLikeMe, 160 Second Street, Cambridge, MA, 02142, United States, 1 617 499 4003, echiauzzi@patientslikeme.com %K cognition %K cognitive function %K depression %K major depressive disorder %K patient-centered care %K patient preference %K relapse %K remission %K symptoms %D 2019 %7 16.05.2019 %9 Original Paper %J J Participat Med %G English %X Background: Major depressive disorder (MDD) is a common and burdensome condition. The clinical understanding of MDD is shaped by current research, which lacks insight into the patient perspective. Objective: This two-part study aimed to generate data from PatientsLikeMe, an online patient network, on the perception of cognitive symptoms and their prioritization in MDD. Methods: A retrospective data analysis (study 1) was used to analyze data from the PatientsLikeMe community with self-reported MDD. Information on patient demographics, comorbidities, self-rated severity of MDD, treatment effectiveness, and specific symptoms of MDD was analyzed. A prospective electronic survey (study 2) was emailed to longstanding and recently active members of the PatientsLikeMe MDD community. Study 1 analysis informed the objectives of the study 2 survey, which were to determine symptom perception and prioritization, cognitive symptoms of MDD, residual symptoms, and medication effectiveness. Results: In study 1 (N=17,166), cognitive symptoms were frequently reported, including “severe” difficulty in concentrating (28%). Difficulty in concentrating was reported even among patients with no/mild depression (80%) and those who considered their treatment successful (17%). In study 2 (N=2525), 23% (118/508) of patients cited cognitive symptoms as a treatment priority. Cognitive symptoms correlated with depression severity, including difficulty in making decisions, concentrating, and thinking clearly (rs=0.32, 0.36, and 0.34, respectively). Cognitive symptoms interfered with meaningful relationships and daily life tasks and had a profound impact on patients’ ability to work and recover from depression. Conclusions: Patients acknowledge that cognitive dysfunction in MDD limits their ability to recover fully and return to a normal level of social and occupational functioning. Further clinical understanding and characterization of MDD for symptom prioritization and relapse risk due to residual cognitive impairment are required to help patients return to normal cognitive function and aid their overall recovery. %R 10.2196/11167 %U https://jopm.jmir.org/2019/2/e11167/ %U https://doi.org/10.2196/11167 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e12794 %T Using Smartphone-Based Psychoeducation to Reduce Postnatal Depression Among First-Time Mothers: Randomized Controlled Trial %A Chan,Ko Ling %A Leung,Wing Cheong %A Tiwari,Agnes %A Or,Ka Lun %A Ip,Patrick %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,, China (Hong Kong), 852 2766 5709, koling.chan@polyu.edu.hk %K smartphone technology %K postnatal depression %K psychoeducation %K randomized controlled trial %D 2019 %7 14.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based psychoeducation interventions may be a low-cost, user-friendly alternative to resource-consuming, face-to-face antenatal classes to educate expectant mothers. Objective: This study aimed to empirically examine whether such an intervention would lead to reduced postnatal depression, anxiety, or stress and result in a better health-related quality of life. Methods: A single-blind randomized controlled trial was conducted in Hong Kong. All first-time expectant mothers with less than 24 weeks of gestation remaining and attending the antenatal clinic at a public hospital were included. Participants were assigned to the intervention group or the control group by drawing lots. The lots, presented in sealed opaque envelopes, were randomly designated as “intervention” or “control” by stratified randomization. The intervention, a psychoeducational mobile app, was provided in addition to the treatment as usual (TAU) services from the hospital. Follow up with participants took place at 4 weeks postpartum. The primary outcome was the difference in the levels of antenatal and postnatal depression, assessed by the Edinburgh Postnatal Depression Scale (EPDS). The intention-to-treat approach was employed in the analyses. Results: The final sample was 660 expectant mothers (nintervention=330 and ncontrol=330). The mean difference in EPDS scores between the two groups was −0.65 (95% CI −1.29 to 0.00; P=.049) after adjusting for confounding factors. Associations were found between participation in the intervention and reduced depression, and attendance in TAU classes and increased stress levels. Conclusions: The smartphone-based intervention plus TAU services was effective in reducing postnatal depression at 4 weeks postpartum compared with a control condition of TAU only, making this a cost-effective alternative to TAU education for expectant mothers. Limitations of the study included the short postpartum period after which the follow-up assessment was conducted and the inclusion of first-time mothers rather than all mothers. Trial Registration: HKU Clinical Trials Registry HKUCTR-2024; http://www.hkuctr.com/Study/Show/ 34f62a2f6d594273a290491827206384 %M 31094354 %R 10.2196/12794 %U http://mhealth.jmir.org/2019/5/e12794/ %U https://doi.org/10.2196/12794 %U http://www.ncbi.nlm.nih.gov/pubmed/31094354 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11349 %T Reducing Stress and Preventing Depression (RESPOND): Randomized Controlled Trial of Web-Based Rumination-Focused Cognitive Behavioral Therapy for High-Ruminating University Students %A Cook,Lorna %A Mostazir,Mohammod %A Watkins,Edward %+ SMART Lab, Mood Disorders Centre, School of Psychology, University of Exeter, Sir Henry Wellcome Building for Mood Disorders Research, Queens Drive, Exeter, EX4 4QG, United Kingdom, 44 (0) 139272 ext 4692, E.R.Watkins@exeter.ac.uk %K cognitive behavioral therapy %K depression %K prevention %K rumination, cognitive %K stress, psychological %K student health services %D 2019 %7 13.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Prevention of depression is a priority to reduce its global disease burden. Targeting specific risk factors, such as rumination, may improve prevention. Rumination-focused Cognitive Behavioral Therapy (RFCBT) was developed to specifically target depressive rumination. Objective: The primary objective of this study was to test whether guided Web-based RFCBT (i-RFCBT) would prevent the incidence of major depression relative to usual care in UK university students. The secondary objective was to test the feasibility and estimated effect sizes of unguided i-RFCBT. Methods: To address the primary objective, a phase III randomized controlled trial was designed and powered to compare high risk university students (N=235), selected with elevated worry/rumination, recruited via an open access website in response to circulars within universities and internet advertisements, randomized to receive either guided i-RFCBT (interactive Web-based RFCBT, supported by asynchronous written Web-based support from qualified therapists) or usual care control. To address the secondary objective, participants were also randomized to an adjunct arm of unguided (self-administered) i-RFCBT. The primary outcome was the onset of a major depressive episode over 15 months, assessed with structured diagnostic interviews at 3 (postintervention), 6, and 15 months post randomization, conducted by telephone, blind to the condition. Secondary outcomes of symptoms of depression and anxiety and levels of worry and rumination were self-assessed through questionnaires at baseline and the same follow-up intervals. Results: Participants were randomized to guided i-RFCBT (n=82), unguided i-RFCBT (n=76), or usual care (n=77). Guided i-RFCBT reduced the risk of depression by 34% relative to usual care (hazard ratio [HR] 0.66, 95% CI 0.35 to 1.25; P=.20). Participants with higher levels of baseline stress benefited most from the intervention (HR 0.43, 95% CI 0.21 to 0.87; P=.02). Significant improvements in rumination, worry, and depressive symptoms were found in the short-to-medium term. Of the 6 modules, guided participants completed a mean of 3.46 modules (SD 2.25), with 46% (38/82) being compliant (completing ≥4 modules). Similar effect sizes and compliance rates were found for unguided i-RFCBT. Conclusions: Guided i-RFCBT can reduce the onset of depression in high-risk young people reporting high levels of worry/rumination and stress. The feasibility study argues for formally testing unguided i-RFCBT for prevention: if the observed effect sizes are robustly replicated in a phase III trial, it has potential as a scalable prevention intervention. Trial Registration: ISRCTN Registry ISRCTN12683436; https://www.isrctn.com/ISRCTN12683436 (Archived by WebCite at http://www.webcitation.org/77fqycyBX) International Registered Report Identifier (IRRID): RR2-10.1186/s13063-015-1128-9 %M 31094331 %R 10.2196/11349 %U https://www.jmir.org/2019/5/e11349/ %U https://doi.org/10.2196/11349 %U http://www.ncbi.nlm.nih.gov/pubmed/31094331 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11705 %T Proactive Suicide Prevention Online (PSPO): Machine Identification and Crisis Management for Chinese Social Media Users With Suicidal Thoughts and Behaviors %A Liu,Xingyun %A Liu,Xiaoqian %A Sun,Jiumo %A Yu,Nancy Xiaonan %A Sun,Bingli %A Li,Qing %A Zhu,Tingshao %+ Institute of Psychology, Chinese Academy of Sciences, No.16, Lincui Road, Beijing,, China, 86 150 1096 5509, tszhu@psych.ac.cn %K suicide identification %K crisis management %K machine learning %K microblog direct message %K social network %K Chinese young people %D 2019 %7 08.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a great public health challenge. Two hundred million people attempt suicide in China annually. Existing suicide prevention programs require the help-seeking initiative of suicidal individuals, but many of them have a low motivation to seek the required help. We propose that a proactive and targeted suicide prevention strategy can prompt more people with suicidal thoughts and behaviors to seek help. Objective: The goal of the research was to test the feasibility and acceptability of Proactive Suicide Prevention Online (PSPO), a new approach based on social media that combines proactive identification of suicide-prone individuals with specialized crisis management. Methods: We first located a microblog group online. Their comments on a suicide note were analyzed by experts to provide a training set for the machine learning models for suicide identification. The best-performing model was used to automatically identify posts that suggested suicidal thoughts and behaviors. Next, a microblog direct message containing crisis management information, including measures that covered suicide-related issues, depression, help-seeking behavior and an acceptability test, was sent to users who had been identified by the model to be at risk of suicide. For those who replied to the message, trained counselors provided tailored crisis management. The Simplified Chinese Linguistic Inquiry and Word Count was also used to analyze the users’ psycholinguistic texts in 1-month time slots prior to and postconsultation. Results: A total of 27,007 comments made in April 2017 were analyzed. Among these, 2786 (10.32%) were classified as indicative of suicidal thoughts and behaviors. The performance of the detection model was good, with high precision (.86), recall (.78), F-measure (.86), and accuracy (.88). Between July 3, 2017, and July 3, 2018, we sent out a total of 24,727 direct messages to 12,486 social media users, and 5542 (44.39%) responded. Over one-third of the users who were contacted completed the questionnaires included in the direct message. Of the valid responses, 89.73% (1259/1403) reported suicidal ideation, but more than half (725/1403, 51.67%) reported that they had not sought help. The 9-Item Patient Health Questionnaire (PHQ-9) mean score was 17.40 (SD 5.98). More than two-thirds of the participants (968/1403, 69.00%) thought the PSPO approach was acceptable. Moreover, 2321 users replied to the direct message. In a comparison of the frequency of word usage in their microblog posts 1-month before and after the consultation, we found that the frequency of death-oriented words significantly declined while the frequency of future-oriented words significantly increased. Conclusions: The PSPO model is suitable for identifying populations that are at risk of suicide. When followed up with proactive crisis management, it may be a useful supplement to existing prevention programs because it has the potential to increase the accessibility of antisuicide information to people with suicidal thoughts and behaviors but a low motivation to seek help. %M 31344675 %R 10.2196/11705 %U https://www.jmir.org/2019/5/e11705/ %U https://doi.org/10.2196/11705 %U http://www.ncbi.nlm.nih.gov/pubmed/31344675 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e9766 %T An Approach for Data Mining of Electronic Health Record Data for Suicide Risk Management: Database Analysis for Clinical Decision Support %A Berrouiguet,Sofian %A Billot,Romain %A Larsen,Mark Erik %A Lopez-Castroman,Jorge %A Jaussent,Isabelle %A Walter,Michel %A Lenca,Philippe %A Baca-García,Enrique %A Courtet,Philippe %+ Adult Psychiatry, Brest Medical University Hospital at Bohars, Route de Ploudalmezeau, Brest, 29200, France, 33 668204178, sofian.berrouiguet@gmail.com %K clinical decision support system %K data mining %K electronic health %K mobile phone %K prevention %K suicide %K suicide attempts %D 2019 %7 07.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: In an electronic health context, combining traditional structured clinical assessment methods and routine electronic health–based data capture may be a reliable method to build a dynamic clinical decision-support system (CDSS) for suicide prevention. Objective: The aim of this study was to describe the data mining module of a Web-based CDSS and to identify suicide repetition risk in a sample of suicide attempters. Methods: We analyzed a database of 2802 suicide attempters. Clustering methods were used to identify groups of similar patients, and regression trees were applied to estimate the number of suicide attempts among these patients. Results: We identified 3 groups of patients using clustering methods. In addition, relevant risk factors explaining the number of suicide attempts were highlighted by regression trees. Conclusions: Data mining techniques can help to identify different groups of patients at risk of suicide reattempt. The findings of this study can be combined with Web-based and smartphone-based data to improve dynamic decision making for clinicians. %M 31066693 %R 10.2196/mental.9766 %U https://mental.jmir.org/2019/5/e9766/ %U https://doi.org/10.2196/mental.9766 %U http://www.ncbi.nlm.nih.gov/pubmed/31066693 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11860 %T Effects, Adherence, and Therapists’ Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study %A Schuster,Raphael %A Kalthoff,Inanna %A Walther,Alexandra %A Köhldorfer,Lena %A Partinger,Edith %A Berger,Thomas %A Laireiter,Anton-Rupert %+ Center for Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, Salzburg, 5020, Austria, 43 6644156146, raphael.schuster@stud.sbg.ac.at %K eHealth %K mobile phone %K computer-assisted therapy %K monitoring %K group therapy %K depression %K professional-patient relations %D 2019 %7 06.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients’ adherence to and therapists’ perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings. Objective: This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format. Methods: A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey. Results: Primary symptom reduction was high (d=1.31 to 1.51) and remained stable for the follow-up period. Therapists identified advantages (eg, patient engagement, treatment intensification, and improved therapeutic relation) and disadvantages (eg, increased workload, data issues, and undesired effects) of bGT. The required online guidance time was 10.3 min per patient and week, including guidance on exercises (67% or 6.9 min) and intimate communication (33% or 3.4 min). Concerning patients’ adherence to bGT, tracked completion of all Web-based and mobile tasks was high and comparable with group attendance. Conclusions: Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions. %M 31066700 %R 10.2196/11860 %U https://www.jmir.org/2019/5/e11860/ %U https://doi.org/10.2196/11860 %U http://www.ncbi.nlm.nih.gov/pubmed/31066700 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e13183 %T Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org %A Whiteside,Ursula %A Richards,Julie %A Huh,David %A Hidalgo,Rianna %A Nordhauser,Rebecca %A Wong,Albert J %A Zhang,Xiaoshan %A Luxton,David D %A Ellsworth,Michael %A Lezine,DeQuincy %+ NowMattersNow.org, 2331 E Madison St, Seattle, WA, 98112, United States, 1 206 679 6349, ursulawhiteside@gmail.com %K dialectical behavior therapy %K suicide %K internet %K help-seeking behavior %K behavior therapy %K crisis intervention %K primary care %K integrated health care systems %D 2019 %7 02.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need. Objective: This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys. Methods: NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated. Results: During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or “completely overwhelming” when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (–0.21, P<.001) and negative emotions (–0.32, P<.001), including decreases for users with the most severe suicidal thoughts (–6.4%, P<.001), most severe negative emotions (–10.9%, P<.001), and for middle-aged men (–0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet). Conclusions: Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions. %M 31045498 %R 10.2196/13183 %U http://www.jmir.org/2019/5/e13183/ %U https://doi.org/10.2196/13183 %U http://www.ncbi.nlm.nih.gov/pubmed/31045498 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e11800 %T Expanding Access to Depression Treatment in Kenya Through Automated Psychological Support: Protocol for a Single-Case Experimental Design Pilot Study %A Green,Eric P %A Pearson,Nicholas %A Rajasekharan,Sathyanath %A Rauws,Michiel %A Joerin,Angela %A Kwobah,Edith %A Musyimi,Christine %A Bhat,Chaya %A Jones,Rachel M %A Lai,Yihuan %+ Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, United States, 1 919 681 7289, eric.green@duke.edu %K telemedicine %K mental health %K depression %K artificial intelligence %K Kenya %K text messaging %K chatbot %K conversational agent %D 2019 %7 29.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users. Objective: The objective of this pilot study is to test the Healthy Moms perinatal depression intervention using a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya. Methods: We will invite patients to complete a brief, automated screening delivered via text messages to determine their eligibility. Enrolled participants will be randomized to a 1- or 2-week baseline period and then invited to begin using Zuri. Participants will be prompted to rate their mood via short message service every 3 days during the baseline and intervention periods. We will review system logs and conduct in-depth interviews with participants to study engagement with the intervention, feasibility, and acceptability. We will use visual inspection, in-depth interviews, and Bayesian estimation to generate preliminary data about the potential response to treatment. Results: Our team adapted the intervention content in April and May 2018 and completed an initial prepilot round of formative testing with 10 women from a private maternity hospital in May and June. In preparation for this pilot study, we used feedback from these users to revise the structure and content of the intervention. Recruitment for this protocol began in early 2019. Results are expected toward the end of 2019. Conclusions: The main limitation of this pilot study is that we will recruit women who live in urban and periurban centers in one part of Kenya. The results of this study may not generalize to the broader population of Kenyan women, but that is not an objective of this phase of work. Our primary objective is to gather preliminary data to know how to build and test a more robust service. We are working toward a larger study with a more diverse population. International Registered Report Identifier (IRRID): DERR1-10.2196/11800 %M 31033448 %R 10.2196/11800 %U http://www.researchprotocols.org/2019/4/e11800/ %U https://doi.org/10.2196/11800 %U http://www.ncbi.nlm.nih.gov/pubmed/31033448 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11698 %T Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru %A Menezes,Paulo %A Quayle,Julieta %A Garcia Claro,Heloísa %A da Silva,Simone %A Brandt,Lena R %A Diez-Canseco,Francisco %A Miranda,J Jaime %A Price,LeShawndra N %A Mohr,David C %A Araya,Ricardo %+ Department of Preventive Medicine, University of São Paulo, Rua Doutor Arnaldo 455, Cerqueira César, São Paulo, 01246903, Brazil, 55 1130617093, pmenezes@usp.br %K depression %K mHealth %K pilot study %K feasibility study %K PHQ-9 %D 2019 %7 26.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings. %M 31025949 %R 10.2196/11698 %U http://mental.jmir.org/2019/4/e11698/ %U https://doi.org/10.2196/11698 %U http://www.ncbi.nlm.nih.gov/pubmed/31025949 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11410 %T Improving Moderator Responsiveness in Online Peer Support Through Automated Triage %A Milne,David N %A McCabe,Kathryn L %A Calvo,Rafael A %+ School of Information, Systems and Modelling, Faculty of Engineering and Information Technology, University of Technology, Sydney, PO Box 123, Sydney, NSW 2007, Australia, 61 (02) 9514 3171, david.milne@uts.edu.au %K social support %K triage %K classification %K natural language processing %D 2019 %7 26.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Online peer support forums require oversight to ensure they remain safe and therapeutic. As online communities grow, they place a greater burden on their human moderators, which increases the likelihood that people at risk may be overlooked. This study evaluated the potential for machine learning to assist online peer support by directing moderators’ attention where it is most needed. Objective: This study aimed to evaluate the accuracy of an automated triage system and the extent to which it influences moderator behavior. Methods: A machine learning classifier was trained to prioritize forum messages as green, amber, red, or crisis depending on how urgently they require attention from a moderator. This was then launched as a set of widgets injected into a popular online peer support forum hosted by ReachOut.com, an Australian Web-based youth mental health service that aims to intervene early in the onset of mental health problems in young people. The accuracy of the system was evaluated using a holdout test set of manually prioritized messages. The impact on moderator behavior was measured as response ratio and response latency, that is, the proportion of messages that receive at least one reply from a moderator and how long it took for these replies to be made. These measures were compared across 3 periods: before launch, after an informal launch, and after a formal launch accompanied by training. Results: The algorithm achieved 84% f-measure in identifying content that required a moderator response. Between prelaunch and post-training periods, response ratios increased by 0.9, 4.4, and 10.5 percentage points for messages labelled as crisis, red, and green, respectively, but decreased by 5.0 percentage points for amber messages. Logistic regression indicated that the triage system was a significant contributor to response ratios for green, amber, and red messages, but not for crisis messages. Response latency was significantly reduced (P<.001), between the same periods, by factors of 80%, 80%, 77%, and 12% for crisis, red, amber, and green messages, respectively. Regression analysis indicated that the triage system made a significant and unique contribution to reducing the time taken to respond to green, amber, and red messages, but not to crisis messages, after accounting for moderator and community activity. Conclusions: The triage system was generally accurate, and moderators were largely in agreement with how messages were prioritized. It had a modest effect on response ratios, primarily because moderators were already more likely to respond to high priority content before the introduction of triage. However, it significantly and substantially reduced the time taken for moderators to respond to prioritized content. Further evaluations are needed to assess the impact of mistakes made by the triage algorithm and how changes to moderator responsiveness impact the well-being of forum members. %M 31025945 %R 10.2196/11410 %U https://www.jmir.org/2019/4/e11410/ %U https://doi.org/10.2196/11410 %U http://www.ncbi.nlm.nih.gov/pubmed/31025945 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11401 %T Evaluating the Feasibility of an Innovative Self-Confidence Webinar Intervention for Depression in the Workplace: A Proof-of-Concept Study %A Wan Mohd Yunus,Wan Mohd Azam %A Musiat,Peter %A Brown,June SL %+ Department of Psychology, School of Human Resource Development and Psychology, Faculty of Social Sciences and Humanities, Universiti Teknologi Malaysia, UTM Johor Bahru, Skudai, Johor, 81310, Malaysia, 60 176136163, azam.yunus@kcl.ac.uk %K online %K videoconferencing %K cognitive behavioral therapy %K depression %K workplace %D 2019 %7 26.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression in the workplace is a very common problem that exacerbates employees’ functioning and consequently influences the productivity of organizations. Despite the commonness of the problem and the currently available interventions, a high proportion of employees do not seek help. A new intervention, a webinar (Web-based seminar), was developed, which integrated the use of technology and the traditional guided therapist support to provide accessible help for the problem of depression in the workplace. Objective: The aim of this study was to explore the feasibility, preliminary outcome, and acceptability of the webinar intervention conducted in organizations. Methods: In total, 2 organizations were invited to participate, and 33 employees participated in this proof-of-concept study. The webinar intervention consisted of 6 1-hour sessions conducted via the Adobe Connect platform, developed by Adobe Inc. The intervention was developed based on a systematic review, focus group studies, and face-to-face self-confidence workshops that utilized cognitive behavior therapy (CBT). The final webinar intervention used CBT and the coping flexibility approach. The structure of the intervention included PowerPoint presentations, animation videos, utilization of chat panels, and whiteboard features. The intervention was conducted live and guided by a consultant psychologist assisted by a moderator. Study outcomes were self-assessed using self-reported Web surveys. The acceptability of the intervention was assessed using self-reported user experience Web surveys and open-ended questions. Results: The findings showed: (1) evidence of feasibility of the intervention: the webinar intervention was successfully conducted in 3 groups, with 6 1-hour sessions for each group, with 82% (23/28) participants completing all 6 sessions; (2) positive improvements in depression: the linear mixed effects modeling analysis recorded a significant overall effect of time primarily for depression (F2, 48.813=31.524; P<.001) with a Hedge g effect size of 0.522 at 1-month follow-up. Individually, 8 subjects showed significant reliable and clinically significant changes, with 3 subjects showing clinically significant change only; and (3) encouraging evidence regarding the acceptability of the webinar intervention among the employees: the user experience score was above average for 4 out of 6 domains measured (perspicuity mean 1.198 [95% CI 0.832-1.564], efficiency mean 1.000 [95% CI 0.571-1.429], dependability mean 1.208 [95% CI 0.899-1.517], and stimulation mean 1.323 [95% CI 0.987-1.659]). The open-ended questions also yielded 52% (47/91) of the responses that reported facilitators, whereas only 12% (11/91) of the responses reported barriers. Conclusions: The self-confidence webinar intervention appears to be a potentially feasible, effective, and acceptable intervention for depression in the workplace that merits further investigation. %M 31025943 %R 10.2196/11401 %U http://mental.jmir.org/2019/4/e11401/ %U https://doi.org/10.2196/11401 %U http://www.ncbi.nlm.nih.gov/pubmed/31025943 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e12974 %T Seasonality Patterns of Internet Searches on Mental Health: Exploratory Infodemiology Study %A Soreni,Noam %A Cameron,Duncan H %A Streiner,David L %A Rowa,Karen %A McCabe,Randi E %+ Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Office B141, Hamilton, ON, L8P3R2, Canada, 1 9055221155 ext 35373, nsoreni@stjosham.on.ca %K anxiety %K depression %K OCD %K schizophrenia %K autism %K suicide %K seasonality %K Google %K internet %K infodemiology %K infoveillance %K mental health %D 2019 %7 24.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The study of seasonal patterns of public interest in psychiatric disorders has important theoretical and practical implications for service planning and delivery. The recent explosion of internet searches suggests that mining search databases yields unique information on public interest in mental health disorders, which is a significantly more affordable approach than population health studies. Objective: This study aimed to investigate seasonal patterns of internet mental health queries in Ontario, Canada. Methods: Weekly data on health queries in Ontario from Google Trends were downloaded for a 5-year period (2012-2017) for the terms “schizophrenia,” “autism,” “bipolar,” “depression,” “anxiety,” “OCD” (obsessive-compulsive disorder), and “suicide.” Control terms were overall search results for the terms “health” and “how.” Time-series analyses using a continuous wavelet transform were performed to isolate seasonal components in the search volume for each term. Results: All mental health queries showed significant seasonal patterns with peak periodicity occurring over the winter months and troughs occurring during summer, except for “suicide.” The comparison term “health” also exhibited seasonal periodicity, while the term “how” did not, indicating that general information seeking may not follow a seasonal trend in the way that mental health information seeking does. Conclusions: Seasonal patterns of internet search volume in a wide range of mental health terms were observed, with the exception of “suicide.” Our study demonstrates that monitoring internet search trends is an affordable, instantaneous, and naturalistic method to sample public interest in large populations and inform health policy planners. %M 31017582 %R 10.2196/12974 %U https://mental.jmir.org/2019/4/e12974/ %U https://doi.org/10.2196/12974 %U http://www.ncbi.nlm.nih.gov/pubmed/31017582 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11081 %T How Confidence in Prior Attitudes, Social Tag Popularity, and Source Credibility Shape Confirmation Bias Toward Antidepressants and Psychotherapy in a Representative German Sample: Randomized Controlled Web-Based Study %A Schweiger,Stefan %A Cress,Ulrike %+ Knowledge Construction Lab, Knowledge Media Research Center, Leibniz-Institut für Wissensmedien, Schleichstrasse 6, Tuebingen, 72076, Germany, 49 6702023838, schw.stefan@gmail.com %K attitude %K psychotherapy %K antidepressive agents %K culture %K Germany %K health literacy %K professional competence %K information systems %K consumer health information %K information dissemination %D 2019 %7 23.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In health-related, Web-based information search, people should select information in line with expert (vs nonexpert) information, independent of their prior attitudes and consequent confirmation bias. Objective: This study aimed to investigate confirmation bias in mental health–related information search, particularly (1) if high confidence worsens confirmation bias, (2) if social tags eliminate the influence of prior attitudes, and (3) if people successfully distinguish high and low source credibility. Methods: In total, 520 participants of a representative sample of the German Web-based population were recruited via a panel company. Among them, 48.1% (250/520) participants completed the fully automated study. Participants provided prior attitudes about antidepressants and psychotherapy. We manipulated (1) confidence in prior attitudes when participants searched for blog posts about the treatment of depression, (2) tag popularity —either psychotherapy or antidepressant tags were more popular, and (3) source credibility with banners indicating high or low expertise of the tagging community. We measured tag and blog post selection, and treatmentefficacy ratings after navigation. Results: Tag popularity predicted the proportion of selected antidepressant tags (beta=.44, SE 0.11; P<.001) and blog posts (beta=.46, SE 0.11; P<.001). When confidence was low (−1 SD), participants selected more blog posts consistent with prior attitudes (beta=−.26, SE 0.05; P<.001). Moreover, when confidence was low (−1 SD) and source credibility was high (+1 SD), the efficacy ratings of attitude-consistent treatments increased (beta=.34, SE 0.13; P=.01). Conclusions: We found correlational support for defense motivation account underlying confirmation bias in the mental health–related search context. That is, participants tended to select information that supported their prior attitudes, which is not in line with the current scientific evidence. Implications for presenting persuasive Web-based information are also discussed. Trial Registration: ClinicalTrials.gov NCT03899168; https://clinicaltrials.gov/ct2/show/NCT03899168 (Archived by WebCite at http://www.webcitation.org/77Nyot3Do) %M 31012865 %R 10.2196/11081 %U http://www.jmir.org/2019/4/e11081/ %U https://doi.org/10.2196/11081 %U http://www.ncbi.nlm.nih.gov/pubmed/31012865 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11706 %T Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis %A Romijn,Geke %A Batelaan,Neeltje %A Kok,Robin %A Koning,Jeroen %A van Balkom,Anton %A Titov,Nickolai %A Riper,Heleen %+ Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam Public Health Research Institute, Van der Boechorstraat 7, Amsterdam,, Netherlands, 31 20 59 89009, g.a.romijn@vu.nl %K anxiety disorders %K cognitive behavioral therapy %K internet %K recruitment method %K efficacy %K effectiveness %D 2019 %7 17.04.2019 %9 Review %J J Med Internet Res %G English %X Background: Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects. Objective: This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome. Methods: We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials. Results: We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls. Conclusions: iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings. %M 30994462 %R 10.2196/11706 %U http://www.jmir.org/2019/4/e11706/ %U https://doi.org/10.2196/11706 %U http://www.ncbi.nlm.nih.gov/pubmed/30994462 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11029 %T Mood Prediction of Patients With Mood Disorders by Machine Learning Using Passive Digital Phenotypes Based on the Circadian Rhythm: Prospective Observational Cohort Study %A Cho,Chul-Hyun %A Lee,Taek %A Kim,Min-Gwan %A In,Hoh Peter %A Kim,Leen %A Lee,Heon-Jeong %+ Korea University College of Medicine, Department of Psychiatry, Anam Hospital, Korea University College of Medicine, Seoul,, Republic of Korea, 82 029205815, leehjeong@korea.ac.kr %K mood disorder %K circadian rhythm %K projections and predictions %K machine learning %K digital phenotype %K wearable device %D 2019 %7 17.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtually, all organisms on Earth have their own circadian rhythm, and humans are no exception. Circadian rhythms are associated with various human states, especially mood disorders, and disturbance of the circadian rhythm is known to be very closely related. Attempts have also been made to derive clinical implications associated with mood disorders using the vast amounts of digital log that is acquired by digital technologies develop and using computational analysis techniques. Objective: This study was conducted to evaluate the mood state or episode, activity, sleep, light exposure, and heart rate during a period of about 2 years by acquiring various digital log data through wearable devices and smartphone apps as well as conventional clinical assessments. We investigated a mood prediction algorithm developed with machine learning using passive data phenotypes based on circadian rhythms. Methods: We performed a prospective observational cohort study on 55 patients with mood disorders (major depressive disorder [MDD] and bipolar disorder type 1 [BD I] and 2 [BD II]) for 2 years. A smartphone app for self-recording daily mood scores and detecting light exposure (using the installed sensor) were provided. From daily worn activity trackers, digital log data of activity, sleep, and heart rate were collected. Passive digital phenotypes were processed into 130 features based on circadian rhythms, and a mood prediction algorithm was developed by random forest. Results: The mood state prediction accuracies for the next 3 days in all patients, MDD patients, BD I patients, and BD II patients were 65%, 65%, 64%, and 65% with 0.7, 0.69, 0.67, and 0.67 area under the curve (AUC) values, respectively. The accuracies of all patients for no episode (NE), depressive episode (DE), manic episode (ME), and hypomanic episode (HME) were 85.3%, 87%, 94%, and 91.2% with 0.87, 0.87, 0.958, and 0.912 AUC values, respectively. The prediction accuracy in BD II patients was distinctively balanced as high showing 82.6%, 74.4%, and 87.5% of accuracy (with generally good sensitivity and specificity) with 0.919, 0.868, and 0.949 AUC values for NE, DE, and HME, respectively. Conclusions: On the basis of the theoretical basis of chronobiology, this study proposed a good model for future research by developing a mood prediction algorithm using machine learning by processing and reclassifying digital log data. In addition to academic value, it is expected that this study will be of practical help to improve the prognosis of patients with mood disorders by making it possible to apply actual clinical application owing to the rapid expansion of digital technology. %M 30994461 %R 10.2196/11029 %U http://www.jmir.org/2019/4/e11029/ %U https://doi.org/10.2196/11029 %U http://www.ncbi.nlm.nih.gov/pubmed/30994461 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11965 %T User Involvement in Developing the MYPLAN Mobile Phone Safety Plan App for People in Suicidal Crisis: Case Study %A Buus,Niels %A Juel,Anette %A Haskelberg,Hila %A Frandsen,Hanne %A Larsen,Jette Louise Skovgaard %A River,Jo %A Andreasson,Kate %A Nordentoft,Merete %A Davenport,Tracey %A Erlangsen,Annette %+ Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, 88, Mallett St, Camperdown, 2050, Australia, 61 0429835019, niels.buus@sydney.edu.au %K mobile apps %K patient participation %K primary prevention %K self-injurious behavior %K suicide, attempted %D 2019 %7 16.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The effect of safety planning for people in suicidal crisis is not yet determined, but using safety plans to mitigate acute psychological crisis is regarded as best practice. Between 2016 and 2017, Australian and Danish stakeholders were involved in revising and updating the Danish MYPLAN mobile phone safety plan and translating the app into a culturally appropriate version for Australia. Objective: The objective of this study was to examine the negotiation of stakeholders’ suggestions and contributions to the design, function, and content of the MYPLAN app and to characterize significant developments in the emerging user-involving processes. Methods: We utilized a case study design where 4 focus groups and 5 user-involving workshops in Denmark and Australia were subjected to thematic analysis. Results: The analyses identified 3 consecutive phases in the extensive development of the app: from phase 1, Suggesting core functions, through phase 2, Refining functions, to phase 3, Negotiating the finish. The user-involving processes continued to prevent closure and challenged researchers and software developers to repeatedly reconsider the app’s basic user interface and functionality. It was a limitation that the analysis did not include potentially determinative backstage dimensions of the decision-making process. Conclusions: The extended user involvement prolonged the development process, but it also allowed for an extensive exploration of different user perspectives and needs. %M 30990456 %R 10.2196/11965 %U http://mental.jmir.org/2019/4/e11965/ %U https://doi.org/10.2196/11965 %U http://www.ncbi.nlm.nih.gov/pubmed/30990456 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e13202 %T Transdiagnostic Mobile Health: Smartphone Intervention Reduces Depressive Symptoms in People With Mood and Psychotic Disorders %A Ben-Zeev,Dror %A Buck,Benjamin %A Chu,Phuonguyen Vu %A Razzano,Lisa %A Pashka,Nicole %A Hallgren,Kevin A %+ Behavioral Research In Technology and Engineering Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 685 9655, dbenzeev@uw.edu %K mHealth %K schizophrenia %K bipolar disorder %K depression %K illness management %K symptoms %K transdiagnostic %D 2019 %7 12.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is the most prevalent mental health problem. The need for effective treatments for depression far outstrips the availability of trained mental health professionals. Smartphones and other widely available technologies are increasingly being leveraged to deliver treatments for depression. Whether there are patient characteristics that affect the potency of smartphone interventions for depression is not well understood. Objective: This study aimed to evaluate whether patient characteristics including clinical diagnosis, depression severity, psychosis status, and current use of antidepressant medications impact the effects of an evidence-based smartphone intervention on depressive symptoms. Methods: Data were collected as part of a 2-arm randomized controlled trial comparing a multimodal smartphone intervention called FOCUS with a clinic-based intervention. Here, we report on 82 participants assigned to 12 weeks of FOCUS treatment. We conducted assessments of depressive symptoms using the Beck Depression Inventory-second edition (BDI-II) at baseline, postintervention (3 months), and follow-up (6 months). We tested for differences in the amount of improvement in BDI-II scores from baseline to posttreatment and 6-month follow-up between each of the following patient subgroups using 2 (group) × 2 (time) mixed effects models: diagnosis (ie, schizophrenia spectrum disorder vs bipolar disorder vs major depressive disorder), depression severity (ie, minimal-mild vs moderate-severe depression), psychosis status (ie, presence vs absence of psychotic symptoms), and antidepressant use (ie, taking antidepressants vs not taking antidepressants). Results: The majority of participants were male (60%, 49/82), African American (65%, 53/82), and middle-aged (mean age 49 years), with a high school education or lower (62%, 51/82). There were no differences in patient demographics across the variables that were used to stratify the analyses. There was a significant group × time interaction for baseline depression severity (F1,76.8=5.26, P=.02 [posttreatment] and F1,77.4=6.56, P=.01 [6-month follow-up]). Participants with moderate or severe depression had significant improvements (t42=3.20, P=.003 [posttreatment] and t42=4.20, P<.001 [6-month follow-up]), but participants with minimal or mild depression did not (t31=0.20, P=.84 [posttreatment] and t30=0.43, P=.67 [6-month follow-up]). There were no significant group × time interactions for diagnosis, psychosis status, or antidepressant medication use. Participants with minimal or mild depression had negligible nonsignificant improvements (<1 point on the BDI-II). Reduction in depression in all other groups was larger (range 1.7-6.5 points on the BDI-II). Conclusions: Our results suggest that FOCUS can be deployed to treat moderate to severe depressive symptoms among people with schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder, in concert with antidepressant medications or without them, in both people with and without active psychotic symptoms. The study results are consistent with research on transdiagnostic models in psychotherapy and extend our knowledge about the potential of transdiagnostic mobile health. Trial Registration: ClinicalTrials.gov NCT02421965; http://clinicaltrials.gov/ct2/show/NCT02421965 (Archived by WebCite at http://www.webcitation.org/76pyDlvAS) %M 30977736 %R 10.2196/13202 %U http://mental.jmir.org/2019/4/e13202/ %U https://doi.org/10.2196/13202 %U http://www.ncbi.nlm.nih.gov/pubmed/30977736 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12578 %T The Role of Data Type and Recipient in Individuals’ Perspectives on Sharing Passively Collected Smartphone Data for Mental Health: Cross-Sectional Questionnaire Study %A Nicholas,Jennifer %A Shilton,Katie %A Schueller,Stephen M %A Gray,Elizabeth L %A Kwasny,Mary J %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, 10th Floor, CBITs, Chicago, IL, 60611, United States, 1 3125034156, j.nicholas@northwestern.edu %K mHealth %K privacy %K personal sensing %K digital mental health %K depression %K anxiety %K mobile phone %D 2019 %7 05.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The growing field of personal sensing harnesses sensor data collected from individuals’ smartphones to understand their behaviors and experiences. Such data could be a powerful tool within mental health care. However, it is important to note that the nature of these data differs from the information usually available to, or discussed with, health care professionals. To design digital mental health tools that are acceptable to users, understanding how personal sensing data can be used and shared is critical. Objective: This study aimed to investigate individuals’ perspectives about sharing different types of sensor data beyond the research context, specifically with doctors, electronic health record (EHR) systems, and family members. Methods: A questionnaire assessed participants’ comfort with sharing six types of sensed data: physical activity, mood, sleep, communication logs, location, and social activity. Participants were asked about their comfort with sharing these data with three different recipients: doctors, EHR systems, and family members. A series of principal component analyses (one for each data recipient) was performed to identify clusters of sensor data types according to participants’ comfort with sharing them. Relationships between recipients and sensor clusters were then explored using generalized estimating equation logistic regression models. Results: A total of 211 participants completed the questionnaire. The majority were female (171/211, 81.0%), and the mean age was 38 years (SD 10.32). Principal component analyses consistently identified two clusters of sensed data across the three data recipients: “health information,” including sleep, mood, and physical activity, and “personal data,” including communication logs, location, and social activity. Overall, participants were significantly more comfortable sharing any type of sensed data with their doctor than with the EHR system or family members (P<.001) and more comfortable sharing “health information” than “personal data” (P<.001). Participant characteristics such as age or presence of depression or anxiety did not influence participants’ comfort with sharing sensed data. Conclusions: The comfort level in sharing sensed data was dependent on both data type and recipient, but not individual characteristics. Given the identified differences in comfort with sensed data sharing, contextual factors of data type and recipient appear to be critically important as we design systems that harness sensor data for mental health treatment and support. %M 30950799 %R 10.2196/12578 %U http://mhealth.jmir.org/2019/4/e12578/ %U https://doi.org/10.2196/12578 %U http://www.ncbi.nlm.nih.gov/pubmed/30950799 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11387 %T Identification of Anxiety and Depression Symptoms in Patients With Cancer: Comparison Between Short and Long Web-Based Questionnaires %A Mattsson,Susanne %A Olsson,Erik Martin Gustaf %A Carlsson,Maria %A Johansson,Birgitta Beda Kristina %+ Lifestyle and Rehabilitation in long term illness, Public Health and Caring Sciences, Uppsala University, Box 564, Uppsala, 75122, Sweden, 46 184710000 ext 6637, susanne.mattsson@pubcare.uu.se %K screening %K cancer %K depression %K anxiety %K internet %K eHealth %D 2019 %7 05.