%0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e71071 %T Mental Health Apps Available in App Stores for Indian Users: Protocol for a Systematic Review %A Mehrotra,Seema %A Tripathi,Ravikesh %A Sengupta,Pramita %A Karishiddimath,Abhishek %A Francis,Angelina %A Sharma,Pratiksha %A Sudhir,Paulomi %A TK,Srikanth %A Rao,Girish N %A Sagar,Rajesh %+ Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, 560029, India, 91 9448503853, drmehrotra_seema@yahoo.com %K mental health apps %K mHealth %K review of apps %K smartphone apps %K MHApps for Indian users %K India %K mobile phones %D 2025 %7 16.4.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: There has been a surge in mental health apps over the past few years. While these have great potential to address the unmet mental health needs of the population, the recent proliferation of mental health apps in the commercial marketplace has raised several concerns, such as privacy, evidence-based, and quality. Although there is mounting research on the effectiveness of mental health apps, the majority of these are not accessible to the public and most of those available have not been researched. Despite the rapid growth of the digital health market in India, there are no comprehensive reviews of publicly available mental health apps for Indian users. Hence it becomes important to review mental health apps freely available to potential end users in terms of their scope, functions, and quality. Objective: This study aims to systematically evaluate mental health apps available to Indian users in app stores. Methods: This systematic review of mental health apps will be performed following the Target user, Evaluation focus, Connectedness and Health domain approach and the PASSR (Protocol for App Store Systematic Reviews) checklist. Fifteen key search terms covering various mental health conditions and therapies will be used on the Android and iOS stores. The identified apps will be further screened and reviewed based on the inclusion and exclusion criteria. The pool of eligible apps will be downloaded for detailed review. The following steps will be adopted to streamline the review process and interrater consistency. Six apps will be randomly selected from the downloaded apps, for joint discussion and review by a team of 4 primary reviewers and 2 mentors. Following this, a new set of 6 randomly selected apps will be rated independently by the primary reviewers and the differences in ratings will be jointly discussed for generating consensus. Subsequently, the primary reviewers will individually review the remaining apps in the list. Data will be extracted based on predecided parameters such as privacy policy, basic purpose, type of developer, nature of intervention strategies, and guided versus unguided nature. Additionally, the apps will be reviewed for quality using the Mobile Application Rating Scale. The data analysis and synthesis strategy will incorporate descriptive statistics based on quality evaluation using the Mobile Application Rating Scale and examining the content of the apps for generating descriptive information. Results: The initial screening of mental health apps available for Indian users on the Google Play Store and Apple App Store was initiated in October 2024. We expect to complete the detailed systematic review by April 2025. Conclusions: This study will offer a comprehensive review of mental health apps available in digital marketplaces for Indian users and has implications for end users, policy makers, developers, and mental health professionals. Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY2024100035; https://inplasy.com/inplasy-2024-10-0035/ International Registered Report Identifier (IRRID): DERR1-10.2196/71071 %M 40239205 %R 10.2196/71071 %U https://www.researchprotocols.org/2025/1/e71071 %U https://doi.org/10.2196/71071 %U http://www.ncbi.nlm.nih.gov/pubmed/40239205 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66301 %T Evaluating User Engagement With a Real-Time, Text-Based Digital Mental Health Support App: Cross-Sectional, Retrospective Study %A Coffield,Edward %A Kausar,Khadeja %+ , Department of Population Health, Hofstra University, 255 Hofstra University, 101 Oak Street Center, Room 100A, Hempstead, NY, 11549, United States, 1 516 463 7019, edward.coffield@hofstra.edu %K mental health support %K text %K app %K utilization %K mobile %K on demand %K scheduled %K mHealth %K mobile health %K app %K student %K university %K college %K mental health %K employee %K job %K work %K occupational health %K counselor %K counseling %K usage %K engagement %K self-reported %D 2025 %7 14.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Approximately 20% of US adults identify as having a mental illness. Structural and other barriers prevent many people from receiving mental health services. Digital mental health apps that provide 24-hour, real-time access to human support may improve access to mental health services. However, information is needed regarding how and why people engage with licensed counselors through a digital, real-time, text-based mental health support app in nonexperimental settings. Objective: This study aimed to evaluate how people engage with Counslr, a 24-hour, digital, mental health support app where users communicate in real time with human counselors through text messaging. Specifically, access patterns (eg, day of the week and time of session) and reasons for accessing the platform were examined. Furthermore, whether differences existed between session types (on-demand or scheduled) and membership types (education or noneducation) in regard to access patterns and why people accessed the platform were evaluated. Methods: The study population (users) consisted of students whose schools, universities, or colleges partnered with Counslr and employees whose organizations also partnered with Counslr. Users participated in text-based mental health support sessions. In these sessions, users engaged with licensed counselors through digital, text-based messaging in real time. Users could initiate an on-demand session or schedule a session 24 hours a day. User engagement patterns were evaluated through session length, session day, session time, and self-reported reasons for initiating the session. The data were stratified by membership type (education [students] or noneducation [employees]) and session type (on-demand or scheduled) to evaluate whether differences existed in usage patterns and self-reported reasons for initiating sessions by membership and session types. Results: Most students (178/283, 62.9%) and employees (28/44, 63.6%) accessed Counslr through on-demand sessions. The average and median session times were 40 (SD 15.3) and 45 minutes. On-demand sessions (37.9 minutes) were shorter (P=.001) than scheduled sessions (43.5 minutes). Most users (262/327, 80.1%) accessed Counslr between 7 PM and 5 AM. The hours that users accessed Counslr did not statistically differ by membership type (P=.19) or session type (P=.10). Primary self-reported reasons for accessing Counslr were relationship reasons, depression, and anxiety; however, users initiated sessions for a variety of reasons. Statistically significant differences existed between membership and session types (P<.05) for some of the reasons why people initiated sessions. Conclusions: The novel findings of this study illustrate that real-time, digital mental health support apps, which offer people the opportunity to engage with licensed counselors outside of standard office hours for a variety of mental health conditions, may help address structural barriers to accessing mental health support services. Additional research is needed to evaluate the effectiveness of human-based apps such as Counslr and whether such apps can also address disparities in access to mental health support services among different demographic groups. %M 40228290 %R 10.2196/66301 %U https://formative.jmir.org/2025/1/e66301 %U https://doi.org/10.2196/66301 %U http://www.ncbi.nlm.nih.gov/pubmed/40228290 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e67381 %T Impact of Conversational and Animation Features of a Mental Health App Virtual Agent on Depressive Symptoms and User Experience Among College Students: Randomized Controlled Trial %A Six,Stephanie %A Schlesener,Elizabeth %A Hill,Victoria %A Babu,Sabarish V %A Byrne,Kaileigh %K depression %K mental health app %K virtual agents %K cognitive behavioral therapy %K conversational agents %K virtual agent %K animations %K college student %K CBT %K ANOVA %K randomized controlled trial %K depressive symptoms %K mental disorder %K mental illness %K user experience %K mHealth %K digital health %D 2025 %7 11.4.2025 %9 %J JMIR Ment Health %G English %X Background: Numerous mental health apps purport to alleviate depressive symptoms. Strong evidence suggests that brief cognitive behavioral therapy (bCBT)-based mental health apps can decrease depressive symptoms, yet there is limited research elucidating the specific features that may augment its therapeutic benefits. One potential design feature that may influence effectiveness and user experience is the inclusion of virtual agents that can mimic realistic, human face-to-face interactions. Objective: The goal of the current experiment was to determine the effect of conversational and animation features of a virtual agent within a bCBT-based mental health app on depressive symptoms and user experience in college students with and without depressive symptoms. Methods: College students (N=209) completed a 2-week intervention in which they engaged with a bCBT-based mental health app with a customizable therapeutic virtual agent that varied in conversational and animation features. A 2 (time: baseline vs 2-week follow-up) × 2 (conversational vs non-conversational agent) × 2 (animated vs non-animated agent) randomized controlled trial was used to assess mental health symptoms (Patient Health Questionnaire-8, Perceived Stress Scale-10, and Response Rumination Scale questionnaires) and user experience (mHealth App Usability Questionnaire, MAUQ) in college students with and without current depressive symptoms. The mental health app usability and qualitative questions regarding users’ perceptions of their therapeutic virtual agent interactions and customization process were assessed at follow-up. Results: Mixed ANOVA (analysis of variance) results demonstrated a significant decrease in symptoms of depression (P=.002; mean [SD]=5.5 [4.86] at follow-up vs mean [SD]=6.35 [4.71] at baseline), stress (P=.005; mean [SD]=15.91 [7.67] at follow-up vs mean [SD]=17.02 [6.81] at baseline), and rumination (P=.03; mean [SD]=40.42 [12.96] at follow-up vs mean [SD]=41.92 [13.61] at baseline); however, no significant effect of conversation or animation was observed. Findings also indicate a significant increase in user experience in animated conditions. This significant increase in animated conditions is also reflected in the user’s ease of use and satisfaction (F(1, 201)=102.60, P<.001), system information arrangement (F(1, 201)=123.12, P<.001), and usefulness of the application (F(1, 201)=3667.62, P<.001). Conclusions: The current experiment provides support for bCBT-based mental health apps featuring customizable, humanlike therapeutic virtual agents and their ability to significantly reduce negative symptomology over a brief timeframe. The app intervention reduced mental health symptoms, regardless of whether the agent included conversational or animation features, but animation features enhanced the user experience. These effects were observed in both users with and without depressive symptoms. Trial Registration: Open Science Framework B2HX5; https://doi.org/10.17605/OSF.IO/B2HX5 %R 10.2196/67381 %U https://mental.jmir.org/2025/1/e67381 %U https://doi.org/10.2196/67381 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64138 %T Safety and Efficacy of Modular Digital Psychotherapy for Social Anxiety: Randomized Controlled Trial %A Garvert,Mona M %A McFadyen,Jessica %A Linke,Stuart %A McCloud,Tayla %A Meyer,Sofie S %A Sobanska,Sandra %A Sharp,Paul B %A Long,Alex %A Huys,Quentin J M %A Ahmadi,Mandana %+ Alena, 25 Wilton Rd, Pimlico, London, SW1V 1LW, United Kingdom, 44 09313185834, mona.garvert@gmail.com %K social anxiety disorder %K randomized controlled trial %K digital mental health %K cognitive behavioral therapy %K internet-delivered CBT %D 2025 %7 10.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Social anxiety disorder is a common mental health condition characterized by an intense fear of social situations that can lead to significant impairment in daily life. Cognitive behavioral therapy (CBT) has been recognized as an effective treatment; however, access to therapists is limited, and the fear of interacting with therapists can delay treatment seeking. Furthermore, not all individuals respond. Tailoring modular treatments to individual cognitive profiles may improve efficacy. We developed a novel digital adaptation of CBT for social anxiety that is both modular and fully digital without a therapist in the loop and implemented it in the smartphone app Alena. Objective: This study aimed to evaluate the safety, acceptability, and efficacy of the new treatment in online participants with symptoms of social anxiety. Methods: In total, 2 web-based randomized controlled trials (RCTs) comparing individuals with access to the treatment through the app to a waitlist control group were conducted. Participants were recruited on the web and reported Social Phobia Inventory (SPIN) total scores of ≥30. Primary outcomes were safety and efficacy over 6 weeks in 102 women aged 18 to 35 years (RCT 1) and symptom reduction (SPIN scores) after 8 weeks in 248 men and women aged 18 to 75 years (RCT 2). Results: In RCT 1, active and control arm adverse event frequency and severity were not distinguishable (intervention: 7/52, 13%; waitlist control: 8/50, 16%; χ21=0.007; P=.93). App acceptability was high, with a median completion rate of 90.91% (IQR 54.55%-100%). Secondary outcomes suggested greater symptom reduction in the active arm (mean SPIN score reduction −9.83, SD 12.80) than in the control arm (mean SPIN score reduction −4.13, SD 11.59; t90=−2.23; false discovery rate P=.04; Cohen d=0.47). RCT 2 replicated these findings. Adverse event frequency was comparable across the 2 groups (intervention: 20/124, 16.1%; waitlist control: 21/124, 16.8%; χ21<0.001; P>.99). Despite a longer treatment program, median completion remained high (84.85%, IQR 51.52%-96.97%). SPIN score reduction was greater in the active arm (mean −12.89, SD 13.87) than in the control arm (mean −7.48, SD 12.24; t227=−3.13; false discovery rate P=.008; Cohen d=0.42). Conclusions: The web-only, modular social anxiety CBT program appeared safe, acceptable, and efficacious in 2 independent RCTs on online patient groups with self-reported symptoms of social anxiety. Trial Registration: ClinicalTrials.gov NCT05858294; https://clinicaltrials.gov/study/NCT05858294 (RCT 1) and ClinicalTrials.gov NCT05987969; https://clinicaltrials.gov/study/NCT05987969 (RCT 2) %M 40208666 %R 10.2196/64138 %U https://www.jmir.org/2025/1/e64138 %U https://doi.org/10.2196/64138 %U http://www.ncbi.nlm.nih.gov/pubmed/40208666 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e65889 %T Co-Designing a Web-Based and Tablet App to Evaluate Clinical Outcomes of Early Psychosis Service Users in a Learning Health Care Network: User-Centered Design Workshop and Pilot Study %A Burch,Kathleen E %A Tryon,Valerie L %A Pierce,Katherine M %A Tully,Laura M %A Ereshefsky,Sabrina %A Savill,Mark %A Smith,Leigh %A Wilcox,Adam B %A Hakusui,Christopher Komei %A Padilla,Viviana E %A McNamara,Amanda P %A Kado-Walton,Merissa %A Padovani,Andrew J %A Miller,Chelyah %A Miles,Madison J %A Sharma,Nitasha %A Nguyen,Khanh Linh H %A Zhang,Yi %A Niendam,Tara A %+ Department of Psychiatry & Behavioral Sciences, University of California-Davis, 4701 X St, Sacramento, CA, 95817, United States, 1 916 699 5193, knye@ucdavis.edu %K eHealth %K user-centered design %K learning health system %K psychosis %K early psychosis %K user-driven development %K web-based %K data visualization %K surveys and questionnaires %K measurement-based care %D 2025 %7 9.4.2025 %9 Original Paper %J JMIR Hum Factors %G English %X Background: The Early Psychosis Intervention Network of California project, a learning health care network of California early psychosis intervention (EPI) programs, prioritized incorporation of community partner feedback while designing its eHealth app, Beehive. Though eHealth apps can support learning health care network data collection aims, low user acceptance or adoption can pose barriers to successful implementation. Adopting user-centered design (UCD) approaches, such as incorporation of user feedback, prototyping, iterative design, and continuous evaluation, can mitigate these potential barriers. Objective: We aimed to use UCD during development of a data collection and data visualization web-based and tablet app, Beehive, to promote engagement with Beehive as part of standard EPI care across a diverse user-base. Methods: Our UCD approach included incorporation of user feedback, prototyping, iterative design, and continuous evaluation. This started with user journey mapping to create storyboards, which were then presented in UCD workshops with service users, their support persons, and EPI providers. We incorporated feedback from these workshops into the alpha version of Beehive, which was also presented in a UCD workshop. Feedback was again incorporated into the beta version of Beehive. We provided Beehive training to 4 EPI programs who then piloted Beehive’s beta version. During piloting, service users, their support persons, and EPI program providers completed Beehive surveys at enrollment and every 6 months after treatment initiation. To examine preliminary user acceptance and adoption during the piloting phase, we assessed rates of participant enrollment and survey completion, with a particular focus on completion of a prioritized survey: the Modified Colorado Symptom Index. Results: UCD workshop feedback resulted in the creation of new workflows and interface changes in Beehive to improve the user experience. During piloting, 48 service users, 42 support persons, and 72 EPI program providers enrolled in Beehive. Data were available for 88% (n=42) of service users, including self-reported data for 79% (n=38), collateral-reported data for 42% (n=20), and clinician-entered data for 17% (n=8). The Modified Colorado Symptom Index was completed by 54% (n=26) of service users (total score: mean 24.16, SD 16.81). In addition, 35 service users had a support person who could complete the Modified Colorado Symptom Index, and 56% (n=19) of support persons completed it (mean 26.71, SD 14.43). Conclusions: Implementing UCD principles while developing the Beehive app resulted in early workflow changes and produced an app that was acceptable and feasible for collection of self-reported clinical outcomes data from service users. Additional support is needed to increase collateral-reported and clinician-entered data. %M 40203298 %R 10.2196/65889 %U https://humanfactors.jmir.org/2025/1/e65889 %U https://doi.org/10.2196/65889 %U http://www.ncbi.nlm.nih.gov/pubmed/40203298 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e65788 %T The Use of Mobile Apps in Adolescent Psychotherapy: Assessment of Psychotherapists’ Perspectives %A Wüllner,Sarah %A Hermenau,Katharin %A Hecker,Tobias %A Siniatchkin,Michael %+ University Clinic of Child and Adolescent Psychiatry and Psychotherapy, Medical School EWL, Protestant Hospital Bethel, Bielefeld University, Remterweg 13a, Bielefeld, 33617, Germany, 49 5211063166, sarah.wuellner@uni-bielefeld.de %K mental health app %K psychotherapy %K adolescent %K mHealth %K youth %K feasibility %K implementation %K app features %K barriers %K drivers %D 2025 %7 8.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Therapy-accompanying mental health apps can play an important role in the psychotherapeutic treatment of adolescents. They can enhance adolescents’ engagement and autonomy, provide immediate support in critical situations, and positively influence the therapeutic working alliance. Nevertheless, mental health apps are rarely used by psychotherapists. Furthermore, due to the limited or nonexistent use of apps in psychotherapy, little is known about the actual barriers and drivers affecting their integration into psychotherapists’ daily routines. To better understand how mental health apps should be designed for practical use, it is essential to explore psychotherapists’ perspectives on key app features and characteristics, as well as the factors influencing their integration into clinical practice. Objective: This study aims to analyze which app features and characteristics are essential for psychotherapists to use a mobile app in psychotherapy with adolescents and to identify the key drivers and barriers influencing the integration of a psychotherapeutic app from the psychotherapists’ perspectives. Methods: We conducted 3 feasibility studies using Steps, a transdiagnostic, therapy-accompanying app for adolescents, across 3 different psychotherapeutic treatment contexts: inpatient treatment, treatment in psychiatric outpatient clinics, and outpatient treatment with psychotherapists in private practice. All studies followed a qualitative quasi-experimental design. Participants provided information on their age, occupation, years of work experience, media affinity, attitudes toward psychotherapeutic apps, perceived app quality and feasibility, and the implementation process of the therapy-accompanying app. Qualitative data were analyzed using deductive qualitative content analysis. A total of 40 mental health professionals participated across the 3 studies (study 1: n=18; study 2: n=13; study 3: n=9). Results: Study participation and app usage rates were low across all studies. Six core features for a transdiagnostic, therapy-accompanying app were identified: mood checks, library, reminders, goals and tasks, emergency kit, and questionnaires. Additionally, the integration of mental health apps into daily routines was influenced by various drivers and barriers. The most significant barriers included technological issues and practical constraints, such as limited time and resources. The most important driver was the perceived improvement in treatment quality. Conclusions: Overall, psychotherapists were generally open to using a therapy-accompanying mental health app. However, study participation and app usage remained low. As psychotherapists act as gatekeepers for patients’ use of mental health apps, their needs should be prioritized in the development and implementation of such apps. Trial Registration: German Clinical Trials Register DRKS00031258; https://drks.de/search/en/trial/DRKS00031258/details %M 40198916 %R 10.2196/65788 %U https://formative.jmir.org/2025/1/e65788 %U https://doi.org/10.2196/65788 %U http://www.ncbi.nlm.nih.gov/pubmed/40198916 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e65356 %T Psychotherapy Access Barriers and Interest in Digital Mental Health Interventions Among Adults With Treatment Needs: Survey Study %A Starvaggi,Isabella %A Lorenzo-Luaces,Lorenzo %+ , Indiana University Bloomington, 1101 E 10th St, Bloomington, IN, 47405, United States, 1 (812) 855 2012, irstarva@iu.edu %K psychotherapy %K internet-based cognitive behavior therapy %K internet-based interventions %K guided self-help %K public health %K treatment access barriers %K digital mental health %K treatment attitudes %D 2025 %7 1.4.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital mental health interventions (DMHIs) are a promising approach to reducing the public health burden of mental illness. DMHIs are efficacious, can provide evidence-based treatment with few resources, and are highly scalable relative to one-on-one face-to-face psychotherapy. There is potential for DMHIs to substantially reduce unmet treatment needs by circumventing structural barriers to treatment access (eg, cost, geography, and time). However, epidemiological research on perceived barriers to mental health care use demonstrates that attitudinal barriers, such as the lack of perceived need for treatment, are the most common self-reported reasons for not accessing care. Thus, the most important barriers to accessing traditional psychotherapy may also be barriers to accessing DMHIs. Objective: This study aimed to explore whether attitudinal barriers to traditional psychotherapy access might also serve as barriers to DMHI uptake. We explored the relationships between individuals’ structural versus attitudinal barriers to accessing psychotherapy and their indicators of potential use of internet-delivered guided self-help (GSH). Methods: We collected survey data from 971 US adults who were recruited online via Prolific and screened for the presence of psychological distress. Participants provided information about demographic characteristics, current symptoms, and the use of psychotherapy in the past year. Those without past-year psychotherapy use (640/971, 65.9%) answered questions about perceived barriers to psychotherapy access, selecting all contributing barriers to not using psychotherapy and a primary barrier. Participants also read detailed information about a GSH intervention. Primary outcomes were participants’ self-reported interest in the GSH intervention and self-reported likelihood of using the intervention if offered to them. Results: Individuals who had used psychotherapy in the past year reported greater interest in GSH than those who had not (odds ratio [OR] 2.38, 95% CI 1.86-3.06; P<.001) and greater self-reported likelihood of using GSH (OR 2.25, 95% CI 1.71-2.96; P<.001). Attitudinal primary barriers (eg, lack of perceived need; 336/640, 52.5%) were more common than structural primary barriers (eg, money or insurance; 244/640, 38.1%). Relative to endorsing a structural primary barrier, endorsing an attitudinal primary barrier was associated with lower interest in GSH (OR 0.44, 95% CI 0.32-0.6; across all 3 barrier types, P<.001) and lower self-reported likelihood of using GSH (OR 0.61, 95% CI 0.43-0.87; P=.045). We found no statistically significant differences in primary study outcomes by race or ethnicity or by income, but income had a statistically significant relationship with primary barrier type (ORs 0.27-3.71; P=.045). Conclusions: Our findings suggest that attitudinal barriers to traditional psychotherapy use may also serve as barriers to DMHI use, suggesting that disregarding the role of attitudinal barriers may limit the reach of DMHIs. Future research should seek to further understand the relationship between general treatment-seeking attitudes and attitudes about DMHIs to inform the design and marketing of DMHIs. %M 40168039 %R 10.2196/65356 %U https://mental.jmir.org/2025/1/e65356 %U https://doi.org/10.2196/65356 %U http://www.ncbi.nlm.nih.gov/pubmed/40168039 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e68362 %T Mental Health Professionals’ Technology Usage and Attitudes Toward Digital Health for Psychosis: Comparative Cross-Sectional Survey Study %A Zhang,Xiaolong %A Berry,Natalie %A Di Basilio,Daniela %A Richardson,Cara %A Eisner,Emily %A Bucci,Sandra %K digital mental health %K psychosis %K attitudes %K implementation %K smartphone app %D 2025 %7 31.3.2025 %9 %J JMIR Ment Health %G English %X Background: Digital health technologies (DHTs) for psychosis have been developed and tested rapidly in recent years. However, research examining mental health professionals’ views on the use of DHTs for people with psychosis is limited. Given the increased accessibility and availability of DHTs for psychosis, an up-to-date understanding of staff perception of DHTs for psychosis is warranted. Objective: In this study, we aimed to investigate mental health professionals’ usage of technology and their perception of service users’ technology usage; their views toward the use of DHTs for psychosis, including their concerns; and barriers for implementing DHTs in a mental health setting. Methods: Two cross-sectional surveys were distributed to mental health care staff who had experience of working with individuals experiencing psychosis in the United Kingdom. Survey 1 (from April 2018 to September 2020) was distributed to 3 local UK National Health Service (NHS) trusts in Northwest England; survey 2 was administered nationally across 31 UK NHS trusts or health boards (from November 2022 to March 2024). The COVID-19 pandemic occurred between the 2 survey periods. Data were analyzed descriptively. Results: A total of 155 and 352 participants completed surveys 1 and 2, respectively. Staff reported high levels of technology ownership and usage in both surveys. In general, staff expressed positive views regarding the use of DHTs for psychosis; however, barriers and concerns, including affordability, digital literacy, and potential negative effects on service users’ mental health, were also reported. We did not find notable changes in terms of staff use of digital technology in clinical practice over time. Conclusions: Staff sampled from a broad and diverse range expressed consistent optimism about the potential implementation of DHTs in practice, though they also noted some concerns regarding safety and access. While the COVID-19 pandemic is frequently regarded as a catalyst for the adoption of digital health care tools, the sustainability of this transition from traditional to digital health care appeared to be suboptimal. To address staff concerns regarding safety and potentially facilitate the implementation of DHTs, systematic evaluation of adverse effects of using DHTs and dissemination of evidence are needed. Organizational support and training should be offered to staff to help address barriers and increase confidence in recommending and using DHTs with service users. %R 10.2196/68362 %U https://mental.jmir.org/2025/1/e68362 %U https://doi.org/10.2196/68362 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64746 %T Use of e-Mental Health Tools for Suicide Prevention in Clinical Practice by Mental Health Professionals in NSW, Australia: Cross-Sectional Survey %A Hood,Carol %A Hunt,Sally %A Metse,Alexandra P %A Hodder,Rebecca K %A Colyvas,Kim %A Sheather-Reid,Rachel %A Duerden,David %A Bowman,Jenny %+ , School of Psychological Sciences, The University of Newcastle, College of Engineering, Science and Environment, Callaghan, 2308, Australia, 61 2 4921 5958, Carol.Hood@uon.edu.au %K suicide prevention %K digital mental health %K mental health professionals %K peer support %K internet %K mobile apps %K clinical practice %K cross-sectional survey %K Australia %K e-mental health tools %D 2025 %7 26.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a significant global health concern. In the context of increased demand for mental health services and workforce shortages, exacerbated by the COVID-19 pandemic, electronic mental health (eMH) tools represent a promising means of augmenting mental health care generally and for suicide prevention specifically. A significant research gap exists however with respect to the use and uptake of eMH tools, especially electronic mental health tools for suicide prevention (eMH-SP). Objective: This study aimed to investigate the use of eMH tools by Australian mental health professionals, both in general and with respect to suicide prevention specifically, examining changes in use since COVID-19. Further, it explored factors associated with frequent use of eMH-SP, including sociodemographic and professional characteristics. Methods: A web-based cross-sectional survey was conducted across 15 local health districts (LHDs) in New South Wales, Australia, from May 2022 to July 2023. The sample was drawn from over 10,000 mental health professionals working in government services statewide. The survey explored the use of electronic mental health tools for general mental health issues (eMH-gen) and eMH-SP, explored the changes in the use of both since COVID-19, and used multivariable logistic regression to identify factors associated with the current use of eMH-SP. Results: Among 469 participants, increased use since COVID-19 was reported by over half (247/469, 52.7%) for eMH-gen, and by approximately one-third (141/386, 36.6%) for eMH-SP. The proportion reporting frequent use increased significantly from before to after COVID-19 for both eMH-gen (243/469, 51.8% to 283/469, 60.3%; P<.001) and eMH-SP (152/386, 39.4% to 170/385, 44.2%; P=.01). Since COVID-19, the most frequently used types of eMH tools for eMH-gen and eMH-SP, respectively, were information sites (231/469, 49.3% and 130/385, 33.8%), phone/online counseling (173/469, 36.9% and 130/385, 33.8%), and apps (145/469, 30.9% and 107/385, 27.8%). Professionals more likely to use eMH-SP frequently were females (odds ratio [OR] 3.32, 95% CI 1.88-5.87; P<.001) compared with males; peer workers (OR 2.17, 95% CI 1.0-4.71; P<.001) compared with nurses; those located in regional/rural LHDs (OR 1.65, 95% CI 1.04-2.61; P=.03) compared with metropolitan LHDs; and those practicing in emergency health care settings (OR 8.31, 95% CI 2.17-31.75; P=.03) compared with inpatient settings. Conclusions: The study’s findings highlight the increasing adoption of eMH tools and delivery of remote care by mental health professionals and provide valuable new insights into sociodemographic factors associated with the use of eMH for suicide prevention specifically. Continued research on the role eMH is playing is essential for guiding policy, optimizing resources, and enhancing mental health care and suicide prevention efforts. %M 40138690 %R 10.2196/64746 %U https://www.jmir.org/2025/1/e64746 %U https://doi.org/10.2196/64746 %U http://www.ncbi.nlm.nih.gov/pubmed/40138690 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e68165 %T Effectiveness of General Practitioner Referral Versus Self-Referral Pathways to Guided Internet-Delivered Cognitive Behavioral Therapy for Depression, Panic Disorder, and Social Anxiety Disorder: Naturalistic Study %A Bjarke,Jill %A Gjestad,Rolf %A Nordgreen,Tine %K referral pathway %K GP-referral %K self-referral %K guided internet-delivered cognitive behavioral therapy %K ICBT %K routine care clinic %K depression %K panic disorder %K social anxiety disorder %K psychological therapy %K referrals %K cognitive %K behavioral therapy %K anxiety %K SAD %K treatment effectiveness %K mental health %K pathways %D 2025 %7 25.3.2025 %9 %J JMIR Ment Health %G English %X Background: Therapist-guided, internet-delivered cognitive behavioral therapy (guided ICBT) appears to be efficacious for depression, panic disorder (PD), and social anxiety disorder (SAD) in routine care clinical settings. However, implementation of guided ICBT in specialist mental health services is limited partly due to low referral rates from general practitioners (GP), which may stem from lack of awareness, limited knowledge of its effectiveness, or negative attitudes toward the treatment format. In response, self-referral systems were introduced in mental health care about a decade ago to improve access to care, yet little is known about how referral pathways may affect treatment outcomes in guided ICBT. Objective: This study aims to compare the overall treatment effectiveness of GP referral and self-referral to guided ICBT for patients with depression, PD, or SAD in a specialized routine care clinic. This study also explores if the treatment effectiveness varies between referral pathways and the respective diagnoses. Methods: This naturalistic open effectiveness study compares treatment outcomes from pretreatment to posttreatment and from pretreatment to 6-month follow-up across 2 referral pathways. All patients underwent module-based guided ICBT lasting up to 14 weeks. The modules covered psychoeducation, working with negative or automatic thoughts, exposure training, and relapse prevention. Patients received weekly therapist guidance through asynchronous messaging, with therapists spending an average of 10‐30 minutes per patient per week. Patients self-reported symptoms before, during, immediately after, and 6 months posttreatment. Level and change in symptom severity were measured across all diagnoses. Results: In total, 460 patients met the inclusion criteria, of which 305 were GP-referred (“GP” group) and 155 were self-referred (“self” group). Across the total sample, about 60% were female, and patients had a mean age of 32 years and average duration of disorder of 10 years. We found no significant differences in pretreatment symptom levels between referral pathways and across the diagnoses. Estimated effect sizes based on linear mixed modeling showed large improvements from pretreatment to posttreatment and from pretreatment to follow-up across all diagnoses, with statistically significant differences between referral pathways (GP: 0.97‐1.22 vs self: 1.34‐1.58, P<.001-.002) and for the diagnoses separately: depression (GP: 0.86‐1.26, self: 1.97‐2.07, P<.001-.02), PD (GP: 1.32‐1.60 vs self: 1.64‐2.08, P=.06-.02) and SAD (GP: 0.80‐0.99 vs self: 0.99‐1.19, P=.18-.22). Conclusions: Self-referral to guided ICBT for depression and PD appears to yield greater treatment outcomes compared to GP referrals. We found no difference in outcome between referral pathway for SAD. This study underscores the potential of self-referral pathways to enhance access to evidence-based psychological treatment, improve treatment outcomes, and promote sustained engagement in specialist mental health services. Future studies should examine the effect of the self-referral pathway when it is implemented on a larger scale. %R 10.2196/68165 %U https://mental.jmir.org/2025/1/e68165 %U https://doi.org/10.2196/68165 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e60435 %T Generative AI–Enabled Therapy Support Tool for Improved Clinical Outcomes and Patient Engagement in Group Therapy: Real-World Observational Study %A Habicht,Johanna %A Dina,Larisa-Maria %A McFadyen,Jessica %A Stylianou,Mona %A Harper,Ross %A Hauser,Tobias U %A Rollwage,Max %+ Limbic Ltd, Kemp House, 128 City Road, London, EC1V 2NX, United Kingdom, 44 020 3818 3240, max@limbic.ai %K artificial intelligence %K National Health Service %K NHS Talking Therapies %K mental health %K therapy support tool %K cognitive behavioral therapy %K CBT %K chatbot %K conversational agent %K clinical %K patient engagement %K therapist %K treatment %K medication %K depression %K anxiety disorder %K exercise %K observational study %K control group %K patient adherence %D 2025 %7 10.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive behavioral therapy (CBT) is a highly effective treatment for depression and anxiety disorders. Nonetheless, a substantial proportion of patients do not respond to treatment. The lack of engagement with therapeutic materials and exercises between sessions, a necessary component of CBT, is a key determinant of unsuccessful treatment. Objective: The objective of this study was to test whether the deployment of a generative artificial intelligence (AI)–enabled therapy support tool, which helps patients to engage with therapeutic materials and exercises in between sessions, leads to improved treatment success and patient treatment adherence compared with the standard delivery of CBT exercises through static workbooks. Methods: We conducted a real-world observational study of 244 patients receiving group-based CBT in 5 of the United Kingdom’s National Health Service Talking Therapies services, comparing 150 (61.5%) patients who used the AI-enabled therapy support tool to 94 (38.5%) patients who used the standard delivery of CBT exercises. The groups were equivalent with respect to the content of the CBT materials and the human-led therapy sessions; however, the intervention group received support from the AI-enabled therapy support tool in conducting CBT exercises. Results: Patients using the AI-enabled therapy support tool exhibited greater attendance at therapy sessions and fewer dropouts from treatment. Furthermore, these patients demonstrated higher reliable improvement, recovery, and reliable recovery rates when compared to the control group, which was related to the degree of use of the AI-enabled therapy support tool. Moreover, we found that engagement with AI-supported CBT interventions, relative to psychoeducational materials, predicted better treatment adherence and treatment success, highlighting the role of personalization in the intervention’s effectiveness. To investigate the mechanisms of these effects further, we conducted a separate qualitative experiment in a nonclinical sample of users (n=113). Results indicated that users perceived the AI-enabled therapy support tool as most useful for discussing their problems to gain awareness and clarity of their situation as well as learning how to apply coping skills and CBT techniques in their daily lives. Conclusions: Our results show that an AI-enabled, personalized therapy support tool in combination with human-led group therapy is a promising avenue to improve the efficacy of and adherence to mental health care. %M 40063074 %R 10.2196/60435 %U https://www.jmir.org/2025/1/e60435 %U https://doi.org/10.2196/60435 %U http://www.ncbi.nlm.nih.gov/pubmed/40063074 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e63431 %T Understanding Problematic Smartphone and Social Media Use Among Adults in France: Cross-Sectional Survey Study %A Karila,Laurent %A Scher,Nathaniel %A Draghi,Clement %A Lichte,Delphine %A Darmon,Ilan %A Boudabous,Hanene %A Lamallem,Hanah %A Bauduceau,Olivier %A Bollet,Marc %A Toledano,Alain %K problematic smartphone use %K digital mental health %K compulsive behavior %K social network addiction %K nomophobia %K phubbing %K screen time effects %K public health interventions %K cross-sectional %K French %K smartphone use %K social media %K France %K mobile phone %D 2025 %7 6.3.2025 %9 %J JMIR Ment Health %G English %X Background: The Evaluation of Digital Addiction (EVADD) study investigates problematic smartphone use in the digital age, as global smartphone users reached 55.88 million in France in 2023. With increased screen time from digital devices, especially smartphones, the study highlights adult use issues and associated risks. Objective: The aim of the study is to assess the prevalence of compulsive smartphone use among French adults and identify patterns of problematic behaviors, including their impact on daily activities, sleep, and safety. Methods: The EVADD study used a cross-sectional, nonprobability sample design, conducted from May 3 to June 5, 2023. Participants were recruited through the French mutual insurance company PRO-BTP. Data were collected anonymously via a digital questionnaire, including the Smartphone Compulsive Use Test, capturing information on social network engagement, device ownership, and daily screen use. Results: A total of 21,244 adults (average age 53, SD 15 years; 9844 female participants) participated. Among 21,244 participants, 8025 of 12,034 (66.7%) respondents exhibited compulsive smartphone use (P<.001). Additionally, 7,020 (36.7%) participants scored ≥8 on the Smartphone Compulsion Test, indicating addiction. Younger participants (18‐39 years) were significantly more likely to show signs of addiction (2504/4394, 57%; odds ratio 2.5, 95% CI 1.9‐3.2) compared to participants aged ≥60 years. Problematic behaviors included unsafe smartphone use while driving (5736/12,953, 44.3%), frequent smartphone use before bedtime (9136/21,244, 43%), and using smartphones in the bathroom (7659/21,244, 36.1%). Sleep disturbances and risky behaviors correlated strongly with higher compulsion scores (P<.01). Conclusions: The EVADD study highlights the complex relationship between adults and smartphones, revealing the prevalence of compulsive behaviors and their impact on daily life, sleep, and safety. These findings emphasize the need for public awareness campaigns, preventive strategies, and therapeutic interventions to mitigate health risks associated with excessive smartphone use. Trial Registration: ClinicalTrials.gov NCT05860660; https://clinicaltrials.gov/ct2/show/NCT05860660 %R 10.2196/63431 %U https://mental.jmir.org/2025/1/e63431 %U https://doi.org/10.2196/63431 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63279 %T Testing a Dashboard Intervention for Tracking Digital Social Media Activity in Clinical Care of Individuals With Mood and Anxiety Disorders: Protocol and Design Considerations for a Pragmatic Randomized Trial %A Nesbitt,Brittany %A Virgadamo,Danielle %A Aguirre,Carlos %A DeCamp,Matthew %A Dredze,Mark %A Harrigian,Keith %A Lhaksampa,Tenzin %A Meuchel,Jennifer M %A Meyer,Aja M %A Walker,Alex %A Zirikly,Ayah %A Chisolm,Margaret S %A Zandi,Peter P %A Miller,Leslie %+ Johns Hopkins University School of Medicine, 5500 East Lombard St, Baltimore, MD, 21224, United States, 1 410 550 0091, lmille84@jhmi.edu %K digital mental health %K mental health %K dashboards %K psychiatry %K measurement-based care %K electronic communication %K social media %K depression %K anxiety %K personal health information %D 2025 %7 5.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mood and anxiety disorders are prevalent mental health diagnoses. Numerous studies have shown that measurement-based care, which is used to monitor patient symptoms, functioning, and treatment progress and help guide clinical decisions and collaboration on treatment goals, can improve outcomes in patients with these disorders. Including digital information regarding patients’ electronic communications and social media activity is an innovative approach to augmenting measurement-based care. Recent data indicate interest and willingness from both mental health clinicians and patients to share this type of digital information in treatment sessions. However, the clinical benefit of systematically doing this has been minimally evaluated. Objective: This study aims to develop an electronic dashboard for tracking patients’ digital social activity and a protocol for a pragmatic randomized trial to test the feasibility and efficacy of using the dashboard in real-world clinical care of patients with depression or anxiety disorders. Methods: We developed a personalized electronic dashboard that tracks patients’ electronic communications and social media activity, visualizes data on these interactions through key graphics and figures, and provides a tool that can be readily integrated into routine clinical care for use by clinicians and patients during treatment sessions. We then designed a randomized trial to evaluate the feasibility and effectiveness of using the electronic dashboard in real-world care compared to treatment as usual. The trial included patients aged ≥12 years with a mood or anxiety disorder who were receiving treatment in outpatient psychiatry clinics in the Johns Hopkins Health System and the Kennedy Krieger Institute. The primary outcome includes changes in patient-rated depression symptoms. Secondary outcomes include changes in patient-rated anxiety symptoms and overall functioning. Exploratory analyses examine the impact of the intervention on measures of therapeutic alliance and the detection of clinically actionable targets. Results: We successfully developed an electronic dashboard for tracking patients’ electronic communications and social media activity, and we implemented a protocol for evaluating the feasibility and efficacy of using the dashboard in routine care for mood or anxiety disorders. The protocol was approved by the Johns Hopkins University School of Medicine Institutional Review Board. In this study, we report the technological, ethical, and pragmatic considerations in developing the dashboard and testing it in a real-world setting. Conclusions: The integration of an electronic dashboard to monitor digital social activity in mental health care treatment is novel. This study examines the feasibility and effectiveness of the dashboard and the challenges in implementing this protocol. The lessons learned from developing and implementing the study will inform ongoing discussions about the value of gathering collateral information on patients’ digital social activity and how to do so in a way that is acceptable and clinically effective. Trial Registration: ClinicalTrials.gov NCT03925038; https://clinicaltrials.gov/study/NCT03925038 International Registered Report Identifier (IRRID): DERR1-10.2196/63279 %M 40053788 %R 10.2196/63279 %U https://www.researchprotocols.org/2025/1/e63279 %U https://doi.org/10.2196/63279 %U http://www.ncbi.nlm.nih.gov/pubmed/40053788 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e60096 %T Understanding Appropriation of Digital Self-Monitoring Tools in Mental Health Care: Qualitative Analysis %A de Thurah,Lena %A Kiekens,Glenn %A Weermeijer,Jeroen %A Uyttebroek,Lotte %A Wampers,Martien %A Bonnier,Rafaël %A Myin-Germeys,Inez %K digital self-monitoring %K technology appropriation %K experience sampling method %K mental health care %K mental health %K self-monitoring %K digital health %K adoption %K implementation %K thematic %K usability %K interview %K experience %K attitude %K opinion %K perception %K perspective %K acceptance %D 2025 %7 3.3.2025 %9 %J JMIR Hum Factors %G English %X Background: Digital self-monitoring tools, such as the experience sampling method (ESM), enable individuals to collect detailed information about their mental health and daily life context and may help guide and support person-centered mental health care. However, similar to many digital interventions, the ESM struggles to move from research to clinical integration. To guide the implementation of self-monitoring tools in mental health care, it is important to understand why and how clinicians and clients adopted, adapted, and incorporated these tools in practice. Objective: Therefore, this study examined how clinicians and clients within a psychiatric center appropriated an ESM-based self-monitoring tool within their therapy. Methods: Twelve clinicians and 24 clients participated in the piloting of the ESM tool, IMPROVE. After utilizing the tool, 7 clinicians and 11 clients took part in semistructured interviews. A thematic framework analysis was performed focusing on participants’ prior knowledge and expectations, actual use in practice, and potential future use of ESM tools. Results: Many participants experienced that the ESM tool provided useful information about clients’ mental health, especially when clinicians and clients engaged in collaborative data interpretation. However, clinicians experienced several mismatches between system usability and their technical competencies, and many clients found it difficult to comply with the self-assessments. Importantly, most participants wanted to use digital self-monitoring tools in the future. Conclusions: Clinicians’ and clients’ choice to adopt and integrate self-monitoring tools in their practice seems to depend upon the perceived balance between the added benefits and the effort required to achieve them. Enhancing user support or redesigning ESM tools to reduce workload and data burden could help overcome implementation barriers. Future research should involve end users in the development of ESM self-monitoring tools for mental health care and further investigate the perspectives of nonadopters. %R 10.2196/60096 %U https://humanfactors.jmir.org/2025/1/e60096 %U https://doi.org/10.2196/60096 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56418 %T Depression Self-Care Apps’ Characteristics and Applicability to Older Adults: Systematic Assessment %A Yin,Ruoyu %A Rajappan,Dakshayani %A Martinengo,Laura %A Chan,Frederick H F %A Smith,Helen %A Griva,Konstadina %A Subramaniam,Mythily %A Tudor Car,Lorainne %+ Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Clinical Sciences Building, Singapore, 308232, Singapore, 65 65138572, l.tudor.car@imperial.ac.uk %K older adults %K elder %K elderly %K mental health %K mental illness %K mental disorders %K mHealth %K mobile health %K mobile application %K app %K application %K smartphone %K depression %K self-care %K mobile apps %K systematic assessment %K assessment %K effectiveness %K self-care %K Android app %K mental health apps %K mobile interventions %K behaviour %K therapy %K mood monitoring %K adaptations %K online communities %K impairments %D 2025 %7 21.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression affects 32% of older adults. Loneliness and social isolation are common risk factors for depression in older adults. Mobile apps can connect users and are also effective in depression management in the general population. However, older adults have specific needs in terms of the content of depression self-care interventions and their accessibility. It remains unknown whether existing apps for depression self-care are applicable to older adults. Objective: The initial aim of this assessment was to systematically identify interactive depression self-care apps specifically designed for older adults. As we did not find any, we assessed the applicability of existing depression self-care apps to the needs of older adult users. Methods: Using an established app assessment methodology, we searched for Android and iOS interactive mental health apps providing self-care for depression in English and Chinese in the 42Matters database, Chinese Android app stores, and the first 10 pages of Google and Baidu. We developed an assessment rubric based on extensive revision of the literature. The rubric consisted of the following sections: general characteristics of the apps (eg, developer, platform, and category), app content (eg, epidemiology and risk factors of depression in older adults, techniques to improve mood and well-being), and technical aspects (eg, accessibility, privacy and confidentiality, and engagement). Results: We identified 23 apps (n=19, 82.6%, English and n=4, 17.4%, Chinese apps), with 5 (21.7%) iOS-only apps, 3 (13%) Android-only apps, and 15 (65.2%) apps on both platforms. None specifically targeted older adults with depression. All apps were designed by commercial companies and were free to download. Most of the apps incorporated cognitive behavior therapy, mood monitoring, or journaling. All but 3 (13%) apps had a privacy and confidentiality policy. In addition, 14 (60.9%) apps covered depression risk factors in older adults, and 3 (13%) apps delivered information about depression epidemiology in older adults via a chatbot. Furthermore, 17 (73.9%) apps mentioned other topics relevant to older adults, such as pain management, grief, loneliness, and social isolation. Around 30% (n=7) of the apps were supported by an online forum. Common accessibility issues included a lack of adaptations for users with visual or hearing impairments and incompatibility with larger font sizes in the phone settings. Conclusions: There are no depression apps developed specifically for older adults. Available mobile apps have limited applicability to older adults in terms of their clinical and technical features. Depression self-care apps should aim to incorporate content relevant to older adults, such as grief and loss; include online communities; and improve accessibility to adapt to potential health impairments in older adults. %M 39983112 %R 10.2196/56418 %U https://www.jmir.org/2025/1/e56418 %U https://doi.org/10.2196/56418 %U http://www.ncbi.nlm.nih.gov/pubmed/39983112 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e57512 %T Nomophobia, Psychopathology, and Smartphone-Inferred Behaviors in Youth With Depression: Longitudinal Study %A Zhang,Tianyi %A Camargo,Andres %A Schmaal,Lianne %A Kostakos,Vassilis %A D'Alfonso,Simon %+ School of Computing and Information Systems, University of Melbourne, Level 4, Melbourne Connect (Building 290), Melbourne, 3010, Australia, 61 449930128, tianyiz4@student.unimelb.edu.au %K mobile sensing %K nomophobia %K digital phenotyping %K depression %K mental health %K smartphone use %K personal sensing %K behavior analysis %K machine learning %K mobile health %K mobile phone %D 2025 %7 19.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Smartphones have become an indispensable part of people’s lives, and the fear of being without them, what has been termed “no mobile phone phobia” (nomophobia), is a growing phenomenon. The rise of problematic smartphone use highlights the urgent need to explore the intricate relationship between smartphones and human behavior. However, the connections between nomophobia, mental health indicators, smartphone use patterns, and daily activities remain largely underexplored. Objective: This study aimed to explore the relationship between young adults with depression and smartphones and investigate nomophobia by analyzing data obtained from a pilot study of depression in a youth cohort. Exploring nomophobia can enhance our understanding of the dynamics between young adults and smartphone use, potentially empowering them to manage and regulate their smartphone use more effectively. Methods: During an 8-week period, data collected via smartphone sensors, such as locations and screen status, were gathered from a cohort of 41 individuals diagnosed with major depressive disorder. In addition to passive-sensing smartphone data, the study collected ecological momentary assessments and psychometric measures, including the Nomophobia Questionnaire, which formed the basis of our investigation. We explored statistical associations among smartphone-derived behavioral features, psychometric indicators, and nomophobia. In addition, we used behavioral and psychometric data to develop regression models demonstrating the prediction of nomophobia levels. Results: Our findings revealed that the level of nomophobia was positively associated with depression and negative affect, lower geolocation movements, and higher comfort with smartphone sensing. The exploratory predictive linear regression models demonstrated the feasibility of predicting an individual’s Nomophobia Questionnaire score based on their smartphone sensing data. These models effectively used input features derived from both a combination of smartphone sensing data and psychometric measures and from smartphone sensing data alone. Conclusions: Our work is the first to explore the relationship between nomophobia and smartphone sensor data. It provides valuable insights into the predictors of nomophobia level, contributing to the understanding of the relationship between smartphones and human behavior and paving the way for future studies. %M 39969982 %R 10.2196/57512 %U https://formative.jmir.org/2025/1/e57512 %U https://doi.org/10.2196/57512 %U http://www.ncbi.nlm.nih.gov/pubmed/39969982 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e62663 %T Designing a Smartphone-Based Virtual Reality App for Relaxation: Qualitative Crossover Study %A Verstegen,Amandine %A Van Daele,Tom %A Bonroy,Bert %A Debard,Glen %A Sels,Romy %A van Loo,Marlon %A Bernaerts,Sylvie %+ Psychology and technology, Centre of Expertise - Care and Well-being, Thomas More University of Applied Sciences, Molenstraat 8, Antwerp, 2018, Belgium, 32 34324050, sylvie.bernaerts@thomasmore.be %K smartphone-based virtual reality %K virtual reality %K relaxation %K stress %K user experience %K mobile phone %D 2025 %7 13.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Accumulating evidence supports the use of virtual reality (VR) in mental health care, with one potential application being its use to assist individuals with relaxation exercises. Despite studies finding support for the potential of VR to effectively aid in relaxation, its implementation remains limited outside of specialized clinics. Known barriers are insufficient knowledge regarding VR operation, lack of availability of VR relaxation apps tailored to local health care systems, and cost concerns. Unfortunately, many VR relaxation apps are designed exclusively for stand-alone headsets, limiting accessibility for a broad audience. Objective: We aimed to design an accessible, smartphone-based VR relaxation app based on user preferences. This paper describes the assessment of 2 stand-alone VR relaxation apps and the resulting smartphone-based VR relaxation app design. Methods: Overall, 30 participants (n=23, 77% women; n=7, 23% men) took part in 2 separate VR sessions, assessing 1 of the 2 VR relaxation apps (Flowborne and Calm Place) in each session. After each session, participants were presented with open-ended questions to assess their experiences via a web-based survey tool. These questions explored positive and negative features, shortcomings, and suggestions for improvements while also allowing space for additional remarks concerning the 2 VR relaxation apps. Three of the authors analyzed the responses using inductive thematic analysis, a process comprising 6 phases. Results: Across both the apps, 5 recurring themes and 13 recurring subthemes were identified in the participants’ answers: audio (music and sounds, guidance), visuals (content, realism, variation and dynamics in the environment), features (language, options, feedback and instructions, duration, exercise), implementation (technical aspects, cybersickness, acceptability and usability), and experience. We analyzed the participants’ findings and conducted a literature review, which served as the basis for developing the app. The resulting app is a Dutch-language, smartphone-based VR relaxation app, with customization options including 3 types of relaxation exercises, 2 guiding voices, and 3 different environments. Efforts have been made to ensure maximum variation and dynamism in the environments. Calming music and nature sounds accompany the exercises. The efficacy and effectiveness of the resulting app design were not assessed. Conclusions: This study provides insights into key features of VR relaxation apps, which were subsequently used for the development of a novel smartphone-based VR relaxation app. Further research concerning the effectiveness of this app, along with a broader evaluation of the efficacy and user feedback for smartphone-based VR relaxation apps, is needed. More generally, there is a clear need for more research on the impact of interactivity, biofeedback, and type of environment in VR relaxation. %M 39946693 %R 10.2196/62663 %U https://formative.jmir.org/2025/1/e62663 %U https://doi.org/10.2196/62663 %U http://www.ncbi.nlm.nih.gov/pubmed/39946693 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e58434 %T Assessing the Uses, Benefits, and Limitations of Digital Technologies Used by Health Professionals in Supporting Obesity and Mental Health Communication: Scoping Review %A Kearns,Amanda %A Moorhead,Anne %A Mulvenna,Maurice %A Bond,Raymond %+ Life and Health Sciences, Institute for Nursing and Health Research, Ulster University, 2-24 York Street, Belfast, BT15 1AP, United Kingdom, 44 7706848477, kearns-a7@ulster.ac.uk %K digital communication %K digital technology %K digital transformation %K health professional %K mental health %K obesity %K complex needs %K artificial intelligence %K AI %K PRISMA %D 2025 %7 10.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Obesity and mental health issues present interconnected public health challenges that impair physical, social, and mental well-being. Digital technologies offer potential for enhancing health care communication between health professionals (HPs) and individuals living with obesity and mental health issues, but their effectiveness is not fully understood. Objective: This scoping review aims to identify and understand the different types of technologies used by HPs in supporting obesity and mental health communication. Methods: A comprehensive scoping review, which followed a validated methodology, analyzed studies published between 2013 and 2023 across 8 databases. The data extraction focused on HPs’ use of communication technologies, intervention types, biopsychosocial considerations, and perceptions of technology use. The review was guided by the following research question: “What are the uses, benefits, and limitations of digital technologies in supporting communication between HPs and persons living with obesity and mental health issues?” Results: In total, 8 studies—featuring web-based platforms, social media, synchronous video calls, telephone calls, automated SMS text messaging, and email—met the inclusion criteria. Technologies such as virtual learning collaborative dashboards and videoconferencing, supported by automated SMS text messaging and social media (Facebook and WhatsApp groups), were commonly used. Psychologists, dietitians, social workers, and health coaches used digital tools to facilitate virtual appointments, diet and mental health monitoring, and motivational and educational support through group therapy, 1-on-1 sessions, and hybrid models. Benefits included enhanced access to care and engagement, personalized digital cognitive behavioral therapy, perceived stigma reduction, privacy, and improved physical health outcomes in weight reduction. However, improvements in mental health outcomes were not statistically significant in studies reporting P values (P≥.05). The limitations included engagement difficulties due to conflicting personal family and work commitments; variable communication mode preferences, with some preferring in-person sessions; and misinterpretations of SMS text messaging prompts. Conflicts arose from cultural and individual differences, weight stigma, and confusion over HP roles in obesity and mental health care. Conclusions: Digital technologies have diversified the approaches HPs can take in delivering education, counseling, and motivation to individuals with obesity and mental health issues, facilitating private, stigma-reduced environments for personalized care. While the interventions were effective in obesity management, the review revealed a shortfall in addressing mental health needs. This highlights an urgent need for digital tools to serve as media for a deeper engagement with individuals’ complex biopsychosocial needs. The integration of data science and technological advancements offers promising avenues for tailored digital solutions. The findings advocate the importance of continued innovation and adaptation in digital health care communication strategies, with clearer HP roles and an interdisciplinary, empathetic approach focused on individual needs. %M 39928923 %R 10.2196/58434 %U https://www.jmir.org/2025/1/e58434 %U https://doi.org/10.2196/58434 %U http://www.ncbi.nlm.nih.gov/pubmed/39928923 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56203 %T Efficacy of a Blended Low-Intensity Internet-Delivered Psychological Program in Patients With Multimorbidity in Primary Care: Randomized Controlled Trial %A Monreal-Bartolomé,Alicia %A Castro,Adoración %A Pérez-Ara,M Ángeles %A Gili,Margalida %A Mayoral,Fermín %A Hurtado,María Magdalena %A Varela Moreno,Esperanza %A Botella,Cristina %A García-Palacios,Azucena %A Baños,Rosa M %A López-Del-Hoyo,Yolanda %A García-Campayo,Javier %A Montero-Marin,Jesus %+ Aragon Institute for Health Research, IIS Aragon, C. de Pedro Cerbuna, 12, Zaragoza, 50009, Spain, 34 686 673 302, jgarcamp@gmail.com %K multimorbidity %K depression %K type 2 diabetes %K low back pain %K primary care %K blended %K internet %K randomized controlled trial %K RCT %D 2025 %7 10.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Multimorbidity is a highly prevalent phenomenon whose presence causes a profound physical, psychological, and economic impact. It hinders help seeking, diagnosis, quality of care, and adherence to treatment, and it poses a significant dilemma for present-day health care systems. Objective: This study aimed to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression and type 2 diabetes or low back pain) in primary care settings. Methods: A 2-armed, parallel-group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to “intervention + iTAU” (combining a face-to-face intervention with a supporting web-based program) or “iTAU” alone. The main outcome consisted of a standardized composite score to consider (1) severity of depressive symptoms and (2a) diabetes control or (2b) pain intensity and physical disability 3 months after the end of treatment as the primary end point. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity and openness to the future. Results: At 3-month follow-up, the intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B=–0.34, 95% CI –0.64 to –0.04; Hedges g=0.39) as well as in depression and negative affect and improvements in perceived health, positive affect, and openness to the future. Similar positive effects were observed after the intervention, including improvements in physical disability. No significant differences were found in glycosylated hemoglobin, pain intensity, or disability at 3-month follow-up (P=.60; P=.79; and P=.43, respectively). Path analyses revealed that the intervention had a significant impact on the primary outcome, mediated by both positive and negative affect (positive affect: indirect effect=–0.15, bootstrapped 95% CI –0.28 to –0.03; negative affect: indirect effect=–0.14, bootstrapped 95% CI –0.28 to –0.02). Conclusions: This study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in primary care. It justifies the exploration of the conceptualization of depression in type 2 diabetes as well as the analysis of the implementation of such interventions in routine clinical practice. Trial Registration: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709 International Registered Report Identifier (IRRID): RR2-10.1186/S12888-019-2037-3 %M 39928931 %R 10.2196/56203 %U https://www.jmir.org/2025/1/e56203 %U https://doi.org/10.2196/56203 %U http://www.ncbi.nlm.nih.gov/pubmed/39928931 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 13 %N %P e56185 %T Utility of Digital Phenotyping Based on Wrist Wearables and Smartphones in Psychosis: Observational Study %A Yang,Zixu %A Heaukulani,Creighton %A Sim,Amelia %A Buddhika,Thisum %A Abdul Rashid,Nur Amirah %A Wang,Xuancong %A Zheng,Shushan %A Quek,Yue Feng %A Basu,Sutapa %A Lee,Kok Wei %A Tang,Charmaine %A Verma,Swapna %A Morris,Robert J T %A Lee,Jimmy %K schizophrenia %K psychosis %K digital phenotyping %K wrist wearables %K mobile phone %D 2025 %7 5.2.2025 %9 %J JMIR Mhealth Uhealth %G English %X Background: Digital phenotyping provides insights into an individual’s digital behaviors and has potential clinical utility. Objective: In this observational study, we explored digital biomarkers collected from wrist-wearable devices and smartphones and their associations with clinical symptoms and functioning in patients with schizophrenia. Methods: We recruited 100 outpatients with schizophrenia spectrum disorder, and we collected various digital data from commercially available wrist wearables and smartphones over a 6-month period. In this report, we analyzed the first week of digital data on heart rate, sleep, and physical activity from the wrist wearables and travel distance, sociability, touchscreen tapping speed, and screen time from the smartphones. We analyzed the relationships between these digital measures and patient baseline measurements of clinical symptoms assessed with the Positive and Negative Syndrome Scale, Brief Negative Symptoms Scale, and Calgary Depression Scale for Schizophrenia, as well as functioning as assessed with the Social and Occupational Functioning Assessment Scale. Linear regression was performed for each digital and clinical measure independently, with the digital measures being treated as predictors. Results: Digital data were successfully collected from both the wearables and smartphones throughout the study, with 91% of the total possible data successfully collected from the wearables and 82% from the smartphones during the first week of the trial—the period under analysis in this report. Among the clinical outcomes, negative symptoms were associated with the greatest number of digital measures (10 of the 12 studied here), followed by overall measures of psychopathology symptoms, functioning, and positive symptoms, which were each associated with at least 3 digital measures. Cognition and cognitive/disorganization symptoms were each associated with 1 or 2 digital measures. Conclusions: We found significant associations between nearly all digital measures and a wide range of symptoms and functioning in a community sample of individuals with schizophrenia. These findings provide insights into the digital behaviors of individuals with schizophrenia and highlight the potential of using commercially available wrist wearables and smartphones for passive monitoring in schizophrenia. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-046552 %R 10.2196/56185 %U https://mhealth.jmir.org/2025/1/e56185 %U https://doi.org/10.2196/56185 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e57201 %T Evaluating the Effectiveness of InsightApp for Anxiety, Valued Action, and Psychological Resilience: Longitudinal Randomized Controlled Trial %A Amo,Victoria %A Lieder,Falk %+ Max Planck Institute for Intelligent Systems, Max-Planck-Ring 8, Tübingen, 72076, Germany, 49 15730645508, victoria.amo@tuebingen.mpg.de %K ecological momentary intervention %K serious game %K mindfulness-based intervention %K acceptance and commitment therapy %K cognitive behavioral therapy %K metacognition %K stress %K anxiety %K mobile phone %D 2025 %7 4.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anxiety disorders are among the most prevalent mental disorders, and stress plays a significant role in their development. Ecological momentary interventions (EMIs) hold great potential to help people manage stress and anxiety by training emotion regulation and coping skills in real-life settings. InsightApp is a gamified EMI and research tool that incorporates elements from evidence-based therapeutic approaches. It is designed to strengthen people’s metacognitive skills for coping with challenging real-life situations and embracing anxiety and other emotions. Objective: This randomized controlled trial aims to examine the effectiveness of InsightApp in (1) improving individuals’ metacognitive strategies for coping with stress and anxiety and (2) promoting value-congruent action. It also evaluates how long these effects are retained. This experiment advances our understanding of the role of metacognition in emotional and behavioral reactivity to stress. Methods: We conducted a randomized controlled trial with 228 participants (completion rate: n=197, 86.4%; mean age 38, SD 11.50 years; age range 20-80 years; female: n=101, 52.6%; and White: n=175, 91.1%), who were randomly assigned to either the treatment or the active placebo control group. During the 1-week intervention phase, the treatment group engaged with InsightApp, while participants in the control group interacted with a placebo version of the app that delivered executive function training. We assessed the differences between the 2 groups in posttest and follow-up assessments of mental health and well-being while controlling for preexisting differences. Moreover, we used a multilevel model to analyze the longitudinal data, focusing on the within-participant causal effects of the intervention on emotional and behavioral reactivity to daily stressors. Specifically, we measured daily anxiety, struggle with anxiety, and value-congruent action. Results: The intervention delivered by InsightApp yielded mixed results. On one hand, we found no significant posttest scores on mental health and well-being measures directly after the intervention or 7 days later (all P>.22). In contrast, when confronted with real-life stress, the treatment group experienced a 15% lower increase in anxiety (1-tailed t test, t197=–2.4; P=.009) and a 12% lower increase in the struggle with anxiety (t197=–1.87; P=.031) than the control group. Furthermore, individuals in the treatment group demonstrated a 7% higher tendency to align their actions with their values compared to the control group (t197=3.23; P=.002). After the intervention period, InsightApp’s positive effects on the struggle with anxiety in reaction to stress were sustained, and increased to an 18% lower reactivity to stress (t197=–2.84; P=.002). Conclusions: As our study yielded mixed results, further studies are needed to obtain an accurate and reliable understanding of the effectiveness of InsightApp. Overall, our findings tentatively suggest that guiding people to apply adaptive metacognitive strategies for coping with real-life stress daily with a gamified EMI is a promising approach that deserves further evaluation. Trial Registration: OSF Registries osf.io/k3b5d; https://osf.io/k3b5d %M 39904504 %R 10.2196/57201 %U https://mental.jmir.org/2025/1/e57201 %U https://doi.org/10.2196/57201 %U http://www.ncbi.nlm.nih.gov/pubmed/39904504 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e60747 %T Exploring the Differentiation of Self-Concepts in the Physical and Virtual Worlds Using Euclidean Distance Analysis and Its Relationship With Digitalization and Mental Health Among Young People: Cross-Sectional Study %A Chan,Kai Tai %A Hui,Christy LM %A Cheung,Charlton %A Suen,Yi Nam %A Wong,Stephanie Ming Yin %A Wong,Corine SM %A Kam,Bosco PH %A Chen,Eric Yu Hai %+ Department of Psychiatry, University of Hong Kong, Rm 222, New Clinical Buildling, Queen Mary Hospital, 102, Pokfulam Road, Hong Kong, China (Hong Kong), 852 22554486, ericchen.hku@gmail.com %K digitalization %K self %K identity %K psychiatric symptomatology %K youth mental health %K Euclidean distance analysis %K self-differentiation %K smartphone addiction %K personal attributes %D 2025 %7 31.1.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Increasing observation and evidence suggest that the process of digitalization could have profound impact to the development of human mind and self, with potential mental health consequences. Self-differentiation is important in human identity and self-concept formation, which is believed to be involved in the process of digitalization. Objective: This study aimed to investigate the relationship between digitalization and personal attributes in the actual selves in the physical and virtual worlds. Methods: A community cohort of 397 participants aged 15 to 24 years old was recruited consecutively over about 3 months. Assessment was conducted upon the indicators of digitalization (smartphone use time, leisure online time, and age of first smartphone ownership), smartphone addiction, 14 selected personal attributes in the actual selves in the physical and virtual worlds, psychiatric symptomatology and personality traits. Euclidean distance analysis between the personal attributes in the actual selves in the physical and virtual worlds for the similarities of the 2 selves was performed in the analysis. Results: The current primary findings are the negative correlations between the similarity of the personal attributes in the physical actual self and virtual actual self, and smartphone use time, smartphone addiction as well as anxiety symptomatology respectively (P<.05 to P<.01). Conclusions: The current findings provide empirical evidence for the importance of maintaining a congruent self across the physical and virtual worlds, regulating smartphone use time, preventing smartphone addiction, and safeguarding mental health. %M 39889302 %R 10.2196/60747 %U https://mental.jmir.org/2025/1/e60747 %U https://doi.org/10.2196/60747 %U http://www.ncbi.nlm.nih.gov/pubmed/39889302 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e54216 %T Self-Guided Smartphone App (Vimbo) for the Reduction of Symptoms of Depression and Anxiety in South African Adults: Pilot Quantitative Single-Arm Study %A Steyn,Sherrie %A Slabbert,Meggan %+ Vimbo Health SA (Pty) Ltd, 20 Riverclub Mews, 7 Sycamore Avenue, Riverclub, Sandton, 2191, South Africa, 27 63 861 6780, sherrie@vimbohealth.com %K treatment gap %K mental health %K health %K depression %K anxiety %K South Africa %K CBT %K cognitive behavioral therapy %K app-based intervention %K mobile health %K mental health app %K smartphone %K mobile phone %D 2025 %7 30.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Barriers to mental health assessment and intervention have been well documented within South Africa, in both urban and rural settings. Internationally, evidence has emerged for the effectiveness of technology and, specifically, app-based mental health tools and interventions to help overcome some of these barriers. However, research on digital interventions specific to the South African context and mental health is limited. Objective: This pilot study investigated the feasibility of using an app (Vimbo) to treat symptoms of anxiety and depression in South African adults recruited from a community sample. The Vimbo app is a self-guided, cognitive behavioral therapy–based digital intervention for common mental health difficulties developed for the South African context. Methods: This pilot study used a naturalistic, single-arm design testing the Vimbo app over 12 weeks, from October 2020 to February 2021. Participants were recruited through the South African Depression and Anxiety Group and social media advertisements online. A 2-week retention period was used to allow for a minimum of 2 datasets. App usage and engagement metrics were extracted directly from the back end of the app. Based on the model, researchers expected many users to discontinue usage when their symptom levels entered a healthy range. Pre-post review of symptom levels was used to reflect on clinical recovery status at discontinuation after the retention period. Results: A total of 218 applicants met study eligibility criteria and were invited to download the Vimbo app. Of these, 52% (114/218) of the participants registered with the app, who indicated multiple variances of depression and anxiety symptoms ranging in severity from mild to severe. Two participants users withdrew from the study. Moreover, 69% (77/112) of users were retained, including 8 who had technical issues with their treatment. When comparing broad uptake across all interested participants, chi-square analysis indicated significantly reduced uptake in participants identifying as “unemployed but seeking employment” (χ24=10.47; N=251; P=.03). When considering app usage for the entire cohort (n=69, excluding participants with technical issues), there was a mean of 72.87 (SD 71.425) total module pages read, a mean of 30% (SD 29.473%) of prescribed content completed, and a mean of 19.93 (SD 27.517) times engaging with tools and skills. Conclusions: Our findings support the case for continued exploration of app-based interventions for treating depression and anxiety in South Africa. Developing strategies to increase access and improve intervention uptake may prove essential to helping mobile health interventions make as significant an impact as possible. Future research should include a randomized controlled trial with a larger sample to further assess the efficacy of app-based interventions in treating mental health difficulties in South Africa. %M 39883938 %R 10.2196/54216 %U https://formative.jmir.org/2025/1/e54216 %U https://doi.org/10.2196/54216 %U http://www.ncbi.nlm.nih.gov/pubmed/39883938 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e65222 %T Testing the Feasibility, Acceptability, and Potential Efficacy of an Innovative Digital Mental Health Care Delivery Model Designed to Increase Access to Care: Open Trial of the Digital Clinic %A Macrynikola,Natalia %A Chen,Kelly %A Lane,Erlend %A Nguyen,Nic %A Pinto,Jennifer %A Yen,Shirley %A Torous,John %+ Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States, 1 617 667 4735, jtorous@bidmc.harvard.edu %K digital interventions %K transdiagnostic treatment %K evidence-based treatment %K digital navigator %K access to care %K mobile phone %D 2025 %7 29.1.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health concerns have become increasingly prevalent; however, care remains inaccessible to many. While digital mental health interventions offer a promising solution, self-help and even coached apps have not fully addressed the challenge. There is now a growing interest in hybrid, or blended, care approaches that use apps as tools to augment, rather than to entirely guide, care. The Digital Clinic is one such model, designed to increase access to high-quality mental health services. Objective: To assess the feasibility, acceptability, and potential efficacy of the Digital Clinic model, this study aims to conduct a nonrandomized open trial with participants experiencing depression, anxiety, or both, at various levels of clinical severity. Methods: Clinicians were trained in conducting brief transdiagnostic evidence-based treatment augmented by a mental health app (mindLAMP); digital navigators were trained in supporting participants’ app engagement and digital literacy while also sharing app data with both patients and clinicians. Feasibility and acceptability of this 8-week program were assessed against a range of benchmarks. Potential efficacy was assessed by calculating pre-post change in symptoms of depression (Patient Health Questionnaire-9; PHQ-9), anxiety (7-item Generalized Anxiety Disorder; GAD-7), and comorbid depression and anxiety (Patient Health Questionnaire Anxiety and Depression Scale; PHQ-ADS), as well as rates of clinically meaningful improvement and remission. Secondary outcomes included change in functional impairment, self-efficacy in managing emotions, and flourishing. Results: Of the 258 enrolled participants, 215 (83.3%) completed the 8-week program. Most were White (n=151, 70.2%) and identified as cisgender women (n=136, 63.3%), with a mean age of 41 (SD 14) years. Feasibility and acceptability were good to excellent across a range of domains. The program demonstrated potential efficacy: the average PHQ-9 score was moderate to moderately severe at baseline (mean 13.39, SD 4.53) and decreased to subclinical (mean 7.79, SD 4.61) by the end of the intervention (t126=12.50, P<.001, Cohen d=1.11). Similarly, the average GAD-7 score decreased from moderate at baseline (mean 12.93, SD 3.67) to subclinical (mean 7.35, SD 4.19) by the end of the intervention (t113=13, P<.001, Cohen d=1.22). Participation in the program was also associated with high rates of clinically significant improvement and remission. Conclusions: Results suggest that the Digital Clinic model is feasible, acceptable, and potentially efficacious, warranting a future randomized controlled trial to establish the efficacy of this innovative model of care. %M 39879612 %R 10.2196/65222 %U https://mental.jmir.org/2025/1/e65222 %U https://doi.org/10.2196/65222 %U http://www.ncbi.nlm.nih.gov/pubmed/39879612 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e59461 %T Feasibility of a Mobile App–Based Cognitive-Behavioral Perinatal Skills Program: Protocol for Nonrandomized Pilot Trial %A Temkin-Yu,Andrea B %A Ayaz,Aliza %A Blicker,Ella %A Liu,Michael X %A Oh,Ace %A Siegel,Isabelle E %A Seewald,Meredith J %A Hermann,Alison D %A Givrad,Soudebah %A Baez,Lara M %A Osborne,Lauren M %A Green,Cori M %A Schier,Maddy M %A Davis,Alexandra M %A Zhu,Shasha %A Falk,Avital %A Bennett,Shannon M %+ Psychiatry Department, Weill Cornell Medicine, 525 E 68th Street, New York, NY, 10065, United States, 1 6402038301, andreabtemkin@gmail.com %K perinatal mood and anxiety disorders %K apps %K smartphones %K digital intervention %K cognitive behavioral therapy %K feasibility %K pilot trial %K mobile phones %D 2025 %7 28.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental illness is one of the top causes of preventable pregnancy-related deaths in the United States. There are many barriers that interfere with the ability of perinatal individuals to access traditional mental health care. Digital health interventions, including app-based programs, have the potential to increase access to useful tools for these individuals. Although numerous mental health apps exist, there is little research on developing programs to address the unique needs of perinatal individuals. In an effort to fill this gap, a multidisciplinary team of experts in psychology, psychiatry, obstetrics, and pediatric primary care collaborated to develop the novel Perinatal Skills Program within Maya, a flexible and customizable cognitive-behavioral skills app. Maya-Perinatal Skills Program (M-PSP) uses evidence-based strategies to help individuals manage their mood and anxiety symptoms during pregnancy and post partum. Objective: This pilot study aims to assess the feasibility, acceptability, and usability of M-PSP and explore links between program use and symptoms of anxiety and low mood. Methods: This single-arm trial will recruit 50 pregnant or postpartum individuals with mild-to-moderate anxiety or mood symptoms. Participants will be recruited from a variety of public and private insurance-based psychiatry, obstetrics, and primary care clinics at a large academic medical center located in New York City. Participants will complete all sessions of M-PSP and provide feedback. Outcome measures will include qualitative and quantitative assessments of feasibility, acceptability, and usability, passively collected program usage data, and symptom measures assessing mood, anxiety, and trauma. Planned data analysis includes the use of the grounded theory approach to identify common themes in qualitative feedback, as well as an exploration of possible associations between quantitative data regarding program use and symptoms. Results: The recruitment began on August 2023. As of October 2024, a total of 32 participants have been enrolled. The recruitment will continue until 50 participants have been enrolled. Conclusions: Digital health interventions, like M-PSP, have the potential to create new pathways to reach individuals struggling with their mental health. The results of this study will be the groundwork for future iterations of M-PSP in the hopes of providing an accessible and helpful tool for pregnant and postpartum individuals. Trial Registration: ClinicalTrials.gov NCT05897619; https://classic.clinicaltrials.gov/ct2/show/NCT05897619 International Registered Report Identifier (IRRID): PRR1-10.2196/59461 %M 39874578 %R 10.2196/59461 %U https://www.researchprotocols.org/2025/1/e59461 %U https://doi.org/10.2196/59461 %U http://www.ncbi.nlm.nih.gov/pubmed/39874578 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e64959 %T Establishment and Maintenance of a Digital Therapeutic Alliance in People Living With Negative Symptoms of Schizophrenia: Two Exploratory Single-Arm Studies %A Snipes,Cassandra %A Dorner‑Ciossek,Cornelia %A Hare,Brendan D %A Besedina,Olya %A Campellone,Tim %A Petrova,Mariya %A Lakhan,Shaheen E %A Pratap,Abhishek %+ Boehringer Ingelheim International GmbH, Binger Straße 173, Ingelheim am Rhein, 55216, Germany, 49 (7351) 54 97758, cornelia.dorner-ciossek@boehringer-ingelheim.com %K therapeutic alliance %K digital working alliance %K experiential negative symptoms %K schizophrenia %K digital therapeutics %K digital literacy %D 2025 %7 27.1.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Evidence-based digital therapeutics represent a new treatment modality in mental health, potentially providing cost-efficient, accessible means of augmenting existing treatments for chronic mental illnesses. CT-155/BI 3972080 is a prescription digital therapeutic under development as an adjunct to standard of care treatments for patients 18 years of age and older with experiential negative symptoms (ENS) of schizophrenia. Individual components of CT-155/BI 3972080 are designed based on the underlying principles of face-to-face treatment. A positive therapeutic alliance between patients and health care providers is linked with improved clinical outcomes in mental health. Likewise, establishing a similar therapeutic alliance with a digital therapeutic (ie, digital working alliance [DWA]) may be important for engagement and treatment effectiveness of this modality. Objective: This study aimed to investigate the establishment and maintenance of a DWA between a beta version of CT-155/BI 3972080 (CT-155 beta) and adults with ENS of schizophrenia. Methods: Two multicenter, exploratory, single-arm studies (study 1: CT-155-C-001 and study 2: CT-155-C-002) enrolled adults with schizophrenia and ENS receiving stable antipsychotic medication (≥12 weeks). Participants had access to CT-155 beta and were presented with daily in-app activities during a 3-week orientation phase that included lessons designed to facilitate building of a DWA. In study 2, the 3-week orientation phase was followed by an abbreviated active 4-week phase. Digital literacy at baseline was evaluated using the Mobile Device Proficiency Questionnaire (MDPQ). The mobile Agnew Relationship Measure (mARM) was used to assess DWA establishment after 3 weeks in both studies, and after 7 weeks in study 2 to assess DWA maintenance. Participant safety, digital literacy, and correlations between negative symptom severity and DWA were assessed in both studies. Results: Of the enrolled participants, 94% (46/49) and 86% (43/50) completed studies 1 and 2, respectively. Most were male (study 1: 71%, 35/49; study 2: 80%, 40/50). The baseline digital literacy assessed through MDPQ score was comparable in both studies (study 1: mean 30.56, SD 8.06; study 2: mean 28.69, SD 8.31) indicating proficiency in mobile device use. After 3 weeks, mARM scores (study 1: mean 5.16, SD 0.8; study 2: mean 5.36, SD 1.06) indicated that a positive DWA was established in both studies. In study 2, the positive DWA established at week 3 was maintained at week 7 (mARM: mean 5.48, SD 0.97). There were no adverse events (AEs) in study 1, and 3 nonserious and nontreatment-related AEs in study 2. Conclusions: A positive DWA was established between participants and CT-155 beta within 3 weeks. The second 7-week study showed maintenance of the DWA to the end of the study. Results support the establishment and maintenance of a DWA between adults with ENS of schizophrenia and a beta version of CT-155/BI 3972080, a prescription digital therapeutic under development to target these symptoms. Trial Registration: Clinicaltrials.gov NCT05486312; https://clinicaltrials.gov/study/NCT05486312 %M 39869902 %R 10.2196/64959 %U https://mental.jmir.org/2025/1/e64959 %U https://doi.org/10.2196/64959 %U http://www.ncbi.nlm.nih.gov/pubmed/39869902 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e65246 %T Barriers and Facilitators of User Engagement With Digital Mental Health Interventions for People With Psychosis or Bipolar Disorder: Systematic Review and Best-Fit Framework Synthesis %A Eisner,Emily %A Faulkner,Sophie %A Allan,Stephanie %A Ball,Hannah %A Di Basilio,Daniela %A Nicholas,Jennifer %A Priyam,Aansha %A Wilson,Paul %A Zhang,Xiaolong %A Bucci,Sandra %+ Division of Psychology and Mental Health, University of Manchester, Jean McFarlane Building, Manchester, M13 9PL, United Kingdom, 44 1613066000, emily.eisner@manchester.ac.uk %K psychosis %K bipolar %K schizophrenia %K smartphone %K digital %K wearable %K mobile phone %K PRISMA %D 2025 %7 20.1.2025 %9 Review %J JMIR Ment Health %G English %X Background: Digital mental health interventions (DMHIs) to monitor and improve the health of people with psychosis or bipolar disorder show promise; however, user engagement is variable, and integrated clinical use is low. Objective: This prospectively registered systematic review examined barriers and facilitators of clinician and patient engagement with DMHIs, to inform implementation within real-world settings. Methods: A systematic search of 7 databases identified empirical studies reporting qualitative or quantitative data about factors affecting staff or patient engagement with DMHIs aiming to monitor or improve the mental or physical health of people with psychosis or bipolar disorder. The Consolidated Framework for Implementation Research was used to synthesize data on barriers and facilitators, following a best-fit framework synthesis approach. Results: The review included 175 papers (150 studies; 11,446 participants) describing randomized controlled trials; surveys; qualitative interviews; and usability, cohort, and case studies. Samples included people with schizophrenia spectrum psychosis (98/150, 65.3% of studies), bipolar disorder (62/150, 41.3% of studies), and clinicians (26/150, 17.3% of studies). Key facilitators were a strong recognition of DMHIs’ relative advantages, a clear link between intervention focus and specific patient needs, a simple, low-effort digital interface, human-supported delivery, and device provision where needed. Although staff thought patients would lose, damage, or sell devices, reviewed studies found only 11% device loss. Barriers included intervention complexity, perceived risks, user motivation, discomfort with self-reflection, digital poverty, symptoms of psychosis, poor compatibility with existing clinical workflows, staff and patient fears that DMHIs would replace traditional face-to-face care, infrastructure limitations, and limited financial support for delivery. Conclusions: Identified barriers and facilitators highlight key considerations for DMHI development and implementation. As to broader implications, sustainable business models are needed to ensure that evidence-based DMHIs are maintained and deployed. Trial Registration: PROSPERO CRD42021282871; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=282871 %M 39832352 %R 10.2196/65246 %U https://mental.jmir.org/2025/1/e65246 %U https://doi.org/10.2196/65246 %U http://www.ncbi.nlm.nih.gov/pubmed/39832352 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e57614 %T A Mobile Health Intervention to Support Collaborative Decision-Making in Mental Health Care: Development and Usability %A Romm,Kristin Lie %A Skoge,Mari %A Barrett,Elizabeth Ann %A Berentzen,Lars-Christian %A Bergsager,Dagfinn %A Fugelli,Pål %A Bjella,Thomas %A Gardsjord,Erlend Strand %A Kling,Kristine %A Kruse,Sindre Hembre %A Kværner,Kari Jorunn %A Melle,Ingrid %A Mork,Erlend %A Ihler,Henrik Myhre %A Rognli,Eline Borger %A Simonsen,Carmen %A Værnes,Tor Gunnar %A Aminoff,Sofie Ragnhild %+ Early Intervention in Psychosis Advisory Unit for South-East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Sognsvannsveien 21, Oslo, 0372, Norway, 47 91 50 27 70, k.l.romm@medisin.uio.no %K eHealth %K shared decision-making %K user involvement %K user-centered design %K mental disorder %K mobile technology %K illness course %K recovery %K mobile apps %K mHealth %D 2025 %7 17.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Shared decision-making between clinicians and service users is crucial in mental health care. One significant barrier to achieving this goal is the lack of user-centered services. Integrating digital tools into mental health services holds promise for addressing some of these challenges. However, the implementation of digital tools, such as mobile apps, remains limited, and attrition rates for mental health apps are typically high. Design thinking can support the development of tools tailored to the needs of service users and clinicians. Objective: This study aims to develop and beta test a digital tool designed for individuals with severe mental disorders or substance use disorders to facilitate shared decision-making on treatment goals and strategies within mental health services. Methods: We used a user-centered design approach to develop iTandem, an app facilitating collaborative treatment between service users and clinicians. Through qualitative interviews and workshops, we engaged 6 service users with severe mental disorders or substance use disorders, 6 clinicians, and 1 relative to identify and design relevant app modules. A beta test of iTandem was conducted to refine the app and plan for a pilot trial in a clinical setting. After 6 weeks of app use, 5 clinicians and 4 service users were interviewed to provide feedback on the concept, implementation, and technical issues. Safety and ethical considerations were thoroughly discussed and addressed. Results: To avoid overload for the service users, we applied a pragmatic take on module content and size. Thus, iTandem includes the following 8 modules, primarily based on the needs of service users and clinicians: Sleep (sleep diary), Medication (intake and side effects), Recovery (measures, including well-being and personal recovery, and exercises, including good things and personal strengths), Mood (mood diary and report of daily feelings), Psychosis (level of positive symptoms and their consequences and level of negative symptoms), Activity (goal setting and progress), Substance use (weekly use, potential triggers or strategies used to abstain), and Feedback on therapy (of individual sessions and overall rating of the past week). For the beta testing, service users and clinicians collaborated in choosing 2-3 modules in iTandem to work with during treatment sessions. The testing showed that the app was well received by service users, and that facilitation for implementation is crucial. Conclusions: iTandem and similar apps have the potential to enhance treatment outcomes by facilitating shared decision-making and tailoring treatment to the needs of service users. However, successful implementation requires thorough testing, iterative development, and evaluations of both utility and treatment effects. There is a critical need to focus on how technology integrates into clinical settings—from development to implementation—and to conduct further research on early health technology assessments to guide these processes. %M 39823632 %R 10.2196/57614 %U https://formative.jmir.org/2025/1/e57614 %U https://doi.org/10.2196/57614 %U http://www.ncbi.nlm.nih.gov/pubmed/39823632 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e51022 %T Determinants of Dropout From a Virtual Agent–Based App for Insomnia Management in a Self-Selected Sample of Users With Insomnia Symptoms: Longitudinal Study %A Sanchez Ortuño,María Montserrat %A Pecune,Florian %A Coelho,Julien %A Micoulaud-Franchi,Jean Arthur %A Salles,Nathalie %A Auriacombe,Marc %A Serre,Fuschia %A Levavasseur,Yannick %A De Sevin,Etienne %A Sagaspe,Patricia %A Philip,Pierre %K insomnia %K digital behavioral therapy %K mobile health %K dropout %K virtual agent–based app %K virtual agent %K user %K digital intervention %K smartphone %K mental health %K implementation %K cognitive behavioral therapy %K CBT %D 2025 %7 15.1.2025 %9 %J JMIR Ment Health %G English %X Background: Fully automated digital interventions delivered via smartphone apps have proven efficacious for a wide variety of mental health outcomes. An important aspect is that they are accessible at a low cost, thereby increasing their potential public impact and reducing disparities. However, a major challenge to their successful implementation is the phenomenon of users dropping out early. Objective: The purpose of this study was to pinpoint the factors influencing early dropout in a sample of self-selected users of a virtual agent (VA)–based behavioral intervention for managing insomnia, named KANOPEE, which is freely available in France. Methods: From January 2021 to December 2022, of the 9657 individuals, aged 18 years or older, who downloaded and completed the KANOPEE screening interview and had either subclinical or clinical insomnia symptoms, 4295 (44.5%) dropped out (ie, did not return to the app to continue filling in subsequent assessments). The primary outcome was a binary variable: having dropped out after completing the screening assessment (early dropout) or having completed all the treatment phases (n=551). Multivariable logistic regression analysis was used to identify predictors of dropout among a set of sociodemographic, clinical, and sleep diary variables, and users’ perceptions of the treatment program, collected during the screening interview. Results: The users’ mean age was 47.95 (SD 15.21) years. Of those who dropped out early and those who completed the treatment, 65.1% (3153/4846) were women and 34.9% (1693/4846) were men. Younger age (adjusted odds ratio [AOR] 0.98, 95% CI 0.97‐0.99), lower education level (compared to middle school; high school: AOR 0.56, 95% CI 0.35‐0.90; bachelor’s degree: AOR 0.35, 95% CI 0.23‐0.52; master’s degree or higher: AOR 0.35, 95% CI 0.22‐0.55), poorer nocturnal sleep (sleep efficiency: AOR 0.64, 95% CI 0.42‐0.96; number of nocturnal awakenings: AOR 1.13, 95% CI 1.04‐1.23), and more severe depression symptoms (AOR 1.12, 95% CI 1.04‐1.21) were significant predictors of dropping out. When measures of perceptions of the app were included in the model, perceived benevolence and credibility of the VA decreased the odds of dropout (AOR 0.91, 95% CI 0.85‐0.97). Conclusions: As in traditional face-to-face cognitive behavioral therapy for insomnia, the presence of significant depression symptoms plays an important role in treatment dropout. This variable represents an important target to address to increase early engagement with fully automated insomnia management programs. Furthermore, our results support the contention that a VA can provide relevant user stimulation that will eventually pay out in terms of user engagement. Trial Registration: ClinicalTrials.gov NCT05074901; https://clinicaltrials.gov/study/NCT05074901?a=1 %R 10.2196/51022 %U https://mental.jmir.org/2025/1/e51022 %U https://doi.org/10.2196/51022 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66181 %T Acceptance, Safety, and Effect Sizes in Online Dialectical Behavior Therapy for Borderline Personality Disorder: Interventional Pilot Study %A Vonderlin,Ruben %A Boritz,Tali %A Claus,Carola %A Senyüz,Büsra %A Mahalingam,Saskia %A Tennenhouse,Rachel %A Lis,Stefanie %A Schmahl,Christian %A Margraf,Jürgen %A Teismann,Tobias %A Kleindienst,Nikolaus %A McMain,Shelley %A Bohus,Martin %+ Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, J5, Mannheim, 68159, Germany, 49 621 1703 4445, ruben.vonderlin@zi-mannheim.de %K dialectical behavior therapy %K borderline personality disorder %K online psychotherapy %K virtual psychotherapy %K telehealth %K personality disorders %K mental %K psychotherapy %K online %K internet %K telemedicine %K psychiatry %K psychiatric %K acceptance %D 2025 %7 14.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: The potential of telehealth psychotherapy (ie, the online delivery of treatment via a video web-based platform) is gaining increased attention. However, there is skepticism about its acceptance, safety, and efficacy for patients with high emotional and behavioral dysregulation. Objective: This study aims to provide initial effect size estimates of symptom change from pre- to post treatment, and the acceptance and safety of telehealth dialectical behavior therapy (DBT) for individuals diagnosed with borderline personality disorder (BPD). Methods: A total of 39 individuals meeting the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) criteria for BPD received 1 year of outpatient telehealth DBT at 3 sites in Germany and Canada. Effect size estimates were assessed using pre-post measures of BPD symptoms, dissociation, and quality of life. Safety was evaluated by analyzing suicide attempts and self-harm. Additionally, acceptance and feasibility, satisfaction with treatment, useability of the telehealth format, and the quality of the therapeutic alliance were assessed from both therapists’ and patients’ perspectives. All analyses were conducted on both the intention-to-treat (ITT) and according-to-protocol (ATP) samples. Results: Analyses showed significant and large pre-post effect sizes for BPD symptoms (d=1.13 in the ITT sample and d=1.44 in the ATP sample; P<.001) and for quality of life (d=0.65 in the ITT sample and d=1.24 in the ATP sample). Dissociative symptoms showed small to nonsignificant reductions. Self-harm behaviors decreased significantly from 80% to 28% of all patients showing at least 1 self-harm behavior in the last 10 weeks (risk ratio 0.35). A high dropout rate of 38% was observed. One low-lethality suicide attempt was reported. Acceptance, feasibility, and satisfaction measures were high, although therapists reported only moderate useability of the telehealth format. Conclusions: Telehealth DBT for BPD showed large pre-post effect sizes for BPD symptoms and quality of life. While the telehealth format appeared feasible and well-accepted, the dropout rate was relatively high. Future research should compare the efficacy of telehealth DBT with in-person formats in randomized controlled trials. Overall, telehealth DBT might offer a potentially effective alternative treatment option, enhancing treatment accessibility. However, strategies for decreasing drop-out should be considered. Trial Registration: German Clinical Trials Register DRKS00027824; https://drks.de/search/en/trial/DRKS00027824 %M 39808784 %R 10.2196/66181 %U https://formative.jmir.org/2025/1/e66181 %U https://doi.org/10.2196/66181 %U http://www.ncbi.nlm.nih.gov/pubmed/39808784 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59540 %T Effectiveness of a Videoconference-Based Cognitive Behavioral Therapy Program for Patients with Schizophrenia: Pilot Randomized Controlled Trial %A Katsushima,Masayuki %A Nakamura,Hideki %A Shiko,Yuki %A Hanaoka,Hideki %A Shimizu,Eiji %+ Department of Rehabilitation, Faculty of Health Care and Medical Sports, Teikyo Heisei University, 4-1 UruidoMinami, Ichihara, 290-0193, Japan, 81 436 74 6915, m.katsushima@thu.ac.jp %K schizophrenia %K randomized controlled trial %K cognitive behavioral therapy %K videoconference %K remote therapy %D 2025 %7 14.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Cognitive behavioral therapy for psychosis (CBTp) is not sufficiently widespread in clinical practice, although evidence has been presented. Objective: The purpose of this study was to explore whether one-on-one videoconference-based CBTp (vCBTp) is more effective than usual care (UC) alone for improving psychiatric symptoms in patients with schizophrenia attending outpatient clinics. Methods: In this exploratory randomized controlled trial, patients with schizophrenia and schizoaffective disorders who were still taking medication in an outpatient clinic were randomly assigned to either the vCBTp plus UC group (n=12) or the UC group (n=12). The vCBTp program was conducted once a week, with each session lasting for 50 minutes, for a total of 7 sessions conducted in real-time and in a one-on-one format remotely using a loaned tablet computer (iPad). The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score, which measures the difference in the mean change from baseline (week 0) to posttest (week 8). Results: The study included 24 participants. There were no significant differences between the 2 groups at baseline. With regard to significant differences between the 2 groups in terms of the primary outcome, the mean change in the PANSS total score from baseline to week 8 in the vCBTp plus UC group was –9.5 (95% CI –12.09 to –6.91) and the mean change in the UC alone group was 6.9 (95% CI 1.54-12.30). The difference between the 2 groups was significant (P<.001). In addition, significant improvements were observed in the subscales of positive (P<.001) and negative (P=.004) symptoms and general psychopathology (P<.001). Significant differences were also observed in the secondary outcomes of the General Anxiety Disorder-7 (GAD-7; P=.04) and EQ-5D-5L (P=.005). There were no dropouts and no serious adverse events in this study. Conclusions: A total of 7 remote vCBTp sessions conducted in the vCBTp plus UC group could be safely administered to patients with schizophrenia. They were also observed to be effective for psychiatric symptoms, general anxiety, and quality of life. However, because of the observed worsening of scores in the UC group, caution is required in interpreting significant differences between the 2 groups. This approach is expected to improve accessibility to CBTp for outpatients with schizophrenia and social anxiety regarding transportation use and financial and physical burdens related to transportation, and to contribute to promoting CBTp acceptability by compensating for the shortage of implementers. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000043396; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000049544 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2022-069734 %M 39610049 %R 10.2196/59540 %U https://formative.jmir.org/2025/1/e59540 %U https://doi.org/10.2196/59540 %U http://www.ncbi.nlm.nih.gov/pubmed/39610049 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 13 %N %P e53850 %T A Mobile App–Based Gratitude Intervention’s Effect on Mental Well-Being in University Students: Randomized Controlled Trial %A Fuller,Chloë %A Marin-Dragu,Silvia %A Iyer,Ravishankar Subramani %A Meier,Sandra Melanie %K gratitude intervention %K smartphone app %K gratitude exercises %K psychological well-being %K mobile phone %D 2025 %7 14.1.2025 %9 %J JMIR Mhealth Uhealth %G English %X Background: Gratitude interventions are used to cultivate a sense of gratitude for life and others. There have been mixed results of the efficacy of gratitude interventions’ effect on psychological well-being with a variety of populations and methodologies. Objectives: The objective of our study was to test the effectiveness of a gratitude intervention smartphone app on university students’ psychological well-being. Methods: We used a randomized experimental design to test our objective. Participants were recruited undergraduate students from a web-based university study recruitment system. Participants completed 90 web-based survey questions on their emotional well-being and personality traits at the beginning and end of the 3-week research period. Their depression, anxiety, and stress levels were measured with the Depression, Anxiety, and Stress Scale (DASS-21). After the baseline survey, participants were randomly assigned to either the control or the intervention. Participants in the intervention group used both a fully automated mobile sensing app and a gratitude intervention mobile iOS smartphone app designed for youth users and based on previous gratitude interventions and exercises. The gratitude intervention app prompted users to complete daily gratitude exercises on the app including a gratitude journal, a gratitude photo book, an imagine exercise, a speech exercise, and meditation. Participants in the control group used only the mobile sensing app, which passively collected smartphone sensory data on mobility, screen time, sleep, and social interactions. Results: A total of 120 participants met the inclusion criteria, and 27 were lost to follow-up for a total of 41 participants in the intervention group and 52 in the control group providing complete data. Based on clinical cutoffs from the baseline assessment, 56 out of 120 participants were identified as being in a subsample with at least moderate baseline symptomatology. Participants in the subsample with at least moderate baseline symptomatology reported significantly lower symptoms of depression, anxiety, and stress postintervention (Cohen d=−0.68; P=.04) but not in the full sample with low baseline symptomatology (Cohen d=0.16; P=.46). The number of times the app was accessed was not correlated with changes in either the subsample (r=0.01; P=.98) or the full sample (r=−0.04; P=.79). Conclusions: University students experiencing moderate to severe distress can benefit from a gratitude intervention smartphone app to improve symptoms of depression, anxiety, and stress. The number of times the gratitude intervention app was used is not related to well-being outcomes. Clinicians could look at incorporating gratitude apps with other mental health treatments or for those waitlisted as a cost-effective and minimally guided option for university students experiencing psychological distress. Trial Registration: Clinicaltrials.gov NCT06621745; http://clinicaltrials.gov/ct2/show/NCT06621745 %R 10.2196/53850 %U https://mhealth.jmir.org/2025/1/e53850 %U https://doi.org/10.2196/53850 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 13 %N %P e52764 %T mHealth-Augmented Care for Reducing Depression Symptom Severity Among Patients With Chronic Pain: Exploratory, Retrospective Cohort Study %A Holley,Dan %A Brooks,Amanda %A Hartz,Matthew %A Rao,Sudhir %A Zaubler,Thomas %K mHealth %K mobile health %K app %K behavioral health care %K depression %K mental health %K screening %K pain %K chronic pain %K psychiatric screenings %K digital health care %K psychiatry %K psychiatric %K longitudinal %K assessment %K behavioral %K self-help %K integrated %K comorbidity %K augmented care %D 2025 %7 10.1.2025 %9 %J JMIR Mhealth Uhealth %G English %X Background: Depression and chronic pain are commonly comorbid, mutually reinforcing, and debilitating. Emerging approaches to mobile behavioral health care (mHealth) promise to improve outcomes for patients with comorbid depression and chronic pain by integrating with existing care models to bolster support and continuity between clinical visits; however, the evidence base supporting the use of mHealth to augment care for this patient population is limited. Objective: To develop an evidence base that sets the stage for future research, we aimed to explore the associations between changes in depression severity and various integrated care models, with and without mHealth augmentation, among patients with comorbid depression and nonmalignant chronic pain. Methods: Our team leveraged retrospective, real-world data from 3837 patients with comorbid depression and nonmalignant chronic pain who received integrated behavioral health care (IBH) at a subspecialty pain clinic. We analyzed one IBH-only, non-mHealth cohort (n=2765), an mHealth-augmented cohort (n=844), and a collaborative care (CoCM)+mHealth cohort (n=136), which were supported by the NeuroFlow mHealth platform, and a pre-CoCM mHealth cohort (n=92), which was supported by the mHealth platform for 3 months prior to beginning the chronic pain treatment. We evaluated changes in depression severity between treatment cohorts via longitudinal analyses of both clinician- and mHealth-administered Patient Health Questionnaire-9 (PHQ-9) assessments. Results: mHealth-augmented integrated care led to significantly greater proportions of patients reaching clinical benchmarks for reduction (725/844, 86% vs 2112/2765, 76%), response (689/844, 82% vs 2027/2765, 73%), and remission (629/844, 75% vs 1919/2765, 69%) compared with integrated care alone. Furthermore, hierarchical regression modeling revealed that patients who received mHealth-augmented psychiatric CoCM experienced the greatest sustained reductions in on-average depression severity compared with other cohorts, irrespective of clinical benchmarks. In addition, patients who engaged with an mHealth platform before entering CoCM experienced a 7.2% reduction in average depression severity before starting CoCM treatment. Conclusions: Our findings suggest that mHealth platforms have the potential to improve treatment outcomes for patients with comorbid chronic pain and depression by providing remote measurement–based care, tailored interventions, and improved continuity between appointments. Moreover, our study set the stage for further research, including randomized controlled trials to evaluate causal relationships between mHealth engagement and treatment outcomes in integrated care settings. %R 10.2196/52764 %U https://mhealth.jmir.org/2025/1/e52764 %U https://doi.org/10.2196/52764 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e57624 %T The Trifecta of Industry, Academic, and Health System Partnership to Improve Mental Health Care Through Smartphone-Based Remote Patient Monitoring: Development and Usability Study %A Epperson,C Neill %A Davis,Rachel %A Dempsey,Allison %A Haller,Heinrich C %A Kupfer,David J %A Love,Tiffany %A Villarreal,Pamela M %A Matthews,Mark %A Moore,Susan L %A Muller,Kimberly %A Schneck,Christopher D %A Scott,Jessica L %A Zane,Richard D %A Frank,Ellen %+ Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, 1890 N Revere Ct, Suite 4003, Mail Stop F546, Aurora, CO, 80045, United States, 1 303 724 4940, neill.epperson@cuanschutz.edu %K digital health %K mobile intervention %K telepsychiatry %K artificial intelligence %K psychiatry %K mental health %K depression %K mood %K bipolar %K monitor %K diagnostic tool %K diagnosis %K electronic health record %K EHR %K alert %K notification %K prediction %K mHealth %K mobile health %K smartphone %K passive %K self-reported %K patient generated %D 2025 %7 7.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health treatment is hindered by the limited number of mental health care providers and the infrequency of care. Digital mental health technology can help supplement treatment by remotely monitoring patient symptoms and predicting mental health crises in between clinical visits. However, the feasibility of digital mental health technologies has not yet been sufficiently explored. Rhythms, from the company Health Rhythms, is a smartphone platform that uses passively acquired smartphone data with artificial intelligence and predictive analytics to alert patients and providers to an emerging mental health crisis. Objective: The objective of this study was to test the feasibility and acceptability of Rhythms among patients attending an academic psychiatric outpatient clinic. Methods: Our group embedded Rhythms into the electronic health record of a large health system. Patients with a diagnosis of major depressive disorder, bipolar disorder, or other mood disorder were contacted online and enrolled for a 6-week trial of Rhythms. Participants provided data by completing electronic surveys as well as by active and passive use of Rhythms. Emergent and urgent alerts were monitored and managed according to passively collected data and patient self-ratings. A purposively sampled group of participants also participated in qualitative interviews about their experience with Rhythms at the end of the study. Results: Of the 104 participants, 89 (85.6%) completed 6 weeks of monitoring. The majority of the participants were women (72/104, 69.2%), White (84/104, 80.8%), and non-Hispanic (100/104, 96.2%) and had a diagnosis of major depressive disorder (71/104, 68.3%). Two emergent alerts and 19 urgent alerts were received and managed according to protocol over 16 weeks. More than two-thirds (63/87, 72%) of those participating continued to use Rhythms after study completion. Comments from participants indicated appreciation for greater self-awareness and provider connection, while providers reported that Rhythms provided a more nuanced understanding of patient experience between clinical visits. Conclusions: Rhythms is a user-friendly, electronic health record–adaptable, smartphone-based tool that provides patients and providers with a greater understanding of patient mental health status. Integration of Rhythms into health systems has the potential to facilitate mental health care and improve the experience of both patients and providers. %M 39773396 %R 10.2196/57624 %U https://formative.jmir.org/2025/1/e57624 %U https://doi.org/10.2196/57624 %U http://www.ncbi.nlm.nih.gov/pubmed/39773396 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e63034 %T Assessing Health Technology Literacy and Attitudes of Patients in an Urban Outpatient Psychiatry Clinic: Cross-Sectional Survey Study %A Tartaglia,Julia %A Jaghab,Brendan %A Ismail,Mohamed %A Hänsel,Katrin %A Meter,Anna Van %A Kirschenbaum,Michael %A Sobolev,Michael %A Kane,John M %A Tang,Sunny X %+ Department of Psychiatry, Northwell Health, Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY, 11004, United States, 1 914 682 5482, jut4006@med.cornell.edu %K digital literacy %K attitudes %K mental health %K digital health technology %K cluster analysis %K psychiatry %K mobile phone %D 2024 %7 30.12.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital health technologies are increasingly being integrated into mental health care. However, the adoption of these technologies can be influenced by patients’ digital literacy and attitudes, which may vary based on sociodemographic factors. This variability necessitates a better understanding of patient digital literacy and attitudes to prevent a digital divide, which can worsen existing health care disparities. Objective: This study aimed to assess digital literacy and attitudes toward digital health technologies among a diverse psychiatric outpatient population. In addition, the study sought to identify clusters of patients based on their digital literacy and attitudes, and to compare sociodemographic characteristics among these clusters. Methods: A survey was distributed to adult psychiatric patients with various diagnoses in an urban outpatient psychiatry program. The survey included a demographic questionnaire, a digital literacy questionnaire, and a digital health attitudes questionnaire. Multiple linear regression analyses were used to identify predictors of digital literacy and attitudes. Cluster analysis was performed to categorize patients based on their responses. Pairwise comparisons and one-way ANOVA were conducted to analyze differences between clusters. Results: A total of 256 patients were included in the analysis. The mean age of participants was 32 (SD 12.6, range 16-70) years. The sample was racially and ethnically diverse: White (100/256, 38.9%), Black (39/256, 15.2%), Latinx (44/256, 17.2%), Asian (59/256, 23%), and other races and ethnicities (15/256, 5.7%). Digital literacy was high for technologies such as smartphones, videoconferencing, and social media (items with >75%, 193/256 of participants reporting at least some use) but lower for health apps, mental health apps, wearables, and virtual reality (items with <42%, 108/256 reporting at least some use). Attitudes toward using technology in clinical care were generally positive (9 out of 10 items received >75% positive score), particularly for communication with providers and health data sharing. Older age (P<.001) and lower educational attainment (P<.001) negatively predicted digital literacy scores, but no demographic variables predicted attitude scores. Cluster analysis identified 3 patient groups. Relative to the other clusters, cluster 1 (n=30) had lower digital literacy and intermediate acceptance of digital technology. Cluster 2 (n=50) had higher literacy and lower acceptance. Cluster 3 (n=176) displayed both higher literacy and acceptance. Significant between-cluster differences were observed in mean age and education level between clusters (P<.001), with cluster 1 participants being older and having lower levels of formal education. Conclusions: High digital literacy and acceptance of digital technologies were observed among our patients, indicating a generally positive outlook for digital health clinics. Our results also found that patients of older age and lower formal levels of educational attainment had lower digital literacy, highlighting the need for targeted interventions to support those who may struggle with adopting digital health tools. %M 39753220 %R 10.2196/63034 %U https://mental.jmir.org/2024/1/e63034 %U https://doi.org/10.2196/63034 %U http://www.ncbi.nlm.nih.gov/pubmed/39753220 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56897 %T When and Why Adults Abandon Lifestyle Behavior and Mental Health Mobile Apps: Scoping Review %A Kidman,Patrick G %A Curtis,Rachel G %A Watson,Amanda %A Maher,Carol A %+ Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide, 5001, Australia, 61 883026558, carol.maher@unisa.edu.au %K mobile health apps %K smartphone applications %K app abandonment %K app attrition %K user engagement %K health behavior %K user retention %K lifestyle management %K quantitative analysis %K qualitative analysis %K mobile phone %D 2024 %7 18.12.2024 %9 Review %J J Med Internet Res %G English %X Background: With 1 in 3 adults globally living with chronic conditions and the rise in smartphone ownership, mobile health apps have become a prominent tool for managing lifestyle-related health behaviors and mental health. However, high rates of app abandonment pose challenges to their effectiveness. Objective: We explored the abandonment of apps used for managing physical activity, diet, alcohol, smoking, and mental health in free-living conditions, examining the duration of app use before abandonment and the underlying reasons. Methods: A scoping review was conducted based on the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines and eligibility criteria were designed according to the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework. In total, 4 databases were searched (MEDLINE, Scopus, Embase, and PsycINFO) to identify quantitative and qualitative studies with outcome measures related to app abandonment in adults with free-living conditions, including reasons for abandonment and duration of use, for mobile apps related to WHO (World Health Organization) modifiable health behaviors and mental health. The included studies’ risk of bias was appraised based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and COREQ (Consolidated Criteria for Reporting Qualitative Research) checklists. To enable data synthesis across different methodologies, app domains, demographic data, and outcome measures were categorized. Results are presented in 2 sections: quantitatively in a scatterplot to understand when users abandon apps and qualitatively through basic qualitative content analysis to identify the underlying reasons. Results: Eighteen eligible studies (525,824 participants) published between 2014 and 2022, predominantly from the United States, Canada, the United Kingdom, and Germany, were identified. Findings revealed a curvilinear pattern of app abandonment, with sharper abandonment soon after acquisition, followed by a slowing rate of abandonment over time. Taken together, a median of 70% of users discontinued use within the first 100 days. The abandonment rate appeared to vary by app domain, with apps focusing on alcohol and smoking exhibiting faster abandonment, and physical activity and mental health exhibiting longer usage durations. In total, 22 unique reasons for abandonment were organized into six categories: (1) technical and functional issues, (2) privacy concerns, (3) poor user experience, (4) content and features, (5) time and financial costs, and (6) evolving user needs and goals. Conclusions: This study highlights the complex nature of health app abandonment and the need for an improved understanding of user engagement over time, underscoring the importance of addressing various factors contributing to abandonment, from technical issues to evolving user needs. Our findings also emphasize the need for longitudinal studies and a consistent definition of app abandonment to better understand and mitigate this phenomenon, thereby enhancing the effectiveness of health apps in supporting public health initiatives. %M 39693620 %R 10.2196/56897 %U https://www.jmir.org/2024/1/e56897 %U https://doi.org/10.2196/56897 %U http://www.ncbi.nlm.nih.gov/pubmed/39693620 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e63316 %T Efficacy of the mHealth App Intellect in Improving Subclinical Obsessive-Compulsive Disorder in University Students: Randomized Controlled Trial With a 4-Week Follow-Up %A Lee Yoon Li,Madeline %A Lee Si Min,Stephanie %A Sündermann,Oliver %+ National University of Singapore, 9 Arts Link, #13-02, Singapore, 117570, Singapore, 65 80435120 ext 5120, psymos@nus.edu.sg %K mobile health app %K self-guided interventions %K obsessive-compulsive disorder %K cognitive behavioral therapy %K maladaptive perfectionism %K randomized controlled trial %K behavioral %K efficacy %K mHealth app %K university students %K Singapore %K symptoms %D 2024 %7 16.12.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obsessive-compulsive disorder (OCD) is the third most prevalent mental health disorder in Singapore, with a high degree of burden and large treatment gaps. Self-guided programs on mobile apps are accessible and affordable interventions, with the potential to address subclinical OCD before symptoms escalate. Objective: This randomized controlled trial aimed to examine the efficacy of a self-guided OCD program on the mobile health (mHealth) app Intellect in improving subclinical OCD and maladaptive perfectionism (MP) as a potential moderator of this predicted relationship. Methods: University students (N=225) were randomly assigned to an 8-day, self-guided app program on OCD (intervention group) or cooperation (active control). Self-reported measures were obtained at baseline, after the program, and at a 4-week follow-up. The primary outcome measure was OCD symptom severity (Obsessive Compulsive Inventory–Revised [OCI-R]). Baseline MP was assessed as a potential moderator. Depression, anxiety, and stress (Depression Anxiety and Stress Scales-21) were controlled for during statistical analyses. Results: The final sample included 192 participants. The intervention group reported significantly lower OCI-R scores compared with the active control group after the intervention (partial eta-squared [ηp2]=0.031; P=.02) and at 4-week follow-up (ηp2=0.021; P=.044). A significant, weak positive correlation was found between MP and OCI-R levels at baseline (r=0.28; P<.001). MP was not found to moderate the relationship between condition and OCI-R scores at postintervention (P=.70) and at 4-week follow-up (P=.88). Conclusions: This study provides evidence that the self-guided OCD program on the Intellect app is effective in reducing subclinical OCD among university students in Singapore. Future studies should include longer follow-up durations and study MP as a moderator in a broader spectrum of OCD symptom severity. Trial Registration: ClinicalTrials.gov NCT06202677; https://clinicaltrials.gov/study/NCT06202677 %M 39680884 %R 10.2196/63316 %U https://mhealth.jmir.org/2024/1/e63316 %U https://doi.org/10.2196/63316 %U http://www.ncbi.nlm.nih.gov/pubmed/39680884 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e46860 %T Participant Adherence and Contact Behavior in a Guided Internet Intervention for Depressive Symptoms: Exploratory Study %A Bur,Oliver Thomas %A Berger,Thomas %K internet intervention %K depression %K guidance %K contact behavior %K messages %K adherence %K online %K intervention %K digital health %K therapy %K participant %D 2024 %7 16.12.2024 %9 %J JMIR Form Res %G English %X Background: The number of studies on internet-based guided self-help has rapidly increased during the last 2 decades. Guided self-help comprises 2 components: a self-help program that patients work through and usually weekly guidance from therapists who support patients using the self-management program. Little is known about participants' behavior patterns while interacting with therapists and their use of self-help programs in relation to intervention outcomes. Objective: This exploratory study aimed to investigate whether the number of messages sent to the therapist (ie, contact behavior) is an indicator of the outcome, that is, a reduction in depressive symptoms. Furthermore, we investigated whether adherence was associated with outcome. Most importantly, we investigated whether different combinations of adherence and contact behavior were associated with outcome. Methods: Drawing on a completer sample (n=113) from a randomized full factorial trial, participants were categorized into 4 groups. The groups were based on median splits of 2 variables, that is, the number of messages sent to therapists (low: groups 1 and 2; high: groups 3 and 4) and adherence (low: groups 1 and 3; high: groups 2 and 4). The 4 groups were compared in terms of change in depressive symptoms (measured with the Patient Health Questionnaire-9) from pre- to posttreatment and pretreatment to follow-up, respectively. Results: On average, participants sent 4.5 (SD 3.7) messages to their therapist and completed 18.2 (SD 5.2) pages of the program in 6.39 (SD 5.39) hours. Overall, analyses revealed no main effect for participants’ messages (H1=0.18, P=.67) but a significant main effect for adherence on changes in depressive symptoms from pre- to posttreatment (H1=5.10, P=.02). The combined consideration of adherence and messages sent to the therapist revealed group differences from pre- to posttreatment (H3=8.26, P=.04). Group 3 showed a significantly smaller improvement in symptoms compared with group 4 (Z=–2.84, P=.002). Furthermore, there were group differences from pretreatment to follow-up (H3=8.90, P=.03). Again, group 3 showed a significantly smaller improvement in symptoms compared with group 4 (Z=–2.62, P=.004) and group 2 (Z=–2.47, P=.007). All other group comparisons did not yield significant differences. Conclusion: This exploratory study suggests that participants characterized by low adherence and frequent messaging do not improve their symptoms as much as other participants. These participants might require more personalized support beyond the scope of guided internet interventions. The paper underscores the importance of considering individual differences in contact behavior when tailoring interventions. The results should be interpreted with caution and further investigated in future studies. Trial Registration: ClinicalTrials.gov NCT04318236; https://www.clinicaltrials.gov/study/NCT04318236 %R 10.2196/46860 %U https://formative.jmir.org/2024/1/e46860 %U https://doi.org/10.2196/46860 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56205 %T mHealth Apps in German Outpatient Mental Health Care: Protocol for a Mixed Methods Approach %A Höfer,Klemens %A Plescher,Felix %A Schlierenkamp,Sarah %A Solar,Stefanie %A Neusser,Silke %A Schneider,Udo %A Best,Dieter %A Wasem,Jürgen %A Abels,Carina %A Bußmann,Anna %+ Institute for Healthcare Management and Research, University of Duisburg-Essen, Thea-Leymann-Straße 9, Essen, 45127, Germany, 49 2011834037, klemens.hoefer@medman.uni-due.de %K mental health care %K mHealth %K digital health applications %K Digitale Gesundheitsanwendungen %K mental disorders %K health care research %K applications %K app %K mental health %K outpatient %K digital health %K adults %K Germany %K mobile health apps %K treatment %D 2024 %7 10.12.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental disorders are complex diseases that affect 28% (about 17.8 million people) of the adult population in Germany annually. Since 2020, certain mobile health (mHealth) apps, so-called digital health applications (DiGA), are reimbursable in the German statutory health insurance system. A total of 27 of the 56 currently available DiGA are approved for the treatment of mental and behavioral diseases. An indicator of existing problems hindering the use of DiGA is the rather hesitant prescribing behavior. Objective: This project aims to develop health policy recommendations for the optimal integration of DiGA into outpatient psychotherapeutic care. The project is funded by the Innovation Fund of the Joint Federal Committee (grant 01VSF22029). The current status quo of the use of DiGA will be analyzed. Furthermore, concepts for the integration of mHealth apps, as well as their transfer into the care process will be investigated. In addition, barriers will be identified, and existing expectations of different perspectives captured. Methods: The project will be based on a mixed methods approach. A scoping review and a qualitative analysis of focus groups and expert interviews will be carried out. Additionally, an analysis of claims data of the statutory health insurance will be conducted. This will be followed by a written survey of insured persons and health care providers. Finally, health policy recommendations will be derived in cooperation with stakeholders. Results: The scoping reviews and qualitative analyses have been completed, and the quantitative surveys are currently being carried out. The target number of responses in the survey of insured persons has already been achieved. Furthermore, the analysis claims data of the statutory health insurance is currently being conducted. Conclusions: There is a need for research on how DiGA can be optimally integrated into the care process of patients with mental disorders as evidence regarding the topic is limited and prescribing behavior low. Although the potential of DiGA in mental health care has not yet fully unfolded, Germany serves as a model for other countries regarding reimbursable mHealth apps. This project aims to explore the potentials of DiGA and to describe the organizational, institutional, and procedural steps necessary for them to best support mental health care. International Registered Report Identifier (IRRID): DERR1-10.2196/56205 %M 39657173 %R 10.2196/56205 %U https://www.researchprotocols.org/2024/1/e56205 %U https://doi.org/10.2196/56205 %U http://www.ncbi.nlm.nih.gov/pubmed/39657173 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e53280 %T The Use of a Digital Well-Being App (Stay Strong App) With Indigenous People in Prison: Randomized Controlled Trial %A Perdacher,Elke %A Kavanagh,David %A Sheffield,Jeanie %A Dale,Penny %A Heffernan,Edward %+ Queensland Forensic Mental Health Service, Level 5, 270 Roma Street, Brisbane, Queensland, 4000, Australia, 61 7 3837 5820, elke.perdacher@health.qld.gov.au %K First Nations %K Indigenous %K digital mental health %K e-mental health %K mental health %K social and emotional well-being %K SEWB %K prisoner %K prison %D 2024 %7 6.12.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Indigenous Australians in custody experience much greater rates of poor mental health and well-being than those of the general community, and these problems are not adequately addressed. Digital mental health strategies offer innovative opportunities to address the problems, but little is known about their feasibility in or impact on this population. Objective: This study aims to conduct a pilot trial evaluating the impact of adding the Stay Strong app to mental health and well-being services for Indigenous women and men in custody. The trial compared immediate and 3-month delayed use of the app by the health service, assessing its effects on well-being, empowerment, and psychological distress at 3 and 6 months after the baseline. Methods: Indigenous participants were recruited from 3 high-security Australian prisons from January 2017 to September 2019. The outcome measures assessed well-being (Warwick-Edinburgh Mental Wellbeing Scale), empowerment (Growth and Empowerment Measure [GEM]—giving total, 14-item Emotional Empowerment Scale, and 12 Scenarios scores), and psychological distress (Kessler Psychological Distress Scale). Intention-to-treat effects on these outcomes were analyzed using linear mixed models. Results: Substantial challenges in obtaining ethical and institutional approval for the trial were encountered, as were difficulties in timely recruitment and retention due to staff shortages and the release of participants from prison before follow-up assessments and an inability to follow up with participants after release. A total of 132 prisoners (age: mean 33, SD 8 y) were randomized into either an immediate (n=82) or a delayed treatment (n=52) group. However, only 56 (42.4%) could be assessed at 3 months and 37 (28%) at 6 months, raising questions concerning the representativeness of the results. Linear improvements over time were seen in all outcomes (GEM total: Cohen d=0.99; GEM 14-item Emotional Empowerment Scale: Cohen d=0.94; GEM 12 Scenarios: Cohen d=0.87; Warwick-Edinburgh Mental Wellbeing Scale: Cohen d=0.76; Kessler Psychological Distress Scale: Cohen d=0.49), but no differential effects for group or the addition of the Stay Strong app were found. Conclusions: We believe this to be Australia’s first evaluation of a digital mental health app in prison and the first among Indigenous people in custody. While the study demonstrated that the use of a well-being app within a prison was feasible, staff shortages led to delayed recruitment and a consequent low retention, and significant beneficial effects of the app’s use within a forensic mental health service were not seen. Additional staff resources and a longer intervention may be needed to allow a demonstration of satisfactory retention and impact in future research. Trial Registration: ANZCTR ACTRN12624001261505; https://www.anzctr.org.au/ACTRN12624001261505.aspx %M 39642362 %R 10.2196/53280 %U https://mental.jmir.org/2024/1/e53280 %U https://doi.org/10.2196/53280 %U http://www.ncbi.nlm.nih.gov/pubmed/39642362 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e60461 %T Acceptability, User Satisfaction, and Feasibility of an App-Based Support Service During the COVID-19 Pandemic in a Psychiatric Outpatient Setting: Prospective Longitudinal Observational Study %A Golsong,Konstanze %A Kaufmann,Luisa %A Baldofski,Sabrina %A Kohls,Elisabeth %A Rummel-Kluge,Christine %+ Department of Psychiatry and Psychotherapy, University of Leipzig Medical Center, Haus 13, Semmelweisstraße 10, Leipzig, Germany, 49 341 9724464, Christine.Rummel-Kluge@medizin.uni-leipzig.de %K mental health %K eHealth %K app %K health care %K app-based support %K psychiatric symptoms %K mobile phone %K COVID-19 %D 2024 %7 4.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with mental disorders often have difficulties maintaining a daily routine, which can lead to exacerbated symptoms. It is known that apps can help manage mental health in a low-threshold way and can be used in therapeutic settings to complement existing therapies. Objective: The aim of this study was to evaluate the acceptability, usability, and feasibility of an app-based support service specifically developed for outpatients with severe mental disorders in addition to regular face-to-face therapy during the COVID-19 pandemic. Methods: Patients in a psychiatric outpatient department at a German university hospital were invited to use an app-based support service designed transdiagnostically for mental disorders for 4 weeks. The app included 7 relaxation modules, consisting of video, audio, and psychoeducational text; ecological momentary assessment–like questionnaires on daily mood answered via a visual smiley-face scale; and an activity button to record and encourage daily activities. Standardized questionnaires at baseline (T0; preintervention time point) and after 4 weeks (T2; postintervention time point) were analyzed. Feedback via the smiley-face scale was provided after using the app components (T1; during the intervention). Measures included depressive symptoms, quality of life, treatment credibility and expectancy, and satisfaction. Furthermore, participation rates, use of app modules and the activity button, and daily mood and the provided feedback were analyzed (T2). Results: In total, 57 patients participated in the study, and the data of 38 (67%) were analyzed; 17 (30%) dropped out. Satisfaction with the app was high, with 53% (30/57) of the participants stating being rather satisfied or satisfied. Furthermore, 79% (30/38) of completers stated they would be more likely or were definitely likely to use an app-based support service again and recommend it. Feasibility and acceptability were high, with nearly half (18/38, 47%) of the completers trying relaxation modules and 71% (27/38) regularly responding to the ecological momentary assessment–like questionnaire between 15 and 28 times (mean 19.91, SD 7.57 times). The activity button was used on average 12 (SD 15.72) times per completer, and 58% (22/38) felt “definitely” or “rather” encouraged to perform the corresponding activities. Depressive symptomatology improved significantly at the postintervention time point (P=.02). Quality of life showed a nonsignificant increase in the physical, psychological, and social domains (P=.59, P=.06, and P=.42, respectively) and a significant improvement in the environment domain (P=.004). Treatment credibility and expectancy scores were moderate and significantly decreased at T2 (P=.02 and P<.001, respectively). Posttreatment expectancy scores were negatively associated with posttreatment depressive symptomatology (r=–0.36; P=.03). Conclusions: App-based programs seem to be an accessible tool for stabilizing patients with severe mental disorders, supporting them in maintaining a daily routine, complementing existing face-to-face treatments, and overall helping respond to challenging situations such as the COVID-19 pandemic. %M 39630503 %R 10.2196/60461 %U https://formative.jmir.org/2024/1/e60461 %U https://doi.org/10.2196/60461 %U http://www.ncbi.nlm.nih.gov/pubmed/39630503 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55736 %T Biomarkers of Response to Internet-Based Psychological Interventions: Systematic Review %A Gotti,Giulia %A Gabelli,Chiara %A Russotto,Sophia %A Madeddu,Fabio %A Courtet,Philippe %A Lopez-Castroman,Jorge %A Zeppegno,Patrizia %A Gramaglia,Carla Maria %A Calati,Raffaella %+ Department of Psychology, University of Milan-Bicocca, Piazza dell'Ateneo Nuovo 1, U6 Building, Room 3129, Milan, 20126, Italy, 39 3477752087, raffaella.calati@unimib.it %K biomarker %K cognitive behavioral therapy %K internet-based intervention %K systematic review %K psychological intervention %K mental health intervention %K meta analysis %K psychiatric %K blood glucose %K mindfulness %K stress management %K immune response %K smoking %K cortisol %D 2024 %7 29.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Internet-based psychological interventions provide accessible care to a wide range of users, overcoming some obstacles—such as distance, costs, and safety—that might discourage seeking help for mental issues. It is well known that psychological treatments and programs affect the body, as well as the mind, producing physiological changes that ought to be considered when assessing the efficacy of the intervention. However, the literature investigating changes in biomarkers specifically after internet-based psychological and mental health interventions has not yet extensively inquired into this topic. Objective: This systematic review aims to provide a synthesis of literature examining the effects of internet-based psychological interventions—targeting both clinical (mental and physical) and nonclinical conditions—on biomarkers. A secondary aim was to evaluate whether the biomarkers’ variations were related to a complementary modification of the psychological or physical symptoms or to a general improvement of the participants’ well-being. Methods: This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. A literature search was performed through 3 databases (PubMed, PsycINFO, and Scopus). Studies examining changes in biomarkers before and after internet-based psychological interventions or programs targeting both clinical and nonclinical samples were included, with no exclusion criteria concerning mental or physical conditions. Results: A total of 24 studies fulfilled the inclusion criteria. These studies involved individuals with psychiatric or psychological problems (n=6, 25%), those with organic or medical diseases (n=10, 42%), and nonclinical populations (n=8, 33%). Concerning psychiatric or psychological problems, cognitive behavioral therapy (CBT) and CBT-informed interventions showed partial effectiveness in decreasing glycated hemoglobin blood glucose level (n=1) and chemokines (n=1) and in increasing connectivity between the default-mode network and the premotor or dorsolateral prefrontal cortex (n=1). Among individuals with organic or medical diseases, studies reported a significant change in cardiac or cardiovascular (n=3), inflammatory (n=2), cortisol (n=2), glycated hemoglobin (n=2), and immune response (n=1) biomarkers after CBT and CBT-informed interventions, and mindfulness and stress management interventions. Lastly, mindfulness, CBT and CBT-informed interventions, and music therapy succeeded in modifying immune response (n=2), cortisol (n=1), α amylase (n=1), posterior cingulate cortex reactivity to smoking cues (n=1), and carbon monoxide (n=1) levels in nonclinical populations. In some of the included studies (n=5), the psychological intervention or program also produced an improvement of the mental or physical condition of the participants or of their general well-being, alongside significant variations in biomarkers; CBT and CBT-informed interventions proved effective in reducing both psychological (n=2) and physical symptoms (n=2), while a mindfulness program successfully lowered cigarette consumption in a nonclinical sample (n=1). Conclusions: Although further evidence is required, we hope to raise awareness on the potential impact of internet-based interventions on biomarkers related to mental and physical health. %M 39612489 %R 10.2196/55736 %U https://www.jmir.org/2024/1/e55736 %U https://doi.org/10.2196/55736 %U http://www.ncbi.nlm.nih.gov/pubmed/39612489 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e64380 %T Public Perception on Artificial Intelligence–Driven Mental Health Interventions: Survey Research %A Varghese,Mahima Anna %A Sharma,Poonam %A Patwardhan,Maitreyee %+ Department of Social Science and Language, Vellore Institute of Technology, Vellore Campus, Tiruvalam Road, Vellore, 632014, India, 91 9702872251, poonam.sharma@vit.ac.in %K public perception %K artificial intelligence %K AI %K AI-driven %K human-driven %K mental health inteventions %K mental health stigma %K trust in AI %K public perception %K digital health %K India %K mobile phone %D 2024 %7 28.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Artificial intelligence (AI) has become increasingly important in health care, generating both curiosity and concern. With a doctor-patient ratio of 1:834 in India, AI has the potential to alleviate a significant health care burden. Public perception plays a crucial role in shaping attitudes that can facilitate the adoption of new technologies. Similarly, the acceptance of AI-driven mental health interventions is crucial in determining their effectiveness and widespread adoption. Therefore, it is essential to study public perceptions and usage of existing AI-driven mental health interventions by exploring user experiences and opinions on their future applicability, particularly in comparison to traditional, human-based interventions. Objective: This study aims to explore the use, perception, and acceptance of AI-driven mental health interventions in comparison to traditional, human-based interventions. Methods: A total of 466 adult participants from India voluntarily completed a 30-item web-based survey on the use and perception of AI-based mental health interventions between November and December 2023. Results: Of the 466 respondents, only 163 (35%) had ever consulted a mental health professional. Additionally, 305 (65.5%) reported very low knowledge of AI-driven interventions. In terms of trust, 247 (53%) expressed a moderate level of Trust in AI-Driven Mental Health Interventions, while only 24 (5.2%) reported a high level of trust. By contrast, 114 (24.5%) reported high trust and 309 (66.3%) reported moderate Trust in Human-Based Mental Health Interventions; 242 (51.9%) participants reported a high level of stigma associated with using human-based interventions, compared with only 50 (10.7%) who expressed concerns about stigma related to AI-driven interventions. Additionally, 162 (34.8%) expressed a positive outlook toward the future use and social acceptance of AI-based interventions. The majority of respondents indicated that AI could be a useful option for providing general mental health tips and conducting initial assessments. The key benefits of AI highlighted by participants were accessibility, cost-effectiveness, 24/7 availability, and reduced stigma. Major concerns included data privacy, security, the lack of human touch, and the potential for misdiagnosis. Conclusions: There is a general lack of awareness about AI-driven mental health interventions. However, AI shows potential as a viable option for prevention, primary assessment, and ongoing mental health maintenance. Currently, people tend to trust traditional mental health practices more. Stigma remains a significant barrier to accessing traditional mental health services. Currently, the human touch remains an indispensable aspect of human-based mental health care, one that AI cannot replace. However, integrating AI with human mental health professionals is seen as a compelling model. AI is positively perceived in terms of accessibility, availability, and destigmatization. Knowledge and perceived trustworthiness are key factors influencing the acceptance and effectiveness of AI-driven mental health interventions. %M 39607994 %R 10.2196/64380 %U https://formative.jmir.org/2024/1/e64380 %U https://doi.org/10.2196/64380 %U http://www.ncbi.nlm.nih.gov/pubmed/39607994 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63732 %T A Personalized, Transdiagnostic Smartphone App (Mello) Targeting Repetitive Negative Thinking for Depression and Anxiety: Qualitative Analysis of Young People’s Experience %A Valentine,Lee %A Arnold,Chelsea %A Nicholas,Jennifer %A Castagnini,Emily %A Malouf,Jessi %A Alvarez-Jimenez,Mario %A Bell,Imogen H %+ Orygen, 35 Poplar Rd, Melbourne, 3052, Australia, 61 9966 9100, lee.valentine@orygen.org.au %K repetitive negative thinking %K rumination %K anxiety %K depression %K mobile app %K just-in-time adaptive interventions %K youth mental health %K adolescent %K mobile phone %D 2024 %7 27.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The increasing rates of mental health challenges among young people highlight an urgent need for accessible and effective treatment. However, current mental health systems face unprecedented demand, leaving most young people globally with unmet mental health needs. Smartphones present a promising solution to this issue by offering in-the-moment support through innovative just-in-time adaptive interventions, which provide support based on real-time data. Objective: This study explores young people’s experiences with Mello, a just-in-time adaptive intervention that focuses on the transdiagnostic mechanism of repetitive negative thinking (RNT), a significant factor contributing to youth depression and anxiety. Methods: Semistructured qualitative interviews were conducted with 15 participants aged 16 to 25 years, all of whom had previously participated in a pilot randomized controlled trial of Mello. Of the 15 participants, 9 (60%) identified as women, 4 (27%) as men (including 1 transgender man), and 2 (13%) as nonbinary. Interviews focused on participants’ experiences with the Mello app, factors influencing engagement, perceived benefits and limitations, and suggestions for future improvements. Thematic analysis was used to analyze the data. Results: The analysis identified three superordinate themes: Mello as a tool for intentional reflection; doing therapy your own way; and barriers to engagement during low mood, anxiety, and RNT. Theme 1 explored young people’s experiences of how the app facilitated active management of negative thoughts and supported the development of reflective habits, contrasting with their typical strategies of avoidance or resistance. Theme 2 highlighted the value of the app’s self-guided nature, with a particular focus on its flexibility and accessibility, particularly when compared to traditional face-to-face therapy. Finally, theme 3 addressed barriers to engagement, particularly during emotionally difficult times, with participants reporting feeling “stuck” in their negative thoughts. To mitigate these challenges, participants suggested incorporating gamification elements, such as progress-tracking visuals, to enhance motivation and increase engagement with the app. Conclusions: Our findings underscored the value of Mello in promoting intentional engagement and reflection with RNT, consistent with prior research that emphasizes the effectiveness of tailored interventions. Although some users valued the self-guided nature of the application, others encountered difficulties with motivation. Future research should explore strategies to enhance engagement for young people with low mood and motivation, such as co-design methodologies, advanced personalization features, and gamification techniques. %M 39602793 %R 10.2196/63732 %U https://www.jmir.org/2024/1/e63732 %U https://doi.org/10.2196/63732 %U http://www.ncbi.nlm.nih.gov/pubmed/39602793 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51978 %T Characterizing Performance on a Suite of English-Language NeuroUX Mobile Cognitive Tests in a US Adult Sample: Ecological Momentary Cognitive Testing Study %A Paolillo,Emily W %A Bomyea,Jessica %A Depp,Colin A %A Henneghan,Ashley M %A Raj,Anunay %A Moore,Raeanne C %+ Department of Psychiatry, University of California San Diego School of Medicine, 9500 Gilman Dr., La Jolla, CA, 92093, United States, 1 619 543 5378, r6moore@health.ucsd.edu %K digital health %K cognition %K cognitive aging %K neuropsychology %K mobile health %K psychometrics %K mobile phone %K Ecological Momentary Assessment %K EMA %K NeuroUX %D 2024 %7 25.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile cognitive testing is growing in popularity, with numerous advantages over traditional cognitive testing; however, the field lacks studies that deeply examine mobile cognitive test data from general adult samples. Objective: This study characterized performance for a suite of 8 mobile cognitive tests from the NeuroUX platform in a sample of US adults across the adult lifespan. Methods: Overall, 393 participants completed 8 NeuroUX cognitive tests and a brief ecological momentary assessment survey once per day on their smartphones for 10 consecutive days; each test was administered 5 times over the testing period. The tests tapped the domains of executive function, processing speed, reaction time, recognition memory, and working memory. Participants also completed a poststudy usability feedback survey. We examined alternate form test-retest reliability; practice effects; and associations between scores (averages and intraindividual variability) and demographics as well as test-taking context (ie, smartphone type, being at home vs not at home, and being alone vs not alone). Results: Our final sample consisted of 393 English-speaking US residents (aged 20-79 y; female: n=198, 50.4%). Of the 367 participants who provided responses about their race and ethnicity, 258 (70.3%) were White. Of the 393 participants, 181 (46.1%) were iOS users, and 212 (53.9%) were Android users. Of 12 test scores derived from the 8 tests, 9 (75%) showed good to excellent test-retest reliability (intraclass correlation coefficients >0.76). Practice effects (ie, improvements in performance) were observed for 4 (33%) of the 12 scores. Older age was associated with worse performance on most of the test scores (9/12, 75%) and greater within-person variability for nearly all reaction time scores (3/4, 75%). Relationships with smartphone type showed better performance among iOS users and those with newer Android software versions compared to those with older software. Being at home (vs not at home) was associated with better performance on tests of processing speed. Being alone (vs not alone) was associated with better performance on tests of recognition and working memory. Poststudy feedback indicated that participants found NeuroUX easy to learn and use, an enjoyable experience, and an app that would be helpful in understanding their thinking skills. Only 4.2% (16/379) endorsed privacy concerns, and 77.3% (293/379) reported that they would be willing to share their results with their health care provider. Older age—but not other demographics—was associated with finding the tests more challenging. Conclusions: In a sample of adults across a wide age range, this study characterized features that are particularly important for the interpretation of remote, repeated mobile cognitive testing performance, including test-retest reliability, practice effects, smartphone type, and test-taking context. These data enhance the understanding and application of mobile cognitive testing, paving the way for improved clinical decision-making, personalized interventions, and advancements in cognitive research. %M 39586088 %R 10.2196/51978 %U https://www.jmir.org/2024/1/e51978 %U https://doi.org/10.2196/51978 %U http://www.ncbi.nlm.nih.gov/pubmed/39586088 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e64681 %T Mobile App for Improving the Mental Health of Youth in Out-of-Home Care: Development Study Using an Intervention Mapping Approach %A Park,Jinyoung %A Lee,Jungeun %A Noh,Dabok %+ College of Nursing, Eulji University, 553 Sanseong-daero, Sujeong-gu, Seongnam-si, Gyeonggi-do, 13135, Republic of Korea, 82 31 740 7415, daboknoh@eulji.ac.kr %K out-of-home youth %K mental health intervention %K mobile app %K intervention mapping %K youth %K mental health %K mHealth %K mobile health %K app %K interview %K need %K focus group %K emotion %K emotional %K young adult %K independent living %K emotional support %K tool %K emotion regulation %K user %K app usage %D 2024 %7 21.11.2024 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Youth in out-of-home care encounter substantial mental health challenges because of the absence of stable family and social support systems. Their vulnerability is heightened by trauma, neglect, and abuse. They struggle, especially when transitioning to independent living, coping with loneliness, anxiety, and pressure. Objective: This study aimed to develop a mobile app with high accessibility and long-term continuous effects to support independent living and improve mental health among youth in out-of-home care. The approach used was the systematic and step-by-step intervention mapping (IM) framework. Methods: The program was created using the IM framework and had 6 steps. Drawing from data from individual and focus group interviews and literature reviews, we developed a logical model of the problem. We established program outcomes and objectives, defining performance objectives and variable determinants. We identified theoretical and evidence-based methods that influence determinants. The app design integrated these methods into practical applications, allowing for the creation of self-management and emotional support tools. The development process included ongoing discussions between app designers and the research team to ensure that user needs and preferences were addressed. Results: Individual interviews and focus group discussions revealed challenges in managing daily routines and regulating emotions. The program design was based on the transtheoretical model, social cognitive theory, and elaboration likelihood model. Key features included goal setting, structured routines, emotion recognition flashcards, character models demonstrating emotion regulation strategies, verbal persuasion, and self-monitoring tools to support habit formation and emotion regulation. An implementation plan was developed to facilitate the app’s adoption, execution, and maintenance, while an evaluation plan was established, including app usage analytics, user logs, and feedback surveys. A randomized controlled trial will be conducted to assess the app’s impact on mental health outcomes, focusing on reducing anxiety and depressive symptoms, improving emotion regulation, and enhancing daily living skills. Conclusions: The IM framework was beneficial in developing a mobile app to enhance the mental health of youth in out-of-home care. The study produced a program grounded in theory and evidence that caters to the needs of these individuals. Further research should aim to verify the app’s effectiveness in real-world settings and refine it continuously based on user input. %M 39571152 %R 10.2196/64681 %U https://humanfactors.jmir.org/2024/1/e64681 %U https://doi.org/10.2196/64681 %U http://www.ncbi.nlm.nih.gov/pubmed/39571152 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57109 %T Engagement and Acceptability of Acceptance and Commitment Therapy in Daily Life in Early Psychosis: Secondary Findings From a Multicenter Randomized Controlled Trial %A van Aubel,Evelyne %A Vaessen,Thomas %A Uyttebroek,Lotte %A Steinhart,Henrietta %A Beijer-Klippel,Annelie %A Batink,Tim %A van Winkel,Ruud %A de Haan,Lieuwe %A van der Gaag,Mark %A van Amelsvoort,Thérèse %A Marcelis,Machteld %A Schirmbeck,Frederike %A Reininghaus,Ulrich %A Myin-Germeys,Inez %+ Center for Contextual Psychiatry, Psychiatry Research Group, Department of Neurosciences, KU Leuven, Herestraat 49, ON5B bus 1029, Leuven, 3000, Belgium, 32 16 37 31 74, lotte.uyttebroek@kuleuven.be %K acceptance and commitment therapy %K ACT %K first episode of psychosis %K FEP %K ultrahigh risk for psychosis %K UHR %K ecological momentary intervention %K EMI %K mobile health %K mHealth %K blended care %K mobile phone %D 2024 %7 21.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Acceptance and commitment therapy (ACT) is promising in the treatment of early psychosis. Augmenting face-to-face ACT with mobile health ecological momentary interventions may increase its treatment effects and empower clients to take treatment into their own hands. Objective: This study aimed to investigate and predict treatment engagement with and acceptability of acceptance and commitment therapy in daily life (ACT-DL), a novel ecological momentary intervention for people with an ultrahigh risk state and a first episode of psychosis. Methods: In the multicenter randomized controlled trial, 148 individuals with ultrahigh risk or first-episode psychosis aged 15-65 years were randomized to treatment as usual only (control) or to ACT-DL combined with treatment as usual (experimental), consisting of 8 face-to-face sessions augmented with an ACT-based smartphone app, delivering ACT skills and techniques in daily life. For individuals in the intervention arm, we collected data on treatment engagement with and acceptability of ACT-DL during and after the intervention. Predictors of treatment engagement and acceptability included baseline demographic, clinical, and functional outcomes. Results: Participants who received ACT-DL in addition to treatment as usual (n=71) completed a mean of 6 (SD 3) sessions, with 59% (n=42) of participants completing all sessions. App engagement data (n=58) shows that, on a weekly basis, participants used the app 13 times and were compliant with 6 of 24 (25%) notifications. Distribution plots of debriefing scores (n=46) show that 85%-96% of participants reported usefulness on all acceptability items to at least some extent (scores ≥2; 1=no usefulness) and that 91% (n=42) of participants reported perceived burden by number and length of notifications (scores ≥2; 1=no burden). Multiple linear regression models were fitted to predict treatment engagement and acceptability. Ethnic minority backgrounds predicted lower notification response compliance (B=–4.37; P=.01), yet higher app usefulness (B=1.25; P=.049). Negative (B=–0.26; P=.01) and affective (B=0.14; P=.04) symptom severity predicted lower and higher ACT training usefulness, respectively. Being female (B=–1.03; P=.005) predicted lower usefulness of the ACT metaphor images on the app. Conclusions: Our results corroborate good treatment engagement with and acceptability of ACT-DL in early psychosis. We provide recommendations for future intervention optimization. Trial Registration: OMON NL46439.068.13; https://onderzoekmetmensen.nl/en/trial/24803 %M 39570655 %R 10.2196/57109 %U https://formative.jmir.org/2024/1/e57109 %U https://doi.org/10.2196/57109 %U http://www.ncbi.nlm.nih.gov/pubmed/39570655 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53236 %T Investigating the Effectiveness of Technology-Based Distal Interventions for Postpartum Depression and Anxiety: Systematic Review and Meta-Analysis %A Brocklehurst,Sarah P %A Morse,Alyssa R %A Cruwys,Tegan %A Batterham,Philip J %A Leach,Liana %A Robertson,Alysia M %A Sahib,Aseel %A Burke,Colette T %A Nguyen,Jessica %A Calear,Alison L %+ Centre for Mental Health Research, The Australian National University, 63 Eggleston Road, Acton, Canberra, 2601, Australia, 61 2 6125 8406, alison.calear@anu.edu.au %K postpartum %K depression %K anxiety %K birth %K adoptive %K parents %K mobile phone %D 2024 %7 19.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Postpartum anxiety and depression are common in new parents. While effective interventions exist, they are often delivered in person, which can be a barrier for some parents seeking help. One approach to overcoming these barriers is the delivery of evidence-based self-help interventions via websites, smartphone apps, and other digital media. Objective: This study aims to evaluate the effectiveness of technology-based distal interventions in reducing or preventing symptoms of postpartum depression or anxiety in male and female birth and adoptive parents, explore the effectiveness of technology-based distal interventions in increasing social ties, and determine the level of adherence to and satisfaction with technology-based distal interventions. Methods: A systematic review and series of meta-analyses were conducted. Three electronic bibliographic databases (PsycINFO, PubMed, and Cochrane Library) were searched for randomized controlled trials evaluating technology-based distal interventions for postpartum depression or anxiety in birth and adoptive parents. Searches were updated on August 1, 2023, before conducting the final meta-analyses. Data on trial characteristics, effectiveness, adherence, satisfaction, and quality were extracted. Screening and data extraction were conducted by 2 reviewers. Risk of bias was assessed using the Joanna Briggs Institute quality rating scale for randomized controlled trials. Studies were initially synthesized qualitatively. Where possible, studies were also quantitatively synthesized through 5 meta-analyses. Results: Overall, 18 articles met the inclusion criteria for the systematic review, with 14 (78%) providing sufficient data for a meta-analysis. A small significant between-group effect on depression favored the intervention conditions at the postintervention (Cohen d=–0.28, 95% CI –0.41 to –0.15; P<.001) and follow-up (Cohen d=–0.27, 95% CI –0.52 to –0.02; P=.03) time points. A small significant effect on anxiety also favored the intervention conditions at the postintervention time point (Cohen d=–0.29, 95% CI –0.48 to –0.10; P=.002), with a medium effect at follow-up (Cohen d=–0.47, 95% CI –0.88 to –0.05; P=.03). The effect on social ties was not significant at the postintervention time point (Cohen d=0.04, 95% CI –0.12 to 0.21; P=.61). Effective interventions tended to be web-based cognitive behavioral therapy programs with reminders. Adherence varied considerably between studies, whereas satisfaction tended to be high for most studies. Conclusions: Technology-based distal interventions are effective in reducing symptoms of postpartum depression and anxiety in birth mothers. Key limitations of the reviewed evidence include heterogeneity in outcome measures, studies being underpowered to detect modest effects, and the exclusion of key populations from the evidence base. More research needs to be conducted with birth fathers and adoptive parents to better ascertain the effectiveness of interventions in these populations, as well as to further assess the effect of technology-based distal interventions on social ties. Trial Registration: PROSPERO CRD42021290525; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=290525 %M 39561361 %R 10.2196/53236 %U https://www.jmir.org/2024/1/e53236 %U https://doi.org/10.2196/53236 %U http://www.ncbi.nlm.nih.gov/pubmed/39561361 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56400 %T Mental Health Monitoring for Young People Through Mood Apps: Protocol for a Scoping Review and Systematic Search in App Stores %A Boege,Selina %A Milne-Ives,Madison %A Ananthakrishnan,Ananya %A Cong,Cen %A Sharma,Aditya %A Anderson,David %A Meinert,Edward %+ Translational and Clinical Research Institute, Newcastle University, Edwardson Building, Newcastle upon Tyne, NE4 5PL, United Kingdom, 44 191 20 83811, edward.meinert@newcastle.ac.uk %K digital health %K mental health %K mood apps %K mobile apps %K mobile phone %D 2024 %7 19.