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Physicians and nurses in cancer care easily fail to detect symptoms of psychological distress because of barriers such as lack of time, training on screening methods, and knowledge about how to diagnose anxiety and depression. National guidelines in several countries recommend routine screening for emotional distress in patients with cancer, but in many clinics, this is not implemented. By inventing screening methods that are time-efficient, such as digitalized and automatized screenings with short instruments, we can alleviate the burden on patients and staff. Objective: The aim of this study was to compare Web-based versions of the ultrashort electronic Visual Analogue Scale (eVAS) anxiety and eVAS depression and the short Hospital Anxiety and Depression Scale (HADS) with Web-based versions of the longer Montgomery Åsberg Depression Rating Scale-Self-report (MADRS-S) and the State Trait Anxiety Inventory- State (STAI-S) with regard to their ability to identify symptoms of anxiety and depression in patients with cancer. Methods: Data were obtained from a consecutive sample of patients with newly diagnosed (<6 months) breast, prostate, or colorectal cancer or with recurrence of colorectal cancer (N=558). The patients were recruited at 4 hospitals in Sweden between April 2013 and September 2015, as part of an intervention study administered via the internet. All questionnaires were completed on the Web at the baseline assessment in the intervention study. Results: The ultrashort and short Web-based-delivered eVAS anxiety, eVAS depression and HADS were found to have an excellent ability to discriminate between persons with and without clinical levels of symptoms of anxiety and depression compared with recommended cutoffs of the longer instruments MADRS-S and STAI-S (area under the curve: 0.88-0.94). Cutoffs of >6 on HADS anxiety and >7 hundredths (hs) on eVAS anxiety identified patients with anxiety symptoms with high accuracy. For HADS depression, at a cutoff of >5 and eVAS depression at a cutoff of >7 hs, the accuracy was very high likewise. Conclusions: The use of the short and ultrashort tools, eVAS and HADS, may be a suitable initial method of Web-based screening in busy clinical settings. However, there are still a proportion of patients who lack access to the internet or the ability to use it. There is a need to find solutions for this group to find all the patients with psychological distress. %M 30950804 %R 10.2196/11387 %U https://www.jmir.org/2019/4/e11387/ %U https://doi.org/10.2196/11387 %U http://www.ncbi.nlm.nih.gov/pubmed/30950804 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e13239 %T Effectiveness of a Web- and Mobile-Guided Psychological Intervention for Depressive Symptoms in Turkey: Protocol for a Randomized Controlled Trial %A Ünlü Ince,Burçin %A Gökçay,Didem %A Riper,Heleen %A Cuijpers,Pim %+ Department of Medical Informatics / Informatics Institute, Middle East Technical University, Üniversiteler Mahallesi, Çankaya, Ankara, 06800, Turkey, 90 312 2103741, unlu_burcin@outlook.com %K randomized controlled trial %K depressive symptoms %K mobile app %K psychotherapy %K telemedicine %K depression %D 2019 %7 05.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: In Turkey, there are serious deficiencies in mental health care. Although depression is highly prevalent, only a small number of people seek professional help. Innovative solutions are needed to overcome this treatment gap. Web-based problem-solving therapy (PST) is an intervention proven to be effective in the treatment of depression, although little is known about its clinical effects in Turkey. Objective: This study aims to test the clinical effects of a Web and mobile app of an adapted PST for depressive symptoms among the general population in Turkey. Methods: Participants will be recruited through announcements in social media and the Middle East Technical University. Adults (18-55 years) with mild to moderate depressive symptoms (Beck Depression Inventory-II [BDI-II] score between 10-29) will be included in the study. Participants with a medium-to-high suicidal risk (according to the Mini-International Neuropsychiatric Interview) will be excluded. A 3-armed randomized controlled trial with a waiting control group will be utilized. A sample size of 444 participants will be randomized across 3 groups. The first experimental group will receive direct access to the Web version of the intervention; the second experimental group will receive direct access to the mobile app of the intervention as well as automated supportive short message service text messages based on PST. The control group consists of a wait-list and will gain access to the intervention 4 months after the baseline. The intervention is based on an existing PST for the Turkish population, Her Şey Kontrol Altında (HŞKA), consisting of 5 modules each with a duration of 1 week and is guided by a clinical psychologist. The primary outcome is change in depressive symptoms measured by the BDI-II. Secondary outcomes include symptoms of anxiety, stress, worry, self-efficacy, and quality of life. Furthermore, satisfaction with, usability and acceptability of the intervention are important features that will be evaluated. All outcomes will take place online through self-assessment at posttest (6-8 weeks after baseline) and at follow-up (4 months after baseline). Results: We will recruit a total of 444 participants with mild to moderate depressive symptoms from March 2018 to February 2019 or until the recruitment is complete. We expect the final trial results to be available by the end of May 2019. This trial is funded by the Scientific and Technological Research Council of Turkey (National Postdoctoral Research Fellowship Programme 2016/1). Conclusions: Results from this study will reveal more information about the clinical effects of HŞKA as well as its applicability in a Turkish setting through the Web and mobile platforms. On the basis of the results, a guided Web- and mobile-based PST intervention might become an appropriate alternative for treating mild to moderate depressive symptoms. Trial Registration: ClinicalTrials.gov NCT03754829; https://clinicaltrials.gov/ct2/show/NCT03754829 (Archived by WebCite at http://www.webcitation.org/74HugwLo7). International Registered Report Identifier (IRRID): DERR1-10.2196/13239 %M 30950802 %R 10.2196/13239 %U http://www.researchprotocols.org/2019/4/e13239/ %U https://doi.org/10.2196/13239 %U http://www.ncbi.nlm.nih.gov/pubmed/30950802 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11671 %T Utilization of Patient-Generated Data Collected Through Mobile Devices: Insights From a Survey on Attitudes Toward Mobile Self-Monitoring and Self-Management Apps for Depression %A Hartmann,Ralf %A Sander,Christian %A Lorenz,Noah %A Böttger,Daniel %A Hegerl,Ulrich %+ Research Center of the German Depression Foundation, Semmelweisstraße 10, Leipzig, 04103, Germany, 49 3419724506, ralf.hartmann@medizin.uni-leipzig.de %K mHealth %K depression %K adherence %K mobile applications, self-management %D 2019 %7 03.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a severe psychiatric disease with high prevalence and an elevated risk for recurrence and chronicity. A substantial proportion of individuals with a diagnosis of unipolar depressive disorder do not receive treatment as advised by national guidelines. Consequently, self-monitoring and self-management become increasingly important. New mobile technologies create unique opportunities to obtain and utilize patient-generated data. As common adherence rates to mobile technologies are scarce, a profound knowledge of user behavior and attitudes and preferences is important throughout any developmental process of mobile technologies and apps. Objective: The aim of this survey was to provide descriptive data upon usage and anticipated usage of self-monitoring and self-management of depression and preferences of potential users in terms of documented parameters and data-sharing options. Methods: A Web-based survey comprising 55 questions was conducted to obtain data on the usage of mobile devices, app usage, and participant’s attitudes and preferences toward mobile health apps for the self-monitoring and self-management of depression. Results: A total of 825 participants provided information. Moreover, two-thirds of the sample self-reported to be affected by depressive symptoms, but only 12.1% (81/668) of those affected by depression have ever used any mobile self-monitoring or self-management app. Analysis showed that people want personally relevant information and feedback but also focus on handling sensitive data. Conclusions: New mobile technologies and smartphone apps, especially in combination with mobile sensor systems, offer unique opportunities to overcome challenges in the treatment of depression by utilizing the potential of patient-generated data. Focus on patient-relevant information, security and safe handling of sensitive personal data, as well as options to share data with self-selected third parties should be considered mandatory throughout any development process. %M 30942693 %R 10.2196/11671 %U https://mental.jmir.org/2019/4/e11671/ %U https://doi.org/10.2196/11671 %U http://www.ncbi.nlm.nih.gov/pubmed/30942693 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11521 %T Service Use History of Individuals Enrolling in a Web-Based Suicidal Ideation Treatment Trial: Analysis of Baseline Data %A Wong,Quincy JJ %A Werner-Seidler,Aliza %A Torok,Michelle %A van Spijker,Bregje %A Calear,Alison L %A Christensen,Helen %+ School of Social Sciences and Psychology, Western Sydney University, Kingswood Campus, Sydney,, Australia, 61 2 4736 0080, q.wong@westernsydney.edu.au %K internet %K treatment %K service use %K health service %K suicidal ideation %K suicide, attempted %K suicide %K facilities and services utilization %K telehealth %D 2019 %7 02.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: A significant recent innovation is the development of internet-based psychological treatments for suicidal thinking. However, we know very little about individuals experiencing suicidal ideation who seek help through Web-based services and, in particular, their previous health service use patterns. Objective: We aimed to examine service use history and its correlates among adults experiencing suicidal ideation who enrolled in a Web-based suicidal ideation treatment trial. Methods: We used baseline data of 418 individuals seeking Web-based treatment for their suicidal ideation recruited into a randomized controlled trial of a 6-week Web-based self-help program. Participants at preintervention reported demographic information, clinical characteristics, and health service use over the previous 6 months. Results: Participants had a high rate of service use in the 6 months before enrolling in the treatment trial (404/418, 96.7% of participants had contact with services). The two most common contact points were general practitioners (385/418, 92.1% of participants) and mental health professionals (295/418, 70.6% of participants). Notably, those with a previous single suicide attempt had lower odds of contact with any service than those with no attempt (odds ratio [OR] 0.21, 95% CI 0.05-0.86; P=.03). Those living in rural or remote areas had lower odds of contacting general practitioners (OR 0.35, 95% CI 0.13-0.91; P=.03) or mental health professionals (OR 0.44, 95% CI 0.23-0.83; P=.01) than those living in metropolitan areas. Conclusions: Individuals enrolling in an electronic health intervention trial have often received treatment from general practitioners or mental health professionals. These services can therefore play an important role in preventing the escalation of suicidal thinking. Enrollment in our Web-based treatment trial suggested, though, that face-to-face health services may not be enough. Our study also highlighted the need to improve the provision of coordinated and assertive care after a suicide attempt, as well as health service availability and utilization for those living in rural and remote areas. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595 %M 30938686 %R 10.2196/11521 %U https://mental.jmir.org/2019/4/e11521/ %U https://doi.org/10.2196/11521 %U http://www.ncbi.nlm.nih.gov/pubmed/30938686 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11215 %T Methodological Strategies for Ecological Momentary Assessment to Evaluate Mood and Stress in Adult Patients Using Mobile Phones: Systematic Review %A Yang,Yong Sook %A Ryu,Gi Wook %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K review %K experience sampling method %K ecological momentary assessment %K mobile apps %K mood %K stress %D 2019 %7 01.04.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Ecological momentary assessment (EMA) has utility for measuring psychological properties in daily life. EMA has also allowed researchers to collect data on diverse experiences and symptoms from various subjects. Objective: The aim of this study was to review methodological strategies and useful related information for EMA using mobile phones to capture changes of mood and stress in adult patients seeking health care. Methods: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Library, PsycINFO, and Web of Science. This review included studies published in peer-reviewed journals in English between January 2008 and November 2017 that used basic- or advanced-feature mobile phones to measure momentary mood or stress in adult patients seeking health care in outpatient departments. We excluded studies of smoking and substance addictions and studies of mental disorder patients who had been diagnosed by physicians. Results: We reviewed 12 selected articles that used EMA via mobile phones to measure momentary mood and stress and other related variables from various patients with chronic fatigue syndrome, breast cancer, migraine, HIV, tinnitus, temporomandibular disorder, end-stage kidney disease, and traumatic brain injury. Most of the selected studies (11/12, 92%) used signal contingency and in 8 of the 12 studies (67%) alarms were sent at random or semirandom intervals to prompt the momentary measurement. Out of 12 studies, 7 (58%) used specific apps directly installed on mobile phones, 3 (25%) used mobile phones to link to Web-based survey programs, and 2 (17%) used an interactive voice-response system. Conclusions: This study provides researchers with useful information regarding methodological details for utilizing EMA to measure mood and stress in adult patients. This review shows that EMA methods could be effective and reasonable for measuring momentary mood and stress, given that basic- and advanced-feature mobile phones are ubiquitous, familiar, and easy to approach. Therefore, researchers could adopt and utilize EMA methods using mobile phones to measure psychological health outcomes, such as mood and stress, in adult patients. %M 30932866 %R 10.2196/11215 %U https://mhealth.jmir.org/2019/4/e11215/ %U https://doi.org/10.2196/11215 %U http://www.ncbi.nlm.nih.gov/pubmed/30932866 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 3 %P e12392 %T Screening Depression and Related Conditions via Text Messaging Versus Interview Assessment: Protocol for a Randomized Study %A Jin,Haomiao %A Wu,Shinyi %+ Department of Adult Mental Health and Wellness, Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 South Hill Street, Suite 360, Los Angeles, CA, 90015, United States, 1 213 821 9361, haomiaoj@usc.edu %K depression %K diabetes %K comorbidity %K screening %K primary care %K health information technology %K information and communication technology %K text messaging %K patient-reported outcome measures %D 2019 %7 29.03.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is an often underdiagnosed and, therefore, untreated comorbidity for low-income, racially or ethnically diverse patients with a chronic illness such as diabetes. Recent updates from the US Preventive Services Task Force guidelines in 2016 recommend depression screening for every adult but does not suggest the mode of assessment. Short message service (SMS) text messaging is an inexpensive, private, and scalable approach to provide depression screening and monitoring; it can also alleviate many barriers, such as transportation, childcare, and clinical visit time faced by the low-income population, in receiving a diagnosis of depression. Current evidence is inconsistent in comparing technology-mediated assessment versus interviewer (INTW) assessment in collecting sensitive health information, as some studies suggest that technology encourages self-disclosure while the other studies show the opposite effect. Objective: The proposed study will test the use of SMS text messaging to assess depression and its related conditions, including functional disability, pain, and anxiety, in low-income, culturally diverse, safety-net primary care populations with diabetes. The study will examine the concordance between SMS text message and interviewer assessments and evaluate test-retest reliability. Methods: The proposed study will adopt a randomized design with 200 patients assigned to four study groups: SMS/INTW, INTW/SMS, SMS/SMS, and INTW/INTW. The first two groups will be used to examine the concordance between SMS text message and interviewer assessments. The third and fourth groups will be used to evaluate test-retest reliability. Participants of the study will be recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial, a large comparative effectiveness research trial in collaboration with the Los Angeles County Department of Health Services. Test-retest reliability and concordance between SMS text message and interviewer assessments will be evaluated by the interclass correlation coefficient and the kappa statistic. Missing data patterns will be explored to understand whether participants are willing to self-disclose information related to depression in SMS text message assessments. Results: Recruitment of participants was conducted from June 2017 to November 2017. A total of 206 participants were enrolled: 52 (25.2%) in SMS/INTW, 53 (25.7%) in SMS/SMS, 49 (23.8%) in INTW/SMS, and 52 (25.2%) in INTW/INTW. The average age of the participants was 57.1 years (SD 9.2). A total of 57.8% (119/206) of participants were female, 93.2% (192/206) were Latino, and 77.7% (160/206) chose Spanish as their preferred language. Analysis of the SMS text message assessment shows the cost of distributing the 16 questions is about US $0.50 per person per assessment. Full results of the study will be reported elsewhere. Conclusions: This study is anticipated to establish the feasibility of using SMS text messaging to assess depression and its related conditions in low-income, culturally diverse, safety-net primary care populations with diabetes. We also expect to generate knowledge about whether patients in the targeted population are willing to reply and self-disclose sensitive information about depression and its related conditions through SMS text message assessments. International Registered Report Identifier (IRRID): DERR1-10.2196/12392 %M 30924787 %R 10.2196/12392 %U http://www.researchprotocols.org/2019/3/e12392/ %U https://doi.org/10.2196/12392 %U http://www.ncbi.nlm.nih.gov/pubmed/30924787 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e12613 %T Relationship Between Sleep Quality and Mood: Ecological Momentary Assessment Study %A Triantafillou,Sofia %A Saeb,Sohrab %A Lattie,Emily G %A Mohr,David C %A Kording,Konrad Paul %+ Department of Biomedical Engineering, School of Engineering and Applied Sciences, University of Pennsylvania, , Philadelphia, PA,, United States, 1 412 624 7198, sof.triantafillou@gmail.com %K sleep %K affect %K ecological momentary assessment %K smartphone %K depression %K causality %D 2019 %7 27.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Sleep disturbances play an important role in everyday affect and vice versa. However, the causal day-to-day interaction between sleep and mood has not been thoroughly explored, partly because of the lack of daily assessment data. Mobile phones enable us to collect ecological momentary assessment data on a daily basis in a noninvasive manner. Objective: This study aimed to investigate the relationship between self-reported daily mood and sleep quality. Methods: A total of 208 adult participants were recruited to report mood and sleep patterns daily via their mobile phones for 6 consecutive weeks. Participants were recruited in 4 roughly equal groups: depressed and anxious, depressed only, anxious only, and controls. The effect of daily mood on sleep quality and vice versa were assessed using mixed effects models and propensity score matching. Results: All methods showed a significant effect of sleep quality on mood and vice versa. However, within individuals, the effect of sleep quality on next-day mood was much larger than the effect of previous-day mood on sleep quality. We did not find these effects to be confounded by the participants’ past mood and sleep quality or other variables such as stress, physical activity, and weather conditions. Conclusions: We found that daily sleep quality and mood are related, with the effect of sleep quality on mood being significantly larger than the reverse. Correcting for participant fixed effects dramatically affected results. Causal analysis suggests that environmental factors included in the study and sleep and mood history do not mediate the relationship. %M 30916663 %R 10.2196/12613 %U http://mental.jmir.org/2019/3/e12613/ %U https://doi.org/10.2196/12613 %U http://www.ncbi.nlm.nih.gov/pubmed/30916663 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e12235 %T Do Search Engine Helpline Notices Aid in Preventing Suicide? Analysis of Archival Data %A Cheng,Qijin %A Yom-Tov,Elad %+ Microsoft Research, 13 Shenkar Street, Herzeliya, 46733, Israel, 972 747111359, eladyt@yahoo.com %K search engines %K suicide %D 2019 %7 26.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Search engines display helpline notices when people query for suicide-related information. Objective: In this study, we aimed to examine if these notices and other information displayed in response to suicide-related queries are correlated with subsequent searches for suicide prevention rather than harmful information. Methods: Anonymous suicide-related searches made on Bing and Google in the United States, the United Kingdom, Hong Kong, and Taiwan in a span of 10 months were extracted. Descriptive analyses and regression models were fit to the data to assess the correlation with observed behaviors. Results: Display of helpline notices was not associated with an observed change in the likelihood of or future suicide searches (P=.42). No statistically significant differences were observed in the likelihood of people making future suicide queries (both generally and specific types of suicide queries) when comparing search engines in locations that display helpline notices versus ones that do not. Pages with higher rank, being neutral to suicide, and those shown among more antisuicide pages were more likely to be clicked on. Having more antisuicide Web pages displayed was the only factor associated with further searches for suicide prevention information (hazard=1.18, P=.002). Conclusions: Helpline notices are not associated with harm. If they cause positive change in search behavior, it is small. This is possibly because of the variability in intent of users seeking suicide-related information. Nonetheless, helpline notice should be displayed, but more efforts should be made to improve the visibility and ranking of suicide prevention Web pages. %M 30912753 %R 10.2196/12235 %U http://www.jmir.org/2019/3/e12235/ %U https://doi.org/10.2196/12235 %U http://www.ncbi.nlm.nih.gov/pubmed/30912753 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 2 %N 1 %P e12850 %T Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing %A Sikder,Abu Taher %A Yang,Francis Cheng %A Schafer,Rhiana %A Dowling,Glenna A %A Traeger,Lara %A Jain,Felipe Ananda %+ Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 6th Floor, Boston, MA, 02114, United States, 1 617 643 4682, felipe.jain@post.harvard.edu %K family caregivers %K mindfulness %K depression %K mobile apps %K psychotherapy %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Aging %G English %X Background: Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. Objective: We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. Methods: A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants’ perceived feasibility and benefits. Results: A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain “centered” despite caregiving challenges and positive reframing of the caregiver experience. Conclusions: App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials. %M 31518275 %R 10.2196/12850 %U http://aging.jmir.org/2019/1/e12850/ %U https://doi.org/10.2196/12850 %U http://www.ncbi.nlm.nih.gov/pubmed/31518275 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e11572 %T Exploring the Use of Multiple Mental Health Apps Within a Platform: Secondary Analysis of the IntelliCare Field Trial %A Kwasny,Mary J %A Schueller,Stephen M %A Lattie,Emily %A Gray,Elizabeth L %A Mohr,David C %+ Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Suite 1400, 680 N Lake Shore Drive, Chicago, IL, 60611, United States, 1 3125032294, m-kwasny@northwestern.edu %K mobile apps %K depression %K anxiety %K mobile phone %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: IntelliCare is a mental health app platform with 14 apps that are elemental, simple and brief to use, and eclectic. Although a variety of apps may improve engagement, leading to better outcomes, they may require navigation aids such as recommender systems that can quickly direct a person to a useful app. Objective: As the first step toward developing navigation and recommender tools, this study explored app-use patterns across the IntelliCare platform and their relationship with depression and anxiety outcomes. Methods: This is a secondary analysis of the IntelliCare Field Trial, which recruited people with depression or anxiety. Participants of the trial received 8 weeks of coaching, primarily by text, and weekly random recommendations for apps. App-use metrics included frequency and lifetime use. Depression and anxiety, measured using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, respectively, were assessed at baseline and end of treatment. Cluster analysis was utilized to determine patterns of app use; ordinal logistic regression models and log-rank tests were used to determine if these use metrics alone, or in combination, predicted improvement or remission in depression or anxiety. Results: The analysis included 96 people who generally followed recommendations to download and try new apps each week. Apps were clustered into 5 groups: Thinking (apps that targeted or relied on thinking), Calming (relaxation and insomnia), Checklists (apps that used checklists), Activity (behavioral activation and activity), and Other. Both overall frequency of use and lifetime use predicted response for depression and anxiety. The Thinking, Calming, and Checklist clusters were associated with improvement in depression and anxiety, and the Activity cluster was associated with improvement in Anxiety only. However, the use of clusters was less strongly associated with improvement than individual app use. Conclusions: Participants in the field trial remained engaged with a suite of apps for the full 8 weeks of the trial. App-use patterns did fall into clusters, suggesting that some knowledge about the use of one app may be useful in selecting another app that the person is more likely to use and may help suggest apps based on baseline symptomology and personal preference. %M 30896433 %R 10.2196/11572 %U http://mental.jmir.org/2019/3/e11572/ %U https://doi.org/10.2196/11572 %U http://www.ncbi.nlm.nih.gov/pubmed/30896433 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e11224 %T Health-Related Internet Usage and Design Feature Preference for E-Mental Health Programs Among Men and Women %A Smail-Crevier,Rachel %A Powers,Gabrielle %A Noel,Chelsea %A Wang,JianLi %+ Work & Mental Health Research Unit, The Royal's Institute of Mental Health Research, University of Ottawa, 1145 Carling Ave, Ottawa, ON, K1Z 7K4, Canada, 1 613 722 6521 ext 6057, jianli.wang@theroyal.ca %K occupational health %K workplace %K mental health %K preventive health program %K depression %K internet %D 2019 %7 18.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive episodes (MDEs) are prevalent in the workplace and affect workers’ health and productivity. Therefore, there is a pressing need for innovation in the prevention of MDEs in the workplace. Electronic mental (e-mental) health programs are a cost-effective approach toward the self-management of stress and emotional issues. E-mental health dropout rate, MDE prevalence, and symptoms greatly vary by sex and age. Thus, the development and implementation of e-mental health programs for the prevention of MDEs need to be examined through a sex and age lens to enhance program use and effectiveness. Objective: This study aimed to examine design feature preferences based on sex and age for an e-mental health program targeted toward depression prevention. Methods: Household residents across Canada were contacted using the random digit dialing method. 500 women and 511 men who were 18 years and older and who were at high risk of having MDEs were interviewed. Internet use was assessed using questions from the 2012 Canadian Internet Use Survey conducted by Statistics Canada, and preferred design features of e-mental health program questions were developed by the BroMatters team members. The proportions of likely use of specific features of e-mental health programs in women were estimated and compared with those in men using chi-square tests. The comparisons were made overall and by age groups. Results: Men (181/511, 35.4%) and women (211/500, 42.2%) differed significantly in their likelihood of using an e-mental health program. Compared with men (307/489, 62.8%), women (408/479, 85.2%) were more likely to use the internet for medical or health-related information. Women were more likely to use the following design features: practices and exercises to help reduce symptoms of stress and depression (350/500, 70.7%), a self-help interactive program that provides information about stress and work problems (302/500, 61.8%), the ability to ask questions and receive answers from mental health professionals via email or text message (294/500, 59.9%), and to receive printed materials by mail (215/500, 43.4%). Men preferred to receive information in a video game format (156/511, 30.7%). Younger men (46/73, 63%) and younger women (49/60, 81%) were more likely to access a program through a mobile phone or an app, and younger men preferred having access to information in a video game format. Conclusions: Factors such as sex and age influenced design feature preferences for an e-mental health program. Working women who are at high risk for MDEs preferred interactive programs incorporating practice and exercise for reducing stress, quality information about work stress, and some guidance from professionals. This suggests that sex and age should be taken into account when designing e-mental health programs to meet the needs of individuals seeking help via Web-based mental health programs and to enhance their use. %M 30882361 %R 10.2196/11224 %U http://www.jmir.org/2019/3/e11224/ %U https://doi.org/10.2196/11224 %U http://www.ncbi.nlm.nih.gov/pubmed/30882361 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 3 %P e11255 %T A Game-Based School Program for Mental Health Literacy and Stigma Regarding Depression (Moving Stories): Protocol for a Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 24 3612076, a.tuijnman@pwo.ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %D 2019 %7 14.03.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: The prevalence of elevated depressive symptoms among youth in most western societies is high. Yet, most adolescents who are experiencing depressive symptoms do not seek help. Low mental health literacy, high stigma, and low social support have been shown to hinder help-seeking. A small number of interventions has been developed to target mental health literacy and stigma, but few focus on actual help-seeking and first aid behavior. We have developed a game-based school program called Moving Stories that targets mental health literacy, including knowledge and behavior, and stigma among adolescents, in regard to depression specifically. Objective: Our aim is to describe the protocol for a study that will test the effectiveness of the program Moving Stories in a Dutch adolescent sample. We hypothesize that adolescents who participate in the program Moving Stories will have better mental health literacy and less stigma regarding depression compared to adolescents in the nonintervention control group at posttest and at 3- and 6-months follow-up. We also expect a positive change in actual help-seeking and first aid behavior at 3- and 6-months follow-up. Methods: Moving Stories has been developed by a professional game design company in collaboration with researchers and relevant stakeholders. The effectiveness of Moving Stories will be tested through a randomized controlled trial with two conditions: Moving Stories versus control. Participants will fill in questionnaires at pretest, posttest, and 3- and 6-months follow-up. Our power analysis showed a required sample size of 180 adolescents. Results: Four high schools have agreed to participate with a total of 10 classes. A total of 185 adolescents filled in the pretest questionnaire. The last of the follow-up data was collected in December 2018. Conclusions: If Moving Stories proves to be effective, it could be implemented as a school-based program to target mental health literacy and stigma regarding depression; this could, in turn, improve early help-seeking in adolescents suffering from depression. Trial Registration: Nederlands Trial Register NTR7033; https://www.trialregister.nl/trial/6855 International Registered Report Identifier (IRRID): DERR1-10.2196/11255 %M 30869652 %R 10.2196/11255 %U https://www.researchprotocols.org/2019/3/e11255/ %U https://doi.org/10.2196/11255 %U http://www.ncbi.nlm.nih.gov/pubmed/30869652 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11711 %T How Do Adolescents Use Electronic Diaries? A Mixed-Methods Study Among Adolescents With Depressive Symptoms %A Metsäranta,Kiki %A Kurki,Marjo %A Valimaki,Maritta %A Anttila,Minna %+ Department of Nursing Science, University of Turku, Hoitotieteen laitos, Joukahaisenkatu 3-5, Turun yliopisto, 20014, Finland, 358 456716156, kianme@utu.fi %K adolescent %K depression %K electronic diary %K mental health %K mobile phone %K outpatient care %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression in adolescence is common. Less than half of the adolescents with depression receive mental health care; furthermore, treatment tends to be suspended, and its success rates are low. There is a need for these adolescents to have a safe place to share their thoughts. Studies have shown that writing may be a useful treatment method for people with mental health problems. Objective: This study aims to describe the use of an electronic diary (e-diary) among adolescents with depressive symptoms. Methods: This paper describes a substudy of a randomized controlled trial. We used a mixed-methods approach to understand the way in which e-diaries were used by participants in the intervention under the randomized controlled trial. Data were collected during 2008-2010 at 2 university hospitals in Finland. Study participants (N=89) were 15-17-year-old adolescents who had been referred to an adolescent outpatient psychiatric clinic due to depressive symptoms. Participants were instructed to use the e-diary at least once a week to describe their thoughts, feelings, and moods. The content of the e-diary data was analyzed using descriptive statistics and inductive content analysis. Results: Overall, 53% (47/89) of the adolescents used the e-diary. Most of them (39/47, 83%) logged into the program during the first week, and about one-third (19/47, 40%) logged into the e-diary weekly as suggested. The number of words used in the e-diary per each log ranged between 8 and 1442 words. The 3 topics most often written about in the e-diary were related to mental health problems (mental disorder), social interaction (relationship), and one’s own development (identity). Conclusions: An e-diary may be a usable tool to reflect experiences and thoughts, especially among adolescents who have signs of depression. The results of this study can be used to develop user-centered electronic health applications that allow users to express their own thoughts and experiences in ways other than systematic mood monitoring. %M 30785408 %R 10.2196/11711 %U http://www.jmir.org/2019/2/e11711/ %U https://doi.org/10.2196/11711 %U http://www.ncbi.nlm.nih.gov/pubmed/30785408 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12894 %T Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders %A Joyce,Sadhbh %A Shand,Fiona %A Lal,Tara J %A Mott,Brendan %A Bryant,Richard A %A Harvey,Samuel B %+ School of Psychiatry, Faculty of Medicine, University of New South Wales, The Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 401297711, sadhbh.joyce@unsw.edu.au %K resilience training %K workplace mental health %K occupational health %K well-being %K online intervention %K employee resilience %K health and safety %K psychological health %K first responders %D 2019 %7 19.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time. Objective: This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers. Methods: We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills. Results: Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002). Conclusions: The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw). %M 30777846 %R 10.2196/12894 %U http://www.jmir.org/2019/2/e12894/ %U https://doi.org/10.2196/12894 %U http://www.ncbi.nlm.nih.gov/pubmed/30777846 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 2 %P e12121 %T Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects %A Beidas,Rinad S %A Volpp,Kevin G %A Buttenheim,Alison N %A Marcus,Steven C %A Olfson,Mark %A Pellecchia,Melanie %A Stewart,Rebecca E %A Williams,Nathaniel J %A Becker-Haimes,Emily M %A Candon,Molly %A Cidav,Zuleyha %A Fishman,Jessica %A Lieberman,Adina %A Zentgraf,Kelly %A Mandell,David %+ Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St, Philadelphia, PA, 19104, United States, 1 215 746 1759, rbeidas@upenn.edu %K implementation science %K behavioral economics %K mental health %D 2019 %7 12.02.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings. Objective: The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span. Methods: Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches. Results: Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted. Conclusions: This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders. Trial Registration: ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD) International Registered Report Identifier (IRRID): DERR1-10.2196/12121 %M 30747719 %R 10.2196/12121 %U http://www.researchprotocols.org/2019/2/e12121/ %U https://doi.org/10.2196/12121 %U http://www.ncbi.nlm.nih.gov/pubmed/30747719 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11325 %T Barriers to and Facilitators of Engagement With mHealth Technology for Remote Measurement and Management of Depression: Qualitative Analysis %A Simblett,Sara %A Matcham,Faith %A Siddi,Sara %A Bulgari,Viola %A Barattieri di San Pietro,Chiara %A Hortas López,Jorge %A Ferrão,José %A Polhemus,Ashley %A Haro,Josep Maria %A de Girolamo,Giovanni %A Gamble,Peter %A Eriksson,Hans %A Hotopf,Matthew %A Wykes,Til %A , %+ Institute of Psychology, Psychiatry and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, United Kingdom, 44 207 848 0762, sara.simblett@kcl.ac.uk %K acceptability %K barriers %K depression %K facilitators %K feasibility %K mHealth %K qualitative %D 2019 %7 30.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile technology has the potential to provide accurate, impactful data on the symptoms of depression, which could improve health management or assist in early detection of relapse. However, for this potential to be achieved, it is essential that patients engage with the technology. Although many barriers to and facilitators of the use of this technology are common across therapeutic areas and technology types, many may be specific to cultural and health contexts. Objective: This study aimed to determine the potential barriers to and facilitators of engagement with mobile health (mHealth) technology for remote measurement and management of depression across three Western European countries. Methods: Participants (N=25; 4:1 ratio of women to men; age range, 25-73 years) who experienced depression participated in five focus groups held in three countries (two in the United Kingdom, two in Spain, and one in Italy). The focus groups investigated the potential barriers to and facilitators of the use of mHealth technology. A systematic thematic analysis was used to extract themes and subthemes. Results: Facilitators and barriers were categorized as health-related factors, user-related factors, and technology-related factors. A total of 58 subthemes of specific barriers and facilitators or moderators emerged. A core group of themes including motivation, potential impact on mood and anxiety, aspects of inconvenience, and ease of use was noted across all countries. Conclusions: Similarities in the barriers to and facilitators of the use of mHealth technology have been observed across Spain, Italy, and the United Kingdom. These themes provide guidance on ways to promote the design of feasible and acceptable cross-cultural mHealth tools. %M 30698535 %R 10.2196/11325 %U http://mhealth.jmir.org/2019/1/e11325/ %U https://doi.org/10.2196/11325 %U http://www.ncbi.nlm.nih.gov/pubmed/30698535 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11041 %T Using Passive Smartphone Sensing for Improved Risk Stratification of Patients With Depression and Diabetes: Cross-Sectional Observational Study %A Sarda,Archana %A Munuswamy,Suresh %A Sarda,Shubhankar %A Subramanian,Vinod %+ Touchkin eServices Private Limited, 1st Floor, Manjusha, No 532, 16th Cross, 2nd Main Road, 2nd Stage, Indira Nagar, Bangalore, 560038, India, 91 9762665119, shubhankar@touchkin.com %K depression %K diabetes %K mental health %K comorbidity %K passive sensing %K smartphone %K classification %K machine learning %K mHealth %K risk assessment %D 2019 %7 29.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research studies are establishing the use of smartphone sensing to measure mental well-being. Smartphone sensor information captures behavioral patterns, and its analysis helps reveal well-being changes. Depression in diabetes goes highly underdiagnosed and underreported. The comorbidity has been associated with increased mortality and worse clinical outcomes, including poor glycemic control and self-management. Clinical-only intervention has been found to have a very modest effect on diabetes management among people with depression. Smartphone technologies could play a significant role in complementing comorbid care. Objective: This study aimed to analyze the association between smartphone-sensing parameters and symptoms of depression and to explore an approach to risk-stratify people with diabetes. Methods: A cross-sectional observational study (Project SHADO—Analyzing Social and Health Attributes through Daily Digital Observation) was conducted on 47 participants with diabetes. The study’s smartphone-sensing app passively collected data regarding activity, mobility, sleep, and communication from each participant. Self-reported symptoms of depression using a validated Patient Health Questionnaire-9 (PHQ-9) were collected once every 2 weeks from all participants. A descriptive analysis was performed to understand the representation of the participants. A univariate analysis was performed on each derived sensing variable to compare behavioral changes between depression states—those with self-reported major depression (PHQ-9>9) and those with none (PHQ-9≤9). A classification predictive modeling, using supervised machine-learning methods, was explored using derived sensing variables as input to construct and compare classifiers that could risk-stratify people with diabetes based on symptoms of depression. Results: A noticeably high prevalence of self-reported depression (30 out of 47 participants, 63%) was found among the participants. Between depression states, a significant difference was found for average activity rates (daytime) between participant-day instances with symptoms of major depression (mean 16.06 [SD 14.90]) and those with none (mean 18.79 [SD 16.72]), P=.005. For average number of people called (calls made and received), a significant difference was found between participant-day instances with symptoms of major depression (mean 5.08 [SD 3.83]) and those with none (mean 8.59 [SD 7.05]), P<.001. These results suggest that participants with diabetes and symptoms of major depression exhibited lower activity through the day and maintained contact with fewer people. Using all the derived sensing variables, the extreme gradient boosting machine-learning classifier provided the best performance with an average cross-validation accuracy of 79.07% (95% CI 74%-84%) and test accuracy of 81.05% to classify symptoms of depression. Conclusions: Participants with diabetes and self-reported symptoms of major depression were observed to show lower levels of social contact and lower activity levels during the day. Although findings must be reproduced in a broader randomized controlled study, this study shows promise in the use of predictive modeling for early detection of symptoms of depression in people with diabetes using smartphone-sensing information. %M 30694197 %R 10.2196/11041 %U http://mhealth.jmir.org/2019/1/e11041/ %U https://doi.org/10.2196/11041 %U http://www.ncbi.nlm.nih.gov/pubmed/30694197 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e11334 %T Adoption of Mobile Apps for Depression and Anxiety: Cross-Sectional Survey Study on Patient Interest and Barriers to Engagement %A Lipschitz,Jessica %A Miller,Christopher J %A Hogan,Timothy P %A Burdick,Katherine E %A Lippin-Foster,Rachel %A Simon,Steven R %A Burgess,James %+ Department of Psychiatry, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA, 02115, United States, 1 617 732 6548, jlipschitz@bwh.harvard.edu %K mHealth %K depression %K anxiety %K mobile apps %K patient preference %D 2019 %7 25.01.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emerging research suggests that mobile apps can be used to effectively treat common mental illnesses like depression and anxiety. Despite promising efficacy results and ease of access to these interventions, adoption of mobile health (mHealth; mobile device–delivered) interventions for mental illness has been limited. More insight into patients’ perspectives on mHealth interventions is required to create effective implementation strategies and to adapt existing interventions to facilitate higher rates of adoption. Objective: The aim of this study was to examine, from the patient perspective, current use and factors that may impact the use of mHealth interventions for mental illness. Methods: This was a cross-sectional survey study of veterans who had attended an appointment at a single Veterans Health Administration facility in early 2016 that was associated with one of the following mental health concerns: unipolar depression, any anxiety disorder, or posttraumatic stress disorder. We used the Veteran Affairs Corporate Data Warehouse to create subsets of eligible participants demographically stratified by gender (male or female) and minority status (white or nonwhite). From each subset, 100 participants were selected at random and mailed a paper survey with items addressing the demographics, overall health, mental health, technology ownership or use, interest in mobile app interventions for mental illness, reasons for use or nonuse, and interest in specific features of mobile apps for mental illness. Results: Of the 400 potential participants, 149 (37.3%, 149/400) completed and returned a survey. Most participants (79.9%, 119/149) reported that they owned a smart device and that they use apps in general (71.1%, 106/149). Most participants (73.1%, 87/149) reported interest in using an app for mental illness, but only 10.7% (16/149) had done so. Paired samples t tests indicated that ratings of interest in using an app recommended by a clinician were significantly greater than general interest ratings and even greater when the recommending clinician was a specialty mental health provider. The most frequent concerns related to using an app for mental illness were lacking proof of efficacy (71.8%, 107/149), concerns about data privacy (59.1%, 88/149), and not knowing where to find such an app (51.0%, 76/149). Participants expressed interest in a number of app features with particularly high-interest ratings for context-sensitive apps (85.2%, 127/149), and apps focused on the following areas: increasing exercise (75.8%, 113/149), improving sleep (73.2%, 109/149), changing negative thinking (70.5%, 105/149), and increasing involvement in activities (67.1%, 100/149). Conclusions: Most respondents had access to devices to use mobile apps for mental illness, already used apps for other purposes, and were interested in mobile apps for mental illness. Key factors that may improve adoption include provider endorsement, greater publicity of efficacious apps, and clear messaging about efficacy and privacy of information. Finally, multifaceted apps that address a range of concerns, from sleep to negative thought patterns, may be best received. %M 30681968 %R 10.2196/11334 %U http://mental.jmir.org/2019/1/e11334/ %U https://doi.org/10.2196/11334 %U http://www.ncbi.nlm.nih.gov/pubmed/30681968 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e10948 %T Effectiveness of a Multimodal Digital Psychotherapy Platform for Adult Depression: A Naturalistic Feasibility Study %A Marcelle,Enitan T %A Nolting,Laura %A Hinshaw,Stephen P %A Aguilera,Adrian %+ Department of Psychology, University of California, Berkeley, Tolman Hall, Berkeley, CA,, United States, 1 2164968894, emarcelle@berkeley.edu %K cognitive therapy %K depression %K digital health %K live chat %K mHealth %K mental health %K text messaging %K video %K mobile phone %D 2019 %7 23.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although psychotherapy is one of the most efficacious and effective treatments for depression, limited accessibility to trained providers markedly limits access to care. In an attempt to overcome this obstacle, several platforms seeking to provide these services using digital modalities (eg, video, text, and chat) have been developed. However, the use of these modalities individually poses barriers to intervention access and acceptability. Multimodal platforms, comprising those that allow users to select from a number of available modalities, may be able to provide a solution to these concerns. Objective: We aimed to investigate the preliminary effectiveness of providing psychotherapy through a multimodal digital psychotherapy platform. In addition, we aimed to examine differential responses to intervention by gender, self-reported physical health status, and self-reported financial status, as well as how prior exposure to traditional face-to-face psychotherapy affected the effectiveness of a multimodal digital psychotherapy intervention. Finally, we aimed to examine the dose-response effect. Methods: Data were collected from a total of 318 active users of BetterHelp, a multimodal digital psychotherapy platform. Data on physical health status, financial status, and prior exposure to psychotherapy were obtained using self-report measures. Effectiveness was determined by the extent of symptom severity change, which was measured using the Patient Health Questionnaire at Time 1 (time of enrollment) and Time 2 (3 months after enrollment). Intervention dosage was measured as the sum of individual therapist-user interactions across modalities. Results: Depression symptom severity was significantly reduced after the use of the multimodal digital psychotherapy intervention (P<.001). Individuals without prior traditional psychotherapy experience revealed increased improvement after intervention (P=.006). We found no significant dose-response effect of therapy, nor significant differences in outcomes across gender, self-reported financial status, and self-reported physical health status. Conclusions: Users of BetterHelp experienced significantly reduced depression symptom severity after engaging with the platform. Study findings suggest that this intervention is equally effective across gender, self-reported financial status, and self-reported physical health status and particularly effective for individuals without a history of psychotherapy. Overall, study results suggest that multimodal digital psychotherapy is a potentially effective treatment for adult depression; nevertheless, experimental trials are needed. We discuss directions for future research. %M 30674448 %R 10.2196/10948 %U http://mhealth.jmir.org/2019/1/e10948/ %U https://doi.org/10.2196/10948 %U http://www.ncbi.nlm.nih.gov/pubmed/30674448 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11509 %T Feasibility of a Therapist-Supported, Mobile Phone–Delivered Online Intervention for Depression: Longitudinal Observational Study %A Goldin,Philippe R %A Lindholm,Riku %A Ranta,Kristian %A Hilgert,Outi %A Helteenvuori,Tiia %A Raevuori,Anu %+ Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA, 95817, United States, 1 4156769793, philippegoldin@gmail.com %K cognitive therapy %K depression %K digital health %K digital therapeutics %K mindfulness %K online intervention %D 2019 %7 22.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Depression is a very common condition that impairs functioning and is often untreated. More than 60% of the treatments for depressive disorder are administered in primary care settings by care providers who lack the time and expertise to treat depression. To address this issue, we developed Ascend, a therapist-supported, mobile phone–delivered 8-week intervention administered at the Meru Health Online Clinic in Finland. Objective: We conducted two pilot studies to examine the feasibility of the Ascend intervention, specifically, dropout rates, daily practice, weekly group chat use, and changes in depression symptoms. We also explored whether daily practice and weekly group chat use were associated with changes in depression symptoms. Methods: A total of 117 Finnish adults with elevated depressive symptoms enrolled in Ascend, a program that included daily cognitive behavioral and mindfulness meditation exercises delivered through a mobile phone app, anonymous group chat with other users, and chat/phone access to a licensed therapist. Eight weekly themes were delivered in a fixed, sequential format. Depression symptoms were measured at baseline, every second week during the intervention, immediately after the intervention, and 4 weeks after completion of the intervention. Data were analyzed using intent-to-treat repeated-measures analysis of variance and linear regression models. Results: For studies 1 and 2, we observed dropout rates of 27% and 15%, respectively, decreasing daily practice and group chat use, and decreased depression symptoms from baseline to immediately and 4 weeks after the intervention (P<.001). We found that both more daily practice and chat group use predicted the occurrence of fewer depressive symptoms at 4 weeks postintervention (Study 1: ∆R2=.38, P=.004 and ∆R2=.38, P=.002, respectively; Study 2: ∆R2=.16, P<.001 and ∆R2=.08, P=.002, respectively). Conclusions: This therapist-supported, mobile phone–delivered treatment for depression is feasible and associated with reduced depression symptoms. Design features that enhance daily practice and group chat use are areas of future investigation. Validation of these results using a controlled study design is needed to establish the evidence base for the Ascend intervention. %R 10.2196/11509 %U http://formative.jmir.org/2019/1/e11509/ %U https://doi.org/10.2196/11509 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e10675 %T Web-Based Measure of Life Events Using Computerized Life Events and Assessment Record (CLEAR): Preliminary Cross-Sectional Study of Reliability, Validity, and Association With Depression %A Bifulco,Antonia %A Spence,Ruth %A Nunn,Stephen %A Kagan,Lisa %A Bailey-Rodriguez,Deborah %A Hosang,Georgina M %A Taylor,Matthew %A Fisher,Helen L %+ Centre for Abuse and Trauma Studies, Department of Psychology, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom, 44 02084113705, a.bifulco@mdx.ac.uk %K depression %K life change events %K life stress %K health technology %K internet %K psychometrics %K psychological tests %D 2019 %7 08.01.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given the criticisms of life event checklists and the costs associated with interviews, life event research requires a sophisticated but easy-to-use measure for research and clinical practice. Therefore, the Computerized Life Events and Assessment Record (CLEAR), based on the Life Events and Difficulties Schedule (LEDS), was developed. Objective: The objective of our study was 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) were completed by 328 participants (126 students; 202 matched midlife sample: 127 unaffected 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 the overall number of life events (0.89) and severe life events (.60). Long-term problems showed similar findings. In terms of validity, CLEAR severe life events had moderate sensitivity (59.1%) and specificity (65.4%) when compared with LEDS. CLEAR demonstrated moderate sensitivity (43.1%) and specificity (78.6%) when compared with LTE-Q. CLEAR severe life events and long-term problems were significantly associated with depression (odds ratio, OR 3.50, 95% CI 2.10 to 5.85, P<.001; OR 3.38, 95% CI 2.02 to 5.67, P<.001, respectively), whereas LTE-Q events were not (OR 1.06, 95% CI 0.43 to 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-related factors for the onset and maintenance of depression and related disorders. %M 30622088 %R 10.2196/10675 %U https://mental.jmir.org/2019/1/e10675/ %U https://doi.org/10.2196/10675 %U http://www.ncbi.nlm.nih.gov/pubmed/30622088 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10179 %T How Search Engine Data Enhance the Understanding of Determinants of Suicide in India and Inform Prevention: Observational Study %A Adler,Natalia %A Cattuto,Ciro %A Kalimeri,Kyriaki %A Paolotti,Daniela %A Tizzoni,Michele %A Verhulst,Stefaan %A Yom-Tov,Elad %A Young,Andrew %+ ISI Foundation, Via Chisola 5, Torino, 10126, Italy, 39 011 660 3090, daniela.paolotti@isi.it %K internet data %K India %K suicide %K mobile phone %D 2019 %7 04.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: India is home to 20% of the world’s suicide deaths. Although statistics regarding suicide in India are distressingly high, data and cultural issues likely contribute to a widespread underreporting of the problem. Social stigma and only recent decriminalization of suicide are among the factors hampering official agencies’ collection and reporting of suicide rates. Objective: As the product of a data collaborative, this paper leverages private-sector search engine data toward gaining a fuller, more accurate picture of the suicide issue among young people in India. By combining official statistics on suicide with data generated through search queries, this paper seeks to: add an additional layer of information to more accurately represent the magnitude of the problem, determine whether search query data can serve as an effective proxy for factors contributing to suicide that are not represented in traditional datasets, and consider how data collaboratives built on search query data could inform future suicide prevention efforts in India and beyond. Methods: We combined official statistics on demographic information with data generated through search queries from Bing to gain insight into suicide rates per state in India as reported by the National Crimes Record Bureau of India. We extracted English language queries on “suicide,” “depression,” “hanging,” “pesticide,” and “poison”. We also collected data on demographic information at the state level in India, including urbanization, growth rate, sex ratio, internet penetration, and population. We modeled the suicide rate per state as a function of the queries on each of the 5 topics considered as linear independent variables. A second model was built by integrating the demographic information as additional linear independent variables. Results: Results of the first model fit (R2) when modeling the suicide rates from the fraction of queries in each of the 5 topics, as well as the fraction of all suicide methods, show a correlation of about 0.5. This increases significantly with the removal of 3 outliers and improves slightly when 5 outliers are removed. Results for the second model fit using both query and demographic data show that for all categories, if no outliers are removed, demographic data can model suicide rates better than query data. However, when 3 outliers are removed, query data about pesticides or poisons improves the model over using demographic data. Conclusions: In this work, we used search data and demographics to model suicide rates. In this way, search data serve as a proxy for unmeasured (hidden) factors corresponding to suicide rates. Moreover, our procedure for outlier rejection serves to single out states where the suicide rates have substantially different correlations with demographic factors and query rates. %M 30609976 %R 10.2196/10179 %U https://www.jmir.org/2019/1/e10179/ %U https://doi.org/10.2196/10179 %U http://www.ncbi.nlm.nih.gov/pubmed/30609976 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 1 %P e11560 %T Recruitment and Baseline Characteristics of Participants in the Social, Emotional, and Economic Empowerment Through Knowledge of Group Support Psychotherapy Study (SEEK-GSP): Cluster Randomized Controlled Trial %A Nakimuli-Mpungu,Etheldreda %A Musisi,Seggane %A Wamala,Kizito %A Okello,James %A Ndyanabangi,Sheila %A Birungi,Josephine %A Nanfuka,Mastula %A Etukoit,Michael %A Mojtabai,Ramin %A Nachega,Jean %A Harari,Ofir %A Mills,Edward %+ Department of Psychiatry, College of Health Sciences, Makerere University, Old Mulago Hospital Complex, Mulago Hill Road, Kampala, 256, Uganda, 256 788994050, ethelmpungu@yahoo.com %K cluster randomized trial %K group support psychotherapy %K lay health workers %K depression %K recruitment %K psychosocial stressors %K persons living with HIV/AIDS %K Uganda %D 2019 %7 03.01.2019 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Psychosocial characteristics, including self-esteem, perceived social support, coping skills, stigma, discrimination, and poverty, are strongly correlated with depression symptoms. However, data on the extent of these correlations among persons living with HIV and the associations between psychosocial characteristics and HIV treatment outcomes are limited in sub-Saharan Africa. Objective: This paper aims to describe the recruitment process and baseline characteristics associated with depression in a sample of HIV-positive people in a cluster randomized trial of group support psychotherapy (GSP) for depression delivered by trained lay health workers (LHWs). Methods: Thirty eligible primary care health centers across three districts in Uganda were randomly allocated to have their LHWs trained to deliver GSP (intervention arm) or group HIV education and treatment as usual (control arm) to persons living with HIV comorbid with depression. Baseline demographic, socioeconomic, and psychosocial characteristics were collected via interviewer-administered questionnaires. Among eligible participants, differences between those enrolled versus those who refused enrollment were assessed using chi square for categorical variables and t tests for continuous variables. Spearman rank order correlation analyses were conducted to determine associations between baseline depression symptoms and adherence to antiretroviral therapy (ART), viral load suppression, and other psychosocial variables. Results: The study screened 1473 people and 1140 were found to be eligible and enrolled over 14 weeks. Participants recruited comprised 95% of the target sample size of 1200. The sample’s mean age was 38.5 (SD 10.9) years and both genders were well represented (males: 46.32%, 528/1140). Most participants met the diagnostic criteria for major depressive disorder (96.92%, 1105/1140), had significant posttraumatic stress symptoms (72.46%, 826/1140), reported moderate suicide risk (52.54%, 599/1140), had primary or no formal education (86.22%, 983/1140), and reported no income-generating activity (72.63%, 828/1140) and no food insecurity (81.67%, 931/1140). Among eligible participants, 48 of 1140 (4.21%) refused to participate in the interventions; these participants were more likely to be males (χ21=4.0, P=.045) and have significantly lower depression symptoms scores (t2=2.36, P=.01) than those who participated in the interventions. There was a significant positive correlation between viral load and number of traumatic experiences (ρ=.12, P=.05). Adherence to ART was positively correlated with perceived social support (ρ=.15, P<.001), but negatively correlated with depression symptoms (ρ=–.11, P=.05) and stigma (ρ=–.14, P<.001). Conclusions: Men and women with HIV and depression experience multiple social and economic vulnerabilities and disadvantages. Culturally tailored psychological interventions aimed at these individuals should address these socioeconomic disadvantages in addition to addressing their mental health care needs. Trial Registration: Pan African Clinical Trials Registry PACTR201608001738234; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1738 (Archived by WebCite at http://www.webcitation.org/74NtMphom) %M 30609989 %R 10.2196/11560 %U http://www.researchprotocols.org/2019/1/e11560/ %U https://doi.org/10.2196/11560 %U http://www.ncbi.nlm.nih.gov/pubmed/30609989 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11683 %T Use of In-Game Rewards to Motivate Daily Self-Report Compliance: Randomized Controlled Trial %A Taylor,Sara %A Ferguson,Craig %A Peng,Fengjiao %A Schoeneich,Magdalena %A Picard,Rosalind W %+ Affective Computing Group, Department of Media Arts and Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, E14-348V, Cambridge, MA, 02142, United States, 1 6128608622, sataylor@mit.edu %K self-reports %K protocol compliance %K recreational games %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Encouraging individuals to report daily information such as unpleasant disease symptoms, daily activities and behaviors, or aspects of their physical and emotional state is difficult but necessary for many studies and clinical trials that rely on patient-reported data as primary outcomes. Use of paper diaries is the traditional method of completing daily diaries, but digital surveys are becoming the new standard because of their increased compliance; however, they still fall short of desired compliance levels. Objective: Mobile games using in-game rewards offer the opportunity to increase compliance above the rates of digital diaries and paper diaries. We conducted a 5-week randomized control trial to compare the completion rates of a daily diary across 3 conditions: a paper-based participant-reported outcome diary (Paper PRO), an electronic-based participant-reported outcome diary (ePRO), and a novel ePRO diary with in-game rewards (Game-Motivated ePRO). Methods: We developed a novel mobile game that is a combination of the idle and pet collection genres to reward individuals who complete a daily diary with an in-game reward. Overall, 197 individuals aged 6 to 24 years (male: 100 and female: 97) were enrolled in a 5-week study after being randomized into 1 of the 3 methods of daily diary completion. Moreover, 157 participants (male: 84 and female: 69) completed at least one diary and were subsequently included in analysis of compliance rates. Results: We observed a significant difference (F2,124=6.341; P=.002) in compliance to filling out daily diaries, with the Game-Motivated ePRO group having the highest compliance (mean completion 86.4%, SD 19.6%), followed by the ePRO group (mean completion 77.7%, SD 24.1%), and finally, the Paper PRO group (mean completion 70.6%, SD 23.4%). The Game-Motivated ePRO (P=.002) significantly improved compliance rates above the Paper PRO. In addition, the Game-Motivated ePRO resulted in higher compliance rates than the rates of ePRO alone (P=.09). Equally important, even though we observed significant differences in completion of daily diaries between groups, we did not observe any statistically significant differences in association between the responses to a daily mood question and study group, the average diary completion time (P=.52), or the System Usability Scale score (P=.88). Conclusions: The Game-Motivated ePRO system encouraged individuals to complete the daily diaries above the compliance rates of the Paper PRO and ePRO without altering the participants’ responses. Trial Registration: ClinicalTrials.gov NCT03738254; http://clinicaltrials.gov/ct2/show/NCT03738254 (Archived by WebCite at http://www.webcitation.org/74T1p8u52) %M 30609986 %R 10.2196/11683 %U https://www.jmir.org/2019/1/e11683/ %U https://doi.org/10.2196/11683 %U http://www.ncbi.nlm.nih.gov/pubmed/30609986 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e11249 %T How LGBT+ Young People Use the Internet in Relation to Their Mental Health and Envisage the Use of e-Therapy: Exploratory Study %A Lucassen,Mathijs %A Samra,Rajvinder %A Iacovides,Ioanna %A Fleming,Theresa %A Shepherd,Matthew %A Stasiak,Karolina %A Wallace,Louise %+ School of Health, Wellbeing and Social Care, The Open University, Walton Hall, Milton Keynes, MK7 6AA, United Kingdom, 44 1908652987, mathijs.lucassen@open.ac.uk %K sexuality %K LGBT %K transgender %K depression %K adolescent %K psychotherapy %K mental health %K computer games %K computerized CBT %K e-therapy %D 2018 %7 21.12.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game–based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people. Objective: This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people’s and professionals’ views about e-therapies, drawing on the example of Rainbow SPARX. Methods: A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data. Results: LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes. Conclusions: LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people. %M 30578194 %R 10.2196/11249 %U http://games.jmir.org/2018/4/e11249/ %U https://doi.org/10.2196/11249 %U http://www.ncbi.nlm.nih.gov/pubmed/30578194 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11467 %T Supported Internet-Delivered Cognitive Behavioral Therapy Programs for Depression, Anxiety, and Stress in University Students: Open, Non-Randomised Trial of Acceptability, Effectiveness, and Satisfaction %A Palacios,Jorge E %A Richards,Derek %A Palmer,Riley %A Coudray,Carissa %A Hofmann,Stefan G %A Palmieri,Patrick A %A Frazier,Patricia %+ E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin, College Green, Dublin,, Ireland, 353 18961000, jorge.palacios@tcd.ie %K depression %K anxiety %K cognitive therapy %K students %D 2018 %7 14.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many university campuses have limited mental health services that cannot cope with the high demand. One alternative is to use internet-delivered cognitive behavioral therapy (iCBT) as a way of tackling barriers such as lack of availability and scheduling issues. Objective: This study aimed to assess feasibility, acceptability, effectiveness, and satisfaction of a supported iCBT intervention offering 3 programs on depression, anxiety, and stress to university students. The design was an open or nonrandomized feasibility trial. Methods: Participants were recruited from 3 counseling centers at a large midwestern University in the United States. Those agreeing to take part chose 1 of 3 iCBT programs—Space from Depression, Space from Anxiety, or Space from Stress —all comprised 8 modules of media-rich interactive content. Participants were supported throughout the trial by a trained professional. The Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) questionnaire, and stress subscale of the Depression Anxiety and Stress Scale (DASS-21) were completed at baseline, 8 weeks, and 3-month follow-up. A Satisfaction With Treatment (SAT) questionnaire was completed at 8 weeks, and qualitative interviews were completed by a subsample of participants at 3 months. Results: A total of 102 participants were recruited, with 52 choosing Space from Anxiety, 31 choosing Space from Depression, and 19 choosing Space from Stress. Mixed-effects models showed a significant decrease in symptoms of depression (F4=6.36, P<.001), anxiety (F4=7.97, P<.001), and stress (F4=8.50, P<.001) over time across all 3 programs. The largest decreases in PHQ-9 scores at 8 weeks were among participants who chose the Space from Depression program (d=0.84); at 3 months, the largest decreases in PHQ-9 scores were among those who chose the Space from Stress program (d=0.74). The largest decreases in GAD-7 scores were among those who chose the Space from Anxiety program (d=0.74 at 8 weeks and d=0.94 at 3 months). The largest decrease in DASS-21 stress subscale scores was among those who chose the Space from Stress program (d=0.49 at 8 weeks and d=1.16 at 3 months). The mean time spent using the platform per session was 27.4 min (SD 33.8), and participants completed 53% (SD 37.6) of the total program content on average. Most (37/53, 69%) participants found the programs helpful or very helpful and liked the convenience and flexibility of the intervention. Qualitative interviews (n=14) indicated the intervention met students’ expectations, and they saw it as a valuable complement to face-to-face treatment. Conclusions: The iCBT programs tested in our study appear to be feasible, acceptable, and effective in a university environment. Participants described the benefits of having a flexible, supported Web-based intervention available on campus. Larger trials should be conducted to further test the effectiveness of supported Web-based interventions that give students a choice of program depending on their symptom profile. %M 30552076 %R 10.2196/11467 %U http://mental.jmir.org/2018/4/e11467/ %U https://doi.org/10.2196/11467 %U http://www.ncbi.nlm.nih.gov/pubmed/30552076 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11483 %T Monitoring Online Discussions About Suicide Among Twitter Users With Schizophrenia: Exploratory Study %A Hswen,Yulin %A Naslund,John A %A Brownstein,John S %A Hawkins,Jared B %+ Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA, 02115, United States, 1 6177751889, yhswen@gmail.com %K schizophrenia %K social media %K suicide %K Twitter %K digital technology %K mental health %D 2018 %7 13.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: People with schizophrenia experience elevated risk of suicide. Mental health symptoms, including depression and anxiety, contribute to increased risk of suicide. Digital technology could support efforts to detect suicide risk and inform suicide prevention efforts. Objective: This exploratory study examined the feasibility of monitoring online discussions about suicide among Twitter users who self-identify as having schizophrenia. Methods: Posts containing the terms suicide or suicidal were collected from a sample of Twitter users who self-identify as having schizophrenia (N=203) and a random sample of control users (N=173) over a 200-day period. Frequency and timing of posts about suicide were compared between groups. The associations between posting about suicide and common mental health symptoms were examined. Results: Twitter users who self-identify as having schizophrenia posted more tweets about suicide (mean 7.10, SD 15.98) compared to control users (mean 1.89, SD 4.79; t374=-4.13, P<.001). Twitter users who self-identify as having schizophrenia showed greater odds of tweeting about suicide compared to control users (odds ratio 2.15, 95% CI 1.42-3.28). Among all users, tweets about suicide were associated with tweets about depression (r=0.62, P<.001) and anxiety (r=0.45, P<.001). Conclusions: Twitter users who self-identify as having schizophrenia appear to commonly discuss suicide on social media, which is associated with greater discussion about other mental health symptoms. These findings should be interpreted cautiously, as it is not possible to determine whether online discussions about suicide correlate with suicide risk. However, these patterns of online discussion may be indicative of elevated risk of suicide observed in this patient group. There may be opportunities to leverage social media for supporting suicide prevention among individuals with schizophrenia. %M 30545811 %R 10.2196/11483 %U http://mental.jmir.org/2018/4/e11483/ %U https://doi.org/10.2196/11483 %U http://www.ncbi.nlm.nih.gov/pubmed/30545811 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e64 %T Using Psychological Artificial Intelligence (Tess) to Relieve Symptoms of Depression and Anxiety: Randomized Controlled Trial %A Fulmer,Russell %A Joerin,Angela %A Gentile,Breanna %A Lakerink,Lysanne %A Rauws,Michiel %+ Northwestern University, 633 Clark Street, Evanston, IL, United States, 1 312 609 5300 ext 699, russell.fulmer@northwestern.edu %K artificial intelligence %K mental health services %K depression %K anxiety %K students %D 2018 %7 13.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Students in need of mental health care face many barriers including cost, location, availability, and stigma. Studies show that computer-assisted therapy and 1 conversational chatbot delivering cognitive behavioral therapy (CBT) offer a less-intensive and more cost-effective alternative for treating depression and anxiety. Although CBT is one of the most effective treatment methods, applying an integrative approach has been linked to equally effective posttreatment improvement. Integrative psychological artificial intelligence (AI) offers a scalable solution as the demand for affordable, convenient, lasting, and secure support grows. Objective: This study aimed to assess the feasibility and efficacy of using an integrative psychological AI, Tess, to reduce self-identified symptoms of depression and anxiety in college students. Methods: In this randomized controlled trial, 75 participants were recruited from 15 universities across the United States. All participants completed Web-based surveys, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Positive and Negative Affect Scale (PANAS) at baseline and 2 to 4 weeks later (T2). The 2 test groups consisted of 50 participants in total and were randomized to receive unlimited access to Tess for either 2 weeks (n=24) or 4 weeks (n=26). The information-only control group participants (n=24) received an electronic link to the National Institute of Mental Health’s (NIMH) eBook on depression among college students and were only granted access to Tess after completion of the study. Results: A sample of 74 participants completed this study with 0% attrition from the test group and less than 1% attrition from the control group (1/24). The average age of participants was 22.9 years, with 70% of participants being female (52/74), mostly Asian (37/74, 51%), and white (32/74, 41%). Group 1 received unlimited access to Tess, with daily check-ins for 2 weeks. Group 2 received unlimited access to Tess with biweekly check-ins for 4 weeks. The information-only control group was provided with an electronic link to the NIMH’s eBook. Multivariate analysis of covariance was conducted. We used an alpha level of .05 for all statistical tests. Results revealed a statistically significant difference between the control group and group 1, such that group 1 reported a significant reduction in symptoms of depression as measured by the PHQ-9 (P=.03), whereas those in the control group did not. A statistically significant difference was found between the control group and both test groups 1 and 2 for symptoms of anxiety as measured by the GAD-7. Group 1 (P=.045) and group 2 (P=.02) reported a significant reduction in symptoms of anxiety, whereas the control group did not. A statistically significant difference was found on the PANAS between the control group and group 1 (P=.03) and suggests that Tess did impact scores. Conclusions: This study offers evidence that AI can serve as a cost-effective and accessible therapeutic agent. Although not designed to appropriate the role of a trained therapist, integrative psychological AI emerges as a feasible option for delivering support. Trial Registration: International Standard Randomized Controlled Trial Number: ISRCTN61214172; https://doi.org/10.1186/ISRCTN61214172. %M 30545815 %R 10.2196/mental.9782 %U http://mental.jmir.org/2018/4/e64/ %U https://doi.org/10.2196/mental.9782 %U http://www.ncbi.nlm.nih.gov/pubmed/30545815 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11513 %T Video-Delivered Family Therapy for Home Visited Young Mothers With Perinatal Depressive Symptoms: Quasi-Experimental Implementation-Effectiveness Hybrid Trial %A Cluxton-Keller,Fallon %A Williams,Melony %A Buteau,Jennifer %A Donnelly,Craig L %A Stolte,Patricia %A Monroe-Cassel,Maggie %A Bruce,Martha L %+ Department of Psychiatry, Geisel School of Medicine at Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4724, Fallon.P.Cluxton-Keller@dartmouth.edu %K videoconferencing %K family therapy, depression %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas. Objective: This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation. Methods: A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act–compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes. Results: No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms (P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004). Conclusions: This pilot study yielded preliminary findings that support the feasibility, acceptability, and effectiveness of the video-delivered family therapy intervention for underserved home visited families in rural areas. Our findings are very promising, but more research is needed to ultimately influence mental health practices and policies that pertain to video-delivered mental health interventions in unsupervised settings (eg, homes). %M 30530456 %R 10.2196/11513 %U http://mental.jmir.org/2018/4/e11513/ %U https://doi.org/10.2196/11513 %U http://www.ncbi.nlm.nih.gov/pubmed/30530456 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11290 %T Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A Preliminary Randomized Controlled Trial %A Smyth,Joshua M %A Johnson,Jillian A %A Auer,Brandon J %A Lehman,Erik %A Talamo,Giampaolo %A Sciamanna,Christopher N %+ Department of Biobehavioral Health, The Pennsylvania State University, 231 Biobehavioral Health Building, The Pennsylvania State University, University Park, PA, 16802, United States, 1 8148638402, jms1187@psu.edu %K adult %K anxiety %K depression %K emotions %K expressed emotion %K internet %K stress, psychological/physiopathology %K surveys and questionnaires %K treatment outcome %K writing %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for Web-based dissemination to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical conditions. Objective: This study aimed to examine the impact of a 12-week Web-based PAJ intervention on psychological distress and quality of life in general medical patients. Methods: A total of 70 adults with various medical conditions and elevated anxiety symptoms were recruited from local clinics and randomly assigned to a Web-based PAJ intervention (n=35) or usual care (n=35). The intervention group completed 15-min Web-based PAJ sessions on 3 days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed. Results: Patients evidenced moderate sustained adherence to Web-based intervention. PAJ was associated with decreased mental distress and increased well-being relative to baseline. PAJ was also associated with less depressive symptoms and anxiety after 1 month and greater resilience after the first and second month, relative to usual care. Conclusions: Web-based PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical care to improve quality of life. Trial Registration: ClinicalTrials.gov NCT01873599; https://clinicaltrials.gov/ct2/show/NCT01873599 (Archived by WebCite at http://www.webcitation.org/73ZGFzD2Z) %M 30530460 %R 10.2196/11290 %U http://mental.jmir.org/2018/4/e11290/ %U https://doi.org/10.2196/11290 %U http://www.ncbi.nlm.nih.gov/pubmed/30530460 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 12 %P e11135 %T An Electronic Clinical Decision Support System for the Assessment and Management of Suicidality in Primary Care: Protocol for a Mixed-Methods Study %A Horrocks,Matthew %A Michail,Maria %A Aubeeluck,Aimee %A Wright,Nicola %A Morriss,Richard %+ Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Wollaton Road, Nottingham, NG7 2TU, United Kingdom, 44 (0) 115 8231427, matthew.horrocks@nottingham.ac.uk %K suicide %K primary care %K general practitioner %K clinical decision support system %D 2018 %7 07.12.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management are areas that many general practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalize, and assess suicide risk, which subsequently has an impact on clinical decision making. Clinical decision support systems (CDSS) have been widely implemented across different health care settings, including primary care to support practitioners in clinical decision making. A CDSS may reduce inconsistencies in the identification, assessment, and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialized mental health services. Objective: Our aim is to co-develop and test with end users (eg, GPs, primary care attendees, mental health professionals) an electronic clinical decision support system (e-CDSS) to support GPs in the identification, assessment, and management of suicidality in primary care. Methods: Ours is an ongoing embedded mixed-methods study with four phases: (1) qualitative interviews with GPs to explore their views on the content, format, and use of the e-CDSS, as well as consultation with two service-user advisory groups (people aged ≤25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; (2) participatory co-production workshops with GPs, service users, and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity and identify pathways to implementation, using the Consolidated Framework for Implementation Research; (3) building the e-CDSS so that it guides the GP through a consultation; and (4) usability testing of the e-CDSS with GPs and service users in one primary care practice involving a nonlive and a live stage. Results: The study was funded for four years, to take place between 2015 and 2019, and is currently completing phase 4 data collection. The first results are expected to be submitted for publication in June 2019. The findings will enable us to evaluate the feasibility, acceptability, and usability of a suicide-specific, electronic, guided decision support system in primary care. Conclusions: This study will be the first to explore the feasibility, acceptability, and usability of an electronic, guided decision support system for use in primary care consultations for the improved assessment and management of suicidality. International Registered Report Identifier (IRRID): RR1-10.2196/11135 %M 30530459 %R 10.2196/11135 %U http://www.researchprotocols.org/2018/12/e11135/ %U https://doi.org/10.2196/11135 %U http://www.ncbi.nlm.nih.gov/pubmed/30530459 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 12 %P e11817 %T Exploring the Utility of Community-Generated Social Media Content for Detecting Depression: An Analytical Study on Instagram %A Ricard,Benjamin J %A Marsch,Lisa A %A Crosier,Benjamin %A Hassanpour,Saeed %+ Department of Biomedical Data Science, Dartmouth College, One Medical Center Drive, HB 7261, Lebanon, NH, 03756, United States, 1 603 650 1983, Saeed.Hassanpour@dartmouth.edu %K machine learning %K depression %K social media %K mental health %D 2018 %7 06.12.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The content produced by individuals on various social media platforms has been successfully used to identify mental illness, including depression. However, most of the previous work in this area has focused on user-generated content, that is, content created by the individual, such as an individual’s posts and pictures. In this study, we explored the predictive capability of community-generated content, that is, the data generated by a community of friends or followers, rather than by a sole individual, to identify depression among social media users. Objective: The objective of this research was to evaluate the utility of community-generated content on social media, such as comments on an individual’s posts, to predict depression as defined by the clinically validated Patient Health Questionnaire-8 (PHQ-8) assessment questionnaire. We hypothesized that the results of this research may provide new insights into next generation of population-level mental illness risk assessment and intervention delivery. Methods: We created a Web-based survey on a crowdsourcing platform through which participants granted access to their Instagram profiles as well as provided their responses to PHQ-8 as a reference standard for depression status. After data quality assurance and postprocessing, the study analyzed the data of 749 participants. To build our predictive model, linguistic features were extracted from Instagram post captions and comments, including multiple sentiment scores, emoji sentiment analysis results, and meta-variables such as the number of likes and average comment length. In this study, 10.4% (78/749) of the data were held out as a test set. The remaining 89.6% (671/749) of the data were used to train an elastic-net regularized linear regression model to predict PHQ-8 scores. We compared different versions of this model (ie, a model trained on only user-generated data, a model trained on only community-generated data, and a model trained on the combination of both types of data) on a test set to explore the utility of community-generated data in our predictive analysis. Results: The 2 models, the first trained on only community-generated data (area under curve [AUC]=0.71) and the second trained on a combination of user-generated and community-generated data (AUC=0.72), had statistically significant performances for predicting depression based on the Mann-Whitney U test (P=.03 and P=.02, respectively). The model trained on only user-generated data (AUC=0.63; P=.11) did not achieve statistically significant results. The coefficients of the models revealed that our combined data classifier effectively amalgamated both user-generated and community-generated data and that the 2 feature sets were complementary and contained nonoverlapping information in our predictive analysis. Conclusions: The results presented in this study indicate that leveraging community-generated data from social media, in addition to user-generated data, can be informative for predicting depression among social media users. %M 30522991 %R 10.2196/11817 %U http://www.jmir.org/2018/12/e11817/ %U https://doi.org/10.2196/11817 %U http://www.ncbi.nlm.nih.gov/pubmed/30522991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e11661 %T Preliminary Effectiveness of a Smartphone App to Reduce Depressive Symptoms in the Workplace: Feasibility and Acceptability Study %A Deady,Mark %A Johnston,David %A Milne,David %A Glozier,Nick %A Peters,Dorian %A Calvo,Rafael %A Harvey,Samuel %+ Black Dog Institute, Faculty of Medicine, University of New South Wales, Hospital Road, Randwick, Sydney,, Australia, 61 293824517, m.deady@unsw.edu.au %K depression %K workplace %K mHealth %K smartphone %K eHealth %K pilot %D 2018 %7 04.