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The researchers have used mobile phones to assist in monitoring, analyzing, and managing moods to acquire insight into mood patterns. There is a lack of evidence in their use as clinical tools and interventions, which necessitates a comprehensive review and quality assessment to understand barriers and facilitators for app implementation as an impactful clinical intervention. Objective: This review aims to (1) provide an overview of the recent evidence on mobile mood-monitoring apps that are intended for facilitating self-management and support of mental health in children, adolescents, and young people; and (2) investigate the quality of publicly available apps. Methods: The study will first involve a scoping review of the literature on mood-monitoring apps for children, adolescents, and young people followed by an evaluation of features of the apps available in the marketplace. The scoping review will follow the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines and search 6 databases— Embase, CINAHL, PubMed, ACM Digital Library, Scopus, and Springer LNCS—for relevant studies and reviews published in the last 3 years. The author will then screen the references, extract data from the included studies, and analyze them to synthesize the evidence on mood apps. Next, the Apple App Store and Google Play Store will be searched for mood apps. A total of 2 independent reviewers will screen the apps based on eligibility criteria, and disagreements will be resolved through consensus. The features of the selected apps will then be evaluated using the Mobile Health Index and Navigation framework, and descriptive analysis will be used to synthesize the findings. Results: Literature search and screening began soon after submission of the protocol and is expected to be completed by September 2024. The app evaluation will be completed by October 2024. Conclusions: Combined, the scoping literature review and app evaluation will provide an in-depth overview of the most recent scientific evidence related to mood apps and the quality of apps actually available for use. International Registered Report Identifier (IRRID): PRR1-10.2196/56400 %M 39561357 %R 10.2196/56400 %U https://www.researchprotocols.org/2024/1/e56400 %U https://doi.org/10.2196/56400 %U http://www.ncbi.nlm.nih.gov/pubmed/39561357 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e62725 %T Assessing Digital Phenotyping for App Recommendations and Sustained Engagement: Cohort Study %A Dwyer,Bridget %A Flathers,Matthew %A Burns,James %A Mikkelson,Jane %A Perlmutter,Elana %A Chen,Kelly %A Ram,Nanik %A Torous,John %+ Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02115, United States, 1 6176676700, jtorous@bidmc.harvard.edu %K engagement %K mental health %K digital phenotype %K pilot study %K phenotyping %K smartphone sensors %K anxiety %K sleep %K fitness %K depression %K qualitative %K app recommendation %K app use %K mobile phone %D 2024 %7 19.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Low engagement with mental health apps continues to limit their impact. New approaches to help match patients to the right app may increase engagement by ensuring the app they are using is best suited to their mental health needs. Objective: This study aims to pilot how digital phenotyping, using data from smartphone sensors to infer symptom, behavioral, and functional outcomes, could be used to match people to mental health apps and potentially increase engagement Methods: After 1 week of collecting digital phenotyping data with the mindLAMP app (Beth Israel Deaconess Medical Center), participants were randomly assigned to the digital phenotyping arm, receiving feedback and recommendations based on those data to select 1 of 4 predetermined mental health apps (related to mood, anxiety, sleep, and fitness), or the control arm, selecting the same apps but without any feedback or recommendations. All participants used their selected app for 4 weeks with numerous metrics of engagement recorded, including objective screentime measures, self-reported engagement measures, and Digital Working Alliance Inventory scores. Results: A total of 82 participants enrolled in the study; 17 (21%) dropped out of the digital phenotyping arm and 18 (22%) dropped out from the control arm. Across both groups, few participants chose or were recommended the insomnia or fitness app. The majority (39/47, 83%) used a depression or anxiety app. Engagement as measured by objective screen time and Digital Working Alliance Inventory scores were higher in the digital phenotyping arm. There was no correlation between self-reported and objective metrics of app use. Qualitative results highlighted the importance of habit formation in sustained app use. Conclusions: The results suggest that digital phenotyping app recommendation is feasible and may increase engagement. This approach is generalizable to other apps beyond the 4 apps selected for use in this pilot, and practical for real-world use given that the study was conducted without any compensation or external incentives that may have biased results. Advances in digital phenotyping will likely make this method of app recommendation more personalized and thus of even greater interest. %M 39560976 %R 10.2196/62725 %U https://formative.jmir.org/2024/1/e62725 %U https://doi.org/10.2196/62725 %U http://www.ncbi.nlm.nih.gov/pubmed/39560976 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52788 %T Acceptance and Use of eHealth in Support and Psychological Therapy for People With Intellectual Disabilities: Two Cross-Sectional Studies of Health Care Professionals %A Oudshoorn,Cathelijn %A Frielink,Noud %A Riper,Heleen %A Embregts,Petri %+ Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, 5037 DB, Tilburg, Netherlands, 31 0134662969, c.e.m.oudshoorn@tilburguniversity.edu %K acceptance %K health care professionals %K intellectual disabilities %K eHealth %K disability %K psychological therapy %K support %K cross-sectional survey %D 2024 %7 12.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Acceptance of health care professionals is of paramount importance for the uptake and implementation of eHealth. The Unified Theory of Acceptance and Use of Technology (UTAUT) model is a widely used framework for studying health care professionals’ acceptance and actual use of eHealth among general client populations. However, there is limited understanding of the eHealth acceptance of health care professionals working with people with intellectual disabilities (ID). Objective: This study aimed to explore the applicability of the UTAUT model toward understanding the acceptance, intention to use, and actual use of eHealth among support staff and therapists working with people with ID. Methods: A total of 2 cross-sectional survey studies were conducted among health care professionals from 5 health care organizations for people with ID in the Netherlands in 2018 (n=311) and in 2021 during the COVID-19 pandemic (n=326). In addition to confirmatory and exploratory factor analyses to evaluate both the original UTAUT model and an extended version, descriptive analysis was used to explore participants’ characteristics, acceptance levels, and eHealth usage. Moderator analysis and multiple regression analysis were also used. Results: A confirmatory factor analysis indicated a poor fit for both the original 4-factor UTAUT model and the extended version. An exploratory factor analysis was then conducted, resulting in a more satisfactory 5-factor model after removing 1 item with a factor loading <.40. Internal consistency of the 5 factors ranged from acceptable to good (Cronbach α=.76-.85). Collectively, all factors predicted the intention to use eHealth in 2018 (R2=0.47; F5,305=54.885; P<.001) and in 2021 (R2=0.43; F5,320=49.32; P<.001). Participants scored moderately on all 5 acceptance factors in both 2018 and 2021. Moderator analysis indicated that age and voluntariness influence the relationship between factors that determined acceptance and intention to use eHealth. Conclusions: The findings from 2 cross-sectional studies conducted in 2018 and 2021, using an extended UTAUT model, gave a deeper understanding of eHealth acceptance among health care professionals who work with people with ID. %M 39531275 %R 10.2196/52788 %U https://formative.jmir.org/2024/1/e52788 %U https://doi.org/10.2196/52788 %U http://www.ncbi.nlm.nih.gov/pubmed/39531275 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e51832 %T Exploring Psychotherapists’ Attitudes on Internet- and Mobile-Based Interventions in Germany: Thematic Analysis %A Hildebrand,Anne Sophie %A Planert,Jari %A Machulska,Alla %A Margraf,Lena Maria %A Roesmann,Kati %A Klucken,Tim %+ Department of Clinical Psychology and Psychotherapy, University of Siegen, Obergraben 23, Siegen, 57072, Germany, 49 271 740 3688, Anne.Hildebrand@uni-siegen.de %K eHealth %K psychotherapy %K psychotherapists’ perspectives %K thematic analysis %K internet- and mobile-based intervention %D 2024 %7 7.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: In recent years, internet- and mobile-based interventions (IMIs) have become increasingly relevant in mental health care and have sparked societal debates. Psychotherapists’ perspectives are essential for identifying potential opportunities for improvement, facilitating conditions, and barriers to the implementation of these interventions. Objective: This study aims to explore psychotherapists’ perspectives on opportunities for improvement, facilitating conditions, and barriers to using IMIs. Methods: The study used a qualitative research design, utilizing open-ended items in a cross-sectional survey. A total of 350 psychotherapists were asked to provide their written opinions on various aspects of IMIs. Thematic analysis was conducted to analyze the data and identify core themes. Results: The analysis revealed 11 core themes related to the use of IMIs, which were categorized into 4 superordinate categories: “Applicability,” “Treatment Resources,” “Technology,” and “Perceived Risks and Barriers.” While many psychotherapists viewed IMIs as a valuable support for conventional psychotherapy, they expressed skepticism about using IMIs as a substitute. Several factors were perceived as hindrances to the applicability of IMIs in clinical practice, including technological issues, subjective concerns about potential data protection risks, a lack of individualization due to the manualized nature of most IMIs, and the high time and financial costs for both psychotherapists and patients. They expressed a desire for easily accessible information on evidence and programs to reduce the time and effort required for training and advocated for this information to be integrated into the conceptualization of new IMIs. Conclusions: The findings of this study emphasize the importance of considering psychotherapists’ attitudes in the development, evaluation, and implementation of IMIs. This study revealed that psychotherapists recognized both the opportunities and risks associated with the use of IMIs, with most agreeing that IMIs serve as a tool to support traditional psychotherapy rather than as a substitute for it. Furthermore, it is essential to involve psychotherapists in discussions about IMIs specifically, as well as in the development of new methodologies in psychotherapy more broadly. Overall, this study can advance the use of IMIs in mental health care and contribute to the ongoing societal debate surrounding these interventions. %M 39510514 %R 10.2196/51832 %U https://formative.jmir.org/2024/1/e51832 %U https://doi.org/10.2196/51832 %U http://www.ncbi.nlm.nih.gov/pubmed/39510514 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e60441 %T The Journey From Nonimmersive to Immersive Multiuser Applications in Mental Health Care: Systematic Review %A Fajnerova,Iveta %A Hejtmánek,Lukáš %A Sedlák,Michal %A Jablonská,Markéta %A Francová,Anna %A Stopková,Pavla %+ Research Center for Virtual Reality in Mental Health and Neuroscience, National Institute of Mental Health, Topolová 748, Klecany, 250 67, Czech Republic, 420 283 088 478, Iveta.fajnerova@nudz.cz %K digital health %K mental health care %K clinical interventions %K multiuser %K immersive %K virtual reality %K VR %K app %K mental health %K online tools %K synthesis %K mobile phone %K PRISMA %D 2024 %7 7.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Over the past 25 years, the development of multiuser applications has seen considerable advancements and challenges. The technological development in this field has emerged from simple chat rooms through videoconferencing tools to the creation of complex, interactive, and often multisensory virtual worlds. These multiuser technologies have gradually found their way into mental health care, where they are used in both dyadic counseling and group interventions. However, some limitations in hardware capabilities, user experience designs, and scalability may have hindered the effectiveness of these applications. Objective: This systematic review aims at summarizing the progress made and the potential future directions in this field while evaluating various factors and perspectives relevant to remote multiuser interventions. Methods: The systematic review was performed based on a Web of Science and PubMed database search covering articles in English, published from January 1999 to March 2024, related to multiuser mental health interventions. Several inclusion and exclusion criteria were determined before and during the records screening process, which was performed in several steps. Results: We identified 49 records exploring multiuser applications in mental health care, ranging from text-based interventions to interventions set in fully immersive environments. The number of publications exploring this topic has been growing since 2015, with a large increase during the COVID-19 pandemic. Most digital interventions were delivered in the form of videoconferencing, with only a few implementing immersive environments. The studies used professional or peer-supported group interventions or a combination of both approaches. The research studies targeted diverse groups and topics, from nursing mothers to psychiatric disorders or various minority groups. Most group sessions occurred weekly, or in the case of the peer-support groups, often with a flexible schedule. Conclusions: We identified many benefits to multiuser digital interventions for mental health care. These approaches provide distributed, always available, and affordable peer support that can be used to deliver necessary help to people living outside of areas where in-person interventions are easily available. While immersive virtual environments have become a common tool in many areas of psychiatric care, such as exposure therapy, our results suggest that this technology in multiuser settings is still in its early stages. Most identified studies investigated mainstream technologies, such as videoconferencing or text-based support, substituting the immersive experience for convenience and ease of use. While many studies discuss useful features of virtual environments in group interventions, such as anonymity or stronger engagement with the group, we discuss persisting issues with these technologies, which currently prevent their full adoption. %M 39509153 %R 10.2196/60441 %U https://www.jmir.org/2024/1/e60441 %U https://doi.org/10.2196/60441 %U http://www.ncbi.nlm.nih.gov/pubmed/39509153 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58409 %T Automated Real-Time Tool for Promoting Crisis Resource Use for Suicide Risk (ResourceBot): Development and Usability Study %A Coppersmith,Daniel DL %A Bentley,Kate H %A Kleiman,Evan M %A Jaroszewski,Adam C %A Daniel,Merryn %A Nock,Matthew K %+ Department of Psychology, Harvard University, 33 Kirkland St, Cambridge, MA, 02138, United States, 1 617 495 3800, dcoppersmith@g.harvard.edu %K suicidal thoughts %K suicidal behaviors %K ecological momentary assessment %K crisis resources %K real-time tool %K self-report %K psychoeducation %K app %D 2024 %7 31.10.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Real-time monitoring captures information about suicidal thoughts and behaviors (STBs) as they occur and offers great promise to learn about STBs. However, this approach also introduces questions about how to monitor and respond to real-time information about STBs. Given the increasing use of real-time monitoring, there is a need for novel, effective, and scalable tools for responding to suicide risk in real time. Objective: The goal of this study was to develop and test an automated tool (ResourceBot) that promotes the use of crisis services (eg, 988) in real time through a rule-based (ie, if-then) brief barrier reduction intervention. Methods: ResourceBot was tested in a 2-week real-time monitoring study of 74 adults with recent suicidal thoughts. Results: ResourceBot was deployed 221 times to 36 participants. There was high engagement with ResourceBot (ie, 87% of the time ResourceBot was deployed, a participant opened the tool and submitted a response to it), but zero participants reported using crisis services after engaging with ResourceBot. The most reported reasons for not using crisis services were beliefs that the resources would not help, wanting to handle things on one’s own, and the resources requiring too much time or effort. At the end of the study, participants rated ResourceBot with good usability (mean of 75.6 out of 100) and satisfaction (mean of 20.8 out of 32). Conclusions: This study highlights both the possibilities and challenges of developing effective real-time interventions for suicide risk and areas for refinement in future work. %M 39481100 %R 10.2196/58409 %U https://mental.jmir.org/2024/1/e58409 %U https://doi.org/10.2196/58409 %U http://www.ncbi.nlm.nih.gov/pubmed/39481100 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e49660 %T Blended Psychological Therapy for the Treatment of Psychological Disorders in Adult Patients: Systematic Review and Meta-Analysis %A Ferrao Nunes-Zlotkowski,Kelly %A Shepherd,Heather L %A Beatty,Lisa %A Butow,Phyllis %A Shaw,Joanne Margaret %+ Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Rm 311B Level 3 Griffith Taylor (A19), Manning Road, Sydney, NSW 2006, Australia, 61 2 9351 3761, joanne.shaw@sydney.edu.au %K systematic review %K blended psychological therapy %K blended care %K face-to-face %K online %K psychological intervention %K intervention design %K digital care %K digital mental health %K psychological disorder %D 2024 %7 29.10.2024 %9 Review %J Interact J Med Res %G English %X Background: Blended therapy (BT) combines digital with face-to-face psychological interventions. BT may improve access to treatment, therapy uptake, and adherence. However, research is scarce on the structure of BT models. Objective: We synthesized the literature to describe BT models used for the treatment of psychological disorders in adults. We investigated whether BT structure, content, and ratio affected treatment efficacy, uptake, and adherence. We also conducted meta-analyses to examine treatment efficacy in intervention-control dyads and associations between treatment outcomes versus BT model structure. Methods: PsycINFO, CINAHL, Embase, ProQuest, and MEDLINE databases were searched. Eligibility criteria included articles published in English till March 2023 that described digital and face-to-face elements as part of an intervention plan for treating psychological disorders in adult patients. We developed a coding framework to characterize the BT interventions. A meta-analysis was conducted to calculate effect size (ES; Cohen d and 95% CIs) regarding pre- and posttreatment outcomes in depression and anxiety versus BT structure. The review was registered with PROSPERO and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Searches identified 8436 articles, and data were extracted from 29 studies. BT interventions were analyzed and classified according to mode of interaction between digital and face-to-face components (integrated vs sequential), role of the components (core vs supplementary), component delivery (alternate vs case-by-case), and digital materials assignment mode (standardized vs personalized). Most BT interventions (n=24) used a cognitive behavioral therapy approach for anxiety or depression treatment. Mean rates of uptake (91%) and adherence (81%) were reported across individual studies. BT interventions were more effective or noninferior to treatment as usual, with large spread in the data and a moderate to large ES in the treatment of depression (n=9; Cohen d=–1.1, 95% CI –0.6 to –1.6, P<.001, and z score=–4.3). A small, nonsignificant ES was found for anxiety outcomes (n=5; Cohen d=–0.1, 95% CI –0.3 to 0.05, P=.17, and z score=–1.4). Higher ESs were found in blended interventions with supplementary design (depression: n=11, Cohen d=–0.75, 95% CI –0.56 to –0.95; anxiety: n=8, Cohen d=–0.9, 95% CI –0.6 to –1.2); fewer (≤6) face-to-face sessions (depression: n=9, Cohen d=–0.7, 95% CI –0.5 to –0.9; anxiety: n=7, Cohen d=–0.8, 95% CI –0.3 to –1.3); and a lower ratio (≤50%) of face-to-face versus digital sessions (depression: n=5, Cohen d=–0.8, 95% CI –0.6 to –1.1; anxiety: n=4, Cohen d=–0.8, 95% CI 0.006 to –1.6). Conclusions: This study confirmed integrated BT models as feasible to deliver. We found BT to be effective in depression treatment, but anxiety treatment results were nonsignificant. Future studies assessing outcomes across different psychological disorders and therapeutic approaches are required. Trial Registration: PROSPERO CRD42021258977; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258977 %M 39470720 %R 10.2196/49660 %U https://www.i-jmr.org/2024/1/e49660 %U https://doi.org/10.2196/49660 %U http://www.ncbi.nlm.nih.gov/pubmed/39470720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52609 %T Acceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review %A Lau,Carrie K Y %A Saad,Anthony %A Camara,Bettina %A Rahman,Dia %A Bolea-Alamanac,Blanca %+ Department of Psychiatry, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 647 331 2707, Blanca.BoleaAlamanac@wchospital.ca %K acceptability %K mental health %K depression %K anxiety %K mobile app %K internet %K mobile phone %K mobile health %K mHealth %K digital health %D 2024 %7 28.10.2024 %9 Review %J J Med Internet Res %G English %X Background: Depression and anxiety disorders are common, and treatment often includes psychological interventions. Digital health interventions, delivered through technologies such as web-based programs and mobile apps, are increasingly used in mental health treatment. Acceptability, the extent to which an intervention is viewed positively, has been identified as contributing to patient adherence and engagement with digital health interventions. Acceptability, therefore, impacts the benefit derived from using digital health interventions in treatment. Understanding the acceptability of digital mental health interventions among patients with depression or anxiety disorders is essential to maximize the effectiveness of their treatment. Objective: This review investigated the acceptability of technology-based interventions among patients with depression or anxiety disorders. Methods: A systematic review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines. We searched PubMed, Web of Science, and Ovid in May 2022. Studies were included if they evaluated digital interventions for the treatment of depression or anxiety disorders and investigated their acceptability among adult patients. Studies were excluded if they targeted only specific populations (eg, those with specific physical health conditions), investigated acceptability in healthy individuals or patients under the age of 18 years, involved no direct interaction between patients and technologies, used technology only as a platform for traditional care (eg, videoconferencing), had patients using technologies only in clinical or laboratory settings, or involved virtual reality technologies. Acceptability outcome data were narratively synthesized by the direction of acceptability using vote counting. Included studies were evaluated using levels of evidence from the Oxford Centre for Evidence-Based Medicine. The risk of bias was assessed using a tool designed for this review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Results: A total of 143 articles met the inclusion criteria, comprising 67 (47%) articles on interventions for depression, 65 (45%) articles on interventions for anxiety disorders, and 11 (8%) articles on interventions for both. Overall, 90 (63%) were randomized controlled trials, 50 (35%) were other quantitative studies, and 3 (2%) were qualitative studies. Interventions used web-based programs, mobile apps, and computer programs. Cognitive behavioral therapy was the basis of 71% (102/143) of the interventions. Digital mental health interventions were generally acceptable among patients with depression or anxiety disorders, with 88% (126/143) indicating positive acceptability, 8% (11/143) mixed results, and 4% (6/143) insufficient information to categorize the direction of acceptability. The available research evidence was of moderate quality. Conclusions: Digital mental health interventions seem to be acceptable to patients with depression or anxiety disorders. Consistent use of validated measures for acceptability would enhance the quality of evidence. Careful design of acceptability as an evaluation outcome can further improve the quality of evidence and reduce the risk of bias. Trial Registration: Open Science Framework Y7MJ4; https://doi.org/10.17605/OSF.IO/SPR8M %M 39466300 %R 10.2196/52609 %U https://www.jmir.org/2024/1/e52609 %U https://doi.org/10.2196/52609 %U http://www.ncbi.nlm.nih.gov/pubmed/39466300 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e51259 %T Digital Phenotyping of Mental and Physical Conditions: Remote Monitoring of Patients Through RADAR-Base Platform %A Rashid,Zulqarnain %A Folarin,Amos A %A Zhang,Yuezhou %A Ranjan,Yatharth %A Conde,Pauline %A Sankesara,Heet %A Sun,Shaoxiong %A Stewart,Callum %A Laiou,Petroula %A Dobson,Richard J B %K digital biomarkers %K mHealth %K mobile apps %K Internet of Things %K remote data collection %K wearables %K real-time monitoring %K platform %K biomarkers %K wearable %K smartphone %K data collection %K open-source platform %K RADAR-base %K phenotyping %K mobile phone %K IoT %D 2024 %7 23.10.2024 %9 %J JMIR Ment Health %G English %X Background: The use of digital biomarkers through remote patient monitoring offers valuable and timely insights into a patient’s condition, including aspects such as disease progression and treatment response. This serves as a complementary resource to traditional health care settings leveraging mobile technology to improve scale and lower latency, cost, and burden. Objective: Smartphones with embedded and connected sensors have immense potential for improving health care through various apps and mobile health (mHealth) platforms. This capability could enable the development of reliable digital biomarkers from long-term longitudinal data collected remotely from patients. Methods: We built an open-source platform, RADAR-base, to support large-scale data collection in remote monitoring studies. RADAR-base is a modern remote data collection platform built around Confluent’s Apache Kafka to support scalability, extensibility, security, privacy, and quality of data. It provides support for study design and setup and active (eg, patient-reported outcome measures) and passive (eg, phone sensors, wearable devices, and Internet of Things) remote data collection capabilities with feature generation (eg, behavioral, environmental, and physiological markers). The back end enables secure data transmission and scalable solutions for data storage, management, and data access. Results: The platform has been used to successfully collect longitudinal data for various cohorts in a number of disease areas including multiple sclerosis, depression, epilepsy, attention-deficit/hyperactivity disorder, Alzheimer disease, autism, and lung diseases. Digital biomarkers developed through collected data are providing useful insights into different diseases. Conclusions: RADAR-base offers a contemporary, open-source solution driven by the community for remotely monitoring, collecting data, and digitally characterizing both physical and mental health conditions. Clinicians have the ability to enhance their insight through the use of digital biomarkers, enabling improved prevention, personalization, and early intervention in the context of disease management. %R 10.2196/51259 %U https://mental.jmir.org/2024/1/e51259 %U https://doi.org/10.2196/51259 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51110 %T Exploring the Role of Mobile Apps for Insomnia in Depression: Systematic Review %A Chiu,Yi-Hang %A Lee,Yen-Fen %A Lin,Huang-Li %A Cheng,Li-Chen %+ Department of Information and Finance Management, National Taipei University of Technology, Number 1, Section 3, Zhongxiao East Road, Da’an District, Taipei City, 10608, Taiwan, 886 2771 2171 ext 6720, lijen.cheng@gmail.com %K depression %K insomnia %K chatbots %K conversational agents %K medical apps %K systematic review %K technical aspects %K PRISMA %D 2024 %7 18.10.2024 %9 Review %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has profoundly affected mental health, leading to an increased prevalence of depression and insomnia. Currently, artificial intelligence (AI) and deep learning have thoroughly transformed health care–related mobile apps, offered more effective mental health support, and alleviated the psychological stress that may have emerged during the pandemic. Early reviews outlined the use of mobile apps for dealing with depression and insomnia separately. However, there is now an urgent need for a systematic evaluation of mobile apps that address both depression and insomnia to reveal new applications and research gaps. Objective: This study aims to systematically review and evaluate mobile apps targeting depression and insomnia, highlighting their features, effectiveness, and gaps in the current research. Methods: We systematically searched PubMed, Scopus, and Web of Science for peer-reviewed journal articles published between 2017 and 2023. The inclusion criteria were studies that (1) focused on mobile apps addressing both depression and insomnia, (2) involved young people or adult participants, and (3) provided data on treatment efficacy. Data extraction was independently conducted by 2 reviewers. Title and abstract screening, as well as full-text screening, were completed in duplicate. Data were extracted by a single reviewer and verified by a second reviewer, and risk of bias assessments were completed accordingly. Results: Of the initial 383 studies we found, 365 were excluded after title, abstract screening, and removal of duplicates. Eventually, 18 full-text articles met our criteria and underwent full-text screening. The analysis revealed that mobile apps related to depression and insomnia were primarily utilized for early detection, assessment, and screening (n=5 studies); counseling and psychological support (n=3 studies); and cognitive behavioral therapy (CBT; n=10 studies). Among the 10 studies related to depression, our findings showed that chatbots demonstrated significant advantages in improving depression symptoms, a promising development in the field. Additionally, 2 studies evaluated the effectiveness of mobile apps as alternative interventions for depression and sleep, further expanding the potential applications of this technology. Conclusions: The integration of AI and deep learning into mobile apps, particularly chatbots, is a promising avenue for personalized mental health support. Through innovative features, such as early detection, assessment, counseling, and CBT, these apps significantly contribute toward improving sleep quality and addressing depression. The reviewed chatbots leveraged advanced technologies, including natural language processing, machine learning, and generative dialog, to provide intelligent and autonomous interactions. Compared with traditional face-to-face therapies, their feasibility, acceptability, and potential efficacy highlight their user-friendly, cost-effective, and accessible nature with the aim of enhancing sleep and mental health outcomes. %M 39423009 %R 10.2196/51110 %U https://www.jmir.org/2024/1/e51110 %U https://doi.org/10.2196/51110 %U http://www.ncbi.nlm.nih.gov/pubmed/39423009 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e59512 %T Empowering Mental Health Monitoring Using a Macro-Micro Personalization Framework for Multimodal-Multitask Learning: Descriptive Study %A Song,Meishu %A Yang,Zijiang %A Triantafyllopoulos,Andreas %A Zhang,Zixing %A Nan,Zhe %A Tang,Muxuan %A Takeuchi,Hiroki %A Nakamura,Toru %A Kishi,Akifumi %A Ishizawa,Tetsuro %A Yoshiuchi,Kazuhiro %A Schuller,Björn %A Yamamoto,Yoshiharu %+ Educational Physiology Laboratory, Graduate School of Education, The University of Tokyo, 7 Chome-3-1 Hongo, Bunkyo City, Tokyo, 1130033, Japan, 81 09035784363, yamamoto@p.u-tokyo.ac.jp %K multimodal %K multitask %K daily mental health %K mental health %K monitoring %K macro %K micro %K framework %K personalization %K strategies %K prediction %K emotional state %K wristbands %K smartphone %K mobile phones %K physiological %K signals %K speech data %K %D 2024 %7 18.10.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The field of mental health technology presently has significant gaps that need addressing, particularly in the domain of daily monitoring and personalized assessments. Current noninvasive devices such as wristbands and smartphones are capable of collecting a wide range of data, which has not yet been fully used for mental health monitoring. Objective: This study aims to introduce a novel dataset for personalized daily mental health monitoring and a new macro-micro framework. This framework is designed to use multimodal and multitask learning strategies for improved personalization and prediction of emotional states in individuals. Methods: Data were collected from 298 individuals using wristbands and smartphones, capturing physiological signals, speech data, and self-annotated emotional states. The proposed framework combines macro-level emotion transformer embeddings with micro-level personalization layers specific to each user. It also introduces a Dynamic Restrained Uncertainty Weighting method to effectively integrate various data types for a balanced representation of emotional states. Several fusion techniques, personalization strategies, and multitask learning approaches were explored. Results: The proposed framework was evaluated using the concordance correlation coefficient, resulting in a score of 0.503. This result demonstrates the framework’s efficacy in predicting emotional states. Conclusions: The study concludes that the proposed multimodal and multitask learning framework, which leverages transformer-based techniques and dynamic task weighting strategies, is superior for the personalized monitoring of mental health. The study indicates the potential of transforming daily mental health monitoring into a more personalized app, opening up new avenues for technology-based mental health interventions. %M 39422993 %R 10.2196/59512 %U https://mental.jmir.org/2024/1/e59512 %U https://doi.org/10.2196/59512 %U http://www.ncbi.nlm.nih.gov/pubmed/39422993 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e60434 %T Intention to Use a Mental Health App for Menopause: Health Belief Model Approach %A Martin-Key,Nayra A %A Funnell,Erin L %A Benacek,Jiri %A Spadaro,Benedetta %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K menopause %K menopause transition %K mental health %K perimenopause %K women’s health %K psychological framework %K symptom tracking %K app usage %K app %K Health Belief Model %D 2024 %7 16.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Menopause presents a period of heightened vulnerability for mental health issues. Despite this, mental health screening is not consistently integrated into menopausal health care, and access to psychological interventions is limited. Digital technologies, such as web and smartphone apps, may offer a way to facilitate and improve mental health care provision throughout menopause. However, little is known about potential users’ intention to use such technologies during this critical phase of life. Objective: To examine the factors that impact the intention of potential users to use a mental health app during menopause, we used the Health Belief Model (HBM), a psychological framework widely used to understand and predict individuals’ health-related behaviors. Methods: An online survey was generated. Convenience sampling was used, with participants recruited via social media and email, through relevant foundations and support groups, and by word of mouth. Structural equation modeling with maximum likelihood estimation was conducted to explore whether the factor structure of the HBM is a good fit for predicting the intention to use a mental health app for menopause. A Cronbach α value of .05 was used for determining statistical significance. Results: A total of 1154 participants commenced the survey, of which 82.49% (n=952) completed at least 97% of the survey. Of these, 86.76% (n=826) expressed that their menopausal symptoms had negatively affected their mental health, and went on to answer questions regarding their experiences and interest in using a web or smartphone app for mental health symptoms related to menopause. Data from this subgroup (N=826) were analyzed. In total, 74.09% (n=612) of respondents sought online help for mental health symptoms related to menopause. The most common topics searched for were symptom characteristics (n=435, 52.66%) and treatment or therapy options (n=210, 25.42%). Psychoeducation (n=514, 62.23%) was the most desired mental health app feature, followed by symptom tracking (n=499, 60.41%) and self-help tips (n=469, 56.78%). In terms of the intention to use a mental health app, the Satorra-Bentler–scaled fit statistics indicated a good fit for the model (χ2278=790.44, P<.001; comparative fit index=0.933, root mean square error of approximation=0.047, standardized root mean square residual=0.056), with cues to action emerging as the most significant predictor of intention (β=.48, P<.001). This was followed by perceived barriers (β=–.25, P<.001), perceived susceptibility (β=.15, P<.001), and perceived benefits (β=.13, P<.001). Perceived severity (β=.01, P=.869) and self-efficacy (β=.03, P=.286) were not significantly associated with behavioral intention. Conclusions: This study reveals important factors that influence the intention to use a mental health app during menopause. It emphasizes the need to address barriers to app usage, while highlighting the impact of credible endorsements and psychoeducation. Furthermore, the study underscores the significance of improving accessibility for users with lower digital literacy or limited resources. %M 39412868 %R 10.2196/60434 %U https://formative.jmir.org/2024/1/e60434 %U https://doi.org/10.2196/60434 %U http://www.ncbi.nlm.nih.gov/pubmed/39412868 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e57439 %T Smartphone Screen Time Characteristics in People With Suicidal Thoughts: Retrospective Observational Data Analysis Study %A Karas,Marta %A Huang,Debbie %A Clement,Zachary %A Millner,Alexander J %A Kleiman,Evan M %A Bentley,Kate H %A Zuromski,Kelly L %A Fortgang,Rebecca G %A DeMarco,Dylan %A Haim,Adam %A Donovan,Abigail %A Buonopane,Ralph J %A Bird,Suzanne A %A Smoller,Jordan W %A Nock,Matthew K %A Onnela,Jukka-Pekka %K smartphone %K mobile apps %K mobile health %K screen time %K suicidal thoughts and behavior %K suicidal %K app %K observational data %K data analysis study %K monitor %K survey %K psychiatric %K screen %K mental health %K feasibility %K suicidal ideation %K mobile phone %D 2024 %7 11.10.2024 %9 %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based monitoring in natural settings provides opportunities to monitor mental health behaviors, including suicidal thoughts and behaviors. To date, most suicidal thoughts and behaviors research using smartphones has primarily relied on collecting so-called “active” data, requiring participants to engage by completing surveys. Data collected passively from smartphone sensors and logs may offer an objectively measured representation of an individual’s behavior, including smartphone screen time. Objective: This study aims to present methods for identifying screen-on bouts and deriving screen time characteristics from passively collected smartphone state logs and to estimate daily smartphone screen time in people with suicidal thinking, providing a more reliable alternative to traditional self-report. Methods: Participants (N=126; median age 22, IQR 16-33 years) installed the Beiwe app (Harvard University) on their smartphones, which passively collected phone state logs for up to 6 months after discharge from an inpatient psychiatric unit (adolescents) or emergency department visit (adults). We derived daily screen time measures from these logs, including screen-on time, screen-on bout duration, screen-off bout duration, and screen-on bout count. We estimated the mean of these measures across age subgroups (adults and adolescents), phone operating systems (Android and iOS), and monitoring stages after the discharge (first 4 weeks vs subsequent weeks). We evaluated the sensitivity of daily screen time measures to changes in the parameters of the screen-on bout identification method. Additionally, we estimated the impact of a daylight time change on minute-level screen time using function-on-scalar generalized linear mixed-effects regression. Results: The median monitoring period was 169 (IQR 42‐169) days. For adolescents and adults, mean daily screen-on time was 254.6 (95% CI 231.4-277.7) and 271.0 (95% CI 252.2-289.8) minutes, mean daily screen-on bout duration was 4.233 (95% CI 3.565-4.902) and 4.998 (95% CI 4.455-5.541) minutes, mean daily screen-off bout duration was 25.90 (95% CI 20.09-31.71) and 26.90 (95% CI 22.18-31.66) minutes, and mean daily screen-on bout count (natural logarithm transformed) was 4.192 (95% CI 4.041-4.343) and 4.090 (95% CI 3.968-4.213), respectively; there were no significant differences between smartphone operating systems (all P values were >.05). The daily measures were not significantly different for the first 4 weeks compared to the fifth week onward (all P values were >.05), except average screen-on bout in adults (P value = .018). Our sensitivity analysis indicated that in the screen-on bout identification method, the cap on an individual screen-on bout duration has a substantial effect on the resulting daily screen time measures. We observed time windows with a statistically significant effect of daylight time change on screen-on time (based on 95% joint confidence intervals bands), plausibly attributable to sleep time adjustments related to clock changes. Conclusions: Passively collected phone logs offer an alternative to self-report measures for studying smartphone screen time characteristics in people with suicidal thinking. Our work demonstrates the feasibility of this approach, opening doors for further research on the associations between daily screen time, mental health, and other factors. %R 10.2196/57439 %U https://mhealth.jmir.org/2024/1/e57439 %U https://doi.org/10.2196/57439 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56691 %T Long-Term Effects of Internet-Based Cognitive Behavioral Therapy on Depression Prevention Among University Students: Randomized Controlled Factorial Trial %A Nakagami,Yukako %A Uwatoko,Teruhisa %A Shimamoto,Tomonari %A Sakata,Masatsugu %A Toyomoto,Rie %A Yoshida,Kazufumi %A Luo,Yan %A Shiraishi,Nao %A Tajika,Aran %A Sahker,Ethan %A Horikoshi,Masaru %A Noma,Hisashi %A Iwami,Taku %A Furukawa,Toshi A %K iCBT %K depression prevention %K student mental health %K factorial randomized controlled trial %K mobile phone %D 2024 %7 24.9.2024 %9 %J JMIR Ment Health %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) shows promise in the prevention of depression. However, the specific iCBT components that contribute to its effectiveness remain unclear. Objective: We aim to evaluate the effects of iCBT components in preventing depression among university students. Methods: Using a smartphone cognitive behavioral therapy (CBT) app, we randomly allocated university students to the presence or absence of 5 different iCBT components: self-monitoring, behavioral activation, cognitive restructuring, assertiveness training, and problem-solving. The active intervention lasted 8 weeks but the app remained accessible through the follow-up. The primary outcome was the onset of a major depressive episode (MDE) between baseline and the follow-up after 52 weeks, as assessed with the computerized World Health Organization Composite International Diagnostic Interview. Secondary outcomes included changes in the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, and CBT Skills Scale. Results: During the 12-month follow-up, 133 of 1301 (10.22%) participants reported the onset of an MDE. There were no significant differences in the incidence of MDEs between the groups with or without each component (hazard ratios ranged from 0.85, 95% CI 0.60‐1.20, for assertiveness training to 1.26, 95% CI 0.88‐1.79, for self-monitoring). Furthermore, there were no significant differences in the changes on the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, or for CBT Skills Scale between component allocation groups. However, significant reductions in depression and anxiety symptoms were observed among all participants at the 52-week follow-up. Conclusions: In this study, we could not identify any specific iCBT components that were effective in preventing depression or the acquisition of CBT skills over the 12-month follow-up period, but all participants with and without intervention of each iCBT component demonstrated significant improvements in depressive and anxiety symptoms. Further research is needed to explore the potential impact of frequency of psychological assessments, nonspecific intervention effects, natural change in the mental state, and the baseline depression level. Trial Registration: UMINCTR UMIN000031307; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035735 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-2719-z %R 10.2196/56691 %U https://mental.jmir.org/2024/1/e56691 %U https://doi.org/10.2196/56691 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e51366 %T Engagement, Acceptability, and Effectiveness of the Self-Care and Coach-Supported Versions of the Vira Digital Behavior Change Platform Among Young Adults at Risk for Depression and Obesity: Pilot Randomized Controlled Trial %A Weiner,Lauren S %A Crowley,Ryann N %A Sheeber,Lisa B %A Koegler,Frank H %A Davis,Jon F %A Wells,Megan %A Funkhouser,Carter J %A Auerbach,Randy P %A Allen,Nicholas B %+ Ksana Health, 2288 Alder Street, Eugene, OR, 97405, United States, 1 541 912 2883, lauren.weiner@ksanahealth.com %K depression %K behavioral activation %K digital health %K mental health %K behavior change %K mobile sensing %K anxiety %K health coaching %K mobile phone %D 2024 %7 19.9.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adolescence and early adulthood are pivotal stages for the onset of mental health disorders and the development of health behaviors. Digital behavioral activation interventions, with or without coaching support, hold promise for addressing risk factors for both mental and physical health problems by offering scalable approaches to expand access to evidence-based mental health support. Objective: This 2-arm pilot randomized controlled trial evaluated 2 versions of a digital behavioral health product, Vira (Ksana Health Inc), for their feasibility, acceptability, and preliminary effectiveness in improving mental health in young adults with depressive symptoms and obesity risk factors. Methods: A total of 73 participants recruited throughout the United States were randomly assigned to use Vira either as a self-guided product (Vira Self-Care) or with support from a health coach (Vira+Coaching) for 12 weeks. The Vira smartphone app used passive sensing of behavioral data related to mental health and obesity risk factors (ie, activity, sleep, mobility, and language patterns) and offered users personalized insights into patterns of behavior associated with their daily mood. Participants completed self-reported outcome measures at baseline and follow-up (12 weeks). All study procedures were completed via digital communications. Results: Both versions of Vira showed strong user engagement, acceptability, and evidence of effectiveness in improving mental health and stress. However, users receiving coaching exhibited more sustained engagement with the platform and reported greater reductions in depression (Cohen d=0.45, 95% CI 0.10-0.82) and anxiety (Cohen d=0.50, 95% CI 0.13-0.86) compared to self-care users. Both interventions also resulted in reduced stress (Vira+Coaching: Cohen d=–1.05, 95% CI –1.57 to –-0.50; Vira Self-Care: Cohen d=–0.78, 95% CI –1.33 to –0.23) and were perceived as useful and easy to use. Coached users also reported reductions in sleep-related impairment (Cohen d=–0.51, 95% CI –1.00 to –0.01). Moreover, participants increased their motivation for and confidence in making behavioral changes, with greater improvements in confidence among coached users. Conclusions: An app-based intervention using passive mobile sensing to track behavior and deliver personalized insights into behavior-mood associations demonstrated feasibility, acceptability, and preliminary effectiveness for reducing depressive symptoms and other mental health problems in young adults. Future directions include (1) optimizing the interventions, (2) conducting a fully powered trial that includes an active control condition, and (3) testing mediators and moderators of outcome effects. Trial Registration: ClinicalTrials.gov NCT05638516; https://clinicaltrials.gov/study/NCT05638516 %M 39298763 %R 10.2196/51366 %U https://mental.jmir.org/2024/1/e51366 %U https://doi.org/10.2196/51366 %U http://www.ncbi.nlm.nih.gov/pubmed/39298763 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58462 %T Patient Perspectives on AI for Mental Health Care: Cross-Sectional Survey Study %A Benda,Natalie %A Desai,Pooja %A Reza,Zayan %A Zheng,Anna %A Kumar,Shiveen %A Harkins,Sarah %A Hermann,Alison %A Zhang,Yiye %A Joly,Rochelle %A Kim,Jessica %A Pathak,Jyotishman %A Reading Turchioe,Meghan %+ School of Nursing, Columbia University, 560 168th Street, New York, NY, 10032, United States, 1 917 426 3069, nb3115@cumc.columbia.edu %K artificial intelligence %K AI %K mental health %K patient perspectives %K patients %K public survey %K application %K applications %K health care %K health professionals %K somatic issues %K radiology %K perinatal health %K Black %K professional relationship %K patient-health %K autonomy %K risk %K confidentiality %K machine learning %K digital mental health %K computing %K coding %K mobile phone %D 2024 %7 18.9.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The application of artificial intelligence (AI) to health and health care is rapidly increasing. Several studies have assessed the attitudes of health professionals, but far fewer studies have explored the perspectives of patients or the general public. Studies investigating patient perspectives have focused on somatic issues, including those related to radiology, perinatal health, and general applications. Patient feedback has been elicited in the development of specific mental health care solutions, but broader perspectives toward AI for mental health care have been underexplored. Objective: This study aims to understand public perceptions regarding potential benefits of AI, concerns about AI, comfort with AI accomplishing various tasks, and values related to AI, all pertaining to mental health care. Methods: We conducted a 1-time cross-sectional survey with a nationally representative sample of 500 US-based adults. Participants provided structured responses on their perceived benefits, concerns, comfort, and values regarding AI for mental health care. They could also add free-text responses to elaborate on their concerns and values. Results: A plurality of participants (245/497, 49.3%) believed AI may be beneficial for mental health care, but this perspective differed based on sociodemographic variables (all P<.05). Specifically, Black participants (odds ratio [OR] 1.76, 95% CI 1.03-3.05) and those with lower health literacy (OR 2.16, 95% CI 1.29-3.78) perceived AI to be more beneficial, and women (OR 0.68, 95% CI 0.46-0.99) perceived AI to be less beneficial. Participants endorsed concerns about accuracy, possible unintended consequences such as misdiagnosis, the confidentiality of their information, and the loss of connection with their health professional when AI is used for mental health care. A majority of participants (80.4%, 402/500) valued being able to understand individual factors driving their risk, confidentiality, and autonomy as it pertained to the use of AI for their mental health. When asked who was responsible for the misdiagnosis of mental health conditions using AI, 81.6% (408/500) of participants found the health professional to be responsible. Qualitative results revealed similar concerns related to the accuracy of AI and how its use may impact the confidentiality of patients’ information. Conclusions: Future work involving the use of AI for mental health care should investigate strategies for conveying the level of AI’s accuracy, factors that drive patients’ mental health risks, and how data are used confidentially so that patients can determine with their health professionals when AI may be beneficial. It will also be important in a mental health care context to ensure the patient–health professional relationship is preserved when AI is used. %M 39293056 %R 10.2196/58462 %U https://mental.jmir.org/2024/1/e58462 %U https://doi.org/10.2196/58462 %U http://www.ncbi.nlm.nih.gov/pubmed/39293056 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56650 %T Digital Mental Health Interventions for Alleviating Depression and Anxiety During Psychotherapy Waiting Lists: Systematic Review %A Huang,Sijia %A Wang,Yiyue %A Li,Gen %A Hall,Brian J %A Nyman,Thomas J %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley, Reading, RG6 6ET, United Kingdom, 44 1189875123, t.nyman@reading.ac.uk %K digital health %K digital technology %K digital intervention %K digital interventions %K waiting list %K digital mental health intervention %K DMHI %K digital mental health interventions %K DMHIs %K digital mental health %K mental health intervention %K mental health interventions %K mental health %K mental illness %K mental disease %K mental diseases %K mental illnesses %K depression %K depressed %K major depressive disorder %K MDD %K depressive disorder %K depressive %K anxiety %K anxious %K self-guided %K self-guidance %K self-mediated %K self-mediation %K systematic review %K systematic reviews %K mood disorder %K therapy %K tele-therapy %K web-based therapy %D 2024 %7 10.9.2024 %9 Review %J JMIR Ment Health %G English %X Background: Depression and anxiety have become increasingly prevalent across the globe. The rising need for treatment and the lack of clinicians has resulted in prolonged waiting times for patients to receive their first session. Responding to this gap, digital mental health interventions (DMHIs) have been found effective in treating depression and anxiety and are potentially promising pretreatments for patients who are awaiting face-to-face psychotherapy. Nevertheless, whether digital interventions effectively alleviate symptoms for patients on waiting lists for face-to-face psychotherapy remains unclear. Objective: This review aimed to synthesize the effectiveness of DMHIs for relieving depression and anxiety symptoms of patients on waiting lists for face-to-face therapy. This review also investigated the features, perceived credibility, and usability of DMHIs during waiting times. Methods: In this systematic review, we searched PubMed, PsycINFO, Cochrane, and Web of Science for research studies investigating the effectiveness of DMHIs in reducing either depression or anxiety symptoms among individuals waiting for face-to-face psychotherapy. The search was conducted in June 2024, and we have included the studies that met the inclusion criteria and were published before June 6, 2024. Results: Of the 9267 unique records identified, 8 studies met the eligibility criteria and were included in the systematic review. Five studies were randomized controlled trials (RCTs), and 3 studies were not. Among the RCTs, we found that digital interventions reduced depression and anxiety symptoms, but the majority of interventions were not more effective compared to the control groups where participants simply waited or received a self-help book. For the non-RCTs, the interventions also reduced symptoms, but without control groups, the interpretation of the findings is limited. Finally, participants in the included studies perceived the digital interventions to be credible and useful, but high dropout rates raised concerns about treatment adherence. Conclusions: Due to the lack of effective interventions among the reviewed studies, especially among the RCTs, our results suggest that waiting list DMHIs are not more effective compared to simply waiting or using a self-help book. However, more high-quality RCTs with larger sample sizes are warranted in order to draw a more robust conclusion. Additionally, as this review revealed concerns regarding the high dropout rate in digital interventions, future studies could perhaps adopt more personalized and human-centered functions in interventions to increase user engagement, with the potential to increase treatment adherence and effectiveness. %M 39255015 %R 10.2196/56650 %U https://mental.jmir.org/2024/1/e56650 %U https://doi.org/10.2196/56650 %U http://www.ncbi.nlm.nih.gov/pubmed/39255015 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56326 %T Smartphone-Delivered Attentional Bias Modification Training for Mental Health: Systematic Review and Meta-Analysis %A Banire,Bilikis %A Orr,Matt %A Burns,Hailey %A McGowan,Youna %A Orji,Rita %A Meier,Sandra %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, Sir Charles Tupper Building, 13th Fl., 5850 College Street, Halifax, NS, B34 3H7, Canada, 1 17828825242, banire.bilikis.o@gmail.com %K attentional bias %K mental health problem %K anxiety %K depression %K systematic review %K meta-analysis %K smartphone %K mobile phone %D 2024 %7 2.9.2024 %9 Review %J JMIR Ment Health %G English %X Background: Smartphone-delivered attentional bias modification training (ABMT) intervention has gained popularity as a remote solution for alleviating symptoms of mental health problems. However, the existing literature presents mixed results indicating both significant and insignificant effects of smartphone-delivered interventions. Objective: This systematic review and meta-analysis aims to assess the impact of smartphone-delivered ABMT on attentional bias and symptoms of mental health problems. Specifically, we examined different design approaches and methods of administration, focusing on common mental health issues, such as anxiety and depression, and design elements, including gamification and stimulus types. Methods: Our search spanned from 2014 to 2023 and encompassed 4 major databases: MEDLINE, PsycINFO, PubMed, and Scopus. Study selection, data extraction, and critical appraisal were performed independently by 3 authors using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. When necessary, we pooled the standardized mean difference with a 95% CI. In addition, we conducted sensitivity, subgroup, and meta-regression analyses to explore moderator variables of active and placebo ABMT interventions on reducing symptoms of mental health problems and attentional bias. Results: Our review included 12 papers, involving a total of 24,503 participants, and we were able to conduct a meta-analysis on 20 different study samples from 11 papers. Active ABMT exhibited an effect size (Hedges g) of –0.18 (P=.03) in reducing symptoms of mental health problems, while the overall effect remained significant. Similarly, placebo ABMT showed an effect size of –0.38 (P=.008) in reducing symptoms of mental health problems. In addition, active ABMT (Hedges g –0.17; P=.004) had significant effects on reducing attentional bias, while placebo ABMT did not significantly alter attentional bias (Hedges g –0.04; P=.66). Conclusions: Our understanding of smartphone-delivered ABMT’s potential highlights the value of both active and placebo interventions in mental health care. The insights from the moderator analysis also showed that tailoring smartphone-delivered ABMT interventions to specific threat stimuli and considering exposure duration are crucial for optimizing their efficacy. This research underscores the need for personalized approaches in ABMT to effectively reduce attentional bias and symptoms of mental health problems. Trial Registration: PROSPERO CRD42023460749; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=460749 %M 39222349 %R 10.2196/56326 %U https://mental.jmir.org/2024/1/e56326 %U https://doi.org/10.2196/56326 %U http://www.ncbi.nlm.nih.gov/pubmed/39222349 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e54252 %T Examining a Fully Automated Mobile-Based Behavioral Activation Intervention in Depression: Randomized Controlled Trial %A Santopetro,Nicholas %A Jones,Danielle %A Garron,Andrew %A Meyer,Alexandria %A Joyner,Keanan %A Hajcak,Greg %K digital intervention %K digital health %K digital application %K digital applications %K mobile health %K mHealth %K automation %K automate %K automated %K behavioral activation %K BA %K BA intervention %K depression %K depressed %K depressive %K depressive symptoms %K anhedonia %K anhedonia symptoms %K anxiety %K anxious %K anxiety symptoms %K adults %K adult %K psychiatry %K psych %K psychology %K major depressive disorder %K MDD %D 2024 %7 30.8.2024 %9 %J JMIR Ment Health %G English %X Background: Despite significant progress in our understanding of depression, prevalence rates have substantially increased in recent years. Thus, there is an imperative need for more cost-effective and scalable mental health treatment options, including digital interventions that minimize therapist burden. Objective: This study focuses on a fully automated digital implementation of behavioral activation (BA)—a core behavioral component of cognitive behavioral therapy for depression. We examine the efficacy of a 1-month fully automated SMS text message–based BA intervention for reducing depressive symptoms and anhedonia. Methods: To this end, adults reporting at least moderate current depressive symptoms (8-item Patient Health Questionnaire score ≥10) were recruited online across the United States and randomized to one of three conditions: enjoyable activities (ie, BA), healthy activities (ie, an active control condition), and passive control (ie, no contact). Participants randomized to enjoyable and healthy activities received daily SMS text messages prompting them to complete 2 activities per day; participants also provided a daily report on the number and enjoyment of activities completed the prior day. Results: A total of 126 adults (mean age 32.46, SD 7.41 years) with current moderate depressive symptoms (mean score 16.53, SD 3.90) were recruited. Participants in the enjoyable activities condition (BA; n=39) experienced significantly greater reductions in depressive symptoms compared to participants in the passive condition (n=46). Participants in both active conditions—enjoyable activities and healthy activities (n=41)—reported reduced symptoms of anxiety compared to those in the control condition. Conclusions: These findings provide preliminary evidence regarding the efficacy of a fully automated digital BA intervention for depression and anxiety symptoms. Moreover, reminders to complete healthy activities may be a promising intervention for reducing anxiety symptoms. Trial Registration: ClincalTrials.gov NCT06492824; https://clinicaltrials.gov/study/NCT06492824 %R 10.2196/54252 %U https://mental.jmir.org/2024/1/e54252 %U https://doi.org/10.2196/54252 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e57401 %T Evaluation of Digital Mental Health Technologies in the United States: Systematic Literature Review and Framework Synthesis %A Catania,Julianna %A Beaver,Steph %A Kamath,Rakshitha S %A Worthington,Emma %A Lu,Minyi %A Gandhi,Hema %A Waters,Heidi C %A Malone,Daniel C %+ Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Room 4922, 30 S 2000 East, Salt Lake City, UT, 84112, United States, 1 801 581 6257, dan.malone@utah.edu %K mental health %K mobile health %K mHealth %K digital health %K digital therapeutics %K systematic review %K framework synthesis %K mixed methods %D 2024 %7 30.8.2024 %9 Review %J JMIR Ment Health %G English %X Background: Digital mental health technologies (DMHTs) have the potential to enhance mental health care delivery. However, there is little information on how DMHTs are evaluated and what factors influence their use. Objective: A systematic literature review was conducted to understand how DMHTs are valued in the United States from user, payer, and employer perspectives. Methods: Articles published after 2017 were identified from MEDLINE, Embase, PsycINFO, Cochrane Library, the Health Technology Assessment Database, and digital and mental health congresses. Each article was evaluated by 2 independent reviewers to identify US studies reporting on factors considered in the evaluation of DMHTs targeting mental health, Alzheimer disease, epilepsy, autism spectrum disorder, or attention-deficit/hyperactivity disorder. Study quality was assessed using the Critical Appraisal Skills Program Qualitative and Cohort Studies Checklists. Studies were coded and indexed using the American Psychiatric Association’s Mental Health App Evaluation Framework to extract and synthesize relevant information, and novel themes were added iteratively as identified. Results: Of the 4353 articles screened, data from 26 unique studies from patient, caregiver, and health care provider perspectives were included. Engagement style was the most reported theme (23/26, 88%), with users valuing DMHT usability, particularly alignment with therapeutic goals through features including anxiety management tools. Key barriers to DMHT use included limited internet access, poor technical literacy, and privacy concerns. Novel findings included the discreetness of DMHTs to avoid stigma. Conclusions: Usability, cost, accessibility, technical considerations, and alignment with therapeutic goals are important to users, although DMHT valuation varies across individuals. DMHT apps should be developed and selected with specific user needs in mind. %M 39213023 %R 10.2196/57401 %U https://mental.jmir.org/2024/1/e57401 %U https://doi.org/10.2196/57401 %U http://www.ncbi.nlm.nih.gov/pubmed/39213023 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56758 %T Acceptability and Engagement of a Smartphone-Delivered Interpretation Bias Intervention in a Sample of Black and Latinx Adults: Open Trial %A Ferguson,IreLee %A George,Grace %A Narine,Kevin O %A Turner,Amari %A McGhee,Zelda %A Bajwa,Harris %A Hart,Frances G %A Carter,Sierra %A Beard,Courtney %+ Department of Psychiatry, McLean Hospital/Harvard Medical School, 115 Mill St, Belmont, MA, 02478, United States, 1 617 855 3557, cbeard@mclean.harvard.edu %K interpretation bias %K anxiety %K depression %K Black %K Latinx %K smartphone %K mobile phone %D 2024 %7 31.7.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Access to evidence-based interventions is urgently required, especially for individuals of minoritized identities who experience unique barriers to mental health care. Digital mental health interventions have the potential to increase accessibility. Previous pilot studies testing HabitWorks, a smartphone app providing an interpretation bias intervention, have found strong engagement and adherence for HabitWorks; however, previous trials’ samples consisted of predominantly non-Hispanic, White individuals. Objective: This study conducted an open trial of HabitWorks in a community sample of adults who identified as Black, Hispanic or Latinx, or both. This study aims to test safety, acceptability, and engagement with the HabitWorks app for Black and Latinx adults. Methods: Black, Hispanic or Latinx adults (mean age 32.83, SD 11.06 y; 22/31, 71% women) who endorsed symptoms of anxiety or depression were asked to complete interpretation modification exercises via HabitWorks 3 times per week for 1 month. Interpretation bias and anxiety and depression symptoms were assessed at baseline and posttreatment assessments. Participants completed qualitative interviews to assess overall perceptions of HabitWorks. Results: Of the 31 participants that downloaded the app, 27 (87%) used HabitWorks all 4 weeks. On average, participants completed 15.74 (SD 7.43) exercises out of the 12 prescribed, demonstrating high engagement. Acceptability ratings met all a priori benchmarks except for relevancy. Qualitative interviews also demonstrated high acceptability and few negative experiences. Significant improvements were found in interpretation style (t30=2.29; P<.001), with a large effect size (Cohen d=1.53); anxiety symptoms (t30=2.29; P=.03), with a small effect size (Cohen d=0.41); and depression symptoms (t30=3.065; P=.005), with a medium effect size (Cohen d=0.55). Conclusions: This study adds to the literature evaluating digital mental health interventions in Black and Latinx adults. Preliminary results further support a future controlled trial testing the effectiveness of HabitWorks as an intervention. %M 39083330 %R 10.2196/56758 %U https://mental.jmir.org/2024/1/e56758 %U https://doi.org/10.2196/56758 %U http://www.ncbi.nlm.nih.gov/pubmed/39083330 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48964 %T The Acceptability, Engagement, and Feasibility of Mental Health Apps for Marginalized and Underserved Young People: Systematic Review and Qualitative Study %A Bear,Holly Alice %A Ayala Nunes,Lara %A Ramos,Giovanni %A Manchanda,Tanya %A Fernandes,Blossom %A Chabursky,Sophia %A Walper,Sabine %A Watkins,Edward %A Fazel,Mina %+ Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom, 44 01865 6182, holly.bear@psych.ox.ac.uk %K adolescent mental health %K marginalized groups %K smartphone apps %K engagement %K implementation science %K mobile app %K smartphone %K mobile health %K mHealth %K mental health %K challenges %K acceptability %K young %K effectiveness %K mobile phone %D 2024 %7 30.7.2024 %9 Review %J J Med Internet Res %G English %X Background: Smartphone apps may provide an opportunity to deliver mental health resources and interventions in a scalable and cost-effective manner. However, young people from marginalized and underserved groups face numerous and unique challenges to accessing, engaging with, and benefiting from these apps. Objective: This study aims to better understand the acceptability (ie, perceived usefulness and satisfaction with an app) and feasibility (ie, the extent to which an app was successfully used) of mental health apps for underserved young people. A secondary aim was to establish whether adaptations can be made to increase the accessibility and inclusivity of apps for these groups. Methods: We conducted 2 sequential studies, consisting of a systematic literature review of mental health apps for underserved populations followed by a qualitative study with underserved young male participants (n=20; age: mean 19). Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, an electronic search of 5 databases was conducted in 2021. The search yielded 18,687 results, of which 14 articles met the eligibility criteria. Results: The included studies comprised a range of groups, including those affected by homelessness, having physical health conditions, living in low- and middle-income countries, and those with sexual and gender minority identities. Establishing and maintaining user engagement was a pervasive challenge across mental health apps and populations, and dropout was a reported problem among nearly all the included studies. Positive subjective reports of usability, satisfaction, and acceptability were insufficient to determine users’ objective engagement. Conclusions: Despite the significant amount of funding directed to the development of mental health apps, juxtaposed with only limited empirical evidence to support their effectiveness, few apps have been deliberately developed or adapted to meet the heterogeneous needs of marginalized and underserved young people. Before mental health apps are scaled up, a greater understanding is needed of the types of services that more at-risk young people and those in limited-resource settings prefer (eg, standard vs digital) followed by more rigorous and consistent demonstrations of acceptability, effectiveness, and cost-effectiveness. Adopting an iterative participatory approach by involving young people in the development and evaluation process is an essential step in enhancing the adoption of any intervention, including apps, in “real-world” settings and will support future implementation and sustainability efforts to ensure that marginalized and underserved groups are reached. Trial Registration: PROSPERO CRD42021254241; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254241 %M 39078699 %R 10.2196/48964 %U https://www.jmir.org/2024/1/e48964 %U https://doi.org/10.2196/48964 %U http://www.ncbi.nlm.nih.gov/pubmed/39078699 %0 Journal Article %@ 2291-5222 %I %V 12 %N %P e49393 %T The Impact of User Engagement With Exposure Components on Posttraumatic Stress Symptoms in an mHealth Mobile App: Secondary Analysis of a Randomized Controlled Trial %A Davis,C Adrian %A Miller,Madeleine %A McLean,Carmen P %K posttraumatic stress disorder %K PTSD %K mHealth apps %K user engagement %K mHealth interventions %K digital interventions %K veterans %D 2024 %7 18.7.2024 %9 %J JMIR Mhealth Uhealth %G English %X Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of “Renew” (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users’ self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app (ΔF3,62=4.42; P=.007). The number of characters written during imaginal exposure (β=.37; P=.009) and the amount of time spent completing exposure activities (β=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD. Trial Registration: ClinicalTrials.gov NCT04155736; https://clinicaltrials.gov/ct2/show/NCT04155736 %R 10.2196/49393 %U https://mhealth.jmir.org/2024/1/e49393 %U https://doi.org/10.2196/49393 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e42319 %T Evaluating the Acceptability of the Drink Less App and the National Health Service Alcohol Advice Web Page: Qualitative Interview Process Evaluation %A Oldham,Melissa %A Dina,Larisa-Maria %A Loebenberg,Gemma %A Perski,Olga %A Brown,Jamie %A Angus,Colin %A Beard,Emma %A Burton,Robyn %A Field,Matt %A Greaves,Felix %A Hickman,Matthew %A Kaner,Eileen %A Michie,Susan %A Munafò,Marcus R %A Pizzo,Elena %A Garnett,Claire %+ Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 20 7679 883, m.oldham@ucl.ac.uk %K alcohol reduction %K digital intervention %K acceptability %K mobile health %K mHealth %K mobile phone %D 2024 %7 18.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The extent to which interventions are perceived as acceptable to users impacts engagement and efficacy. Objective: In this study, we evaluated the acceptability of (1) the smartphone app Drink Less (intervention) and (2) the National Health Service (NHS) alcohol advice web page (usual digital care and comparator) among adult drinkers in the United Kingdom participating in a randomized controlled trial evaluating the effectiveness of the Drink Less app. Methods: A subsample of 26 increasing- and higher-risk drinkers (Alcohol Use Disorders Identification Test score≥8) assigned to the intervention group (Drink Less; n=14, 54%; female: n=10, 71%; age: 22-72 years; White: n=9, 64%) or usual digital care group (NHS alcohol advice web page; n=12, 46%; female: n=5, 42%; age: 23-68 years: White: n=9, 75%) took part in semistructured interviews. The interview questions were mapped on to the 7 facets of acceptability according to the Theoretical Framework of Acceptability: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Alongside these constructs, we also included a question on perceived personal relevance, which previous research has linked to acceptability and engagement. Framework and thematic analysis of data was undertaken. Results: The Drink Less app was perceived as being ethical, easy, user-friendly, and effective for the period the app was used. Participants reported particularly liking the tracking and feedback sections of the app, which they reported increased personal relevance and which resulted in positive affect when achieving their goals. They reported no opportunity cost. Factors such as negative affect when not meeting goals and boredom led to disengagement in the longer term for some participants. The NHS alcohol advice web page was rated as being easy and user-friendly with no opportunity costs. However, the information presented was not perceived as being personally relevant or effective in changing drinking behavior. Most participants reported neutral or negative affect, most participants thought the alcohol advice web page was accessible, and some participants reported ethical concerns around the availability of suggested resources. Some participants reported that it had acted as a starting point or a signpost to other resources. Participants in both groups discussed motivation to change and contextual factors such as COVID-19 lockdowns, which influenced their perceived self-efficacy regardless of their assigned intervention. Conclusions: Drink Less appears to be an acceptable digital intervention among the recruited sample. The NHS alcohol advice web page was generally considered unacceptable as a stand-alone intervention among the recruited sample, although it may signpost and help people access other resources and interventions. %M 39024575 %R 10.2196/42319 %U https://www.jmir.org/2024/1/e42319 %U https://doi.org/10.2196/42319 %U http://www.ncbi.nlm.nih.gov/pubmed/39024575 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53541 %T Mindful Self-Compassion Smartphone Intervention for Worker Mental Health in Japan: Protocol for a Randomized Controlled Trial %A Kurosawa,Takumu %A Adachi,Koichiro %A Takizawa,Ryu %+ Department of Clinical Psychology, Graduate School of Education, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan, 81 358411397, takizawar-tky@umin.ac.jp %K self-compassion %K mindfulness %K smartphone apps %K preventive intervention %K mental health %K work performance %K smartphone intervention %K workers %K psychological support %K mindfulness meditation %K meditation %K work-related outcomes %K mobile phone %D 2024 %7 15.7.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental health problems among workers cause enormous losses to companies in Japan. However, workers have been considered to have limited access to psychological support because of time constraints, which makes it difficult for them to engage in face-to-face psychological support interventions. Objective: This study aimed to present an intervention protocol that describes a randomized controlled trial to examine whether brief guided mindfulness meditation (MM) or self-compassion meditation (SCM) provided by a smartphone app is effective for mental health and work-related outcomes among workers. Methods: This is an open-label, 3-arm randomized controlled trial. The participants will be recruited through an open call on relevant websites with the following inclusion criteria: (1) employees who are working more than 20 hours per week, (2) between the ages of 18 and 54 years, (3) not on a leave of absence, (4) not business owners or students, and (5) not currently diagnosed with a mental disorder and have a Kessler Psychological Distress Scale-6 score below 13 points. We will include 200 participants and randomly assign them to an SCM course (n=67), an MM course (n=67), and a waitlist group (n=66). The intervention groups (SCM and MM) will be instructed to engage in daily guided self-help, self-compassion, and MMs lasting 6-12 minutes per day over 4 weeks. Primary outcomes will include psychological distress and job performance, and secondary outcomes will include somatic symptoms, cognitive flexibility, self-esteem, self-compassion, perceived stress, well-being, emotion regulation, work engagement, anger, psychological safety, and creativity. All procedures were approved by the ethics committee of the University of Tokyo (22-326). All participants will be informed of the study via the websites, and written informed consent will be collected via web-based forms. Results: The recruitment of participants began in December 2022, and the intervention began in January 2023. As of September 2023, a total of 375 participants have been enrolled. The intervention and data collection were completed in late October 2023. Conclusions: This study will contribute to the development of effective self-care intervention content that will improve mental health, work performance, and related outcomes and promote mindful and self-compassionate attitudes when faced with distress. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000049466; https://tinyurl.com/23x8m8nf International Registered Report Identifier (IRRID): DERR1-10.2196/53541 %M 39008345 %R 10.2196/53541 %U https://www.researchprotocols.org/2024/1/e53541 %U https://doi.org/10.2196/53541 %U http://www.ncbi.nlm.nih.gov/pubmed/39008345 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e59198 %T Media Use and Its Associations With Paranoia in Schizophrenia and Bipolar Disorder: Ecological Momentary Assessment %A Paquin,Vincent %A Ackerman,Robert A %A Depp,Colin A %A Moore,Raeanne C %A Harvey,Philip D %A Pinkham,Amy E %K paranoia %K social media %K digital media %K technology %K psychosis %K schizophrenia %K schizoaffective %K bipolar disorder %K ecological momentary assessment %K spectrum %K sociodemographic %K linear mixed model %K media use %K mental health %K digital intervention %K adult %K adults %K medical center %K mental health clinic %K psychiatry %K psychiatrist %D 2024 %7 3.7.2024 %9 %J JMIR Ment Health %G English %X Background: Paranoia is a spectrum of fear-related experiences that spans diagnostic categories and is influenced by social and cognitive factors. The extent to which social media and other types of media use are associated with paranoia remains unclear. Objective: We aimed to examine associations between media use and paranoia at the within- and between-person levels. Methods: Participants were 409 individuals diagnosed with schizophrenia spectrum or bipolar disorder. Measures included sociodemographic and clinical characteristics at baseline, followed by ecological momentary assessments (EMAs) collected 3 times daily over 30 days. EMA evaluated paranoia and 5 types of media use: social media, television, music, reading or writing, and other internet or computer use. Generalized linear mixed models were used to examine paranoia as a function of each type of media use and vice versa at the within- and between-person levels. Results: Of the 409 participants, the following subgroups reported at least 1 instance of media use: 261 (63.8%) for using social media, 385 (94.1%) for watching TV, 292 (71.4%) for listening to music, 191 (46.7%) for reading or writing, and 280 (68.5%) for other internet or computer use. Gender, ethnoracial groups, educational attainment, and diagnosis of schizophrenia versus bipolar disorder were differentially associated with the likelihood of media use. There was a within-person association between social media use and paranoia: using social media was associated with a subsequent decrease of 5.5% (fold-change 0.945, 95% CI 0.904-0.987) in paranoia. The reverse association, from paranoia to subsequent changes in social media use, was not statistically significant. Other types of media use were not significantly associated with paranoia. Conclusions: This study shows that social media use was associated with a modest decrease in paranoia, perhaps reflecting the clinical benefits of social connection. However, structural disadvantage and individual factors may hamper the accessibility of media activities, and the mental health correlates of media use may further vary as a function of contents and contexts of use. %R 10.2196/59198 %U https://mental.jmir.org/2024/1/e59198 %U https://doi.org/10.2196/59198 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55302 %T Longitudinal Assessment of Seasonal Impacts and Depression Associations on Circadian Rhythm Using Multimodal Wearable Sensing: Retrospective Analysis %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Stewart,Callum %A Conde,Pauline %A Sankesara,Heet %A Laiou,Petroula %A Matcham,Faith %A White,Katie M %A Oetzmann,Carolin %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Vairavan,Srinivasan %A Myin-Germeys,Inez %A Mohr,David C %A Wykes,Til %A Haro,Josep Maria %A Annas,Peter %A Penninx,Brenda WJH %A Narayan,Vaibhav A %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SGDP Centre, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 7579856617, yuezhou.zhang@kcl.ac.uk %K circadian rhythm %K biological rhythms %K mental health %K major depressive disorder %K MDD %K wearable %K mHealth %K mobile health %K digital health %K monitoring %D 2024 %7 28.6.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous mobile health (mHealth) studies have revealed significant links between depression and circadian rhythm features measured via wearables. However, the comprehensive impact of seasonal variations was not fully considered in these studies, potentially biasing interpretations in real-world settings. Objective: This study aims to explore the associations between depression severity and wearable-measured circadian rhythms while accounting for seasonal impacts. Methods: Data were sourced from a large longitudinal mHealth study, wherein participants’ depression severity was assessed biweekly using the 8-item Patient Health Questionnaire (PHQ-8), and participants’ behaviors, including sleep, step count, and heart rate (HR), were tracked via Fitbit devices for up to 2 years. We extracted 12 circadian rhythm features from the 14-day Fitbit data preceding each PHQ-8 assessment, including cosinor variables, such as HR peak timing (HR acrophase), and nonparametric features, such as the onset of the most active continuous 10-hour period (M10 onset). To investigate the association between depression severity and circadian rhythms while also assessing the seasonal impacts, we used three nested linear mixed-effects models for each circadian rhythm feature: (1) incorporating the PHQ-8 score as an independent variable, (2) adding seasonality, and (3) adding an interaction term between season and the PHQ-8 score. Results: Analyzing 10,018 PHQ-8 records alongside Fitbit data from 543 participants (n=414, 76.2% female; median age 48, IQR 32-58 years), we found that after adjusting for seasonal effects, higher PHQ-8 scores were associated with reduced daily steps (β=–93.61, P<.001), increased sleep variability (β=0.96, P<.001), and delayed circadian rhythms (ie, sleep onset: β=0.55, P=.001; sleep offset: β=1.12, P<.001; M10 onset: β=0.73, P=.003; HR acrophase: β=0.71, P=.001). Notably, the negative association with daily steps was more pronounced in spring (β of PHQ-8 × spring = –31.51, P=.002) and summer (β of PHQ-8 × summer = –42.61, P<.001) compared with winter. Additionally, the significant correlation with delayed M10 onset was observed solely in summer (β of PHQ-8 × summer = 1.06, P=.008). Moreover, compared with winter, participants experienced a shorter sleep duration by 16.6 minutes, an increase in daily steps by 394.5, a delay in M10 onset by 20.5 minutes, and a delay in HR peak time by 67.9 minutes during summer. Conclusions: Our findings highlight significant seasonal influences on human circadian rhythms and their associations with depression, underscoring the importance of considering seasonal variations in mHealth research for real-world applications. This study also indicates the potential of wearable-measured circadian rhythms as digital biomarkers for depression. %M 38941600 %R 10.2196/55302 %U https://www.jmir.org/2024/1/e55302 %U https://doi.org/10.2196/55302 %U http://www.ncbi.nlm.nih.gov/pubmed/38941600 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e54634 %T Long-Term Efficacy of a Mobile Mental Wellness Program: Prospective Single-Arm Study %A McCallum,Meaghan %A Baldwin,Matthew %A Thompson,Paige %A Blessing,Kelly %A Frisch,Maria %A Ho,Annabell %A Ainsworth,Matthew Cole %A Mitchell,Ellen Siobhan %A Michaelides,Andreas %A May,Christine N %+ Academic Research, Noom, Inc, 450 West 33rd Street, New York City, NY, 10001, United States, 1 8882665071, meaghanm@noom.com %K mHealth %K psychological distress %K Noom Mood %K digital mental wellness programs %K mobile phone %D 2024 %7 27.6.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Rising rates of psychological distress (symptoms of depression, anxiety, and stress) among adults in the United States necessitate effective mental wellness interventions. Despite the prevalence of smartphone app–based programs, research on their efficacy is limited, with only 14% showing clinically validated evidence. Our study evaluates Noom Mood, a commercially available smartphone-based app that uses cognitive behavioral therapy and mindfulness-based programming. In this study, we address gaps in the existing literature by examining postintervention outcomes and the broader impact on mental wellness. Objective: Noom Mood is a smartphone-based mental wellness program designed to be used by the general population. This prospective study evaluates the efficacy and postintervention outcomes of Noom Mood. We aim to address the rising psychological distress among adults in the United States. Methods: A 1-arm study design was used, with participants having access to the Noom Mood program for 16 weeks (N=273). Surveys were conducted at baseline, week 4, week 8, week 12, week 16, and week 32 (16 weeks’ postprogram follow-up). This study assessed a range of mental health outcomes, including anxiety symptoms, depressive symptoms, perceived stress, well-being, quality of life, coping, emotion regulation, sleep, and workplace productivity (absenteeism or presenteeism). Results: The mean age of participants was 40.5 (SD 11.7) years. Statistically significant improvements in anxiety symptoms, depressive symptoms, and perceived stress were observed by week 4 and maintained through the 16-week intervention and the 32-week follow-up. The largest changes were observed in the first 4 weeks (29% lower, 25% lower, and 15% lower for anxiety symptoms, depressive symptoms, and perceived stress, respectively), and only small improvements were observed afterward. Reductions in clinically relevant anxiety (7-item generalized anxiety disorder scale) and depression (8-item Patient Health Questionnaire depression scale) criteria were also maintained from program initiation through the 16-week intervention and the 32-week follow-up. Work productivity also showed statistically significant results, with participants gaining 2.57 productive work days from baseline at 16 weeks, and remaining relatively stable (2.23 productive work days gained) at follow-up (32 weeks). Additionally, effects across all coping, sleep disturbance (23% lower at 32 weeks), and emotion dysregulation variables exhibited positive and significant trends at all time points (15% higher, 23% lower, and 25% higher respectively at 32 weeks). Conclusions: This study contributes insights into the promising positive impact of Noom Mood on mental health and well-being outcomes, extending beyond the intervention phase. Though more rigorous studies are necessary to understand the mechanism of action at play, this exploratory study addresses critical gaps in the literature, highlighting the potential of smartphone-based mental wellness programs to lessen barriers to mental health support and improve diverse dimensions of well-being. Future research should explore the scalability, feasibility, and long-term adherence of such interventions across diverse populations. %M 38935946 %R 10.2196/54634 %U https://mhealth.jmir.org/2024/1/e54634 %U https://doi.org/10.2196/54634 %U http://www.ncbi.nlm.nih.gov/pubmed/38935946 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e54945 %T A Chatbot-Delivered Stress Management Coaching for Students (MISHA App): Pilot Randomized Controlled Trial %A Ulrich,Sandra %A Lienhard,Natascha %A Künzli,Hansjörg %A Kowatsch,Tobias %+ School of Applied Psychology, Zurich University of Applied Sciences, Pfingstweidstrasse 96, Zurich, 8005, Switzerland, 41 58 934 ext 8451, sandra.ulrich@zhaw.ch %K conversational agent %K mobile health %K mHealth %K smartphone %K stress management %K lifestyle %K behavior change %K coaching %K mobile phone %D 2024 %7 26.6.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Globally, students face increasing mental health challenges, including elevated stress levels and declining well-being, leading to academic performance issues and mental health disorders. However, due to stigma and symptom underestimation, students rarely seek effective stress management solutions. Conversational agents in the health sector have shown promise in reducing stress, depression, and anxiety. Nevertheless, research on their effectiveness for students with stress remains limited. Objective: This study aims to develop a conversational agent–delivered stress management coaching intervention for students called MISHA and to evaluate its effectiveness, engagement, and acceptance. Methods: In an unblinded randomized controlled trial, Swiss students experiencing stress were recruited on the web. Using a 1:1 randomization ratio, participants (N=140) were allocated to either the intervention or waitlist control group. Treatment effectiveness on changes in the primary outcome, that is, perceived stress, and secondary outcomes, including depression, anxiety, psychosomatic symptoms, and active coping, were self-assessed and evaluated using ANOVA for repeated measure and general estimating equations. Results: The per-protocol analysis revealed evidence for improvement of stress, depression, and somatic symptoms with medium effect sizes (Cohen d=−0.36 to Cohen d=−0.60), while anxiety and active coping did not change (Cohen d=−0.29 and Cohen d=0.13). In the intention-to-treat analysis, similar results were found, indicating reduced stress (β estimate=−0.13, 95% CI −0.20 to −0.05; P<.001), depressive symptoms (β estimate=−0.23, 95% CI −0.38 to −0.08; P=.003), and psychosomatic symptoms (β estimate=−0.16, 95% CI −0.27 to −0.06; P=.003), while anxiety and active coping did not change. Overall, 60% (42/70) of the participants in the intervention group completed the coaching by completing the postintervention survey. They particularly appreciated the quality, quantity, credibility, and visual representation of information. While individual customization was rated the lowest, the target group fitting was perceived as high. Conclusions: Findings indicate that MISHA is feasible, acceptable, and effective in reducing perceived stress among students in Switzerland. Future research is needed with different populations, for example, in students with high stress levels or compared to active controls. Trial Registration: German Clinical Trials Register DRKS 00030004; https://drks.de/search/en/trial/DRKS00030004 %M 38922677 %R 10.2196/54945 %U https://mhealth.jmir.org/2024/1/e54945 %U https://doi.org/10.2196/54945 %U http://www.ncbi.nlm.nih.gov/pubmed/38922677 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56074 %T Mobile Health App (DIGICOG-MS) for Self-Assessment of Cognitive Impairment in People With Multiple Sclerosis: Instrument Validation and Usability Study %A Podda,Jessica %A Tacchino,Andrea %A Ponzio,Michela %A Di Antonio,Federica %A Susini,Alessia %A Pedullà,Ludovico %A Battaglia,Mario Alberto %A Brichetto,Giampaolo %+ Scientific Research Area, Italian Multiple Sclerosis Foundation, Via Operai 40, Genoa, 16149, Italy, 39 0102713306, jessica.podda@aism.it %K cognitive assessment %K cognitive impairment %K digital health %K mHealth app %K multiple sclerosis %K self-management %K usability %D 2024 %7 20.6.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Mobile health (mHealth) apps have proven useful for people with multiple sclerosis (MS). Thus, easy-to-use digital solutions are now strongly required to assess and monitor cognitive impairment, one of the most disturbing symptoms in MS that is experienced by almost 43% to 70% of people with MS. Therefore, we developed DIGICOG-MS (Digital assessment of Cognitive Impairment in Multiple Sclerosis), a smartphone- and tablet-based mHealth app to self-assess cognitive impairment in MS. Objective: This study aimed to test the validity and usability of the novel mHealth app with a sample of people with MS. Methods: DIGICOG-MS includes 4 digital tests assumed to evaluate the most affected cognitive domains in MS (visuospatial memory [VSM], verbal memory [VM], semantic fluency [SF], and information processing speed [IPS]) and inspired by traditional paper-based tests that assess the same cognitive functions (10/36 Spatial Recall Test, Rey Auditory Verbal Learning Test, Word List Generation, Symbol Digit Modalities Test). Participants were asked to complete both digital and traditional assessments in 2 separate sessions. Convergent validity was analyzed using the Pearson correlation coefficient to determine the strength of the associations between digital and traditional tests. To test the app’s reliability, the agreement between 2 repeated measurements was assessed using intraclass correlation coefficients (ICCs). Usability of DIGICOG-MS was evaluated using the System Usability Scale (SUS) and mHealth App Usability Questionnaire (MAUQ) administered at the conclusion of the digital session. Results: The final sample consisted of 92 people with MS (60 women) followed as outpatients at the Italian Multiple Sclerosis Society (AISM) Rehabilitation Service of Genoa (Italy). They had a mean age of 51.38 (SD 11.36) years, education duration of 13.07 (SD 2.74) years, disease duration of 12.91 (SD 9.51) years, and a disability level (Expanded Disability Status Scale) of 3.58 (SD 1.75). Relapsing-remitting MS was most common (68/92, 74%), followed by secondary progressive (15/92, 16%) and primary progressive (9/92, 10%) courses. Pearson correlation analyses indicated significantly strong correlations for VSM, VM, SF, and IPS (all P<.001), with r values ranging from 0.58 to 0.78 for all cognitive domains. Test-retest reliability of the mHealth app was excellent (ICCs>0.90) for VM and IPS and good for VSM and SF (ICCs>0.80). Moreover, the SUS score averaged 84.5 (SD 13.34), and the mean total MAUQ score was 104.02 (SD 17.69), suggesting that DIGICOG-MS was highly usable and well appreciated. Conclusions: The DIGICOG-MS tests were strongly correlated with traditional paper-based evaluations. Furthermore, people with MS positively evaluated DIGICOG-MS, finding it highly usable. Since cognitive impairment poses major limitations for people with MS, these findings open new paths to deploy digital cognitive tests for MS and further support the use of a novel mHealth app for cognitive self-assessment by people with MS in clinical practice. %M 38900535 %R 10.2196/56074 %U https://formative.jmir.org/2024/1/e56074 %U https://doi.org/10.2196/56074 %U http://www.ncbi.nlm.nih.gov/pubmed/38900535 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e55283 %T Web-Based Therapist-Guided Mindfulness-Based Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Pilot Randomized Controlled Trial %A Kerry,Camrie %A Mann,Prabhdeep %A Babaei,Nazanin %A Katz,Joel %A Pirbaglou,Meysam %A Ritvo,Paul %+ School of Kinesiology and Health Sciences, York University, 4700 Keele St, Toronto, ON, M3J 1P3, Canada, 1 416 580 8021, camrie@yorku.ca %K body dysmorphic disorder %K BDD %K dysmorphophobia %K obsessive-compulsive and related disorders %K OCD %K internet-delivered cognitive behavior therapy %K iCBT %K cognitive behavior therapy %K mindfulness-based cognitive therapy %K mindfulness %K eMental health %K randomized controlled trial %D 2024 %7 12.6.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-based cognitive behavioral therapy (CBT) and stand-alone mindfulness meditation interventions are gaining empirical support for a wide variety of mental health conditions. In this study, we test the efficacy of web-based therapist-guided mindfulness-based cognitive behavioral therapy (CBT-M) for body dysmorphic disorder (BDD), a psychiatric disorder characterized by preoccupations with perceived defects in appearance. Objective: This study aims to determine whether CBT-M for BDD delivered on the web is feasible and acceptable and whether mindfulness meditation adds to CBT treatment effects for BDD. Methods: In this 8-week, 2-arm, parallel pilot randomized controlled trial, n=28 adults (aged between 18 and 55 years) were randomly allocated to an experimental group (web-based therapist-guided CBT-M) or a control group (web-based therapist-guided CBT). Study retention, accrual, and intervention adherence were assessed, along with self-report measures for BDD, depression, anxiety, and pain intensity taken at baseline and postintervention. Results: This study was feasible to implement and deemed acceptable by participants. After 8 weeks, significant improvements were found on all outcome measures for both treatment groups, and large between-group effect sizes favoring CBT-M were found for BDD symptom severity (d=–0.96), depression (d=–1.06), pain severity (d=–1.12), and pain interference (d=–1.28). However, linear mixed models demonstrated no significant differences between the groups over 8 weeks. Conclusions: The results suggest that mindfulness meditation may add to beneficial web-based CBT treatment effects for BDD. An adequately powered randomized control trial of web-based CBT-M is warranted. Trial Registration: ClinicalTrials.gov NCT05402475, http://clinicaltrials.gov/ct2/show/NCT05402475 %M 38865704 %R 10.2196/55283 %U https://mental.jmir.org/2024/1/e55283 %U https://doi.org/10.2196/55283 %U http://www.ncbi.nlm.nih.gov/pubmed/38865704 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e46895 %T Characterizing Longitudinal Patterns in Cognition, Mood, And Activity in Depression With 6-Week High-Frequency Wearable Assessment: Observational Study %A Cormack,Francesca %A McCue,Maggie %A Skirrow,Caroline %A Cashdollar,Nathan %A Taptiklis,Nick %A van Schaik,Tempest %A Fehnert,Ben %A King,James %A Chrones,Lambros %A Sarkey,Sara %A Kroll,Jasmin %A Barnett,Jennifer H %+ Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge, CB25 9TU, United Kingdom, 44 7961910560, jasmin.kroll@camcog.com %K cognition %K depression %K digital biomarkers %K ecological momentary assessment %K mobile health %K remote testing %D 2024 %7 31.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive symptoms are an underrecognized aspect of depression that are often untreated. High-frequency cognitive assessment holds promise for improving disease and treatment monitoring. Although we have previously found it feasible to remotely assess cognition and mood in this capacity, further work is needed to ascertain the optimal methodology to implement and synthesize these techniques. Objective: The objective of this study was to examine (1) longitudinal changes in mood, cognition, activity levels, and heart rate over 6 weeks; (2) diurnal and weekday-related changes; and (3) co-occurrence of fluctuations between mood, cognitive function, and activity. Methods: A total of 30 adults with current mild-moderate depression stabilized on antidepressant monotherapy responded to testing delivered through an Apple Watch (Apple Inc) for 6 weeks. Outcome measures included cognitive function, assessed with 3 brief n-back tasks daily; self-reported depressed mood, assessed once daily; daily total step count; and average heart rate. Change over a 6-week duration, diurnal and day-of-week variations, and covariation between outcome measures were examined using nonlinear and multilevel models. Results: Participants showed initial improvement in the Cognition Kit N-Back performance, followed by a learning plateau. Performance reached 90% of individual learning levels on average 10 days after study onset. N-back performance was typically better earlier and later in the day, and step counts were lower at the beginning and end of each week. Higher step counts overall were associated with faster n-back learning, and an increased daily step count was associated with better mood on the same (P<.001) and following day (P=.02). Daily n-back performance covaried with self-reported mood after participants reached their learning plateau (P=.01). Conclusions: The current results support the feasibility and sensitivity of high-frequency cognitive assessments for disease and treatment monitoring in patients with depression. Methods to model the individual plateau in task learning can be used as a sensitive approach to better characterize changes in behavior and improve the clinical relevance of cognitive data. Wearable technology allows assessment of activity levels, which may influence both cognition and mood. %M 38819909 %R 10.2196/46895 %U https://mental.jmir.org/2024/1/e46895 %U https://doi.org/10.2196/46895 %U http://www.ncbi.nlm.nih.gov/pubmed/38819909 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 10 %N %P e52386 %T Engagement With a Relaxation and Mindfulness Mobile App Among People With Cancer: Exploratory Analysis of Use Data and Self-Reports From a Randomized Controlled Trial %A Schläpfer,Sonja %A Schneider,Fabian %A Santhanam,Prabhakaran %A Eicher,Manuela %A Kowatsch,Tobias %A Witt,Claudia M %A Barth,Jürgen %+ Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Sonneggstrasse 6, Zurich, 8091, Switzerland, 41 44 255 94 51, sonja.schlaepfer@usz.ch %K mobile health %K mHealth %K digital health %K eHealth %K smartphone %K mobile phone %K implementation %K adherence %K self-guided %K unguided %K fully automated %K conversational agent %K chatbot %K behavior change %K tailoring %K self-care %K cancer %K app development %D 2024 %7 31.5.2024 %9 Original Paper %J JMIR Cancer %G English %X Background: Mobile health (mHealth) apps offer unique opportunities to support self-care and behavior change, but poor user engagement limits their effectiveness. This is particularly true for fully automated mHealth apps without any human support. Human support in mHealth apps is associated with better engagement but at the cost of reduced scalability. Objective: This work aimed to (1) describe the theory-informed development of a fully automated relaxation and mindfulness app to reduce distress in people with cancer (CanRelax app 2.0), (2) describe engagement with the app on multiple levels within a fully automated randomized controlled trial over 10 weeks, and (3) examine whether engagement was related to user characteristics. Methods: The CanRelax app 2.0 was developed in iterative processes involving input from people with cancer and relevant experts. The app includes evidence-based relaxation exercises, personalized weekly coaching sessions with a rule-based conversational agent, 39 self-enactable behavior change techniques, a self-monitoring dashboard with gamification elements, highly tailored reminder notifications, an educational video clip, and personalized in-app letters. For the larger study, German-speaking adults diagnosed with cancer within the last 5 years were recruited via the web in Switzerland, Austria, and Germany. Engagement was analyzed in a sample of 100 study participants with multiple measures on a micro level (completed coaching sessions, relaxation exercises practiced with the app, and feedback on the app) and a macro level (relaxation exercises practiced without the app and self-efficacy toward self-set weekly relaxation goals). Results: In week 10, a total of 62% (62/100) of the participants were actively using the CanRelax app 2.0. No associations were identified between engagement and level of distress at baseline, sex assigned at birth, educational attainment, or age. At the micro level, 71.88% (3520/4897) of all relaxation exercises and 714 coaching sessions were completed in the app, and all participants who provided feedback (52/100, 52%) expressed positive app experiences. At the macro level, 28.12% (1377/4897) of relaxation exercises were completed without the app, and participants’ self-efficacy remained stable at a high level. At the same time, participants raised their weekly relaxation goals, which indicates a potential relative increase in self-efficacy. Conclusions: The CanRelax app 2.0 achieved promising engagement even though it provided no human support. Fully automated social components might have compensated for the lack of human involvement and should be investigated further. More than one-quarter (1377/4897, 28.12%) of all relaxation exercises were practiced without the app, highlighting the importance of assessing engagement on multiple levels. %M 38819907 %R 10.2196/52386 %U https://cancer.jmir.org/2024/1/e52386 %U https://doi.org/10.2196/52386 %U http://www.ncbi.nlm.nih.gov/pubmed/38819907 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53204 %T Prospective Acceptability of Digital Therapy for Major Depressive Disorder in France: Multicentric Real-Life Study %A Amiot,Odile %A Sauvaget,Anne %A Alamome,Isabelle %A Bulteau,Samuel %A Charpeaud,Thomas %A Clair,Anne-Hélène %A Courtet,Philippe %A Drapier,Dominique %A Haffen,Emmanuel %A Fakra,Eric %A Gaudeau-Bosma,Christian %A Gaillard,Adeline %A Mouchabac,Stéphane %A Pineau,Fanny %A Narboni,Véronique %A Duburcq,Anne %A Lecardeur,Laurent %+ DueL, 8 Quai des Docks, Nice, 06300, France, 33 635568024, laurentlecardeur@gmail.com %K prospective acceptability %K digital health %K depression %K e-mental health %K deprexis %K psychotherapy %D 2024 %7 20.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Major depressive disorder is one of the leading causes of disability worldwide. Although most international guidelines recommend psychological and psychosocial interventions as first-line treatment for mild to moderate depression, access remains limited in France due to the limited availability of trained clinicians, high costs for patients in the context of nonreimbursement, and the fear of stigmatization. Therefore, online blended psychological treatment such as Deprexis could improve access to care for people with depression. It has several advantages, such as easy accessibility and scalability, and it is supported by evidence. Objective: This study aims to evaluate the real-life acceptability of Deprexis for people with depression in France outside of a reimbursement pathway. Methods: Deprexis Acceptability Study Measure in Real Life (DARE) was designed as a multicenter cross-sectional study in which Deprexis was offered to any patient meeting the inclusion criteria during the fixed inclusion period (June 2022-March 2023). Inclusion criteria were (1) depression, (2) age between 18 and 65 years, (3) sufficient French language skills, and (4) access to the internet with a device to connect to the Deprexis platform. Exclusion criteria were previous or current diagnoses of bipolar disorder, psychotic symptoms, and suicidal thoughts during the current episode. The primary objective was to measure the prospective acceptability of Deprexis, a new digital therapy. Secondary objectives were to examine differences in acceptability according to patient and clinician characteristics and to identify reasons for refusal. All investigators received video-based training on Deprexis before enrollment to ensure that they all had the same level of information and understanding of the program. Results: A total of 245 patients were eligible (n=159, 64.9% were women and n=138, 56.3% were single). The mean age was 40.7 (SD 14.1) years. A total of 78% (n=191) of the patients had moderate to severe depression (according to the Patient Health Questionnaire-9 [PHQ-9]). More than half of the population had another psychiatric comorbidity (excluding bipolar disorder, psychotic disorders, and suicidal ideation). A total of 33.9% (n=83) of patients accepted the idea of using Deprexis; the main reason for refusal was financial at 83.3% (n=135). Multivariate logistic regression identified factors that might favor the acceptability of Deprexis. Among these, being a couple, being treated with an antidepressant, or having a low severity level favored the acceptance of Deprexis. Conclusions: DARE is the first French study aiming at evaluating the prospective acceptability of digital therapy in the treatment of depression. The main reason for the refusal of Deprexis was financial. DARE will allow better identification of factors influencing acceptability in a natural setting. This study highlights the importance of investigating factors that may be associated with the acceptability of digital interventions, such as marital status, medication use, and severity of depression. %M 38568139 %R 10.2196/53204 %U https://formative.jmir.org/2024/1/e53204 %U https://doi.org/10.2196/53204 %U http://www.ncbi.nlm.nih.gov/pubmed/38568139 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e42547 %T Optimizing Outcomes in Psychotherapy for Anxiety Disorders Using Smartphone-Based and Passive Sensing Features: Protocol for a Randomized Controlled Trial %A Müller-Bardorff,Miriam %A Schulz,Ava %A Paersch,Christina %A Recher,Dominique %A Schlup,Barbara %A Seifritz,Erich %A Kolassa,Iris Tatjana %A Kowatsch,Tobias %A Fisher,Aaron %A Galatzer-Levy,Isaac %A Kleim,Birgit %+ Experimental Psychopathology and Psychotherapy, Department of Psychiatry and Psychology, University of Zurich, Lenggstrasse 31, Zurich, 8032, Switzerland, 41 0443842351, birgit.kleim@uzh.ch %K cognitive behavioral therapy %K CBT %K transdiagnostic %K anxiety %K digital %K ecological momentary assessment %K EMA %K passive sensing %D 2024 %7 14.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Psychotherapies, such as cognitive behavioral therapy (CBT), currently have the strongest evidence of durable symptom changes for most psychological disorders, such as anxiety disorders. Nevertheless, only about half of individuals treated with CBT benefit from it. Predictive algorithms, including digital assessments and passive sensing features, could better identify patients who would benefit from CBT, and thus, improve treatment choices. Objective: This study aims to establish predictive features that forecast responses to transdiagnostic CBT in anxiety disorders and to investigate key mechanisms underlying treatment responses. Methods: This study is a 2-armed randomized controlled clinical trial. We include patients with anxiety disorders who are randomized to either a transdiagnostic CBT group or a waitlist (referred to as WAIT). We index key features to predict responses prior to starting treatment using subjective self-report questionnaires, experimental tasks, biological samples, ecological momentary assessments, activity tracking, and smartphone-based passive sensing to derive a multimodal feature set for predictive modeling. Additional assessments take place weekly at mid- and posttreatment and at 6- and 12-month follow-ups to index anxiety and depression symptom severity. We aim to include 150 patients, randomized to CBT versus WAIT at a 3:1 ratio. The data set will be subject to full feature and important features selected by minimal redundancy and maximal relevance feature selection and then fed into machine leaning models, including eXtreme gradient boosting, pattern recognition network, and k-nearest neighbors to forecast treatment response. The performance of the developed models will be evaluated. In addition to predictive modeling, we will test specific mechanistic hypotheses (eg, association between self-efficacy, daily symptoms obtained using ecological momentary assessments, and treatment response) to elucidate mechanisms underlying treatment response. Results: The trial is now completed. It was approved by the Cantonal Ethics Committee, Zurich. The results will be disseminated through publications in scientific peer-reviewed journals and conference presentations. Conclusions: The aim of this trial is to improve current CBT treatment by precise forecasting of treatment response and by understanding and potentially augmenting underpinning mechanisms and personalizing treatment. Trial Registration: ClinicalTrials.gov NCT03945617; https://clinicaltrials.gov/ct2/show/results/NCT03945617 International Registered Report Identifier (IRRID): DERR1-10.2196/42547 %M 38743473 %R 10.2196/42547 %U https://www.researchprotocols.org/2024/1/e42547 %U https://doi.org/10.2196/42547 %U http://www.ncbi.nlm.nih.gov/pubmed/38743473 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e41573 %T A Curriculum on Digital Psychiatry for a US-Based Psychiatry Residency Training Program: Pilot Implementation Study %A Noori,Sofia %A Khasnavis,Siddharth %A DeCroce-Movson,Eliza %A Blay-Tofey,Morkeh %A Vitiello,Evan %+ Department of Psychiatry, University of North Carolina School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27514, United States, 1 9194450221, evan.vitiello@gmail.com %K digital psychiatry %K digital mental health %K didactic curriculum %K residency training %K psychiatry residency %K training classes %K trainee response %K residency curriculum %K trainee feedback %D 2024 %7 13.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital psychiatry, defined as the application of health technologies to the prevention, assessment, and treatment of mental health illnesses, is a growing field. Interest in the clinical use of these technologies continues to grow. However, psychiatric trainees receive limited or no formal education on the topic. Objective: This study aims to pilot a curriculum on digital psychiatry for a US-based psychiatry residency training program and examine the change in learner confidence regarding appraisal and clinical recommendation of digital mental health apps. Methods: Two 60-minute sessions were presented through a web-based platform to postgraduate year 2-4 residents training in psychiatry at a US-based adult psychiatry residency program. Learner confidence was assessed using pre- and postsession surveys. Results: Matched pre- and postsession quizzes showed improved confidence in multiple domains aligning with the course objectives. This included the structured appraisal of digital mental health apps (P=.03), assessment of a patient’s digital health literacy (P=.01), formal recommendation of digital health tools (P=.03), and prescription of digital therapeutics to patients (P=.03). Though an improvement from baseline, mean ratings for confidence did not exceed “somewhat comfortable” on any of the above measures. Conclusions: Our study shows the feasibility of implementing a digital psychiatry curriculum for residents in multiple levels of training. We also identified an opportunity to increase learner confidence in the appraisal and clinical use of digital mental health apps through the use of a formal curriculum. %M 38739423 %R 10.2196/41573 %U https://formative.jmir.org/2024/1/e41573 %U https://doi.org/10.2196/41573 %U http://www.ncbi.nlm.nih.gov/pubmed/38739423 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e54007 %T Veteran Experiences With an mHealth App to Support Measurement-Based Mental Health Care: Results From a Mixed Methods Evaluation %A Higashi,Robin T %A Etingen,Bella %A Richardson,Eric %A Palmer,Jennifer %A Zocchi,Mark S %A Bixler,Felicia R %A Smith,Bridget %A McMahon,Nicholas %A Frisbee,Kathleen L %A Fortney,John C %A Turvey,Carolyn %A Evans,Jennifer %A Hogan,Timothy P %+ Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, United States, 1 (214) 648 3645, Robin.Higashi@UTSouthwestern.edu %K measurement-based care %K mobile health app %K mental health %K veteran %K mHealth %K support %K mixed-methods evaluation %K digital health %D 2024 %7 10.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care. Objective: This study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health. Methods: Our mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ2 tests. We analyzed interview data using thematic analysis. Results: We received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care). Conclusions: Although experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA’s Collect-Share-Act model of MBC. %M 38728684 %R 10.2196/54007 %U https://mental.jmir.org/2024/1/e54007 %U https://doi.org/10.2196/54007 %U http://www.ncbi.nlm.nih.gov/pubmed/38728684 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52369 %T Feasibility and Acceptability of a Mobile App–Based TEAM-CBT (Testing Empathy Assessment Methods–Cognitive Behavioral Therapy) Intervention (Feeling Good) for Depression: Secondary Data Analysis %A Bisconti,Nicholas %A Odier,Mackenzie %A Becker,Matthew %A Bullock,Kim %+ PGSP-Stanford PsyD. Consortium, 401 Quarry Rd, Palo Alto, CA, 94304, United States, 1 6506449946, nbisco@stanford.edu %K depression %K mobile health %K mHealth %K cognitive behavioral therapy %K mobile phone %D 2024 %7 10.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Feeling Good App is an automated stand-alone digital mobile mental health tool currently undergoing beta testing with the goal of providing evidence-informed self-help lessons and exercises to help individuals reduce depressive symptoms without guidance from a mental health provider. Users work through intensive basic training (IBT) and ongoing training models that provide education regarding cognitive behavioral therapy principles from a smartphone. Objective: The key objective of this study was to perform a nonsponsored third-party academic assessment of an industry-generated data set; this data set focused on the safety, feasibility, and accessibility of a commercial automated digital mobile mental health app that was developed to reduce feelings associated with depression. Methods: The Feeling Good App development team created a waitlist cohort crossover design and measured symptoms of depression and anxiety using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and an app-specific measure of negative feelings called the 7 Dimension Emotion Slider (7-DES). The waitlist cohort crossover design divided the participants into 2 groups, where 48.6% (141/290) of the participants were given immediate access to the apps, while 51.4% (149/290) were placed on a 2-week waitlist before being given access to the app. Data collected by the Feeling Good App development team were deidentified and provided to the authors of this paper for analysis through a nonsponsored university data use agreement. All quantitative data were analyzed using SPSS Statistics (version 28.0; IBM Corp). Descriptive statistics were calculated for demographic variables. Feasibility and acceptability were descriptively assessed. All participants included in the quantitative data were given access to the Feeling Good App; this study did not include a control group. Results: In terms of safety, there was no statistically significant change in suicidality from preintervention to postintervention time points (t288=0.0; P>.99), and there was a statistically significant decrease in hopelessness from preintervention to postintervention time points (F289=30.16; P<.01). In terms of acceptability, 72.2% (166/230) of the users who started the initial 2-day IBT went on to complete it, while 34.8% (80/230) of the users who started IBT completed the entirety of the apps’ 4-week protocol (150/230, 65.22% dropout rate over 4 weeks). Conclusions: This study is the first reported proof-of-concept evaluation of the Feeling Good App in terms of safety, feasibility, and statistical trends within the data set. It demonstrates a feasible and novel approach to industry and academic collaboration in the process of developing a digital mental health technology translated from an existing evidence-informed treatment. The results support the prototype app as safe for a select nonclinical population. The app had acceptable levels of engagement and dropouts throughout the intervention. Those who stay engaged showed reductions in symptom severity of depression warranting further investigation of the app’s efficacy. %M 38728080 %R 10.2196/52369 %U https://mental.jmir.org/2024/1/e52369 %U https://doi.org/10.2196/52369 %U http://www.ncbi.nlm.nih.gov/pubmed/38728080 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e50259 %T Digital Phenotypes for Early Detection of Internet Gaming Disorder in Adolescent Students: Explorative Data-Driven Study %A Cho,Kwangsu %A Kim,Minah %A Cho,Youngeun %A Hur,Ji-Won %A Kim,Do Hyung %A Park,Seonghyeon %A Park,Sunghyun %A Jang,Moonyoung %A Lee,Chang-Gun %A Kwon,Jun Soo %+ Department of Neuropsychiatry, Seoul National University Hospital, 101 Dahak-no, Jongno-gu, Seoul, 03080, Republic of Korea, 82 2 2072 2972, kwonjs@snu.ac.kr %K adolescents %K digital biomarkers %K digital phenotyping %K digital psychiatry %K early detection %K IGD %K internet gaming disorder %K pediatric psychiatry %K proactive medicine %K secondary school %K universal screening %D 2024 %7 29.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Limited awareness, social stigma, and access to mental health professionals hinder early detection and intervention of internet gaming disorder (IGD), which has emerged as a significant concern among young individuals. Prevalence estimates vary between 0.7% and 15.6%, and its recognition in the International Classification of Diseases, 11th Revision and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition underscores its impact on academic functioning, social isolation, and mental health challenges. Objective: This study aimed to uncover digital phenotypes for the early detection of IGD among adolescents in learning settings. By leveraging sensor data collected from student tablets, the overarching objective is to incorporate these digital indicators into daily school activities to establish these markers as a mental health screening tool, facilitating the early identification and intervention for IGD cases. Methods: A total of 168 voluntary participants were engaged, consisting of 85 students with IGD and 83 students without IGD. There were 53% (89/168) female and 47% (79/168) male individuals, all within the age range of 13-14 years. The individual students learned their Korean literature and mathematics lessons on their personal tablets, with sensor data being automatically collected. Multiple regression with bootstrapping and multivariate ANOVA were used, prioritizing interpretability over predictability, for cross-validation purposes. Results: A negative correlation between IGD Scale (IGDS) scores and learning outcomes emerged (r166=–0.15; P=.047), suggesting that higher IGDS scores were associated with lower learning outcomes. Multiple regression identified 5 key indicators linked to IGD, explaining 23% of the IGDS score variance: stroke acceleration (β=.33; P<.001), time interval between keys (β=–0.26; P=.01), word spacing (β=–0.25; P<.001), deletion (β=–0.24; P<.001), and horizontal length of strokes (β=0.21; P=.02). Multivariate ANOVA cross-validated these findings, revealing significant differences in digital phenotypes between potential IGD and non-IGD groups. The average effect size, measured by Cohen d, across the indicators was 0.40, indicating a moderate effect. Notable distinctions included faster stroke acceleration (Cohen d=0.68; P=<.001), reduced word spacing (Cohen d=.57; P=<.001), decreased deletion behavior (Cohen d=0.33; P=.04), and longer horizontal strokes (Cohen d=0.34; P=.03) in students with potential IGD compared to their counterparts without IGD. Conclusions: The aggregated findings show a negative correlation between IGD and learning performance, highlighting the effectiveness of digital markers in detecting IGD. This underscores the importance of digital phenotyping in advancing mental health care within educational settings. As schools adopt a 1-device-per-student framework, digital phenotyping emerges as a promising early detection method for IGD. This shift could transform clinical approaches from reactive to proactive measures. %M 38683658 %R 10.2196/50259 %U https://mental.jmir.org/2024/1/e50259 %U https://doi.org/10.2196/50259 %U http://www.ncbi.nlm.nih.gov/pubmed/38683658 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e53712 %T Testing the Efficacy of a Brief, Self-Guided Mindfulness Ecological Momentary Intervention on Emotion Regulation and Self-Compassion in Social Anxiety Disorder: Randomized Controlled Trial %A Zainal,Nur Hani %A Tan,Hui Han %A Hong,Ryan Yee Shiun %A Newman,Michelle Gayle %+ Department of Psychology, National University of Singapore, 9 Arts Link, Singapore, 117572, Singapore, 65 917 767 7088, hanizainal@nus.edu.sg %K social anxiety disorder %K mindfulness %K ecological momentary intervention %K randomized controlled trial %K emotion regulation %K self-compassion %K mechanisms of change %K mobile phone %K momentary interventions %K self-monitoring app %K regulations %K participant %D 2024 %7 19.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Theories propose that brief, mobile, self-guided mindfulness ecological momentary interventions (MEMIs) could enhance emotion regulation (ER) and self-compassion. Such changes are posited to be mechanisms of change. However, rigorous tests of these theories have not been conducted. Objective: In this assessor-blinded, parallel-group randomized controlled trial, we aimed to test these theories in social anxiety disorder (SAD). Methods: Participants with SAD (defined as having a prerandomization cut-off score ≥20 on the Social Phobia Inventory self-report) were randomized to a 14-day fully self-guided MEMI (96/191, 50.3%) or self-monitoring app (95/191, 49.7%) arm. They completed web-based self-reports of 6 clinical outcome measures at prerandomization, 15-day postintervention (administered the day after the intervention ended), and 1-month follow-up time points. ER and self-compassion were assessed at preintervention and 7-day midintervention time points. Multilevel modeling determined the efficacy of MEMI on ER and self-compassion domains from pretrial to midintervention time points. Bootstrapped parallel multilevel mediation analysis examined the mediating role of pretrial to midintervention ER and self-compassion domains on the efficacy of MEMI on 6 clinical outcomes. Results: Participants demonstrated strong compliance, with 78% (149/191) engaging in at least 80% of the MEMI and self-monitoring prompts. MEMI was more efficacious than the self-monitoring app in decreasing ER goal–directed behavior difficulties (between-group Cohen d=−0.24) and lack of emotional clarity (Cohen d=0.16) and increasing self-compassion social connectedness (Cohen d=0.19), nonidentification with emotions (Cohen d=0.16), and self-kindness (Cohen d=0.19) from pretrial to midintervention time points. The within-group effect sizes from pretrial to midintervention were larger in the MEMI arm than in the self-monitoring app arm (ER goal–directed behavior difficulties: Cohen d=−0.73 vs −0.29, lack of emotional clarity: Cohen d=−0.39 vs −0.21, self-compassion domains of social connectedness: Cohen d=0.45 vs 0.19, nonidentification with emotions: Cohen d=0.63 vs 0.48, and self-kindness: Cohen d=0.36 vs 0.10). Self-monitoring, but not MEMI, alleviated ER emotional awareness issues (between-group Cohen d=0.11 and within-group: Cohen d=−0.29 vs −0.13) and reduced self-compassion acknowledging shared human struggles (between-group Cohen d=0.26 and within-group: Cohen d=−0.23 vs 0.13). No ER and self-compassion domains were mediators of the effect of MEMI on SAD symptoms (P=.07-<.99), generalized anxiety symptoms (P=.16-.98), depression severity (P=.20-.94), repetitive negative thinking (P=.12-.96), and trait mindfulness (P=.18-.99) from pretrial to postintervention time points. Similar nonsignificant mediation effects emerged for all of these clinical outcomes from pretrial to 1-month follow-up time points (P=.11-.98). Conclusions: Brief, fully self-guided, mobile MEMIs efficaciously increased specific self-compassion domains and decreased ER difficulties associated with goal pursuit and clarity of emotions from pretrial to midintervention time points. Higher-intensity MEMIs may be required to pinpoint the specific change mechanisms in ER and self-compassion domains of SAD. Trial Registration: Open Science Framework (OSF) Registries; osf.io/m3kxz https://osf.io/m3kxz %M 38640015 %R 10.2196/53712 %U https://mental.jmir.org/2024/1/e53712 %U https://doi.org/10.2196/53712 %U http://www.ncbi.nlm.nih.gov/pubmed/38640015 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e49929 %T Mobile Apps to Support Mental Health Response in Natural Disasters: Scoping Review %A Ezeonu,Nwamaka Alexandra %A Hertelendy,Attila J %A Adu,Medard Kofi %A Kung,Janice Y %A Itanyi,Ijeoma Uchenna %A Dias,Raquel da Luz %A Agyapong,Belinda %A Hertelendy,Petra %A Ohanyido,Francis %A Agyapong,Vincent Israel Opoku %A Eboreime,Ejemai %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans' Memorial Lane, 8th Floor Abbie J Lane Memorial Building, QEII Health Sciences Centre, Halifax, NS, B3H 2E2, Canada, 1 9024732479, ejemai.eboreime@nshealth.ca %K mental health %K disasters %K mobile health %K mHealth %K application %K applications %K app %K apps %K smartphone %K stress %K psychological %K traumatic %K disaster %K disasters %K hazard %K hazards %K emergency %K psychological trauma %K mobile apps %K trauma %K scoping %K review methods %K review methodology %K mobile phone %D 2024 %7 17.4.2024 %9 Review %J J Med Internet Res %G English %X Background: Disasters are becoming more frequent due to the impact of extreme weather events attributed to climate change, causing loss of lives, property, and psychological trauma. Mental health response to disasters emphasizes prevention and mitigation, and mobile health (mHealth) apps have been used for mental health promotion and treatment. However, little is known about their use in the mental health components of disaster management. Objective: This scoping review was conducted to explore the use of mobile phone apps for mental health responses to natural disasters and to identify gaps in the literature. Methods: We identified relevant keywords and subject headings and conducted comprehensive searches in 6 electronic databases. Studies in which participants were exposed to a man-made disaster were included if the sample also included some participants exposed to a natural hazard. Only full-text studies published in English were included. The initial titles and abstracts of the unique papers were screened by 2 independent review authors. Full texts of the selected papers that met the inclusion criteria were reviewed by the 2 independent reviewers. Data were extracted from each selected full-text paper and synthesized using a narrative approach based on the outcome measures, duration, frequency of use of the mobile phone apps, and the outcomes. This scoping review was reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Results: Of the 1398 papers retrieved, 5 were included in this review. A total of 3 studies were conducted on participants exposed to psychological stress following a disaster while 2 were for disaster relief workers. The mobile phone apps for the interventions included Training for Life Skills, Sonoma Rises, Headspace, Psychological First Aid, and Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioural Health Disaster Response Apps. The different studies assessed the effectiveness or efficacy of the mobile app, feasibility, acceptability, and characteristics of app use or predictors of use. Different measures were used to assess the effectiveness of the apps’ use as either the primary or secondary outcome. Conclusions: A limited number of studies are exploring the use of mobile phone apps for mental health responses to disasters. The 5 studies included in this review showed promising results. Mobile apps have the potential to provide effective mental health support before, during, and after disasters. However, further research is needed to explore the potential of mobile phone apps in mental health responses to all hazards. %M 38520699 %R 10.2196/49929 %U https://www.jmir.org/2024/1/e49929 %U https://doi.org/10.2196/49929 %U http://www.ncbi.nlm.nih.gov/pubmed/38520699 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53726 %T Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool %A Louch,Gemma %A Berzins,Kathryn %A Walker,Lauren %A Wormald,Gemma %A Blackwell,Kirstin %A Stephens,Michael %A Brown,Mark %A Baker,John %+ School of Healthcare, University of Leeds, Baines Wing, Leeds, LS2 9JT, United Kingdom, 44 0113343 ext 7173, g.e.louch@leeds.ac.uk %K patient safety %K mental health %K patient involvement %K qualitative %K digital innovation %K real time %K monitoring %K safety %K develop %K development %K design %K perception %K perceptions %K prototype %K evidence scan %K interview %K interviews %K logic model %K programme theory %K dashboard %K dashboards %K interface %D 2024 %7 12.4.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need. Objective: This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory. Methods: The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool. Results: We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, “getting worse” or “getting better”; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code. Conclusions: Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively. %M 38607663 %R 10.2196/53726 %U https://formative.jmir.org/2024/1/e53726 %U https://doi.org/10.2196/53726 %U http://www.ncbi.nlm.nih.gov/pubmed/38607663 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58631 %T Digital Tools to Facilitate the Detection and Treatment of Bipolar Disorder: Key Developments and Future Directions %A de Azevedo Cardoso,Taiane %A Kochhar,Shruti %A Torous,John %A Morton,Emma %+ JMIR Publications, 130 Queens Quay E Suite 1100, Toronto, ON, M5A 0P6, Canada, 1 2899411482, taiane.cardoso@jmir.org %K bipolar disorder %K digital phenotyping %K machine learning %K mobile health interventions %K mobile health %K mHealth %K apps %D 2024 %7 1.4.2024 %9 Editorial %J JMIR Ment Health %G English %X Bipolar disorder (BD) impacts over 40 million people around the world, often manifesting in early adulthood and substantially impacting the quality of life and functioning of individuals. Although early interventions are associated with a better prognosis, the early detection of BD is challenging given the high degree of similarity with other psychiatric conditions, including major depressive disorder, which corroborates the high rates of misdiagnosis. Further, BD has a chronic, relapsing course, and the majority of patients will go on to experience mood relapses despite pharmacological treatment. Digital technologies present promising results to augment early detection of symptoms and enhance BD treatment. In this editorial, we will discuss current findings on the use of digital technologies in the field of BD, while debating the challenges associated with their implementation in clinical practice and the future directions. %M 38557724 %R 10.2196/58631 %U https://mental.jmir.org/2024/1/e58631 %U https://doi.org/10.2196/58631 %U http://www.ncbi.nlm.nih.gov/pubmed/38557724 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52186 %T Effectiveness of Virtual Reality–Based Well-Being Interventions for Stress Reduction in Young Adults: Systematic Review %A Xu,Joy %A Khanotia,Areej %A Juni,Shmuel %A Ku,Josephine %A Sami,Hana %A Lin,Vallen %A Walterson,Roberta %A Payne,Evelyn %A Jo,Helen %A Rahimpoor-Marnani,Parmin %+ David Geffen School of Medicine at UCLA, 417 Charles E Young Drive West, Los Angeles, CA, 90024, United States, 1 3109481476, joyjxu@gmail.com %K well-being %K well-being %K virtual reality %K VR %K stress, nature %K academic %K student %K intervention %K young adults %K teens %K adolescent %K stressors %K stress management %K systematic review %K accessible %K accessibility %K students %K affordable %D 2024 %7 29.3.2024 %9 Review %J JMIR Ment Health %G English %X Background: Adolescents can be especially vulnerable to various stressors as they are still in their formative years and transitioning into adulthood. Hence, it is important for them to have effective stress management strategies. Objective: This systematic review investigates current well-being interventions that are aimed at reducing stress among young adults. In particular, interventions using the medium of virtual reality (VR) are explored. Methods: This mixed methods systematic review follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines, and papers were gathered from databases such as PsycINFO, PubMed, Science Direct, Web of Science, OpenGrey, and Edutopia. Predetermined criteria and specific keywords were used to search for the papers. Search results were screened and extracted with all article screening or extraction delegated among all authors. Any disagreements after reconciliation were settled by a third author. The quality and risk of bias of included studies were assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) Tool for Quantitative Studies. Studies were analyzed qualitatively. Results: In total, 20 studies were included, and qualitative analysis was performed to evaluate the effectiveness of VR-based interventions in 3 domains: nature, stress, and academics. Conclusions: Studies using VR interventions, overall, promoted a reduction in stress and an increase in well-being. The findings suggest that VR may serve as an accessible and affordable medium of stress reduction for students and young adults. Larger sample sizes, and a greater number of included studies, may be required in future directions. %M 38551625 %R 10.2196/52186 %U https://mental.jmir.org/2024/1/e52186 %U https://doi.org/10.2196/52186 %U http://www.ncbi.nlm.nih.gov/pubmed/38551625 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e48027 %T The Effectiveness of a Cell Phone eHealth App in Changing Knowledge, Stigmatizing Attitudes, and Intention to Seek Help Associated With Obsessive-Compulsive Disorder: Pilot Questionnaire Study %A Chaves,Antonio %A Arnáez,Sandra %A García-Soriano,Gemma %+ Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Universitat de València, Avda Blasco Ibáñez, 21, Valencia, 46010, Spain, 34 963983389, gemma.garcia@uv.es %K obsessive-compulsive disorder %K OCD %K mental health literacy %K stigma %K app %K help-seeking intention %K seek help %K mobile phone %D 2024 %7 29.3.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obsessive-compulsive disorder (OCD) is a disabling disorder associated with high interference in people’s lives. However, patients with OCD either do not seek help or delay seeking help. Research suggests that this could be explained by poor mental health literacy about the disorder and the associated stigma. Objective: This study aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a mental health mobile app, esTOCma, developed to improve knowledge about OCD and its treatment, increase help-seeking intention, and reduce stigmatizing attitudes and social distance associated with OCD. Methods: We used preintervention, postintervention, and 3-month follow-up assessments in this single-arm pilot intervention. Overall, 90 participants were recruited from the community using the snowball sampling method. We used esTOCma to defeat the “stigma monster” over the course of 10 missions. The participants completed the sociodemographic information and Obsessive-Compulsive Inventory–Revised at preassessment and an acceptability questionnaire at postassessment. All other measures were completed at the preassessment, postassessment, and 3-month follow-up (ie, the Spanish Mental Illness Stigma Attribution Questionnaire–27, the General Help-Seeking Questionnaire, the Social Distance Scale, and the Mental Health Literacy Questionnaire). Results: Of the 90 participants from the community that were assessed for eligibility, 86% (n=78) were allocated to intervention. Of these 78 participants, 79% (n=62) completed the game and answered the postintervention assessment (completer group). Overall, 69% (43/62) of the participants also completed the 3-month follow-up assessment. The participants completing the study were older (P=.003) and had a higher baseline knowledge of OCD (P=.05). The participants took an average of 13.64 (SD 10.50) days to complete the intervention, including the pre- and postassessments. The participants spent an average of 4.56 (SD 3.33) days completing the 10 missions included in the app. Each mission took a mean of between 2 (SD 3.01) and 9.35 (SD 3.06) minutes. The app was rated as useful or very useful by the vast majority of participants 90% (56/62). Moreover, 90% (56/62) of the participants reported that they had learned or learned a lot, and 98% (61/62) of the participants reported that they would recommend the app to a friend. Repeated measures ANOVA (43/62, 69%) showed that after the intervention participants showed an increased knowledge of mental health and intention to seek help as well as fewer stigmatizing attitudes and less social distance. Conclusions: Preliminary data show that esTOCma is a feasible and acceptable app, and after completing its 10 missions, there is an increase in the understanding of OCD and help-seeking intention along with a decrease in the social stigma and social distance associated with OCD that lasts for at least 3 months. The results support the potential of technology-based interventions to increase the intention to seek help and reduce the stigma associated with OCD. A larger, community-controlled study is also recommended. %M 38551629 %R 10.2196/48027 %U https://mhealth.jmir.org/2024/1/e48027 %U https://doi.org/10.2196/48027 %U http://www.ncbi.nlm.nih.gov/pubmed/38551629 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e53096 %T Combining mHealth Technology and Pharmacotherapy to Improve Mental Health Outcomes and Reduce Human Rights Abuses in West Africa: Intervention Field Trial %A Ben-Zeev,Dror %A Larsen,Anna %A Attah,Dzifa A %A Obeng,Kwadwo %A Beaulieu,Alexa %A Asafo,Seth M %A Gavi,Jonathan Kuma %A Kadakia,Arya %A Sottie,Emmanuel Quame %A Ohene,Sammy %A Kola,Lola %A Hallgren,Kevin %A Snyder,Jaime %A Collins,Pamela Y %A Ofori-Atta,Angela %A , %K mHealth %K mobile health %K app %K apps %K applications %K human rights %K Africa %K healers %K healer %K alternative %K complementary %K CAM %K schizophrenia %K bipolar disorder %K depression %K bipolar %K depressive %K mental %K schizophrenic %K schizophrenics %K psychosocial %K training %K abuse %K behavior change %K behaviour change %K medication %K medications %K pharmacology %K pharmacological %K pharmacotherapy %K feasibility, acceptability, safety %D 2024 %7 27.3.2024 %9 %J JMIR Ment Health %G English %X Background: In West Africa, healers greatly outnumber trained mental health professionals. People with serious mental illness (SMI) are often seen by healers in “prayer camps” where they may also experience human rights abuses. We developed “M&M,” an 8-week-long dual-pronged intervention involving (1) a smartphone-delivered toolkit designed to expose healers to brief psychosocial interventions and encourage them to preserve human rights (M-Healer app), and (2) a visiting nurse who provides medications to their patients (Mobile Nurse). Objective: We examined the feasibility, acceptability, safety, and preliminary effectiveness of the M&M intervention in real-world prayer camp settings. Methods: We conducted a single-arm field trial of M&M with people with SMI and healers at a prayer camp in Ghana. Healers were provided smartphones with M-Healer installed and were trained by practice facilitators to use the digital toolkit. In parallel, a study nurse visited their prayer camp to administer medications to their patients. Clinical assessors administered study measures to participants with SMI at pretreatment (baseline), midtreatment (4 weeks) and post treatment (8 weeks). Results: Seventeen participants were enrolled and most (n=15, 88.3%) were retained. Participants had an average age of 44.3 (SD 13.9) years and 59% (n=10) of them were male. Fourteen (82%) participants had a diagnosis of schizophrenia and 2 (18%) were diagnosed with bipolar disorder. Four healers were trained to use M-Healer. On average, they self-initiated app use 31.9 (SD 28.9) times per week. Healers watched an average of 19.1 (SD 21.2) videos, responded to 1.5 (SD 2.4) prompts, and used the app for 5.3 (SD 2.7) days weekly. Pre-post analyses revealed a significant and clinically meaningful reduction in psychiatric symptom severity (Brief Psychiatric Rating Scale score range 52.3 to 30.9; Brief Symptom Inventory score range 76.4 to 27.9), psychological distress (Talbieh Brief Distress Inventory score range 37.7 to 16.9), shame (Other as Shamer Scale score range 41.9 to 28.5), and stigma (Brief Internalized Stigma of Mental Illness Scale score range 11.8 to 10.3). We recorded a significant reduction in days chained (1.6 to 0.5) and a promising trend for reduction in the days of forced fasting (2.6 to 0.0, P=.06). We did not identify significant pre-post changes in patient-reported working alliance with healers (Working Alliance Inventory), depressive symptom severity (Patient Health Questionnaire-9), quality of life (Lehman Quality of Life Interview for the Mentally Ill), beliefs about medication (Beliefs about Medications Questionnaire–General Harm subscale), or other human rights abuses. No major side effects, health and safety violations, or serious adverse events occurred over the course of the trial. Conclusions: The M&M intervention proved to be feasible, acceptable, safe, and clinically promising. Preliminary findings suggest that the M-Healer toolkit may have shifted healers’ behaviors at the prayer camp so that they commit fewer human rights abuses. %R 10.2196/53096 %U https://mental.jmir.org/2024/1/e53096 %U https://doi.org/10.2196/53096 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e55528 %T Efficacy of BrighterSide, a Self-Guided App for Suicidal Ideation: Randomized Controlled Trial %A Josifovski,Natasha %A Torok,Michelle %A Batterham,Philip %A Wong,Quincy %A Beames,Joanne R %A Theobald,Adam %A Holland,Sarah %A Huckvale,Kit %A Riley,Jo %A Cockayne,Nicole %A Christensen,Helen %A Larsen,Mark %K suicidal ideation %K suicide prevention %K digital health %K clinical trial %D 2024 %7 18.3.2024 %9 %J JMIR Ment Health %G English %X Background: Self-guided digital interventions can reduce the severity of suicidal ideation, although there remain relatively few rigorously evaluated smartphone apps targeting suicidality. Objective: This trial evaluated whether the BrighterSide smartphone app intervention was superior to a waitlist control group at reducing the severity of suicidal ideation. Methods: A total of 550 adults aged 18 to 65 years with recent suicidal ideation were recruited from the Australian community. In this randomized controlled trial, participants were randomly assigned to receive either the BrighterSide app or to a waitlist control group that received treatment as usual. The app was self-guided, and participants could use the app at their own pace for the duration of the study period. Self-report measures were collected at baseline, 6 weeks, and 12 weeks. The primary outcome was severity and frequency of suicidal ideation, and secondary outcomes included psychological distress and functioning and recovery. Additional data were collected on app engagement and participant feedback. Results: Suicidal ideation reduced over time for all participants, but there was no significant interaction between group and time. Similar improvements were observed for self-harm, functioning and recovery, days out of role, and coping. Psychological distress was significantly lower in the intervention group at the 6-week follow-up, but this was not maintained at 12 weeks. Conclusions: The BrighterSide app did not lead to a significant improvement in suicidal ideation relative to a waitlist control group. Possible reasons for this null finding are discussed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621000712808; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12621000712808 %R 10.2196/55528 %U https://mental.jmir.org/2024/1/e55528 %U https://doi.org/10.2196/55528 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48467 %T Preliminary Efficacy of a Digital Intervention for Adolescent Depression: Randomized Controlled Trial %A Peake,Emily %A Miller,Ian %A Flannery,Jessica %A Chen,Lang %A Lake,Jessica %A Padmanabhan,Aarthi %+ Limbix Health Inc, 548 Market St, PMB 91609, San Francisco, CA, 94104, United States, 1 888 546 2495, aarthi.padmanabhan@bighealth.com %K adolescent %K depression %K randomized controlled trial %K mobile phone %K digital therapeutics %K mobile app %K cognitive behavioral therapy %K behavioral activation %K mobile health %D 2024 %7 7.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Adolescent depression is a significant public health concern; however, access to effective mental health care is limited. Digital therapeutics (DTx) can improve access to evidence-based interventions; however, their efficacy in adolescents is sparsely documented. Objective: This study aims to examine the efficacy of a mobile app DTx versus an active control as an adjunct treatment for adolescent depression symptoms. Methods: An internet-based open-label randomized control trial was conducted nationwide with a partial crossover design, and 168 adolescents aged 13 to 21 years with symptoms of depression were recruited between November 2020 and September 2021. Participants were randomized (1:1) to the cognitive behavioral therapy–based treatment app (Spark) or to a psychoeducational control app (control), which they would use for a duration of 5 weeks. The primary outcome was a between-group (Spark vs control) difference in the change in depression symptoms from baseline to postintervention, as measured by the Patient Health Questionnaire-8 (PHQ-8) using a linear mixed-effects analysis. The PHQ-8 ranges from 0 to 24, with scores of 5 to 9 indicating mild depression symptoms, scores of 10 to 14 indicating moderate symptoms, scores of 15 to 19 indicating moderately severe symptoms, and scores of 20 to 24 indicating severe symptoms. A minimal clinically important difference (5-point reduction between baseline and postintervention) in the Spark arm and group differences in remission and treatment response rates based on the PHQ-8 at postintervention were also investigated. Results: A total of 160 participants were randomized, 80 in the Spark arm (mean age 16.89, SD 2.5 y) and 80 in the control arm (mean age 16.79, SD 2.59 y). Data from 121 participants (Spark: n=63; control: n=58) with moderate to severe (PHQ-8≥10) symptoms at baseline were included in the primary analyses following a modified intention-to-treat principle. A linear mixed-effect analysis revealed a nonsignificant difference between the study arms in depression symptom change over the intervention period. The Spark arm met a minimal clinically important difference threshold (mean −5.08, 95% CI −6.72 to −3.42). The remission rate in the Spark arm was significantly higher than that in the control arm (11/63, 17% vs 2/58, 3%; χ21=6.2; P=.01; false discovery rate–adjusted P=.03). The treatment response rates were not significantly different between the study arms (P=.07; false discovery rate–adjusted P=.16). Post hoc analyses including participants with mild to severe (PHQ-8 score ≥5) symptoms at baseline revealed promising evidence that Spark is effective in those with mild to severe symptoms. Conclusions: There is initial evidence that a self-guided, cognitive behavioral therapy–based DTx intervention may effectively treat mild to severe depression symptoms in adolescents. DTx may improve access to mental health care for adolescents or serve as an important adjunct to the standard of care. Trial Registration: ClinicalTrials.gov NCT04524598; https://clinicaltrials.gov/study/NCT04524598 %M 38324367 %R 10.2196/48467 %U https://www.jmir.org/2024/1/e48467 %U https://doi.org/10.2196/48467 %U http://www.ncbi.nlm.nih.gov/pubmed/38324367 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e44029 %T Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study %A Vanderkruik,Rachel C %A Ferguson,Craig %A Kobylski,Lauren A %A Locascio,Joseph J %A Hamlett,Gabriella E %A Killenberg,Parker C %A Lewis,Robert %A Jones,Noah %A Rossa,Ella T %A Dineen,Hannah %A Picard,Rosalind %A Cohen,Lee S %+ Center for Women's Mental Health, Massachusetts General Hospital, 185 Cambridge St, Ste 2200, Boston, MA, 02114, United States, 1 781 691 9071, rvanderkruik@mgh.harvard.edu %K perinatal depression %K pregnancy %K behavioral activation %K mobile app %K digital intervention %K mobile phone %D 2024 %7 26.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services. Objective: The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms. Methods: This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews. Results: The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (β=−.35; t61=−3.05; P=.003), number of activities completed (β=−.12; t61=−2.05; P=.04), days played (β=−.12; t58=−2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (β=−3.05; t45=−2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications. Conclusions: Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression. %M 38277191 %R 10.2196/44029 %U https://formative.jmir.org/2024/1/e44029 %U https://doi.org/10.2196/44029 %U http://www.ncbi.nlm.nih.gov/pubmed/38277191 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e50222 %T Exploring Adolescents’ Attitudes Toward Mental Health Apps: Concurrent Mixed Methods Study %A Høgsdal,Helene %A Kyrrestad,Henriette %A Rye,Marte %A Kaiser,Sabine %+ Regional Centre for Child and Youth Mental Health and Child Welfare - North, Faculty of Health Sciences, UiT The Arctic University of Norway, Campus Tromsø, Tromsø, 9019, Norway, 47 77646619, helene.hogsdal@uit.no %K mental health applications %K mental health %K adolescents %K adolescent %K youth %K mobile health %K app %K apps %K application %K applications %K opinion %K opinions %K cross sectional %K survey %K surveys %K questionnaire %D 2024 %7 15.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Adolescence is a critical time in which many psychological disorders develop. Mental health promotion is important, especially during this period. In recent years, an increasing number of mobile apps geared toward mental health promotion and preventing mental illness have been developed specifically for adolescents, with the goal of strengthening their mental health and well-being. Objective: This study aims to explore adolescents’ attitudes toward mental health apps, as well as the perceived usefulness of mental health apps. Methods: In this mixed methods study, a total of 183 adolescents (mean age 15.62, SD 3.21 years) answered a cross-sectional questionnaire, with 10 questions (eg, “What do you think about mental health apps in general?”). To complement the quantitative findings, individual interviews were conducted with 9 adolescents, during which they could elaborate on their opinions about mental health apps. Results: A total of 30% (56/183) of the adolescents in the quantitative study had used a mental health app. Over half of the respondents (77/126, 61.1%) reported that they would use a mental health app if they had a mental health problem as well as that they thought mental health apps were somewhat or very useful (114/183, 62.3%). Availability was the most frequently reported advantage of mental health apps (107/183, 58.8%). Possible associated costs of mental health apps were the most frequently mentioned barrier to their use (87/183, 47.5%). Findings from the interviews also pointed to the importance of the availability of mental health apps as well as their credibility and potential to provide adolescents with autonomy when seeking mental health advice and help. Conclusions: Overall, the results indicate that adolescents have a positive attitude toward and an interest in mental health apps. However, adolescents are also more or less unaware of such apps, which might be one reason why they are often not used. The findings of this study have important implications for future research on mental health apps and for developers of mental health apps that target young people. The insights gained from this study can inform the development of more effective mental health apps that better meet the needs and preferences of adolescents. %M 38224474 %R 10.2196/50222 %U https://formative.jmir.org/2024/1/e50222 %U https://doi.org/10.2196/50222 %U http://www.ncbi.nlm.nih.gov/pubmed/38224474 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46778 %T Digital Phenotyping for Monitoring Mental Disorders: Systematic Review %A Bufano,Pasquale %A Laurino,Marco %A Said,Sara %A Tognetti,Alessandro %A Menicucci,Danilo %+ Institute of Clinical Physiology, National Research Council, via Giuseppe Moruzzi,1, Pisa, 56124, Italy, 39 0503152181, marco.laurino@cnr.it %K digital phenotyping %K mobile %K mental health %K smartphone %K mobile sensing %K passive sensing %K active sensing %K digital phenotype %K digital biomarker %K mobile phone %D 2023 %7 13.12.2023 %9 Review %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has increased the impact and spread of mental illness and made health services difficult to access; therefore, there is a need for remote, pervasive forms of mental health monitoring. Digital phenotyping is a new approach that uses measures extracted from spontaneous interactions with smartphones (eg, screen touches or movements) or other digital devices as markers of mental status. Objective: This review aimed to evaluate the feasibility of using digital phenotyping for predicting relapse or exacerbation of symptoms in patients with mental disorders through a systematic review of the scientific literature. Methods: Our research was carried out using 2 bibliographic databases (PubMed and Scopus) by searching articles published up to January 2023. By following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines, we started from an initial pool of 1150 scientific papers and screened and extracted a final sample of 29 papers, including studies concerning clinical populations in the field of mental health, which were aimed at predicting relapse or exacerbation of symptoms. The systematic review has been registered on the web registry Open Science Framework. Results: We divided the results into 4 groups according to mental disorder: schizophrenia (9/29, 31%), mood disorders (15/29, 52%), anxiety disorders (4/29, 14%), and substance use disorder (1/29, 3%). The results for the first 3 groups showed that several features (ie, mobility, location, phone use, call log, heart rate, sleep, head movements, facial and vocal characteristics, sociability, social rhythms, conversations, number of steps, screen on or screen off status, SMS text message logs, peripheral skin temperature, electrodermal activity, light exposure, and physical activity), extracted from data collected via the smartphone and wearable wristbands, can be used to create digital phenotypes that could support gold-standard assessment and could be used to predict relapse or symptom exacerbations. Conclusions: Thus, as the data were consistent for almost all the mental disorders considered (mood disorders, anxiety disorders, and schizophrenia), the feasibility of this approach was confirmed. In the future, a new model of health care management using digital devices should be integrated with the digital phenotyping approach and tailored mobile interventions (managing crises during relapse or exacerbation). %M 38090800 %R 10.2196/46778 %U https://www.jmir.org/2023/1/e46778 %U https://doi.org/10.2196/46778 %U http://www.ncbi.nlm.nih.gov/pubmed/38090800 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51423 %T User-Centered Design of a Gamified Mental Health App for Adolescents in Sub-Saharan Africa: Multicycle Usability Testing Study %A Pozuelo,Julia R %A Moffett,Bianca D %A Davis,Meghan %A Stein,Alan %A Cohen,Halley %A Craske,Michelle G %A Maritze,Meriam %A Makhubela,Princess %A Nabulumba,Christine %A Sikoti,Doreen %A Kahn,Kathleen %A Sodi,Tholene %A , %A van Heerden,Alastair %A O’Mahen,Heather A %+ Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, 641 Huntington Avenue, Boston, MA, 02115, United States, 1 617 432 1707, julia_ruizpozuelo@hms.harvard.edu %K depression %K adolescents %K mental health app %K behavioral activation %K user-centered design %K low- and middle-income countries %K mobile phone %D 2023 %7 30.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa. Objective: This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing. Methods: An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development. Results: A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules (“episodes”) played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement. Conclusions: The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention’s feasibility, acceptability, and efficacy in reducing depressive symptoms. %M 38032691 %R 10.2196/51423 %U https://formative.jmir.org/2023/1/e51423 %U https://doi.org/10.2196/51423 %U http://www.ncbi.nlm.nih.gov/pubmed/38032691 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e51459 %T Effectiveness of Technology-Based Interventions for School-Age Children With Attention-Deficit/Hyperactivity Disorder: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Wong,Ka Po %A Qin,Jing %A Xie,Yao Jie %A Zhang,Bohan %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, 11 Yuk Choi Road, Hong Kong, China (Hong Kong), 852 64860214, portia.wong@polyu.edu.hk %K attention-deficit/hyperactivity disorder %K school-age children %K computer-assisted training program %K ADHD %K neurofeedback training %K virtual reality %K cognitive functions %D 2023 %7 21.11.2023 %9 Review %J JMIR Ment Health %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is relatively common among school-age children. Technology-based interventions, such as computer-assisted training programs, neurofeedback training, and virtual reality, show promise in regulating the behaviors and cognitive functions of children with ADHD. An increasing number of randomized controlled trials have been conducted to evaluate the effectiveness of these technologies in improving the conditions of children with ADHD. Objective: This study aims to conduct a systematic review of technological interventions for school-age children with ADHD and perform a meta-analysis of the outcomes of technology-based interventions. Methods: A total of 19 randomized controlled studies involving 1843 participants were selected from a pool of 2404 articles across 7 electronic databases spanning from their inception to April 2022. ADHD behaviors, cognitive functions, learning ability, and quality of life were addressed in this study. Results: Random effects meta-analyses found that children with ADHD receiving technology-based intervention showed small and significant effect sizes in computer-rated inattention (standardized mean difference [SMD] −0.35; P<.04), parent-rated overall executive function measured by the Behavior Rating Inventory of Executive Function (SMD −0.35; P<.04), parent-rated disruptive behavior disorder measured by the Child Behavior Checklist (SMD −0.50; P<.001) and Disruptive Behavior Disorder Rating Scale (SMD −0.31; P<.02), and computer-rated visual attention measured by the Continuous Performance Test (SMD −0.42; P<.001) and Reaction Time (SMD −0.43; P<.02). Conclusions: Technology-based interventions are promising treatments for improving certain ADHD behaviors and cognitive functions among school-age children with ADHD. Trial Registration: PROSPERO CRD42023446924; https://tinyurl.com/7ee5t24n %M 37988139 %R 10.2196/51459 %U https://mental.jmir.org/2023/1/e51459 %U https://doi.org/10.2196/51459 %U http://www.ncbi.nlm.nih.gov/pubmed/37988139 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e48821 %T Usability of the Experience Sampling Method in Specialized Mental Health Care: Pilot Evaluation Study %A Weermeijer,Jeroen Dennis Merlijn %A Wampers,Martien %A de Thurah,Lena %A Bonnier,Rafaël %A Piot,Maarten %A Kuppens,Peter %A Myin-Germeys,Inez %A Kiekens,Glenn %+ Center for Contextual Psychiatry, KU Leuven, Herestraat 49 ON5B bus 1029, Leuven, 3000, Belgium, 32 16 32 72 27, jeroen.weermeijer@kuleuven.be %K experience sampling %K ecological momentary assessment %K implementation %K digital mental health %K mobile phone %D 2023 %7 21.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health problems occur in interactions in daily life. Yet, it is challenging to bring contextual information into the therapy room. The experience sampling method (ESM) may facilitate this by assessing clients’ thoughts, feelings, symptoms, and behaviors as they are experienced in everyday life. However, the ESM is still primarily used in research settings, with little uptake in clinical practice. One aspect that may facilitate clinical implementation concerns the use of ESM protocols, which involves providing practitioners with ready-to-use ESM questionnaires, sampling schemes, visualizations, and training. Objective: This pilot study’s objective was to evaluate the usability of an ESM protocol for using the ESM in a specialized mental health care setting. Methods: We created the ESM protocol using the m-Path software platform and tested its usability in clinical practice. The ESM protocol consists of a dashboard for practitioners (ie, including the setup of the template and data visualizations) and an app for clients (ie, for completing the ESM questionnaires). A total of 8 practitioners and 17 clients used the ESM in practice between December 1, 2020, and July 31, 2021. Usability was assessed using questionnaires, ESM compliance rates, and semistructured interviews. Results: The usability was overall rated reasonable to good by practitioners (mean scores of usability items ranging from 5.33, SD 0.91, to 6.06, SD 0.73, on a scale ranging from 1 to 7). However, practitioners expressed difficulty in personalizing the template and reported insufficient guidelines on how to use the ESM in clinical practice. On average, clients completed 55% (SD 25%) of the ESM questionnaires. They rated the usability as reasonable to good, but their scores were slightly lower and more variable than those of the practitioners (mean scores of usability items ranging from 4.18, SD 1.70, to 5.94, SD 1.50 on a scale ranging from 1 to 7). Clients also voiced several concerns over the piloted ESM template, with some indicating no interest in the continued use of the ESM. Conclusions: The findings suggest that using an ESM protocol may facilitate the implementation of the ESM as a mobile health assessment tool in psychiatry. However, additional adaptions should be made before further implementation. Adaptions include providing training on personalizing questionnaires, adding additional sampling scheme formats as well as an open-text field, and creating a dynamic data visualization interface. Future studies should also identify factors determining the suitability of the ESM for specific treatment goals among different client populations. %M 37988137 %R 10.2196/48821 %U https://formative.jmir.org/2023/1/e48821 %U https://doi.org/10.2196/48821 %U http://www.ncbi.nlm.nih.gov/pubmed/37988137 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51334 %T mHealth Intervention to Promote Physical Activity Among Employees Using a Deep Learning Model for Passive Monitoring of Depression and Anxiety: Single-Arm Feasibility Trial %A Watanabe,Kazuhiro %A Okusa,Shoichi %A Sato,Mitsuhiro %A Miura,Hideki %A Morimoto,Masahiro %A Tsutsumi,Akizumi %+ Department of Public Health, Kitasato University School of Medicine, 1-15-1 Kitazato, Minami-ku, Sagamihara, 252-0374, Japan, 81 427789352, kzwatanabe-tky@umin.ac.jp %K eHealth %K behavioral change %K mobile phone %K smartphone %K mHealth %K mobile health %K app %K apps %K applications %K monitor %K monitoring %K physical activity %K exercise %K fitness %K application %K workplace %K distress %K depression %K depressive %K anxiety %K mental health %K worker %K workers %K employee %K employees %K occupational health %K satisfaction %K feasibility %K acceptability %D 2023 %7 17.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Physical activity effectively prevents depression and anxiety. Although mobile health (mHealth) technologies offer promising results in promoting physical activity and improving mental health, conflicting evidence exists on their effectiveness, and employees face barriers to using mHealth services. To address these problems, we recently developed a smartphone app named ASHARE to prevent depression and anxiety in the working population; it uses a deep learning model for passive monitoring of depression and anxiety from information about physical activity. Objective: This study aimed to preliminarily investigate (1) the effectiveness of the developed app in improving physical activity and reducing depression and anxiety and (2) the app’s implementation outcomes (ie, its acceptability, appropriateness, feasibility, satisfaction, and potential harm). Methods: We conducted a single-arm interventional study. From March to April 2023, employees aged ≥18 years who were not absent were recruited. The participants were asked to install and use the app for 1 month. The ideal usage of the app was for the participants to take about 5 minutes every day to open the app, check the physical activity patterns and results of an estimated score of psychological distress, and increase their physical activity. Self-reported physical activity (using the Global Physical Activity Questionnaire, version 2) and psychological distress (using the 6-item Kessler Psychological Distress Scale) were measured at baseline and after 1 month. The duration of physical activity was also recorded digitally. Paired t tests (two-tailed) and chi-square tests were performed to evaluate changes in these variables. Implementation Outcome Scales for Digital Mental Health were also measured for acceptability, appropriateness, feasibility, satisfaction, and harm. These average scores were assessed by comparing them with those reported in previous studies. Results: This study included 24 employees. On average, the app was used for 12.54 days (44.8% of this study’s period). After using the app, no significant change was observed in physical activity (–12.59 metabolic equivalent hours per week, P=.31) or psychological distress (–0.43 metabolic equivalent hours per week, P=.93). However, the number of participants with severe psychological distress decreased significantly (P=.01). The digitally recorded duration of physical activity increased during the intervention period (+0.60 minutes per day, P=.08). The scores for acceptability, appropriateness, and satisfaction were lower than those in previous mHealth studies, whereas those for feasibility and harm were better. Conclusions: The ASHARE app was insufficient in promoting physical activity or improving psychological distress. At this stage, the app has many issues that are to be addressed in terms of both implementation and effectiveness. The main reason for this low effectiveness might be the poor evaluation of the implementation outcomes by app users. Improving acceptability, appropriateness, and satisfaction are identified as key issues to be addressed in future implementation. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000050430; https://tinyurl.com/mrx5ntcmrecptno=R000057438 %M 37976094 %R 10.2196/51334 %U https://formative.jmir.org/2023/1/e51334 %U https://doi.org/10.2196/51334 %U http://www.ncbi.nlm.nih.gov/pubmed/37976094 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e50643 %T Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project %A Shin,Hwayeon Danielle %A Zaheer,Juveria %A Torous,John %A Strudwick,Gillian %+ Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 9022922836, hdanielle.shin@mail.utoronto.ca %K implementation science %K suicide prevention %K eHealth %K mental health %K health informatics %K integrated knowledge translation %K co-design %K research protocol %K mobile phone %D 2023 %7 9.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization. Objective: The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians’ perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2). Methods: We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1. Results: This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway. Conclusions: Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians’ behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature. International Registered Report Identifier (IRRID): PRR1-10.2196/50643 %M 37943582 %R 10.2196/50643 %U https://www.researchprotocols.org/2023/1/e50643 %U https://doi.org/10.2196/50643 %U http://www.ncbi.nlm.nih.gov/pubmed/37943582 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44469 %T Cultural Adaptation of the Actionable Health App Evaluation in Japan: Protocol for a Web-Based Modified Delphi Expert Consensus Study %A Yokomitsu,Kengo %A Takashina,Hikari N %A Takebayashi,Yoshitake %A Muranaka,Seiji %+ School of Psychological Sciences, University of Human Environments, 9-12, Dogo-himata, Matsuyama, Ehime, 790-0825, Japan, 81 89 926 7007, yokomitsuken5@gmail.com %K mobile %K eHealth %K mHealth apps %K mobile health %K modified Delphi study %K Japan %D 2023 %7 3.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: With an increase in both the number of mental health disorders people are experiencing and the difficulty in accessing mental health care, the demand for accessible mental health care services has increased. The use of mobile devices has allowed people to receive care in their daily lives without restrictions on time or location. However, the majority of publicly available mobile health apps are not evidence-based, and the top-rated apps are not always safe or user-friendly and may not offer clinically beneficial results. Objective: This study aims to create a cultural adaptation of the American Psychiatric Association’s comprehensive app evaluation framework in Japan using a web-based modified Delphi expert consensus. Methods: A web-based modified Delphi study includes developing the Japanese version of the comprehensive app evaluation framework and 3 Delphi rounds. In the first round, our working group sends a questionnaire to the panelists, who then complete it. In the second and third rounds, the working group sends a questionnaire and a summary of the panelists’ answers based on each of the previous rounds. The panelists answer the questionnaires based on this summary. The summarization procedure is automated to help reduce the biases that can be generated when panelists’ answers are summarized and when the panelists receive them. The working group sends only the result of the summarization with the next round’s questionnaire. All interactions between the working group and the panelists will be conducted on Qualtrics (Qualtrics Japan LLC), a questionnaire platform. To culturally validate the comprehensive mental health app evaluation framework, participants from the following three categories will be recruited in Japan: (1) researchers, (2) practitioners, and (3) app developers. Results: This study received funding from a crowdfunding campaign in Japan (April 2023). The Delphi study began in January 2023 and will be completed in December 2023. We had already completed the translation of the 105 original app evaluation item questions by December 2022. Conclusions: While the need for treatment using mental health apps is increasing, no framework that can be used to develop a centralized database for health apps is available or accessible, and no consensus has been reached among stakeholders in Japan about an appropriate framework. The results of the web-based modified Delphi method presented in this paper may provide direction for the development and use of mental health apps in the future among the relevant stakeholders. Furthermore, this study will enhance recognition of the framework among researchers, clinicians, mental health app developers, and users, in addition to devising new instruments to help users or practitioners efficiently choose the right app for their situations. International Registered Report Identifier (IRRID): PRR1-10.2196/44469 %M 37921839 %R 10.2196/44469 %U https://www.researchprotocols.org/2023/1/e44469 %U https://doi.org/10.2196/44469 %U http://www.ncbi.nlm.nih.gov/pubmed/37921839 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48112 %T Participants’ Engagement With and Results From a Web-Based Integrative Population Mental Wellness Program (CHAMindWell) During the COVID-19 Pandemic: Program Evaluation Study %A Rosansky,Joseph A %A Okst,Kayley %A Tepper,Miriam C %A Baumgart Schreck,Ana %A Fulwiler,Carl %A Wang,Philip S %A Schuman-Olivier,Zev %+ Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA, 02139, United States, 1 617 591 6132, zschuman@cha.harvard.edu %K COVID-19 pandemic %K digital psychiatry %K early identification %K integrative medicine %K mental wellness %K mindfulness %K population mental health %K prevention %K stratified care %D 2023 %7 26.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic involved a prolonged period of collective trauma and stress during which substantial increases in mental health concerns, like depression and anxiety, were observed across the population. In this context, CHAMindWell was developed as a web-based intervention to improve resilience and reduce symptom severity among a public health care system’s patient population. Objective: This program evaluation was conducted to explore participants’ engagement with and outcomes from CHAMindWell by retrospectively examining demographic information and mental health symptom severity scores throughout program participation. Methods: We examined participants’ symptom severity scores from repeated, web-based symptom screenings through Computerized Adaptive Testing for Mental Health (CAT-MH) surveys, and categorized participants into symptom severity-based tiers (tier 1=asymptomatic to mild; tier 2=moderate; and tier 3=severe). Participants were provided tier-based mindfulness resources, treatment recommendations, and referrals. Logistic regressions were conducted to evaluate associations between demographic variables and survey completion. The McNemar exact test and paired sample t tests were performed to evaluate changes in the numbers of participants in tier 1 versus tier 2 or 3 and changes in depression, anxiety, and posttraumatic stress disorder severity scores between baseline and follow-up. Results: The program enrolled 903 participants (664/903, 73.5% female; 556/903, 61.6% White; 113/903, 12.5% Black; 84/903, 9.3% Asian; 7/903, 0.8% Native; 36/903, 4% other; and 227/903, 25.1% Hispanic) between December 16, 2020, and March 17, 2022. Of those, 623 (69%) completed a baseline CAT-MH survey, and 196 completed at least one follow-up survey 3 to 6 months after baseline. White racial identity was associated with completing baseline CAT-MH (odds ratio [OR] 1.80, 95% CI 1.14-2.84; P=.01). Participants’ odds of having symptom severity below the clinical threshold (ie, tier 1) were significantly greater at follow-up (OR 2.60, 95% CI 1.40-5.08; P=.001), and significant reductions were observed across symptom domains over time. Conclusions: CHAMindWell is associated with reduced severity of mental health symptoms. Future work should aim to address program engagement inequities and attrition and compare the impacts of CHAMindWell to a control condition to better characterize its effects. %M 37883149 %R 10.2196/48112 %U https://mental.jmir.org/2023/1/e48112 %U https://doi.org/10.2196/48112 %U http://www.ncbi.nlm.nih.gov/pubmed/37883149 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e48365 %T Real-World User Demographics of Three Web-Based Digital Mental Health Interventions Provided by the US Department of Veterans Affairs: Observational Study Using Web Analytics Data %A Ryan,Arthur T %A Stearns-Yoder,Kelly A %A Brenner,Lisa A %+ Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling St, G-3-116M, Aurora, CO, 80045, United States, 1 720 723 7493, arthur.t.ryan@gmail.com %K digital intervention %K unguided %K web-based %K internet-delivered %K mental health %K veterans %K Google Analytics %K insomnia %K anger %K depression %K mobile phone %D 2023 %7 18.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively. Objective: This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population. Methods: Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported. Results: In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI’s age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users. Conclusions: Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers. %M 37851501 %R 10.2196/48365 %U https://formative.jmir.org/2023/1/e48365 %U https://doi.org/10.2196/48365 %U http://www.ncbi.nlm.nih.gov/pubmed/37851501 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47903 %T Enhancing Mental Health and Medication Adherence Among Men Who Have Sex With Men Recently Diagnosed With HIV With a Dialectical Behavior Therapy–Informed Intervention Incorporating mHealth, Online Skills Training, and Phone Coaching: Development Study Using Human-Centered Design Approach %A Wang,Liying %A Yuwen,Weichao %A Hua,Wenzhe %A Chen,Lingxiao %A Forsythe Cox,Vibh %A Zheng,Huang %A Ning,Zhen %A Zhao,Zhuojun %A Liu,Zhaoyu %A Jiang,Yunzhang %A Li,Xinran %A Guo,Yawen %A Simoni,Jane M %+ Department of Psychology, University of Washington, 3921 W Stevens Way NE, Seattle, WA, 98195, United States, 1 (206) 543 2640, liyingw@uw.edu %K intervention mapping %K participatory approach %K cultural adaptation %K dialectical behavior therapy %K DBT %K men who have sex with men %K MSM %K coping skill training %D 2023 %7 13.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health problems are common among men who have sex with men (MSM) living with HIV and may negatively affect medication adherence. Psychosocial interventions designed to address these urgent needs are scarce in China. Incorporating behavioral health theories into intervention development strengthens the effectiveness of these interventions. The absence of a robust theoretical basis for interventions may also present challenges to identify active intervention ingredients. Objective: This study aims to systematically describe the development of a mobile health–based intervention for MSM recently diagnosed with HIV in China, including the theoretical basis for the content and the considerations for its technological delivery. Methods: We used intervention mapping (IM) to guide overall intervention development, a behavioral intervention technology model for technological delivery design, and a human-centered design and cultural adaptation model for intervention tailoring throughout all steps of IM. Results: The dialectical behavior therapy (DBT)–informed intervention, Turning to Sunshine, comprised 3 components: app-based individual skills learning, group-based skills training, and on-demand phone coaching. The theoretical basis for the intervention content is based on the DBT model of emotions, which fits our conceptualization of the intervention user’s mental health needs. The intervention aims to help MSM recently diagnosed with HIV (1) survive moments of high emotional intensity and strong action urges, (2) change emotional expression to regulate emotions, and (3) reduce emotional vulnerability, as well as (4) augment community resources for mental health services. Technological delivery considerations included rationale of the medium, complexity, and esthetics of information delivery; data logs; data visualization; notifications; and passive data collection. Conclusions: This study laid out the steps for the development of a DBT-informed mobile health intervention that integrated app-based individual learning, group-based skills training, and phone coaching. This intervention, Turning to Sunshine, aims to improve mental health outcomes for MSM newly diagnosed with HIV in China. The IM framework informed by human-centered design principles and cultural adaptation considerations offered a systematic approach to develop the current intervention and tailor it to the target intervention users. The behavioral intervention technology model facilitated the translation of behavioral intervention strategies into technological delivery components. The systematic development and reporting of the current intervention can serve as a guide for similar intervention studies. The content of the current intervention could be adapted for a broader population with similar emotional struggles to improve their mental health outcomes. %M 37831497 %R 10.2196/47903 %U https://formative.jmir.org/2023/1/e47903 %U https://doi.org/10.2196/47903 %U http://www.ncbi.nlm.nih.gov/pubmed/37831497 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48843 %T Patient Experience of Digitalized Follow-up of Antidepressant Treatment in Psychiatric Outpatient Care: Qualitative Analysis %A Hamlin,Matilda %A Holmén,Joacim %A Wentz,Elisabet %A Aiff,Harald %A Ali,Lilas %A Steingrimsson,Steinn %+ Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Universitetsplatsen 1, Gothenburg, 405 30, Sweden, 46 31786 00 00, steinn.steingrimsson@vgregion.se %K major depressive disorder %K digital psychiatry %K mobile app %K adherence %K antidepressant %K antidepressants %K depressive %K depression %K mHealth %K mobile health %K app %K apps %K application %K applications %K experience %K interview %K interviews %K medication %K prescribe %K prescription %K dose %D 2023 %7 11.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Nonadherence to pharmaceutical antidepressant treatment is common among patients with depression. Digitalized follow-up (ie, self-monitoring systems through mobile apps) has been suggested as an effective adjunct to conventional antidepressant treatment to increase medical adherence, improve symptoms of depression, and reduce health care resource use. Objective: The aim of this study was to determine patients’ experience of digitalized follow-up using a mobile app as an adjunct to treatment concurrent with a new prescription, a change of antidepressant, or a dose increase. Methods: This was a qualitative, descriptive study. Patients at 2 psychiatric outpatient clinics were recruited at the time of changing antidepressant medication. After using a mobile app (either a commercial app or a public app) for 4-6 weeks with daily registrations of active data, such as medical intake and questions concerning general mental health status, individual semistructured interviews were conducted. Recorded data were transcribed and then analyzed using content analysis. Results: In total, 13 patients completed the study. The mean age was 35 (range 20-67) years, 8 (61.5%) were female, and all reported high digital literacy. Overall, the emerging themes indicated that the patients found the digital app to be a valuable adjunct to antidepressant treatment but with potential for improvement. Both user adherence and medical adherence were positively affected by a daily reminder and the app’s ease of use. User adherence was negatively affected by the severity of depression. The positive experience of visually presented data as graphs was a key finding, which was beneficial for self-awareness, the patient-physician relationship, and user adherence. Finally, the patients had mixed reactions to the app’s content and requested tailored content. Conclusions: The patients identified several factors addressing both medical adherence and user adherence to a digital app when using it for digitalized follow-up concurrent with the critical time related to changes in antidepressant medication. The findings highlight the need for rigorous evidence-based empirical studies to generate sustainable research results. %M 37819697 %R 10.2196/48843 %U https://mental.jmir.org/2023/1/e48843 %U https://doi.org/10.2196/48843 %U http://www.ncbi.nlm.nih.gov/pubmed/37819697 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46473 %T Engagement, Satisfaction, and Mental Health Outcomes Across Different Residential Subgroup Users of a Digital Mental Health Relational Agent: Exploratory Single-Arm Study %A Forman-Hoffman,Valerie L %A Pirner,Maddison C %A Flom,Megan %A Kirvin-Quamme,Andrew %A Durden,Emily %A Kissinger,Jennifer A %A Robinson,Athena %+ Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, United States, 1 415 273 9742, valerie_hoffman@woebothealth.com %K adoption %K anxiety %K chatbot %K cognitive behavioral therapy %K conversational agent %K CBT %K depression %K digital health %K medically underserved area %K mental health %K mhealth %K mobile app %K mobile health %K mobile phone %K mood %K psychotherapy %K relational agent %K rural %K satisfaction %K smartphone app %K smartphone %K underserved %K usage %K vulnerable %D 2023 %7 27.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental illness is a pervasive worldwide public health issue. Residentially vulnerable populations, such as those living in rural medically underserved areas (MUAs) or mental health provider shortage areas (MHPSAs), face unique access barriers to mental health care. Despite the growth of digital mental health interventions using relational agent technology, little is known about their use patterns, efficacy, and favorability among residentially vulnerable populations. Objective: This study aimed to explore differences in app use, therapeutic alliance, mental health outcomes, and satisfaction across residential subgroups (metropolitan, nonmetropolitan, or rural), MUAs (yes or no), and MHPSAs (yes or no) among users of a smartphone-based, digital mental health intervention, Woebot LIFE (WB-LIFE). WB-LIFE was designed to help users better understand and manage their moods and features a relational agent, Woebot, that converses through text-based messages. Methods: We used an exploratory study that examined data from 255 adults enrolled in an 8-week, single-arm trial of WB-LIFE. Analyses compared levels of app use and therapeutic alliance total scores as well as subscales (goal, task, and bond), mental health outcomes (depressive and anxiety symptoms, stress, resilience, and burnout), and program satisfaction across residential subgroups. Results: Few study participants resided in nonmetropolitan (25/255, 10%) or rural (3/255, 1%) areas, precluding estimates across this variable. Despite a largely metropolitan sample, nearly 39% (99/255) resided in an MUA and 55% (141/255) in an MHPSA. There were no significant differences in app use or satisfaction by MUA or MHPSA status. There also were no differences in depressive symptoms, anxiety, stress, resilience, or burnout, with the exception of MUA participants having higher baseline depressive symptoms among those starting in the moderate range or higher (Patient Health Questionnaire-8 item scale≥10) than non-MUA participants (mean 16.50 vs 14.41, respectively; P=.01). Although working alliance scores did not differ by MHPSA status, those who resided in an MUA had higher goal (2-tailed t203.47=2.21; P=.03), and bond (t203.47=1.94; P=.05) scores at day 3 (t192.98=2.15; P=.03), and higher goal scores at week 8 (t186.19=2.28; P=.02) as compared with those not living in an MUA. Conclusions: Despite the study not recruiting many participants from rural or nonmetropolitan populations, sizable proportions resided in an MUA or an MHPSA. Analyses revealed few differences in app use, therapeutic alliance, mental health outcomes (including baseline levels), or satisfaction across MUA or MHPSA status over the 8-week study. Findings suggest that vulnerable residential populations may benefit from using digital agent–guided cognitive behavioral therapy. Trial Registration: ClinicalTrials.gov NCT05672745; https://clinicaltrials.gov/study/NCT05672745 %M 37756047 %R 10.2196/46473 %U https://formative.jmir.org/2023/1/e46473 %U https://doi.org/10.2196/46473 %U http://www.ncbi.nlm.nih.gov/pubmed/37756047 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e49684 %T Exploring User Perspectives of and Ethical Experiences With Teletherapy Apps: Qualitative Analysis of User Reviews %A Jo,Eunkyung %A Kouaho,Whitney-Jocelyn %A Schueller,Stephen M %A Epstein,Daniel A %+ Department of Informatics, University of California, 6093 Donald Bren Hall, Irvine, CA, 92697, United States, 1 949 824 4197, epstein@ics.uci.edu %K teletherapy %K therapy %K ethical guidelines %K ethics %K qualitative research %K digital mental health %K mobile phone %D 2023 %7 22.9.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Teletherapy apps have emerged as a promising alternative to traditional in-person therapy, especially after the COVID-19 pandemic, as they help overcome a range of geographical and emotional barriers to accessing care. However, the rapid proliferation of teletherapy apps has occurred in an environment in which development has outpaced the various regulatory and ethical considerations of this space. Thus, researchers have raised concerns about the ethical implications and potential risks of teletherapy apps given the lack of regulation and oversight. Teletherapy apps have distinct aims to more directly replicate practices of traditional care, as opposed to mental health apps, which primarily provide supplemental support, suggesting a need to examine the ethical considerations of teletherapy apps from the lens of existing ethical guidelines for providing therapy. Objective: In this study, we examined user reviews of commercial teletherapy apps to understand user perceptions of whether and how ethical principles are followed and incorporated. Methods: We identified 8 mobile apps that (1) provided teletherapy on 2 dominant mobile app stores (Google Play and Apple App Store) and (2) had received >5000 app reviews on both app stores. We wrote Python scripts (Python Software Foundation) to scrape user reviews from the 8 apps, collecting 3268 user reviews combined across 2 app stores. We used thematic analysis to qualitatively analyze user reviews, developing a codebook drawing from the ethical codes of conduct for psychologists, psychiatrists, and social workers. Results: The qualitative analysis of user reviews revealed the ethical concerns and opportunities of teletherapy app users. Users frequently perceived unprofessionalism in their teletherapists, mentioning that their therapists did not listen to them, were distracted during therapy sessions, and did not keep their appointments. Users also noted technical glitches and therapist unavailability on teletherapy apps that might affect their ability to provide continuity of care. Users held varied opinions on the affordability of those apps, with some perceiving them as affordable and others not. Users further brought up that the subscription model resulted in unfair pricing and expressed concerns about the lack of cost transparency. Users perceived that these apps could help promote access to care by overcoming geographical and social constraints. Conclusions: Our study suggests that users perceive commercial teletherapy apps as adhering to many ethical principles pertaining to therapy but falling short in key areas regarding professionalism, continuity of care, cost fairness, and cost transparency. Our findings suggest that, to provide high-quality care, teletherapy apps should prioritize fair compensation for therapists, develop more flexible and transparent payment models, and invest in measures to ensure app stability and therapist availability. Future work is needed to develop standards for teletherapy and improve the quality and accessibility of those services. %M 37738085 %R 10.2196/49684 %U https://mental.jmir.org/2023/1/e49684 %U https://doi.org/10.2196/49684 %U http://www.ncbi.nlm.nih.gov/pubmed/37738085 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42541 %T Evaluating the Effectiveness of Apps Designed to Reduce Mobile Phone Use and Prevent Maladaptive Mobile Phone Use: Multimethod Study %A Rahmillah,Fety Ilma %A Tariq,Amina %A King,Mark %A Oviedo-Trespalacios,Oscar %+ Faculty of Technology, Policy and Management, Delft University of Technology, Jaffalaan 5, Delft, 2628 BX, Netherlands, 31 15 2783887, O.OviedoTrespalacios@tudelft.nl %K mobile phone %K maladaptive mobile phone use %K apps %K features %K problematic phone use %D 2023 %7 29.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps are a popular strategy for reducing mobile phone use and preventing maladaptive mobile phone use (MMPU). Previous research efforts have been made to understand the features of apps that have the potential to reduce mobile phone use and MMPU. However, there has been a lack of a comprehensive examination of the effectiveness of such apps and their features. Objective: This paper investigated existing apps designed to reduce mobile phone use and prevent MMPU and examined the evidence of their effectiveness. The research aimed to provide a comprehensive analysis of app features that can reduce mobile phone use and MMPU, while also assessing their effectiveness. In addition, we explored users’ perceptions of these apps and the various features the apps offer to understand potential adoption issues and identify opportunities. Methods: This study used 3 methods: a review of scientific evidence, content analysis, and sentiment analysis. Results: Our study comprehensively examine the common features of 13 apps designed to reduce mobile phone use. We extracted and classified the features into 7 types: self-tracking, social tracking, goal setting, blocking, gamification, simplification, and assessment. The effectiveness of these apps in reducing mobile phone use and MMPU varied from weak to strong. On the basis of content analysis, self-tracking and goal setting were the most frequently used features, whereas gamification and assessment were used the least frequently. The intervention strategies that effectively reduce mobile phone use and MMPU included using grayscale mode, app limit features, and mixed interventions. Overall, users tended to accept these apps, as indicated by sentiment scores ranging from 61 to 86 out of 100. Conclusions: This study demonstrates that app-based management has the potential to reduce mobile phone use and MMPU. However, further research is required to evaluate the effectiveness of app-based interventions. Collaborations among researchers, app developers, mobile phone manufacturers, and policy makers could enhance the process of delivering, evaluating, and optimizing apps aimed at reducing mobile phone use and MMPU. %M 37643002 %R 10.2196/42541 %U https://www.jmir.org/2023/1/e42541 %U https://doi.org/10.2196/42541 %U http://www.ncbi.nlm.nih.gov/pubmed/37643002 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e46508 %T Evaluating a Smartphone App (MeT4VeT) to Support the Mental Health of UK Armed Forces Veterans: Feasibility Randomized Controlled Trial %A Parkes,Steven %A Croak,Bethany %A Brooks,Samantha K %A Stevelink,Sharon A M %A Leightley,Daniel %A Fear,Nicola T %A Rafferty,Laura %A Greenberg,Neil %+ King’s Centre for Military Health Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, 10 Cutcombe Road, London, SE5 9RJ, United Kingdom, 44 0207848 ext 5335, steven.j.parkes@kcl.ac.uk %K military %K veteran %K mental health %K military to civilian transition %K digital health %K mobile apps %K smartphone %K mobile phone %K mobile health %K mHealth %K digital intervention %K support %K app %K feasibility %K acceptability %K engagement %K usability %D 2023 %7 28.8.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support. Objective: A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app. Methods: Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention. Results: In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health. Conclusions: The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial. Trial Registration: ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676 %M 37639295 %R 10.2196/46508 %U https://mental.jmir.org/2023/1/e46508 %U https://doi.org/10.2196/46508 %U http://www.ncbi.nlm.nih.gov/pubmed/37639295 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e47220 %T Developing A Mobile App With a Human-Centered Design Lens to Improve Access to Mental Health Care (Mentallys Project): Protocol for an Initial Co-Design Process %A Vial,Stéphane %A Boudhraâ,Sana %A Dumont,Mathieu %A Tremblay,Melanie %A Riendeau,Sophie %+ Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, École de Design, Université du Québec à Montréal, 1440 rue Sanguinet, Montréal, QC, H2X 3X9, Canada, 1 514 987 3000 ext 3919, vial.stephane@uqam.ca %K co-design %K human-centered design %K e-mental health %K design expertise %K user engagement %K patient-centered design %K imaginary prototype %D 2023 %7 22.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Co-design is one of the human-centered design approaches that allows end users to significantly and positively impact the design of mental health technologies. It is a promising approach to foster user acceptance and engagement in digital mental health solutions. Surprisingly, there is a lack of understanding of what co-design is in this field. In this paper, co-design is approached as a cocreation process involving persons with a lived experience of mental health problems, health professionals, and design experts who lead and facilitate the overall creative process. Objective: This paper describes an initial co-design research protocol for the development of a mobile app that aims to improve access to mental health care. It highlights the characteristics of a co-design approach in e–mental health rooted in human-centered design and led by design experts alongside health experts. The paper focuses on the first steps (phase 1) of the co-design process of the ongoing Mentallys project. Methods: This Mentallys project will be located in Montréal (Quebec, Canada). The method approach will be based on the “method stories,” depicting the “making of” this project and reflecting adjustments needed to the protocol throughout the project in specific situations. Phase 1 of the process will focus on the desirability of the app. Targeted participants will include people with a lived experience of mental health problems, peer support workers and clinicians, and 3 facilitators (all design experts or researchers). Web-based sessions will be organized because of the COVID-19 pandemic, using Miro (RealtimeBoard Inc) and Zoom (Zoom Video Communications, Inc). Data collection will be based on the comments, thoughts, and new ideas of participants around the imaginary prototypes. Thematic analysis will be carried out after each session to inform a new version of the prototype. Results: We conducted 2 stages in phase 1 of the process. During stage 1, we explored ideas through group co-design workshops (divergent thinking). Six co-design workshops were held: 2 with only clinicians (n=7), 2 with peer support workers (n=5) and people with a lived experience of mental health problems (n=2), and 2 with all of them (n=14). A total of 6 facilitators participated in conducting activities in subgroups. During stage 2, ideas were refined through 10 dyad co-design sessions (convergent thinking). Stage 2 involved 3 participants (n=3) and 1 facilitator. Thematic analysis was performed after stage 1, while analytic questioning is being performed for stage 2. Both stages allowed several iterations of the prototypes. Conclusions: The design of the co-design process, the leadership of the design expertise throughout the process, and the different forms of co-design activities are key elements in this project. We highly recommend that health researchers partner with professional designers or design researchers who are familiar with co-design. International Registered Report Identifier (IRRID): DERR1-10.2196/47220 %M 37606978 %R 10.2196/47220 %U https://www.researchprotocols.org/2023/1/e47220 %U https://doi.org/10.2196/47220 %U http://www.ncbi.nlm.nih.gov/pubmed/37606978 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47380 %T Understanding Mental Health Clinicians’ Perceptions and Concerns Regarding Using Passive Patient-Generated Health Data for Clinical Decision-Making: Qualitative Semistructured Interview Study %A Nghiem,Jodie %A Adler,Daniel A %A Estrin,Deborah %A Livesey,Cecilia %A Choudhury,Tanzeem %+ College of Computing and Information Science, Cornell Tech, 2 W Loop Rd, New York, NY, 10044, United States, 1 2155953769, daa243@cornell.edu %K digital technology %K clinical decision support %K mobile health %K mHealth %K qualitative research %K mental health %K clinician %K perception %K patient-generated health data %K mobile app %K digital app %K wearables %K mobile phone %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital health-tracking tools are changing mental health care by giving patients the ability to collect passively measured patient-generated health data (PGHD; ie, data collected from connected devices with little to no patient effort). Although there are existing clinical guidelines for how mental health clinicians should use more traditional, active forms of PGHD for clinical decision-making, there is less clarity on how passive PGHD can be used. Objective: We conducted a qualitative study to understand mental health clinicians’ perceptions and concerns regarding the use of technology-enabled, passively collected PGHD for clinical decision-making. Our interviews sought to understand participants’ current experiences with and visions for using passive PGHD. Methods: Mental health clinicians providing outpatient services were recruited to participate in semistructured interviews. Interview recordings were deidentified, transcribed, and qualitatively coded to identify overarching themes. Results: Overall, 12 mental health clinicians (n=11, 92% psychiatrists and n=1, 8% clinical psychologist) were interviewed. We identified 4 overarching themes. First, passive PGHD are patient driven—we found that current passive PGHD use was patient driven, not clinician driven; participating clinicians only considered passive PGHD for clinical decision-making when patients brought passive data to clinical encounters. The second theme was active versus passive data as subjective versus objective data—participants viewed the contrast between active and passive PGHD as a contrast between interpretive data on patients’ mental health and objective information on behavior. Participants believed that prioritizing passive over self-reported, active PGHD would reduce opportunities for patients to reflect upon their mental health, reducing treatment engagement and raising questions about how passive data can best complement active data for clinical decision-making. Third, passive PGHD must be delivered at appropriate times for action—participants were concerned with the real-time nature of passive PGHD; they believed that it would be infeasible to use passive PGHD for real-time patient monitoring outside clinical encounters and more feasible to use passive PGHD during clinical encounters when clinicians can make treatment decisions. The fourth theme was protecting patient privacy—participating clinicians wanted to protect patient privacy within passive PGHD-sharing programs and discussed opportunities to refine data sharing consent to improve transparency surrounding passive PGHD collection and use. Conclusions: Although passive PGHD has the potential to enable more contextualized measurement, this study highlights the need for building and disseminating an evidence base describing how and when passive measures should be used for clinical decision-making. This evidence base should clarify how to use passive data alongside more traditional forms of active PGHD, when clinicians should view passive PGHD to make treatment decisions, and how to protect patient privacy within passive data–sharing programs. Clear evidence would more effectively support the uptake and effective use of these novel tools for both patients and their clinicians. %M 37561561 %R 10.2196/47380 %U https://formative.jmir.org/2023/1/e47380 %U https://doi.org/10.2196/47380 %U http://www.ncbi.nlm.nih.gov/pubmed/37561561 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44323 %T The Influence of Greenspace Exposure on Affect in People With and Those Without Schizophrenia: Exploratory Study %A Kangarloo,Tairmae %A Mote,Jasmine %A Abplanalp,Samuel %A Gold,Alisa %A James,Peter %A Gard,David %A Fulford,Daniel %+ Sargent College of Health and Rehabilitation Sciences, Boston University, 635 Commonwealth Ave, Boston, MA, 02215, United States, 1 6035681431, tairmaek@bu.edu %K greenspace %K mental health %K mobile technology %K affect %K smartphone %K sensing %K schizophrenia %K natural vegetation %K mental health %K exposure %K assessment %K mechanism %D 2023 %7 3.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Exposure to natural vegetation (ie, “greenspace”) is related to beneficial outcomes, including higher positive and lower negative affect, in individuals with and those without mental health concerns. Researchers have yet to examine dynamic associations between greenspace exposure and affect within individuals over time. Smartphone-based ecological momentary assessment (EMA) and passive sensors (eg, GPS, microphone) allow for frequent sampling of data that may reveal potential moment-to-moment mechanisms through which greenspace exposure impacts mental health. Objective: In this study, we examined associations between greenspace exposure and affect (both self-reported and inferred through speech) in people with and those without schizophrenia spectrum disorder (SSD) at the daily level using smartphones. Methods: Twenty people with SSD and 14 healthy controls reported on their current affect 3 times per day over 7 days using smartphone-based EMA. Affect expressed through speech was labeled from ambient audio data collected via the phone’s microphone using Linguistic Inquiry and Word Count (LIWC). Greenspace exposure, defined as the normalized difference vegetation index (NDVI), was quantified based on continuous geo-location data collected from the phone’s GPS. Results: Overall, people with SSD used significantly more positive affect words (P=.04) and fewer anger words (P=.04) than controls. Groups did not significantly differ in mean EMA-reported positive or negative affect, LIWC total word count, or NDVI exposure. Greater greenspace exposure showed small to moderate associations with lower EMA-reported negative affect across groups. In controls, greenspace exposure on a given day was associated with significantly lower EMA-reported anxiety on that day (b=–0.40, P=.03, 95% CI –0.76 to –0.04) but significantly higher use of negative affect words (b=0.66, P<.001, 95% CI 0.29-1.04). There were no significant associations between greenspace exposure and affect at the daily level among participants with SSD. Conclusions: Our findings speak to the utility of passive and active smartphone assessments for identifying potential mechanisms through which greenspace exposure influences mental health. We identified preliminary evidence that greenspace exposure could be associated with improved mental health by reducing experiences of negative affect. Future directions will focus on furthering our understanding of the relationship between greenspace exposure and affect on individuals with and those without SSD. %M 37535418 %R 10.2196/44323 %U https://formative.jmir.org/2023/1/e44323 %U https://doi.org/10.2196/44323 %U http://www.ncbi.nlm.nih.gov/pubmed/37535418 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47285 %T The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: Large-Scale Randomized Controlled Trial %A Litvin,Silja %A Saunders,Rob %A Jefferies,Philip %A Seely,Hayley %A Pössel,Patrick %A Lüttke,Stefan %+ Department Psychologie, Ludwig-Maximilians-Universität, Geschwister-Scholl-Platz 1, München, 80539, Germany, 49 89 21800, silja@psycapps.com %K mobile health %K mHealth %K gamification %K resilience %K randomized controlled trial %K RCT %K mental health %K apps %K mobile health %K mobile game %K mobile games %K serious game %K depression %K anxiety %K university %K college %K student %K students %K controlled trial %K controlled trials %K young adult %K mobile phone %D 2023 %7 21.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: With many digital mental health interventions failing to engage clients for enough time to demonstrate substantive changes to their well-being and with only 2% of all digital solutions on app stores having undergone randomized controlled trials, the rising demand for mental health prevention and early intervention care is not being met. Young adults in particular struggle to find digital well-being apps that suit their needs. Objective: This study explored the effects of eQuoo, an evidence-based mental health game that teaches psychological skills through gamification, on resilience, depression, anxiety, and attrition in a student population. Methods: In total, 1165 students from 180 universities in the United Kingdom participated in a 5-week, 3-armed randomized controlled trial. Participants were randomly allocated into 1 of 3 groups: eQuoo users, users of a treatment-as-usual evidence-based cognitive behavioral health app called Sanvello, and a no-intervention waitlist. The Rugged Resilience Scale, Generalized Anxiety Disorder–7, and Patient Health Questionnaire–8 were administered to all participants at baseline and every 7 days until completion. Results: A repeated measures–ANOVA revealed statistically significant increases in resilience scores in the test group (P<.001) compared with both control groups (Sanvello: P=.10 and waitlist: P=.82) over 5 weeks. The app also significantly decreased anxiety and depression scores (both P<.001). With 64.5% (251/389) adherence, the eQuoo group retained 42% more participants than the control groups. Conclusions: Digital health interventions such as eQuoo are effective, scalable, and low-cost solutions for supporting young adults and are available on all leading mobile platforms. Further investigation could clarify the extent to which specific elements of the eQuoo app (including gamification) led to better outcomes. Trial Registration: German Clinical Trials Register (DRKS) DRKS00027638; https://drks.de/search/en/trial/DRKS00027638 %M 37477955 %R 10.2196/47285 %U https://mental.jmir.org/2023/1/e47285 %U https://doi.org/10.2196/47285 %U http://www.ncbi.nlm.nih.gov/pubmed/37477955 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e39817 %T Dynamic Modelling of Mental Resilience in Young Adults: Protocol for a Longitudinal Observational Study (DynaM-OBS) %A Wackerhagen,Carolin %A Veer,Ilya M %A van Leeuwen,Judith M C %A Reppmann,Zala %A Riepenhausen,Antje %A Bögemann,Sophie A %A Mor,Netali %A Puhlmann,Lara M C %A Uściƚko,Aleksandra %A Zerban,Matthias %A Mituniewicz,Julian %A Lerner,Avigail %A Yuen,Kenneth S L %A Köber,Göran %A Marciniak,Marta A %A Pooseh,Shakoor %A Weermeijer,Jeroen %A Arias-Vásquez,Alejandro %A Binder,Harald %A de Raedt,Walter %A Kleim,Birgit %A Myin-Germeys,Inez %A Roelofs,Karin %A Timmer,Jens %A Tüscher,Oliver %A Hendler,Talma %A Kobylińska,Dorota %A Hermans,Erno J %A Kalisch,Raffael %A Walter,Henrik %+ Research Division of Mind and Brain, Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany, 49 30 450 517 141, henrik.walter@charite.de %K resilience %K stress %K stressor reactivity %K resilience factors %K mental health %K stress disorders %K longitudinal %K prospective %K neuroimaging %K ecological momentary assessment %K mobile phone %D 2023 %7 4.7.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Stress-related mental disorders are highly prevalent and pose a substantial burden on individuals and society. Improving strategies for the prevention and treatment of mental disorders requires a better understanding of their risk and resilience factors. This multicenter study aims to contribute to this endeavor by investigating psychological resilience in healthy but susceptible young adults over 9 months. Resilience is conceptualized in this study as the maintenance of mental health or quick recovery from mental health perturbations upon exposure to stressors, assessed longitudinally via frequent monitoring of stressors and mental health. Objective: This study aims to investigate the factors predicting mental resilience and adaptive processes and mechanisms contributing to mental resilience and to provide a methodological and evidence-based framework for later intervention studies. Methods: In a multicenter setting, across 5 research sites, a sample with a total target size of 250 young male and female adults was assessed longitudinally over 9 months. Participants were included if they reported at least 3 past stressful life events and an elevated level of (internalizing) mental health problems but were not presently affected by any mental disorder other than mild depression. At baseline, sociodemographic, psychological, neuropsychological, structural, and functional brain imaging; salivary cortisol and α-amylase levels; and cardiovascular data were acquired. In a 6-month longitudinal phase 1, stressor exposure, mental health problems, and perceived positive appraisal were monitored biweekly in a web-based environment, while ecological momentary assessments and ecological physiological assessments took place once per month for 1 week, using mobile phones and wristbands. In a subsequent 3-month longitudinal phase 2, web-based monitoring was reduced to once a month, and psychological resilience and risk factors were assessed again at the end of the 9-month period. In addition, samples for genetic, epigenetic, and microbiome analyses were collected at baseline and at months 3 and 6. As an approximation of resilience, an individual stressor reactivity score will be calculated. Using regularized regression methods, network modeling, ordinary differential equations, landmarking methods, and neural net–based methods for imputation and dimension reduction, we will identify the predictors and mechanisms of stressor reactivity and thus be able to identify resilience factors and mechanisms that facilitate adaptation to stressors. Results: Participant inclusion began in October 2020, and data acquisition was completed in June 2022. A total of 249 participants were assessed at baseline, 209 finished longitudinal phase 1, and 153 finished longitudinal phase 2. Conclusions: The Dynamic Modelling of Resilience–Observational Study provides a methodological framework and data set to identify predictors and mechanisms of mental resilience, which are intended to serve as an empirical foundation for future intervention studies. International Registered Report Identifier (IRRID): DERR1-10.2196/39817 %M 37402143 %R 10.2196/39817 %U https://www.researchprotocols.org/2023/1/e39817 %U https://doi.org/10.2196/39817 %U http://www.ncbi.nlm.nih.gov/pubmed/37402143 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46179 %T m-RESIST, a Mobile Therapeutic Intervention for Treatment-Resistant Schizophrenia: Feasibility, Acceptability, and Usability Study %A Grasa,Eva %A Seppälä,Jussi %A Alonso-Solis,Anna %A Haapea,Marianne %A Isohanni,Matti %A Miettunen,Jouko %A Caro Mendivelso,Johanna %A Almazan,Cari %A Rubinstein,Katya %A Caspi,Asaf %A Unoka,Zsolt %A Farkas,Kinga %A Usall,Judith %A Ochoa,Susana %A van der Graaf,Shenja %A Jewell,Charlotte %A Triantafillou,Anna %A Stevens,Matthias %A Reixach,Elisenda %A Berdun,Jesus %A , %A Corripio,Iluminada %+ Mental Health Division, Fundació Althaia, Xarxa Assistencial Universitaria de Manresa, Llatjos St, Manresa, 08243, Spain, 34 93 8742112, aalonso@althaia.cat %K schizophrenia %K treatment-resistant %K digital mental health %K mHealth %K mobile health %K mental health %K mental illness %K mental disorder %K psychosis %K symptom management %K adherence %K acceptability %K usability %K feasibility %K digital intervention %K mobile intervention %K mobile phone %D 2023 %7 30.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: In the European Union, around 5 million people are affected by psychotic disorders, and approximately 30%-50% of people with schizophrenia have treatment-resistant schizophrenia (TRS). Mobile health (mHealth) interventions may be effective in preventing relapses, increasing treatment adherence, and managing some of the symptoms of schizophrenia. People with schizophrenia seem willing and able to use smartphones to monitor their symptoms and engage in therapeutic interventions. mHealth studies have been performed with other clinical populations but not in populations with TRS. Objective: The purpose of this study was to present the 3-month prospective results of the m-RESIST intervention. This study aims to assess the feasibility, acceptability, and usability of the m-RESIST intervention and the satisfaction among patients with TRS after using this intervention. Methods: A prospective multicenter feasibility study without a control group was undertaken with patients with TRS. This study was performed at 3 sites: Sant Pau Hospital (Barcelona, Spain), Semmelweis University (Budapest, Hungary), and Sheba Medical Center and Gertner Institute of Epidemiology and Health Policy Research (Ramat-Gan, Israel). The m-RESIST intervention consisted of a smartwatch, a mobile app, a web-based platform, and a tailored therapeutic program. The m-RESIST intervention was delivered to patients with TRS and assisted by mental health care providers (psychiatrists and psychologists). Feasibility, usability, acceptability, and user satisfaction were measured. Results: This study was performed with 39 patients with TRS. The dropout rate was 18% (7/39), the main reasons being as follows: loss to follow-up, clinical worsening, physical discomfort of the smartwatch, and social stigma. Patients’ acceptance of m-RESIST ranged from moderate to high. The m-RESIST intervention could provide better control of the illness and appropriate care, together with offering user-friendly and easy-to-use technology. In terms of user experience, patients indicated that m-RESIST enabled easier and quicker communication with clinicians and made them feel more protected and safer. Patients’ satisfaction was generally good: 78% (25/32) considered the quality of service as good or excellent, 84% (27/32) reported that they would use it again, and 94% (30/32) reported that they were mostly satisfied. Conclusions: The m-RESIST project has provided the basis for a new modular program based on novel technology: the m-RESIST intervention. This program was well-accepted by patients in terms of acceptability, usability, and satisfaction. Our results offer an encouraging starting point regarding mHealth technologies for patients with TRS. Trial Registration: ClinicalTrials.gov NCT03064776; https://clinicaltrials.gov/ct2/show/record/NCT03064776 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2017-021346 %M 37389933 %R 10.2196/46179 %U https://formative.jmir.org/2023/1/e46179 %U https://doi.org/10.2196/46179 %U http://www.ncbi.nlm.nih.gov/pubmed/37389933 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44877 %T Mindcraft, a Mobile Mental Health Monitoring Platform for Children and Young People: Development and Acceptability Pilot Study %A Kadirvelu,Balasundaram %A Bellido Bel,Teresa %A Wu,Xiaofei %A Burmester,Victoria %A Ananth,Shayma %A Cabral C C Branco,Bianca %A Girela-Serrano,Braulio %A Gledhill,Julia %A Di Simplicio,Martina %A Nicholls,Dasha %A Faisal,A Aldo %+ Brain & Behaviour Lab, Department of Computing and Department of Bioengineering, Imperial College London, Royal School of Mines, London, SW7 2AZ, United Kingdom, 44 20 7594 6373, a.faisal@imperial.ac.uk %K mobile mental health %K passive sensing %K smartphone apps for mental health %K children and young people %K adolescents %K digital tools %K mobile apps %D 2023 %7 26.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Children and young people's mental health is a growing public health concern, which is further exacerbated by the COVID-19 pandemic. Mobile health apps, particularly those using passive smartphone sensor data, present an opportunity to address this issue and support mental well-being. Objective: This study aimed to develop and evaluate a mobile mental health platform for children and young people, Mindcraft, which integrates passive sensor data monitoring with active self-reported updates through an engaging user interface to monitor their well-being. Methods: A user-centered design approach was used to develop Mindcraft, incorporating feedback from potential users. User acceptance testing was conducted with a group of 8 young people aged 15-17 years, followed by a pilot test with 39 secondary school students aged 14-18 years, which was conducted for a 2-week period. Results: Mindcraft showed encouraging user engagement and retention. Users reported that they found the app to be a friendly tool helping them to increase their emotional awareness and gain a better understanding of themselves. Over 90% of users (36/39, 92.5%) answered all active data questions on the days they used the app. Passive data collection facilitated the gathering of a broader range of well-being metrics over time, with minimal user intervention. Conclusions: The Mindcraft app has shown promising results in monitoring mental health symptoms and promoting user engagement among children and young people during its development and initial testing. The app's user-centered design, the focus on privacy and transparency, and a combination of active and passive data collection strategies have all contributed to its efficacy and receptiveness among the target demographic. By continuing to refine and expand the app, the Mindcraft platform has the potential to contribute meaningfully to the field of mental health care for young people. %M 37358901 %R 10.2196/44877 %U https://formative.jmir.org/2023/1/e44877 %U https://doi.org/10.2196/44877 %U http://www.ncbi.nlm.nih.gov/pubmed/37358901 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43788 %T Design and Implementation of a Digitally Enabled Care Pathway to Improve Management of Depression in a Large Health Care System: Protocol for the Implementation of a Patient Care Platform %A Khatib,Rasha %A McCue,Maggie %A Blair,Chris %A Roy,Anit %A Franco,John %A Fehnert,Ben %A King,James %A Sarkey,Sara %A Chrones,Lambros %A Martin,Michael %A Kabir,Christopher %A Kemp,David E %+ Takeda Pharmaceuticals U.S.A., Inc., 95 Hayden Ave, Lexington, MA, 02421, United States, 1 781 482 0426, chris.blair@takeda.com %K mental health %K depression %K depressive %K major depressive disorder %K depression management %K primary care %K patient engagement %K measurement-based care %K shared decision-making %K user-centered design %K mobile app %K digital platform %K mobile phone %K mobile health %K adherence %D 2023 %7 23.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) is a serious public health concern worldwide. A treatment approach that incorporates measurement-based care (MBC) and shared decision-making between patients with MDD and their providers may foster patient engagement and improve clinical outcomes. While digital tools such as mobile apps show promise for expanding health interventions, these apps are rarely integrated into clinical practice. Objective: The primary objective of this ongoing study is to determine whether implementation of a digital tool—the Pathway Platform—in primary care improves adherence to MBC practices; here, we present the study methods. Methods: This large-scale, real-world implementation study is based on a pilot study of an earlier iteration of a mobile app (the Pathway app) that confirmed the feasibility of using the app in patients with MDD and showed a positive trend in patient engagement in the app arm. In addition, a user-centered design approach that included qualitative assessments from patients and providers was used to improve understanding of the patient journey and care team workflows. User feedback highlighted the need for enhanced features, education modules, and real-time data sharing via integration with the electronic health record. The current iteration of the Platform includes the newest version of the Pathway app, education modules for both patients and providers, and real-time patient-level data sharing with the electronic health record. The study takes place in primary care sites within the Advocate Aurora Health system in Illinois and includes adult patients with MDD who were recently prescribed monotherapy antidepressant medication (defined as a new start, medication switch, or dose change in the past 3 months). Clinical performance and selected patient outcomes will be compared before and after the implementation of the Platform. Results: Patient recruitment was completed in July 2022, with initial results expected in mid-2023. Conclusions: This study will provide useful insights into real-world integration of a digital platform within a large health system. The methods presented here highlight the unique user-centric development of the Pathway Platform, which has resulted in an enhanced digital tool with the potential to foster MBC and shared decision-making, improve patient-provider communication, and ultimately lead to optimized treatment outcomes for patients with MDD. Trial Registration: ClinicalTrials.gov NCT04891224; https://clinicaltrials.gov/ct2/show/NCT04891224 International Registered Report Identifier (IRRID): DERR1-10.2196/43788 %M 37351941 %R 10.2196/43788 %U https://www.researchprotocols.org/2023/1/e43788 %U https://doi.org/10.2196/43788 %U http://www.ncbi.nlm.nih.gov/pubmed/37351941 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44429 %T A Gamified Mobile App That Helps People Develop the Metacognitive Skills to Cope With Stressful Situations and Difficult Emotions: Formative Assessment of the InsightApp %A Amo,Victoria %A Prentice,Mike %A Lieder,Falk %+ Max Planck Institute for Intelligent Systems, Max Planck Ring 4, Tübingen, 72076, Germany, 49 15730645508, victoria.amo@tuebingen.mpg.de %K ecological momentary interventions %K serious games %K mindfulness-based interventions %K acceptance and commitment therapy %K cognitive behavioral therapy %K mobile phone %D 2023 %7 16.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Ecological momentary interventions open up new and exciting possibilities for delivering mental health interventions and conducting research in real-life environments via smartphones. This makes designing psychotherapeutic ecological momentary interventions a promising step toward cost-effective and scalable digital solutions for improving mental health and understanding the effects and mechanisms of psychotherapy. Objective: The first objective of this study was to formatively assess and improve the usability and efficacy of a gamified mobile app, the InsightApp, for helping people learn some of the metacognitive skills taught in cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based interventions. The app aims to help people constructively cope with stressful situations and difficult emotions in everyday life. The second objective of this study was to test the feasibility of using the InsightApp as a research tool for investigating the efficacy of psychological interventions and their underlying mechanisms. Methods: We conducted 2 experiments. In experiment 1 (n=65; completion rate: 63/65, 97%), participants (mean age 27, SD 14.9; range 19-55 years; 41/60, 68% female) completed a single session with the InsightApp. The intervention effects on affect, belief endorsement, and propensity for action were measured immediately before and after the intervention. Experiment 2 (n=200; completion rate: 142/200, 71%) assessed the feasibility of conducting a randomized controlled trial using the InsightApp. We randomly assigned participants to an experimental or a control condition, and they interacted with the InsightApp for 2 weeks (mean age 37, SD 12.16; range 20-78 years; 78/142, 55% female). Experiment 2 included all the outcome measures of experiment 1 except for the self-reported propensity to engage in predefined adaptive and maladaptive behaviors. Both experiments included user experience surveys. Results: In experiment 1, a single session with the app seemed to decrease participants’ emotional struggle, the intensity of their negative emotions, their endorsement of negative beliefs, and their self-reported propensity to engage in maladaptive coping behaviors (P<.001 in all cases; average effect size=−0.82). Conversely, participants’ endorsement of adaptive beliefs and their self-reported propensity to act in accordance with their values significantly increased (P<.001 in all cases; average effect size=0.48). Experiment 2 replicated the findings of experiment 1 (P<.001 in all cases; average effect size=0.55). Moreover, experiment 2 identified a critical obstacle to conducting a randomized controlled trial (ie, asymmetric attrition) and how it might be overcome. User experience surveys suggested that the app’s design is suitable for helping people apply psychotherapeutic techniques to cope with everyday stress and anxiety. User feedback provided valuable information on how to further improve app usability. Conclusions: In this study, we tested the first prototype of the InsightApp. Our encouraging preliminary results show that it is worthwhile to continue developing the InsightApp and further evaluate it in a randomized controlled trial. %M 37327040 %R 10.2196/44429 %U https://formative.jmir.org/2023/1/e44429 %U https://doi.org/10.2196/44429 %U http://www.ncbi.nlm.nih.gov/pubmed/37327040 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45234 %T Promoting Engagement With Smartphone Apps for Suicidal Ideation in Young People: Development of an Adjunctive Strategy Using a Lived Experience Participatory Design Approach %A Gan,Daniel Z Q %A McGillivray,Lauren %A Larsen,Mark Erik %A Bloomfield,Taylor %A Torok,Michelle %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, NSW 2031, Australia, 61 423828945, danielzqgan@gmail.com %K eHealth %K digital mental health %K smartphone app %K engagement %K youth suicide prevention %K qualitative methods %K suicide %K development %K youth %K mental health %K support %K user-centered %K design %K survey %K interview %K prototype %K prevention %K participatory design %K mobile phone %D 2023 %7 6.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide among young people is a worrying public health concern. Despite this, there is a lack of suitable interventions aligned with the needs of this priority population. Emerging evidence supports the effectiveness of digital interventions in alleviating the severity of suicidal thoughts. However, their efficacy may be undermined by poor engagement. Technology-supported strategies (eg, electronic prompts and reminders) have been deployed alongside digital interventions to increase engagement with the latter. However, evidence of their efficacy is inconclusive. User-centered design approaches may be key to developing feasible and effective engagement strategies. Currently, no study has been published on how such an approach might be expressly applied toward developing strategies for promoting engagement with digital interventions. Objective: This study aimed to detail the processes and activities involved in developing an adjunctive strategy for promoting engagement with LifeBuoy—a smartphone app that helps young people manage suicidal thoughts. Methods: Development of the engagement strategy took place in 2 phases. The discovery phase aimed to create an initial prototype by synthesizing earlier findings—from 2 systematic reviews and a cross-sectional survey of the broader mental health app user population—with qualitative insights from LifeBuoy users. A total of 16 web-based interviews were conducted with young people who participated in the LifeBuoy trial. Following the discovery phase, 3 interviewees were invited by the research team to take part in the workshops in the design phase, which sought to create a final prototype by making iterative improvements to the initial prototype. These improvements were conducted over 2 workshops. Thematic analysis was used to analyze the qualitative data obtained from the interviews and workshops. Results: Main themes from the interviews centered around the characteristics of the strategy, timing of notifications, and suitability of social media platforms. Subsequently, themes that emerged from the design workshops emphasized having a wider variety of content, greater visual consistency with LifeBuoy, and a component with more detailed information to cater to users with greater informational needs. Thus, refinements to the prototype were focused on (1) improving the succinctness, variety, and practical value of Instagram content, (2) creating a blog containing articles contributed by mental health professionals and young people with lived experience of suicide, and (3) standardizing the use of marine-themed color palettes across the Instagram and blog components. Conclusions: This is the first study to describe the development of a technology-supported adjunctive strategy for promoting engagement with a digital intervention. It was developed by integrating perspectives from end users with lived experience of suicide with evidence from the existing literature. The development process documented in this study may be useful for guiding similar projects aimed at supporting the use of digital interventions for suicide prevention or mental health. %M 37279058 %R 10.2196/45234 %U https://formative.jmir.org/2023/1/e45234 %U https://doi.org/10.2196/45234 %U http://www.ncbi.nlm.nih.gov/pubmed/37279058 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 11 %N %P e44838 %T An Overview of Chatbot-Based Mobile Mental Health Apps: Insights From App Description and User Reviews %A Haque,M D Romael %A Rubya,Sabirat %+ Department of Computer Science, Marquette University, 1313 W Wisconsin Ave, Milwaukee, WI, 53233, United States, 1 4144397646, mdromael.haque@marquette.edu %K chatbot %K mobile mental health apps %K consumer reviews %K health care app %K mental health app %K app development %K user experience %K mHealth intervention %K mobile health %D 2023 %7 22.5.2023 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Chatbots are an emerging technology that show potential for mental health care apps to enable effective and practical evidence-based therapies. As this technology is still relatively new, little is known about recently developed apps and their characteristics and effectiveness. Objective: In this study, we aimed to provide an overview of the commercially available popular mental health chatbots and how they are perceived by users. Methods: We conducted an exploratory observation of 10 apps that offer support and treatment for a variety of mental health concerns with a built-in chatbot feature and qualitatively analyzed 3621 consumer reviews from the Google Play Store and 2624 consumer reviews from the Apple App Store. Results: We found that although chatbots’ personalized, humanlike interactions were positively received by users, improper responses and assumptions about the personalities of users led to a loss of interest. As chatbots are always accessible and convenient, users can become overly attached to them and prefer them over interacting with friends and family. Furthermore, a chatbot may offer crisis care whenever the user needs it because of its 24/7 availability, but even recently developed chatbots lack the understanding of properly identifying a crisis. Chatbots considered in this study fostered a judgment-free environment and helped users feel more comfortable sharing sensitive information. Conclusions: Our findings suggest that chatbots have great potential to offer social and psychological support in situations where real-world human interaction, such as connecting to friends or family members or seeking professional support, is not preferred or possible to achieve. However, there are several restrictions and limitations that these chatbots must establish according to the level of service they offer. Too much reliance on technology can pose risks, such as isolation and insufficient assistance during times of crisis. Recommendations for customization and balanced persuasion to inform the design of effective chatbots for mental health support have been outlined based on the insights of our findings. %M 37213181 %R 10.2196/44838 %U https://mhealth.jmir.org/2023/1/e44838 %U https://doi.org/10.2196/44838 %U http://www.ncbi.nlm.nih.gov/pubmed/37213181 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e37727 %T A Mobile Self-control Training App to Improve Self-control and Physical Activity in People With Severe Mental Illness: Protocol for 2 Single-Case Experimental Designs %A Dekkers,Tessa %A Heirbaut,Tahnee %A Schouten,Stephanie E %A Kelders,Saskia M %A Beerlage-de Jong,Nienke %A Ludden,Geke D S %A Deenik,Jeroen %A Bouman,Yvonne H A %A Kip,Hanneke %+ Centre for eHealth and Wellbeing Research, Department of Technology, Human and Institutional Behaviour, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 534896536, t.dekkers@utwente.nl %K mobile health %K mHealth %K mobile apps %K self-control %K physical activity %K accelerometry %K single-case experimental design %K mobile phone %D 2023 %7 5.5.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Lack of physical activity is a common issue with detrimental consequences for the health of people with severe mental illness (SMI). Existing physical activity interventions show suboptimal effects as they require substantial cognitive skills, including goal setting and writing, whereas cognitive deficits are common in this population. To bolster the effectiveness of physical activity interventions, self-control training (SCT), in which users practice the ability to override unwanted thoughts and behaviors, can be used in addition. Recent research has demonstrated the initial effectiveness of a mobile SCT app, but this has not been studied in psychiatric clinical practice. Objective: This study aims to evaluate to what extent adding a mobile SCT app designed for and with people with SMI to a mobile lifestyle intervention aimed at increasing physical activity increases physical activity and self-control levels. Methods: A mixed methods approach incorporating 2 single-case experimental designs (SCEDs) and qualitative interviews was used to evaluate and optimize SCT. Overall, 12 participants with SMI will be recruited from 2 organizations offering outpatient and inpatient care to people with SMI. Each experiment will include 6 patients. SCED I is a concurrent multiple-baseline design across participants that explores initial effectiveness and optimal intervention duration. Using accelerometry and experience sampling questionnaires, participants’ physical activity and self-control will be monitored for ≥5 days from baseline, followed by the sequential introduction of Google Fit, the physical activity intervention, for 7 days and the addition of SCIPP: Self-Control Intervention App for 28 days. SCED II is an introduction/withdrawal design in which optimized SCT will be introduced and withdrawn to validate the findings from SCED I. In both experiments, the daily average of total activity counts per hour and the state level of self-control will serve as the primary and secondary outcome measures. Data will be analyzed using visual analysis and piecewise linear regression models. Results: The study was designated as not subject to the Dutch Medical Research Involving Human Subjects Act by the Medical Research Ethical Committee Oost-Nederland and approved by the Ethics Committee/domain Humanities and Social Sciences of the Faculty of Behavioural, Management, and Social Sciences at the University of Twente. Participant recruitment started in January 2022, and we expect to publish the results in early 2023. Conclusions: The mobile SCT app is expected to be feasible and effective. It is self-paced and scalable and can increase patient motivation, making it a suitable intervention for people with SMI. SCED is a relatively novel yet promising method for gaining insights into whether and how mobile apps work that can handle heterogeneous samples and makes it possible to involve a diverse population with SMI without having to include a large number of participants. International Registered Report Identifier (IRRID): PRR1-10.2196/37727 %M 37145845 %R 10.2196/37727 %U https://www.researchprotocols.org/2023/1/e37727 %U https://doi.org/10.2196/37727 %U http://www.ncbi.nlm.nih.gov/pubmed/37145845 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43862 %T Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials %A He,Yuhao %A Yang,Li %A Qian,Chunlian %A Li,Tong %A Su,Zhengyuan %A Zhang,Qiang %A Hou,Xiangqing %+ Institute of Applied Psychology, College of Education, Tianjin University, 135 Yaguan Road, Jinnan District, Tianjin, 300354, China, 86 15034071215, 2020212056@tju.edu.cn %K chatbot and conversational agent %K mental health %K meta-analysis %K depression %K anxiety %K quality of life %K stress %K mobile health %K mHealth %K digital medicine %K meta-regression %K mobile phone %D 2023 %7 28.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Mental health problems are a crucial global public health concern. Owing to their cost-effectiveness and accessibility, conversational agent interventions (CAIs) are promising in the field of mental health care. Objective: This study aims to present a thorough summary of the traits of CAIs available for a range of mental health problems, find evidence of efficacy, and analyze the statistically significant moderators of efficacy via a meta-analysis of randomized controlled trial. Methods: Web-based databases (Embase, MEDLINE, PsycINFO, CINAHL, Web of Science, and Cochrane) were systematically searched dated from the establishment of the database to October 30, 2021, and updated to May 1, 2022. Randomized controlled trials comparing CAIs with any other type of control condition in improving depressive symptoms, generalized anxiety symptoms, specific anxiety symptoms, quality of life or well-being, general distress, stress, mental disorder symptoms, psychosomatic disease symptoms, and positive and negative affect were considered eligible. This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were extracted by 2 independent reviewers, checked by a third reviewer, and pooled using both random effect models and fixed effects models. Hedges g was chosen as the effect size. Results: Of the 6900 identified records, a total of 32 studies were included, involving 6089 participants. CAIs showed statistically significant short-term effects compared with control conditions in improving depressive symptoms (g=0.29, 95% CI 0.20-0.38), generalized anxiety symptoms (g=0.29, 95% CI 0.21-0.36), specific anxiety symptoms (g=0.47, 95% CI 0.07-0.86), quality of life or well-being (g=0.27, 95% CI 0.16-0.39), general distress (g=0.33, 95% CI 0.20-0.45), stress (g=0.24, 95% CI 0.08-0.41), mental disorder symptoms (g=0.36, 95% CI 0.17-0.54), psychosomatic disease symptoms (g=0.62, 95% CI 0.14-1.11), and negative affect (g=0.28, 95% CI 0.05-0.51). However, the long-term effects of CAIs for the most mental health outcomes were not statistically significant (g=−0.04 to 0.39). Personalization and empathic response were 2 critical facilitators of efficacy. The longer duration of interaction with conversational agents was associated with the larger pooled effect sizes. Conclusions: The findings show that CAIs are research-proven interventions that ought to be implemented more widely in mental health care. CAIs are effective and easily acceptable for those with mental health problems. The clinical application of this novel digital technology will conserve human health resources and optimize the allocation of mental health services. Trial Registration: PROSPERO CRD42022350130; https://tinyurl.com/mvhk6w9p %M 37115595 %R 10.2196/43862 %U https://www.jmir.org/2023/1/e43862 %U https://doi.org/10.2196/43862 %U http://www.ncbi.nlm.nih.gov/pubmed/37115595 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e43565 %T Situating Meditation Apps Within the Ecosystem of Meditation Practice: Population-Based Survey Study %A Lam,Sin U %A Xie,Qiang %A Goldberg,Simon B %+ Department of Counseling Psychology, University of Wisconsin-Madison, 335 Education Building, 1000 Bascom Mall, Madison, WI, 53706, United States, 1 6082624807, sbgoldberg@wisc.edu %K mindfulness %K meditation %K consumer behavior %K user engagement %K mobile health %K digital health %K mobile phone %D 2023 %7 28.4.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Meditation apps have the potential to increase access to evidence-based strategies to promote mental health. However, it is currently unclear how meditation apps are situated within the broader landscape of meditation practice and what factors may influence engagement with them. Objective: This study aimed to clarify the prevalence and correlates of meditation app use in a population-based sample of individuals with lifetime exposure to meditation in the United States. In addition, we sought to identify the concerns and desired features of meditation apps among those with lifetime exposure to meditation. Methods: A total of 953 participants completed an initial screening survey. Of these 953 participants, 434 (45.5%) reported lifetime exposure to meditation and completed a follow-up survey (434/470, 92.3% response rate) assessing their meditation app use, anxiety, depression, loneliness, initial motivation for meditation, and concerns about and desired features of meditation apps. Results: Almost half (434/953, 45.5%) of the participants who completed the screening survey reported lifetime exposure to meditation. Among those with lifetime exposure to meditation (ie, meditators), more than half (255/434, 58.8%) had used meditation apps at least once in their lives, and 21.7% (94/434) used meditation apps weekly or daily (ie, active users). Younger age, higher anxiety, and a mental health motivation for practicing meditation were associated with lifetime exposure to meditation apps. Among meditators, those with lifetime exposure to meditation apps were more likely to report concerns about apps, including concerns regarding the cost and effectiveness of apps, time required for use, technical issues with apps, and app user-friendliness. Meditators who used meditation apps weekly or daily (ie, active users) were younger, less likely to be men and non-Latinx White individuals and have lower income, and more likely to have an initial spiritual motivation for meditation. Active users reported more concerns regarding usability and technical problems and were less likely to report disinterest in apps. Headspace and Calm were the most frequently used apps. Tips and reminders for practice, encouragement of “mini” practices, and mental health content were the most desired features. Participants were less interested in social features (eg, the ability to communicate with other users or teachers). Conclusions: Meditation apps are commonly used by meditators in the United States, with a higher use among certain demographic groups. Future studies may increase user engagement in meditation apps by addressing concerns (eg, cost and effectiveness) and incorporating desired features (eg, tips and reminders for practice). %M 37115618 %R 10.2196/43565 %U https://mental.jmir.org/2023/1/e43565 %U https://doi.org/10.2196/43565 %U http://www.ncbi.nlm.nih.gov/pubmed/37115618 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46281 %T Telehealth-Based Music Therapy Versus Cognitive Behavioral Therapy for Anxiety in Cancer Survivors: Rationale and Protocol for a Comparative Effectiveness Trial %A Liou,Kevin T %A McConnell,Kelly M %A Currier,M Beatriz %A Baser,Raymond E %A MacLeod,Jodi %A Walker,Desiree %A Casaw,Camila %A Wong,Greta %A Piulson,Lauren %A Popkin,Karen %A Lopez,Ana Maria %A Panageas,Katherine %A Bradt,Joke %A Mao,Jun J %+ Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY, 10065, United States, 1 646 608 8558, liouk@mskcc.org %K oncology %K anxiety %K cognitive behavioral therapy %K music therapy %K telehealth %K cancer survivorship %K mental health %K digital health %K mobile phone %D 2023 %7 27.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cancer survivors represent one of the fastest growing populations in the United States. Unfortunately, nearly 1 in 3 survivors experience anxiety symptoms as a long-term consequence of cancer and its treatment. Characterized by restlessness, muscle tension, and worry, anxiety worsens the quality of life; impairs daily functioning; and is associated with poor sleep, depressed mood, and fatigue. Although pharmacological treatment options are available, polypharmacy has become a growing concern for cancer survivors. Music therapy (MT) and cognitive behavioral therapy (CBT) are evidence-based, nonpharmacological treatments that have demonstrated effectiveness in treating anxiety symptoms in cancer populations and can be adapted for remote delivery to increase access to mental health treatments. However, the comparative effectiveness of these 2 interventions delivered via telehealth is unknown. Objective: The aims of the Music Therapy Versus Cognitive Behavioral Therapy for Cancer-related Anxiety (MELODY) study are to determine the comparative effectiveness of telehealth-based MT versus telehealth-based CBT for anxiety and comorbid symptoms in cancer survivors and to identify patient-level factors associated with greater anxiety symptom reduction for MT and CBT. Methods: The MELODY study is a 2-arm, parallel-group randomized clinical trial that aims to compare the effectiveness of MT versus CBT for anxiety and comorbid symptoms. The trial will enroll 300 English- or Spanish-speaking survivors of any cancer type or stage who have experienced anxiety symptoms for at least 1 month. Participants will receive 7 weekly sessions of MT or CBT delivered remotely via Zoom (Zoom Video Communications, Inc) over 7 weeks. Validated instruments to assess anxiety (primary outcome), comorbid symptoms (fatigue, depression, insomnia, pain, and cognitive dysfunction), and health-related quality of life will be administered at baseline and at weeks 4, 8 (end of treatment), 16, and 26. Semistructured interviews will be conducted at week 8 with a subsample of 60 participants (30 per treatment arm) to understand individual experiences with the treatment sessions and their impact. Results: The first study participant was enrolled in February 2022. As of January 2023, 151 participants have been enrolled. The trial is expected to be completed by September 2024. Conclusions: This study is the first and largest randomized clinical trial to compare the short- and long-term effectiveness of remotely delivered MT and CBT for anxiety in cancer survivors. Limitations include the lack of usual care or placebo control groups and the lack of formal diagnostic assessments for psychiatric disorders among trial participants. The study findings will help guide treatment decisions for 2 evidence-based, scalable, and accessible interventions to promote mental well-being during cancer survivorship. International Registered Report Identifier (IRRID): DERR1-10.2196/46281 %M 37103999 %R 10.2196/46281 %U https://www.researchprotocols.org/2023/1/e46281 %U https://doi.org/10.2196/46281 %U http://www.ncbi.nlm.nih.gov/pubmed/37103999 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41005 %T An Unguided, Computerized Cognitive Behavioral Therapy Intervention (TreadWill) in a Lower Middle-Income Country: Pragmatic Randomized Controlled Trial %A Ghosh,Arka %A Cherian,Rithwik J %A Wagle,Surbhit %A Sharma,Parth %A Kannan,Karthikeyan R %A Bajpai,Alok %A Gupta,Nitin %+ Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, IIT Campus, Kanpur, 208016, India, 91 5122594384, guptan@iitk.ac.in %K computerized cognitive behavioral therapy %K cCBT %K depression %K digital intervention %K mobile phone %D 2023 %7 26.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Globally, most individuals who are susceptible to depression do not receive adequate or timely treatment. Unguided computerized cognitive behavioral therapy (cCBT) has the potential to bridge this treatment gap. However, the real-world effectiveness of unguided cCBT interventions, particularly in low- and middle-income countries (LMICs), remains inconclusive. Objective: In this study, we aimed to report the design and development of a new unguided cCBT–based multicomponent intervention, TreadWill, and its pragmatic evaluation. TreadWill was designed to be fully automated, engaging, easy to use, and accessible to LMICs. Methods: To evaluate the effectiveness of TreadWill and the engagement level, we performed a double-blind, fully remote, and randomized controlled trial with 598 participants in India and analyzed the data using a completer’s analysis. Results: The users who completed at least half of the modules in TreadWill showed significant reduction in depression-related (P=.04) and anxiety-related (P=.02) symptoms compared with the waitlist control. Compared with a plain-text version with the same therapeutic content, the full-featured version of TreadWill showed significantly higher engagement (P=.01). Conclusions: Our study provides a new resource and evidence for the use of unguided cCBT as a scalable intervention in LMICs. Trial Registration: ClinicalTrials.gov NCT03445598; https://clinicaltrials.gov/ct2/show/NCT03445598 %M 37099376 %R 10.2196/41005 %U https://www.jmir.org/2023/1/e41005 %U https://doi.org/10.2196/41005 %U http://www.ncbi.nlm.nih.gov/pubmed/37099376 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 6 %N %P e46154 %T Using Digital Measurement–Based Care for the Treatment of Anxiety and Depression in Children and Adolescents: Observational Retrospective Analysis of Bend Health Data %A Huffman,Landry Goodgame %A Lawrence-Sidebottom,Darian %A Huberty,Jennifer %A Roots,Monika %A Roots,Kurt %A Parikh,Amit %A Guerra,Rachael %A Weiser,Jaclyn %+ Bend Health Inc, 9450 SW Gemini Drive, Beaverton, OR, 97008, United States, 1 800 516 0975, landry.huffman@bendhealth.com %K digital mental health intervention %K anxiety %K depression %K child %K adolescent %K collaborative care %K mental health %K caregiver %K pediatric %K youth %K demographic %K health outcome %K retrospective %K treatment %K e-mental health %K symptoms %D 2023 %7 20.4.2023 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: A growing body of evidence supports the efficacy of measurement-based care (MBC) for children and adolescents experiencing mental health concerns, particularly anxiety and depression. In recent years, MBC has increasingly transitioned to web-based spaces in the form of digital mental health interventions (DMHIs), which render high-quality mental health care more accessible nationwide. Although extant research is promising, the emergence of MBC DMHIs means that much is unknown regarding their effectiveness as a treatment for anxiety and depression, particularly among children and adolescents. Objective: This study uses preliminary data from children and adolescents participating in an MBC DMHI administered by Bend Health Inc, a mental health care provider that uses a collaborative care model to assess changes in anxiety and depressive symptoms during participation in the MBC DMHI. Methods: Caregivers of children and adolescents participating in Bend Health Inc for anxiety or depressive symptoms reported measures of their children’s symptoms every 30 days throughout the duration of participation in Bend Health Inc. Data from 114 children (age 6-12 years) and adolescents (age 13-17 years) were used for the analyses (anxiety symptom group: n=98, depressive symptom group: n=61). Results: Among children and adolescents participating in care with Bend Health Inc, 73% (72/98) exhibited improvements in anxiety symptoms and 73% (44/61) exhibited improvement in depressive symptoms, as indicated by either a decrease in symptom severity or screening out of completing the complete assessment. Among those with complete assessment data, group-level anxiety symptom T-scores exhibited a moderate decrease of 4.69 points (P=.002) from the first to the last assessment. However, members’ depressive symptom T-scores remained largely stable throughout their involvement. Conclusions: As increasing numbers of young people and families seek DMHIs over traditional mental health treatments due to their accessibility and affordability, this study offers promising early evidence that youth anxiety symptoms decrease during involvement in an MBC DMHI such as Bend Health Inc. However, further analyses with enhanced longitudinal symptom measures are necessary to determine whether depressive symptoms show similar improvements among those involved in Bend Health Inc. %M 37079366 %R 10.2196/46154 %U https://pediatrics.jmir.org/2023/1/e46154 %U https://doi.org/10.2196/46154 %U http://www.ncbi.nlm.nih.gov/pubmed/37079366 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44548 %T Evaluating Conversational Agents for Mental Health: Scoping Review of Outcomes and Outcome Measurement Instruments %A Jabir,Ahmad Ishqi %A Martinengo,Laura %A Lin,Xiaowen %A Torous,John %A Subramaniam,Mythily %A Tudor Car,Lorainne %+ Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 18, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K conversational agent %K chatbot %K mental health %K mHealth %K mobile health %K taxonomy %K outcomes %K core outcome set %D 2023 %7 19.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Rapid proliferation of mental health interventions delivered through conversational agents (CAs) calls for high-quality evidence to support their implementation and adoption. Selecting appropriate outcomes, instruments for measuring outcomes, and assessment methods are crucial for ensuring that interventions are evaluated effectively and with a high level of quality. Objective: We aimed to identify the types of outcomes, outcome measurement instruments, and assessment methods used to assess the clinical, user experience, and technical outcomes in studies that evaluated the effectiveness of CA interventions for mental health. Methods: We undertook a scoping review of the relevant literature to review the types of outcomes, outcome measurement instruments, and assessment methods in studies that evaluated the effectiveness of CA interventions for mental health. We performed a comprehensive search of electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, Embase (Ovid), PsychINFO, and Web of Science, as well as Google Scholar and Google. We included experimental studies evaluating CA mental health interventions. The screening and data extraction were performed independently by 2 review authors in parallel. Descriptive and thematic analyses of the findings were performed. Results: We included 32 studies that targeted the promotion of mental well-being (17/32, 53%) and the treatment and monitoring of mental health symptoms (21/32, 66%). The studies reported 203 outcome measurement instruments used to measure clinical outcomes (123/203, 60.6%), user experience outcomes (75/203, 36.9%), technical outcomes (2/203, 1.0%), and other outcomes (3/203, 1.5%). Most of the outcome measurement instruments were used in only 1 study (150/203, 73.9%) and were self-reported questionnaires (170/203, 83.7%), and most were delivered electronically via survey platforms (61/203, 30.0%). No validity evidence was cited for more than half of the outcome measurement instruments (107/203, 52.7%), which were largely created or adapted for the study in which they were used (95/107, 88.8%). Conclusions: The diversity of outcomes and the choice of outcome measurement instruments employed in studies on CAs for mental health point to the need for an established minimum core outcome set and greater use of validated instruments. Future studies should also capitalize on the affordances made available by CAs and smartphones to streamline the evaluation and reduce participants’ input burden inherent to self-reporting. %M 37074762 %R 10.2196/44548 %U https://www.jmir.org/2023/1/e44548 %U https://doi.org/10.2196/44548 %U http://www.ncbi.nlm.nih.gov/pubmed/37074762 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40671 %T Sensa Mobile App for Managing Stress, Anxiety, and Depression Symptoms: Pilot Cohort Study %A Valinskas,Sarunas %A Nakrys,Marius %A Aleknavicius,Kasparas %A Jonusas,Justinas %+ KiloHealth, Antakalnio st. 17, Vilnius, LT 10312, Lithuania, 370 61456067, justinas.jonusas@kilo.health %K depression %K anxiety %K stress %K depressive %K DASS-21 %K mobile application %K CBT %K cognitive behavioral therapy %K psychotherapy %K mHealth %K mobile health %K Sensa %K app %K application %K health care %K intervention %K effectiveness %K assessment %K symptoms %K treatment %K mental health %D 2023 %7 13.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: An increase in depression, anxiety, and stress symptoms worldwide, attributed to the COVID-19 pandemic, has been reported. If not treated, it may negatively affect a person's everyday life by altering physical and social well-being and productivity and increasing expenditure on health care. Cognitive behavioral therapy (CBT)–based interventions are gaining popularity as a means to reduce stress and alleviate anxiety and depression symptoms. Moreover, CBT delivered through a mobile app has the same elements as traditional CBT training (eg, guided discovery). However, unlike conventional training, users of mobile apps are allowed to tailor their own experience at their own speed and schedule. Objective: This study aims to analyze Sensa users’ retrospective data and explore the dose-duration effect to find the optimal usage time when the user showed results. Methods: The study cohort comprised 381 consecutive community-based nonclinical users who started using Sensa between October 2021 and March 2022. All users included in the study took the Depression Anxiety Stress Scale-21 (DASS-21) assessment at least 2 times. Other parameters from the database containing all self-reported data were gender, number of active days, total time of use, and age. The primary outcome of the study was a change in the DASS-21 score. Statistical analyses were performed using GraphPad Prism (version 9, GraphPad Software). In addition, a logistic regression model was created to predict how the obtained independent parameters influenced the DASS-21 score. Results: The main finding of our study was that the majority of participants who started using Sensa were experiencing depression, anxiety, and stress symptoms (92.13%, 80.05%, and 87.93%, respectively). There was a statistically significant decrease of the DASS-21 subdomain scores after the use of the application (anxiety: mean 7.25, SD 4.03 vs mean 6.12, SD 4.00; P=.001; depression: mean 11.05, SD 4.26 vs mean 9.01, SD 4.77; P=.001; stress: mean 11.42, SD 3.44 vs mean 9.96, SD 3.65; P<.001). Finally, the logistic regression model showed that users who were using the app for more than 24 days and had at least 12 active days during that time had 3.463 (95% CI 1.142-11.93) and 2.644 (95% CI 1.024-7.127) times higher chances to reduce their DASS-21 subdomain scores of depression and anxiety, respectively. Conclusions: Using the Sensa mobile app was related to decreased depression, anxiety, and stress symptoms. %M 37052990 %R 10.2196/40671 %U https://formative.jmir.org/2023/1/e40671 %U https://doi.org/10.2196/40671 %U http://www.ncbi.nlm.nih.gov/pubmed/37052990 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45970 %T Barriers to and Facilitators of a Blended Cognitive Behavioral Therapy Program for Depression and Anxiety Based on Experiences of University Students: Qualitative Interview Study %A Braun,Pia %A Atik,Ece %A Guthardt,Lisa %A Apolinário-Hagen,Jennifer %A Schückes,Magnus %+ Institute of Occupational, Social and Environmental Medicine, Faculty of Medicine, Centre for Health and Society, Heinrich Heine University Düsseldorf, Moorenstr. 5, Düsseldorf, 40225, Germany, 49 211 8106477, jennifer.apolinario.hagen@hhu.de %K digital therapeutics %K blended cognitive behavioral therapy %K bCBT %K depression %K anxiety %K acceptance %K user experiences %K university students %K mobile phone %D 2023 %7 12.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Blended cognitive behavioral therapy (bCBT) programs have been proposed to increase the acceptance and adoption of digital therapeutics (DTx) such as digital health apps. These programs allow for more personalized care by combining regular face-to-face therapy sessions with DTx. However, facilitators of and barriers to the use of DTx in bCBT programs have rarely been examined among students, who are particularly at risk for developing symptoms of depression and anxiety disorders. Objective: This study aimed to evaluate the facilitators of and barriers to the use of a bCBT program with the elona therapy app among university students with mild to moderate depression or anxiety symptoms. Methods: Semistructured interviews were conducted via videoconference between January 2022 and April 2022 with 102 students (mean age 23.93, SD 3.63 years; 89/102, 87.2% female) from universities in North Rhine-Westphalia, Germany, after they had completed weekly individual cognitive behavioral therapy sessions (25 minutes each) via videoconference for 6 weeks and regularly used the depression (n=67, 65.7%) or anxiety (n=35, 34.3%) module of the app. The interviews were coded based on grounded theory. Results: Many participants highlighted the intuitive handling of the app and indicated that they perceived it as a supportive tool between face-to-face sessions. Participants listed other benefits, such as increased self-reflection and disorder-specific knowledge as well as the transfer of the content of therapy sessions into their daily lives. Some stated that they would have benefited from more personalized and interactive tasks. In general, participants mentioned the time requirement, increased use of the smartphone, and the feeling of being left alone with potentially arising emotions while working on tasks for the next therapy session as possible barriers to the use of the app. Data security was not considered a major concern. Conclusions: Students mostly had positive attitudes toward elona therapy as part of the bCBT program. Our study shows that DTx complementing face-to-face therapy sessions can be perceived as a helpful tool for university students with mild to moderate anxiety or depression symptoms in their daily lives. Future research could elaborate on whether bCBT programs might also be suitable for students with more severe symptoms of mental disorders. In addition, the methods by which such bCBT programs could be incorporated into the university context to reach students in need of psychological support should be explored. %M 37043272 %R 10.2196/45970 %U https://formative.jmir.org/2023/1/e45970 %U https://doi.org/10.2196/45970 %U http://www.ncbi.nlm.nih.gov/pubmed/37043272 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44216 %T Tailoring a Digital Mental Health Program for Patients With Sickle Cell Disease: Qualitative Study %A Nikolajski,Cara %A O'Brien,Julia %A Nardo,Emily %A Szigethy,Eva %A Jonassaint,Charles %+ Center for Research on Health Care, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, United States, 1 412 586 9850, cjonassaint@pitt.edu %K mental health %K sickle cell disease %K digital health %K cognitive behavioral therapy %K digital cognitive behavioral therapy %D 2023 %7 6.4.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and other mental health disorders are prevalent among people living with chronic health conditions. Although digital cognitive behavioral therapy (CBT) is considered an effective treatment, African American individuals are less likely to engage in and adhere to digital therapies for mental health disorders compared with White individuals. Objective: The aim of this study was to understand digital CBT mental health treatment perceptions and preferences of African American individuals with sickle cell disease (SCD). Methods: African American individuals with SCD from various US locations were invited to participate in a series of focus groups. Participants were introduced to a health coach–supported mental health app and then asked a series of questions about the usability and appeal of the program as well as, more generally, what would make a digital mental health program effective for them. The authors reviewed the focus group transcripts and conducted a qualitative analysis of the results. Results: A total of 25 people participated in 5 focus groups. Overall, 5 primary themes emerged regarding how app content and related coaching could be modified to enhance digital CBT engagement. These themes included connection with others living with SCD, the personalization of app content and coaching, characteristics of coaches, journaling and pain tracking, and considerations for optimal engagement. Conclusions: Enhancing the user experience by making digital CBT tools relevant to patient populations is critical for optimizing program engagement and its uptake. Our findings highlight potential strategies to modify and design digital CBT tools for users with SCD and may also be applicable to patients with other chronic conditions. Trial Registration: ClinicalTrials.gov NCT04587661; https://clinicaltrials.gov/ct2/show/NCT04587661 %M 37023443 %R 10.2196/44216 %U https://mental.jmir.org/2023/1/e44216 %U https://doi.org/10.2196/44216 %U http://www.ncbi.nlm.nih.gov/pubmed/37023443 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44862 %T The Effectiveness of a Smartphone Intervention Targeting Suicidal Ideation in Young Adults: Randomized Controlled Trial Examining the Influence of Loneliness %A McGillivray,Lauren %A Keng-Meng Hui,Nicholas %A Wong,Quincy J J %A Han,Jin %A Qian,Jiahui %A Torok,Michelle %+ Black Dog Institute, University of New South Wales, Hospital Rd, Sydney, 2031, Australia, 61 2 9065 9133, m.torok@unsw.edu.au %K loneliness %K suicidal ideation %K suicide prevention %K digital therapeutics %K smartphone intervention %K apps %D 2023 %7 30.3.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Loneliness is commonly reported by young people and has been shown to contribute to the rapid onset and escalation of depression and suicidal ideation during adolescence. Lonely people may also be particularly susceptible to disengaging from treatment early given the likelihood of their more complex clinical profiles leading to cognitive fatigue. While a smartphone intervention (LifeBuoy) has been shown to effectively reduce suicidal ideation in young adults, poor engagement is a well-documented issue for this therapeutic modality and has been shown to result in poorer treatment outcomes. Objective: This study aims to determine whether loneliness affects how young people experiencing suicidal ideation engage with and benefit from a therapeutic smartphone intervention (LifeBuoy). Methods: A total of 455 community-based Australian young adults (aged 18-25 years) experiencing recent suicidal ideation were randomized to use a dialectical behavioral therapy–based smartphone intervention (LifeBuoy) or an attention-matched control app (LifeBuoy-C) for 6 weeks. Participants completed measures of suicidal ideation, depression, anxiety, and loneliness at baseline (T0), post intervention (T1), and 3 months post intervention (T2). Piecewise linear mixed models were used to examine whether loneliness levels moderated the effect of LifeBuoy and LifeBuoy-C on suicidal ideation and depression across time (T0 to T1; T1 to T2). This statistical method was then used to examine whether app engagement (number of modules completed) influenced the relationship between baseline loneliness and suicidal ideation and depression across time. Results: Loneliness was positively associated with higher levels of overall suicidal ideation (B=0.75, 95% CI 0.08-1.42; P=.03) and depression (B=0.88, 95% CI 0.45-1.32; P<.001), regardless of time point or allocated condition. However, loneliness did not affect suicidal ideation scores across time (time 1: B=1.10, 95% CI –0.25 to 2.46; P=.11; time 2: B=0.43, 95% CI –1.25 to 2.12; P=.61) and depression scores across time (time 1: B=0.00, 95% CI –0.67 to 0.66; P=.99; time 2: B=0.41, 95% CI –0.37 to 1.18; P=.30) in either condition. Similarly, engagement with the LifeBuoy app was not found to moderate the impact of loneliness on suicidal ideation (B=0.00, 95% CI –0.17 to 0.18; P=.98) or depression (B=–0.08, 95% CI –0.19 to 0.03; P=.14). Conclusions: Loneliness was not found to affect young adults’ engagement with a smartphone intervention (LifeBuoy) nor any clinical benefits derived from the intervention. LifeBuoy, in its current form, can effectively engage and treat individuals regardless of how lonely they may be. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001671156; https://tinyurl.com/yvpvn5n8 International Registered Report Identifier (IRRID): RR2-10.2196/23655 %M 36995752 %R 10.2196/44862 %U https://mental.jmir.org/2023/1/e44862 %U https://doi.org/10.2196/44862 %U http://www.ncbi.nlm.nih.gov/pubmed/36995752 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e43942 %T Understanding the Adoption and Use of Digital Mental Health Apps Among College Students: Secondary Analysis of a National Survey %A Bautista,Justine %A Schueller,Stephen M %+ School of Social Ecology, University of California, Irvine, Social Ecology I, 102, Irvine, CA, 92617, United States, 1 (949) 824 6861, Jrbautis@uci.edu %K mental health %K mental health apps %K college students %K digital health %K app %K anxiety %D 2023 %7 22.3.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Increasing rates of mental health diagnoses in college students signal the need for new opportunities to support the mental health of this population. With many mental health apps being efficacious, they may be a promising resource for college campuses to provide support to their students. However, it is important to understand why (or why not) students might want to use apps and their desired features. Objective: Information on students’ interest in mental health apps may inform which apps are to be provided and how campuses can support their use. This study aimed to understand the interest and hesitation in app use and the relationship between mental health needs, as defined by depression, anxiety, and positive mental health, and app use. Methods: The web-based Healthy Minds Study collected information on mental health needs, perceptions, and service use across colleges and universities. We used a sample of 989 participants who completed the survey between 2018 and 2020 and an elective module on digital mental health. We analyzed the elective module responses using a mixed methods approach, including both descriptive and inferential statistics, along with thematic coding for open text responses. Results: The Results from this study revealed that anxiety (b=−0.07; P<.001), but not depression (b=0.03; P=.12) and positive mental health (b=−0.02; P=.17), was a significant predictor of app adoption. Prominent qualitative findings indicated that the most desired app features included tips and advice, access to resources and information, and on-demand support that involves interaction throughout the day. The participants also suggested an overall desire for human interaction to be integrated into an app. As predicted, hesitancy was encountered, and the qualitative results suggested that there was a lack of interest in the adoption of mental health app and preference. Conclusions: The findings from this study underscore that simply providing digital mental health apps as tools may be insufficient to support their use in college campuses. Although many students were open to using a mental health app, hesitation and uncertainty were common in the participant responses. Working with colleges and universities to increase digital literacy and provide resources that allow students to gauge when app use is appropriate may be helpful when implementing mental health apps as resources in college campuses. %M 36947115 %R 10.2196/43942 %U https://mental.jmir.org/2023/1/e43942 %U https://doi.org/10.2196/43942 %U http://www.ncbi.nlm.nih.gov/pubmed/36947115 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44542 %T Exploring the Perceptions of mHealth Interventions for the Prevention of Common Mental Disorders in University Students in Singapore: Qualitative Study %A Salamanca-Sanabria,Alicia %A Jabir,Ahmad Ishqi %A Lin,Xiaowen %A Alattas,Aishah %A Kocaballi,A Baki %A Lee,Jimmy %A Kowatsch,Tobias %A Tudor Car,Lorainne %+ Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Level 18, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K interventions %K students %K mobile health %K mHealth %K mental health %K mental disorders %K university %K common mental disorders %K anxiety %K depression %D 2023 %7 20.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health interventions delivered through mobile health (mHealth) technologies can increase the access to mental health services, especially among university students. The development of mHealth intervention is complex and needs to be context sensitive. There is currently limited evidence on the perceptions, needs, and barriers related to these interventions in the Southeast Asian context. Objective: This qualitative study aimed to explore the perception of university students and mental health supporters in Singapore about mental health services, campaigns, and mHealth interventions with a focus on conversational agent interventions for the prevention of common mental disorders such as anxiety and depression. Methods: We conducted 6 web-based focus group discussions with 30 university students and one-to-one web-based interviews with 11 mental health supporters consisting of faculty members tasked with student pastoral care, a mental health first aider, counselors, psychologists, a clinical psychologist, and a psychiatrist. The qualitative analysis followed a reflexive thematic analysis framework. Results: The following 6 main themes were identified: a healthy lifestyle as students, access to mental health services, the role of mental health promotion campaigns, preferred mHealth engagement features, factors that influence the adoption of mHealth interventions, and cultural relevance of mHealth interventions. The interpretation of our findings shows that students were reluctant to use mental health services because of the fear of stigma and a possible lack of confidentiality. Conclusions: Study participants viewed mHealth interventions for mental health as part of a blended intervention. They also felt that future mental health mHealth interventions should be more personalized and capable of managing adverse events such as suicidal ideation. %M 36939808 %R 10.2196/44542 %U https://www.jmir.org/2023/1/e44542 %U https://doi.org/10.2196/44542 %U http://www.ncbi.nlm.nih.gov/pubmed/36939808 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42646 %T Capturing the Dynamics of the Social Environment Through Experience Sampling Methods, Passive Sensing, and Egocentric Networks: Scoping Review %A Langener,Anna M %A Stulp,Gert %A Kas,Martien J %A Bringmann,Laura F %+ Groningen Institute for Evolutionary Life Sciences, Nijenborgh 7, Groningen, 9747 AG, Netherlands, 31 050 363 8, langener95@gmail.com %K social context %K experience sampling method %K egocentric network %K digital phenotyping %K passive measures %K ambulatory assessment %K mobile phone %D 2023 %7 17.3.2023 %9 Review %J JMIR Ment Health %G English %X Background: Social interactions are important for well-being, and therefore, researchers are increasingly attempting to capture people’s social environment. Many different disciplines have developed tools to measure the social environment, which can be highly variable over time. The experience sampling method (ESM) is often used in psychology to study the dynamics within a person and the social environment. In addition, passive sensing is often used to capture social behavior via sensors from smartphones or other wearable devices. Furthermore, sociologists use egocentric networks to track how social relationships are changing. Each of these methods is likely to tap into different but important parts of people’s social environment. Thus far, the development and implementation of these methods have occurred mostly separately from each other. Objective: Our aim was to synthesize the literature on how these methods are currently used to capture the changing social environment in relation to well-being and assess how to best combine these methods to study well-being. Methods: We conducted a scoping review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: We included 275 studies. In total, 3 important points follow from our review. First, each method captures a different but important part of the social environment at a different temporal resolution. Second, measures are rarely validated (>70% of ESM studies and 50% of passive sensing studies were not validated), which undermines the robustness of the conclusions drawn. Third, a combination of methods is currently lacking (only 15/275, 5.5% of the studies combined ESM and passive sensing, and no studies combined all 3 methods) but is essential in understanding well-being. Conclusions: We highlight that the practice of using poorly validated measures hampers progress in understanding the relationship between the changing social environment and well-being. We conclude that different methods should be combined more often to reduce the participants’ burden and form a holistic perspective on the social environment. %M 36930210 %R 10.2196/42646 %U https://mental.jmir.org/2023/1/e42646 %U https://doi.org/10.2196/42646 %U http://www.ncbi.nlm.nih.gov/pubmed/36930210 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44853 %T Study Features and Response Compliance in Ecological Momentary Assessment Research in Borderline Personality Disorder: Systematic Review and Meta-analysis %A Davanzo,Antonella %A d´Huart,Delfine %A Seker,Süheyla %A Moessner,Markus %A Zimmermann,Ronan %A Schmeck,Klaus %A Behn,Alex %+ Escuela de Psicología, Pontificia Universidad Católica de Chile, Instituto Milenio para la Investigación en Depresión y Personalidad, Av. Vicuña Mackenna 4860, Santiago, 7820436, Chile, 56 942152484, albehn@uc.cl %K borderline personality disorder %K ecological momentary assessment %K compliance %K study design features %K e–mental health %K mobile phone %D 2023 %7 15.3.2023 %9 Review %J J Med Internet Res %G English %X Background: Borderline personality disorder (BPD) is characterized by frequent and intense moment-to-moment changes in affect, behavior, identity, and interpersonal relationships, which typically result in significant and negative deterioration of the person’s overall functioning and well-being. Measuring and characterizing the rapidly changing patterns of instability in BPD dysfunction as they occur in a person’s daily life can be challenging. Ecological momentary assessment (EMA) is a method that can capture highly dynamic processes in psychopathology research and, thus, is well suited to study intense variability patterns across areas of dysfunction in BPD. EMA studies are characterized by frequent repeated assessments that are delivered to participants in real-life, real-time settings using handheld devices capable of registering responses to short self-report questions in daily life. Compliance in EMA research is defined as the proportion of prompts answered by the participant, considering all planned prompts sent. Low compliance with prompt schedules can compromise the relative advantages of using this method. Despite the growing EMA literature on BPD in recent years, findings regarding study design features that affect compliance with EMA protocols have not been compiled, aggregated, and estimated. Objective: This systematic meta-analytic review aimed to investigate the relationship between study design features and participant compliance in EMA research of BPD. Methods: A systematic review was conducted on November 12, 2021, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analyses of Observational Studies in Epidemiology) guidelines to search for articles featuring EMA studies of BPD that reported compliance rates and included sufficient data to extract relevant design features. For studies with complete data, random-effect models were used to estimate the overall compliance rate and explore its association with design features. Results: In total, 28 peer-reviewed EMA studies comprising 2052 participants were included in the study. Design features (sampling strategy, average prompting frequency, number of items, response window, sampling device, financial incentive, and dropout rate) showed a large variability across studies, and many studies did not report design features. The meta-analytic synthesis was restricted to 64% (18/28) of articles and revealed a pooled compliance rate of 79% across studies. We did not find any significant relationship between design features and compliance rates. Conclusions: Our results show wide variability in the design and reporting of EMA studies assessing BPD. Compliance rates appear to be stable across varying setups, and it is likely that standard design features are not directly responsible for improving or diminishing compliance. We discuss possible nonspecific factors of study design that may have an impact on compliance. Given the promise of EMA research in BPD, we also discuss the importance of unifying standards for EMA reporting so that data stemming from this rich literature can be aggregated and interpreted jointly. %M 36920466 %R 10.2196/44853 %U https://www.jmir.org/2023/1/e44853 %U https://doi.org/10.2196/44853 %U http://www.ncbi.nlm.nih.gov/pubmed/36920466 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41040 %T Attitudes of Physicians and Individuals Toward Digital Mental Health Tools: Protocol for a Web-Based Survey Research Project %A Nogueira-Leite,Diogo %A Cruz-Correia,Ricardo %+ Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, Porto, 4200-450, Portugal, 351 913667140, diogo.fdnl@gmail.com %K mental health %K mobile apps %K digital technology %K government regulation %D 2023 %7 14.3.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Digital transformation is impacting health care delivery. Great market dynamism is bringing opportunities and concerns alike into public discussion. Digital health apps are a vibrant segment where regulation is emerging, with Germany paving the way with its DiGA (Digitale Gesundheitsanwendungen, in German, meaning digital health apps) program. Simultaneously, mental ill-health constitutes a global health concern, and prevalence is expected to worsen due to the COVID-19 pandemic and its containment measures. Portugal and its National Health System may be a useful testbed for digital health interventions. Objective: The paper outlines the protocol for a research project on the attitudes of physicians and potential users toward digital mental health apps to improve access to care, patient outcomes, and reduce the burden of disease of mental ill-health. Methods: Web surveys will be conducted to acquire data from the main stakeholders (physicians and the academic community). Data analysis will replicate the statistical analysis performed in the studies from Dahlhausen and Borghouts to derive conclusions regarding the relative acceptance and likelihood of successful implementation of digital mental health apps in Portugal. Results: The findings of the proposed studies will elicit important information on how physicians and individuals perceive digital mental health app interventions to improve access to care, patient outcomes, and reduce the burden of disease of mental ill-health. Data collection ran between September 26 and November 6, 2022, for the first study and September 20 and October 20, 2022, for the second study. We obtained 160 responses to the first study’s survey and 539 answers to the second study’s survey. Data analysis is concluded, and both studies’ results are expected to be published in 2023. Conclusions: The results of the studies projected in this research protocol will have implications for researchers and academia, industry, and policy makers concerning the adoption and implementation of digital health mental apps and associated interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/41040 %M 36917172 %R 10.2196/41040 %U https://www.researchprotocols.org/2023/1/e41040 %U https://doi.org/10.2196/41040 %U http://www.ncbi.nlm.nih.gov/pubmed/36917172 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44205 %T Using a Safety Planning Mobile App to Address Suicidality in Young People Attending Community Mental Health Services in Ireland: Protocol for a Pilot Randomized Controlled Trial %A Melia,Ruth %A Francis,Kady %A Duggan,Jim %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Chambers,Derek %A McInerney,Shane J %A O'Dea,Edmond %A Bernert,Rebecca %+ Department of Psychology, University of Limerick, Castletroy, Limerick, V94 T9PX, Ireland, 353 61 202 700, ruth.melia@ul.ie %K suicide prevention %K mobile health %K mHealth %K safety planning %K SafePlan %K mobile phone %D 2023 %7 21.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Over 700,000 people die by suicide annually, making it the fourth leading cause of death among those aged 15-29 years globally. Safety planning is recommended best practice when individuals at risk of suicide present to health services. A safety plan, developed in collaboration with a health care practitioner, details the steps to be taken in an emotional crisis. SafePlan, a safety planning mobile app, was designed to support young people experiencing suicidal thoughts and behaviors and to record their plan in a way that is accessible immediately and in situ. Objective: The aim of this study is to assess the feasibility and acceptability of the SafePlan mobile app for patients experiencing suicidal thoughts and behaviors and their clinicians within Irish community mental health services, examine the feasibility of study procedures for both patients and clinicians, and determine if the SafePlan condition yields superior outcomes when compared with the control condition. Methods: A total of 80 participants aged 16-35 years accessing Irish mental health services will be randomized (1:1) to receive the SafePlan app plus treatment as usual or treatment as usual plus a paper-based safety plan. The feasibility and acceptability of the SafePlan app and study procedures will be evaluated using both qualitative and quantitative methodologies. The primary outcomes are feasibility outcomes and include the acceptability of the app to participants and clinicians, the feasibility of delivery in this setting, recruitment, retention, and app use. The feasibility and acceptability of the following measures in a full randomized controlled trial will also be assessed: the Beck Scale for Suicide Ideation, Columbia Suicide Severity Rating Scale, Coping Self-Efficacy Scale, Interpersonal Needs Questionnaire, and Client Service Receipt Inventory. A repeated measures design with outcome data collected at baseline, post intervention (8 weeks), and at 6-month follow-up will be used to compare changes in suicidal ideation for the intervention condition relative to the waitlist control condition. A cost-outcome description will also be undertaken. Thematic analyses will be used to analyze the qualitative data gathered through semistructured interviews with patients and clinicians. Results: As of January 2023, funding and ethics approval have been acquired, and clinician champions across mental health service sites have been established. Data collection is expected to commence by April 2023. The submission of completed manuscript is expected by April 2025. Conclusions: The framework for Decision-making after Pilot and feasibility Trials will inform the decision to progress to a full trial. The results will inform patients, researchers, clinicians, and health services of the feasibility and acceptability of the SafePlan app in community mental health services. The findings will have implications for further research and policy regarding the broader integration of safety planning apps. Trial Registration: OSF Registries osf.io/3y54m; https://osf.io/3y54m International Registered Report Identifier (IRRID): PRR1-10.2196/44205 %M 36809171 %R 10.2196/44205 %U https://www.researchprotocols.org/2023/1/e44205 %U https://doi.org/10.2196/44205 %U http://www.ncbi.nlm.nih.gov/pubmed/36809171 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e39258 %T Digital Phenotyping Data to Predict Symptom Improvement and Mental Health App Personalization in College Students: Prospective Validation of a Predictive Model %A Currey,Danielle %A Torous,John %+ Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02446, United States, 1 6176676700, jtorous@gmail.com %K mHealth %K mental health %K smartphones %K phenotype %K symptom %K college %K students %K young adults %K responsive %K personalized %K app %K application %K intervention %K effectiveness %K protocol %K model %K digital %K engagement %K algorithm %K usage %D 2023 %7 9.2.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health apps offer a transformative means to increase access to scalable evidence-based care for college students. Yet low rates of engagement currently preclude the effectiveness of these apps. One promising solution is to make these apps more responsive and personalized through digital phenotyping methods able to predict symptoms and offer tailored interventions. Objective: Following our protocol and using the exact model shared in that paper, our primary aim in this study is to assess the prospective validity of mental health symptom prediction using the mindLAMP app through a replication study. We also explored secondary aims around app intervention personalization and correlations of engagement with the Technology Acceptance Model (TAM) and Digital Working Alliance Inventory scale in the context of automating the study. Methods: The study was 28 days in duration and followed the published protocol, with participants collecting digital phenotyping data and being offered optional scheduled and algorithm-recommended app interventions. Study compensation was tied to the completion of weekly surveys and was not otherwise tied to engagement or use of the app. Results: The data from 67 participants were used in this analysis. The area under the curve values for the symptom prediction model ranged from 0.58 for the UCLA Loneliness Scale to 0.71 for the Patient Health Questionnaire-9. Engagement with the scheduled app interventions was high, with a study mean of 73%, but few participants engaged with the optional recommended interventions. The perceived utility of the app in the TAM was higher (P=.01) among those completing at least one recommended intervention. Conclusions: Our results suggest how digital phenotyping methods can be used to create generalizable models that may help create more personalized and engaging mental health apps. Automating studies is feasible, and our results suggest targets to increase engagement in future studies. International Registered Report Identifier (IRRID): RR2-10.2196/37954 %M 36757759 %R 10.2196/39258 %U https://www.jmir.org/2023/1/e39258 %U https://doi.org/10.2196/39258 %U http://www.ncbi.nlm.nih.gov/pubmed/36757759 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e42919 %T Mobile Mental Health in Women’s Community-Based Organizations: Protocol for a Pilot Randomized Controlled Trial %A Bhat,Amritha %A Goud,B Ramakrishna %A Kalidindi,Bharat %A Ruben,Johnson Pradeep %A Devadass,Dhinagaran %A Waghmare,Abijeet %A Collins,Pamela Y %A Raj,Tony %A Srinivasan,Krishnamachari %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195, United States, 1 2065433117, amritha@uw.edu %K mobile mental health %K women %K community-based %K depression %K rural %K stepped care %D 2023 %7 8.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Of every 10 women in rural India, 1 suffers from a common mental disorder such as depression, and untreated depression is associated with significant morbidity and mortality. Several factors lead to a large treatment gap, specifically for women in rural India, including stigma, lack of provider mental health workforce, and travel times. There is an urgent need to improve the rates of detection and treatment of depression among women in rural India without overburdening the scarce mental health resources. Objective: We propose to develop, test, and deploy a mental health app, MITHRA (Multiuser Interactive Health Response Application), for depression screening and brief intervention, designed for use in women’s self-help groups (SHGs) in rural India. Methods: We will use focus groups with SHG members and community health workers to guide the initial development of the app, followed by iterative modification based on input from a participatory design group consisting of proposed end users of the app (SHG members). The final version of the app will then be deployed for testing in a pilot cluster randomized trial, with 3 SHGs randomized to receive the app and 3 to receive enhanced care as usual. Results: This study was funded in June 2021. As of September 2022, we have completed both focus groups, 1 participatory design group, and app development. Conclusions: Delivering app-based depression screening and treatment in community settings such as SHGs can address stigma and transportation-related barriers to access to depression care and overcome cultural and contextual barriers to mobile health use. It can also address the mental health workforce shortage. If we find that the MITHRA approach is feasible, we will test the implementation and effectiveness of MITHRA in multiple SHGs across India in a larger randomized controlled trial. This approach of leveraging community-based organizations to improve the reach of depression screening and treatment is applicable in rural and underserved areas across the globe. International Registered Report Identifier (IRRID): DERR1-10.2196/42919 %M 36753310 %R 10.2196/42919 %U https://www.researchprotocols.org/2023/1/e42919 %U https://doi.org/10.2196/42919 %U http://www.ncbi.nlm.nih.gov/pubmed/36753310 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41422 %T ReachCare Mobile Apps for Patients Experiencing Suicidality in the Emergency Department: Development and Usability Testing Using Mixed Methods %A Larkin,Celine %A Djamasbi,Soussan %A Boudreaux,Edwin D %A Varzgani,Fatima %A Garner,Roscoe %A Siddique,Mariam %A Pietro,John %A Tulu,Bengisu %+ Department of Emergency Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave, Worcester, MA, 01655, United States, 1 7743291688, celine.larkin@umassmed.edu %K suicide %K emergency department %K mobile app %K usability %K engagement %K mobile phone %D 2023 %7 27.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Many individuals with suicide risk present to acute care settings such as emergency departments (EDs). However, staffing and time constraints mean that many EDs are not well equipped to deliver evidence-based interventions for patients experiencing suicidality. An existing intervention initiated in the ED for patients with suicide risk (Emergency Department Safety Assessment and Follow-up Evaluation [ED-SAFE]) has been found to be effective but faces trenchant barriers for widespread adoption. Objective: On the basis of the ED-SAFE intervention, we aimed to develop 2 apps for patients with suicide risk: a web app guiding patients through safety planning in the ED (ED app) and a smartphone app providing patients components of the ED-SAFE program on their phones after discharge (patient app). We then tested the usability of these apps with patients presenting to the ED with suicide risk. Methods: Using a user-centered design framework, we first developed user personas to explore the needs and characteristics of patients who are at risk for suicide using inputs from clinicians (n=3) and suicidologists (n=4). Next, we validated these personas during interviews with individuals with lived experience of suicidality (n=6) and used them to inform our application designs. We field-tested the apps with ED patients presenting with suicide risk (n=14) in 2 iterative cycles to assess their usability and engagement using a mixed methods approach. We also rated the quality and fidelity of the safety plans created. Results: We developed 2 interoperable and complementary apps. The first is a web app designed for use on a tablet device during ED admission that guides the patient by creating a safety plan using a chatbot-style interface. The second is a smartphone app for use after discharge and allows the patient to view, edit, and share their completed safety plan; access self-care education, helplines, and behavioral health referrals; and track follow-up appointments with the study clinician. The initial prototype usability testing (n=9) demonstrated satisfactory scores (ED app System Usability Scale [SUS], mean 78.6/100, SD 24.1; User Engagement Scale, mean 3.74/5, SD 0.72; patient app SUS, mean 81.7/100, SD 20.1). After refining the apps based on participant feedback, the second cycle testing (n=5) showed improvement (ED app SUS, mean 90.5/100, SD 9.9; User Engagement Scale, mean 4.07/5, SD 0.36; patient app SUS, mean 97.0/100, SD 1.9). The quality ratings for completed safety plans were satisfactory (Safety Planning Intervention Scoring Algorithm-Brief, mean 27.4, SD 3.4). Conclusions: By adopting a user-centered approach and creating personas to guide development, we were able to create apps for ED patients with suicide risk and obtain satisfactory usability, engagement, and quality scores. Developing digital health tools based on user-centered design principles that deliver evidence-based intervention components may help overcome trenchant implementation barriers in challenging health care settings. %M 36705961 %R 10.2196/41422 %U https://formative.jmir.org/2023/1/e41422 %U https://doi.org/10.2196/41422 %U http://www.ncbi.nlm.nih.gov/pubmed/36705961 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e37293 %T A Mobile Health App (ChillTime) Promoting Emotion Regulation in Dual Disorders: Acceptability and Feasibility Pilot Study %A Pennou,Antoine %A Lecomte,Tania %A Potvin,Stéphane %A Riopel,Gabrielle %A Vézina,Camille %A Villeneuve,Marie %A Abdel-Baki,Amal %A Khazaal,Yasser %+ Département de Psychologie, Université de Montréal, 90 Avenue Vincent d’Indy, Bur. C-358, Pavillon Marie-Victorin, succ Centre-Ville, post office box 6128, Montreal, QC, H2C 3J7, Canada, 1 514 343 6274, tania.lecomte@umontreal.ca %K dual disorder %K concomitant disorder %K mental disorder %K mental illness %K satisfaction %K mobile app %K mHealth %K mobile health %K emotion regulation %K distress management %K substance use disorder %K substance use %K emotion %K distress %K mental health %K acceptability %K feasibility %K psychosis %K psychotic %K schizophrenia %K emotional health %K pilot study %D 2023 %7 27.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: A growing number of studies highlight the importance of emotion regulation in the treatment and recovery of individuals with psychosis and concomitant disorders such as substance use disorder (SUD), for whom access to integrated dual-disorder treatments is particularly difficult. In this context, dedicated smartphone apps may be useful tools to provide immediate support to individuals in need. However, few studies to date have focused on the development and assessment of apps aimed at promoting emotional regulation for people with psychosis. Objective: The aim of this study was to evaluate the feasibility, acceptability, and potential clinical impact of a dedicated app (ChillTime) for individuals with psychotic disorders and concurrent SUD. The app design process followed recommendations for reducing cognitive effort on a mobile app. A total of 20 coping strategies regrouped in four categories (behavioral, emotional, cognitive, spiritual) were included in the app. Methods: This open pilot study followed a pre-post design. After the initial assessment, researchers asked participants to use the app as part of their treatment over a 30-day period. Feasibility was determined by the frequency of use of the app and measured using the number of completed strategies. Acceptability was determined by measuring ease of use, ease of learning, satisfaction, and perceived utility at the end of the 30-day study period based on responses to satisfaction questionnaires. Clinical scales measuring emotion regulation, substance use (ie, type of substance, amount taken, and frequency of use), and various psychiatric symptoms were administered at the beginning and end of the 30-day period. Results: A total of 13 participants were recruited from two first-episode psychosis clinics in Montreal, Quebec, Canada. All participants were symptomatically stable, were between 18 and 35 years of age (mostly men; 70% of the sample), and had a schizophrenia spectrum disorder with a comorbid substance use diagnosis. A total of 11 participants completed the study (attrition<20%). Approximately half of the participants used the tool at least 33% of the days (11-21 days). Cognitive and emotion-focused techniques were rated the highest in terms of usefulness and were the most frequently used. The majority of participants gave positive answers about the ease of use and the ease of learning the tool. A nonsignificant association of ChillTime use with negative symptoms and drug use was observed. No other statistically significant changes were observed. Conclusions: The ChillTime app showed good feasibility (approximately half of the participants used the tool at least 33% of the days) and acceptability among people with schizophrenia spectrum disorder and SUD. Trends suggesting a potential impact on certain clinical outcomes will need to be replicated in larger-sample studies before any conclusion can be drawn. %M 36705963 %R 10.2196/37293 %U https://formative.jmir.org/2023/1/e37293 %U https://doi.org/10.2196/37293 %U http://www.ncbi.nlm.nih.gov/pubmed/36705963 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42866 %T The Feasibility of Implementing Remote Measurement Technologies in Psychological Treatment for Depression: Mixed Methods Study on Engagement %A de Angel,Valeria %A Adeleye,Fadekemi %A Zhang,Yuezhou %A Cummins,Nicholas %A Munir,Sara %A Lewis,Serena %A Laporta Puyal,Estela %A Matcham,Faith %A Sun,Shaoxiong %A Folarin,Amos A %A Ranjan,Yatharth %A Conde,Pauline %A Rashid,Zulqarnain %A Dobson,Richard %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, E3.08, 3rd Floor East Wing, de Crespigny park, London, SE5 8AF, United Kingdom, 44 20 7848 0002, valeria.de_angel@kcl.ac.uk %K depression %K anxiety %K digital health %K wearable devices %K smartphone %K passive sensing %K mobile health %K mHealth %K digital phenotyping %K mobile phone %D 2023 %7 24.1.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Remote measurement technologies (RMTs) such as smartphones and wearables can help improve treatment for depression by providing objective, continuous, and ecologically valid insights into mood and behavior. Engagement with RMTs is varied and highly context dependent; however, few studies have investigated their feasibility in the context of treatment. Objective: A mixed methods design was used to evaluate engagement with active and passive data collection via RMT in people with depression undergoing psychotherapy. We evaluated the effects of treatment on 2 different types of engagement: study attrition (engagement with study protocol) and patterns of missing data (engagement with digital devices), which we termed data availability. Qualitative interviews were conducted to help interpret the differences in engagement. Methods: A total of 66 people undergoing psychological therapy for depression were followed up for 7 months. Active data were gathered from weekly questionnaires and speech and cognitive tasks, and passive data were gathered from smartphone sensors and a Fitbit (Fitbit Inc) wearable device. Results: The overall retention rate was 60%. Higher-intensity treatment (χ21=4.6; P=.03) and higher baseline anxiety (t56.28=−2.80, 2-tailed; P=.007) were associated with attrition, but depression severity was not (t50.4=−0.18; P=.86). A trend toward significance was found for the association between longer treatments and increased attrition (U=339.5; P=.05). Data availability was higher for active data than for passive data initially but declined at a sharper rate (90%-30% drop in 7 months). As for passive data, wearable data availability fell from a maximum of 80% to 45% at 7 months but showed higher overall data availability than smartphone-based data, which remained stable at the range of 20%-40% throughout. Missing data were more prevalent among GPS location data, followed by among Bluetooth data, then among accelerometry data. As for active data, speech and cognitive tasks had lower completion rates than clinical questionnaires. The participants in treatment provided less Fitbit data but more active data than those on the waiting list. Conclusions: Different data streams showed varied patterns of missing data, despite being gathered from the same device. Longer and more complex treatments and clinical characteristics such as higher baseline anxiety may reduce long-term engagement with RMTs, and different devices may show opposite patterns of missingness during treatment. This has implications for the scalability and uptake of RMTs in health care settings, the generalizability and accuracy of the data collected by these methods, feature construction, and the appropriateness of RMT use in the long term. %M 36692937 %R 10.2196/42866 %U https://mental.jmir.org/2023/1/e42866 %U https://doi.org/10.2196/42866 %U http://www.ncbi.nlm.nih.gov/pubmed/36692937 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e38831 %T Content Recommendation Systems in Web-Based Mental Health Care: Real-world Application and Formative Evaluation %A Chaturvedi,Akhil %A Aylward,Brandon %A Shah,Setu %A Graziani,Grant %A Zhang,Joan %A Manuel,Bobby %A Telewa,Emmanuel %A Froelich,Stefan %A Baruwa,Olalekan %A Kulkarni,Prathamesh Param %A Ξ,Watson %A Kunkle,Sarah %+ Headspace Health, 595 Market St, 7th floor, San Francisco, CA, 94105, United States, 1 720 243 4668, akhilchatur@gmail.com %K behavioral coaching %K recommender systems %K mental health %K machine learning %K natural language processing %K telemental health %K mobile health %K mHealth %K digital health %K digital coaching %K health platform %D 2023 %7 19.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Recommender systems have great potential in mental health care to personalize self-guided content for patients, allowing them to supplement their mental health treatment in a scalable way. Objective: In this paper, we describe and evaluate 2 knowledge-based content recommendation systems as parts of Ginger, an on-demand mental health platform, to bolster engagement in self-guided mental health content. Methods: We developed two algorithms to provide content recommendations in the Ginger mental health smartphone app: (1) one that uses users' responses to app onboarding questions to recommend content cards and (2) one that uses the semantic similarity between the transcript of a coaching conversation and the description of content cards to make recommendations after every session. As a measure of success for these recommendation algorithms, we examined the relevance of content cards to users’ conversations with their coach and completion rates of selected content within the app measured over 14,018 users. Results: In a real-world setting, content consumed in the recommendations section (or “Explore” in the app) had the highest completion rates (3353/7871, 42.6%) compared to other sections of the app, which had an average completion rate of 37.35% (21,982/58,614; P<.001). Within the app’s recommendations section, conversation-based content recommendations had 11.4% (1108/2364) higher completion rates per card than onboarding response-based recommendations (1712/4067; P=.003) and 26.1% higher than random recommendations (534/1440; P=.005). Studied via subject matter experts’ annotations, conversation-based recommendations had a 16.1% higher relevance rate for the top 5 recommended cards, averaged across sessions of varying lengths, compared to a random control (110 conversational sessions). Finally, it was observed that both age and gender variables were sensitive to different recommendation methods, with responsiveness to personalized recommendations being higher if the users were older than 35 years or identified as male. Conclusions: Recommender systems can help scale and supplement digital mental health care with personalized content and self-care recommendations. Onboarding-based recommendations are ideal for “cold starting” the process of recommending content for new users and users that tend to use the app just for content but not for therapy or coaching. The conversation-based recommendation algorithm allows for dynamic recommendations based on information gathered during coaching sessions, which is a critical capability, given the changing nature of mental health needs during treatment. The proposed algorithms are just one step toward the direction of outcome-driven personalization in mental health. Our future work will involve a robust causal evaluation of these algorithms using randomized controlled trials, along with consumer feedback–driven improvement of these algorithms, to drive better clinical outcomes. %M 36656628 %R 10.2196/38831 %U https://formative.jmir.org/2023/1/e38831 %U https://doi.org/10.2196/38831 %U http://www.ncbi.nlm.nih.gov/pubmed/36656628 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e41773 %T Training Staff Across the Veterans Affairs Health Care System to Use Mobile Mental Health Apps: A National Quality Improvement Project %A McGee-Vincent,Pearl %A Mackintosh,Margaret-Anne %A Jamison,Andrea L %A Juhasz,Katherine %A Becket-Davenport,Colleen %A Bosch,Jeane %A Avery,Timothy J %A Glamb,Lauren %A Hampole,Shilpa %+ Office of Mental Health and Suicide Prevention, Veterans Health Administration, 795 Willow Rd (334-NCPTSD), Menlo Park, CA, 94025, United States, 1 650 353 8847, pearl.mcgee-vincent@va.gov %K mental health %K mobile apps %K digital health %K technology %K veterans %K training %D 2023 %7 12.1.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: The National Center for PTSD, within the Department of Veterans Affairs (VA), has developed a suite of free, publicly available, evidence-informed apps that can reach an increasing number of veterans and bridge gaps in care by providing resources to those who are not engaged in mental health treatment. To expand the reach of these apps, staff across VA service lines learned about these apps, their features and limitations, and how to introduce them to veterans. Objective: This study aimed to develop, disseminate, and evaluate a training for multidisciplinary staff as part of a national quality improvement project to increase the reach of mobile mental health apps as a resource for veterans. Methods: Sites from all of VA’s 18 geographic regions enrolled in this project. At each site, a minimum of 25 VA staff members who had direct contact with veterans, including staff from the mental health service line and all other service lines, were recruited to participate. Training included a 3-hour multidisciplinary core module, and a 1-hour clinical integration module designed specifically for mental health clinicians. Owing to the COVID-19 pandemic, the trainings were adapted to a live, web-based format. Pre- and posttraining surveys assessed program reach (ie, participants enrolled per site), satisfaction, and effectiveness of the training as measured by changes in knowledge, basic skills, and behavioral intentions to use apps with veterans. Results: A total of 1110 participants representing 34 disciplines at 19 VA sites completed the training. Overall, 67% (743/1109) of participants were mental health staff members. Sites averaged 58.4 participants (SD 36.49, median [IQR] 51). Most (961/1024, 93.85%) participants were satisfied with the training and reported that they (941/1018, 92.44%) would recommend it to others. App knowledge scores significantly increased from pretraining (mean 80.8% correct, SD 15.77%) to posttraining (mean 91.1% correct, SD 9.57%; P<.001). At posttraining, participants also reported greater confidence in their ability to show veterans how to download (z=−13.86; P<.001) and use VA mental health apps (z=−15.13; P<.001). There was near universal endorsement by staff for their intentions to recommend apps to veterans as well as their ability to think of at least one specific veteran to whom they could recommend an app. Staff also reported a strong motivation to encourage other VA staff to share apps with veterans. Conclusions: The training far exceeded the initial goals for staff recruitment and training for all three metrics. Overall, 33% (366/1109) of participants came from service lines outside of mental health, indicating the feasibility of introducing these mental health resources during medical appointments and in other contexts. %M 36633895 %R 10.2196/41773 %U https://mental.jmir.org/2023/1/e41773 %U https://doi.org/10.2196/41773 %U http://www.ncbi.nlm.nih.gov/pubmed/36633895 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41546 %T Young Adults’ Perceptions of 2 Publicly Available Digital Resources for Self-injury: Qualitative Study of a Peer Support App and Web-Based Factsheets %A Kruzan,Kaylee Payne %A Whitlock,Janis %A Chapman,Julia %A Bhandari,Aparajita %A Bazarova,Natalya %+ Department of Preventive Medicine, Northwestern University, 750 N Lakeshore Drive, Chicago, IL, 60611, United States, 1 312 503 3114, kaylee.kruzan@northwestern.edu %K nonsuicidal self-injury %K self-harm %K digital mental health %K mobile app %K design %K intervention %K peer support %K psychoeducation %D 2023 %7 12.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital resources have the potential to bridge the gaps in mental health services for young people who self-injure. Most research on digital resources for this population has involved observational studies of content in web-based communities or formative studies focused on the design and early evaluation of new interventions. Far less research has sought to understand young people’s experiences with publicly available digital resources or to identify specific components of these resources that are perceived to be of value in their recovery. Objective: This study aimed to understand young people’s experiences with 2 publicly available digital resources for self-injury—a peer support app and web-based factsheets—and to disentangle potential explanatory mechanisms associated with perceived benefits and harms. Methods: Participants were 96 individuals (aged 16-25 years) with nonsuicidal self-injury behavior in the past month, who recently completed a pilot randomized controlled trial designed to assess the efficacy of a peer support app as compared with web-based factsheets to reduce self-injury behavior. The trial showed that participants using the peer support app reported less self-injury behavior relative to those receiving the web-based factsheets over 8 weeks. In this study, we used a conventional approach to content analysis of responses to 2 open-ended questions delivered at the end of the trial with the aims of exploring participants’ overall experiences with these resources and identifying the qualities of these resources that were perceived to be beneficial to or harmful for participants’ recovery. Results: Overall, participants were more likely to report benefits than harms. Participants who used the peer support app reported more harms than those who received the web-based factsheets. In the open coding phase, clear benefits were also derived from repeated weekly surveys about self-injury. Key benefits across digital resources included enhanced self-knowledge, reduction in self-injury activity, increased outreach or informal conversations, improved attitudes toward therapy, improved mood, and feeling supported and less alone. Key challenges included worsened or unchanged self-injury activity, diminished mood, and increased barriers to outreach. The most prominent benefit derived from the web-based factsheets and weekly surveys was improved self-understanding. However, the way this manifested differed, with factsheets providing insight on why participants engage in self-injury and the function it serves them and surveys making the frequency and severity of participants’ behaviors more apparent. The benefits perceived from using the peer support app were general improvements in mood and feeling less alone. Conclusions: Findings contribute a nuanced understanding of young people’s experiences with these digital resources and have implications for the optimization of existing platforms and the design of novel resources to support individuals who self-injure. %M 36633896 %R 10.2196/41546 %U https://formative.jmir.org/2023/1/e41546 %U https://doi.org/10.2196/41546 %U http://www.ncbi.nlm.nih.gov/pubmed/36633896 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e42119 %T A Universal Mental Health–Promoting Mobile App for Adolescents: Protocol for a Cluster Randomized Controlled Trial %A Kaiser,Sabine %A Rye,Marte %A Jakobsen,Reidar %A Martinussen,Monica %A Høgsdal,Helene %A Kyrrestad,Henriette %+ Regional Centre for Child and Youth Mental Health and Child Welfare - North, Faculty of Health Sciences, UiT The Arctic University of Norway, Campus Tromsø, Breivika, MH 2, plan 9 og 10, Tromsø, 9019, Norway, 47 77 64 58 50, sabine.kaiser@uit.no %K mental health promotion %K mobile app %K mobile phone %K adolescents %K Opp %K teens %K application %K effectiveness %K intervention %K effect %K health %K health promotion %D 2023 %7 11.1.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: In times of increasing mental health problems among young people, strengthening efforts to improve mental health through mental health promotion and prevention becomes increasingly important. Effective measures that support young people in coping with negative thoughts, feelings, and stress are essential, not just for the individual but also for society. Objective: The aim of this paper is to provide a description of a cluster randomized controlled trial that will be conducted to examine the effectiveness of Opp, a universal mental health–promoting mobile app for adolescents aged 13 to 19 years that provides information and exercises to better cope with stress, negative thoughts, and negative feelings. The protocol was developed in accordance with the SPIRIT checklist. Methods: An effectiveness study will be conducted with 3 measurement points: preintervention (T1), 2 weeks after the intervention (T2), and about 1 month after the intervention (T3). Adolescents will be recruited from middle and high schools in Norway and randomly assigned to the intervention or control groups. Randomization will be conducted on the school level. Opp can be downloaded from the Google Play or App Store but is password protected with a 4-digit code, which will be removed after study completion. Participants in the intervention group will receive a text message with the code to unlock the app. The participants in the intervention group can use Opp without limits on length or time of use. Objective data on how long or how often the participants use the app will not be collected. However, the second and third questionnaires for the intervention group contain app-specific questions on, for example, the use of the app. Results: Recruitment and data collection started in August and September 2022. So far, 381 adolescents have answered the first questionnaire. Data collection was expected to end in December 2022 but has had to be prolonged to approximately June 2023. The results of the study will be available in 2023 at the earliest. Conclusions: This project will contribute unique knowledge to the field, as there are few studies that have examined the effects of universal health-promoting mobile apps for adolescents. However, several limitations have to be taken into account when interpreting the results, such as randomization on the school level, the short time frame in which the study was conducted, and the lack of objective data to monitor the use of the app. Trial Registration: ClinicalTrials.gov NCT05211713; https://www.clinicaltrials.gov/ct2/show/NCT05211713 International Registered Report Identifier (IRRID): PRR1-10.2196/42119 %M 36630167 %R 10.2196/42119 %U https://www.researchprotocols.org/2023/1/e42119 %U https://doi.org/10.2196/42119 %U http://www.ncbi.nlm.nih.gov/pubmed/36630167 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40773 %T Adolescents’ Assessment of Two Mental Health–Promoting Mobile Apps: Results of Two User Surveys %A Høgsdal,Helene %A Kaiser,Sabine %A Kyrrestad,Henriette %+ Regional Centre for Child and Youth Mental Health and Child Welfare - North, UiT The Arctic University of Norway, Campus Tromsø, Breivika, Tromsø, Norway, 47 77 64 66 19, helene.hogsdal@uit.no %K mental health app %K mobile app %K mental health %K mental health promotion %K cyberbullying %K adolescents %K user satisfaction %K system usability %K app quality %K mental health intervention %K health promotion %K app usability %K user experience %D 2023 %7 6.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: The importance of mental health promotion is irrevocable and is especially important at a young age. More mental health-promoting mobile apps have been developed in the last few years. However, their usability and quality have been rarely assessed. Objective: The aim of this study is to investigate how adolescents assess the usability, quality, and potential goal achievement of Opp and NettOpp. Opp is a universal mental health–promoting mobile app aimed at 13- to 19-year-olds, and NettOpp is a mobile app for children and adolescents between 11 to 16 years of age that have experienced negative incidents online. Methods: A total of 45 adolescents tested either Opp (n=30) or NettOpp (n=15) for a period of 3 weeks and answered a questionnaire. The System Usability Scale (SUS) was used to measure the usability of the apps. A SUS score above 70 indicates acceptable usability. Items from the Mobile Application Rating Scale were adapted for study purposes and used to measure the quality and perceived goal achievement that Opp and NettOpp might have on adolescents’ knowledge, attitudes, and intention to change behavior. Furthermore, adolescents could answer an open comment question. Results: Opp had a mean SUS score of 80.37 (SD 9.27), and NettOpp’s mean SUS score was 80.33 (SD 10.30). In the overall evaluation, Opp and NettOpp were given a mean score of 3.78 (SD 0.42) and 4.20 (SD 0.56), respectively, on a 5-point scale, where 5 was best. Most adolescents who evaluated Opp rated that the app would increase knowledge about mental health and help young people deal with stress and difficult emotions or situations. Most adolescents who evaluated NettOpp agreed that the app would increase awareness and knowledge about cyberbullying, change attitudes toward cyberbullying, and motivate them to address cyberbullying. Some adolescents stated that Opp was difficult to navigate and consisted of too much text. Some of the adolescents that tested NettOpp stated that the app had crashed and that the design was a bit childish. Conclusions: All in all, this study indicates that Opp and NettOpp have good usability and that adolescents are satisfied with both apps. It also indicates that the potential goal achievement of the apps, for example, increasing knowledge about mental health (Opp) or cyberbullying (NettOpp) is promising. While there are some comments from the users that are more difficult to solve (eg, Opp is too text-based), some comments helped improve the apps (eg, that the app crashed). Overall, the user evaluation provided valuable knowledge about how adolescents assess Opp and NettOpp. However, more extensive effectiveness studies are necessary to measure their actual goal achievement. %M 36607734 %R 10.2196/40773 %U https://formative.jmir.org/2023/1/e40773 %U https://doi.org/10.2196/40773 %U http://www.ncbi.nlm.nih.gov/pubmed/36607734 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e37270 %T Assessment and Disruption of Ruminative Episodes to Enhance Mobile Cognitive Behavioral Therapy Just-in-Time Adaptive Interventions in Clinical Depression: Pilot Randomized Controlled Trial %A Wang,Liyuan %A Miller,Lynn %+ Children's Hospital, Los Angeles, Department of Adolescent and Young Adult, 3250 Wilshire Blvd, Suite 1202, Los Angeles, CA, 90027-0000, United States, 1 7654911022, liwang@chla.usc.edu %K depressive rumination %K mobile health %K mHealth %K just-in-time adaptive intervention %K depression %K mental health %K mobile phone %D 2023 %7 5.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: A just-in-time adaptive intervention (JITAI) is “designed to address the dynamically changing needs of individuals via the provision of the type or amount of support needed, at the right time when needed.” If and how rumination-focused cognitive behavioral therapy (RFCBT), the gold standard, blocks emotional cascades underlying rumination is unclear. Furthermore, cognitive behavioral therapy has been successfully used as a mobile variant, but RFCBT has not been adapted for a mobile variant (mobile RFCBT [MRFCBT]) or for a JITAI variant. Objective: This study aimed to pilot-test a fully automated JITAI leveraging RFCBT and ways to identify and block cascading depressive rumination. Methods: Patients in therapy for clinical depression were recruited for a randomized controlled trial (RCT). After consenting to be part of the RCT, they were randomly assigned to either of the 2 mobile versions of the RFCBT conditions personalized to the individual’s rumination timing patterns (JITAI-MRFCBT) or a no-treatment control condition through a double-blind procedure. Although the initial design was to have a 3-armed trial with 2 JITAI conditions (a JITAI and a narrative JITAI condition), we later opted to collapse those 2 conditions into 1 JITAI condition because of the low number of participants. All participants were recruited and participated through their smartphones, receiving 5 SMS text message reminders on each of the 35 days to self-report their rumination-related symptoms (eg, rumination episodes and duration). In the JITAI-MRFCBT condition, they also received treatment materials. The first 7 days provided a rumination baseline, and the last 7 days provided a postintervention rumination value. In total, 42% (25/59) of volunteers were eligible and provided their phone numbers, 20% (5/25) of whom never replied to the SMS text message reminding them to start the RCT. A total of 90% (18/20) of volunteers completed it (ie, finishing, as prespecified, 80% of the questionnaires and training tasks) and, therefore, were included in the analysis. Results: Using independent 2-tailed t tests with bootstrapping, results showed that participants in the JITAI-MRFCBT condition, compared with those in the control condition, reported a greater reduction in counts of rumination episodes (mean −25.28, SD 14.50 vs mean 1.44, SD 4.12, P<.001) and greater reduced average time (minutes) spent in rumination (mean −21.53, SD 17.6 vs mean 1.47, SD 1.5; P=.04). Results also suggest that, compared with those in the control group, those in treatment reduced ruminative carryover from one episode to the next. Conclusions: The results suggest that JITAI-MRFCBT may reduce negative rumination by providing RFCBT just in time following rumination, thereby blocking the next rumination episode using the same trigger. This study supports a subsequent, full-scale JITAI and the importance of leveraging mobile smartphone technology with MRFCBT to curb depressive symptoms. Trial Registration: ClinicalTrials.gov NCT04554706; https://clinicaltrials.gov/ct2/show/NCT04554706 %M 36602841 %R 10.2196/37270 %U https://formative.jmir.org/2023/1/e37270 %U https://doi.org/10.2196/37270 %U http://www.ncbi.nlm.nih.gov/pubmed/36602841 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 12 %P e42301 %T Leveraging Mobile Health to Manage Mental Health/Behavioral Health Disorders: Systematic Literature Review %A Kruse,Clemens Scott %A Betancourt,Jose A %A Gonzales,Matthew %A Dickerson,Kennedy %A Neer,Miah %+ School of Health Administration, Texas State University, 601 University Drive, Encino, 250, San Marcos, TX, 78666, United States, 1 512 245 4462, scottkruse@txstate.edu %K mHealth %K telemedicine %K mental health %K behavioral health %K anxiety %K mobile device %K smartphone %K SMS text messaging %K RCT %D 2022 %7 27.12.2022 %9 Review %J JMIR Ment Health %G English %X Background: Mental health is a complex condition, highly related to emotion. The COVID-19 pandemic caused a significant spike in depression (from isolation) and anxiety (event related). Mobile Health (mHealth) and telemedicine offer solutions to augment patient care, provide education, improve symptoms of depression, and assuage fears and anxiety. Objective: This review aims to assess the effectiveness of mHealth to provide mental health care by analyzing articles published in the last year in peer-reviewed, academic journals using strong methodology (randomized controlled trial). Methods: We queried 4 databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Web of Science, and ScienceDirect) using a standard Boolean search string. We conducted this systematic literature review in accordance with the Kruse protocol and reported it in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) 2020 checklist (n=33). Results: A total of 4 interventions (mostly mHealth) from 14 countries identified improvements in primary outcomes of depression and anxiety as well as in several secondary outcomes, namely, quality of life, mental well-being, cognitive flexibility, distress, sleep, self-efficacy, anger, decision conflict, decision regret, digestive disturbance, pain, and medication adherence. Conclusions: mHealth interventions can provide education, treatment augmentation, and serve as the primary modality in mental health care. The mHealth modality should be carefully considered when evaluating modes of care. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42022343489; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=343489 %M 36194896 %R 10.2196/42301 %U https://mental.jmir.org/2022/12/e42301 %U https://doi.org/10.2196/42301 %U http://www.ncbi.nlm.nih.gov/pubmed/36194896 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e34893 %T Digital Medicine System in Veterans With Severe Mental Illness: Feasibility and Acceptability Study %A Gonzales,Sarah %A Okusaga,Olaoluwa O %A Reuteman-Fowler,J Corey %A Oakes,Megan M %A Brown,Jamie N %A Moore,Scott %A Lewinski,Allison A %A Rodriguez,Cristin %A Moncayo,Norma %A Smith,Valerie A %A Malone,Shauna %A List,Justine %A Cho,Raymond Y %A Jeffreys,Amy S %A Bosworth,Hayden B %+ Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 W. Chapel Hill Street, Suite 600, Durham, NC, 27701, United States, 1 919 286 0411 ext 7101, hayden.bosworth@duke.edu %K ABILIFY MYCITE %K digital medicine %K adherence %K aripiprazole %K Veterans %K qualitative methods %K mental illness %K mental health %K medication %K mobile phone %D 2022 %7 22.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Suboptimal medication adherence is a significant problem for patients with serious mental illness. Measuring medication adherence through subjective and objective measures can be challenging, time-consuming, and inaccurate. Objective: The primary purpose of this feasibility and acceptability study was to evaluate the impact of a digital medicine system (DMS) among Veterans (patients) with serious mental illness as compared with treatment as usual (TAU) on medication adherence. Methods: This open-label, 2-site, provider-randomized trial assessed aripiprazole refill adherence in Veterans with schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder. We randomized 26 providers such that their patients either received TAU or DMS for a period of 90 days. Semistructured interviews with patients and providers were used to examine the feasibility and acceptability of using the DMS. Results: We enrolled 46 patients across 2 Veterans Health Administration sites: 21 (46%) in DMS and 25 (54%) in TAU. There was no difference in the proportion of days covered by medication refill over 3 and 6 months (0.82, SD 0.24 and 0.75, SD 0.26 in DMS vs 0.86, SD 0.19 and 0.82, SD 0.21 in TAU, respectively). The DMS arm had 0.85 (SD 0.20) proportion of days covered during the period they were engaged with the DMS (mean 144, SD 100 days). Interviews with patients (n=14) and providers (n=5) elicited themes salient to using the DMS. Patient findings described the positive impact of the DMS on medication adherence, challenges with the DMS patch connectivity and skin irritation, and challenges with the DMS app that affected overall use. Providers described an overall interest in using a DMS as an objective measure to support medication adherence in their patients. However, providers described challenges with the DMS dashboard and integrating DMS data into their workflow, which decreased the usability of the DMS for providers. Conclusions: There was no observed difference in refill rates. Among those who engaged in the DMS arm, the proportion of days covered by refills were relatively high (mean 0.85, SD 0.20). The qualitative analyses highlighted areas for further refinement of the DMS. Trial Registration: ClinicalTrials.gov NCT03881449; https://clinicaltrials.gov/ct2/show/NCT03881449 %M 36548028 %R 10.2196/34893 %U https://formative.jmir.org/2022/12/e34893 %U https://doi.org/10.2196/34893 %U http://www.ncbi.nlm.nih.gov/pubmed/36548028 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 4 %P e40133 %T Health Tracking via Mobile Apps for Depression Self-management: Qualitative Content Analysis of User Reviews %A Polhemus,Ashley %A Simblett,Sara %A Dawe-Lane,Erin %A Gilpin,Gina %A Elliott,Benjamin %A Jilka,Sagar %A Novak,Jan %A Nica,Raluca Ileana %A Temesi,Gergely %A Wykes,Til %+ Merck Research Labs Information Technology, Merck, Sharpe, & Dohme, The Circle 66, Zurich, 8058, Switzerland, 41 762519453, polhemusam@gmail.com %K depression %K mental health %K health tracking %K self-management %K data visualization %K mobile phone %D 2022 %7 23.11.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Tracking and visualizing health data using mobile apps can be an effective self-management strategy for mental health conditions. However, little evidence is available to guide the design of mental health–tracking mechanisms. Objective: The aim of this study was to analyze the content of user reviews of depression self-management apps to guide the design of data tracking and visualization mechanisms for future apps. Methods: We systematically reviewed depression self-management apps on Google Play and iOS App stores. English-language reviews of eligible apps published between January 1, 2018, and December 31, 2021, were extracted from the app stores. Reviews that referenced health tracking and data visualization were included in sentiment and qualitative framework analyses. Results: The search identified 130 unique apps, 26 (20%) of which were eligible for inclusion. We included 783 reviews in the framework analysis, revealing 3 themes. Impact of app-based mental health tracking described how apps increased reviewers’ self-awareness and ultimately enabled condition self-management. The theme designing impactful mental health–tracking apps described reviewers’ feedback and requests for app features during data reporting, review, and visualization. It also described the desire for customization and contexts that moderated reviewer preference. Finally, implementing impactful mental health–tracking apps described considerations for integrating apps into a larger health ecosystem, as well as the influence of paywalls and technical issues on mental health tracking. Conclusions: App-based mental health tracking supports depression self-management when features align with users’ individual needs and goals. Heterogeneous needs and preferences raise the need for flexibility in app design, posing challenges for app developers. Further research should prioritize the features based on their importance and impact on users. %M 36416875 %R 10.2196/40133 %U https://humanfactors.jmir.org/2022/4/e40133 %U https://doi.org/10.2196/40133 %U http://www.ncbi.nlm.nih.gov/pubmed/36416875 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 11 %P e41482 %T Development of the First Episode Digital Monitoring mHealth Intervention for People With Early Psychosis: Qualitative Interview Study With Clinicians %A Stefancic,Ana %A Rogers,R Tyler %A Styke,Sarah %A Xu,Xiaoyan %A Buchsbaum,Richard %A Nossel,Ilana %A Cabassa,Leopoldo J %A Stroup,T Scott %A Kimhy,David %+ Department of Psychiatry, Icahn School of Medicine, One Gustave L Levy Place, Box 1230, New York, NY, 10029, United States, 1 212 659 8752, david.kimhy@mssm.edu %K first-episode psychosis %K early psychosis %K coordinated specialty care %K mental health treatment %K shared decision-making %K mobile health %K smartphone apps %K qualitative %K digital psychiatry %K mobile phone %D 2022 %7 4.11.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile health (mHealth) technologies have been used extensively in psychosis research. In contrast, their integration into real-world clinical care has been limited despite the broad availability of smartphone-based apps targeting mental health care. Most apps developed for treatment of individuals with psychosis have focused primarily on encouraging self-management skills of patients via practicing cognitive behavioral techniques learned during face-to-face clinical sessions (eg, challenging dysfunctional thoughts and relaxation exercises), reminders to engage in health-promoting activities (eg, exercising, sleeping, and socializing), or symptom monitoring. In contrast, few apps have sought to enhance the clinical encounter itself to improve shared decision-making (SDM) and therapeutic relationships with clinicians, which have been linked to positive clinical outcomes. Objective: This qualitative study sought clinicians’ input to develop First Episode Digital Monitoring (FREEDoM), an app-based mHealth intervention. FREEDoM was designed to improve the quality, quantity, and timeliness of clinical and functional data available to clinicians treating patients experiencing first-episode psychosis (FEP) to enhance their therapeutic relationship and increase SDM. Methods: Following the app’s initial development, semistructured qualitative interviews were conducted with 11 FEP treatment providers at 3 coordinated specialty care clinics to elicit input on the app’s design, the data report for clinicians, and planned usage procedures. We then generated a summary template and conducted matrix analysis to systematically categorize suggested adaptations to the evidence-based intervention using dimensions of the Framework for Reporting Adaptations and Modifications‐Enhanced (FRAME) and documented the rationale for adopting or rejecting suggestions. Results: The clinicians provided 31 suggestions (18 adopted and 13 rejected). Suggestions to add or refine the content were most common (eg, adding questions in the app). Adaptations to context were most often related to plans for implementing the intervention, how the reported data were displayed to clinicians, and with whom the reports were shared. Reasons for suggestions primarily included factors related to health narratives and priorities of the patients (eg, focus on the functional impact of symptoms vs their severity), providers’ clinical judgment (eg, need for clinically relevant information), and organizations’ mission and culture. Reasons for rejecting suggestions included requests for data and procedures beyond the intervention’s scope, concerns regarding dilution of the intervention’s core components, and concerns about increasing patient burden while using the app. Conclusions: FREEDoM focuses on a novel target for the deployment of mHealth technologies in the treatment of FEP patients—the enhancement of SDM and improvement of therapeutic relationships. This study illustrates the use of the FRAME, along with methods and tools for rapid qualitative analysis, to systematically track adaptations to the app as part of its development process. Such adaptations may contribute to enhanced acceptance of the intervention by clinicians and a higher likelihood of integration into clinical care. Trial Registration: ClinicalTrials.gov NCT04248517; https://tinyurl.com/tjuyxvv6 %M 36331539 %R 10.2196/41482 %U https://mental.jmir.org/2022/11/e41482 %U https://doi.org/10.2196/41482 %U http://www.ncbi.nlm.nih.gov/pubmed/36331539 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e38460 %T Brief App-Based Cognitive Behavioral Therapy for Anxiety Symptoms in Psychiatric Inpatients: Feasibility Randomized Controlled Trial %A Sharma,Gaurav %A Schlosser,Lisa %A Jones,Brett D M %A Blumberger,Daniel M %A Gratzer,David %A Husain,M Omair %A Mulsant,Benoit H %A Rappaport,Lance %A Stergiopoulos,Vicky %A Husain,Muhammad Ishrat %+ Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, ON, M5T 1R8, Canada, 1 416 979 6948, mr.sharma@mail.utoronto.ca %K inpatient %K mental health %K mental disorder %K psychiatry %K psychiatric %K smartphone app %K cognitive behavioral therapy %K CBT %K anxiety %K mobile app %K mobile health %K mHealth %K health app %K digital health %K eHealth %K feasibility study %K randomized controlled trial %K RCT %K feasibility %K acceptability %D 2022 %7 2.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychiatric inpatients often have limited access to psychotherapeutic education or skills for managing anxiety, a common transdiagnostic concern in severe and acute mental illness. COVID-19–related restrictions further limited access to therapy groups on inpatient psychiatric units. App-based interventions may improve access, but evidence supporting the feasibility of their use, acceptability, and effectiveness in psychiatric inpatient settings is limited. MindShift CBT is a free app based on cognitive behavioral therapy principles with evidence for alleviating anxiety symptoms in the outpatient setting. Objective: We aimed to recruit 24 participants from an acute general psychiatric inpatient ward to a 1-month randomized control study assessing the feasibility and acceptability of providing patients with severe and acute mental illness access to the MindShift CBT app for help with managing anxiety symptoms. Methods: Recruitment, data collection, analysis, and interpretation were completed collaboratively by clinician and peer researchers. Inpatients were randomized to two conditions: treatment as usual (TAU) versus TAU plus use of the MindShift CBT app over 6 days. We collected demographic and quantitative data on acceptability and usability of the intervention. Symptoms of depression, anxiety, and psychological distress were measured in pre- and poststudy surveys for preliminary signals of efficacy. We conducted individual semistructured interviews with participants in the MindShift CBT app group at the end of their trial period, which were interpreted using a standardized protocol for thematic analysis. Results: Over 4 weeks, 33 inpatients were referred to the study, 24 consented to participate, 20 were randomized, and 11 completed the study. Of the 9 randomized participants who did not complete the study, 7 were withdrawn because they were discharged or transferred prior to study completion, with a similar distribution among both conditions. Among the enrolled patients, 65% (13/20) were admitted for a psychotic disorder and no patient was admitted primarily for an anxiety disorder. The average length of stay was 20 days (SD 4.4; range 3-21) and 35% (7/20) of patients were involuntarily admitted to hospital. Small sample sizes limited accurate interpretation of the efficacy data. Themes emerging from qualitative interviews included acceptability and usability of the app, and patient agency associated with voluntary participation in research while admitted to hospital. Conclusions: Our study benefitted from collaboration between peer and clinician researchers. Due to rapid patient turnover in the acute inpatient setting, additional flexibility in recruitment and enrollment is needed to determine the efficacy of using app-based psychotherapy on an acute psychiatric ward. Despite the limited sample size, our study suggests that similar interventions may be feasible and acceptable for acutely unwell inpatients. Further study is needed to compare the efficacy of psychotherapeutic apps with existing standards of care in this setting. Trial Registration: ClinicalTrials.gov NCT04841603; https://clinicaltrials.gov/ct2/show/NCT04841603 %M 36322113 %R 10.2196/38460 %U https://formative.jmir.org/2022/11/e38460 %U https://doi.org/10.2196/38460 %U http://www.ncbi.nlm.nih.gov/pubmed/36322113 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e33871 %T An App-Based Digit Symbol Substitution Test for Assessment of Cognitive Deficits in Adults With Major Depressive Disorder: Evaluation Study %A McIntyre,Roger S %A Lipsitz,Orly %A Rodrigues,Nelson B %A Subramaniapillai,Mehala %A Nasri,Flora %A Lee,Yena %A Fehnert,Ben %A King,James %A Chrones,Lambros %A Kratiuk,Kevin %A Uddin,Sharif %A Rosenblat,Joshua D %A Mansur,Rodrigo B %A McCue,Maggie %+ Brain and Cognition Discovery Foundation, 73 Mathersfield Drive, Toronto, ON, M4W 3W4, Canada, 1 416 603 5279, roger.mcintyre@bcdf.org %K depression %K DSST %K Digit Symbol Substitution Test %K smartphone %K technology %K measurement-based care %K cognition %D 2022 %7 27.10.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive dysfunction is an impairing core symptom of depression. Among adults with major depressive disorder (MDD) treated with antidepressants, residual cognitive symptoms interfere with patient-reported outcomes. The foregoing characterization of cognitive symptoms provides the rationale for screening and assessing the severity of cognitive symptoms at point of care. However, clinical neurocognitive assessments are time-consuming and difficult, and they require specialist expertise to interpret them. A smartphone-delivered neurocognitive test may offer an effective and accessible tool that can be readily implemented into a measurement-based care framework. Objective: We aimed to evaluate the use of a smartphone-delivered app-based version of the established Cognition Kit Digit Symbol Substitution Test (DSST) neurocognitive assessment compared to a traditional paper-and-pencil version. Methods: Convergent validity and test-retest reliability of the 2 versions were evaluated. Patient satisfaction with the app was also assessed. Results: Assessments made using the app-based Cognition Kit DSST were highly correlated with the standard paper-and-pencil version of the test, both at the baseline visit (r=0.69, df=27; P<.001) and at the end-of-study visit (r=0.82, df=27; P<.001), and they were positively evaluated by 30 patients as being user-friendly, easy to navigate, and preferable over the paper-and-pencil version of the DSST. However, although the app-based Cognition Kit DSST was validated in patients with MDD, it still needs to be evaluated in healthy controls. Conclusions: App-based DSST may facilitate a more personalized, convenient, and cost-effective method of cognitive assessment, helping to guide measurement-based care and psychotherapeutic and pharmacologic treatment options for patients with MDD. Trial Registration: ClinicalTrials.gov NCT03999567; https://tinyurl.com/2p8pnyv7 %M 36301615 %R 10.2196/33871 %U https://mental.jmir.org/2022/10/e33871 %U https://doi.org/10.2196/33871 %U http://www.ncbi.nlm.nih.gov/pubmed/36301615 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e34923 %T Mobile App to Enhance Patient Activation and Patient-Provider Communication in Major Depressive Disorder Management: Collaborative, Randomized Controlled Pilot Study %A McCue,Maggie %A Blair,Christopher %A Fehnert,Ben %A King,James %A Cormack,Francesca %A Sarkey,Sara %A Eramo,Anna %A Kabir,Christopher %A Khatib,Rasha %A Kemp,David %+ Takeda Pharmaceuticals USA, Inc, 95 Hayden Ave, Lexington, MA, 02421, United States, 1 224 554 2820, Maggie.McCue@takeda.com %K depression %K major depressive disorder %K depression management %K patient engagement %K patient satisfaction %K mobile app %K patient-reported outcomes %K mobile phone %D 2022 %7 27.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Enhanced patient-provider engagement can improve patient health outcomes in chronic conditions, including major depressive disorder (MDD). Objective: We evaluated the impact of a digitally enabled care mobile app, Pathway, designed to improve MDD patient-provider engagement. Patients used a mobile interface to assess treatment progress and share this information with primary care providers (PCPs). Methods: In this 52-week, real-world effectiveness and feasibility study conducted in primary care clinics, 40 patients with MDD who were recently prescribed antidepressant monotherapy were randomized to use a mobile app with usual care (20/40, 50%) or usual care alone (20/40, 50%). Patients in the app arm engaged with the app daily for 18 weeks; a report was generated at 6-week intervals and shared with the PCPs to facilitate shared treatment decision-making discussions. The patients discontinued the app at week 18 and were followed through year 1. Coprimary outcome measures, assessed via research visits, included change from baseline in the 13-item Patient Activation Measure (PAM-13) and 7-item Patient-Provider Engagement Scale scores at week 18. Additional outcome measures included depression severity (9-item Patient Health Questionnaire [PHQ-9]) and cognitive symptoms (5-item Perceived Deficits Questionnaire–Depression). Results: All 37 patients (app arm: n=18, 49%; usual care arm: n=19, 51%) who completed the 18-week follow-up period (n=31, 84% female, mean age 36, SD 11.3 years) had moderate to moderately severe depression. Improvements in PAM-13 and PHQ-9 scores were observed in both arms. Increases in PAM-13 scores from baseline to 18 weeks were numerically greater in the app arm than in the usual care arm (mean 10.5, SD 13.2 vs mean 8.8, SD 9.4; P=.65). At 52 weeks, differences in PAM-13 scores from baseline demonstrated significantly greater improvements in the app arm than in the usual care arm (mean 20.2, SD 17.7 vs mean 1.6, SD 14.2; P=.04). Compared with baseline, PHQ-9 scores decreased in both the app arm and the usual care arm at 18 weeks (mean 7.8, SD 7.2 vs mean 7.0, SD 6.5; P=.73) and 52 weeks (mean 9.5, SD 4.0 vs mean 4.7, SD 6.0; P=.07). Improvements in 7-item Patient-Provider Engagement Scale and WHO-5 scores were observed in both arms at 18 weeks and were sustained through 52 weeks in the app arm. Improvements in WHO-5 scores at 52 weeks were significantly greater in the app arm than in the usual care arm (41.5 vs 20.0; P=.02). Conclusions: Patients with MDD will engage with a mobile app designed to track treatment and disease progression. PCPs will use the data generated as part of their assessment to inform clinical care. The study results suggest that an app-enabled clinical care pathway may enhance patient activation and benefit MDD management. Trial Registration: ClinicalTrials.gov NCT03242213; https://clinicaltrials.gov/ct2/show/NCT03242213 %M 36301599 %R 10.2196/34923 %U https://formative.jmir.org/2022/10/e34923 %U https://doi.org/10.2196/34923 %U http://www.ncbi.nlm.nih.gov/pubmed/36301599 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 10 %P e40292 %T A Smartphone App to Promote Patient Activation and Support Shared Decision-making in People With a Diagnosis of Schizophrenia in Outpatient Treatment Settings (Momentum Trial): Randomized Controlled Assessor-Blinded Trial %A Vitger,Tobias %A Hjorthøj,Carsten %A Austin,Stephen F %A Petersen,Lone %A Tønder,Esben Sandvik %A Nordentoft,Merete %A Korsbek,Lisa %+ Competence Center for Rehabilitation and Recovery, Mental Health Center Ballerup, Mental Health Services in the Capital Region of Denmark, Maglevænget 19, Ballerup, 2750, Denmark, 45 51408519, tobias246@hotmail.com %K mobile health %K mHealth %K digital intervention %K shared decision-making %K patient activation %K schizophrenia %K schizotypal %K early intervention %K randomized clinical trial %K mobile phone %D 2022 %7 26.10.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Shared decision-making (SDM) is a process aimed at facilitating patient-centered care by ensuring that the patient and provider are actively involved in treatment decisions. In mental health care, SDM has been advocated as a means for the patient to gain or regain control and responsibility over their life and recovery process. To support the process of patient-centered care and SDM, digital tools may have advantages in terms of accessibility, structure, and reminders. Objective: In this randomized controlled trial, we aimed to investigate the effect of a digital tool to support patient activation and SDM. Methods: The trial was designed as a randomized, assessor-blinded, 2-armed, parallel-group multicenter trial investigating the use of a digital SDM intervention for 6 months compared with treatment as usual. Participants with a diagnosis of schizophrenia, schizotypal or delusional disorder were recruited from 9 outpatient treatment sites in the Capital Region of Denmark. The primary outcome was the self-reported level of activation at the postintervention time point. The secondary outcomes included self-efficacy, hope, working alliance, satisfaction, preparedness for treatment consultation, symptom severity, and level of functioning. Explorative outcomes on the effect of the intervention at the midintervention time point along with objective data on the use of the digital tool were collected. Results: In total, 194 participants were included. The intention-to-treat analysis revealed a statistically significant effect favoring the intervention group on patient activation (mean difference 4.39, 95% CI 0.99-7.79; Cohen d=0.33; P=.01), confidence in communicating with one’s provider (mean difference 1.85, 95% CI 0.01-3.69; Cohen d=0.24; P=.05), and feeling prepared for decision-making (mean difference 5.12, 95% CI 0.16-10.08; Cohen d=0.27; P=.04). We found no effect of the digital SDM tool on treatment satisfaction, hope, self-efficacy, working alliance, severity of symptoms, level of functioning, use of antipsychotic medicine, and number or length of psychiatric hospital admissions. Conclusions: This trial showed a significant effect of a digital SDM tool on the subjective level of patient activation, confidence in communicating with one’s provider, and feeling prepared for decision-making at the postintervention time point. The effect size was smaller than the 0.42 effect size that we had anticipated and sampled for. The trial contributes to the evidence on how digital tools may support patient-centered care and SDM in mental health care. Trial Registration: ClinicalTrials.gov NCT03554655; https://clinicaltrials.gov/ct2/show/NCT03554655 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2143-2 %M 36287604 %R 10.2196/40292 %U https://www.jmir.org/2022/10/e40292 %U https://doi.org/10.2196/40292 %U http://www.ncbi.nlm.nih.gov/pubmed/36287604 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 10 %P e39204 %T Digital Mental Health Interventions for Depression: Scoping Review of User Engagement %A Lipschitz,Jessica M %A Van Boxtel,Rachel %A Torous,John %A Firth,Joseph %A Lebovitz,Julia G %A Burdick,Katherine E %A Hogan,Timothy P %+ 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 mobile apps %K engagement %K adherence %K randomized controlled trials %K depression %D 2022 %7 14.10.2022 %9 Review %J J Med Internet Res %G English %X Background: While many digital mental health interventions (DMHIs) have been found to be efficacious, patient engagement with DMHIs has increasingly emerged as a concern for implementation in real-world clinical settings. To address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare with other treatments. Objective: This scoping review aims to examine the state of reporting on intervention engagement in RCTs of mobile app–based interventions intended to treat symptoms of depression. We sought to identify what engagement metrics are and are not routinely reported as well as what the metrics that are reported reflect about standard engagement levels. Methods: We conducted a systematic search of 7 databases to identify studies meeting our eligibility criteria, namely, RCTs that evaluated use of a mobile app–based intervention in adults, for which depressive symptoms were a primary outcome of interest. We then extracted 2 kinds of information from each article: intervention details and indices of DMHI engagement. A 5-element framework of minimum necessary DMHI engagement reporting was derived by our team and guided our data extraction. This framework included (1) recommended app use as communicated to participants at enrollment and, when reported, app adherence criteria; (2) rate of intervention uptake among those assigned to the intervention; (3) level of app use metrics reported, specifically number of uses and time spent using the app; (4) duration of app use metrics (ie, weekly use patterns); and (5) number of intervention completers. Results: Database searching yielded 2083 unique records. Of these, 22 studies were eligible for inclusion. Only 64% (14/22) of studies included in this review specified rate of intervention uptake. Level of use metrics was only reported in 59% (13/22) of the studies reviewed. Approximately one-quarter of the studies (5/22, 23%) reported duration of use metrics. Only half (11/22, 50%) of the studies reported the number of participants who completed the app-based components of the intervention as intended or other metrics related to completion. Findings in those studies reporting metrics related to intervention completion indicated that between 14.4% and 93.0% of participants randomized to a DMHI condition completed the intervention as intended or according to a specified adherence criteria. Conclusions: Findings suggest that engagement was underreported and widely varied. It was not uncommon to see completion rates at or below 50% (11/22) of those participants randomized to a treatment condition or to simply see completion rates not reported at all. This variability in reporting suggests a failure to establish sufficient reporting standards and limits the conclusions that can be drawn about level of engagement with DMHIs. Based on these findings, the 5-element framework applied in this review may be useful as a minimum necessary standard for DMHI engagement reporting. %M 36240001 %R 10.2196/39204 %U https://www.jmir.org/2022/10/e39204 %U https://doi.org/10.2196/39204 %U http://www.ncbi.nlm.nih.gov/pubmed/36240001 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 10 %P e41282 %T Mental Health Mobile Apps in the French App Store: Assessment Study of Functionality and Quality %A Carrouel,Florence %A du Sartz de Vigneulles,Benjamin %A Bourgeois,Denis %A Kabuth,Bernard %A Baltenneck,Nicolas %A Nusbaum,Fanny %A Burge,Valérie %A Roy,Sylvain %A Buchheit,Sophie %A Carrion-Martinaud,Marie-Line %A Massoubre,Catherine %A Fraticelli,Laurie %A Dussart,Claude %+ Health Systemic Process, Research Unit UR4129, University Claude Bernard Lyon 1, University of Lyon, 7 rue Guillaume Paradin, Lyon, 69372, France, 33 0478785745, florence.carrouel@univ-lyon1.fr %K mobile apps %K behavior change %K mental %K prevention %K mobile health %K mHealth %K lifestyle %K French %K well-being %D 2022 %7 12.10.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Approximately 800 million people, representing 11% of the world’s population, are affected by mental health problems. The COVID-19 pandemic exacerbated problems and triggered a decline in well-being, with drastic increase in the incidence of conditions such as anxiety, depression, and stress. Approximately 20,000 mental health apps are listed in mobile app stores. However, no significant evaluation of mental health apps in French, spoken by approximately 300 million people, has been identified in the literature yet. Objective: This study aims to review the mental health mobile apps currently available on the French Apple App Store and Google Play Store and to evaluate their quality using Mobile App Rating Scale–French (MARS-F). Methods: Screening of mental health apps was conducted from June 10, 2022, to June 17, 2022, on the French Apple App Store and Google Play Store. A shortlist of 12 apps was identified using the criteria of selection and assessed using MARS-F by 9 mental health professionals. Intraclass correlation was used to evaluate interrater agreement. Mean (SD) scores and their distributions for each section and item were calculated. Results: The highest scores for MARS-F quality were obtained by Soutien psy avec Mon Sherpa (mean 3.85, SD 0.48), Evoluno (mean 3.54, SD 0.72), and Teale (mean 3.53, SD 0.87). Mean engagement scores (section A) ranged from 2.33 (SD 0.69) for Reflexe reussite to 3.80 (SD 0.61) for Soutien psy avec Mon Sherpa. Mean aesthetics scores (section C) ranged from 2.52 (SD 0.62) for Mental Booster to 3.89 (SD 0.69) for Soutien psy avec Mon Sherpa. Mean information scores (section D) ranged from 2.00 (SD 0.75) for Mental Booster to 3.46 (SD 0.77) for Soutien psy avec Mon Sherpa. Mean Mobile App Rating Scale subjective quality (section E) score varied from 1.22 (SD 0.26) for VOS – journal de l’humeur to 2.69 (SD 0.84) for Soutien psy avec Mon Sherpa. Mean app specificity (section F) score varied from 1.56 (SD 0.97) for Mental Booster to 3.31 (SD 1.22) for Evoluno. For all the mental health apps studied, except Soutien psy avec Mon Sherpa (11/12, 92%), the subjective quality score was always lower than the app specificity score, which was always lower than the MARS-F quality score, and that was lower than the rating score from the iPhone Operating System or Android app stores. Conclusions: Mental health professionals assessed that, despite the lack of scientific evidence, the mental health mobile apps available on the French Apple App Store and Google Play Store were of good quality. However, they are reluctant to use them in their professional practice. Additional investigations are needed to assess their compliance with recommendations and their long-term impact on users. %M 36223178 %R 10.2196/41282 %U https://mhealth.jmir.org/2022/10/e41282 %U https://doi.org/10.2196/41282 %U http://www.ncbi.nlm.nih.gov/pubmed/36223178 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e37184 %T A Digital Intervention Using Daily Financial Incentives to Increase Medication Adherence in Severe Mental Illness: Single-Arm Longitudinal Pilot Study %A Guinart,Daniel %A Sobolev,Michael %A Patil,Bhagyashree %A Walsh,Megan %A Kane,John M %+ Department of Psychiatry, The Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY, 11004, United States, 1 7184704139, daniguinart@gmail.com %K antipsychotic %K adherence %K digital %K mobile health %K mHealth %K financial incentives %D 2022 %7 12.10.2022 %9 Short Paper %J JMIR Ment Health %G English %X Background: Medication nonadherence is prevalent in severe mental illness and is associated with multiple negative outcomes. Mobile technology and financial incentives show promise to improve medication adherence; however, studies in mental health, especially with oral medications, are lacking. Objective: The aim of this paper is to assess the feasibility and effectiveness of offering financial incentives through a mobile app based on behavioral economics principles to improve medication adherence in severe mental illness. Methods: A 10-week, single-arm longitudinal pilot study was conducted. Patients earned rewards in the context of app-based adherence incentives. The reward was split into biweekly payments made in increments of US $15, minus any US $2 per day penalties for missed check-ins. Time-varying effect modeling was used to summarize the patients’ response during the study. Results: A total of 25 patients were enrolled in this pilot study, of which 72% (n=18) were female, and 48% (n=12) were of a White racial background. Median age was 24 (Q1-Q3: 20.5-30) years. Participants were more frequently diagnosed with schizophrenia and related disorders (n=9, 36%), followed by major depressive disorder (n=8, 32%). App engagement and medication adherence in the first 2 weeks were higher than in the last 8 weeks of the study. At study endpoint, app engagement remained high (n=24, Z=–3.17; P<.001), but medication adherence was not different from baseline (n=24, Z=–0.59; P=.28). Conclusions: Financial incentives were effectively delivered using an app and led to high engagement throughout the study and a significantly increased medication adherence for 2 weeks. Leveraging behavioral economics and mobile health technology can increase medication adherence in the short term. Trial Registration: ClinicalTrials.gov NCT04191876; https://clinicaltrials.gov/ct2/show/NCT04191876 %M 36222818 %R 10.2196/37184 %U https://mental.jmir.org/2022/10/e37184 %U https://doi.org/10.2196/37184 %U http://www.ncbi.nlm.nih.gov/pubmed/36222818 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e39813 %T Comparing Professional and Consumer Ratings of Mental Health Apps: Mixed Methods Study %A Hudson,Georgie %A Negbenose,Esther %A Neary,Martha %A Jansli,Sonja M %A Schueller,Stephen M %A Wykes,Til %A Jilka,Sagar %+ Warwick Medical School, University of Warwick, Medical School Building, Coventry, CV4 7AL, United Kingdom, 44 7708715627, sagar.jilka@warwick.ac.uk %K well-being %K apps %K patient and public involvement %K coproduction %K mental health %K service user %K technology %K mobile health %K mHealth %K digital %K mobile phone %D 2022 %7 23.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: As the number of mental health apps has grown, increasing efforts have been focused on establishing quality tailored reviews. These reviews prioritize clinician and academic views rather than the views of those who use them, particularly those with lived experiences of mental health problems. Given that the COVID-19 pandemic has increased reliance on web-based and mobile mental health support, understanding the views of those with mental health conditions is of increasing importance. Objective: This study aimed to understand the opinions of people with mental health problems on mental health apps and how they differ from established ratings by professionals. Methods: A mixed methods study was conducted using a web-based survey administered between December 2020 and April 2021, assessing 11 mental health apps. We recruited individuals who had experienced mental health problems to download and use 3 apps for 3 days and complete a survey. The survey consisted of the One Mind PsyberGuide Consumer Review Questionnaire and 2 items from the Mobile App Rating Scale (star and recommendation ratings from 1 to 5). The consumer review questionnaire contained a series of open-ended questions, which were thematically analyzed and using a predefined protocol, converted into binary (positive or negative) ratings, and compared with app ratings by professionals and star ratings from app stores. Results: We found low agreement between the participants’ and professionals’ ratings. More than half of the app ratings showed disagreement between participants and professionals (198/372, 53.2%). Compared with participants, professionals gave the apps higher star ratings (3.58 vs 4.56) and were more likely to recommend the apps to others (3.44 vs 4.39). Participants’ star ratings were weakly positively correlated with app store ratings (r=0.32, P=.01). Thematic analysis found 11 themes, including issues of user experience, ease of use and interactivity, privacy concerns, customization, and integration with daily life. Participants particularly valued certain aspects of mental health apps, which appear to be overlooked by professional reviewers. These included functions such as the ability to track and measure mental health and providing general mental health education. The cost of apps was among the most important factors for participants. Although this is already considered by professionals, this information is not always easily accessible. Conclusions: As reviews on app stores and by professionals differ from those by people with lived experiences of mental health problems, these alone are not sufficient to provide people with mental health problems with the information they desire when choosing a mental health app. App rating measures must include the perspectives of mental health service users to ensure ratings represent their priorities. Additional work should be done to incorporate the features most important to mental health service users into mental health apps. %M 36149733 %R 10.2196/39813 %U https://formative.jmir.org/2022/9/e39813 %U https://doi.org/10.2196/39813 %U http://www.ncbi.nlm.nih.gov/pubmed/36149733 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e39476 %T A Web-Based Positive Psychology App for Patients With Bipolar Disorder: Development Study %A Geerling,Bart %A Kelders,Saskia M %A Stevens,Anja W M M %A Kupka,Ralph W %A Bohlmeijer,Ernst T %+ Department of Psychology, Health and Technology, Centre for eHealth and Wellbeing Research, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 0622274351, b.geerling@dimence.nl %K bipolar disorder %K positive psychology %K cocreation %K mobile health %K mHealth %K web-based %K psychology %K bipolar %K intervention %K quality of life %K mental illness %K pilot %K self-esteem %K acceptance %K social isolation %K manic episode %K manic %K self-help %K positive %K mobile phone %D 2022 %7 19.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with bipolar disorder (BD) report lower quality of life and lower levels of well-being than the general population. Despite the growing availability of psychotherapeutic and self-management interventions, important unmet needs remain. These unmet needs are closely linked to positive psychology domains. Although a growing number of studies have evaluated the impact of positive psychology interventions (PPIs) on patients with severe mental illness in general, only few have addressed the application of positive psychology for BD. Objective: This study aimed to gain insight into the opinions of patients with BD and health care professionals about (web-based) PPIs for BD and to develop and pilot-test an app containing PPIs specifically designed for patients with BD. Methods: The study was conducted in accordance with the Center for eHealth and Disease Management road map principles and incorporated cocreation and designing for implementation. Data were collected using focus group discussions, questionnaires, rapid prototyping, and web-based feedback on a prototype from the participants. In total, 3 focus groups were conducted with 62% (8/13) of patients with BD and 38% (5/13) of professionals. The collected data were used to develop a smartphone app containing short PPIs. The content was based on PPIs for which a solid base of evidence is available. Finally, a pilot test was conducted to test the app. Results: Focus groups revealed that PPIs as part of the current BD treatment can potentially meet the following needs: offering hope, increasing self-esteem, expressing feelings, acceptance, and preventing social isolation. Some patients expressed concern that PPIs may provoke a manic or hypomanic episode by increasing positive affect. The pilot of the app showed that the PPIs are moderately to highly valued by the participants. There were no adverse effects such as increase in manic or hypomanic symptoms. Conclusions: With the systematic use of user involvement (patients and professionals) in all steps of the development process, we were able to create an app that can potentially fulfill some of the current unmet needs in the treatment of BD. We reached consensus among consumers and professionals about the potential benefits of PPIs to address the unmet needs of patients with BD. The use of PPI for BD is intriguing and can be usefully explored in further studies. We emphasize that more evaluation studies (quantitative and qualitative) that are focused on the effect of PPIs in the treatment of BD should be conducted. In addition, to establish the working mechanisms in BD, explorative, qualitative, designed studies are required to reveal whether PPIs can address unmet needs in BD. %M 35946327 %R 10.2196/39476 %U https://formative.jmir.org/2022/9/e39476 %U https://doi.org/10.2196/39476 %U http://www.ncbi.nlm.nih.gov/pubmed/35946327 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 9 %P e39454 %T Effectiveness and Minimum Effective Dose of App-Based Mobile Health Interventions for Anxiety and Depression Symptom Reduction: Systematic Review and Meta-Analysis %A Lu,Sheng-Chieh %A Xu,Mindy %A Wang,Mei %A Hardi,Angela %A Cheng,Abby L %A Chang,Su-Hsin %A Yen,Po-Yin %+ Department of Symptom Research, University of Texas MD Anderson Cancer Center, 6565 MD Anderson Blvd, Houston, TX, 77030, United States, 1 7137944453, Slu4@mdanderson.org %K mental health %K mobile health %K smartphone apps %K intervention dose effectiveness %K systematic review and meta-analysis %D 2022 %7 7.9.2022 %9 Review %J JMIR Ment Health %G English %X Background: Mobile health (mHealth) apps offer new opportunities to deliver psychological treatments for mental illness in an accessible, private format. The results of several previous systematic reviews support the use of app-based mHealth interventions for anxiety and depression symptom management. However, it remains unclear how much or how long the minimum treatment “dose” is for an mHealth intervention to be effective. Just-in-time adaptive intervention (JITAI) has been introduced in the mHealth domain to facilitate behavior changes and is positioned to guide the design of mHealth interventions with enhanced adherence and effectiveness. Objective: Inspired by the JITAI framework, we conducted a systematic review and meta-analysis to evaluate the dose effectiveness of app-based mHealth interventions for anxiety and depression symptom reduction. Methods: We conducted a literature search on 7 databases (ie, Ovid MEDLINE, Embase, PsycInfo, Scopus, Cochrane Library (eg, CENTRAL), ScienceDirect, and ClinicalTrials, for publications from January 2012 to April 2020. We included randomized controlled trials (RCTs) evaluating app-based mHealth interventions for anxiety and depression. The study selection and data extraction process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We estimated the pooled effect size using Hedge g and appraised study quality using the revised Cochrane risk-of-bias tool for RCTs. Results: We included 15 studies involving 2627 participants for 18 app-based mHealth interventions. Participants in the intervention groups showed a significant effect on anxiety (Hedge g=–.10, 95% CI –0.14 to –0.06, I2=0%) but not on depression (Hedge g=–.08, 95% CI –0.23 to 0.07, I2=4%). Interventions of at least 7 weeks’ duration had larger effect sizes on anxiety symptom reduction. Conclusions: There is inconclusive evidence for clinical use of app-based mHealth interventions for anxiety and depression at the current stage due to the small to nonsignificant effects of the interventions and study quality concerns. The recommended dose of mHealth interventions and the sustainability of intervention effectiveness remain unclear and require further investigation. %M 36069841 %R 10.2196/39454 %U https://mental.jmir.org/2022/9/e39454 %U https://doi.org/10.2196/39454 %U http://www.ncbi.nlm.nih.gov/pubmed/36069841 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 9 %P e37354 %T The Apple Watch for Monitoring Mental Health–Related Physiological Symptoms: Literature Review %A Lui,Gough Yumu %A Loughnane,Dervla %A Polley,Caitlin %A Jayarathna,Titus %A Breen,Paul P %+ The MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Locked Bag 1797, Penrith, NSW, 2751, Australia, 61 298525222, G.Lui@westernsydney.edu.au %K Apple Watch %K data %K validation %K mental health %K psychology %K precision medicine %K heart rate variability %K energy expenditure %K sleep tracking %K digital health %K mobile phone %D 2022 %7 7.9.2022 %9 Review %J JMIR Ment Health %G English %X Background: An anticipated surge in mental health service demand related to COVID-19 has motivated the use of novel methods of care to meet demand, given workforce limitations. Digital health technologies in the form of self-tracking technology have been identified as a potential avenue, provided sufficient evidence exists to support their effectiveness in mental health contexts. Objective: This literature review aims to identify current and potential physiological or physiologically related monitoring capabilities of the Apple Watch relevant to mental health monitoring and examine the accuracy and validation status of these measures and their implications for mental health treatment. Methods: A literature review was conducted from June 2021 to July 2021 of both published and gray literature pertaining to the Apple Watch, mental health, and physiology. The literature review identified studies validating the sensor capabilities of the Apple Watch. Results: A total of 5583 paper titles were identified, with 115 (2.06%) reviewed in full. Of these 115 papers, 19 (16.5%) were related to Apple Watch validation or comparison studies. Most studies showed that the Apple Watch could measure heart rate acceptably with increased errors in case of movement. Accurate energy expenditure measurements are difficult for most wearables, with the Apple Watch generally providing the best results compared with peers, despite overestimation. Heart rate variability measurements were found to have gaps in data but were able to detect mild mental stress. Activity monitoring with step counting showed good agreement, although wheelchair use was found to be prone to overestimation and poor performance on overground tasks. Atrial fibrillation detection showed mixed results, in part because of a high inconclusive result rate, but may be useful for ongoing monitoring. No studies recorded validation of the Sleep app feature; however, accelerometer-based sleep monitoring showed high accuracy and sensitivity in detecting sleep. Conclusions: The results are encouraging regarding the application of the Apple Watch in mental health, particularly as heart rate variability is a key indicator of changes in both physical and emotional states. Particular benefits may be derived through avoidance of recall bias and collection of supporting ecological context data. However, a lack of methodologically robust and replicated evidence of user benefit, a supportive health economic analysis, and concerns about personal health information remain key factors that must be addressed to enable broader uptake. %M 36069848 %R 10.2196/37354 %U https://mental.jmir.org/2022/9/e37354 %U https://doi.org/10.2196/37354 %U http://www.ncbi.nlm.nih.gov/pubmed/36069848 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 10 %N 9 %P e30094 %T A Free App for Diagnosing Burnout (BurnOut App): Development Study %A Godia,Jordi %A Pifarré,Marc %A Vilaplana,Jordi %A Solsona,Francesc %A Abella,Francesc %A Calvo,Antoni %A Mitjans,Anna %A Gonzalez-Olmedo,Maria Pau %+ Universitat de Lleida, Jaume II, 69, Lleida, 25001, Spain, 34 973702735, francesc.solsona@udl.cat %K diagnose burnout %K Android app %K medical informatics %K health care %K health professionals %K mobile health %K digital health %K health applications %K online health %K mobile phone %D 2022 %7 6.9.2022 %9 Original Paper %J JMIR Med Inform %G English %X Background: Health specialists take care of us, but who takes care of them? These professionals are the most vulnerable to the increasingly common syndrome known as burnout. Burnout is a syndrome conceptualized as a result of chronic workplace stress that has not been successfully managed. Objective: This study aims to develop a useful app providing burnout self-diagnosis and tracking of burnout through a simple, intuitive, and user-friendly interface. Methods: We present the BurnOut app, an Android app developed using the Xamarin and MVVMCross platforms, which allows users to detect critical cases of psychological discomfort by implementing the Goldberg and Copenhagen Burnout Inventory tests. Results: The BurnOut app is robust, user-friendly, and efficient. The good performance of the app was demonstrated by comparing its features with those of similar apps in the literature. Conclusions: The BurnOut app is very useful for health specialists or users, in general, to detect burnout early and track its evolution. %M 36066932 %R 10.2196/30094 %U https://medinform.jmir.org/2022/9/e30094 %U https://doi.org/10.2196/30094 %U http://www.ncbi.nlm.nih.gov/pubmed/36066932 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e33545 %T Operationalizing Engagement With an Interpretation Bias Smartphone App Intervention: Case Series %A Ramadurai,Ramya %A Beckham,Erin %A McHugh,R Kathryn %A Björgvinsson,Thröstur %A Beard,Courtney %+ Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC, 20016, United States, 1 202 885 8000, rr4748a@student.american.edu %K engagement %K mental health apps %K cognitive bias modification %K human support %K mobile health %K mHealth %K mobile phone %D 2022 %7 17.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Engagement with mental health smartphone apps is an understudied but critical construct to understand in the pursuit of improved efficacy. Objective: This study aimed to examine engagement as a multidimensional construct for a novel app called HabitWorks. HabitWorks delivers a personalized interpretation bias intervention and includes various strategies to enhance engagement such as human support, personalization, and self-monitoring. Methods: We examined app use in a pilot study (n=31) and identified 5 patterns of behavioral engagement: consistently low, drop-off, adherent, high diary, and superuser. Results: We present a series of cases (5/31, 16%) from this trial to illustrate the patterns of behavioral engagement and cognitive and affective engagement for each case. With rich participant-level data, we emphasize the diverse engagement patterns and the necessity of studying engagement as a heterogeneous and multifaceted construct. Conclusions: Our thorough idiographic exploration of engagement with HabitWorks provides an example of how to operationalize engagement for other mental health apps. %M 35976196 %R 10.2196/33545 %U https://mental.jmir.org/2022/8/e33545 %U https://doi.org/10.2196/33545 %U http://www.ncbi.nlm.nih.gov/pubmed/35976196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 8 %P e33696 %T Analyzing the Impact of Mobile App Engagement on Mental Health Outcomes: Secondary Analysis of the Unwinding Anxiety Program %A Nardi,William %A Roy,Alexandra %A Dunsiger,Shira %A Brewer,Judson %+ Department of Behavioral and Social Sciences, Brown University, 121 South Main Street, Providence, RI, 02903, United States, 1 8609649144, william_nardi@brown.edu %K anxiety %K worry %K engagement %K mobile app %K mental health %K mobile phone %D 2022 %7 15.8.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: App-based interventions provide a promising avenue for mitigating the burden on mental health services by complimenting therapist-led treatments for anxiety. However, it remains unclear how specific systems’ use of app features may be associated with changes in mental health outcomes (eg, anxiety and worry). Objective: This study was a secondary analysis of engagement data from a stage 1 randomized controlled trial testing the impact of the Unwinding Anxiety mobile app among adults with generalized anxiety disorder. The aims of this study were 2-fold: to investigate whether higher microengagement with the primary intervention feature (ie, educational modules) is associated with positive changes in mental health outcomes at 2 months (ie, anxiety, worry, interoceptive awareness, and emotional reactivity) and to investigate whether the use of adjunctive app features is also associated with changes in mental health outcomes. Methods: We analyzed the intervention group during the stage 1 trial of the Unwinding Anxiety mobile app. The total use of specific mobile app features and the use specific to each feature were calculated. We used multivariate linear models with a priori significance of α=.05 to investigate the impact of cumulative app use on anxiety, worry, interoceptive awareness, and emotional regulation at 2 months, controlling for baseline scores, age, and education level in all models. Significant relationships between system use metrics and baseline participant characteristics were assessed for differences in use groupings using between-group testing (ie, 2-tailed t tests for continuous data and chi-square analyses for categorical data). Results: The sample was primarily female (25/27, 93%), and the average age was 42.9 (SD 15.6) years. Educational module completion, the central intervention component, averaged 20.2 (SD 11.4) modules out of 32 for the total sample. Multivariate models revealed that completing >75% of the program was associated with an average 22.6-point increase in interoceptive awareness (b=22.6; SE 8.32; P=.01; 95% CI 5.3-39.8) and an 11.6-point decrease in worry (b=−11.6; SE 4.12; P=.01; 95% CI −20.2 to −3.1). In addition, a single log unit change in the total number of meditations was associated with a 0.62-point reduction in the Generalized Anxiety Disorder-7 scale scores (b=0.62; SE 0.27; P=.005; 95% CI −1.2 to −0.6), whereas a single log unit use of the stress meter was associated with an average of a 0.5-point increase in emotional regulation scores (Five Facet Mindfulness Questionnaire; b=0.5; SE 0.21; P=.03; 95% CI 0.1-0.9). Conclusions: This study offers a clearer understanding of the impact of engagement with app features on broader engagement with the health outcomes of interest. This study highlights the importance of comprehensive investigations of engagement during the development of evidence-based mobile apps. %M 35969440 %R 10.2196/33696 %U https://www.jmir.org/2022/8/e33696 %U https://doi.org/10.2196/33696 %U http://www.ncbi.nlm.nih.gov/pubmed/35969440 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e38934 %T Clinical Targets and Attitudes Toward Implementing Digital Health Tools for Remote Measurement in Treatment for Depression: Focus Groups With Patients and Clinicians %A de Angel,Valeria %A Lewis,Serena %A White,Katie M %A Matcham,Faith %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, E3.08, 3rd floor East Wing, 16 De Crespigny Park, London, SE5 8AF , United Kingdom, 44 7415838882, valeria.de_angel@kcl.ac.uk %K depression %K digital health tools %K implementation %K qualitative %K wearable devices %K smartphone %K passive sensing %K sensor data %K mobile health %K mHealth %K mood disorders %K digital phenotyping %K mobile phone %D 2022 %7 15.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Remote measurement technologies, such as smartphones and wearable devices, can improve treatment outcomes for depression through enhanced illness characterization and monitoring. However, little is known about digital outcomes that are clinically meaningful to patients and clinicians. Moreover, if these technologies are to be successfully implemented within treatment, stakeholders’ views on the barriers to and facilitators of their implementation in treatment must be considered. Objective: This study aims to identify clinically meaningful targets for digital health research in depression and explore attitudes toward their implementation in psychological services. Methods: A grounded theory approach was used on qualitative data from 3 focus groups of patients with a current diagnosis of depression and clinicians with >6 months of experience with delivering psychotherapy (N=22). Results: Emerging themes on clinical targets fell into the following two main categories: promoters and markers of change. The former are behaviors that participants engage in to promote mental health, and the latter signal a change in mood. These themes were further subdivided into external changes (changes in behavior) or internal changes (changes in thoughts or feelings) and mapped with potential digital sensors. The following six implementation acceptability themes emerged: technology-related factors, information and data management, emotional support, cognitive support, increased self-awareness, and clinical utility. Conclusions: The promoters versus markers of change differentiation have implications for a causal model of digital phenotyping in depression, which this paper presents. Internal versus external subdivisions are helpful in determining which factors are more susceptible to being measured by using active versus passive methods. The implications for implementation within psychotherapy are discussed with regard to treatment effectiveness, service provision, and patient and clinician experience. %M 35969448 %R 10.2196/38934 %U https://mental.jmir.org/2022/8/e38934 %U https://doi.org/10.2196/38934 %U http://www.ncbi.nlm.nih.gov/pubmed/35969448 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e39516 %T The Effect of Mental Health App Customization on Depressive Symptoms in College Students: Randomized Controlled Trial %A Six,Stephanie G %A Byrne,Kaileigh A %A Aly,Heba %A Harris,Maggie W %+ Department of Psychology, Clemson University, 418 Brackett Hall, Clemson University, Clemson, SC, 29634-0001, United States, 1 864 656 3935, kaileib@clemson.edu %K depression %K mental health apps %K customization %K personalization %K cognitive behavioral therapy %K avatars %K mobile phone %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health apps have shown promise in improving mental health symptoms, including depressive symptoms. However, limited research has been aimed at understanding how specific app features and designs can optimize the therapeutic benefits and adherence to such mental health apps. Objective: The primary purpose of this study is to investigate the effect of avatar customization on depressive symptoms and adherence to use a novel cognitive behavioral therapy (CBT)–based mental health app. The secondary aim is to examine whether specific app features, including journaling, mood tracking, and reminders, affect the usability of the mental health app. Methods: College students were recruited from a university study recruitment pool website and via flyer advertisements throughout campus. A total of 94 participants completed a randomized controlled trial in which they were randomized to either customization or no customization version of the app. Customization involved personalizing a virtual avatar and a travel vehicle to one’s own preferences and use of one’s name throughout the app. Participants completed a 14-day trial using a novel CBT-based mental health app called AirHeart. Self-report scores for depressive symptoms, anxiety, and stress were measured at baseline and after the intervention. Postintervention survey measures also included usability and avatar identification questionnaires. Results: Of the 94 enrolled participants, 83 (88%) completed the intervention and postintervention assessments. AirHeart app use significantly reduced symptoms of depression (P=.006) from baseline to the end of the 2-week intervention period for all participants, regardless of the customization condition. However, no differences in depressive symptoms (P=.17) or adherence (P=.80) were observed between the customization (39/83, 47%) and no customization (44/83, 53%) conditions. The frequency of journaling, usefulness of mood tracking, and helpfulness of reminders were not associated with changes in depressive symptoms or adherence (P>.05). Exploratory analyses showed that there were 3 moderate positive correlations between avatar identification and depressive symptoms (identification: r=−0.312, P=.02; connection: r=−0.305, P=.02; and lack of relatability: r=0.338, P=.01). Conclusions: These results indicate that CBT mental health apps, such as AirHeart, have the potential to reduce depressive symptoms over a short intervention period. The randomized controlled trial results demonstrated that customization of app features, such as avatars, does not further reduce depressive symptoms over and above the CBT modules and standard app features, including journal, reminders, and mood tracking. However, further research elucidating the relationship between virtual avatar identification and mental health systems is needed as society becomes increasingly more digitized. These findings have potential implications for improving the optimization of mental health app designs. Trial Registration: Open Science Framework t28gm; https://osf.io/t28gm %M 35943788 %R 10.2196/39516 %U https://mental.jmir.org/2022/8/e39516 %U https://doi.org/10.2196/39516 %U http://www.ncbi.nlm.nih.gov/pubmed/35943788 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e35482 %T Adding an App-Based Intervention to the Cognitive Behavioral Analysis System of Psychotherapy in Routine Outpatient Psychotherapy Treatment: Proof-of-Concept Study %A Netter,Anna-Lena %A Beintner,Ina %A Brakemeier,Eva-Lotta %+ Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenberg Strasse 18, Marburg, 32035, Germany, 49 64212823757, anna-lena.netter@uni-marburg.de %K Cognitive Behavioral Analysis System of Psychotherapy %K persistent depressive disorder %K blended therapy %K internet and mobile-based Interventions %K routine clinical care %K eHealth %K mobile phone %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is an empirically supported psychotherapeutic treatment developed specifically for persistent depressive disorder. However, given the high rates of nonresponse and relapse, there is a need for optimization. Studies suggest that outcomes can be improved by increasing the treatment dose via, for example, the continuous web-based application of therapy strategies between sessions. The strong emphasis in CBASP on the therapeutic relationship, combined with limited therapeutic availabilities, encourages the addition of web-based interventions to face-to-face therapy in terms of blended therapy. Objective: The aim of this study was to test an app-based intervention called CBASPath, which was designed to be used as a blended therapy tool. CBASPath offers 8 sequential modules with app-based exercises to facilitate additional engagement with the therapy content and a separate exercise to conduct situational analyses within the app at any time. Methods: CBASPath was tested in an open pilot study as part of routine outpatient CBASP treatment. Participating patients were asked to report their use patterns and blended use (integrated use of the app as part of therapy sessions) at 3 assessment points over the 6-month test period and rate the usability and quality of and their satisfaction with CBASPath. Results: The results of the pilot trial showed that 93% (12/13) of participants used CBASPath as a blended tool during their therapy and maintained this throughout the study period. Overall, they reported good usability and quality ratings along with high user satisfaction. All participants showed favorable engagement with CBASPath; however, the frequency of use differed widely among the participants and assessment points. Situational analysis was used by all participants, and the number of completed modules ranged from 1 to 7. All participants reported blended use, although the frequency of integration in the face-to-face sessions varied widely. Conclusions: Our findings suggest that the digital augmentation of complex and highly interactive CBASP therapy in the form of blended therapy with CBASPath is feasible in routine outpatient care. Therapeutic guidance might contribute to high adherence and increase patient self-management. A few adjustments, such as saving entries directly in the app, could facilitate higher user engagement. A randomized controlled trial is now needed to investigate the efficacy and added value of this blended approach. In the long term, CBASPath could help optimize persistent depressive disorder treatment and reduce relapse by intensifying therapy and providing long-term patient support through the app. %M 35943764 %R 10.2196/35482 %U https://formative.jmir.org/2022/8/e35482 %U https://doi.org/10.2196/35482 %U http://www.ncbi.nlm.nih.gov/pubmed/35943764 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e35636 %T Preliminary Real-World Evidence Supporting the Efficacy of a Remote Neurofeedback System in Improving Mental Health: Retrospective Single-Group Pretest-Posttest Study %A Whitehead,Jocelyne C %A Neeman,Ron %A Doniger,Glen M %+ Integrated Program in Neuroscience, McGill University, 845 Rue Sherbrooke O, Montreal, QC, H3A 0G4, Canada, 1 866 994 3210, jocelyne.whitehead@mail.mcgill.ca %K EEG biofeedback %K remote care %K neurofeedback %K attention-deficit/hyperactivity disorder %K delta/alpha ratio %D 2022 %7 8.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Neurofeedback training (NFT) has been shown to be effective in treating several disorders (eg, attention-deficit/hyperactivity disorder [ADHD], anxiety, and depression); however, little is currently known regarding the effectiveness of remote NFT systems. Objective: This retrospective study provides real-world data (N=593) to assess the efficacy of app-based remote NFT in improving brain health and cognitive performance. Methods: Improvement was measured from pre- to postintervention of in-app assessments that included validated symptom questionnaires (the 12-item General Health Questionnaire, the ADHD Rating Scale IV, the Adult ADHD Self-Report Scale, the 7-item Generalized Anxiety Disorder scale, and the 9-item Patient Health Questionnaire), a cognitive test of attention and executive functioning (ie, continuous performance task), and resting electroencephalography (EEG) markers. Clinically significant improvement was evaluated using standard approaches. Results: The greatest improvement was reported for the anxiety questionnaire, for which 69% (68/99) of participants moved from abnormal to healthy score ranges. Overall, adult and child participants who engaged in neurofeedback to improve attention and executive functions demonstrated improved ADHD scores and enhanced performance on a cognitive (ie, response inhibition) task. Adults with ADHD additionally demonstrated elevated delta/alpha and theta/alpha ratios at baseline and a reduction in the delta/alpha ratio indicator following neurofeedback. Conclusions: Preliminary findings suggest the efficacy of app-based remote neurofeedback in improving mental health, given the reduced symptom severity from pre- to postassessment for general psychological health, ADHD, anxiety, and depression, as well as adjusted resting EEG neural markers for individuals with symptoms of ADHD. Collectively, this supports the utility of the in-app assessment in monitoring behavioral and neural indices of mental health. %M 35802411 %R 10.2196/35636 %U https://formative.jmir.org/2022/7/e35636 %U https://doi.org/10.2196/35636 %U http://www.ncbi.nlm.nih.gov/pubmed/35802411 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e30230 %T Feasibility of Mobile Health and Social Media–Based Interventions for Young Adults With Early Psychosis and Clinical Risk for Psychosis: Survey Study %A Franco,Olivia H %A Calkins,Monica E %A Giorgi,Salvatore %A Ungar,Lyle H %A Gur,Raquel E %A Kohler,Christian G %A Tang,Sunny X %+ Feinstein Institutes for Medical Research, Northwell Health, 75-59 263rd St, Glen Oaks, NY, 11004, United States, 1 631 786 3737, stang3@northwell.edu %K social media %K psychosis %K clinical high risk %K technology %K digital health %D 2022 %7 8.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital technology, the internet, and social media are increasingly investigated as promising means for monitoring symptoms and delivering mental health treatment. These apps and interventions have demonstrated preliminary acceptability and feasibility, but previous reports suggest that access to technology may still be limited among individuals with psychotic disorders relative to the general population. Objective: We evaluated and compared access to and use of technology and social media in young adults with psychotic disorders (PD), young adults with clinical risk for psychosis (CR), and psychosis-free youths (PF). Methods: Participants were recruited through a coordinated specialty care clinic dedicated toward early psychosis as well as ongoing studies. We surveyed 21 PD, 23 CR, and 15 PF participants regarding access to technology and use of social media, specifically Facebook and Twitter. Statistical analyses were conducted in R. Categorical variables were compared among groups using Fisher exact test, continuous variables were compared using 1-way ANOVA, and multiple linear regressions were used to evaluate for covariates. Results: Access to technology and social media were similar among PD, CR, and PF participants. Individuals with PD, but not CR, were less likely to post at a weekly or higher frequency compared to PF individuals. We found that decreased active social media posting was unique to psychotic disorders and did not occur with other psychiatric diagnoses or demographic variables. Additionally, variation in age, sex, and White versus non-White race did not affect posting frequency. Conclusions: For young people with psychosis spectrum disorders, there appears to be no “technology gap” limiting the implementation of digital and mobile health interventions. Active posting to social media was reduced for individuals with psychosis, which may be related to negative symptoms or impairment in social functioning. %M 35802420 %R 10.2196/30230 %U https://formative.jmir.org/2022/7/e30230 %U https://doi.org/10.2196/30230 %U http://www.ncbi.nlm.nih.gov/pubmed/35802420 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e38684 %T Smartphone Ownership, Smartphone Utilization, and Interest in Using Mental Health Apps to Address Substance Use Disorders: Literature Review and Cross-sectional Survey Study Across Two Sites %A Hsu,Michael %A Martin,Bianca %A Ahmed,Saeed %A Torous,John %A Suzuki,Joji %+ Department of Psychiatry, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States, 1 617 732 6753, mhsu24@emory.edu %K smartphone %K mobile phone %K addiction %K substance use %K phone ownership %K health equity %K digital psychiatry %K digital phenotyping %K phone applications %K substance abuse %K mHealth %K phone utilization %K mental health %K mindfulness %K digital mental health %D 2022 %7 7.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: In recent years, there has been increasing interest in implementing digital technologies to diagnose, monitor, and intervene in substance use disorders. Smartphones are now a vehicle for facilitating telepsychiatry visits, measuring health metrics, and communicating with health care professionals. In light of the COVID-19 pandemic and the movement toward web-based and hybrid clinic visits and meetings, it has become especially salient to assess phone ownership among individuals with substance use disorders and their comfort in navigating phone functionality and using phones for mental health purposes. Objective: The aims of this study were to summarize the current literature around smartphone ownership, smartphone utilization, and the acceptability of using smartphones for mental health purposes and assess these variables across two disparate substance use treatment sites. Methods: We performed a focused literature review via a search of two academic databases (PubMed and Google Scholar) for publications since 2007 on the topics of smartphone ownership, smartphone utilization, and the acceptability of using mobile apps for mental health purposes among the substance use population. Additionally, we conducted a cross-sectional survey study that included 51 participants across two sites in New England—an inpatient detoxification unit that predominantly treats patients with alcohol use disorder and an outpatient methadone maintenance treatment clinic. Results: Prior studies indicated that mobile phone ownership among the substance use population between 2013 and 2019 ranged from 83% to 94%, while smartphone ownership ranged from 57% to 94%. The results from our study across the two sites indicated 96% (49/51) mobile phone ownership and 92% (47/51) smartphone ownership among the substance use population. Although most (43/49, 88%) patients across both sites reported currently using apps on their phone, a minority (19/48, 40%) reported previously using any apps for mental health purposes. More than half of the participants reported feeling at least neutrally comfortable with a mental health app gathering information regarding appointment reminders (32/48, 67%), medication reminders (33/48, 69%), and symptom surveys (26/45, 58%). Most patients were concerned about privacy (34/51, 67%) and felt uncomfortable with an app gathering location (29/47, 62%) and social (27/47, 57%) information for health care purposes. Conclusions: The majority of respondents reported owning a mobile phone (49/51, 96%) and smartphone (47/51, 92%), consistent with prior studies. Many respondents felt comfortable with mental health apps gathering most forms of personal information and with communicating with their clinician about their mental health. The differential results from the two sites, namely greater concerns about the cost of mental health apps among the methadone maintenance treatment cohort and less experience with downloading apps among the older inpatient detoxification cohort, may indicate that clinicians should tailor technological interventions based on local demographics and practice sites and that there is likely not a one-size-fits-all digital psychiatry solution. %M 35797102 %R 10.2196/38684 %U https://formative.jmir.org/2022/7/e38684 %U https://doi.org/10.2196/38684 %U http://www.ncbi.nlm.nih.gov/pubmed/35797102 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 7 %P e30976 %T The Efficacy of “Foundations,” a Digital Mental Health App to Improve Mental Well-being During COVID-19: Proof-of-Principle Randomized Controlled Trial %A Catuara-Solarz,Silvina %A Skorulski,Bartlomiej %A Estella-Aguerri,Iñaki %A Avella-Garcia,Claudia Bibiana %A Shepherd,Sarah %A Stott,Emily %A Hemmings,Nicola R %A Ruiz de Villa,Aleix %A Schulze,Laura %A Dix,Sophie %+ Koa Health, Carrer de la Ciutat de Granada 121, Barcelona, 08018, Spain, 44 7702 500882, sophie.dix@koahealth.com %K mental well-being %K digital health %K cognitive behavioral therapy %K positive psychology %K insomnia %K COVID-19 %K mental health %K mobile app %K anxiety %K health app %D 2022 %7 1.7.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Against a long-term trend of increasing demand, the COVID-19 pandemic has led to a global rise in common mental disorders. Now more than ever, there is an urgent need for scalable, evidence-based interventions to support mental well-being. Objective: The aim of this proof-of-principle study was to evaluate the efficacy of a mobile-based app in adults with self-reported symptoms of anxiety and stress in a randomized control trial that took place during the first wave of the COVID-19 pandemic in the United Kingdom. Methods: Adults with mild to severe anxiety and moderate to high levels of perceived stress were randomized to either the intervention or control arm. Participants in the intervention arm were given access to the Foundations app for the duration of the 4-week study. All participants were required to self-report a range of validated measures of mental well-being (10-item Connor-Davidson Resilience scale [CD-RISC-10], 7-item Generalized Anxiety Disorder scale [GAD-7], Office of National Statistics Four Subjective Well-being Questions [ONS-4], World Health Organization-5 Well-Being Index [WHO-5]) and sleep (Minimal Insomnia Scale [MISS]) at baseline and at weeks 2 and 4. The self-reported measures of perceived stress (10-item Perceived Stress Score [PSS-10]) were obtained weekly. Results: A total of 136 participants completed the study and were included in the final analysis. The intervention group (n=62) showed significant improvements compared to the control group (n=74) on measures of anxiety, with a mean GAD-7 score change from baseline of –1.35 (SD 4.43) and –0.23 (SD 3.24), respectively (t134=1.71, P=.04); resilience, with a mean change in CD-RISC score of 1.79 (SD 4.08) and –0.31 (SD 3.16), respectively (t134=–3.37, P<.001); sleep, with a mean MISS score change of –1.16 (SD 2.67) and –0.26 (SD 2.29), respectively (t134=2.13, P=.01); and mental well-being, with a mean WHO-5 score change of 1.53 (SD 5.30) and –0.23 (SD 4.20), respectively (t134=–2.16, P=.02), within 2 weeks of using Foundations, with further improvements emerging at week 4. Perceived stress was also reduced within the intervention group, although the difference did not reach statistical significance relative to the control group, with a PSS score change from baseline to week 2 of –2.94 (SD 6.84) and –2.05 (SD 5.34), respectively (t134= 0.84, P=.20). Conclusions: This study provides a proof of principle that the digital mental health app Foundations can improve measures of mental well-being, anxiety, resilience, and sleep within 2 weeks of use, with greater effects after 4 weeks. Foundations therefore offers potential as a scalable, cost-effective, and accessible solution to enhance mental well-being, even during times of crisis such as the COVID-19 pandemic. Trial Registration: OSF Registries osf.io/f6djb; https://osf.io/vm3xq %M 34978535 %R 10.2196/30976 %U https://mhealth.jmir.org/2022/7/e30976 %U https://doi.org/10.2196/30976 %U http://www.ncbi.nlm.nih.gov/pubmed/34978535 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 6 %P e33750 %T The Effectiveness of a Brief Telehealth and Smartphone Intervention for College Students Receiving Traditional Therapy: Longitudinal Study Using Ecological Momentary Assessment Data %A Taylor,Madison E %A Lozy,Olivia %A Conti,Kaileigh %A Wacha-Montes,Annmarie %A Bentley,Kate H %A Kleiman,Evan M %+ Department of Psychology, Rutgers, The State University of New Jersey, Tillet Hall, 53 Avenue E, Piscataway, NJ, 08854, United States, 1 717 394 1180, metaylor1116@gmail.com %K college students %K digital mental health %K brief interventions %D 2022 %7 29.6.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Brief interventions such as mental health apps and single-session interventions are increasingly popular, efficacious, and accessible delivery formats that may be beneficial for college students whose mental health needs may not be adequately met by college counseling centers. However, no studies so far have examined the effectiveness of these modes of treatment for college students who are already receiving traditional therapy, despite it being common among this population. Objective: The aim of this study was to compare the differences in self-reported momentary negative affect between college students in therapy and not in therapy who received a brief single-session intervention delivered by counseling center staff and a supplemental mobile app. Methods: Data for this study were drawn from E-Manage, a brief mobile health intervention geared toward college students. Participants in the study were 173 college students who indicated whether they had received therapy. We conducted a multilevel model to determine whether there were differences between those in therapy versus not in therapy in negative affect reported throughout the study. Following this, we conducted multilevel models with therapy status as the predictor and negative affect as the outcome. Results: Results of the multilevel model testing showed that the cross-level interaction between the time point (ie, pre- vs postexercise) and therapy status was significant (P=.008), with the reduction in negative affect from pre- to postexercise greater for those in therapy (b=–0.65, 95% CI –0.91 to –0.40; P<.001) than it was for those not in therapy (b=–0.31, 95% CI –0.43 to –0.19; P<.001). Therapy status was unassociated with both the pre-exercise (b=–1.69, 95% CI –3.51 to 0.13; P=.07) and postexercise (b=–1.37, 95% CI –3.17 to 0.43; P=.14) ratings of negative affect. Conclusions: These findings suggest that app-based and single-session interventions are also appropriate to use among college students who are receiving traditional therapy. A randomized controlled trial comparing students receiving therapy to students receiving therapy and E-Manage will be necessary to determine to what extent E-Manage contributed to the reductions in negative affect that therapy-attending college students experienced. %M 35767338 %R 10.2196/33750 %U https://mental.jmir.org/2022/6/e33750 %U https://doi.org/10.2196/33750 %U http://www.ncbi.nlm.nih.gov/pubmed/35767338 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e35086 %T An Intervention to Connect Patients With Psychosis and Volunteers via Smartphone (the Phone Pal): Development Study %A Pinto da Costa,Mariana %A , %+ Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16 De Crespigny, London, SE58AB, United Kingdom, 44 02078480002, mariana.pintodacosta@gmail.com %K intervention %K intervention development %K digital mental health %K psychosis %K severe mental illness %K volunteering %K volunteer %K mental health %K mental illness %K development %K design %K user centered design %K smartphone %K mobile phone %K mobile health %K mHealth %K MRC framework %K Medical Research Council framework %D 2022 %7 2.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Intervention development is a critical stage. However, evidence indicates that the substandard reporting of intervention details is widespread. Objective: This study aimed to provide an overview of the guiding frameworks, methodology, and stages for the design and construction of a new complex intervention—the Phone Pal. Methods: The intervention development process followed the Medical Research Council framework for developing complex interventions as well as the person-based approach. The intervention was developed following the evidence synthesis of a literature review, a focus group study, and a survey after consultation and input from advisory groups with a range of stakeholders, including patients, volunteers, clinicians, and academics. Results: The developed logic model outlines the contextual factors, intervention, mechanisms of change, and short- and long-term outcomes. The operationalized intervention required matching 1 patient with 1 volunteer to communicate with each other through a smartphone via SMS text messages, WhatsApp messages or email, and audio or video calls. Each participant was encouraged to communicate with their match at least once per week for a 12-week period using informal conversation. Conclusions: The systematic process and theoretically sound strategy through which this intervention was developed can provide insights to future researchers on the reality of developing and preparing the operationalization of a digital intervention using multiple components. %M 35653171 %R 10.2196/35086 %U https://formative.jmir.org/2022/6/e35086 %U https://doi.org/10.2196/35086 %U http://www.ncbi.nlm.nih.gov/pubmed/35653171 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e37302 %T Adherence and Engagement With a Cognitive Behavioral Therapy–Based Conversational Agent (Wysa for Chronic Pain) Among Adults With Chronic Pain: Survival Analysis %A Sinha,Chaitali %A Cheng,Abby L %A Kadaba,Madhura %+ Wysa, 131 Dartmouth St, Boston, MA, 02116, United States, 1 7819219969, chaitali@wysa.io %K retention %K engagement %K Wysa %K chronic pain %K digital health %K digital application %K app %K mental health %K digital intervention %K health intervention %K symptom management %K user engagement %K conversational agent %D 2022 %7 23.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital applications are commonly used to support mental health and well-being. However, successfully retaining and engaging users to complete digital interventions is challenging, and comorbidities such as chronic pain further reduce user engagement. Digital conversational agents (CAs) may improve user engagement by applying engagement principles that have been implemented within in-person care settings. Objective: To evaluate user retention and engagement with an artificial intelligence–led digital mental health app (Wysa for Chronic Pain) that is customized for individuals managing mental health symptoms and coexisting chronic pain. Methods: In this ancillary survival analysis of a clinical trial, participants included 51 adults who presented to a tertiary care center for chronic musculoskeletal pain, who endorsed coexisting symptoms of depression or anxiety (Patient-Reported Outcomes Measurement Information System score of ≥55 for depression or anxiety), and initiated onboarding to an 8-week subscription of Wysa for Chronic Pain. The study outcomes were user retention, defined as revisiting the app each week and on the last day of engagement, and user engagement, defined by the number of sessions the user completed. Results: Users engaged in a cumulative mean of 33.3 sessions during the 8-week study period. The survival analysis depicted a median user retention period (i.e., time to complete disengagement) of 51 days, with the usage of a morning check-in feature having a significant relationship with a longer retention period (P=.001). Conclusions: Our findings suggest that user retention and engagement with a CBT-based CA built for users with chronic pain is higher than standard industry metrics. These results have clear implications for addressing issues of suboptimal engagement of digital health interventions and improving access to care for chronic pain. Future work should use these findings to inform the design of evidence-based interventions for individuals with chronic pain and to enhance user retention and engagement of digital health interventions more broadly. Trial Registration: ClinicalTrials.gov NCT04640090; https://clinicaltrials.gov/ct2/show/NCT04640090 %M 35526201 %R 10.2196/37302 %U https://formative.jmir.org/2022/5/e37302 %U https://doi.org/10.2196/37302 %U http://www.ncbi.nlm.nih.gov/pubmed/35526201 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e30907 %T Screening Depressive Symptoms and Incident Major Depressive Disorder Among Chinese Community Residents Using a Mobile App–Based Integrated Mental Health Care Model: Cohort Study %A Zhang,Huimin %A Liao,Yuhua %A Han,Xue %A Fan,Beifang %A Liu,Yifeng %A Lui,Leanna M W %A Lee,Yena %A Subramaniapillai,Mehala %A Li,Lingjiang %A Guo,Lan %A Lu,Ciyong %A McIntyre,Roger S %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, No.74, Zhongshan 2nd, Guangzhou, 510080, China, 86 020 87332477, luciyong@mail.sysu.edu.cn %K screening %K depressive symptoms %K incident major depressive disorder %K Chinese community residents %K electronic-based integrated mental health care model %D 2022 %7 20.5.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is associated with significant morbidity and human capital costs globally. Early screening for depressive symptoms and timely depressive disorder case identification and intervention may improve health outcomes and cost-effectiveness among affected individuals. China’s public and academic communities have reached a consensus on the need to improve access to early screening, diagnosis, and treatment of depression. Objective: This study aims to estimate the screening prevalence and associated factors of subthreshold depressive symptoms among Chinese residents enrolled in the cohort study using a mobile app–based integrated mental health care model and investigate the 12-month incidence rate and related factors of major depressive disorder (MDD) among those with subthreshold depressive symptoms. Methods: Data were drawn from the Depression Cohort in China (DCC) study. A total of 4243 community residents aged 18 to 64 years living in Nanshan district, Shenzhen city, in Guangdong province, China, were encouraged to participate in the DCC study when visiting the participating primary health care centers, and 4066 (95.83%) residents who met the DCC study criteria were screened for subthreshold depressive symptoms using the Patient Health Questionnaire-9 at baseline. Of the 4066 screened residents, 3168 (77.91%) with subthreshold depressive symptoms were referred to hospitals to receive a psychiatric diagnosis of MDD within 12 months. Sleep duration, anxiety symptoms, well-being, insomnia symptoms, and resilience were also investigated. The diagnosis of MDD was provided by trained psychiatrists using the Mini-International Neuropsychiatric Interview. Univariate and multivariate logistic regression models were performed to explore the potential factors related to subthreshold depressive symptoms at baseline, and Cox proportional hazards models were performed to explore the potential factors related to incident MDD. Results: Anxiety symptoms (adjusted odds ratio [AOR] 1.63, 95% CI 1.42-1.87) and insomnia symptoms (AOR 1.13, 95% CI 1.05-1.22) were associated with an increased risk of subthreshold depressive symptoms, whereas well-being (AOR 0.93, 95% CI 0.87-0.99) was negatively associated with depressive symptoms. During the follow-up period, the 12-month incidence rate of MDD among participants with subthreshold depressive symptoms was 5.97% (189/3168). After incorporating all significant variables from the univariate analyses, the multivariate Cox proportional hazards model reported that a history of comorbidities (adjusted hazard ratio [AHR] 1.49, 95% CI 1.04-2.14) and anxiety symptoms (AHR 1.13, 95% CI 1.09-1.17) were independently associated with an increased risk of incident MDD. The 5-item World Health Organization Well-Being Index was associated with a decreased risk of incident MDD (AHR 0.90, 95% CI 0.86-0.94). Conclusions: Elevated anxiety symptoms and unfavorable general well-being were significantly associated with subthreshold depressive symptoms and incident MDD among Chinese residents in Shenzhen. Early screening for subthreshold depressive symptoms and related factors may be helpful for identifying populations at high risk of incident MDD. %M 35594137 %R 10.2196/30907 %U https://www.jmir.org/2022/5/e30907 %U https://doi.org/10.2196/30907 %U http://www.ncbi.nlm.nih.gov/pubmed/35594137 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 5 %N 2 %P e33856 %T Assessment of Social Behavior Using a Passive Monitoring App in Cognitively Normal and Cognitively Impaired Older Adults: Observational Study %A Muurling,Marijn %A Reus,Lianne M %A de Boer,Casper %A Wessels,Sterre C %A Jagesar,Raj R %A Vorstman,Jacob A S %A Kas,Martien J H %A Visser,Pieter Jelle %+ Alzheimer Center, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam University Medical Center, De Boelelaan 1118, Amsterdam, 1081 HZ, Netherlands, 31 (0)204448527, m.muurling@amsterdamumc.nl %K passive monitoring %K smartphone app %K cognitive impairment %K social behavior %K dementia %K mHealth %K mobile app %K cognitive %K mental health %K social withdrawal %K well-being %D 2022 %7 20.5.2022 %9 Original Paper %J JMIR Aging %G English %X Background: In people with cognitive impairment, loss of social interactions has a major impact on well-being. Therefore, patients would benefit from early detection of symptoms of social withdrawal. Current measurement techniques such as questionnaires are subjective and rely on recall, in contradiction to smartphone apps, which measure social behavior passively and objectively. Objective: This study uses the remote monitoring smartphone app Behapp to assess social behavior, and aims to investigate (1) the association between social behavior, demographic characteristics, and neuropsychiatric symptoms in cognitively normal (CN) older adults, and (2) if social behavior is altered in cognitively impaired (CI) participants. In addition, we explored in a subset of individuals the association between Behapp outcomes and neuropsychiatric symptoms. Methods: CN, subjective cognitive decline (SCD), and CI older adults installed the Behapp app on their own Android smartphone for 7 to 42 days. CI participants had a clinical diagnosis of mild cognitive impairment (MCI) or Alzheimer-type dementia. The app continuously measured communication events, app use and location. Neuropsychiatric Inventory (NPI) total scores were available for 20 SCD and 22 CI participants. Linear models were used to assess group differences on Behapp outcomes and to assess the association of Behapp outcomes with the NPI. Results: We included CN (n=209), SCD (n=55) and CI (n=22) participants. Older cognitively normal participants called less frequently and made less use of apps (P<.05). No sex effects were found. Compared to the CN and SCD groups, CI individuals called less unique contacts (β=–0.7 [SE 0.29], P=.049) and contacted the same contacts relatively more often (β=0.8 [SE 0.25], P=.004). They also made less use of apps (β=–0.83 [SE 0.25], P=.004). Higher total NPI scores were associated with further traveling (β=0.042 [SE 0.015], P=.03). Conclusions: CI individuals show reduced social activity, especially those activities that are related to repeated and unique behavior, as measured by the smartphone app Behapp. Neuropsychiatric symptoms seemed only marginally associated with social behavior as measured with Behapp. This research shows that the Behapp app is able to objectively and passively measure altered social behavior in a cognitively impaired population. %M 35594063 %R 10.2196/33856 %U https://aging.jmir.org/2022/2/e33856 %U https://doi.org/10.2196/33856 %U http://www.ncbi.nlm.nih.gov/pubmed/35594063 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e37736 %T A Machine Learning Approach for Detecting Digital Behavioral Patterns of Depression Using Nonintrusive Smartphone Data (Complementary Path to Patient Health Questionnaire-9 Assessment): Prospective Observational Study %A Choudhary,Soumya %A Thomas,Nikita %A Ellenberger,Janine %A Srinivasan,Girish %A Cohen,Roy %+ Research, Behavidence Inc, 99 Wall Street #4004, New York, NY, 10005, United States, 1 6372493366, soumya@behavidence.com %K mobile phone %K depression %K digital phenotyping %K digital mental health %D 2022 %7 16.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a major global cause of morbidity, an economic burden, and the greatest health challenge leading to chronic disability. Mobile monitoring of mental conditions has long been a sought-after metric to overcome the problems associated with the screening, diagnosis, and monitoring of depression and its heterogeneous presentation. The widespread availability of smartphones has made it possible to use their data to generate digital behavioral models that can be used for both clinical and remote screening and monitoring purposes. This study is novel as it adds to the field by conducting a trial using private and nonintrusive sensors that can help detect and monitor depression in a continuous, passive manner. Objective: This study demonstrates a novel mental behavioral profiling metric (the Mental Health Similarity Score), derived from analyzing passively monitored, private, and nonintrusive smartphone use data, to identify and track depressive behavior and its progression. Methods: Smartphone data sets and self-reported Patient Health Questionnaire-9 (PHQ-9) depression assessments were collected from 558 smartphone users on the Android operating system in an observational study over an average of 10.7 (SD 23.7) days. We quantified 37 digital behavioral markers from the passive smartphone data set and explored the relationship between the digital behavioral markers and depression using correlation coefficients and random forest models. We leveraged 4 supervised machine learning classification algorithms to predict depression and its severity using PHQ-9 scores as the ground truth. We also quantified an additional 3 digital markers from gyroscope sensors and explored their feasibility in improving the model’s accuracy in detecting depression. Results: The PHQ-9 2-class model (none vs severe) achieved the following metrics: precision of 85% to 89%, recall of 85% to 89%, F1 of 87%, and accuracy of 87%. The PHQ-9 3-class model (none vs mild vs severe) achieved the following metrics: precision of 74% to 86%, recall of 76% to 83%, F1 of 75% to 84%, and accuracy of 78%. A significant positive Pearson correlation was found between PHQ-9 questions 2, 6, and 9 within the severely depressed users and the mental behavioral profiling metric (r=0.73). The PHQ-9 question-specific model achieved the following metrics: precision of 76% to 80%, recall of 75% to 81%, F1 of 78% to 89%, and accuracy of 78%. When a gyroscope sensor was added as a feature, the Pearson correlation among questions 2, 6, and 9 decreased from 0.73 to 0.46. The PHQ-9 2-class model+gyro features achieved the following metrics: precision of 74% to 78%, recall of 67% to 83%, F1 of 72% to 78%, and accuracy of 76%. Conclusions: Our results demonstrate that the Mental Health Similarity Score can be used to identify and track depressive behavior and its progression with high accuracy. %M 35420993 %R 10.2196/37736 %U https://formative.jmir.org/2022/5/e37736 %U https://doi.org/10.2196/37736 %U http://www.ncbi.nlm.nih.gov/pubmed/35420993 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 2 %P e35057 %T A Web-Based Stratified Stepped Care Mental Health Platform (TourHeart): Semistructured Interviews With Stakeholders %A Tsoi,Emily W S %A Mak,Winnie W S %A Ho,Connie Y Y %A Yeung,Gladys T Y %+ Department of Psychology, The Chinese University of Hong Kong, Room 354 Sino Building, Shatin, NT, China (Hong Kong), 852 39436577, wwsmak@cuhk.edu.hk %K stepped care %K recovery %K engagement %K eHealth %K mental health %K mental well-being %K psychological intervention %D 2022 %7 13.5.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: TourHeart, a web-based stratified stepped care mental health platform, is a one-stop solution that integrates psychoeducation and other well-being promotional tools for mental health promotion and mental illness prevention and evidence-based, low-intensity psychological interventions for the treatment of people with anxiety and depressive symptoms. Instead of focusing only on symptom reduction, the platform aims to be person-centered and recovery-oriented, and continual feedback from stakeholders is sought. Understanding the perspectives of users and service providers enables platform developers to fine-tune both the design and content of the services for enhanced service personalization and personal recovery. Objective: This qualitative study evaluated a web-based mental health platform by incorporating the perspectives of both users and service providers who administered the platform and provided coaching services. The platform included both web-based and offline services targeting adults along the mental health spectrum based on the two-continua model of mental health and mental illness. Methods: Interview questions were designed based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework (RE-AIM). Views on offline services, the design of the web-based platform, user experience, and the contents of the platform were explored using semistructured interviews. A total of 27 service users and 22 service providers were recruited using purposive criterion sampling. A hybrid thematic analysis was performed to identify salient aspects of users’ and providers’ experiences with and views of the platform. Results: Totally, 3 broad themes (namely, the quality of the platform, drivers for platform use, and coaching services) emerged from the interview data that highlighted users’ views of and experiences with the web-based platform. The platform’s general esthetics, operations, and contents were found to be critical features and drivers for continued use. Although coaching services were indispensable, participants preferred the autonomy and anonymity associated with web-based mental health services. Conclusions: This study highlights the importance of web-based mental health services being easy to navigate and understand, being user-centric, and providing adequate guidance in self-help. It also confirms existing design standards and recommendations and suggests that more rigorous, iterative user experience research and robust evaluation should be conducted in the future adaptation of web-based stratified stepped care services, so that they can be more personalized and better promote personal recovery. %M 35560109 %R 10.2196/35057 %U https://humanfactors.jmir.org/2022/2/e35057 %U https://doi.org/10.2196/35057 %U http://www.ncbi.nlm.nih.gov/pubmed/35560109 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35159 %T Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review %A Philippe,Tristan J %A Sikder,Naureen %A Jackson,Anna %A Koblanski,Maya E %A Liow,Eric %A Pilarinos,Andreas %A Vasarhelyi,Krisztina %+ Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada, 1 604 875 4111 ext 64710, Krisztina.Vasarhelyi@vch.ca %K digital health %K telepsychology %K computer-assisted therapy %K online therapy %K mobile applications %K mobile apps %K telemedicine %K telepsychiatry %K virtual reality exposure therapy %K mental health %K COVID-19 %D 2022 %7 12.5.2022 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions. Objective: To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions. Methods: We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care. Results: Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence. Conclusions: Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions. %M 35551058 %R 10.2196/35159 %U https://mental.jmir.org/2022/5/e35159 %U https://doi.org/10.2196/35159 %U http://www.ncbi.nlm.nih.gov/pubmed/35551058 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e30716 %T Ownership, Use of, and Interest in Digital Mental Health Technologies Among Clinicians and Young People Across a Spectrum of Clinical Care Needs: Cross-sectional Survey %A Bell,Imogen H %A Thompson,Andrew %A Valentine,Lee %A Adams,Sophie %A Alvarez-Jimenez,Mario %A Nicholas,Jennifer %+ Orygen, 35 Poplar Rd, Parkville, 3052, Australia, 61 430156222, imogen.bell@orygen.org.au %K adolescent %K youth mental health %K mental health %K attitude %K digital technology %K internet-based interventions %K digital mental health %K mental health services %K clinician %K mobile phone %D 2022 %7 11.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is currently an increased interest in and acceptance of technology-enabled mental health care. To adequately harness this opportunity, it is critical that the design and development of digital mental health technologies be informed by the needs and preferences of end users. Despite young people and clinicians being the predominant users of such technologies, few studies have examined their perspectives on different digital mental health technologies. Objective: This study aims to understand the technologies that young people have access to and use in their everyday lives and what applications of these technologies they are interested in to support their mental health. The study also explores the technologies that youth mental health clinicians currently use within their practice and what applications of these technologies they are interested in to support their clients’ mental health. Methods: Youth mental health service users (aged 12-25 years) from both primary and specialist services, young people from the general population (aged 16-25 years), and youth mental health clinicians completed a web-based survey exploring technology ownership, use of, and interest levels in using different digital interventions to support their mental health or that of their clients. Results: A total of 588 young people and 73 youth mental health clinicians completed the survey. Smartphone ownership or private access among young people within mental health services and the general population was universal (611/617, 99%), with high levels of access to computers and social media. Youth technology use was frequent, with 63.3% (387/611) using smartphones several times an hour. Clinicians reported using smartphones (61/76, 80%) and video chat (69/76, 91%) commonly in clinical practice and found them to be helpful. Approximately 50% (296/609) of the young people used mental health apps, which was significantly less than the clinicians (χ23=28.8, n=670; P<.001). Similarly, clinicians were significantly more interested in using technology for mental health support than young people (H3=55.90; P<.001), with 100% (73/73) of clinicians being at least slightly interested in technology to support mental health compared with 88% (520/591) of young people. Follow-up tests revealed no difference in interest between young people from the general population, primary mental health services, and specialist mental health services (all P>.23). Young people were most interested in web-based self-help, mobile self-help, and blended therapy. Conclusions: Technology access is pervasive among young people within and outside of youth mental health services; clinicians are already using technology to support clinical care, and there is widespread interest in digital mental health technologies among these groups of end users. These findings provide important insights into the perspectives of young people and clinicians regarding the value of digital mental health interventions in supporting youth mental health. %M 35544295 %R 10.2196/30716 %U https://mental.jmir.org/2022/5/e30716 %U https://doi.org/10.2196/30716 %U http://www.ncbi.nlm.nih.gov/pubmed/35544295 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35273 %T Momentary Self-regulation: Scale Development and Preliminary Validation %A Scherer,Emily A %A Kim,Sunny Jung %A Metcalf,Stephen A %A Sweeney,Mary Ann %A Wu,Jialing %A Xie,Haiyi %A Mazza,Gina L %A Valente,Matthew J %A MacKinnon,David P %A Marsch,Lisa A %+ Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth, Suite 315, 46 Centerra Pkwy, Lebanon, NH, 03766, United States, 1 603 646 7000, blood.emily@gmail.com %K self-regulation %K momentary self-regulation %K ecological momentary assessment %K psychometric %K health behavior change %K health risk behaviors %K mobile phone %D 2022 %7 10.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Self-regulation refers to a person’s ability to manage their cognitive, emotional, and behavioral processes to achieve long-term goals. Most prior research has examined self-regulation at the individual level; however, individual-level assessments do not allow the examination of dynamic patterns of intraindividual variability in self-regulation and thus cannot aid in understanding potential malleable processes of self-regulation that may occur in response to the daily environment. Objective: This study aims to develop a brief, psychometrically sound momentary self-regulation scale that can be practically administered through participants’ mobile devices at a momentary level. Methods: This study was conducted in 2 phases. In the first phase, in a sample of 522 adults collected as part of a larger self-regulation project, we examined 23 previously validated assessments of self-regulation containing 594 items in total to evaluate the underlying structure of self-regulation via exploratory and confirmatory factor analyses. We then selected 20 trait-level items to be carried forward to the second phase. In the second phase, we converted each item into a momentary question and piloted the momentary items in a sample of 53 adults over 14 days. Using the results from the momentary pilot study, we explored the psychometric properties of the items and assessed their underlying structure. We then proposed a set of subscale and total score calculations. Results: In the first phase, the selected individual-level items appeared to measure 4 factors of self-regulation. The factors identified were perseverance, sensation seeking, emotion regulation, and mindfulness. In the second phase of the ecological momentary assessment pilot, the selected items demonstrated strong construct validity as well as predictive validity for health risk behaviors. Conclusions: Our findings provide preliminary evidence for a 12-item momentary self-regulation scale comprising 4 subscales designed to capture self-regulatory dynamics at the momentary level. %M 35536605 %R 10.2196/35273 %U https://mental.jmir.org/2022/5/e35273 %U https://doi.org/10.2196/35273 %U http://www.ncbi.nlm.nih.gov/pubmed/35536605 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35526 %T Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, Palo Alto University, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 800 818 6136, mdpaul@stanford.edu %K virtual reality %K major depressive disorder %K behavioral activation %K depression %D 2022 %7 6.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD. Objective: We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD. Methods: A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire–9. Results: Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant’s clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire–9 score. Conclusions: The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs. Trial Registration: ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316 International Registered Report Identifier (IRRID): RR2-10.2196/24331 %M 35404830 %R 10.2196/35526 %U https://mental.jmir.org/2022/5/e35526 %U https://doi.org/10.2196/35526 %U http://www.ncbi.nlm.nih.gov/pubmed/35404830 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35549 %T Smartphone Sensor Data for Identifying and Monitoring Symptoms of Mood Disorders: A Longitudinal Observational Study %A Braund,Taylor A %A Zin,May The %A Boonstra,Tjeerd W %A Wong,Quincy J J %A Larsen,Mark E %A Christensen,Helen %A Tillman,Gabriel %A O’Dea,Bridianne %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 2 9065 9255, t.braund@blackdog.org.au %K depression %K bipolar disorder %K sensors %K mobile app %K circadian rhythm %K mobile phone %D 2022 %7 4.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mood disorders are burdensome illnesses that often go undetected and untreated. Sensor technologies within smartphones may provide an opportunity for identifying the early changes in circadian rhythm and social support/connectedness that signify the onset of a depressive or manic episode. Objective: Using smartphone sensor data, this study investigated the relationship between circadian rhythm, which was determined by GPS data, and symptoms of mental health among a clinical sample of adults diagnosed with major depressive disorder or bipolar disorder. Methods: A total of 121 participants were recruited from a clinical setting to take part in a 10-week observational study. Self-report questionnaires for mental health outcomes, social support, social connectedness, and quality of life were assessed at 6 time points throughout the study period. Participants consented to passively sharing their smartphone GPS data for the duration of the study. Circadian rhythm (ie, regularity of location changes in a 24-hour rhythm) was extracted from GPS mobility patterns at baseline. Results: Although we found no association between circadian rhythm and mental health functioning at baseline, there was a positive association between circadian rhythm and the size of participants’ social support networks at baseline (r=0.22; P=.03; R2=0.049). In participants with bipolar disorder, circadian rhythm was associated with a change in anxiety from baseline; a higher circadian rhythm was associated with an increase in anxiety and a lower circadian rhythm was associated with a decrease in anxiety at time point 5. Conclusions: Circadian rhythm, which was extracted from smartphone GPS data, was associated with social support and predicted changes in anxiety in a clinical sample of adults with mood disorders. Larger studies are required for further validations. However, smartphone sensing may have the potential to monitor early symptoms of mood disorders. %M 35507385 %R 10.2196/35549 %U https://mental.jmir.org/2022/5/e35549 %U https://doi.org/10.2196/35549 %U http://www.ncbi.nlm.nih.gov/pubmed/35507385 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e36775 %T Therapeutic Alliance in Online and Face-to-face Psychological Treatment: Comparative Study %A Mercadal Rotger,Josep %A Cabré,Victor %+ Institut Universitari de Salut Mental Vidal i Barraquer, Universitat Ramon Llull, C/ Sant Gervasi de Cassoles 88-90, Barcelona, 08022, Spain, 34 660221557, jmercadal@fvb.cat %K online psychological intervention %K therapeutic alliance %K digital health %K mental health %K mental health education %K mental health treatment %K health interventions %K health professional %K online health %K web-based health %K intervention modality %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Since the COVID-19 pandemic, the number of online mental health treatments have grown exponentially. Additionally, it seems inevitable that this technical resource is here to stay at health centers. However, there is still very little scholarly literature published on this topic, and therefore, the impact of the changes that have had to be dealt with in this regard has not been studied. Objective: This study aims to evaluate the differences in the establishment of the therapeutic alliance (TA) based on the intervention modality (online or face-to-face), the type of attachment, and diagnosis. Methods: A total of 291 subjects participated in the study, 149 (51.2%) of whom were men and 142 were (48.8%) women between the ages of 18 and 30 years. The instruments used were sociodemographic data, SOFTA-o (System for Observing Family Therapeutic Alliances—observational), and Relationship Questionnaire. Results: The results show that the treatments conducted face-to-face obtain significantly better scores in the creation of the TA than those conducted online (t=–42.045, df=289, P<.001). The same holds true with attachment, in that users with secure attachment show a better TA than those with insecure attachment (t=6.068, P<.001,), although there were no significant differences with the diagnosis (F=4.566, P=.44), age (r=0.02, P=.70), and sex (t=0.217, P=.33). Conclusions: We believe that professionals are not yet prepared to conduct remote treatment with a degree of efficacy similar to that of face-to-face. It is essential for professionals to receive training in this new technical resource and to understand and incorporate the variants it entails into their daily practice. %M 35499910 %R 10.2196/36775 %U https://mental.jmir.org/2022/5/e36775 %U https://doi.org/10.2196/36775 %U http://www.ncbi.nlm.nih.gov/pubmed/35499910 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35048 %T Engagement, Predictors, and Outcomes of a Trauma Recovery Digital Mental Health Intervention: Longitudinal Study %A Yeager,Carolyn M %A Benight,Charles C %+ Lyda Hill Institute for Human Resilience, University of Colorado Colorado Springs, Fourth Floor, 4863 North Nevada Avenue, Colorado Springs, CO, 80918, United States, 1 (719) 413 8075, cyeager@uccs.edu %K engagement %K digital health %K digital mental health intervention %K social cognitive theory %K SCT %K self-efficacy %K outcome expectations %K trauma %K posttraumatic stress disorder %K PTSD %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Worldwide, exposure to potentially traumatic events is extremely common, and many individuals develop posttraumatic stress disorder (PTSD) along with other disorders. Unfortunately, considerable barriers to treatment exist. A promising approach to overcoming treatment barriers is a digital mental health intervention (DMHI). However, engagement with DMHIs is a concern, and theoretically based research in this area is sparse and often inconclusive. Objective: The focus of this study is on the complex issue of DMHI engagement. On the basis of the social cognitive theory framework, the conceptualization of engagement and a theoretically based model of predictors and outcomes were investigated using a DMHI for trauma recovery. Methods: A 6-week longitudinal study with a national sample of survivors of trauma was conducted to measure engagement, predictors of engagement, and mediational pathways to symptom reduction while using a trauma recovery DMHI (time 1: N=915; time 2: N=350; time 3: N=168; and time 4: N=101). Results: Confirmatory factor analysis of the engagement latent constructs of duration, frequency, interest, attention, and affect produced an acceptable model fit (χ22=8.3; P=.02; comparative fit index 0.973; root mean square error of approximation 0.059; 90% CI 0.022-0.103). Using the latent construct, the longitudinal theoretical model demonstrated adequate model fit (comparative fit index 0.929; root mean square error of approximation 0.052; 90% CI 0.040-0.064), indicating that engagement self-efficacy (β=.35; P<.001) and outcome expectations (β=.37; P<.001) were significant predictors of engagement (R2=39%). The overall indirect effect between engagement and PTSD symptom reduction was significant (β=–.065; P<.001; 90% CI –0.071 to –0.058). This relationship was serially mediated by both skill activation self-efficacy (β=.80; P<.001) and trauma coping self-efficacy (β=.40; P<.001), which predicted a reduction in PTSD symptoms (β=−.20; P=.02). Conclusions: The results of this study may provide a solid foundation for formalizing the nascent science of engagement. Engagement conceptualization comprised general measures of attention, interest, affect, and use that could be applied to other applications. The longitudinal research model supported 2 theoretically based predictors of engagement: engagement self-efficacy and outcome expectancies. A total of 2 task-specific self-efficacies—skill activation and trauma coping—proved to be significant mediators between engagement and symptom reduction. Taken together, this model can be applied to other DMHIs to understand engagement, as well as predictors and mechanisms of action. Ultimately, this could help improve the design and development of engaging and effective trauma recovery DMHIs. %M 35499857 %R 10.2196/35048 %U https://mental.jmir.org/2022/5/e35048 %U https://doi.org/10.2196/35048 %U http://www.ncbi.nlm.nih.gov/pubmed/35499857 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e36541 %T Development of a Mobile Assessment Tool for Understanding Social Comparison Processes Among Individuals With Schizophrenia: Two-Phase Survey Study %A Arigo,Danielle %A Torous,John %+ Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson 116G, Glassboro, NJ, 08028, United States, 1 8562564500 ext 53775, arigo@rowan.edu %K schizophrenia %K social comparison %K mobile assessment %K smartphone app %K variability %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital tools may help to address social deficits in schizophrenia, particularly those that engage social comparison processes (ie, evaluating oneself relative to others). Yet, little is known about social comparison processes in schizophrenia or how best to capture between- versus within-person variability, which is critical to engaging comparisons in digital interventions. Objective: The goals of this pilot study were to (1) better understand affective responses to social comparisons among individuals with schizophrenia, relative to healthy controls, using a validated global self-report measure; and (2) test a new brief, mobile assessment of affective responses to social comparison among individuals with schizophrenia, relative to the full measure. This study was conducted in 2 phases. Methods: We first compared self-reported affective responses to social comparisons between individuals with schizophrenia (n=39) and healthy controls (n=38) using a traditional self-report measure, at 2 time points. We examined the temporal stability in responses and differences between groups. We then evaluated the performance of brief, mobile assessment of comparison responses among individuals with schizophrenia, completed over 12 weeks (n=31). Results: Individuals with schizophrenia showed greater variability in affective responses to social comparison than controls on traditional measures and completed an average of 7.46 mobile assessments over 12 weeks. Mobile assessments captured within-person variability in affective responses in the natural environment (intraclass correlation coefficients of 0.40-0.60). Average scores for mobile assessments were positively correlated with responses to traditional measures. Conclusions: Affective responses to social comparison vary both between and within individuals with schizophrenia and capturing this variability via smartphone surveys shows some evidence of feasibility. As affective variability is a potential indicator of poor outcomes among individuals with mental health conditions, in the future, a brief, mobile assessment of affective responses to social comparisons may be useful for screening among individuals with schizophrenia. Further research on this process is needed to identify when specific comparison messaging may be most effective in digital interventions and could suggest new therapeutic targets for illnesses such as schizophrenia. %M 35499856 %R 10.2196/36541 %U https://formative.jmir.org/2022/5/e36541 %U https://doi.org/10.2196/36541 %U http://www.ncbi.nlm.nih.gov/pubmed/35499856 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e25249 %T Data Visualization for Chronic Neurological and Mental Health Condition Self-management: Systematic Review of User Perspectives %A Polhemus,Ashley %A Novak,Jan %A Majid,Shazmin %A Simblett,Sara %A Morris,Daniel %A Bruce,Stuart %A Burke,Patrick %A Dockendorf,Marissa F %A Temesi,Gergely %A Wykes,Til %+ Merck Research Labs, Information Technology, Merck, Sharpe, & Dohme, The Circle 66, Zurich, 8058, Switzerland, 41 764922388, ashley.polhemus@uzh.ch %K digital health %K remote measurement technology %K neurology %K mental health %K data visualization %K user-centered design %D 2022 %7 28.4.2022 %9 Review %J JMIR Ment Health %G English %X Background: Remote measurement technologies (RMT) such as mobile health devices and apps are increasingly used by those living with chronic neurological and mental health conditions. RMT enables real-world data collection and regular feedback, providing users with insights about their own conditions. Data visualizations are an integral part of RMT, although little is known about visualization design preferences from the perspectives of those living with chronic conditions. Objective: The aim of this review was to explore the experiences and preferences of individuals with chronic neurological and mental health conditions on data visualizations derived from RMT to manage health. Methods: In this systematic review, we searched peer-reviewed literature and conference proceedings (PubMed, IEEE Xplore, EMBASE, Web of Science, Association for Computing Machinery Computer-Human Interface proceedings, and the Cochrane Library) for original papers published between January 2007 and September 2021 that reported perspectives on data visualization of people living with chronic neurological and mental health conditions. Two reviewers independently screened each abstract and full-text article, with disagreements resolved through discussion. Studies were critically appraised, and extracted data underwent thematic synthesis. Results: We identified 35 eligible publications from 31 studies representing 12 conditions. Coded data coalesced into 3 themes: desire for data visualization, impact of visualizations on condition management, and visualization design considerations. Data visualizations were viewed as an integral part of users’ experiences with RMT, impacting satisfaction and engagement. However, user preferences were diverse and often conflicting both between and within conditions. Conclusions: When used effectively, data visualizations are valuable, engaging components of RMT. They can provide structure and insight, allowing individuals to manage their own health more effectively. However, visualizations are not “one-size-fits-all,” and it is important to engage with potential users during visualization design to understand when, how, and with whom the visualizations will be used to manage health. %M 35482368 %R 10.2196/25249 %U https://mental.jmir.org/2022/4/e25249 %U https://doi.org/10.2196/25249 %U http://www.ncbi.nlm.nih.gov/pubmed/35482368 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e32146 %T Detecting Mental Health Behaviors Using Mobile Interactions: Exploratory Study Focusing on Binge Eating %A Vega,Julio %A Bell,Beth T %A Taylor,Caitlin %A Xie,Jue %A Ng,Heidi %A Honary,Mahsa %A McNaney,Roisin %+ Department of Human Centred Computing, Monash University, Wellington Rd, Clayton, VIC 3800, Australia, 61 3 9902 6000, roisin.mcnaney@monash.edu %K eating disorder %K binge eating %K mental health %K mobile sensing %K context-aware computing %K NAP %K EMA %K mobile phone %D 2022 %7 25.4.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Binge eating is a subjective loss of control while eating, which leads to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviors (eg, meal skipping, overexercising, or vomiting). Objective: The aim of this study was to explore the potential of mobile sensing to detect indicators of binge-eating episodes, with a view toward informing the design of future context-aware mobile interventions. Methods: This study was conducted in 2 stages. The first involved the development of the DeMMI (Detecting Mental health behaviors using Mobile Interactions) app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were useful and appropriate, as well as to gather feedback on some specific app features relating to self-reporting. The second stage involved conducting a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted after the study, which discussed their experience using the app, and 8 participants (n=3, 38% binge eating and n=5, 63% comparisons) consented. Results: The findings showed unique differences in the types of sensor data that were triangulated with the individuals’ episodes (with nearby Bluetooth devices, screen and app use features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased participants’ awareness of and reflection on their mood and phone usage patterns. Moreover, they expressed no privacy concerns as these were alleviated by the study information sheet. Conclusions: This study contributes a series of recommendations for future studies wishing to scale our approach and for the design of bespoke mobile interventions to support this population. %M 35086064 %R 10.2196/32146 %U https://mental.jmir.org/2022/4/e32146 %U https://doi.org/10.2196/32146 %U http://www.ncbi.nlm.nih.gov/pubmed/35086064 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e31730 %T Toward Research-Informed Design Implications for Interventions Limiting Smartphone Use: Functionalities Review of Digital Well-being Apps %A Almoallim,Sultan %A Sas,Corina %+ School of Computing and Communications, Lancaster University, InfoLab21, Bailrigg, Lancaster, LA1 4YW, United Kingdom, 44 07453728107, s.almoallim@lancaster.ac.uk %K digital well-being %K smartphone apps %K tracking use %K monitoring against set use limits %K interventions for limiting use %K barriers %K design for friction %K screen time %K attention %K self-regulation %K mobile phone %D 2022 %7 19.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Much research in human-computer interaction has focused on well-being and how it can be better supported through a range of technologies, from affective interfaces to mindfulness systems. At the same time, we have seen a growing number of commercial digital well-being apps. However, there has been limited scholarly work reviewing these apps. Objective: This paper aims to report on an autoethnographic study and functionality review of the 39 most popular commercial digital well-being apps on Google Play Store and 17 apps described in academic papers. Methods: From 1250 apps on Google Play Store, we selected 39 (3.12%) digital well-being apps, and from Google Scholar, we identified 17 papers describing academic apps. Both sets of digital well-being apps were analyzed through a review of their functionalities based on their descriptions. The commercial apps were also analyzed through autoethnography, wherein the first author interacted with them to understand how these functionalities work and how they may be experienced by users in their daily lives. Results: Our findings indicate that these apps focus mostly on limiting screen time, and we advanced a richer conversation about such apps, articulating the distinctions among monitoring use, tracking use against set limits, and 4 specific interventions supporting limited use. Conclusions: We conclude with 6 implications for designing digital well-being apps, namely calling to move beyond screen time and support the broader focus of digital well-being; supporting meaningful use rather than limiting meaningless use; leveraging (digital) navigation in design for friction; supporting collaborative interaction to limit phone overuse; supporting explicit, time-based visualizations for monitoring functionality; and supporting the ethical design of digital well-being apps. %M 35188897 %R 10.2196/31730 %U https://formative.jmir.org/2022/4/e31730 %U https://doi.org/10.2196/31730 %U http://www.ncbi.nlm.nih.gov/pubmed/35188897 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 2 %P e35668 %T Evaluating User Feedback for an Artificial Intelligence–Enabled, Cognitive Behavioral Therapy–Based Mental Health App (Wysa): Qualitative Thematic Analysis %A Malik,Tanya %A Ambrose,Adrian Jacques %A Sinha,Chaitali %+ Wysa Inc, 131 Dartmouth St, Boston, MA, United States, 1 9874803442, tanya@wysa.io %K digital mental health %K artificial intelligence %K user reviews %K cognitive behavioral therapy %K CBT %D 2022 %7 12.4.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Digital mental health apps are rapidly becoming a common source of accessible support across the world, but their effectiveness is often influenced by limited helpfulness and engagement. Objective: This study’s primary objective was to analyze feedback content to understand users’ experiences with engaging with a digital mental health app. As a secondary objective, an exploratory analysis captured the types of mental health app users. Methods: This study utilized a user-led approach to understanding factors for engagement and helpfulness in digital mental health by analyzing feedback (n=7929) reported on Google Play Store about Wysa, a mental health app (1-year period). The analysis of keywords in the user feedback categorized and evaluated the reported user experience into the core domains of acceptability, usability, usefulness, and integration. The study also captured key deficits and strengths of the app and explored salient characteristics of the types of users who benefit from accessible digital mental health support. Results: The analysis of user feedback found the app to be overwhelmingly positively reviewed (6700/7929, 84.50% 5-star rating). The themes of engaging exercises, interactive interface, and artificial intelligence (AI) conversational ability indicated the acceptability of the app, while the nonjudgmentality and ease of conversation highlighted its usability. The app’s usefulness was portrayed by themes such as improvement in mental health, convenient access, and cognitive restructuring exercises. Themes of privacy and confidentiality underscored users’ preference for the integrated aspects of the app. Further analysis revealed 4 predominant types of individuals who shared app feedback on the store. Conclusions: Users reported therapeutic elements of a comfortable, safe, and supportive environment through using the digital mental health app. Digital mental health apps may expand mental health access to those unable to access traditional forms of mental health support and treatments. %M 35249886 %R 10.2196/35668 %U https://humanfactors.jmir.org/2022/2/e35668 %U https://doi.org/10.2196/35668 %U http://www.ncbi.nlm.nih.gov/pubmed/35249886 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e33307 %T Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review %A Bernstein,Emily E %A Weingarden,Hilary %A Wolfe,Emma C %A Hall,Margaret D %A Snorrason,Ivar %A Wilhelm,Sabine %+ Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States, 1 6177246032, eebernstein@mgh.harvard.edu %K digital health %K mental health %K cognitive behavioral therapy %K coaching %K guided %K mobile app %K emotional disorder %K mobile phone %D 2022 %7 8.4.2022 %9 Review %J J Med Internet Res %G English %X Background: Smartphone app–based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions. Objective: The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach. Methods: We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded. Results: Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present. Conclusions: Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis. %M 35394434 %R 10.2196/33307 %U https://www.jmir.org/2022/4/e33307 %U https://doi.org/10.2196/33307 %U http://www.ncbi.nlm.nih.gov/pubmed/35394434 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e32157 %T Using the Stay Strong App for the Well-being of Indigenous Australian Prisoners: Feasibility Study %A Perdacher,Elke %A Kavanagh,David %A Sheffield,Jeanie %A Healy,Karyn %A Dale,Penny %A Heffernan,Edward %+ Queensland Forensic Mental Health Service, GPO Box 8161, Brisbane, 4001, Australia, 61 7 3837 5820, elke.perdacher@health.qld.gov.au %K First Nation %K Indigenous %K digital mental health %K e-mental health %K mental health %K social and emotional well-being %K SEWB %K prisoner %K prison %K mobile phone %D 2022 %7 8.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The gap between mental health needs and resources for Aboriginal and Torres Strait Islander people, the Indigenous people of Australia, is most marked in the prison population. Indigenous people are overrepresented in Australian prisons. In prison, this group experiences mental disorders to a greater degree than non-Indigenous prisoners. This group has also been found to experience mental disorder at a higher rate than Indigenous people in the community. In addition to pre-existing determinants of poor mental health, these high prevalence rates may reflect poor engagement in mainstream interventions or the efficacy of available interventions. In community populations, the use of digital mental health resources may help to increase access to well-being support. However, culturally appropriate digital tools have not been available to Indigenous people in prisons. The absence of feasibility and efficacy studies of these tools needs to be addressed. Objective: The aim of this study is to determine the feasibility of the Stay Strong app as a digital well-being and mental health tool for use by Indigenous people in prison. Methods: Dual government agency (health and corrective services) precondition requirements of implementation were identified and resolved. This was essential given that the Stay Strong app was to be delivered by an external health agency to Indigenous prisoners. Then, acceptability at a practice level was tested using postuse qualitative interviews with clients and practitioners of the Indigenous Mental Health Intervention Program. All Indigenous Mental Health Intervention Program practitioners (10/37, 27%) and client participants who had completed their second follow-up (review of the Stay Strong app; 27/37, 73%) during the study period were invited to participate. Results: Owing to the innovative nature of this project, identifying and resolving the precondition requirements of implementation was challenging but provided support for the implementation of the app in practice. Acceptability of the app by clients and practitioners at a practice level was demonstrated, with nine themes emerging across the interviews: satisfaction with the current Stay Strong app, supported client goal setting, increased client self-insight, improved client empowerment, cultural appropriateness, enhanced engagement, ease of use, problems with using an Android emulator, and recommendations to improve personalization. Conclusions: The Stay Strong Custody Project is a pioneering example of digital mental health tools being implemented within Australian prisons. Using the app within high-security prison settings was found to be feasible at both strategic and practice levels. Feedback from both clients and practitioners supported the use of the app as a culturally safe digital mental health and well-being tool for Aboriginal and Torres Strait Islander people in prison. %M 35394444 %R 10.2196/32157 %U https://formative.jmir.org/2022/4/e32157 %U https://doi.org/10.2196/32157 %U http://www.ncbi.nlm.nih.gov/pubmed/35394444 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e29726 %T Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial %A Ritvo,Paul %A Gratzer,David %A Knyahnytska,Yuliya %A Ortiz,Abigail %A Walters,Clarice %A Katz,Joel %A Laposa,Judith %A Baldissera,Christopher %A Wayne,Noah %A Pfefer-Litman,Donna %A Tomlinson,George %A Daskalakis,Zafiris %+ School of Kinesiology and Health Science, York University, C/O School of Kinesiology and Health Science, Bethune Building, York University, 4700 Keele St., Toronto, ON, M3J1P3, Canada, 1 4165808021, pritvo@yorku.ca %K online intervention %K randomized controlled trial %K major depressive disorder %D 2022 %7 8.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: The incidence of mental health disorders in Canada is increasing with costs of CAD $51 billion (US $40 billion) per year. Depression is the most prevalent cause of disability while cognitive behavioral therapy (CBT) is the best validated behavioral depression treatment. CBT, when combined with mindfulness meditation (CBT-M), has strong evidence for increased efficacy. While randomized controlled trials (RCTs) have demonstrated online CBT-M efficacy, comparisons with in-office delivery are lacking. Objective: The aim of this research is to assess whether online group CBT-M (with standard psychiatric care) is non-inferior in efficacy and more cost-effective than office-based, on-site group CBT-M at post-intervention and 6-months follow-up in major depressive disorder. The study will also assess whether digitally recorded data (ie, online workbooks completed, Fitbit step count, and online text messages) predict depression symptom reduction in online participants. Methods: This single-center, two-arm, noninferiority RCT employs assessor-blinded and self-report outcomes and economic evaluation. The research site is the Centre for Addiction and Mental Health (Toronto), a research-based psychiatry institution where participants will be identified from service wait lists and through contacts with other Toronto clinics. Inclusion criteria are as follows: (1) aged 18-60 years, any ethnicity; (2) Beck Depression Inventory-II (BDI-II) of mild severity (score ≥14) with no upper severity limit; (3) Mini-International Neuropsychiatric Interview-confirmed, psychiatric major depressive disorder diagnosis; (4) fluent in English. All patients are diagnosed by staff psychiatrists. Exclusion criteria are as follows: (1) receipt of weekly structured psychotherapy; (2) observation of Diagnostic and Statistical Manual of Mental Disorders (5th Edition) criteria for severe alcohol or substance use disorder (in past 3 months), borderline personality disorder, schizophrenia (or other primary psychotic disorder), bipolar disorder, or obsessive-compulsive disorder; (3) clinically significant suicidal ideation (imminent intent or attempted suicide in the past 6 months); and (4) treatment-resistant depression. All participants receive standard psychiatric care, experimental participants receive online group CBT-M, and controls receive standard care in-office group CBT-M. The online group program (in collaboration with NexJ Health, Inc) combines smartphone and computer-accessed workbooks with mental health phone counselling (16 hours in 16 weeks) that coordinates software interactions (eg, secure text messaging and Fitbit-tracked walking). The primary outcome is BDI-II, and secondary outcomes are anxiety (Beck Anxiety Inventory), depression (ie, Quick Inventory of Depressive Symptomatology and 17-item Hamilton Depression Rating Scale), mindfulness (Five-Facet Mindfulness Questionnaire), quality of life (European Quality of Life Five Dimension), and pain (Brief Pain Inventory). Results: Based on prior studies with the BDI-II and 80% power to reject an inferiority hypothesis with a 1-sided type I error rate of 5%, a sample of 78 per group is adequate to detect small-to-medium–effect sizes. Conclusions: This study assesses online CBT-M efficacy and noninferiority in relation to in-person CBT, and the cost-effectiveness of both interventions. Trial Registration: ClinicalTrials.gov NCT04825535; https://www.clinicaltrials.gov/ct2/show/NCT04825535 International Registered Report Identifier (IRRID): DERR1-10.2196/29726 %M 35393942 %R 10.2196/29726 %U https://www.researchprotocols.org/2022/4/e29726 %U https://doi.org/10.2196/29726 %U http://www.ncbi.nlm.nih.gov/pubmed/35393942 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 3 %P e36910 %T Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence–Enabled App (Wysa): Protocol for a Prospective Pilot Study %A Gupta,Megha %A Malik,Tanya %A Sinha,Chaitali %+ Wysa Inc, 131 Dartmouth St, 3rd floor, Boston, MA, 02116, United States, 1 987 480 3442, tanya@wysa.io %K chronic pain %K AI-enabled mental health assistant %K digital health intervention %K mental health conversational agent %K artificial intelligence %K depression %K mental health %K anxiety %K health care cost %K conversational agent %K chatbot %K digital health %D 2022 %7 31.3.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with chronic pain often experience coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial intelligence–supported cognitive behavioral therapy (AI-CBT) interventions could offer cost-effective, accessible, and potentially effective resources to address this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain. Objective: This prospective cohort study aims to examine the efficacy and use of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app, Wysa Inc) using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text–based conversational agent. Methods: Participants with self-reported chronic pain (n=500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is received from participants within the app, and the Wysa for Chronic Pain intervention is delivered remotely for 8 weeks. Outcome measures including a numeric pain rating scale and Patient-Reported Outcomes Measurement Information System–Pain Interference, Generalized Anxiety Disorder–7, and Patient Health Questionnaire–9 questionnaires administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the Working Alliance Inventory–Short Revised instrument. Retention and use statistics will be observed for adherence and engagement. Results: The study will open for recruitment in April 2022, and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late 2022. Conclusions: Mental health conversational agents driven by artificial intelligence could be effective in helping patients with chronic pain learn to self-manage their pain and common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions that include a human therapist. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain. International Registered Report Identifier (IRRID): PRR1-10.2196/36910 %M 35314423 %R 10.2196/36910 %U https://www.researchprotocols.org/2022/3/e36910 %U https://doi.org/10.2196/36910 %U http://www.ncbi.nlm.nih.gov/pubmed/35314423 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 3 %P e33423 %T Effectiveness of a Mindfulness-Based Mobile Application for the Treatment of Depression in Ambulatory Care: Protocol for a Randomized Controlled Trial %A Sarlon,Jan %A Doll,Jessica P K %A Schmassmann,Aline %A Brand,Serge %A Ferreira,Naomi %A Muehlhauser,Markus %A Urech-Meyer,Stefanie %A Schweinfurth,Nina %A Lang,Undine Emmi %A Bruehl,Annette Beatrix %+ University Psychiatric Clinics, University of Basel, Wilhelm Klein-Strasse 27, Basel, 4002, Switzerland, 41 613255097, jan.sarlon@upk.ch %K depression %K mindfulness %K mhealth %K ehealth %K stress level %D 2022 %7 31.3.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with major depressive disorder (MDD) often experience relapses despite regular treatment with pharmacotherapy and psychotherapy. Further, long waiting lists and more demand than treatment capacity characterize ambulatory settings. Mindfulness-based interventions proved to be effective in relapse prevention in MDD. Next, mindfulness-based interventions in the form of free mobile applications can be an effective augmentation of the treatment as usual and can fill a gap in ambulatory care. Objective: Given this background, the aim of this randomized controlled study is to assess the effectiveness of additional MBI via a mobile app on the symptom severity and stress levels, compared to treatment as usual. Methods: A total of 140 individuals with MDD will be randomly allocated to the intervention or control condition. The intervention consists of the daily use of the mindfulness mobile application Headspace for thirty days (up to 10 minutes a day). The control condition will be treatment as usual. At baseline and four weeks later, the following key outcome dimensions will be assessed: self-rated (Beck Depression Inventory) and experts’ rated symptoms of MDD (Hamilton Depression Rating Scale); secondary outcome variables will be blood pressure, heart rate, and respiratory rate and changes in tobacco and alcohol consumption and medication as a proxy of perceived stress. Results: This study was funded in February 2021 and approved by the institutional review board on April 15, 2021, and it started in May 2021. As of December 2021, we enrolled 30 participants. The findings are expected to be published in spring 2023. Conclusions: We hypothesize that compared to the control conditions, individuals with MDD of the mobile app-condition will have both lower self- and experts’ rated symptoms of MDD and more favorable stress-related levels. While the risk for medical events is low, the immediate benefit for participants could be a decrease in symptom severity and reduction of the stress level. Trial Registration: Clinical Trials.gov NCT05060393; https://clinicaltrials.gov/ct2/show/NCT05060393. International Registered Report Identifier (IRRID): DERR1-10.2196/33423 %M 35357325 %R 10.2196/33423 %U https://www.researchprotocols.org/2022/3/e33423 %U https://doi.org/10.2196/33423 %U http://www.ncbi.nlm.nih.gov/pubmed/35357325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e32824 %T The Current State and Validity of Digital Assessment Tools for Psychiatry: Systematic Review %A Martin-Key,Nayra A %A Spadaro,Benedetta %A Funnell,Erin %A Barker,Eleanor Jane %A Schei,Thea Sofie %A Tomasik,Jakub %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K diagnostic accuracy %K digital mental health %K digital questionnaire %K psychiatry %K systematic review %D 2022 %7 30.3.2022 %9 Review %J JMIR Ment Health %G English %X Background: Given the role digital technologies are likely to play in the future of mental health care, there is a need for a comprehensive appraisal of the current state and validity (ie, screening or diagnostic accuracy) of digital mental health assessments. Objective: The aim of this review is to explore the current state and validity of question-and-answer–based digital tools for diagnosing and screening psychiatric conditions in adults. Methods: This systematic review was based on the Population, Intervention, Comparison, and Outcome framework and was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, Cochrane Library, ASSIA, Web of Science Core Collection, CINAHL, and PsycINFO were systematically searched for articles published between 2005 and 2021. A descriptive evaluation of the study characteristics and digital solutions and a quantitative appraisal of the screening or diagnostic accuracy of the included tools were conducted. Risk of bias and applicability were assessed using the revised tool for the Quality Assessment of Diagnostic Accuracy Studies 2. Results: A total of 28 studies met the inclusion criteria, with the most frequently evaluated conditions encompassing generalized anxiety disorder, major depressive disorder, and any depressive disorder. Most of the studies used digitized versions of existing pen-and-paper questionnaires, with findings revealing poor to excellent screening or diagnostic accuracy (sensitivity=0.32-1.00, specificity=0.37-1.00, area under the receiver operating characteristic curve=0.57-0.98) and a high risk of bias for most of the included studies. Conclusions: The field of digital mental health tools is in its early stages, and high-quality evidence is lacking. International Registered Report Identifier (IRRID): RR2-10.2196/25382 %M 35353053 %R 10.2196/32824 %U https://mental.jmir.org/2022/3/e32824 %U https://doi.org/10.2196/32824 %U http://www.ncbi.nlm.nih.gov/pubmed/35353053 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e34301 %T Barriers and Considerations in the Design and Implementation of Digital Behavioral Interventions: Qualitative Analysis %A Marcu,Gabriela %A Ondersma,Steven J %A Spiller,Allison N %A Broderick,Brianna M %A Kadri,Reema %A Buis,Lorraine R %+ Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI, 48104-1213, United States, 1 734 998 7120, buisl@umich.edu %K computers %K mobile apps %K screening %K brief interventions %K diagnosis %K computer-assisted/methods %K surveys and questionnaires %K motivational interviewing %K therapy %K implementation %K qualitative %K mobile phone %D 2022 %7 30.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital behavioral interventions have become increasingly popular for their ability to support patient diagnosis and treatment, chronic disease self-management, behavior change, and adherence to recommended care. However, digital intervention development is impeded by challenges such as limited technical skills, limited access to developers, and cost. The purpose of this study is to elicit in-depth qualitative feedback from intervention developers who have interest in digital behavioral interventions but lack programming skills regarding the barriers they experience and key considerations in the design and implementation of digital interventions. Objective: This study aims to understand barriers in the design and implementation of digital behavioral interventions, as well as to identify key considerations for researchers who are developing these interventions. Methods: We conducted semistructured qualitative interviews with 18 researchers who had experience either designing (but not coding) digital behavioral interventions or running research studies with them. Participants were a convenience sample of users of the Computerized Intervention Authoring System platform, an existing no-code development platform for building digital intervention content, and were recruited through either direct email solicitation or snowball sampling. All interviews were conducted and recorded over videoconference between February and April 2020. Recordings from interviews were transcribed and thematically analyzed by multiple coders. Results: Interviews were completed with 18 participants and lasted between 24 and 65 (mean 46.9, SD 11.3) minutes. Interviewees were predominantly female (17/18, 94%) and represented different job roles, ranging from researcher to project/study staff. Three key barriers in the development of digital behavior interventions were identified during interviews: lack of cross-disciplinary understanding; variability in recipients’ technology access, infrastructure, and literacy; and the idea that evidence-based in-person interactions do not translate directly to digital interactions. Interviewees identified several key considerations that interventionists learned to prioritize, which have the potential to overcome these barriers and lead to successful interventions. Conclusions: Barriers in the development of digital behavioral interventions are often created by a lack of cross-disciplinary understanding, which can lead to difficulties conceptualizing interventions, unrealistic expectations in terms of cost, and confusion about the development process. Moreover, concerns about research study participant characteristics and access to technology, as well as the translation of in-person interventions to digital, are apparent. Appropriate training in how to work with software development teams may help future digital behavior intervention creators overcome these barriers and may lead to new, exciting innovations in this space. %M 35353043 %R 10.2196/34301 %U https://www.jmir.org/2022/3/e34301 %U https://doi.org/10.2196/34301 %U http://www.ncbi.nlm.nih.gov/pubmed/35353043 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e34300 %T The Perceived Benefits of Digital Interventions for Behavioral Health: Qualitative Interview Study %A Marcu,Gabriela %A Ondersma,Steven J %A Spiller,Allison N %A Broderick,Brianna M %A Kadri,Reema %A Buis,Lorraine R %+ Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI, 48104-1213, United States, 1 734 998 7120, buisl@umich.edu %K computers %K mobile apps %K screening %K brief interventions %K diagnosis %K computer-assisted/methods %K surveys and questionnaires %K motivational interviewing %K therapy %K computer-assisted/methods %K implementation %K qualitative %K mobile phone %D 2022 %7 30.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital interventions have gained momentum in terms of behavioral health. However, owing to lacking standard approaches or tools for creating digital behavioral interventions, clinical researchers follow widely varying conceptions of how best to go about digital intervention development. Researchers also face significant cost-, time-, and expertise-related challenges in digital intervention development. Improving the availability of tools and guidance for researchers will require a thorough understanding of the motivations and needs of researchers seeking to create digital interventions. Objective: This study aims to understand the perceptions of behavioral researchers toward digital interventions, and inform the use of these interventions, by documenting the reasons why researchers are increasingly focusing their efforts on digital interventions and their perspectives on the perceived benefits that digital approaches can provide for researchers and intervention recipients. Methods: We conducted semistructured qualitative interviews with 18 researchers who had experience designing digital behavioral interventions or running studies with them. A convenience sample of interviewees was recruited from among users of the Computerized Intervention Authoring System platform, a web-based tool that facilitates the process of creating and deploying digital interventions in behavioral research. Interviews were conducted over teleconference between February and April 2020. Recordings from the interviews were transcribed and thematically analyzed by multiple coders. Results: Interviews were completed with 18 individuals and lasted between 24 and 65 (mean 46.9, SD 11.3) minutes. Interviewees were predominantly female (17/18, 94%) and represented different job roles, ranging from researcher to project or study staff. Four major themes came out of the interviews concerning the benefits of digital interventions for behavioral health: convenience and flexibility for interventionists and recipients, support for implementing evidence-based interventions with fidelity, scaling and improving access to interventions, and getting a foot in the door despite stigma and disenfranchisement. Conclusions: Interviewees described a number of important potential benefits of digital interventions, particularly with respect to scientific rigor, scalability, and overcoming barriers to reaching more people. There are complex considerations with regard to translating behavior change strategies into digital forms of delivery, and interventionists make individual, sometimes unexpected, choices with minimal evidence of their relative effectiveness. Future research should investigate how behavioral researchers can be supported in making these choices toward usability, ease of access, and approachability of digital interventions. Our study underscores the need for authoring platforms that can facilitate the process of creating and deploying digital interventions to reach their full potential for interventionists and recipients alike. %M 35353045 %R 10.2196/34300 %U https://www.jmir.org/2022/3/e34300 %U https://doi.org/10.2196/34300 %U http://www.ncbi.nlm.nih.gov/pubmed/35353045 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e34760 %T Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews %A Villarreal-Zegarra,David %A Alarcon-Ruiz,Christoper A %A Melendez-Torres,GJ %A Torres-Puente,Roberto %A Navarro-Flores,Alba %A Cavero,Victoria %A Ambrosio-Melgarejo,Juan %A Rojas-Vargas,Jefferson %A Almeida,Guillermo %A Albitres-Flores,Leonardo %A Romero-Cabrera,Alejandra B %A Huarcaya-Victoria,Jeff %+ Unidad de Psiquiatría de Enlace, Departamento de Psiquiatría, Hospital Nacional Guillermo Almenara Irigoyen, Av Grau 800, Lima, 15001, Peru, 51 987382101, jeff.huarcaya@upsjb.edu.pe %K telemedicine %K digital health %K internet-based intervention %K mental health %K mental disorders %K systematic reviews %K qualitative research %K realist review %K mHealth %K eHealth %K telehealth %D 2022 %7 29.3.2022 %9 Review %J JMIR Ment Health %G English %X Background: The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation. Objective: The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems. Methods: The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach. Results: A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist. Conclusions: We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811 International Registered Report Identifier (IRRID): RR2-10.12688/f1000research.27150.2 %M 35348469 %R 10.2196/34760 %U https://mental.jmir.org/2022/3/e34760 %U https://doi.org/10.2196/34760 %U http://www.ncbi.nlm.nih.gov/pubmed/35348469 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e34744 %T PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public %A Hallenbeck,Haijing Wu %A Jaworski,Beth K %A Wielgosz,Joseph %A Kuhn,Eric %A Ramsey,Kelly M %A Taylor,Katherine %A Juhasz,Katherine %A McGee-Vincent,Pearl %A Mackintosh,Margaret-Anne %A Owen,Jason E %+ Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, United States, 1 650 493 5000, haijing.hallenbeck@stanford.edu %K posttraumatic stress disorder %K trauma %K mental health %K mHealth %K mobile app %K public health %K self-management %K mobile phone %D 2022 %7 29.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated. Objective: We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach. Methods: We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users. Results: During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean −1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean −4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements. Conclusions: PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement. %M 35348458 %R 10.2196/34744 %U https://mental.jmir.org/2022/3/e34744 %U https://doi.org/10.2196/34744 %U http://www.ncbi.nlm.nih.gov/pubmed/35348458 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e29154 %T A Smartphone-Based Intervention as an Adjunct to Standard-of-Care Treatment for Schizophrenia: Randomized Controlled Trial %A Ghaemi,S Nassir %A Sverdlov,Oleksandr %A van Dam,Joris %A Campellone,Timothy %A Gerwien,Robert %+ Novaris Institutes for Biomedical Research, 220 Massachusetts Avenue, Cambridge, MA, 02139, United States, 1 857 253 8950, nassir.ghaemi@tufts.edu %K digital therapeutics %K schizophrenia %K smartphones %K randomized controlled trial %K mobile phone %D 2022 %7 28.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Antipsychotic medications have limited benefits in schizophrenia, and cognitive behavioral therapy may be beneficial as an adjunct. There may be potential for implementing mobile cognitive behavioral therapy–based treatment for schizophrenia in addition to standard antipsychotic medications. Objective: This study aims to determine whether PEAR-004, a smartphone-based investigational digital therapeutic, improves the symptoms of an acute psychotic exacerbation of schizophrenia when it is added to standard treatments. Methods: This was a 12-week, multicenter, randomized, sham-controlled, rater-blinded, parallel group proof‑of‑concept study of 112 participants with moderate acute psychotic exacerbation in schizophrenia. This study was conducted in 6 clinical trial research sites in the United States from December 2018 to September 2019. The primary outcome, change in Positive and Negative Syndrome Scale (PANSS) from baseline to week 12 or the last available visit, was analyzed using the mixed-effects regression model for repeated measures, applied to an intent-to-treat sample. Results: The total PANSS scores slightly decreased from baseline over the study period in both groups; the treatment difference at day 85 between PEAR-004 and sham was 2.7 points, in favor of the sham (2-sided P=.09). The secondary scales found no benefit, except for transient improvement in depressive symptoms with PEAR-004. Application engagement was good, and patient and clinical investigator satisfaction was high. No safety concerns were observed. There was some evidence of study site heterogeneity for the onboarding processes and directions on PEAR-004 product use at baseline and throughout the study. However, these differences did not affect the efficacy results. Conclusions: In the largest-to-date randomized, sham-controlled study of a digital therapeutic in schizophrenia, PEAR-004 did not demonstrate an effect on the primary outcome—total PANSS scores—when compared with a nonspecific digital sham control. The secondary and exploratory results also did not demonstrate any notable benefits, except for possible temporary improvement in depressive symptoms. This study provided many useful scientific and operational insights that can be used in the further clinical development of PEAR-004 and other investigational digital therapeutics. Trial Registration: ClinicalTrials.gov NCT03751280; https://clinicaltrials.gov/ct2/show/NCT03751280 %M 35343910 %R 10.2196/29154 %U https://formative.jmir.org/2022/3/e29154 %U https://doi.org/10.2196/29154 %U http://www.ncbi.nlm.nih.gov/pubmed/35343910 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e29114 %T Process and Outcome Evaluations of Smartphone Apps for Bipolar Disorder: Scoping Review %A Tatham,Iona %A Clarke,Ellisiv %A Grieve,Kelly Ann %A Kaushal,Pulkit %A Smeddinck,Jan %A Millar,Evelyn Barron %A Sharma,Aditya Narain %+ Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Academic Psychiatry, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, United Kingdom, 44 1912875262, aditya.sharma@ncl.ac.uk %K child and adolescent mental health %K scoping review %K bipolar disorder %K mental health %D 2022 %7 23.3.2022 %9 Review %J J Med Internet Res %G English %X Background: Mental health apps (MHAs) provide opportunities for accessible, immediate, and innovative approaches to better understand and support the treatment of mental health disorders, especially those with a high burden, such as bipolar disorder (BD). Many MHAs have been developed, but few have had their effectiveness evaluated. Objective: This systematic scoping review explores current process and outcome measures of MHAs for BD with the aim to provide a comprehensive overview of current research. This will identify the best practice for evaluating MHAs for BD and inform future studies. Methods: A systematic literature search of the health science databases PsycINFO, MEDLINE, Embase, EBSCO, Scopus, and Web of Science was undertaken up to January 2021 (with no start date) to narratively assess how studies had evaluated MHAs for BD. Results: Of 4051 original search results, 12 articles were included. These 12 studies included 435 participants, and of these, 343 had BD type I or II. Moreover, 11 of the 12 studies provided the ages (mean 37 years) of the participants. One study did not report age data. The male to female ratio of the 343 participants was 137:206. The most widely employed validated outcome measure was the Young Mania Rating Scale, being used 8 times. The Hamilton Depression Rating Scale-17/Hamilton Depression Rating Scale was used thrice; the Altman Self-Rating Mania Scale, Quick Inventory of Depressive Symptomatology, and Functional Assessment Staging Test were used twice; and the Coping Inventory for Stressful Situations, EuroQoL 5-Dimension Health Questionnaire, Generalized Anxiety Disorder Scale-7, Inventory of Depressive Symptomatology, Mindfulness Attention Awareness Scale, Major Depression Index, Morisky-Green 8-item, Perceived Stress Scale, and World Health Organization Quality of Life-BREF were used once. Self-report measures were captured in 9 different studies, 6 of which used MONARCA. Mood and energy levels were the most commonly used self-report measures, being used 4 times each. Furthermore, 11 of the 12 studies discussed the various confounding factors and barriers to the use of MHAs for BD. Conclusions: Reported low adherence rates, usability challenges, and privacy concerns act as barriers to the use of MHAs for BD. Moreover, as MHA evaluation is itself developing, guidance for clinicians in how to aid patient choices in mobile health needs to develop. These obstacles could be ameliorated by incorporating co-production and co-design using participatory patient approaches during the development and evaluation stages of MHAs for BD. Further, including qualitative aspects in trials that examine patient experience of both mental ill health and the MHA itself could result in a more patient-friendly fit-for-purpose MHA for BD. %M 35319470 %R 10.2196/29114 %U https://www.jmir.org/2022/3/e29114 %U https://doi.org/10.2196/29114 %U http://www.ncbi.nlm.nih.gov/pubmed/35319470 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e28081 %T App-Based Ecological Momentary Assessment to Enhance Clinical Care for Postpartum Depression: Pilot Acceptability Study %A Krohn,Holly %A Guintivano,Jerry %A Frische,Rachel %A Steed,Jamie %A Rackers,Hannah %A Meltzer-Brody,Samantha %+ Department of Psychiatry, University of North Carolina at Chapel Hill, 333 S. Columbia Street, MacNider 304 CB 7160, Chapel Hill, NC, 27599, United States, 1 919 445 0218, holly_krohn@med.unc.edu %K postpartum care %K depression %K mobile health %K mHealth %K ecological momentary assessment (EMA) %K mobile apps %K personalized care %K mobile phone %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Wearable tracking devices and mobile health technology are increasingly used in an effort to enhance clinical care and the delivery of personalized medical treatment. Postpartum depression is the most frequently diagnosed complication of childbirth; however, significant gaps in screening and treatment remain. Objective: This study aims to investigate the clinical utility, predictive ability, and acceptability of using ecological momentary assessment to collect daily mood, sleep, and activity data through the use of an Apple Watch and mobile app among women with postpartum depression. Methods: This was a pilot study consisting of 3 in-person research visits over the course of a 6-week enrollment period. Questionnaires to assess depression, anxiety, and maternal functioning were periodically collected, along with daily self-reported symptoms and passively collected physiological data via an Apple Watch. Feedback was collected from study participants and the study clinician to determine the utility and acceptability of daily tracking. Logistic regression was used to determine whether mood scores in the 2 weeks before a visit predicted scores at follow-up. Compliance with daily assessments was also measured. Results: Of the 26 women enrolled, 23 (88%) completed the 6-week study period. On average, the participants completed 67% (34.4/51.5 days) of all active daily assessments and 74% (38/51.5 days) of all passive measures. Furthermore, all 23 participants completed the 3 required visits with the research team. Predictive correlations were found between self-reported mood and Edinburgh Postnatal Depression Scale score at follow-up, self-reported anxiety and EDPS, and sleep quality and Edinburgh Postnatal Depression Scale. Conclusions: Using ecological momentary assessment to track daily symptoms of postpartum depression using a wearable device was largely endorsed as acceptable and clinically useful by participants and the study clinician and could be an innovative solution to increase care access during the COVID-19 pandemic. %M 35319483 %R 10.2196/28081 %U https://formative.jmir.org/2022/3/e28081 %U https://doi.org/10.2196/28081 %U http://www.ncbi.nlm.nih.gov/pubmed/35319483 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e30231 %T Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis %A Jensen,Esben Skov %A Ladegaard,Nicolai %A Mellentin,Angelina Isabella %A Ebert,David Daniel %A Titzler,Ingrid %A Araya,Ricardo %A Cerga Pashoja,Arlinda %A Hazo,Jean-Baptiste %A Holtzmann,Jérôme %A Cieslak,Roman %A Smoktunowicz,Ewelina %A Baños,Rosa %A Herrero,Rocio %A García-Palacios,Azucena %A Botella,Cristina %A Berger,Thomas %A Krieger,Tobias %A Holmberg,Trine Theresa %A Topooco,Naira %A Andersson,Gerhard %A van Straten,Annemieke %A Kemmeren,Lise %A Kleiboer,Annet %A Riper,Heleen %A Mathiasen,Kim %+ Centre for Telepsychiatry, Mental Health Services of Southern Denmark, Odense, Denmark, 1 61677747, kmathiasen@health.sdu.dk %K blended care %K bCBT %K cognitive behavioral therapy %K digital intervention %K major depressive disorder %K sleep disturbance %K sleep disorder %K mental health %K digital health %K mobile phone %D 2022 %7 21.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally. Objective: The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally. Methods: The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time. Results: Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI –0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=–.23, 95% CI −0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI −0.11 to 0.23) or 6-month (β=.09, 95% CI −0.10 to 0.28) follow-up. Conclusions: Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis. %M 35311687 %R 10.2196/30231 %U https://www.jmir.org/2022/3/e30231 %U https://doi.org/10.2196/30231 %U http://www.ncbi.nlm.nih.gov/pubmed/35311687 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e33092 %T Treatment Interruptions and Telemedicine Utilization in Serious Mental Illness: Retrospective Longitudinal Claims Analysis %A Ainslie,Marcy %A Brunette,Mary F %A Capozzoli,Michelle %+ Department of Nursing, University of New Hampshire, 4 library way, hewitt hall, Durham, NH, 03824, United States, 1 603 562 8833, marcy.ainslie@unh.edu %K telemedicine %K mental health %K serious mental illness %K retention %K mental illness %K telehealth %D 2022 %7 21.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Avoiding interruptions and dropout in outpatient care can prevent mental illness symptom exacerbation and costly crisis services, such as emergency room visits and inpatient psychiatric hospitalization. During the COVID-19 pandemic, to attempt to maintain care continuity, telemedicine services were increasingly utilized, despite the lack of data on efficacy in patients with serious mental illness. Patients with serious mental illness are challenging to enroll and sustain in randomized controlled trials over time due to fluctuations in disease exacerbation. However, capturing and examining utilization and efficacy data in community mental health center (CMHC) patients with serious mental illness during the pandemic is a unique opportunity to inform future clinical and policy decision-making. Objective: We aimed to identify and describe the characteristics of CMHC patients with serious mental illness who experienced treatment interruptions and who utilized telemedicine during the pandemic. Methods: We conducted a retrospective observational study of treatment interruptions and telemedicine use during the period from December 2019 to June 2020 (compared to the period from December 2018 to June 2019) in New Hampshire CMHC patients. The study population included all Medicaid beneficiaries with serious mental illness engaged in treatment 3 months prior to the declaration of a state of emergency in response to the COVID-19 pandemic. We used chi-square tests of independence and logistic regression to explore associations between treatment interruptions and variables (gender, age, rurality, and diagnosis). Telemedicine utilization was categorized as low (<25%), medium (25%-75%), or high (>75%) use. Results: A total of 16,030 patients were identified. New Hampshire CMHCs demonstrated only a 4.9% increase in treatment interruptions compared with the year prior. Patients who were male (odds ratio [OR] 1.27, 95% CI 1.17-1.38; P<.001), under the age of 18 years (ages 0-12 years: OR 1.37, 95% CI 0.62-0.86, P<.001; aged 13-17 years: OR 1.49, 95% CI 0.57-0.79, P<.001), or among milder diagnostic categories, such as anxiety disorders (OR 3.77, 95% CI 3.04-4.68; P<.001) and posttraumatic stress disorder (OR 3.69, 95% CI 2.96-4.61; P<.001), were most likely to experience treatment interruptions. Patients who were female (OR 0.89, CI 0.65-0.74), 18 to 34 years old (OR 0.74, CI 0.70-0.79), or among milder diagnostic categories, such as anxiety disorder (OR 0.69, CI 0.65-0.74) or posttraumatic stress disorder (OR 0.77, CI 0.72-0.83), and with major depressive disorder (OR 0.73, CI 0.68-0.78) were less likely to be in the low telemedicine utilization group. Conclusions: The integration of telemedicine supported care continuity for most CMHC patients; yet, retention varied by subpopulation, as did telemedicine utilization. The development of policies and clinical practice guidelines requires empirical evidence on the effectiveness and limitations of telemedicine in patients with serious mental illness. %M 35311673 %R 10.2196/33092 %U https://mental.jmir.org/2022/3/e33092 %U https://doi.org/10.2196/33092 %U http://www.ncbi.nlm.nih.gov/pubmed/35311673 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e32123 %T The Effectiveness of a Nonguided Mindfulness App on Perceived Stress in a Nonclinical Dutch Population: Randomized Controlled Trial %A Kranenburg,Leonieke W %A Gillis,Jamie %A Mayer,Birgit %A Hoogendijk,Witte J G %+ Section of Medical Psychology, Department of Psychiatry, Erasmus University Medical Center, PO Box 2040, Rotterdam, 3000 CA, Netherlands, 31 10 7040139, l.kranenburg@erasmusmc.nl %K mHealth %K mindfulness %K stress %K burnout %K non-clinical population %K nonclinical %D 2022 %7 18.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mindfulness has become increasingly popular, and positive outcomes have been reported for mindfulness-based interventions (MBIs) in reducing stress. These findings make room for innovative perspectives on how MBIs could be applied, for instance through mobile health (mHealth). Objective: The aim of this study is to investigate whether a nonguided mindfulness mobile app can decrease perceived stress in a nonclinical Dutch population over the course of 8 weeks, with follow-up at 6 months. Methods: A randomized controlled trial was performed to compare an experimental group that made use of a structured 8-week mHealth mindfulness program and a control group after 8 weeks, with follow-up after 6 months. Participants were recruited via a national television program. The primary outcome measure was perceived stress as measured by the Perceived Stress Scale, secondary outcomes were symptoms of burnout (measured using the visual analog scale [VAS]) and psychological symptoms (measured using the Four-Dimensional Symptom Questionnaire [4DSQ] at follow-up). Outcomes were analyzed using a multilevel regression model. Results: At baseline, 587 respondents were included. Results showed no postintervention differences between groups for the level of perceived stress. With regard to the secondary outcome measures, the VAS for emotional exhaustion and physical exhaustion showed significantly lower scores for the experimental group after 8 weeks (P=.04 and P=.01, respectively), but not at follow-up. There were no differences between groups for psychological symptoms measured using the 4DSQ. Conclusions: These findings do not support our hypothesis that using the mindfulness app would reduce stress levels. However, our findings related to diminished exhaustion at 8 weeks are encouraging and require further investigation. Trial Registration: ClinicalTrials.gov NCT05246800; https://clinicaltrials.gov/show/NCT05246800 %M 35302504 %R 10.2196/32123 %U https://mental.jmir.org/2022/3/e32123 %U https://doi.org/10.2196/32123 %U http://www.ncbi.nlm.nih.gov/pubmed/35302504 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e34898 %T Longitudinal Relationships Between Depressive Symptom Severity and Phone-Measured Mobility: Dynamic Structural Equation Modeling Study %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Vairavan,Srinivasan %A Bendayan,Rebecca %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Laiou,Petroula %A Sankesara,Heet %A Matcham,Faith %A White,Katie M %A Oetzmann,Carolin %A Ivan,Alina %A Lamers,Femke %A Siddi,Sara %A Vilella,Elisabet %A Simblett,Sara %A Rintala,Aki %A Bruce,Stuart %A Mohr,David C %A Myin-Germeys,Inez %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda WJH %A Narayan,Vaibhav A %A Annas,Peter %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 20 7848 0473, richard.j.dobson@kcl.ac.uk %K depression %K mobile health %K location data %K mobility %K dynamic structural equation modeling %K mHealth %K mental health %K medical informatics %K modeling %D 2022 %7 11.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The mobility of an individual measured by phone-collected location data has been found to be associated with depression; however, the longitudinal relationships (the temporal direction of relationships) between depressive symptom severity and phone-measured mobility have yet to be fully explored. Objective: We aimed to explore the relationships and the direction of the relationships between depressive symptom severity and phone-measured mobility over time. Methods: Data used in this paper came from a major EU program, called the Remote Assessment of Disease and Relapse–Major Depressive Disorder, which was conducted in 3 European countries. Depressive symptom severity was measured with the 8-item Patient Health Questionnaire (PHQ-8) through mobile phones every 2 weeks. Participants’ location data were recorded by GPS and network sensors in mobile phones every 10 minutes, and 11 mobility features were extracted from location data for the 2 weeks prior to the PHQ-8 assessment. Dynamic structural equation modeling was used to explore the longitudinal relationships between depressive symptom severity and phone-measured mobility. Results: This study included 2341 PHQ-8 records and corresponding phone-collected location data from 290 participants (age: median 50.0 IQR 34.0, 59.0) years; of whom 215 (74.1%) were female, and 149 (51.4%) were employed. Significant negative correlations were found between depressive symptom severity and phone-measured mobility, and these correlations were more significant at the within-individual level than the between-individual level. For the direction of relationships over time, Homestay (time at home) (φ=0.09, P=.01), Location Entropy (time distribution on different locations) (φ=−0.04, P=.02), and Residential Location Count (reflecting traveling) (φ=0.05, P=.02) were significantly correlated with the subsequent changes in the PHQ-8 score, while changes in the PHQ-8 score significantly affected (φ=−0.07, P<.001) the subsequent periodicity of mobility. Conclusions: Several phone-derived mobility features have the potential to predict future depression, which may provide support for future clinical applications, relapse prevention, and remote mental health monitoring practices in real-world settings. %M 35275087 %R 10.2196/34898 %U https://mental.jmir.org/2022/3/e34898 %U https://doi.org/10.2196/34898 %U http://www.ncbi.nlm.nih.gov/pubmed/35275087 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e27791 %T Implementation of Cognitive Behavioral Therapy in e–Mental Health Apps: Literature Review %A Denecke,Kerstin %A Schmid,Nicole %A Nüssli,Stephan %+ Institute for Medical Informatics, Bern University of Applied Sciences, Quellgasse 21, Biel, 2501, Switzerland, 41 32 321 67 94, kerstin.denecke@bfh.ch %K cognitive behavioral therapy %K mHealth %K e–mental health %K chatbot %K mobile phone %D 2022 %7 10.3.2022 %9 Review %J J Med Internet Res %G English %X Background: To address the matter of limited resources for treating individuals with mental disorders, e–mental health has gained interest in recent years. More specifically, mobile health (mHealth) apps have been suggested as electronic mental health interventions accompanied by cognitive behavioral therapy (CBT). Objective: This study aims to identify the therapeutic aspects of CBT that have been implemented in existing mHealth apps and the technologies used. From these, we aim to derive research gaps that should be addressed in the future. Methods: Three databases were screened for studies on mHealth apps in the context of mental disorders that implement techniques of CBT: PubMed, IEEE Xplore, and ACM Digital Library. The studies were independently selected by 2 reviewers, who then extracted data from the included studies. Data on CBT techniques and their technical implementation in mHealth apps were synthesized narratively. Results: Of the 530 retrieved citations, 34 (6.4%) studies were included in this review. mHealth apps for CBT exploit two groups of technologies: technologies that implement CBT techniques for cognitive restructuring, behavioral activation, and problem solving (exposure is not yet realized in mHealth apps) and technologies that aim to increase user experience, adherence, and engagement. The synergy of these technologies enables patients to self-manage and self-monitor their mental state and access relevant information on their mental illness, which helps them cope with mental health problems and allows self-treatment. Conclusions: There are CBT techniques that can be implemented in mHealth apps. Additional research is needed on the efficacy of the mHealth interventions and their side effects, including inequalities because of the digital divide, addictive internet behavior, lack of trust in mHealth, anonymity issues, risks and biases for user groups and social contexts, and ethical implications. Further research is also required to integrate and test psychological theories to improve the impact of mHealth and adherence to the e–mental health interventions. %M 35266875 %R 10.2196/27791 %U https://www.jmir.org/2022/3/e27791 %U https://doi.org/10.2196/27791 %U http://www.ncbi.nlm.nih.gov/pubmed/35266875 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e33060 %T Informing the Future of Integrated Digital and Clinical Mental Health Care: Synthesis of the Outcomes From Project Synergy %A LaMonica,Haley M %A Iorfino,Frank %A Lee,Grace Yeeun %A Piper,Sarah %A Occhipinti,Jo-An %A Davenport,Tracey A %A Cross,Shane %A Milton,Alyssa %A Ospina-Pinillos,Laura %A Whittle,Lisa %A Rowe,Shelley C %A Dowling,Mitchell %A Stewart,Elizabeth %A Ottavio,Antonia %A Hockey,Samuel %A Cheng,Vanessa Wan Sze %A Burns,Jane %A Scott,Elizabeth M %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, 2050, Australia, 61 426955658, haley.lamonica@sydney.edu.au %K mental health %K technology %K co-design %K participatory research %K health care reform %K stakeholder participation %K mobile phone %D 2022 %7 9.