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The workplace represents a unique setting for mental health interventions. Due to range of job-related factors, employees in male-dominated industries are at an elevated risk. However, these at-risk groups are often overlooked. HeadGear is a smartphone app–based intervention designed to reduce depressive symptoms and increase well-being in these populations. Objective: This paper presents the development and pilot testing of the app’s usability, acceptability, feasibility, and preliminary effectiveness. Methods: The development process took place from January 2016 to August 2017. Participants for prototype testing (n=21; stage 1) were recruited from industry partner organizations to assess acceptability and utility. A 5-week effectiveness and feasibility pilot study (n=84; stage 2) was then undertaken, utilizing social media recruitment. Demographic data, acceptability and utility questionnaires, depression (Patient Health Questionnaire-9), and other mental health measures were collected. Results: The majority of respondents felt HeadGear was easy to use (92%), easily understood (92%), were satisfied with the app (67%), and would recommend it to a friend (75%; stage 1). Stage 2 found that compared with baseline, depression and anxiety symptoms were significantly lower at follow-up (t30=2.53; P=.02 and t30=2.18; P=.04, respectively), days of sick leave in past month (t28=2.38; P=.02), and higher self-reported job performance (t28=−2.09; P=.046; stage 2). Over 90% of respondents claimed it helped improve their mental fitness, and user feedback was again positive. Attrition was high across the stages. Conclusions: Overall, HeadGear was well received, and preliminary findings indicate it may provide an innovative new platform for improving mental health outcomes. Unfortunately, attrition was a significant issue, and findings should be interpreted with caution. The next stage of evaluation will be a randomized controlled trial. If found to be efficacious, the app has the potential to reduce disease burden and improve health in this at-risk group. %M 30514694 %R 10.2196/11661 %U https://mhealth.jmir.org/2018/12/e11661/ %U https://doi.org/10.2196/11661 %U http://www.ncbi.nlm.nih.gov/pubmed/30514694 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 12 %P e291 %T Accessibility and Applicability of Currently Available e-Mental Health Programs for Depression for People With Poststroke Aphasia: Scoping Review %A Clunne,Stephanie Jane %A Ryan,Brooke Jade %A Hill,Annie Jane %A Brandenburg,Caitlin %A Kneebone,Ian %+ School of Health and Rehabilitation Sciences, The University of Queensland, 84A Services Road, St Lucia, Brisbane, QLD 4067, Australia, 61 336 51380, brooke.ryan@uq.edu.au %K aphasia %K stroke %K depression %K mental health %K internet %K technology %K access to health care %D 2018 %7 04.12.2018 %9 Review %J J Med Internet Res %G English %X Background: Depression affects approximately 60% of people with aphasia 1 year post stroke and is associated with disability, lower quality of life, and mortality. Web-delivered mental health (e-mental health) programs are effective, convenient, and cost-effective for the general population and thus are increasingly used in the management of depression. However, it is unknown if such services are applicable and communicatively accessible to people with poststroke aphasia. Objective: The aim of this study was to identify freely available e-mental health programs for depression and determine their applicability and accessibility for people with poststroke aphasia. Methods: A Web-based search was conducted to identify and review freely available e-mental health programs for depression. These programs were then evaluated in terms of their (1) general features via a general evaluation tool, (2) communicative accessibility for people with aphasia via an aphasia-specific communicative accessibility evaluation tool, and (3) empirical evidence for the general population and stroke survivors with and without aphasia. The program that met the most general evaluation criteria and aphasia-specific communicative accessibility evaluation criteria was then trialed by a small subgroup of people with poststroke aphasia. Results: A total of 8 programs were identified. Of these, 4 had published evidence in support of their efficacy for use within the general population. However, no empirical evidence was identified that specifically supported any programs’ use for stroke survivors with or without aphasia. One evidence-based program scored at least 80% (16/19 and 16/20, respectively) on both the general and aphasia-specific communicative accessibility evaluation tools and was subject to a preliminary trial by 3 people with poststroke aphasia. During this trial, participants were either unable to independently use the program or gave it low usability scores on a post-trial satisfaction survey. On this basis, further evaluation was considered unwarranted. Conclusions: Despite fulfilling majority of the general evaluation and aphasia-specific evaluation criteria, the highest rated program was still found to be unsuitable for people with poststroke aphasia. Thus, e-mental health programs require substantial redevelopment if they are likely to be useful to people with poststroke aphasia. %M 30514696 %R 10.2196/jmir.9864 %U https://www.jmir.org/2018/12/e291/ %U https://doi.org/10.2196/jmir.9864 %U http://www.ncbi.nlm.nih.gov/pubmed/30514696 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e11508 %T The Association Between the Use of Antenatal Care Smartphone Apps in Pregnant Women and Antenatal Depression: Cross-Sectional Study %A Mo,Yushi %A Gong,Wenjie %A Wang,Joyce %A Sheng,Xiaoqi %A Xu,Dong R %+ XiangYa School of Public Health, Central South University, 238 Shangmayuanling Lane, Xiangya Road, KaiFu District, Changsha,, China, 86 13607445252, gongwenjie@csu.edu.cn %K antenatal care %K antenatal depression %K app %K mobile phone %D 2018 %7 29.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Antenatal care smartphone apps are increasingly used by pregnant women, but studies on their use and impact are scarce. Objective: This study investigates the use of antenatal care apps in pregnant women and explores the association between the use of these apps and antenatal depression. Methods: This study used a convenient sample of pregnant women recruited from Hunan Provincial Maternal and Child Health Hospital in November 2015. The participants were surveyed for their demographic characteristics, use of antenatal care apps, and antenatal depression. Factors that influenced antenatal pregnancy were analyzed using logistic regression. Results: Of the 1304 pregnant women, 71.31% (930/1304) used antenatal care apps. Higher usage of apps was associated with urban residency, nonmigrant status, first pregnancy, planned pregnancy, having no previous children, and opportunity to communicate with peer pregnant women. The cutoff score of the Edinburgh Postnatal Depression Scale was 10, and 46.11% (601/1304) of the pregnant women had depression. Logistic regression showed that depression was associated with the availability of disease-screening functions in the apps (odds ratio (OR) 1.78, 95% CI 1.03-3.06) and spending 30 minutes or more using the app (OR 2.05, 95% CI 1.19-3.52). Using apps with social media features was a protective factor for antenatal depression (OR 0.33, 95% CI 0.12-0.89). Conclusions: The prevalence of the use of prenatal care apps in pregnant women is high. The functions and time spent on these apps are associated with the incidence of antenatal depression. %M 30497996 %R 10.2196/11508 %U http://mhealth.jmir.org/2018/11/e11508/ %U https://doi.org/10.2196/11508 %U http://www.ncbi.nlm.nih.gov/pubmed/30497996 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10927 %T Guided Internet-Based Cognitive Behavioral Therapy for Adult Depression and Anxiety in Routine Secondary Care: Observational Study %A Mathiasen,Kim %A Riper,Heleen %A Andersen,Tonny E %A Roessler,Kirsten K %+ Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark, 45 61677747, kim.mathiasen@rsyd.dk %K anxiety %K cognitive therapy %K cohort studies %K depression %K Internet %K secondary care %D 2018 %7 28.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) is a promising new treatment method for depression and anxiety. However, it is important to determine whether its results can be replicated in routine care before its implementation on a large scale. Although many studies have demonstrated the efficacy of iCBT under controlled conditions, only a few studies have investigated its effectiveness in routine care. Furthermore, several effects of iCBT such as treatment effects in routine care are unclear. Objective: This study aimed to evaluate the clinical effectiveness of iCBT for depression and anxiety in routine secondary care. Methods: n a retrospective cohort study, we analysed patients treated for depression or anxiety in a dedicated iCBT clinic in secondary care in Denmark. Patients were examined before treatment and weekly thereafter by using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 scales for the diagnoses of depression and anxiety, respectively. Primary analyses were conducted using a linear mixed-effects model with random slope and intercept. Secondary analyses were conducted using baseline characteristics as predictors (gender, age, highest level of education, occupational status, marital status, psychotropic medication use, consumption of alcohol, and leisure drugs). Additionally, logistic regression analyses were used to predict noncompletion of treatment. Results: A total of 203 (depression, N=60; anxiety, N=143) patients were included. Participants were mainly female (78.3% with depression and 65.7% with anxiety), with a mean age of 36.03 (SD 10.97) years (range, 19-67 years) for patients with depression and 36.80 (SD 13.55) years (range, 19-69 years) for patients with anxiety. The completion rates were 62% (37) and 40% (57) for depression and anxiety treatments, respectively. The primary analyses revealed large and significant reductions in the symptom levels of depression (beta=-6.27, SE 0.83, P<.001, d=1.0) and anxiety (beta=-3.78, SE 0.43, P<.001, d=1.1). High baseline severity of the primary disorder was associated with high treatment gains (r=-0.31 for depression; r=-0.41 for anxiety). In patients with anxiety, high baseline severity also predicted a high risk of noncompletion (odds ratio=1.08, CI=1.01-1.16, P=.03). An increase in the baseline severity of the comorbid disorder slightly increased the risk of noncompletion for both disorders (depression: odds ratio=1.03, CI=1.01-1.06, P=.02; anxiety: odds ratio=1.08, CI=1.01-1.16, P=.03). Conclusions: iCBT can be clinically effective in routine care. Since depression and anxiety are costly and debilitating disorders that are vastly undertreated, this finding is important. Additionally, iCBT may help bridge the gap between the need for treatment and its provision. Our results are comparable to the within-group results of efficacy and effectiveness studies. Our noncompletion rates are similar to those observed in psychotherapy but are higher than those reported in similar clinics. Multiple factors predicted outcome and noncompletion. However, all predictor effects were statistically weak. %M 30487118 %R 10.2196/10927 %U http://www.jmir.org/2018/11/e10927/ %U https://doi.org/10.2196/10927 %U http://www.ncbi.nlm.nih.gov/pubmed/30487118 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10437 %T Economic Evaluation of an Internet-Based Preventive Cognitive Therapy With Minimal Therapist Support for Recurrent Depression: Randomized Controlled Trial %A Klein,Nicola S %A Bockting,Claudi LH %A Wijnen,Ben %A Kok,Gemma D %A van Valen,Evelien %A Riper,Heleen %A Cuijpers,Pim %A Dekker,Jack %A van der Heiden,Colin %A Burger,Huibert %A Smit,Filip %+ Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam,, Netherlands, 31 20 891 3610, c.l.bockting@amc.uva.nl %K major depressive disorders %K recurrence %K cognitive therapy %K internet %K prevention %K cost effectiveness %D 2018 %7 26.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder (MDD) is highly recurrent and has a significant disease burden. Although the effectiveness of internet-based interventions has been established for the treatment of acute MDD, little is known about their cost effectiveness, especially in recurrent MDD. Objectives: Our aim was to evaluate the cost effectiveness and cost utility of an internet-based relapse prevention program (mobile cognitive therapy, M-CT). Methods: The economic evaluation was performed alongside a single-blind parallel group randomized controlled trial. Participants were recruited via media, general practitioners, and mental health care institutions. In total, 288 remitted individuals with a history of recurrent depression were eligible, of whom 264 were randomly allocated to M-CT with minimal therapist support added to treatment as usual (TAU) or TAU alone. M-CT comprised 8 online lessons, and participants were advised to complete 1 lesson per week. The economic evaluation was performed from a societal perspective with a 24-month time horizon. The health outcomes were number of depression-free days according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria assessed with the Structured Clinical Interview for DSM-IV axis I disorders by blinded interviewers after 3, 12, and 24 months. Quality-adjusted life years (QALYs) were self-assessed with the three level version of the EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Costs were assessed with the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness (TiC-P). Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that M-CT is cost effective compared to TAU. Results: Mean total costs over 24 months were €8298 (US $9415) for M-CT and €7296 (US $8278) for TAU. No statistically significant differences were found between M-CT and TAU regarding depression-free days and QALYs (P=.37 and P=.92, respectively). The incremental costs were €179 (US $203) per depression-free day and €230,816 (US $261,875) per QALY. The cost-effectiveness acceptability curves suggested that for depression-free days, high investments have to be made to reach an acceptable probability that M-CT is cost effective compared to TAU. Regarding QALYs, considerable investments have to be made but the probability that M-CT is cost effective compared to TAU does not rise above 40%. Conclusions: The results suggest that adding M-CT to TAU is not effective and cost effective compared to TAU alone. Adherence rates were similar to other studies and therefore do not explain this finding. The participants scarcely booked additional therapist support, resulting in 17.3 minutes of mean total therapist support. More studies are needed to examine the cost effectiveness of internet-based interventions with respect to long-term outcomes and the role and optimal dosage of therapist support. Overall, more research is needed on scalable and cost-effective interventions that can reduce the burden of recurrent MDD. Trial registration: Netherlands Trial Register NTR2503; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2503 (Archived by WebCite at http://www.webcitation.org/73aBn41r3) %M 30478021 %R 10.2196/10437 %U http://www.jmir.org/2018/11/e10437/ %U https://doi.org/10.2196/10437 %U http://www.ncbi.nlm.nih.gov/pubmed/30478021 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e12106 %T An Empathy-Driven, Conversational Artificial Intelligence Agent (Wysa) for Digital Mental Well-Being: Real-World Data Evaluation Mixed-Methods Study %A Inkster,Becky %A Sarda,Shubhankar %A Subramanian,Vinod %+ School of Clinical Medicine, Department of Psychiatry, University of Cambridge, Box 189, Cambridge Biomedical Campus, Cambridge, CB2 2QQ, United Kingdom, 44 773 847 8045, becky.inkster@gmail.com %K mental health %K conversational agents %K artificial intelligence %K chatbots %K coping skills %K resilience, psychological %K depression %K mHealth %K emotions %K empathy %D 2018 %7 23.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A World Health Organization 2017 report stated that major depression affects almost 5% of the human population. Major depression is associated with impaired psychosocial functioning and reduced quality of life. Challenges such as shortage of mental health personnel, long waiting times, perceived stigma, and lower government spends pose barriers to the alleviation of mental health problems. Face-to-face psychotherapy alone provides only point-in-time support and cannot scale quickly enough to address this growing global public health challenge. Artificial intelligence (AI)-enabled, empathetic, and evidence-driven conversational mobile app technologies could play an active role in filling this gap by increasing adoption and enabling reach. Although such a technology can help manage these barriers, they should never replace time with a health care professional for more severe mental health problems. However, app technologies could act as a supplementary or intermediate support system. Mobile mental well-being apps need to uphold privacy and foster both short- and long-term positive outcomes. Objective: This study aimed to present a preliminary real-world data evaluation of the effectiveness and engagement levels of an AI-enabled, empathetic, text-based conversational mobile mental well-being app, Wysa, on users with self-reported symptoms of depression. Methods: In the study, a group of anonymous global users were observed who voluntarily installed the Wysa app, engaged in text-based messaging, and self-reported symptoms of depression using the Patient Health Questionnaire-9. On the basis of the extent of app usage on and between 2 consecutive screening time points, 2 distinct groups of users (high users and low users) emerged. The study used mixed-methods approach to evaluate the impact and engagement levels among these users. The quantitative analysis measured the app impact by comparing the average improvement in symptoms of depression between high and low users. The qualitative analysis measured the app engagement and experience by analyzing in-app user feedback and evaluated the performance of a machine learning classifier to detect user objections during conversations. Results: The average mood improvement (ie, difference in pre- and post-self-reported depression scores) between the groups (ie, high vs low users; n=108 and n=21, respectively) revealed that the high users group had significantly higher average improvement (mean 5.84 [SD 6.66]) compared with the low users group (mean 3.52 [SD 6.15]); Mann-Whitney P=.03 and with a moderate effect size of 0.63. Moreover, 67.7% of user-provided feedback responses found the app experience helpful and encouraging. Conclusions: The real-world data evaluation findings on the effectiveness and engagement levels of Wysa app on users with self-reported symptoms of depression show promise. However, further work is required to validate these initial findings in much larger samples and across longer periods. %M 30470676 %R 10.2196/12106 %U http://mhealth.jmir.org/2018/11/e12106/ %U https://doi.org/10.2196/12106 %U http://www.ncbi.nlm.nih.gov/pubmed/30470676 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e63 %T Lamotrigine Therapy for Bipolar Depression: Analysis of Self-Reported Patient Data %A Nzeyimana,Antoine %A Saunders,Kate EA %A Geddes,John R %A McSharry,Patrick E %+ Department of Geography, University of Oregon, 1251 University of Oregon, Eugene, OR, 97403-1251, United States, 1 541 346 0785, anzeyima@uoregon.edu %K bipolar disorder %K CEQUEL study %K data analysis %K depressive symptoms %K lamotrigine %K time series %D 2018 %7 22.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression in people with bipolar disorder is a major cause of long-term disability, possibly leading to early mortality and currently, limited safe and effective therapies exist. Although existing monotherapies such as quetiapine have limited proven efficacy and practical tolerability, treatment combinations may lead to improved outcomes. Lamotrigine is an anticonvulsant currently licensed for the prevention of depressive relapses in individuals with bipolar disorder. A double-blinded randomized placebo-controlled trial (comparative evaluation of Quetiapine-Lamotrigine [CEQUEL] study) was conducted to evaluate the efficacy of lamotrigine plus quetiapine versus quetiapine monotherapy in patients with bipolar type I or type II disorders. Objective: Because the original CEQUEL study found significant depressive symptom improvements, the objective of this study was to reanalyze CEQUEL data and determine an unbiased classification accuracy for active lamotrigine versus placebo. We also wanted to establish the time it took for the drug to provide statistically significant outcomes. Methods: Between October 21, 2008 and April 27, 2012, 202 participants from 27 sites in United Kingdom were randomly assigned to two treatments; 101: lamotrigine, 101: placebo. The primary variable used for estimating depressive symptoms was based on the Quick Inventory of Depressive Symptomatology—self report version 16 (QIDS-SR16). The original CEQUEL study findings were confirmed by performing t test and linear regression. Multiple features were computed from the QIDS-SR16 time series; different linear and nonlinear binary classifiers were trained to distinguish between the two groups. Various feature-selection techniques were used to select a feature set with the greatest explanatory power; a 10-fold cross-validation was used. Results: From weeks 10 to 14, the mean difference in QIDS-SR16 ratings between the groups was −1.6317 (P=.09; sample size=81, 77; 95% CI −0.2403 to 3.5036). From weeks 48 to 52, the mean difference was −2.0032 (P=.09; sample size=54, 48; 95% CI −0.3433 to 4.3497). The coefficient of variation (σ/μ) and detrended fluctuation analysis (DFA) exponent alpha had the greatest explanatory power. The out-of-sample classification accuracy for the 138 participants who reported more than 10 times after week 12 was 62%. A consistent classification accuracy higher than the no-information benchmark was obtained in week 44. Conclusions: Adding lamotrigine to quetiapine treatment decreased depressive symptoms in patients with bipolar disorder. Our classification model suggested that lamotrigine increased the coefficient of variation in the QIDS-SR16 scores. The lamotrigine group also tended to have a lower DFA exponent, implying a substantial temporal instability in the time series. The performance of the model over time suggested that a trial of at least 44 weeks was required to achieve consistent results. The selected model confirmed the original CEQUEL study findings and helped in understanding the temporal dynamics of bipolar depression during treatment. Trial Registration: EudraCT Number 2007-004513-33; https://www.clinicaltrialsregister.eu/ctr-search/trial/2007-004513-33/GB (Archived by WebCite at http://www.webcitation.org/73sNaI29O). %M 30467104 %R 10.2196/mental.9026 %U http://mental.jmir.org/2018/4/e63/ %U https://doi.org/10.2196/mental.9026 %U http://www.ncbi.nlm.nih.gov/pubmed/30467104 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11124 %T The Mediating Role of Perceived Social Support Between Physical Activity Habit Strength and Depressive Symptoms in People Seeking to Decrease Their Cardiovascular Risk: Cross-Sectional Study %A Storm,Vera %A Reinwand,Dominique Alexandra %A Wienert,Julian %A Tan,Shu-Ling %A Lippke,Sonia %+ Institute of Sport and Exercise Sciences, Department of Sport and Exercise Psychology, University of Münster, Horstmarer Landweg 62b, Münster, 48149, Germany, 49 251 83 31805, vera.storm@uni-muenster.de %K physical activity %K habit %K social support %K depressive symptoms %K cardiac diseases %D 2018 %7 14.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Regular physical activity treatment has been advocated for the prevention and rehabilitation of patients at risk of cardiovascular diseases and depressive symptoms. How physical activity is related to depressive symptoms is widely discussed. Objective: The aim of this internet-based study was to investigate the role of perceived social support in the relationship between physical activity habit strength and depressive symptoms. Methods: In total, 790 participants (mean 50.9 years, SD 12.2, range 20-84 years) who were interested in reducing their cardiovascular risk were recruited in Germany and the Netherlands. Data collection was conducted via an internet-based questionnaire addressing physical activity habit strength, depressive symptoms, and perceived social support. Cross-sectional data analysis was done with SPSS version 24 using the Macro PROCESS version 2 16.3 by Hayes with bootstrapping (10,000 samples), providing 95% CIs. Results: Physical activity habit strength was negatively related to depressive symptoms (r=–.13, P=.006), but this interrelation disappeared when controlling for perceived social support (beta=–.14, SE 0.09, P=.11). However, there was an indirect relationship between physical activity habit strength and depressive symptoms, which was mediated via perceived social support (beta=–.13; SE 0.04, 95% CI –0.21 to 0.06). The negative relationship between physical activity habit strength and depressive symptoms was fully mediated by perceived social support. Conclusions: We suggest that physical activity treatment in people interested in reducing their cardiovascular risk should also embed social support to target depressive symptoms. Internet-based interventions and electronic health may provide a good option for doing so. Trial Registration: ClinicalTrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/73Y9RfdiY) %M 30429112 %R 10.2196/11124 %U http://mental.jmir.org/2018/4/e11124/ %U https://doi.org/10.2196/11124 %U http://www.ncbi.nlm.nih.gov/pubmed/30429112 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10113 %T The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis %A Lorenzo-Luaces,Lorenzo %A Johns,Emily %A Keefe,John R %+ Department of Psychological and Brain Sciences, Indiana University Bloomington, 1101 East 10th Street, Room 158, Bloomington, IN, 47401, United States, 1 787 222 2493, lolorenz@indiana.edu %K depression %K psychotherapy %K CBT %K internet-based therapy %K pharmacotherapy %K generalizability %K exclusion criteria %K cognitive therapy %K telemedicine %K drug therapy %K patient selection %D 2018 %7 09.11.2018 %9 Review %J J Med Internet Res %G English %X Background: Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. Objective: We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes. Methods: We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review. Results: Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. Conclusions: A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies. %M 30413400 %R 10.2196/10113 %U http://www.jmir.org/2018/11/e10113/ %U https://doi.org/10.2196/10113 %U http://www.ncbi.nlm.nih.gov/pubmed/30413400 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e10114 %T Using Mobile Phones to Examine and Enhance Perceptions of Control in Mildly Depressed and Nondepressed Volunteers: Intervention Study %A Msetfi,Rachel %A O'Sullivan,Donal %A Walsh,Amy %A Nelson,John %A Van de Ven,Pepijn %+ Department of Psychology, Health Research Institute, University of Limerick, Castletroy, Limerick,, Ireland, 353 61202709, rachel.msetfi@ul.ie %K perception of control %K illusory control %K well-being %K depression %K health %K intervention %K causal learning %D 2018 %7 09.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Perceived control is strongly linked to healthy outcomes, mental healthiness, and psychological well-being. This is particularly important when people have little control over things that are happening to them. Perceived control studies have been performed extensively in laboratory settings and show that perceived control can be increased by experimental manipulations. Although these studies suggest that it may be possible to improve people’s mental health by increasing their perceived control, there is very little evidence to date to suggest that perceived control can also be influenced in the real world. Objective: The first aim of this study was to test for evidence of a link between noncontrol situations and psychological well-being in the real world using a mobile phone app. The second and arguably more important aim of the study was to test whether a simple instructional intervention on the nature of alternative causes would enhance people’s perceptions of their own control in these noncontrol situations. Methods: We implemented a behavioral action-outcome contingency judgment task using a mobile phone app. An opportunity sample of 106 healthy volunteers scoring low (n=56, no depression) or high (n=50, mild depression) on a depression scale participated. They were given no control over the occurrence of a low- or high-frequency stimulus that was embedded in everyday phone interactions during a typical day lasting 8 hours. The intervention involved instructions that either described a consistent alternative cause against which to assess their own control, or dynamic alternative causes of the outcome. Throughout the day, participants rated their own control over the stimulus using a quantitative judgment scale. Results: Participants with no evidence of depression overestimated their control, whereas those who were most depressed were more accurate in their control ratings. Instructions given to all participants about the nature of alternative causes significantly affected the pattern of perceived control ratings. Instructions describing discrete alternative causes enhanced perceived control for all participants, whereas dynamic alternative causes were linked to less perceived control. Conclusions: Perceptions of external causes are important to perceived control and can be used to enhance people’s perceptions. Theoretically motivated interventions can be used to enhance perceived control using mobile phone apps. This is the first study to do so in a real-world setting. %M 30413398 %R 10.2196/10114 %U http://mhealth.jmir.org/2018/11/e10114/ %U https://doi.org/10.2196/10114 %U http://www.ncbi.nlm.nih.gov/pubmed/30413398 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e61 %T Identifying and Understanding Communities Using Twitter to Connect About Depression: Cross-Sectional Study %A DeJohn,Amber D %A Schulz,Emily English %A Pearson,Amber L %A Lachmar,E Megan %A Wittenborn,Andrea K %+ Department of Geography, Environment, and Spatial Sciences, Michigan State University, Geography Building, 673 Auditorium Road, East Lansing, MI, 48824, United States, 1 5173554649, apearson@msu.edu %K depression %K Web-based %K social connection %K Twitter %K tweet %K online communities %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is the leading cause of diseases globally and is often characterized by a lack of social connection. With the rise of social media, it is seen that Twitter users are seeking Web-based connections for depression. Objective: This study aimed to identify communities where Twitter users tweeted using the hashtag #MyDepressionLooksLike to connect about depression. Once identified, we wanted to understand which community characteristics correlated to Twitter users turning to a Web-based community to connect about depression. Methods: Tweets were collected using NCapture software from May 25 to June 1, 2016 during the Mental Health Month (n=104) in the northeastern United States and Washington DC. After mapping tweets, we used a Poisson multilevel regression model to predict tweets per community (county) offset by the population and adjusted for percent female, percent population aged 15-44 years, percent white, percent below poverty, and percent single-person households. We then compared predicted versus observed counts and calculated tweeting index values (TIVs) to represent undertweeting and overtweeting. Last, we examined trends in community characteristics by TIV using Pearson correlation. Results: We found significant associations between tweet counts and area-level proportions of females, single-person households, and population aged 15-44 years. TIVs were lower than expected (TIV 1) in eastern, seaboard areas of the study region. There were communities tweeting as expected in the western, inland areas (TIV 2). Counties tweeting more than expected were generally scattered throughout the study region with a small cluster at the base of Maine. When examining community characteristics and overtweeting and undertweeting by county, we observed a clear upward gradient in several types of nonprofits and TIV values. However, we also observed U-shaped relationships for many community factors, suggesting that the same characteristics were correlated with both overtweeting and undertweeting. Conclusions: Our findings suggest that Web-based communities, rather than replacing physical connection, may complement or serve as proxies for offline social communities, as seen through the consistent correlations between higher levels of tweeting and abundant nonprofits. Future research could expand the spatiotemporal scope to confirm these findings. %M 30401662 %R 10.2196/mental.9533 %U http://mental.jmir.org/2018/4/e61/ %U https://doi.org/10.2196/mental.9533 %U http://www.ncbi.nlm.nih.gov/pubmed/30401662 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 1 %N 2 %P e10973 %T Feasibility and Conceptualization of an e-Mental Health Treatment for Depression in Older Adults: Mixed-Methods Study %A Eichenberg,Christiane %A Schott,Markus %A Sawyer,Adam %A Aumayr,Georg %A Plößnig,Manuela %+ Sigmund Freud Privat Universität Wien, Freudpl. 1, Vienna, 1020, Austria, 43 15124049991, markus.s.c.schott@gmail.com %K depression %K online therapy %K e-mental health %D 2018 %7 23.10.2018 %9 Original Paper %J JMIR Aging %G English %X Background: Depression is one of the most common mental disorders in older adults. Unfortunately, it often goes unrecognized in the older population. Objective: The aim of this study was to identify how Web-based apps can recognize and help treat depression in older adults. Methods: Focus groups were conducted with mental health care experts. A Web-based survey of 56 older adults suffering from depression was conducted. Qualitative interviews were conducted with 2 individuals. Results: Results of the focus groups highlighted that there is a need for a collaborative care platform for depression in old age. Findings from the Web-based study showed that younger participants (aged 50 to 64 years) used electronic media more often than older participants (aged 65 years and older). The interviews pointed in a comparable direction. Conclusions: Overall, an e-mental (electronic mental) health treatment for depression in older adults would be well accepted. Web-based care platforms should be developed, evaluated, and in case of evidence for their effectiveness, integrated into the everyday clinic. %M 31518235 %R 10.2196/10973 %U http://aging.jmir.org/2018/2/e10973/ %U https://doi.org/10.2196/10973 %U http://www.ncbi.nlm.nih.gov/pubmed/31518235 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10698 %T Individualized Web-Based Exercise for the Treatment of Depression: Randomized Controlled Trial %A Haller,Nils %A Lorenz,Sonja %A Pfirrmann,Daniel %A Koch,Cora %A Lieb,Klaus %A Dettweiler,Ulrich %A Simon,Perikles %A Jung,Patrick %+ Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Strasse 8, Mainz, 55131, Germany, 49 69633909719, patrick.jung@unimedizin-mainz.de %K depression %K exercise %K Web-based intervention %K eHealth %D 2018 %7 12.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Due to the high prevalence of depressive disorders, it is mandatory to develop therapeutic strategies that provide universal access and require limited financial and human resources. Web-based therapeutic approaches fulfill these conditions. Objective: The objective of our study was to assess the feasibility, acceptability, and efficacy of a supervised, individualized 8-week Web-based exercise intervention conducted for patients with moderate to severe depression. Methods: We recruited 20 patients with unipolar depression and randomly assigned them into 2 groups (intervention, exercise program group, n=14, and control, treatment-as-usual group, n=6). At baseline, depressive symptoms were rated via the Quick Inventory of Depressive Symptomatology (QIDS) by patients themselves (QIDS–self-report, QIDS-SR) and by a blinded psychiatrist (QIDS–clinician rating, QIDS-C). In addition, performance diagnostics (lactate analysis, spiroergometry during a treadmill walking test) were conducted. Quality of life was assessed via the Short Form-36 questionnaire (SF-36) and self-efficacy via the General Self-Efficacy scale (GSE). In addition, habitual physical activity (HPA) was determined via the Baecke questionnaire. Participants of the intervention group received exercise schedules once weekly with endurance and strength training instructions. Rating of depressive symptoms was repeated after 6-12 days and 8 weeks; performance diagnostics and the completion of all the questionnaires were repeated after 8 weeks only. Results: The severity of depression subsided significantly in the intervention group after 8 weeks (median change in QIDS-SR: −5; interquartile range, IQR: −2 to −10), although it was already evident within the first 6-12 days (median change in QIDS-SR: −6; IQR: −2 to −8). During the intervention, participants undertook a median of 75 (IQR: 63 to 98) minutes of endurance training per week or 84% (16 [IQR: 9 to 19] of 19 [IQR: 15 to 21]) recommended endurance units in total. In addition, 9 (IQR: 4 to 12) of 10 (IQR: 8 to 13) recommended strength training exercise units were conducted during the 8 weeks. Performance diagnostics revealed a substantial increase in the maximum output in Watt for the intervention group after 8 weeks. Moreover, the intervention showed a favorable effect on SF-36 items “emotional well-being” and “social functioning” as well as on GSE and HPA scores. Conclusions: Our individualized Web-based exercise intervention for moderate to severe depression was highly accepted by the patients and led to a significant and clinically relevant improvement of depressive symptoms. Trial Registration: ClinicalTrials.gov NCT02874833; https://clinicaltrials.gov/ct2/show/NCT02874833 (Archived by WebCite at http://www.webcitation.org/72ZUUR4tE) %M 30314962 %R 10.2196/10698 %U http://mental.jmir.org/2018/4/e10698/ %U https://doi.org/10.2196/10698 %U http://www.ncbi.nlm.nih.gov/pubmed/30314962 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 10 %P e10754 %T Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction: Machine Learning Insights From the U-CARE Heart Randomized Controlled Trial %A Wallert,John %A Gustafson,Emelie %A Held,Claes %A Madison,Guy %A Norlund,Fredrika %A von Essen,Louise %A Olsson,Erik Martin Gustaf %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, SE-75185, Uppsala,, Sweden, 46 729999217, john.wallert@kbh.uu.se %K applied predictive modeling %K cardiac rehabilitation %K linguistics %K supervised machine learning %K recursive feature elimination %K treatment adherence and compliance %K Web-based interventions %D 2018 %7 10.10.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care. Objectives: The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients. Methods: Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10–fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers. Results: Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment. Conclusions: For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated. Trial registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22) %M 30305255 %R 10.2196/10754 %U http://www.jmir.org/2018/10/e10754/ %U https://doi.org/10.2196/10754 %U http://www.ncbi.nlm.nih.gov/pubmed/30305255 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10726 %T Identifying the Underlying Factors Associated With Patients’ Attitudes Toward Antidepressants: Qualitative and Quantitative Analysis of Patient Drug Reviews %A Zolnoori,Maryam %A Fung,Kin Wah %A Fontelo,Paul %A Kharrazi,Hadi %A Faiola,Anthony %A Wu,Yi Shuan Shirley %A Stoffel,Virginia %A Patrick,Timothy %+ Section of Medical Informatics, Department of Health Science Research, Mayo Clinic, 200 First Street SW, Rochester, MN,, United States, 1 3175151950, Zolnoori.Maryam@mayo.edu %K medication adherence %K attitude %K perception %K antidepressive agents %K patient-centered care %K chronic disease %K depression %K community networks %K internet %K social media %K data mining %K framework method %D 2018 %7 30.9.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Nonadherence to antidepressants is a major obstacle to deriving antidepressants’ therapeutic benefits, resulting in significant burdens on the individuals and the health care system. Several studies have shown that nonadherence is weakly associated with personal and clinical variables but strongly associated with patients’ beliefs and attitudes toward medications. Patients’ drug review posts in online health care communities might provide a significant insight into patients’ attitude toward antidepressants and could be used to address the challenges of self-report methods such as patients’ recruitment. Objective: The aim of this study was to use patient-generated data to identify factors affecting the patient’s attitude toward 4 antidepressants drugs (sertraline [Zoloft], escitalopram [Lexapro], duloxetine [Cymbalta], and venlafaxine [Effexor XR]), which in turn, is a strong determinant of treatment nonadherence. We hypothesized that clinical variables (drug effectiveness; adverse drug reactions, ADRs; perceived distress from ADRs, ADR-PD; and duration of treatment) and personal variables (age, gender, and patients’ knowledge about medications) are associated with patients’ attitude toward antidepressants, and experience of ADRs and drug ineffectiveness are strongly associated with negative attitude. Methods: We used both qualitative and quantitative methods to analyze the dataset. Patients’ drug reviews were randomly selected from a health care forum called askapatient. The Framework method was used to build the analytical framework containing the themes for developing structured data from the qualitative drug reviews. Then, 4 annotators coded the drug reviews at the sentence level using the analytical framework. After managing missing values, we used chi-square and ordinal logistic regression to test and model the association between variables and attitude. Results: A total of 892 reviews posted between February 2001 and September 2016 were analyzed. Most of the patients were females (680/892, 76.2%) and aged less than 40 years (540/892, 60.5%). Patient attitude was significantly (P<.001) associated with experience of ADRs, ADR-PD, drug effectiveness, perceived lack of knowledge, experience of withdrawal, and duration of usage, whereas oth age (F4,874=0.72, P=.58) and gender (χ24=2.7, P=.21) were not found to be associated with patient attitudes. Moreover, modeling the relationship between variables and attitudes showed that drug effectiveness and perceived distress from adverse drug reactions were the 2 most significant factors affecting patients’ attitude toward antidepressants. Conclusions: Patients’ self-report experiences of medications in online health care communities can provide a direct insight into the underlying factors associated with patients’ perceptions and attitudes toward antidepressants. However, it cannot be used as a replacement for self-report methods because of the lack of information for some of the variables, colloquial language, and the unstructured format of the reports. %M 30287417 %R 10.2196/10726 %U http://mental.jmir.org/2018/4/e10726/ %U https://doi.org/10.2196/10726 %U http://www.ncbi.nlm.nih.gov/pubmed/30287417 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10204 %T Supported Internet-Delivered Cognitive Behavior Treatment for Adults with Severe Depressive Symptoms: A Secondary Analysis %A Richards,Derek %A Duffy,Daniel %A Burke,John %A Anderson,Melissa %A Connell,Sarah %A Timulak,Ladislav %+ Clinical Research & Innovation, SilverCloud Health, One Stephen Street, Stephen Street Upper, Dublin, D08 DR9P, Ireland, 353 15549771, derek.richards@silvercloudhealth.com %K severe depression %K internet-delivered interventions %K iCBT %D 2018 %7 02.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a highly prevalent mental health issue that exacts significant economic, societal, personal, and interpersonal costs. Innovative internet-delivered interventions have been designed to increase accessibility to and cost-effectiveness of treatments. These treatments have mainly targeted mild to moderate levels of depression. The increased risk associated with severe depression, particularly of suicidal ideation often results in this population being excluded from research studies. As a result, the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) in more severely depressed cohorts is less researched. Objective: The aim of this study is to examine the effect of iCBT on symptoms of severe depression, comorbid symptoms of anxiety, and levels of work and social functioning. Methods: Retrospective consent was provided by participants with elevated scores (>28 severe depression symptoms) on the Beck Depression Inventory (BDI-II) who accessed an iCBT intervention (Space from Depression) with support for up to 8 weeks. Data were collected at baseline, posttreatment, and 3-month follow-up on the primary outcome (BDI-II), and secondary outcomes (the Generalized Anxiety Disorder-7 and the Work and Social Adjustment Scale). Results: A significant change was observed on all measures between pre- and postmeasurement and maintained at 3-month follow-up. Clinical improvement was observed for participants on the BDI-II from pre- to postmeasurement, and suicidal ideation also reduced from pre- to postmeasurement. Conclusions: Users of Space from Depression with symptoms of severe depression were found to have decreased symptoms of depression and anxiety and increased levels of work and social functioning. The intervention also demonstrated its potential to decrease suicidal ideation. Further investigation is required to determine why some individuals improve, and others do not. iCBT may have the potential to be used as an adjunct treatment for severe depression symptoms, but participants may require further treatment if they receive iCBT as a standalone intervention. Although promising, further research incorporating control groups is needed to support the utility of Space from Depression for use in or as an adjunct to treatment for severe depression. %M 30279154 %R 10.2196/10204 %U https://mental.jmir.org/2018/4/e10204/ %U https://doi.org/10.2196/10204 %U http://www.ncbi.nlm.nih.gov/pubmed/30279154 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 10 %P e10455 %T Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial %A Wijnen,Ben FM %A Lokman,Suzanne %A Leone,Stephanie %A Evers,Silvia MAA %A Smit,Filip %+ Centre for Economic Evaluation, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, Utrecht, 3521 VS, Netherlands, 31 030 297 1100, b.wijnen@maastrichtuniversity.nl %K prevention %K depression %K internet-based intervention %K economic evaluation %K quality of life %K cost-effectiveness analysis %K cost-utility analysis %K early medical intervention %K cost-benefit analysis %D 2018 %7 01.10.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact. Objective: The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective. Methods: This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained. Results: Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9% (23/165) in the CDMI group and 7.3% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were €2094 for the CDMI group and €2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. Conclusions: Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale. Trial Registration: Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM) %M 30274958 %R 10.2196/10455 %U https://www.jmir.org/2018/10/e10455/ %U https://doi.org/10.2196/10455 %U http://www.ncbi.nlm.nih.gov/pubmed/30274958 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10035 %T Mobile App Use by Primary Care Patients to Manage Their Depressive Symptoms: Qualitative Study %A Pung,Alison %A Fletcher,Susan Louise %A Gunn,Jane Maree %+ Department of General Practice, The University of Melbourne, 200 Berkeley Street, Victoria, 3053, Australia, 61 3 9035 4872, susanlf@unimelb.edu.au %K mobile apps %K depression %K health care %K general practice %D 2018 %7 27.09.