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users’ needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care. Objective: Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms. Methods: Participating health care organizations included the following: Open Arms–Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation’s National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention. Results: Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted. Conclusions: Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care. %M 34974414 %R 10.2196/33060 %U https://mental.jmir.org/2022/3/e33060 %U https://doi.org/10.2196/33060 %U http://www.ncbi.nlm.nih.gov/pubmed/34974414 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 1 %P e28301 %T Coaching to Support Mental Health Apps: Exploratory Narrative Review %A Meyer,Ashley %A Wisniewski,Hannah %A Torous,John %+ Division of Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02115, United States, 1 6176676700, jtorous@bidmc.harvard.edu %K smartphone %K apps %K mental health %K coaching %K engagement %D 2022 %7 8.3.2022 %9 Review %J JMIR Hum Factors %G English %X Background: The therapeutic alliance is crucial for the success of face-to-face therapies. Little is known about how coaching functions and fosters the therapeutic alliance in asynchronous treatment modalities such as smartphone apps. Objective: The aim of this paper was to assess how coaching functions and fosters the therapeutic alliance in asynchronous treatment modalities. Methods: We conducted a selected review to gather preliminary data about the role of coaching in mobile technology use for mental health care. We identified 26 trials using a 2019 review by Tønning et al and a 2021 scoping review by Tokgöz et al to assess how coaching is currently being used across different studies. Results: Our results showed a high level of heterogeneity as studies used varying types of coaching methods but provided little information about coaching protocols and training. Coaching was feasible by clinicians and nonclinicians, scheduled and on demand, and across all technologies ranging from phone calls to social media. Conclusions: Further research is required to better understand the effects of coaching in mobile mental health treatments, but examples offered from reviewed papers suggest several options to implement coaching today. Coaching based on replicable protocols that are verifiable for fidelity will enable the scaling of this model and a better exploration of the digital therapeutic alliance. %M 35258468 %R 10.2196/28301 %U https://humanfactors.jmir.org/2022/1/e28301 %U https://doi.org/10.2196/28301 %U http://www.ncbi.nlm.nih.gov/pubmed/35258468 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 1 %P e33038 %T Lessons for Uptake and Engagement of a Smartphone App (SURE Recovery) for People in Recovery From Alcohol and Other Drug Problems: Interview Study of App Users %A Neale,Joanne %A Bowen,Alice May %+ National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom, 44 7511319855, alice.m.bowen@kcl.ac.uk %K apps %K digital literacy %K mHealth %K substance use %K recovery %K qualitative %K mobile phone %D 2022 %7 8.3.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Mobile health apps promoting health and well-being have substantial potential but low uptake and engagement. Barriers common to addiction treatment app uptake and engagement include poor access to mobile technology, Wi-Fi, or mobile data, plus low motivation among non–treatment-seeking users to cut down or quit. Working with people who used substances, we had previously designed and published an app to support recovery from alcohol and other drug problems. The app, which is available for free from the Apple App Store and Google Play, is called SURE Recovery. Objective: The aim of this paper is to undertake a qualitative study to ascertain end users’ views and experiences of the SURE Recovery app, including how it might be improved, and present the findings on uptake and engagement to assist other researchers and app developers working on similar apps for people experiencing alcohol and other drug problems. Methods: Semistructured telephone interviews were conducted with 20 people (n=12, 60%, men and n=8, 40%, women aged 25-63 years; all identifying as White British) who had varied patterns of using the app. The audio recordings were transcribed, and the data were coded and analyzed through Iterative Categorization. Results: Analyses identified three main factors relevant to uptake (discoverability of the app, personal relevance, and expectations and motivations) and three main factors relevant to engagement (the appeal and relevance of specific features, perceived benefits, and the need for improvements). The findings on uptake and engagement were largely consistent with our own earlier developmental work and with other published literature. However, we additionally found that uptake was strongly affected by first impressions, including trust and personal recommendations; that users were attracted to the app by their need for support and curiosity but had relatively modest expectations; that engagement increased if the app made users feel positive; and that people were unlikely to download, or engage with, the app if they could not relate to, or identify with, aspects of its content. Conclusions: Incorporating end-user views into app design and having a network of supportive partners (ie, credible organizations and individuals who will champion the app) seem to increase uptake and engagement among people experiencing alcohol and other drug problems. Although better digital literacy and access to devices and mobile data are needed if addiction recovery apps are to reach their full potential, we should not evaluate them based only on observable changes in substance use behaviors. How using an app makes a person feel is more transient and difficult to quantify but also relevant to uptake and engagement. %M 35258474 %R 10.2196/33038 %U https://humanfactors.jmir.org/2022/1/e33038 %U https://doi.org/10.2196/33038 %U http://www.ncbi.nlm.nih.gov/pubmed/35258474 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e26479 %T A Web-Based Cognitive Behavioral Therapy, Mindfulness Meditation, and Yoga Intervention for Posttraumatic Stress Disorder: Single-Arm Experimental Clinical Trial %A Kirk,Megan A %A Taha,Bilal %A Dang,Kevin %A McCague,Hugh %A Hatzinakos,Dimitrios %A Katz,Joel %A Ritvo,Paul %+ Yale Center for Emotional Intelligence, Yale School of Medicine, Yale University, 350 George Street, 3rd Floor, New Haven, CT, 06511, United States, 1 203 432 4326 ext 24326, megan.kirkchang@yale.edu %K posttraumatic stress disorder %K cognitive therapy %K internet delivery %K pupillometry %K psychophysiology %K PTSD %K therapy %K cognitive behavioral therapy %K mindfulness %K intervention %D 2022 %7 28.2.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Posttraumatic stress disorder (PTSD) is a debilitating, undertreated condition. The web-based delivery of cognitive behavioral therapy supplemented with mindfulness meditation and yoga is a viable treatment that emphasizes self-directed daily practice. Objective: This study aims to examine the effectiveness of a web-based cognitive behavioral therapy, mindfulness, and yoga (CBT-MY) program designed for daily use. Methods: We conducted an 8-week, single-arm, experimental, registered clinical trial on adults reporting PTSD symptoms (n=22; aged 18-35 years). Each participant received web-based CBT-MY content and an hour of web-based counseling each week. Pre-post outcomes included self-reported PTSD symptom severity, depression, anxiety, chronic pain, and mindfulness. Pre-post psychophysiological outcomes included peak pupil dilation (PPD) and heart rate variability (HRV). HRV and PPD were also compared with cross-sectional data from a non-PTSD comparison group without a history of clinical mental health diagnoses and CBT-MY exposure (n=46). Results: Pre-post intention-to-treat analyses revealed substantial improvements in PTSD severity (d=1.60), depression (d=0.83), anxiety (d=0.99), and mindfulness (d=0.88). Linear multilevel mixed models demonstrated a significant pre-post reduction in PPD (B=−0.06; SE=0.01; P<.001; d=0.90) but no significant pre-post change in HRV (P=.87). Overall, participants spent an average of 11.53 (SD 22.76) min/day on self-directed mindfulness practice. Conclusions: Web-based CBT-MY was associated with clinically significant symptom reductions and significant PPD changes, suggesting healthier autonomic functioning. Future randomized controlled trials are needed to further examine the gains apparent in this single-arm study. Trial Registration: ClinicalTrials.gov NCT03684473; https://clinicaltrials.gov/ct2/show/NCT03684473 %M 34499613 %R 10.2196/26479 %U https://mental.jmir.org/2022/2/e26479 %U https://doi.org/10.2196/26479 %U http://www.ncbi.nlm.nih.gov/pubmed/34499613 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 2 %P e30710 %T A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial %A Goulding,Evan H %A Dopke,Cynthia A %A Rossom,Rebecca C %A Michaels,Tania %A Martin,Clair R %A Ryan,Chloe %A Jonathan,Geneva %A McBride,Alyssa %A Babington,Pamela %A Bernstein,Mary %A Bank,Andrew %A Garborg,C Spencer %A Dinh,Jennifer M %A Begale,Mark %A Kwasny,Mary J %A Mohr,David C %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 303 E Chicago Ave., Chicago, IL, 60611, United States, 1 3125031189, e-goulding@fsm.northwestern.edu %K bipolar disorder %K self-management %K mHealth %K eHealth %K smartphone %K mobile phone %K mental health %K mobile health %D 2022 %7 21.2.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment. Objective: A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response. Methods: The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk. Results: Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022. Conclusions: This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders. Trial Registration: ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462 International Registered Report Identifier (IRRID): DERR1-10.2196/30710 %M 35188473 %R 10.2196/30710 %U https://www.researchprotocols.org/2022/2/e30710 %U https://doi.org/10.2196/30710 %U http://www.ncbi.nlm.nih.gov/pubmed/35188473 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e30810 %T Digital and Mobile Health Technology in Collaborative Behavioral Health Care: Scoping Review %A Moon,Khatiya %A Sobolev,Michael %A Kane,John M %+ Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, Glen Oaks, NY, 11004, United States, 1 718 470 4597, KMoon2@northwell.edu %K collaborative care %K integrated care %K augmented care %K digital health %K mobile health %K behavioral health %K review %D 2022 %7 16.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: The collaborative care model (CoCM) is a well-established system of behavioral health care in primary care settings. There is potential for digital and mobile technology to augment the CoCM to improve access, scalability, efficiency, and clinical outcomes. Objective: This study aims to conduct a scoping review to synthesize the evidence available on digital and mobile health technology in collaborative care settings. Methods: This review included cohort and experimental studies of digital and mobile technologies used to augment the CoCM. Studies examining primary care without collaborative care were excluded. A literature search was conducted using 4 electronic databases (MEDLINE, Embase, Web of Science, and Google Scholar). The search results were screened in 2 stages (title and abstract screening, followed by full-text review) by 2 reviewers. Results: A total of 3982 nonduplicate reports were identified, of which 20 (0.5%) were included in the analysis. Most studies used a combination of novel technologies. The range of digital and mobile health technologies used included mobile apps, websites, web-based platforms, telephone-based interactive voice recordings, and mobile sensor data. None of the identified studies used social media or wearable devices. Studies that measured patient and provider satisfaction reported positive results, although some types of interventions increased provider workload, and engagement was variable. In studies where clinical outcomes were measured (7/20, 35%), there were no differences between groups, or the differences were modest. Conclusions: The use of digital and mobile health technologies in CoCM is still limited. This study found that technology was most successful when it was integrated into the existing workflow without relying on patient or provider initiative. However, the effect of digital and mobile health on clinical outcomes in CoCM remains unclear and requires additional clinical trials. %M 35171105 %R 10.2196/30810 %U https://mental.jmir.org/2022/2/e30810 %U https://doi.org/10.2196/30810 %U http://www.ncbi.nlm.nih.gov/pubmed/35171105 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 10 %N 2 %P e33063 %T Panic Attack Prediction Using Wearable Devices and Machine Learning: Development and Cohort Study %A Tsai,Chan-Hen %A Chen,Pei-Chen %A Liu,Ding-Shan %A Kuo,Ying-Ying %A Hsieh,Tsung-Ting %A Chiang,Dai-Lun %A Lai,Feipei %A Wu,Chia-Tung %+ Department of Computer Science and Information Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei City, 106319, Taiwan, 886 978006469, tony006469@gmail.com %K panic disorder %K panic attack %K prediction %K wearable device %K machine learning %K lifestyle %D 2022 %7 15.2.2022 %9 Original Paper %J JMIR Med Inform %G English %X Background: A panic attack (PA) is an intense form of anxiety accompanied by multiple somatic presentations, leading to frequent emergency department visits and impairing the quality of life. A prediction model for PAs could help clinicians and patients monitor, control, and carry out early intervention for recurrent PAs, enabling more personalized treatment for panic disorder (PD). Objective: This study aims to provide a 7-day PA prediction model and determine the relationship between a future PA and various features, including physiological factors, anxiety and depressive factors, and the air quality index (AQI). Methods: We enrolled 59 participants with PD (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and the Mini International Neuropsychiatric Interview). Participants used smartwatches (Garmin Vívosmart 4) and mobile apps to collect their sleep, heart rate (HR), activity level, anxiety, and depression scores (Beck Depression Inventory [BDI], Beck Anxiety Inventory [BAI], State-Trait Anxiety Inventory state anxiety [STAI-S], State-Trait Anxiety Inventory trait anxiety [STAI-T], and Panic Disorder Severity Scale Self-Report) in their real life for a duration of 1 year. We also included AQIs from open data. To analyze these data, our team used 6 machine learning methods: random forests, decision trees, linear discriminant analysis, adaptive boosting, extreme gradient boosting, and regularized greedy forests. Results: For 7-day PA predictions, the random forest produced the best prediction rate. Overall, the accuracy of the test set was 67.4%-81.3% for different machine learning algorithms. The most critical variables in the model were questionnaire and physiological features, such as the BAI, BDI, STAI, MINI, average HR, resting HR, and deep sleep duration. Conclusions: It is possible to predict PAs using a combination of data from questionnaires and physiological and environmental data. %M 35166679 %R 10.2196/33063 %U https://medinform.jmir.org/2022/2/e33063 %U https://doi.org/10.2196/33063 %U http://www.ncbi.nlm.nih.gov/pubmed/35166679 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e31018 %T Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review %A Skaczkowski,Gemma %A van der Kruk,Shannen %A Loxton,Sophie %A Hughes-Barton,Donna %A Howell,Cate %A Turnbull,Deborah %A Jensen,Neil %A Smout,Matthew %A Gunn,Kate %+ Department of Rural Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, 5001, Australia, 61 417852537, kate.gunn@unisa.edu.au %K web-based interventions %K depression %K anxiety %K suicide %K well-being %K mental health %K technology %K access to health care %D 2022 %7 8.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs. Objective: This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach. Results: Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%. Conclusions: There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist. %M 35133281 %R 10.2196/31018 %U https://mental.jmir.org/2022/2/e31018 %U https://doi.org/10.2196/31018 %U http://www.ncbi.nlm.nih.gov/pubmed/35133281 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e27388 %T Characteristics of Mobile Health Platforms for Depression and Anxiety: Content Analysis Through a Systematic Review of the Literature and Systematic Search of Two App Stores %A Leong,Qiao Ying %A Sridhar,Shreya %A Blasiak,Agata %A Tadeo,Xavier %A Yeo,GeckHong %A Remus,Alexandria %A Ho,Dean %+ N.1 Institute for Health, National University of Singapore, 28 Medical Drive, Singapore, 117456, Singapore, 65 86118796, bieamr@nus.edu.sg %K mHealth %K digital medicine %K anxiety %K depression %K systematic review %K mental health conditions %K mobile phone %D 2022 %7 4.2.2022 %9 Review %J J Med Internet Res %G English %X Background: Mobile health (mHealth) platforms show promise in the management of mental health conditions such as anxiety and depression. This has resulted in an abundance of mHealth platforms available for research or commercial use. Objective: The objective of this review is to characterize the current state of mHealth platforms designed for anxiety or depression that are available for research, commercial use, or both. Methods: A systematic review was conducted using a two-pronged approach: searching relevant literature with prespecified search terms to identify platforms in published research and simultaneously searching 2 major app stores—Google Play Store and Apple App Store—to identify commercially available platforms. Key characteristics of the mHealth platforms were synthesized, such as platform name, targeted condition, targeted group, purpose, technology type, intervention type, commercial availability, and regulatory information. Results: The literature and app store searches yielded 169 and 179 mHealth platforms, respectively. Most platforms developed for research purposes were designed for depression (116/169, 68.6%), whereas the app store search reported a higher number of platforms developed for anxiety (Android: 58/179, 32.4%; iOS: 27/179, 15.1%). The most common purpose of platforms in both searches was treatment (literature search: 122/169, 72.2%; app store search: 129/179, 72.1%). With regard to the types of intervention, cognitive behavioral therapy and referral to care or counseling emerged as the most popular options offered by the platforms identified in the literature and app store searches, respectively. Most platforms from both searches did not have a specific target age group. In addition, most platforms found in app stores lacked clinical and real-world evidence, and a small number of platforms found in the published research were available commercially. Conclusions: A considerable number of mHealth platforms designed for anxiety or depression are available for research, commercial use, or both. The characteristics of these mHealth platforms greatly vary. Future efforts should focus on assessing the quality—utility, safety, and effectiveness—of the existing platforms and providing developers, from both commercial and research sectors, a reporting guideline for their platform description and a regulatory framework to facilitate the development, validation, and deployment of effective mHealth platforms. %M 35119370 %R 10.2196/27388 %U https://www.jmir.org/2022/2/e27388 %U https://doi.org/10.2196/27388 %U http://www.ncbi.nlm.nih.gov/pubmed/35119370 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 2 %P e32982 %T A Digital Therapeutic Intervention Delivering Biofeedback for Panic Attacks (PanicMechanic): Feasibility and Usability Study %A McGinnis,Ellen %A O'Leary,Aisling %A Gurchiek,Reed %A Copeland,William E %A McGinnis,Ryan %+ M-Sense Research Group, University of Vermont, 33 Colchester Avenue, Burlington, VT, 05401, United States, 1 2025095783, ryan.mcginnis@uvm.edu %K mental health %K mHealth %K biofeedback %K panic attack %K digital medicine %K app %K mobile health %K application %K biofeedback %K mobile phone %D 2022 %7 3.2.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Panic attacks (PAs) are an impairing mental health problem that affects >11% of adults every year. PAs are episodic, and it is difficult to predict when or where they may occur; thus, they are challenging to study and treat. Objective: The aim of this study is to present PanicMechanic, a novel mobile health app that captures heart rate–based data and delivers biofeedback during PAs. Methods: In our first analysis, we leveraged this tool to capture profiles of real-world PAs in the largest sample to date (148 attacks from 50 users). In our second analysis, we present the results from a pilot study to assess the usefulness of PanicMechanic as a PA intervention (N=18). Results: The results demonstrate that heart rate fluctuates by about 15 beats per minute during a PA and takes approximately 30 seconds to return to baseline from peak, cycling approximately 4 times during each attack despite the consistently decreasing anxiety ratings. Thoughts about health were the most common trigger and potential lifestyle contributors include slightly worse stress, sleep, and eating habits and slightly less exercise and drug or alcohol consumption than typical. Conclusions: The pilot study revealed that PanicMechanic is largely feasible to use but would be made more so with modifications to the app and the integration of consumer wearables. Similarly, participants found PanicMechanic useful, with 94% (15/16) indicating that they would recommend PanicMechanic to others who have PAs. These results highlight the need for future development and a controlled trial to establish the effectiveness of this digital therapeutic for preventing PAs. %M 35113031 %R 10.2196/32982 %U https://formative.jmir.org/2022/2/e32982 %U https://doi.org/10.2196/32982 %U http://www.ncbi.nlm.nih.gov/pubmed/35113031 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e31565 %T Real-world Implementation of a Smartphone-Based Psychoeducation Program for Bipolar Disorder: Observational Ecological Study %A García-Estela,Aitana %A Cantillo,Jordi %A Angarita-Osorio,Natalia %A Mur-Milà,Estanislao %A Anmella,Gerard %A Pérez,Víctor %A Vieta,Eduard %A Hidalgo-Mazzei,Diego %A Colom,Francesc %+ Mental Health Research Group, Hospital del Mar Medical Research Institute (IMIM), Office 202, PRBB Building, Doctor Aiguader, 88, Barcelona, 08003, Spain, 34 933160400 ext 1493, fcolom@imim.es %K bipolar disorder %K psychoeducation %K smartphone %K app %K SIMPLe %K Intervention %K mobile phone %D 2022 %7 2.2.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: SIMPLe is an internet‐delivered self‐management mobile app for bipolar disorder (BD) designed to combine technology with evidence-based interventions and facilitate access to psychoeducational content. The SIMPLe app was launched to the real world to make it available worldwide within the context of BD treatment. Objective: The main aims of this study are as follows: to describe app use, engagement, and retention rates based on server data; to identify patterns of user retention over the first 6-month follow-up of use; and to explore potential factors contributing to discontinuation of app use. Methods: This was an observational ecological study in which we pooled available data from a real-world implementation of the SIMPLe app. Participation was open on the project website, and the data-collection sources were a web-based questionnaire on clinical data and treatment history administered at inclusion and at 6 months, subjective data gathered through continuous app use, and the use patterns captured by the app server. Characteristics and engagement of regular users, occasional users, and no users were compared using 2-tailed t tests or analysis of variance or their nonparametric equivalent. Survival analysis and risk functions were applied to regular users’ data to examine and compare use and user retention. In addition, a user evaluation analysis was performed based on satisfaction, perceived usefulness, and reasons to discontinue app use. Results: We included 503 participants with data collected between 2016 and 2018, of whom 77.5% (n=390) used the app. Among the app users, 44.4% (173/390) completed the follow-up assessment, and data from these participants were used in our analyses. Engagement declined gradually over the first 6 months of use. The probability of retention of the regular users after 1 month of app use was 67.4% (263/390; 95% CI 62.7%-72.4%). Age (P=.002), time passed since illness onset (P<.001), and years since diagnosis of BD (P=.048) correlate with retention duration. In addition, participants who had been diagnosed with BD for longer used the app on more days (mean 97.73, SD 69.15 days; P=.002) than those who had had a more recent onset (mean 66.49, SD 66.18 days; P=.002) or those who had been diagnosed more recently (mean 73.45, SD 66 days; P=.01). Conclusions: The user retention rate of the app decreased rapidly after each month until reaching only one-third of the users at 6 months. There exists a strong association between age and app engagement of individuals with BD. Other variables such as years lived with BD, diagnosis of an anxiety disorder, and taking antipsychotics seem relevant as well. Understanding these associations can help in the definition of the most suitable user profiles for predicting trends of engagement, optimization of app prescription, and management. %M 35107440 %R 10.2196/31565 %U https://www.jmir.org/2022/2/e31565 %U https://doi.org/10.2196/31565 %U http://www.ncbi.nlm.nih.gov/pubmed/35107440 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e32832 %T Diagnostic Performance of an App-Based Symptom Checker in Mental Disorders: Comparative Study in Psychotherapy Outpatients %A Hennemann,Severin %A Kuhn,Sebastian %A Witthöft,Michael %A Jungmann,Stefanie M %+ Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, University of Mainz, Wallstr 3, Mainz, 55122, Germany, 49 61313939215, s.hennemann@uni-mainz.de %K mHealth %K symptom checker %K diagnostics %K mental disorders %K psychotherapy %K mobile phone %D 2022 %7 31.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital technologies have become a common starting point for health-related information-seeking. Web- or app-based symptom checkers aim to provide rapid and accurate condition suggestions and triage advice but have not yet been investigated for mental disorders in routine health care settings. Objective: This study aims to test the diagnostic performance of a widely available symptom checker in the context of formal diagnosis of mental disorders when compared with therapists’ diagnoses based on structured clinical interviews. Methods: Adult patients from an outpatient psychotherapy clinic used the app-based symptom checker Ada–check your health (ADA; Ada Health GmbH) at intake. Accuracy was assessed as the agreement of the first and 1 of the first 5 condition suggestions of ADA with at least one of the interview-based therapist diagnoses. In addition, sensitivity, specificity, and interrater reliabilities (Gwet first-order agreement coefficient [AC1]) were calculated for the 3 most prevalent disorder categories. Self-reported usability (assessed using the System Usability Scale) and acceptance of ADA (assessed using an adapted feedback questionnaire) were evaluated. Results: A total of 49 patients (30/49, 61% women; mean age 33.41, SD 12.79 years) were included in this study. Across all patients, the interview-based diagnoses matched ADA’s first condition suggestion in 51% (25/49; 95% CI 37.5-64.4) of cases and 1 of the first 5 condition suggestions in 69% (34/49; 95% CI 55.4-80.6) of cases. Within the main disorder categories, the accuracy of ADA’s first condition suggestion was 0.82 for somatoform and associated disorders, 0.65 for affective disorders, and 0.53 for anxiety disorders. Interrater reliabilities ranged from low (AC1=0.15 for anxiety disorders) to good (AC1=0.76 for somatoform and associated disorders). The usability of ADA was rated as high in the System Usability Scale (mean 81.51, SD 11.82, score range 0-100). Approximately 71% (35/49) of participants would have preferred a face-to-face over an app-based diagnostic. Conclusions: Overall, our findings suggest that a widely available symptom checker used in the formal diagnosis of mental disorders could provide clinicians with a list of condition suggestions with moderate-to-good accuracy. However, diagnostic performance was heterogeneous between disorder categories and included low interrater reliability. Although symptom checkers have some potential to complement the diagnostic process as a screening tool, the diagnostic performance should be tested in larger samples and in comparison with further diagnostic instruments. %M 35099395 %R 10.2196/32832 %U https://mental.jmir.org/2022/1/e32832 %U https://doi.org/10.2196/32832 %U http://www.ncbi.nlm.nih.gov/pubmed/35099395 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 1 %P e30766 %T User Experience, Engagement, and Popularity in Mental Health Apps: Secondary Analysis of App Analytics and Expert App Reviews %A Kaveladze,Benjamin T %A Wasil,Akash R %A Bunyi,John B %A Ramirez,Veronica %A Schueller,Stephen M %+ Department of Psychological Science, University of California, 4201 Social & Behavioral Sciences Gateway, Irvine, CA, 92697-7085, United States, 1 310 984 9318, bkavelad@uci.edu %K mental health apps %K engagement %K user experience %K digital mental health %K user retention %D 2022 %7 31.1.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: User experience and engagement are critical elements of mental health apps’ abilities to support users. However, work examining the relationships among user experience, engagement, and popularity has been limited. Understanding how user experience relates to engagement with and popularity of mental health apps can demonstrate the relationship between subjective and objective measures of app use. In turn, this may inform efforts to develop more effective and appealing mental health apps and ensure that they reach wide audiences. Objective: We aimed to examine the relationship among subjective measures of user experience, objective measures of popularity, and engagement in mental health apps. Methods: We conducted a preregistered secondary data analysis in a sample of 56 mental health apps. To measure user experience, we used expert ratings on the Mobile App Rating Scale (MARS) and consumer ratings from the Apple App Store and Google Play. To measure engagement, we acquired estimates of monthly active users (MAU) and user retention. To measure app popularity, we used download count, total app revenue, and MAU again. Results: MARS total score was moderately positively correlated with app-level revenue (Kendall rank [T]=0.30, P=.002), MAU (T=0.39, P<.001), and downloads (T=0.41, P<.001). However, the MARS total score and each of its subscales (Engagement, Functionality, Aesthetics, and Information) showed extremely small correlations with user retention 1, 7, and 30 days after downloading. Furthermore, the total MARS score only correlated with app store rating at T=0.12, which, at P=.20, did not meet our threshold for significance. Conclusions: More popular mental health apps receive better ratings of user experience than less popular ones. However, user experience does not predict sustained engagement with mental health apps. Thus, mental health app developers and evaluators need to better understand user experience and engagement, as well as to define sustained engagement, what leads to it, and how to create products that achieve it. This understanding might be supported by better collaboration between industry and academic teams to advance a science of engagement. %M 35099398 %R 10.2196/30766 %U https://humanfactors.jmir.org/2022/1/e30766 %U https://doi.org/10.2196/30766 %U http://www.ncbi.nlm.nih.gov/pubmed/35099398 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e28095 %T The Association Between Home Stay and Symptom Severity in Major Depressive Disorder: Preliminary Findings From a Multicenter Observational Study Using Geolocation Data From Smartphones %A Laiou,Petroula %A Kaliukhovich,Dzmitry A %A Folarin,Amos A %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Sun,Shaoxiong %A Zhang,Yuezhou %A Matcham,Faith %A Ivan,Alina %A Lavelle,Grace %A Siddi,Sara %A Lamers,Femke %A Penninx,Brenda WJH %A Haro,Josep Maria %A Annas,Peter %A Cummins,Nicholas %A Vairavan,Srinivasan %A Manyakov,Nikolay V %A Narayan,Vaibhav A %A Dobson,Richard JB %A Hotopf,Matthew %A , %+ Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Memory Lane, London, SE5 8AF, United Kingdom, 44 20 7848 0002, petroula.laiou@kcl.ac.uk %K major depressive disorder %K PHQ-8 %K smartphone %K GPS %K home stay %K mobile phone %D 2022 %7 28.1.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Most smartphones and wearables are currently equipped with location sensing (using GPS and mobile network information), which enables continuous location tracking of their users. Several studies have reported that various mobility metrics, as well as home stay, that is, the amount of time an individual spends at home in a day, are associated with symptom severity in people with major depressive disorder (MDD). Owing to the use of small and homogeneous cohorts of participants, it is uncertain whether the findings reported in those studies generalize to a broader population of individuals with MDD symptoms. Objective: The objective of this study is to examine the relationship between the overall severity of depressive symptoms, as assessed by the 8-item Patient Health Questionnaire, and median daily home stay over the 2 weeks preceding the completion of a questionnaire in individuals with MDD. Methods: We used questionnaire and geolocation data of 164 participants with MDD collected in the observational Remote Assessment of Disease and Relapse–Major Depressive Disorder study. The participants were recruited from three study sites: King’s College London in the United Kingdom (109/164, 66.5%); Vrije Universiteit Medisch Centrum in Amsterdam, the Netherlands (17/164, 10.4%); and Centro de Investigación Biomédica en Red in Barcelona, Spain (38/164, 23.2%). We used a linear regression model and a resampling technique (n=100 draws) to investigate the relationship between home stay and the overall severity of MDD symptoms. Participant age at enrollment, gender, occupational status, and geolocation data quality metrics were included in the model as additional explanatory variables. The 95% 2-sided CIs were used to evaluate the significance of model variables. Results: Participant age and severity of MDD symptoms were found to be significantly related to home stay, with older (95% CI 0.161-0.325) and more severely affected individuals (95% CI 0.015-0.184) spending more time at home. The association between home stay and symptoms severity appeared to be stronger on weekdays (95% CI 0.023-0.178, median 0.098; home stay: 25th-75th percentiles 17.8-22.8, median 20.9 hours a day) than on weekends (95% CI −0.079 to 0.149, median 0.052; home stay: 25th-75th percentiles 19.7-23.5, median 22.3 hours a day). Furthermore, we found a significant modulation of home stay by occupational status, with employment reducing home stay (employed participants: 25th-75th percentiles 16.1-22.1, median 19.7 hours a day; unemployed participants: 25th-75th percentiles 20.4-23.5, median 22.6 hours a day). Conclusions: Our findings suggest that home stay is associated with symptom severity in MDD and demonstrate the importance of accounting for confounding factors in future studies. In addition, they illustrate that passive sensing of individuals with depression is feasible and could provide clinically relevant information to monitor the course of illness in patients with MDD. %M 35089148 %R 10.2196/28095 %U https://mhealth.jmir.org/2022/1/e28095 %U https://doi.org/10.2196/28095 %U http://www.ncbi.nlm.nih.gov/pubmed/35089148 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e26049 %T FOCUS mHealth Intervention for Veterans With Serious Mental Illness in an Outpatient Department of Veterans Affairs Setting: Feasibility, Acceptability, and Usability Study %A Buck,Benjamin %A Nguyen,Janelle %A Porter,Shelan %A Ben-Zeev,Dror %A Reger,Greg M %+ Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 221 8518, buckbe@uw.edu %K mHealth %K veterans %K schizophrenia %K serious mental illness %K mobile phone %D 2022 %7 28.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Veterans with serious mental illnesses (SMIs) face barriers to accessing in-person evidence-based interventions that improve illness management. Mobile health (mHealth) has been demonstrated to be feasible, acceptable, effective, and engaging among individuals with SMIs in community mental health settings. mHealth for SMIs has not been tested within the Department of Veterans Affairs (VA). Objective: This study examines the feasibility, acceptability, and preliminary effectiveness of an mHealth intervention for SMI in the context of VA outpatient care. Methods: A total of 17 veterans with SMIs were enrolled in a 1-month pilot trial of FOCUS, a smartphone-based self-management intervention for SMI. At baseline and posttest, they completed measures examining symptoms and functional recovery. The participants provided qualitative feedback related to the usability and acceptability of the intervention. Results: Veterans completed on an average of 85.0 (SD 96.1) interactions with FOCUS over the 1-month intervention period. They reported high satisfaction, usability, and acceptability, with nearly all participants (16/17, 94%) reporting that they would recommend the intervention to a fellow veteran. Clinicians consistently reported finding mHealth-related updates useful for informing their care. Qualitative feedback indicated that veterans thought mHealth complemented their existing VA services well and described potential opportunities to adapt FOCUS to specific subpopulations (eg, combat veterans) as well as specific delivery modalities (eg, groups). In the 1-month period, the participants experienced small improvements in self-assessed recovery, auditory hallucinations, and quality of life. Conclusions: The FOCUS mHealth intervention is feasible, acceptable, and usable among veterans. Future work should develop and examine VA-specific implementation approaches of FOCUS for this population. %M 35089151 %R 10.2196/26049 %U https://mental.jmir.org/2022/1/e26049 %U https://doi.org/10.2196/26049 %U http://www.ncbi.nlm.nih.gov/pubmed/35089151 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e31712 %T Social Equity in the Efficacy of Computer-Based and In-Person Brief Alcohol Interventions Among General Hospital Patients With At-Risk Alcohol Use: A Randomized Controlled Trial %A Freyer-Adam,Jennis %A Baumann,Sophie %A Bischof,Gallus %A Staudt,Andreas %A Goeze,Christian %A Gaertner,Beate %A John,Ulrich %+ Institute for Medical Psychology, University Medicine Greifswald, Walther-Rathenau-Str. 48, Greifswald, 17475, Germany, 49 3834865606, Jennis.Freyer-Adam@med.uni-greifswald.de %K brief alcohol intervention %K electronic %K eHealth %K digital %K motivational interviewing %K socioeconomic status %K equity %K social inequality %K transtheoretical model %K moderator %K mental health %K public health %K alcohol interventions %K digital intervention %K digital health intervention %K alcohol use %D 2022 %7 28.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social equity in the efficacy of behavior change intervention is much needed. While the efficacy of brief alcohol interventions (BAIs), including digital interventions, is well established, particularly in health care, the social equity of interventions has been sparsely investigated. Objective: We aim to investigate whether the efficacy of computer-based versus in-person delivered BAIs is moderated by the participants’ socioeconomic status (ie, to identify whether general hospital patients with low-level education and unemployed patients may benefit more or less from one or the other way of delivery compared to patients with higher levels of education and those that are employed). Methods: Patients with nondependent at-risk alcohol use were identified through systematic offline screening conducted on 13 general hospital wards. Patients were approached face-to-face and asked to respond to an app for self-assessment provided by a mobile device. In total, 961 (81% of eligible participants) were randomized and received their allocated intervention: computer-generated and individually tailored feedback letters (CO), in-person counseling by research staff trained in motivational interviewing (PE), or assessment only (AO). CO and PE were delivered on the ward and 1 and 3 months later, were based on the transtheoretical model of intentional behavior change and required the assessment of intervention data prior to each intervention. In CO, the generation of computer-based feedback was created automatically. The assessment of data and sending out feedback letters were assisted by the research staff. Of the CO and PE participants, 89% (345/387) and 83% (292/354) received at least two doses of intervention, and 72% (280/387) and 54% (191/354) received all three doses of intervention, respectively. The outcome was change in grams of pure alcohol per day after 6, 12, 18, and 24 months, with the latter being the primary time-point of interest. Follow-up interviewers were blinded. Study group interactions with education and employment status were tested as predictors of change in alcohol use using latent growth modeling. Results: The efficacy of CO and PE did not differ by level of education (P=.98). Employment status did not moderate CO efficacy (Ps≥.66). Up to month 12 and compared to employed participants, unemployed participants reported significantly greater drinking reductions following PE versus AO (incidence rate ratio 0.44, 95% CI 0.21-0.94; P=.03) and following PE versus CO (incidence rate ratio 0.48, 95% CI 0.24–0.96; P=.04). After 24 months, these differences were statistically nonsignificant (Ps≥.31). Conclusions: Computer-based and in-person BAI worked equally well independent of the patient’s level of education. Although findings indicate that in the short-term, unemployed persons may benefit more from BAI when delivered in-person rather than computer-based, the findings suggest that both BAIs have the potential to work well among participants with low socioeconomic status. Trial Registration: ClinicalTrials.gov NCT01291693; https://clinicaltrials.gov/ct2/show/NCT01291693 %M 35089156 %R 10.2196/31712 %U https://mental.jmir.org/2022/1/e31712 %U https://doi.org/10.2196/31712 %U http://www.ncbi.nlm.nih.gov/pubmed/35089156 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e29621 %T Impact of Smartphone App–Based Psychological Interventions for Reducing Depressive Symptoms in People With Depression: Systematic Literature Review and Meta-analysis of Randomized Controlled Trials %A Serrano-Ripoll,Maria J %A Zamanillo-Campos,Rocío %A Fiol-DeRoque,Maria A %A Castro,Adoración %A Ricci-Cabello,Ignacio %+ Balearic Islands Health Services, Primary Care Research Unit of Mallorca, Escola Graduada, 3, Palma de Mallorca, 07002, Spain, 34 971175883, mjserranor@yahoo.es %K smartphone technology %K mental health interventions %K depression %K eHealth %K mHealth %K apps %K systematic review %K meta-analysis %K mobile phone %D 2022 %7 27.1.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility. Objective: We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Methods: We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success. Results: After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] −0.51, 95% CI −0.69 to −0.33; 2018/2859, 70.58% of the participants; I2=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD −0.67, 95% CI −0.79 to −0.55), compared with trials with participants exhibiting mild to moderate depression (SMD −0.15, 95% CI −0.43 to −0.12). Conclusions: App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention. Trial Registration: PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689 %M 35084346 %R 10.2196/29621 %U https://mhealth.jmir.org/2022/1/e29621 %U https://doi.org/10.2196/29621 %U http://www.ncbi.nlm.nih.gov/pubmed/35084346 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e29008 %T Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study %A Lockwood,Joanna %A Williams,Laura %A Martin,Jennifer L %A Rathee,Manjul %A Hill,Claire %+ National Institute of Health Research MindTech MedTech Co-operative, School of Medicine, University of Nottingham, Institute of Mental Health, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231294, joanna.lockwood@nottingham.ac.uk %K anxiety %K children %K exposure therapy %K cognitive behavioral therapy %K immersive gaming %K digital intervention %K app %K smartphone %K mobile phone %D 2022 %7 24.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition. Objective: In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova. Methods: Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app’s effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined. Results: Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t29=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data. Conclusions: This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch. %M 35072644 %R 10.2196/29008 %U https://mental.jmir.org/2022/1/e29008 %U https://doi.org/10.2196/29008 %U http://www.ncbi.nlm.nih.gov/pubmed/35072644 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 1 %P e26276 %T Facial and Vocal Markers of Schizophrenia Measured Using Remote Smartphone Assessments: Observational Study %A Abbas,Anzar %A Hansen,Bryan J %A Koesmahargyo,Vidya %A Yadav,Vijay %A Rosenfield,Paul J %A Patil,Omkar %A Dockendorf,Marissa F %A Moyer,Matthew %A Shipley,Lisa A %A Perez-Rodriguez,M Mercedez %A Galatzer-Levy,Isaac R %+ AiCure, 214 Sullivan Street 6C, New York, NY, 10012, United States, 1 8005700448, anzar@anzarabbas.com %K digital biomarkers %K phenotyping %K computer vision %K facial expressivity %K negative symptoms %K vocal acoustics %D 2022 %7 21.1.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Machine learning–based facial and vocal measurements have demonstrated relationships with schizophrenia diagnosis and severity. Demonstrating utility and validity of remote and automated assessments conducted outside of controlled experimental or clinical settings can facilitate scaling such measurement tools to aid in risk assessment and tracking of treatment response in populations that are difficult to engage. Objective: This study aimed to determine the accuracy of machine learning–based facial and vocal measurements acquired through automated assessments conducted remotely through smartphones. Methods: Measurements of facial and vocal characteristics including facial expressivity, vocal acoustics, and speech prevalence were assessed in 20 patients with schizophrenia over the course of 2 weeks in response to two classes of prompts previously utilized in experimental laboratory assessments: evoked prompts, where subjects are guided to produce specific facial expressions and speech; and spontaneous prompts, where subjects are presented stimuli in the form of emotionally evocative imagery and asked to freely respond. Facial and vocal measurements were assessed in relation to schizophrenia symptom severity using the Positive and Negative Syndrome Scale. Results: Vocal markers including speech prevalence, vocal jitter, fundamental frequency, and vocal intensity demonstrated specificity as markers of negative symptom severity, while measurement of facial expressivity demonstrated itself as a robust marker of overall schizophrenia symptom severity. Conclusions: Established facial and vocal measurements, collected remotely in schizophrenia patients via smartphones in response to automated task prompts, demonstrated accuracy as markers of schizophrenia symptom severity. Clinical implications are discussed. %M 35060906 %R 10.2196/26276 %U https://formative.jmir.org/2022/1/e26276 %U https://doi.org/10.2196/26276 %U http://www.ncbi.nlm.nih.gov/pubmed/35060906 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e28647 %T Behavioral and Self-reported Data Collected From Smartphones for the Assessment of Depressive and Manic Symptoms in Patients With Bipolar Disorder: Prospective Observational Study %A Dominiak,Monika %A Kaczmarek-Majer,Katarzyna %A Antosik-Wójcińska,Anna Z %A Opara,Karol R %A Olwert,Anna %A Radziszewska,Weronika %A Hryniewicz,Olgierd %A Święcicki,Łukasz %A Wojnar,Marcin %A Mierzejewski,Paweł %+ Department of Pharmacology and Physiology of the Nervous System, Institute of Psychiatry and Neurology, Sobieskiego 9, Warsaw, 02-957, Poland, 48 507183375, mdominia@wp.pl %K bipolar disorder %K generalized linear model %K mixed-effects regression %K classification %K manic episodes %K depressive episodes %K smartphone %K behavioral markers %K mHealth %K remote monitoring %D 2022 %7 19.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones allow for real-time monitoring of patients’ behavioral activities in a naturalistic setting. These data are suggested as markers for the mental state of patients with bipolar disorder (BD). Objective: We assessed the relations between data collected from smartphones and the clinically rated depressive and manic symptoms together with the corresponding affective states in patients with BD. Methods: BDmon, a dedicated mobile app, was developed and installed on patients’ smartphones to automatically collect the statistics about their phone calls and text messages as well as their self-assessments of sleep and mood. The final sample for the numerical analyses consisted of 51 eligible patients who participated in at least two psychiatric assessments and used the BDmon app (mean participation time, 208 [SD 132] days). In total, 196 psychiatric assessments were performed using the Hamilton Depression Rating Scale and the Young Mania Rating Scale. Generalized linear mixed-effects models were applied to quantify the strength of the relation between the daily statistics on the behavioral data collected automatically from smartphones and the affective symptoms and mood states in patients with BD. Results: Objective behavioral data collected from smartphones were found to be related with the BD states as follows: (1) depressed patients tended to make phone calls less frequently than euthymic patients (β=−.064, P=.01); (2) the number of incoming answered calls during depression was lower than that during euthymia (β=−.15, P=.01) and, concurrently, missed incoming calls were more frequent and increased as depressive symptoms intensified (β=4.431, P<.001; β=4.861, P<.001, respectively); (3) the fraction of outgoing calls was higher in manic states (β=2.73, P=.03); (4) the fraction of missed calls was higher in manic/mixed states as compared to that in the euthymic state (β=3.53, P=.01) and positively correlated to the severity of symptoms (β=2.991, P=.02); (5) the variability of the duration of the outgoing calls was higher in manic/mixed states (β=.0012, P=.045) and positively correlated to the severity of symptoms (β=.0017, P=.02); and (6) the number and length of the sent text messages was higher in manic/mixed states as compared to that in the euthymic state (β=.031, P=.01; β=.015, P=.01; respectively) and positively correlated to the severity of manic symptoms (β=.116, P<.001; β=.022, P<.001; respectively). We also observed that self-assessment of mood was lower in depressive (β=−1.452, P<.001) and higher in manic states (β=.509, P<.001). Conclusions: Smartphone-based behavioral parameters are valid markers for assessing the severity of affective symptoms and discriminating between mood states in patients with BD. This technology opens a way toward early detection of worsening of the mental state and thereby increases the patient’s chance of improving in the course of the illness. %M 34874015 %R 10.2196/28647 %U https://www.jmir.org/2022/1/e28647 %U https://doi.org/10.2196/28647 %U http://www.ncbi.nlm.nih.gov/pubmed/34874015 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e26453 %T Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation %A Voth,Melissa %A Chisholm,Shannon %A Sollid,Hannah %A Jones,Chelsea %A Smith-MacDonald,Lorraine %A Brémault-Phillips,Suzette %+ Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, 1-94 Corbett Hall, 8205 - 114 Street Edmonton, Edmonton, AB, T6G 2G4, Canada, 1 7804920404, cweiman@ualberta.ca %K occupational stress injury %K trauma %K mHealth %K resilience %K mental health %K military %K veteran %K public safety personnel %K OSI %K PTSD %K mental health intervention %K mobile phone %D 2022 %7 19.1.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Military members (MMs) and public safety personnel (PSP) are vulnerable to occupational stress injuries because of their job demands. When MMs and PSP transition out of these professions, they may continue to experience mental health challenges. The development and implementation of resilience-building mobile health (mHealth) apps as an emergent mental health intervention platform has allowed for targeted, cost-effective, and easily accessible treatment when in-person therapy may be limited or unavailable. However, current mHealth app development is not regulated, and often lacks both clear evidence-based research and the input of health care professionals. Objective: This study aims to evaluate the evidence-based quality, efficacy, and effectiveness of resilience-building mobile apps targeted toward the MMs, PSP, and veteran populations via a scoping literature review of the current evidence base regarding resilience apps for these populations and an evaluation of free resilience apps designed for use among these populations. Methods: The studies were selected using a comprehensive search of MEDLINE, CINAHL Plus, PsycINFO, SocINDEX, Academic Search Complete, Embase, and Google and were guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A narrative synthesis of the resulting papers was performed. The Alberta Rating Index for Apps was used to conduct a review of each of the identified apps. The inclusion criteria consisted of apps that were free to download in either the Google Play Store or the Apple App Store; updated within the last 3 years; available in English and in Canada; and intended for use by MMs, veterans, and PSP. Results: In total, 22 apps met the inclusion criteria for evaluation. The resilience strategies offered by most apps included psychoeducation, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy. Overall, 50% (11/22) of apps had been tested in randomized controlled trials, 7 (32%) apps had been evaluated using other research methods, and 5 (23%) apps had not been studied. Using the Alberta Rating Index for Apps, the app scores ranged from 37 to 56 out of 72, with higher rated apps demonstrating increased usability and security features. Conclusions: The mHealth apps reviewed are well-suited to providing resilience strategies for MMs, PSP, and veterans. They offer easy accessibility to evidence-based tools while working to encourage the use of emotional and professional support with safety in mind. Although not intended to function as a substitute for professional services, research has demonstrated that mHealth apps have the potential to foster a significant reduction in symptom severity for posttraumatic stress disorder, depression, anxiety, and other mental health conditions. In clinical practice, apps can be used to supplement treatment and provide clients with population-specific confidential tools to increase engagement in the treatment process. %M 35044307 %R 10.2196/26453 %U https://mhealth.jmir.org/2022/1/e26453 %U https://doi.org/10.2196/26453 %U http://www.ncbi.nlm.nih.gov/pubmed/35044307 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e34103 %T A New Digital Assessment of Mental Health and Well-being in the Workplace: Development and Validation of the Unmind Index %A Sierk,Anika %A Travers,Eoin %A Economides,Marcos %A Loe,Bao Sheng %A Sun,Luning %A Bolton,Heather %+ Unmind Ltd, 180 Borough High Street, London, SE1 1LB, United Kingdom, eoin.travers@unmind.com %K mental health %K well-being %K mHealth %K measurement %D 2022 %7 17.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Unmind is a workplace, digital, mental health platform with tools to help users track, maintain, and improve their mental health and well-being (MHWB). Psychological measurement plays a key role on this platform, providing users with insights on their current MHWB, the ability to track it over time, and personalized recommendations, while providing employers with aggregate information about the MHWB of their workforce. Objective: Due to the limitations of existing measures for this purpose, we aimed to develop and validate a novel well-being index for digital use, to capture symptoms of common mental health problems and key aspects of positive well-being. Methods: In Study 1A, questionnaire items were generated by clinicians and screened for face validity. In Study 1B, these items were presented to a large sample (n=1104) of UK adults, and exploratory factor analysis was used to reduce the item pool and identify coherent subscales. In Study 2, the final measure was presented to a new nationally representative UK sample (n=976), along with a battery of existing measures, with 238 participants retaking the Umind Index after 1 week. The factor structure and measurement invariance of the Unmind Index was evaluated using confirmatory factor analysis, convergent and discriminant validity by estimating correlations with existing measures, and reliability by examining internal consistency and test-retest intraclass correlations. Results: Studies 1A and 1B yielded a 26-item measure with 7 subscales: Calmness, Connection, Coping, Happiness, Health, Fulfilment, and Sleep. Study 2 showed that the Unmind Index is fitted well by a second-order factor structure, where the 7 subscales all load onto an overall MHWB factor, and established measurement invariance by age and gender. Subscale and total scores correlate well with existing mental health measures and generally diverge from personality measures. Reliability was good or excellent across all subscales. Conclusions: The Unmind Index is a robust measure of MHWB that can help to identify target areas for intervention in nonclinical users of a mental health app. We argue that there is value in measuring mental ill health and mental well-being together, rather than treating them as separate constructs. %M 35037895 %R 10.2196/34103 %U https://mental.jmir.org/2022/1/e34103 %U https://doi.org/10.2196/34103 %U http://www.ncbi.nlm.nih.gov/pubmed/35037895 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 1 %P e33438 %T Patients’ Expectations and Experiences With a Mental Health–Focused Supportive Text Messaging Program: Mixed Methods Evaluation %A Shalaby,Reham %A Vuong,Wesley %A Eboreime,Ejemai %A Surood,Shireen %A Greenshaw,Andrew J %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre (WMC), 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 17807144315, vincent.agyapong@nshealth.ca %K supportive text messages %K patients’ experience %K mental health %K mixed methods %D 2022 %7 11.1.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Web-based services are an economical and easily scalable means of support that uses existing technology. Text4Support is a supportive, complementary text messaging service that supports people with different mental health conditions after they are discharged from inpatient psychiatric care. Objective: In this study, we aim to assess user satisfaction with the Text4Support service to gain a better understanding of subscribers’ experiences. Methods: This was a mixed methods study using secondary data from a pilot observational controlled trial. The trial included 181 patients discharged from acute psychiatric care and distributed into 4 randomized groups. Out of the 4 study groups in the initial study, 2 groups who received supportive text messages (89/181, 49.2% of patients), either alone or alongside a peer support worker, were included. Thematic and descriptive analyses were also performed. Differences in feedback based on sex at birth and primary diagnosis were determined using univariate analysis. The study was registered with ClinicalTrials.gov (trial registration number: NCT03404882). Results: Out of 89 participants, 36 (40%) completed the follow-up survey. The principal findings were that Text4Support was well perceived with a high satisfaction rate either regarding the feedback of the messages or their perceived impact. Meanwhile, there was no statistically significant difference between satisfactory items based on the subscriber’s sex at birth or primary diagnosis. The patients’ initial expectations were either neutral or positive in relation to the expected nature or the impact of the text messages received on their mental well-being. In addition, the subscribers were satisfied with the frequency of the messages, which were received once daily for 6 consecutive months. The participants recommended more personalized messages or mutual interaction with health care personnel. Conclusions: Text4Support was generally well perceived by patients after hospital discharge, regardless of their sex at birth or mental health diagnosis. Further personalization and interactive platforms were recommended by participants that may need to be considered when designing similar future services. %M 35014972 %R 10.2196/33438 %U https://formative.jmir.org/2022/1/e33438 %U https://doi.org/10.2196/33438 %U http://www.ncbi.nlm.nih.gov/pubmed/35014972 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e34054 %T Multipurpose Mobile Apps for Mental Health in Chinese App Stores: Content Analysis and Quality Evaluation %A Wu,Xiaoqian %A Xu,Lin %A Li,PengFei %A Tang,TingTing %A Huang,Cheng %+ College of Medical Informatics, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China, 86 023 6848 0060, huangcheng@cqmu.edu.cn %K mobile apps %K app %K mental health %K mHealth %K content analysis %D 2022 %7 4.1.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental disorders impose varying degrees of burden on patients and their surroundings. However, people are reluctant to take the initiative to seek mental health services because of the uneven distribution of resources and stigmatization. Thus, mobile apps are considered an effective way to eliminate these obstacles and improve mental health awareness. Objective: This study aims to evaluate the quality, function, privacy measures, and evidence-based and professional background of multipurpose mental health apps in Chinese commercial app stores. Methods: A systematic search was conducted on iOS and Android platforms in China to identify multipurpose mental health apps. Two independent reviewers evaluated the identified mobile apps using the Mobile App Rating Scale (MARS). Each app was downloaded, and the general characteristics, privacy and security measures, development background, and functional characteristics of each app were evaluated. Results: A total of 40 apps were analyzed, of which 35 (87.5%) were developed by companies and 33 (82.5%) provided links to access the privacy policy; 21 (52.5%) apps did not mention the involvement of relevant professionals or the guidance of a scientific basis in the app development process. The main built-in functions of these apps include psychological education (38/40, 95%), self-assessment (34/40, 85%), and counseling (33/40, 82.5%). The overall quality average MARS score of the 40 apps was 3.54 (SD 0.39), and the total score was between 2.96 and 4.30. The total MARS score was significantly positively correlated with the scores of each subscale (r=0.62-0.88, P<.001). However, the user score of the app market was not significantly correlated with the total MARS score (r=0.17, P=.33). Conclusions: The quality of multipurpose mental health apps in China’s main app market is generally good. However, health professionals are less involved in the development of these apps, and the privacy protection policy of the apps also needs to be described in more detail. This study provides a reference for the development of multipurpose mental health apps. %M 34982717 %R 10.2196/34054 %U https://mhealth.jmir.org/2022/1/e34054 %U https://doi.org/10.2196/34054 %U http://www.ncbi.nlm.nih.gov/pubmed/34982717 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e31633 %T Breaking the Data Value-Privacy Paradox in Mobile Mental Health Systems Through User-Centered Privacy Protection: A Web-Based Survey Study %A Zhang,Dongsong %A Lim,Jaewan %A Zhou,Lina %A Dahl,Alicia A %+ The University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC, 28223-0001, United States, 1 7046871893, dzhang15@uncc.edu %K mobile apps %K mental health %K privacy concerns %K privacy protection %K mobile phone %D 2021 %7 24.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile mental health systems (MMHS) have been increasingly developed and deployed in support of monitoring, management, and intervention with regard to patients with mental disorders. However, many of these systems rely on patient data collected by smartphones or other wearable devices to infer patients’ mental status, which raises privacy concerns. Such a value-privacy paradox poses significant challenges to patients’ adoption and use of MMHS; yet, there has been limited understanding of it. Objective: To address the significant literature gap, this research aims to investigate both the antecedents of patients’ privacy concerns and the effects of privacy concerns on their continuous usage intention with regard to MMHS. Methods: Using a web-based survey, this research collected data from 170 participants with MMHS experience recruited from online mental health communities and a university community. The data analyses used both repeated analysis of variance and partial least squares regression. Results: The results showed that data type (P=.003), data stage (P<.001), privacy victimization experience (P=.01), and privacy awareness (P=.08) have positive effects on privacy concerns. Specifically, users report higher privacy concerns for social interaction data (P=.007) and self-reported data (P=.001) than for biometrics data; privacy concerns are higher for data transmission (P=.01) and data sharing (P<.001) than for data collection. Our results also reveal that privacy concerns have an effect on attitude toward privacy protection (P=.001), which in turn affects continuous usage intention with regard to MMHS. Conclusions: This study contributes to the literature by deepening our understanding of the data value-privacy paradox in MMHS research. The findings offer practical guidelines for breaking the paradox through the design of user-centered and privacy-preserving MMHS. %M 34951604 %R 10.2196/31633 %U https://mental.jmir.org/2021/12/e31633 %U https://doi.org/10.2196/31633 %U http://www.ncbi.nlm.nih.gov/pubmed/34951604 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e30268 %T Acceptability of an mHealth App for Youth With Substance Use and Mental Health Needs: Iterative, Mixed Methods Design %A Adams,Zachary %A Grant,Miyah %A Hupp,Samantha %A Scott,Taylor %A Feagans,Amanda %A Phillips,Meredith Lois %A Bixler,Kristina %A Nallam,Phani Teja %A La Putt,Dorothy %+ Department of Psychiatry, Indiana University School of Medicine, 340 W 10th St., Indianapolis, IN, 46202, United States, 1 317 278 0591, zwadams@iu.edu %K mobile health %K user-centered design %K adolescents %K substance use disorders %K mental health %K mHealth %K cognitive behavioral therapy %K homework %K technology acceptance model %K trauma %K mobile phone %D 2021 %7 24.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Treating substance use disorders (SUDs) during adolescence can prevent adult addiction and improve youth outcomes. However, it can be challenging to keep adolescents with SUDs engaged in ongoing services, thus limiting potential benefits. Developmentally appropriate tools are needed to improve treatment engagement during and between sessions for youth with SUDs and mental health disorders. Mobile health apps may augment or replace psychotherapy components; however, few have been developed specifically for youth with SUDs following user-guided design principles, which may limit their appropriateness and utility. Formative research on acceptability to intended end users is needed before the efficacy of such tools can be examined. Objective: This study involves user-centered, iterative development and initial user testing of a web-based app for adolescents with SUDs and mental health concerns. Methods: Adolescents aged 14 to 17 years with past-year involvement in outpatient psychotherapy and behavioral health clinicians with adolescent SUD treatment caseloads were recruited. Across 2 assessment phases, 40 participants (alpha: 10 youths and 10 clinicians; beta: 10 youths and 10 clinicians) viewed an app demonstration and completed semistructured interviews and questionnaires about app content and functionality. Results: Participants expressed positive impressions of the app and its potential utility in augmenting outpatient therapy for youth with SUDs and mental health concerns. Noted strengths included valuable educational content, useful embedded resources, and a variety of activities. Adolescents and clinicians favored the app over conventional (paper-and-pencil) modalities, citing convenience and familiarity. The app was found to be user-friendly and likely to improve treatment engagement. Adolescents suggested the inclusion of privacy settings, and clinicians recommended more detailed instructions and simplified language. Conclusions: The novel app developed here appears to be a promising, acceptable, and highly scalable resource to support adolescents with SUDs and mental health concerns. Future studies should test the efficacy of such apps in enhancing adolescent behavioral health treatment engagement and outcomes. %M 34951593 %R 10.2196/30268 %U https://formative.jmir.org/2021/12/e30268 %U https://doi.org/10.2196/30268 %U http://www.ncbi.nlm.nih.gov/pubmed/34951593 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e27991 %T The Extent of User Involvement in the Design of Self-tracking Technology for Bipolar Disorder: Literature Review %A Majid,Shazmin %A Reeves,Stuart %A Figueredo,Grazziela %A Brown,Susan %A Lang,Alexandra %A Moore,Matthew %A Morriss,Richard %+ School of Computer Science, Horizon Centre for Doctoral Training, University of Nottingham, Computer Science Building, Wollaton Rd, Nottingham, NG8 1BB, United Kingdom, 44 7713508981, shazmin.majid1@nottingham.ac.uk %K user-centered design %K participatory design %K human-computer interaction %K patient and public involvement %K self-monitoring technology %K bipolar disorder %K mobile phone %D 2021 %7 20.12.2021 %9 Review %J JMIR Ment Health %G English %X Background: The number of self-monitoring apps for bipolar disorder (BD) is increasing. The involvement of users in human-computer interaction (HCI) research has a long history and is becoming a core concern for designers working in this space. The application of models of involvement, such as user-centered design, is becoming standardized to optimize the reach, adoption, and sustained use of this type of technology. Objective: This paper aims to examine the current ways in which users are involved in the design and evaluation of self-monitoring apps for BD by investigating 3 specific questions: are users involved in the design and evaluation of technology? If so, how does this happen? And what are the best practice ingredients regarding the design of mental health technology? Methods: We reviewed the available literature on self-tracking technology for BD and make an overall assessment of the level of user involvement in design. The findings were reviewed by an expert panel, including an individual with lived experience of BD, to form best practice ingredients for the design of mental health technology. This combines the existing practices of patient and public involvement and HCI to evolve from the generic guidelines of user-centered design and to those that are tailored toward mental health technology. Results: For the first question, it was found that out of the 11 novel smartphone apps included in this review, 4 (36%) self-monitoring apps were classified as having no mention of user involvement in design, 1 (9%) self-monitoring app was classified as having low user involvement, 4 (36%) self-monitoring apps were classified as having medium user involvement, and 2 (18%) self-monitoring apps were classified as having high user involvement. For the second question, it was found that despite the presence of extant approaches for the involvement of the user in the process of design and evaluation, there is large variability in whether the user is involved, how they are involved, and to what extent there is a reported emphasis on the voice of the user, which is the ultimate aim of such design approaches. For the third question, it is recommended that users are involved in all stages of design with the ultimate goal of empowering and creating empathy for the user. Conclusions: Users should be involved early in the design process, and this should not just be limited to the design itself, but also to associated research ensuring end-to-end involvement. Communities in health care–based design and HCI design need to work together to increase awareness of the different methods available and to encourage the use and mixing of the methods as well as establish better mechanisms to reach the target user group. Future research using systematic literature search methods should explore this further. %M 34931992 %R 10.2196/27991 %U https://mental.jmir.org/2021/12/e27991 %U https://doi.org/10.2196/27991 %U http://www.ncbi.nlm.nih.gov/pubmed/34931992 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e30000 %T Understanding Engagement Strategies in Digital Interventions for Mental Health Promotion: Scoping Review %A Saleem,Maham %A Kühne,Lisa %A De Santis,Karina Karolina %A Christianson,Lara %A Brand,Tilman %A Busse,Heide %+ Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, Bremen, 28359, Germany, 49 42121856 ext 923, saleem@leibniz-bips.de %K digital interventions %K mental health promotion %K engagement %K scoping review %K mobile phone %D 2021 %7 20.12.2021 %9 Review %J JMIR Ment Health %G English %X Background: Digital interventions offer a solution to address the high demand for mental health promotion, especially when facing physical contact restrictions or lacking accessibility. Engagement with digital interventions is critical for their effectiveness; however, retaining users’ engagement throughout the intervention is challenging. It remains unclear what strategies facilitate engagement with digital interventions that target mental health promotion. Objective: Our aim is to conduct a scoping review to investigate user engagement strategies and methods to evaluate engagement with digital interventions that target mental health promotion in adults. Methods: This scoping review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. The search was conducted in 7 electronic databases from inception to April 2020. The inclusion criteria for studies were as follows: adult (aged ≥18 years) users of digital interventions for mental health promotion from the general population; any digital intervention for mental health promotion; and user engagement strategies described in the intervention design. We extracted the following data items: study characteristics, digital intervention (type and engagement strategy), evaluation of engagement strategy (method and result specifying whether the strategy was effective at facilitating engagement), and features of engagement (extent of use and subjective experience of users). Results: A total of 2766 studies were identified, of which 16 (0.58%) met the inclusion criteria. The 16 studies included randomized controlled trials (6/16, 37%), studies analyzing process data (5/16, 31%), observational studies (3/16, 19%), and qualitative studies (2/16, 13%). The digital interventions for mental health promotion were either web based (12/16, 75%) or mobile app based (4/16, 25%). The engagement strategies included personalized feedback about intervention content or users’ mental health status; guidance regarding content and progress through e-coaching; social forums, and interactivity with peers; content gamification; reminders; and flexibility and ease of use. These engagement strategies were deemed effective based on qualitative user feedback or responses on questionnaires or tools (4/16, 25%), usability data (5/16, 31%), or both (7/16, 44%). Most studies identified personalized support in the form of e-coaching, peer support through a social platform, personalized feedback, or joint videoconference sessions as an engaging feature. Conclusions: Personalized support during the intervention, access to social support, and personalized feedback seem to promote engagement with digital interventions for mental health promotion. These findings need to be interpreted with caution because the included studies were heterogeneous, had small sample sizes, and typically did not address engagement as the primary outcome. Despite the importance of user engagement for the effectiveness of digital interventions, this field has not yet received much attention. Further research is needed on the effectiveness of different strategies required to facilitate user engagement in digital interventions for mental health promotion. %M 34931995 %R 10.2196/30000 %U https://mental.jmir.org/2021/12/e30000 %U https://doi.org/10.2196/30000 %U http://www.ncbi.nlm.nih.gov/pubmed/34931995 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e26814 %T An Adjunctive Internet-Based Intervention to Enhance Treatment for Depression in Adults: Randomized Controlled Trial %A Pérez,J Carola %A Fernández,Olga %A Cáceres,Cristián %A Carrasco,Álvaro E %A Moessner,Markus %A Bauer,Stephanie %A Espinosa-Duque,Daniel %A Gloger,Sergio %A Krause,Mariane %+ Facultad de Psicología, Universidad del Desarrollo, Avda La Plaza 680, Las Condes, Santiago, 7610658, Chile, 56 997 051 989, janetperez@udd.cl %K depression %K e-mental health %K blended care %K internet %D 2021 %7 16.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-based interventions promise to enhance the accessibility of mental health care for a greater number of people and in more remote places. Their effectiveness has been shown for the prevention and treatment of various mental disorders. However, their potential when delivered as add-on to conventional treatment (ie, blended care) is less clear. Objective: The aim of this study is to study the effectiveness of an internet intervention (ASCENSO) implemented in addition to face-to-face treatment as usual (TAU) for depression. Methods: A 2-arm, parallel-group, randomized controlled trial was conducted in an outpatient private mental health care center in Chile. In all, 167 adults, diagnosed with major depressive disorder, without severe comorbidities, and with internet access, were included. Eighty-four participants were assigned to the intervention group and received medical and psychological TAU from the mental health center plus access to the ASCENSO online platform. The control group (n=83) received only TAU. The ASCENSO platform includes psycho-educational information, depressive symptom monitoring and feedback, and managing emergencies based on the principles of cognitive behavioral therapy. Emergency management was mental health provider–assisted. TAU includes access to primary care physicians and psychiatrists, to a brief individual psychotherapy, and to medication when needed. The baseline questionnaires were administered in person, and 6- and 9-months assessments were conducted online. Depression symptoms and quality of life were measured by self-administered questionnaires, and treatment adherence was determined via the Mental Health Center’s internal records. The usage of ASCENSO was assessed by server logs. Reduction on depressive symptomatology was considered as the primary outcome of the intervention and quality of life as a secondary outcome. Results: Of the 84 participants in the intervention group, 5 participants (6%) never accessed the online platform. Of the remaining 79 participants who accessed ASCENSO, 1 (1%, 1/79) did not answer any of the symptom questionnaire, and most participants (72/79, 91%) answered the monitoring questionnaires irregularly. The ASCENSO intervention implemented in addition to face-to-face care did not improve the outcome of the usual care delivered at the mental health center, either in terms of reduction of depressive symptoms (F2,6087= 0.48; P=.62) or in the improvement of quality of life (EQ-5D-3L: F2,7678=0.24; P=.79 and EQ-VAS: F2,6670= 0.13; P=.88). In contrast, for the primary (F2,850=78.25; P<.001) and secondary outcomes (EQ-5D-3L: F2,1067=37.87; EQ-VAS: F2,4390= 51.69; P<.001) in both groups, there was an improvement from baseline to 6 months (P<.001), but there was no change at 9 months. In addition, no effects on adherence to or use of TAU were found. Finally, the dropout rate for the face-to-face treatment component was 54% (45/84) for the intervention group versus 39% (32/83) for the control group (P=.07). Conclusions: The fact that the adjunctive access to ASCENSO did not improve outcome could be due to both the rather high effectiveness of TAU and to patients’ limited use of the online platform. Trial Registration: ClinicalTrials.gov NCT03093467; https://clinicaltrials.gov/ct2/show/NCT03093467 %M 34927594 %R 10.2196/26814 %U https://mental.jmir.org/2021/12/e26814 %U https://doi.org/10.2196/26814 %U http://www.ncbi.nlm.nih.gov/pubmed/34927594 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e17062 %T User Reviews of Depression App Features: Sentiment Analysis %A Meyer,Julien %A Okuboyejo,Senanu %+ School of Health Services Management, Ted Rogers School of Management, Ryerson University, 350 Victoria Street, Office: TRS 3-081, Toronto, ON, M4T 1G6, Canada, 1 4169795000 ext 6296, julien.meyer@ryerson.ca %K mHealth %K depression %K app reviews %K natural language processing %K app features %K emotions %K use %K linguistic inquiry word count %K mobile phone %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health in general, and depression in particular, remain undertreated conditions. Mobile health (mHealth) apps offer tremendous potential to overcome the barriers to accessing mental health care and millions of depression apps have been installed and used. However, little is known about the effect of these apps on a potentially vulnerable user population and the emotional reactions that they generate, even though emotions are a key component of mental health. App reviews, spontaneously posted by the users on app stores, offer up-to-date insights into the experiences and emotions of this population and are increasingly decisive in influencing mHealth app adoption. Objective: This study aims to investigate the emotional reactions of depression app users to different app features by systematically analyzing the sentiments expressed in app reviews. Methods: We extracted 3261 user reviews of depression apps. The 61 corresponding apps were categorized by the features they offered (psychoeducation, medical assessment, therapeutic treatment, supportive resources, and entertainment). We then produced word clouds by features and analyzed the reviews using the Linguistic Inquiry Word Count 2015 (Pennebaker Conglomerates, Inc), a lexicon-based natural language analytical tool that analyzes the lexicons used and the valence of a text in 4 dimensions (authenticity, clout, analytic, and tone). We compared the language patterns associated with the different features of the underlying apps. Results: The analysis highlighted significant differences in the sentiments expressed for the different features offered. Psychoeducation apps exhibited more clout but less authenticity (ie, personal disclosure). Medical assessment apps stood out for the strong negative emotions and the relatively negative ratings that they generated. Therapeutic treatment app features generated more positive emotions, even though user feedback tended to be less authentic but more analytical (ie, more factual). Supportive resources (connecting users to physical services and people) and entertainment apps also generated fewer negative emotions and less anxiety. Conclusions: Developers should be careful in selecting the features they offer in their depression apps. Medical assessment features may be riskier as users receive potentially disturbing feedback on their condition and may react with strong negative emotions. In contrast, offering information, contacts, or even games may be safer starting points to engage people with depression at a distance. We highlight the necessity to differentiate how mHealth apps are assessed and vetted based on the features they offer. Methodologically, this study points to novel ways to investigate the impact of mHealth apps and app features on people with mental health issues. mHealth apps exist in a rapidly changing ecosystem that is driven by user satisfaction and adoption decisions. As such, user perceptions are essential and must be monitored to ensure adoption and avoid harm to a fragile population that may not benefit from traditional health care resources. %M 34904955 %R 10.2196/17062 %U https://formative.jmir.org/2021/12/e17062 %U https://doi.org/10.2196/17062 %U http://www.ncbi.nlm.nih.gov/pubmed/34904955 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e32450 %T The Life Goals Self-Management Mobile App for Bipolar Disorder: Consumer Feasibility, Usability, and Acceptability Study %A Ryan,Kelly A %A Smith,Shawna N %A Yocum,Anastasia K %A Carley,Isabel %A Liebrecht,Celeste %A Navis,Bethany %A Vest,Erica %A Bertram,Holli %A McInnis,Melvin G %A Kilbourne,Amy M %+ Department of Psychiatry, University of Michigan, 2101 Commonwealth Blvd, Suite C, Ann Arbor, MI, 48105, United States, 1 734 936 5524, karyan@umich.edu %K self-management %K app %K bipolar disorder %K symptom management %K mental health %K feasibility %K usability %K acceptability %K intervention %K bipolar %K coping %K survey %K engagement %D 2021 %7 13.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Life Goals is an evidence-based self-management intervention that assists individuals with bipolar disorder (BD) by aligning BD symptom coping strategies with their personal goals. The intervention can be availed via in-person and telephonic sessions, and it has been recently developed as an individualized, customizable mobile app. Objective: We examined the feasibility, usability, and acceptability of the Life Goals self-management app among individuals diagnosed with BD who used the app for up to 6 months. Methods: A total of 28 individuals with BD used the Life Goals app on their personal smartphone for 6 months. They completed key clinical outcome measurements of functioning, disability, and psychiatric symptoms at baseline, 3 months, and 6 months, in addition to a poststudy survey about usability and satisfaction. Results: Participants used the app for a median of 25 times (IQR 13-65.75), and for a longer time during the first 3 months of the study. The modules on depression and anxiety were the most frequently used, accounting for 35% and 22% of total usage, respectively. Overall, the study participants found the app useful (15/25, 60%) and easy to use (18/25, 72%), and they reported that the screen displayed the material adequately (22/25, 88%). However, less than half of the participants found the app helpful in managing their health (10/25, 40%) or in making progress on their wellness goals (9/25, 36%). Clinical outcomes showed a trend for improvements in mental and physical health and mania-related well-being. Conclusions: The Life Goals app showed feasibility of use among individuals with BD. Higher user engagement was observed in the initial 3 months with users interested more frequently in the mood modules than other wellness modules. Participants reported acceptability with the ease of app use and satisfaction with the app user interface, but the app showed low success in encouraging self-management within this small sample. The Life Goals app is a mobile health technology that can provide individuals with serious mental illness with more flexible access to evidence-based treatments. %M 34898452 %R 10.2196/32450 %U https://formative.jmir.org/2021/12/e32450 %U https://doi.org/10.2196/32450 %U http://www.ncbi.nlm.nih.gov/pubmed/34898452 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e32948 %T The Application of e-Mental Health in Response to COVID-19: Scoping Review and Bibliometric Analysis %A Ellis,Louise A %A Meulenbroeks,Isabelle %A Churruca,Kate %A Pomare,Chiara %A Hatem,Sarah %A Harrison,Reema %A Zurynski,Yvonne %A Braithwaite,Jeffrey %+ Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, Sydney, NSW 2113, Australia, 61 9850 2484, louise.ellis@mq.edu.au %K e-mental health %K mental health %K COVID-19 %K bibliometrics %K health systems %D 2021 %7 6.12.2021 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic and its mitigation measures and impacts, such as shelter-in-place orders, social isolation, restrictions on freedoms, unemployment, financial insecurity, and disrupted routines, have led to declines in mental health worldwide and concomitant escalating demands for mental health services. Under the circumstances, electronic mental health (e-mental health) programs and services have rapidly become the “new normal.” Objective: The aim of this study was to assess key characteristics and evidence gaps in the e-mental health literature published in relation to the COVID-19 pandemic via a scoping review and bibliometric analysis. Methods: We conducted a search of four academic databases (ie, MEDLINE, Embase, PsycInfo, and CINAHL) for documents published from December 31, 2019, to March 31, 2021, using keywords for e-mental health and COVID-19. Article information was extracted that was relevant to the review objective, including journal, type of article, keywords, focus, and corresponding author. Information was synthesized by coding these attributes and was then summarized through descriptive statistics and narrative techniques. Article influence was examined from Altmetric and CiteScore data, and a network analysis was conducted on article keywords. Results: A total of 356 publications were included in the review. Articles on e-mental health quickly thrived early in the pandemic, with most articles being nonempirical, chiefly commentaries or opinions (n=225, 63.2%). Empirical publications emerged later and became more frequent as the pandemic progressed. The United States contributed the most articles (n=160, 44.9%), though a notable number came from middle-income countries (n=59, 16.6%). Articles were spread across 165 journals and had above-average influence (ie, almost half of the articles were in the top 25% of output scores by Altmetric, and the average CiteScore across articles was 4.22). The network analysis of author-supplied keywords identified key topic areas, including specific mental disorders, eHealth modalities, issues and challenges, and populations of interest. These were further explored via full-text analysis. Applications of e-mental health during the pandemic overcame, or were influenced by, system, service, technology, provider, and patient factors. Conclusions: COVID-19 has accelerated applications of e-mental health. Further research is needed to support the implementation of e-mental health across system and service infrastructures, alongside evidence of the relative effectiveness of e-mental health in comparison to traditional modes of care. %M 34666306 %R 10.2196/32948 %U https://mental.jmir.org/2021/12/e32948 %U https://doi.org/10.2196/32948 %U http://www.ncbi.nlm.nih.gov/pubmed/34666306 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e26987 %T Clinical Efficacy and Psychological Mechanisms of an App-Based Digital Therapeutic for Generalized Anxiety Disorder: Randomized Controlled Trial %A Roy,Alexandra %A Hoge,Elizabeth A %A Abrante,Pablo %A Druker,Susan %A Liu,Tao %A Brewer,Judson A %+ Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, United States, 1 401 863 2826, judson_brewer@brown.edu %K anxiety %K generalized anxiety disorder %K worry %K mindfulness %K mHealth %K digital therapeutics %K mobile phone %D 2021 %7 2.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Current treatments for generalized anxiety disorder (GAD) often yield suboptimal outcomes, partly because of insufficient targeting of underlying psychological mechanisms (eg, avoidance reinforcement learning). Mindfulness training (MT) has shown efficacy for anxiety; yet, widespread adoption has been limited, partly because of the difficulty in scaling in-person–based delivery. Digital therapeutics are emerging as potentially viable treatments; however, very few have been empirically validated. Objective: The aim of this study is to test the efficacy and mechanism of an app-delivered MT that was designed to target a potential mechanism of anxiety (reinforcement learning), based on which previous studies have shown concern regarding feedback and the perpetuation of anxiety through negative reinforcement. Methods: Individuals with GAD were recruited using social media advertisements and randomized during an in-person visit to receive treatment as usual (n=33) or treatment as usual+app−delivered MT (Unwinding Anxiety; n=32). The latter was composed of 30 modules to be completed over a 2-month period. Associated changes in outcomes were assessed using self-report questionnaires 1 and 2 months after treatment initiation. Results: We randomized 65 participants in this study, and a modified intent-to-treat approach was used for analysis. The median number of modules completed by the MT group was 25.5 (IQR 17) out of 30; 46% (13/28) of the participants completed the program. In addition, the MT group demonstrated a significant reduction in anxiety (GAD-7) compared with the control group at 2 months (67% vs 14%; median change in GAD-7: –8.5 [IQR 6.5] vs –1.0 [IQR 5.0]; P<.001; 95% CI 6-10). Increases in mindfulness at 1 month (nonreactivity subscale) mediated decreases in worry at 2 months (Penn State Worry Questionnaire; P=.02) and decreases in worry at 1 month mediated reductions in anxiety at 2 months (P=.03). Conclusions: To our knowledge, this is the first report on the efficacy and mechanism of an app-delivered MT for GAD. These findings demonstrate the clinical efficacy of MT as a digital therapeutic for individuals with anxiety (number needed to treat=1.6). These results also link recent advances in our mechanistic understanding of anxiety with treatment development, showing that app-delivered MT targets key reinforcement learning pathways, resulting in tangible, clinically meaningful reductions in worry and anxiety. Evidence-based, mechanistically targeted digital therapeutics have the potential to improve health at a population level at a low cost. Trial Registration: ClinicalTrials.gov NCT03683472; https://clinicaltrials.gov/ct2/show/NCT03683472 %M 34860673 %R 10.2196/26987 %U https://www.jmir.org/2021/12/e26987 %U https://doi.org/10.2196/26987 %U http://www.ncbi.nlm.nih.gov/pubmed/34860673 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e30053 %T A Conversational Artificial Intelligence Agent for a Mental Health Care App: Evaluation Study of Its Participatory Design %A Danieli,Morena %A Ciulli,Tommaso %A Mousavi,Seyed Mahed %A Riccardi,Giuseppe %+ Speech and Interactive Signal Lab, Department of Engineering and Computer Science, Università degli Studi di Trento, Via Sommarive 5, Povo di Trento, Trento, 38123, Italy, 39 0461282087, morena.danieli@unitn.it %K mental health care %K conversational AI %K mHealth %K personal health care agents %K participatory design %K psychotherapy %D 2021 %7 1.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Mobile apps for mental health are available on the market. Although they seem to be promising for improving the accessibility of mental health care, little is known about their acceptance, design methodology, evaluation, and integration into psychotherapy protocols. This makes it difficult for health care professionals to judge whether these apps may help them and their patients. Objective: Our aim is to describe and evaluate a protocol for the participatory design of mobile apps for mental health. In this study, participants and psychotherapists are engaged in the early phases of the design and development of the app empowered by conversational artificial intelligence (AI). The app supports interventions for stress management training based on cognitive behavioral theory. Methods: A total of 21 participants aged 33-61 years with mild to moderate levels of stress, anxiety, and depression (assessed by administering the Italian versions of the Symptom Checklist-90-Revised, Occupational Stress Indicator, and Perceived Stress Scale) were assigned randomly to 2 groups, A and B. Both groups received stress management training sessions along with cognitive behavioral treatment, but only participants assigned to group A received support through a mobile personal health care agent, designed for mental care and empowered by AI techniques. Psychopathological outcomes were assessed at baseline (T1), after 8 weeks of treatment (T2), and 3 months after treatment (T3). Focus groups with psychotherapists who administered the therapy were held after treatment to collect their impressions and suggestions. Results: Although the intergroup statistical analysis showed that group B participants could rely on better coping strategies, group A participants reported significant improvements in obsessivity and compulsivity and positive distress symptom assessment. The psychotherapists’ acceptance of the protocol was good. In particular, they were in favor of integrating an AI-based mental health app into their practice because they could appreciate the increased engagement of patients in pursuing their therapy goals. Conclusions: The integration into practice of an AI-based mobile app for mental health was shown to be acceptable to both mental health professionals and users. Although it was not possible in this experiment to show that the integration of AI-based conversational technologies into traditional remote psychotherapy significantly decreased the participants’ levels of stress and anxiety, the experimental results showed significant trends of reduction of symptoms in group A and their persistence over time. The mental health professionals involved in the experiment reported interest in, and acceptance of, the proposed technology as a promising tool to be included in a blended model of psychotherapy. %M 34855607 %R 10.2196/30053 %U https://formative.jmir.org/2021/12/e30053 %U https://doi.org/10.2196/30053 %U http://www.ncbi.nlm.nih.gov/pubmed/34855607 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e27404 %T Self-directed Technology-Based Therapeutic Methods for Adult Patients Receiving Mental Health Services: Systematic Review %A Saad,Anthony %A Bruno,Deanna %A Camara,Bettina %A D’Agostino,Josephine %A Bolea-Alamanac,Blanca %+ Department of Psychiatry, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 6473312707, Blanca.BoleaAlamanac@wchospital.ca %K digital therapeutics %K self-directed %K mental health %K telehealth %K technology %K mobile applications %K telemedicine %K internet %K mobile phone %D 2021 %7 26.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: Technological interventions used to treat illnesses and promote health are grouped under the umbrella term of digital therapeutics. The use of digital therapeutics is becoming increasingly common in mental health. Although many technologies are currently being implemented, research supporting their usability, efficacy, and risk requires further examination, especially for those interventions that can be used without support. Objective: This review aims to identify the evidence-based, self-directed, technology-based methods of care that can be used in adult patients after they are discharged from mental health services. The interventions reviewed are automated with no human input required (either at the patient’s or at the technology’s end), so the patients can implement them without any support. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines in 3 databases: PubMed, Web of Science, and OVID. The inclusion criteria were self-directed, automated, and technology-based interventions related to mental health, primarily for adults, having a solid evaluation process. The interventions had to be self-directed, in that the participants could use the technology without any external guidance. Results: We identified 36 papers that met the inclusion criteria: 26 randomized controlled trials, 9 nonrandomized controlled trial quantitative studies, and 1 qualitative study. The technologies used included websites, automated text messaging, phone apps, videos, computer software, and integrated voice response. There were 22 studies focused on internet-based cognitive behavioral therapies as a therapeutic paradigm compared with the waitlist, web-based human-delivered therapy, and other interventions. Among these studies, 14 used paradigms other than the internet-based cognitive behavioral therapy. Of the 8 studies comparing guided and unguided digital care, 3 showed no differences, 3 favored guided interventions, and 2 favored unguided interventions. The research also showed that dropout rates were as high as 80%, citing potential problems with the acceptability of the suggested technologies. Conclusions: There is limited research on the efficacy and suitability of self-directed technology-based care options for mental health. Digital technologies have the potential to bridge the gap between ambulatory care and independent living. However, these interventions may need to be developed collaboratively with the users to encourage their acceptability and to avoid high dropout rates. %M 34842556 %R 10.2196/27404 %U https://mental.jmir.org/2021/11/e27404 %U https://doi.org/10.2196/27404 %U http://www.ncbi.nlm.nih.gov/pubmed/34842556 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e29267 %T Development of a Wearable Biocueing App (Sense-IT) Among Forensic Psychiatric Outpatients With Aggressive Behavior: Design and Evaluation Study %A ter Harmsel,Annemieke %A van der Pol,Thimo %A Swinkels,Lise %A Goudriaan,Anna E %A Popma,Arne %A Noordzij,Matthijs L %+ Inforsa, Forensic Mental Health Care, Vlaardingenlaan 5, Amsterdam, 1059 GL, Netherlands, 31 653810776, annemieke.ter.harmsel@inforsa.nl %K biocueing %K biosensing %K biofeedback %K aggression %K forensic psychiatry %K wearable technology %K mobile apps %K usability %K evaluation %K mHealth %D 2021 %7 24.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The ability to regulate anger is often impaired in forensic psychiatric patients, frequently resulting in aggressive behavior. Although some treatment programs are partially successful in enhancing aggression regulation and reducing recidivism among specific subgroups, generalizable conclusions on the effectiveness of these interventions cannot be drawn to date. In forensic outpatient care, low treatment adherence and a predominant focus on cognitive control in most treatment programs may entail some of the factors impeding treatment. Technology-based interventions may address some of these treatment challenges. Objective: The aim of this study is to explore whether a new technology-based biocueing intervention, the Sense-IT app, can be a valuable addition to aggression regulation treatment programs in forensic outpatient care. The Sense-IT app, which provides the user with real-time physiological feedback and behavioral support, is developed to strengthen emotional awareness and facilitate real-life practice. In this study, we aim to develop and evaluate an updated version of the Sense-IT app that is suitable for forensic outpatients with aggressive behavior. Methods: First, we conducted a design study to assess the attitudes of forensic professionals and patients toward biocueing and to collect requirements for a biocueing app for this specific population. On the basis of this information, we developed an updated version of the Sense-IT app. In an evaluation study, 10 forensic outpatients used the app for 2 weeks. The app’s acceptability, usability, and clinical outcomes (aggression, anger, and recognition of bodily signals related to anger) were measured before and after the intervention using both quantitative and qualitative measures. Results: The design study revealed a cautiously positive attitude toward the use of biocueing as an addition to aggression regulation therapy. The evaluation study among forensic outpatients demonstrated moderate acceptability and adequate usability for the new version of the Sense-IT app. Exploratory analysis revealed a significant decrease in trait aggression postintervention; no significant changes were found in other anger-related clinical outcomes. To further increase acceptability and usability, a stable functioning app with self-adjustable settings, the use of smartwatches with a longer battery life, and the use of the patient’s own smartphone devices were recommended. Conclusions: This study, which is one of the first attempts to enroll and evaluate the real-life use of a biocueing intervention among forensic outpatients, emphasized the importance of involving both patients and therapists throughout the development and implementation process. In the future, experimental studies, including single-case experimental designs using ecological momentary assessment, should be performed to evaluate the effectiveness of the Sense-IT intervention on clinical outcomes. An open attitude toward new technology, allowing exploration of the potential benefits of the Sense-IT app case-by-case, and training of therapists in using the app are expected to facilitate its integration in therapy. %M 34821567 %R 10.2196/29267 %U https://formative.jmir.org/2021/11/e29267 %U https://doi.org/10.2196/29267 %U http://www.ncbi.nlm.nih.gov/pubmed/34821567 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 11 %P e26397 %T A Mobile Intervention for Self-Efficacious and Goal-Directed Smartphone Use in the General Population: Randomized Controlled Trial %A Keller,Jan %A Roitzheim,Christina %A Radtke,Theda %A Schenkel,Konstantin %A Schwarzer,Ralf %+ Department of Education and Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, Berlin, 14195, Germany, 49 30 8385 4906, jan.keller@fu-berlin.de %K problematic smartphone use %K smartphone unlocks %K smartphone time %K behavior change %K self-efficacy %K action planning %K digital detox %K time-out %K randomized controlled trial %D 2021 %7 23.11.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: People spend large parts of their everyday life using their smartphones. Despite various advantages of the smartphone for daily life, problematic forms of smartphone use exist that are related to negative psychological and physiological consequences. To reduce problematic smartphone use, existing interventions are oftentimes app-based and include components that help users to monitor and restrict their smartphone use by setting timers and blockers. These kinds of digital detox interventions, however, fail to exploit psychological resources, such as through promoting self-efficacious and goal-directed smartphone use. Objective: The aim of this study is to evaluate the theory-based smartphone app “Not Less But Better” that was developed to make people aware of psychological processes while using the smartphone and to support them in using their smartphone in accordance with their goals and values. Methods: In a randomized controlled trial, effects of a 20-day intervention app consisting of five 4-day training modules to foster a goal-directed smartphone use were evaluated. In the active control condition (treatment as usual), participants received a digital detox treatment and planned daily time-outs of at least 1 hour per day. Up to a 3-week follow-up, self-reported problematic smartphone use, objectively measured daily smartphone unlocks, time of smartphone use, self-efficacy, and planning towards goal-directed smartphone use were assessed repeatedly. Linear 2-level models tested intervention effects. Mediation models served to analyze self-efficacy and planning as potential mechanisms of the intervention. Results: Out of 232 enrolled participants, 110 (47.4%; 55 participants in each condition) provided data at postintervention and 88 (37.9%; 44 participants in each condition) at 3-week follow-up. Both conditions manifested substantial reductions in problematic smartphone use and in the amount of time spent with the smartphone. The number of daily unlocks did not change over time. Further, modelling changes in self-efficacy as a mediator between the intervention and problematic smartphone use at follow-up fit well to the data and showed an indirect effect (b=–0.09; 95% bias-corrected bootstrap CI –0.26 to –0.01), indicating that self-efficacy was an important intervention mechanism. Another mediation model revealed an indirect effect from changes in planning via smartphone unlocks at postintervention on problematic smartphone use at follow-up (b=–0.029, 95% bias-corrected bootstrap CI –0.078 to –0.003). Conclusions: An innovative, theory-based intervention app on goal-directed smartphone use has been found useful in lowering problematic smartphone use and time spent with the smartphone. However, observed reductions in both outcomes were not superior to the active control condition (ie, digital detox treatment). Nonetheless, the present findings highlight the importance in promoting self-efficacy and planning goal-directed smartphone use to achieve improvements in problematic smartphone use. This scalable intervention app appears suitable for practical use and as an alternative to common digital detox apps. Future studies should address issues of high attrition by adding just-in-time procedures matched to smartphone users’ needs. Trial Registration: German Clinical Trials Register DRKS00017606; https://tinyurl.com/27c9kmwy %M 34817388 %R 10.2196/26397 %U https://mhealth.jmir.org/2021/11/e26397 %U https://doi.org/10.2196/26397 %U http://www.ncbi.nlm.nih.gov/pubmed/34817388 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32306 %T A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process %A Jonathan,Geneva K %A Dopke,Cynthia A %A Michaels,Tania %A Martin,Clair R %A Ryan,Chloe %A McBride,Alyssa %A Babington,Pamela %A Goulding,Evan H %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 680 N Lake Shore Dr Suite 1520, Chicago, IL, 60660, United States, 1 312 503 1189, e-goulding@fsm.northwestern.edu %K behavioral intervention technology %K mHealth %K bipolar disorder %K depression %K illness management %K smartphone %K behavior change %K early warning signs %K self-management %K qualitative %K behavior %K intervention %K management %K user experience %K perception %K utilization %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Bipolar disorder is a severe mental illness characterized by recurrent episodes of depressed, elevated, and mixed mood states. The addition of psychotherapy to pharmacological management can decrease symptoms, lower relapse rates, and improve quality of life; however, access to psychotherapy is limited. Mental health technologies such as smartphone apps are being studied as a means to increase access to and enhance the effectiveness of adjunctive psychotherapies for bipolar disorder. Individuals with bipolar disorder find this intervention format acceptable, but our understanding of how people utilize and integrate these tools into their behavior change and maintenance processes remains limited. Objective: The objective of this study was to explore how individuals with bipolar disorder perceive and utilize a smartphone intervention for health behavior change and maintenance. Methods: Individuals with bipolar disorder were recruited via flyers placed at university-affiliated and private outpatient mental health practices to participate in a pilot study of LiveWell, a smartphone-based self-management intervention. At the end of the study, all participants completed in-depth qualitative exit interviews. The behavior change framework developed to organize the intervention design was used to deductively code behavioral targets and determinants involved in target engagement. Inductive coding was used to identify themes not captured by this framework. Results: In terms of behavioral targets, participants emphasized the importance of managing mood episode–related signs and symptoms. They also discussed the importance of maintaining regular routines, sleep duration, and medication adherence. Participants emphasized that receiving support from a coach as well as seeking and receiving assistance from family, friends, and providers were important for managing behavioral targets and staying well. In terms of determinants, participants stressed the important role of monitoring for their behavior change and maintenance efforts. Monitoring facilitated self-awareness and reflection, which was considered valuable for staying well. Some participants also felt that the intervention facilitated learning information necessary for managing bipolar disorder but others felt that the information provided was too basic. Conclusions: In addition to addressing acceptability, satisfaction, and engagement, a person-based design of mental health technologies can be used to understand how people experience the impact of these technologies on their behavior change and maintenance efforts. This understanding may then be used to guide ongoing intervention development. The participants’ perceptions aligned with the intervention’s primary behavioral targets and use of a monitoring tool as a core intervention feature. Participant feedback further indicates that developing additional content and tools to address building and engaging social support may be an important avenue for improving LiveWell. A comprehensive behavior change framework to understand participant perceptions of their behavior change and maintenance efforts may help facilitate ongoing intervention development. %M 34813488 %R 10.2196/32306 %U https://mental.jmir.org/2021/11/e32306 %U https://doi.org/10.2196/32306 %U http://www.ncbi.nlm.nih.gov/pubmed/34813488 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e30590 %T Effectiveness of Self-Guided Virtual Reality–Based Cognitive Behavioral Therapy for Panic Disorder: Randomized Controlled Trial %A Shin,Bokyoung %A Oh,Jooyoung %A Kim,Byung-Hoon %A Kim,Hesun Erin %A Kim,Hyunji %A Kim,Suji %A Kim,Jae-Jin %+ Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3342, ojuojuoju@yuhs.ac %K virtual reality %K panic disorder %K cognitive behavioral therapy %K exposure therapy %K intervention %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Virtual reality (VR) is as effective a technique as traditional cognitive behavioral therapy (CBT) and a promising tool for treating panic disorder symptoms because VR exposure can be safer and has better acceptability than in vivo exposure and is more immersive than exposure through imagination. CBT techniques can be delivered more effectively using VR as well. So far, VR has required high-quality devices, but the development of mobile VR technology has improved user availability. At the same time, a well-structured form of VR can be reproduced and used anywhere. This means that VR can be used to provide a self-guided form of treatment and address the high treatment costs of evidence-based therapy and the lack of professional therapists. This study aimed to investigate the potential of self-guided VR as an alternative to high-cost treatment. Objective: The main goal of this study was to offer data about the efficacy of a mobile app-based self-led VR CBT in the treatment of panic disorder. Methods: A total of 54 subjects with panic disorder were enrolled in this study and randomly assigned to either the VR treatment group or waitlist group. The VR treatment was designed to be total 12 sessions for 4 weeks. The VR treatment consists of 4 steps in which patients are gradually exposed to phobic stimuli while learning to cope with panic symptoms in each stage. The effectiveness of treatment was assessed through the Panic Disorder Severity Scale, Hamilton Rating Scale for Depression, Body Sensations Questionnaire, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Korean Inventory of Social Avoidance and Distress Scale, Korean Inventory of Depressive Symptomatology, and Perceived Stress Scale. In addition, physiological changes using heart rate variability were evaluated. Results: In within-group analyses, the VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after 4 weeks, while the waitlist group did not show any significant improvement. Compared to the waitlist group, the VR treatment group showed significantly greater improvements in the Panic Disorder Severity Scale in both completer analysis and intention-to-treat analysis. Heart rate variability in the VR treatment group showed improvement in normalized high frequency from baseline to postassessment with no significant differences in any outcome measure between groups. Conclusions: The self-guided, mobile app-based VR intervention was effective in the treatment of panic symptoms and restoring the autonomic nervous system demonstrating the validity of the use of VR for self-guided treatment. VR treatment can be a cost-effective therapeutic approach. Trial Registration: ClinicalTrials.gov NCT04985019; https://clinicaltrials.gov/ct2/show/NCT04985019 %M 34813486 %R 10.2196/30590 %U https://mental.jmir.org/2021/11/e30590 %U https://doi.org/10.2196/30590 %U http://www.ncbi.nlm.nih.gov/pubmed/34813486 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e30915 %T Opening the Black Box of Daily Life in Nonsuicidal Self-injury Research: With Great Opportunity Comes Great Responsibility %A Kiekens,Glenn %A Robinson,Kealagh %A Tatnell,Ruth %A Kirtley,Olivia J %+ Faculty of Psychology and Educational Sciences, Clinical Psychology, KU Leuven, Tiensestraat 102, Leuven, 3720, Belgium, 32 16372852, glenn.kiekens@kuleuven.be %K real-time monitoring %K nonsuicidal self-injury %K NSSI %K experience sampling %K ecological momentary assessment %K digital psychiatry %D 2021 %7 19.11.2021 %9 Viewpoint %J JMIR Ment Health %G English %X Although nonsuicidal self-injury (NSSI)—deliberate damaging of body tissue without suicidal intent—is a behavior that occurs in interaction with real-world contexts, studying NSSI in the natural environment has historically been impossible. Recent advances in real-time monitoring technologies have revolutionized our ability to do exactly that, providing myriad research and clinical practice opportunities. In this viewpoint paper, we review new research pathways to improve our ability to understand, predict, and prevent NSSI, and provide critical perspectives on the responsibilities inherent to conducting real-time monitoring studies on NSSI. Real-time monitoring brings unique opportunities to advance scientific understanding about (1) the dynamic course of NSSI, (2) the real-time predictors thereof and ability to detect acute risk, (3) the ecological validity of theoretical models, (4) the functional mechanisms and outcomes of NSSI, and (5) the promotion of person-centered care and novel technology-based interventions. By considering the opportunities of real-time monitoring research in the context of the accompanying responsibilities (eg, inclusive recruitment, sound and transparent research practices, participant safety and engagement, measurement reactivity, researcher well-being and training), we provide novel insights and resources to open the black box of daily life in the next decade(s) of NSSI research. %M 34807835 %R 10.2196/30915 %U https://mental.jmir.org/2021/11/e30915 %U https://doi.org/10.2196/30915 %U http://www.ncbi.nlm.nih.gov/pubmed/34807835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e29201 %T A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE %A Ben-Zeev,Dror %A Chander,Ayesha %A Tauscher,Justin %A Buck,Benjamin %A Nepal,Subigya %A Campbell,Andrew %A Doron,Guy %+ 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 mobile health %K schizophrenia %K bipolar disorder %K depression %K mobile phone %D 2021 %7 12.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority. Objective: The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains. Methods: Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods. Results: Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F1,313=13.38; P<.001), GAD-7 (F1,313=5.87; P=.01), RAS (F1,313=23.42; P<.001), RSES (F1,313=19.28; P<.001), and SDS (F1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3. Conclusions: We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond. Trial Registration: ClinicalTrials.gov NCT04068467; https://clinicaltrials.gov/ct2/show/NCT04068467 %M 34766913 %R 10.2196/29201 %U https://www.jmir.org/2021/11/e29201 %U https://doi.org/10.2196/29201 %U http://www.ncbi.nlm.nih.gov/pubmed/34766913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e22369 %T Remote Digital Psychiatry for Mobile Mental Health Assessment and Therapy: MindLogger Platform Development Study %A Klein,Arno %A Clucas,Jon %A Krishnakumar,Anirudh %A Ghosh,Satrajit S %A Van Auken,Wilhelm %A Thonet,Benjamin %A Sabram,Ihor %A Acuna,Nino %A Keshavan,Anisha %A Rossiter,Henry %A Xiao,Yao %A Semenuta,Sergey %A Badioli,Alessandra %A Konishcheva,Kseniia %A Abraham,Sanu Ann %A Alexander,Lindsay M %A Merikangas,Kathleen R %A Swendsen,Joel %A Lindner,Ariel B %A Milham,Michael P %+ MATTER Lab, Child Mind Institute, 101 East 56th Street, New York, NY, 10022, United States, 1 347 577 2091, arno@childmind.org %K mental health %K mHealth %K mobile health %K digital health %K eHealth %K digital psychiatry %K digital phenotyping %K teletherapy %K mobile device %K mobile phone %K smartphone %K ecological momentary assessment %K ecological momentary intervention %K EMA %K EMI %K ESM %K experience sampling %K experience sampling methods %D 2021 %7 11.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Universal access to assessment and treatment of mental health and learning disorders remains a significant and unmet need. There are many people without access to care because of economic, geographic, and cultural barriers, as well as the limited availability of clinical experts who could help advance our understanding and treatment of mental health. Objective: This study aims to create an open, configurable software platform to build clinical measures, mobile assessments, tasks, and interventions without programming expertise. Specifically, our primary requirements include an administrator interface for creating and scheduling recurring and customized questionnaires where end users receive and respond to scheduled notifications via an iOS or Android app on a mobile device. Such a platform would help relieve overwhelmed health systems and empower remote and disadvantaged subgroups in need of accurate and effective information, assessment, and care. This platform has the potential to advance scientific research by supporting the collection of data with instruments tailored to specific scientific questions from large, distributed, and diverse populations. Methods: We searched for products that satisfy these requirements. We designed and developed a new software platform called MindLogger, which exceeds the requirements. To demonstrate the platform’s configurability, we built multiple applets (collections of activities) within the MindLogger mobile app and deployed several of them, including a comprehensive set of assessments underway in a large-scale, longitudinal mental health study. Results: Of the hundreds of products we researched, we found 10 that met our primary requirements with 4 that support end-to-end encryption, 2 that enable restricted access to individual users’ data, 1 that provides open-source software, and none that satisfy all three. We compared features related to information presentation and data capture capabilities; privacy and security; and access to the product, code, and data. We successfully built MindLogger mobile and web applications, as well as web browser–based tools for building and editing new applets and for administering them to end users. MindLogger has end-to-end encryption, enables restricted access, is open source, and supports a variety of data collection features. One applet is currently collecting data from children and adolescents in our mental health study, and other applets are in different stages of testing and deployment for use in clinical and research settings. Conclusions: We demonstrated the flexibility and applicability of the MindLogger platform through its deployment in a large-scale, longitudinal, mobile mental health study and by building a variety of other mental health–related applets. With this release, we encourage a broad range of users to apply the MindLogger platform to create and test applets to advance health care and scientific research. We hope that increasing the availability of applets designed to assess and administer interventions will facilitate access to health care in the general population. %M 34762054 %R 10.2196/22369 %U https://www.jmir.org/2021/11/e22369 %U https://doi.org/10.2196/22369 %U http://www.ncbi.nlm.nih.gov/pubmed/34762054 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e27897 %T Mediating Effects of Stigma and Depressive Symptoms in a Social Media–Based Intervention to Improve Long-term Quality of Life Among People Living With HIV: Secondary Analysis of a Randomized Controlled Trial %A Li,Yiran %A Guo,Yan %A Hong,Y Alicia %A Zeng,Chengbo %A Zeng,Yu %A Zhang,Hanxi %A Zhu,Mengting %A Qiao,Jiaying %A Cai,Weiping %A Li,Linghua %A Liu,Cong %+ Department of Medical Statistics, School of Public Health, Sun Yat-sen University, #74 2nd Zhongshan Road, Guangzhou, 510080, China, 86 020 87334202, guoy8@mail.sysu.edu.cn %K mHealth %K HIV %K depressive symptoms %K quality of life %K structural equation model %D 2021 %7 9.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile health (mHealth) interventions have been shown to effectively improve the quality of life (QOL) among people living with HIV. However, little is known about the long-term effects of mHealth interventions. Objective: This study aims to explore the intervention mechanisms of a social media–based intervention, Run4Love, on the QOL of people with HIV over across a 9-month follow-up period. Methods: We recruited people living with HIV who were concurrently experiencing elevated depressive symptoms from an HIV outpatient clinic in South China. A total of 300 eligible participants were randomized either to the intervention group or the control group in a 1:1 ratio after they provided informed consent and completed a baseline survey. The intervention group received a 3-month WeChat-based intervention, comprising cognitive-behavioral stress management (CBSM) courses and physical activity promotion. The control group received a printed brochure on nutrition guidelines in addition to the usual care for HIV treatment. Neither participants nor the research staff were blinded to group assignment. All patients were followed at 3, 6, and 9 months. The primary outcome was depressive symptoms. Structural equation model (SEM) with longitudinal data was conducted to examine the sequential mediating effects of HIV-related stigma and depressive symptoms on the long-term intervention effects on participants’ QOL. Results: About 91.3% (274/300), 88.3% (265/300), and 86.7% (260/300) of all participants completed follow-up surveys at 3, 6, and 9 months, respectively. Results showed that the intervention had significantly improved participants' QOL at 9 months, via complete mediating effects of reduced HIV-related stigma at 3 months and decreased depressive symptoms at 6 months. No adverse events were reported. Conclusions: These findings underscore the critical roles of HIV-related stigma and depressive symptoms in an mHealth intervention with long-term effects on QOL improvements. We call for targeted mHealth interventions to improve QOL among people living with HIV, especially social media–based interventions that can address HIV-related stigma and alleviate depressive symptoms. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019 %M 34751654 %R 10.2196/27897 %U https://www.jmir.org/2021/11/e27897 %U https://doi.org/10.2196/27897 %U http://www.ncbi.nlm.nih.gov/pubmed/34751654 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e18969 %T Exploring the Barriers to and Motivators for Using Digital Mental Health Interventions Among Construction Personnel in Nigeria: Qualitative Study %A Nwaogu,Janet Mayowa %A Chan,Albert P C %A Naslund,John A %A Hon,Carol K H %A Belonwu,Christopher %A Yang,Jackie %+ Department of Building and Real Estate, The Hong Kong Polytechnic University, Kowloon, Hong Kong, 852 52243597, janet.nwaogu@connect.polyu.hk %K mental health %K construction personnel %K digital technology %K digital intervention %K barriers %K motivators %K mobile phone %D 2021 %7 9.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Work-related stress in the construction industry increases the prevalence of depression and anxiety among personnel. In low-resource settings such as Nigeria, construction personnel face high demands and severe working conditions but only have a few services to address their mental health needs. With emerging research showing that digital interventions can be used to self-manage mental health across diverse settings, there may be new opportunities to support construction personnel in the construction industry. Objective: This study aims to determine the use of digital interventions for mental health management among construction personnel in Nigeria and to explore the factors that facilitate or impede the use of these interventions. Methods: This qualitative study explored the perspectives of a convenience sample of 62 construction personnel. The data were subjected to inductive content analysis. Results: A total of 6 barrier and 3 motivator themes were identified and categorized into 2 groups. The barrier themes were subcategorized into barriers to adoption and barriers to persistent use, whereas the motivator themes were subcategorized into intrinsic and extrinsic motivators. Lack of awareness and knowledge about the interventions may constitute a barrier to adoption and use. Participants frequently reported concerns regarding their effectiveness and usability. Conclusions: This study provides an understanding of the design needs required to facilitate sustained self-management of mental health based on the experiences and expectations of construction personnel with digital interventions. %M 34751652 %R 10.2196/18969 %U https://formative.jmir.org/2021/11/e18969 %U https://doi.org/10.2196/18969 %U http://www.ncbi.nlm.nih.gov/pubmed/34751652 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 11 %P e31789 %T An App-Based Intervention for Adolescents Exposed to Cyberbullying in Norway: Protocol for a Randomized Controlled Trial %A Kaiser,Sabine %A Martinussen,Monica %A Adolfsen,Frode %A Breivik,Kyrre %A Kyrrestad,Henriette %+ Regional Centre for Child and Youth Mental Health and Child Welfare - North, UiT The Arctic University of Norway, Campus Tromsø, Breivika, Tromsø, 9019, Norway, 47 77645850, sabine.kaiser@uit.no %K cyberbullying %K intervention %K mobile app %K adolescents %K NettOpp %K mental health %K adolescents %K health care %D 2021 %7 8.11.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents exposed to negative online events are at high risk to develop mental health problems. Little is known about what is effective for treatment in this group. NettOpp is a new mobile app for adolescents who have been exposed to cyberbullying or negative online experiences in Norway. Objective: The aim of this paper is to provide a description of the content of the intervention and about a randomized controlled trial that will be conducted to examine the effectiveness of NettOpp. This protocol is written in accordance with the Spirit 2013 Checklist. Methods: An effectiveness study with a follow-up examination after 3 months will be conducted to evaluate the mobile app. Adolescents will be recruited through schools and will be randomly assigned to the intervention (NettOpp) group and a waiting-list control group. The adolescents (aged 11 to 16 years) will respond to self-report questionnaires on the internet. Primary outcomes will be changes in mental health assessed with the Strengths and Difficulties Questionnaire, the WHO-Five Well-being Index, and the Child and Adolescent Trauma Screen. Results: Recruitment will start in January 2022. The results from this study will be available in 2023. Conclusions: There are few published evaluation studies on app-based interventions. This project and its publications will contribute new knowledge to the field. Trial Registration: ClinicalTrials.gov NCT04176666; https://clinicaltrials.gov/ct2/show/NCT04176666 International Registered Report Identifier (IRRID): PRR1-10.2196/31789 %M 34747704 %R 10.2196/31789 %U https://www.researchprotocols.org/2021/11/e31789 %U https://doi.org/10.2196/31789 %U http://www.ncbi.nlm.nih.gov/pubmed/34747704 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e27282 %T Identifying App-Based Meditation Habits and the Associated Mental Health Benefits: Longitudinal Observational Study %A Stecher,Chad %A Berardi,Vincent %A Fowers,Rylan %A Christ,Jaclyn %A Chung,Yunro %A Huberty,Jennifer %+ College of Health Solutions, Arizona State University, 500 N 3rd Street, Phoenix, AZ, 85003, United States, 1 6024960957, chad.stecher@asu.edu %K behavioral habits %K habit formation %K mindfulness meditation %K mental health %K mHealth %K mobile health %K dynamic time warping %K mobile phone %D 2021 %7 4.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Behavioral habits are often initiated by contextual cues that occur at approximately the same time each day; so, it may be possible to identify a reflexive habit based on the temporal similarity of repeated daily behavior. Mobile health tools provide the detailed, longitudinal data necessary for constructing such an indicator of reflexive habits, which can improve our understanding of habit formation and help design more effective mobile health interventions for promoting healthier habits. Objective: This study aims to use behavioral data from a commercial mindfulness meditation mobile phone app to construct an indicator of reflexive meditation habits based on temporal similarity and estimate the association between temporal similarity and meditation app users’ perceived health benefits. Methods: App-use data from June 2019 to June 2020 were analyzed for 2771 paying subscribers of a meditation mobile phone app, of whom 86.06% (2359/2771) were female, 72.61% (2012/2771) were college educated, 86.29% (2391/2771) were White, and 60.71% (1664/2771) were employed full-time. Participants volunteered to complete a survey assessing their perceived changes in physical and mental health from using the app. Receiver operating characteristic curve analysis was used to evaluate the ability of the temporal similarity measure to predict future behavior, and variable importance statistics from random forest models were used to corroborate these findings. Logistic regression was used to estimate the association between temporal similarity and self-reported physical and mental health benefits. Results: The temporal similarity of users’ daily app use before completing the survey, as measured by the dynamic time warping (DTW) distance between app use on consecutive days, significantly predicted app use at 28 days and at 6 months after the survey, even after controlling for users’ demographic and socioeconomic characteristics, total app sessions, duration of app use, and number of days with any app use. In addition, the temporal similarity measure significantly increased in the area under the receiver operating characteristic curve (AUC) for models predicting any future app use in 28 days (AUC=0.868 with DTW and 0.850 without DTW; P<.001) and for models predicting any app use in 6 months (AUC=0.821 with DTW and 0.802 without DTW; P<.001). Finally, a 1% increase in the temporal similarity of users’ daily meditation practice with the app over 6 weeks before the survey was associated with increased odds of reporting mental health improvements, with an odds ratio of 2.94 (95% CI 1.832-6.369). Conclusions: The temporal similarity of the meditation app use was a significant predictor of future behavior, which suggests that this measure can identify reflexive meditation habits. In addition, temporal similarity was associated with greater perceived mental health benefits, which demonstrates that additional mental health benefits may be derived from forming reflexive meditation habits. %M 34734826 %R 10.2196/27282 %U https://www.jmir.org/2021/11/e27282 %U https://doi.org/10.2196/27282 %U http://www.ncbi.nlm.nih.gov/pubmed/34734826 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e25298 %T A Text Messaging Intervention (StayWell at Home) to Counteract Depression and Anxiety During COVID-19 Social Distancing: Pre-Post Study %A Aguilera,Adrian %A Hernandez-Ramos,Rosa %A Haro-Ramos,Alein Y %A Boone,Claire Elizabeth %A Luo,Tiffany Christina %A Xu,Jing %A Chakraborty,Bibhas %A Karr,Chris %A Darrow,Sabrina %A Figueroa,Caroline Astrid %+ School of Social Welfare, University of California, Berkeley, 120 Haviland Hall, MC7400, School of Social Welfare, Berkeley, CA, 94720, United States, 1 (510) 642 8564, aguila@berkeley.edu %K mobile health %K COVID-19 %K text messaging %K cognitive behavioral therapy %K anxiety %K depression %K microrandomized trials %K mHealth %K intervention %K mental health %K SMS %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19–related depression and anxiety symptoms among people who speak English and Spanish in the United States. Objective: This paper describes the changes in StayWell participants’ anxiety and depression levels after 60 days of exposure to skills-based SMS text messages. Methods: We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Questionnaire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used 2-tailed paired t tests to detect changes in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later. Results: The analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of –1.72 (95% CI –2.35 to –1.09) in PHQ-8 scores and –0.48 (95% CI –0.71 to –0.25) in GAD-2 scores. These improvements translated to an 18.5% and 17.2% reduction in mean PHQ-8 and GAD-2 scores, respectively. Conclusions: StayWell is an accessible, low-intensity population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health. Trial Registration: ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 International Registered Report Identifier (IRRID): RR2-10.2196/23592 %M 34543230 %R 10.2196/25298 %U https://mental.jmir.org/2021/11/e25298 %U https://doi.org/10.2196/25298 %U http://www.ncbi.nlm.nih.gov/pubmed/34543230 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e31064 %T Acceptability, Engagement, and Exploratory Outcomes of an Emotional Well-being App: Mixed Methods Preliminary Evaluation and Descriptive Analysis %A Eisenstadt,Amelia %A Liverpool,Shaun %A Metaxa,Athina-Marina %A Ciuvat,Roberta Maria %A Carlsson,Courtney %+ Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, The Kantor Centre of Excellence, 4-8 Rodney Street, London, N1 9JH, United Kingdom, 44 20 7794 2313, mia.eisenstadt@annafreud.org %K smartphone %K app %K well-being %K awareness %K mental health %K formative %K mobile phone %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: There is growing evidence suggesting that the emotional well-being of the public has been negatively affected in the past year. Consequently, demand for well-being support has increased. Although there is substantial empirical support for mental health apps that target diagnosed conditions, there is less research on emotional well-being apps. Among existing well-being apps, few studies have been conducted on apps that are based on lived experience and those that seek to enhance users’ understanding of their emotional patterns. Thus, the acceptability of these novel apps requires further evaluation before upscaling. Objective: This evaluation aims to describe the acceptability, engagement, and preliminary outcomes of using an app (Paradym) designed to promote emotional well-being and positive mental health. Methods: This is a pre-post, mixed-methods, single-arm evaluation that is aggregated with digital analytics data. We anonymously collected real-world data on the demographics and well-being of the participants as well as the usability and acceptance of the app using validated questionnaires and open-ended questions. Participants tested the app for a minimum of 2 weeks before completing the follow-up measures. Google Analytics was used to record the level of app engagement. Chi-square and 2-tailed t tests were conducted to analyze quantitative data, and a thematic analysis approach was adopted for qualitative data. Results: A total of 115 participants completed baseline questionnaires, of which 79.1% (91/115) users downloaded the app. The sample was diverse in terms of ethnicity, including 43.4% (50/115) people who self-identified as belonging to minority ethnic groups. Most of the participants were female (78/115, 67.8%) and between the ages of 18 and 25 years (39/115, 33.9%). A total of 34 app users who completed questionnaires at baseline and follow-up provided valuable feedback to inform the future directions of Paradym. Favorable themes emerged describing the app’s content, functionality, and underlying principles. Although usability feedback varied across items, a considerable number of participants (22/34, 64%) found that the app was easy to use. Google Analytics revealed that at least 79% (27/34) of people used the app daily. On the basis of preliminary observations, app users experience increased mental well-being. Post hoc analyses indicated that the reduction in depression scores (t33=−2.16) and the increase in the well-being measures (t33=2.87) were statistically significant. No adverse events were reported during the follow-up period. Conclusions: The findings of this evaluation are encouraging and document positive preliminary evidence for the Paradym app. %M 34569466 %R 10.2196/31064 %U https://formative.jmir.org/2021/11/e31064 %U https://doi.org/10.2196/31064 %U http://www.ncbi.nlm.nih.gov/pubmed/34569466 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 10 %P e20638 %T A Mobile Sensing App to Monitor Youth Mental Health: Observational Pilot Study %A MacLeod,Lucy %A Suruliraj,Banuchitra %A Gall,Dominik %A Bessenyei,Kitti %A Hamm,Sara %A Romkey,Isaac %A Bagnell,Alexa %A Mattheisen,Manuel %A Muthukumaraswamy,Viswanath %A Orji,Rita %A Meier,Sandra %+ Department of Psychiatry, Dalhousie University, 5850/5980 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada, 1 782414 ext 8054, sandra.m.meier@gmail.com %K mobile sensing %K youth %K psychiatry %K feasibility %K mobile phone %D 2021 %7 26.10.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Internalizing disorders are the most common psychiatric problems observed among youth in Canada. Sadly, youth with internalizing disorders often avoid seeking clinical help and rarely receive adequate treatment. Current methods of assessing internalizing disorders usually rely on subjective symptom ratings, but internalizing symptoms are frequently underreported, which creates a barrier to the accurate assessment of these symptoms in youth. Therefore, novel assessment tools that use objective data need to be developed to meet the highest standards of reliability, feasibility, scalability, and affordability. Mobile sensing technologies, which unobtrusively record aspects of youth behaviors in their daily lives with the potential to make inferences about their mental health states, offer a possible method of addressing this assessment barrier. Objective: This study aims to explore whether passively collected smartphone sensor data can be used to predict internalizing symptoms among youth in Canada. Methods: In this study, the youth participants (N=122) completed self-report assessments of symptoms of anxiety, depression, and attention-deficit hyperactivity disorder. Next, the participants installed an app, which passively collected data about their mobility, screen time, sleep, and social interactions over 2 weeks. Then, we tested whether these passive sensor data could be used to predict internalizing symptoms among these youth participants. Results: More severe depressive symptoms correlated with more time spent stationary (r=0.293; P=.003), less mobility (r=0.271; P=.006), higher light intensity during the night (r=0.227; P=.02), and fewer outgoing calls (r=−0.244; P=.03). In contrast, more severe anxiety symptoms correlated with less time spent stationary (r=−0.249; P=.01) and greater mobility (r=0.234; P=.02). In addition, youths with higher anxiety scores spent more time on the screen (r=0.203; P=.049). Finally, adding passively collected smartphone sensor data to the prediction models of internalizing symptoms significantly improved their fit. Conclusions: Passively collected smartphone sensor data provide a useful way to monitor internalizing symptoms among youth. Although the results replicated findings from adult populations, to ensure clinical utility, they still need to be replicated in larger samples of youth. The work also highlights intervention opportunities via mobile technology to reduce the burden of internalizing symptoms early on. %M 34698650 %R 10.2196/20638 %U https://mhealth.jmir.org/2021/10/e20638 %U https://doi.org/10.2196/20638 %U http://www.ncbi.nlm.nih.gov/pubmed/34698650 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e32100 %T Outcomes of a Blended Care Coaching Program for Clients Presenting With Moderate Levels of Anxiety and Depression: Pragmatic Retrospective Study %A Wu,Monica S %A Chen,Shih-Yin %A Wickham,Robert E %A O’Neil-Hart,Shane %A Chen,Connie %A Lungu,Anita %+ Lyra Health, 287 Lorton Ave, Burlingame, CA, 94010, United States, 1 877 505 7147, mwu@lyrahealth.com %K blended care %K coaching %K cognitive %K behavior %K depression %K anxiety %K digital health %K retrospective %K mental health %K CBT %K cognitive behavioral therapy %K outcome %K video conference %D 2021 %7 21.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety are leading causes of disability worldwide, but access to quality mental health care is limited by myriad factors. Cognitive-behavioral coaching is rooted in evidence-based principles and has the potential to address some of these unmet care needs. Harnessing technology to facilitate broader dissemination within a blended care model shows additional promise for overcoming barriers to care. Objective: The aim of this study is to evaluate the outcomes of a blended care coaching (BCC) program for clients presenting with moderate levels of anxiety and depression in real-world settings. Methods: This study examined retrospective data from US-based individuals (N=1496) who presented with moderate levels of depression and anxiety symptoms and who received blended care coaching services. Using a short-term framework, clients met with coaches via a secure video conference platform and also received digital video lessons and exercises. To evaluate the effectiveness of the BCC program, mixed effects modeling was used to examine growth trajectories of anxiety and depression scores over the course of care. Results: Out of the total sample of 1496 clients, 75.9% (n=1136) demonstrated reliable improvement, and 88.6% (n=1326) recovered based on either the Generalized Anxiety Disorder-7 scale (anxiety) or Patient Health Questionnaire-9 (depression). On average, clients exhibited a significant decline in anxiety and depression symptoms during the initial weeks of coaching, with a continued decline over subsequent weeks at a lower rate. Engaging in a coaching session was associated with lower anxiety (b=–1.04) and depression (b=–0.79) symptoms in the same week, as well as lower anxiety (b=–0.74) and depression (b=–0.91) symptoms the following week (P<.001). Conclusions: The BCC program demonstrated strong outcomes in decreasing symptomology for clients presenting with moderate levels of anxiety and depression. When clients received coaching sessions, significant decreases in symptoms were observed, reflecting the importance of session attendance. Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. Collectively, these findings have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner. %M 34673534 %R 10.2196/32100 %U https://mental.jmir.org/2021/10/e32100 %U https://doi.org/10.2196/32100 %U http://www.ncbi.nlm.nih.gov/pubmed/34673534 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e29160 %T A Mobile App to Identify Lifestyle Indicators Related to Undergraduate Mental Health (Smart Healthy Campus): Observational App-Based Ecological Momentary Assessment %A Brogly,Chris %A Shoemaker,J Kevin %A Lizotte,Daniel J %A Kueper,Jacqueline K %A Bauer,Michael %+ Faculty of Information and Media Studies, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada, 1 (519) 661 2111, cbrogly@uwo.ca %K smartphones %K undergraduates %K mental health %K lifestyle %K postsecondary institutions %K mHealth %K mobile application %K ecological momentary assessment %K mobile phone %D 2021 %7 19.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Undergraduate studies are challenging, and mental health issues can frequently occur in undergraduate students, straining campus resources that are already in demand for somatic problems. Cost-effective measures with ubiquitous devices, such as smartphones, offer the potential to deliver targeted interventions to monitor and affect lifestyle, which may result in improvements to student mental health. However, the avenues by which this can be done are not particularly well understood, especially in the Canadian context. Objective: The aim of this study is to deploy an initial version of the Smart Healthy Campus app at Western University, Canada, and to analyze corresponding data for associations between psychosocial factors (measured by a questionnaire) and behaviors associated with lifestyle (measured by smartphone sensors). Methods: This preliminary study was conducted as an observational app-based ecological momentary assessment. Undergraduate students were recruited over email, and sampling using a custom 7-item questionnaire occurred on a weekly basis. Results: First, the 7-item Smart Healthy Campus questionnaire, derived from fully validated questionnaires—such as the Brief Resilience Scale; General Anxiety Disorder-7; and Depression, Anxiety, and Stress Scale–21—was shown to significantly correlate with the mental health domains of these validated questionnaires, illustrating that it is a viable tool for a momentary assessment of an overview of undergraduate mental health. Second, data collected through the app were analyzed. There were 312 weekly responses and 813 sensor samples from 139 participants from March 2019 to March 2020; data collection concluded when COVID-19 was declared a pandemic. Demographic information was not collected in this preliminary study because of technical limitations. Approximately 69.8% (97/139) of participants only completed one survey, possibly because of the absence of any incentive. Given the limited amount of data, analysis was not conducted with respect to time, so all data were analyzed as a single collection. On the basis of mean rank, students showing more positive mental health through higher questionnaire scores tended to spend more time completing questionnaires, showed more signs of physical activity based on pedometers, and had their devices running less and plugged in charging less when sampled. In addition, based on mean rank, students on campus tended to report more positive mental health through higher questionnaire scores compared with those who were sampled off campus. Some data from students found in or near residences were also briefly examined. Conclusions: Given these limited data, participants tended to report a more positive overview of mental health when on campus and when showing signs of higher levels of physical activity. These early findings suggest that device sensors related to physical activity and location are useful for monitoring undergraduate students and designing interventions. However, much more sensor data are needed going forward, especially given the sweeping changes in undergraduate studies due to COVID-19. %M 34665145 %R 10.2196/29160 %U https://formative.jmir.org/2021/10/e29160 %U https://doi.org/10.2196/29160 %U http://www.ncbi.nlm.nih.gov/pubmed/34665145 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e29615 %T Validity and Reliability of the Self-administered Psycho-TherApy-SystemS (SELFPASS) Item Pool for the Daily Mood Tracking of Depressive Symptoms: Cross-sectional Web-Based Survey %A Mayer,Gwendolyn %A Hummel,Svenja %A Gronewold,Nadine %A Oetjen,Neele %A Hilbel,Thomas %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 130 3, Heidelberg, 69120, Germany, 49 6221 56 35685, gwendolyn.mayer@med.uni-heidelberg.de %K self-management %K mood tracking %K validity %K reliability %K item pool %K questionnaire %K depression %K anxiety %K mood assessment %D 2021 %7 18.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: e-Mental health apps targeting depression have gained increased attention in mental health care. Daily self-assessment is an essential part of e-mental health apps. The Self-administered Psycho-TherApy-SystemS (SELFPASS) app is a self-management app to manage depressive and comorbid anxiety symptoms of patients with a depression diagnosis. A self-developed item pool with 40 depression items and 12 anxiety items is included to provide symptom-specific suggestions for interventions. However, the psychometric properties of the item pool have not yet been evaluated. Objective: The aim of this study is to investigate the validity and reliability of the SELFPASS item pool. Methods: A weblink with the SELFPASS item pool and validated mood assessment scales was distributed to healthy subjects and patients who had received a diagnosis of a depressive disorder within the last year. Two scores were derived from the SELFPASS item pool: SELFPASS depression (SP-D) and SELFPASS anxiety (SP-A). Reliability was examined using Cronbach α. Construct validity was assessed through Pearson correlations with the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder Scale-7 (GAD-7), and the WHO-5-Wellbeing-Scale (WHO-5). Logistic regression analysis was performed as an indicator for concurrent criterion validity of SP-D and SP-A. Factor analysis was performed to provide information about the underlying factor structure of the item pool. Item-scale correlations were calculated in order to determine item quality. Results: A total of 284 participants were included, with 192 (67.6%) healthy subjects and 92 (32.4%) patients. Cronbach α was set to .94 for SP-D and α=.88 for SP-A. We found significant positive correlations between SP-D and PHQ-9 scores (r=0.87; P<.001) and between SP-A and GAD-7 scores (r=0.80; P<.001), and negative correlations between SP-D and WHO-5 scores (r=–0.80; P<.001) and between SP-A and WHO-5 scores (r=–0.69; P<.001). Increasing scores of SP-D and SP-A led to increased odds of belonging to the patient group (SP-D: odds ratio 1.03, 95% CI 1.01-1.05; P<.001; SP-A: 1.05, 1.05-1.01; P=.01). The item pool yielded 2 factors: one that consisted of mood-related items and another with somatic-related items. Conclusions: The SELFPASS item pool showed good psychometric properties in terms of reliability, construct, and criterion validity. The item pool is an appropriate source for daily mood tracking in future e-mental health apps among patients with depression. Our study provides general recommendations for future developments as well as recommendations within the item pool. %M 34661547 %R 10.2196/29615 %U https://mental.jmir.org/2021/10/e29615 %U https://doi.org/10.2196/29615 %U http://www.ncbi.nlm.nih.gov/pubmed/34661547 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e27507 %T Building the Digital Mental Health Ecosystem: Opportunities and Challenges for Mobile Health Innovators %A Spadaro,Benedetta %A Martin-Key,Nayra A %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K digital implementation %K digital mental health %K digital psychiatry %K digital technology %K viewpoint %D 2021 %7 13.10.2021 %9 Viewpoint %J J Med Internet Res %G English %X Digital mental health technologies such as mobile health (mHealth) tools can offer innovative ways to help develop and facilitate mental health care provision, with the COVID-19 pandemic acting as a pivot point for digital health implementation. This viewpoint offers an overview of the opportunities and challenges mHealth innovators must navigate to create an integrated digital ecosystem for mental health care moving forward. Opportunities exist for innovators to develop tools that can collect a vast range of active and passive patient and transdiagnostic symptom data. Moving away from a symptom-count approach to a transdiagnostic view of psychopathology has the potential to facilitate early and accurate diagnosis, and can further enable personalized treatment strategies. However, the uptake of these technologies critically depends on the perceived relevance and engagement of end users. To this end, behavior theories and codesigning approaches offer opportunities to identify behavioral drivers and address barriers to uptake, while ensuring that products meet users’ needs and preferences. The agenda for innovators should also include building strong evidence-based cases for digital mental health, moving away from a one-size-fits-all well-being approach to embrace the development of comprehensive digital diagnostics and validated digital tools. In particular, innovators have the opportunity to make their clinical evaluations more insightful by assessing effectiveness and feasibility in the intended context of use. Finally, innovators should adhere to standardized evaluation frameworks introduced by regulators and health care providers, as this can facilitate transparency and guide health care professionals toward clinically safe and effective technologies. By laying these foundations, digital services can become integrated into clinical practice, thus facilitating deeper technology-enabled changes. %M 34643537 %R 10.2196/27507 %U https://www.jmir.org/2021/10/e27507 %U https://doi.org/10.2196/27507 %U http://www.ncbi.nlm.nih.gov/pubmed/34643537 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e29495 %T Text Messaging Versus Email Messaging to Support Patients With Major Depressive Disorder: Protocol for a Randomized Hybrid Type II Effectiveness-Implementation Trial %A Adu,Medard Kofi %A Shalaby,Reham %A Eboreime,Ejemai %A Sapara,Adegboyega %A Nkire,Nnamdi %A Chawla,Rajan %A Chima,Chidi %A Achor,Michael %A Osiogo,Felix %A Chue,Pierre %A Greenshaw,Andrew J %A Agyapong,Vincent Israel %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans' Memorial Lane, 8th Floor Abbie J. Lane Memorial Building QEII Health Sciences Centre, Halifax, NS, T6G 2B7, Canada, 1 7807144315, vincent.agyapong@nshealth.ca %K email messaging %K text messaging %K supportive %K major depressive disorder %K randomized trial %K mental health %K digital health %K mobile health %K mHealth %K patient care %K health policy %K decision-making %K health care resources %D 2021 %7 13.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) accounts for 40.5% of disability-adjusted life years caused by mental and substance use disorders. Barriers such as stigma and financial and physical access to care have been reported, highlighting the need for innovative, accessible, and cost-effective psychological interventions. The effectiveness of supportive SMS text messaging in alleviating depression symptoms has been proven in clinical trials, but this approach can only help those with mobile phones. Objective: This paper presents the protocol for a study that will aim to evaluate the feasibility, comparative effectiveness, and user satisfaction of daily supportive email messaging as an effective strategy compared to daily supportive text messaging as part of the treatment of patients with MDD. Methods: This trial will be carried out using a hybrid type II implementation-effectiveness design. This design evaluates the effectiveness of an implementation strategy or intervention, while also evaluating the implementation context associated with the intervention. Patients with MDD receiving usual care will be randomized to receive either daily supportive email messaging or daily supportive text messaging of the same content for 6 months. The Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the 5-item World Health Organization Well-Being Index will be used to evaluate the effectiveness of both strategies. The implementation evaluation will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, as well as the Consolidated Framework for Implementation Research. All outcome measures will be analyzed using descriptive and inferential statistics. Qualitative data will be analyzed using thematic analysis. Results: Data collection for this trial began in April 2021. We expect the study results to be available within 18 months of study commencement. The results will shed light on the feasibility, acceptability, and effectiveness of using automated emails as a strategy for delivering supportive messages to patients with MDD in comparison to text messaging. Conclusions: The outcome of this trial will have translational impact on routine patient care and access to mental health, as well as potentially support mental health policy decision-making for health care resource allocation. Trial Registration: ClinicalTrials.gov NCT04638231; https://clinicaltrials.gov/ct2/show/NCT04638231 International Registered Report Identifier (IRRID): DERR1-10.2196/29495 %M 34643541 %R 10.2196/29495 %U https://www.researchprotocols.org/2021/10/e29495 %U https://doi.org/10.2196/29495 %U http://www.ncbi.nlm.nih.gov/pubmed/34643541 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e31173 %T A Personalized, Interactive, Cognitive Behavioral Therapy–Based Digital Therapeutic (MODIA) for Adjunctive Treatment of Opioid Use Disorder: Development Study %A Meyer,Björn %A Utter,Geri-Lynn %A Hillman,Catherine %+ GAIA AG, Hans-Henny-Jahnn-Weg 53, Hamburg, 22085, Germany, 49 40351052 ext 31, bjoern.meyer@gaia-group.com %K MODIA %K opioid use disorder %K digital therapeutic %K cognitive behavioral therapy %K medication-assisted treatment %K Broca %D 2021 %7 8.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Opioid use disorder (OUD) is characterized by the inability to control opioid use despite attempts to stop use and negative consequences to oneself and others. The burden of opioid misuse and OUD is a national crisis in the United States with substantial public health, social, and economic implications. Although medication-assisted treatment (MAT) has demonstrated efficacy in the management of OUD, access to effective counseling and psychosocial support is a limiting factor and a significant problem for many patients and physicians. Digital therapeutics are an innovative class of interventions that help prevent, manage, or treat diseases by delivering therapy using software programs. These applications can circumvent barriers to uptake, improve treatment adherence, and enable broad delivery of evidence-based management strategies to meet service gaps. However, few digital therapeutics specifically targeting OUD are available, and additional options are needed. Objective: To this end, we describe the development of the novel digital therapeutic MODIA. Methods: MODIA was developed by an international, multidisciplinary team that aims to provide effective, accessible, and sustainable management for patients with OUD. Although MODIA is aligned with principles of cognitive behavioral therapy, it was not designed to present any 1 specific treatment and uses a broad range of evidence-based behavior change techniques drawn from cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and motivational interviewing. Results: MODIA uses proprietary software that dynamically tailors content to the users’ responses. The MODIA program comprises 24 modules or “chats” that patients are instructed to work through independently. Patient responses dictate subsequent content, creating a “simulated dialogue” experience between the patient and program. MODIA also includes brief motivational text messages that are sent regularly to prompt patients to use the program and help them transfer therapeutic techniques into their daily routines. Thus, MODIA offers individuals with OUD a custom-tailored, interactive digital psychotherapy intervention that maximizes the personal relevance and emotional impact of the interaction. Conclusions: As part of a clinician-supervised MAT program, MODIA will allow more patients to begin psychotherapy concurrently with opioid maintenance treatment. We expect access to MODIA will improve the OUD management experience and provide sustainable positive outcomes for patients. %M 34623309 %R 10.2196/31173 %U https://mental.jmir.org/2021/10/e31173 %U https://doi.org/10.2196/31173 %U http://www.ncbi.nlm.nih.gov/pubmed/34623309 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e29963 %T Attitudes About COVID-19 and Health (ATTACH): Online Survey and Mixed Methods Study %A Hood,Anna M %A Stotesbury,Hanne %A Murphy,Jennifer %A Kölbel,Melanie %A Slee,April %A Springall,Charlie %A Paradis,Matthew %A Corral-Frías,Nadia Saraí %A Reyes-Aguilar,Azalea %A Cuellar Barboza,Alfredo B %A Noser,Amy E %A Gomes,Stacey %A Mitchell,Monica %A Watkins,Sharon M %A Butsch Kovacic,Melinda %A Kirkham,Fenella J %A Crosby,Lori E %+ Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom, 44 02079052744, a.hood@ucl.ac.uk %K COVID-19 %K mental health %K international %K mitigation strategies %K deprivation %D 2021 %7 7.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Behavioral mitigation strategies to slow the spread of COVID-19 have resulted in sweeping lifestyle changes, with short- and long-term psychological, well-being, and quality of life implications. The Attitudes About COVID-19 and Health (ATTACH) study focuses on understanding attitudes and beliefs while considering the impact on mental and physical health and the influence of broader demographic and geographic factors on attitudes, beliefs, and mental health burden. Objective: In this assessment of our first wave of data collection, we provide baseline cohort description of the ATTACH study participants in the United Kingdom, the United States, and Mexico. Additionally, we assess responses to daily poll questions related to COVID-19 and conduct a cross-sectional analysis of baseline assessments collected in the UK between June 26 and October 31, 2020. Methods: The ATTACH study uses smartphone app technology and online survey data collection. Participants completed poll questions related to COVID-19 2 times daily and a monthly survey assessing mental health, social isolation, physical health, and quality of life. Poll question responses were graphed using 95% Clopper–Pearson (exact) tests with 95% CIs. Pearson correlations, hierarchical linear regression analyses, and generalized linear models assessed relationships, predictors of self-reported outcomes, and group differences, respectively. Results: By October 31, 2020, 1405, 80, and 90 participants had consented to participate in the UK, United States, and Mexico, respectively. Descriptive data for the UK daily poll questions indicated that participants generally followed social distancing measures, but worry and negative impacts on families increased as the pandemic progressed. Although participants generally reported feeling that the reasons for current measures had been made clear, there was low trust that the government was doing everything in its power to meet public needs. In the UK, 1282 participants also completed a monthly survey (94.99% [1326/1396] White, 72.22% [1014/1404] female, and 20.12% [277/1377] key or essential workers); 18.88% (242/1282) of UK participants reported a preexisting mental health disorder, 31.36% (402/1282) reported a preexisting chronic medical illness, and 35.11% (493/1404) were aged over 65; 57.72% (740/1282) of participants reported being more sedentary since the pandemic began, and 41.89% (537/1282) reported reduced access to medical care. Those with poorer mental health outcomes lived in more deprived neighborhoods, in larger households (Ps<.05), had more preexisting mental health disorders and medical conditions, and were younger than 65 years (all Ps<.001). Conclusions: Communities who have been exposed to additional harm during the COVID-19 pandemic were experiencing worse mental outcomes. Factors including having a medical condition, or living in a deprived neighborhood or larger household were associated with heightened risk. Future longitudinal studies should investigate the link between COVID-19 exposure, mental health, and sociodemographic and residential characteristics. %M 34357877 %R 10.2196/29963 %U https://mental.jmir.org/2021/10/e29963 %U https://doi.org/10.2196/29963 %U http://www.ncbi.nlm.nih.gov/pubmed/34357877 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e29412 %T Just-in-Time Adaptive Mechanisms of Popular Mobile Apps for Individuals With Depression: Systematic App Search and Literature Review %A Teepe,Gisbert W %A Da Fonseca,Ashish %A Kleim,Birgit %A Jacobson,Nicholas C %A Salamanca Sanabria,Alicia %A Tudor Car,Lorainne %A Fleisch,Elgar %A Kowatsch,Tobias %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 76 419 09 91, gteepe@ethz.ch %K depression %K digital mental health %K smartphone applications %K just-in-time adaptive interventions %K effectiveness %K mobile phone %D 2021 %7 28.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of smartphone apps that focus on the prevention, diagnosis, and treatment of depression is increasing. A promising approach to increase the effectiveness of the apps while reducing the individual’s burden is the use of just-in-time adaptive intervention (JITAI) mechanisms. JITAIs are designed to improve the effectiveness of the intervention and reduce the burden on the person using the intervention by providing the right type of support at the right time. The right type of support and the right time are determined by measuring the state of vulnerability and the state of receptivity, respectively. Objective: The aim of this study is to systematically assess the use of JITAI mechanisms in popular apps for individuals with depression. Methods: We systematically searched for apps addressing depression in the Apple App Store and Google Play Store, as well as in curated lists from the Anxiety and Depression Association of America, the United Kingdom National Health Service, and the American Psychological Association in August 2020. The relevant apps were ranked according to the number of reviews (Apple App Store) or downloads (Google Play Store). For each app, 2 authors separately reviewed all publications concerning the app found within scientific databases (PubMed, Cochrane Register of Controlled Trials, PsycINFO, Google Scholar, IEEE Xplore, Web of Science, ACM Portal, and Science Direct), publications cited on the app’s website, information on the app’s website, and the app itself. All types of measurements (eg, open questions, closed questions, and device analytics) found in the apps were recorded and reviewed. Results: None of the 28 reviewed apps used JITAI mechanisms to tailor content to situations, states, or individuals. Of the 28 apps, 3 (11%) did not use any measurements, 20 (71%) exclusively used self-reports that were insufficient to leverage the full potential of the JITAIs, and the 5 (18%) apps using self-reports and passive measurements used them as progress or task indicators only. Although 34% (23/68) of the reviewed publications investigated the effectiveness of the apps and 21% (14/68) investigated their efficacy, no publication mentioned or evaluated JITAI mechanisms. Conclusions: Promising JITAI mechanisms have not yet been translated into mainstream depression apps. Although the wide range of passive measurements available from smartphones were rarely used, self-reported outcomes were used by 71% (20/28) of the apps. However, in both cases, the measured outcomes were not used to tailor content and timing along a state of vulnerability or receptivity. Owing to this lack of tailoring to individual, state, or situation, we argue that the apps cannot be considered JITAIs. The lack of publications investigating whether JITAI mechanisms lead to an increase in the effectiveness or efficacy of the apps highlights the need for further research, especially in real-world apps. %M 34309569 %R 10.2196/29412 %U https://www.jmir.org/2021/9/e29412 %U https://doi.org/10.2196/29412 %U http://www.ncbi.nlm.nih.gov/pubmed/34309569 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e28538 %T Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study %A Silfee,Valerie %A Williams,Kelly %A Leber,Brett %A Kogan,Jane %A Nikolajski,Cara %A Szigethy,Eva %A Serio,Catherine %+ UPMC Health Plan, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA, 15219, United States, 1 4124549008, silfeev@upmc.edu %K digital health %K mHealth %K implementation %K cognitive behavioral therapy %K anxiety %K depression %K smartphone %K mobile phone %D 2021 %7 28.