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps are emerging as tools with the potential to revolutionize the treatment of mental health conditions such as depression. At the forefront of the community health sector, general practitioners are in a unique position to guide the integration of technology and depression management; however, little is currently known about how primary care patients with depressive symptoms are currently using apps. Objective: The objective of our study was to explore the natural patterns of mobile app use among patients with depressive symptoms to facilitate the understanding of the potential role for mobile apps in managing depressive symptoms in the community. Methods: Semistructured phone interviews were conducted with primary care patients in Victoria, Australia, who reported symptoms of depression and were enrolled in a larger randomized controlled trial of depression care. Interviews explored current depression management strategies and the use of mobile apps (if any). Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was iteratively conducted using QSR NVivo 11 Pro to identify emergent themes. Results: A total of 16 participants, aged between 20 to 58 years, took part in the interviews with 11 reporting the use of at least one mobile app to manage depressive symptoms and 5 reporting no app use. A variety of apps were described including relaxation, mindfulness, cognitive, exercise, gaming, social media, and well-being apps to aid with depressive symptoms. Among users, there were the following 4 main patterns of app use: skill acquisition, social connectedness, inquisitive trial, and safety netting. Factors that influenced app use included accessibility, perceptions of technology, and personal compatibility. Health care providers also had a role in initiating app use. Conclusions: Mobile apps are being utilized for self-management of depressive symptoms by primary care patients. This study provided insight into the natural patterns and perspectives of app use, which enhanced the understanding of how this technology may be integrated into the toolbox for the management of depression. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000537459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367152 (Archived at WebCite at http://www.webcitation.org/71Vf06X2T) %M 30262449 %R 10.2196/10035 %U http://www.jmir.org/2018/9/e10035/ %U https://doi.org/10.2196/10035 %U http://www.ncbi.nlm.nih.gov/pubmed/30262449 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10278 %T Web-Based Mindfulness Interventions for Mental Health Treatment: Systematic Review and Meta-Analysis %A Sevilla-Llewellyn-Jones,Julia %A Santesteban-Echarri,Olga %A Pryor,Ingrid %A McGorry,Patrick %A Alvarez-Jimenez,Mario %+ Institute of Psychiatry and Mental Health, Health Research Institute (IdISSC). Hospital Clínico San Carlos, Av/ Prof Martin Lago s/n, Madrid, 28040, Spain, 34 651563055, juliasevill@gmail.com %K mindfulness %K anxiety disorder %K depressive disorder %K internetinternet-based %K treatment %K meta-analysis %K mental health. %K systematic review %D 2018 %7 25.9.2018 %9 Review %J JMIR Ment Health %G English %X Background: Web-based mindfulness interventions are increasingly delivered through the internet to treat mental health conditions. Objective: The objective of this study was to determine the effectiveness of web-based mindfulness interventions in clinical mental health populations. Secondary aims were to explore the impact of study variables on the effectiveness of web-based mindfulness interventions. Methods: We performed a systematic review and meta-analysis of studies investigating the effects of web-based mindfulness interventions on clinical populations. Results: The search strategy yielded 12 eligible studies. Web-based mindfulness interventions were effective in reducing depression in the total clinical sample (n=656 g=−0.609, P=.004) and in the anxiety disorder subgroup (n=313, g=−0.651, P<.001), but not in the depression disorder subgroup (n=251, P=.18). Similarly, web-based mindfulness interventions significantly reduced anxiety in the total clinical sample (n=756, g=−0.433, P=.004) and the anxiety disorder subgroup (n=413, g=−0.719, P<.001), but not in the depression disorder group (n=251, g=−0.213, P=.28). Finally, web-based mindfulness interventions improved quality of life and functioning in the total sample (n=591, g=0.362, P=.02) in the anxiety disorder subgroup (n=370, g=0.550, P=.02) and mindfulness skills in the total clinical sample (n=251, g=0.724, P<.001). Conclusions: Results support the effectiveness of web-based mindfulness interventions in reducing depression and anxiety and in enhancing quality of life and mindfulness skills, particularly in those with clinical anxiety. Results should be interpreted with caution given the high heterogeneity of web-based mindfulness interventions and the low number of studies included. %M 30274963 %R 10.2196/10278 %U http://mental.jmir.org/2018/3/e10278/ %U https://doi.org/10.2196/10278 %U http://www.ncbi.nlm.nih.gov/pubmed/30274963 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10743 %T Web-Based Cognitive Behavioral Therapy Blended With Face-to-Face Sessions for Major Depression: Randomized Controlled Trial %A Nakao,Shigetsugu %A Nakagawa,Atsuo %A Oguchi,Yoshiyo %A Mitsuda,Dai %A Kato,Noriko %A Nakagawa,Yuko %A Tamura,Noriko %A Kudo,Yuka %A Abe,Takayuki %A Hiyama,Mitsunori %A Iwashita,Satoru %A Ono,Yutaka %A Mimura,Masaru %+ Clinical and Translational Research Center, Keio University Hospital, 35, Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan, 81 3 3353 1211, anakagawa@keio.jp %K blended cognitive behavioral therapy %K cognitive behavioral therapy %K major depressive disorder %K major depression %K randomized controlled trial %D 2018 %7 21.9.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Meta-analyses of several randomized controlled trials have shown that cognitive behavioral therapy (CBT) has comparable efficacy to antidepressant medication, but therapist availability and cost-effectiveness is a problem. Objective: This study aimed to evaluate the effectiveness of Web-based CBT blended with face-to-face sessions that reduce therapist time in patients with major depression who were unresponsive to antidepressant medications. Methods: A 12-week, assessor-masked, parallel-group, waiting- list controlled, randomized trial was conducted at 3 medical institutions in Tokyo. Outpatients aged 20-65 years with a primary diagnosis of major depression who were taking ≥1 antidepressant medications at an adequate dose for ≥6 weeks and had a 17-item GRID-Hamilton Depression Rating Scale (HAMD) score of ≥14 were randomly assigned (1:1) to blended CBT or waiting-list groups using a computer allocation system, stratified by the study site with the minimization method, to balance age and baseline GRID-HAMD score. The CBT intervention was given in a combined format, comprising a Web-based program and 12 45-minute face-to-face sessions. Thus, across 12 weeks, a participant could receive up to 540 minutes of contact with a therapist, which is approximately two-thirds of the therapist contact time provided in the conventional CBT protocol, which typically provides 16 50-minute sessions. The primary outcome was the alleviation of depressive symptoms, as measured by a change in the total GRID-HAMD score from baseline (at randomization) to posttreatment (at 12 weeks). Moreover, in an exploratory analysis, we investigated whether the expected positive effects of the intervention were sustained during follow-up, 3 months after the posttreatment assessment. Analyses were performed on an intention-to-treat basis, and the primary outcome was analyzed using a mixed-effects model for repeated measures. Results: We randomized 40 participants to either blended CBT (n=20) or waiting-list (n=20) groups. All patients completed the 12-week treatment protocol and were included in the intention-to-treat analyses. Participants in the blended CBT group had significantly alleviated depressive symptoms at week 12, as shown by greater least squares mean changes in the GRID-HAMD score, than those in the waiting list group (−8.9 points vs −3.0 points; mean between-group difference=−5.95; 95% CI −9.53 to −2.37; P<.001). The follow-up effects within the blended CBT group, as measured by the GRID-HAMD score, were sustained at the 3-month follow-up (week 24) and posttreatment (week 12): posttreatment, 9.4 (SD 5.2), versus follow-up, 7.2 (SD 5.7); P=.009. Conclusions: Although our findings warrant confirmation in larger and longer term studies with active controls, these suggest that a combined form of CBT is effective in reducing depressive symptoms in patients with major depression who are unresponsive to antidepressant medications. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry: UMIN000009242; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000010852 (Archived by WebCite at http://www.webcitation. org/729VkpyYL) %M 30249583 %R 10.2196/10743 %U http://www.jmir.org/2018/9/e10743/ %U https://doi.org/10.2196/10743 %U http://www.ncbi.nlm.nih.gov/pubmed/30249583 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 3 %N 3 %P e13 %T Web-Based Interventions for Depression in Individuals with Diabetes: Review and Discussion %A Franco,Pamela %A Gallardo,Ana María %A Urtubey,Xavier %+ Psychology Department, Universidad del Desarrollo, Av Plaza 680, Santiago, 7610658, Chile, 56 223279110, p.franco@udd.cl %K Web-based intervention %K internet %K depression %K diabetes %K cognitive behavioral therapy %D 2018 %7 14.09.2018 %9 Review %J JMIR Diabetes %G English %X Background: Depression is twice as common in people with diabetes, and this comorbidity worsens the course of both pathologies. In clinical practice guidelines, screening and treatment of depression in patients with diabetes are highly recommended. However, depression is still both underrecognized and undertreated. To find ways to enhance their reach, psychological treatments have taken advantage of benefits of internet and technological devices as delivery formats, providing interventions that require considerably less (or even no) interaction time with therapists. Web-based treatments hold promise for effective interventions at low cost with positive results. Objective: The objectives of this review were to describe Web-based interventions for depression in individuals with diabetes and to discuss these studies’ procedures and findings in light of evidence from a wider range of interventions for depression and diabetes. Methods: A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included when they met the following selection criteria: the study was available in a peer-reviewed journal mainly publishing studies written in either English or Spanish; the studied sample comprised individuals with diabetes; the intervention targeted depression symptomatology; the intervention was accessible via the internet; and the intervention was accessible via the internet with little or no clinician support. Results: Overall, 5 research studies were identified in the review. All studies were randomized controlled trials, and most used a wait list as a control; 4 studies reported treatment dropout, rates of which varied from 13% to 42%. Studies supported the notion that the Web-based format is a suitable psychology service delivery option for diabetic individuals with depression (effect size range for completers 0.7-0.89). Interventions varied in their characteristics but most were clinical-assisted, had a cognitive behavioral therapy approach, used diabetes-specific topics, had a weekly modular display, used homework assignments, and had some adherence management strategy. These characteristics are consistent with the intervention features associated with positive results in the literature. Conclusions: The analyzed studies’ findings and procedures are discussed in light of evidence drawn from a wider range of reviews on Web-based interventions for depression and diabetes. Consistent with previous research on depression treatment, Web-based interventions for depression among individuals with diabetes have shown positive results. Future research should contribute new evidence as to why these interventions are effective, for whom, and which particular aspects can increase patients’ adherence. %M 30291082 %R 10.2196/diabetes.9694 %U http://diabetes.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/diabetes.9694 %U http://www.ncbi.nlm.nih.gov/pubmed/30291082 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 10 %N 3 %P e10655 %T Phase I of the Detecting and Evaluating Childhood Anxiety and Depression Effectively in Subspecialties (DECADES) Study: Development of an Integrated Mental Health Care Model for Pediatric Gastroenterology %A Hullmann,Stephanie E %A Keller,Stacy A %A Lynch,Dustin O %A Jenkins,Kelli %A Moore,Courtney %A Cockrum,Brandon %A Wiehe,Sarah E %A Carroll,Aaron E %A Bennett Jr,William E %+ Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, 410 W 10th Street, HITS Building, Indianapolis, IN, 46202, United States, 1 3172786928, webjr@iu.edu %K qualitative research %K patient-reported outcomes %K depression %K anxiety %D 2018 %7 10.09.2018 %9 Original Paper %J J Participat Med %G English %X Background: Children with gastrointestinal symptoms have a very high rate of anxiety and depression. Rapid identification of comorbid anxiety and depression is essential for effective treatment of a wide variety of functional gastrointestinal disorders. Objective: The objective of our study was to determine patient and parent attitudes toward depression, anxiety, and mental health screening during gastroenterology (GI) visits and to determine patient and parent preferences for communication of results and referral to mental health providers after a positive screen. Methods: We augmented standard qualitative group session methods with patient-centered design methods to assess patient and parent preferences. We used a variety of specific design methods in these sessions, including card sorting, projective methods, experience mapping, and constructive methods. Results: Overall, 11 families (11 patients and 14 parents) participated in 2 group sessions. Overall, patients and their parents found integrated mental health care to be acceptable in the subspecialty setting. Patients’ primary concerns were for the privacy and confidentiality of their screening results. Patients and their parents emphasized the importance of mental health services not interfering with the GI visit and collaboration between the GI physician, psychologist, and primary care provider. Conclusions: Patients and their families are open to integrated mental health care in the pediatric subspecialty clinic. The next phase of the DECADES study will translate patient and parent preferences into an integrated mental health care system and test its efficacy in the pediatric GI office. %R 10.2196/10655 %U http://jopm.jmir.org/2018/3/e10655/ %U https://doi.org/10.2196/10655 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10302 %T Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study %A Lundgren,Johan %A Johansson,Peter %A Jaarsma,Tiny %A Andersson,Gerhard %A Kärner Köhler,Anita %+ Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, Campus Norrköping, Kåkenhus, Norrköping, SE-601 74, Sweden, 46 01136 ext 3592, johan.lundgren@liu.se %K cognitive therapy %K content analysis %K depression %K heart failure %K internet %K patient experience %K telehealth %D 2018 %7 05.09.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT. Objective: The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms. Methods: In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research & Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories. Results: Overall, six categories were identified during the analysis process. They were as follows: “Something other than usual health care,” “Relevance and recognition,” “Flexible, understandable, and safe,” “Technical problems,” “Improvements by real-time contact,” and “Managing my life better.” One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care. Conclusions: Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perceived anonymity and not postponing the work with the program. wCBT appears to be a valuable tool for managing depressive symptoms. %M 30185405 %R 10.2196/10302 %U http://www.jmir.org/2018/9/e10302/ %U https://doi.org/10.2196/10302 %U http://www.ncbi.nlm.nih.gov/pubmed/30185405 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10334 %T The Effortless Assessment of Risk States (EARS) Tool: An Interpersonal Approach to Mobile Sensing %A Lind,Monika N %A Byrne,Michelle L %A Wicks,Geordie %A Smidt,Alec M %A Allen,Nicholas B %+ Center for Digital Mental Health, Department of Psychology, University of Oregon, 1227 University Street, Eugene, OR, 97403, United States, 1 541 346 4075, nallen3@uoregon.edu %K passive mobile sensing %K personal sensing %K mobile sensing %K mental health %K risk assessment %K crisis prevention %K individual big data %K telemedicine %K mobile apps %K cell phone %K depression %D 2018 %7 28.08.2018 %9 Viewpoint %J JMIR Ment Health %G English %X Background: To predict and prevent mental health crises, we must develop new approaches that can provide a dramatic advance in the effectiveness, timeliness, and scalability of our interventions. However, current methods of predicting mental health crises (eg, clinical monitoring, screening) usually fail on most, if not all, of these criteria. Luckily for us, 77% of Americans carry with them an unprecedented opportunity to detect risk states and provide precise life-saving interventions. Smartphones present an opportunity to empower individuals to leverage the data they generate through their normal phone use to predict and prevent mental health crises. Objective: To facilitate the collection of high-quality, passive mobile sensing data, we built the Effortless Assessment of Risk States (EARS) tool to enable the generation of predictive machine learning algorithms to solve previously intractable problems and identify risk states before they become crises. Methods: The EARS tool captures multiple indices of a person’s social and affective behavior via their naturalistic use of a smartphone. Although other mobile data collection tools exist, the EARS tool places a unique emphasis on capturing the content as well as the form of social communication on the phone. Signals collected include facial expressions, acoustic vocal quality, natural language use, physical activity, music choice, and geographical location. Critically, the EARS tool collects these data passively, with almost no burden on the user. We programmed the EARS tool in Java for the Android mobile platform. In building the EARS tool, we concentrated on two main considerations: (1) privacy and encryption and (2) phone use impact. Results: In a pilot study (N=24), participants tolerated the EARS tool well, reporting minimal burden. None of the participants who completed the study reported needing to use the provided battery packs. Current testing on a range of phones indicated that the tool consumed approximately 15% of the battery over a 16-hour period. Installation of the EARS tool caused minimal change in the user interface and user experience. Once installation is completed, the only difference the user notices is the custom keyboard. Conclusions: The EARS tool offers an innovative approach to passive mobile sensing by emphasizing the centrality of a person’s social life to their well-being. We built the EARS tool to power cutting-edge research, with the ultimate goal of leveraging individual big data to empower people and enhance mental health. %M 30154072 %R 10.2196/10334 %U http://mental.jmir.org/2018/3/e10334/ %U https://doi.org/10.2196/10334 %U http://www.ncbi.nlm.nih.gov/pubmed/30154072 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e54 %T A Mobile App–Based Intervention for Depression: End-User and Expert Usability Testing Study %A Fuller-Tyszkiewicz,Matthew %A Richardson,Ben %A Klein,Britt %A Skouteris,Helen %A Christensen,Helen %A Austin,David %A Castle,David %A Mihalopoulos,Cathrine %A O'Donnell,Renee %A Arulkadacham,Lilani %A Shatte,Adrian %A Ware,Anna %+ School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, 3220, Australia, 61 392517344, matthewf@deakin.edu.au %K depression %K eHealth %K mHealth %K young adult %D 2018 %7 23.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite the growing number of mental health apps available for smartphones, the perceived usability of these apps from the perspectives of end users or health care experts has rarely been reported. This information is vital, particularly for self-guided mHealth interventions, as perceptions of navigability and quality of content are likely to impact participant engagement and treatment compliance. Objective: The aim of this study was to conduct a usability evaluation of a personalized, self-guided, app-based intervention for depression. Methods: Participants were administered the System Usability Scale and open-ended questions as part of a semistructured interview. There were 15 participants equally divided into 3 groups: (1) individuals with clinical depression who were the target audience for the app, (2) mental health professionals, and (3) researchers who specialize in the area of eHealth interventions and/or depression research. Results: The end-user group rated the app highly, both in quantitative and qualitative assessments. The 2 expert groups highlighted the self-monitoring features and range of established psychological treatment options (such as behavioral activation and cognitive restructuring) but had concerns that the amount and layout of content may be difficult for end users to navigate in a self-directed fashion. The end-user data did not confirm these concerns. Conclusions: Encouraging participant engagement via self-monitoring and feedback, as well as personalized messaging, may be a viable way to maintain participation in self-guided interventions. Further evaluation is necessary to determine whether levels of engagement with these features enhance treatment effects. %M 30139722 %R 10.2196/mental.9445 %U http://mental.jmir.org/2018/3/e54/ %U https://doi.org/10.2196/mental.9445 %U http://www.ncbi.nlm.nih.gov/pubmed/30139722 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e10748 %T Veterans’ Attitudes Toward Smartphone App Use for Mental Health Care: Qualitative Study of Rurality and Age Differences %A Connolly,Samantha L %A Miller,Christopher J %A Koenig,Christopher J %A Zamora,Kara A %A Wright,Patricia B %A Stanley,Regina L %A Pyne,Jeffrey M %+ Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S Huntington Avenue, Building 9 Room 208F, Boston, MA, 02130, United States, 1 857 364 5987, Samantha.connolly@va.gov %K smartphone apps %K mobile phone %K mhealth %K mental health %K qualitative analysis %K rurality %K age %K veterans %K depression %K anxiety disorders %K posttraumatic stress disorder %K PTSD %K alcohol abuse %D 2018 %7 22.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health smartphone apps provide support, skills, and symptom tracking on demand and come at minimal to no additional cost to patients. Although the Department of Veterans Affairs has established itself as a national leader in the creation of mental health apps, veterans’ attitudes regarding the use of these innovations are largely unknown, particularly among rural and aging populations who may benefit from increased access to care. Objective: The objective of our study was to examine veterans’ attitudes toward smartphone apps and to assess whether openness toward this technology varies by age or rurality. Methods: We conducted semistructured qualitative interviews with 66 veterans from rural and urban areas in Maine, Arkansas, and California. Eligible veterans aged 18 to 70 years had screened positive for postraumatic stress disorder (PTSD), alcohol use disorder, or major depressive disorder, but a history of mental health service utilization was not required. Interviews were digitally recorded, professionally transcribed, and coded by a research team using an established codebook. We then conducted a thematic analysis of segments pertaining to smartphone use, informed by existing theories of technology adoption. Results: Interviews revealed a marked division regarding openness to mental health smartphone apps, such that veterans either expressed strongly positive or negative views about their usage, with few participants sharing ambivalent or neutral opinions. Differences emerged between rural and urban veterans’ attitudes, with rural veterans tending to oppose app usage, describe smartphones as hard to navigate, and cite barriers such as financial limitations and connectivity issues, more so than urban populations. Moreover, rural veterans more often described smartphones as being opposed to their values. Differences did not emerge between younger and older (≥50) veterans regarding beliefs that apps could be effective or compatible with their culture and identity. However, compared with younger veterans, older veterans more often reported not owning a smartphone and described this technology as being difficult to use. Conclusions: Openness toward the use of smartphone apps in mental health treatment may vary based on rurality, and further exploration of the barriers cited by rural veterans is needed to improve access to care. In addition, findings indicate that older patients may be more open to integrating technology into their mental health care than providers might assume, although such patients may have more trouble navigating these devices and may benefit from simplified app designs or smartphone training. Given the strong opinions expressed either for or against smartphone apps, our findings suggest that apps may not be an ideal adjunctive treatment for all patients, but it is important to identify those who are open to and may greatly benefit from this technology. %M 30135050 %R 10.2196/10748 %U http://mhealth.jmir.org/2018/8/e10748/ %U https://doi.org/10.2196/10748 %U http://www.ncbi.nlm.nih.gov/pubmed/30135050 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10277 %T Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach %A Abraham,Traci H %A Marchant-Miros,Kathy %A McCarther,Michael B %A Craske,Michelle G %A Curran,Geoffrey M %A Kearney,Lisa K %A Greene,Carolyn %A Lindsay,Jan A %A Cucciare,Michael A %+ Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, United States, 1 501 257 1744, Traci.Abraham@va.gov %K therapy %K veterans %K depression %K anxiety disorders %K posttraumatic stress disorder %K PTSD %D 2018 %7 22.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. Objective: The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program’s acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. Methods: An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. Results: Key stakeholders suggested modifications to the original CALM program that altered its modules’ appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. Conclusions: The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP. %M 30135051 %R 10.2196/10277 %U http://mental.jmir.org/2018/3/e10277/ %U https://doi.org/10.2196/10277 %U http://www.ncbi.nlm.nih.gov/pubmed/30135051 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e165 %T Correlations Between Objective Behavioral Features Collected From Mobile and Wearable Devices and Depressive Mood Symptoms in Patients With Affective Disorders: Systematic Review %A Rohani,Darius A %A Faurholt-Jepsen,Maria %A Kessing,Lars Vedel %A Bardram,Jakob E %+ Embedded Systems Engineering, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, Bldg 324, 1st Floor, Room 160, Kongens Lyngby, 2800, Denmark, 45 61452393, daroh@dtu.dk %K mood disorder %K affective disorder %K depression %K depressive mood symptoms %K bipolar disorder %K objective features %K correlation %K behavior %K sensor data %K mobile phone %K wearable devices %K systematic review %D 2018 %7 13.08.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Several studies have recently reported on the correlation between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms in patients with affective disorders (unipolar and bipolar disorders). However, individual studies have reported on different and sometimes contradicting results, and no quantitative systematic review of the correlation between objective behavioral features and depressive mood symptoms has been published. Objective: The objectives of this systematic review were to (1) provide an overview of the correlations between objective behavioral features and depressive mood symptoms reported in the literature and (2) investigate the strength and statistical significance of these correlations across studies. The answers to these questions could potentially help identify which objective features have shown most promising results across studies. Methods: We conducted a systematic review of the scientific literature, reported according to the preferred reporting items for systematic reviews and meta-analyses guidelines. IEEE Xplore, ACM Digital Library, Web of Sciences, PsychINFO, PubMed, DBLP computer science bibliography, HTA, DARE, Scopus, and Science Direct were searched and supplemented by hand examination of reference lists. The search ended on April 27, 2017, and was limited to studies published between 2007 and 2017. Results: A total of 46 studies were eligible for the review. These studies identified and investigated 85 unique objective behavioral features, covering 17 various sensor data inputs. These features were divided into 7 categories. Several features were found to have statistically significant and consistent correlation directionality with mood assessment (eg, the amount of home stay, sleep duration, and vigorous activity), while others showed directionality discrepancies across the studies (eg, amount of text messages [short message service] sent, time spent between locations, and frequency of mobile phone screen activity). Conclusions: Several studies showed consistent and statistically significant correlations between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms. Hence, continuous and everyday monitoring of behavioral aspects in affective disorders could be a promising supplementary objective measure for estimating depressive mood symptoms. However, the evidence is limited by methodological issues in individual studies and by a lack of standardization of (1) the collected objective features, (2) the mood assessment methodology, and (3) the statistical methods applied. Therefore, consistency in data collection and analysis in future studies is needed, making replication studies as well as meta-analyses possible. %M 30104184 %R 10.2196/mhealth.9691 %U http://mhealth.jmir.org/2018/8/e165/ %U https://doi.org/10.2196/mhealth.9691 %U http://www.ncbi.nlm.nih.gov/pubmed/30104184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10231 %T Differences in the Effect of Internet-Based Cognitive Behavioral Therapy for Improving Nonclinical Depressive Symptoms Among Workers by Time Preference: Randomized Controlled Trial %A Imamura,Kotaro %A Furukawa,Toshi A %A Matsuyama,Yutaka %A Shimazu,Akihito %A Kuribayashi,Kazuto %A Kasai,Kiyoto %A Kawakami,Norito %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan, 81 3 5841 3522, nkawakami@m.u-tokyo.ac.jp %K internet-based computerized cognitive behavioral therapy %K time preference %K nonclinical depressive symptoms %K workers %D 2018 %7 10.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous randomized controlled trials (RCTs) have shown a significant intervention effect of internet-based computerized cognitive behavioral therapy (iCBT) on improving nonclinical depressive symptoms among healthy workers and community residents in a primary prevention setting. Time preference is one’s relative valuation for having a reward (eg, money) at present than at a later date. Time preference may affect the effectiveness of cognitive behavioral therapy. Objective: This RCT aimed to test the difference of intervention effect of an iCBT program on improving nonclinical depressive symptoms between two subgroups classified post-hoc on the basis of time preference among workers in Japan. Methods: All workers in one corporate group (approximate n=20,000) were recruited. Participants who fulfilled the inclusion criteria were randomly allocated to either intervention or control groups. Participants in the intervention group completed 6 weekly lessons and homework assignments within the iCBT program. The Beck Depression Inventory-II (BDI-II) and Kessler’s Psychological Distress Scale (K6) measures were obtained at baseline and 3-, 6-, and 12-month follow-ups. Two subgroups were defined by the median of time preference score at baseline. Results: Only few (835/20,000, 4.2%) workers completed the baseline survey. Of the 835 participants, 706 who fulfilled the inclusion criteria were randomly allocated to the intervention or control group. Participants who selected irrational time preference options were excluded (21 and 18 participants in the intervention and control groups, respectively). A three-way interaction (group [intervention/control] × time [baseline/follow-up] × time preference [higher/lower]) effect of iCBT was significant for BDI-II (t1147.42=2.33, P=.02) and K6 (t1254.04=2.51, P=.01) at the 3-month follow-up, with a greater effect of the iCBT in the group with higher time preference. No significant three-way interaction was found at the 6- and 12-month follow-ups. Conclusions: The effects of the iCBT were greater for the group with higher time preference at the shorter follow-up, but it was leveled off later. Workers with higher time preference may change their cognition or behavior more quickly, but these changes may not persist. Trial Registration: UMIN Clinical Trials Registry UMIN000014146; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000016466 (Archived by WebCite at http://www.webcitation.org/70o2rNk2V) %M 30097419 %R 10.2196/10231 %U http://www.jmir.org/2018/8/e10231/ %U https://doi.org/10.2196/10231 %U http://www.ncbi.nlm.nih.gov/pubmed/30097419 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10130 %T Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial %A Pratap,Abhishek %A Renn,Brenna N %A Volponi,Joshua %A Mooney,Sean D %A Gazzaley,Adam %A Arean,Patricia A %A Anguera,Joaquin A %+ Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, UW Medicine South Lake Union, Building C, Box 358047, 850 Republican Street, Seattle, WA, 98109, United States, 1 206 928 8263, apratap@uw.edu %K mobile apps %K smartphone %K depression %K Hispanics %K Latinos %K clinical trial %K cognition %K problem solving %K mHealth %K minority groups %D 2018 %7 09.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches. Objective: This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control). Methods: We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys. Results: We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=–2.66, P=.006) over the treatment course, outcomes did not vary by treatment app. Conclusions: Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of “low-touch” research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement. Trial Registration: Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz) %M 30093372 %R 10.2196/10130 %U http://www.jmir.org/2018/8/e10130/ %U https://doi.org/10.2196/10130 %U http://www.ncbi.nlm.nih.gov/pubmed/30093372 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10153 %T Emotion Recognition Using Smart Watch Sensor Data: Mixed-Design Study %A Quiroz,Juan Carlos %A Geangu,Elena %A Yong,Min Hooi %+ Department of Psychology, Sunway University, 5 Jalan Universiti, Bandar Sunway, 47500, Malaysia, 60 374918622, mhyong@sunway.edu.my %K emotion recognition %K accelerometer %K supervised learning %K psychology %D 2018 %7 08.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research in psychology has shown that the way a person walks reflects that person’s current mood (or emotional state). Recent studies have used mobile phones to detect emotional states from movement data. Objective: The objective of our study was to investigate the use of movement sensor data from a smart watch to infer an individual’s emotional state. We present our findings of a user study with 50 participants. Methods: The experimental design is a mixed-design study: within-subjects (emotions: happy, sad, and neutral) and between-subjects (stimulus type: audiovisual “movie clips” and audio “music clips”). Each participant experienced both emotions in a single stimulus type. All participants walked 250 m while wearing a smart watch on one wrist and a heart rate monitor strap on the chest. They also had to answer a short questionnaire (20 items; Positive Affect and Negative Affect Schedule, PANAS) before and after experiencing each emotion. The data obtained from the heart rate monitor served as supplementary information to our data. We performed time series analysis on data from the smart watch and a t test on questionnaire items to measure the change in emotional state. Heart rate data was analyzed using one-way analysis of variance. We extracted features from the time series using sliding windows and used features to train and validate classifiers that determined an individual’s emotion. Results: Overall, 50 young adults participated in our study; of them, 49 were included for the affective PANAS questionnaire and 44 for the feature extraction and building of personal models. Participants reported feeling less negative affect after watching sad videos or after listening to sad music, P<.006. For the task of emotion recognition using classifiers, our results showed that personal models outperformed personal baselines and achieved median accuracies higher than 78% for all conditions of the design study for binary classification of happiness versus sadness. Conclusions: Our findings show that we are able to detect changes in the emotional state as well as in behavioral responses with data obtained from the smartwatch. Together with high accuracies achieved across all users for classification of happy versus sad emotional states, this is further evidence for the hypothesis that movement sensor data can be used for emotion recognition. %M 30089610 %R 10.2196/10153 %U http://mental.jmir.org/2018/3/e10153/ %U https://doi.org/10.2196/10153 %U http://www.ncbi.nlm.nih.gov/pubmed/30089610 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10131 %T Using Mobile Phone Sensor Technology for Mental Health Research: Integrated Analysis to Identify Hidden Challenges and Potential Solutions %A Boonstra,Tjeerd W %A Nicholas,Jennifer %A Wong,Quincy JJ %A Shaw,Frances %A Townsend,Samuel %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney,, Australia, 61 2 9382 9285, t.boonstra@unsw.edu.au %K passive sensing %K mental health %K ubiquitous computing %K ethics %K depression %K mobile health %K smartphone %K wearable sensors %D 2018 %7 30.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile phone sensor technology has great potential in providing behavioral markers of mental health. However, this promise has not yet been brought to fruition. Objective: The objective of our study was to examine challenges involved in developing an app to extract behavioral markers of mental health from passive sensor data. Methods: Both technical challenges and acceptability of passive data collection for mental health research were assessed based on literature review and results obtained from a feasibility study. Socialise, a mobile phone app developed at the Black Dog Institute, was used to collect sensor data (Bluetooth, location, and battery status) and investigate views and experiences of a group of people with lived experience of mental health challenges (N=32). Results: On average, sensor data were obtained for 55% (Android) and 45% (iOS) of scheduled scans. Battery life was reduced from 21.3 hours to 18.8 hours when scanning every 5 minutes with a reduction of 2.5 hours or 12%. Despite this relatively small reduction, most participants reported that the app had a noticeable effect on their battery life. In addition to battery life, the purpose of data collection, trust in the organization that collects data, and perceived impact on privacy were identified as main factors for acceptability. Conclusions: Based on the findings of the feasibility study and literature review, we recommend a commitment to open science and transparent reporting and stronger partnerships and communication with users. Sensing technology has the potential to greatly enhance the delivery and impact of mental health care. Realizing this requires all aspects of mobile phone sensor technology to be rigorously assessed. %M 30061092 %R 10.2196/10131 %U http://www.jmir.org/2018/7/e10131/ %U https://doi.org/10.2196/10131 %U http://www.ncbi.nlm.nih.gov/pubmed/30061092 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e15 %T Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis %A Grant,Sean %A Spears,Asya %A Pedersen,Eric R %+ RAND Corporation, 1776 Main Street, Santa Monica, CA,, United States, 1 310 393 0411 ext 6438, sgrant@rand.org %K behavioral health %K replication %K veterans %K video games %D 2018 %7 26.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. %M 30049668 %R 10.2196/games.9327 %U http://games.jmir.org/2018/3/e15/ %U https://doi.org/10.2196/games.9327 %U http://www.ncbi.nlm.nih.gov/pubmed/30049668 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10496 %T For Better or for Worse? A Systematic Review of the Evidence on Social Media Use and Depression Among Lesbian, Gay, and Bisexual Minorities %A Escobar-Viera,César G %A Whitfield,Darren L %A Wessel,Charles B %A Shensa,Ariel %A Sidani,Jaime E %A Brown,Andre L %A Chandler,Cristian J %A Hoffman,Beth L %A Marshal,Michael P %A Primack,Brian A %+ Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, 230 McKee Place, Suite 600.11, Pittsburgh, PA, 15213, United States, 1 412 692 4297, escobar-viera@pitt.edu %K social media %K social networking sites %K sexual minorities %K lesbian %K gay %K bisexual %K depression %K systematic review %D 2018 %7 23.07.2018 %9 Review %J JMIR Ment Health %G English %X Background: Over 90% of adults in the United States have at least one social media account, and lesbian, gay, and bisexual (LGB) persons are more socially active on social media than heterosexuals. Rates of depression among LGB persons are between 1.5- and 2-fold higher than those among their heterosexual counterparts. Social media allows users to connect, interact, and express ideas, emotions, feelings, and thoughts. Thus, social media use might represent both a protective and a risk factor for depression among LGB persons. Studying the nature of the relationship between social media use and depression among LGB individuals is a necessary step to inform public health interventions for this population. Objective: The objective of this systematic review was to synthesize and critique the evidence on social media use 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, were in English, assessed social media use either quantitatively or qualitatively, measured depression, and focused on LGB populations. A minimum of two 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: We included 11 articles in the review; 9 studies were quantitative and cross-sectional and 2 were qualitative. Appropriate reporting of results varied greatly. Across quantitative studies, we found heterogeneity in how social media use was defined and measured. Cyberbullying was the most studied social media experience and was associated with depression and suicidality. Qualitative studies found that while social media provides a space to disclose minority experiences and share ways to cope and get support, constant surveillance of one’s social media 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 social media use on depression outcomes among LBG persons. Using social media may be both a protective and a risk factor for depression among LGB individuals. Support gained via social media may buffer the impact of geographic isolation and loneliness. Negative experiences such as cyberbullying and other patterns of use may be associated with depression. Future research would benefit from more consistent definitions of both social media use and study populations. Moreover, use of larger samples and accounting for patterns of use and individuals’ experiences on social media may help better understand the factors that impact LGB mental health disparities. %M 30037786 %R 10.2196/10496 %U http://mental.jmir.org/2018/3/e10496/ %U https://doi.org/10.2196/10496 %U http://www.ncbi.nlm.nih.gov/pubmed/30037786 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e241 %T Predicting Mood Disturbance Severity with Mobile Phone Keystroke Metadata: A BiAffect Digital Phenotyping Study %A Zulueta,John %A Piscitello,Andrea %A Rasic,Mladen %A Easter,Rebecca %A Babu,Pallavi %A Langenecker,Scott A %A McInnis,Melvin %A Ajilore,Olusola %A Nelson,Peter C %A Ryan,Kelly %A Leow,Alex %+ University of Illinois at Chicago, 1601 W Taylor St, Chicago, IL, 60612, United States, 1 312 996 7383, aleow@psych.uic.edu %K digital phenotype %K mHealth %K ecological momentary assessment %K keystroke dynamics %K bipolar disorder %K depression %K mania %K mobile phone %D 2018 %7 20.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mood disorders are common and associated with significant morbidity and mortality. Better tools are needed for their diagnosis and treatment. Deeper phenotypic understanding of these disorders is integral to the development of such tools. This study is the first effort to use passively collected mobile phone keyboard activity to build deep digital phenotypes of depression and mania. Objective: The objective of our study was to investigate the relationship between mobile phone keyboard activity and mood disturbance in subjects with bipolar disorders and to demonstrate the feasibility of using passively collected mobile phone keyboard metadata features to predict manic and depressive signs and symptoms as measured via clinician-administered rating scales. Methods: Using a within-subject design of 8 weeks, subjects were provided a mobile phone loaded with a customized keyboard that passively collected keystroke metadata. Subjects were administered the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) weekly. Linear mixed-effects models were created to predict HDRS and YMRS scores. The total number of keystrokes was 626,641, with a weekly average of 9791 (7861), and that of accelerometer readings was 6,660,890, with a weekly average 104,076 (68,912). Results: A statistically significant mixed-effects regression model for the prediction of HDRS-17 item scores was created: conditional R2=.63, P=.01. A mixed-effects regression model for YMRS scores showed the variance accounted for by random effect was zero, and so an ordinary least squares linear regression model was created: R2=.34, P=.001. Multiple significant variables were demonstrated for each measure. Conclusions: Mood states in bipolar disorder appear to correlate with specific changes in mobile phone usage. The creation of these models provides evidence for the feasibility of using passively collected keyboard metadata to detect and monitor mood disturbances. %M 30030209 %R 10.2196/jmir.9775 %U http://www.jmir.org/2018/7/e241/ %U https://doi.org/10.2196/jmir.9775 %U http://www.ncbi.nlm.nih.gov/pubmed/30030209 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10402 %T The Association Between Increased Levels of Patient Engagement With an Internet Support Group and Improved Mental Health Outcomes at 6-Month Follow-Up: Post-Hoc Analyses From a Randomized Controlled Trial %A Geramita,Emily M %A Herbeck Belnap,Bea %A Abebe,Kaleab Z %A Rothenberger,Scott D %A Rotondi,Armando J %A Rollman,Bruce L %+ Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, United States, 1 412 692 2659, rollmanbl@upmc.edu %K internet support group %K patient engagement %K anxiety %K depression %D 2018 %7 17.