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. Objective: This study assessed providers’ views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. Methods: Participating providers included BH and physical health (PH) providers from a women’s health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. Results: A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. Conclusions: Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow. %M 34529583 %R 10.2196/28538 %U https://formative.jmir.org/2021/9/e28538 %U https://doi.org/10.2196/28538 %U http://www.ncbi.nlm.nih.gov/pubmed/34529583 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e20892 %T Effectiveness of Using Mobile Technology to Improve Cognitive and Social Skills Among Individuals With Autism Spectrum Disorder: Systematic Literature Review %A Leung,Phil Wai Shun %A Li,Shirley Xin %A Tsang,Carmen Sze Oi %A Chow,Bellavista Long Ching %A Wong,William Chi Wai %+ Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China (Hong Kong), 852 25185657, wongwcw@hku.hk %K autism spectrum disorder %K mobile devices %K systematic review %K randomized controlled trial %K social skills %K cognitive skills %D 2021 %7 28.9.2021 %9 Review %J JMIR Ment Health %G English %X Background: Mobile technology has become a necessity in the lives of people in many countries. Its characteristics and advantages also make it a potential medium of intervention for people with autism spectrum disorder (ASD). Objective: The objective of this review was to evaluate previous evidence, obtained in randomized controlled trials (RCTs), on the effectiveness of using mobile devices as the medium of intervention targeting social and cognitive skills among individuals with ASD. Methods: Literature search was conducted on electronic databases including Medline, PsycInfo, PsycArticles, Education Resources Information Centre, and Social Science Citation Index. Only RCTs published in English and after year 2000 were included for this review. Data extraction was carried out by 2 independent reviewers using constant comparative methods. Results: Totally 10 RCTs were identified. Most of the findings indicated that mobile devices could be an effective medium of intervention for people with ASD, among which 6 indicated significant intervention effects and 2 showed mixed findings. Effective intervention was more likely to be achieved in the studies that recruited older participants (aged over 9 years), targeting practical skills that could be readily applied in real life, or using pictures or materials that were highly relevant in daily life in the apps or mobile devices. Furthermore, the use of mobile devices was also reported to promote participation in the intervention among individuals with ASD. Conclusions: The results suggested that mobile devices could be a promising means for the delivery of interventions targeting people with ASD. Although including a small number of studies was a limitation of this review, the results provided useful implications for designing effective mobile technology–assisted interventions for the ASD population in future studies. %M 34581681 %R 10.2196/20892 %U https://mental.jmir.org/2021/9/e20892 %U https://doi.org/10.2196/20892 %U http://www.ncbi.nlm.nih.gov/pubmed/34581681 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e29681 %T Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review %A Baghaei,Nilufar %A Chitale,Vibhav %A Hlasnik,Andrej %A Stemmet,Lehan %A Liang,Hai-Ning %A Porter,Richard %+ Department of Natural and Computational Sciences, Massey University, Oteha Rohe Albany Highway, Albany, Auckland, 0632, New Zealand, 64 800 627 739, n.baghaei@massey.ac.nz %K virtual reality %K mental health %K depression %K anxiety %K CBT %D 2021 %7 23.9.2021 %9 Review %J JMIR Ment Health %G English %X Background: Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression. Objective: This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety. Methods: We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum. Results: Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56%) studies, whereas in the remaining 4 (44%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression. Conclusions: Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression. %M 34554097 %R 10.2196/29681 %U https://mental.jmir.org/2021/9/e29681 %U https://doi.org/10.2196/29681 %U http://www.ncbi.nlm.nih.gov/pubmed/34554097 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28066 %T The Associations Between Mental Health Problems and Attitudes Toward Web-Based Health and Social Care Services: Evidence From a Finnish Population-Based Study %A Rantanen,Teemu %A Gluschkoff,Kia %A Silvennoinen,Piia %A Heponiemi,Tarja %+ Unit of Digital Education and Master Programmes, Laurea University of Applied Sciences, Ratatie 22, Vantaa, 01300, Finland, 358 408306149, teemu.rantanen@laurea.fi %K digital inclusion %K digital exclusion %K digital divide %K mental health %K attitudes %D 2021 %7 21.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The significance of web-based health and social care services has been highlighted in recent years. There is a risk that the digitalization of public services will reinforce the digital and social exclusion of vulnerable groups, such as individuals with mental health problems. Objective: This study aims to examine the associations between mental health problems and attitudes toward web-based health and social care services in the general population. The attitudes measured include lack of interest, perceived need for face-to-face encounters, and concern for safety. The study also evaluates whether sociodemographic characteristics (age, gender, education level, and poverty) modify these associations. Methods: Cross-sectional population-based data were collected from 4495 Finnish adults in 2017. Linear regression was used to examine the main effects and interactions of poor mental health and sociodemographic characteristics on attitudes toward web-based health and social care services. Results: The results show that mental health was associated with attitudes toward web-based health and social care services. Individuals with mental health problems were especially concerned about the safety of web-based services. Poor mental health was independently associated with negative attitudes toward web-based services over the effects of sociodemographic factors. Some of the associations between poor mental health and negative attitudes toward web-based services were stronger among older people and men. With regard to sociodemographic characteristics, particularly higher age, low education, and poverty were associated with negative attitudes toward web-based health and social care services. Conclusions: Poor mental health is associated with negative attitudes toward web-based health and social care services and thus indirectly with exclusion. It seems that being older and being male both reinforce the link between poor mental health and exclusion. In supporting the digital inclusion of people with mental health problems, attention should be paid to guidance and counseling, reliability, and the user-friendliness of web-based services as well as to the prevention of poverty. In addition, it is essential to see web-based services as complementary to, and not a substitute for, face-to-face services. %M 34546184 %R 10.2196/28066 %U https://www.jmir.org/2021/9/e28066 %U https://doi.org/10.2196/28066 %U http://www.ncbi.nlm.nih.gov/pubmed/34546184 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e27570 %T Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study %A Anton,Margaret T %A Greenberger,Heidi Mochari %A Andreopoulos,Evie %A Pande,Reena L %+ AbleTo, Inc, 320 W, 37th Street, 5th floor, New York, NY, 10018, United States, 1 (347) 926 5527, margaret.anton@ableto.com %K digital mental health %K mHealth %K iCBT %K coaching %K depression %K generalized anxiety %K social anxiety %K mobile phone %D 2021 %7 21.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context. Objective: The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching. Methods: In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated. Results: Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (β=−1.2; P<.001), generalized anxiety (β=−1.1; P<.001), and social anxiety (β=−2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=−2.1; P=.03). Conclusions: This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program. %M 34546170 %R 10.2196/27570 %U https://formative.jmir.org/2021/9/e27570 %U https://doi.org/10.2196/27570 %U http://www.ncbi.nlm.nih.gov/pubmed/34546170 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 9 %P e26603 %T Psychoeducational Social Anxiety Mobile Apps: Systematic Search in App Stores, Content Analysis, and Evaluation %A Hammond,Trent Ernest %A Lampe,Lisa %A Campbell,Andrew %A Perisic,Steve %A Brakoulias,Vlasios %+ Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, 62 Derby Street, Kingswood, New South Wales, 2747, Australia, 61 431931448, trent.hammond@sydney.edu.au %K anxiety %K app %K cell phone %K mobile app %K mobile phone %K SAD %K smartphone %K social anxiety %K social phobia %K tablet %D 2021 %7 21.9.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The wide use of mobile health apps has created new possibilities in social anxiety education and treatment. However, the content and quality of social anxiety apps have been quite unclear, which makes it difficult for people to choose appropriate apps to use on smartphones and tablets. Objective: This study aims to identify the psychoeducational social anxiety apps in the two most popular Australian app stores, report the descriptive and technical information provided in apps exclusively for social anxiety, evaluate app quality, and identify whether any apps would be appropriate for people with social anxiety or others who know someone with social anxiety. Methods: This systematic stepwise app search was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards and entailed searching for, identifying, and selecting apps in the Australian Apple App and Google Play Stores; downloading, using, and reviewing the identified apps; reporting technical and descriptive information in the app stores, an online app warehouse, and individual apps; evaluating app quality; and deciding whether to recommend the use of the apps. Results: In the app stores, 1043 apps were identified that contained the keywords social anxiety, social phobia, or shyness in their names or descriptions. Of these, 1.15% (12/1043) were evaluated (3 iOS apps and 9 Android apps). At the time of evaluation, the apps were compatible with smartphones and tablet devices; 9 were free to download from the app stores, whereas 3 were priced between US $2.95 (Aus $3.99) and US $3.69 (Aus $5.00). Among the evaluated apps, 3 were intended for treatment purposes, 3 provided supportive resources, 1 was intended for self-assessment, and the remaining 5 were designed for multiple purposes. At the time of downloading, app store ratings were available for 5 apps. The overall app quality was acceptable according to the Mobile App Rating Scale (MARS). On the basis of the MARS app quality rating subscale (sections A-D), the apps functioned well in performance, ease of use, navigation, and gestural design. However, app quality was less favorable when rated using the MARS app subjective quality subscale (section E). Conclusions: The psychoeducational social anxiety apps evaluated in our study may benefit people with social anxiety, health professionals, and other community members. However, given that none of the apps appeared to contain empirical information or were shown to clinically reduce social anxiety (or aid in managing social anxiety), we cannot recommend their use. App accessibility could be improved by developing apps that are free and available for a wider range of operating systems, both between and within countries and regions. Information communication and technology professionals should collaborate with academics, mental health clinicians, and end users (ie, co-design) to develop current, evidence-based apps. %M 34546179 %R 10.2196/26603 %U https://mhealth.jmir.org/2021/9/e26603 %U https://doi.org/10.2196/26603 %U http://www.ncbi.nlm.nih.gov/pubmed/34546179 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28369 %T Mental Health Screening in General Practices as a Means for Enhancing Uptake of Digital Mental Health Interventions: Observational Cohort Study %A Whitton,Alexis E %A Hardy,Rebecca %A Cope,Kate %A Gieng,Chilin %A Gow,Leanne %A MacKinnon,Andrew %A Gale,Nyree %A O'Moore,Kathleen %A Anderson,Josephine %A Proudfoot,Judith %A Cockayne,Nicole %A O'Dea,Bridianne %A Christensen,Helen %A Newby,Jill Maree %+ Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 293828507, a.whitton@unsw.edu.au %K depression %K anxiety %K general practice %K screening %K digital mental health %D 2021 %7 16.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking. Objective: This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (StepCare) for improving the identification of anxiety and depression in general practice and, subsequently, uptake of digital mental health interventions. Methods: StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening. Results: Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it. Conclusions: Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits. %M 34528896 %R 10.2196/28369 %U https://www.jmir.org/2021/9/e28369 %U https://doi.org/10.2196/28369 %U http://www.ncbi.nlm.nih.gov/pubmed/34528896 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e26317 %T Privacy Practices of Health Information Technologies: Privacy Policy Risk Assessment Study and Proposed Guidelines %A LaMonica,Haley M %A Roberts,Anna E %A Lee,Grace Yeeun %A Davenport,Tracey A %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 88 Mallett Street, Camperdown, 2050, Australia, 61 0426955658, haley.lamonica@sydney.edu.au %K privacy %K mental health %K technology %K digital tools %K smartphone %K apps %D 2021 %7 16.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Along with the proliferation of health information technologies (HITs), there is a growing need to understand the potential privacy risks associated with using such tools. Although privacy policies are designed to inform consumers, such policies have consistently been found to be confusing and lack transparency. Objective: This study aims to present consumer preferences for accessing privacy information; develop and apply a privacy policy risk assessment tool to assess whether existing HITs meet the recommended privacy policy standards; and propose guidelines to assist health professionals and service providers with understanding the privacy risks associated with HITs, so that they can confidently promote their safe use as a part of care. Methods: In phase 1, participatory design workshops were conducted with young people who were attending a participating headspace center, their supportive others, and health professionals and service providers from the centers. The findings were knowledge translated to determine participant preferences for the presentation and availability of privacy information and the functionality required to support its delivery. Phase 2 included the development of the 23-item privacy policy risk assessment tool, which incorporated material from international privacy literature and standards. This tool was then used to assess the privacy policies of 34 apps and e-tools. In phase 3, privacy guidelines, which were derived from learnings from a collaborative consultation process with key stakeholders, were developed to assist health professionals and service providers with understanding the privacy risks associated with incorporating HITs as a part of clinical care. Results: When considering the use of HITs, the participatory design workshop participants indicated that they wanted privacy information to be easily accessible, transparent, and user-friendly to enable them to clearly understand what personal and health information will be collected and how these data will be shared and stored. The privacy policy review revealed consistently poor readability and transparency, which limited the utility of these documents as a source of information. Therefore, to enable informed consent, the privacy guidelines provided ensure that health professionals and consumers are fully aware of the potential for privacy risks in using HITs to support health and well-being. Conclusions: A lack of transparency in privacy policies has the potential to undermine consumers’ ability to trust that the necessary measures are in place to secure and protect the privacy of their personal and health information, thus precluding their willingness to engage with HITs. The application of the privacy guidelines will improve the confidence of health professionals and service providers in the privacy of consumer data, thus enabling them to recommend HITs to provide or support care. %M 34528895 %R 10.2196/26317 %U https://www.jmir.org/2021/9/e26317 %U https://doi.org/10.2196/26317 %U http://www.ncbi.nlm.nih.gov/pubmed/34528895 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e27745 %T Understanding Mental Health App Use Among Community College Students: Web-Based Survey Study %A Borghouts,Judith %A Eikey,Elizabeth V %A Mark,Gloria %A De Leon,Cinthia %A Schueller,Stephen M %A Schneider,Margaret %A Stadnick,Nicole %A Zheng,Kai %A Mukamel,Dana B %A Sorkin,Dara H %+ Department of Medicine, University of California, Irvine, 100 Theory, Irvine, CA, 92617, United States, 1 9498240246, jborghou@uci.edu %K mHealth %K mental health %K community college %K students %K structural equation modeling %K mobile apps %K services %K mental health services %K stress %K privacy %D 2021 %7 14.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health concerns are a significant issue among community college students, who often have less access to resources than traditional university college students. Mobile apps have the potential to increase access to mental health care, but there has been little research investigating factors associated with mental health app use within the community college population. Objective: This study aimed to understand facilitators of and barriers to mental health app use among community college students. Methods: A web-based survey was administered to a randomly selected sample of 500 community college students from April 16 to June 30, 2020. Structural equation modeling was used to test the relationships between the use of mental health apps, perceived stress, perceived need to seek help for mental health concerns, perceived stigma, past use of professional mental health services, privacy concerns, and social influence of other people in using mental health apps. Results: Of the 500 participants, 106 (21.2%) reported use of mental health apps. Perceived stress, perceived need to seek help, past use of professional services, and social influence were positively associated with mental health app use. Furthermore, the effect of stress was mediated by a perceived need to seek help. Privacy concerns were negatively associated with mental health app use. Stigma, age, and gender did not have a statistically significant effect. Conclusions: These findings can inform development of new digital interventions and appropriate outreach strategies to engage community college students in using mental health apps. %M 34519668 %R 10.2196/27745 %U https://www.jmir.org/2021/9/e27745 %U https://doi.org/10.2196/27745 %U http://www.ncbi.nlm.nih.gov/pubmed/34519668 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e30292 %T Designing Videos With and for Adults With ADHD for an Online Intervention: Participatory Design Study and Thematic Analysis of Evaluation %A Flobak,Eivind %A Nordby,Emilie Sektnan %A Guribye,Frode %A Kenter,Robin %A Nordgreen,Tine %A Lundervold,Astri J %+ Department of Information Science and Media Studies, University of Bergen, Faculty of Social Sciences, 5th Fl, Lauritz Meltzers House, Fosswinckels gate 6, Bergen, 5007, Norway, 47 41146623, eivind.flobak@uib.no %K participatory design %K ADHD %K online intervention %K video %K therapeutic content %K stigma %K attention deficit hyperactivity disorder %K design %K participatory %K intervention %K experience %K mental health %D 2021 %7 14.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adults with attention deficit hyperactivity disorder (ADHD) represent a heterogeneous group with both strengths and difficulties associated with the diagnosis. An online intervention attuned to their needs may improve their everyday functioning. When designing online interventions, it is important to adapt the therapeutic content to the values and needs of the target group. Objective: This paper describes and evaluates a participatory process used to produce content for an online intervention for adults with ADHD by producing video vignettes clarifying core training principles grounded in the participants' everyday experiences. Methods: We report on the qualitative data from 2 research phases: the design and evaluation of video vignettes for an online intervention. In the first phase, 12 adults with ADHD, 2 clinicians, and 2 research assistants participated in the production of video vignettes for the online intervention. In the second phase, participants (n=109) gave feedback on the videos as part of a clinical trial of the intervention. A subgroup (n=7) was interviewed in-depth regarding their experiences with the videos. The qualitative data were analyzed using thematic analysis. Results: In the first phase, the participants with ADHD contributed with experiences from challenging everyday situations. In the process, we navigated between therapeutic principles and the participants' experiential perspectives to create content relevant and consistent with the target group's values and experiences. In the second phase, we identified 3 themes related to the participants' experiences and interpretation of the video vignettes: (1) recognition of ADHD-related challenges, (2) connection with the characters and the situations, and (3) video protagonists as companions and role models for change. Conclusions: A participatory design process for designing online mental health interventions can be used to probe and balance between the therapeutic principles defined by clinicians and the participants’ experiences with mental health issues in the production of therapeutic content. In our study, the inclusion of video vignettes in an online intervention enabled a contextualized and relevant presentation of everyday experiences and psychosocial factors in the life of an adult with ADHD. Trial Registration: ClinicalTrials.gov NCT04511169; https://clinicaltrials.gov/ct2/show/NCT04511169 %M 34519666 %R 10.2196/30292 %U https://mental.jmir.org/2021/9/e30292 %U https://doi.org/10.2196/30292 %U http://www.ncbi.nlm.nih.gov/pubmed/34519666 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e22844 %T Evaluation of Changes in Depression, Anxiety, and Social Anxiety Using Smartphone Sensor Features: Longitudinal Cohort Study %A Meyerhoff,Jonah %A Liu,Tony %A Kording,Konrad P %A Ungar,Lyle H %A Kaiser,Susan M %A Karr,Chris J %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, 750 N Lake Shore Dr, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K mHealth %K personal sensing %K digital phenotyping %K passive sensing %K ecological momentary assessment %K depression %K anxiety %K digital biomarkers %K digital phenotyping %K mental health assessment %K mobile device %K mobile phone %K internet technology %K psychiatric disorders %K mobile phone %D 2021 %7 3.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The assessment of behaviors related to mental health typically relies on self-report data. Networked sensors embedded in smartphones can measure some behaviors objectively and continuously, with no ongoing effort. Objective: This study aims to evaluate whether changes in phone sensor–derived behavioral features were associated with subsequent changes in mental health symptoms. Methods: This longitudinal cohort study examined continuously collected phone sensor data and symptom severity data, collected every 3 weeks, over 16 weeks. The participants were recruited through national research registries. Primary outcomes included depression (8-item Patient Health Questionnaire), generalized anxiety (Generalized Anxiety Disorder 7-item scale), and social anxiety (Social Phobia Inventory) severity. Participants were adults who owned Android smartphones. Participants clustered into 4 groups: multiple comorbidities, depression and generalized anxiety, depression and social anxiety, and minimal symptoms. Results: A total of 282 participants were aged 19-69 years (mean 38.9, SD 11.9 years), and the majority were female (223/282, 79.1%) and White participants (226/282, 80.1%). Among the multiple comorbidities group, depression changes were preceded by changes in GPS features (Time: r=−0.23, P=.02; Locations: r=−0.36, P<.001), exercise duration (r=0.39; P=.03) and use of active apps (r=−0.31; P<.001). Among the depression and anxiety groups, changes in depression were preceded by changes in GPS features for Locations (r=−0.20; P=.03) and Transitions (r=−0.21; P=.03). Depression changes were not related to subsequent sensor-derived features. The minimal symptoms group showed no significant relationships. There were no associations between sensor-based features and anxiety and minimal associations between sensor-based features and social anxiety. Conclusions: Changes in sensor-derived behavioral features are associated with subsequent depression changes, but not vice versa, suggesting a directional relationship in which changes in sensed behaviors are associated with subsequent changes in symptoms. %M 34477562 %R 10.2196/22844 %U https://www.jmir.org/2021/9/e22844 %U https://doi.org/10.2196/22844 %U http://www.ncbi.nlm.nih.gov/pubmed/34477562 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e28075 %T Scoping the Need for a Tailored mHealth App to Improve Health and Well-being Behavioral Transformation in the Police: Exploring the Views of UK Police Workers via Web-Based Surveys and Client Meetings %A Swanston,Emma %A Pulman,Andy %A Dogan,Huseyin %A Murphy,Jane %A Bitters,Fiona %+ Faculty of Science and Technology, Bournemouth University, Poole House, Talbot Campus,, Fern Barrow, Poole, BH12 5BB, United Kingdom, 44 1202 961047, apulman@bournemouth.ac.uk %K nutrition %K food %K behavior change %K mobile health %K police %K lifestyle management %K well-being %K mobile phone %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Police officers often work long, unsocial hours in a highly pressurized environment and may experience difficulties in managing their health and well-being. Their jobs can be highly stressful and feature unusual working hours and multiple shift patterns. When considering the policing environment of 2021, many roles that were previously the domain of warranted officers are now being carried out by nonwarranted police staff equivalents. These police staff roles are relatively new to policing but put staff under some of the same stresses as police officers. A UK police force requested help to investigate technologies that could be used to improve health and well-being and research how these technologies could be used to measure and track health behavior change. Objective: Historical research studies need to be appraised in light of this new policing environment, and new research also needs to include this shift in dynamics when considering aspects of policing, including their health and well-being. This study explores police officer and staff attitudes toward and their use of existing health-related technology, highlights existing practices, and gathers views about how technology could be used more effectively. Methods: A web-based survey was completed by police officers and staff (N=213) during the initial period of the UK lockdown in 2020. The survey was designed to find the solutions that participants used outside of those supplied by their employer, identify issues or problems, and find what they would like a hypothetical app to focus on. Additional requirements data were captured through client meetings, including discussions concerning previously attempted solutions and those currently in place. Thematic analysis was undertaken to identify the key themes. Results: Attitudes toward and uses of existing health-related technology were captured, and existing practices were highlighted. Participants identified a need for an app to consider that a user was on shift—an important point, as many issues and problems with elements of their health and well-being involved shift work. Data also highlighted that a multifunctional tool would be more beneficial to participants than focusing on just 1 element. The key features and four domains were identified for app coverage. The prioritized order of importance of the four domains was activity, food and diet, sleep, and fluid intake. Conclusions: For police officers and staff, research data suggest that there is a previously unidentified requirement for a mobile app that could provide an easily accessible platform for them to use, regardless of the current location; one that could provide guidelines on diet, lifestyle habits, and health behavior to help the user make informed decisions to assist in personalized behavior change. Notably, one which is multifunctional and which also aligns effectively with the irregular shift patterns of its users. %M 34463625 %R 10.2196/28075 %U https://formative.jmir.org/2021/8/e28075 %U https://doi.org/10.2196/28075 %U http://www.ncbi.nlm.nih.gov/pubmed/34463625 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e27379 %T Integration of Digital Tools Into Community Mental Health Care Settings That Serve Young People: Focus Group Study %A Knapp,Ashley A %A Cohen,Katherine %A Nicholas,Jennifer %A Mohr,David C %A Carlo,Andrew D %A Skerl,Joshua J %A Lattie,Emily G %+ Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, Chicago, IL, 60611, United States, 1 312 503 3751, Ashley.knapp@northwestern.edu %K digital mental health %K treatment %K young people %K children %K adolescents %K community mental health care %K mobile phone %D 2021 %7 19.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital mental health tools have substantial potential to be easily integrated into people’s lives and fundamentally impact public health. Such tools can extend the reach and maximize the impact of mental health interventions. Before implementing digital tools in new settings, it is critical to understand what is important to organizations and individuals who will implement and use these tools. Given that young people are highly familiar with technology and many mental health concerns emerge in childhood and adolescence, it is especially crucial to understand how digital tools can be integrated into settings that serve young people. Objective: This study aims to learn about considerations and perspectives of community behavioral health care providers on incorporating digital tools into their clinical care for children and adolescents. Methods: Data were analyzed from 5 focus groups conducted with clinicians (n=37) who work with young people at a large community service organization in the United States. This organization provides care to more than 27,000 people annually, most of whom are of low socioeconomic status. The transcripts were coded using thematic analysis. Results: Clinicians first provided insight into the digital tools they were currently using in their treatment sessions with young people, such as web-based videos and mood-tracking apps. They explained that their main goals in using these tools were to help young people build skills, facilitate learning, and monitor symptoms. Benefits were expressed, such as engagement of adolescents in treatment, along with potential challenges (eg, accessibility and limited content) and developmental considerations (eg, digital devices getting taken away as punishment). Clinicians discussed their desire for a centralized digital platform that securely connects the clinician, young person, and caregivers. Finally, they offered several considerations for integrating digital tools into mental health care, such as setting up expectations with clients and the importance of human support. Conclusions: Young people have unique considerations related to complex accessibility patterns and technology expectations that may not be observed when adults are the intended users of mental health technologies. Therefore, these findings provide critical insights to inform the development of future tools, specifically regarding connectivity, conditional restraints (eg, devices taken away as punishment and school restrictions), expectations of users from different generations, and the blended nature in which digital tools can support young people. %M 34420928 %R 10.2196/27379 %U https://mental.jmir.org/2021/8/e27379 %U https://doi.org/10.2196/27379 %U http://www.ncbi.nlm.nih.gov/pubmed/34420928 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e24393 %T Development of a Mobile App to Support Self-management of Anxiety and Depression in African American Women: Usability Study %A McCall,Terika %A Ali,Muhammad Osama %A Yu,Fei %A Fontelo,Paul %A Khairat,Saif %+ Center for Medical Informatics, Yale School of Medicine, 300 George Street, Suite 501, New Haven, CT, 06511, United States, 1 203 737 5379, terika.mccall@yale.edu %K African Americans %K women %K mental health %K anxiety %K depression %K telemedicine %K mHealth %K mobile applications %K digital health %K user-centered design %K mobile phone %D 2021 %7 17.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Anxiety and depressive disorders are the most common mental health conditions among African American women. Despite the need for mental health care, African American women significantly underuse mental health services. Previous mobile health studies revealed significant improvements in anxiety or depressive symptoms after intervention. The use of mobile apps offers the potential to eliminate or mitigate barriers for African American women who are seeking access to mental health services and resources. Objective: This study aims to evaluate the usability of the prototype of an app that is designed for supporting the self-management of anxiety and depression in African American women. Methods: Individual usability testing sessions were conducted with 15 participants in Chapel Hill, North Carolina. Cognitive walkthrough and think-aloud protocols were used to evaluate the user interface. Eye-tracking glasses were used to record participants’ visual focus and gaze path as they performed the tasks. The Questionnaire for User Interface Satisfaction was administered after each session to assess the participants’ acceptance of the app. Results: Participants rated the usability of the prototype positively and provided recommendations for improvement. The average of the mean scores for usability assessments (ie, overall reactions to the software, screen, terminology and app information, learning, and app capabilities) ranged from 7.2 to 8.8 on a scale of 0-9 (low to high rating) for user tasks. Most participants were able to complete each task with limited or no assistance. Design recommendations included improving the user interface by adding graphics and color, adding a tutorial for first-time users, curating a list of Black women therapists within the app, adding details about tracking anxiety and depression in the checkup graphs, informing users that they can use the talk-to-text feature for journal entries to reduce burden, relabeling the mental health information icon, monitoring for crisis support, and improving clickthrough sequencing. Conclusions: This study provides a better understanding of user experience with an app tailored to support the management of anxiety and depression for African American women, which is an underserved group. As African American women have high rates of smartphone ownership, there is a great opportunity to use mobile technology to provide access to needed mental health services and resources. Future work will include incorporating feedback from usability testing and focus group sessions to refine and develop the app further. The updated app will undergo iterative usability testing before launching the pilot study to evaluate the feasibility and acceptability of the prototype. %M 34133313 %R 10.2196/24393 %U https://formative.jmir.org/2021/8/e24393 %U https://doi.org/10.2196/24393 %U http://www.ncbi.nlm.nih.gov/pubmed/34133313 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e28918 %T Automated Screening for Social Anxiety, Generalized Anxiety, and Depression From Objective Smartphone-Collected Data: Cross-sectional Study %A Di Matteo,Daniel %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Mason,Geneva %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, 10 King's College Road, Toronto, ON, Canada, 1 416 978 6992, daniel.dimatteo@utoronto.ca %K mobile sensing %K passive EMA %K passive sensing %K psychiatric assessment %K mood and anxiety disorders %K mobile apps %K mhealth %K mobile phone %K digital health %K digital phenotyping %D 2021 %7 13.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The lack of access to mental health care could be addressed, in part, through the development of automated screening technologies for detecting the most common mental health disorders without the direct involvement of clinicians. Objective smartphone-collected data may contain sufficient information about individuals’ behaviors to infer their mental states and therefore screen for anxiety disorders and depression. Objective: The objective of this study is to compare how a single set of recognized and novel features, extracted from smartphone-collected data, can be used for predicting generalized anxiety disorder (GAD), social anxiety disorder (SAD), and depression. Methods: An Android app was designed, together with a centralized server system, to collect periodic measurements of objective smartphone data. The types of data included samples of ambient audio, GPS location, screen state, and light sensor data. Subjects were recruited into a 2-week observational study in which the app was run on their personal smartphones. The subjects also completed self-report severity measures of SAD, GAD, and depression. The participants were 112 Canadian adults from a nonclinical population. High-level features were extracted from the data of 84 participants, and predictive models of SAD, GAD, and depression were built and evaluated. Results: Models of SAD and depression achieved a significantly greater screening accuracy than uninformative models (area under the receiver operating characteristic means of 0.64, SD 0.13 and 0.72, SD 0.12, respectively), whereas models of GAD failed to be predictive. Investigation of the model coefficients revealed key features that were predictive of SAD and depression. Conclusions: We demonstrate the ability of a common set of features to act as predictors in the models of both SAD and depression. This suggests that the types of behaviors that can be inferred from smartphone-collected data are broad indicators of mental health, which can be used to study, assess, and track psychopathology simultaneously across multiple disorders and diagnostic boundaries. %M 34397386 %R 10.2196/28918 %U https://www.jmir.org/2021/8/e28918 %U https://doi.org/10.2196/28918 %U http://www.ncbi.nlm.nih.gov/pubmed/34397386 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e29368 %T Understanding People’s Use of and Perspectives on Mood-Tracking Apps: Interview Study %A Schueller,Stephen M %A Neary,Martha %A Lai,Jocelyn %A Epstein,Daniel A %+ Department of Psychological Science, University of California, Irvine, 4201 Social and Behavioral Sciences Gateway, Irvine, CA, 92697, United States, 1 9498243850, s.schueller@uci.edu %K mental health %K mobile apps %K mHealth %K emotions %K affect %K self-tracking %D 2021 %7 11.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Supporting mental health and wellness is of increasing interest due to a growing recognition of the prevalence and burden of mental health issues. Mood is a central aspect of mental health, and several technologies, especially mobile apps, have helped people track and understand it. However, despite formative work on and dissemination of mood-tracking apps, it is not well understood how mood-tracking apps used in real-world contexts might benefit people and what people hope to gain from them. Objective: To address this gap, the purpose of this study was to understand motivations for and experiences in using mood-tracking apps from people who used them in real-world contexts. Methods: We interviewed 22 participants who had used mood-tracking apps using a semistructured interview and card sorting task. The interview focused on their experiences using a mood-tracking app. We then conducted a card sorting task using screenshots of various data entry and data review features from mood-tracking apps. We used thematic analysis to identify themes around why people use mood-tracking apps, what they found useful about them, and where people felt these apps fell short. Results: Users of mood-tracking apps were primarily motivated by negative life events or shifts in their own mental health that prompted them to engage in tracking and improve their situation. In general, participants felt that using a mood-tracking app facilitated self-awareness and helped them to look back on a previous emotion or mood experience to understand what was happening. Interestingly, some users reported less inclination to document their negative mood states and preferred to document their positive moods. There was a range of preferences for personalization and simplicity of tracking. Overall, users also liked features in which their previous tracked emotions and moods were visualized in figures or calendar form to understand trends. One gap in available mood-tracking apps was the lack of app-facilitated recommendations or suggestions for how to interpret their own data or improve their mood. Conclusions: Although people find various features of mood-tracking apps helpful, the way people use mood-tracking apps, such as avoiding entering negative moods, tracking infrequently, or wanting support to understand or change their moods, demonstrate opportunities for improvement. Understanding why and how people are using current technologies can provide insights to guide future designs and implementations. %M 34383678 %R 10.2196/29368 %U https://mental.jmir.org/2021/8/e29368 %U https://doi.org/10.2196/29368 %U http://www.ncbi.nlm.nih.gov/pubmed/34383678 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e27589 %T Toward a Mobile Platform for Real-world Digital Measurement of Depression: User-Centered Design, Data Quality, and Behavioral and Clinical Modeling %A Nickels,Stefanie %A Edwards,Matthew D %A Poole,Sarah F %A Winter,Dale %A Gronsbell,Jessica %A Rozenkrants,Bella %A Miller,David P %A Fleck,Mathias %A McLean,Alan %A Peterson,Bret %A Chen,Yuanwei %A Hwang,Alan %A Rust-Smith,David %A Brant,Arthur %A Campbell,Andrew %A Chen,Chen %A Walter,Collin %A Arean,Patricia A %A Hsin,Honor %A Myers,Lance J %A Marks Jr,William J %A Mega,Jessica L %A Schlosser,Danielle A %A Conrad,Andrew J %A Califf,Robert M %A Fromer,Menachem %+ Verily Life Sciences, 269 E Grand Ave, South San Francisco, CA, 94080, United States, 1 833 391 8633, stefnickels@verily.com %K mental health %K mobile sensing %K mobile phone %K mHealth %K depression %K location %K GPS %K app usage %K voice diaries %K adherence %K engagement %K mobility %K sleep %K physical activity %K digital phenotyping %K user-centered design %D 2021 %7 10.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although effective mental health treatments exist, the ability to match individuals to optimal treatments is poor, and timely assessment of response is difficult. One reason for these challenges is the lack of objective measurement of psychiatric symptoms. Sensors and active tasks recorded by smartphones provide a low-burden, low-cost, and scalable way to capture real-world data from patients that could augment clinical decision-making and move the field of mental health closer to measurement-based care. Objective: This study tests the feasibility of a fully remote study on individuals with self-reported depression using an Android-based smartphone app to collect subjective and objective measures associated with depression severity. The goals of this pilot study are to develop an engaging user interface for high task adherence through user-centered design; test the quality of collected data from passive sensors; start building clinically relevant behavioral measures (features) from passive sensors and active inputs; and preliminarily explore connections between these features and depression severity. Methods: A total of 600 participants were asked to download the study app to join this fully remote, observational 12-week study. The app passively collected 20 sensor data streams (eg, ambient audio level, location, and inertial measurement units), and participants were asked to complete daily survey tasks, weekly voice diaries, and the clinically validated Patient Health Questionnaire (PHQ-9) self-survey. Pairwise correlations between derived behavioral features (eg, weekly minutes spent at home) and PHQ-9 were computed. Using these behavioral features, we also constructed an elastic net penalized multivariate logistic regression model predicting depressed versus nondepressed PHQ-9 scores (ie, dichotomized PHQ-9). Results: A total of 415 individuals logged into the app. Over the course of the 12-week study, these participants completed 83.35% (4151/4980) of the PHQ-9s. Applying data sufficiency rules for minimally necessary daily and weekly data resulted in 3779 participant-weeks of data across 384 participants. Using a subset of 34 behavioral features, we found that 11 features showed a significant (P<.001 Benjamini-Hochberg adjusted) Spearman correlation with weekly PHQ-9, including voice diary–derived word sentiment and ambient audio levels. Restricting the data to those cases in which all 34 behavioral features were present, we had available 1013 participant-weeks from 186 participants. The logistic regression model predicting depression status resulted in a 10-fold cross-validated mean area under the curve of 0.656 (SD 0.079). Conclusions: This study finds a strong proof of concept for the use of a smartphone-based assessment of depression outcomes. Behavioral features derived from passive sensors and active tasks show promising correlations with a validated clinical measure of depression (PHQ-9). Future work is needed to increase scale that may permit the construction of more complex (eg, nonlinear) predictive models and better handle data missingness. %M 34383685 %R 10.2196/27589 %U https://mental.jmir.org/2021/8/e27589 %U https://doi.org/10.2196/27589 %U http://www.ncbi.nlm.nih.gov/pubmed/34383685 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e30813 %T Smartphone Delivery of Cognitive Behavioral Therapy for Postintensive Care Syndrome-Family: Protocol for a Pilot Study %A Petrinec,Amy B %A Hughes,Joel W %A Zullo,Melissa D %A Wilk,Cindy %A George,Richard L %+ College of Nursing, Kent State University, Henderson Hall, 1375 University Esplanade, Kent, OH, 44242, United States, 1 3307152987, apetrine@kent.edu %K postintensive care syndrome-family %K mobile health app %K cognitive behavioral therapy %K mobile phone %D 2021 %7 4.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Family members of critically ill patients experience symptoms of postintensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder. Postintensive care syndrome-family reduces the quality of life of the families of critically ill patients and may impede the recovery of such patients. Cognitive behavioral therapy has become a first-line nonpharmacological treatment of many psychological symptoms and disorders, including anxiety, depression, and posttraumatic stress. With regard to managing mild-to-moderate symptoms, the delivery of cognitive behavioral therapy via mobile technology without input from a clinician has been found to be feasible and well accepted, and its efficacy rivals that of face-to-face therapy. Objective: The purpose of our pilot study is to examine the efficacy of using a smartphone mobile health (mHealth) app to deliver cognitive behavioral therapy and diminish the severity and prevalence of PICS-F symptoms in family members of critically ill patients. Methods: For our pilot study, 60 family members of critically ill patients will be recruited. A repeated-measures longitudinal study design that involves the randomization of participants to 2 groups (the control and intervention groups) will be used. The intervention group will receive cognitive behavioral therapy, which will be delivered via a smartphone mHealth app. Bandura’s social cognitive theory and an emphasis on mental health self-efficacy form the theoretical framework of the study. Results: Recruitment for the study began in August 2020. Data collection and analysis are expected to be completed by March 2022. Conclusions: The proposed study represents a novel approach to the treatment of PICS-F symptoms and is an extension of previous work conducted by the research team. The study will be used to plan a fully powered randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04316767; https://clinicaltrials.gov/ct2/show/NCT04316767 International Registered Report Identifier (IRRID): DERR1-10.2196/30813 %M 34346900 %R 10.2196/30813 %U https://www.researchprotocols.org/2021/8/e30813 %U https://doi.org/10.2196/30813 %U http://www.ncbi.nlm.nih.gov/pubmed/34346900 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e26852 %T Patients’ Experiences of Using a Self-help App for Posttraumatic Stress Disorder: Qualitative Study %A Riisager,Lisa H G %A Christensen,Anne Bryde %A Scharff,Frederik Bernt %A Arendt,Ida-Marie T P %A Ismail,Israa %A Lau,Marianne Engelbrecht %A Moeller,Stine Bjerrum %+ Department of Psychology, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark, 45 25300977, lisagr@health.sdu.dk %K app %K PTSD %K mHealth %K qualitative analysis %K patient experience %K posttraumatic stress disorder %K thematic analysis %K smartphone %K intervention %K mobile phone %D 2021 %7 4.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Posttraumatic stress disorder (PTSD) is a common disorder that requires more treatment options. Mobile health (mHealth) app interventions are promising for patients with PTSD, as they can provide easily accessible support, strategies, and information. However, knowledge about mHealth interventions is sparse and primarily based on quantitative studies. Objective: The aim of this study is to qualitatively explore the experiences of patients with PTSD with regard to using an mHealth app as a stand-alone intervention before commencing psychotherapeutic treatment. Methods: We conducted semistructured interviews with 14 participants 6 weeks after they received the app. The participants were all referred to PTSD treatment and were waiting to commence psychotherapeutic treatment. During this waiting time, the participants had no contact with the health staff. Interviews were transcribed and were analyzed using thematic analysis. Results: A total of 3 themes were identified—the use of app, being a patient, and the overall evaluation of the app. The use of the app was described with the subtheme of habits, and the theme of being a patient included the subthemes of having negative experiences with the app and being a part of a research project. The use of the app encompassed how psychological factors and technical problems could interfere with the use of the app. The theme of being a patient depicted that the waiting time before starting treatment was long, and a subgroup of patients experienced feeling worse during this time, which they partly attributed to using the app. Several suggestions for change have been described in the overall evaluation of the app. Conclusions: The findings in this study revealed that emotional arousal influenced the use of the app and that it was difficult for participants to establish a habit of using the app, thus reflecting the importance of supporting habit formation when implementing an mHealth app in mental health care services. This study makes an important contribution to the field of mHealth research, as it revealed that some participants had negative experiences resulting from using the app, thus reflecting the potential harm of having an mHealth app without the support of a clinician. It is therefore recommended to use a blended care treatment or an approach in which mental health care professionals prescribe an mHealth app for relevant patients to avoid increased suicidal risk. %M 34346896 %R 10.2196/26852 %U https://formative.jmir.org/2021/8/e26852 %U https://doi.org/10.2196/26852 %U http://www.ncbi.nlm.nih.gov/pubmed/34346896 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e29840 %T Predicting Depressive Symptom Severity Through Individuals’ Nearby Bluetooth Device Count Data Collected by Mobile Phones: Preliminary Longitudinal Study %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Laiou,Petroula %A Matcham,Faith %A Oetzmann,Carolin %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Rintala,Aki %A Mohr,David C %A Myin-Germeys,Inez %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda W J H %A Narayan,Vaibhav A %A Annas,Peter %A Hotopf,Matthew %A Dobson,Richard J B %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SGDP Centre, IoPPN, Box PO 80, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 20 7848 0473, richard.j.dobson@kcl.ac.uk %K mental health %K depression %K digital biomarkers %K digital phenotyping %K digital health %K Bluetooth %K hierarchical Bayesian model %K mobile health %K mHealth %K monitoring %D 2021 %7 30.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research in mental health has found associations between depression and individuals’ behaviors and statuses, such as social connections and interactions, working status, mobility, and social isolation and loneliness. These behaviors and statuses can be approximated by the nearby Bluetooth device count (NBDC) detected by Bluetooth sensors in mobile phones. Objective: This study aimed to explore the value of the NBDC data in predicting depressive symptom severity as measured via the 8-item Patient Health Questionnaire (PHQ-8). Methods: The data used in this paper included 2886 biweekly PHQ-8 records collected from 316 participants recruited from three study sites in the Netherlands, Spain, and the United Kingdom as part of the EU Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) study. From the NBDC data 2 weeks prior to each PHQ-8 score, we extracted 49 Bluetooth features, including statistical features and nonlinear features for measuring the periodicity and regularity of individuals’ life rhythms. Linear mixed-effect models were used to explore associations between Bluetooth features and the PHQ-8 score. We then applied hierarchical Bayesian linear regression models to predict the PHQ-8 score from the extracted Bluetooth features. Results: A number of significant associations were found between Bluetooth features and depressive symptom severity. Generally speaking, along with depressive symptom worsening, one or more of the following changes were found in the preceding 2 weeks of the NBDC data: (1) the amount decreased, (2) the variance decreased, (3) the periodicity (especially the circadian rhythm) decreased, and (4) the NBDC sequence became more irregular. Compared with commonly used machine learning models, the proposed hierarchical Bayesian linear regression model achieved the best prediction metrics (R2=0.526) and a root mean squared error (RMSE) of 3.891. Bluetooth features can explain an extra 18.8% of the variance in the PHQ-8 score relative to the baseline model without Bluetooth features (R2=0.338, RMSE=4.547). Conclusions: Our statistical results indicate that the NBDC data have the potential to reflect changes in individuals’ behaviors and statuses concurrent with the changes in the depressive state. The prediction results demonstrate that the NBDC data have a significant value in predicting depressive symptom severity. These findings may have utility for the mental health monitoring practice in real-world settings. %M 34328441 %R 10.2196/29840 %U https://mhealth.jmir.org/2021/7/e29840 %U https://doi.org/10.2196/29840 %U http://www.ncbi.nlm.nih.gov/pubmed/34328441 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e26796 %T A Mobile Peer Intervention for Preventing Mental Health and Substance Use Problems in Adolescents: Protocol for a Randomized Controlled Trial (The Mind Your Mate Study) %A Birrell,Louise %A Furneaux-Bate,Ainsley %A Chapman,Cath %A Newton,Nicola C %+ The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Level 6, Jane Foss Russell Building, G02, Camperdown, Sydney, 2006, Australia, 61 8627 6904, ainsley.furneaux-bate@sydney.edu.au %K prevention %K mental health %K substance use %K peer support %K depression %K anxiety %K help-seeking %K mobile phone %D 2021 %7 30.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety, mood, and substance use disorders have significant social and economic impacts, which are largely attributable to their early age of onset and chronic disabling course. Therefore, it is critical to intervene early to prevent chronic and debilitating trajectories. Objective: This paper describes the study protocol of a CONSORT (Consolidated Standards of Reporting Trials)-compliant randomized controlled trial for evaluating the effectiveness of the Mind your Mate program, a mobile health (mHealth) peer intervention that aims to prevent mental health (focusing on anxiety and depression) and substance use problems in adolescents. Methods: Participants will consist of approximately 840 year 9 or year 10 students (60 students per grade per school) from 14 New South Wales high schools in Sydney, Australia. Schools will be recruited from a random selection of independent and public schools across the New South Wales Greater Sydney Area by using publicly available contact details. The intervention will consist of 1 introductory classroom lesson and a downloadable mobile app that will be available for use for 12 months. Schools will be randomly allocated to receive either the mHealth peer intervention or a waitlist control (health education as usual). All students will be given web-based self-assessments at baseline and at 6- and 12-month follow-ups. The primary outcomes of the trial will be the self-reported use of alcohol and drugs, anxiety and depression symptoms, knowledge about mental health and substance use, motives for not drinking, and willingness to seek help. Secondary outcomes will include positive well-being, the quality of life, and the impact of the COVID-19 pandemic. Analyses will be conducted using mixed-effects linear regression analyses for normally distributed data and mixed-effects logistic regression analyses for categorical data. Results: The Mind your Mate study was funded by an Australian Rotary Health Bruce Edwards Postdoctoral Research Fellowship from 2019 to 2022. Some of the development costs for the Mind your Mate intervention came from a seed funding grant from the Brain and Mind Centre of the University of Sydney. The enrollment of schools began in July 2020; 12 of 14 schools were enrolled at the time of submission. Baseline assessments are currently underway, and the first results are expected to be submitted for publication in 2022. Conclusions: The Mind your Mate study will generate vital new knowledge about the effectiveness of a peer support prevention strategy in real-world settings for the most common mental disorders in youth. If effective, this intervention will constitute a scalable, low-cost prevention strategy that has significant potential to reduce the impact of mental and substance use disorders. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000753954; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379738&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/26796 %M 34328426 %R 10.2196/26796 %U https://www.researchprotocols.org/2021/7/e26796 %U https://doi.org/10.2196/26796 %U http://www.ncbi.nlm.nih.gov/pubmed/34328426 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e31385 %T The Digital Therapeutic Alliance: Prospects and Considerations %A Lederman,Reeva %A D'Alfonso,Simon %+ School of Computing and Information Systems, The University of Melbourne, Melbourne Connect, 700 Swanston Street, Carlton, 3053, Australia, 61 390355511, dalfonso@unimelb.edu.au %K therapeutic alliance %K digital therapeutic alliance %K digital mental health %K mental health apps %K teletherapy %K chatbots %D 2021 %7 20.7.2021 %9 Editorial %J JMIR Ment Health %G English %X The growing prevalence of digital approaches to mental health care raises a range of questions and considerations. A notion that has recently emerged is that of the digital therapeutic alliance, prompting consideration of whether and how the concept of therapeutic alliance, which has proven to be a central ingredient of successful traditional psychotherapy, could translate to mental health care via digital technologies. This special issue editorial article outlines the topic of digital therapeutic alliance and introduces the five articles that comprise the special issue. %M 34283035 %R 10.2196/31385 %U https://mental.jmir.org/2021/7/e31385 %U https://doi.org/10.2196/31385 %U http://www.ncbi.nlm.nih.gov/pubmed/34283035 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e16643 %T A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial %A Lukas,Christian Aljoscha %A Eskofier,Bjoern %A Berking,Matthias %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nuremberg, Naegelsbachstr 25a, Erlangen, 91052, Germany, 49 176 80526686, christian.aljoscha.lukas@fau.de %K smartphone technology %K depression %K cognitive behavioral therapy %K approach/avoidance %K gamification %D 2021 %7 20.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Available smartphone-based interventions for depression predominantly use evidence-based strategies from cognitive-behavioral therapy (CBT), but patient engagement and reported effect sizes are small. Recently, studies have demonstrated that smartphone-based interventions combining CBT with gamified approach-avoidance bias modification training (AAMT) can foster patient engagement and reduce symptoms of several mental health problems. Objective: Based on these findings, we developed a gamified smartphone-based intervention, mentalis Phoenix (MT-Phoenix), and hypothesized the program would both engage patients and produce preliminary evidence for the reduction of depressive symptoms. Methods: To test this hypothesis, we evaluated MT-Phoenix in a randomized controlled pilot trial including 77 individuals with elevated depression scores (Patient Health Questionnaire-9 scores ≥5). Participants were either instructed to train for 14 days with MT-Phoenix or assigned to a waitlist control condition. Engagement with the intervention was measured by assessing usage data. The primary outcome was reduction in depressive symptom severity at postassessment. Results: Data from this pilot trial shows that participants in the intervention group used the smartphone-based intervention for 46% of all days (6.4/14) and reported a significantly greater reduction of depressive symptoms than did participants in the control condition (F1,74=19.34; P=.001), with a large effect size (d=1.02). Effects were sustained at a 3-month follow-up. Conclusions: A gamified smartphone-based intervention combining CBT with AAMT may foster patient engagement and effectively target depressive symptoms. Future studies should evaluate the effectiveness of this intervention in a phase 3 trial using clinical samples. Moreover, the intervention should be compared to active control conditions. Trial Registration: German Clinical Trial Registry DRKS00012769; https://tinyurl.com/47mw8du7 %M 34283037 %R 10.2196/16643 %U https://mental.jmir.org/2021/7/e16643 %U https://doi.org/10.2196/16643 %U http://www.ncbi.nlm.nih.gov/pubmed/34283037 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e27018 %T User Engagement and Usability of Suicide Prevention Apps: Systematic Search in App Stores and Content Analysis %A Wilks,Chelsey R %A Chu,Carol %A Sim,DongGun %A Lovell,Josh %A Gutierrez,Peter %A Joiner,Thomas %A Kessler,Ronald C %A Nock,Matthew K %+ Department of Psychological Sciences, University of Missouri-St. Louis, 1 University Way, St Louis, MO, 63121, United States, 1 (314) 516 5383, chelseywilks@umsl.edu %K suicide %K mHealth %K usability %K engagement %K mobile phone %D 2021 %7 14.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: People with suicidal thoughts are more inclined to seek technology-delivered interventions than in-person forms of treatment, making mobile apps for suicide prevention an ideal platform for treatment delivery. This review examines apps designed for suicide prevention, with a specific focus on user engagement. Objective: This study aims to update the literature and broadly evaluate the landscape of mobile health apps for suicide prevention; examine apps with key features and primary approaches to suicide prevention; and systematically evaluate the engagement, functionality, aesthetics, and information of the apps. Methods: All apps related to suicidal thoughts and behaviors were identified in the Google Play and iOS app stores and were systematically reviewed for their content and quality. The mobile app rating scale (MARS) was used to evaluate app usability and engagement. Results: Of the 66 apps identified, 42 (64%) were specifically designed for people with suicidal ideation, and 59 (89%) had at least one best practice feature for suicide risk reduction. The mean overall MARS score of all apps was 3.5 (range 2.1-4.5), with 83% (55/66) of apps having a minimum acceptability score of 3. The total MARS score was not associated with the user app rating (r=−0.001; P=.99) or the number of features (r=0.24; P=.09). Conclusions: This study identified many usable and engaging apps in app stores designed for suicide prevention. However, there are only limited apps for clinicians. Thus, mobile apps for suicide prevention should be carefully developed and clinically evaluated. %M 34259163 %R 10.2196/27018 %U https://formative.jmir.org/2021/7/e27018 %U https://doi.org/10.2196/27018 %U http://www.ncbi.nlm.nih.gov/pubmed/34259163 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e26540 %T Predicting Depression From Smartphone Behavioral Markers Using Machine Learning Methods, Hyperparameter Optimization, and Feature Importance Analysis: Exploratory Study %A Opoku Asare,Kennedy %A Terhorst,Yannik %A Vega,Julio %A Peltonen,Ella %A Lagerspetz,Eemil %A Ferreira,Denzil %+ Center for Ubiquitous Computing, University of Oulu, Erkki Koiso-Kanttilan katu 3, PO Box 4500, Oulu, FI-90014, Finland, 358 294 482807, kennedy.opokuasare@oulu.fi %K mHealth %K mental health %K mobile phone %K digital biomarkers %K digital phenotyping %K smartphone %K supervised machine learning %K depression %D 2021 %7 12.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is a prevalent mental health challenge. Current depression assessment methods using self-reported and clinician-administered questionnaires have limitations. Instrumenting smartphones to passively and continuously collect moment-by-moment data sets to quantify human behaviors has the potential to augment current depression assessment methods for early diagnosis, scalable, and longitudinal monitoring of depression. Objective: The objective of this study was to investigate the feasibility of predicting depression with human behaviors quantified from smartphone data sets, and to identify behaviors that can influence depression. Methods: Smartphone data sets and self-reported 8-item Patient Health Questionnaire (PHQ-8) depression assessments were collected from 629 participants in an exploratory longitudinal study over an average of 22.1 days (SD 17.90; range 8-86). We quantified 22 regularity, entropy, and SD behavioral markers from the smartphone data. We explored the relationship between the behavioral features and depression using correlation and bivariate linear mixed models (LMMs). We leveraged 5 supervised machine learning (ML) algorithms with hyperparameter optimization, nested cross-validation, and imbalanced data handling to predict depression. Finally, with the permutation importance method, we identified influential behavioral markers in predicting depression. Results: Of the 629 participants from at least 56 countries, 69 (10.97%) were females, 546 (86.8%) were males, and 14 (2.2%) were nonbinary. Participants’ age distribution is as follows: 73/629 (11.6%) were aged between 18 and 24, 204/629 (32.4%) were aged between 25 and 34, 156/629 (24.8%) were aged between 35 and 44, 166/629 (26.4%) were aged between 45 and 64, and 30/629 (4.8%) were aged 65 years and over. Of the 1374 PHQ-8 assessments, 1143 (83.19%) responses were nondepressed scores (PHQ-8 score <10), while 231 (16.81%) were depressed scores (PHQ-8 score ≥10), as identified based on PHQ-8 cut-off. A significant positive Pearson correlation was found between screen status–normalized entropy and depression (r=0.14, P<.001). LMM demonstrates an intraclass correlation of 0.7584 and a significant positive association between screen status–normalized entropy and depression (β=.48, P=.03). The best ML algorithms achieved the following metrics: precision, 85.55%-92.51%; recall, 92.19%-95.56%; F1, 88.73%-94.00%; area under the curve receiver operating characteristic, 94.69%-99.06%; Cohen κ, 86.61%-92.90%; and accuracy, 96.44%-98.14%. Including age group and gender as predictors improved the ML performances. Screen and internet connectivity features were the most influential in predicting depression. Conclusions: Our findings demonstrate that behavioral markers indicative of depression can be unobtrusively identified from smartphone sensors’ data. Traditional assessment of depression can be augmented with behavioral markers from smartphones for depression diagnosis and monitoring. %M 34255713 %R 10.2196/26540 %U https://mhealth.jmir.org/2021/7/e26540 %U https://doi.org/10.2196/26540 %U http://www.ncbi.nlm.nih.gov/pubmed/34255713 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e26873 %T Usability and Acceptability of Two Smartphone Apps for Smoking Cessation Among Young Adults With Serious Mental Illness: Mixed Methods Study %A Gowarty,Minda A %A Longacre,Meghan R %A Vilardaga,Roger %A Kung,Nathan J %A Gaughan-Maher,Ashley E %A Brunette,Mary F %+ Departments of Internal Medicine and Community and Family Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 6036536868, minda.a.gowarty@hitchcock.org %K smoking cessation %K mHealth %K serious mental illness %K smartphone application %K digital health %K psychiatric illness %K tobacco treatment %K mobile phone %D 2021 %7 7.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Young adults with serious mental illness (SMI) have higher smoking rates and lower cessation rates than young adults without SMI. Scalable interventions such as smartphone apps with evidence-based content (eg, the National Cancer Institute’s [NCI’s] QuitGuide and quitSTART) could increase access to potentially appealing and effective treatment for this group but have yet to be tested in this population. Objective: The goal of this user-centered design study is to determine the user experience (including usability and acceptability) of 2 widely available apps developed by the NCI—QuitGuide and quitSTART—among young adult tobacco users with SMI. Methods: We conducted usability and acceptability testing of QuitGuide and quitSTART among participants with SMI aged between 18 and 35 years who were stable in community mental health treatment between 2019 and 2020. Participants were randomly assigned to use QuitGuide or quitSTART on their smartphones. App usability was evaluated at baseline and following a 2-week field test of independent use via a video-recorded task completion protocol. Using a mixed method approach, we triangulated 4 data sources: nonparticipant observation, open-ended interviews, structured interviews (including the System Usability Scale [SUS]), and backend app use data obtained from the NCI. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using thematic analysis. Results: Participants were 17 smokers who were not interested in quitting, with a mean age of 29 (SD 4) years; 41% (n=7) presented with psychotic disorders. Participants smoked an average of 15 (SD 7) cigarettes per day. The mean SUS scores for QuitGuide were similar at visits one and two (mean 64, SD 18 and mean 66, SD 18, respectively). The mean SUS scores for quitSTART numerically increased from visit one (mean 55, SD 20) to visit two (mean 64, SD 16). Acceptability scores followed the same pattern. Observed task completion rates were at least 75% (7/9 for QuitGuide, 6/8 for quitSTART) for both apps at both visits for all but 2 tasks. During the 13-day trial period, QuitGuide and quitSTART users interacted with their assigned app on an average of 4.6 (SD 2.8) days versus 10.8 (SD 3.5) days, for a mean total of 5.6 (SD 3.8) interactions versus 41 (SD 26) interactions, and responded to a median of 1 notification (range 0-8) versus 18.5 notifications (range 0-37), respectively. Qualitative comments indicated moderate to high satisfaction overall but also included concerns about the accuracy of the apps’ feedback. Conclusions: Both QuitGuide and quitSTART had acceptable levels of usability and mixed levels of acceptability among young adults with SMI. The higher level of engagement with quitSTART suggests that quitSTART may be a favorable tool for young adult smokers with SMI. However, clinical support or coaching may be needed to overcome initial usability issues. %M 34255699 %R 10.2196/26873 %U https://mental.jmir.org/2021/7/e26873 %U https://doi.org/10.2196/26873 %U http://www.ncbi.nlm.nih.gov/pubmed/34255699 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e28526 %T A Digital Toolkit (M-Healer) to Improve Care and Reduce Human Rights Abuses Against People With Mental Illness in West Africa: User-Centered Design, Development, and Usability Study %A Ben-Zeev,Dror %A Meller,Suzanne %A Snyder,Jaime %A Attah,Dzifa A %A Albright,Liam %A Le,Hoa %A Asafo,Seth M %A Collins,Pamela Y %A Ofori-Atta,Angela %+ BRiTE Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 2066859655, dbenzeev@uw.edu %K mobile phone %K low- and middle-income country %K schizophrenia %K bipolar disorder %D 2021 %7 2.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The resources of West African mental health care systems are severely constrained, which contributes to significant unmet mental health needs. Consequently, people with psychiatric conditions often receive care from traditional and faith healers. Healers may use practices that constitute human rights violations, such as flogging, caging, forced fasting, and chaining. Objective: The aim of this study is to partner with healers in Ghana to develop a smartphone toolkit designed to support the dissemination of evidence-based psychosocial interventions and the strengthening of human rights awareness in the healer community. Methods: We conducted on-site observations and qualitative interviews with healers, a group co-design session, content development and prototype system build-out, and usability testing. Results: A total of 18 healers completed individual interviews. Participants reported on their understanding of the causes and treatments of mental illnesses. They identified situations in which they elect to use mechanical restraints and other coercive practices. Participants described an openness to using a smartphone-based app to help introduce them to alternative practices. A total of 12 healers participated in the co-design session. Of the 12 participants, 8 (67%) reported having a smartphone. Participants reported that they preferred spiritual guidance but that it was acceptable that M-Healer would provide mostly nonspiritual content. They provided suggestions for who should be depicted as the toolkit protagonist and ranked their preferred content delivery modality in the following order: live-action video, animated video, comic strip, and still images with text. Participants viewed mood board prototypes and rated their preferred visual design in the following order: religious theme, nature motif, community or medical, and Ghanaian culture. The content was organized into modules, including an introduction to the system, brief mental health interventions, verbal de-escalation strategies, guided relaxation techniques, and human rights training. Each module contained several scripted digital animation videos, with audio narration in English or Twi. The module menu was represented by touchscreen icons and a single word or phrase to maximize accessibility to users with limited literacy. In total, 12 participants completed the M-Healer usability testing. Participants commented that they liked the look and functionality of the app and understood the content. The participants reported that the information and displays were clear. They successfully navigated the app but identified several areas where usability could be enhanced. Posttesting usability measures indicated that participants found M-Healer to be feasible, acceptable, and usable. Conclusions: This study is the first to develop a digital mental health toolkit for healers in West Africa. Engaging healers in user-centered development produced an accessible and acceptable resource. Future field testing will determine whether M-Healer can improve healer practices and reduce human rights abuses. %M 34255712 %R 10.2196/28526 %U https://mental.jmir.org/2021/7/e28526 %U https://doi.org/10.2196/28526 %U http://www.ncbi.nlm.nih.gov/pubmed/34255712 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25808 %T Effects of Mobile App–Based Intervention for Depression in Middle-Aged and Older Adults: Mixed Methods Feasibility Study %A Gould,Christine E %A Carlson,Chalise %A Ma,Flora %A Forman-Hoffman,Valerie %A Ranta,Kristian %A Kuhn,Eric %+ Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, United States, 1 6504935000 ext 68899, cegould@stanford.edu %K aging %K depression %K digital health %K digital therapeutics %K mHealth %K mobile phone %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital mental health interventions may help middle-aged and older adults with depression overcome barriers to accessing traditional care, but few studies have investigated their use in this population. Objective: This pilot study examines the feasibility, acceptability, and potential efficacy of the Meru Health Program, an 8-week mobile app–delivered intervention. Methods: A total of 20 community-dwelling middle-aged and older adults (age: mean 61.7 years, SD 11.3) with elevated depressive symptoms participated in a single-arm pilot study investigating the Meru Health Program, an app-delivered intervention supported by remote therapists. The program primarily uses mindfulness and cognitive behavioral skills to target depressive symptoms. A semistructured interview was completed at the baseline to establish current psychiatric diagnoses. Depressive symptoms were measured using the Patient Health Questionnaire and Patient-Reported Outcomes Measurement Information System (PROMIS) depression measures. Anxiety symptoms were measured using the Generalized Anxiety Disorder Scale and the PROMIS Anxiety measure. User experience and acceptability were examined through surveys and qualitative interviews. Results: In total, 90% (18/20) of the participants completed the program, with 75% (15/20) completing at least 7 of the 8 introductory weekly lessons. On average, participants completed 60 minutes of practice and exchanged 5 messages with their therapists every week. The app was rated as helpful by 89% (17/19) participants. Significant decreases in depressive (P=.03) and anxiety symptom measures (P=.01) were found; 45% (9/20) of participants showed clinically significant improvement in either depressive symptoms or anxiety symptoms. Conclusions: The findings suggest that the commercially available Meru Health Program may be feasible, acceptable, and potentially beneficial to middle-aged and older adults. Although larger controlled trials are needed to demonstrate efficacy, these findings suggest that digital health interventions may benefit adults of all ages. %M 34185000 %R 10.2196/25808 %U https://formative.jmir.org/2021/6/e25808 %U https://doi.org/10.2196/25808 %U http://www.ncbi.nlm.nih.gov/pubmed/34185000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e27218 %T Machine Learning Analysis to Identify Digital Behavioral Phenotypes for Engagement and Health Outcome Efficacy of an mHealth Intervention for Obesity: Randomized Controlled Trial %A Kim,Meelim %A Yang,Jaeyeong %A Ahn,Woo-Young %A Choi,Hyung Jin %+ Department of Biomedical Sciences, Seoul National University College of Medicine, 28 Yungun-Dong, Chongno-Gu, Seoul, Republic of Korea, 82 27408204, hjchoi@snu.ac.kr %K digital phenotype %K clinical efficacy %K in-app engagement %K machine learning analysis %K mobile phone %D 2021 %7 24.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The digital health care community has been urged to enhance engagement and clinical outcomes by analyzing multidimensional digital phenotypes. Objective: This study aims to use a machine learning approach to investigate the performance of multivariate phenotypes in predicting the engagement rate and health outcomes of digital cognitive behavioral therapy. Methods: We leveraged both conventional phenotypes assessed by validated psychological questionnaires and multidimensional digital phenotypes within time-series data from a mobile app of 45 participants undergoing digital cognitive behavioral therapy for 8 weeks. We conducted a machine learning analysis to discriminate the important characteristics. Results: A higher engagement rate was associated with higher weight loss at 8 weeks (r=−0.59; P<.001) and 24 weeks (r=−0.52; P=.001). Applying the machine learning approach, lower self-esteem on the conventional phenotype and higher in-app motivational measures on digital phenotypes commonly accounted for both engagement and health outcomes. In addition, 16 types of digital phenotypes (ie, lower intake of high-calorie food and evening snacks and higher interaction frequency with mentors) predicted engagement rates (mean R2 0.416, SD 0.006). The prediction of short-term weight change (mean R2 0.382, SD 0.015) was associated with 13 different digital phenotypes (ie, lower intake of high-calorie food and carbohydrate and higher intake of low-calorie food). Finally, 8 measures of digital phenotypes (ie, lower intake of carbohydrate and evening snacks and higher motivation) were associated with a long-term weight change (mean R2 0.590, SD 0.011). Conclusions: Our findings successfully demonstrated how multiple psychological constructs, such as emotional, cognitive, behavioral, and motivational phenotypes, elucidate the mechanisms and clinical efficacy of a digital intervention using the machine learning method. Accordingly, our study designed an interpretable digital phenotype model, including multiple aspects of motivation before and during the intervention, predicting both engagement and clinical efficacy. This line of research may shed light on the development of advanced prevention and personalized digital therapeutics. Trial Registration: ClinicalTrials.gov NCT03465306; https://clinicaltrials.gov/ct2/show/NCT03465306 %M 34184991 %R 10.2196/27218 %U https://www.jmir.org/2021/6/e27218/ %U https://doi.org/10.2196/27218 %U http://www.ncbi.nlm.nih.gov/pubmed/34184991 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e26771 %T Acceptability and Effectiveness of Artificial Intelligence Therapy for Anxiety and Depression (Youper): Longitudinal Observational Study %A Mehta,Ashish %A Niles,Andrea Nicole %A Vargas,Jose Hamilton %A Marafon,Thiago %A Couto,Diego Dotta %A Gross,James Jonathan %+ Department of Psychology, Stanford University, Building 420, 450 Jane Stanford Way, Stanford, CA, 94305, United States, 1 650 724 5436, ashm@stanford.edu %K digital mental health treatment %K acceptability %K effectiveness %K anxiety %K depression %D 2021 %7 22.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Youper is a widely used, commercially available mobile app that uses artificial intelligence therapy for the treatment of anxiety and depression. Objective: Our study examined the acceptability and effectiveness of Youper. Further, we tested the cumulative regulation hypothesis, which posits that cumulative emotion regulation successes with repeated intervention engagement will predict longer-term anxiety and depression symptom reduction. Methods: We examined data from paying Youper users (N=4517) who allowed their data to be used for research. To characterize the acceptability of Youper, we asked users to rate the app on a 5-star scale and measured retention statistics for users’ first 4 weeks of subscription. To examine effectiveness, we examined longitudinal measures of anxiety and depression symptoms. To test the cumulative regulation hypothesis, we used the proportion of successful emotion regulation attempts to predict symptom reduction. Results: Youper users rated the app highly (mean 4.36 stars, SD 0.84), and 42.66% (1927/4517) of users were retained by week 4. Symptoms decreased in the first 2 weeks of app use (anxiety: d=0.57; depression: d=0.46). Anxiety improvements were maintained in the subsequent 2 weeks, but depression symptoms increased slightly with a very small effect size (d=0.05). A higher proportion of successful emotion regulation attempts significantly predicted greater anxiety and depression symptom reduction. Conclusions: Youper is a low-cost, completely self-guided treatment that is accessible to users who may not otherwise access mental health care. Our findings demonstrate the acceptability and effectiveness of Youper as a treatment for anxiety and depression symptoms and support continued study of Youper in a randomized clinical trial. %M 34155984 %R 10.2196/26771 %U https://www.jmir.org/2021/6/e26771 %U https://doi.org/10.2196/26771 %U http://www.ncbi.nlm.nih.gov/pubmed/34155984 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e27475 %T Preliminary Outcomes of an Ecological Momentary Intervention for Social Functioning in Schizophrenia: Pre-Post Study of the Motivation and Skills Support App %A Fulford,Daniel %A Gard,David E %A Mueser,Kim T %A Mote,Jasmine %A Gill,Kathryn %A Leung,Lawrence %A Mow,Jessica %+ Department of Occupational Therapy, Boston University, 635 Commonwealth Avenue, Boston, MA, 02215, United States, 1 6173582889, dfulford@bu.edu %K schizophrenia %K psychosis %K social functioning %K social skills %K motivation %K mHealth %K smartphone %K mobile phone %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: People with schizophrenia and other serious mental illnesses often lack access to evidence-based interventions, particularly interventions that target meaningful recovery outcomes such as social functioning and quality of life. Mobile technologies, including smartphone apps, have the potential to provide scalable support that places elements of evidence-based interventions at the palm of patients’ hands. Objective: We aim to develop a smartphone app—called Motivation and Skills Support—to provide targeted social goal support (eg, making new friends and improving existing relationships) for people with schizophrenia enrolled in a stand-alone open trial. Methods: In this paper, we presented preliminary outcomes of 31 participants who used the Motivation and Skills Support app for 8 weeks, including social functioning pre- to postintervention, and momentary reports of treatment targets (eg, social motivation and appraisals) during the intervention. Results: The findings suggest that the intervention improved self-reported social functioning from baseline to treatment termination, particularly in female participants. Gains were not maintained at the 3-month follow-up. Furthermore, increased social functioning was predicted by momentary reports of social appraisals, including perceived social competence and the extent to which social interactions were worth the effort. Conclusions: The implications of these findings and future directions for addressing social functioning in schizophrenia using mobile technology have been discussed. Trial Registration: ClinicalTrials.gov NCT03404219; https://clinicaltrials.gov/ct2/show/NCT03404219 %M 34128812 %R 10.2196/27475 %U https://mental.jmir.org/2021/6/e27475 %U https://doi.org/10.2196/27475 %U http://www.ncbi.nlm.nih.gov/pubmed/34128812 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 6 %P e24115 %T Adaptation of the World Health Organization Electronic Mental Health Gap Action Programme Intervention Guide App for Mobile Devices in Nepal and Nigeria: Protocol for a Feasibility Cluster Randomized Controlled Trial %A Taylor Salisbury,Tatiana %A Kohrt,Brandon A %A Bakolis,Ioannis %A Jordans,Mark JD %A Hull,Louise %A Luitel,Nagendra P %A McCrone,Paul %A Sevdalis,Nick %A Pokhrel,Pooja %A Carswell,Kenneth %A Ojagbemi,Akin %A Green,Eric P %A Chowdhary,Neerja %A Kola,Lola %A Lempp,Heidi %A Dua,Tarun %A Milenova,Maria %A Gureje,Oye %A Thornicroft,Graham %+ Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF, United Kingdom, 44 0207 848 5071, tatiana.salisbury@kcl.ac.uk %K mental health %K community mental health %K digital technology %K primary health care %K intervention %K eHealth %K mHealth %K LMIC %K remote supervision %K training %K mobile phone %D 2021 %7 15.6.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a growing global need for scalable approaches to training and supervising primary care workers (PCWs) to deliver mental health services. Over the past decade, the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) and associated training and implementation guidance have been disseminated to more than 100 countries. On the basis of the opportunities provided by mobile technology, an updated electronic Mental Health Gap Action Programme Intervention Guide (e-mhGAP-IG) is now being developed along with a clinical dashboard and guidance for the use of mobile technology in supervision. Objective: This study aims to assess the feasibility, acceptability, adoption, and other implementation parameters of the e-mhGAP-IG for diagnosis and management of depression in 2 lower-middle-income countries (Nepal and Nigeria) and to conduct a feasibility cluster randomized controlled trial (cRCT) to evaluate trial procedures for a subsequent fully powered trial comparing the clinical effectiveness and cost-effectiveness of the e-mhGAP-IG and remote supervision with standard mhGAP-IG implementation. Methods: A feasibility cRCT will be conducted in Nepal and Nigeria to evaluate the feasibility of the e-mhGAP-IG for use in depression diagnosis and treatment. In each country, an estimated 20 primary health clinics (PHCs) in Nepal and 6 PHCs in Nigeria will be randomized to have their staff trained in e-mhGAP-IG or the paper version of mhGAP-IG v2.0. The PHC will be the unit of clustering. All PCWs within a facility will receive the same training (e-mhGAP-IG vs paper mhGAP-IG). Approximately 2-5 PCWs, depending on staffing, will be recruited per clinic (estimated 20 health workers per arm in Nepal and 15 per arm in Nigeria). The primary outcomes of interest will be the feasibility and acceptability of training, supervision, and care delivery using the e-mhGAP-IG. Secondary implementation outcomes include the adoption of the e-mhGAP-IG and feasibility of trial procedures. The secondary intervention outcome—and the primary outcome for a subsequent fully powered trial—will be the accurate identification of depression by PCWs. Detection rates before and after training will be compared in each arm. Results: To date, qualitative formative work has been conducted at both sites to prepare for the pilot feasibility cRCT, and the e-mhGAP-IG and remote supervision guidelines have been developed. Conclusions: The incorporation of mobile digital technology has the potential to improve the scalability of mental health services in primary care and enhance the quality and accuracy of care. Trial Registration: ClinicalTrials.gov NCT04522453; https://clinicaltrials.gov/ct2/show/NCT04522453. International Registered Report Identifier (IRRID): PRR1-10.2196/24115 %M 34128819 %R 10.2196/24115 %U https://www.researchprotocols.org/2021/6/e24115 %U https://doi.org/10.2196/24115 %U http://www.ncbi.nlm.nih.gov/pubmed/34128819 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e27022 %T Needs and Experiences of Users of Digital Navigation Tools for Mental Health Treatment and Supportive Services: Survey Study %A Stafford,Elizabeth %A Brister,Teri %A Duckworth,Ken %A Rauseo-Ricupero,Natali %A Lagan,Sarah %+ The National Alliance on Mental Illness, 4301 Wilson Boulevard, Suite 300, Arlington, VA, 22203, United States, 1 7035247600, estafford@nami.org %K mental health %K supportive services %K perception %K quality %K satisfaction %K needs %K digital tools %K directories %K navigation %D 2021 %7 9.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite a recent proliferation in web-based and digital resources that are designed to assist users in finding appropriate mental health treatment and supportive services, it can be overwhelming, confusing, and difficult for an individual or family member to access and use an appropriate navigation tool. As digital resources are increasingly sought after, there is an urgent need for a clearer understanding of digital navigation tools in order to help link individuals with the tool that is best suited to their needs. Objective: The objective of this study was to determine the needs of individuals seeking mental health treatment and supportive services and to quantify their experiences and satisfaction with available digital navigation tools. Methods: A survey was offered via an email newsletter and social media posting throughout the extended membership of the National Alliance on Mental Illness, which includes both individuals with a mental health condition and their family members and support networks. A 13-item anonymous survey, which consisted of multiple-choice and open response options, was developed to measure participants’ past use of and experiences with web-based, mobile, and phone-based navigation tools. The survey was available from April 9 through May 21, 2020. Results: A total of 478 respondents completed the survey; the majority of respondents were female (397/478, 83.1%) and aged ≥35 years (411/478, 86%). Younger respondents were more likely to report seeking mental health services for themselves, while older respondents were more likely to be searching for such services on behalf of a family member. The majority of respondents seeking such services on behalf of a family member (113/194, 58.2%) required a combination of mental health treatment and supportive services. Furthermore, two-thirds of respondents (322/478, 67.4%) used a navigation tool to find treatment or services. The majority of respondents who provided feedback about their experiences with navigation tools (224/280, 80%) reported difficulties, with data availability and accuracy being the most commonly reported issues. Conclusions: The survey results suggest that issues with data availability and accuracy in available navigation tools remain a major barrier for locating timely and appropriate mental health treatment and supportive services within the population of individuals seeking such services. Particularly for individuals seeking care on behalf of a family member, improving the accuracy of and users’ experiences with navigation tools could have a major impact on effectively connecting people to treatment and support services. %M 34106079 %R 10.2196/27022 %U https://mental.jmir.org/2021/6/e27022 %U https://doi.org/10.2196/27022 %U http://www.ncbi.nlm.nih.gov/pubmed/34106079 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e27132 %T Proof-of-Concept Support for the Development and Implementation of a Digital Assessment for Perinatal Mental Health: Mixed Methods Study %A Martin-Key,Nayra Anna %A Spadaro,Benedetta %A Schei,Thea Sofie %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K COM-B %K COVID-19 %K digital mental health %K maternal mental health %K paternal mental health %K perinatal mental health %K mental health %K support %K development %K implementation %K assessment %K mother %K women %D 2021 %7 4.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Perinatal mental health symptoms commonly remain underdiagnosed and undertreated in maternity care settings in the United Kingdom, with outbreaks of disease, like the COVID-19 pandemic, further disrupting access to adequate mental health support. Digital technologies may offer an innovative way to support the mental health needs of women and their families throughout the perinatal period, as well as assist midwives in the recognition of perinatal mental health concerns. However, little is known about the acceptability and perceived benefits and barriers to using such technologies. Objective: The aim of this study was to conduct a mixed methods evaluation of the current state of perinatal mental health care provision in the United Kingdom, as well as users’ (women and partners) and midwives’ interest in using a digital mental health assessment throughout the perinatal period. Methods: Women, partners, and midwives were recruited to participate in the study, which entailed completing an online survey. Quantitative data were explored using descriptive statistics. Open-ended response data were first investigated using thematic analysis. Resultant themes were then mapped onto the components of the Capability, Opportunity, and Motivation Behavior model and summarized using descriptive statistics. Results: A total of 829 women, 103 partners, and 90 midwives participated in the study. The provision of adequate perinatal mental health care support was limited, with experiences varying significantly across respondents. There was a strong interest in using a digital mental health assessment to screen, diagnose, and triage perinatal mental health concerns, particularly among women and midwives. The majority of respondents (n=781, 76.42%) expressed that they would feel comfortable or very comfortable using or recommending a digital mental health assessment. The majority of women and partners showed a preference for in-person consultations (n=417, 44.74%), followed by a blended care approach (ie, both in-person and online consultations) (n=362, 38.84%), with fewer participants preferring online-only consultations (n=120, 12.88%). Identified benefits and barriers mainly related to physical opportunity (eg, accessibility), psychological capability (eg, cognitive skills), and automatic motivation (eg, emotions). Conclusions: This study provides proof-of-concept support for the development and implementation of a digital mental health assessment to inform clinical decision making in the assessment of perinatal mental health concerns in the United Kingdom. %M 34033582 %R 10.2196/27132 %U https://www.jmir.org/2021/6/e27132 %U https://doi.org/10.2196/27132 %U http://www.ncbi.nlm.nih.gov/pubmed/34033582 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 5 %P e24567 %T Using Digital Tools to Engage Patients With Psychosis and Their Families in Research: Survey Recruitment and Completion in an Early Psychosis Intervention Program %A Polillo,Alexia %A Voineskos,Aristotle N %A Foussias,George %A Kidd,Sean A %A Sav,Andreea %A Hawley,Steve %A Soklaridis,Sophie %A Stergiopoulos,Vicky %A Kozloff,Nicole %+ Centre for Addiction and Mental Health, 1025 Queen Street West, B1-4345, Toronto, ON, M6J 1H1, Canada, 1 416 535 8501, n.kozloff@mail.utoronto.ca %K digital %K online %K psychosis %K schizophrenia %K early psychosis intervention %K surveys %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Barriers to recruiting and retaining people with psychosis and their families in research are well-established, potentially biasing clinical research samples. Digital research tools, such as online platforms, mobile apps, and text messaging, have the potential to address barriers to research by facilitating remote participation. However, there has been limited research on leveraging these technologies to engage people with psychosis and their families in research. Objective: The objective of this study was to assess the uptake of digital tools to engage patients with provisional psychosis and their families in research and their preferences for different research administration methods. Methods: This study used Research Electronic Data Capture (REDCap)—a secure web-based platform with built-in tools for data collection and storage—to send web-based consent forms and surveys on service engagement via text message or email to patients and families referred to early psychosis intervention services; potential participants were also approached or reminded about the study in person. We calculated completion rates and timing using remote and in-person methods and compensation preferences. Results: A total of 447 patients with provisional psychosis and 187 of their family members agreed to receive the web-based consent form, and approximately half of the patients (216/447, 48.3%) and family members (109/187, 58.3%) consented to participate in the survey. Most patients (182/229, 79.5%) and family members (75/116, 64.7%) who completed the consent form did so remotely, with more family members (41/116, 35.3%) than patients (47/229, 20.5%) completing it in person. Of those who consented, 77.3% (167/216) of patients and 72.5% (79/109) of family members completed the survey, and most did the survey remotely. Almost all patients (418/462, 90.5%) and family members (174/190, 91.6%) requested to receive the consent form and survey by email, and only 4.1% (19/462) and 3.2% (6/190), respectively, preferred text message. Just over half of the patients (91/167, 54.5%) and family members (42/79, 53.2%) preferred to receive electronic gift cards from a coffee shop as study compensation. Most surveys were completed on weekdays between 12 PM and 6 PM. Conclusions: When offered the choice, most participants with psychosis and their families chose remote administration methods, suggesting that digital tools may enhance research recruitment and participation in this population, particularly in the context of the COVID-19 global pandemic. %M 34057421 %R 10.2196/24567 %U https://mental.jmir.org/2021/5/e24567 %U https://doi.org/10.2196/24567 %U http://www.ncbi.nlm.nih.gov/pubmed/34057421 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 5 %P e27965 %T Engagement and Effectiveness of a Healthy-Coping Intervention via Chatbot for University Students During the COVID-19 Pandemic: Mixed Methods Proof-of-Concept Study %A Gabrielli,Silvia %A Rizzi,Silvia %A Bassi,Giulia %A Carbone,Sara %A Maimone,Rosa %A Marchesoni,Michele %A Forti,Stefano %+ Digital Health Lab, Fondazione Bruno Kessler, Via Sommarive 18, Trento, 38123, Italy, 39 0461 312 47 ext 247, sgabrielli@fbk.eu %K mobile mental health %K chatbots %K anxiety %K stress %K university students %K digital health %K healthy-coping intervention %K COVID-19 %D 2021 %7 28.5.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: University students are increasingly reporting common mental health problems, such as stress, anxiety, and depression, and they frequently face barriers to seeking psychological support because of stigma, cost, and availability of mental health services. This issue is even more critical in the challenging time of the COVID-19 pandemic. Digital mental health interventions, such as those delivered via chatbots on mobile devices, offer the potential to achieve scalability of healthy-coping interventions by lowering cost and supporting prevention. Objective: The goal of this study was to conduct a proof-of-concept evaluation measuring the engagement and effectiveness of Atena, a psychoeducational chatbot supporting healthy coping with stress and anxiety, among a population of university students. Methods: In a proof-of-concept study, 71 university students were recruited during the COVID-19 pandemic; 68% (48/71) were female, they were all in their first year of university, and their mean age was 20.6 years (SD 2.4). Enrolled students were asked to use the Atena psychoeducational chatbot for 4 weeks (eight sessions; two per week), which provided healthy-coping strategies based on cognitive behavioral therapy, positive psychology, and mindfulness techniques. The intervention program consisted of conversations combined with audiovisual clips delivered via the Atena chatbot. Participants were asked to complete web-based versions of the 7-item Generalized Anxiety Disorder scale (GAD-7), the 10-item Perceived Stress Scale (PSS-10), and the Five-Facet Mindfulness Questionnaire (FFMQ) at baseline and postintervention to assess effectiveness. They were also asked to complete the User Engagement Scale–Short Form at week 2 to assess engagement with the chatbot and to provide qualitative comments on their overall experience with Atena postintervention. Results: Participants engaged with the Atena chatbot an average of 78 (SD 24.8) times over the study period. A total of 61 out of 71 (86%) participants completed the first 2 weeks of the intervention and provided data on engagement (10/71, 14% attrition). A total of 41 participants out of 71 (58%) completed the full intervention and the postintervention questionnaires (30/71, 42% attrition). Results from the completer analysis showed a significant decrease in anxiety symptoms for participants in more extreme GAD-7 score ranges (t39=0.94; P=.009) and a decrease in stress symptoms as measured by the PSS-10 (t39=2.00; P=.05) for all participants postintervention. Participants also improved significantly in the describing and nonjudging facets, based on their FFMQ subscale scores, and asked for some improvements in the user experience with the chatbot. Conclusions: This study shows the benefit of deploying a digital healthy-coping intervention via a chatbot to support university students experiencing higher levels of distress. While findings collected during the COVID-19 pandemic show promise, further research is required to confirm conclusions. %M 33950849 %R 10.2196/27965 %U https://mhealth.jmir.org/2021/5/e27965 %U https://doi.org/10.2196/27965 %U http://www.ncbi.nlm.nih.gov/pubmed/33950849 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 5 %P e25708 %T Social Representations of e-Mental Health Among the Actors of the Health Care System: Free-Association Study %A Morgiève,Margot %A Mesdjian,Pierre %A Las Vergnas,Olivier %A Bury,Patrick %A Demassiet,Vincent %A Roelandt,Jean-Luc %A Sebbane,Déborah %+ WHO Collaborating Centre for Research and Training in Mental Health, EPSM Lille Metropole, 211 rue Roger Salengro, Hellemmes, 59260, France, 33 320437100, deborah.sebbane@ghtpy-npdc.fr %K e-mental health %K social representations %K free association task %K psychiatry %K mental health %K mental health service users %K technology %K digital health %D 2021 %7 27.5.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Electronic mental (e-mental) health offers an opportunity to overcome many challenges such as cost, accessibility, and the stigma associated with mental health, and most people with lived experiences of mental problems are in favor of using applications and websites to manage their mental health problems. However, the use of these new technologies remains weak in the area of mental health and psychiatry. Objective: This study aimed to characterize the social representations associated with e-mental health by all actors to implement new technologies in the best possible way in the health system. Methods: A free-association task method was used. The data were subjected to a lexicometric analysis to qualify and quantify words by analyzing their statistical distribution, using the ALCESTE method with the IRaMuTeQ software. Results: In order of frequency, the terms most frequently used to describe e-mental health in the whole corpus are: “care” (n=21), “internet” (n=21), “computing” (n=15), “health” (n=14), “information” (n=13), “patient” (n=12), and “tool” (n=12). The corpus of text is divided into 2 themes, with technological and computing terms on one side and medical and public health terms on the other. The largest family is focused on “care,” “advances,” “research,” “life,” “quality,” and “well-being,” which was significantly associated with users. The nursing group used very medical terms such as “treatment,” “diagnosis,” “psychiatry”,” and “patient” to define e-mental health. Conclusions: This study shows that there is a gap between the representations of users on e-mental health as a tool for improving their quality of life and those of health professionals (except nurses) that are more focused on the technological potential of these digital care tools. Developers, designers, clinicians, and users must be aware of the social representation of e-mental health conditions uses and intention of use. This understanding of everyone’s stakes will make it possible to redirect the development of tools to adapt them as much as possible to the needs and expectations of the actors of the mental health system. %M 34042591 %R 10.2196/25708 %U https://mental.jmir.org/2021/5/e25708 %U https://doi.org/10.2196/25708 %U http://www.ncbi.nlm.nih.gov/pubmed/34042591 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e25078 %T Changes in Perceived Stress Following a 10-Week Digital Mindfulness-Based Stress Reduction Program: Retrospective Study %A Venkatesan,Aarathi %A Krymis,Holly %A Scharff,Jenny %A Waber,Art %+ Vida Health, 100 Montgomery St #750, San Francisco, CA, 94104, United States, 1 (415) 989 1017, aarathi.venkatesan@vida.com %K perceived stress %K health coaching %K digital mental health intervention %K digital therapeutics %K mobile phone %D 2021 %7 25.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: As the need for effective scalable interventions for mental health conditions such as depression, anxiety, and stress has grown, the digital delivery of mindfulness-based stress reduction (MBSR) has gained interest as a promising intervention in this domain. Objective: This study aims to evaluate the changes in perceived stress following a 10-week digital MBSR program that combined an app-based digital program with weekly one-on-one remote sessions with a health coach. Methods: This study used a retrospective, observational design. A total of 229 participants with moderate-to-high perceived stress scores as assessed by the Perceived Stress Scale (PSS)-10 enrolled in the 10-week Vida Health MBSR program. The program included weekly remote sessions with a certified health coach and digital content based on concepts fundamental to mindfulness practice. The PSS-10 was used to evaluate perceived stress. Of the 229 participants, 131 (57.2%) were considered program completers and provided at least one follow-up PSS-10. A secondary analysis examined the changes in stress scores at 6 months. This analysis was restricted to participants who had been enrolled in the program for at least 6 months (n=121). To account for random and fixed effects, linear mixed effects modeling was used to assess changes in stress scores over time. An intention-to-treat approach was used to evaluate the changes in perceived stress across the entire study cohort, including those who were lost to follow-up. In addition, a reliable change index was computed to evaluate the changes in scores from the baseline. Results: The findings revealed a significant positive association between program time and stress reduction (B=−0.365; P<.001) at 12 weeks. We observed an average reduction in stress scores of 3.17 points (95% CI −3.93 to −2.44) by program week 6 and 4.86 points (95% CI −5.86 to −3.85) by program week 12. Overall, 83.2% (109/131) of participants showed a reduction in stress scores by week 12, with 40.5% (53/131) of participants showing reliable improvement at 12 weeks and 47.8% (56/131) of participants showing a shift to a lower stress level category (ie, moderate-to-low stress). The intention-to-treat analysis revealed a significant, although attenuated, reduction in stress scores at 12 weeks (B=−0.23; P<.001). Participants who completed more lessons had an increased likelihood of moving down at least one stress level category (odds ratio 1.512, 95% CI 1.056 to 2.166; P=.02). In assessing medium-term outcomes, among participants who had completed at least 6 months in the program, 48.8% (59/121) of members provided a 6-month assessment. We observed a significant reduction in stress scores at 6 months (t58=10.24; P<.001), with 61% (36/59) of participants showing reliable improvement. Conclusions: The findings of this retrospective, observational study suggest that a blended, digital mindfulness-based intervention may support program uptake and meaningful, sustained reduction in stress outcomes. %M 34032571 %R 10.2196/25078 %U https://formative.jmir.org/2021/5/e25078 %U https://doi.org/10.2196/25078 %U http://www.ncbi.nlm.nih.gov/pubmed/34032571 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e25140 %T mHealth Interventions for Self-Harm: Scoping Review %A Cliffe,Bethany %A Tingley,Jessica %A Greenhalgh,Isobel %A Stallard,Paul %+ Department for Health, University of Bath, Claverton Down, Bath, , United Kingdom, 44 01225 388388, bc731@bath.ac.uk %K mHealth %K self-harm %K digital interventions %K self-injury %K NSSI %K mobile phone %D 2021 %7 30.4.2021 %9 Review %J J Med Internet Res %G English %X Background: Self-harm is a growing issue with increasing prevalence rates; however, individuals who self-harm do not often receive treatment. Mobile health (mHealth) interventions are a possible solution to some of the barriers that individuals face when seeking support, and they have also been found to be effective in improving mental health. Thus far, reviews of mHealth interventions for self-harm have been limited by study type. Therefore, we determined that a broader scoping review will provide a more exhaustive understanding of mHealth interventions for self-harm. Objective: This scoping review aims to identify mHealth interventions for self-harm within the literature, understand the types and features of interventions that have been developed and evaluated, highlight research findings around mHealth interventions for self-harm, and determine what outcomes are typically used to assess the efficacy of interventions. Methods: A search was conducted using Embase, PubMed, PsycINFO, PsycEXTRA, Web of Science, and the Cochrane Library. Studies were included if they described an mHealth intervention designed to have a direct (ie, if the intervention was designed for self-harm or for people who self-harm) or indirect (ie, if self-harm was measured as an outcome) treatment effect and if the paper was available in English. There were no exclusion criteria based on the study design. Results: A total of 36 papers were included in the review, and most of them were randomized controlled trials published within the last 4 years. The interventions were mostly smartphone apps and calling or texting services, with 62% (21/34) having underlying therapeutic models to inform the intervention content. They were generally shown to be promising and appealing, but only 5 were widely available for use. Outcomes focused on a reduction of self-harm and suicidality, mood, and the users’ experiences of the intervention. Samples were typically nondiverse, and there was limited variety in the study designs and in the measurements of self-harm recovery. Conclusions: Promising and appealing mHealth interventions have been developed but are not widely available. Research could benefit from greater diversity as well as a broader and more nuanced understanding of recovery from self-harm. %M 33929329 %R 10.2196/25140 %U https://www.jmir.org/2021/4/e25140 %U https://doi.org/10.2196/25140 %U http://www.ncbi.nlm.nih.gov/pubmed/33929329 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e25462 %T Evaluation of the Implementation and Effectiveness of Community-Based Brain-Computer Interface Cognitive Group Training in Healthy Community-Dwelling Older Adults: Randomized Controlled Implementation Trial %A Yeo,Pei Shi %A Nguyen,Tu Ngoc %A Ng,Mary Pei Ern %A Choo,Robin Wai Munn %A Yap,Philip Lin Kiat %A Ng,Tze Pin %A Wee,Shiou Liang %+ Geriatric Education and Research Institute, 2 Yishun Central 2, Tower E, Level 4, Singapore, 768024, Singapore, 65 6592 4606, weeshiouliang@gmail.com %K group-based computerized cognitive training %K cognition %K gait %K community program implementation %K healthy older adults %K cognitive %K community program %K cognitive training %K elderly %K aging %D 2021 %7 27.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Cognitive training can improve cognition in healthy older adults. Objective: The objectives are to evaluate the implementation of community-based computerized cognitive training (CCT) and its effectiveness on cognition, gait, and balance in healthy older adults. Methods: A single-blind randomized controlled trial with baseline and follow-up assessments was conducted at two community centers in Singapore. Healthy community-dwelling adults aged 55 years and older participated in a 10-week CCT program with 2-hour instructor-led group classes twice a week. Participants used a mobile app to play games targeting attention, memory, decision making, visuospatial abilities, and cognitive flexibility. Implementation was assessed at the participant, provider, and community level (eg, reach, implementation, and facilitators and barriers). Effectiveness measures were the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Color Trails Test 2 (CTT-2), Berg Balance Scale, and GAITRite walkway measures (single and dual task gait speed, dual task cost, and single and dual task gait variability index [GVI]). Results: A total of 94 healthy community-dwelling adults participated in the CCT program (mean age 68.8 [SD 6.3] years). Implementation measures revealed high reach (125/155, 80.6%) and moderate adherence but poor penetration of sedentary older adults (43/125, 34.4%). The effectiveness data were based on intention-to-treat (ITT) and per-protocol (PP) analysis. In the ITT analysis, single task GVI increased (b=2.32, P=.02, 95% CI [0.30 to 4.35]) and RBANS list recognition subtest deteriorated (b=–0.57, P=.01, 95% CI [–1.00 to –0.14]) in both groups. In the PP analysis, time taken to complete CTT-2 (b=–13.5, P=.01, 95% CI [–23.95 to –3.14]; Cohen d effect size = 0.285) was faster in the intervention group. Single task gait speed was not statistically significantly maintained in the intervention group (b=5.38, P=.06, 95% CI [–0.30 to 11.36]) and declined in the control group (Cohen d effect size = 0.414). PP analyses also showed interaction terms for RBANS list recall subtest (b=–0.36, P=.08, 95% CI [–0.75 to 0.04]) and visuospatial domain (b=0.46, P=.08, 95% CI [–0.05 to 0.96]) that were not statistically significant. Conclusions: CCT can be implemented in community settings to improve attention and executive function among healthy older adults. Findings help to identify suitable healthy aging programs that can be implemented on a larger scale within communities. Trial Registration: ClinicalTrials.gov NCT04439591; https://clinicaltrials.gov/ct2/show/NCT04439591 %M 33904819 %R 10.2196/25462 %U https://formative.jmir.org/2021/4/e25462 %U https://doi.org/10.2196/25462 %U http://www.ncbi.nlm.nih.gov/pubmed/33904819 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e24180 %T Mobile Sensing Apps and Self-management of Mental Health During the COVID-19 Pandemic: Web-Based Survey %A Suruliraj,Banuchitra %A Bessenyei,Kitti %A Bagnell,Alexa %A McGrath,Patrick %A Wozney,Lori %A Orji,Rita %A Meier,Sandra %+ Department of Psychiatry, Dalhousie University, 5850/5980 University Avenue, PO Box 970, Halifax, NS, B3K 6R8, Canada, 1 782 414 8054, sandra.m.meier@gmail.com %K app %K awareness %K behavior %K COVID-19 %K helpfulness %K mobile health %K mobile sensing %K self-management %K sensing %K web-based survey %D 2021 %7 26.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: During the COVID-19 pandemic, people had to adapt their daily life routines to the currently implemented public health measures, which is likely to have resulted in a lack of in-person social interactions, physical activity, or sleep. Such changes can have a significant impact on mental health. Mobile sensing apps can passively record the daily life routines of people, thus making them aware of maladaptive behavioral adjustments to the pandemic. Objective: This study aimed to explore the views of people on mobile sensing apps that passively record behaviors and their potential to increase awareness and helpfulness for self-managing mental health during the pandemic. Methods: We conducted an anonymous web-based survey including people with and those without mental disorders, asking them to rate the helpfulness of mobile sensing apps for the self-management of mental health during the COVID-19 pandemic. The survey was conducted in May 2020. Results: The majority of participants, particularly those with a mental disorder (n=106/148, 72%), perceived mobile sensing apps as very or extremely helpful for managing their mental health by becoming aware of maladaptive behaviors. The perceived helpfulness of mobile sensing apps was also higher among people who experienced a stronger health impact of the COVID-19 pandemic (β=.24; 95% CI 0.16-0.33; P<.001), had a better understanding of technology (β=.17; 95% CI 0.08-0.25; P<.001), and had a higher education (β=.1; 95% CI 0.02-0.19; P=.02). Conclusions: Our findings highlight the potential of mobile sensing apps to assist in mental health care during the pandemic. %M 33872181 %R 10.2196/24180 %U https://formative.jmir.org/2021/4/e24180 %U https://doi.org/10.2196/24180 %U http://www.ncbi.nlm.nih.gov/pubmed/33872181 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e24482 %T Youth and Provider Perspectives on Behavior-Tracking Mobile Apps: Qualitative Analysis %A Armstrong,Courtney C %A Odukoya,Erica J %A Sundaramurthy,Keerthi %A Darrow,Sabrina M %+ Department of Psychology, University of California, Berkeley, 2121 Berkeley Way, University of California, Berkeley, CA, 94720, United States, 1 9178417015, courtney.armstrong@berkeley.edu %K qualitative %K mHealth %K mobile phone %K behavior monitoring %K youth %D 2021 %7 22.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile health apps stand as one possible means of improving evidence-based mental health interventions for youth. However, a better understanding of youth and provider perspectives is necessary to support widespread implementation. Objective: The objective of this research was to explore both youth and provider perspectives on using mobile apps to enhance evidence-based clinical care, with an emphasis on gathering perspectives on behavior-tracking apps. Methods: Inductive qualitative analysis was conducted on data obtained from semistructured interviews held with 10 youths who received psychotherapy and 12 mental health care providers who conducted therapy with youths aged 13-26 years. Interviews were independently coded by multiple coders and consensus meetings were held to establish reliability. Results: During the interviews, the youths and providers broadly agreed on the benefits of behavior tracking and believed that tracking via app could be more enjoyable and accessible. Providers and youths also shared similar concerns that negative emotions and user burden could limit app usage. Participants also suggested potential app features that, if implemented, would help meet the clinical needs of providers and support long-term use among youth. Such features included having a pleasant user interface, reminders for clients, and graphical output of data to clients and providers. Conclusions: Youths and providers explained that the integration of mobile health into psychotherapy has the potential to make treatment, particularly behavior tracking, easy and more accessible. However, both groups had concerns about the increased burden that could be placed on the clients and providers. %M 33885364 %R 10.2196/24482 %U https://mental.jmir.org/2021/4/e24482 %U https://doi.org/10.2196/24482 %U http://www.ncbi.nlm.nih.gov/pubmed/33885364 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e21678 %T Chatbot-Based Assessment of Employees’ Mental Health: Design Process and Pilot Implementation %A Hungerbuehler,Ines %A Daley,Kate %A Cavanagh,Kate %A Garcia Claro,Heloísa %A Kapps,Michael %+ Vitalk, TNH Health, R. Pais Leme, 215 - Sala 2504, Pinheiros, São Paulo, 05424-150, Brazil, 55 11963883018, drkatedaley@gmail.com %K chatbot %K conversational agent %K online %K digital health %K mobile phone %K mental health %K workplace %K work stress %K survey %K response rate %D 2021 %7 21.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Stress, burnout, and mental health problems such as depression and anxiety are common, and can significantly impact workplaces through absenteeism and reduced productivity. To address this issue, organizations must first understand the extent of the difficulties by mapping the mental health of their workforce. Online surveys are a cost-effective and scalable approach to achieve this but typically have low response rates, in part due to a lack of interactivity. Chatbots offer one potential solution, enhancing engagement through simulated natural human conversation and use of interactive features. Objective: The aim of this study was to explore if a text-based chatbot is a feasible approach to engage and motivate employees to complete a workplace mental health assessment. This paper describes the design process and results of a pilot implementation. Methods: A fully automated chatbot (“Viki”) was developed to evaluate employee risks of suffering from depression, anxiety, stress, insomnia, burnout, and work-related stress. Viki uses a conversation style and gamification features to enhance engagement. A cross-sectional analysis was performed to gain first insights of a pilot implementation within a small to medium–sized enterprise (120 employees). Results: The response rate was 64.2% (77/120). In total, 98 employees started the assessment, 77 of whom (79%) completed it. The majority of participants scored in the mild range for anxiety (20/40, 50%) and depression (16/28, 57%), in the moderate range for stress (10/22, 46%), and at the subthreshold level for insomnia (14/20, 70%) as defined by their questionnaire scores. Conclusions: A chatbot-based workplace mental health assessment seems to be a highly engaging and effective way to collect anonymized mental health data among employees with response rates comparable to those of face-to-face interviews. %M 33881403 %R 10.2196/21678 %U https://formative.jmir.org/2021/4/e21678 %U https://doi.org/10.2196/21678 %U http://www.ncbi.nlm.nih.gov/pubmed/33881403 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e25358 %T Participant Perceptions of Facilitators and Barriers to Adherence in a Digital Mental Health Intervention for a Nonclinical Cohort: Content Analysis %A Renfrew,Melanie Elise %A Morton,Darren Peter %A Northcote,Maria %A Morton,Jason Kyle %A Hinze,Jason Scott %A Przybylko,Geraldine %+ Lifestyle Medicine and Health Research Centre, Avondale University College, 582 Freemans Drive, Cooranbong, NSW, 2265, Australia, 61 405445151, melanie.renfrew@avondale.edu.au %K web-based mental health %K health promotion %K eHealth %K adherence %K participant perceptions %K mobile phone %D 2021 %7 14.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital mental health promotion interventions (MHPIs) present a scalable opportunity to attenuate the risk of mental health distress among nonclinical cohorts. However, adherence is frequently suboptimal, and little is known about participants’ perspectives concerning facilitators and barriers to adherence in community-based settings. Objective: This study aimed to examine participants’ perceptions of facilitators and barriers to adherence in a web- and mobile app–based MHPI for a nonclinical cohort. Methods: This qualitative study used inductive, reflexive thematic analysis to explore free-text responses in a postintervention evaluation of a 10-week digital MHPI. The intervention was administered using a web and mobile app from September to December 2018. Participants (N=320) were Australian and New Zealand members of a faith-based organization who self-selected into the study, owned a mobile phone with messaging capability, had an email address and internet access, were fluent in English, provided informed consent, and gave permission for their data to be used for research. The postintervention questionnaire elicited participants’ perceptions of facilitators and barriers to adherence during the intervention period. Results: Key factors that facilitated adherence were engaging content, time availability and management, ease of accessibility, easy or enjoyable practical challenges, high perceived value, and personal motivation to complete the intervention. The primary perceived barrier to adherence was the participants’ lack of time. Other barriers included completing and recording practical activities, length of video content, technical difficulties, and a combination of personal factors. Conclusions: Time scarcity was the foremost issue for the nonclinical cohort engaged in this digital MHPI. Program developers should streamline digital interventions to minimize the time investment for participants. This may include condensed content, optimization of intuitive web and app design, simplified recording of activities, and greater participant autonomy in choosing optional features. Nonetheless, participants identified a multiplicity of other interindividual factors that facilitated or inhibited adherence. %M 33851925 %R 10.2196/25358 %U https://www.jmir.org/2021/4/e25358 %U https://doi.org/10.2196/25358 %U http://www.ncbi.nlm.nih.gov/pubmed/33851925 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e20424 %T A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach %A Jonathan,Geneva K %A Dopke,Cynthia A %A Michaels,Tania %A Bank,Andrew %A Martin,Clair R %A Adhikari,Krina %A Krakauer,Rachel L %A Ryan,Chloe %A McBride,Alyssa %A Babington,Pamela %A Frauenhofer,Ella %A Silver,Jamilah %A Capra,Courtney %A Simon,Melanie %A Begale,Mark %A Mohr,David C %A Goulding,Evan H %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States, 1 3125031189, e-goulding@fsm.northwestern.edu %K behavioral intervention technology %K mHealth %K bipolar disorder %K depression %K illness management %K smartphone %K behavior change %K early warning signs %K self-management %K qualitative %D 2021 %7 12.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. Objective: This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions. Methods: Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback. Results: The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support. Conclusions: User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development. %M 33843607 %R 10.2196/20424 %U https://mental.jmir.org/2021/4/e20424 %U https://doi.org/10.2196/20424 %U http://www.ncbi.nlm.nih.gov/pubmed/33843607 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e26562 %T Technology-Based Psychological Interventions for Young Adults With Early Psychosis and Cannabis Use Disorder: Qualitative Study of Patient and Clinician Perspectives %A Tatar,Ovidiu %A Abdel-Baki,Amal %A Tra,Christophe %A Mongeau-Pérusse,Violaine %A Arruda,Nelson %A Kaur,Navdeep %A Landry,Vivianne %A Coronado-Montoya,Stephanie %A Jutras-Aswad,Didier %+ Research Center, Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 St-Denis Street Viger Tower, 5th floor, room R05.740, Montreal, QC, H2X 1P1, Canada, 1 514 890 8000 ext 35703, didier.jutras-aswad@umontreal.ca %K psychology %K intervention %K cannabis misuse %K cannabis use disorder %K young adult %K clinician %K psychosis %K schizophrenia %K dual diagnosis %K qualitative %K acceptability %K technology-based %K telemedicine %K mHealth %K digital health %K eHealth %K application %K smartphone %K mobile phone %D 2021 %7 5.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The persistence of cannabis use disorder (CUD) in young adults with first-episode psychosis (FEP) is associated with poor clinical and functional outcomes. Face-to-face psychological interventions are effective in treating CUD. However, their use in early intervention services (EISs) for psychosis is inconsistent because of barriers, including high workload and heterogeneity in training of clinicians and lack of motivation for treatment among patients. Tailoring new technology-based psychological interventions (TBPIs) to overcome these barriers is necessary to ensure their optimal acceptability. Objective: The aim of this study is twofold: to explore psychological intervention practices and intervention targets that are relevant for treating CUD in individuals with early psychosis and to explore factors related to the development and implementation of a technology-assisted psychological intervention. Methods: A total of 10 patients undergoing treatment for FEP and CUD in EISs participated in a focus group in June 2019. Semistructured individual interviews were conducted with 10 clinicians working in first-episode clinics in the province of Québec, Canada. A hybrid inductive-deductive approach was used to analyze data. For the deductive analysis, we used categories of promoting strategies found in the literature shown to increase adherence to web-based interventions for substance use (ie, tailoring, reminders, delivery strategies, social support, and incentives). For the inductive analysis, we identified new themes through an iterative process of reviewing the data multiple times by two independent reviewers. Results: Data were synthesized into five categories of factors that emerged from data collection, and a narrative synthesis of commonalities and differences between patient and clinician perspectives was produced. The categories included attitudes and beliefs related to psychological interventions (eg, behavioral stage of change), strategies for psychological interventions (eg, motivational interviewing, cognitive behavioral therapy, psychoeducation, stress management), incentives (eg, contingency management), general interest in TBPIs (eg, facilitators and barriers of TBPIs), and tailoring of TBPIs (eg, application needs and preferences, outcome measures of interest for clinicians). Conclusions: This study provides a comprehensive portrait of the multifaceted needs and preferences of patients and clinicians related to TBPIs. Our results can inform the development of smartphone- or web-based psychological interventions for CUD in young adults with early psychosis. %M 33818397 %R 10.2196/26562 %U https://formative.jmir.org/2021/4/e26562 %U https://doi.org/10.2196/26562 %U http://www.ncbi.nlm.nih.gov/pubmed/33818397 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e23447 %T Postsecondary Student Engagement With a Mental Health App and Online Platform (Thought Spot): Qualitative Study of User Experience %A Wong,Howard W %A Lo,Brian %A Shi,Jenny %A Hollenberg,Elisa %A Abi-Jaoude,Alexxa %A Johnson,Andrew %A Chaim,Gloria %A Cleverley,Kristin %A Henderson,Joanna %A Levinson,Andrea %A Robb,Janine %A Voineskos,Aristotle %A Wiljer,David %+ UHN Digital, University Health Network, R. Fraser Elliott Building RFE 3-411, 190 Elizabeth Street, Toronto, ON, M5G 2C4, Canada, 1 416 340 6322, david.wiljer@uhn.ca %K transition-aged youth %K qualitative study %K user experience %K help-seeking %K mental health %K postsecondary %K mobile apps %K adolescent %D 2021 %7 2.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is growing interest in using mobile apps and online tools to support postsecondary student mental health, but most of these solutions have suboptimal user engagement in real-world settings. Poor engagement can limit long-term effectiveness and usefulness of these tools. Previous literature has proposed several theories that link factors such as low usability and poor user-centered design to app disengagement. However, few studies provide direct evidence showing what factors contribute to suboptimal user engagement in the context of mobile mental health apps for postsecondary students. Objective: This study focuses on understanding postsecondary students’ attitudes and behaviors when using Thought Spot, a co-designed mental health app and online platform, to understand factors related to engagement and user experience. Methods: Students who were given access to Thought Spot for 6 months during a randomized trial of the intervention were invited to participate in one-on-one semistructured interviews. The interviews explored participants’ overall experiences and perceptions of the app, along with factors that affected their usage of various features. All interviews were recorded, and template analysis was used to analyze transcripts. Results: User satisfaction was mixed among users of Thought Spot. The degree of engagement with the app appeared to be affected by factors that can be grouped into 5 themes: (1) Students valued detailed, inclusive, and relevant content; (2) Technical glitches and a lack of integration with other apps affected the overall user experience and satisfaction with the app; (3) Using the app to support peers or family can increase engagement; (4) Crowdsourced information from peers about mental health resources drove user engagement, but was difficult to obtain; and (5) Users often turned to the app when they had an immediate need for mental health information, rather than using it to track mental health information over time. Conclusions: Content, user experience, user-centeredness, and peer support are important determinants of user engagement with mobile mental health apps among postsecondary students. In this study, participants disengaged when the app did not meet their expectations on these determinants. Future studies on user engagement should further explore the effectiveness of different features and the relative importance of various criteria for high-quality apps. Further focus on these issues may inform the creation of interventions that increase student engagement and align with their mental health needs. Trial Registration: ClinicalTrials.gov NCT03412461; https://clinicaltrials.gov/ct2/show/NCT03412461 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.6446 %M 33797395 %R 10.2196/23447 %U https://mental.jmir.org/2021/4/e23447 %U https://doi.org/10.2196/23447 %U http://www.ncbi.nlm.nih.gov/pubmed/33797395 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e25810 %T Development of Coaching Support for LiveWell: A Smartphone-Based Self-Management Intervention for Bipolar Disorder %A Dopke,Cynthia A %A McBride,Alyssa %A Babington,Pamela %A Jonathan,Geneva K %A Michaels,Tania %A Ryan,Chloe %A Duffecy,Jennifer %A Mohr,David C %A Goulding,Evan H %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 303 E Chicago Ave., Suite 7-102, Chicago, IL, 60611, United States, 1 3125031189, e-goulding@fsm.northwestern.edu %K human support %K adherence %K self-management %K behavior change %K mHealth %K bipolar disorder %D 2021 %7 24.3.2021 %9 Viewpoint %J JMIR Form Res %G English %X Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to recurrence of episodes, long episode durations, and persistence of interepisode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates, with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, timing of delivery, and the training and supervision for coaching support of the LiveWell technology. This support includes clearly defined and structured roles that aim to encourage the use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention. %M 33759798 %R 10.2196/25810 %U https://formative.jmir.org/2021/3/e25810 %U https://doi.org/10.2196/25810 %U http://www.ncbi.nlm.nih.gov/pubmed/33759798 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24387 %T Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review %A Borghouts,Judith %A Eikey,Elizabeth %A Mark,Gloria %A De Leon,Cinthia %A Schueller,Stephen M %A Schneider,Margaret %A Stadnick,Nicole %A Zheng,Kai %A Mukamel,Dana %A Sorkin,Dara H %+ University of California Irvine, 6210 Donald Bren Hall, Irvine, CA, 92697-3425, United States, 1 9498240246, jborghou@uci.edu %K mHealth %K eHealth %K mental health %K depression %K anxiety %K behavior %K mobile phone %D 2021 %7 24.3.2021 %9 Review %J J Med Internet Res %G English %X Background: Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions. Objective: This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs. Methods: A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included. Results: A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health. Conclusions: Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions. %M 33759801 %R 10.2196/24387 %U https://www.jmir.org/2021/3/e24387 %U https://doi.org/10.2196/24387 %U http://www.ncbi.nlm.nih.gov/pubmed/33759801 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24023 %T Development of a Smartphone App to Predict and Improve the Rates of Suicidal Ideation Among Transgender Persons (TransLife): Qualitative Study %A Dubov,Alex %A Fraenkel,Liana %A Goldstein,Zil %A Arroyo,Hansel %A McKellar,Derek %A Shoptaw,Steve %+ School of Behavioral Health, Loma Linda University, 11065 Campus Street, Loma Linda, CA, 92350, United States, 1 9095581900, adubov@llu.edu %K mobile health %K mHealth %K mobile app %K pilot study %K qualitative research %K user-centered design %K acceptability study %K health services for transgender persons %K suicide prevention %K mental health %K mobile phone %D 2021 %7 24.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Transgender people are at a high risk of suicidal ideation, suicide attempts, and deaths. Among transgender individuals, 77% and 41% engage in suicidal ideation and suicide attempt in their lifetime, respectively, which exceeds the general population rates (9.2% and 2.7%, respectively). Traditionally, suicide risk factors have been studied over a long period between measurements, making it difficult to understand the short-term variability in suicide risk. Mobile phone apps offer an opportunity to understand the immediate precursors of suicidality through the assessment of behaviors and moods in real time. This is the first study to use a mobile phone app (TransLife) to understand the short-term risk factors for suicide among transgender individuals. Objective: This study aims to beta test the usability of an evidence-informed mobile health (mHealth) suicide prevention phone app, TransLife. The primary aims are to obtain preliminary data on user engagement and satisfaction with the app, and to assess the feasibility of completing ecological momentary assessments (mood logs) within the app. Methods: We used qualitative methods and an exploratory research approach that combined naturalistic app use, focus groups, and semistructured phone interviews. The focus group was informed about the development of the prototype. We conducted a 3-week evaluation to determine engagement and obtain detailed user feedback about the app. After participation in the pilot, phone-based, semistructured, and audio-recorded exit interviews were conducted with the research participants. Results: In total, 16 transgender individuals participated in this study. On average, users logged in 4 (SD 2.7) times a week and spent approximately 5 (SD 3.5) minutes on the app per log-in. A total of 6 major themes emerged in this study. These themes focused on the app’s functionality, satisfaction with using the app, perceived ease of use, perceived safety of providing personal data within the app, trusting the app enough to share personal feelings, and features that make this app engaging. These themes suggest that TransLife is an engaging, useful, and acceptable mHealth intervention. Participants reported that the app was easy to use and understand, supported mental self-care, promoted self-awareness, and helped them identify triggers of negative moods. Conclusions: The results of this pilot study indicate that TransLife is an engaging, acceptable, and potentially effective mHealth intervention. Transgender participants reported many advantages of using TransLife, such as being able to track their mood, connecting to the community, and accessing local resources. This study provides initial support for the acceptability and usability of TransLife as an mHealth intervention designed for the transgender community. %M 33596181 %R 10.2196/24023 %U https://www.jmir.org/2021/3/e24023 %U https://doi.org/10.2196/24023 %U http://www.ncbi.nlm.nih.gov/pubmed/33596181 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e24465 %T Predicting Emotional States Using Behavioral Markers Derived From Passively Sensed Data: Data-Driven Machine Learning Approach %A Sükei,Emese %A Norbury,Agnes %A Perez-Rodriguez,M Mercedes %A Olmos,Pablo M %A Artés,Antonio %+ Signal Theory and Communications Department, Universidad Carlos III de Madrid, Torres Quevedo Bldg, Av de la Universidad, 30, Leganés, 28911, Spain, 34 916248839, esukei@tsc.uc3m.es %K mental health %K affect %K mobile health %K mobile phone %K digital phenotype %K machine learning %K Bayesian analysis %K probabilistic models %K personalized models %D 2021 %7 22.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health disorders affect multiple aspects of patients’ lives, including mood, cognition, and behavior. eHealth and mobile health (mHealth) technologies enable rich sets of information to be collected noninvasively, representing a promising opportunity to construct behavioral markers of mental health. Combining such data with self-reported information about psychological symptoms may provide a more comprehensive and contextualized view of a patient’s mental state than questionnaire data alone. However, mobile sensed data are usually noisy and incomplete, with significant amounts of missing observations. Therefore, recognizing the clinical potential of mHealth tools depends critically on developing methods to cope with such data issues. Objective: This study aims to present a machine learning–based approach for emotional state prediction that uses passively collected data from mobile phones and wearable devices and self-reported emotions. The proposed methods must cope with high-dimensional and heterogeneous time-series data with a large percentage of missing observations. Methods: Passively sensed behavior and self-reported emotional state data from a cohort of 943 individuals (outpatients recruited from community clinics) were available for analysis. All patients had at least 30 days’ worth of naturally occurring behavior observations, including information about physical activity, geolocation, sleep, and smartphone app use. These regularly sampled but frequently missing and heterogeneous time series were analyzed with the following probabilistic latent variable models for data averaging and feature extraction: mixture model (MM) and hidden Markov model (HMM). The extracted features were then combined with a classifier to predict emotional state. A variety of classical machine learning methods and recurrent neural networks were compared. Finally, a personalized Bayesian model was proposed to improve performance by considering the individual differences in the data and applying a different classifier bias term for each patient. Results: Probabilistic generative models proved to be good preprocessing and feature extractor tools for data with large percentages of missing observations. Models that took into account the posterior probabilities of the MM and HMM latent states outperformed those that did not by more than 20%, suggesting that the underlying behavioral patterns identified were meaningful for individuals’ overall emotional state. The best performing generalized models achieved a 0.81 area under the curve of the receiver operating characteristic and 0.71 area under the precision-recall curve when predicting self-reported emotional valence from behavior in held-out test data. Moreover, the proposed personalized models demonstrated that accounting for individual differences through a simple hierarchical model can substantially improve emotional state prediction performance without relying on previous days’ data. Conclusions: These findings demonstrate the feasibility of designing machine learning models for predicting emotional states from mobile sensing data capable of dealing with heterogeneous data with large numbers of missing observations. Such models may represent valuable tools for clinicians to monitor patients’ mood states. %M 33749612 %R 10.2196/24465 %U https://mhealth.jmir.org/2021/3/e24465 %U https://doi.org/10.2196/24465 %U http://www.ncbi.nlm.nih.gov/pubmed/33749612 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e23144 %T Investigating Associations Between Screen Time and Symptomatology in Individuals With Serious Mental Illness: Longitudinal Observational Study %A Henson,Philip %A Rodriguez-Villa,Elena %A Torous,John %+ Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Fenwood Rd, Office 618, Boston, MA, 02115, United States, 1 6177541213, jtorous@bidmc.harvard.edu %K mHealth %K schizophrenia %K apps %K mobile %K screen time %D 2021 %7 10.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Increasing screen time exposure from digital devices like smartphones has shown a variety of mixed associations with cognition, behavior, and well-being in adults and children but little is known about its associations with symptomatology in individuals with serious mental illness. Objective: To determine the range of associations between screen time and symptoms of individuals with mental illness, we utilized a method called specification curve analysis. Methods: In this observational study, we recruited smartphone-owning adults (≥18 years old) with schizophrenia and healthy controls. We installed 2 research-source smartphone apps, mindLAMP and Beiwe, to collect survey results, cognitive test results, and screen time metrics over a period of 3 months. Surveys were scheduled for twice a week, but participants were instructed to take the surveys naturally as much or as little as they wanted. Screen time was collected continuously in the background. A total of 140 participants was recruited from the outpatient clinic population as well as through general public advertising. Age-matched, smartphone-owning healthy controls were also part of the recruitment pool. A specification curve analysis was a priori designed to explore the relationship between every combination of independent variable and dependent variable in order to demonstrate to what degree screen time relates to symptoms in individuals with serious mental illness. Results: The sample consisted of 88 participants (54 with schizophrenia and 34 healthy controls) who completed both the initial and follow-up visits, completed at least one self-reported survey, and had a minimum passive data cutoff of 5 consecutive days. While we found an association between smartphone screen time metrics and cognition (adjusted R2=0.107, P<.001), specification curve analysis revealed a wide range of heterogenous associations with screen time from very negative to very positive. The effects differed based on diagnostic group, age bracket, type of regression model used, and the specific independent and dependent variables selected for analysis. Conclusions: The associations between screen time and mental health in patients with schizophrenia are heterogenous when examined with methods that reduce analytical bias. The heterogeneity in associations suggests that complex and personalized potential effects must be understood in the greater context of an individual. This analysis of longitudinally collected screen time data shows potential for future research that could benefit from high resolution metrics on smartphone use. %M 33688835 %R 10.2196/23144 %U https://www.jmir.org/2021/3/e23144 %U https://doi.org/10.2196/23144 %U http://www.ncbi.nlm.nih.gov/pubmed/33688835 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e24365 %T Tracking and Monitoring Mood Stability of Patients With Major Depressive Disorder by Machine Learning Models Using Passive Digital Data: Prospective Naturalistic Multicenter Study %A Bai,Ran %A Xiao,Le %A Guo,Yu %A Zhu,Xuequan %A Li,Nanxi %A Wang,Yashen %A Chen,Qinqin %A Feng,Lei %A Wang,Yinghua %A Yu,Xiangyi %A Wang,Chunxue %A Hu,Yongdong %A Liu,Zhandong %A Xie,Haiyong %A Wang,Gang %+ The National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, No 5 Ankang Lane, Xicheng District, Beijing, 100088, China, 86 13466604224, gangwangdoc@ccmu.edu.cn %K digital phenotype %K major depressive disorder %K machine learning %K mobile phone %D 2021 %7 8.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Major depressive disorder (MDD) is a common mental illness characterized by persistent sadness and a loss of interest in activities. Using smartphones and wearable devices to monitor the mental condition of patients with MDD has been examined in several studies. However, few studies have used passively collected data to monitor mood changes over time. Objective: The aim of this study is to examine the feasibility of monitoring mood status and stability of patients with MDD using machine learning models trained by passively collected data, including phone use data, sleep data, and step count data. Methods: We constructed 950 data samples representing time spans during three consecutive Patient Health Questionnaire-9 assessments. Each data sample was labeled as Steady or Mood Swing, with subgroups Steady-remission, Steady-depressed, Mood Swing-drastic, and Mood Swing-moderate based on patients’ Patient Health Questionnaire-9 scores from three visits. A total of 252 features were extracted, and 4 feature selection models were applied; 6 different combinations of types of data were experimented with using 6 different machine learning models. Results: A total of 334 participants with MDD were enrolled in this study. The highest average accuracy of classification between Steady and Mood Swing was 76.67% (SD 8.47%) and that of recall was 90.44% (SD 6.93%), with features from all types of data being used. Among the 6 combinations of types of data we experimented with, the overall best combination was using call logs, sleep data, step count data, and heart rate data. The accuracies of predicting between Steady-remission and Mood Swing-drastic, Steady-remission and Mood Swing-moderate, and Steady-depressed and Mood Swing-drastic were over 80%, and the accuracy of predicting between Steady-depressed and Mood Swing-moderate and the overall Steady to Mood Swing classification accuracy were over 75%. Comparing all 6 aforementioned combinations, we found that the overall prediction accuracies between Steady-remission and Mood Swing (drastic and moderate) are better than those between Steady-depressed and Mood Swing (drastic and moderate). Conclusions: Our proposed method could be used to monitor mood changes in patients with MDD with promising accuracy by using passively collected data, which can be used as a reference by doctors for adjusting treatment plans or for warning patients and their guardians of a relapse. Trial Registration: Chinese Clinical Trial Registry ChiCTR1900021461; http://www.chictr.org.cn/showprojen.aspx?proj=36173 %M 33683207 %R 10.2196/24365 %U https://mhealth.jmir.org/2021/3/e24365 %U https://doi.org/10.2196/24365 %U http://www.ncbi.nlm.nih.gov/pubmed/33683207 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e26550 %T Digital Interventions to Support Population Mental Health in Canada During the COVID-19 Pandemic: Rapid Review %A Strudwick,Gillian %A Sockalingam,Sanjeev %A Kassam,Iman %A Sequeira,Lydia %A Bonato,Sarah %A Youssef,Alaa %A Mehta,Rohan %A Green,Nadia %A Agic,Branka %A Soklaridis,Sophie %A Impey,Danielle %A Wiljer,David %A Crawford,Allison %+ Centre for Addiction and Mental Health, 1001 Queen St W, Toronto, ON, M6J 1H4, Canada, 1 416 535 8501, gillian.strudwick@camh.ca %K digital health %K psychiatry %K mental health %K informatics %K pandemic %K COVID-19 %K telemedicine %K eHealth %K public health %K virtual care %K mobile apps %K population health %D 2021 %7 2.3.2021 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has resulted in a number of negative health related consequences, including impacts on mental health. More than 22% of Canadians reported that they had felt depressed in the last week, in response to a December 2020 national survey. Given the need to physically distance during the pandemic, and the increase in demand for mental health services, digital interventions that support mental health and wellness may be beneficial. Objective: The purpose of this research was to identify digital interventions that could be used to support the mental health of the Canadian general population during the COVID-19 pandemic. The objectives were to identify (1) the populations these interventions were developed for, inclusive of exploring areas of equity such as socioeconomic status, sex/gender, race/ethnicity and culture, and relevance to Indigenous peoples and communities; (2) the effect of the interventions; and (3) any barriers or facilitators to the use of the intervention. Methods: This study was completed using a Cochrane Rapid Review methodology. A search of Embase, PsycInfo, Medline, and Web of Science, along with Google, Million Short, and popular mobile app libraries, was conducted. Two screeners were involved in applying inclusion criteria using Covidence software. Academic articles and mobile apps identified were screened using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields resource, the American Psychiatric Association App Evaluation Framework, and the Mental Health Commission of Canada’s guidance on app assessment and selection. Results: A total of 31 mobile apps and 114 web-based resources (eg, telemedicine, virtual peer support groups, discussion forums, etc) that could be used to support the mental health of the Canadian population during the pandemic were identified. These resources have been listed on a publicly available website along with search tags that may help an individual make a suitable selection. Variability exists in the populations that the interventions were developed for, and little assessment has been done with regard to areas of equity. The effect of the interventions was not reported for all those identified in this synthesis; however, for those that did report the effect, it was shown that they were effective in the context that they were used. A number of barriers and facilitators to using these interventions were identified, such as access, cost, and connectivity. Conclusions: A number of digital interventions that could support population mental health in Canada during the global COVID-19 pandemic were identified, indicating that individuals have several options to choose from. These interventions vary in their purpose, approach, design, cost, and targeted user group. While some research and digital interventions addressed equity-related considerations, more research and focused attention should be given to this area. %M 33650985 %R 10.2196/26550 %U https://mental.jmir.org/2021/3/e26550 %U https://doi.org/10.2196/26550 %U http://www.ncbi.nlm.nih.gov/pubmed/33650985 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e23022 %T Using a Tablet-Based App to Deliver Evidence-Based Practices for Suicidal Patients in the Emergency Department: Pilot Randomized Controlled Trial %A Dimeff,Linda A %A Jobes,David A %A Koerner,Kelly %A Kako,Nadia %A Jerome,Topher %A Kelley-Brimer,Angela %A Boudreaux,Edwin D %A Beadnell,Blair %A Goering,Paul %A Witterholt,Suzanne %A Melin,Gabrielle %A Samike,Vicki %A Schak,Kathryn M %+ Evidence Based Practice Institute, Inc, 7241 36th Avenue SW, Seattle, WA, 98126, United States, 1 206 284 7371, linda.dimeff@jasprhealth.com %K suicide %K emergency department %K digital technology %K suicide prevention %D 2021 %7 1.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emergency departments (EDs) have the potential to provide evidence-based practices for suicide prevention to patients who are acutely suicidal. However, few EDs have adequate time and personnel resources to deliver recommended evidence-based assessment and interventions. To raise the clinical standard of care for patients who are suicidal and seeking psychiatric crisis services in the ED, we developed Jaspr Health, a tablet-based app for direct use by such patients, which enables the delivery of 4 evidence-based practices. Objective: This study aims to evaluate the feasibility, acceptability, and effectiveness of Jaspr Health among suicidal adults in EDs. Methods: Patients who were acutely suicidal and seeking psychiatric crisis services participated in an unblinded pilot randomized controlled trial while in the ED. Participants were randomly assigned to Jaspr Health (n=14) or care as usual (control; n=17) groups. Participants were assessed at baseline, and a 2-hour posttest using self-report measures and a semistructured interview were conducted. Results: Conditions differed significantly at baseline with regard to age but not other demographic variables or baseline measures. On average, participants had been in the ED for 17 hours before enrolling in the study. Over their lifetime, 84% (26/31) of the sample had made a suicide attempt (mean 3.4, SD 6.4) and 61% (19/31) had engaged in nonsuicidal self-injurious behaviors, with an average rate of 8.8 times in the past 3 months. All established feasibility and acceptability criteria were met: no adverse events occurred, participants’ app use was high, Jaspr Health app user satisfaction ratings were high, and all participants using Jaspr Health recommended its use for other suicidal ED patients. Comparisons between study conditions provide preliminary support for the effectiveness of the app: participants using Jaspr Health reported a statistically significant increase in receiving 4 evidence-based suicide prevention interventions and overall satisfaction ratings with their ED experience. In addition, significant decreases in distress and agitation, along with significant increases in learning to cope more effectively with current and future suicidal thoughts, were observed among participants using Jaspr Health compared with those receiving care as usual. Conclusions: Even with limited statistical power, the results showed that Jaspr Health is feasible, acceptable, and clinically effective for use by ED patients who are acutely suicidal and seeking ED-based psychiatric crisis services. Trial Registration: ClinicalTrials.gov NCT03584386; https://clinicaltrials.gov/ct2/show/NCT03584386 %M 33646129 %R 10.2196/23022 %U https://mental.jmir.org/2021/3/e23022 %U https://doi.org/10.2196/23022 %U http://www.ncbi.nlm.nih.gov/pubmed/33646129 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e18172 %T Co-Designing a Mobile App to Improve Mental Health and Well-Being: Focus Group Study %A Alqahtani,Felwah %A Winn,Andrea %A Orji,Rita %+ Faculty of Computer Science, Dalhousie University, 6299 South St, Halifax, NS, B3H 4R2, Canada, 1 9027892230, Felwah.alqahtani@dal.ca %K mental health %K mobile app %K focus groups %K design recommendation %K mobile phone %D 2021 %7 26.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Recent advances in mobile technology have created opportunities to develop mobile apps to aid and assist people in achieving various health and wellness goals. Mental health apps hold significant potential to assist people affected by various mental health issues at any time they may need it, considering the ubiquitous nature of mobile phones. However, there is a need for research to explore and understand end users’ perceptions, needs, and concerns with respect to such technologies. Objective: The aim of this paper is to explore the opinions, perceptions, preferences, and experiences of people who have experienced some form of mental health issues based on self-diagnosis to inform the design of a next-generation mental health app that would be substantially more engaging and effective than the currently available apps to improve mental health and well-being. Methods: We conducted six focus group sessions with people who had experienced mental health issues based on self-diagnosis (average age 26.7 years, SD 23.63; 16/32, 50% male; 16/32, 50% female). We asked participants about their experiences with mental health issues and their viewpoints regarding two existing mental health apps (the Happify app and the Self-Help Anxiety Management app). Finally, participants were engaged in a design session where they each sketched a design for their ideal mental health and well-being mobile app. Results: Our findings revealed that participants used strategies to deal with their mental health issues: doing something to distract themselves from their current negative mood, using relaxation exercises and methods to relieve symptoms, interacting with others to share their issues, looking for an external source to solve their problems, and motivating themselves by repeating motivational sentences to support themselves or by following inspirational people. Moreover, regarding the design of mental health apps, participants identified that general design characteristics; personalization of the app, including tracking and feedback, live support, and social community; and providing motivational content and relaxation exercises are the most important features that users want in a mental health app. In contrast, games, relaxation audio, the Google map function, personal assistance to provide suggestions, goal setting, and privacy preservation were surprisingly the least requested features. Conclusions: Understanding end users’ needs and concerns about mental health apps will inform the future design of mental health apps that are useful to and used by many people. %M 33635281 %R 10.2196/18172 %U https://formative.jmir.org/2021/2/e18172 %U https://doi.org/10.2196/18172 %U http://www.ncbi.nlm.nih.gov/pubmed/33635281 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e20329 %T Induction of Efficacy Expectancies in an Ambulatory Smartphone-Based Digital Placebo Mental Health Intervention: Randomized Controlled Trial %A Stalujanis,Esther %A Neufeld,Joel %A Glaus Stalder,Martina %A Belardi,Angelo %A Tegethoff,Marion %A Meinlschmidt,Gunther %+ Department of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University Berlin, Stromstraße 1, Berlin, 10555, Germany, 49 30 300117 710, gunther.meinlschmidt@ipu-berlin.de %K digital placebo effect %K efficacy expectancies %K ecological momentary assessment %K mHealth %K mobile phone %K placebo effect %K randomized controlled trial %K smartphone-based intervention %D 2021 %7 17.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is certain evidence on the efficacy of smartphone-based mental health interventions. However, the mechanisms of action remain unclear. Placebo effects contribute to the efficacy of face-to-face mental health interventions and may also be a potential mechanism of action in smartphone-based interventions. Objective: This study aimed to investigate whether different types of efficacy expectancies as potential factors underlying placebo effects could be successfully induced in a smartphone-based digital placebo mental health intervention, ostensibly targeting mood and stress. Methods: We conducted a randomized, controlled, single-blinded, superiority trial with a multi-arm parallel design. Participants underwent an Android smartphone-based digital placebo mental health intervention for 20 days. We induced prospective efficacy expectancies via initial instructions on the purpose of the intervention and retrospective efficacy expectancies via feedback on the success of the intervention at days 1, 4, 7, 10, and 13. A total of 132 healthy participants were randomized to a prospective expectancy–only condition (n=33), a retrospective expectancy–only condition (n=33), a combined expectancy condition (n=34), or a control condition (n=32). As the endpoint, we assessed changes in efficacy expectancies with the Credibility Expectancy Questionnaire, before the intervention and on days 1, 7, 14, and 20. For statistical analyses, we used a random effects model for the intention-to-treat sample, with intervention day as time variable and condition as two factors: prospective expectancy (yes vs no) and retrospective expectancy (yes vs no), allowed to vary over participant and intervention day. Results: Credibility (β=−1.63; 95% CI −2.37 to −0.89; P<.001) and expectancy (β=−0.77; 95% CI −1.49 to −0.05; P=.04) decreased across the intervention days. For credibility and expectancy, we found significant three-way interactions: intervention day×prospective expectancy×retrospective expectancy (credibility: β=2.05; 95% CI 0.60-3.50; P=.006; expectancy: β=1.55; 95% CI 0.14-2.95; P=.03), suggesting that efficacy expectancies decreased least in the combined expectancy condition and the control condition. Conclusions: To our knowledge, this is the first empirical study investigating whether efficacy expectancies can be successfully induced in a specifically designed placebo smartphone-based mental health intervention. Our findings may pave the way to diminish or exploit digital placebo effects and help to improve the efficacy of digital mental health interventions. Trial Registration: Clinicaltrials.gov NCT02365220; https://clinicaltrials.gov/ct2/show/NCT02365220. %M 33594991 %R 10.2196/20329 %U http://mhealth.jmir.org/2021/2/e20329/ %U https://doi.org/10.2196/20329 %U http://www.ncbi.nlm.nih.gov/pubmed/33594991 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e20213 %T Blending Cognitive Analytic Therapy With a Digital Support Tool: Mixed Methods Study Involving a User-Centered Design of a Prototype App %A Easton,Katherine %A Kellett,Stephen %A Cooper,Martin %A Millings,Abigail %A Varela,Jo %A Parry,Glenys %+ School of Education, University of Sheffield, 241 Glossop Rd, Sheffield, S10 2GW, United Kingdom, 44 114 222 817, k.a.easton@sheffield.ac.uk %K cognitive analytic therapy %K digital app %K relational awareness %K user-centered design %K acceptability %K user testing %D 2021 %7 1.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Patients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks. Objective: We aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the “recognition” phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress. Methods: A national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients. Results: Among the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app. Conclusions: The user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective. %M 33522979 %R 10.2196/20213 %U https://mental.jmir.org/2021/2/e20213 %U https://doi.org/10.2196/20213 %U http://www.ncbi.nlm.nih.gov/pubmed/33522979 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e22723 %T Smartphone-Detected Ambient Speech and Self-Reported Measures of Anxiety and Depression: Exploratory Observational Study %A Di Matteo,Daniel %A Wang,Wendy %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 mobile sensing %K passive sensing %K psychiatric assessment %K mood and anxiety disorders %K mobile apps %K linguistics %K speech recognition %K speech content %K lexical choice %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The ability to objectively measure the severity of depression and anxiety disorders in a passive manner could have a profound impact on the way in which these disorders are diagnosed, assessed, and treated. Existing studies have demonstrated links between both depression and anxiety and the linguistic properties of words that people use to communicate. Smartphones offer the ability to passively and continuously detect spoken words to monitor and analyze the linguistic properties of speech produced by the speaker and other sources of ambient speech in their environment. The linguistic properties of automatically detected and recognized speech may be used to build objective severity measures of depression and anxiety. Objective: The aim of this study was to determine if the linguistic properties of words passively detected from environmental audio recorded using a participant’s smartphone can be used to find correlates of symptom severity of social anxiety disorder, generalized anxiety disorder, depression, and general impairment. Methods: An Android app was designed to collect periodic audiorecordings of participants’ environments and to detect English words using automatic speech recognition. Participants were recruited into a 2-week observational study. The app was installed on the participants’ personal smartphones to record and analyze audio. The participants also completed self-report severity measures of social anxiety disorder, generalized anxiety disorder, depression, and functional impairment. Words detected from audiorecordings were categorized, and correlations were measured between words counts in each category and the 4 self-report measures to determine if any categories could serve as correlates of social anxiety disorder, generalized anxiety disorder, depression, or general impairment. Results: The participants were 112 adults who resided in Canada from a nonclinical population; 86 participants yielded sufficient data for analysis. Correlations between word counts in 67 word categories and each of the 4 self-report measures revealed a strong relationship between the usage rates of death-related words and depressive symptoms (r=0.41, P<.001). There were also interesting correlations between rates of word usage in the categories of reward-related words with depression (r=–0.22, P=.04) and generalized anxiety (r=–0.29, P=.007), and vision-related words with social anxiety (r=0.31, P=.003). Conclusions: In this study, words automatically recognized from environmental audio were shown to contain a number of potential associations with severity of depression and anxiety. This work suggests that sparsely sampled audio could provide relevant insight into individuals’ mental health. %M 33512325 %R 10.2196/22723 %U http://formative.jmir.org/2021/1/e22723/ %U https://doi.org/10.2196/22723 %U http://www.ncbi.nlm.nih.gov/pubmed/33512325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e25019 %T mPulse Mobile Sensing Model for Passive Detection of Impulsive Behavior: Exploratory Prediction Study %A Wen,Hongyi %A Sobolev,Michael %A Vitale,Rachel %A Kizer,James %A Pollak,J P %A Muench,Frederick %A Estrin,Deborah %+ Cornell Tech, Cornell University, Bloomberg Center, 2 West Loop Road, New York, NY, 10044, United States, 1 929 350 7072, hw557@cornell.edu %K mobile sensing %K digital phenotyping %K impulse control %K impulsivity %K self-regulation %K self-control %K mobile health %K mHealth %D 2021 %7 27.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile health technology has demonstrated the ability of smartphone apps and sensors to collect data pertaining to patient activity, behavior, and cognition. It also offers the opportunity to understand how everyday passive mobile metrics such as battery life and screen time relate to mental health outcomes through continuous sensing. Impulsivity is an underlying factor in numerous physical and mental health problems. However, few studies have been designed to help us understand how mobile sensors and self-report data can improve our understanding of impulsive behavior. Objective: The objective of this study was to explore the feasibility of using mobile sensor data to detect and monitor self-reported state impulsivity and impulsive behavior passively via a cross-platform mobile sensing application. Methods: We enrolled 26 participants who were part of a larger study of impulsivity to take part in a real-world, continuous mobile sensing study over 21 days on both Apple operating system (iOS) and Android platforms. The mobile sensing system (mPulse) collected data from call logs, battery charging, and screen checking. To validate the model, we used mobile sensing features to predict common self-reported impulsivity traits, objective mobile behavioral and cognitive measures, and ecological momentary assessment (EMA) of state impulsivity and constructs related to impulsive behavior (ie, risk-taking, attention, and affect). Results: Overall, the findings suggested that passive measures of mobile phone use such as call logs, battery charging, and screen checking can predict different facets of trait and state impulsivity and impulsive behavior. For impulsivity traits, the models significantly explained variance in sensation seeking, planning, and lack of perseverance traits but failed to explain motor, urgency, lack of premeditation, and attention traits. Passive sensing features from call logs, battery charging, and screen checking were particularly useful in explaining and predicting trait-based sensation seeking. On a daily level, the model successfully predicted objective behavioral measures such as present bias in delay discounting tasks, commission and omission errors in a cognitive attention task, and total gains in a risk-taking task. Our models also predicted daily EMA questions on positivity, stress, productivity, healthiness, and emotion and affect. Perhaps most intriguingly, the model failed to predict daily EMA designed to measure previous-day impulsivity using face-valid questions. Conclusions: The study demonstrated the potential for developing trait and state impulsivity phenotypes and detecting impulsive behavior from everyday mobile phone sensors. Limitations of the current research and suggestions for building more precise passive sensing models are discussed. Trial Registration: ClinicalTrials.gov NCT03006653; https://clinicaltrials.gov/ct2/show/NCT03006653 %M 33502330 %R 10.2196/25019 %U http://mental.jmir.org/2021/1/e25019/ %U https://doi.org/10.2196/25019 %U http://www.ncbi.nlm.nih.gov/pubmed/33502330 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e20314 %T Mobile Phone Use and Acceptability for the Delivery of Mental Health Information Among Perinatal Adolescents in Nigeria: Survey Study %A Kola,Lola %A Abiona,Dolapo %A Adefolarin,Adeyinka Olufolake %A Ben-Zeev,Dror %+ University of Ibadan, Department of Psychiatry, College of Medicine, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Ibadan, , Nigeria, 234 8057943775, lola_kola2004@yahoo.com %K mHealth %K perinatal adolescent %K perinatal depression %K community %K low income %D 2021 %7 26.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: There are several barriers that may hamper adolescent mothers’ utilization of available health interventions for perinatal depression. Innovative treatment approaches are needed to increase adolescent mothers’ access to mental health care for improved maternal and child health outcomes. Mobile phones have the potential to serve as important conduits to mental health care in Africa. However, mobile phone use patterns and needs among young mothers in Nigeria are not well documented. Objective: This study sought to determine the prevalence of mobile phone use among perinatal adolescents and report patterns of use, as well as to assess the openness of young mothers to mobile health (mHealth) mental health interventions. Methods: We surveyed 260 adolescent mothers (ages 16-19 years) in their perinatal or postnatal periods of pregnancies in 33 primary health care clinics in Ibadan, Oyo State, Nigeria in 2020. Respondents were included if they were pregnant with a gestation age of greater than or equal to 4 weeks, or had babies (which they had birthed) that were younger than 12 months. Results: The total study sample consisted of 260 adolescent mothers with a mean age of 18.4 (SD 0.88) years. The majority of the respondents (233/260, 89.6%) owned mobile phones (eg, keypad, keypad and internet, smartphones); 22 (8.5%) of the 260 mothers had access to phones that belonged to relatives who lived in the same household, while 5 (1.9%) had access only to public paid phones. Only 23% (54/233) of phone owners (which is 20.5% of the total study population) had smartphones. On average, respondents reported first using mobile phones at 15.5 (SD 2.06) years old. The majority of respondents (222/260, 85.4%) reported using their phones for an average of 45 minutes daily for calls to family members. Facebook was the social media platform that was most often used among respondents who had phones with internet access (122/146 minutes per day, 83.4%). The majority of the sample responded as being “interested” and “very interested” in the use of mobile phones for preventive interventions (250/260, 96.2%) and treatment (243/260, 93.5%) information on mental illness such as depression and “hearing voices.” Half of the respondents (126/233, 50.4%) preferred to receive such information in the form of text messages. Conclusions: Findings from this study suggest that the vast majority of perinatal adolescents in Nigeria own and use mobile phones and that they are interested in leveraging these devices for prevention, treatment, and informational campaigns focused on mental health. The use of smartphones in this population is relatively low, and health intervention through text messages were favored by the women. %M 33496678 %R 10.2196/20314 %U http://mental.jmir.org/2021/1/e20314/ %U https://doi.org/10.2196/20314 %U http://www.ncbi.nlm.nih.gov/pubmed/33496678 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e17116 %T Psychiatric Profiles of eHealth Users Evaluated Using Data Mining Techniques: Cohort Study %A Lopez-Castroman,Jorge %A Abad-Tortosa,Diana %A Cobo Aguilera,Aurora %A Courtet,Philippe %A Barrigón,Maria Luisa %A Artés,Antonio %A Baca-García,Enrique %+ Institute of Functional Genomics, CNRS-INSERM, 39 Ave Charles Flauhault, Montpellier, 34093, France, 33 4996145, jorgecastroman@gmail.com %K mental disorders %K suicide prevention %K suicidal ideation %K data mining %K digital phenotyping %D 2021 %7 20.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: New technologies are changing access to medical records and the relationship between physicians and patients. Professionals can now use e-mental health tools to provide prompt and personalized responses to patients with mental illness. However, there is a lack of knowledge about the digital phenotypes of patients who use e-mental health apps. Objective: This study aimed to reveal the profiles of users of a mental health app through machine learning techniques. Methods: We applied a nonparametric model, the Sparse Poisson Factorization Model, to discover latent features in the response patterns of 2254 psychiatric outpatients to a short self-assessment on general health. The assessment was completed through a mental health app after the first login. Results: The results showed the following four different profiles of patients: (1) all patients had feelings of worthlessness, aggressiveness, and suicidal ideas; (2) one in four reported low energy and difficulties to cope with problems; (3) less than a quarter described depressive symptoms with extremely high scores in suicidal thoughts and aggressiveness; and (4) a small number, possibly with the most severe conditions, reported a combination of all these features. Conclusions: User profiles did not overlap with clinician-made diagnoses. Since each profile seems to be associated with a different level of severity, the profiles could be useful for the prediction of behavioral risks among users of e-mental health apps. %M 33470943 %R 10.2196/17116 %U http://mental.jmir.org/2021/1/e17116/ %U https://doi.org/10.2196/17116 %U http://www.ncbi.nlm.nih.gov/pubmed/33470943 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e17828 %T Perceptions and Opinions of Patients About Mental Health Chatbots: Scoping Review %A Abd-Alrazaq,Alaa A %A Alajlani,Mohannad %A Ali,Nashva %A Denecke,Kerstin %A Bewick,Bridgette M %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, PO Box 5825, Doha Al Luqta St, Ar-Rayyan, Doha, RT542, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K chatbots %K conversational agents %K mental health %K mental disorders %K perceptions %K opinions %K mobile phone %D 2021 %7 13.1.2021 %9 Review %J J Med Internet Res %G English %X Background: Chatbots have been used in the last decade to improve access to mental health care services. Perceptions and opinions of patients influence the adoption of chatbots for health care. Many studies have been conducted to assess the perceptions and opinions of patients about mental health chatbots. To the best of our knowledge, there has been no review of the evidence surrounding perceptions and opinions of patients about mental health chatbots. Objective: This study aims to conduct a scoping review of the perceptions and opinions of patients about chatbots for mental health. Methods: The scoping review was carried out in line with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews guidelines. Studies were identified by searching 8 electronic databases (eg, MEDLINE and Embase) in addition to conducting backward and forward reference list checking of the included studies and relevant reviews. In total, 2 reviewers independently selected studies and extracted data from the included studies. Data were synthesized using thematic analysis. Results: Of 1072 citations retrieved, 37 unique studies were included in the review. The thematic analysis generated 10 themes from the findings of the studies: usefulness, ease of use, responsiveness, understandability, acceptability, attractiveness, trustworthiness, enjoyability, content, and comparisons. Conclusions: The results demonstrated overall positive perceptions and opinions of patients about chatbots for mental health. Important issues to be addressed in the future are the linguistic capabilities of the chatbots: they have to be able to deal adequately with unexpected user input, provide high-quality responses, and have to show high variability in responses. To be useful for clinical practice, we have to find ways to harmonize chatbot content with individual treatment recommendations, that is, a personalization of chatbot conversations is required. %M 33439133 %R 10.2196/17828 %U http://www.jmir.org/2021/1/e17828/ %U https://doi.org/10.2196/17828 %U http://www.ncbi.nlm.nih.gov/pubmed/33439133 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e22575 %T Participant Engagement in a Transmedia Storytelling Web-Based App Intervention for Mental Health of Latina Women: Qualitative Analysis %A Soderlund,Patricia D %A Martinez Hollingsworth,Adrienne S %A Heilemann,MarySue V %+ School of Nursing, University of California, Los Angeles, Factor Building, Box 6919, Los Angeles, CA, 90095-6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K transmedia %K Latina %K mental health %K mobile applications %K internet %K depression %K anxiety %K storytelling %K mobile phone %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Stigma, fear, and lack of knowledge regarding treatment options or where to get help create delays for Latina women in accessing needed mental health help. Story-based media interventions hold appeal for Latina women. Thus, we drew upon the Social Cognitive Theory by Bandura to create an evidence-based, transmedia storytelling web-based app for mental health called Catalina: Confronting My Emotions to connect Latina women to a curated set of mental health resources. Understanding how Latina women perceive various aspects of the web-based app will help design future expansions. Objective: A previously published analysis led to the development of a category on how participants related to the lead character (Catalina) in the story line of the web-based app as a real person. However, the purpose of this analysis was to gain an understanding of participants’ experiences with the extension of the dramatic story line of the web-based app beyond Catalina to a Latina nurse-therapist character named Veronica, who was featured prominently in the app’s interactive content and bonus videos. Methods: Qualitative analyses were conducted with interview data from a community-based sample of 28 English-speaking Latina women aged between 21 and 50 years who scored above the threshold for anxiety (Generalized Anxiety Disorder-7) and/or depression (Patient Health Questionnaire-9) but were not suicidal at screening. Data were collected 72 hours after participants engaged with our transmedia storytelling web-based app for mental health. Grounded theory methodology guided the analysis and interpretation of data that had been collected telephonically, recorded, and transcribed with identifiers removed. Analyses included initial and focused coding using process codes (gerund form of verbs in codes focused on action), informed by symbolic interactionism, and the development of categories with properties through constant comparison, memo writing, and the use of charts and diagrams. Results: Our participants experienced a multiphase process that was most heavily related to Veronica, the Latina nurse-therapist character in our web-based app, who led them through a process to a place of action. We conceptualized this process as moving from passive viewer to active participant of a transmedia storytelling web-based app intervention. Overall, 3 new conceptual categories provided insight into women’s experiences, including encountering a trustworthy nurse-therapist character, taking in messages that dispel old beliefs, and preparing when and how to take action. Each category has nuanced properties that reflect participants’ experiences. Conclusions: Active engagement with our web-based app led our sample to successfully transition from the viewpoint of the observer to the viewpoint of the experiencer, moving from a passive position of watching to active engagement that involved imagining, thinking, reflecting, and acting. Careful development of dramatic material for health-related web-based apps using transmedia story extension and bonus videos needs to be based on input from the target group from the start of development through evaluation and testing. %M 33439137 %R 10.2196/22575 %U http://mental.jmir.org/2021/1/e22575/ %U https://doi.org/10.2196/22575 %U http://www.ncbi.nlm.nih.gov/pubmed/33439137 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e24333 %T Smartphone-Based Self-Reports of Depressive Symptoms Using the Remote Monitoring Application in Psychiatry (ReMAP): Interformat Validation Study %A Goltermann,Janik %A Emden,Daniel %A Leehr,Elisabeth Johanna %A Dohm,Katharina %A Redlich,Ronny %A Dannlowski,Udo %A Hahn,Tim %A Opel,Nils %+ Department of Psychiatry, University of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany, 49 251 8356610, n_opel01@uni-muenster.de %K mobile monitoring %K smartphone %K digital biomarkers %K digital phenotyping %K course of illness %K psychometric quality %K mood disorders %K depression %K affective disorders %K mobile phone %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone-based symptom monitoring has gained increased attention in psychiatric research as a cost-efficient tool for prospective and ecologically valid assessments based on participants’ self-reports. However, a meaningful interpretation of smartphone-based assessments requires knowledge about their psychometric properties, especially their validity. Objective: The goal of this study is to systematically investigate the validity of smartphone-administered assessments of self-reported affective symptoms using the Remote Monitoring Application in Psychiatry (ReMAP). Methods: The ReMAP app was distributed to 173 adult participants of ongoing, longitudinal psychiatric phenotyping studies, including healthy control participants, as well as patients with affective disorders and anxiety disorders; the mean age of the sample was 30.14 years (SD 11.92). The Beck Depression Inventory (BDI) and single-item mood and sleep information were assessed via the ReMAP app and validated with non–smartphone-based BDI scores and clinician-rated depression severity using the Hamilton Depression Rating Scale (HDRS). Results: We found overall high comparability between smartphone-based and non–smartphone-based BDI scores (intraclass correlation coefficient=0.921; P<.001). Smartphone-based BDI scores further correlated with non–smartphone-based HDRS ratings of depression severity in a subsample (r=0.783; P<.001; n=51). Higher agreement between smartphone-based and non–smartphone-based assessments was found among affective disorder patients as compared to healthy controls and anxiety disorder patients. Highly comparable agreement between delivery formats was found across age and gender groups. Similarly, smartphone-based single-item self-ratings of mood correlated with BDI sum scores (r=–0.538; P<.001; n=168), while smartphone-based single-item sleep duration correlated with the sleep item of the BDI (r=–0.310; P<.001; n=166). Conclusions: These findings demonstrate that smartphone-based monitoring of depressive symptoms via the ReMAP app provides valid assessments of depressive symptomatology and, therefore, represents a useful tool for prospective digital phenotyping in affective disorder patients in clinical and research applications. %M 33433392 %R 10.2196/24333 %U https://mental.jmir.org/2021/1/e24333 %U https://doi.org/10.2196/24333 %U http://www.ncbi.nlm.nih.gov/pubmed/33433392 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24045 %T Clinical Advice by Voice Assistants on Postpartum Depression: Cross-Sectional Investigation Using Apple Siri, Amazon Alexa, Google Assistant, and Microsoft Cortana %A Yang,Samuel %A Lee,Jennifer %A Sezgin,Emre %A Bridge,Jeffrey %A Lin,Simon %+ The Ohio State University University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, United States, 1 614 355 3703, samuel.yang@nationwidechildrens.org %K voice assistant %K virtual assistant %K conversational agent %K postpartum depression %K mobile health %K mental health %D 2021 %7 11.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A voice assistant (VA) is inanimate audio-interfaced software augmented with artificial intelligence, capable of 2-way dialogue, and increasingly used to access health care advice. Postpartum depression (PPD) is a common perinatal mood disorder with an annual estimated cost of $14.2 billion. Only a small percentage of PPD patients seek care due to lack of screening and insufficient knowledge of the disease, and this is, therefore, a prime candidate for a VA-based digital health intervention. Objective: In order to understand the capability of VAs, our aim was to assess VA responses to PPD questions in terms of accuracy, verbal response, and clinically appropriate advice given. Methods: This cross-sectional study examined four VAs (Apple Siri, Amazon Alexa, Google Assistant, and Microsoft Cortana) installed on two mobile devices in early 2020. We posed 14 questions to each VA that were retrieved from the American College of Obstetricians and Gynecologists (ACOG) patient-focused Frequently Asked Questions (FAQ) on PPD. We scored the VA responses according to accuracy of speech recognition, presence of a verbal response, and clinically appropriate advice in accordance with ACOG FAQ, which were assessed by two board-certified physicians. Results: Accurate recognition of the query ranged from 79% to 100%. Verbal response ranged from 36% to 79%. If no verbal response was given, queries were treated like a web search between 33% and 89% of the time. Clinically appropriate advice given by VA ranged from 14% to 29%. We compared the category proportions using the Fisher exact test. No single VA statistically outperformed other VAs in the three performance categories. Additional observations showed that two VAs (Google Assistant and Microsoft Cortana) included advertisements in their responses. Conclusions: While the best performing VA gave clinically appropriate advice to 29% of the PPD questions, all four VAs taken together achieved 64% clinically appropriate advice. All four VAs performed well in accurately recognizing a PPD query, but no VA achieved even a 30% threshold for providing clinically appropriate PPD information. Technology companies and clinical organizations should partner to improve guidance, screen patients for mental health disorders, and educate patients on potential treatment. %M 33427680 %R 10.2196/24045 %U http://mhealth.jmir.org/2021/1/e24045/ %U https://doi.org/10.2196/24045 %U http://www.ncbi.nlm.nih.gov/pubmed/33427680 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e16490 %T Smartphone-Based Interventions and Internalizing Disorders in Youth: Systematic Review and Meta-analysis %A Buttazzoni,Adrian %A Brar,Keshbir %A Minaker,Leia %+ School of Planning, University of Waterloo, 200 University Avenue W, Waterloo, ON, N2L 3G1, Canada, 1 519 888 4567 ext 46564, anbuttazzoni@uwaterloo.ca %K mental health %K meta-analysis %K mobile phone %K smartphone %K systematic review %K youth %D 2021 %7 11.1.2021 %9 Review %J J Med Internet Res %G English %X Background: Mental health disorders in youth are a global issue that have important implications for the future quality of life and morbidity of affected individuals. In the context of public health initiatives, smartphone-based interventions have been suggested to hold the potential to be an effective strategy to reduce the symptoms of mental health disorders in youth; however, further evaluation is needed to confirm their effectiveness. This systematic review and meta-analysis documents and synthesizes existing research on smartphone-based interventions targeting internalizing disorders in youth populations. Objective: This study aims to synthesize existing research on smartphone-based interventions targeting internalizing disorders in youth populations. Methods: PubMed and SCOPUS were searched in 2019, and 4334 potentially relevant articles were found. A total of 12 studies were included in the final synthesis. We used the Hedges g meta-analysis approach and a random effects model for analysis. Results: The results of this review note that depression and anxiety are the most commonly targeted symptoms, and unlike other similar topics, most studies reviewed were linked to a proven treatment. The overall pooled effect from the meta-analysis showed small but significant effects (κ=12; N=1370; Hedges g=0.20; 95% CI 0.02-0.38) for interventions in reducing the symptoms of internalizing disorders. In total, 4 subgroup analyses examining specific symptoms and intervention styles found varied small significant and nonsignificant effects. Conclusions: Future research should focus on developing robust evaluative frameworks and examining interventions among more diverse populations and settings. More robust research is needed before smartphone-based interventions are scaled up and used at the population level to address youth internalizing disorders. %M 33427682 %R 10.2196/16490 %U http://www.jmir.org/2021/1/e16490/ %U https://doi.org/10.2196/16490 %U http://www.ncbi.nlm.nih.gov/pubmed/33427682 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e25087 %T Adverse Childhood Experiences and Building Resilience With the JoyPop App: Evaluation Study %A MacIsaac,Angela %A Mushquash,Aislin R %A Mohammed,Shakira %A Grassia,Elizabeth %A Smith,Savanah %A Wekerle,Christine %+ Lakehead University, 955 Oliver Road, Thunder Bay, ON, , Canada, 1 8073438771, aislin.mushquash@lakeheadu.ca %K adverse childhood experiences %K resilience %K emotion regulation %K smartphone %K app %K childhood %K emotion %K mental health %K transition %K innovation %K intervention %D 2021 %7 4.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The effects of adverse childhood experiences (ACEs) on mental health, self-regulatory capacities, and overall resilience are well-known. Given such effects, ACEs may play a role in how individuals adjust to challenges later in life. Of interest in this study is the transition to university, a time of heightened stress when adapting to circumstances is required and when those with ACEs may need additional in-the-moment support to exercise resilience. A smartphone app may provide a worthwhile and readily accessible medium for a resilience intervention, provided behavioral outcomes are adequately evaluated. Objective: This study evaluates the impact of an innovative, smartphone app–based resilience intervention. The JoyPop app was designed to promote resilience through the use of self-regulatory skills such as emotion regulation and executive functioning. Among a sample of first-year undergraduate students, we explored whether use of the app would be associated with positive changes in resilience and related outcomes, and whether these benefits were influenced by level of childhood adversity. Methods: Participants (N=156) were requested to use the JoyPop app for 4 weeks, at least twice daily. Changes in resilience, emotion regulation, executive functioning, and depression were assessed after 2 and 4 weeks of app usage using multilevel modeling. Results: The sample of 156 participants included 123 females and 33 males, with a mean age of 19.02 years (SD 2.90). On average participants used the app on 20.43 of the possible 28 days (SD 7.14). App usage was associated with improvements in emotion regulation (χ21=44.46; P<.001), such that it improved by 0.25 points on the 18-point scale for each additional day of app usage, and symptoms of depression (χ21=25.12; P<.001), such that depression symptoms were reduced by .08 points on the 9-point scale with each additional day of app usage. An interaction between ACEs and days of app usage existed for emotion regulation, such that participants with more adversity evidenced a faster rate of change in emotion regulation (P=.02). Conclusions: Results highlight that daily incorporation of an app-based resilience intervention can help youth who have experienced adversity to improve emotion regulation skills and experience reductions in depression. The JoyPop app represents an important step forward in the integration of resilience intervention research with a technology-based medium that provides in-the-moment support. %M 33393908 %R 10.2196/25087 %U http://mhealth.jmir.org/2021/1/e25087/ %U https://doi.org/10.2196/25087 %U http://www.ncbi.nlm.nih.gov/pubmed/33393908 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e21895 %T The Digital Therapeutic Alliance and Human-Computer Interaction %A D'Alfonso,Simon %A Lederman,Reeva %A Bucci,Sandra %A Berry,Katherine %+ School of Computing and Information Systems, University of Melbourne, Doug McDonell Building, Parkville, 3010, Australia, 61 3 9035 5511, dalfonso@unimelb.edu.au %K therapeutic alliance %K digital mental health %K affective computing %K persuasive computing %K positive computing %K mobile phone %K mHealth %D 2020 %7 29.12.2020 %9 Viewpoint %J JMIR Ment Health %G English %X The therapeutic alliance (TA), the relationship that develops between a therapist and a client/patient, is a critical factor in the outcome of psychological therapy. As mental health care is increasingly adopting digital technologies and offering therapeutic interventions that may not involve human therapists, the notion of a TA in digital mental health care requires exploration. To date, there has been some incipient work on developing measures to assess the conceptualization of a digital TA for mental health apps. However, the few measures that have been proposed have more or less been derivatives of measures from psychology used to assess the TA in traditional face-to-face therapy. This conceptual paper explores one such instrument that has been proposed in the literature, the Mobile Agnew Relationship Measure, and examines it through a human-computer interaction (HCI) lens. Through this process, we show how theories from HCI can play a role in shaping or generating a more suitable, purpose-built measure of the digital therapeutic alliance (DTA), and we contribute suggestions on how HCI methods and knowledge can be used to foster the DTA in mental health apps. %M 33372897 %R 10.2196/21895 %U http://mental.jmir.org/2020/12/e21895/ %U https://doi.org/10.2196/21895 %U http://www.ncbi.nlm.nih.gov/pubmed/33372897 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e22423 %T Changes in Stress, Anxiety, and Depression Levels of Subscribers to a Daily Supportive Text Message Program (Text4Hope) During the COVID-19 Pandemic: Cross-Sectional Survey Study %A Agyapong,Vincent Israel Ouoku %A Hrabok,Marianne %A Vuong,Wesley %A Shalaby,Reham %A Noble,Jasmine Marie %A Gusnowski,April %A Mrklas,Kelly J %A Li,Daniel %A Urichuk,Liana %A Snaterse,Mark %A Surood,Shireen %A Cao,Bo %A Li,Xin-Min %A Greiner,Russell %A Greenshaw,Andrew James %+ 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, 1 780 215 7771, agyapong@ualberta.ca %K COVID-19 %K mobile technology %K text %K anxiety %K depression %K stress %K outbreak %K pandemic %K mental health %K outreach %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: In addition to the obvious physical medical impact of COVID-19, the disease poses evident threats to people’s mental health, psychological safety, and well-being. Provision of support for these challenges is complicated by the high number of people requiring support and the need to maintain physical distancing. Text4Hope, a daily supportive SMS text messaging program, was launched in Canada to mitigate the negative mental health impacts of the pandemic among Canadians. Objective: This paper describes the changes in the stress, anxiety, and depression levels of subscribers to the Text4Hope program after 6 weeks of exposure to daily supportive SMS text messages. Methods: We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of Text4Hope subscribers. Perceived stress, anxiety, and depression were measured with the 10-Item Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder–7 (GAD-7) scale, and the Patient Health Questionnaire–9 (PHQ-9) scale at baseline and sixth week time points. Moderate or high perceived stress, likely generalized anxiety disorder, and likely major depressive disorder were assessed using cutoff scores of ≥14 for the PSS-10, ≥10 for the GAD-7, and ≥10 for the PHQ-9, respectively. At 6 weeks into the program, 766 participants had completed the questionnaires at both time points. Results: At the 6-week time point, there were statistically significant reductions in mean scores on the PSS-10 and GAD-7 scales but not on the PHQ-9 scale. Effect sizes were small overall. There were statistically significant reductions in the prevalence rates of moderate or high stress and likely generalized anxiety disorder but not likely major depressive disorder for the group that completed both the baseline and 6-week assessments. The largest reductions in mean scores and prevalence rates were for anxiety (18.7% and 13.5%, respectively). Conclusions: Text4Hope is a convenient, cost-effective, and accessible means of implementing a population-level psychological intervention. This service demonstrated significant reductions in anxiety and stress levels during the COVID-19 pandemic and could be used as a population-level mental health intervention during natural disasters and other emergencies. International Registered Report Identifier (IRRID): RR2-10.2196/19292 %M 33296330 %R 10.2196/22423 %U http://mental.jmir.org/2020/12/e22423/ %U https://doi.org/10.2196/22423 %U http://www.ncbi.nlm.nih.gov/pubmed/33296330 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e19888 %T Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series %A Kellett,Stephen %A Easton,Katherine %A Cooper,Martin %A Millings,Abigail %A Simmonds-Buckley,Melanie %A Parry,Glenys %+ Sheffield Health & Social Care NHS Foundation Trust, University of Sheffield, 1 Vicar Lane, Sheffield, S1 2LT, United Kingdom, 44 114 222 6537, s.kellett@sheffield.ac.uk %K cognitive analytic therapy %K case series %K effectiveness %K outcome %K eHealth %K app %K awareness %K mHealth %K innovation %K therapy %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). Objective: We aimed to assess patients’ and therapists’ experience of using the technology (ie, the “CAT-App”) and to evaluate the relationship between app usage and clinical outcome. Methods: The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. Results: Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients’ themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. Conclusions: The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required. %M 33337342 %R 10.2196/19888 %U http://mental.jmir.org/2020/12/e19888/ %U https://doi.org/10.2196/19888 %U http://www.ncbi.nlm.nih.gov/pubmed/33337342 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e19593 %T Visual and Personalized Quality of Life Assessment App for People With Severe Mental Health Problems: Qualitative Evaluation %A Buitenweg,David %A van de Mheen,Dike %A Grund,Jean-Paul %A van Oers,Hans %A van Nieuwenhuizen,Chijs %+ Geestelijke Gezondheids Zorg Eindhoven Institute for Mental Health Care, , Eindhoven, , Netherlands, 31 40 297 01 70, david.buitenweg@ggze.nl %K quality of life %K qualitative evaluation %K visual assessment %K e-mental health %K assessment app %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: QoL-ME is a digital visual personalized quality of life assessment app for people with severe mental health problems. Research reveals that e-mental health apps frequently suffer from low engagement and fall short of expectations regarding their impact on patients’ daily lives. Studies often indicate that e-mental health apps ought to respect the needs and preferences of end users to achieve optimal user engagement. Objective: The aim of this study was to explore the experiences of users regarding the usability and functionality of QoL-ME and whether the app is actionable and beneficial for patients. Methods: End users (n=8) of QoL-ME contributed to semistructured interviews. An interview guide was used to direct the interviews. All interviews were audiorecorded and transcribed verbatim. Transcriptions were analyzed and coded thematically. Results: Analysis revealed 3 main themes: (1) benefit, (2) actionability, and (3) characteristics of the QoL-ME. The first theme reveals that the QoL-ME app was beneficial for the majority of respondents, primarily by prompting them to reflect on their quality of life. The current version is not yet actionable; the actionability of the QoL-ME app may be improved by enabling users to view their scores over time and by supplying practical advice for quality of life improvements. Overall, participants had positive experiences with the usability, design, and content of the app. Conclusions: The QoL-ME app can be beneficial to users as it provides them with insight into their quality of life and elicits reflection. Incorporating more functionalities that facilitate self-management, such as advice and strategies for improving areas that are lacking, will likely make the app actionable. Patients positively regarded the usability, design, and contents of the QoL-ME app. %M 33270036 %R 10.2196/19593 %U https://mental.jmir.org/2020/12/e19593 %U https://doi.org/10.2196/19593 %U http://www.ncbi.nlm.nih.gov/pubmed/33270036 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e24406 %T Mobile-Assisted Cognitive Behavioral Therapy for Negative Symptoms: Open Single-Arm Trial With Schizophrenia Patients %A Granholm,Eric %A Holden,Jason %A Dwyer,Kristen %A Mikhael,Tanya %A Link,Peter %A Depp,Colin %+ VA San Diego Healthcare System, 9500 Gilman Drive #0737, San Diego, CA , United States, 1 858 534 2542, egranholm@ucsd.edu %K motivation %K persistent negative symptoms %K dysfunctional attitudes %K mHealth %K blended intervention %K mobile phone %D 2020 %7 1.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn). Objective: The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia. Methods: Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms. Results: Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes. Conclusions: The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia. Trial Registration: ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696 %M 33258792 %R 10.2196/24406 %U https://mental.jmir.org/2020/12/e24406 %U https://doi.org/10.2196/24406 %U http://www.ncbi.nlm.nih.gov/pubmed/33258792 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e14296 %T Usage and Acceptability of the iBobbly App: Pilot Trial for Suicide Prevention in Aboriginal and Torres Strait Islander Youth %A Tighe,Joseph %A Shand,Fiona %A McKay,Kathy %A Mcalister,Taylor-Jai %A Mackinnon,Andrew %A Christensen,Helen %+ Black Dog Institute, Hospital Rd, Randwick, Sydney, Australia, 61 292824530, joetighe@hotmail.com %K mHealth %K suicide %K depression %K eHealth %K Indigenous %K Aboriginal %K First Nations %K mental health %K suicide ideation %K apps %D 2020 %7 1.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The proliferation of mental health apps purporting to target and improve psychological wellbeing is ever-growing and also concerning: Few apps have been rigorously evaluated, and, indeed, the safety of the vast majority of them has not been determined. Over 10,000 self-help apps exist but most are not used much after being downloaded. Gathering and analyzing usage data and the acceptability of apps are critical to inform consumers, researchers, and app developers. Objective: This paper presents pilot usage and acceptability data from the iBobbly suicide prevention app, an app distributed through a randomized controlled trial. Methods: Aboriginal and Torres Strait Islander participants from the Kimberley region of Western Australia completed a survey measuring their technology use in general (n=13), and data on their experiences with and views of the iBobbly app were also collected in semistructured interviews (n=13) and thematically analyzed. Finally, engagement with the app, such as the number of sessions completed and time spent on various acceptance-based therapeutic activities, was analyzed (n=18). Both groups were participants in the iBobbly app pilot randomized controlled trial (n=61) completed in 2015. Results: Regression analysis indicated that app use improved psychological outcomes, although only minimally, and effects were not significant. However, results of the thematic analysis indicated that the iBobbly app was deemed effective, acceptable, and culturally appropriate by those interviewed. Conclusions: There is a scarcity of randomized controlled trials and eHealth interventions in Indigenous communities, while extremely high rates of psychological distress and suicide persist. In this environment, studies that can add evidence from mixed-methods approaches are important. While the regression analysis in this study did not indicate a significant effect of app use on psychological wellbeing, this was predictable considering the small sample size (n=18) and typically brief app use. The results on engagement with the iBobbly app were however positive. This study showed that Indigenous youth are early and frequent users of technology in general, and they regarded the iBobbly app to be culturally safe and of therapeutic value. Qualitative analyses demonstrated that iBobbly app use was associated with self-reported improvements in psychological wellbeing, mental health literacy, and reductions in shame. Importantly, participants reported that they would recommend other similar apps if available to their peers. %M 33258782 %R 10.2196/14296 %U https://mental.jmir.org/2020/12/e14296 %U https://doi.org/10.2196/14296 %U http://www.ncbi.nlm.nih.gov/pubmed/33258782 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e22634 %T Screening for Depression in Daily Life: Development and External Validation of a Prediction Model Based on Actigraphy and Experience Sampling Method %A Minaeva,Olga %A Riese,Harriëtte %A Lamers,Femke %A Antypa,Niki %A Wichers,Marieke %A Booij,Sanne H %+ Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9713 GZ, Netherlands, 31 50 361 2065, o.minaeva@umcg.nl %K actigraphy %K activity tracker %K depression %K experience sampling method %K prediction model %K screening %D 2020 %7 1.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remain unidentified. Introducing additional screening tools may facilitate the diagnostic process. Objective: This study aimed to examine whether experience sampling method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from nondepressed individuals. In addition, the added value of actigraphy-based measures was examined. Methods: We used data from 2 samples to develop and validate prediction models. The development data set included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and nondepressed individuals (n=82). The validation data set included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and nondepressed individuals (n=27). Backward stepwise logistic regression analysis was applied to build the prediction models. Performance of the models was assessed with goodness-of-fit indices, calibration curves, and discriminative ability (area under the receiver operating characteristic curve [AUC]). Results: In the development data set, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for both the ESM (AUC=0.991) and the combined-domains model (AUC=0.993). In the validation data set, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for both the ESM (AUC=0.891) and the combined-domains model (AUC=0.892). Conclusions: ESM is a good diagnostic predictor and is easy to calculate, and it therefore holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor but might still be useful when ESM use is restricted. %M 33258783 %R 10.2196/22634 %U https://www.jmir.org/2020/12/e22634 %U https://doi.org/10.2196/22634 %U http://www.ncbi.nlm.nih.gov/pubmed/33258783 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e22631 %T Mobile Texting and Lay Health Supporters to Improve Schizophrenia Care in a Resource-Poor Community in Rural China (LEAN Trial): Randomized Controlled Trial Extended Implementation %A Cai,Yiyuan %A Gong,Wenjie %A He,Hua %A Hughes,James P %A Simoni,Jane %A Xiao,Shuiyuan %A Gloyd,Stephen %A Lin,Meijuan %A Deng,Xinlei %A Liang,Zichao %A He,Wenjun %A Dai,Bofeng %A Liao,Jing %A Hao,Yuantao %A Xu,Dong (Roman) %+ School of Public Health, Sun Yat-sen University, No 74 Zhongshan Road 2, Yuexiu District, Guangzhou, China, 86 020 87335523, haoyt@mail.sysu.edu.cn %K medication adherence %K mobile texting %K lay health worker %K resource-poor community %K primary health care %K quality of care %K mHealth %K schizophrenia %D 2020 %7 1.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Schizophrenia is a severe and disabling condition that presents a dire health equity challenge. Our initial 6-month trial (previously reported) using mobile texting and lay health supporters, called LEAN, significantly improved medication adherence from 0.48 to 0.61 (adjusted mean 0.11, 95% CI 0.03 to 0.20, P=.007) for adults with schizophrenia living in a resource-poor village in rural China. Objective: We explored the effectiveness of our texting program in improving participants’ medication adherence, functioning, and symptoms in an extended implementation of the intervention after its initial phase. Methods: In an approximated stepped-wedge wait-list design randomized controlled trial, 277 community-dwelling villagers with schizophrenia were assigned 1:1 in phase 1 into intervention and wait-list control groups. The intervention group received (1) lay health supporters (medication or care supervisors), (2) e-platform (mobile-texting reminders and education message) access, (3) a token gift for positive behavioral changes, and (4) integration with the existing government community-mental health program (the 686 Program) while the wait-listed control group initially only received the 686 Program. Subsequently (in the extended period), both groups received the LEAN intervention plus the 686 Program. The primary outcome was antipsychotic medication adherence (percentage of dosages taken over the past month assessed by unannounced home-based pill counts). The secondary outcomes were symptoms measured during visits to 686 Program psychiatrists using the Clinical Global Impression scale for schizophrenia and functioning measured by trained student assessors using the World Health Organization Disability Assessment Schedule 2.0. Other outcomes included data routinely collected in the 686 Program system (refill records, rehospitalization due to schizophrenia, death for any reason, suicide, wandering, and violent behaviors). We used intention-to-treat analysis and missing data were imputed. A generalized estimating equation model was used to assess program effects on antipsychotics medication adherence, symptoms, and functioning. Results: Antipsychotics medication adherence improved from 0.48 in the control period to 0.58 in the extended intervention period (adjusted mean difference 0.11, 95% CI 0.04 to 0.19; P=.004). We also noted an improvement in symptoms (adjusted mean difference –0.26, 95% CI –0.50 to –0.02; P=.04; Cohen d effect size 0.20) and a reduction in rehospitalization (0.37, 95% CI 0.18 to 0.76; P=.007; number-needed-to-treat 8.05, 95% CI 4.61 to 21.41). There was no improvement in functioning (adjusted mean difference 0.02, 95% CI –0.01 to 0.06; P=.18; Cohen d effect size 0.04). Conclusions: In an extended implementation, our intervention featuring mobile texting messages and lay health workers in a resource-poor community setting was more effective than the 686 Program alone in improving medication adherence, improving symptoms, and reducing rehospitalization. Trial Registration: Chinese Clinical Trial Registry; ChiCTR-ICR-15006053 https://tinyurl.com/y5hk8vng %M 33258788 %R 10.2196/22631 %U https://www.jmir.org/2020/12/e22631 %U https://doi.org/10.2196/22631 %U http://www.ncbi.nlm.nih.gov/pubmed/33258788 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e24536 %T Parents’ Perceptions of Their Children’s Engagement in a Consumer-Based Meditation Mobile App: Cross-Sectional Survey Study %A Puzia,Megan %A Laird,Breanne %A Green,Jeni %A Huberty,Jennifer %+ Behavioral Research and Analytics LLC, 154 S Street, Salt Lake City, UT, 84103, United States, 1 7046043782, meganpuzia@gmail.com %K mindfulness %K meditation %K children %K mental health %K sleep %K mHealth %D 2020 %7 13.11.2020 %9 Short Paper %J JMIR Pediatr Parent %G English %X Background: In the United States, nearly half (48%) of school-aged children experience sleep disturbance that results in less than the recommended sleep duration, which may negatively impact mental health and behavior. Mindfulness interventions may improve sleep and mental health in youth. However, there are gaps in the literature regarding how children (2-12 years) and adolescents (13-17 years) practice mindfulness and the extent to which they benefit from these practices. Objective: The purpose of this study was to determine parents’ perceptions of their children’s engagement with a consumer-based mindfulness meditation app and the extent to which they believe their children have benefitted from using the app, particularly with regard to sleep. Methods: This study is a secondary analysis of a cross-sectional survey in adult subscribers (N=11,108) to the mindfulness meditation mobile app Calm. Participants who indicated that they had a child or children younger than 18 years (2944/11,108) who used the Calm app were asked additional questions related to their perceptions of their children’s engagement with Calm. Descriptive statistics were used to assess children’s app engagement, and chi-square tests and binary logistic regression models were used to assess differences in children’s usage based on gender and age. Results: Among the survey respondents, approximately half of the parents (1537/2944, 52.21%) reported that their children used Calm. Children used Calm mostly for (1) sleep (1168/1537, 75.99%), (2) stress (491/1537, 31.95%), (3) depression or anxiety (430/1537, 27.98%), and (4) improvement of overall health (215/1537,13.99%). Older children were more likely to begin using Calm to reduce stress, depression, or anxiety, whereas younger children were more likely begin using Calm to improve sleep. Most children used Calm when lying down to go to bed (1113/1529, 72.79%). Children were most likely to use sleep stories at night (1144/1207, 94.78%), followed by music and soundscapes (749/1114, 67.24%), meditations (736/1120, 65.71%), and breathing exercises (610/1092, 55.86%). Nearly all parents believed that using sleep stories was helpful for their children’s sleep (1090/1128, 96.63%), and the majority of parents felt that the other components were also helpful for their children’s sleep (music and soundscapes [570/728, 78.30%], meditations [445/696, 63.94%], and breathing exercises [610/1092, 55.86%]). Conclusions: To our knowledge, this is the first study to explore parents’ perceptions of how their children or adolescents use a popular consumer-based mindfulness mobile app (ie, Calm). As the majority of children use the app for sleep, mindfulness meditation mobile apps should consider incorporating age-appropriate sleep content to meet the needs of this audience. More research is needed to confirm the feasibility and effectiveness of mindfulness meditation apps for improving sleep and mental health in children and adolescents. %M 33185564 %R 10.2196/24536 %U http://pediatrics.jmir.org/2020/2/e24536/ %U https://doi.org/10.2196/24536 %U http://www.ncbi.nlm.nih.gov/pubmed/33185564 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e18067 %T Effectiveness of a Smartphone App (BioBase) for Reducing Anxiety and Increasing Mental Well-Being: Pilot Feasibility and Acceptability Study %A Kawadler,Jamie M %A Hemmings,Nicola Rose %A Ponzo,Sonia %A Morelli,Davide %A Bird,Geoffrey %A Plans,David %+ Huma Therapeutics Limited, 13th Floor Millbank Tower, 21-24 Millbank, , London, , United Kingdom, 44 7527016574, jamie@biobeats.com %K health and well-being %K health promotion %K organizational and leadership support %K workplace %D 2020 %7 10.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The prevalence of workplace-related stress and anxiety is high, resulting in stress-related physical and mental illness. Digital self-guided interventions aimed at key areas of workplace design may be able to provide remote anxiolytic effects. Objective: The aim of this feasibility study is to assess changes in anxiety and mental well-being after use of the BioBase programme, a mobile phone platform for psycho-educational modules, tools, and real-time feedback of physiological data. Methods: A 4-week observational study was carried out in 55 healthy adults who were screened for stress with the Depression Anxiety Stress Scale (DASS) Stress subscale. Participants completed anxiety (6-item State-Trait Anxiety Inventory [STAI]) and mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) questionnaires at baseline and at 4 weeks. Feedback questionnaires were administered after 4 weeks. Results: After 4 weeks of using the programme and controlling for any effect of being paid to take part in the study, STAI significantly decreased (baseline mean 45.52 [SD 13.2]; 4-week mean 39.82 [SD 11.2]; t54=–3.51; P<.001; CI –8.88 to –2.52; Cohen d=0.96) and WEMWBS significantly increased (baseline mean 48.12 [SD 6.4]; 4-week mean 50.4 [SD 6.9]; t53=2.41; P=.019; CI 0.44-4.23; Cohen d=0.66). Further, higher baseline stress was significantly associated with a greater decrease in STAI (t53=–3.41; P=.001; CI –8.10 to –2.10; R2=0.180) and a greater increase in WEMWBS (t52=2.41; P=.019; CI 0.38-4.11, R2=0.101). On feedback, participants found the programme easy to use/navigate, with the content being acceptable and relevant to workplace-related stressors; 70% (21/30) of participants would recommend the programme to a friend. Conclusions: The BioBase programme is a potentially effective intervention in decreasing anxiety and increasing mental well-being, with larger changes in those with higher baseline levels of stress. %M 32969341 %R 10.2196/18067 %U https://formative.jmir.org/2020/11/e18067 %U https://doi.org/10.2196/18067 %U http://www.ncbi.nlm.nih.gov/pubmed/32969341 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e22997 %T ReMindCare App for Early Psychosis: Pragmatic Real World Intervention and Usability Study %A Bonet,Lucia %A Torous,John %A Arce,David %A Blanquer,Ignacio %A Sanjuan,Julio %+ Department of Mental Health, Sanitary Research Institute of Valencia, University Clinic Hospital of Valencia, Menéndez y Pelayo St, 4,, Valencia, Spain, 34 961 97 35 17, julio.sanjuan@uv.es %K app %K clinical practice %K mental health %K psychosis %K real-world intervention %K telemedicine %D 2020 %7 6.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: eHealth interventions are widely used in clinical trials and increasingly in care settings as well; however, their efficacy in real-world contexts remains unknown. ReMindCare is a smartphone app that has been systematically implemented in a first episode of psychosis program (FEPP) for patients with early psychosis since 2018. Objective: The objective of this study was to assess the efficacy of ReMindCare after 19 months of use in the clinic and varying use by individual patients. Methods: The integration of the ReMindCare app into the FEPP started in October 2018. Patients with early psychosis self-selected to the app (ReMindCare group) or treatment as usual (TAU group). The outcome variables considered were adherence to the intervention and number of relapses, hospital admissions, and visits to urgent care units. Data from 90 patients with early psychosis were analyzed: 59 in the ReMindCare group and 31 in the TAU group. The mean age of the sample was 32.8 (SD 9.4) years, 73% (66/90) were males, 91% (83/90) were White, and 81% (74/90) were single. Results: Significant differences between the ReMindCare and TAU groups were found in the number of relapses, hospitalizations, and visits to urgent care units, with each showing benefits for the app. Only 20% (12/59) of patients from the ReMindCare group had a relapse, while 58% (18/31) of the TAU patients had one or more relapses (χ2=13.7, P=.001). Moreover, ReMindCare patients had fewer visits to urgent care units (χ2=7.4, P=.006) and fewer hospitalizations than TAU patients (χ2=4.6, P=.03). The mean of days using the app was 352.2 (SD 191.2; min/max: 18-594), and the mean of engagement was 84.5 (SD 16.04). Conclusions: To our knowledge, this is the first eHealth intervention that has preliminarily proven its benefits in the real-world treatment of patients with early psychosis. International Registered Report Identifier (IRRID): RR2-10.1111/eip.12960 %M 33155986 %R 10.2196/22997 %U https://mhealth.jmir.org/2020/11/e22997 %U https://doi.org/10.2196/22997 %U http://www.ncbi.nlm.nih.gov/pubmed/33155986 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e18812 %T A Patient-Centered Framework for Measuring the Economic Value of the Clinical Benefits of Digital Health Apps: Theoretical Modeling %A Powell,Adam %A Torous,John %+ Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, United States, 1 617 667 6700, jtorous@bidmc.harvard.edu %K value %K digital health %K apps %K payment models %D 2020 %7 30.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: As digital health tools such as smartphone apps evolve and enter clinical use, questions regarding their value must be addressed. Although there are scarce generalizable data on the value of health apps given their nascency and diverse use cases, it is possible to estimate the economic value of the clinical improvement they bring to patients using a quality-adjusted life-year (QALY)-based approach and generalized values from existing literature. Objective: This paper aims to provide a patient-centered framework for assessing the economic value of the clinical benefits delivered by digital health apps. Methods: We proposed a model based upon 5 levers: country-specific monetary value of a QALY, QALYs lost due to the condition, engagement rate of app users, average effect size of the app’s health impact, and duration of the app’s impact before remission. Results: Using 2 digital health apps from the United States and United Kingdom as examples, we explored how this model could generate country-specific estimates of the economic value of the clinical benefits of health apps. Conclusions: This new framework can help drive research priorities for digital health by elucidating the factors that influence the economic value. %M 33124995 %R 10.2196/18812 %U https://mental.jmir.org/2020/10/e18812 %U https://doi.org/10.2196/18812 %U http://www.ncbi.nlm.nih.gov/pubmed/33124995 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e19887 %T Adaptation of a Digital Health Innovation to Prevent Relapse and Support Recovery in Youth Receiving Services for First-Episode Psychosis: Results From the Horyzons-Canada Phase 1 Study %A Lal,Shalini %A Gleeson,John %A Rivard,Lysanne %A D'Alfonso,Simon %A Joober,Ridha %A Malla,Ashok %A Alvarez-Jimenez,Mario %+ School of Rehabilitation, Faculty of Medicine, University of Montréal, C.P. 6128, succursale Centre-ville, Montréal, QC, H3C 3J7, Canada, 1 514 890 8000 ext 31581, shalini.lal@umontreal.ca %K psychotic disorders %K mental health %K telemedicine %K young adult %K mental health services %K cultural adaptation %K mobile phone %K e-mental health %K virtual care %K schizophrenia %K e-health %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Developing a digital health innovation can require a substantial amount of financial and human resource investment before it can be scaled for implementation across geographical, cultural, and health care contexts. As such, there is an increased interest in leveraging eHealth innovations developed and tested in one country or jurisdiction and using these innovations in local settings. However, limited knowledge exists on the processes needed to appropriately adapt digital health innovations to optimize their transferability across geographical, cultural, and contextual settings. Objective: We report on the results of an adaptation study of Horyzons, a digital health innovation originally developed and tested in Australia. Horyzons is designed to prevent relapses and support recovery in young people receiving services for first-episode psychosis (FEP). The aim of this study is to assess the initial acceptability of Horyzons and adapt it in preparation for pilot testing in Canada. Methods: This research took place in 2 specialized early intervention clinics for FEP, located in 1 urban and 1 urban-rural setting, in 2 Canadian provinces. A total of 26 participants were recruited: 15 clinicians (age range 26-56 years) and 11 patients (age range 19-37 years). Following the digital health adaptation framework developed by our team, we used a mixed methods approach, combining descriptive quantitative and qualitative methods across 3 stages of data collection (focus groups, interviews, and consultations), analysis, and adaptations. Results: Overall, patients and clinicians appreciated the strengths-based approach and social media features of Horyzons. However, participants expressed concerns related to implementation, especially in relation to capacity (eg, site moderation, crisis management, internet speed in rural locations). They also provided suggestions for adapting content and features, for example, in relation to community resources, volume of text, universal accessibility (eg, for individuals with limitations in vision), and optimization of platform accessibility through mobile devices. Additional aspects of the innovation were flagged for adaptation during the final stages of preparing it for live implementation. These included terms of use, time zone configuration to reflect local time and date, safety and moderation protocols, the need help now feature, and the list of trigger words to flag posts indicative of potential risk. Conclusions: In the context of the COVID-19 pandemic and public health guidelines for social distancing, there is an increasing interest and need to leverage the internet and mobile technologies for delivering youth mental health services. As countries look to one another for guidance on how to navigate changing social dynamics, knowledge on how to utilize and adapt existing innovations across contexts is now more important than ever. Using a systematic approach, this study illustrates the methods, processes, results, and lessons learned on adapting a digital health innovation to enhance its local acceptability. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8810 %M 33118945 %R 10.2196/19887 %U http://formative.jmir.org/2020/10/e19887/ %U https://doi.org/10.2196/19887 %U http://www.ncbi.nlm.nih.gov/pubmed/33118945 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e17453 %T Smartphone-Based Self-Monitoring, Treatment, and Automatically Generated Data in Children, Adolescents, and Young Adults With Psychiatric Disorders: Systematic Review %A Melbye,Sigurd %A Kessing,Lars Vedel %A Bardram,Jakob Eyvind %A Faurholt-Jepsen,Maria %+ The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Centre Copenhagen, Rigshospitalet, Blegdamsvej 9, København Ø, 2200, Denmark, 45 28966634, sigurd.arne.melbye@regionh.dk %K mHealth %K child and adolescent psychiatry %K eHealth %K systematic review %K psychiatry %K mobile phone %D 2020 %7 29.10.2020 %9 Review %J JMIR Ment Health %G English %X Background: Psychiatric disorders often have an onset at an early age, and early identification and intervention help improve prognosis. A fine-grained, unobtrusive, and effective way to monitor symptoms and level of function could help distinguish severe psychiatric health problems from normal behavior and potentially lead to a more efficient use of clinical resources in the current health care system. The use of smartphones to monitor and treat children, adolescents, and young adults with psychiatric disorders has been widely investigated. However, no systematic review concerning smartphone-based monitoring and treatment in this population has been published. Objective: This systematic review aims at describing the following 4 features of the eligible studies: (1) monitoring features such as self-assessment and automatically generated data, (2) treatment delivered by the app, (3) adherence to self-monitoring, and (4) results of the individual studies. Methods: We conducted a systematic literature search of the PubMed, Embase, and PsycInfo databases. We searched for studies that (1) included a smartphone app to collect self-monitoring data, a smartphone app to collect automatically generated smartphone-based data, or a smartphone-based system for treatment; (2) had participants who were diagnosed with psychiatric disorders or received treatment for a psychiatric disorder, which was verified by an external clinician; (3) had participants who were younger than 25 years; and (4) were published in a peer-reviewed journal. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The risk of bias in each individual study was systematically assessed. Results: A total of 2546 unique studies were identified through literature search; 15 of these fulfilled the criteria for inclusion. These studies covered 8 different diagnostic groups: psychosis, eating disorders, depression, autism, self-harm, anxiety, substance abuse, and suicidal behavior. Smartphone-based self-monitoring was used in all but 1 study, and 11 of them reported on the participants’ adherence to self-monitoring. Most studies were feasibility/pilot studies, and all studies on feasibility reported positive attitudes toward the use of smartphones for self-monitoring. In 2 studies, automatically generated data were collected. Three studies were randomized controlled trials investigating the effectiveness of smartphone-based monitoring and treatment, with 2 of these showing a positive treatment effect. In 2 randomized controlled trials, the researchers were blinded for randomization, but the participants were not blinded in any of the studies. All studies were determined to be at high risk of bias in several areas. Conclusions: Smartphones hold great potential as a modern, widely available technology platform to help diagnose, monitor, and treat psychiatric disorders in children and adolescents. However, a higher level of homogeneity and rigor among studies regarding their methodology and reporting of adherence would facilitate future reviews and meta-analyses. %M 33118950 %R 10.2196/17453 %U http://mental.jmir.org/2020/10/e17453/ %U https://doi.org/10.2196/17453 %U http://www.ncbi.nlm.nih.gov/pubmed/33118950 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e19876 %T Investigating the Impact of COVID-19 Lockdown on the Psychological Health of University Students and Their Attitudes Toward Mobile Mental Health Solutions: Two-Part Questionnaire Study %A Drissi,Nidal %A Alhmoudi,Ayat %A Al Nuaimi,Hana %A Alkhyeli,Mahra %A Alsalami,Shaikha %A Ouhbi,Sofia %+ United Arab Emirates University, , Al Ain, United Arab Emirates, 971 37135568, sofia.ouhbi@uaeu.ac.ae %K COVID-19 %K GHQ-12 %K mobile %K apps %K m-health %K m-mental health %K UAE %K attitudes %K university students %K questionnaire %D 2020 %7 20.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 outbreak was first reported to the World Health Organization on December 31, 2019, and it was officially declared a public health emergency of international concern on January 30, 2020. The COVID-19 outbreak and the safety measures taken to control it caused many psychological issues in populations worldwide, such as depression, anxiety, and stress. Objective: The objectives of this study were to assess the psychological effects of the lockdown due to the COVID-19 outbreak on university students in the United Arab Emirates (UAE) and to investigate the students’ awareness of mobile mental health care apps as well as their attitudes toward the use of these apps. Methods: A two-part self-administered web-based questionnaire was delivered to students at United Arab Emirates University. The first part of the questionnaire assessed the mental state of the participants using the 12-item General Health Questionnaire (GHQ-12), while the second part contained questions investigating the participants’ awareness of and attitudes toward mental health care apps. Students were invited to fill out the web-based questionnaire via social media and mailing lists. Results: A total of 154 students participated in the survey, and the majority were female. The results of the GHQ-12 analysis showed that the students were experiencing psychological issues related to depression and anxiety as well as social dysfunction. The results also revealed a lack of awareness of mental health care apps and uncertainty regarding the use of such apps. Approximately one-third of the participants (44/154, 28.6%) suggested preferred functionalities and characteristics of mobile mental health care apps, such as affordable price, simple design, ease of use, web-based therapy, communication with others experiencing the same issues, and tracking of mental status. Conclusions: Like many groups of people worldwide, university students in the UAE were psychologically affected by the lockdown due to the COVID-19 outbreak. Although apps can be useful tools for mental health care delivery, especially in circumstances such as those produced by the outbreak, the students in this study showed a lack of awareness of these apps and mixed attitudes toward them. Improving the digital health literacy of university students in the UAE by increasing their awareness of mental health care apps and the treatment methods and benefits of the apps, as well as involving students in the app creation process, may encourage students to use these tools for mental health care. %M 32969340 %R 10.2196/19876 %U http://formative.jmir.org/2020/10/e19876/ %U https://doi.org/10.2196/19876 %U http://www.ncbi.nlm.nih.gov/pubmed/32969340 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21496 %T Smartphone App to Address Loneliness Among College Students: Pilot Randomized Controlled Trial %A Bruehlman-Senecal,Emma %A Hook,Cayce J %A Pfeifer,Jennifer H %A FitzGerald,Caroline %A Davis,Brittany %A Delucchi,Kevin L %A Haritatos,Jana %A Ramo,Danielle E %+ Hopelab, 100 California Street #1150, San Francisco, CA, 94111, United States, 1 415 728 8387, dramo@hopelab.org %K loneliness %K mental health %K smartphone app %K college %K app %K student %K young adult %K randomized controlled trial %K efficacy %K feasibility %K desirability %D 2020 %7 20.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Loneliness is a widespread and significant problem on college campuses. Prolonged loneliness in young adulthood is a risk factor for concurrent and future mental health problems and attrition, making college a critical time for support. Cognitive and behavioral interventions show promise for decreasing loneliness and can be widely disseminated through technology. Objective: This pilot randomized controlled trial was conducted to examine the initial efficacy, feasibility, and desirability of a smartphone app, Nod, designed to deliver cognitive and behavioral skill-building exercises to reduce loneliness during the transition to college. Methods: First-year college students (N=221, mean age 18.7 years, 59% female) were recruited online during incoming student orientation, and randomized to either receive immediate access to Nod (experimental group, n=100) or access after 4 weeks (control group, n=121). The app delivered skills via fully automated (1) “social challenges,” suggested activities designed to build social connections; (2) reflections, brief cognitive reframing exercises; and (3) student testimonials that encouraged a growth mindset toward social connection building. Main intention-to-treat analyses were used to compare the conditions on self-assessed loneliness, depressive symptoms, and other mental health and college adjustment outcomes at week 4, controlling for baseline values on those variables. Analyses were also performed to test the hypothesis that the treatment benefits would be particularly pronounced for participants with heightened psychological vulnerability at baseline (ie, higher baseline depressive symptoms and loneliness). Results: Retention was 97% at week 4, and participants viewed an average 36.7 pages of app content. There were no significant condition differences in loneliness at week 4 (F1, 211=0.05, P=.82; ηp2 <.001). However, there was a significant condition-by-baseline depression interaction to predict week-4 loneliness (F1,209=9.65, P=.002; ηp2 =.04). Simple slope analyses indicated that baseline depression positively predicted week-4 loneliness among control participants (r=0.30, t209=3.81, P<.001), but not among experimental participants (r=–0.09, t209=–0.84, P=.40), suggesting that Nod buffered participants with high baseline depression scores from experiencing heightened midquarter loneliness. Similarly, there were no significant condition differences in other week-4 outcomes. However, moderation by baseline vulnerability was found for week-4 depressive symptoms, sleep quality, and indices of college adjustment (eg, perceived social support and campus belonging). Conclusions: Although Nod exposure did not impact outcomes for the full sample, these results provide initial evidence of its benefit for vulnerable students. The results of this trial suggest that cognitive and behavioral skills delivered via a mobile app can buffer psychologically vulnerable college students against heightened loneliness and depressive symptoms, as well as other negative college adjustment outcomes. Future work will aim to improve upon app engagement, and to address loneliness among other key populations. Trial Registration: ClinicalTrials.gov NCT04164654; https://clinicaltrials.gov/ct2/show/NCT04164654 %M 33079071 %R 10.2196/21496 %U http://mental.jmir.org/2020/10/e21496/ %U https://doi.org/10.2196/21496 %U http://www.ncbi.nlm.nih.gov/pubmed/33079071 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18545 %T App-Based Delivery of Clinical Emotional Freedom Techniques: Cross-Sectional Study of App User Self-Ratings %A Church,Dawson %A Stapleton,Peta %A Sabot,Debbie %+ School of Psychology, Faculty of Society & Design, Bond University, 14 University Drive, Robina, 4226, Australia, 61 755952515, dsabot@bond.edu.au %K anxiety %K stress %K meditation %K mobile health %K Emotional Freedom Techniques (EFT) %K mobile phone %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The burgeoning area of mobile health (mHealth) has experienced rapid growth in mobile apps designed to address mental health issues. Although abundant apps offer strategies for managing symptoms of anxiety and stress, information regarding their efficacy is scarce. Objective: This study aimed to assess the effect of an mHealth app on user self-ratings of psychological distress in a sample of 270,461 app users. The Tapping Solution App guides users through the therapeutic protocols of Clinical Emotional Freedom Techniques (EFT), an evidence-based psychophysiological intervention that combines acupressure with elements of cognitive and exposure therapies. Methods: App users provided self-ratings of emotional intensity before and after app sessions (termed “tapping meditations”) using an 11-point Subjective Units of Distress scale. App user data for 23 tapping meditations, which addressed psychological symptoms of anxiety and stress, were gathered between October 2018 and October 2019, totaling 380,034 completed app sessions. Results: Across 12 anxiety-tapping meditations, the difference in emotional intensity ratings from presession (mean 6.66, SD 0.25) to postsession (mean 3.75, SD 0.30) was statistically significant (P<.001; 95% CI −2.92 to −2.91). Across 11 stress-tapping meditations, a statistically significant difference was also found from presession (mean 6.91, SD 0.48) to postsession (mean 3.83, SD 0.54; P<.001; 95% CI −3.08 to −3.07). The results are consistent with the literature on the efficacy of Clinical EFT for anxiety and stress when offered in conventional therapeutic formats. Conclusions: The findings provide preliminary support for the effectiveness of the mHealth app in the immediate reduction of self-rated psychological distress. As an adjunct to professional mental health care, the app promises accessible and convenient therapeutic benefits. %M 32862128 %R 10.2196/18545 %U http://mhealth.jmir.org/2020/10/e18545/ %U https://doi.org/10.2196/18545 %U http://www.ncbi.nlm.nih.gov/pubmed/32862128 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21075 %T Examining an App-Based Mental Health Self-Care Program, IntelliCare for College Students: Single-Arm Pilot Study %A Lattie,Emily %A Cohen,Katherine A %A Winquist,Nathan %A Mohr,David C %+ Department of Medical Social Sciences, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 3125033741, emily.lattie@northwestern.edu %K mHealth %K college students %K depression %K anxiety %K mobile phone %D 2020 %7 10.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: In recent years, there has been an increase in symptoms of depression, anxiety, and other mental illnesses in college student populations alongside a steady rise in the demand for counseling services. Digital mental health programs, such as those delivered through mobile apps, can add to the array of available services but must be tested for usability and acceptability before implementation. Objective: This study aims to examine how students used IntelliCare for College Students over an 8-week period to examine the preliminary associations between app use and psychosocial targets and to gather user feedback about usability issues that need to be remedied before a larger implementation study. Methods: IntelliCare for College Students is an app-based platform that provides symptom assessments with personalized feedback, information about campus resources, lessons on mental health and wellness topics, and access to the suite of interactive skill–focused IntelliCare apps. A total of 20 students were recruited to participate in an 8-week study. To test for a broad range of potential users, we recruited a mixed sample of students with elevated symptoms of depression or anxiety and students without elevated symptoms. Participants completed psychosocial questionnaires at baseline, week 4, and week 8. Participants also completed user feedback interviews at weeks 4 and 8 in which they provided feedback on their experience using the app and suggestions for changes they would like to be made to the app. Results: Of the 20 students who downloaded the app, 19 completed the study, indicating a high rate of retention. Over the study period, participants completed an average of 5.85 (SD 2.1; range 1-8) symptom assessments. Significant improvements were observed in the Anxiety Literacy Questionnaire scores (Z=−2.006; P=.045) and in the frequency with which participants used both cognitive (Z=−2.091; P=.04) and behavioral (Z=−2.249; P=.03) coping skills. In the feedback interviews, we identified a high degree of usability with minor bugs in the app software, which were quickly fixed. Furthermore, in feedback interviews, we identified that users found the app to be convenient and appreciated the ability to use the program in short bursts of time. Conclusions: The findings indicate that the IntelliCare for College Students program was perceived as largely usable and engaging. Although the program demonstrated usability and preliminary benefits to students, further testing is needed to determine its clinical utility among college students. Trial Registration: ClinicalTrials.gov NCT04035577; https://clinicaltrials.gov/ct2/show/NCT04035577 %M 33037874 %R 10.2196/21075 %U http://mental.jmir.org/2020/10/e21075/ %U https://doi.org/10.2196/21075 %U http://www.ncbi.nlm.nih.gov/pubmed/33037874 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18140 %T User Perspectives of Mood-Monitoring Apps Available to Young People: Qualitative Content Analysis %A Widnall,Emily %A Grant,Claire Ellen %A Wang,Tao %A Cross,Lauren %A Velupillai,Sumithra %A Roberts,Angus %A Stewart,Robert %A Simonoff,Emily %A Downs,Johnny %+ Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 16 De Crespigny Park, London, United Kingdom, 44 7730683269, emily.widnall@kcl.ac.uk %K mood monitoring %K engagement %K mobile applications %K mHealth %K mental health %K smartphone %K qualitative research %K mobile phone %D 2020 %7 10.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health apps are increasingly available and used in a clinical context to monitor young people’s mood and mental health. Despite the benefits of accessibility and cost-effectiveness, consumer engagement remains a hurdle for uptake and continued use. Hundreds of mood-monitoring apps are publicly available to young people on app stores; however, few studies have examined consumer perspectives. App store reviews held on Google and Apple platforms provide a large, rich source of naturally generated, publicly available user reviews. Although commercial developers use these data to modify and improve their apps, to date, there has been very little in-depth evaluation of app store user reviews within scientific research, and our current understanding of what makes apps engaging and valuable to young people is limited. Objective: This study aims to gain a better understanding of what app users consider useful to encourage frequent and prolonged use of mood-monitoring apps appropriate for young people. Methods: A systematic approach was applied to the selection of apps and reviews. We identified mood-monitoring apps (n=53) by a combination of automated application programming interface (API) methods. We only included apps appropriate for young people based on app store age categories (apps available to those younger than 18 years). We subsequently downloaded all available user reviews via API data scraping methods and selected a representative subsample of reviews (n=1803) for manual qualitative content analysis. Results: The qualitative content analysis revealed 8 main themes: accessibility (34%), flexibility (21%), recording and representation of mood (18%), user requests (17%), reflecting on mood (16%), technical features (16%), design (13%), and health promotion (11%). A total of 6 minor themes were also identified: notification and reminders; recommendation; privacy, security, and transparency; developer; adverts; and social/community. Conclusions: Users value mood-monitoring apps that can be personalized to their needs, have a simple and intuitive design, and allow accurate representation and review of complex and fluctuating moods. App store reviews are a valuable repository of user engagement feedback and provide a wealth of information about what users value in an app and what user needs are not being met. Users perceive mood-monitoring apps positively, but over 20% of reviews identified the need for improvement. %M 33037875 %R 10.2196/18140 %U http://mhealth.jmir.org/2020/10/e18140/ %U https://doi.org/10.2196/18140 %U http://www.ncbi.nlm.nih.gov/pubmed/33037875 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e19860 %T Perceptions of Mobile Apps for Smoking Cessation Among Young People in Community Mental Health Care: Qualitative Study %A Gowarty,Minda A %A Kung,Nathan J %A Maher,Ashley E %A Longacre,Meghan R %A Brunette,Mary F %+ Departments of Internal Medicine and Community and Family Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 6036536868, minda.a.gowarty@hitchcock.org %K smoking cessation %K mHealth %K serious mental illness %K smartphone application %K digital health %K psychiatric illness %K tobacco treatment %D 2020 %7 2.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Young adults with serious mental illness are over twice as likely to have tobacco use disorder than those in the general population and are less likely to utilize proven treatment methods during quit attempts. However, little research has evaluated the efficacy of interventions for this group. Smartphone apps may be an underutilized tool for tobacco use disorder among young adults with serious mental illness. Objective: The aim of this study was to explore attitudes toward smoking cessation apps and preferences regarding app design in young adult smokers with serious mental illness. Methods: Five focus groups involving 25- to 35-year-old adults with serious mental illness receiving treatment at a community mental health center were conducted between May 2019 and August 2019. Three researchers independently coded transcripts and identified themes using thematic analysis. Results: Participants (n=22) were individuals who smoke daily: 10 (46%) self-identified as female, 18 (82%) self-identified as White, and 9 (41%) had psychotic disorders. Key themes that emerged included a general interest in using health apps; a desire for apps to provide ongoing motivation during a quit attempt via social support, progress tracking, and rewards; a desire for apps to provide distraction from smoking; concerns about app effectiveness due to a lack of external accountability; and concerns that apps could trigger cravings or smoking behavior by mentioning cigarettes or the act of smoking. Conclusions: Apps have the potential to support smoking cessation or reduction efforts among young adults with serious mental illness. However, they may require tailoring, optimization, and clinical support to effectively promote cessation in this population. %M 33006560 %R 10.2196/19860 %U https://formative.jmir.org/2020/10/e19860 %U https://doi.org/10.2196/19860 %U http://www.ncbi.nlm.nih.gov/pubmed/33006560 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e18407 %T Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users %A Bruen,Ashley Jane %A Wall,Abbie %A Haines-Delmont,Alina %A Perkins,Elizabeth %+ Department of Primary Care and Mental Health, University of Liverpool, Waterhouse Building, 2nd Floor, Block H, Liverpool, L693GF, United Kingdom, 44 0151 795 5343, ashley.bruen@liverpool.ac.uk %K mobile applications %K smartphone %K mobile phone %K mHealth %K mental health %K suicide %K social media %D 2020 %7 28.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data. Objective: This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies. Methods: Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected. Results: Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality. Conclusions: To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting. %M 32985995 %R 10.2196/18407 %U http://mental.jmir.org/2020/9/e18407/ %U https://doi.org/10.2196/18407 %U http://www.ncbi.nlm.nih.gov/pubmed/32985995 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e19476 %T A Smartphone App to Monitor Mood Symptoms in Bipolar Disorder: Development and Usability Study %A Ryan,Kelly Ann %A Babu,Pallavi %A Easter,Rebecca %A Saunders,Erika %A Lee,Andy Jinseok %A Klasnja,Predrag %A Verchinina,Lilia %A Micol,Valerie %A Doil,Brent %A McInnis,Melvin G %A Kilbourne,Amy M %+ Department of Psychiatry, University of Michigan, 2101 Commonwealth Blvd, Suite C, Ann Arbor, MI, 49105, United States, 1 734 936 5524, karyan@umich.edu %K bipolar disorder %K momentary assessment %K mood %K mobile phone %K mobile app %D 2020 %7 22.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is considerable scientific interest in finding new and innovative ways to capture rapid fluctuations in functioning within individuals with bipolar disorder (BD), a severe, recurrent mental disorder associated with frequent shifts in symptoms and functioning. The use of smartphones can provide valid and real-world tools for use in measurement-based care and could be used to inform more personalized treatment options for this group, which can improve standard of care. Objective: We examined the feasibility and usability of a smartphone to capture daily fluctuations in mood within BD and to relate daily self-rated mood to smartphone use behaviors indicative of psychomotor activity or symptoms of the illness. Methods: Participants were 26 individuals with BD and 12 healthy control individuals who were recruited from the Prechter Longitudinal Study of BD. All were given a smartphone with a custom-built app and prompted twice a day to complete questions of mood for 28 days. The app automatically and unobtrusively collected phone usage data. A poststudy satisfaction survey was also completed. Results: Our sample showed a very high adherence rate to the daily momentary assessments (91% of the 58 prompts completed). Multivariate mixed effect models showed that an increase in rapid thoughts over time was associated with a decrease in outgoing text messages (β=–.02; P=.04), and an increase in impulsivity self-ratings was related to a decrease in total call duration (β=–.29; P=.02). Participants generally reported positive experiences using the smartphone and completing daily prompts. Conclusions: Use of mobile technology shows promise as a way to collect important clinical information that can be used to inform treatment decision making and monitor outcomes in a manner that is not overly burdensome to the patient or providers, highlighting its potential use in measurement-based care. %M 32960185 %R 10.2196/19476 %U http://mental.jmir.org/2020/9/e19476/ %U https://doi.org/10.2196/19476 %U http://www.ncbi.nlm.nih.gov/pubmed/32960185 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e18347 %T Perceptions and Attitudes Toward a Mobile Phone App for Mental Health for College Students: Qualitative Focus Group Study %A Holtz,Bree E %A McCarroll,Alexis M %A Mitchell,Katharine M %+ Michigan State University, 404 Wilson Road, Room 309, East Lansing, MI, United States, 1 5178844537, bholtz@msu.edu %K mental health %K mobile phone %K mHealth %D 2020 %7 7.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Many college students who have mental health issues do not receive professional care for various reasons. Students who do not receive help often have both short- and long-term adverse health outcomes. Mobile apps for mental health services such as MySSP, a service provided to college students through their university, may help eliminate barriers to seeking mental health care and result in more positive outcomes for college students. Objective: This qualitative study aims to better understand college students’ perceptions and attitudes toward the adoption and use of a mobile phone app for mental health, MySSP, using the technology acceptance model (TAM). Methods: A series of nine focus groups were conducted with college students (N=30) between February and May 2019 at a large, public Midwestern university. The moderator’s guide was based on the TAM, and focus group sessions primarily focused on the use and knowledge of apps for mental health, specifically, MySSP. The focus group transcriptions were hand-coded to develop a set of themes that encompassed students’ perceptions and attitudes toward MySSP. Results: The analysis of the focus groups suggested the following themes: (1) existing awareness of the app, (2) perceived usefulness, (3) perceived ease of use, (4) attitudes toward apps for mental health and MySSP, and (5) social influence. Conclusions: The results of this study provide deeper insights into the perceptions of a mobile app for mental health among college students. Future research should explore the specific contexts in which an app for mental health will be most effective for college students. %M 32667892 %R 10.2196/18347 %U https://formative.jmir.org/2020/8/e18347 %U https://doi.org/10.2196/18347 %U http://www.ncbi.nlm.nih.gov/pubmed/32667892 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e17204 %T The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review %A Tremain,Hailey %A McEnery,Carla %A Fletcher,Kathryn %A Murray,Greg %+ Centre for Mental Health, Faculty of Health, Arts and Design, Swinburne University of Technology, John St, Hawthorn, 3122, Australia, 61 4039966 9100, htremain@swin.edu.au %K mental health %K mHealth %K eHealth %K telehealth %K psychosis %K bipolar disorder %K mobile phone %D 2020 %7 7.8.2020 %9 Review %J JMIR Ment Health %G English %X Background: Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses. Objective: This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses. Methods: A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance. Results: Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features. Conclusions: More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions. %M 32763881 %R 10.2196/17204 %U https://mental.jmir.org/2020/8/e17204 %U https://doi.org/10.2196/17204 %U http://www.ncbi.nlm.nih.gov/pubmed/32763881 %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 %@ 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 %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14915 %T Mobile Mental Health Apps in China: Systematic App Store Search %A Yin,Huifang %A Wardenaar,Klaas J %A Wang,Yuhao %A Wang,Nan %A Chen,Wenjin %A Zhang,Yan %A Xu,Guangming %A Schoevers,Robert A %+ Tianjin Anding Hospital, No 13, Liulin Road, Hexi district, Tianjin, China, 86 15122997716, xugm@ymail.com %K smartphone %K app %K mobile mental health %K mental illness %K mental health problem %K China %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones have become ubiquitous in China, offering a promising way to deliver mental health interventions; however, little is known about the current use and characteristics of smartphone apps for mental health. Objective: The purpose of this study was to gain insight into mobile mental health apps available in China as of December 2018. Methods: A systematic search was conducted to identify and evaluate the most downloaded apps from iOS and Android platforms. Apps were categorized according to their main purpose and downloaded to evaluate their content. Each app’s affiliation, cost, target users, information security, and evidence-based nature were evaluated. Results: Of the 172 unique apps that were identified, there were 37 apps (21.5%) for psychological counseling, 50 apps (29.1%) for assessment, 12 apps (7.0%) to relieve stress, 24 apps (14.0%) for psychoeducation, and 49 (28.4%) multipurpose apps (ie, a combination of counseling and assessment). Most apps were developed for adults in the general population (166/172, 96.5%), rather than for psychiatric patients. App-based counseling was mostly provided by psychologists, and of the assessed apps, only 40% (70/172) used evidence-based scales to assess mental health problems such as anxiety or depressed mood. Guided meditation was used as the main technique in stress-relieving apps. Conclusions: Many apps contained useful and evidence-based elements, such as good quality information, validated measurements, and useful meditation methods; however, for mobile apps to contribute significantly to mental health care in China, considerable challenges remain, including the need for more patient-focused apps that can actually take on the role of a health care provider. In addition, efficacy studies are needed. %M 32716301 %R 10.2196/14915 %U https://www.jmir.org/2020/7/e14915 %U https://doi.org/10.2196/14915 %U http://www.ncbi.nlm.nih.gov/pubmed/32716301 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16215 %T Potential of Mobile Technology to Relieve the Urgent Mental Health Needs in China: Web-Based Survey %A Tan,Yuxi %A Teng,Ziwei %A Qiu,Yan %A Tang,Hui %A Xiang,Hui %A Chen,Jindong %+ Department of Psychiatry, The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011, China, 86 0731 85292158, chenjindong@csu.edu.cn %K mental health %K mobile health %K mobile phone %K mobile app %K needs %D 2020 %7 7.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the rapid development of information technology and mobile devices, an increasing number of mobile medical services and platforms have emerged. However, China’s current mental health situation necessitates further discussion and research on how to provide more patient-centered services in the face of many challenges and opportunities. Objective: This study aims to explore the attitudes and preferences of mental health service stakeholders regarding mobile mental health services and discuss the challenges and opportunities faced by mobile technology developers in China. Methods: A web-based survey was conducted by following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist. A total of 586 valid questionnaires were collected. Respondents included 184 patients or their family members, 225 mental health professionals, and 177 people from the general population. Data analysis was completed using SPSS 24.0. Results: Among the various problems perceived regarding the current mental health medical environment, difficulty in finding appropriate psychologists and limited visit times ranked highest. Social media (n=380/586, 64.9%) was the most preferred platform among all participants, whereas professionals showed a higher preference for smartphone apps (n=169/225, 75.1%). Professional instruction, psychological consultation, and mental health education (ranked top 3) were the most commonly identified needs. Mental health professionals generally emphasized more on treatment-related mobile mental health service needs, especially medication reminders (χ22=70.7; P<.001), symptom monitoring (χ22=24.0; P<.001), and access to mental health resources (χ22=38.6; P<.001). However, patients and their family members focused more on convenient web-based prescriptions (χ22=7.7; P=.02), with the general population interested in web-based psychological consultation (χ22=23.1; P<.001) and mental health knowledge (χ22=9.1; P=.01). Almost half of the participants regarded mobile mental health services as highly acceptable or supported their use, but less than 30% of participants thought mobile mental health services might be very helpful. Concerns about mobile mental health mainly focused on information security. Service receivers also suspected the quality and professionalism of content, and mental health professionals were worried about time and energy consumption as well as medical safety. Conclusions: In terms of service flow, mobile services could be used to expand service time and improve efficiency before and after diagnosis. More individualized mobile mental health service content in more acceptable forms should be developed to meet the various needs of different mental health stakeholders. Multidisciplinary training and communication could be incorporated to facilitate the integration and cooperation of more well-rounded service teams. A standard medical record system and data format would better promote the development of future intelligent medical care. Issues such as ensuring service quality, solving safety risks, and better integrating mobile services with regular medical workflows also need to be addressed. %M 32673239 %R 10.2196/16215 %U https://mhealth.jmir.org/2020/7/e16215 %U https://doi.org/10.2196/16215 %U http://www.ncbi.nlm.nih.gov/pubmed/32673239 %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 %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e15942 %T Surveying the Role of Analytics in Evaluating Digital Mental Health Interventions for Transition-Aged Youth: Scoping Review %A Lo,Brian %A Shi,Jenny %A Hollenberg,Elisa %A Abi-Jaoudé,Alexxa %A Johnson,Andrew %A Wiljer,David %+ Education, Technology and Innovation, University Health Network, 3-RFE-441, 190 Elizabeth Street, Toronto, ON, M5G 2C4, Canada, 1 4163404800 ext 6322, David.Wiljer@uhn.ca %K user engagement %K mobile apps %K mHealth %K telemedicine %K mental health %K adolescent %K data analytics %D 2020 %7 25.6.2020 %9 Review %J JMIR Ment Health %G English %X Background: Consumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions. Objective: This review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years). Methods: A scoping review was conducted using the Arksey and O’Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis. Results: Of the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected. Conclusions: This review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority. %M 32348261 %R 10.2196/15942 %U https://mental.jmir.org/2020/6/e15942 %U https://doi.org/10.2196/15942 %U http://www.ncbi.nlm.nih.gov/pubmed/32348261 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e19292 %T Closing the Psychological Treatment Gap During the COVID-19 Pandemic With a Supportive Text Messaging Program: Protocol for Implementation and Evaluation %A Agyapong,Vincent Israel Opoku %A Hrabok,Marianne %A Vuong,Wesley %A Gusnowski,April %A Shalaby,Reham %A Mrklas,Kelly %A Li,Daniel %A Urichuk,Liana %A Snaterse,Mark %A Surood,Shireen %A Cao,Bo %A Li,Xin-Min %A Greiner,Russ %A Greenshaw,Andrew James %+ 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 7807144315, agyapong@ualberta.ca %K COVID-19 %K Text4Hope %K mobile phones %K text %K anxiety %K depression %K stress %K pandemic %K e-mental health %D 2020 %7 22.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Coronavirus disease (COVID-19) has spread globally with far-reaching, significant, and unprecedented impacts on health and everyday life. Threats to mental health, psychological safety, and well-being are now emerging, increasing the impact of this virus on world health. Providing support for these challenges is difficult because of the high number of people requiring support in the context of a need to maintain physical distancing. This protocol describes the use of SMS text messaging (Text4Hope) as a convenient, cost-effective, and accessible population-level mental health intervention. This program is evidence-based, with prior research supporting good outcomes and high user satisfaction. Objective: The project goal is to implement a program of daily supportive SMS text messaging (Text4Hope) to reduce distress related to the COVID-19 crisis, initially among Canadians. The prevalence of stress, anxiety, and depressive symptoms; the demographic correlates of the same; and the outcomes of the Text4Hope intervention in mitigating distress will be evaluated. Methods: Self-administered anonymous online questionnaires will be used to assess stress (Perceived Stress Scale), anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]), and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]). Data will be collected at baseline (onset of SMS text messaging), the program midpoint (6 weeks), and the program endpoint (12 weeks). Results: Data analysis will include parametric and nonparametric techniques, focusing on primary outcomes (ie, stress, anxiety, and depressive symptoms) and metrics of use, including the number of subscribers and user satisfaction. Given the large size of the data set, machine learning and data mining methods will also be used. Conclusions: This COVID-19 project will provide key information regarding prevalence rates of stress, anxiety, and depressive symptoms during the pandemic; demographic correlates of distress; and outcome data related to this scalable population-level intervention. Information from this study will be valuable for practitioners and useful for informing policy and decision making regarding psychological interventions during the pandemic. International Registered Report Identifier (IRRID): DERR1-10.2196/19292 %M 32501805 %R 10.2196/19292 %U http://www.researchprotocols.org/2020/6/e19292/ %U https://doi.org/10.2196/19292 %U http://www.ncbi.nlm.nih.gov/pubmed/32501805 %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 %@ 1929-0748 %I JMIR Publications %V 9 %N 5 %P e17737 %T Daily Self-Monitoring of Symptoms and Skills Learning in Patients With Borderline Personality Disorder Through a Mobile Phone App: Protocol for a Pragmatic Randomized Controlled Trial %A Helweg-Jørgensen,Stig %A Beck Lichtenstein,Mia %A Fruzzetti,Alan E %A Møller Dahl,Christian %A Pedersen,Susanne S %+ Research Unit for Telepsychiatry and E-mental Health, Mental Health Services in the Region of Southern Denmark, Heden 11, Odense, 5000, Denmark, 45 9944 9550, stighj@rsyd.dk %K borderline personality disorder %K dialectical behavior therapy %K mobile app %K psychotherapy %K patient-reported outcome measures %K mhealth %D 2020 %7 25.5.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patient self-monitoring via mobile phones during psychotherapy can enhance and provide an overview of psychotherapeutic progress by graphically displaying current and previous symptom scores, providing feedback to the patient, delivering psychoeducative material, and providing timely data to the therapist or treatment team. Objective: This study will aim to assess the effects of using a mobile phone to self-monitor symptoms and acquire coping skills instead of using pen and paper during psychotherapy in patients with borderline personality disorder (BPD). Dialectical behavior therapy will be performed to treat BPD. The primary outcome is the mean time needed to learn coping skills directed at emotion regulation; the secondary outcome is changes in the BPD symptom score as measured by the Zanarini Rating Scale for Borderline Personality Disorder. Methods: This study is a pragmatic, multicenter randomized controlled trial. Participants were recruited through five public general psychiatric outpatient treatment facilities in Denmark. Patients are randomly assigned, on a 1:1 basis, to either the mobile phone condition (using the Monsenso mDiary mobile app) or pen-and-paper condition. Patients will complete several self-report questionnaires on symptom severity; assessments by trained raters on BPD severity will be performed as well. Survival analysis with a shared frailty model will be used to assess the primary outcome. Results: Recruitment began in June 2017 and was completed in February 2019 after 80 participants were recruited. The study ended in February 2020. It is expected that the benefits of mobile phone–based self-report compared to the pen-and-paper method will be demonstrated for skill learning speed and registration compliance. To our knowledge, this is the first trial exploring the impact of cloud-based mobile registration in BPD treatment. Conclusions: This trial will report on the effectiveness of mobile phone–based self-monitoring during psychiatric treatment. It has the potential to contribute to evidence-based clinical practice since apps are already in use clinically. Trial Registration: ClinicalTrials.gov NCT03191565; https://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID): DERR1-10.2196/17737 %M 32449690 %R 10.2196/17737 %U http://www.researchprotocols.org/2020/5/e17737/ %U https://doi.org/10.2196/17737 %U http://www.ncbi.nlm.nih.gov/pubmed/32449690 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e15561 %T Developing Mental or Behavioral Health Mobile Apps for Pilot Studies by Leveraging Survey Platforms: A Do-it-Yourself Process %A Chow,Philip I %+ Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, 560 Ray C. Hunt Dr., Charlottesville, VA, 22908, United States, 1 434 924 5401, philip.i.chow@gmail.com %K app %K mental health %K mHealth %D 2020 %7 20.4.2020 %9 Tutorial %J JMIR Mhealth Uhealth %G English %X Background: Behavioral health researchers are increasingly recognizing the potential of mobile phone apps to deliver empirically supported treatments. However, current options for developing apps typically require large amounts of expertise or money. Objective: This paper aims to describe a pragmatic do-it-yourself approach for researchers to create and pilot an Android mobile phone app using existing survey software (eg, Qualtrics survey platform). Methods: This study was conducted at an academic research center in the United States focused on developing and evaluating behavioral health technologies. The process outlined in this paper was derived and condensed from the steps to building an existing app intervention, iCanThrive, which was developed to enhance mental well-being in women cancer survivors. Results: This paper describes an inexpensive, practical process that uses a widely available survey software, such as Qualtrics, to create and pilot a mobile phone intervention that is presented to participants as a Web viewer app that is downloaded from the Google Play store. Health researchers who are interested in using this process to pilot apps are encouraged to inquire about the survey platforms available to them, the level of security those survey platforms provide, and the regulatory guidelines set forth by their institution. Conclusions: As app interventions continue to gain interest among researchers and consumers alike, it is important to find new ways to efficiently develop and pilot app interventions before committing a large amount of resources. Mobile phone app interventions are an important component to discovering new ways to reach and support individuals with behavioral or mental health disorders. %M 32310143 %R 10.2196/15561 %U https://mhealth.jmir.org/2020/4/e15561 %U https://doi.org/10.2196/15561 %U http://www.ncbi.nlm.nih.gov/pubmed/32310143 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e14897 %T Smartphone Apps for the Treatment of Mental Disorders: Systematic Review %A Miralles,Ignacio %A Granell,Carlos %A Díaz-Sanahuja,Laura %A Van Woensel,William %A Bretón-López,Juana %A Mira,Adriana %A Castilla,Diana %A Casteleyn,Sven %+ Universitat Jaume I, Av Vicent Sos Baynat, s/n, Castellón de la Plana, 12071, Spain, 34 964728000, mirallei@uji.es %K mental health %K mental disorders %K treatment %K intervention %K mHealth %K smartphone %K mobile phone %K mobile apps %K systematic review %D 2020 %7 2.4.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective. Objective: This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]). Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features. Results: We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods. Conclusions: There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders. %M 32238332 %R 10.2196/14897 %U https://mhealth.jmir.org/2020/4/e14897 %U https://doi.org/10.2196/14897 %U http://www.ncbi.nlm.nih.gov/pubmed/32238332 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e17208 %T A Mobile Health Intervention for Mental Health Promotion Among University Students: Randomized Controlled Trial %A Bendtsen,Marcus %A Müssener,Ulrika %A Linderoth,Catharina %A Thomas,Kristin %+ Linköping University, 581 83 Linköping, Linköping, Sweden, 46 13282546, kristin.thomas@liu.se %K mHealth %K positive mental health %K university students %K randomized controlled trial %D 2020 %7 20.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: High positive mental health, including the ability to cope with the normal stresses of life, work productively, and be able to contribute to one’s community, has been associated with various health outcomes. The role of positive mental health is therefore increasingly recognized in national mental health promotion programs and policies. Mobile health (mHealth) interventions could be a cost-effective way to disseminate positive psychological interventions to the general population. Objective: The aim of this study was to estimate the effect of a fully automated mHealth intervention on positive mental health, and anxiety and depression symptomology among Swedish university students using a randomized controlled trial design. Methods: A 2-arm, single-blind (researchers), parallel-groups randomized controlled trial with an mHealth positive psychology program intervention group and a relevant online mental health information control group was employed to estimate the effect of the novel intervention. Participants were recruited using digital advertising through student health care centers in Sweden. Inclusion criteria were (1) university students, (2) able to read and understand Swedish, (3) and have access to a mobile phone. Exclusion criteria were high positive mental health, as assessed by the Mental Health Continuum Short Form (MHC-SF), or high depression and anxiety symptomology, as assessed by the Hospital Anxiety Depression Scale (HADS). The primary outcome was positive mental health (MHC-SF), and the secondary outcomes were depression and anxiety symptomatology (HADS). The subscales of MHC-SF were also analyzed as exploratory outcomes. Outcomes were measured 3 months after randomization through questionnaires completed on the participants’ mobile phones. Results: A total of 654 participants (median age 25 years), including 510 (78.0%) identifying as female, were randomized to either the intervention (n=348) or control group (n=306). At follow-up, positive mental health was significantly higher in the intervention group compared with the control group (incidence rate ratio [IRR]=1.067, 95% CI 1.024-1.112, P=.002). For both depression and anxiety symptomatology, the intervention group showed significantly lower scores at follow-up compared with the control group (depression: IRR=0.820, 95% CI 0.714-0.942, P=.005; anxiety: IRR=0.899, 95% CI 0.840-0.962, P=.002). Follow-up rates were lower than expected (58.3% for primary outcomes and 52.3% for secondary outcomes); however, attrition analyses did not identify any systematic attrition with respect to baseline variables. Conclusions: The mHealth intervention was estimated to be superior to usual care in increasing positive mental health among university students. A protective effect of the intervention was also found on depressive and anxiety symptoms. These findings demonstrate the feasibility of using an automated mobile phone format to enhance positive mental health, which offers promise for the use of mHealth solutions in public mental health promotion. Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN54748632; http://www.isrctn.com/ISRCTN54748632 %M 32196462 %R 10.2196/17208 %U http://mhealth.jmir.org/2020/3/e17208/ %U https://doi.org/10.2196/17208 %U http://www.ncbi.nlm.nih.gov/pubmed/32196462 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 2 %P e12229 %T A Framework for Competencies for the Use of Mobile Technologies in Psychiatry and Medicine: Scoping Review %A Hilty,Donald %A Chan,Steven %A Torous,John %A Luo,John %A Boland,Robert %+ VA Northern California Health Care System, Mental Health & Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, 10535 Hospital Way, Mather, CA, 95655, United States, 1 6263757857, donh032612@gmail.com %K apps %K behavior %K education %K mobile %K outcome %K competency %K technology %K health %K mobile phone %K framework %D 2020 %7 21.2.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: To ensure quality care, clinicians need skills, knowledge, and attitudes related to technology that can be measured. Objective: This paper sought out competencies for mobile technologies and/or an approach to define them. Methods: A scoping review was conducted to answer the following research question, “What skills are needed for clinicians and trainees to provide quality care via mHealth, have they been published, and how can they be made measurable and reproducible to teach and assess them?” The review was conducted in accordance with the 6-stage scoping review process starting with a keyword search in PubMed/Medical Literature Analysis and Retrieval System Online, APA PsycNET, Cochrane, EMBASE, PsycINFO, Web of Science, and Scopus. The literature search focused on keywords in 4 concept areas: (1) competencies, (2) mobile technologies, (3) telemedicine mode, and (4) health. Moreover, 2 authors independently, in parallel, screened the search results for potentially relevant studies based on titles and abstracts. The authors reviewed the full-text articles for final inclusion based on inclusion/exclusion criteria. Inclusion criteria were keywords used from concept area 1 (competencies) and 2 (mobile technologies) and either 3 (telemedicine mode) or 4 (health). Exclusion criteria included, but were not limited to, keywords used from a concept area in isolation, discussion of skills abstractly, outline or listing of what clinicians need without detail, and listing immeasurable behaviors. Results: From a total of 1232 results, the authors found 78 papers eligible for a full-text review and found 14 papers directly relevant to the 4 key concepts. Although few studies specifically discussed skills, the majority were clinical studies, and the literature included no lists of measurable behaviors or competency sets for mobile technology. Therefore, a framework for mobile technology competencies was built according to the review, expert consensus, and recommendations of the Institute of Medicine’s Health Professions Education Summit and Accreditation Council of Graduate Medical Education framework. This framework borrows from existing competency framework domains in telepsychiatry and social media (patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication) and added domains of mHealth clinical decision support, device/technology assessment/selection, and information flow management across an electronic health record platform. mHealth Asynchronous components require additional traditional learning, teaching, supervisory and evaluation practices. Interactive curricula with case-, problem-, and system-based teaching may help faculty focus on decision making and shape skills and attitudes to complement clinical exposure. Conclusions: Research is needed on how to customize implementation and evaluation of mHealth competencies and to ensure skill development is linked to the quality of care. This will require the management of organizational change with technology and the creation of a positive electronic culture in a complex policy and regulatory environment. %M 32130153 %R 10.2196/12229 %U http://mhealth.jmir.org/2020/2/e12229/ %U https://doi.org/10.2196/12229 %U http://www.ncbi.nlm.nih.gov/pubmed/32130153 %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 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 %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e11551 %T Smartphone and Internet Access and Utilization by People With Schizophrenia in South Australia: Quantitative Survey Study %A Wong,Kwok Tung Gordon %A Liu,Dennis %A Balzan,Ryan %A King,Daniel %A Galletly,Cherrie %+ The University of Adelaide, Discipline of Psychiatry, Adelaide Medical School, Helen Mayo North, Frome Road, Adelaide, 5000, Australia, 61 82698144, cherrie.galletly@adelaide.edu.au %K schizophrenia %K schizoaffective disorder %K internet %K technology %K computer %K smartphone %D 2020 %7 28.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Web-based information and interventions for mental illness are increasingly being provided. There is an expectation that citizens have access to the internet and are competent in using technology. People with schizophrenia are often excluded from social engagement, have cognitive impairment, and have very limited income, all of which may reduce their use of technology. Objective: This study aimed to investigate technology access, use of digital technology, and confidence in using technology among people with schizophrenia living in the community. Methods: Face-to-face structured interviews with 50 people with schizophrenia (aged 18-65 years) living in the northern suburbs of Adelaide, South Australia, were conducted using an instrument designed to assess technology access and utilization. Results: Most participants (42/50, 84%) owned a mobile phone, but only 58% (29/50) owned a smartphone. Two-thirds of participants (33/50, 66%) had access to the internet at home, using a smartphone or computer. Moreover, 40% (20/50) of participants used the internet at least daily, but 30% (15/50) of participants had never accessed the internet from any device. Approximately half of the participants (24/50, 48%) had never used Facebook. Participants rarely used community facilities (eg, libraries and cafes) to access the internet. There were no significant differences (P values ranged from .14 to .70) between younger participants (aged 18-34 years) and older participants (aged 35-64 years) in internet or smartphone access or confidence in using technology. Conclusions: Although the sample size of this study is small, it shows limited technology access, use of digital technology, and confidence in using technology among the participants. This could be a barrier to the online delivery of information and interventions for people with schizophrenia. To better understand the impacts of such technological disadvantage and potential disparities in access and use of online resources, prospective studies should recruit a larger sample size and include control subjects matched for socioeconomic disadvantage. %M 32012068 %R 10.2196/11551 %U https://mental.jmir.org/2020/1/e11551 %U https://doi.org/10.2196/11551 %U http://www.ncbi.nlm.nih.gov/pubmed/32012068 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 1 %P e15058 %T Early Signs Monitoring to Prevent Relapse in Psychosis and Promote Well-Being, Engagement, and Recovery: Protocol for a Feasibility Cluster Randomized Controlled Trial Harnessing Mobile Phone Technology Blended With Peer Support %A Gumley,Andrew %A Bradstreet,Simon %A Ainsworth,John %A Allan,Stephanie %A Alvarez-Jimenez,Mario %A Beattie,Louise %A Bell,Imogen %A Birchwood,Max %A Briggs,Andrew %A Bucci,Sandra %A Castagnini,Emily %A Clark,Andrea %A Cotton,Sue M %A Engel,Lidia %A French,Paul %A Lederman,Reeva %A Lewis,Shon %A Machin,Matthew %A MacLennan,Graeme %A Matrunola,Claire %A McLeod,Hamish %A McMeekin,Nicola %A Mihalopoulos,Cathrine %A Morton,Emma %A Norrie,John %A Reilly,Frank %A Schwannauer,Matthias %A Singh,Swaran P %A Smith,Lesley %A Sundram,Suresh %A Thomson,David %A Thompson,Andrew %A Whitehill,Helen %A Wilson-Kay,Alison %A Williams,Christopher %A Yung,Alison %A Farhall,John %A Gleeson,John %+ Glasgow Institute of Health and Wellbeing, Glasgow Mental Health Research Facility, University of Glasgow, Fleming Pavilion, West of Scotland Science Park (Todd Campus), Glasgow, G20 0XA, United Kingdom, 44 141 330 4852, a.gumley@clinmed.gla.ac.uk %K schizophrenia %K psychosis %K relapse %K mHealth %K randomized controlled trial %D 2020 %7 9.1.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Relapse in schizophrenia is a major cause of distress and disability and is predicted by changes in symptoms such as anxiety, depression, and suspiciousness (early warning signs [EWSs]). These can be used as the basis for timely interventions to prevent relapse. However, there is considerable uncertainty regarding the implementation of EWS interventions. Objective: This study was designed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) against treatment as usual (TAU). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, safety, and outcome signals of a digital health intervention as an adjunct to usual care that is deliverable in the UK National Health Service and Australian community mental health service (CMHS) settings. We will assess the feasibility of candidate primary outcomes, candidate secondary outcomes, and candidate mechanisms for a definitive trial. Methods: We will randomize CMHSs to EMPOWER or TAU. We aim to recruit up to 120 service user participants from 8 CMHSs and follow them for 12 months. Eligible service users will (1) be aged 16 years and above, (2) be in contact with local CMHSs, (3) have either been admitted to a psychiatric inpatient service or received crisis intervention at least once in the previous 2 years for a relapse, and (4) have an International Classification of Diseases-10 diagnosis of a schizophrenia-related disorder. Service users will also be invited to nominate a carer to participate. We will identify the feasibility of the main trial in terms of recruitment and retention to the study and the acceptability, usability, safety, and outcome signals of the EMPOWER intervention. EMPOWER is a mobile phone app that enables the monitoring of well-being and possible EWSs of relapse on a daily basis. An algorithm calculates changes in well-being based on participants’ own baseline to enable tailoring of well-being messaging and clinical triage of possible EWSs. Use of the app is blended with ongoing peer support. Results: Recruitment to the trial began September 2018, and follow-up of participants was completed in July 2019. Data collection is continuing. The database was locked in July 2019, followed by analysis and disclosing of group allocation. Conclusions: The knowledge gained from the study will inform the design of a definitive trial including finalizing the delivery of our digital health intervention, sample size estimation, methods to ensure successful identification, consent, randomization, and follow-up of participants, and the primary and secondary outcomes. The trial will also inform the final health economic model to be applied in the main trial. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 99559262; http://isrctn.com/ISRCTN99559262 International Registered Report Identifier (IRRID): DERR1-10.2196/15058 %M 31917372 %R 10.2196/15058 %U https://www.researchprotocols.org/2020/1/e15058 %U https://doi.org/10.2196/15058 %U http://www.ncbi.nlm.nih.gov/pubmed/31917372 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15337 %T Usability Evaluations of Mobile Mental Health Technologies: Systematic Review %A Inal,Yavuz %A Wake,Jo Dugstad %A Guribye,Frode %A Nordgreen,Tine %+ Department of Information Science and Media Studies, University of Bergen, Fosswinckels Gate 6, Bergen, 5020, Norway, 47 41301855, yavuz.inal@uib.no %K systematic review %K mobile %K mHealth %K mental health %K usability evaluation %D 2020 %7 6.1.2020 %9 Review %J J Med Internet Res %G English %X Background: Many mobile health (mHealth) apps for mental health have been made available in recent years. Although there is reason to be optimistic about their effect on improving health and increasing access to care, there is a call for more knowledge concerning how mHealth apps are used in practice. Objective: This study aimed to review the literature on how usability is being addressed and measured in mHealth interventions for mental health problems. Methods: We conducted a systematic literature review through a search for peer-reviewed studies published between 2001 and 2018 in the following electronic databases: EMBASE, CINAHL, PsycINFO, PubMed, and Web of Science. Two reviewers independently assessed all abstracts against the inclusion and exclusion criteria, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Results: A total of 299 studies were initially identified based on the inclusion keywords. Following a review of the title, abstract, and full text, 42 studies were found that fulfilled the criteria, most of which evaluated usability with patients (n=29) and health care providers (n=11) as opposed to healthy users (n=8) and were directed at a wide variety of mental health problems (n=24). Half of the studies set out to evaluate usability (n=21), and the remainder focused on feasibility (n=10) or acceptability (n=10). Regarding the maturity of the evaluated systems, most were either prototypes or previously tested versions of the technology, and the studies included few accounts of sketching and participatory design processes. The most common reason referred to for developing mobile mental health apps was the availability of mobile devices to users, their popularity, and how people in general became accustomed to using them for various purposes. Conclusions: This study provides a detailed account of how evidence of usability of mHealth apps is gathered in the form of usability evaluations from the perspective of computer science and human-computer interaction, including how users feature in the evaluation, how the study objectives and outcomes are stated, which research methods and techniques are used, and what the notion of mobility features is for mHealth apps. Most studies described their methods as trials, gathered data from a small sample size, and carried out a summative evaluation using a single questionnaire, which indicates that usability evaluation was not the main focus. As many studies described using an adapted version of a standard usability questionnaire, there may be a need for developing a standardized mHealth usability questionnaire. %M 31904579 %R 10.2196/15337 %U https://www.jmir.org/2020/1/e15337 %U https://doi.org/10.2196/15337 %U http://www.ncbi.nlm.nih.gov/pubmed/31904579 %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 %@ 1929-0748 %I JMIR Publications %V 8 %N 12 %P e15634 %T Understanding Implementation of a Digital Self-Monitoring Intervention for Relapse Prevention in Psychosis: Protocol for a Mixed Method Process Evaluation %A Allan,Stephanie %A Mcleod,Hamish %A Bradstreet,Simon %A Beedie,Sara %A Moir,Bethany %A Gleeson,John %A Farhall,John %A Morton,Emma %A Gumley,Andrew %+ Mental Health & Wellbeing, University of Glasgow, Fleming Pavilion, West of Scotland Science Park (Todd Campus), Glasgow, G20 0XA, United Kingdom, 44 0141 3305295, stephanie.allan@glasgow.ac.uk %K telemedicine %K schizophrenia %K implementation science %D 2019 %7 10.12.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Relapse is common in people who experience psychosis and is associated with many negative consequences, both societal and personal. People who relapse often exhibit changes (early warning signs [EWS]) in the period before relapse. Successful identification of EWS offers an opportunity for relapse prevention. However, several known barriers impede the use of EWS monitoring approaches. Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) is a complex digital intervention that uses a mobile app to enhance the detection and management of self-reported changes in well-being. This is currently being tested in a pilot cluster randomized controlled trial. As digital interventions have not been widely used in relapse prevention, little is known about their implementation. Process evaluation studies run in parallel to clinical trials can provide valuable data on intervention feasibility. Objective: This study aims to transparently describe the protocol for the process evaluation element of the EMPOWER trial. We will focus on the development of a process evaluation framework sensitive to the worldview of service users, mental health staff, and carers; the aims of the process evaluation itself; the proposed studies to address these aims; and a plan for integration of results from separate process evaluation studies into one overall report. Methods: The overall process evaluation will utilize mixed methods across 6 substudies. Among them, 4 will use qualitative methodologies, 1 will use a mixed methods approach, and 1 will use quantitative methodologies. Results: The results of all studies will be triangulated into an overall analysis and interpretation of key implementation lessons. EMPOWER was funded in 2016, recruitment finished in January 2018. Data analysis is currently under way and the first results are expected to be submitted for publication in December 2019. Conclusions: The findings from this study will help identify implementation facilitators and barriers to EMPOWER. These insights will inform both upscaling decisions and optimization of a definitive trial. Trial Registration: ISRCTN Registry ISRCTN99559262; http://www.isrctn.com/ISRCTN99559262 International Registered Report Identifier (IRRID): DERR1-10.2196/15634 %M 31821154 %R 10.2196/15634 %U https://www.researchprotocols.org/2019/12/e15634 %U https://doi.org/10.2196/15634 %U http://www.ncbi.nlm.nih.gov/pubmed/31821154 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e14018 %T Acceptance and Expectations of Medical Experts, Students, and Patients Toward Electronic Mental Health Apps: Cross-Sectional Quantitative and Qualitative Survey Study %A Mayer,Gwendolyn %A Gronewold,Nadine %A Alvarez,Simone %A Bruns,Bastian %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 62215635685, gwendolyn.mayer@med.uni-heidelberg.de %K acceptance %K telemedicine %K telehealth %K eHealth %K mHealth %K interventions %K depression %K patients %K students %K experts %K expectation %K risk %D 2019 %7 25.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The acceptability of electronic mental (e-mental) health apps has already been studied. However, the attitudes of medical experts, students, and patients taking into account their knowledge of and previous experiences with e-mental health apps have not been investigated. Objective: The aim of this study was to explore the attitudes, expectations, and concerns of medical experts, including physicians, psychotherapists and nursing staff, students of medicine or psychology, and patients toward e-mental health apps when considering their knowledge of and former experiences with e-mental health apps. Methods: This cross-sectional quantitative and qualitative survey was based on a self-developed questionnaire. A total of 269 participants were included (104 experts, 80 students, and 85 patients), and 124 eligible participants answered a paper version and 145 answered an identical online version of the questionnaire. The measures focused on existing knowledge of and experiences with e-mental health apps, followed by a question on whether electronic health development was generally accepted or disliked. Further, we asked about the expectations for an ideal e-mental health app and possible concerns felt by the participants. All items were either presented on a 5-point Likert scale or as multiple-choice questions. Additionally, 4 items were presented as open text fields. Results: Although 33.7% (35/104) of the experts, 15.0% (12/80) of the students, and 41.2% (35/85) of the patients knew at least one e-mental health app, few had already tried one (9/104 experts [8.7%], 1/80 students [1.3%], 22/85 patients [25.9%]). There were more advocates than skeptics in each group (advocates: 71/104 experts [68.3%], 50/80 students [62.5%], 46/85 patients [54.1%]; skeptics: 31/104 experts [29.8%], 20/80 students [25.0%], 26/85 patients [30.6%]). The experts, in particular, believed, that e-mental health apps will gain importance in the future (mean 1.08, SD 0.68; 95% CI 0.94-1.21). When asked about potential risks, all groups reported slight concerns regarding data security (mean 0.85, SD 1.09; 95% CI 0.72-0.98). Patient age was associated with several attitudes toward e-mental health apps (future expectations: r=–0.31, P=.005; total risk score: r=0.22, P=.05). Attitudes toward e-mental health apps correlated negatively with the professional experience of the experts (rs(94)=–0.23, P=.03). Conclusions: As opposed to patients, medical experts and students lack knowledge of and experience with e-mental health apps. If present, the experiences were assessed positively. However, experts show a more open-minded attitude with less fear of risks. Although some risks were perceived regarding data security, the attitudes and expectations of all groups were rather positive. Older patients and medical experts with long professional experience tend to express more skepticism. Trial Registration: German Clinical Trials Register DRKS00013095; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00013095 %M 31763990 %R 10.2196/14018 %U http://mental.jmir.org/2019/11/e14018/ %U https://doi.org/10.2196/14018 %U http://www.ncbi.nlm.nih.gov/pubmed/31763990 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e15064 %T Predictors of the Number of Installs in Psychiatry Smartphone Apps: Systematic Search on App Stores and Content Analysis %A Pinheiro,Mariana %A Serra,Madalena %A Pereira-Azevedo,Nuno %+ Psychiatric Service of the Psychiatry and Mental Health Department, Centro Hospitalar do Tâmega e Sousa, Av do Hospital Padre Américo, 210, Guilhufe, 4560-136, Portugal, 351 255 714 000, dra.mampi@gmail.com %K eHealth %K mHealth %K mobile applications %K psychiatry %D 2019 %7 19.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health is integral to our salubrity, but mental disorders are very debilitating and common. Therefore, it is critical to provide accessible, timely, and inexpensive mental care. This can be done through mobile health (mHealth), namely, mobile medical apps, which are gaining popularity among clinicians and patients. mHealth is a fast-paced field, and there is significant variation in the number of installs among psychiatry apps. However, the factors that influence psychiatry app installs have yet to be studied. Objective: This study aimed to identify predictors of the number of app installs in psychiatry. Methods: A literature review identified which factors influence app installs. Psychiatry apps available in the Google Play Store were reviewed, and publicly available data were collected. A multivariate ordinal logistic regression analysis was performed to evaluate the effect of said factors on the number of installs. Results: Our search identified 128 psychiatry apps: 2.3% (3/128) had never been installed, approximately half (53.1%, 68/128) had less than 500 installs, and only 0.8% (1/128) had over 10,000,000 installs. A multivariate logistic regression analysis identified that apps with a lower price (P<.001), a higher rating (P<.001), optional in-app purchases (P<.001), and age restriction (P=.04) had a higher number of installs. The involvement of a psychiatrist or other health care professional (HCP) had no statistically significant influence on the number of installs. Only data from the Google Play Store and the developers’ websites were available for analysis, and the depth of involvement of HCPs was impossible to document. Conclusions: Psychiatry apps with a lower price, optional in-app purchases, age restriction, and a higher rating are expected to have a higher number of installs. Unlike other medical fields, in this study, the explicit participation of psychiatrists in app development was not a significant predictor of the number of installs. Research is needed to identify other factors that may influence the number of installs, as that can help mHealth app development. %M 31742560 %R 10.2196/15064 %U https://mental.jmir.org/2019/11/e15064 %U https://doi.org/10.2196/15064 %U http://www.ncbi.nlm.nih.gov/pubmed/31742560 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e16393 %T Smartphone Apps to Support Coordinated Specialty Care for Prodromal and Early Course Schizophrenia Disorders: Systematic Review %A Camacho,Erica %A Levin,Leonard %A Torous,John %+ Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, United States, 1 6176676799, jtorous@bidmc.harvard.edu %K smartphones %K mobile phones %K app %K schizophrenia %D 2019 %7 12.11.2019 %9 Review %J J Med Internet Res %G English %X Background: Demand for mental health services, especially for clinical high-risk and early psychosis, has increased, creating a need for new solutions to increase access to and quality of care. Smartphones and mobile technology are potential tools to support coordinated specialty care for early psychosis, given their potential to augment the six core roles of care: case management and team leadership, recovery-oriented psychotherapy, medication management, support for employment and education, coordination with primary care services, and family education and support. However, the services smartphones are actually offering specifically for coordinated specialty care and the level of evidence are unknown. Objective: This study aimed to review the published literature on smartphone technology to enhance care for patients with prodromal and early course psychosis and schizophrenia and to analyze studies by type, aligned with coordinated specialty care domains. Methods: A systematic literature search was conducted on August 16 and 17, 2019, using the PubMed, EMBASE, Web of Sciences, and PsycINFO electronic databases. The eligible studies were reviewed and screened based on inclusion and exclusion criteria. Results: The search uncovered 388 unique results, of which 32 articles met the initial inclusion criteria; 21 eligible studies on 16 unique app platforms were identified. Feasibility studies showed a high user engagement and interest among patients, monitoring studies demonstrated a correlation between app assessments and clinical outcomes, and intervention studies indicated that these apps have the potential to advance care. Eighteen studies reported on app use for the case management roles of coordinated specialty care. No app studies focused on employment and education, coordination with primary care services, and family education and support. Conclusions: Although the published literature on smartphone apps for prodromal and first-episode psychosis is small, it is growing exponentially and holds promise to augment both monitoring and interventions. Although the research results and protocols for app studies are not well aligned with all coordinated specialty care roles today, high rates of adoption and feasibility suggest the potential for future efforts. These results will be used to develop coordinated specialty care–specific app evaluation scales and toolkits. %M 31714250 %R 10.2196/16393 %U http://www.jmir.org/2019/11/e16393/ %U https://doi.org/10.2196/16393 %U http://www.ncbi.nlm.nih.gov/pubmed/31714250 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14269 %T A New Mental Health Mobile App for Well-Being and Stress Reduction in Working Women: Randomized Controlled Trial %A Coelhoso,Cássia Canha %A Tobo,Patricia Renovato %A Lacerda,Shirley Silva %A Lima,Alex Heitor %A Barrichello,Carla Regina Camara %A Amaro Jr,Edson %A Kozasa,Elisa Harumi %+ Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 bloco A 2ºSS, Sao Paulo, 05601-901, Brazil, 55 11 99179 9721, ehkozasa@gmail.com %K stress, psychological %K mental health %K health promotion %K mobile applications %K mind-body therapies %K meditation %K behavioral symptoms %K behavioral medicine %K psychology %K women’s health %D 2019 %7 7.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although the availability and use of mobile mental health apps has grown exponentially in recent years, little data are available regarding their efficacy. Objective: This study aimed to evaluate the effectiveness of an app developed to promote stress management and well-being among working women compared with a control app. Methods: Female employees at a private hospital were invited to participate in the study via mailing lists and intranet ads. A total of 653 individuals self-enrolled through the website. Eligible participants were randomized between control (n=240) and intervention (n=250) groups. The well-being mobile app provides an 8-week program with 4 classes per week (including a brief theoretical portion and a 15-min guided practice). The active control app also provided 4 assessments per week that encouraged participants to self-observe how they were feeling for 20 min. We also used the app to conduct Web-based questionnaires (10-item Perceived Stress Scale and 5-item World Health Organization Well-Being Index) and ask specific questions to assess subjective levels of stress and well-being at baseline (t1), midintervention (t4=4 weeks after t1) and postintervention (t8=8 weeks after t1). Both apps were fully automated without any human involvement. Outcomes from the control and intervention conditions at the 3 time points were analyzed using a repeated measures analysis of variance. Results: Among the randomized participants (n=490), 185 participants were excluded at the 4-week follow-up and another 79 at the 8-week follow-up because of noncompliance with the experimental protocol. Participants who did not complete t4 and t8 assessments were equally distributed between groups (t4: control group=34.6% [83/240] and intervention group=40.8% [102/250]; P=.16; t8: control group=29.9% [47/157] and intervention group=21.6% [32/148]; P=.10). Both groups showed a significant increase in general well-being as a function of time (F2,426=5.27; P=.006), but only the intervention group presented a significant increase in work-related well-being (F2,426=8.92; P<.001), as well as a significant reduction in work-related and overall stress (F2,426=5.50; P=.004 and F2,426=8.59; P<.001, respectively). Conclusions: The well-being mobile app was effective in reducing employee stress and improving well-being. Trial Registration: Clinicaltrials.gov NCT02637414; https://clinicaltrials.gov/ct2/show/NCT02637414. %M 31697244 %R 10.2196/14269 %U https://www.jmir.org/2019/11/e14269 %U https://doi.org/10.2196/14269 %U http://www.ncbi.nlm.nih.gov/pubmed/31697244 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e13236 %T Mental Health Apps in China: Analysis and Quality Assessment %A Shang,Jie %A Wei,Shaoming %A Jin,Jianbo %A Zhang,Puhong %+ The George Institute for Global Health, Peking University Health Science Center, 18F Jinqiu Tower B, No 6 Zhichun Rd, Haidian District, Beijing, 100088, China, 86 10 8280 0577, zpuhong@georgeinstitute.org.cn %K mental health %K mental disorder %K quality assessment %K mobile health %K digital health %K innovative health %K smartphone application %D 2019 %7 7.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental disorders have been a great burden on health care systems, affecting the quality of life of millions of people worldwide. Developing countries, including China, suffer from the double burden of both the increasing mental health issues in population and the deficiency in mental health care resources. The use of mobile health technologies, especially for mobile phone apps, can be a possible solution. Objective: This review aimed to describe the features and assess the quality of mental health apps in major mobile phone app markets in China and further discuss the priorities for mental health app development. Methods: Keywords including psychology, psychological health, psychological hygiene, psychological health service(s), mental, mental health, mental hygiene, mental health service(s), depression, and anxiety were searched in Chinese in 3 Android app markets (Baidu Mobile Assistant, Tencent MyApp, and 360 Mobile Assistant) and iOS App Store independently. Mental health apps were then selected according to established criteria for in-depth analysis and quality assessment by the Mobile App Rating Scale. Results: In total, 63 of 997 mental health apps were analyzed in depth, of which 78% (49/63) were developed by commercial entities for general population, 17% (11/63) were for patients or clients of specialized psychiatric hospitals or counseling agencies, 3% (2/63) were by government or local Centers for Disease Control and Prevention for general information, and 2% (1/63) for students of a university. Major built-in features of the apps included counseling services, mental health education, and self-assessment of mental health status by validated self-rating scales. The overall quality score of the MH apps was acceptable. Conclusions: Mental health apps are emerging in the area of mobile health in China. Popular mental health apps usually provide a synthetic platform organizing resources of information, knowledge, counseling services, self-tests, and management for the general population with mental health-related inquiries. The quality of the apps was rated as acceptable on average, suggesting some space for improvement. Official guidelines and regulations are urgently required for the field in the future. %M 31697245 %R 10.2196/13236 %U https://mhealth.jmir.org/2019/11/e13236 %U https://doi.org/10.2196/13236 %U http://www.ncbi.nlm.nih.gov/pubmed/31697245 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e15362 %T Methodological Challenges in Randomized Controlled Trials on Smartphone-Based Treatment in Psychiatry: Systematic Review %A Tønning,Morten Lindbjerg %A Kessing,Lars Vedel %A Bardram,Jakob Eivind %A Faurholt-Jepsen,Maria %+ Copenhagen Affective Disorder Research Center, Psychiatric Center Copenhagen, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, Copenhagen, 2100, Denmark, 45 28975755, Morten.lindbjerg.toenning@regionh.dk %K psychiatry %K methodology %K smartphone %K mHealth %K mobile Health %K digital health %K digital psychiatry %K systematic review %D 2019 %7 27.10.2019 %9 Review %J J Med Internet Res %G English %X Background: Smartphone-based technology is developing at high speed, and many apps offer potential new ways of monitoring and treating a range of psychiatric disorders and symptoms. However, the effects of most available apps have not been scientifically investigated. Within medicine, randomized controlled trials (RCTs) are the standard method for providing the evidence of effects. However, their rigidity and long time frame may contrast with the field of information technology research. Therefore, a systematic review of methodological challenges in designing and conducting RCTs within mobile health is needed. Objective: This systematic review aimed to (1) identify and describe RCTs investigating the effect of smartphone-based treatment in adult patients with a psychiatric diagnosis, (2) discuss methodological challenges in designing and conducting individual trials, and (3) suggest recommendations for future trials. Methods: A systematic search in English was conducted in PubMed, PsycINFO, and EMBASE up to August 12, 2019. The search terms were (1) psychiatric disorders in broad term and for specific disorders AND (2) smartphone or app AND (3) RCT. The Consolidated Standards of Reporting Trials electronic health guidelines were used as a template for data extraction. The focus was on trial design, method, and reporting. Only trials having sufficient information on diagnosis and acceptable diagnostic procedures, having a smartphone as a central part of treatment, and using an RCT design were included. Results: A total of 27 trials comprising 3312 patients within a range of psychiatric diagnoses were included. Among them, 2 trials were concerning drug or alcohol abuse, 3 psychosis, 10 affective disorders, 9 anxiety and posttraumatic stress disorder, 1 eating disorder, and 1 attention-deficit/hyperactivity disorder. In addition, 1 trial used a cross-diagnostic design, 7 trials included patients with a clinical diagnosis that was subsequently assessed and validated by the researchers, and 11 trials had a sample size above 100. Generally, large between-trial heterogeneity and multiple approaches to patient recruitment, diagnostic procedures, trial design, comparator, outcome measures, and analyses were identified. Only 5 trials published a trial protocol. Furthermore, 1 trial provided information regarding technological updates, and only 18 trials reported on the conflicts of interest. No trial addressed the ethical aspects of using smartphones in treatment. Conclusions: This first systematic review of the methodological challenges in designing and conducting RCTs investigating smartphone-based treatment in psychiatric patients suggests an increasing number of trials but with a lower quality compared with classic medical RCTs. Heterogeneity and methodological issues in individual trials limit the evidence. Methodological recommendations are presented. %M 31663859 %R 10.2196/15362 %U http://www.jmir.org/2019/10/e15362/ %U https://doi.org/10.2196/15362 %U http://www.ncbi.nlm.nih.gov/pubmed/31663859 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e14567 %T Objective User Engagement With Mental Health Apps: Systematic Search and Panel-Based Usage Analysis %A Baumel,Amit %A Muench,Frederick %A Edan,Stav %A Kane,John M %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa, 3498838, Israel, 972 048240111, abaumel@univ.haifa.ac.il %K user engagement %K usage %K adherence %K retention %K mental health %K depression %K anxiety %K mHealth %D 2019 %7 25.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Understanding patterns of real-world usage of mental health apps is key to maximizing their potential to increase public self-management of care. Although developer-led studies have published results on the use of mental health apps in real-world settings, no study yet has systematically examined usage patterns of a large sample of mental health apps relying on independently collected data. Objective: Our aim is to present real-world objective data on user engagement with popular mental health apps. Methods: A systematic engine search was conducted using Google Play to identify Android apps with 10,000 installs or more targeting anxiety, depression, or emotional well-being. Coding of apps included primary incorporated techniques and mental health focus. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with mobile apps. Results: In total, 93 apps met the inclusion criteria (installs: median 100,000, IQR 90,000). The median percentage of daily active users (open rate) was 4.0% (IQR 4.7%) with a difference between trackers (median 6.3%, IQR 10.2%) and peer-support apps (median 17.0%) versus breathing exercise apps (median 1.6%, IQR 1.6%; all z≥3.42, all P<.001). Among active users, daily minutes of use were significantly higher for mindfulness/meditation (median 21.47, IQR 15.00) and peer support (median 35.08, n=2) apps than for apps incorporating other techniques (tracker, breathing exercise, psychoeducation: medians range 3.53-8.32; all z≥2.11, all P<.05). The medians of app 15-day and 30-day retention rates were 3.9% (IQR 10.3%) and 3.3% (IQR 6.2%), respectively. On day 30, peer support (median 8.9%, n=2), mindfulness/meditation (median 4.7%, IQR 6.2%), and tracker apps (median 6.1%, IQR 20.4%) had significantly higher retention rates than breathing exercise apps (median 0.0%, IQR 0.0%; all z≥2.18, all P≤.04). The pattern of daily use presented a descriptive peak toward the evening for apps incorporating most techniques (tracker, psychoeducation, and peer support) except mindfulness/meditation, which exhibited two peaks (morning and night). Conclusions: Although the number of app installs and daily active minutes of use may seem high, only a small portion of users actually used the apps for a long period of time. More studies using different datasets are needed to understand this phenomenon and the ways in which users self-manage their condition in real-world settings. %M 31573916 %R 10.2196/14567 %U http://www.jmir.org/2019/9/e14567/ %U https://doi.org/10.2196/14567 %U http://www.ncbi.nlm.nih.gov/pubmed/31573916 %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 e12820 %T Mindful Eating Mobile Health Apps: Review and Appraisal %A Lyzwinski,Lynnette Nathalie %A Edirippulige,Sisira %A Caffery,Liam %A Bambling,Matthew %+ Centre for Online Health, School of Medicine, University of Queensland, Princess Alexandria Hospital, Wooloongabba, 4102, Australia, 61 7 3176 7704, lynnettenathalie@icloud.com %K feeding behavior %K mindfulness %K mHealth %K diet %D 2019 %7 22.08.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mindful eating is an emerging area of research for managing unhealthy eating and weight-related behaviors such as binge eating and emotional eating. Although there are numerous commercial mindful eating apps available, their quality, effectiveness, and whether they are accurately based on mindfulness-based eating awareness are unknown. Objective: This review aimed to appraise the quality of the mindful eating apps and to appraise the quality of content on mindful eating apps. Methods: A review of mindful eating apps available on Apple iTunes was undertaken from March to April 2018. Relevant apps meeting the inclusion criteria were subjectively appraised for general app quality using the Mobile App Rating Scale (MARS) guidelines and for the quality of content on mindful eating. A total of 22 apps met the inclusion criteria and were appraised. Results: Many of the reviewed apps were assessed as functional and had moderate scores in aesthetics based on the criteria in the MARS assessment. However, some received lower scores in the domains of information and engagement. The majority of the apps did not teach users how to eat mindfully using all five senses. Hence, they were scored as incomplete in accurately providing mindfulness-based eating awareness. Instead, most apps were either eating timers, hunger rating apps, or diaries. Areas of potential improvement were in comprehensiveness and diversity of media, in the quantity and quality of information, and in the inclusion of privacy and security policies. To truly teach mindful eating, the apps need to provide guided examples involving the five senses beyond simply timing eating or writing in a diary. They also need to include eating meditations to assist people with their disordered eating such as binge eating, fullness, satiety, and craving meditations that may help them with coping when experiencing difficulties. They should also have engaging and entertaining features delivered through diverse media to ensure sustained use and interest by consumers. Conclusions: Future mindful eating apps could be improved by accurate adherence to mindful eating. Further improvement could be achieved by ameliorating the domains of information, engagement, and aesthetics and having adequate privacy policies. %M 31441431 %R 10.2196/12820 %U https://mental.jmir.org/2019/8/e12820/ %U https://doi.org/10.2196/12820 %U http://www.ncbi.nlm.nih.gov/pubmed/31441431 %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 %@ 2368-7959 %I JMIR Publications %V 6 %N 8 %P e14724 %T Reimbursement of Apps for Mental Health: Findings From Interviews %A Powell,Adam C %A Bowman,Matthias B %A Harbin,Henry T %+ Payer+Provider Syndicate, 111 Beach Street, Ste 4E, Boston, MA, 02111, United States, 1 617 939 9168, powell@payerprovider.com %K mental health %K psychiatry %K compensation %K mobile health %K clinical coding %K administrative claims, healthcare %D 2019 %7 06.08.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although apps and other digital and mobile health tools are helping improve the mental health of Americans, they are currently being reimbursed through a varied range of means, and most are not being reimbursed by payers at all. Objective: The aim of this study was to shed light on the state of app reimbursement. We documented ways in which apps can be reimbursed and surveyed stakeholders to understand current reimbursement practices. Methods: Individuals from over a dozen stakeholder organizations in the domains of digital behavioral and mental health, care delivery, and managed care were interviewed. A review of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCSPCS) codes was conducted to determine potential means for reimbursement. Results: Interviews and the review of codes revealed that potential channels for app reimbursement include direct payments by employers, providers, patients, and insurers. Insurers are additionally paying for apps using channels originally designed for devices, drugs, and laboratory tests, as well as via value-based payments and CPT and HCSPCS codes. In many cases, it is only possible to meet the requirements of a CPT or HCSPCS code if an app is used in conjunction with human time and services. Conclusions: Currently, many apps face significant barriers to reimbursement. CPT codes are not a viable means of providing compensation for the use of all apps, particularly those involving little physician work. In some cases, apps have sought clearance from the US Food and Drug Administration for prescription use as digital therapeutics, a reimbursement mechanism with as yet unproven sustainability. There is a need for simpler, more robust reimbursement mechanisms to cover stand-alone app-based treatments. %M 31389336 %R 10.2196/14724 %U http://mental.jmir.org/2019/8/e14724/ %U https://doi.org/10.2196/14724 %U http://www.ncbi.nlm.nih.gov/pubmed/31389336 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 7 %P e12546 %T Use of Smartphone Apps, Social Media, and Web-Based Resources to Support Mental Health and Well-Being: Online Survey %A Stawarz,Katarzyna %A Preist,Chris %A Coyle,David %+ Bristol Interaction Group, Faculty of Engineering, University of Bristol, Queen's Building, University Walk, Bristol, BS8 1TR, United Kingdom, 44 01179545289, k.stawarz@bristol.ac.uk %K mental health %K mobile apps %K mHealth %K social media %K self-instruction programs, computerized %D 2019 %7 12.07.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology can play an important role in supporting mental health. Many studies have explored the effectiveness, acceptability, or context of use of different types of mental health technologies. However, existing research has tended to investigate single types of technology at a time rather than exploring a wider ecosystem that people may use. This narrow focus can limit our understanding of how we could best design mental health technologies. Objective: The aim of this study was to investigate which technologies (smartphone apps, discussion forums and social media, and websites and Web-based programs) people use to support their mental health and why, whether they combine and use more than one technology, what purpose each technology serves, and which features people find the most valuable. Methods: We conducted an online survey to gather responses from members of the public who use technology to support their mental health and well-being. The survey was advertised on social media and via posters at a university. It explored usage patterns, frequently used features, and engagement with technology. To gain deeper insights into users’ preferences, we also thematically analyzed open-ended comments about each technology type and suggestions for improvements provided by the respondents. Results: In total, 81 eligible participants completed the survey. Smartphone apps were the most commonly used technology, with 78% of the participants (63/81) using them, either alone (40%) or in combination with other technologies (38%). Each type of technology was used for specific purposes: apps provided guided activities, relaxation, and enabled tracking; social media and discussion forums allowed participants to learn from the experiences of others and use that knowledge to understand their own situation; and Web-based programs and websites helped to find out how to deal on a day-to-day basis with stress and anxiety. The analysis of open-ended responses showed that although many people valued technology and felt it could support targeted activities, it was not seen as a substitute for traditional face-to-face therapy. Participants wanted technology to be more sophisticated and nuanced, supporting personalized and actionable recommendations. There was evidence that participants mistrusted technology, irrespective of the type, and had broader concerns regarding the impact of overuse of technology. Conclusions: People use different types of technology to support their mental health. Each can serve a specific purpose. Although apps are the most widely used technology, mixing and matching different types of technology is also common. Technology should not be seen as a replacement for traditional psychotherapy, rather it offers new opportunities to support mental health as part of an overall ecosystem. People want technology to be more nuanced and personalized to help them plan informed actions. Future interventions should explore the use of multiple technologies and their combined effects on mental health support. %M 31301126 %R 10.2196/12546 %U http://mental.jmir.org/2019/7/e12546/ %U https://doi.org/10.2196/12546 %U http://www.ncbi.nlm.nih.gov/pubmed/31301126 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 6 %P e12920 %T Mobile Health Adoption in Mental Health: User Experience of a Mobile Health App for Patients With an Eating Disorder %A Anastasiadou,Dimitra %A Folkvord,Frans %A Serrano-Troncoso,Eduardo %A Lupiañez-Villanueva,Francisco %+ Department of Information and Communication Sciences, Universitat Oberta de Catalunya, Rambla del Poblenou, 156, Barcelona, 08018, Spain, 34 93 450 52 74, danastasiadou@uoc.edu %K eating disorders %K mental health %K mHealth %K mobile applications %K focus groups %D 2019 %7 31.5.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low. Objective: This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists. Methods: To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web. Results: The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment (ie, lack of time because of workload, lack of direct interest on a legislative or political level) rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol. Conclusions: In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice. %M 31199329 %R 10.2196/12920 %U https://mhealth.jmir.org/2019/6/e12920/ %U https://doi.org/10.2196/12920 %U http://www.ncbi.nlm.nih.gov/pubmed/31199329 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 6 %P e13364 %T Smartphone, Social Media, and Mental Health App Use in an Acute Transdiagnostic Psychiatric Sample %A Beard,Courtney %A Silverman,Alexandra L %A Forgeard,Marie %A Wilmer,M Taylor %A Torous,John %A Björgvinsson,Thröstur %+ McLean Hospital/Harvard Medical School, 115 Mill St, Mailbox 113, Belmont, MA, 02478, United States, 1 16178553557, CBEARD@MCLEAN.HARVARD.EDU %K mobile health %K smartphone %K social media %K serious mental illness %D 2019 %7 7.6.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite high rates of smartphone ownership in psychiatric populations, there are very little data available characterizing smartphone use in individuals with mental illness. In particular, few studies have examined the interest and use of smartphones to support mental health. Objective: This study aimed to (1) characterize general smartphone app and social media usage in an acute transdiagnostic psychiatric sample with high smartphone ownership, (2) characterize current engagement and interest in the use of smartphone apps to support mental health, and (3) test demographic and clinical predictors of smartphone use. Methods: The survey was completed by all patients attending an adult partial hospital program, with no exclusion criteria. The primary outcomes were frequency of use of general and mental health smartphone apps (smartphone use survey) and the frequency of social media use and phone-checking behavior (mobile technology engagement scale). Results: Overall, 322 patients (aged mean 33.49, SD 13.87 years; 57% female) reported that their most frequently used app functions were texting, email, and social media. Younger individuals reported more frequent use across most types of apps. Baseline depression and anxiety symptoms were not associated with the frequency of app use. Participants reported health care, calendar, and texting apps as most supportive of their mental health and social media apps as most negatively affecting their mental health. Most patients reported an interest in (73.9% [238/322]) and willingness to use (81.3% [262/322]) a smartphone app to monitor their mental health condition. Less than half (44%) of the patients currently had a mental health app downloaded on their smartphone, with mindfulness and meditation apps being the most common type. Conclusions: The high interest in and willingness to use mental health apps, paired with the only moderate current reported usage, indicate a potential unmet treatment opportunity in psychiatric populations. There is potential to optimize non-mental health–specific apps to better support the needs of those with mental illness and to design a new wave of mental health apps that match the needs of these populations as well as the way they use smartphones in daily life. %M 31199338 %R 10.2196/13364 %U https://mhealth.jmir.org/2019/6/e13364/ %U https://doi.org/10.2196/13364 %U http://www.ncbi.nlm.nih.gov/pubmed/31199338 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13882 %T Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study %A Smelror,Runar Elle %A Bless,Josef Johann %A Hugdahl,Kenneth %A Agartz,Ingrid %+ Department of Psychiatric Research, Diakonhjemmet Hospital, PO Box 85 Vinderen, Oslo, 0319, Norway, 47 95744029, runar.smelror@medisin.uio.no %K experience sampling method %K ecological momentary assessment %K schizophrenia %K mHealth %K health care technology %D 2019 %7 14.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care. Objective: The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed. Methods: Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions. Results: One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions. Conclusions: This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made. %M 31094321 %R 10.2196/13882 %U http://formative.jmir.org/2019/2/e13882/ %U https://doi.org/10.2196/13882 %U http://www.ncbi.nlm.nih.gov/pubmed/31094321 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e10039 %T Influence of Personality and Differences in Stress Processing Among Finnish Students on Interest to Use a Mobile Stress Management App: Survey Study %A Ervasti,Mari %A Kallio,Johanna %A Määttänen,Ilmari %A Mäntyjärvi,Jani %A Jokela,Markus %+ VTT Technical Research Centre of Finland Ltd, Kaitoväylä 1, Oulu, FI-90571, Finland, 358 207222434, johanna.kallio@vtt.fi %K mental health %K mobile applications %K psychological stress %K personality %K neuroticism %K mobile phone %K surveys and questionnaires %D 2019 %7 13.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Excessive stress has a negative impact on many aspects of life for both individuals and societies, from studying and working to health and well-being. Each individual has their unique level of stress-proneness, and positive or negative outcomes of stress may be affected by it. Technology-aided interventions have potential efficacy in the self-management of stress. However, current Web-based or mobile stress management solutions may not reach the individuals that would need them the most, that is, stress-sensitive people. Objective: The aim of this study was to examine how personality is associated with stress among Finnish university students and their interest to use apps that help in managing stress. Methods: We used 2 structured online questionnaires (combined, n=1001) that were advertised in the University of Helsinki’s mailing lists. The first questionnaire (n=635) was used to investigate intercorrelations between the Big Five personality variables (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and other stress-related background variables. The second questionnaire (n=366) was used to study intercorrelations between the above-mentioned study variables and interest in using stress management apps. Results: The quantitative findings of the first questionnaire showed that higher levels of extraversion, agreeableness, and conscientiousness were associated with lower self-reported stress. Neuroticism, in turn, was found to be strongly associated with rumination, anxiety, and depression. The findings of the second questionnaire indicated that individuals characterized by the Big Five personality traits of neuroticism and agreeableness were particularly interested to use stress management apps (r=.27, P<.001 and r=.11, P=.032, respectively). Moreover, the binary logistic regression analysis revealed that when a person’s neuroticism is one SD above average (ie, it is higher than among 84% of people), the person has roughly 2 times higher odds of being interested in using a stress management app. Respectively, when a person’s agreeableness is one SD above average, the person has almost 1.4 times higher odds of being interested in using a stress management app. Conclusions: Our results indicated that personality traits may have an influence on the adoption interest of stress management apps. Individuals with high neuroticism are, according to our results, adaptive in the sense that they are interested in using stress management apps that may benefit them. On the contrary, low agreeableness may lead to lower interest to use the mobile stress management apps. The practical implication is that future mobile stress interventions should meaningfully be adjusted to improve user engagement and support health even among less-motivated users, for instance, to successfully engage individuals with low agreeableness. %M 31094358 %R 10.2196/10039 %U https://mental.jmir.org/2019/5/e10039/ %U https://doi.org/10.2196/10039 %U http://www.ncbi.nlm.nih.gov/pubmed/31094358 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e10111 %T Clinicians’ Concerns About Mobile Ecological Momentary Assessment Tools Designed for Emerging Psychiatric Problems: Prospective Acceptability Assessment of the MEmind App %A Lemey,Christophe %A Larsen,Mark Erik %A Devylder,Jordan %A Courtet,Philippe %A Billot,Romain %A Lenca,Philippe %A Walter,Michel %A Baca-García,Enrique %A Berrouiguet,Sofian %+ URCI Mental Health Department, Brest Medical University Hospital, Route de Ploudalmézeau, Brest,, France, 33 619211032, christophe.lemey@chu-brest.fr %K acceptability %K feasibility studies %K mobile applications %K ecological momentary assessment %K decision support systems, clinical %K internet %K outpatients %K young adult %K prodromal symptoms %K mental health %D 2019 %7 25.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Many mental disorders are preceded by a prodromal phase consisting of various attenuated and unspecific symptoms and functional impairment. Electronic health records are generally used to capture these symptoms during medical consultation. Internet and mobile technologies provide the opportunity to monitor symptoms emerging in patients’ environments using ecological momentary assessment techniques to support preventive therapeutic decision making. Objective: The objective of this study was to assess the acceptability of a Web-based app designed to collect medical data during appointments and provide ecological momentary assessment features. Methods: We recruited clinicians at 4 community psychiatry departments in France to participate. They used the app to assess patients and to collect data after viewing a video of a young patient’s emerging psychiatric consultation. We then asked them to answer a short anonymous self-administered questionnaire that evaluated their experience, the acceptability of the app, and their habit of using new technologies. Results: Of 24 practitioners invited, 21 (88%) agreed to participate. Most of them were between 25 and 45 years old, and greater age was not associated with poorer acceptability. Most of the practitioners regularly used new technologies, and 95% (20/21) connected daily to the internet, with 70% (15/21) connecting 3 times a day or more. However, only 57% (12/21) reported feeling comfortable with computers. Of the clinicians, 86% (18/21) would recommend the tool to their colleagues and 67% (14/21) stated that they would be interested in daily use of the app. Most of the clinicians (16/21, 76%) found the interface easy to use and useful. However, several clinicians noted the lack of readability (8/21, 38%) and the need to improve ergonometric features (4/21, 19%), in particular to facilitate browsing through various subsections. Some participants (5/21, 24%) were concerned about the storage of medical data and most of them (11/21, 52%) seemed to be uncomfortable with this. Conclusions: We describe the first step of the development of a Web app combining an electronic health record and ecological momentary assessment features. This online tool offers the possibility to assess patients and to integrate medical data easily into face-to-face conditions. The acceptability of this app supports the feasibility of its broader implementation. This app could help to standardize assessment and to build up a strong database. Used in conjunction with robust data mining analytic techniques, such a database would allow exploration of risk factors, patterns of symptom evolution, and identification of distinct risk subgroups. %M 31021327 %R 10.2196/10111 %U https://www.jmir.org/2019/4/e10111/ %U https://doi.org/10.2196/10111 %U http://www.ncbi.nlm.nih.gov/pubmed/31021327 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11831 %T Smartphone Apps Targeting Alcohol and Illicit Substance Use: Systematic Search in in Commercial App Stores and Critical Content Analysis %A Tofighi,Babak %A Chemi,Chemi %A Ruiz-Valcarcel,Jose %A Hein,Paul %A Hu,Lu %+ Department of Population Health, New York University School of Medicine, 227 East 30th Street, Room 713, New York, NY, 10016, United States, 1 6468017345, babak.tofighi@nyumc.org %K mHealth %K substance use disorder %K mobile health %K alcohol abuse %D 2019 %7 22.