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: We recently reported that depressed and anxious primary care patients randomized to a moderated internet support group (ISG) plus computerized cognitive behavioral therapy (cCBT) did not experience improvements in depression and anxiety over cCBT alone at 6-month follow-up. Objective: The 1% rule posits that 1% of participants in online communities generate approximately 90% of new user-created content. The aims of this study were to apply the 1% rule to categorize patient engagement with the ISG and identify whether any patient subgroups benefitted from ISG use. Methods: We categorized the 302 patients randomized to the ISG as: superusers (3/302, 1.0%), top contributors (30/302, 9.9%), contributors (108/302, 35.8%), observers (87/302, 28.8%) and those who never logged in (74/302, 24.5%). We then applied linear mixed models to examine associations between engagement and 6-month changes in health-related quality of life (HRQoL; Short Form Health Survey Mental Health Component, SF-12 MCS) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System, PROMIS). Results: At baseline, participant mean age was 42.6 years, 81.1% (245/302) were female, and mean Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder scale (GAD-7), and SF-12 MCS scores were 13.4, 12.6, and 31.7, respectively. Of the 75.5% (228/302) who logged in, 61.8 % (141/228) created ≥1 post (median 1, interquartile range, IQR 0-5); superusers created 42.3 % (630/1488) of posts (median 246, IQR 78-306), top contributors created 34.6% (515/1488; median 11, IQR 10-18), and contributors created 23.1 % (343/1488; median 3, IQR 1-5). Compared to participants who never logged in, the combined superuser + top contributor subgroup (n=33) reported 6-month improvements in anxiety (PROMIS: –11.6 vs –7.8; P=.04) and HRQoL (SF-12 MCS: 16.1 vs 10.1; P=.01) but not in depression. No other subgroup reported significant symptom improvements. Conclusions: Patient engagement with the ISG was more broadly distributed than predicted by the 1% rule. The 11% of participants with the highest engagement levels reported significant improvements in anxiety and HRQoL. Trial Registration: ClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/ct2/show/NCT01482806 (Archived by WebCite at http://www.webcitation.org/708Bjlge9). %M 30021711 %R 10.2196/10402 %U http://www.jmir.org/2018/7/e10402/ %U https://doi.org/10.2196/10402 %U http://www.ncbi.nlm.nih.gov/pubmed/30021711 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10139 %T Exploring User Needs for a Mobile Behavioral-Sensing Technology for Depression Management: Qualitative Study %A Meng,Jingbo %A Hussain,Syed Ali %A Mohr,David C %A Czerwinski,Mary %A Zhang,Mi %+ Department of Communication, Michigan State University, , East Lansing, MI,, United States, 1 5173553480, jingbome@msu.edu %K mobile sensing %K mental health %K depression %K counseling %K user-centered design %D 2018 %7 17.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Today, college students are dealing with depression at some of the highest rates in decades. As the primary mental health service provider, university counseling centers are limited in their capacity and efficiency to provide mental health care due to time constraints and reliance on students’ self-reports. A mobile behavioral-sensing platform may serve as a solution to enhance the efficiency and accessibility of university counseling services. Objective: The main objectives of this study are to (1) understand the usefulness of a mobile sensing platform (ie, iSee) in improving counseling services and assisting students’ self-management of their depression conditions, and (2) explore what types of behavioral targets (ie, meaningful information extracted from raw sensor data) and feedback to deliver from both clinician and students’ perspectives. Methods: We conducted semistructured interviews with 9 clinicians and 12 students with depression recruited from a counseling center at a large Midwestern university. The interviews were 40-50 minutes long and were audio recorded and transcribed. The interview data were analyzed using thematic analysis with an inductive approach. Clinician and student interviews were analyzed separately for comparison. The process of extracting themes involved iterative coding, memo writing, theme revisits, and refinement. Results: From the clinician perspective, the mobile sensing platform helps to improve counseling service by providing objective evidence for clinicians and filling gaps in clinician-patient communication. Clinicians suggested providing students with their sensed behavioral targets organized around personalized goals. Clinicians also recommended delivering therapeutic feedback to students based on their sensed behavioral targets, including positive reinforcement, reflection reminders, and challenging negative thoughts. From the student perspective, the mobile sensing platform helps to ease continued self-tracking practices. Students expressed their need for integrated behavioral targets to understand correlations between behaviors and depression. They also pointed out that they would prefer to avoid seeing negative feedback. Conclusions: Although clinician and student participants shared views on the advantages of iSee in supporting university counseling, they had divergent opinions on the types of behavioral targets and feedback to be provided via iSee. This exploratory work gained initial insights into the design of a mobile sensing platform for depression management and informed a more conclusive research project for the future. %M 30021710 %R 10.2196/10139 %U http://www.jmir.org/2018/7/e10139/ %U https://doi.org/10.2196/10139 %U http://www.ncbi.nlm.nih.gov/pubmed/30021710 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10112 %T Web-Based Intervention Using Behavioral Activation and Physical Activity for Adults With Depression (The eMotion Study): Pilot Randomized Controlled Trial %A Lambert,Jeffrey D %A Greaves,Colin J %A Farrand,Paul %A Price,Lisa %A Haase,Anne M %A Taylor,Adrian H %+ Institute for Health Research, Primary Care, University of Exeter Medical School, Smeall Building, Heavitree Roadd, University of Exeter, Exeter, EX1 2LU, United Kingdom, 44 1392725705, j.d.lambert@exeter.ac.uk %K psychological therapy %K mood %K anxiety %K exercise %K eHealth %K feasibility %K acceptability %D 2018 %7 16.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity is a potentially effective treatment for depression and depressive relapse. However, promoting physical activity in people with depression is challenging. Interventions informed by theory and evidence are therefore needed to support people with depression to become more physically active. eMotion is a Web-based intervention combining behavioral activation and physical activity promotion for people in the community with symptoms of depression. Objective: The objectives were to assess the feasibility and acceptability of delivering eMotion to people in the community with symptoms of depression and to explore outcomes. Methods: Participants with elevated depressive symptoms were recruited from the community through various methods (eg, social media) and randomized to eMotion or a waiting list control group for 8 weeks. eMotion is an administratively supported weekly modular program that helps people use key behavior change techniques (eg, graded tasks, action planning, and self-monitoring) to re-engage in routine, pleasurable, and necessary activities, with a focus on physical activities. Feasibility data were collected that included the following: recruitment and trial retention rates; fidelity of intervention delivery, receipt, and enactment; and acceptability of the intervention and data collection procedures. Data were collected for the primary (depression) and secondary outcomes (eg, anxiety, physical activity, fidelity, and client satisfaction) at baseline and 2 months postrandomization using self-reported Web-based questionnaires and accelerometers. Delivery fidelity (logins, modules accessed, time spent) was tracked using Web usage statistics. Exploratory analyses were conducted on the primary and secondary outcomes. Results: Of the 183 people who contacted the research team, 62 were recruited and randomized. The mean baseline score was 14.6 (SD 3.2) on the 8-item Patient Health Questionnaire depression scale (PHQ-8). Of those randomized, 52 participants provided accelerometer-recorded physical activity data at baseline that showed a median of 35.8 (interquartile range [IQR] 0.0-98.6) minutes of moderate-to-vigorous physical activity (MVPA) recorded in at least 10-minute bouts per week, with only 13% (7/52) people achieving guideline levels (150 minutes of MVPA per week). In total, 81% (50/62) of participants provided follow-up data for the primary outcome (PHQ-8), but only 39% (24/62) provided follow-up accelerometer data. Within the intervention group, the median number of logins, modules accessed, and total minutes spent on eMotion was 3 (IQR 2.0-8.0), 3 (IQR 2.0-5.0), and 41.3 (IQR 18.9-90.4), respectively. Acceptability was mixed. Exploratory data analysis showed that PHQ-8 levels were lower for the intervention group than for the control group at 2 months postrandomization (adjusted mean difference −3.6, 95% CI −6.1 to −1.1). Conclusions: It was feasible to deliver eMotion in UK communities to inactive populations. eMotion has the potential to be effective and is ready for testing in a full-scale trial. Further work is needed to improve engagement with both the intervention and data collection procedures. Trial Registration: ClinicalTrials.gov NCT03084055; https://clinicaltrials.gov/ct2/show/NCT03084055 (Archived by WebCite at http://www.webcitation.org/6zoyM8UXa) %M 30012547 %R 10.2196/10112 %U http://www.jmir.org/2018/7/e10112/ %U https://doi.org/10.2196/10112 %U http://www.ncbi.nlm.nih.gov/pubmed/30012547 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10200 %T Measurement of Symptom Change Following Web-Based Psychotherapy: Statistical Characteristics and Analytical Methods for Measuring and Interpreting Change %A Karin,Eyal %A Dear,Blake F %A Heller,Gillian Z %A Gandy,Milena %A Titov,Nickolai %+ eCentreClinic, Department of Psychology, Macquarie University, Building C3A, First Walk Macquarie University NSW, Sydney, 2109, Australia, 61 298508657, eyal.karin@mq.edu.au %K clinical measurement %K treatment evaluation %K symptom change %K symptom scales %K psychotherapeutic change %D 2018 %7 12.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Accurate measurement of treatment-related change is a key part of psychotherapy research and the investigation of treatment efficacy. For this reason, the ability to measure change with accurate and valid methods is critical for psychotherapy. Objective: The aims of this study were to (1) explore the underlying characteristics of depressive symptom change, measured with the nine-item Patient Health Questionnaire (PHQ-9), following psychotherapy, and (2) compare the suitability of different ways to measure and interpret symptom change. A treatment sample of Web-based psychotherapy participants (n=1098) and a waitlist sample (n=96) were used to (1) explore the statistical characteristics of depressive symptom change, and (2) compare the suitability of two common types of change functions: linear and proportional change. Methods: These objectives were explored using hypotheses that tested (1) the relationship between baseline symptoms and the rate of change, (2) the shape of symptom score distribution following treatment, and (3) measurement error associated with linear and proportional measurement models. Results: Findings demonstrated that (1) individuals with severe depressive baseline symptoms had greater reductions in symptom scores than individuals with mild baseline symptoms (11.4 vs 3.7); however, as a percentage measurement, change remained similar across individuals with mild, moderate, or severe baseline symptoms (50%-55%); (2) positive skewness was observed in PHQ-9 score distributions following treatment; and (3) models that measured symptom change as a proportional function resulted in greater model fit and reduced measurement error (<30%). Conclusions: This study suggests that symptom scales, sharing an implicit feature of score bounding, are associated with a proportional function of change. Selecting statistics that overlook this proportional change (eg, Cohen d) is problematic and leads to (1) artificially increased estimates of change with higher baseline symptoms, (2) increased measurement error, and (3) confounded estimates of treatment efficacy and clinical change. Implications, limitations, and idiosyncrasies from these results are discussed. %M 30001999 %R 10.2196/10200 %U http://mental.jmir.org/2018/3/e10200/ %U https://doi.org/10.2196/10200 %U http://www.ncbi.nlm.nih.gov/pubmed/30001999 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e49 %T Patients’ Experiences of Web- and Mobile-Assisted Group Therapy for Depression and Implications of the Group Setting: Qualitative Follow-Up Study %A Schuster,Raphael %A Sigl,Sophia %A Berger,Thomas %A Laireiter,Anton-Rupert %+ Center for Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, Salzburg, 5020, Austria, 43 6628044 ext 5102, raphael.schuster@sbg.ac.at %K internet %K computer-assisted therapy %K smartphone-assisted therapy %K blended therapy %K cognitive behavioral therapy %K depression %K therapeutic process %K working alliance %D 2018 %7 11.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended group therapy combines group sessions with Web- and mobile-based treatment modules. Consequently, blended group therapy widens the choice within blended interventions at reasonable costs. This is the first qualitative study on blended group therapy. Objective: The objective of this study was to investigate the patient-centered feasibility of blended group therapy for major depression, with special emphasis on the fit and dynamic interplay between face-to-face and internet-based elements. Methods: A total of 22 patients who had a variety of experiences through participating in one of the two blended group therapy interventions were interviewed following a semistructured interview guide. In-depth interviews were analyzed by three trained psychologists, using thematic analysis and a rule-guided internet-based program (QCAmap). The transcript of the interviews (113,555 words) was reduced to 1081 coded units, with subsequent extraction of 16 themes. Results: Web- and mobile-based elements were described as a treatment facilitator and motivator, increasing the salience and consolidation of cognitive behavioral therapy materials, resulting in in- and inter-session alignment to the treatment. Additionally, patients valued the option of intimate Web-based self-disclosure (by lateral patient-therapist communication), and therapists were provided with tools for between-session monitoring and reinforcement of exercising. In this context, group phenomena seemed to back up therapists’ efforts to increase treatment engagement. The dissonance because of noncompliance with Web-based tasks and the constriction of in-session group interaction were considered as possible negative effects. Finally, issues of tailoring and structure seemed to fulfill different preconditions compared with individual therapy. Conclusions: Blended group therapy constitutes a structured and proactive approach to work with depression, and the integration of both modalities initiates a beneficial interplay. Results support the patient-centered value of blended group therapy and provide the first insight into blended group therapy’s role in fostering therapeutic treatment factors. However, potential negative effects should be considered carefully. %M 29997106 %R 10.2196/mental.9613 %U http://mental.jmir.org/2018/3/e49/ %U https://doi.org/10.2196/mental.9613 %U http://www.ncbi.nlm.nih.gov/pubmed/29997106 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10078 %T Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans %A Teo,Alan R %A Liebow,Samuel BL %A Chan,Benjamin %A Dobscha,Steven K %A Graham,Amanda L %+ HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Road (R&D 66), Portland, OR, 97239-2964, United States, 1 503 220 8262 ext 52461, teoa@ohsu.edu %K Facebook %K social media %K methodology %K Veterans Affairs %K veterans %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45%), problematic drinking (243/584, 42%), major depression (164/586, 28%), and suicidality (132/585, 23%). Approximately half of the survey participants (285/587, 49%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an “incentive” or “sharing” headline. These 2 ads were also the most cost-effective, at US $4.88 and US $5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). Conclusions: Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups. %M 29980498 %R 10.2196/10078 %U http://mental.jmir.org/2018/3/e10078/ %U https://doi.org/10.2196/10078 %U http://www.ncbi.nlm.nih.gov/pubmed/29980498 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e13 %T Indigenous Adolescents’ Perception of an eMental Health Program (SPARX): Exploratory Qualitative Assessment %A Shepherd,Matthew %A Merry,Sally %A Lambie,Ian %A Thompson,Andrew %+ School of Counselling, Human Services and Social Work, Faculty of Education, The University of Auckland, Gate 4, 60 Epsom Ave, Epsom, Auckland,, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K Māori youth %K indigenous %K depression %K computerized CBT %K consumer views %K serious games %K virtual worlds %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue for indigenous adolescents, yet there is little research conducted about the efficacy and development of psychological interventions for these populations. In New Zealand there is little known about taitamariki (Māori adolescent) opinions regarding the development and effectiveness of psychological interventions, let alone computerized cognitive behavioral therapy. SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a computerized intervention developed in New Zealand to treat mild-to-moderate depression in young people. Users are engaged in a virtual 3D environment where they must complete missions to progress to the next level. In each level there are challenges and puzzles to completeIt was designed to appeal to all young people in New Zealand and incorporates several images and concepts that are specifically Māori. Objective: The aim was to conduct an exploratory qualitative study of Māori adolescents’ opinions about the SPARX program. This is a follow-up to an earlier study where taitamariki opinions were gathered to inform the design of a computerized cognitive behavior therapy program. Methods: Taitamariki were interviewed using a semistructured interview once they had completed work with the SPARX resource. Six participants agreed to complete the interview; the interviews ranged from 10 to 30 minutes. Results: Taitamariki participating in the interviews found SPARX to be helpful. The Māori designs from the SPARX game were appropriate and useful, and the ability to customize the SPARX characters with Māori designs was beneficial and appeared to enhance cultural identity. These helped young people to feel engaged with SPARX which, in turn, assisted with the acquisition of relaxation and cognitive restructuring skills. Overall, using SPARX led to improved mood and increased levels of hope for the participants. In some instances, SPARX was used by wider whānau (Māori word for family) members with reported beneficial effect. Conclusions: Overall, this small group of Māori adolescents reported that cultural designs made it easier for them to engage with SPARX, which, in turn, led to an improvement in their mood and gave them hope. Further research is needed about how SPARX could be best used to support the families of these young people. %M 29980495 %R 10.2196/games.8752 %U http://games.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/games.8752 %U http://www.ncbi.nlm.nih.gov/pubmed/29980495 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10122 %T Data-Driven Learning in High-Resolution Activity Sampling From Patients With Bipolar Depression: Mixed-Methods Study %A Rohani,Darius Adam %A Tuxen,Nanna %A Quemada Lopategui,Andrea %A Kessing,Lars Vedel %A Bardram,Jakob Eyvind %+ Embedded Systems Engineering, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads Bygning 324, Kgs. Lyngby, 2800, Denmark, 45 61452393 ext 45, daroh@dtu.dk %K activities %K behavior %K behavioral activation %K bipolar disorder %K circadian rhythm %K depression %K hourly planning %K psychotherapy %K statistics %D 2018 %7 28.06.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Behavioral activation is a pen and paper-based therapy form for treating depression. The patient registers their activity hourly, and together with the therapist, they agree on a plan to change behavior. However, with the limited clinical personnel, and a growing patient population, new methods are needed to advance behavioral activation. Objective: The objectives of this paper were to (1) automatically identify behavioral patterns through statistical analysis of the paper-based activity diaries, and (2) determine whether it is feasible to move the behavioral activation therapy format to a digital solution. Methods: We collected activity diaries from seven patients with bipolar depression, covering in total 2,480 hours of self-reported activities. A pleasure score, on a 1-10 rating scale, was reported for each activity. The activities were digitalized into 6 activity categories, and statistical analyses were conducted. Results: Across all patients, movement-related activities were associated with the highest pleasure score followed by social activities. On an individual level, through a nonparametric Wilcoxon Signed-Rank test, one patient had a statistically significant larger amount of spare time activities when feeling bad (z=–2.045, P=.041). Through a within-subject analysis of covariance, the patients were found to have a better day than the previous, if that previous day followed their diurnal rhythm (ρ=.265, P=.029). Furthermore, a second-order trend indicated that two hours of daily social activity was optimal for the patients (β2=–0.08, t (63)=–1.22, P=.23). Conclusions: The data-driven statistical approach was able to find patterns within the behavioral traits that could assist the therapist in as well as help design future technologies for behavioral activation. %M 29954726 %R 10.2196/10122 %U http://mental.jmir.org/2018/2/e10122/ %U https://doi.org/10.2196/10122 %U http://www.ncbi.nlm.nih.gov/pubmed/29954726 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e48 %T eMental Healthcare Technologies for Anxiety and Depression in Childhood and Adolescence: Systematic Review of Studies Reporting Implementation Outcomes %A Wozney,Lori %A McGrath,Patrick J %A Gehring,Nicole D %A Bennett,Kathryn %A Huguet,Anna %A Hartling,Lisa %A Dyson,Michele P %A Soleimani,Amir %A Newton,Amanda S %+ Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-526 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, AB, T6G 1C9, Canada, 1 780 248 5581, mandi.newton@ualberta.ca %K eHealth %K mental health %K implementation science %K healthcare planning %K organizational innovation %K decision-making %K healthcare organizations %D 2018 %7 26.06.2018 %9 Review %J JMIR Ment Health %G English %X Background: Anxiety disorders and depression are frequent conditions in childhood and adolescence. eMental healthcare technologies may improve access to services, but their uptake within health systems is limited. Objective: The objective of this review was to examine and describe how the implementation of eMental healthcare technologies for anxiety disorders and depression in children and adolescents has been studied. Methods: We conducted a search of 5 electronic databases and gray literature. Eligible studies were those that assessed an eMental healthcare technology for treating or preventing anxiety or depression, included children or adolescents (<18 years), or their parents or healthcare providers and reported findings on technology implementation. The methodological quality of studies was evaluated using the Mixed Methods Appraisal Tool. Outcomes of interest were based on 8 implementation outcomes: acceptability (satisfaction with a technology), adoption (technology uptake and utilization), appropriateness (“fitness for purpose”), cost (financial impact of technology implementation), feasibility (extent to which a technology was successfully used), fidelity (implementation as intended), penetration (“spread” or “reach” of the technology), and sustainability (maintenance or integration of a technology within a healthcare service). For extracted implementation outcome data, we coded favorable ratings on measurement scales as “positive results” and unfavorable ratings on measurement scales as “negative results.” Those studies that reported both positive and negative findings were coded as having “mixed results.” Results: A total of 46 studies met the inclusion criteria, the majority of which were rated as very good to excellent in methodological quality. These studies investigated eMental healthcare technologies for anxiety (n=23), depression (n=18), or both anxiety and depression (n=5). Studies of technologies for anxiety evaluated the following: (1) acceptability (78%) reported high levels of satisfaction, (2) adoption (43%) commonly reported positive results, and (3) feasibility (43%) reported mixed results. Studies of technologies for depression evaluated the following: (1) appropriateness (56%) reported moderate helpfulness and (2) acceptability (50%) described a mix of both positive and negative findings. Studies of technologies designed to aid anxiety and depression commonly reported mixed experiences with acceptability and adoption and positive findings for appropriateness of the technologies for treatment. Across all studies, cost, fidelity, and penetration and sustainability were the least measured implementation outcomes. Conclusions: Acceptability of eMental healthcare technology is high among users and is the most commonly investigated implementation outcome. Perceptions of the appropriateness and adoption of eMental healthcare technology were varied. Implementation research that identifies, evaluates, and reports on costs, sustainability, and fidelity to clinical guidelines is crucial for making high-quality eMental healthcare available to children and adolescents. %M 29945858 %R 10.2196/mental.9655 %U http://mental.jmir.org/2018/2/e48/ %U https://doi.org/10.2196/mental.9655 %U http://www.ncbi.nlm.nih.gov/pubmed/29945858 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10732 %T Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review %A Tighe,Joseph %A Nicholas,Jennifer %A Shand,Fiona %A Christensen,Helen %+ Black Dog Institute, School of Psychiatry, University of New South Wales, Hospital Road, Randwick, Sydney, 2031, Australia, 61 416747998, j.tighe@blackdog.org.au %K suicidal ideation %K suicide %K deliberate self-harm %K depression %K mental health %K acceptance and commitment therapy %K cognitive behavioral therapy %K mHealth %K psychology %K ACT %D 2018 %7 25.06.2018 %9 Review %J JMIR Ment Health %G English %X Background: Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH). Objective: The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT. Methods: We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes. Results: After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre–post studies, and 1 mHealth randomized controlled trial. Conclusions: The review found that ACT is effective in reducing SI in the 2 pre–post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH. %M 29941419 %R 10.2196/10732 %U http://mental.jmir.org/2018/2/e10732/ %U https://doi.org/10.2196/10732 %U http://www.ncbi.nlm.nih.gov/pubmed/29941419 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e161 %T Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan (PERFORM-J): Protocol for a Prospective Cohort Study %A Sumiyoshi,Tomiki %A Watanabe,Koichiro %A Noto,Shinichi %A Sakamoto,Shigeru %A Moriguchi,Yoshiya %A Okamoto,Shuichi %+ Department of Preventive Intervention for Psychiatric Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi, Kodaira, Tokyo, 187-8551, Japan, 81 42 341 2711, sumiyot@ncnp.go.jp %K antidepressants %K depression %K major depressive disorder %K cognitive dysfunction %K observational study %D 2018 %7 25.06.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with major depressive disorder may exhibit cognitive dysfunction that can affect functional outcomes. However, the prevalence and burden of cognitive dysfunction in Japanese patients with MDD have not been thoroughly examined. Objective: To investigate the time course (over 6 months) of several functional outcomes during treatment with antidepressants in Japanese patients with major depressive disorder. The primary objective is to assess longitudinal changes in cognitive function and depressive symptoms, using both clinician-rated and patient-rated scales. The study incorporates assessments of cognitive function and other functional outcomes (functional capacity, disability, work productivity and impairments of activity, and quality of life), as well as depressive symptoms. Methods: PERFORM-J (Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan) is a 6-month, prospective, multi-center, epidemiological cohort study. Participants are Japanese outpatients aged 18-65 years with a recurrent or new diagnosis of a major depressive episode (according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [DSM-IV-TR]), who are initiating a new antidepressant as monotherapy (either as first-line therapy or after switching from a previous antidepressant). Eligible patients are evaluated objectively during four visits (at baseline and at Months 1, 2, and 6) using physician-rated assessments of severity of depressive symptoms, cognitive function, and functional capacity. Subjective, patient-reported, outcomes are also assessed as indicators of depressive symptoms, disability, work productivity or impairments of activity, and perceived cognitive dysfunction. Results: The study began in September 2016. Patient enrollment was completed on June 30, 2017, with 523 patients having been enrolled from 48 study sites. As of October, 2017, 279 patients had completed the study. Conclusions: PERFORM-J is expected to provide valuable information on the longitudinal relationship between cognitive dysfunction, depressive symptoms, and other functional outcomes in Japanese patients with major depressive disorder who initiate monotherapy with antidepressants. Trial Registration: UMIN Clinical Trials Registry UMIN000024320; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000028011 (Archived by WebCite at http://www.webcitation.org/70K7W9PgC). Registered Report Identifier: RR1-10.2196/9682 %M 29941418 %R 10.2196/resprot.9682 %U http://www.researchprotocols.org/2018/6/e161/ %U https://doi.org/10.2196/resprot.9682 %U http://www.ncbi.nlm.nih.gov/pubmed/29941418 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10144 %T Using Neural Networks with Routine Health Records to Identify Suicide Risk: Feasibility Study %A DelPozo-Banos,Marcos %A John,Ann %A Petkov,Nicolai %A Berridge,Damon Mark %A Southern,Kate %A LLoyd,Keith %A Jones,Caroline %A Spencer,Sarah %A Travieso,Carlos Manuel %+ Swansea University, Swansea University Medical School, Institute of Life Science 2, 3rd Floor, Swansa University Singleton Park Campus, Swansea, SA2 8PP, United Kingdom, 44 1792604094, M.DelPozoBanos@swansea.ac.uk %K suicide prevention %K risk assessment %K electronic health records %K routine data %K machine learning %K artificial neural networks %D 2018 %7 22.06.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Each year, approximately 800,000 people die by suicide worldwide, accounting for 1–2 in every 100 deaths. It is always a tragic event with a huge impact on family, friends, the community and health professionals. Unfortunately, suicide prevention and the development of risk assessment tools have been hindered by the complexity of the underlying mechanisms and the dynamic nature of a person’s motivation and intent. Many of those who die by suicide had contact with health services in the preceding year but identifying those most at risk remains a challenge. Objective: To explore the feasibility of using artificial neural networks with routinely collected electronic health records to support the identification of those at high risk of suicide when in contact with health services. Methods: Using the Secure Anonymised Information Linkage Databank UK, we extracted the data of those who died by suicide between 2001 and 2015 and paired controls. Looking at primary (general practice) and secondary (hospital admissions) electronic health records, we built a binary feature vector coding the presence of risk factors at different times prior to death. Risk factors included: general practice contact and hospital admission; diagnosis of mental health issues; injury and poisoning; substance misuse; maltreatment; sleep disorders; and the prescription of opiates and psychotropics. Basic artificial neural networks were trained to differentiate between the suicide cases and paired controls. We interpreted the output score as the estimated suicide risk. System performance was assessed with 10x10-fold repeated cross-validation, and its behavior was studied by representing the distribution of estimated risk across the cases and controls, and the distribution of factors across estimated risks. Results: We extracted a total of 2604 suicide cases and 20 paired controls per case. Our best system attained a mean error rate of 26.78% (SD 1.46; 64.57% of sensitivity and 81.86% of specificity). While the distribution of controls was concentrated around estimated risks < 0.5, cases were almost uniformly distributed between 0 and 1. Prescription of psychotropics, depression and anxiety, and self-harm increased the estimated risk by ~0.4. At least 95% of those presenting these factors were identified as suicide cases. Conclusions: Despite the simplicity of the implemented system, the proposed methodology obtained an accuracy like other published methods based on specialized questionnaire generated data. Most of the errors came from the heterogeneity of patterns shown by suicide cases, some of which were identical to those of the paired controls. Prescription of psychotropics, depression and anxiety, and self-harm were strongly linked with higher estimated risk scores, followed by hospital admission and long-term drug and alcohol misuse. Other risk factors like sleep disorders and maltreatment had more complex effects. %M 29934287 %R 10.2196/10144 %U http://mental.jmir.org/2018/2/e10144/ %U https://doi.org/10.2196/10144 %U http://www.ncbi.nlm.nih.gov/pubmed/29934287 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e215 %T Detecting Suicidal Ideation on Forums: Proof-of-Concept Study %A Aladağ,Ahmet Emre %A Muderrisoglu,Serra %A Akbas,Naz Berfu %A Zahmacioglu,Oguzhan %A Bingol,Haluk O %+ Department of Computer Engineering, Bogazici University, Bebek, Istanbul, 34342, Turkey, 90 2123594523, emre.aladag@boun.edu.tr %K suicide %K suicidal ideation %K suicidality %K detection %K prevention %K classification model %K text mining %K machine learning %K artificial intelligence %K suicidal surveillance %D 2018 %7 21.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In 2016, 44,965 people in the United States died by suicide. It is common to see people with suicidal ideation seek help or leave suicide notes on social media before attempting suicide. Many prefer to express their feelings with longer passages on forums such as Reddit and blogs. Because these expressive posts follow regular language patterns, potential suicide attempts can be prevented by detecting suicidal posts as they are written. Objective: This study aims to build a classifier that differentiates suicidal and nonsuicidal forum posts via text mining methods applied on post titles and bodies. Methods: A total of 508,398 Reddit posts longer than 100 characters and posted between 2008 and 2016 on SuicideWatch, Depression, Anxiety, and ShowerThoughts subreddits were downloaded from the publicly available Reddit dataset. Of these, 10,785 posts were randomly selected and 785 were manually annotated as suicidal or nonsuicidal. Features were extracted using term frequency-inverse document frequency, linguistic inquiry and word count, and sentiment analysis on post titles and bodies. Logistic regression, random forest, and support vector machine (SVM) classification algorithms were applied on resulting corpus and prediction performance is evaluated. Results: The logistic regression and SVM classifiers correctly identified suicidality of posts with 80% to 92% accuracy and F1 score, respectively, depending on different data compositions closely followed by random forest, compared to baseline ZeroR algorithm achieving 50% accuracy and 66% F1 score. Conclusions: This study demonstrated that it is possible to detect people with suicidal ideation on online forums with high accuracy. The logistic regression classifier in this study can potentially be embedded on blogs and forums to make the decision to offer real-time online counseling in case a suicidal post is being written. %M 29929945 %R 10.2196/jmir.9840 %U http://www.jmir.org/2018/6/e215/ %U https://doi.org/10.2196/jmir.9840 %U http://www.ncbi.nlm.nih.gov/pubmed/29929945 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10001 %T Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study %A Bauer,Amy M %A Baldwin,Scott A %A Anguera,Joaquin A %A Areán,Patricia A %A Atkins,David C %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195 6560, United States, 1 2062218385, abauer1@uw.edu %K Patient Health Questionnaire %K depression %K mobile health %K symptom assessment %D 2018 %7 19.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often on a weekly or monthly basis. Increasingly, patient-provider contacts occur remotely (eg, by telephone and Web-based portals), and mobile health tools can now monitor depressed mood daily or more frequently. However, the reliability and utility of daily ratings are unclear. Objective: This study aimed to examine the association between a daily depressive symptom measure and the Patient Health Questionnaire-9 (PHQ-9), the most widely adopted depression self-report measure, and compare how well these 2 assessment methods predict patient outcomes. Methods: A total of 547 individuals completed smartphone-based measures, including the Patient Health Questionnaire-2 (PHQ-2) modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent depression based on the PHQ-2 (for repeated measures) between weeks 2 and 4 and its correlation with the PHQ-9 at week 4. Regression models predicted week 8 depressive symptoms and disability ratings with daily PHQ-2 and PHQ-9. Results: The daily PHQ-2 and PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r=.80). Findings were robust across demographic groups (age, gender, and ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting week 8 disability and were independent predictors of week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. Conclusions: Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care. %M 29921564 %R 10.2196/10001 %U http://www.jmir.org/2018/6/e10001/ %U https://doi.org/10.2196/10001 %U http://www.ncbi.nlm.nih.gov/pubmed/29921564 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e12 %T Investigating Associations Between Changes in Mobile Phone Use and Emotions Using the Experience Sampling Method: Pilot Study %A Roggeveen,Suzanne %A van Os,Jim %A Bemelmans,Kelly %A van Poll,Mikal %A Lousberg,Richel %+ Department of Psychiatry and Psychology, Maastricht University, Vijverdalseweg 1, Maastricht,, Netherlands, 31 43 3884111, s.roggeveen@maastrichtuniversity.nl %K mobile phone %K experience sampling method %K emotions %K affect %K concentration %D 2018 %7 18.06.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The use of mobile phones has become, especially for young people, an integrated part of everyday life. Using the experience sampling method (ESM) may provide further insight on the association between mobile phone use and mental health. Objective: The objective of this study was to examine associations between mobile phone use and subtle changes in mental state. Methods: The ESM-based PsyMate app was installed on the mobile phones of 2 healthy 20-year-old participants. Over a period of 3 months, participants rated their mental states at 10 semirandom moments in the flow of daily life. Each assessment included present state emotions, environmental circumstances, and phone use. Results: Multilevel regression analyses indicated that an increase in mobile phone use was associated with a small increase in negative affect (particularly feeling bored and feeling lonely; P<.001) and small decreases in positive affect (P=.002) and concentration (P=.001). Treating the data as 2 separate N=1 studies revealed that the association with negative affect was present in both participants, whereas the associations with positive affect and concentration were evident in only 1 of the 2 participants. Conclusions: This pilot study suggests that mobile phone use may be associated with person-specific and group-level changes in emotional state. A larger study is required to study these associations, possible causality, and factors driving underlying heterogeneity in the pattern of associations. Trial registration: ClinicalTrials.gov NCT03221985; https://clinicaltrials.gov/ct2/show/NCT03221985 (archived by WebCite at http://www.webcitation.org/6zJnp61Wj) %M 30684428 %R 10.2196/formative.8499 %U http://formative.jmir.org/2018/1/e12/ %U https://doi.org/10.2196/formative.8499 %U http://www.ncbi.nlm.nih.gov/pubmed/30684428 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 6 %P e139 %T Smartphone Apps for Mindfulness Interventions for Suicidality in Asian Youths: Literature Review %A Choo,Carol C %A Burton,André AD %+ James Cook University, 149 Sims Drive, Singapore,, Singapore, 65 67093760, carol.choo@jcu.edu.au %K suicidality %K Asian youths %K smartphone applications %K mindfulness %D 2018 %7 07.06.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: The advent of mobile technology has ushered in an era in which smartphone apps can be used as interventions for suicidality. Objective: We aimed to review recent research that is relevant to smartphone apps that can be used for mindfulness interventions for suicidality in Asian youths. Methods: The inclusion criteria for this review were: papers published in peer-reviewed journals from 2007 to 2017 with usage of search terms (namely “smartphone application” and “mindfulness”) and screened by an experienced Asian clinician to be of clinical utility for mindfulness interventions for suicidality with Asian youths. Results: The initial search of databases yielded 375 results. Fourteen full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review. Conclusions: This review highlighted the paucity of evidence-based and empirically validated research into effective smartphone apps that can be used for mindfulness interventions for suicidality with Asian youths. %R 10.2196/mhealth.8304 %U http://mhealth.jmir.org/2018/6/e139/ %U https://doi.org/10.2196/mhealth.8304 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10120 %T User Experience of Cognitive Behavioral Therapy Apps for Depression: An Analysis of App Functionality and User Reviews %A Stawarz,Katarzyna %A Preist,Chris %A Tallon,Debbie %A Wiles,Nicola %A Coyle,David %+ Bristol Interaction Group, Faculty of Engineering, University of Bristol, Merchant Venturers Building, Woodland Road, Bristol, BS8 1UB, United Kingdom, 44 1179545289, k.stawarz@bristol.ac.uk %K mental health %K mobile apps %K cognitive behavioral therapy %K depression %K user experience %K mHealth %D 2018 %7 06.