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone apps promise to enhance the reach of evidence-based interventions (cognitive behavior therapy, contingency management and therapeutic education system) for populations with substance use disorders, with minimal disruption to health systems. However, further studies are needed to systematically evaluate smartphone apps targeting alcohol and illicit substances. Objective: The aim of this study was to evaluate the functionality, aesthetics, and quality of information of free or low-cost apps claiming to target alcohol, benzodiazepine, cocaine, crack/cocaine, crystal methamphetamine, and heroin use using the validated Mobile App Rating Scale (MARS) and critical content analysis. Methods: A systematic search of iTunes and Google Play app stores for free or low-cost apps facilitating recovery was conducted in March 2018 and yielded 904 apps using the keywords described in previous studies (eg, recovery, sobriety, sober, alcohol, and heroin). An interdisciplinary team of clinicians, behavioral informatics, and public health reviewers trained in substance use disorders conducted a descriptive analysis of 74 apps categorized as reducing use. In addition to the MARS scale, a descriptive analysis of relevant apps was conducted by the study team to assess for quality indicators emphasized by expert guidelines and review articles. Results: Most apps (n=74) claimed to reduce use or promote abstinence and yielded an overall low median MARS score of 2.82 (0.55) and a wide range of scores (1.64, 4.20). Ratings were also low for engagement (2.75 (0.72)), functionality (3.64 (0.78)), aesthetics (3.03 (0.87)), information (2.82 (0.62)), and satisfaction (1.76 (0.67)) subdomains. Innovative design and content features elicited in the review included initial assessments of substance use following app download, tracking substance use, and related consequences (eg, cost or calorie intake), remote and proximate peer support per geospatial positioning, and allowing users and family members of individuals with substance use disorders to locate 12-step meetings, treatment programs, and mental health services. Few apps integrated evidence-based psychotherapeutic (eg, cognitive behavioral therapy [CBT] or motivational interviewing) and pharmacologic interventions (eg, naloxone or buprenorphine). Conclusions: Few commercially available apps yielded in our search integrated evidence-based interventions (eg, extended-release naltrexone, buprenorphine, naloxone, Self-Management and Recovery Training recovery, or CBT), and a concerning number of apps promoted harmful drinking and illicit substance use. %M 31008713 %R 10.2196/11831 %U https://mhealth.jmir.org/2019/4/e11831/ %U https://doi.org/10.2196/11831 %U http://www.ncbi.nlm.nih.gov/pubmed/31008713 %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 %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11245 %T Mobile Health Interventions: Exploring the Use of Common Relationship Factors %A Grekin,Emily R %A Beatty,Jessica R %A Ondersma,Steven J %+ Department of Psychology, Wayne State University, 5057 Woodward Ave, Detroit, MI, 48202, United States, 1 313 577 2366, grekine@wayne.edu %K mobile health %K mHealth %K smartphone %K empathy %K mobile applications %K therapeutic alliance %D 2019 %7 15.04.2019 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X The use of mobile health (mHealth) interventions has risen dramatically over the past two decades. It is important to consider mHealth intervention research within the broader therapy outcome literature. Among other key findings, this broader literature suggests that common relationship factors such as empathy, positive regard, and genuineness may play a critical role in therapy effectiveness. These findings raise intriguing questions for mobile interventions. For example, can mobile interventions incorporate aspects of common factors to augment their efficacy? Will the absence of relationship-based common factors make mobile interventions less effective? This viewpoint paper addresses these questions as well as related issues such as how to operationalize relationship qualities in the context of a mobile intervention and whether common relationship factors apply to computers or computerized narrators. The paper concludes by outlining a future research agenda guided by theory and empirical studies. %M 30985281 %R 10.2196/11245 %U http://mhealth.jmir.org/2019/4/e11245/ %U https://doi.org/10.2196/11245 %U http://www.ncbi.nlm.nih.gov/pubmed/30985281 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11824 %T Digital Technology for Internet Access by Patients With Early-Stage Schizophrenia in Spain: Multicenter Research Study %A Fernández-Sotos,Patricia %A Fernández-Caballero,Antonio %A González,Pascual %A Aparicio,Ana Isabel %A Martínez-Gras,Isabel %A Torio,Iosune %A Dompablo,Mónica %A García-Fernández,Lorena %A Santos,José Luis %A Rodriguez-Jimenez,Roberto %+ Department of Psychiatry, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Avda. de Córdoba, s/n, Madrid, 28041, Spain, 34 913908426, roberto.rodriguez.jimenez@gmail.com %K information technology %K computers %K internet %K schizophrenia %D 2019 %7 05.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital technology and social networks are part of everyday life in the current internet age, especially among young people. To date, few studies have been published worldwide on the pattern of use of digital technology devices and applications in patients with early-stage schizophrenia and even fewer comparing them with healthy participants (not using data from general population surveys) from the same demographic areas. In Spain, no such study has been carried out. Objective: The aim of this study was to analyze how patients with early-stage schizophrenia use internet and social networks compared with healthy participants matched by age and gender and also to examine which devices are utilized to access internet resources. Methods: A cross-sectional, multicentric study was carried out through a semistructured interview asking about the use of digital technology devices and internet. The sample comprised 90 patients and 90 healthy participants. The semistructured interview was conducted on 30 outpatients and 30 healthy subjects in each of the 3 different cities (Madrid, Alicante, and Cuenca). Student t test was used for continuous variables and chi-square test for categorical variables. In the case of ordinal variables, nonparametric Mann-Whitney U and Kruskal-Wallis H tests for independent samples were performed to compare groups. Results: The results indicated that a large proportion of patients with early-stage schizophrenia have access to different digital devices and use them frequently. In addition, both groups coincide in the order of preference and the purpose for which they use the devices. However, a lower frequency of use of most digital technology devices was detected in patients compared with healthy participants. In the case of some devices, this was due to the impossibility of access and not a lack of interest. Conclusions: To our knowledge, this is the first study to analyze patterns of internet access and use of digital technology devices and applications in Spanish patients with early-stage schizophrenia compared with healthy participants from the same demographic areas. The results on significant access and use of digital technology and internet shown in this cross-sectional study will allow enhanced and more efficient treatment strategies to be planned, utilizing digital technology devices, for patients with early-stage schizophrenia. %M 30950798 %R 10.2196/11824 %U https://www.jmir.org/2019/4/e11824/ %U https://doi.org/10.2196/11824 %U http://www.ncbi.nlm.nih.gov/pubmed/30950798 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 3 %P e11568 %T Development and Long-Term Acceptability of ExPRESS, a Mobile Phone App to Monitor Basic Symptoms and Early Signs of Psychosis Relapse %A Eisner,Emily %A Drake,Richard James %A Berry,Natalie %A Barrowclough,Christine %A Emsley,Richard %A Machin,Matthew %A Bucci,Sandra %+ Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, S42, Zochonis Building (Second Floor), Brunswick Street, Manchester, M13 9PL, United Kingdom, 44 161 306 042, emily.eisner@manchester.ac.uk %K schizophrenia %K psychotic disorders %K recurrence %K telemedicine %K mobile health %K mHealth %K eHealth %K mental health %D 2019 %7 29.03.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. This study addresses 2 developments: adding basic symptoms to checklists of conventional early signs and using a mobile phone app ExPRESS to aid early signs monitoring. Objective: This study aimed to (1) design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); (2) develop and beta test a mobile phone app (ExPRESS) for monitoring early signs, basic symptoms, and psychotic symptoms; and (3) evaluate the long-term acceptability of ExPRESS via qualitative feedback from participants in a 6-month feasibility study. Methods: The BSC items and ExPRESS were developed and then adjusted following feedback from beta testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about experiences of early signs, basic symptoms, and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; 2 were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants’ views on the following a priori themes regarding app acceptability: item content, layout, and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants’ routines; and the app’s extra features. Interview transcripts were analyzed using the framework method, which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored. Results: Participants’ mean age was 38 years (range 22-57 years). Responses to a priori topics indicated that long-term use of ExPRESS was acceptable; small changes for future versions of ExPRESS were suggested. A posteriori themes gave further insight into individuals’ experiences of using ExPRESS. Some reported finding it more accessible than visits from a clinician, as assessments were more frequent, more anonymous, and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (eg, unfamiliarity with smartphones) were also reported. Despite ExPRESS containing no overtly therapeutic components, some participants found that answering the weekly questions prompted self-reflection, which had therapeutic value for them. Conclusions: This study suggests that apps are acceptable for long-term symptom monitoring by individuals with a schizophrenia diagnosis across a wide age range. If the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; most participants in this study were prepared to do so for more than 6 months. Trial Registration: ClinicalTrials.gov NCT03558529; https://clinicaltrials.gov/ct2/show/NCT03558529 (Archived by WebCite at http://www.webcitation.org/70qvtRmZY). %M 30924789 %R 10.2196/11568 %U http://mhealth.jmir.org/2019/3/e11568/ %U https://doi.org/10.2196/11568 %U http://www.ncbi.nlm.nih.gov/pubmed/30924789 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e12378 %T Cocreative Development of the QoL-ME: A Visual and Personalized Quality of Life Assessment App for People With Severe Mental Health Problems %A Buitenweg,David C %A Bongers,Ilja L %A van de Mheen,Dike %A van Oers,Hans AM %A van Nieuwenhuizen,Chijs %+ Scientific Center for Care and Wellbeing (Tranzo), Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037 DB, Netherlands, 31 13 4668338, d.c.buitenweg@tilburguniversity.edu %K mobile app %K quality of life %K mental health %K homeless persons %K medical informatics %D 2019 %7 28.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Quality of life (QoL) is a prominent outcome measure in mental health. However, conventional methods for QoL assessment rely heavily on language‐based communication and therefore may not be optimal for all individuals with severe mental health problems. In addition, QoL assessment is usually based on a fixed number of life domains. This approach conflicts with the notion that QoL is influenced by individual values and preferences. A digital assessment app facilitates both the accessibility and personalization of QoL assessment and may, therefore, help to further advance QoL assessment among individuals with severe mental health problems. Objective: This study focused on the development of an innovative, visual, and personalized QoL assessment app for people with severe mental health problems: the QoL-ME. Methods: This study targeted 3 groups of individuals with severe mental health problems: (1) people with psychiatric problems, (2) people treated in forensic psychiatry, and (3) people who are homeless. A group of 59 participants contributed to the 6 iterations of the cocreative development of the QoL-ME. In the brainstorming stage, consisting of the first iteration, participants’ previous experiences with questionnaires and mobile apps were explored. Participants gave their feedback on initial designs and wireframes in the second to fourth iterations that made up the design stage. In the usability stage that comprised the final 2 iterations, the usability of the QoL-ME was evaluated. Results: In the brainstorming stage, participants stressed the importance of privacy and data security and of receiving feedback when answering questionnaires. Participants in the design stage indicated a preference for paging over scrolling, linear navigation, a clean and minimalist layout, the use of touchscreen functionality in various modes of interaction, and the use of visual analog scales. The usability evaluation in the usability stage revealed good to excellent usability. Conclusions: The cocreative development of the QoL-ME resulted in an app that corresponds to the preferences of participants and has strong usability. Further research is needed to evaluate the psychometric quality of the QoL-ME and to investigate its usefulness in practice. %M 30920381 %R 10.2196/12378 %U http://mental.jmir.org/2019/3/e12378/ %U https://doi.org/10.2196/12378 %U http://www.ncbi.nlm.nih.gov/pubmed/30920381 %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 %@ 2152-7202 %I JMIR Publications %V 11 %N 1 %P e12380 %T Application of Community-Engaged Research to Inform the Development and Implementation of a Peer-Delivered Mobile Health Intervention for Adults With Serious Mental Illness %A Fortuna,Karen %A Barr,Paul %A Goldstein,Carly %A Walker,Robert %A Brewer,LaPrincess %A Zagaria,Alexandra %A Bartels,Stephen %+ Department of Psychiatry, Dartmouth College, 46 Centerra Pkwy, Suite 200, Lebanon, NH, 03766, United States, 1 6036533430, klfortuna@gmail.com %K stakeholder participation %K mental health %K patient participation %K consumer advocacy %K mobile health %D 2019 %7 19.03.2019 %9 Original Paper %J J Participat Med %G English %X Background: Involving certified peer specialists in all phases of intervention development and research is a high priority to advance peer-delivered services. Certified peer specialists are individuals with a lived experience of a mental illness, and they are trained and accredited to provide Medicaid reimbursable mental health services. Community-engaged research can facilitate the development and implementation of peer-delivered interventions; however, little is known about the processes. We present our application of community-engaged research to inform the development and implementation of a peer-delivered mobile health (mHealth) intervention for adults with serious mental illness. Objective: The aim of this study was to present a framework that can be used as a guide for researchers and certified peer specialists to develop and implement peer-delivered mHealth interventions in community settings. Methods: Informed by principles of community-engaged research, we developed the Academic Researchers-Certified Peer Specialists mHealth Research Continuum. Principles of community-engaged research included in the Continuum include the following: (1) develop a clear understanding of the purpose, goal, and population involved in community change; (2) become knowledgeable about all aspects of the community; (3) interact and establish relationships with the community; (4) encourage community self-determination; (5) partner with the community; (6) respect community diversity and culture; (7) activate community assets and develop capacity; (8) maintain flexibility; and (9) commit to long-term collaboration. Results: Overall, 4 certified peer specialists participated in all phases of intervention development and research. Individuals who participated in the Academic Researchers-Certified Peer Specialists’ mHealth Research Continuum collaborated on 5 studies advancing peers’ roles in services delivery using mHealth and secured grant funding from a foundation to sustain their study. The Academic Researchers-Certified Peer Specialists’ mHealth Research Continuum has created a rare environment of inclusion by combining scientific expertise and certified peer specialists’ expertise to achieve a shared vision. Conclusions: This study delineates a process by which academic researchers and certified peer specialists participated in community-engaged research to develop and implement peer-delivered mHealth interventions in community settings. %M 32095314 %R 10.2196/12380 %U http://jopm.jmir.org/2019/1/e12380/ %U https://doi.org/10.2196/12380 %U http://www.ncbi.nlm.nih.gov/pubmed/32095314 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 2 %P e12255 %T Use of Mobile and Computer Devices to Support Recovery in People With Serious Mental Illness: Survey Study %A Noel,Valerie A %A Acquilano,Stephanie C %A Carpenter-Song,Elizabeth %A Drake,Robert E %+ Westat, Inc, 85 Mechanic Street, Suite C3-1, Lebanon, NH, 03766, United States, 1 603 287 4719, valerienoel@westat.com %K app %K mental health %K mHealth %K mobile phone %K serious mental illness %D 2019 %7 20.02.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health recovery refers to an individual’s experience of gaining a sense of personal control, striving towards one’s life goals, and meeting one’s needs. Although people with serious mental illness own and use electronic devices for general purposes, knowledge of their current use and interest in future use for supporting mental health recovery remains limited. Objective: This study aimed to identify smartphone, tablet, and computer apps that mental health service recipients use and want to use to support their recovery. Methods: In this pilot study, we surveyed a convenience sample of 63 mental health service recipients with serious mental illness. The survey assessed current use and interest in mobile and computer devices to support recovery. Results: Listening to music (60%), accessing the internet (59%), calling (59%), and texting (54%) people were the top functions currently used by participants on their device to support their recovery. Participants expressed interest in learning how to use apps for anxiety/stress management (45%), mood management (45%), monitoring mental health symptoms (43%), cognitive behavioral therapy (40%), sleep (38%), and dialectical behavior therapy (38%) to support their recovery. Conclusions: Mental health service recipients currently use general functions such as listening to music and calling friends to support recovery. Nevertheless, they reported interest in trying more specific illness-management apps. %M 30785401 %R 10.2196/12255 %U http://mental.jmir.org/2019/2/e12255/ %U https://doi.org/10.2196/12255 %U http://www.ncbi.nlm.nih.gov/pubmed/30785401 %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 %@ 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 5 %N 4 %P e11715 %T Mental Health Mobile Phone App Usage, Concerns, and Benefits Among Psychiatric Outpatients: Comparative Survey Study %A Torous,John %A Wisniewski,Hannah %A Liu,Gang %A Keshavan,Matcheri %+ Division of Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Fenwood Road, Boston, MA,, United States, 1 617 667 6700, jtorous@bidmc.harvard.edu %K smartphone %K digital health %K mobile phone %K mental health %K schizophrenia %K depression %K psychiatry %K apps %D 2018 %7 16.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite the popularity of mental health apps, it is unknown if they are actually used by those with mental illness. This study assessed whether differences in clinic setting may influence the use of mental health apps and which factors influence patient perception of apps. Objective: The objective of this study was to gain an understanding of how individuals with mental illness use their mobile phones by exploring their access to mobile phones and their use of mental health apps. Methods: A single time point survey study was conducted over a 2-week period in February 2018 at two nearby outpatient psychiatry clinics: one serving largely mood and anxiety disorder patients with private insurance staffed by both faculty and residents and the other serving largely psychotic disorder patients in a state Department of Mental Health (DMH) setting. A total of 25 patients at the state DMH clinic also consented for a single time point observation of apps currently installed on their personal mobile phone. Results: A total of 113 patients at the private insurance clinic and 73 at the state DMH clinic completed the survey. Those in the private insurance clinic were more likely to download a mental health app compared to the state DMH clinic, but actual rates of reported current app usage were comparable at each clinic, approximately 10%. Verifying current apps on patients’ mobile phones at the state DMH clinic confirmed that approximately 10% had mental health apps installed. Patients at both clinics were most concerned about privacy of mental health apps, although those at the state DMH clinic viewed cost savings as the greatest benefit while those at the private clinic reported time as the greatest benefit. Conclusions: High interest in mental health apps does not automatically translate into high use. Our results of low but similar rates of mental health app use at diverse clinics suggests DMH patients with largely psychotic disorders are as interested and engaged with apps as those in a private insurance clinic treating largely mood and anxiety disorders. Results from our study also highlight the importance of understanding how actual patients are using apps instead of relying on internet-based samples, which often yield higher results due to their likelihood of being selected. %M 30446484 %R 10.2196/11715 %U http://mental.jmir.org/2018/4/e11715/ %U https://doi.org/10.2196/11715 %U http://www.ncbi.nlm.nih.gov/pubmed/30446484 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11383 %T The WorkingWell Mobile Phone App for Individuals With Serious Mental Illnesses: Proof-of-Concept, Mixed-Methods Feasibility Study %A Nicholson,Joanne %A Wright,Spenser M %A Carlisle,Alyssa M %A Sweeney,Mary Ann %A McHugo,Gregory J %+ Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS 035, Waltham, MA, 20453, United States, 1 781 736 3978, jnicholson@brandeis.edu %K mHealth %K mobile apps %K mental disorders %K employment %D 2018 %7 25.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The disparities in employment for individuals with serious mental illnesses have been well documented, as have the benefits of work. Mobile technology can provide accessible in-the-moment support for these individuals. The WorkingWell mobile app was developed to meet the need for accessible follow-along supports for individuals with serious mental illnesses in the workplace. Objective: We explore the usability, usage, usefulness, and overall feasibility of the WorkingWell mobile app with individuals with serious mental illnesses who are actively employed and receiving community-based services. Methods: In this proof-of-concept, mixed-methods, 2-month feasibility study (N=40), employed individuals with serious mental illnesses were recruited in mental health agencies. Participants completed surveys regarding background characteristics and cellphone use at enrollment and responded to interview items regarding app usability, usage, and usefulness in technical assistance calls at 1, 2, 4, and 6 weeks of participation and in the exit interview at 8 weeks. Data on the frequency of app usage were downloaded on a daily basis. A version of the System Usability Scale (SUS) was administered in the exit interview. Overall feasibility was determined by the percent of users completing the study, responses to an interview item regarding continued use, and findings on usability, usage, and usefulness. General impressions were obtained from users regarding user support materials, technical assistance, and study procedures. Results: Most participants were male (60%, 24/40), aged 55 or younger (70%, 28/40), white (80%, 32/40), had less than a 4-year college education (78%, 31/40), were employed part-time (98%, 39/40), had been working more than 6 months (60%, 24/40), and indicated a diagnosis of bipolar, schizoaffective, or depressive disorder (84%, 16/25). The majority of participants owned cellphones (95%, 38/40) and used them multiple times per day (83%, 33/40). Their average rating on SUS usability items was 3.93 (SD 0.77, range 1.57-5.00), reflecting positive responses. In general, participants indicated WorkingWell was “very easy,” “straightforward,” “simple,” and “user friendly.” Usability challenges were related to personal issues (eg, memory) or to difficulties with the phone or app. Data on app usage varied considerably. The most frequent navigations were to the home screen, followed by Rate My Day and My Progress, and then by Manage the Moment and Remind Me. The app was described as useful by most participants; 86% (30/35) agreed the app would help them manage better on the job. Of the 40 original participants, 35 (87%) completed the study. Conclusions: The WorkingWell app is a feasible approach to providing accessible, as-needed employment support for individuals with serious mental illnesses. The app would benefit from modifications to address recommendations from feasibility testing. Controlled research with larger samples, more diverse in individual characteristics and workplace settings, is essential to demonstrating the effectiveness of the app. %M 30361199 %R 10.2196/11383 %U http://mental.jmir.org/2018/4/e11383/ %U https://doi.org/10.2196/11383 %U http://www.ncbi.nlm.nih.gov/pubmed/30361199 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10015 %T Patient's Perspective on Using Mobile Technology as an Aid to Psychotherapy %A Cristol,Samantha %+ William James College, 1 Wells Avenue, Newton, MA,, United States, 1 516 761 0114, samantha_cristol@williamjames.edu %K mobile phone app %K technology %K patient perspective %D 2018 %7 24.10.2018 %9 Viewpoint %J JMIR Ment Health %G English %X This piece draws from a patient’s perspective on his treatment using mobile health technology in conjunction with weekly group and individual psychotherapy. Research has demonstrated that using telepsychology as part of mental health treatment shows great promise to help advance the field of psychotherapy. Using mobile health technology such as mobile phone apps allows for collaboration with patients and their providers. This was written after several consultations with an individual diagnosed with borderline personality disorder who prefers to remain anonymous but was forthcoming with information regarding his use of mobile health technology in order to benefit the field of mental telepsychology. %M 30355552 %R 10.2196/10015 %U http://mental.jmir.org/2018/4/e10015/ %U https://doi.org/10.2196/10015 %U http://www.ncbi.nlm.nih.gov/pubmed/30355552 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e58 %T Interaction and Engagement with an Anxiety Management App: Analysis Using Large-Scale Behavioral Data %A Matthews,Paul %A Topham,Phil %A Caleb-Solly,Praminda %+ Data Science Group, Computer Science Research Centre, Department of Computer Science and Creative Technologies, University of the West of England, Coldharbour Lane, Bristol, BS161QY, United Kingdom, 44 11732 ext 83353, paul2.matthews@uwe.ac.uk %K anxiety %K mobile phone %K eMental health %K mHealth %D 2018 %7 1.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: SAM (Self-help for Anxiety Management) is a mobile phone app that provides self-help for anxiety management. Launched in 2013, the app has achieved over one million downloads on the iOS and Android platform app stores. Key features of the app are anxiety monitoring, self-help techniques, and social support via a mobile forum (“the Social Cloud”). This paper presents unique insights into eMental health app usage patterns and explores user behaviors and usage of self-help techniques. Objective: The objective of our study was to investigate behavioral engagement and to establish discernible usage patterns of the app linked to the features of anxiety monitoring, ratings of self-help techniques, and social participation. Methods: We use data mining techniques on aggregate data obtained from 105,380 registered users of the app’s cloud services. Results: Engagement generally conformed to common mobile participation patterns with an inverted pyramid or “funnel” of engagement of increasing intensity. We further identified 4 distinct groups of behavioral engagement differentiated by levels of activity in anxiety monitoring and social feature usage. Anxiety levels among all monitoring users were markedly reduced in the first few days of usage with some bounce back effect thereafter. A small group of users demonstrated long-term anxiety reduction (using a robust measure), typically monitored for 12-110 days, with 10-30 discrete updates and showed low levels of social participation. Conclusions: The data supported our expectation of different usage patterns, given flexible user journeys, and varying commitment in an unstructured mobile phone usage setting. We nevertheless show an aggregate trend of reduction in self-reported anxiety across all minimally-engaged users, while noting that due to the anonymized dataset, we did not have information on users also enrolled in therapy or other intervention while using the app. We find several commonalities between these app-based behavioral patterns and traditional therapy engagement. %M 30287415 %R 10.2196/mental.9235 %U https://mental.jmir.org/2018/4/e58/ %U https://doi.org/10.2196/mental.9235 %U http://www.ncbi.nlm.nih.gov/pubmed/30287415 %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 %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e158 %T The Complexity of Mental Health App Privacy Policies: A Potential Barrier to Privacy %A Powell,Adam C %A Singh,Preeti %A Torous,John %+ Payer+Provider Syndicate, 111 Beach Street Suite 4e, Boston, MA 02111, United States, 1 617 939 9168, powell@payerprovider.com %K apps %K privacy %K ethics %K mobile phone %D 2018 %7 30.7.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In 2017, the Supreme Court of India ruled that privacy is a fundamental right of every citizen. Although mobile phone apps have the potential to help people with noncommunicable diseases, such as diabetes and mental illness, they often contain complex privacy policies, which consumers may not understand. This complexity may impede the ability of consumers to make decisions regarding privacy, a critical issue due to the stigma of mental illness. Objective: Our objective is to determine whether mental health apps have more complex privacy policies than diabetes apps. Methods: The study used privacy policies extracted from apps. The apps pertained to diabetes or mental health, and were all of Indian origin. Privacy policy reading complexity was compared between the two types of apps using a series of 15 readability measures. The universe of applicable apps on the Google Play store, as viewed between May and June 2017, was considered. The measures of readability were compared using chi-square tests. Results: No significant difference was found between the privacy policy readability of the diabetes apps versus the mental health apps for each of the measures considered. The mean Flesch-Kincaid Grade Level was 13.9 for diabetes apps and 13.6 for mental health apps; therefore, the mean policy grade level for both types of apps was written at a college level. Privacy policies in the 25th percentile of complexity were also written at a college level for both types of apps. Conclusions: Privacy policy complexity may be a barrier for informed decision making. %M 30061090 %R 10.2196/mhealth.9871 %U http://mhealth.jmir.org/2018/7/e158/ %U https://doi.org/10.2196/mhealth.9871 %U http://www.ncbi.nlm.nih.gov/pubmed/30061090 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e10016 %T An Assessment Framework for e-Mental Health Apps in Canada: Results of a Modified Delphi Process %A Zelmer,Jennifer %A van Hoof,Krystle %A Notarianni,MaryAnn %A van Mierlo,Trevor %A Schellenberg,Megan %A Tannenbaum,Cara %+ Canadian Institutes of Health Research, Institute of Gender and Health, 4565 chemin Queen Mary, Montreal, QC, H3W 1W5, Canada, 1 5143129019, krystle.van.hoof@criugm.qc.ca %K mental health %K mobile phone apps %K consensus %K Delphi process %K evaluation framework %K telemedicine %D 2018 %7 09.07.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The number of e-mental health apps is increasing rapidly. Studies have shown that the use of some apps is beneficial, whereas others are ineffective or do not meet users’ privacy expectations. Individuals and organizations that curate, recommend, host, use, or pay for apps have an interest in categorizing apps according to the consensus criteria of usability and effectiveness. Others have previously published recommendations for assessing health-related apps; however, the extent to which these recommendations can be generalized across different population groups (eg, culture, gender, and language) remains unclear. This study describes an attempt by Canadian stakeholders to develop an e-mental health assessment framework that responds to the unique needs of people living in Canada in an evidence-based manner. Objective: The objective of our study was to achieve consensus from a broad group of Canadian stakeholders on guiding principles and criteria for a framework to assess e-mental health apps in Canada. Methods: We developed an initial set of guiding principles and criteria from a rapid review and environmental scan of pre-existing app assessment frameworks. The initial list was refined through a two-round modified Delphi process. Participants (N=25) included app developers and users, health care providers, mental health advocates, people with lived experience of a mental health problem or mental illness, policy makers, and researchers. Consensus on each guideline or criterion was defined a priori as at least 70% agreement. The first round of voting was conducted electronically. Prior to Round 2 voting, in-person presentations from experts and a persona empathy mapping process were used to explore the perspectives of diverse stakeholders. Results: Of all respondents, 68% (17/25) in Round 1 and 100% (13/13) in Round 2 agreed that a framework for evaluating health apps is needed to help Canadian consumers identify high-quality apps. Consensus was reached on 9 guiding principles: evidence based, gender responsive, culturally appropriate, user centered, risk based, internationally aligned, enabling innovation, transparent and fair, and based on ethical norms. In addition, 15 informative and evaluative criteria were defined to assess the effectiveness, functionality, clinical applicability, interoperability, usability, transparency regarding security and privacy, security or privacy standards, supported platforms, targeted users, developers’ transparency, funding transparency, price, user desirability, user inclusion, and meaningful inclusion of a diverse range of communities. Conclusions: Canadian mental health stakeholders reached the consensus on a framework of 9 guiding principles and 15 criteria important in assessing e-mental health apps. What differentiates the Canadian framework from other scales is explicit attention to user inclusion at all stages of the development, gender responsiveness, and cultural appropriateness. Furthermore, an empathy mapping process markedly influenced the development of the framework. This framework may be used to inform future mental health policies and programs. %M 29986846 %R 10.2196/10016 %U http://mhealth.jmir.org/2018/7/e10016/ %U https://doi.org/10.2196/10016 %U http://www.ncbi.nlm.nih.gov/pubmed/29986846 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 6 %P e10292 %T A Newly Designed Mobile-Based Computerized Cognitive Addiction Therapy App for the Improvement of Cognition Impairments and Risk Decision Making in Methamphetamine Use Disorder: Randomized Controlled Trial %A Zhu,Youwei %A Jiang,Haifeng %A Su,Hang %A Zhong,Na %A Li,Runji %A Li,Xiaotong %A Chen,Tianzhen %A Tan,Haoye %A Du,Jiang %A Xu,Ding %A Yan,Huan %A Xu,Dawen %A Zhao,Min %+ Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai, 200030, China, 86 2154252689, drminzhao@gmail.com %K methamphetamine %K methamphetamine use disorder %K cognitive function %K impulse control %K risk decision making %K attention bias %D 2018 %7 20.06.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Cognitive rehabilitation therapy has been found to improve cognitive deficits and impulse control problems in methamphetamine use disorder (MUD). However, there is limited research regarding this therapy’s feasibility when using mobile-based health technologies in supporting recovery from MUD in China. Objective: The main aim of this study was to test whether 4 weeks of a newly designed computerized cognitive addiction therapy (CCAT) app can improve cognitive impairments, eliminate drug-related attention bias, and attenuate risk decision-making behaviors in participants with MUD. Methods: Forty MUD participants were assigned randomly to either the CCAT group (n=20), who received 4 weeks of CCAT plus regular detoxification treatment as usual, or the control group (n=20), who only received the regular detoxification treatment as usual, in drug rehabilitation centers in Shanghai. The CCAT was designed by combine methamphetamine use-related picture stimuli with cognitive training with the aim of improving cognitive function and eliminating drug-related attention bias. The CogState Battery, Delay Discounting Task (DDT), Iowa Gambling Task (IGT), and Balloon Analog Risk Task (BART) were administered face-to-face to all participants before and after CCAT interventions. Results: Forty male patients were recruited. The mean age was 32.70 (SD 5.27) years in the CCAT group and mean 35.05 (SD 8.02) years in the control group. Compared to the control group, CCAT improved working memory in the CCAT group (P=.01). Group×time interactions were observed among DDT, IGT, and BART tasks, with rates of discounting delayed rewards, IGT, and BART scores (P<.001) being reduced among those who received CCAT, whereas no changes were found in the control group. Conclusions: The newly designed CCAT can help to improve cognitive impairment and impulsive control in MUD. Further study is needed to understand the underlying brain mechanisms of the cognitive therapy. Trial Registration: ClinicalTrials.gov NCT03318081; https://clinicaltrials.gov/ct2/show/NCT03318081 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT03318081) %M 29925497 %R 10.2196/10292 %U http://mhealth.jmir.org/2018/6/e10292/ %U https://doi.org/10.2196/10292 %U http://www.ncbi.nlm.nih.gov/pubmed/29925497 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e158 %T Workshop on Emerging Technology and Data Analytics for Behavioral Health %A Kotz,David %A Lord,Sarah E %A O'Malley,A James %A Stark,Luke %A Marsch,Lisa A %+ Department of Computer Science, Dartmouth College, 6211 Sudikoff, Hanover, NH, 03755, United States, 1 603 646 1439, David.F.Kotz@dartmouth.edu %K behavioral health %K mobile technology %K wearable devices %K data analytics %K mHealth %D 2018 %7 20.06.2018 %9 Viewpoint %J JMIR Res Protoc %G English %X Wearable and portable digital devices can support self-monitoring for patients with chronic medical conditions, individuals seeking to reduce stress, and people seeking to modify health-related behaviors such as substance use or overeating. The resulting data may be used directly by a consumer, or shared with a clinician for treatment, a caregiver for assistance, or a health coach for support. The data can also be used by researchers to develop and evaluate just-in-time interventions that leverage mobile technology to help individuals manage their symptoms and behavior in real time and as needed. Such wearable systems have huge potential for promoting delivery of anywhere-anytime health care, improving public health, and enhancing the quality of life for many people. The Center for Technology and Behavioral Health at Dartmouth College, a P30 “Center of Excellence” supported by the National Institute on Drug Abuse at the National Institutes of Health, conducted a workshop in February 2017 on innovations in emerging technology, user-centered design, and data analytics for behavioral health, with presentations by a diverse range of experts in the field. The workshop focused on wearable and mobile technologies being used in clinical and research contexts, with an emphasis on applications in mental health, addiction, and health behavior change. In this paper, we summarize the workshop panels on mobile sensing, user experience design, statistics and machine learning, and privacy and security, and conclude with suggested research directions for this important and emerging field of applying digital approaches to behavioral health. Workshop insights yielded four key directions for future research: (1) a need for behavioral health researchers to work iteratively with experts in emerging technology and data analytics, (2) a need for research into optimal user-interface design for behavioral health technologies, (3) a need for privacy-oriented design from the beginning of a novel technology, and (4) the need to develop new analytical methods that can scale to thousands of individuals and billions of data points. %M 29925493 %R 10.2196/resprot.9589 %U http://www.researchprotocols.org/2018/6/e158/ %U https://doi.org/10.2196/resprot.9589 %U http://www.ncbi.nlm.nih.gov/pubmed/29925493 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e210 %T Identifying Objective Physiological Markers and Modifiable Behaviors for Self-Reported Stress and Mental Health Status Using Wearable Sensors and Mobile Phones: Observational Study %A Sano,Akane %A Taylor,Sara %A McHill,Andrew W %A Phillips,Andrew JK %A Barger,Laura K %A Klerman,Elizabeth %A Picard,Rosalind %+ Affective Computing Group, Media Lab, Massachusetts Institute of Technology, 75 Amherst Street, Cambridge, MA, 02139, United States, 1 6178999468, akanes@media.mit.edu %K mobile health %K mood %K machine learning %K wearable electronic devices %K smartphone %K mobile phone %K mental health %K psychological stress %D 2018 %7 08.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Wearable and mobile devices that capture multimodal data have the potential to identify risk factors for high stress and poor mental health and to provide information to improve health and well-being. Objective: We developed new tools that provide objective physiological and behavioral measures using wearable sensors and mobile phones, together with methods that improve their data integrity. The aim of this study was to examine, using machine learning, how accurately these measures could identify conditions of self-reported high stress and poor mental health and which of the underlying modalities and measures were most accurate in identifying those conditions. Methods: We designed and conducted the 1-month SNAPSHOT study that investigated how daily behaviors and social networks influence self-reported stress, mood, and other health or well-being-related factors. We collected over 145,000 hours of data from 201 college students (age: 18-25 years, male:female=1.8:1) at one university, all recruited within self-identified social groups. Each student filled out standardized pre- and postquestionnaires on stress and mental health; during the month, each student completed twice-daily electronic diaries (e-diaries), wore two wrist-based sensors that recorded continuous physical activity and autonomic physiology, and installed an app on their mobile phone that recorded phone usage and geolocation patterns. We developed tools to make data collection more efficient, including data-check systems for sensor and mobile phone data and an e-diary administrative module for study investigators to locate possible errors in the e-diaries and communicate with participants to correct their entries promptly, which reduced the time taken to clean e-diary data by 69%. We constructed features and applied machine learning to the multimodal data to identify factors associated with self-reported poststudy stress and mental health, including behaviors that can be possibly modified by the individual to improve these measures. Results: We identified the physiological sensor, phone, mobility, and modifiable behavior features that were best predictors for stress and mental health classification. In general, wearable sensor features showed better classification performance than mobile phone or modifiable behavior features. Wearable sensor features, including skin conductance and temperature, reached 78.3% (148/189) accuracy for classifying students into high or low stress groups and 87% (41/47) accuracy for classifying high or low mental health groups. Modifiable behavior features, including number of naps, studying duration, calls, mobility patterns, and phone-screen-on time, reached 73.5% (139/189) accuracy for stress classification and 79% (37/47) accuracy for mental health classification. Conclusions: New semiautomated tools improved the efficiency of long-term ambulatory data collection from wearable and mobile devices. Applying machine learning to the resulting data revealed a set of both objective features and modifiable behavioral features that could classify self-reported high or low stress and mental health groups in a college student population better than previous studies and showed new insights into digital phenotyping. %M 29884610 %R 10.2196/jmir.9410 %U http://www.jmir.org/2018/6/e210/ %U https://doi.org/10.2196/jmir.9410 %U http://www.ncbi.nlm.nih.gov/pubmed/29884610 %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 e10048 %T Applying the Principles for Digital Development: Case Study of a Smartphone App to Support Collaborative Care for Rural Patients With Posttraumatic Stress Disorder or Bipolar Disorder %A Bauer,Amy M %A Hodsdon,Sarah %A Bechtel,Jared M %A Fortney,John 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 mHealth %K mental health %K primary health care %K rural health %K post-traumatic stress disorders %K PTSD %K bipolar disorder %K depression %D 2018 %7 06.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders. Objective: The aim of this study was to seek to gain an understanding of how to incorporate a patient-provider mobile health (mHealth) platform to support the delivery of integrated primary care–based mental health services (Collaborative Care) to rural patients with posttraumatic stress disorder and/or bipolar disorder. Methods: Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a mobile system to support Collaborative Care. The system consists of a patient-facing smartphone app that integrates with a Web-based clinical patient registry used by behavioral health care managers and consulting psychiatrists. Throughout development, we engaged representatives from the system’s two user types: (1) providers, who use the Web-based registry and (2) patients, who directly use the mobile app. We extracted mobile metadata to describe the early adoption and use of the system by care managers and patients and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale (SUS). Results: Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean SUS score at week 8 among four patients who completed this measure was 91.9 (range 72.5-100). We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions. Conclusions: Adhering to the Principles for Digital Development, we created and deployed an mHealth system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. On the basis of our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: design for public health impact, add value for all users, test the product and the process, acknowledge disruption, and anticipate variability. %R 10.2196/10048 %U http://www.jmir.org/2018/6/e10048/ %U https://doi.org/10.2196/10048 %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 %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e9 %T Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial %A Pramana,Gede %A Parmanto,Bambang %A Lomas,James %A Lindhiem,Oliver %A Kendall,Philip C %A Silk,Jennifer %+ Department of Health Information Management, University of Pittsburgh, 6025 Forbes Tower, Pittsburgh, PA, 15260, United States, 1 4123836649, parmanto@pitt.edu %K gamification %K mobile health %K ecological momentary intervention %K cognitive behavioral therapy %K child anxiety treatment %K SmartCAT %K childhood anxiety disorders %D 2018 %7 10.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. %M 29748165 %R 10.2196/games.8902 %U http://games.jmir.org/2018/2/e9/ %U https://doi.org/10.2196/games.8902 %U http://www.ncbi.nlm.nih.gov/pubmed/29748165 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 5 %P e108 %T Users’ Perspectives on mHealth Self-Management of Bipolar Disorder: Qualitative Focus Group Study %A Switsers,Lise %A Dauwe,Arthur %A Vanhoudt,Anneleen %A Van Dyck,Hilde %A Lombaerts,Koen %A Oldenburg,JFE %+ Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, Brussels, 1050, Belgium, 32 02 629 26 74, lise.switsers@vub.be %K bipolar disorder %K self-management %K mHealth %K focus groups %D 2018 %7 02.05.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Recent research indicates that current mHealth apps for bipolar disorders (BDs) show crucial shortcomings. They lack important functionality, are of inconsistent quality, and are insufficiently evidence-based. mHealth apps need to be better adapted to the needs of users. The perspectives of adult service users with BD regarding mHealth apps have not been well investigated. Objective: The objective of this study was to examine the needs and expectations of adults with BD regarding mHealth apps. Methods: Two focus group sessions were organized in which patients’ views on self-management and design and functionality of an mHealth app for BD were assessed. During session 1, four focus groups were organized to identify users’ needs regarding support for self-management. Session 2 contained three cocreation focus groups. Through this method, the desired functionality and design were explored. Results: Participants indicated that they were in need of support in various ways. Not only support in psychoeducation, including daily routine, sleep pattern, maintaining social contacts, maintaining a healthy lifestyle, and avoidance of stimuli, was considered important for them but also gaining insight into their illness was found to be crucial. Conclusions: According to the participants, their illness-related information is a key factor in gaining insight into their mood pattern. Participants wanted a functional design that would increase daily use and prevent overstimulation. The results of this study should be taken into account when developing new mHealth apps. %M 29720363 %R 10.2196/mhealth.9529 %U http://mhealth.jmir.org/2018/5/e108/ %U https://doi.org/10.2196/mhealth.9529 %U http://www.ncbi.nlm.nih.gov/pubmed/29720363 %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 %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e90 %T Assessing Therapeutic Alliance in the Context of mHealth Interventions for Mental Health Problems: Development of the Mobile Agnew Relationship Measure (mARM) Questionnaire %A Berry,Katherine %A Salter,Amy %A Morris,Rohan %A James,Susannah %A Bucci,Sandra %+ Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M139PL, United Kingdom, 44 1613060422, katherine.berry@manchester.ac.uk %K mobile health %K health care provider %K digital interventions %K therapeutic alliance %K mental health %K measure development %D 2018 %7 19.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health interventions in the form of smartphone apps aim to improve mental health and enable people access to support as and when needed without having to face the stigma they may experience in accessing services. If we are to evaluate mobile health (mHealth) apps and advance scientific understanding, we also need tools to help us understand in what ways mHealth interventions are effective or not. The concept of therapeutic alliance, a measure of the quality of the relationship between a health care provider and a service user, is a key factor in explaining the effects of mental health interventions. The Agnew Relationship Measure (ARM) is a well-validated measure of therapeutic alliance in face-to-face therapy. Objective: This study presented the first attempt to (1) explore service users’ views of the concept of relationship within mHealth mental health interventions and (2) adapt a well-validated face-to-face measure of therapeutic alliance, the Agnew Relationship Measure (ARM), for use with mHealth interventions. Methods: In stage 1, we interviewed 9 mental health service users about the concept of therapeutic alliance in the context of a digital health intervention and derived key themes from interview transcripts using thematic analysis. In stage 2, we used rating scales and open-ended questions to elicit views from 14 service users and 10 mental health staff about the content and face validity of the scale, which replaced the word “therapist” with the word “app.” In stage 3, we used the findings from stages 1 and 2 to adapt the measure with the support of a decision-making algorithm about which items to drop, retain, or adapt. Results: Findings suggested that service users do identify relationship concepts when thinking about mHealth interventions, including forming a bond with an app and the ability to be open with an app. However, there were key differences between relationships with health professionals and relationships with apps. For example, apps were not as tailored and responsive to each person’s unique needs. Furthermore, apps were not capable of portraying uniquely human-like qualities such as friendliness, collaboration, and agreement. We made a number of changes to the ARM that included revising 16 items; removing 4 items due to lack of suitable alternatives; and adding 1 item to capture a key theme derived from stage 1 of the study (“The app is like having a member of my care team in my pocket”). Conclusions: This study introduces the mHealth version of the ARM, the mARM, that has good face and content validity. We encourage researchers to include this easy-to-use tool in digital health intervention studies to gather further data about its psychometric properties and advance our understanding of how therapeutic alliance influences the efficacy of mHealth interventions. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 34966555; http://www.isrctn.com/ISRCTN34966555 (Archived by WebCite at http://www.webcitation.org/6ymBVwKif) %M 29674307 %R 10.2196/jmir.8252 %U http://www.jmir.org/2018/4/e90/ %U https://doi.org/10.2196/jmir.8252 %U http://www.ncbi.nlm.nih.gov/pubmed/29674307 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e24 %T Standalone Effects of a Cognitive Behavioral Intervention Using a Mobile Phone App on Psychological Distress and Alcohol Consumption Among Japanese Workers: Pilot Nonrandomized Controlled Trial %A Hamamura,Toshitaka %A Suganuma,Shinichiro %A Ueda,Mami %A Mearns,Jack %A Shimoyama,Haruhiko %+ Division of Clinical Psychology, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-0033, Japan, 81 3 5841 3904, hamamura@g.ecc.u-tokyo.ac.jp %K mobile phone intervention %K cognitive behavioral therapy %K psychological distress %K drinking %K Japanese workers %D 2018 %7 22.03.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research that investigates standalone effects of a mobile phone-based cognitive behavioral therapy without any human contact for reducing both psychological distress and risky drinking has been advancing; however, the number of studies is still limited. A mobile phone app called Self Record that facilitates cognitive restructuring through self-monitoring of daily thoughts and activities was developed in Japan. Objective: This study conducted a nonrandomized controlled pilot trial of the Self Record app to investigate standalone effects of the intervention on psychological distress and alcohol consumption among Japanese workers. Additionally, we examined moderating effects of negative mood regulation expectancies, which are beliefs about one’s ability to control one’s negative mood. Methods: A quasi-experimental design with a 1-month follow-up was conducted online in Japan from February 2016 to March 2016. A research marketing company recruited participants. The selection criteria were being a Japanese full-time worker (age 20-59 years), experiencing mild to moderate psychological distress, and having some interest in self-record apps. Assignment to group was based on participants’ willingness to use the app in the study. All participants completed outcome measures of negative mood regulation expectancies, positive well-being, general distress, depression, anxiety, and typical/most weekly alcohol consumption. Results: From the recruitment, 15.65% (1083/6921) of participants met the inclusion criteria. Of these, 51.43% (557/1083) enrolled in the study: 54.9% (306/557) in the intervention group and 45.1% (251/557) in the control group. At the 1-month follow-up, 15.3% (85/557) of participants had dropped out. Intention-to-treat analyses revealed that participants in the intervention group reported increased typical drinking (η2=.009) and heavy drinking (η2=.001). Adherence to using the app was low; 64.8% (199/306) of participants in the intervention group discontinued using the app on the first day. Additionally, 65.7% (366/557) of the total sample did not correctly answer the validity checks in the outcome measures (eg, “Please select ‘mildly agree’ for this item”). Therefore, per-protocol analyses were conducted after removing these participants. Results showed that continuing app users (42/127) in the intervention group reported increases in anxiety (η2=.006), typical drinking (η2=.005), and heavy drinking (η2=.007) compared to those in the control group (85/127). Negative mood regulation expectancies moderated the effects of the intervention for general distress (beta=.39). Conclusions: Results were contrary to our hypotheses. Self-recording methods of standalone mobile phone interventions may heighten individuals’ awareness of their pathological thought and drinking behavior, but may be insufficient to decrease them unless combined with a more intense or face-to-face intervention. Limitations include high attrition in this study; measures to improve the response rate are discussed. %M 29567634 %R 10.2196/mental.8984 %U http://mental.jmir.org/2018/1/e24/ %U https://doi.org/10.2196/mental.8984 %U http://www.ncbi.nlm.nih.gov/pubmed/29567634 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e15 %T A Mobile Health Platform for Clinical Monitoring in Early Psychosis: Implementation in Community-Based Outpatient Early Psychosis Care %A Kumar,Divya %A Tully,Laura M %A Iosif,Ana-Maria %A Zakskorn,Lauren N %A Nye,Kathleen E %A Zia,Aqsa %A Niendam,Tara Ann %+ Department of Psychiatry and Behavioral Sciences, University of California, Davis, 4701 X Street, Sacramento, CA, 95817, United States, 1 916 734 7927, lmtully@ucdavis.edu %K mHealth %K schizophrenia %K smartphone %K ecological momentary assessment %K experience sampling %D 2018 %7 27.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: A growing body of literature indicates that smartphone technology is a feasible add-on tool in the treatment of individuals with early psychosis (EP) . However, most studies to date have been conducted independent of outpatient care or in a research clinic setting, often with financial incentives to maintain user adherence to the technology. Feasibility of dissemination and implementation of smartphone technology into community mental health centers (CMHCs) has yet to be tested, and whether young adults with EP will use this technology for long periods of time without incentive is unknown. Furthermore, although EP individuals willingly adopt smartphone technology as part of their treatment, it remains unclear whether providers are amenable to integrating smartphone technology into treatment protocols. Objective: This study aimed to establish the feasibility of implementing a smartphone app and affiliated Web-based dashboard in 4 community outpatient EP clinics in Northern California. Methods: EP individuals in 4 clinics downloaded an app on their smartphone and responded to daily surveys regarding mood and symptoms for up to 5 months. Treatment providers at the affiliated clinics viewed survey responses on a secure Web-based dashboard in sessions with their clients and between appointments. EP clients and treatment providers filled out satisfaction surveys at study end regarding usability of the app. Results: Sixty-one EP clients and 20 treatment providers enrolled in the study for up to 5 months. Forty-one EP clients completed the study, and all treatment providers remained in the study for their duration in the clinic. Survey completion for all 61 EP clients was moderate: 40% and 39% for daily and weekly surveys, respectively. Completion rates were slightly higher in the participants who completed the study: 44% and 41% for daily and weekly surveys, respectively. Twenty-seven of 41 (66%) EP clients who completed the study and 11 of 13 (85%) treatment providers who responded to satisfaction surveys reported they would continue to use the app as part of treatment services. Six (15%; 6/41) clients and 3 providers (23%; 3/13) stated that technological glitches impeded their engagement with the platform. Conclusions: EP clients and treatment providers in community-based outpatient clinics are responsive to integrating smartphone technology into treatment services. There were logistical and technical challenges associated with enrolling individuals in CMHCs. To be most effective, implementing smartphone technology in CMHC EP care necessitates adequate technical staff and support for utilization of the platform. %M 29487044 %R 10.2196/mental.8551 %U http://mental.jmir.org/2018/1/e15/ %U https://doi.org/10.2196/mental.8551 %U http://www.ncbi.nlm.nih.gov/pubmed/29487044 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e16 %T Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience %A Grist,Rebecca %A Porter,Joanna %A Stallard,Paul %+ Child and Adolescent Mental Health Group, Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, United Kingdom, 44 2253850 ext 86, rg626@bath.ac.uk %K self-injurious behavior %K mobile apps %K adolescents %K telemedicine %K qualitative research %K cognitive therapy %K behavior therapy %D 2018 %7 23.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Self-harm is common among adolescents and is associated with a number of negative psychosocial outcomes including a higher risk of suicide. Recent reviews highlight the lack of research into specific interventions for children and young people who self-harm. Developing innovative interventions that are coproduced with individuals with lived experience and that reduce self-harm are key challenges for self-harm prevention. Objective: The aim of this study was to explore the acceptability, use, and safety of BlueIce, a mobile phone app for young people who self-harm and who are attending child and adolescent mental health services (CAMHS). Methods: This study is part of a mixed methods phase 1 trial of BlueIce. Young people aged 12-17 years attending specialist CAMHS were recruited. Clinicians were invited to refer young people who were self-harming or who had a history of self-harm. On consent being obtained and baseline measures taken, participants used BlueIce as an adjunct to usual care for an initial familiarization period of 2 weeks. If after this time they wanted to continue, they used BlueIce for a further 10 weeks. Semistructured interviews were conducted at postfamiliarization (2 weeks after using BlueIce) and postuse (12 weeks after using BlueIce) to assess the acceptability, use, and safety of BlueIce. We undertook a qualitative analysis using a deductive approach, and then an inductive approach, to investigate common themes. Results: Postfamiliarization interviews were conducted with 40 participants. Of these, 37 participants elected to use BlueIce, with postuse interviews being conducted with 33 participants. Following 6 key themes emerged from the data: (1) appraisal of BlueIce, (2) usability of BlueIce, (3) safety, (4) benefits of BlueIce, (5) agency and control, and (6) BlueIce less helpful. The participants reported that BlueIce was accessible, easy to use, and convenient. Many highlighted the mood diary and mood lifter sections as particularly helpful in offering a way to track their moods and offering new strategies to manage their thoughts to self-harm. No adverse effects were reported. For those who did not find BlueIce helpful, issues around motivation to stop self-harming impeded their ability to use the app. Conclusions: BlueIce was judged to be a helpful and safe way of supporting adolescents to manage thoughts of self-harming. Adolescents reported numerous benefits of using BlueIce, and all would recommend the app to other young people who were struggling with self-harm. These preliminary findings are encouraging and provide initial support for the acceptability of BlueIce as a self-help intervention used in conjunction with the traditional face-to-face therapy. %M 29475823 %R 10.2196/mental.8779 %U http://mental.jmir.org/2018/1/e16/ %U https://doi.org/10.2196/mental.8779 %U http://www.ncbi.nlm.nih.gov/pubmed/29475823 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e4 %T Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a Randomized Controlled Trial %A Furukawa,Toshi A %A Horikoshi,Masaru %A Fujita,Hirokazu %A Tsujino,Naohisa %A Jinnin,Ran %A Kako,Yuki %A Ogawa,Sei %A Sato,Hirotoshi %A Kitagawa,Nobuki %A Shinagawa,Yoshihiro %A Ikeda,Yoshio %A Imai,Hissei %A Tajika,Aran %A Ogawa,Yusuke %A Akechi,Tatsuo %A Yamada,Mitsuhiko %A Shimodera,Shinji %A Watanabe,Norio %A Inagaki,Masatoshi %A Hasegawa,Akio %+ Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku,, Nagoya, 467-8601, Japan, 81 52 753 9491, furukawa@kuhp.kyoto-u.ac.jp %K major depressive disorder %K smartphone %K cognitive therapy %K telemedicine %D 2018 %7 11.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as “test-drive a new car,” “go to a coffee shop after lunch,” or “call up an old friend” were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik) %M 29326098 %R 10.2196/mental.9092 %U http://mental.jmir.org/2018/1/e4/ %U https://doi.org/10.2196/mental.9092 %U http://www.ncbi.nlm.nih.gov/pubmed/29326098 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e56 %T A Mobile Text Message Intervention to Reduce Repeat Suicidal Episodes: Design and Development of Reconnecting After a Suicide Attempt (RAFT) %A Larsen,Mark Erik %A Shand,Fiona %A Morley,Kirsten %A Batterham,Philip J %A Petrie,Katherine %A Reda,Bill %A Berrouiguet,Sofian %A Haber,Paul S %A Carter,Gregory %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 293828508, mark.larsen@blackdog.org.au %K suicide, attempted %K emergency service, hospital %K continuity of patient care %K text messaging %K Internet %D 2017 %7 13.12.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death, particularly among young people. Continuity of care following discharge from hospital is critical, yet this is a time when individuals often lose contact with health care services. Offline brief contact interventions following a suicide attempt can reduce the number of repeat attempts, and text message (short message service, SMS) interventions are currently being evaluated. Objective: The aim of this study was to extend postattempt caring contacts by designing a brief Web-based intervention targeting proximal risk factors and the needs of this population during the postattempt period. This paper details the development process and describes the realized system. Methods: To inform the design of the intervention, a lived experience design group was established. Participants were asked about their experiences of support following their suicide attempt, their needs during this time, and how these could be addressed in a brief contact eHealth intervention. The intervention design was also informed by consultation with lived experience panels external to the project and a clinical design group. Results: Prompt outreach following discharge, initial distraction activities with low cognitive demands, and ongoing support over an extended period were identified as structural requirements of the intervention. Key content areas identified included coping with distressing feelings, safety planning, emotional regulation and acceptance, coping with suicidal thoughts, connecting with others and interpersonal relationships, and managing alcohol consumption. Conclusions: The RAFT (Reconnecting AFTer a suicide attempt) text message brief contact intervention combines SMS contacts with additional Web-based brief therapeutic content targeting key risk factors. It has the potential to reduce the number of repeat suicidal episodes and to provide accessible, acceptable, and cost-effective support for individuals who may not otherwise seek face-to-face treatment. A pilot study to test the feasibility and acceptability of the RAFT intervention is underway. %M 29237584 %R 10.2196/mental.7500 %U http://mental.jmir.org/2017/4/e56/ %U https://doi.org/10.2196/mental.7500 %U http://www.ncbi.nlm.nih.gov/pubmed/29237584 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e398 %T Two Novel Cognitive Behavioral Therapy–Based Mobile Apps for Agoraphobia: Randomized Controlled Trial %A Christoforou,Marina %A Sáez Fonseca,José Andrés %A Tsakanikos,Elias %+ Department of Psychology, University of Roehampton, Holybourne Avenue, London, SW15 4JD, United Kingdom, 44 020 8392 3080, elias.tsakanikos@roehampton.ac.uk %K agoraphobia %K anxiety %K eHealth %K computerized interventions %K mobile applications %K randomized controlled trial %K RCT %D 2017 %7 24.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the large body of literature demonstrating the effectiveness of cognitive behavioral treatments for agoraphobia, many patients remain untreated because of various barriers to treatment. Web-based and mobile-based interventions targeting agoraphobia may provide a solution to this problem, but there is a lack of research investigating the efficacy of such interventions. Objective: The objective of our study was to evaluate for the first time the effectiveness of a self-guided mobile-based intervention primarily targeting agoraphobic symptoms, with respect to a generic mobile app targeting anxiety. Methods: A Web-based randomized controlled trial (RCT) compared a novel mobile app designed to target agoraphobia (called Agoraphobia Free) with a mobile app designed to help with symptoms of anxiety in general (called Stress Free). Both interventions were based on established cognitive behavioral principles. We recruited participants (N=170) who self-identified as having agoraphobia and assessed them online at baseline, midpoint, and end point (posttreatment) over a period of 12 weeks. The primary outcome was symptom severity measured by the Panic and Agoraphobia Scale. Results: Both groups had statistically significant improvements in symptom severity over time (difference –5.97, 95% CI –8.49 to –3.44, P<.001 for Agoraphobia Free and –6.35, 95% CI –8.82 to –3.87, P<.001 for Stress Free), but there were no significant between-group differences on the primary outcome (difference 0.38, 95% CI –1.96 to 3.20, P=.64). Conclusions: This is, to our knowledge, the first RCT to provide evidence that people who identify as having agoraphobia may equally benefit from a diagnosis-specific and a transdiagnostic mobile-based intervention. We also discuss clinical and research implications for the development and dissemination of mobile mental health apps. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 98453199; http://www.isrctn.com /ISRCTN98453199 (Archived by WebCite at http://www.webcitation.org/6uR5vsdZw) %M 29175809 %R 10.2196/jmir.7747 %U http://www.jmir.org/2017/11/e398/ %U https://doi.org/10.2196/jmir.7747 %U http://www.ncbi.nlm.nih.gov/pubmed/29175809 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e373 %T Smartphone Cognitive Behavioral Therapy as an Adjunct to Pharmacotherapy for Refractory Depression: Randomized Controlled Trial %A Mantani,Akio %A Kato,Tadashi %A Furukawa,Toshi A %A Horikoshi,Masaru %A Imai,Hissei %A Hiroe,Takahiro %A Chino,Bun %A Funayama,Tadashi %A Yonemoto,Naohiro %A Zhou,Qi %A Kawanishi,Nao %+ Department of Health Promotion and Human Behavior, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 6068501, Japan, 81 757538941, furukawa@kuhp.kyoto-u.ac.jp %K major depressive disorder %K pharmacotherapy-resistant depression %K mobile phone app %K cognitive behavioral therapy %K eHealth %D 2017 %7 03.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: In the treatment of major depression, antidepressants are effective but not curative. Cognitive behavioral therapy (CBT) is also effective, alone or in combination with pharmacotherapy, but accessibility is a problem. Objective: The aim is to evaluate the effectiveness of a smartphone CBT app as adjunctive therapy among patients with antidepressant-resistant major depression. Methods: A multisite, assessor-masked, parallel-group randomized controlled trial was conducted in 20 psychiatric clinics and hospitals in Japan. Participants were eligible if they had a primary diagnosis of major depression and were antidepressant-refractory after taking one or more antidepressants at an adequate dosage for four or more weeks. After a 1-week run-in in which participants started the medication switch and had access to the welcome session of the app, patients were randomized to medication switch alone or to medication switch plus smartphone CBT app via the centralized Web system. The smartphone app, called Kokoro-app (“kokoro” means “mind” in Japanese), included sessions on self-monitoring, behavioral activation, and cognitive restructuring presented by cartoon characters. The primary outcome was depression severity as assessed by masked telephone assessors with the Patient Health Questionnaire-9 (PHQ-9) at week 9. The secondary outcomes included the Beck Depression Inventory-II (BDI-II) and Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER). Results: In the total sample (N=164), 81 participants were allocated to the smartphone CBT in addition to medication change and 83 to medication change alone. In the former group, all but one participant (80/81, 99%) completed at least half, and 71 (88%) completed at least six of eight sessions. In the intention-to-treat analysis, patients allocated the CBT app scored 2.48 points (95% CI 1.23-3.72, P<.001; standardized mean difference 0.40) lower on PHQ-9 than the control at week 9. The former group also scored 4.1 points (95% CI 1.5-6.6, P=.002) lower on BDI-II and 0.76 points (95% CI –0.05 to 1.58, P=.07) lower on FIBSER. In the per-protocol sample (comfortable with the smartphone app, still symptomatic, and adherent to medication with mild or less side effects after run-in), the intervention group (n=60) scored 1.72 points (95% CI 0.25-3.18, P=.02) lower on PHQ-9, 3.2 points (95% CI –0.01 to 6.3, P=.05) lower on BDI-II, and 0.75 points (95% CI 0.03-1.47, P=.04) lower on FIBSER than the control (n=57). The treatment benefits were maintained up to week 17. Conclusions: This is the first study to demonstrate the effectiveness of a smartphone CBT in the treatment of clinically diagnosed depression. Given the merits of the mobile mental health intervention, including accessibility, affordability, quality control, and effectiveness, it is clinically worthwhile to consider adjunctive use of a smartphone CBT app when treating patients with antidepressant-resistant depression. Research into its effectiveness in wider clinical contexts is warranted. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik) %M 29101095 %R 10.2196/jmir.8602 %U http://www.jmir.org/2017/11/e373/ %U https://doi.org/10.2196/jmir.8602 %U http://www.ncbi.nlm.nih.gov/pubmed/29101095 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e52 %T Use of the Internet and Mobile Phones for Self-Management of Severe Mental Health Problems: Qualitative Study of Staff Views %A Berry,Natalie %A Bucci,Sandra %A Lobban,Fiona %+ Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Room S42, Zochonis Building, Brunswick Street, Manchester, M13 9PL, United Kingdom, 44 1613060428, natalie.berry@manchester.ac.uk %K psychosis %K bipolar disorder %K mHealth %K eHealth %K clinicians %K mobile phone %K Internet %K intervention %D 2017 %7 01.11.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Researchers are currently investigating the feasibility, acceptability, and efficacy of digital health interventions for people who experience severe mental health problems such as psychosis and bipolar disorder. Although the acceptability of digital health interventions for severe mental health problems appears to be relatively high and some people report successfully using the Internet and mobile phones to manage their mental health, the attitudes of mental health care staff toward such approaches have yet to be considered. Objective: The aim of this study was to explore mental health care staff experiences of clients with severe mental health problems engaging with the Internet and mobile phones to self-manage their mental health and their views toward these behaviors. The study also sought to examine the opinions expressed by mental health care staff toward digital health interventions for severe mental health problems to identify potential facilitators and barriers to implementation. Methods: Four focus groups were conducted with 20 staff working in mental health care services in the North West of the England using a topic guide. Focus groups involved 12 staff working in secondary care psychological services (7 participants in focus group 1 and 5 participants in focus group 4), 4 staff working in a rehabilitation unit (focus group 2), and 4 staff working in a community mental health team (focus group 3). Focus groups were transcribed verbatim, and transcripts were analyzed thematically to identify key themes that emerged from the data. Results: Four overarching themes, two with associated subthemes, were identified: (1) staff have conflicting views about the pros and cons of using Web-based resources and digital health interventions to manage mental health; (2) digital health interventions could increase access to mental health support options for severe mental health problems but may perpetuate the digital divide; (3) digital health interventions’ impact on staff roles and responsibilities; and (4) digital health interventions should be used to enhance, not replace, face-to-face support. Conclusions: This study is the first, to our knowledge, to qualitatively explore the experiences and attitudes of mental health care staff toward individuals with severe mental health problems using the Internet, mobile phones, and digital health interventions to self-manage their mental health. Understanding the positive and negative experiences and views shared by staff toward both current and potential digital health intervention use has enabled the identification of several considerations for implementation. Additionally, the findings suggest mental health care staff need clear guidance and training in relation to their responsibilities in recommending reputable and secure websites, forums, and digital health interventions and in how to manage professional boundaries on the Internet. Overall, the study highlights that digital health interventions could be well received by staff working in mental health services but importantly, such management options must be presented to frontline staff as an avenue to enhance care and extend choice, rather than as a method to reduce costs. %M 29092809 %R 10.2196/mental.8311 %U http://mental.jmir.org/2017/4/e52/ %U https://doi.org/10.2196/mental.8311 %U http://www.ncbi.nlm.nih.gov/pubmed/29092809 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 11 %P e160 %T Mobile Phone Use in Psychiatry Residents in the United States: Multisite Cross-Sectional Survey Study %A Gipson,Shih %A Torous,John %A Boland,Robert %A Conrad,Erich %+ Boston Children's Hospital, Department of Psychiatry, 300 Longwood Ave, Boston, MA, 02115, United States, 1 6173556680, mariegipsonmd@gmail.com %K technology %K graduate medical education %K mobile phone %K psychiatry %D 2017 %7 01.11.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile technology ownership in the general US population and medical professionals is increasing, leading to increased use in clinical settings. However, data on use of mobile technology by psychiatry residents remain unclear. Objective: In this study, our aim was to provide data on how psychiatric residents use mobile phones in their clinical education as well as barriers relating to technology use. Methods: An anonymous, multisite survey was given to psychiatry residents in 2 regions in the United States, including New Orleans and Boston, to understand their technology use. Results: All participants owned mobile phones, and 79% (54/68) used them to access patient information. The majority do not use mobile phones to implement pharmacotherapy (62%, 42/68) or psychotherapy plans (90%, 61/68). The top 3 barriers to using mobile technology in clinical care were privacy concerns (56%, 38/68), lack of clinical guidance (40%, 27/68), and lack of evidence (29%, 20/68). Conclusions: We conclude that developing a technology curriculum and engaging in research could address these barriers to using mobile phones in clinical practice. %M 29092807 %R 10.2196/mhealth.7146 %U http://mhealth.jmir.org/2017/11/e160/ %U https://doi.org/10.2196/mhealth.7146 %U http://www.ncbi.nlm.nih.gov/pubmed/29092807 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e45 %T Mental and Emotional Self-Help Technology Apps: Cross-Sectional Study of Theory, Technology, and Mental Health Behaviors %A Crookston,Benjamin T %A West,Joshua H %A Hall,P Cougar %A Dahle,Kaitana Martinez %A Heaton,Thomas L %A Beck,Robin N %A Muralidharan,Chandni %+ Department of Health Science, Brigham Young University, 4103 LSB, Provo, UT, 84602, United States, 1 8014223143, benjamin_crookston@byu.edu %K mental health %K decision theory %K mobile applications %D 2017 %7 17.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental and emotional self-help apps have emerged as potential mental illness prevention and treatment tools. The health behavior theory mechanisms by which these apps influence mental health–related behavior change have not been thoroughly examined. Objective: The objective of this study was to examine the association between theoretical behavior change mechanisms and use of mental and emotional self-help apps and whether the use of such apps is associated with mental health behaviors. Methods: This study utilized a cross-sectional survey of 150 users of mental or emotional health apps in the past 6 months. Survey questions included theory-based items, app engagement and likeability items, and behavior change items. Stata version 14 was used to calculate all statistics. Descriptive statistics were calculated for each of the demographic, theory, engagement, and behavior variables. Multiple regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior after controlling for potentially confounding variables. Results: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. Engagement (P<.001) was positively associated with the reported changes in theory items, whereas perceived behavior change was positively associated with theory (P<.001), engagement (P=.004), frequency of use of apps (P=.01), and income (P=.049). Conclusions: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. This increase in perceptions, beliefs, and attitudes surrounding their mental and emotional health was considerably associated with perceived change in behavior. There was a positive association between the level of engagement with the app and the impact on theory items. Future efforts should consider the value of impacting key theoretical constructs when designing mental and emotional health apps. As apps are evaluated and additional theory-based apps are created, cost-effective self-help apps may become common preventative and treatment tools in the mental health field. %M 29042340 %R 10.2196/mental.7262 %U http://mental.jmir.org/2017/4/e45/ %U https://doi.org/10.2196/mental.7262 %U http://www.ncbi.nlm.nih.gov/pubmed/29042340 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 8 %P e295 %T The Use of Mobile Apps and SMS Messaging as Physical and Mental Health Interventions: Systematic Review %A Rathbone,Amy Leigh %A Prescott,Julie %+ School of Education and Psychology, University of Bolton, Deane Road, Bolton, BL3 5AB, United Kingdom, 44 01204903676, alr3wss@bolton.ac.uk %K mHealth %K smartphone %K health %K review %K systematic %K short message service %K treatment efficacy %K portable electronic applications %K intervention study %D 2017 %7 24.08.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The initial introduction of the World Wide Web in 1990 brought around the biggest change in information acquisition. Due to the abundance of devices and ease of access they subsequently allow, the utility of mobile health (mHealth) has never been more endemic. A substantial amount of interactive and psychoeducational apps are readily available to download concerning a wide range of health issues. mHealth has the potential to reduce waiting times for appointments; eradicate the need to meet in person with a clinician, successively diminishing the workload of mental health professionals; be more cost effective to practices; and encourage self-care tactics. Previous research has given valid evidence with empirical studies proving the effectiveness of physical and mental health interventions using mobile apps. Alongside apps, there is evidence to show that receiving short message service (SMS) messages, which entail psychoeducation, medication reminders, and links to useful informative Web pages can also be advantageous to a patient’s mental and physical well-being. Available mHealth apps and SMS services and their ever improving quality necessitates a systematic review in the area in reference to reduction of symptomology, adherence to intervention, and usability. Objective: The aim of this review was to study the efficacy, usability, and feasibility of mobile apps and SMS messages as mHealth interventions for self-guided care. Methods: A systematic literature search was carried out in JMIR, PubMed, PsychINFO, PsychARTICLES, Google Scholar, MEDLINE, and SAGE. The search spanned from January 2008 to January 2017. The primary outcome measures consisted of weight management, (pregnancy) smoking cessation, medication adherence, depression, anxiety and stress. Where possible, adherence, feasibility, and usability outcomes of the apps or SMS services were evaluated. Between-group and within-group effect sizes (Cohen d) for the mHealth intervention method group were determined. Results: A total of 27 studies, inclusive of 4658 participants were reviewed. The papers included randomized controlled trials (RCTs) (n=19), within-group studies (n=7), and 1 within-group study with qualitative aspect. Studies show improvement in physical health and significant reductions of anxiety, stress, and depression. Within-group and between-group effect sizes ranged from 0.05-3.37 (immediately posttest), 0.05-3.25 (1-month follow-up), 0.08-3.08 (2-month follow-up), 0.00-3.10 (3-month follow-up), and 0.02-0.27 (6-month follow-up). Usability and feasibility of mHealth interventions, where reported, also gave promising, significant results. Conclusions: The review shows the promising and emerging efficacy of using mobile apps and SMS text messaging as mHealth interventions. %M 28838887 %R 10.2196/jmir.7740 %U http://www.jmir.org/2017/8/e295/ %U https://doi.org/10.2196/jmir.7740 %U http://www.ncbi.nlm.nih.gov/pubmed/28838887 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e34 %T Mobile Mindfulness Intervention on an Acute Psychiatric Unit: Feasibility and Acceptability Study %A Mistler,Lisa A %A Ben-Zeev,Dror %A Carpenter-Song,Elizabeth %A Brunette,Mary F %A Friedman,Matthew J %+ Dartmouth-Hitchcock Medical Center, Department of Psychiatry, Geisel School of Medicine at Dartmouth, New Hampshire Hospital, 36 Clinton St, Concord, NH, 03301, United States, 1 6032715300 ext 5436, lisa.a.mistler@dartmouth.edu %K mindfulness %K meditation %K mHealth %K psychiatry %K mobile phone %K aggression %K violence %K schizophrenia %K bipolar disorder %K psychotic disorders %D 2017 %7 21.08.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Aggression and violence on acute psychiatric inpatient units is extensive and leads to negative sequelae for staff and patients. With increasingly acute inpatient milieus due to shorter lengths of stay, inpatient staff is limited in training and time to be able to provide treatments. Mobile technology provides a new platform for offering treatment on such units, but it has not been tested for feasibility or usability in this particular setting. Objective: The aim of this study was to examine the feasibility, usability, and acceptability of a brief mindfulness meditation mobile phone app intended to reduce anger and aggression in acute psychiatric inpatients with schizophrenia, schizoaffective disorder, or bipolar disorder, and a history of violence. Methods: Participants were recruited between November 1, 2015 and June 1, 2016. A total of 13 inpatients at an acute care state hospital carried mobile phones for 1 week and were asked to try a commercially available mindfulness app called Headspace. The participants completed a usability questionnaire and engaged in a qualitative interview upon completion of the 7 days. In addition, measures of mindfulness, state and trait anger, and cognitive ability were administered before and after the intervention. Results: Of the 13 enrolled participants, 10 used the app for the 7 days of the study and completed all measures. Two additional participants used the app for fewer than 7 days and completed all measures. All participants found the app to be engaging and easy to use. Most (10/12, 83%) felt comfortable using Headspace and 83% (10/12) would recommend it to others. All participants made some effort to try the app, with 6 participants (6/12, 50%) completing the first 10 10-minute “foundation” guided meditations. Conclusions: This is the first known study of the use of a commercially available app as an intervention on acute psychiatric inpatient units. Acutely ill psychiatric inpatients at a state hospital found the Headspace app easy to use, were able to complete a series of meditations, and felt the app helped with anxiety, sleep, and boredom on the unit. There were no instances of an increase in psychotic symptoms reported and there were no episodes of aggression or violence noted in the record. %M 28827214 %R 10.2196/mental.7717 %U http://mental.jmir.org/2017/3/e34/ %U https://doi.org/10.2196/mental.7717 %U http://www.ncbi.nlm.nih.gov/pubmed/28827214 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e245 %T Short Text Messages to Encourage Adherence to Medication and Follow-up for People With Psychosis (Mobile.Net): Randomized Controlled Trial in Finland %A Välimäki,Maritta %A Kannisto,Kati Anneli %A Vahlberg,Tero %A Hätönen,Heli %A Adams,Clive E %+ Department of Nursing Science, Joukahaisenkatu 3-5, University of Turku, 20014, Turku,, Finland, 358 40 5599235, mava@utu.fi %K text messaging %K psychotic disorders %K randomized controlled trial %K medication adherence %D 2017 %7 12.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: A text messaging service (short message service [SMS]) has the potential to target large groups of people with long-term illnesses such as serious mental disorders, who may have difficulty with treatment adherence. Robust research on the impact of mobile technology interventions for these patients remains scarce. Objective: The main objective of our study was to investigate the impact of individually tailored short text messages on the rate of psychiatric hospital readmissions, health care service use, and clinical outcomes. In addition, we analyzed treatment costs. Methods: Between September 2011 and November 2012, we randomly assigned 1139 people to a tailored text message intervention (n=569) or usual care (n=570). Participants received semiautomated text messages for up to 12 months or usual care. The primary outcome, based on routinely collected health register data, was patient readmission into a psychiatric hospital during a 12-month follow-up period. Secondary outcomes were related to other service use, coercion, medication, adverse events, satisfaction, social functioning, quality of life, and economic factors (cost analysis). Results: There was 98.24% (1119/1139) follow-up at 12 months. Tailored mobile telephone text messages did not reduce the rate of hospital admissions (242/563, 43.0% of the SMS group vs 216/556, 38.8% of the control group; relative risk 1.11; 95% CI 0.92-1.33; P=.28), time between hospitalizations (mean difference 7.0 days 95% CI –8.0 to 24.0; P=.37), time spent in a psychiatric hospital during the year (mean difference 2.0 days 95% CI –2.0 to 7.0; P=.35), or other service outcomes. People who received text messages were less disabled, based on Global Assessment Scale scores at the time of their readmission, than those who did not receive text messages (odds ratio 0.68; 95% CI 0.47-0.97; P=.04). The costs of treatment were higher for people in the SMS group than in the control group (mean €10,103 vs €9210, respectively, P<.001). Conclusions: High-grade routinely collected data can provide clear outcomes for pragmatic randomized trials. SMS messaging tailored with the input of each individual patient did not decrease the rate of psychiatric hospital visits after the 12 months of follow-up. Although there may have been other, more subtle effects, the results of these were not evident in outcomes of agreed importance to clinicians, policymakers, and patients and their families. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 27704027; http://www.isrctn.com/ISRCTN27704027 (Archived by WebCite at http://www.webcitation.org/6rVzZrbuz). %M 28701292 %R 10.2196/jmir.7028 %U http://www.jmir.org/2017/7/e245/ %U https://doi.org/10.2196/jmir.7028 %U http://www.ncbi.nlm.nih.gov/pubmed/28701292 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e27 %T Patient-Driven Innovation for Mobile Mental Health Technology: Case Report of Symptom Tracking in Schizophrenia %A Torous,John %A Roux,Spencer %+ Digital Psychiatry Program, Department of Psychiatry and Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA,, United States, 1 617 667 7000, jtorous@bidmc.harvard.edu %K schizophrenia %K mobile health technology %K smartphone %K mhealth %K serious mental illness %K apps %D 2017 %7 06.07.2017 %9 Editorial / Patient Perspective %J JMIR Ment Health %G English %X This patient perspective piece presents an important case at the intersection of mobile health technology, mental health, and innovation. The potential of digital technologies to advance mental health is well known, although the challenges are being increasingly recognized. Making mobile health work for mental health will require broad collaborations. We already know that those who experience mental illness are excited by the potential technology, with many actively engaged in research, fundraising, advocacy, and entrepreneurial ventures. But we don’t always hear their voice as often as others. There is a clear advantage for their voice to be heard: so we can all learn from their experiences at the direct intersection of mental health and technology innovation. The case is cowritten with an individual with schizophrenia, who openly shares his name and personal experience with mental health technology in order to educate and inspire others. This paper is the first in JMIR Mental Health’s patient perspective series, and we welcome future contributions from those with lived experience. %M 28684386 %R 10.2196/mental.7911 %U http://mental.jmir.org/2017/3/e27/ %U https://doi.org/10.2196/mental.7911 %U http://www.ncbi.nlm.nih.gov/pubmed/28684386 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 6 %P e83 %T Users’ Adoption of Mental Health Apps: Examining the Impact of Information Cues %A Huang,Hsiao-Ying %A Bashir,Masooda %+ School of Information Sciences, University of Illinois at Urbana-Champaign, 501 Daniel St., Champaign, IL, 61802, United States, 1 217 244 1139, mnb@illinois.edu %K user interaction design %K recommendation system %K mobile app search %K mental health %K anxiety %D 2017 %7 28.06.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Numerous mental health apps have been developed and made available to users on the current app market. Users may find it difficult and overwhelming to select apps from the hundreds of choices that are available in the app marketplace. Clarifying what information cues may impact a user’s selection and adoption of mental health apps is now a critical and pressing issue. Objective: The aim of this study was to investigate the impact of information cues on users’ adoption of anxiety apps using observational data from the Android app market. Methods: A systematic search of anxiety apps was conducted on the Android app store by using keywords search. The title and metadata information of a total of 274 apps that met our criteria were collected and analyzed. Three trained researchers recorded the app rankings from the search results page on different dates and Web browsers. Results: Our results show that ratings (r=.56, P<.001) and reviews (r=.39, P<.001) have significant positive correlations with the number of installs, and app prices have significant negative correlations with installs (r=−.36). The results also reveal that lower-priced apps have higher ratings (r=−.23, P<.001) and a greater number of app permission requests (r=.18, P=.002) from the device. For app titles, we found that apps with titles related to symptoms have significantly lower installs than apps with titles that are not related to symptoms (P<.001). Conclusions: This study revealed a relationship between information cues and users’ adoption of mental health apps by analyzing observational data. As the first of its kind, we found impactful indicators for mental health app adoptions. We also discovered a labeling effect of app titles that could hinder mental health app adoptions and which may provide insight for future designs of mental health apps and their search mechanisms. %M 28659256 %R 10.2196/mhealth.6827 %U http://mhealth.jmir.org/2017/6/e83/ %U https://doi.org/10.2196/mhealth.6827 %U http://www.ncbi.nlm.nih.gov/pubmed/28659256 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e22 %T Health App Use Among Individuals With Symptoms of Depression and Anxiety: A Survey Study With Thematic Coding %A Rubanovich,Caryn Kseniya %A Mohr,David C %A Schueller,Stephen M %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, 750 N. Lake Shore Drive, CBITs, 10th Floor, Chicago, IL,, United States, 1 312 503 1232, schueller@northwestern.edu %K mHealth %K eHealth %K mobile health %K depression %K anxiety %D 2017 %7 23.06.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Researchers have largely turned to commercial app stores, randomized trials, and systematic reviews to make sense of the mHealth landscape. Few studies have approached understanding by collecting information from target end users. The end user perspective is critical as end user interest in and use of mHealth technologies will ultimately drive the efficacy of these tools. Objective: The purpose of this study was to obtain information from end users of mHealth technologies to better understand the physical and mental health apps people use and for what purposes. Methods: People with depressive or anxious symptoms (N=176) seeking entry into a trial of mental health and well-being apps for Android devices completed online questionnaires assessing depression and anxiety (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), past and current mental health treatment-seeking behavior, overall mobile device use, and use of mobile health apps. Participants reported the physical health and mental health apps on their devices and their reasons for using them. Data were extracted from the participant self-reports and apps and app purposes were coded in order to categorize them. Results: Participants were largely white, middle-aged females from the Midwest region of the United States recruited via a health care organization and Web-based advertising (135 female, 41 male, mean age 38.64 years, age range 19-75 years.) Over three-quarters (137/176, 77.8%) of participants indicated having a health app on their device. The top 3 kinds of apps were exercise, fitness, and pedometers or heart rate monitoring apps (93/176, 52.8%); diet, food, or calorie counting apps (65/177, 36.9%); and mental health/wellness apps (46/177, 26.1%). The mean number of mobile physical and mental health apps on a participant’s phone was 2.15 (SD 3.195). Of 176 participants, 107 (60.8%) specifically reported the top 5 health apps that they used and their purposes. Across the 107 participants, a total of 285 apps were reported, with 139 being unique apps. The majority of these apps were free (129/139, 92.8%). Almost two-thirds of participants (67/107, 62.6%) reported using health apps at least on a daily basis. Conclusions: Among those seeking support for their well-being via physical and mental health apps, people are using a variety of health apps. These people use health apps on a daily basis, especially free apps. The most common reason for using a health app is to track some health-related data; for mental health apps specifically, training or habit building was the most popular reason. Understanding the end user perspective is important because it allows us to build on the foundation of previously established mHealth research and may help guide future work in mHealth. Trial Registration: Clinicaltrials.gov NCT02176226; https://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation.org/6rGc1MGyM) %M 28645891 %R 10.2196/mental.7603 %U http://mental.jmir.org/2017/2/e22/ %U https://doi.org/10.2196/mental.7603 %U http://www.ncbi.nlm.nih.gov/pubmed/28645891 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e13 %T Gamification in Stress Management Apps: A Critical App Review %A Hoffmann,Alexandra %A Christmann,Corinna A %A Bleser,Gabriele %+ Junior research group wearHEALTH, Department of Computer Science, University of Kaiserslautern, Gottlieb-Daimler-Str. 48, Kaiserslautern, 67663, Germany, 49 631 205 3456, hoffmann@cs.uni-kl.de %K game element %K mHealth, motivation %K app %K behavior change %K gamification %D 2017 %7 07.06.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: In today’s society, stress is more and more often a cause of disease. This makes stress management an important target of behavior change programs. Gamification has been suggested as one way to support health behavior change. However, it remains unclear to which extend available gamification techniques are integrated in stress management apps, and if their occurrence is linked to the use of elements from behavior change theory. Objective: The aim of this study was to investigate the use of gamification techniques in stress management apps and the cooccurrence of these techniques with evidence-based stress management methods and behavior change techniques. Methods: A total of 62 stress management apps from the Google Play Store were reviewed on their inclusion of 17 gamification techniques, 15 stress management methods, and 26 behavior change techniques. For this purpose, an extended taxonomy of gamification techniques was constructed and applied by 2 trained, independent raters. Results: Interrater-reliability was high, with agreement coefficient (AC)=.97. Results show an average of 0.5 gamification techniques for the tested apps and reveal no correlations between the use of gamification techniques and behavior change techniques (r=.17, P=.20), or stress management methods (r=.14, P=.26). Conclusions: This leads to the conclusion that designers of stress management apps do not use gamification techniques to influence the user’s behaviors and reactions. Moreover, app designers do not exploit the potential of combining gamification techniques with behavior change theory. %M 28592397 %R 10.2196/games.7216 %U http://games.jmir.org/2017/2/e13/ %U https://doi.org/10.2196/games.7216 %U http://www.ncbi.nlm.nih.gov/pubmed/28592397 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e176 %T Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review %A Grist,Rebecca %A Porter,Joanna %A Stallard,Paul %+ Child and Adolescent Mental Health Group, Department for Health, University of Bath, Wessex House, Claverton Down, Bath, BA2 7AY, United Kingdom, 44 2253850 ext 86, r.grist@bath.ac.uk %K mobile apps %K smartphone apps %K mHealth %K mental health %K self-help %K child %K adolescent %K preadolescent %K review %D 2017 %7 25.05.2017 %9 Review %J J Med Internet Res %G English %X Background: There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective: This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years. Methods: The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years. Results: A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate. Conclusions: Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed. %M 28546138 %R 10.2196/jmir.7332 %U http://www.jmir.org/2017/5/e176/ %U https://doi.org/10.2196/jmir.7332 %U http://www.ncbi.nlm.nih.gov/pubmed/28546138 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e105 %T The Reviews Are in: A Qualitative Content Analysis of Consumer Perspectives on Apps for Bipolar Disorder %A Nicholas,Jennifer %A Fogarty,Andrea S %A Boydell,Katherine %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital rd, Prince of Wales Hospital, Sydney, 2031, Australia, 61 293828507, J.nicholas@blackdog.org.au %K mobile applications %K bipolar disorder %K smartphone %K telemedicine %K qualitative research %D 2017 %7 07.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The delivery of mobile health (mHealth) services is acceptable to mental health consumers. However, despite the benefits of accessibility, cost-effectiveness, anonymity, and ability to tailor content to individual needs, consumer engagement remains a hurdle for uptake and continued use. This may be unsurprising as few studies have examined app content from the consumer perspective or assessed consumer preferences for the content of apps for mental health management. An opportunity to examine consumer perspectives exists in using naturally generated data that is publically available in the Google Play and Apple app stores. Whereas commercial developers routinely use this data, to date there has been no in-depth evaluation within scientific research. Objective: The aim of our study was to explore what consumers consider useful content for mental health management apps, identify unmet needs, and understand user expectations of mental health apps within the context of apps for bipolar disorder. Methods: Publically available English language consumer reviews of 48 apps for bipolar disorder were used as data, providing a total of 2173 reviews. Review text was coded and analyzed using a team approach to qualitative content analysis. Results were presented in 2 forms: (1) a quantitative summary of the 9 major and minor themes and (2) a qualitative synthesis of key thematic findings. Results: The majority of reviews were for symptom monitoring apps (87.94%, 1911/2173). The qualitative content analysis revealed 5 main themes: (1) laudatory talk, comments regarding the app’s benefits including helpfulness and successful design features (74.00% of reviews, 1608/2173); (2) unfavorable feedback, negative reviews largely concerning unmet needs, privacy and technical issues, and potential dangers of app use (25.54%, 555/2173); (3) conceptions of community, referring to both communities of users with mental ill-health accessed via the app and a community created among app users and developers (24.25%, 527/2173); (4) wishlist features, app features requested by users (17.53%, 381/2173); and (5) apps and therapy, app use within clinical care (10.58%, 230/2173). Four minor themes were also identified: (1) app cost, (2) privacy and data security, (3) comparisons with traditional monitoring, and (4) evidence-based mHealth. Conclusions: Although mostly positive, the proportion of reviews containing wishlist requests indicates consumer needs are not adequately addressed by currently available disorder management apps. Consumers value content that is helpful, supportive, and easy to use, and they are integrating apps into their health management and clinical care without necessarily considering the evidence-base or clinical effectiveness of the tool. User expectations regarding developer responsiveness to their needs has implications for community-based participatory research and integrated knowledge translation. However, this expectation is incompatible with current mHealth funding structures. %M 28389420 %R 10.2196/jmir.7273 %U http://www.jmir.org/2017/4/e105/ %U https://doi.org/10.2196/jmir.7273 %U http://www.ncbi.nlm.nih.gov/pubmed/28389420 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 2 %P e18 %T Use of a Novel Artificial Intelligence Platform on Mobile Devices to Assess Dosing Compliance in a Phase 2 Clinical Trial in Subjects With Schizophrenia %A Bain,Earle E %A Shafner,Laura %A Walling,David P %A Othman,Ahmed A %A Chuang-Stein,Christy %A Hinkle,John %A Hanina,Adam %+ AiCure, LLC, 19 West 24th Street, 11th Fl., New York, NY, 10010, United States, 1 800 570 0448, laura.shafner@aicure.com %K medication adherence %K artificial intelligence %K clinical trials as topic %D 2017 %7 21.02.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Accurately monitoring and collecting drug adherence data can allow for better understanding and interpretation of the outcomes of clinical trials. Most clinical trials use a combination of pill counts and self-reported data to measure drug adherence, despite the drawbacks of relying on these types of indirect measures. It is assumed that doses are taken, but the exact timing of these events is often incomplete and imprecise. Objective: The objective of this pilot study was to evaluate the use of a novel artificial intelligence (AI) platform (AiCure) on mobile devices for measuring medication adherence, compared with modified directly observed therapy (mDOT) in a substudy of a Phase 2 trial of the α7 nicotinic receptor agonist (ABT-126) in subjects with schizophrenia. Methods: AI platform generated adherence measures were compared with adherence inferred from drug concentration measurements. Results: The mean cumulative pharmacokinetic adherence over 24 weeks was 89.7% (standard deviation [SD] 24.92) for subjects receiving ABT-126 who were monitored using the AI platform, compared with 71.9% (SD 39.81) for subjects receiving ABT-126 who were monitored by mDOT. The difference was 17.9% (95% CI -2 to 37.7; P=.08). Conclusions: Using drug levels, this substudy demonstrates the potential of AI platforms to increase adherence, rapidly detect nonadherence, and predict future nonadherence. Subjects monitored using the AI platform demonstrated a percentage change in adherence of 25% over the mDOT group. Subjects were able to use the technology successfully for up to 6 months in an ambulatory setting with early termination rates that are comparable to subjects outside of the substudy. Trial Registration: ClinicalTrials.gov NCT01655680 https://clinicaltrials.gov/ct2/show/NCT01655680?term=NCT01655680 %M 28223265 %R 10.2196/mhealth.7030 %U http://mhealth.jmir.org/2017/2/e18/ %U https://doi.org/10.2196/mhealth.7030 %U http://www.ncbi.nlm.nih.gov/pubmed/28223265 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e52 %T Creating Live Interactions to Mitigate Barriers (CLIMB): A Mobile Intervention to Improve Social Functioning in People With Chronic Psychotic Disorders %A Biagianti,Bruno %A Schlosser,Danielle %A Nahum,Mor %A Woolley,Josh %A Vinogradov,Sophia %+ Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue LP-253, San Francisco, CA, 94143, United States, 1 4152902122, bruno.biagianti@ucsf.edu %K psychosis %K social cognition %K digital health %K mobile health %D 2016 %7 13.12.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Numerous psychosocial interventions for individuals with chronic psychotic disorders (CPD) have shown positive effects on social cognitive and functional outcome measures. However, access to and engagement with these interventions remains limited. This is partly because these interventions require specially trained therapists, are not available in all clinical settings, and have a high scheduling burden for participants, usually requiring a commitment of several weeks. Delivering interventions remotely via mobile devices may facilitate access, improve scheduling flexibility, and decrease participant burden, thus improving adherence to intervention requirements. To address these needs, we designed the Creating Live Interactions to Mitigate Barriers (CLIMB) digital intervention, which aims to enhance social functioning in people with CPD. CLIMB consists of two treatment components: a computerized social cognition training (SCT) program and optimized remote group therapy (ORGT). ORGT is an innovative treatment that combines remote group therapy with group texting (short message service, SMS). Objectives: The objectives of this single-arm study were to investigate the feasibility of delivering 6 weeks of CLIMB to people with CPD and explore the initial effects on outcomes. Methods: Participants were recruited, screened and enrolled via the Internet, and delivered assessments and interventions remotely using provided tablets (iPads). Participants were asked to complete 18 hours of SCT and to attend 6 remote group therapy sessions. To assess feasibility, adherence to study procedures, attrition rates, engagement metrics, and acceptability of the intervention were evaluated. Changes on measures of social cognition, quality of life, and symptoms were also explored. Results: In total, 27 participants were enrolled over 12 months. Remote assessments were completed successfully on 96% (26/27) of the enrolled participants. Retention in the 6-week trial was 78% (21/27). Of all the iPads used, 95% (22/23) were returned undamaged at the end of the intervention. Participants on average attended 84% of the group therapy sessions, completed a median of 9.5 hours of SCT, and posted a median of 5.2 messages per week on the group text chat. Participants rated CLIMB in the medium range in usability, acceptability, enjoyment, and perceived benefit. Participants showed significant improvements in emotion identification abilities for prosodic happiness (P=.001), prosodic happiness intensity (P=.04), and facial anger (P=.04), with large within-group effect sizes (d=.60 to d=.86). Trend-level improvements were observed on aspects of quality of life (P values less than .09). No improvements were observed for symptoms. Conclusions: It is feasible and acceptable to remotely deliver an intervention aimed at enhancing social functioning in people with CPD using mobile devices. This approach may represent a scalable method to increase treatment access and adherence. Our pilot data also demonstrate within-group gains in some aspects of social cognition after 6 weeks of CLIMB. Future randomized controlled studies in larger samples should evaluate the extent to which CLIMB significantly improves social cognition, symptoms, and quality of life in CPD. %M 27965190 %R 10.2196/mental.6671 %U http://mental.jmir.org/2016/4/e52/ %U https://doi.org/10.2196/mental.6671 %U http://www.ncbi.nlm.nih.gov/pubmed/27965190 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e49 %T Development of a Mobile Phone App to Support Self-Monitoring of Emotional Well-Being: A Mental Health Digital Innovation %A Rickard,Nikki %A Arjmand,Hussain-Abdulah %A Bakker,David %A Seabrook,Elizabeth %+ Emotion and Well-being Research Unit, School of Psychological Sciences, Monash University, Building 18, Wellington Rd, Clayton, 3800, Australia, 61 400 191 768, nikki.rickard@monash.edu %K eHealth %K emotions %K mental health %K mobile phone %K feedback %D 2016 %7 23.11.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emotional well-being is a primary component of mental health and well-being. Monitoring changes in emotional state daily over extended periods is, however, difficult using traditional methodologies. Providing mental health support is also challenging when approximately only 1 in 2 people with mental health issues seek professional help. Mobile phone technology offers a sustainable means of enhancing self-management of emotional well-being. Objective: This paper aims to describe the development of a mobile phone tool designed to monitor emotional changes in a natural everyday context and in real time. Methods: This evidence-informed mobile phone app monitors emotional mental health and well-being, and it provides links to mental health organization websites and resources. The app obtains data via self-report psychological questionnaires, experience sampling methodology (ESM), and automated behavioral data collection. Results: Feedback from 11 individuals (age range 16-52 years; 4 males, 7 females), who tested the app over 30 days, confirmed via survey and focus group methods that the app was functional and usable. Conclusions: Recommendations for future researchers and developers of mental health apps to be used for research are also presented. The methodology described in this paper offers a powerful tool for a range of potential mental health research studies and provides a valuable standard against which development of future mental health apps should be considered. %M 27881358 %R 10.2196/mental.6202 %U http://mental.jmir.org/2016/4/e49/ %U https://doi.org/10.2196/mental.6202 %U http://www.ncbi.nlm.nih.gov/pubmed/27881358 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e112 %T Measuring Users’ Receptivity Toward an Integral Intervention Model Based on mHealth Solutions for Patients With Treatment-Resistant Schizophrenia (m-RESIST): A Qualitative Study %A Huerta-Ramos,Elena %A Escobar-Villegas,Maria Soledad %A Rubinstein,Katya %A Unoka,Zsolt Szabolcs %A Grasa,Eva %A Hospedales,Margarita %A Jääskeläinen,Erika %A Rubio-Abadal,Elena %A Caspi,Asaf %A Bitter,István %A Berdun,Jesus %A Seppälä,Jussi %A Ochoa,Susana %A Fazekas,Kata %A , %A Corripio,Iluminada %A Usall,Judith %+ Parc Sanitari Sant Joan de Déu, CIBERSAM G11, Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona, 08830, Spain, 34 936406350 ext 12347, mehuerta@pssjd.org %K mHealth solution %K treatment-resistant schizophrenia %K intervention model %K qualitative research %K needs assessment %D 2016 %7 28.09.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite the theoretical potential of mHealth solutions in the treatment of patients with schizophrenia, there remains a lack of technological tools in clinical practice. Objective: The aim of this study was to measure the receptivity of patients, informal carers, and clinicians to a European integral intervention model focused on patients with persistent positive symptoms: Mobile Therapeutic Attention for Patients with Treatment-Resistant Schizophrenia (m-RESIST). Methods: Before defining the system requirements, a qualitative study of the needs of outpatients with treatment-resistant schizophrenia was carried out in Spain, Israel, and Hungary. We analyzed the opinions of patients, informal carers, and clinicians concerning the services originally intended to be part of the solution. A total of 9 focus groups (72 people) and 35 individual interviews were carried out in the 3 countries, using discourse analysis as the framework. Results: A webpage and an online forum were perceived as suitable to get both reliable information on the disease and support. Data transmission by a smart watch (monitoring), Web-based visits, and instant messages (clinical treatment) were valued as ways to improve contact with clinicians. Alerts were appreciated as reminders of daily tasks and appointments. Avoiding stressful situations for outpatients, promoting an active role in the management of the disease, and maintaining human contact with clinicians were the main suggestions provided for improving the effectiveness of the solution. Conclusions: Positive receptivity toward m-RESIST services is related to its usefulness in meeting user needs, its capacity to empower them, and the possibility of maintaining human contact. %M 27682896 %R 10.2196/mhealth.5716 %U http://mhealth.jmir.org/2016/3/e112/ %U https://doi.org/10.2196/mhealth.5716 %U http://www.ncbi.nlm.nih.gov/pubmed/27682896 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e103 %T Acceptance and Commitment Therapy in Daily Life Training: A Feasibility Study of an mHealth Intervention %A Batink,Tim %A Bakker,Jindra %A Vaessen,Thomas %A Kasanova,Zuzana %A Collip,Dina %A van Os,Jim %A Wichers,Marieke %A Germeys,Inez %A Peeters,Frenk %+ Department of Psychiatry and Psychology, Maastricht University Medical Centre, Maastricht University, SN2, Vijverdalseweg 1, Maastricht,, Netherlands, 31 620 454 912, tim.batink@maastrichtuniversity.nl %K mHealth %K behavior change %K daily life intervention %K acceptance and commitment therapy %K experience sampling %D 2016 %7 15.09.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the development of mHealth, it is possible to treat patients in their natural environment. Mobile technology helps to bridge the gap between the therapist’s office and the “real world.” The ACT in Daily Life training (ACT-DL) was designed as an add-on intervention to help patients practice with acceptance and commitment therapy in their daily lives. The ACT-DL consists of two main components: daily monitoring using experience sampling and ACT training in daily life. Objectives: To assess the acceptability and feasibility of the ACT-DL in a general outpatient population. A secondary objective was to conduct a preliminary examination of the effectiveness of the ACT-DL. Methods: An observational comparative study was conducted. The experimental group consisted of 49 patients who volunteered for ACT-DL, and the control group consisted of 112 patients who did not volunteer. As part of an inpatient treatment program, both groups received a 6-week ACT training. Participants went home to continue their treatment on an outpatient basis, during which time the experimental group received the 4-week add-on ACT-DL. Acceptability and feasibility of the ACT-DL was assessed weekly by telephone survey. Effectiveness of the ACT-DL was evaluated with several self-report questionnaires ( Flexibility Index Test (FIT-60): psychological flexibility, Brief Symptom Inventory: symptoms, Utrechtse Coping List: coping, and Quality of life visual analog scale (QoL-VAS): quality of life). Results: More than three-quarters of the participants (76%) completed the full 4-week training. User evaluations showed that ACT-DL stimulated the use of ACT in daily life: participants practiced over an hour a week (mean 78.8 minutes, standard deviation 54.4), doing 10.4 exercises (standard deviation 6.0) on average. Both ACT exercises and metaphors were experienced as useful components of the training (rated 5 out of 7). Repeated measures ANCOVA did not show significant effects of the ACT-DL on psychological flexibility (P=.88), symptoms (P=.39), avoidant coping (P=.28), or quality of life (P=.15). Conclusions: This is the first study that uses experience sampling to foster awareness in daily life in combination with acceptance and commitment therapy to foster skill building. Adherence to the ACT-DL was high for an intensive mHealth intervention. ACT-DL appears to be an acceptable and feasible mHealth intervention, suitable for a broad range of mental health problems. However, short-term effectiveness could not be demonstrated. Additional clinical trials are needed to examine both short-term and long-term effects. %M 27634747 %R 10.2196/mhealth.5437 %U http://mhealth.jmir.org/2016/3/e103/ %U https://doi.org/10.2196/mhealth.5437 %U http://www.ncbi.nlm.nih.gov/pubmed/27634747 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e96 %T Quantifying App Store Dynamics: Longitudinal Tracking of Mental Health Apps %A Larsen,Mark Erik %A Nicholas,Jennifer %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 293828508, mark.larsen@blackdog.org.au %K mobile applications %K mobile apps %K mental health %K telemedicine %K depression %K bipolar disorder %K suicide %D 2016 %7 09.08.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: For many mental health conditions, mobile health apps offer the ability to deliver information, support, and intervention outside the clinical setting. However, there are difficulties with the use of a commercial app store to distribute health care resources, including turnover of apps, irrelevance of apps, and discordance with evidence-based practice. Objective: The primary aim of this study was to quantify the longevity and rate of turnover of mental health apps within the official Android and iOS app stores. The secondary aim was to quantify the proportion of apps that were clinically relevant and assess whether the longevity of these apps differed from clinically nonrelevant apps. The tertiary aim was to establish the proportion of clinically relevant apps that included claims of clinical effectiveness. We performed additional subgroup analyses using additional data from the app stores, including search result ranking, user ratings, and number of downloads. Methods: We searched iTunes (iOS) and the Google Play (Android) app stores each day over a 9-month period for apps related to depression, bipolar disorder, and suicide. We performed additional app-specific searches if an app no longer appeared within the main search Results: On the Android platform, 50% of the search results changed after 130 days (depression), 195 days (bipolar disorder), and 115 days (suicide). Search results were more stable on the iOS platform, with 50% of the search results remaining at the end of the study period. Approximately 75% of Android and 90% of iOS apps were still available to download at the end of the study. We identified only 35.3% (347/982) of apps as being clinically relevant for depression, of which 9 (2.6%) claimed clinical effectiveness. Only 3 included a full citation to a published study. Conclusions: The mental health app environment is volatile, with a clinically relevant app for depression becoming unavailable to download every 2.9 days. This poses challenges for consumers and clinicians seeking relevant and long-term apps, as well as for researchers seeking to evaluate the evidence base for publicly available apps. %M 27507641 %R 10.2196/mhealth.6020 %U http://mhealth.jmir.org/2016/3/e96/ %U https://doi.org/10.2196/mhealth.6020 %U http://www.ncbi.nlm.nih.gov/pubmed/27507641 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e34 %T mHealth for Schizophrenia: Patient Engagement With a Mobile Phone Intervention Following Hospital Discharge %A Ben-Zeev,Dror %A Scherer,Emily A %A Gottlieb,Jennifer D %A Rotondi,Armando J %A Brunette,Mary F %A Achtyes,Eric D %A Mueser,Kim T %A Gingerich,Susan %A Brenner,Christopher J %A Begale,Mark %A Mohr,David C %A Schooler,Nina %A Marcy,Patricia %A Robinson,Delbert G %A Kane,John M %+ Dartmouth College, Geisel School of Medicine, Hanover, NH, 03755, United States, 1 6036467016, Dror.Ben-Zeev@Dartmouth.edu %K mHealth %K schizophrenia %K technology %K illness management %K symptoms %K relapse %K engagement %K adherence %K smartphone %D 2016 %7 27.07.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: mHealth interventions that use mobile phones as instruments for illness management are gaining popularity. Research examining mobile phone‒based mHealth programs for people with psychosis has shown that these approaches are feasible, acceptable, and clinically promising. However, most mHealth initiatives involving people with schizophrenia have spanned periods ranging from a few days to several weeks and have typically involved participants who were clinically stable. Objective: Our aim was to evaluate the viability of extended mHealth interventions for people with schizophrenia-spectrum disorders following hospital discharge. Specifically, we set out to examine the following: (1) Can individuals be engaged with a mobile phone intervention program during this high-risk period?, (2) Are age, gender, racial background, or hospitalization history associated with their engagement or persistence in using a mobile phone intervention over time?, and (3) Does engagement differ by characteristics of the mHealth intervention itself (ie, pre-programmed vs on-demand functions)? Methods: We examined mHealth intervention use and demographic and clinical predictors of engagement in 342 individuals with schizophrenia-spectrum disorders who were given the FOCUS mobile phone intervention as part of a technology-assisted relapse prevention program during the 6-month high-risk period following hospitalization. Results: On average, participants engaged with FOCUS for 82% of the weeks they had the mobile phone. People who used FOCUS more often continued using it over longer periods: 44% used the intervention over 5-6 months, on average 4.3 days a week. Gender, race, age, and number of past psychiatric hospitalizations were associated with engagement. Females used FOCUS on average 0.4 more days a week than males. White participants engaged on average 0.7 days more a week than African-Americans and responded to prompts on 0.7 days more a week than Hispanic participants. Younger participants (age 18-29) had 0.4 fewer days of on-demand use a week than individuals who were 30-45 years old and 0.5 fewer days a week than older participants (age 46-60). Participants with fewer past hospitalizations (1-6) engaged on average 0.2 more days a week than those with seven or more. mHealth program functions were associated with engagement. Participants responded to prompts more often than they self-initiated on-demand tools, but both FOCUS functions were used regularly. Both types of intervention use declined over time (on-demand use had a steeper decline). Although mHealth use declined, the majority of individuals used both on-demand and system-prompted functions regularly throughout their participation. Therefore, neither function is extraneous. Conclusions: The findings demonstrated that individuals with schizophrenia-spectrum disorders can actively engage with a clinically supported mobile phone intervention for up to 6 months following hospital discharge. mHealth may be useful in reaching a clinical population that is typically difficult to engage during high-risk periods. %M 27465803 %R 10.2196/mental.6348 %U http://mental.jmir.org/2016/3/e34/ %U https://doi.org/10.2196/mental.6348 %U http://www.ncbi.nlm.nih.gov/pubmed/27465803 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e88 %T Psychologist in a Pocket: Lexicon Development and Content Validation of a Mobile-Based App for Depression Screening %A Cheng,Paula Glenda Ferrer %A Ramos,Roann Munoz %A Bitsch,Jó Ágila %A Jonas,Stephan Michael %A Ix,Tim %A See,Portia Lynn Quetulio %A Wehrle,Klaus %+ The Graduate School, University of Santo Tomas, Thomas Aquinas Research Complex, Espana Boulevard, Manila, 1015, Philippines, 63 7315396 ext 8247, chengpaulaferrer@gmail.com %K depression %K Psychologist in a Pocket %K lexicon development %K text analysis %D 2016 %7 20.07.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Language reflects the state of one’s mental health and personal characteristics. It also reveals preoccupations with a particular schema, thus possibly providing insights into psychological conditions. Using text or lexical analysis in exploring depression, negative schemas and self-focusing tendencies may be depicted. As mobile technology has become highly integrated in daily routine, mobile devices have the capacity for ecological momentary assessment (EMA), specifically the experience sampling method (ESM), where behavior is captured in real-time or closer in time to experience in one’s natural environment. Extending mobile technology to psychological health could augment initial clinical assessment, particularly of mood disturbances, such as depression and analyze daily activities, such as language use in communication. Here, we present the process of lexicon generation and development and the initial validation of Psychologist in a Pocket (PiaP), a mobile app designed to screen signs of depression through text analysis. Objective: The main objectives of the study are (1) to generate and develop a depressive lexicon that can be used for screening text-input in mobile apps to be used in the PiaP; and (2) to conduct content validation as initial validation. Methods: The first phase of our research focused on lexicon development. Words related to depression and its symptoms based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and in the ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines classification systems were gathered from focus group discussions with Filipino college students, interviews with mental health professionals, and the review of established scales for depression and other related constructs. Results: The lexicon development phase yielded a database consisting of 13 categories based on the criteria depressive symptoms in the DSM-5 and ICD-10. For the draft of the depression lexicon for PiaP, we were able to gather 1762 main keywords and 9655 derivatives of main keywords. In addition, we compiled 823,869 spelling variations. Keywords included negatively-valenced words like “sad”, “unworthy”, or “tired” which are almost always accompanied by personal pronouns, such as “I”, “I’m” or “my” and in Filipino, “ako” or “ko”. For the content validation, only keywords with CVR equal to or more than 0.75 were included in the depression lexicon test-run version. The mean of all CVRs yielded a high overall CVI of 0.90. A total of 1498 main keywords, 8911 derivatives of main keywords, and 783,140 spelling variations, with a total of 793, 553 keywords now comprise the test-run version. Conclusions: The generation of the depression lexicon is relatively exhaustive. The breadth of keywords used in text analysis incorporates the characteristic expressions of depression and its related constructs by a particular culture and age group. A content-validated mobile health app, PiaP may help augment a more effective and early detection of depressive symptoms. %M 27439444 %R 10.2196/mhealth.5284 %U http://mhealth.jmir.org/2016/3/e88/ %U https://doi.org/10.2196/mhealth.5284 %U http://www.ncbi.nlm.nih.gov/pubmed/27439444 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 2 %P e24 %T Implementation of a Substance Use Recovery Support Mobile Phone App in Community Settings: Qualitative Study of Clinician and Staff Perspectives of Facilitators and Barriers %A Lord,Sarah %A Moore,Sarah K %A Ramsey,Alex %A Dinauer,Susan %A Johnson,Kimberly %+ Center for Technology and Behavioral Health, Department of Psychiatry, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH, 03766, United States, 1 603 646 7989, sarah.e.lord@dartmouth.edu %K substance abuse %K relapse prevention %K mobile apps %D 2016 %7 28.06.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research supports the effectiveness of technology-based treatment approaches for substance use disorders. These approaches have the potential to broaden the reach of evidence-based care. Yet, there is limited understanding of factors associated with implementation of technology-based care approaches in different service settings. Objectives: In this study, we explored provider and staff perceptions of facilitators and barriers to implementation of a mobile phone substance use recovery support app with clients in 4 service settings. Methods: Interviews were conducted with leadership and provider stakeholders (N=12) from 4 agencies in the first year of an implementation trial of the mobile phone app. We used the Consolidated Framework for Implementation Research as the conceptual foundation for identifying facilitators and barriers to implementation. Results: Implementation process facilitators included careful planning of all aspects of implementation before launch, engaging a dedicated team to implement and foster motivation, working collaboratively with the app development team to address technical barriers and adapt the app to meet client and agency needs, and consistently reviewing app usage data to inform progress. Implementation support strategies included training all staff to promote organization awareness about the recovery support app and emphasize its priority as a clinical care tool, encouraging clients to try the technology before committing to use, scaling rollout to clients, setting clear expectations with clients about use of the app, and using peer coaches and consistent client-centered messaging to promote engagement. Perceived compatibility of the mobile phone app with agency and client needs and readiness to implement emerged as salient agency-level implementation facilitators. Facilitating characteristics of the recovery support app itself included evidence of its impact for recovery support, perceived relative advantage of the app over usual care, the ability to adapt the app to improve client use, and its ease of use. The mobile phone itself was a strong motivation for clients to opt in to use the app in settings that provided phones. App access was limited in settings that did not provide phones owing to lack of mobile phone ownership or incompatibility of the app with clients’ mobile phones. Individual differences in technology literacy and provider beliefs about substance use care either facilitated or challenged implementation. Awareness of patient needs and resources facilitated implementation, whereas external policies and regulations regarding technology use introduced barriers to implementation. Conclusions: The conceptually grounded facilitators and barriers identified in this study can guide systematic targeting of strategies to improve implementation of mobile phone interventions in community treatment settings. Results also inform the design of technology-based therapeutic tools. This study highlights directions for research with regard to implementation of technology-based behavioral health care approaches. %M 27352884 %R 10.2196/mental.4927 %U http://mental.jmir.org/2016/2/e24/ %U https://doi.org/10.2196/mental.4927 %U http://www.ncbi.nlm.nih.gov/pubmed/27352884 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e156 %T Does a Mobile Phone Depression-Screening App Motivate Mobile Phone Users With High Depressive Symptoms to Seek a Health Care Professional’s Help? %A BinDhim,Nasser F %A Alanazi,Eman M %A Aljadhey,Hisham %A Basyouni,Mada H %A Kowalski,Stefan R %A Pont,Lisa G %A Shaman,Ahmed M %A Trevena,Lyndal %A Alhawassi,Tariq M %+ College of Health Sciences, Health Informatics, Saudi Electronic University, Abu Baker St, Riyadh, 11673, Saudi Arabia, 966 112613500 ext 1065, nbin6641@uni.sydney.edu.au %K mental health %K depression %K mobile phone %K public health informatics %K patients’ screening %D 2016 %7 27.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The objective of disease screening is to encourage high-risk subjects to seek health care diagnosis and treatment. Mobile phone apps can effectively screen mental health conditions, including depression. However, it is not known how effective such screening methods are in motivating users to discuss the obtained results of such apps with health care professionals. Does a mobile phone depression-screening app motivate users with high depressive symptoms to seek health care professional advice? This study aimed to address this question. Method: This was a single-cohort, prospective, observational study of a free mobile phone depression app developed in English and released on Apple’s App Store. Apple App Store users (aged 18 or above) in 5 countries, that is, Australia, Canada, New Zealand (NZ), the United Kingdom (UK), and the United States (US), were recruited directly via the app’s download page. The participants then completed the Patient Health Questionnaire (PHQ-9), and their depression screening score was displayed to them. If their score was 11 or above and they had never been diagnosed with depression before, they were advised to take their results to their health care professional. They were to follow up after 1 month. Results: A group of 2538 participants from the 5 countries completed PHQ-9 depression screening with the app. Of them, 322 participants were found to have high depressive symptoms and had never been diagnosed with depression, and received advice to discuss their results with health care professionals. About 74% of those completed the follow-up; approximately 38% of these self-reported consulting their health care professionals about their depression score. Only positive attitude toward depression as a real disease was associated with increased follow-up response rate (odds ratio (OR) 3.2, CI 1.38-8.29). Conclusions: A mobile phone depression-screening app motivated some users to seek a depression diagnosis. However, further study should investigate how other app users use the screening results provided by such apps. %M 27349441 %R 10.2196/jmir.5726 %U http://www.jmir.org/2016/6/e156/ %U https://doi.org/10.2196/jmir.5726 %U http://www.ncbi.nlm.nih.gov/pubmed/27349441 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e65 %T Acceptability of Mental Health Apps for Aboriginal and Torres Strait Islander Australians: A Qualitative Study %A Povey,Josie %A Mills,Patj Patj Janama Robert %A Dingwall,Kylie Maree %A Lowell,Anne %A Singer,Judy %A Rotumah,Darlene %A Bennett-Levy,James %A Nagel,Tricia %+ Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, PO Box 41096, Casuarina, 0811, Australia, 61 407399919, josie_povey@hotmail.com %K mobile apps %K mental health %K indigenous populations %K therapeutics %K cognitive behavioral therapy %K acceptance and commitment therapy %K culturally competent care %D 2016 %7 11.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Aboriginal and Torres Strait Islander Australians experience high rates of mental illness and psychological distress compared to their non-Indigenous counterparts. E-mental health tools offer an opportunity for accessible, effective, and acceptable treatment. The AIMhi Stay Strong app and the ibobbly suicide prevention app are treatment tools designed to combat the disproportionately high levels of mental illness and stress experienced within the Aboriginal and Torres Strait Islander community. Objective: This study aimed to explore Aboriginal and Torres Strait Islander community members’ experiences of using two culturally responsive e-mental health apps and identify factors that influence the acceptability of these approaches. Methods: Using qualitative methods aligned with a phenomenological approach, we explored the acceptability of two culturally responsive e-mental health apps through a series of three 3-hour focus groups with nine Aboriginal and Torres Strait Islander community members. Thematic analysis was conducted and coresearcher and member checking were used to verify findings. Results: Findings suggest strong support for the concept of e-mental health apps and optimism for their potential. Factors that influenced acceptability related to three key themes: personal factors (eg, motivation, severity and awareness of illness, technological competence, and literacy and language differences), environmental factors (eg, community awareness, stigma, and availability of support), and app characteristics (eg, ease of use, content, graphics, access, and security and information sharing). Specific adaptations, such as local production, culturally relevant content and graphics, a purposeful journey, clear navigation, meaningful language, options to assist people with language differences, offline use, and password protection may aid uptake. Conclusions: When designed to meet the needs of Aboriginal and Torres Strait Islander Australians, e-mental health tools add an important element to public health approaches for improving the well-being of Aboriginal and Torres Strait Islander people. %M 26969043 %R 10.2196/jmir.5314 %U http://www.jmir.org/2016/3/e65/ %U https://doi.org/10.2196/jmir.5314 %U http://www.ncbi.nlm.nih.gov/pubmed/26969043 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e7 %T Mental Health Smartphone Apps: Review and Evidence-Based Recommendations for Future Developments %A Bakker,David %A Kazantzis,Nikolaos %A Rickwood,Debra %A Rickard,Nikki %+ School of Psychology and Monash Institute of Cognitive and Clinical Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, 18 Innovation Walk, Wellington Road, Clayton, 3800, Australia, 61 3 9905 4301, david.bakker@monash.edu %K mobile phones %K mental health %K smartphones %K apps %K mobile apps %K depression %K anxiety %K cognitive behavior therapy %K cognitive behavioral therapy %K clinical psychology %D 2016 %7 01.03.2016 %9 Review %J JMIR Mental Health %G English %X Background: The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available. Objective: To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps. Methods: A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design. Results: Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp. Conclusions: Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems. %M 26932350 %R 10.2196/mental.4984 %U http://mental.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/mental.4984 %U http://www.ncbi.nlm.nih.gov/pubmed/26932350 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e10 %T Therapeutic Alliance With a Fully Automated Mobile Phone and Web-Based Intervention: Secondary Analysis of a Randomized Controlled Trial %A Clarke,Janine %A Proudfoot,Judith %A Whitton,Alexis %A Birch,Mary-Rose %A Boyd,Megan %A Parker,Gordon %A Manicavasagar,Vijaya %A Hadzi-Pavlovic,Dusan %A Fogarty,Andrea %+ Black Dog Institute, UNSW Australia, Hospital Road, Randwick NSW 2031, Australia, 61 2 9382 3767, Janine.clarke@unsw.edu.au %K therapeutic alliance %K e-therapy %K Internet interventions %K depression %K computerized cognitive behavior therapy %D 2016 %7 25.02.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Studies of Internet-delivered psychotherapies suggest that clients report development of a therapeutic alliance in the Internet environment. Because a majority of the interventions studied to date have been therapist-assisted to some degree, it remains unclear whether a therapeutic alliance can develop within the context of an Internet-delivered self-guided intervention with no therapist support, and whether this has consequences for program outcomes. Objective: This study reports findings of a secondary analysis of data from 90 participants with mild-to-moderate depression, anxiety, and/or stress who used a fully automated mobile phone and Web-based cognitive behavior therapy (CBT) intervention called “myCompass” in a recent randomized controlled trial (RCT). Methods: Symptoms, functioning, and positive well-being were assessed at baseline and post-intervention using the Depression, Anxiety and Stress Scale (DASS), the Work and Social Adjustment Scale (WSAS), and the Mental Health Continuum-Short Form (MHC-SF). Therapeutic alliance was measured at post-intervention using the Agnew Relationship Measure (ARM), and this was supplemented with qualitative data obtained from 16 participant interviews. Extent of participant engagement with the program was also assessed. Results: Mean ratings on the ARM subscales were above the neutral midpoints, and the interviewees provided rich detail of a meaningful and collaborative therapeutic relationship with the myCompass program. Whereas scores on the ARM subscales did not correlate with treatment outcomes, participants’ ratings of the quality of their emotional connection with the program correlated significantly and positively with program logins, frequency of self-monitoring, and number of treatment modules completed (r values between .32-.38, P≤.002). The alliance (ARM) subscales measuring perceived empowerment (r=.26, P=.02) and perceived freedom to self-disclose (r=.25, P=.04) also correlated significantly in a positive direction with self-monitoring frequency. Conclusions: Quantitative and qualitative findings from this analysis showed that a positive therapeutic alliance can develop in the Internet environment in the absence of therapist support, and that components of the alliance may have implications for program usage. Further investigation of alliance features in the Internet environment and the consequences of these for treatment outcomes and user engagement is warranted. Trial Registration: Australian New Zealand Clinical Trials Registry Number (ACTRN): 12610000625077; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335772&isReview=true (Archived by WebCite at http://www.webcitation.org/6efAc5xj4). %M 26917096 %R 10.2196/mental.4656 %U http://mental.jmir.org/2016/1/e10/ %U https://doi.org/10.2196/mental.4656 %U http://www.ncbi.nlm.nih.gov/pubmed/26917096 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 3 %P e22 %T Feasibility of "CopeSmart": A Telemental Health App for Adolescents %A Kenny,Rachel %A Dooley,Barbara %A Fitzgerald,Amanda %+ School of Psychology, University College Dublin, Belfield, Dublin 4, , Ireland, 353 1 7168147, rachel.kenny.3@ucdconnect.ie %K adolescents %K emotional self-monitoring %K feasibility %K mobile apps %K positive mental health %D 2015 %7 10.08.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Early intervention is important in order to improve mental health outcomes for young people. Given the recent rise in mobile phone ownership among adolescents, an innovative means of delivering such intervention is through the use of mobile phone applications (apps). Objective: The aim of this study was to evaluate the feasibility of “CopeSmart”, a telemental health app developed to foster positive mental health in adolescents through emotional self-monitoring and the promotion of positive coping strategies. Methods: Forty-three adolescents (88% female) aged 15-17 years downloaded the app and used it over a one-week period. They then completed self-report questionnaires containing both open-ended and closed-ended questions about their experiences of using the app. The app itself captured data related to user engagement. Results: On average participants engaged with the app on 4 of the 7 days within the intervention period. Feedback from users was reasonably positive, with 70% of participants reporting that they would use the app again and 70% reporting that they would recommend it to a friend. Thematic analysis of qualitative data identified themes pertaining to users’ experiences of the app, which were both positive (eg, easy to use, attractive layout, emotional self-monitoring, helpful information, notifications, unique) and negative (eg, content issues, did not make user feel better, mood rating issues, password entry, interface issues, engagement issues, technical fixes). Conclusions: Overall findings suggest that telemental health apps have potential as a feasible medium for promoting positive mental health, with the majority of young people identifying such technologies as at least somewhat useful and displaying a moderate level of engagement with them. Future research should aim to evaluate the efficacy of such technologies as tools for improving mental health outcomes in young people. %M 26552425 %R 10.2196/mental.4370 %U http://mental.jmir.org/2015/3/e22/ %U https://doi.org/10.2196/mental.4370 %U http://www.ncbi.nlm.nih.gov/pubmed/26552425 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 1 %N 1 %P e3 %T Global Outreach of a Locally-Developed Mobile Phone App for Undergraduate Psychiatry Education %A Zhang,Melvyn WB %A Cheok,Christopher CS %A Ho,Roger CM %+ National Healthcare Group, Level 9, Department of Psychological Medicine, National University Healthcare Systems (NUHS) Tower Block 5 Lower Kent Ridge Road, Singapore, 119054, Singapore, 65 7725555, melvynzhangweibin@gmail.com %K psychiatry %K education %K eLearning %K mobile phone apps %K mobile phones %K feasibility %K proof of concept %D 2015 %7 08.06.2015 %9 Original Paper %J JMIR Medical Education %G English %X Background: Over the past decade, there have been massive developments in both Web-based and mobile phone technologies. Mobile phones are well accepted by students, trainees, and doctors. A review of the current literature has identified the following specialties that have used mobile phones in education: pediatrics, ophthalmology, nephrology, plastic surgery, orthopedics, pharmacology, and urology. However, to date, there are no published papers examining the application of the latest mobile phone technologies for psychiatry education internationally. Objectives: The main objectives of this study are (1) to determine the feasibility and receptiveness of a locally-developed psychiatry mobile phone app and user perspectives (both quantitative and qualitative) towards it, and (2) to determine the receptiveness of a locally-developed app for psychiatry education internationally. Methods: A Web-based app that contained textbook contents, videos, and quizzes was developed using HTML5 technologies in 2012. Native apps were subsequently developed in 2013. Information about the apps was disseminated locally to Singaporean medical students, but the respective native apps were made available on the app stores. A user perspective survey was conducted locally to determine student’s perception of the app. Results: From the inception of the app until the time of preparation of this manuscript, there have been a cumulative total of 28,500 unique visits of the responsive HTML5 Web-based mobile phone app. There have been a cumulative total of 2200 downloads of the Mastering Psychiatry app from the Apple app store and 7000 downloads of the same app from the Android app store. The initial user perspective survey conducted locally highlighted that approximately a total of 95.2% (177/186) of students felt that having a psychiatry mobile phone app was deemed to be useful. Further chi-squared analysis demonstrated that there was a significant difference between males and females in their perception of having textbook contents in the mobile phone app (χ24=12.9, P=.0012). Conclusions: To the best of our knowledge, this is the first study to demonstrate the feasibility and global acceptance of a local, self-designed educational app for psychiatry education. Whilst the current research has managed to demonstrate the feasibility and acceptance of such an app, future studies would be warranted to look, in-depth, into whether there are cultural differences in terms of perceptions towards having such an app in psychiatry and what contents different cultures and cohorts of students might want within an app. %M 27731838 %R 10.2196/mededu.4179 %U https://medinform.jmir.org/2015/1/e3/ %U https://doi.org/10.2196/mededu.4179 %U http://www.ncbi.nlm.nih.gov/pubmed/27731838 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e10 %T Mental Health Mobile Apps: From Infusion to Diffusion in the Mental Health Social System %A East,Marlene Lynette %A Havard,Byron C %+ East Counseling Services, Inc., Private Counseling Practice, 6521 N Lagoon Dr., Panama City Beach, FL, 32408-3730, United States, 1 850 233 6623, marleneeast@yahoo.com %K clinical efficacy %K counselors %K ethical codes %K innovation diffusion %K instructional technology %K mental health %K mHealth %K mobile health %K smartphone %D 2015 %7 31.03.2015 %9 Viewpoint %J JMIR Mental Health %G English %X The roles of mental health educators and professionals in the diffusion of mental health mobile apps are addressed in this viewpoint article. Mental health mobile apps are emerging technologies that fit under the broad heading of mobile health (mHealth). mHealth, encompassed within electronic health (eHealth), reflects the use of mobile devices for the practice of public health. Well-designed mental health mobile apps that present content in interactive, engaging, and stimulating ways can promote cognitive learning, personal growth, and mental health enhancement. As key influencers in the mental health social system, counselor educators and professional associations may either help or hinder diffusion of beneficial mHealth technologies. As mental health mobile apps move towards ubiquity, research will continue to be conducted. The studies published thus far, combined with the potential of mental health mobile apps for learning and personal growth, offer enough evidence to compel mental health professionals to infuse these technologies into education and practice. Counselor educators and professional associations must use their influential leadership roles to train students and practitioners in how to research, evaluate, and integrate mental health mobile apps into practice. The objectives of this article are to (1) increase awareness of mHealth and mental health mobile apps, (2) demonstrate the potential for continued growth in mental health mobile apps based on technology use and acceptance theory, mHealth organizational initiatives, and evidence about how humans learn, (3) discuss evidence-based benefits of mental health mobile apps, (4) examine the current state of mHealth diffusion in the mental health profession, and (5) offer solutions for impelling innovation diffusion by infusing mental health mobile apps into education, training, and clinical settings. This discussion has implications for counselor educators, mental health practitioners, associations, continuing education providers, and app developers. %M 26543907 %R 10.2196/mental.3954 %U http://mental.jmir.org/2015/1/e10/ %U https://doi.org/10.2196/mental.3954 %U http://www.ncbi.nlm.nih.gov/pubmed/26543907 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e8 %T Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire-9 (PHQ-9) Depressive Symptoms in Patients With Major Depressive Disorder %A Torous,John %A Staples,Patrick %A Shanahan,Meghan %A Lin,Charlie %A Peck,Pamela %A Keshavan,Matcheri %A Onnela,Jukka-Pekka %+ Harvard Longwood Psychiatry Residency Training Prorgam, 330 Brookline Ave, Boston, MA, 02115, United States, 1 (617) 667 6700 ext 11315, jtorous@bidmc.harvard.edu %K medical informatics %K mobile health %K depression %D 2015 %7 24.03.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Accurate reporting of patient symptoms is critical for diagnosis and therapeutic monitoring in psychiatry. Smartphones offer an accessible, low-cost means to collect patient symptoms in real time and aid in care. Objective: To investigate adherence among psychiatric outpatients diagnosed with major depressive disorder in utilizing their personal smartphones to run a custom app to monitor Patient Health Questionnaire-9 (PHQ-9) depression symptoms, as well as to examine the correlation of these scores to traditionally administered (paper-and-pencil) PHQ-9 scores. Methods: A total of 13 patients with major depressive disorder, referred by their clinicians, received standard outpatient treatment and, in addition, utilized their personal smartphones to run the study app to monitor their symptoms. Subjects downloaded and used the Mindful Moods app on their personal smartphone to complete up to three survey sessions per day, during which a randomized subset of PHQ-9 symptoms of major depressive disorder were assessed on a Likert scale. The study lasted 29 or 30 days without additional follow-up. Outcome measures included adherence, measured by the percentage of completed survey sessions, and estimates of daily PHQ-9 scores collected from the smartphone app, as well as from the traditionally administered PHQ-9. Results: Overall adherence was 77.78% (903/1161) and varied with time of day. PHQ-9 estimates collected from the app strongly correlated (r=.84) with traditionally administered PHQ-9 scores, but app-collected scores were 3.02 (SD 2.25) points higher on average. More subjects reported suicidal ideation using the app than they did on the traditionally administered PHQ-9. Conclusions: Patients with major depressive disorder are able to utilize an app on their personal smartphones to self-assess their symptoms of major depressive disorder with high levels of adherence. These app-collected results correlate with the traditionally administered PHQ-9. Scores recorded from the app may potentially be more sensitive and better able to capture suicidality than the traditional PHQ-9. %M 26543914 %R 10.2196/mental.3889 %U http://mental.jmir.org/2015/1/e8/ %U https://doi.org/10.2196/mental.3889 %U http://www.ncbi.nlm.nih.gov/pubmed/26543914 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e1 %T Client Perceptions of the Mental Health Engagement Network: A Secondary Analysis of an Intervention Using Smartphones and Desktop Devices for Individuals Experiencing Mood or Psychotic Disorders in Canada %A Forchuk,Cheryl %A Donelle,Lorie %A Ethridge,Paige %A Warner,Laura %+ Lawson Health Research Institute, Suite 102, 750 Baseline Road East, London, ON, N6C 2R5, Canada, 1 519 685 8500 ext 77034, cforchuk@uwo.ca %K mental health %K mobile health %K eHealth %K personal health records %K mood disorders %K psychotic disorders %K mental disorders %D 2015 %7 21.01.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: The use of innovative technologies in mental health care has the potential to improve system efficiency, enhance quality of care, and increase patient engagement. The Mental Health Engagement Network (MHEN) project developed, delivered, and evaluated an interactive Web-based personal health record, the Lawson SMART Record (LSR), to assist mental health clients in managing their care and connecting with their care providers. This paper presents a secondary analysis of data collected in the MHEN project regarding clients’ perceptions of technology and the use of these technologies in their care. Objective: We aimed to answer six questions: (1) What is the level of comfort with technology within a sample of individuals experiencing mood or psychotic disorders? (2) How easy to use and helpful are the MHEN technologies from the perspective of individuals experiencing a mental illness? (3) Are there differences in how helpful or useful individuals find the smartphone compared to the LSR? (4) Are there specific functions of MHEN technologies (eg, reminders for medications or appointments) that are more valued than others? (5) What are the other ways that individuals are using MHEN technologies in their daily lives? (6) How likely are individuals to be able to retain and maintain their smartphone? Methods: Mental health clients aged 18-80 (N=400) and diagnosed with a mood or psychotic disorder were provided with a smartphone (iPhone 4S) and participating care providers (n=52) were provided with a tablet (iPad) in order to access and engage with the LSR. A delayed implementation design with mixed methods was used. Survey and interview data were collected over the course of 18 months through semistructured interviews conducted by experienced research assistants every 6 months post-implementation of the intervention. Paired t tests were used to determine differences between 6 and 12-month data for perceptions of the MHEN technologies. A paired t test was used to examine whether differences existed between perceptions of the smartphone and the LSR at 12 months post-implementation. Results: Due to dropout or loss of contact, 394 out of 400 individuals completed the study. At the end of the study, 52 devices were lost or unusable. Prior to the intervention, participants reported being comfortable using technology. Perceptions of the MHEN technologies and their functions were generally positive. Positive perceptions of the smartphone increased over time (P=.002), while positive perceptions of the LSR decreased over time (P<.001). Conclusions: Quantitative and qualitative findings from this analysis demonstrated that these technologies positively impacted the lives of individuals experiencing severe mental illnesses and dispeled some of the myths regarding retention of technology among marginalized populations. This secondary analysis supported the acceptability of using mental health technologies within this population and provided considerations for future development. Trial Registration: ClinicalTrials.gov NCT01473550; http://clinicaltrials.gov/show/NCT01473550 (Archived by WebCite at http://www.webcitation.org/6SLNcoKb8). %M 26543906 %R 10.2196/mental.3926 %U http://mental.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/mental.3926 %U http://www.ncbi.nlm.nih.gov/pubmed/26543906 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 1 %N 1 %P e5 %T Patient Smartphone Ownership and Interest in Mobile Apps to Monitor Symptoms of Mental Health Conditions: A Survey in Four Geographically Distinct Psychiatric Clinics %A Torous,John %A Chan,Steven Richard %A Yee-Marie Tan,Shih %A Behrens,Jacob %A Mathew,Ian %A Conrad,Erich J %A Hinton,Ladson %A Yellowlees,Peter %A Keshavan,Matcheri %+ Harvard Longwood Psychiatry Residency Training Program, 330 Brookline Ave, Boston, MA, 02115, United States, 1 6176674630, jtorous@bidmc.harvard.edu %K psychiatry %K mobile health %K smartphone %D 2014 %7 23.12.2014 %9 Original Paper %J JMIR Mental Health %G English %X Background: Despite growing interest in mobile mental health and utilization of smartphone technology to monitor psychiatric symptoms, there remains a lack of knowledge both regarding patient ownership of smartphones and their interest in using such to monitor their mental health. Objective: To provide data on psychiatric outpatients’ prevalence of smartphone ownership and interest in using their smartphones to run applications to monitor their mental health. Methods: We surveyed 320 psychiatric outpatients from four clinics around the United States in order to capture a geographically and socioeconomically diverse patient population. These comprised a state clinic in Massachusetts (n=108), a county clinic in California (n=56), a hybrid public and private clinic in Louisiana (n=50), and a private/university clinic in Wisconsin (n=106). Results: Smartphone ownership and interest in utilizing such to monitor mental health varied by both clinic type and age with overall ownership of 62.5% (200/320), which is slightly higher than the average United States’ rate of ownership of 58% in January 2014. Overall patient interest in utilizing smartphones to monitor symptoms was 70.6% (226/320). Conclusions: These results suggest that psychiatric outpatients are interested in using their smartphones to monitor their mental health and own the smartphones capable of running mental healthcare related mobile applications. %M 26543905 %R 10.2196/mental.4004 %U http://mental.jmir.org/2014/1/e5/ %U https://doi.org/10.2196/mental.4004 %U http://www.ncbi.nlm.nih.gov/pubmed/26543905 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 4 %P e53 %T Enabling Psychiatrists to be Mobile Phone App Developers: Insights Into App Development Methodologies %A Zhang,Melvyn WB %A Tsang,Tammy %A Cheow,Enquan %A Ho,Cyrus SH %A Yeong,Ng Beng %A Ho,Roger CM %+ National Healthcare Group, 10 Buangkok Green Medical Park, Singapore, 539747, Singapore, 65 63892000, melvynzhangweibin@gmail.com %K smartphone application %K mobile application %K creation %D 2014 %7 11.11.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: The use of mobile phones, and specifically smartphones, in the last decade has become more and more prevalent. The latest mobile phones are equipped with comprehensive features that can be used in health care, such as providing rapid access to up-to-date evidence-based information, provision of instant communications, and improvements in organization. The estimated number of health care apps for mobile phones is increasing tremendously, but previous research has highlighted the lack of critical appraisal of new apps. This lack of appraisal of apps has largely been due to the lack of clinicians with technical knowledge of how to create an evidence-based app. Objective: We discuss two freely available methodologies for developing Web-based mobile phone apps: a website builder and an app builder. With these, users can program not just a Web-based app, but also integrate multimedia features within their app, without needing to know any programming language. Methods: We present techniques for creating a mobile Web-based app using two well-established online mobile app websites. We illustrate how to integrate text-based content within the app, as well as integration of interactive videos and rich site summary (RSS) feed information. We will also briefly discuss how to integrate a simple questionnaire survey into the mobile-based app. A questionnaire survey was administered to students to collate their perceptions towards the app. Results: These two methodologies for developing apps have been used to convert an online electronic psychiatry textbook into two Web-based mobile phone apps for medical students rotating through psychiatry in Singapore. Since the inception of our mobile Web-based app, a total of 21,991 unique users have used the mobile app and online portal provided by WordPress, and another 717 users have accessed the app via a Web-based link. The user perspective survey results (n=185) showed that a high proportion of students valued the textbook and objective structured clinical examination videos featured in the app. A high proportion of students concurred that a self-designed mobile phone app would be helpful for psychiatry education. Conclusions: These methodologies can enable busy clinicians to develop simple mobile Web-based apps for academic, educational, and research purposes, without any prior knowledge of programming. This will be beneficial for both clinicians and users at large, as there will then be more evidence-based mobile phone apps, or at least apps that have been appraised by a clinician. %M 25486985 %R 10.2196/mhealth.3425 %U http://mhealth.jmir.org/2014/4/e53/ %U https://doi.org/10.2196/mhealth.3425 %U http://www.ncbi.nlm.nih.gov/pubmed/25486985 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e2 %T Smartphone Ownership and Interest in Mobile Applications to Monitor Symptoms of Mental Health Conditions %A Torous,John %A Friedman,Rohn %A Keshavan,Matcheri %+ Harvard Longwod Psychiatry Residency Training Prorgam, 330 Brookline Ave, Boston, MA, 02215, United States, 1 617 667 4630, jtorous@bidmc.harvard.edu %K psychiatry %K mobile %K smartphone %K depression %K technology %K applications %D 2014 %7 21.01.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Patient retrospective recollection is a mainstay of assessing symptoms in mental health and psychiatry. However, evidence suggests that these retrospective recollections may not be as accurate as data collection though the experience sampling method (ESM), which captures patient data in “real time” and “real life.” However, the difficulties in practical implementation of ESM data collection have limited its impact in psychiatry and mental health. Smartphones with the capability to run mobile applications may offer a novel method of collecting ESM data that may represent a practical and feasible tool for mental health and psychiatry. Objective: This paper aims to provide data on psychiatric patients’ prevalence of smartphone ownership, patterns of use, and interest in utilizing mobile applications to monitor their mental health conditions. Methods: One hundred psychiatric outpatients at a large urban teaching hospital completed a paper-and-pencil survey regarding smartphone ownership, use, and interest in utilizing mobile applications to monitor their mental health condition. Results: Ninety-seven percent of patients reported owning a phone and 72% reported that their phone was a smartphone. Patients in all age groups indicated greater than 50% interest in using a mobile application on a daily basis to monitor their mental health condition. Conclusions: Smartphone and mobile applications represent a practical opportunity to explore new modalities of monitoring, treatment, and research of psychiatric and mental health conditions. %M 25098314 %R 10.2196/mhealth.2994 %U http://mhealth.jmir.org/2014/1/e2/ %U https://doi.org/10.2196/mhealth.2994 %U http://www.ncbi.nlm.nih.gov/pubmed/25098314 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 1 %N 2 %P e8 %T Mobile.net: Mobile Telephone Text Messages to Encourage Adherence to Medication and to Follow up With People With Psychosis: Methods and Protocol for a Multicenter Randomized Controlled Two-Armed Trial %A Välimäki,Maritta %A Hätönen,Heli %A Adams,Clive E %+ Department of Nursing Science, University of Turku and Southwest Hospital District, Lemminkäisenkatu 1, University of Turku, 20014, Finland, 358 406890546, mava@utu.fi %K Adherence %K text messages %K psychosis %D 2012 %7 02.08.2012 %9 Protocol %J JMIR Res Protoc %G English %X Background: Schizophrenia is a high-cost, chronic, serious mental illness. There is a clear need to improve treatments and expand access to care for persons with schizophrenia, but simple, tailored interventions are missing. Objective: To evaluate the impact of tailored mobile telephone text messages to encourage adherence to medication and to follow up with people with psychosis at 12 months. Methods: Mobile.Net is a pragmatic randomized trial with inpatient psychiatric wards allocated to two parallel arms. The trial will include 24 sites and 45 psychiatric hospital wards providing inpatient care in Finland. The participants will be adult patients aged 18–65 years, of either sex, with antipsychotic medication (Anatomical Therapeutic Chemical classification 2011) on discharge from a psychiatric hospital, who have a mobile phone, are able to use the Finnish language, and are able to give written informed consent to participate in the study. The intervention group will receive semiautomatic system (short message service [SMS]) messages after they have been discharged from the psychiatric hospital. Patients will choose the form, content, timing, and frequency of the SMS messages related to their medication, keeping appointments, and other daily care. SMS messages will continue to the end of the study period (12 months) or until participants no longer want to receive the messages. Patients will be encouraged to contact researchers if they feel that they need to adjust the message in any way. At all times, both groups will receive usual care at the discretion of their team (psychiatry and nursing). The primary outcomes are service use and healthy days by 12 months based on routine data (admission to a psychiatric hospital, time to next hospitalization, time in hospital during this year, and healthy days). The secondary outcomes are service use, coercive measures, medication, adverse events, satisfaction with care, the intervention, and the trial, social functioning, and economic factors. Data will be collected 12 months after baseline. The outcomes are based on the national health registers and patients’ subjective evaluations. The primary analysis will be by intention-to-treat. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN): 27704027; http://www.controlled-trials.com/ISRCTN27704027 (Archived by WebCite at http://www.webcitation.org/69FkM4vcq) %M 23611874 %R 10.2196/resprot.2136 %U http://www.researchprotocols.org/2012/2/e8/ %U https://doi.org/10.2196/resprot.2136 %U http://www.ncbi.nlm.nih.gov/pubmed/23611874