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Hundreds of mental health apps are available to the general public. With increasing pressures on health care systems, they offer a potential way for people to support their mental health and well-being. However, although many are highly rated by users, few are evidence-based. Equally, our understanding of what makes apps engaging and valuable to users is limited. Objective: The aim of this paper was to analyze functionality and user opinions of mobile apps purporting to support cognitive behavioral therapy for depression and to explore key factors that have an impact on user experience and support engagement. Methods: We systematically identified apps described as being based on cognitive behavioral therapy for depression. We then conducted 2 studies. In the first, we analyzed the therapeutic functionality of apps. This corroborated existing work on apps’ fidelity to cognitive behavioral therapy theory, but we also extended prior work by examining features designed to support user engagement. Engagement features found in cognitive behavioral therapy apps for depression were compared with those found in a larger group of apps that support mental well-being in a more general sense. Our second study involved a more detailed examination of user experience, through a thematic analysis of publicly available user reviews of cognitive behavioral therapy apps for depression. Results: We identified 31 apps that purport to be based on cognitive behavioral therapy for depression. Functionality analysis (study 1) showed that they offered an eclectic mix of features, including many not based on cognitive behavioral therapy practice. Cognitive behavioral therapy apps used less varied engagement features compared with 253 other mental well-being apps. The analysis of 1287 user reviews of cognitive behavioral therapy apps for depression (study 2) showed that apps are used in a wide range of contexts, both replacing and augmenting therapy, and allowing users to play an active role in supporting their mental health and well-being. Users, including health professionals, valued and used apps that incorporated both core cognitive behavioral therapy and non-cognitive behavioral therapy elements, but concerns were also expressed regarding the unsupervised use of apps. Positivity was seen as important to engagement, for example, in the context of automatic thoughts, users expressed a preference to capture not just negative but also positive ones. Privacy, security, and trust were crucial to the user experience. Conclusions: Cognitive behavioral therapy apps for depression need to improve with respect to incorporating evidence-based cognitive behavioral therapy elements. Equally, a positive user experience is dependent on other design factors, including consideration of varying contexts of use. App designers should be able to clearly identify the therapeutic basis of their apps, but they should also draw on evidence-based strategies to support a positive and engaging user experience. The most effective apps are likely to strike a balance between evidence-based cognitive behavioral therapy strategies and evidence-based design strategies, including the possibility of eclectic therapeutic techniques. %R 10.2196/10120 %U http://www.jmir.org/2018/6/e10120/ %U https://doi.org/10.2196/10120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e199 %T Beyond the Trial: Systematic Review of Real-World Uptake and Engagement With Digital Self-Help Interventions for Depression, Low Mood, or Anxiety %A Fleming,Theresa %A Bavin,Lynda %A Lucassen,Mathijs %A Stasiak,Karolina %A Hopkins,Sarah %A Merry,Sally %+ Faculty of Health, Victoria University of Wellington, Kelburn Parade, Wellington,, New Zealand, 64 800 842 8888, terry.fleming@vuw.ac.nz %K e-therapy %K mobile applications %K eHealth %K depression %K anxiety %D 2018 %7 06.06.2018 %9 Review %J J Med Internet Res %G English %X Background: Digital self-help interventions (including online or computerized programs and apps) for common mental health issues have been shown to be appealing, engaging, and efficacious in randomized controlled trials. They show potential for improving access to therapy and improving population mental health. However, their use in the real world, ie, as implemented (disseminated) outside of research settings, may differ from that reported in trials, and implementation data are seldom reported. Objective: This study aimed to review peer-reviewed articles reporting user uptake and/or ongoing use, retention, or completion data (hereafter usage data or, for brevity, engagement) from implemented pure self-help (unguided) digital interventions for depression, anxiety, or the enhancement of mood. Methods: We conducted a systematic search of the Scopus, Embase, MEDLINE, and PsychINFO databases for studies reporting user uptake and/or usage data from implemented digital self-help interventions for the treatment or prevention of depression or anxiety, or the enhancement of mood, from 2002 to 2017. Additionally, we screened the reference lists of included articles, citations of these articles, and the titles of articles published in Internet Interventions, Journal of Medical Internet Research (JMIR), and JMIR Mental Health since their inception. We extracted data indicating the number of registrations or downloads and usage of interventions. Results: After the removal of duplicates, 970 papers were identified, of which 10 met the inclusion criteria. Hand searching identified 1 additional article. The included articles reported on 7 publicly available interventions. There was little consistency in the measures reported. The number of registrants or downloads ranged widely, from 8 to over 40,000 per month. From 21% to 88% of users engaged in at least minimal use (eg, used the intervention at least once or completed one module or assessment), whereas 7-42% engaged in moderate use (completing between 40% and 60% of modular fixed-length programs or continuing to use apps after 4 weeks). Indications of completion or sustained use (completion of all modules or the last assessment or continuing to use apps after six weeks or more) varied from 0.5% to 28.6%. Conclusions: Available data suggest that uptake and engagement vary widely among the handful of implemented digital self-help apps and programs that have reported this, and that usage may vary from that reported in trials. Implementation data should be routinely gathered and reported to facilitate improved uptake and engagement, arguably among the major challenges in digital health. %R 10.2196/jmir.9275 %U http://www.jmir.org/2018/6/e199/ %U https://doi.org/10.2196/jmir.9275 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e10494 %T A Self-Paced, Web-Based, Positive Emotion Skills Intervention for Reducing Symptoms of Depression: Protocol for Development and Pilot Testing of MARIGOLD %A Cheung,Elaine O %A Addington,Elizabeth L %A Bassett,Sarah M %A Schuette,Stephanie A %A Shiu,Eva W %A Cohn,Michael A %A Leykin,Yan %A Saslow,Laura R %A Moskowitz,Judith T %+ Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan, Suite #2700, Chicago, IL, 60611, United States, 1 3125034388, elaine-cheung@northwestern.edu %K emotions %K depression %K telemedicine %K happiness %K mobile apps %D 2018 %7 05.06.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Living with elevated symptoms of depression can have debilitating consequences for an individual’s psychosocial and physical functioning, quality of life, and health care utilization. A growing body of evidence demonstrates that skills for increasing positive emotion can be helpful to individuals with depression. Although Web-based interventions to reduce negative emotion in individuals with depression are available, these interventions frequently suffer from poor retention and adherence and do not capitalize on the potential benefits of increasing positive emotion. Objective: The aim of this study was to develop and test a Web-based positive emotion skills intervention tailored for individuals living with elevated depressive symptoms, as well as to develop and test enhancement strategies for increasing retention and adherence to that intervention. Methods: This study protocol describes the development and testing for Mobile Affect Regulation Intervention with the Goal of Lowering Depression (MARIGOLD), a Web-based positive emotion skills intervention, adapted for individuals with elevated depressive symptomatology. The intervention development is taking place in three phases. In phase 1, we are tailoring an existing positive emotion skills intervention for individuals with elevated symptoms of depression and are pilot testing the tailored version of the intervention in a randomized controlled trial with two control conditions (N=60). In phase 2, we are developing and testing three enhancements aimed at boosting retention and adherence to the Web-based intervention (N=75): facilitator contact, an online discussion board, and virtual badges. In phase 3, we are conducting a multifactorial, nine-arm pilot trial (N=600) to systematically test these enhancement strategies, individually and in combination. The primary outcome is depressive symptom severity. Secondary outcomes include positive and negative emotion, psychological well-being, and coping resources. Results: The project was funded in August 2014, and data collection was completed in May 2018. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018. Conclusions: Findings from this investigation will enable us to develop an optimal package of intervention content and enhancement strategies for individuals with elevated symptoms of depression. If this intervention proves to be effective, it will provide a cost-effective, anonymous, appealing, and flexible approach for reducing symptoms of depression and improving psychological adjustment through increasing positive emotion. Trial Registration: ClinicalTrials.gov NCT01964820 (Phase 1); https://clinicaltrials.gov/ct2/show/NCT01964820 (Archived by WebCite at http://www.webcitation.org/6zpmKBcyX). ClinicalTrials.gov NCT02861755 (Phase 2); https://clinicaltrials.gov/ct2/show/NCT02861755 (Archived by WebCite at http://www.webcitation.org/6zpmLmy8k). Registered Report Identifier: RR1-10.2196/10494 %R 10.2196/10494 %U http://www.researchprotocols.org/2018/6/e10494/ %U https://doi.org/10.2196/10494 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10425 %T Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test %A Pisani,Anthony R %A Wyman,Peter A %A Gurditta,Kunali %A Schmeelk-Cone,Karen %A Anderson,Carolyn L %A Judd,Emily %+ Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Box PSYC, 300 Crittenden Boulevard, Rochester, NY, 14642, United States, 1 (585) 275 3644, anthony_pisani@urmc.rochester.edu %K suicide prevention %K school-based program %K text messaging %K school health services %D 2018 %7 31.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death among 10- to 19-year-olds in the United States, with 5% to 8% attempting suicide each year. Suicide risk rises significantly during early adolescence and is higher in rural and underserved communities. School-based universal prevention programs offer a promising way of reducing suicide by providing strategies for emotion regulation and encouraging help-seeking behaviors and youth-adult connectedness. However, such programs frequently run into difficulties in trying to engage a broad range of students. Text messaging is a dominant medium of communication among youths, and studies show both efficacy and uptake in text messaging interventions aimed at adolescents. Text-based interventions may, thus, offer a means for school-based universal prevention programs to engage adolescents who would otherwise be difficult to reach. Objective: We field tested Text4Strength, an automated, interactive text messaging intervention that seeks to reach a broad range of early adolescents in rural communities. Text4Strength extends Sources of Strength, a peer-led school suicide prevention program, by encouraging emotion regulation, help-seeking behaviors, and youth-adult connectedness in adolescents. The study tested the appeal and feasibility of Text4Strength and its potential to extend universal school-based suicide prevention. Methods: We field tested Text4Strength with 42 ninth-grade students. Over 9 weeks, students received 28 interactive message sequences across 9 categories (Sources of Strength introduction, positive friend, mentors, family support, healthy activities, generosity, spirituality, medical access, and emotion regulation strategies). The message sequences included games, requests for advice, questions about students’ own experiences, and peer testimonial videos. We measured baseline mental health characteristics, frequency of replies, completion of sequences and video viewing, appeal to students, and their perception of having benefited from the program. Results: Of the 42 participating students, 38 (91%) responded to at least one sequence and 22 (52%) responded to more than a third of the sequences. The proportion of students who completed multistep sequences they had started ranged from 35% (6/17) to 100% (3/3 to 28/28), with responses dropping off when more than 4 replies were needed. With the exception of spirituality and generosity, each of the content areas generated at least a moderate number of student replies from both boys and girls. Students with higher and lower levels of risk and distress interacted with the sequences at similar rates. Contrary to expectations, few students watched videos. Students viewed the intervention as useful—even those who rarely responded to messages. More than 70% found the texts useful (3 items, n range 29-34) and 90% (36) agreed the program should be repeated. Conclusions: Text4Strength offers a potentially engaging way to extend school-based interventions that promote protective factors for suicide. Text4Strength is ready to be revised, based on findings and student feedback from this field test, and rigorously tested for efficacy. %R 10.2196/10425 %U http://mental.jmir.org/2018/2/e10425/ %U https://doi.org/10.2196/10425 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e36 %T A Web-Based Transdiagnostic Intervention for Affective and Mood Disorders: Randomized Controlled Trial %A Tulbure,Bogdan Tudor %A Rusu,Andrei %A Sava,Florin Alin %A Sălăgean,Nastasia %A Farchione,Todd J %+ Psychology Department, West University of Timisoara, Blvd. V. Parvan 4, Timisoara, 300134, Romania, 40 0 745753061, bogdan.tulbure@e-uvt.ro %K transdiagnostic %K anxiety disorders %K depressive disorder %K cognitive therapy %D 2018 %7 24.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research increasingly supports a transdiagnostic conceptualization of emotional disorders (ie applying the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses), and many international researchers are currently investigating this issue. Objective: The aim of this study was to evaluate the efficacy and acceptability of a Web-based transdiagnostic program using a sample of Romanian adults diagnosed with anxiety and/or depression. Methods: Volunteer participants registered for the study and completed a series of online self-report measures. Participants who fulfilled basic inclusion criteria on these measures were contacted for a telephone diagnostic interview using the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders (SCID-I). Enrolled participants were randomized to either the active treatment group (N=69) or the wait-list control group (N=36) using a 2:1 ratio. The transdiagnostic treatment was based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al, 2011) that addresses common underlying mechanisms of anxiety and depression. Participants randomized to the active treatment condition received 10 weeks of Web-based treatment based on the UP. Throughout treatment, graduate students in clinical psychology provided guidance that consisted of asynchronous written communication on a secure Web platform. After the intervention, participants in both study conditions were invited to complete a set of self-report measures and a postintervention SCID-I interview conducted by a different team of graduate students blinded to participants’ group and diagnostic status. Six months later, participants in the active treatment group were invited to complete an online follow-up assessment. Results: During the intervention, active treatment participants completed on average 19 homework assignments (SD 12.10), and we collected data from 79.0% (83/105) at postintervention and 51% (35/69) at follow-up for self-report measures. Postintervention SCID-I interviews were collected from 77.1% (81/105) participants. Relative to the wait-list control group, the transdiagnostic intervention yielded overall medium to large effect sizes for the primary outcome measures (within-group Hedges g=0.52-1.34 and between-group g=0.39-0.86), and also for anxiety sensitivity (g=0.80), symptom interference (g=0.48), and quality of life (g=0.38). Significant within-groups effects only were reported for the active treatment group on Panic Disorder Severity Scale-Self Report (PDSS-SR, g=0.58-0.65) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS, g=0.52-0.58). Conclusions: Insignificant between-group differences for the Y-BOCS and PDSS-SR could be explained by the small number of participants with the associated primary diagnostic (eg, only 3 participants with obsessive compulsive disorder) by the choice of outcome measure (PDSS-SR was not rated among the evidence-based measures) and by the fact that these disorders may be more difficult to treat. However, the overall results suggest that the transdiagnostic intervention tested in this study represents an effective treatment option that may prove easier to disseminate through the use of Web-based delivery systems. Trial Registration: ClinicalTrials.gov CT02739607; https://clinicaltrials.gov/ct2/show/study/NCT02739607 (Archived by WebCite at http://www.webcitation.org/6yY1VeYIZ) %M 29798831 %R 10.2196/mental.8901 %U http://mental.jmir.org/2018/2/e36/ %U https://doi.org/10.2196/mental.8901 %U http://www.ncbi.nlm.nih.gov/pubmed/29798831 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e43 %T Diurnal Variations of Depression-Related Health Information Seeking: Case Study in Finland Using Google Trends Data %A Tana,Jonas Christoffer %A Kettunen,Jyrki %A Eirola,Emil %A Paakkonen,Heikki %+ Department of Health and Welfare, Arcada University of Applied Sciences, Jan-Magnus Janssons plats 1, Helsinki, 00560, Finland, 358 400500090, jonas.tana@arcada.fi %K depression %K consumer health information %K information seeking behavior %K infoveillance %K infodemiology %K mental health %K search engine %D 2018 %7 23.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Some of the temporal variations and clock-like rhythms that govern several different health-related behaviors can be traced in near real-time with the help of search engine data. This is especially useful when studying phenomena where little or no traditional data exist. One specific area where traditional data are incomplete is the study of diurnal mood variations, or daily changes in individuals’ overall mood state in relation to depression-like symptoms. Objective: The objective of this exploratory study was to analyze diurnal variations for interest in depression on the Web to discover hourly patterns of depression interest and help seeking. Methods: Hourly query volume data for 6 depression-related queries in Finland were downloaded from Google Trends in March 2017. A continuous wavelet transform (CWT) was applied to the hourly data to focus on the diurnal variation. Longer term trends and noise were also eliminated from the data to extract the diurnal variation for each query term. An analysis of variance was conducted to determine the statistical differences between the distributions of each hour. Data were also trichotomized and analyzed in 3 time blocks to make comparisons between different time periods during the day. Results: Search volumes for all depression-related query terms showed a unimodal regular pattern during the 24 hours of the day. All queries feature clear peaks during the nighttime hours around 11 PM to 4 AM and troughs between 5 AM and 10 PM. In the means of the CWT-reconstructed data, the differences in nighttime and daytime interest are evident, with a difference of 37.3 percentage points (pp) for the term “Depression,” 33.5 pp for “Masennustesti,” 30.6 pp for “Masennus,” 12.8 pp for “Depression test,” 12.0 pp for “Masennus testi,” and 11.8 pp for “Masennus oireet.” The trichotomization showed peaks in the first time block (00.00 AM-7.59 AM) for all 6 terms. The search volumes then decreased significantly during the second time block (8.00 AM-3.59 PM) for the terms “Masennus oireet” (P<.001), “Masennus” (P=.001), “Depression” (P=.005), and “Depression test” (P=.004). Higher search volumes for the terms “Masennus” (P=.14), “Masennustesti” (P=.07), and “Depression test” (P=.10) were present between the second and third time blocks. Conclusions: Help seeking for depression has clear diurnal patterns, with significant rise in depression-related query volumes toward the evening and night. Thus, search engine query data support the notion of the evening-worse pattern in diurnal mood variation. Information on the timely nature of depression-related interest on an hourly level could improve the chances for early intervention, which is beneficial for positive health outcomes. %M 29792291 %R 10.2196/mental.9152 %U http://mental.jmir.org/2018/2/e43/ %U https://doi.org/10.2196/mental.9152 %U http://www.ncbi.nlm.nih.gov/pubmed/29792291 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e44 %T Internet Use, Depression, and Anxiety in a Healthy Adolescent Population: Prospective Cohort Study %A Thom,Robyn Pauline %A Bickham,David S %A Rich,Michael %+ Harvard Longwood Psychiatry Residency Training Program, Brigham and Women's Hospital & Beth Israel Deaconess Medical Center, 60 Fenwood Road, Department of Psychiatry, Boston, MA, 02115, United States, 1 857 307 5521, rthom@bidmc.harvard.edu %K mental health %K psychiatric disorders %K internet use %K social networking sites %D 2018 %7 22.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Psychiatric disorders, including conduct disturbances, substance abuse, and affective disorders, emerge in approximately 20% of adolescents. In parallel with the rise in internet use, the prevalence of depression among adolescents has increased. It remains unclear whether and how internet use impacts mental health in adolescents. Objective: We assess the association between patterns of internet use and two mental health outcomes (depression and anxiety) in a healthy adolescent population. Methods: A total of 126 adolescents between the ages of 12 and 15 years were recruited. Participants reported their typical computer and internet usage patterns. At baseline and one-year follow-up, they completed the Beck Depression Index for primary care (BDI-PC) and the Beck Anxiety Inventory for Primary Care (BAI-PC). Individual linear regressions were completed to determine the association between markers of internet use at baseline and mental health outcomes at one-year follow-up. All models controlled for age, gender, and ethnicity. Results: There was an inverse correlation between minutes spent on a favorite website per visit and BAI-PC score. No association was found between internet use and BDI-PC score. Conclusions: There is no relationship between internet use patterns and depression in adolescents, whereas internet use may mitigate anxiety in adolescents with higher levels of baseline anxiety. %R 10.2196/mental.8471 %U http://mental.jmir.org/2018/2/e44/ %U https://doi.org/10.2196/mental.8471 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e38 %T Temporal Associations Between Social Activity and Mood, Fatigue, and Pain in Older Adults With HIV: An Ecological Momentary Assessment Study %A Paolillo,Emily W %A Tang,Bin %A Depp,Colin A %A Rooney,Alexandra S %A Vaida,Florin %A Kaufmann,Christopher N %A Mausbach,Brent T %A Moore,David J %A Moore,Raeanne C %+ Department of Psychiatry, University of California, San Diego, 220 Dickinson Street, Suite B, San Diego, CA, 92103, United States, 1 619 543 5378, r6moore@ucsd.edu %K AIDS %K ecological momentary assessment %K social isolation %K happiness %K quality of life %D 2018 %7 14.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social isolation is associated with an increased risk for mental and physical health problems, especially among older persons living with HIV (PLWH). Thus, there is a need to better understand real-time temporal associations between social activity and mood- and health-related factors in this population to inform possible future interventions. Objective: This study aims to examine real-time relationships between social activity and mood, fatigue, and pain in a sample of older PLWH. Methods: A total of 20 older PLWH, recruited from the University of California, San Diego HIV Neurobehavioral Research Program in 2016, completed smartphone-based ecological momentary assessment (EMA) surveys 5 times per day for 1 week. Participants reported their current social activity (alone vs not alone and number of social interactions) and levels of mood (sadness, happiness, and stress), fatigue, and pain. Mixed-effects regression models were used to analyze concurrent and lagged associations among social activity, mood, fatigue, and pain. Results: Participants (mean age 58.8, SD 4.3 years) reported being alone 63% of the time, on average, (SD 31.5%) during waking hours. Being alone was related to lower concurrent happiness (beta=−.300; 95% CI −.525 to −.079; P=.008). In lagged analyses, social activity predicted higher levels of fatigue later in the day (beta=−1.089; 95% CI −1.780 to −0.396; P=.002), and higher pain levels predicted being alone in the morning with a reduced likelihood of being alone as the day progressed (odds ratio 0.945, 95% CI 0.901-0.992; P=.02). Conclusions: The use of EMA elucidated a high rate of time spent alone among older PLWH. Promoting social activity despite the presence of pain or fatigue may improve happiness and psychological well-being in this population. %M 29759960 %R 10.2196/mental.9802 %U http://mental.jmir.org/2018/2/e38/ %U https://doi.org/10.2196/mental.9802 %U http://www.ncbi.nlm.nih.gov/pubmed/29759960 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e168 %T Predicting Depression From Language-Based Emotion Dynamics: Longitudinal Analysis of Facebook and Twitter Status Updates %A Seabrook,Elizabeth M %A Kern,Margaret L %A Fulcher,Ben D %A Rickard,Nikki S %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Melbourne, 3800, Australia, 61 0413170668, elizabeth.seabrook@monash.edu %K automated text analysis %K depression %K Facebook %K Twitter %K emotions %K variability %K instability %D 2018 %7 08.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Frequent expression of negative emotion words on social media has been linked to depression. However, metrics have relied on average values, not dynamic measures of emotional volatility. Objective: The aim of this study was to report on the associations between depression severity and the variability (time-unstructured) and instability (time-structured) in emotion word expression on Facebook and Twitter across status updates. Methods: Status updates and depression severity ratings of 29 Facebook users and 49 Twitter users were collected through the app MoodPrism. The average proportion of positive and negative emotion words used, within-person variability, and instability were computed. Results: Negative emotion word instability was a significant predictor of greater depression severity on Facebook (rs(29)=.44, P=.02, 95% CI 0.09-0.69), even after controlling for the average proportion of negative emotion words used (partial rs(26)=.51, P=.006) and within-person variability (partial rs(26)=.49, P=.009). A different pattern emerged on Twitter where greater negative emotion word variability indicated lower depression severity (rs(49)=−.34, P=.01, 95% CI −0.58 to 0.09). Differences between Facebook and Twitter users in their emotion word patterns and psychological characteristics were also explored. Conclusions: The findings suggest that negative emotion word instability may be a simple yet sensitive measure of time-structured variability, useful when screening for depression through social media, though its usefulness may depend on the social media platform. %M 29739736 %R 10.2196/jmir.9267 %U http://www.jmir.org/2018/5/e168/ %U https://doi.org/10.2196/jmir.9267 %U http://www.ncbi.nlm.nih.gov/pubmed/29739736 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e33 %T Ethical Issues in Addressing Social Media Posts About Suicidal Intentions During an Online Study Among Youth: Case Study %A Young,Sean D %A Garett,Renee %+ University of California Institute for Prediction Technology, Department of Family Medicine, University of California, Los Angeles, Suite 1800, 10880 Wilshire Blvd, Los Angeles, CA,, United States, 1 310 794 8530, sdyoung@mednet.ucla.edu %K suicide %K social media %K undergraduates %D 2018 %7 03.05.2018 %9 Case Study %J JMIR Ment Health %G English %X Due to the popularity of social media, researchers are increasingly conducting studies that monitor and analyze people’s health-related social media conversations. Because social media users can post about any topic at any time, no known best ethical practices exist as to whether and how to monitor participants’ posts for safety-related issues that might be unrelated to the study, such as expressions of suicidal intentions. This is a case study during a social media-based study on sleep and activity among freshman undergraduate students, where we by chance noticed that a student was using social media to express suicidal intentions. Although we connected the student to student psychological services in order to receive treatment, we encountered a number of barriers that initially prevented this from occurring, such as institutional review board and regulatory practices related to lack of experience with these newer types of studies. We discuss the implications of this experience for future research. %M 29724707 %R 10.2196/mental.8971 %U http://mental.jmir.org/2018/2/e33/ %U https://doi.org/10.2196/mental.8971 %U http://www.ncbi.nlm.nih.gov/pubmed/29724707 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e174 %T Behind the Scenes of Online Therapeutic Feedback in Blended Therapy for Depression: Mixed-Methods Observational Study %A Mol,Mayke %A Dozeman,Els %A Provoost,Simon %A van Schaik,Anneke %A Riper,Heleen %A Smit,Johannes H %+ Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 204448180, m.mol@ggzingeest.nl %K cognitive behavioral therapy %K eHealth %K depressive disorder %D 2018 %7 03.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In Internet-delivered cognitive behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given best and which specific therapist behaviors and content are most beneficial for patients. General instructions for written feedback are available, but the uptake and effectiveness of these instructions in iCBT have not been studied yet. Objective: This study aimed to identify therapist behaviors in written online communication with patients in blended CBT for adult depression in routine secondary mental health care, to identify the extent to which the therapists adhere to feedback instructions, and to explore whether therapist behaviors and adherence to feedback instructions are associated with patient outcome. Methods: Adults receiving blended CBT (10 online sessions in combination with 5 face-to-face sessions) for depression in routine mental health care were recruited in the context of the European implementation project MasterMind. A qualitative content analysis was used to identify therapist behaviors in online written feedback messages, and a checklist for the feedback instruction adherence of the therapists was developed. Correlations were explored between the therapist behaviors, therapist instruction adherence, and patient outcomes (number of completed online sessions and symptom change scores). Results: A total of 45 patients (73%, 33/45 female, mean age 35.9 years) received 219 feedback messages given by 19 therapists (84%, 16/19 female). The most frequently used therapist behaviors were informing, encouraging, and affirming. However, these were not related to patient outcomes. Although infrequently used, confronting was positively correlated with session completion (ρ=.342, P=.02). Therapists adhered to most of the feedback instructions. Only 2 feedback aspects were correlated with session completion: the more therapists adhere to instructions containing structure (limiting to 2 subjects and sending feedback within 3 working days) and readability (short sentences and short paragraphs), the less online sessions were completed (ρ=−.340, P=.02 and ρ=−.361, P=.02, respectively). No associations were found with depression symptom change scores. Conclusions: The therapist behaviors found in this study are comparable to previous research. The findings suggest that online feedback instructions for therapists provide sufficient guidance to communicate in a supportive and positive manner with patients. However, the instructions might be improved by adding more therapeutic techniques besides the focus on style and form. %M 29724708 %R 10.2196/jmir.9890 %U http://www.jmir.org/2018/5/e174/ %U https://doi.org/10.2196/jmir.9890 %U http://www.ncbi.nlm.nih.gov/pubmed/29724708 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e10028 %T A Mental Health Storytelling Intervention Using Transmedia to Engage Latinas: Grounded Theory Analysis of Participants’ Perceptions of the Story’s Main Character %A Heilemann,MarySue V %A Martinez,Adrienne %A Soderlund,Patricia D %+ School of Nursing, University of California, Los Angeles, Factor Building, Room 5252, Box 956919, Los Angeles, CA, 90095 6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K depression %K anxiety %K transmedia storytelling %K Internet %K cell phone %K mental health %K eHealth %K mood disorders %K smartphone %D 2018 %7 02.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Transmedia storytelling was used to attract English-speaking Latina women with elevated symptoms of depression and anxiety to engage in an intervention that included videos and a webpage with links to symptom management resources. However, a main character for the storyline who was considered dynamic, compelling, and relatable by the target group was needed. Objective: We conducted interviews with 28 English-speaking Latinas (target group) with elevated symptoms of depression or anxiety who participated in an Internet-accessible transmedia storytelling intervention. The objective of this study was to examine participants’ perceptions of the lead character of the story. Development of this character was informed by deidentified data from previous studies with members of the target group. Critique of the character from a panel of therapists informed editing, as did input from women of the target group. Methods: All interviews were conducted via telephone, audio-recorded, and transcribed. Data analysis was guided by grounded theory methodology. Results: Participants embraced the main character, Catalina, related to her as a person with an emotional life and a temporal reality, reported that they learned from her and wanted more episodes that featured her and her life. Grounded theory analysis led to the development of one category (She “just felt so real”: relating to Catalina as a real person with a past, present, and future) with 4 properties. Properties included (1) relating emotionally to Catalina’s vulnerability, (2) recognizing shared experiences, (3) needing to support others while simultaneously lacking self-support, and (4) using Catalina as a springboard for imagining alternative futures. Participants found Catalina’s efforts to pursue mental health treatment to be meaningful and led them to compare themselves to her and consider how they might pursue treatment themselves. Conclusions: When creating a story-based mental health intervention to be delivered through an app, regardless of type, careful development of the main character is valuable. Theoretical guidance, previous deidentified data from the target group, critique from key stakeholders and members of the target group, and preliminary testing are likely to enhance the main character’s relatability and appropriateness, which can increase sustained engagement. %M 29720357 %R 10.2196/10028 %U http://www.jmir.org/2018/5/e10028/ %U https://doi.org/10.2196/10028 %U http://www.ncbi.nlm.nih.gov/pubmed/29720357 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e158 %T A Remote Collaborative Care Program for Patients with Depression Living in Rural Areas: Open-Label Trial %A Rojas,Graciela %A Guajardo,Viviana %A Martínez,Pablo %A Castro,Ariel %A Fritsch,Rosemarie %A Moessner,Markus %A Bauer,Stephanie %+ Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Tercer Piso, Av Ecuador 3650, Santiago, 9170197, Chile, 56 227182953, pablo.martinezd@usach.cl %K primary health care %K depression %K telemedicine %K rural health care %K medically underserved area %D 2018 %7 30.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. Objective: The aim was to test the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas. Methods: In a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial, physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n=111) or to usual care (n=139). The remote collaborative care program used Web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the Web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment. Results: Six-month follow-up assessments were completed by 84.4% (221/250) of patients. The remote collaborative care program achieved higher user satisfaction (odds ratio [OR] 1.94, 95% CI 1.25-3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02-3.19) at 6 months compared to usual care. There were no statically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of remote collaborative care program were observed at 3 months for mental health-related quality of life (beta 3.11, 95% CI 0.19-6.02). Conclusions: Higher rates of treatment adherence in the remote collaborative care program suggest that technology-assisted interventions may help rural primary care teams in the management of depressive patients. Future cost-effectiveness studies are needed. Trial Registration: Clinicaltrials.gov NCT02200367; https://clinicaltrials.gov/ct2/show/NCT02200367 (Archived by WebCite at http://www.webcitation.org/6xtZ7OijZ) %M 29712627 %R 10.2196/jmir.8803 %U http://www.jmir.org/2018/4/e158/ %U https://doi.org/10.2196/jmir.8803 %U http://www.ncbi.nlm.nih.gov/pubmed/29712627 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e148 %T A Single-Session, Web-Based Parenting Intervention to Prevent Adolescent Depression and Anxiety Disorders: Randomized Controlled Trial %A Cardamone-Breen,Mairead C %A Jorm,Anthony F %A Lawrence,Katherine A %A Rapee,Ronald M %A Mackinnon,Andrew J %A Yap,Marie Bee Hui %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton, Melbourne, 3800, Australia, 61 399050723, marie.yap@monash.edu %K adolescent %K mental health %K depression, anxiety, parenting %K family %K preventive health services %K Internet %D 2018 %7 26.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety disorders are significant contributors to burden of disease in young people, highlighting the need to focus preventive efforts early in life. Despite substantial evidence for the role of parents in the prevention of adolescent depression and anxiety disorders, there remains a need for translation of this evidence into preventive parenting interventions. To address this gap, we developed a single-session, Web-based, tailored psychoeducation intervention that aims to improve parenting practices known to influence the development of adolescent depression and anxiety disorders. Objective: The aim of this study was to evaluate the short-term effects of the intervention on parenting risk and protective factors and symptoms of depression and anxiety in adolescent participants. Methods: We conducted a single-blind, parallel group, superiority randomized controlled trial comparing the intervention with a 3-month waitlist control. The intervention is fully automated and consists of two components: (1) completion of an online self-assessment of current parenting practices against evidence-based parenting recommendations for the prevention of adolescent depression and anxiety disorders and (2) an individually tailored feedback report highlighting each parent’s strengths and areas for improvement based on responses to the self-assessment. A community sample of 349 parents, together with 327 adolescents (aged 12-15 years), were randomized to either the intervention or waitlist control condition. Parents and adolescents completed online self-reported assessments of parenting and adolescent symptoms of depression and anxiety at baseline, 1-month (parent-report of parenting only), and 3-month follow-up. Results: Compared with controls, intervention group parents showed significantly greater improvement in parenting risk and protective factors from baseline to 1-month and 3-month follow-up (F2,331.22=16.36, P<.001), with a small to medium effect size at 3-month follow-up (d=0.33). There were no significant effects of the intervention on adolescent-report of parenting or symptoms of depression or anxiety in the adolescents (all P>.05). Conclusions: Findings suggest that a single-session, individually tailored, Web-based parenting intervention can improve parenting factors that are known to influence the development of depression and anxiety in adolescents. However, our results do not support the effectiveness of the intervention in improving adolescent depression or anxiety symptoms in the short-term. Long-term studies are required to adequately assess the relationship between improving parenting factors and adolescent depression and anxiety outcomes. Nonetheless, this is a promising avenue for the translation of research into a low-cost, sustainable, universal prevention approach. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12615000247572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000247572 (Archived by WebCite at http://www.webcitation.org/6v1ha19XG) %M 29699964 %R 10.2196/jmir.9499 %U http://www.jmir.org/2018/4/e148/ %U https://doi.org/10.2196/jmir.9499 %U http://www.ncbi.nlm.nih.gov/pubmed/29699964 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e30 %T Worker Preferences for a Mental Health App Within Male-Dominated Industries: Participatory Study %A Peters,Dorian %A Deady,Mark %A Glozier,Nick %A Harvey,Samuel %A Calvo,Rafael A %+ Wellbeing Technology Lab, Faculty of Engineering and IT, University of Sydney, Bldg J03, Electrical Engineering, Sydney, 2006, Australia, 61 0289015604, dorian.peters@sydney.edu.au %K mental health %K mhealth %K mobile apps %K workplace %K men %K participatory design %D 2018 %7 25.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 29695371 %R 10.2196/mental.8999 %U http://mental.jmir.org/2018/2/e30/ %U https://doi.org/10.2196/mental.8999 %U http://www.ncbi.nlm.nih.gov/pubmed/29695371 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 4 %P e95 %T Development of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: User-Centered Design %A Wachtler,Caroline %A Coe,Amy %A Davidson,Sandra %A Fletcher,Susan %A Mendoza,Antonette %A Sterling,Leon %A Gunn,Jane %+ Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton, 3053, Australia, 61 83444530, j.gunn@unimelb.edu.au %K user-centered design %K depression %K ehealth %K primary health care %K decision support techniques %K risk %K mental health %D 2018 %7 23.04.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Around the world, depression is both under- and overtreated. The diamond clinical prediction tool was developed to assist with appropriate treatment allocation by estimating the 3-month prognosis among people with current depressive symptoms. Delivering clinical prediction tools in a way that will enhance their uptake in routine clinical practice remains challenging; however, mobile apps show promise in this respect. To increase the likelihood that an app-delivered clinical prediction tool can be successfully incorporated into clinical practice, it is important to involve end users in the app design process. Objective: The aim of the study was to maximize patient engagement in an app designed to improve treatment allocation for depression. Methods: An iterative, user-centered design process was employed. Qualitative data were collected via 2 focus groups with a community sample (n=17) and 7 semistructured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoypes of the app. Results: Iterative development resulted in 3 prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the clinical prediction tool, but there was a need for a personalized treatment recommendation made in conjunction with a consultation with a health professional. Conclusions: User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool that allows users to feel hope, engage in self-reflection, and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial. %M 29685864 %R 10.2196/mhealth.9502 %U http://mhealth.jmir.org/2018/4/e95/ %U https://doi.org/10.2196/mhealth.9502 %U http://www.ncbi.nlm.nih.gov/pubmed/29685864 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e147 %T Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial %A Wu,Shinyi %A Ell,Kathleen %A Jin,Haomiao %A Vidyanti,Irene %A Chou,Chih-Ping %A Lee,Pey-Jiuan %A Gross-Schulman,Sandra %A Sklaroff,Laura Myerchin %A Belson,David %A Nezu,Arthur M %A Hay,Joel %A Wang,Chien-Ju %A Scheib,Geoffrey %A Di Capua,Paul %A Hawkins,Caitlin %A Liu,Pai %A Ramirez,Magaly %A Wu,Brian W %A Richman,Mark %A Myers,Caitlin %A Agustines,Davin %A Dasher,Robert %A Kopelowicz,Alex %A Allevato,Joseph %A Roybal,Mike %A Ipp,Eli %A Haider,Uzma %A Graham,Sharon %A Mahabadi,Vahid %A Guterman,Jeffrey %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 2138216442, shinyiwu@usc.edu %K primary care %K disease management %K depression %K diabetes mellitus %K health information technology %K telemedicine %K comparative effectiveness research %K propensity score %K population health %K patient reported outcome measures %D 2018 %7 23.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. Objective: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. Methods: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). Conclusions: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality. %M 29685872 %R 10.2196/jmir.7692 %U http://www.jmir.org/2018/4/e147/ %U https://doi.org/10.2196/jmir.7692 %U http://www.ncbi.nlm.nih.gov/pubmed/29685872 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e129 %T Self-Harm, Suicidal Behaviours, and Cyberbullying in Children and Young People: Systematic Review %A John,Ann %A Glendenning,Alexander Charles %A Marchant,Amanda %A Montgomery,Paul %A Stewart,Anne %A Wood,Sophie %A Lloyd,Keith %A Hawton,Keith %+ Population Psychiatry, Suicide and Informatics, Medical School, Swansea University, Institute of Life Science 2, Swansea, SA2 8PP, United Kingdom, 44 01792602568 ext 2568, A.John@swansea.ac.uk %K cyberbullying %K bullying %K self-injurious behavior %K suicide %K suicide, attempted %K suicidal ideation %D 2018 %7 19.04.2018 %9 Review %J J Med Internet Res %G English %X Background: Given the concerns about bullying via electronic communication in children and young people and its possible contribution to self-harm, we have reviewed the evidence for associations between cyberbullying involvement and self-harm or suicidal behaviors (such as suicidal ideation, suicide plans, and suicide attempts) in children and young people. Objective: The aim of this study was to systematically review the current evidence examining the association between cyberbullying involvement as victim or perpetrator and self-harm and suicidal behaviors in children and young people (younger than 25 years), and where possible, to meta-analyze data on the associations. Methods: An electronic literature search was conducted for all studies published between January 1, 1996, and February 3, 2017, across sources, including MEDLINE, Cochrane, and PsycINFO. Articles were included if the study examined any association between cyberbullying involvement and self-harm or suicidal behaviors and reported empirical data in a sample aged under 25 years. Quality of included papers was assessed and data were extracted. Meta-analyses of data were conducted. Results: A total of 33 eligible articles from 26 independent studies were included, covering a population of 156,384 children and young people. A total of 25 articles (20 independent studies, n=115,056) identified associations (negative influences) between cybervictimization and self-harm or suicidal behaviors or between perpetrating cyberbullying and suicidal behaviors. Three additional studies, in which the cyberbullying, self-harm, or suicidal behaviors measures had been combined with other measures (such as traditional bullying and mental health problems), also showed negative influences (n=44,526). A total of 5 studies showed no significant associations (n=5646). Meta-analyses, producing odds ratios (ORs) as a summary measure of effect size (eg, ratio of the odds of cyber victims who have experienced SH vs nonvictims who have experienced SH), showed that, compared with nonvictims, those who have experienced cybervictimization were OR 2.35 (95% CI 1.65-3.34) times as likely to self-harm, OR 2.10 (95% CI 1.73-2.55) times as likely to exhibit suicidal behaviors, OR 2.57 (95% CI 1.69-3.90) times more likely to attempt suicide, and OR 2.15 (95% CI 1.70-2.71) times more likely to have suicidal thoughts. Cyberbullying perpetrators were OR 1.21 (95% CI 1.02-1.44) times more likely to exhibit suicidal behaviors and OR 1.23 (95% CI 1.10-1.37) times more likely to experience suicidal ideation than nonperpetrators. Conclusions: Victims of cyberbullying are at a greater risk than nonvictims of both self-harm and suicidal behaviors. To a lesser extent, perpetrators of cyberbullying are at risk of suicidal behaviors and suicidal ideation when compared with nonperpetrators. Policy makers and schools should prioritize the inclusion of cyberbullying involvement in programs to prevent traditional bullying. Type of cyberbullying involvement, frequency, and gender should be assessed in future studies. %M 29674305 %R 10.2196/jmir.9044 %U http://www.jmir.org/2018/4/e129/ %U https://doi.org/10.2196/jmir.9044 %U http://www.ncbi.nlm.nih.gov/pubmed/29674305 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e22 %T “Wish You Were Here”: Examining Characteristics, Outcomes, and Statistical Solutions for Missing Cases in Web-Based Psychotherapeutic Trials %A Karin,Eyal %A Dear,Blake F %A Heller,Gillian Z %A Crane,Monique F %A Titov,Nickolai %+ eCentreClinic, Department of Psychology, Macquarie University, 4 First Walk, Sydney, 2109, Australia, 61 298508657, eyal.karin@mq.edu.au %K psychotherapy %K treatment adherence and compliance %K missing data %K treatment efficacy %K statistical bias %D 2018 %7 19.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 29674311 %R 10.2196/mental.8363 %U http://mental.jmir.org/2018/2/e22/ %U https://doi.org/10.2196/mental.8363 %U http://www.ncbi.nlm.nih.gov/pubmed/29674311 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 4 %P e95 %T Recruitment of Participants and Delivery of Online Mental Health Resources for Depressed Individuals Using Tumblr: Pilot Randomized Control Trial %A Kelleher,Erin %A Moreno,Megan %A Wilt,Megan Pumper %+ Seattle Children's Research Institute, Center for Child Health, Behavior and Development, 2001 8th Ave, Seattle, WA, 98121, United States, 1 8479329259, erin.kelleher6@gmail.com %K adolescents %K depression %K intervention %K social media %K tumblr %D 2018 %7 12.04.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Adolescents and young adults frequently post depression symptom references on social media; previous studies show positive associations between depression posts and self-reported depression symptoms. Depression is common among young people and this population often experiences many barriers to mental health care. Thus, social media may be a new resource to identify, recruit, and intervene with young people at risk for depression. Objective: The purpose of this pilot study was to test a social media intervention on Tumblr. We used social media to identify and recruit participants and to deliver the intervention of online depression resources. Methods: This randomized pilot intervention identified Tumblr users age 15-23 who posted about depression using the search term “#depress”. Eligible participants were recruited via Tumblr messages; consented participants completed depression surveys and were then randomized to an intervention of online mental health resources delivered via a Tumblr message, while control participants did not receive resources. Postintervention online surveys assessed resource access and usefulness and control groups were asked whether they would have liked to receive resources. Analyses included t tests. Results: A total of 25 participants met eligibility criteria. The mean age of the participants was 17.5 (SD 1.9) and 65% were female with average score on the Patient Health Questionnaire-9 of 17.5 (SD 5.9). Among the 11 intervention participants, 36% (4/11) reported accessing intervention resources and 64% (7/11) felt the intervention was acceptable. Among the 14 control participants, only 29% (4/14) of reported that receiving resources online would be acceptable (P=.02). Participants suggested anonymity and ease of use as important characteristics in an online depression resource. Conclusions: The intervention was appropriately targeted to young people at risk for depression, and recruitment via Tumblr was feasible. Most participants in the intervention group felt the social media approach was acceptable, and about a third utilized the online resources. Participants who had not experienced the intervention were less likely to find it acceptable. Future studies should explore this approach in larger samples. Social media may be an appropriate platform for online depression interventions for young people. %M 29650507 %R 10.2196/resprot.9421 %U http://www.researchprotocols.org/2018/4/e95/ %U https://doi.org/10.2196/resprot.9421 %U http://www.ncbi.nlm.nih.gov/pubmed/29650507 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e26 %T Impact of Mental Health Screening on Promoting Immediate Online Help-Seeking: Randomized Trial Comparing Normative Versus Humor-Driven Feedback %A Choi,Isabella %A Milne,David N %A Deady,Mark %A Calvo,Rafael A %A Harvey,Samuel B %A Glozier,Nick %+ Brain and Mind Centre, Central Clinical School, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, 2050, Australia, 61 029515 ext 1593, isabella.choi@sydney.edu.au %K online help-seeking %K screening %K feedback %K randomized trial %K mental health %K resilience %K depression %D 2018 %7 05.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370187 (Archived by WebCite at http://www.webcitation.org/6y8m8sVxr) %M 29622528 %R 10.2196/mental.9480 %U http://mental.jmir.org/2018/2/e26/ %U https://doi.org/10.2196/mental.9480 %U http://www.ncbi.nlm.nih.gov/pubmed/29622528 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e6 %T Gamified Cognitive Control Training for Remitted Depressed Individuals: User Requirements Analysis %A Vervaeke,Jasmien %A Van Looy,Jan %A Hoorelbeke,Kristof %A Baeken,Chris %A Koster,Ernst HW %+ Psychopathology and Affective Neuroscience Lab, Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 92649446, jasmien.vervaeke@ugent.be %K depression %K cognitive dysfunction %K cognitive remediation %K relapse prevention %K qualitative research %K secondary prevention %D 2018 %7 05.04.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high incidence and relapse rates of major depressive disorder demand novel treatment options. Standard treatments (psychotherapy, medication) usually do not target cognitive control impairments, although these seem to play a crucial role in achieving stable remission. The urgent need for treatment combined with poor availability of adequate psychological interventions has instigated a shift toward internet interventions. Numerous computerized programs have been developed that can be presented online and offline. However, their uptake and adherence are oftentimes low. Objective: The aim of this study was to perform a user requirements analysis for an internet-based training targeting cognitive control. This training focuses on ameliorating cognitive control impairments, as these are still present during remission and can be a risk factor for relapse. To facilitate uptake of and adherence to this intervention, a qualitative user requirements analysis was conducted to map mandatory and desirable requirements. Methods: We conducted a user requirements analysis through a focus group with 5 remitted depressed individuals and individual interviews with 6 mental health care professionals. All qualitative data were transcribed and examined using a thematic analytic approach. Results: Results showed mandatory requirements for the remitted sample in terms of training configuration, technological and personal factors, and desirable requirements regarding knowledge and enjoyment. Furthermore, knowledge and therapeutic benefits were key requirements for therapists. Conclusions: The identified requirements provide useful information to be integrated in interventions targeting cognitive control in depression. %M 29622525 %R 10.2196/games.8609 %U http://games.jmir.org/2018/2/e6/ %U https://doi.org/10.2196/games.8609 %U http://www.ncbi.nlm.nih.gov/pubmed/29622525 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 5 %N 1 %P e12 %T General Practitioners’ Attitudes Toward a Web-Based Mental Health Service for Adolescents: Implications for Service Design and Delivery %A Subotic-Kerry,Mirjana %A King,Catherine %A O'Moore,Kathleen %A Achilles,Melinda %A O'Dea,Bridianne %+ Black Dog Institute, Hospital Road, Prince of Wales Hospital, Randwick, Sydney, 2031, Australia, 61 2 9382 8509, m.subotic-kerry@blackdog.org.au %K anxiety %K depression %K adolescent %K general practitioners %K internet %D 2018 %7 23.03.2018 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Anxiety disorders and depression are prevalent among youth. General practitioners (GPs) are often the first point of professional contact for treating health problems in young people. A Web-based mental health service delivered in partnership with schools may facilitate increased access to psychological care among adolescents. However, for such a model to be implemented successfully, GPs’ views need to be measured. Objective: This study aimed to examine the needs and attitudes of GPs toward a Web-based mental health service for adolescents, and to identify the factors that may affect the provision of this type of service and likelihood of integration. Findings will inform the content and overall service design. Methods: GPs were interviewed individually about the proposed Web-based service. Qualitative analysis of transcripts was performed using thematic coding. A short follow-up questionnaire was delivered to assess background characteristics, level of acceptability, and likelihood of integration of the Web-based mental health service. Results: A total of 13 GPs participated in the interview and 11 completed a follow-up online questionnaire. Findings suggest strong support for the proposed Web-based mental health service. A wide range of factors were found to influence the likelihood of GPs integrating a Web-based service into their clinical practice. Coordinated collaboration with parents, students, school counselors, and other mental health care professionals were considered important by nearly all GPs. Confidence in Web-based care, noncompliance of adolescents and GPs, accessibility, privacy, and confidentiality were identified as potential barriers to adopting the proposed Web-based service. Conclusions: GPs were open to a proposed Web-based service for the monitoring and management of anxiety and depression in adolescents, provided that a collaborative approach to care is used, the feedback regarding the client is clear, and privacy and security provisions are assured. %M 29572203 %R 10.2196/humanfactors.8913 %U http://humanfactors.jmir.org/2018/1/e12/ %U https://doi.org/10.2196/humanfactors.8913 %U http://www.ncbi.nlm.nih.gov/pubmed/29572203 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e20 %T Improving Implementation of eMental Health for Mood Disorders in Routine Practice: Systematic Review of Barriers and Facilitating Factors %A Vis,Christiaan %A Mol,Mayke %A Kleiboer,Annet %A Bührmann,Leah %A Finch,Tracy %A Smit,Jan %A Riper,Heleen %+ Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 646098094, p.d.c.vis@vu.nl %K eMental health %K implementation %K routine practice %K determinants of practices %K RE-AIM %K barriers and facilitators %K mood disorders %K review %D 2018 %7 16.03.2018 %9 Review %J JMIR Ment Health %G English %X Background: Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care. Objective: This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice. Methods: A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice. Results: A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH. Conclusions: Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients’ mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided. %M 29549072 %R 10.2196/mental.9769 %U http://mental.jmir.org/2018/1/e20/ %U https://doi.org/10.2196/mental.9769 %U http://www.ncbi.nlm.nih.gov/pubmed/29549072 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e87 %T Treatment Activity, User Satisfaction, and Experienced Usability of Internet-Based Cognitive Behavioral Therapy for Adults With Depression and Anxiety After a Myocardial Infarction: Mixed-Methods Study %A Wallin,Emma %A Norlund,Fredrika %A Olsson,Erik Martin Gustaf %A Burell,Gunilla %A Held,Claes %A Carlsson,Tommy %+ Department of Psychology, Uppsala University, Box 1225, Uppsala, 75142, Sweden, 46 0706606118, emma.wallin@psyk.uu.se %K mental health %K internet %K cognitive behavioral therapy %K computer-assisted therapy %K myocardial infarction %K attrition %K adherence %D 2018 %7 16.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Knowledge about user experiences may lead to insights about how to improve treatment activity in Internet-based cognitive behavioral therapy (iCBT) to reduce symptoms of depression and anxiety among people with a somatic disease. There is a need for studies conducted alongside randomized trials, to explore treatment activity and user experiences related to such interventions, especially among people with older age who are recruited in routine care. Objective: The aim of the study was to explore treatment activity, user satisfaction, and usability experiences among patients allocated to treatment in the U-CARE Heart study, a randomized clinical trial of an iCBT intervention for treatment of depression and anxiety following a recent myocardial infarction. Methods: This was a mixed methods study where quantitative and qualitative approaches were used. Patients were recruited consecutively from 25 cardiac clinics in Sweden. The study included 117 patients allocated to 14 weeks of an iCBT intervention in the U-CARE Heart study. Quantitative data about treatment activity and therapist communication were collected through logged user patterns, which were analyzed with descriptive statistics. Qualitative data with regard to positive and negative experiences, and suggestions for improvements concerning the intervention, were collected through semistructured interviews with 21 patients in the treatment arm after follow-up. The interviews were analyzed with qualitative manifest content analysis. Results: Treatment activity was low with regard to number of completed modules (mean 0.76, SD 0.93, range 0-5) and completed assignments (mean 3.09, SD 4.05, range 0-29). Most of the participants initiated the introduction module (113/117, 96.6%), and about half (63/117, 53.9%) of all participants completed the introductory module, but only 18 (15.4%, 18/117) continued to work with any of the remaining 10 modules, and each of the remaining modules was completed by 7 or less of the participants. On average, patients sent less than 2 internal messages to their therapist during the intervention (mean 1.42, SD 2.56, range 0-16). Interviews revealed different preferences with regard to the internet-based portal, the content of the treatment program, and the therapist communication. Aspects related to the personal situation and required skills included unpleasant emotions evoked by the intervention, lack of time, and technical difficulties. Conclusions: Patients with a recent myocardial infarction and symptoms of depression and anxiety showed low treatment activity in this guided iCBT intervention with regard to completed modules, completed assignments, and internal messages sent to their therapist. The findings call attention to the need for researchers to carefully consider the preferences, personal situation, and technical skills of the end users during the development of these interventions. The study indicates several challenges that need to be addressed to improve treatment activity, user satisfaction, and usability in internet-based interventions in this population. %M 29549067 %R 10.2196/jmir.9690 %U http://www.jmir.org/2018/3/e87/ %U https://doi.org/10.2196/jmir.9690 %U http://www.ncbi.nlm.nih.gov/pubmed/29549067 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e64 %T Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal Study %A Silva Almodovar,Armando %A Surve,Swatee %A Axon,David Rhys %A Cooper,David %A Nahata,Milap C %+ Institute of Therapeutic Innovations and Outcomes, The College of Pharmacy, The Ohio State University, 500 West 12 Ave, Columbus, OH, 43210, United States, 1 6142922472, nahata.1@osu.edu %K mental health %K retrospective studies %K longitudinal studies %K mobile apps %K anxiety %K depression %D 2018 %7 16.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety. Methods: This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001). Conclusions: This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills. %M 29549066 %R 10.2196/mhealth.9612 %U http://mhealth.jmir.org/2018/3/e64/ %U https://doi.org/10.2196/mhealth.9612 %U http://www.ncbi.nlm.nih.gov/pubmed/29549066 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 3 %P e81 %T Evaluation of Technology-Based Peer Support Intervention Program for Preventing Postnatal Depression: Protocol for a Randomized Controlled Trial %A Shorey,Shefaly %A Chee,Cornelia %A Chong,Yap-Seng %A Ng,Esperanza Debby %A Lau,Ying %A Dennis,Cindy-Lee %+ National University of Singapore, Level 2, Clinical Research Centre, 10 Medical Drive, Singapore, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K anxiety %K loneliness %K peer group %K postpartum depression %K social support %K technology %D 2018 %7 14.03.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Multiple international agencies, including the World Health Organization and the International Monetary Fund, have emphasized the importance of maternal mental health for optimal child health and development. Adequate social support is vital for the most vulnerable to postpartum mood disorders. Hence, an urgent need for sustainable social support programs to aid mothers ease into their new parenting role exists. Objective: This study protocol aims to examine the effectiveness of a technology-based peer support intervention program among mothers at risk for postnatal depression in the early postpartum period. Methods: A randomized controlled 2-group pretest and repeated posttest experimental design will be used. The study will recruit 118 mothers from the postnatal wards of a tertiary public hospital in Singapore. Eligible mothers will be randomly allocated to receive either the peer support intervention program or routine perinatal care from the hospital. Peer volunteers will be mothers who have experienced self-reported depression and will be receiving face-to-face training to support new mothers at risk of depression. Outcome measures include postnatal depression, anxiety, loneliness, and social support. Data will be collected at immediate postnatal period (day of discharge from the hospital), at fourth week and twelfth week post childbirth. Results: The recruitment and training of peer support volunteers (N=20) ended in June 2017, whereas recruitment of study participants commenced in July 2017 and is still ongoing. The current recruitment for new mothers stands at 73, with 36 in the control group and 37 in the intervention group. Data collection is projected to be completed by May 2018. Conclusions: This study will identify a potentially effective and clinically useful method to prevent postnatal depression in new mothers, which is the top cause of maternal morbidity. Receiving social support from others who share similar experiences may enhance the positive parenting experiences of mothers, which in turn can improve the psychosocial well-being of the mothers, tighten mother-child bond, and enhance overall family dynamics for mothers and infants. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 (Archived by WebCite at http://www.webcitation.org/6xtBNvBTX) %M 29540338 %R 10.2196/resprot.9416 %U http://www.researchprotocols.org/2018/3/e81/ %U https://doi.org/10.2196/resprot.9416 %U http://www.ncbi.nlm.nih.gov/pubmed/29540338 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e88 %T Internet-Based Cognitive Behavioral Therapy for Symptoms of Depression and Anxiety Among Patients With a Recent Myocardial Infarction: The U-CARE Heart Randomized Controlled Trial %A Norlund,Fredrika %A Wallin,Emma %A Olsson,Erik Martin Gustaf %A Wallert,John %A Burell,Gunilla %A von Essen,Louise %A Held,Claes %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, Uppsala, 75185, Sweden, 46 737441304, fredrika.norlund@kbh.uu.se %K eHealth %K treatment adherence and compliance %K patient acceptance of health care %K patient selection %K cardiac rehabilitation %D 2018 %7 08.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitive behavioral therapy (iCBT) has shown good results in other patient groups. Objective: The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms of depression and anxiety among patients with a recent MI. Methods: In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239 women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided, 14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients. The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessed over the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For the main analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS. Results: There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no difference between the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of 46.2% (54/117) of the iCBT group did not complete the introductory module. Conclusions: iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety compared with TAU. Low treatment adherence might have influenced the result. Trial Registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22) %M 29519777 %R 10.2196/jmir.9710 %U http://www.jmir.org/2018/3/e88/ %U https://doi.org/10.2196/jmir.9710 %U http://www.ncbi.nlm.nih.gov/pubmed/29519777 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e62 %T Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans %A Teo,Alan R %A Marsh,Heather E %A Liebow,Samuel B L %A Chen,Jason I %A Forsberg,Christopher W %A Nicolaidis,Christina %A Saha,Somnath %A Dobscha,Steven K %+ Health Services Research and Development Center to Improve Veteran Involvement in Care, Department of Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR,, United States, 1 503 220 8262 ext 52461, teoa@ohsu.edu %K social media %K social networking sites %K internet %K Facebook %K service use %K utilization %K treatment-seeking %D 2018 %7 26.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems. Objective: This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help. Methods: Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. Results: The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (eg, psychologists), informal (eg, friends), or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults. Conclusions: In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States. %M 29483064 %R 10.2196/jmir.9007 %U http://www.jmir.org/2018/2/e62/ %U https://doi.org/10.2196/jmir.9007 %U http://www.ncbi.nlm.nih.gov/pubmed/29483064 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e17 %T Supporting Our Valued Adolescents (SOVA), a Social Media Website for Adolescents with Depression and/or Anxiety: Technological Feasibility, Usability, and Acceptability Study %A Radovic,Ana %A Gmelin,Theresa %A Hua,Jing %A Long,Cassandra %A Stein,Bradley D %A Miller,Elizabeth %+ Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 3420 Fifth Avenue, Pittsburgh, PA, 15213, United States, 1 412 692 7227, ana.radovic@chp.edu %K adolescent %K adolescent health services %K technology %K depression %K anxiety %D 2018 %7 26.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Supporting Our Valued Adolescents (SOVA), a social media website for adolescents, was designed to increase mental health literacy and address negative health beliefs toward depression and/or anxiety diagnosis and treatment. This stakeholder-informed site underwent iterative user testing to evolve into its current version with daily blog posts, round-the-clock site moderation, and Web-based peer interaction to create an online support community. Objective: The aim of this study was to evaluate the technological feasibility (at least 100 users on the site, logging in 12 to 18 times in the first 6 weeks) and acceptability of the SOVA site determined by the System Usability Scale (SUS). Methods: Adolescents and young adults (aged 14-26 years) with a self-reported history of depressive and/or anxiety symptoms were recruited to access the research website (sova.pitt.edu). Participants were screened out if they reported active suicidality or a prior suicide attempt. Baseline survey measures included demographics, symptomatology using the Patient Health Questionnaire-9 modified for adolescents (PHQ-9A) and Screen for Child Anxiety Related Disorders (SCARED-C), and mental health treatment history. The 6-week follow-up measures taken in addition to the symptomatology, included feasibility (total number of log-ins), usability, and acceptability of SOVA using SUS. Results: Most of the 96 participants identified as female (75% [72/96]) and white (67% [64/96]). Most participants (73% [70/96]) reported having taken prior professional psychological help. The average PHQ-9A score was 11.8 (SD 5.5), and for SCARED-C, 85% (80/94) of the participants reported a score consistent with being susceptible to a diagnosed anxiety disorder. There were 46% (41/90) of eligible users who ever logged in. Out of the total users who ever logged in, the mean of total log-ins over the entire study was 4.1 (SD 6.9). Median number of users rated the user-friendliness of the site as “good.” The average SUS score was 71.2% (SD 18.7), or a “C-grade,” which correlated to an acceptable range. The participants reported to have liked the “easy-to-understand format” and “positive, helpful atmosphere,” but they also reported a desire for greater social interaction. Iterative recruitment resulted in incremental improvements to the site. Conclusions: The SOVA site met feasibility goals of recruiting almost 100 users and establishing acceptable usability. Subsequent interventions are planned to increase site engagement and to evaluate efficacy in increasing uptake of primary care–recommended depression and/or anxiety treatment. %M 29483067 %R 10.2196/mental.9441 %U http://mental.jmir.org/2018/1/e17/ %U https://doi.org/10.2196/mental.9441 %U http://www.ncbi.nlm.nih.gov/pubmed/29483067 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e14 %T Influencing the Conversation About Masculinity and Suicide: Evaluation of the Man Up Multimedia Campaign Using Twitter Data %A Schlichthorst,Marisa %A King,Kylie %A Turnure,Jackie %A Sukunesan,Suku %A Phelps,Andrea %A Pirkis,Jane %+ Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Parkville, 3010, Australia, 61 390353508, marisa.schlichthorst@unimelb.edu.au %K mental health %K suicide %K masculinity %K men’s health %D 2018 %7 15.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 29449203 %R 10.2196/mental.9120 %U http://mental.jmir.org/2018/1/e14/ %U https://doi.org/10.2196/mental.9120 %U http://www.ncbi.nlm.nih.gov/pubmed/29449203 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e13 %T A Web-Based Psychoeducational Intervention for Adolescent Depression: Design and Development of MoodHwb %A Bevan Jones,Rhys %A Thapar,Anita %A Rice,Frances %A Beeching,Harriet %A Cichosz,Rachel %A Mars,Becky %A Smith,Daniel J %A Merry,Sally %A Stallard,Paul %A Jones,Ian %A Thapar,Ajay K %A Simpson,Sharon A %+ Division of Psychological Medicine and Clinical Neurosciences, Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Rd, Cardiff, Wales, CF24 4HQ, United Kingdom, 44 02920688451, bevanjonesr1@cardiff.ac.uk %K adolescent %K depression %K internet %K education %K preventive psychiatry %K early medical intervention %D 2018 %7 15.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 29449202 %R 10.2196/mental.8894 %U http://mental.jmir.org/2018/1/e13/ %U https://doi.org/10.2196/mental.8894 %U http://www.ncbi.nlm.nih.gov/pubmed/29449202 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e15 %T Effectiveness of a Web-Based Self-Help Program for Suicidal Thinking in an Australian Community Sample: Randomized Controlled Trial %A van Spijker,Bregje AJ %A Werner-Seidler,Aliza %A Batterham,Philip J %A Mackinnon,Andrew %A Calear,Alison L %A Gosling,John A %A Reynolds,Julia %A Kerkhof,Ad JFM %A Solomon,Daniela %A Shand,Fiona %A Christensen,Helen %+ Black Dog Institute, Department of Medicine, University of New South Wales, Hospital Road, Randwick,, Australia, 61 293 823 717, h.christensen@blackdog.org.au %K psychosocial interventions %K randomized controlled trial %K suicide %D 2018 %7 14.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Treatment for suicidality can be delivered online, but evidence for its effectiveness is needed. Objective: The goal of our study was to examine the effectiveness of an online self-help intervention for suicidal thinking compared to an attention-matched control program. Methods: A 2-arm randomized controlled trial was conducted with assessment at postintervention, 6, and, 12 months. Through media and community advertizing, 418 suicidal adults were recruited to an online portal and were delivered the intervention program (Living with Deadly Thoughts) or a control program (Living Well). The primary outcome was severity of suicidal thinking, assessed using the Columbia Suicide Severity Rating Scale. Results: Intention-to-treat analyses showed significant reductions in the severity of suicidal thinking at postintervention, 6, and 12 months. However, no overall group differences were found. Conclusions: Living with Deadly Thoughts was of no greater effectiveness than the control group. Further investigation into the conditions under which this program may be beneficial is now needed. Limitations of this trial include it being underpowered given the effect size ultimately observed, a high attrition rate, and the inability of determining suicide deaths or of verifying self-reported suicide attempts. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595 %M 29444769 %R 10.2196/jmir.8595 %U https://www.jmir.org/2018/2/e15/ %U https://doi.org/10.2196/jmir.8595 %U http://www.ncbi.nlm.nih.gov/pubmed/29444769 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e38 %T Digital Peer-Support Platform (7Cups) as an Adjunct Treatment for Women With Postpartum Depression: Feasibility, Acceptability, and Preliminary Efficacy Study %A Baumel,Amit %A Tinkelman,Amanda %A Mathur,Nandita %A Kane,John M %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa,, Israel, 972 482 4011, abaumel@univ.haifa.ac.il %K mhealth %K postpartum depression %K perinatal mood disorder %K peer support %K online %K self-help %D 2018 %7 13.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Peer support is considered to be an important framework of support for mothers experiencing postpartum depression (PPD); however, some barriers exist that may limit its use including peer availability and mothers’ lack of time due to child care. Objective: This non-randomized study was designed to examine the feasibility, acceptance, and preliminary clinical outcomes of using 7 Cups of Tea (7Cups), a digital platform that delivers self-help tools and 24/7 emotional support delivered by trained volunteers, as an adjunct treatment for mothers diagnosed with PPD. Methods: Mothers with PPD were referred during intake to the study coach who provided guidance about 7Cups. 7Cups features included self-help tools and chats with trained volunteers who had experienced a perinatal mood disorder in their past. Acceptability was measured by examining self-reports and user engagement with the program. The primary outcome was the Edinburgh Postnatal Depression Scale (EPDS) change score between pre- and postintervention at 2 months, as collected in usual care by clinicians blinded to the study questions. Using a propensity score matching to control for potential confounders, we compared women receiving 7Cups to women receiving treatment as usual (TAU). Results: Participants (n=19) proactively logged into 7Cups for a median of 12 times and 175 minutes. Program use was mostly through the mobile app (median of mobile use 94%) and between 18:00 and 08:00 when clinicians are unavailable (68% of total program use time). Participants chatted with volunteers for a total of 3064 minutes and have indicated in their responses 0 instances in which they felt unsafe. Intent-to-treat analysis revealed that 7Cups recipients experienced significant decreases in EPDS scores (P<.001, Cohen d=1.17). No significant difference in EPDS decrease over time was found between 7Cups and TAU, yet the effect size was medium favoring 7Cups (P=.05, Cohen d=0.58). Conclusions: This study supports using a computerized method to train lay people, without any in-person guidance or screening, and engage them with patients diagnosed with mental illness as part of usual care. The medium effect size (d=0.58) favoring the 7Cups group relative to TAU suggests that 7Cups might enhance treatment outcomes. A fully powered trial has to be conducted to examine this effect. %M 29439944 %R 10.2196/mhealth.9482 %U http://mhealth.jmir.org/2018/2/e38/ %U https://doi.org/10.2196/mhealth.9482 %U http://www.ncbi.nlm.nih.gov/pubmed/29439944 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 2 %P e37 %T Text-Based Program Addressing the Mental Health of Soon-to-be and New Fathers (SMS4dads): Protocol for a Randomized Controlled Trial %A Fletcher,Richard %A May,Chris %A Attia,John %A Garfield,Craig Franklin %A Skinner,Geoff %+ Family Action Centre, Faculty of Health and Medicine, University of Newcastle, Academic Office Block, University Drive, Callaghan, 2308, Australia, 61 0429152405, richard.fletcher@newcastle.edu.au %K perinatal %K fathers %K online intervention %K randomized controlled trial %K mental health %D 2018 %7 06.02.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Recent estimates indicating that approximately 10% of fathers experience Paternal Perinatal Depression (PPND) and the increasing evidence of the impact of PPND on child development suggest that identifying and assisting distressed fathers is justified on public health grounds. However, addressing new fathers’ mental health needs requires overcoming men’s infrequent contact with perinatal health services and their reluctance to seek help. Text-based interventions delivering information and support have the potential to reach such groups in order to reduce the impact of paternal perinatal distress and to improve the wellbeing of their children. While programs utilising mobile phone technology have been developed for mothers, fathers have not been targeted. Since text messages can be delivered to individual mobile phones to be accessed at a time that is convenient, it may provide a novel channel for engaging with “hard-to-reach” fathers in a critical period of their parenting. Objective: The study will test the efficacy of SMS4dads, a text messaging program designed specifically for fathers including embedded links to online information and regular invitations (Mood Tracker) to monitor their mood, in order to reduce self-reported depression, anxiety and stress over the perinatal period. Methods: A total of 800 fathers-to-be or new fathers from within Australia will be recruited via the SMS4dads website and randomized to the intervention or control arm. The intervention arm will receive 14 texts per month addressing fathers’ physical and mental health, their relationship with their child, and coparenting with their partner. The control, SMS4health, delivers generic health promotion messages twice per month. Messages are timed according to the babies’ expected or actual date of birth and fathers can enroll from 16 weeks into the pregnancy until their infant is 12 weeks of age. Participants complete questionnaires assessing depression, anxiety, stress, and alcohol at baseline and 24 weeks postenrolment. Measures of coparenting and parenting confidence are also completed at baseline and 24 weeks for postbirth enrolments. Results: Participant were recruited between October 2016 and September 2017. Follow-up data collection has commenced and will be completed in March 2018 with results expected in June 2018. Conclusions: This study’s findings will assess the efficacy of a novel text-based program specifically targeting fathers in the perinatal period to improve their depression, anxiety and distress symptoms, coparenting quality, and parenting self-confidence. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000261415; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370085 (Archived by WebCite at http://www.webcitation.org/6wav55wII). %M 29410387 %R 10.2196/resprot.8368 %U http://www.researchprotocols.org/2018/2/e37/ %U https://doi.org/10.2196/resprot.8368 %U http://www.ncbi.nlm.nih.gov/pubmed/29410387 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e35 %T The Effectiveness and Cost-Effectiveness of Web-Based and Home-Based Postnatal Psychoeducational Interventions for First-Time Mothers: Randomized Controlled Trial Protocol %A He,Honggu %A Zhu,Lixia %A Chan,Sally Wai Chi %A Chong,Yap-Seng %A Jiao,Nana %A Chan,Yiong Huak %A Luo,Nan %A Shorey,Shefaly %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2 Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294 ext 1294, nurssh@nus.edu.sg %K mothers %K education %K postpartum period %K Internet %D 2018 %7 31.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: In addition to recuperating from the physical and emotional demands of childbirth, first-time mothers are met with demands of adapting to their social roles while picking up new skills to take care of their newborn. Mothers may not feel adequately prepared for parenthood if they are situated in an unsupported environment. Postnatal psychoeducational interventions have been shown to be useful and can offer a cost-effective solution for improving maternal outcomes. Objective: The objective of this study was to examine the effectiveness and cost-effectiveness of Web-based and home-based postnatal psychoeducational programs for first-time mothers on maternal outcomes. Methods: A randomized controlled three-group pre- and posttests experimental design is proposed. This study plans to recruit 204 first-time mothers on their day of discharge from a public tertiary hospital in Singapore. Eligible first-time mothers will be randomly allocated to either a Web-based psychoeducation group, a home-based psychoeducation group, or a control group receiving standard care. The outcomes include maternal parental self-efficacy, social support, psychological well-being (anxiety and postnatal depression), and cost evaluation. Data will be collected at baseline, 1 month, 3 months, and 6 months post-delivery. Results: The recruitment (n=204) commenced in October 2016 and was completed in February 2017, with 68 mothers in each group. The 6-month follow-up data collection was completed in August 2017. Conclusions: This study may identify an effective and cost-effective Web-based postnatal psychoeducational program to improve first-time mothers’ health outcomes. The provision of a widely-accessed Web-based postnatal psychoeducational program will eventually lead to more positive postnatal experiences for first-time mothers and positively influence their future birth plans. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 45202278; http://www.isrctn.com/ISRCTN45202278 (Archived by WebCite at http://www.webcitation.org/6whx0pQ2F). %M 29386175 %R 10.2196/resprot.9042 %U http://www.researchprotocols.org/2018/1/e35/ %U https://doi.org/10.2196/resprot.9042 %U http://www.ncbi.nlm.nih.gov/pubmed/29386175 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e38 %T Remote Collaborative Depression Care Program for Adolescents in Araucanía Region, Chile: Randomized Controlled Trial %A Martínez,Vania %A Rojas,Graciela %A Martínez,Pablo %A Zitko,Pedro %A Irarrázaval,Matías %A Luttges,Carolina %A Araya,Ricardo %+ Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Av. La Paz 1003, Recoleta, Santiago,, Chile, 56 229788601, graciela.rojas.castillo@gmail.com %K primary health care %K depression %K adolescents %K Internet %K telemedicine %K medically underserved area %D 2018 %7 31.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite evidence on efficacious interventions, a great proportion of depressed adolescents do not receive evidence-based treatment and have no access to specialized mental health care. Remote collaborative depression care (RCDC) may help to reduce the gap between needs and specialized mental health services. Objective: The objective of this study was to assess the feasibility, acceptability, and effectiveness of an RCDC intervention for adolescents with major depressive disorder (MDD) living in the Araucanía Region, Chile. Methods: A cluster randomized, assessor-blind trial was carried out at 16 primary care centers in the Araucanía Region, Chile. Before randomization, all participating primary care teams were trained in clinical guidelines for the treatment of adolescent depression. Adolescents (N=143; 13-19 years) with MDD were recruited. The intervention group (RCDC, N=65) received a 3-month RCDC treatment that included continuous remote supervision by psychiatrists located in Santiago, Chile’s capital city, through shared electronic health records (SEHR) and phone patient monitoring. The control group (enhanced usual care or EUC; N=78) received EUC by clinicians who were encouraged to follow clinical guidelines. Recruitment and response rates and the use of the SEHR system were registered; patient adherence and satisfaction with the treatment and clinician satisfaction with RCDC were assessed at 12-week follow-up; and depressive symptoms and health-related quality of life (HRQoL) were evaluated at baseline and 12-weeks follow-up. Results: More than 60.3% (143/237) of the original estimated sample size was recruited, and a response rate of 90.9% (130/143) was achieved at 12-week follow-up. A mean (SD) of 3.5 (4.0) messages per patient were written on the SEHR system by primary care teams. A third of the patients showed an optimal adherence to psychopharmacological treatment, and adolescents in the RCDC intervention group were more satisfied with psychological assistance than those in EUC group. Primary care clinicians were satisfied with the RCDC intervention, valuing its usefulness. There were no significant differences in depressive symptoms or HRQoL between groups. Satisfaction with psychological care, in both groups, was related to a significant change in depressive symptomatology at 12-weeks follow-up (beta=−4.3, 95% CI −7.2 to −1.3). Conclusions: This is the first trial of its kind in Latin America that includes adolescents from vulnerable backgrounds, with an intervention that proved to be feasible and well accepted by both patients and primary care clinicians. Design and implementation issues may explain similar effectiveness across arms. The effectiveness of the intervention seems to be comparable with an already nationwide established treatment program that proved to be highly efficacious under controlled conditions. Trial Registration: ClinicalTrials.gov: NCT01860443; https://clinicaltrials.gov/ct2/show/NCT01860443 (Archived by WebCite at http://www.webcitation.org/6wafMKlTY) %M 29386172 %R 10.2196/jmir.8021 %U https://www.jmir.org/2018/1/e38/ %U https://doi.org/10.2196/jmir.8021 %U http://www.ncbi.nlm.nih.gov/pubmed/29386172 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e28 %T Mobile Health Technology Interventions for Suicide Prevention: Protocol for a Systematic Review and Meta-Analysis %A Melia,Ruth %A Francis,Kady %A Duggan,Jim %A Bogue,John %A O'Sullivan,Mary %A Chambers,Derek %A Young,Karen %+ Psychology Department, Health Service Executive Mid-West, Child and Adolescent Mental Health Service, Quin Road, Ennis, V95HV18, Ireland, 353 656706601, ruth.melia@hse.ie %K mHealth %K suicide prevention %K systematic review %K meta-analysis %D 2018 %7 26.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Previous research has reported that two of the major barriers to help-seeking for individuals at risk of suicide are stigma and geographical isolation. Mobile technology offers a potential means of delivering evidence-based interventions with greater specificity to the individual, and at the time that it is needed. Despite documented motivation by at-risk individuals to use mobile technology to track mental health and to support psychological interventions, there is a shortfall of outcomes data on the efficacy of mobile health (mHealth) technology on suicide-specific outcomes. Objective: The objective of this study is to develop a protocol for a systematic review and meta-analysis that aims to evaluate the effectiveness of mobile technology-based interventions for suicide prevention. Methods: The search includes the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library), MEDLINE, Embase, PsycINFO, CRESP and relevant sources of gray literature. Studies that have evaluated psychological or nonpsychological interventions delivered via mobile computing and communication technology, and have suicidality as an outcome measure will be included. Two authors will independently extract data and assess the study suitability in accordance with the Cochrane Collaboration Risk of Bias Tool. Studies will be included if they measure at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, suicidal behavior). Secondary outcomes will be measures of symptoms of depression. Where studies are sufficiently homogenous and reported outcomes are amenable for pooled synthesis, meta-analysis will be performed. A narrative synthesis will be conducted if the data is unsuitable for a meta-analysis. Results: The review is in progress, with findings expected by summer 2018. Conclusions: To date, evaluations of mobile technology-based interventions in suicide prevention have focused on evaluating content as opposed to efficacy. Indeed, previous research has identified mobile applications that appear to present harmful content. The current review will address a gap in the literature by evaluating the efficacy of stand-alone mobile technology tools in suicide prevention. It is imperative that research identifies the evidence base for such tools in suicide prevention in order to inform policy, guide clinical practice, inform users and focus future research. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42017072899; https:// www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42017072899  (Archived by WebCite at http://www.webcitation.org/ 6tZAj0yqJ) %M 29374003 %R 10.2196/resprot.8635 %U http://www.researchprotocols.org/2018/1/e28/ %U https://doi.org/10.2196/resprot.8635 %U http://www.ncbi.nlm.nih.gov/pubmed/29374003 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e7 %T Facilitating Factors and Barriers to the Use of Emerging Technologies for Suicide Prevention in Europe: Multicountry Exploratory Study %A Muñoz-Sánchez,Juan-Luis %A Delgado,Carmen %A Sánchez-Prada,Andrés %A Parra-Vidales,Esther %A de Leo,Diego %A Franco-Martín,Manuel %+ Department of Psychiatry, Zamora Hospital, Av Hernán Cortes, 44, Zamora, 49021, Spain, 34 980521816, jlmusa@icloud.com %K suicide %K prevention %K technology %D 2018 %7 24.1.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %R 10.2196/mental.7784 %U http://mental.jmir.org/2018/1/e7/ %U https://doi.org/10.2196/mental.7784 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e9 %T Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation, and Self-Harm %A Hetrick,Sarah Elisabeth %A Robinson,Jo %A Burge,Eloise %A Blandon,Ryan %A Mobilio,Bianca %A Rice,Simon M %A Simmons,Magenta B %A Alvarez-Jimenez,Mario %A Goodrich,Simon %A Davey,Christopher G %+ Centre for Youth Mental Health, University of Melbourne, Locked Bag 10, Parkville, Victoria, Melbourne, 3052, Australia, 61 3 9342 2880, shetrick@unimelb.edu.au %K depression %K suicidal ideation %K suicide, attempted %K self-injurious behavior %K adolescent %K young adult %K cell phone %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 29362208 %R 10.2196/mental.9041 %U http://mental.jmir.org/2018/1/e9/ %U https://doi.org/10.2196/mental.9041 %U http://www.ncbi.nlm.nih.gov/pubmed/29362208 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e5 %T Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial %A Hatcher,Simon %A Whittaker,Robyn %A Patton,Murray %A Miles,Wayne Sylvester %A Ralph,Nicola %A Kercher,Katharina %A Sharon,Cynthia %+ Brain and Mind Research Institute, Department of Psychiatry, The University of Ottawa, Room 4418, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada, 1 (613) 798 5555, shatcher@uottawa.ca %K Internet %K major depressive disorder %K secondary care %K randomized controlled trial %K New Zealand %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X 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