Article

The efficacy of app‐supported smartphone interventions for mental health problems: a meta‐analysis of randomized controlled trials

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Abstract

Although impressive progress has been made toward developing empirically‐supported psychological treatments, the reality remains that a significant proportion of people with mental health problems do not receive these treatments. Finding ways to reduce this treatment gap is crucial. Since app‐supported smartphone interventions are touted as a possible solution, access to up‐to‐date guidance around the evidence base and clinical utility of these interventions is needed. We conducted a meta‐analysis of 66 randomized controlled trials of app‐supported smartphone interventions for mental health problems. Smartphone interventions significantly outperformed control conditions in improving depressive (g=0.28, n=54) and generalized anxiety (g=0.30, n=39) symptoms, stress levels (g=0.35, n=27), quality of life (g=0.35, n=43), general psychiatric distress (g=0.40, n=12), social anxiety symptoms (g=0.58, n=6), and positive affect (g=0.44, n=6), with most effects being robust even after adjusting for various possible biasing factors (type of control condition, risk of bias rating). Smartphone interventions conferred no significant benefit over control conditions on panic symptoms (g=–0.05, n=3), post‐traumatic stress symptoms (g=0.18, n=4), and negative affect (g=–0.08, n=5). Studies that delivered a cognitive behavior therapy (CBT)‐based app and offered professional guidance and reminders to engage produced larger effects on multiple outcomes. Smartphone interventions did not differ significantly from active interventions (face‐to‐face, computerized treatment), although the number of studies was low (n≤13). The efficacy of app‐supported smartphone interventions for common mental health problems was thus confirmed. Although mental health apps are not intended to replace professional clinical services, the present findings highlight the potential of apps to serve as a cost‐effective, easily accessible, and low intensity intervention for those who cannot receive standard psychological treatment.

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... Smartphone-based interventions have shown positive effects on a broad range of outcomes, such as depressive symptoms, anxiety symptoms, stress levels, and quality of life (Linardon et al., 2019). Research has started to link these effects to specific components used in applications. ...
... Receiving personalized feedback on progress has also been associated with positive effects (Fanning et al., 2017;Schoeppe et al., 2016). Similarly, a meta-analysis examining components of smartphone-based interventions for mental health problems found that push notifications as reminders to use the application, and personalized feedback and supportive messages, were related to stronger intervention effects (Linardon et al., 2019). ...
... Personalized feedback and supportive messages, which are partially based on participants' responses in the application, are communicated via the future self, such as the advice they formulate for their present self from the perspective of their future self. Although the feedback and support messages are not provided by a therapist, automatically generated personalized support has been shown to generate equivalent effects (Linardon et al., 2019). ...
Article
Full-text available
Background Short-term mindsets interfere with the consideration of future consequences and therefore predict negative behaviors. We developed a smartphone-based intervention aiming to increase a future-oriented mindset and personal goal attainment by strengthening future self-identification and stimulating episodic future thinking. The aims of the study are 1) to examine users' experiences with the application and their treatment adherence, 2) to examine the effectiveness of the intervention, and 3) to explore which intervention modules generate the strongest changes in key outcomes. Methods First-year university students (N = 166) will be randomly assigned to two conditions: 1) the smartphone-based intervention, or 2) a goal-setting control group. The intervention consists of three week-long modules. Data will be collected at the start of the intervention, at weekly intervals during the intervention, immediately after the intervention, and at 3-month follow-up (and at parallel time points for the control group). We will assess users' experiences, application usage data, primary intervention outcomes (e.g., self-defeating behavior, future orientation, future self-identification), and secondary intervention outcomes (e.g., psychosocial wellbeing, self-efficacy). Discussion The study will provide information about users' experiences with the application, the intervention's general effectiveness, and which intervention modules show most promise. This information will be used to further develop the application and optimize this novel intervention. Trial registration The trial is registered in the Netherlands Trial Register (number: NL9671) on 16 August 2021.
... Emerging in the late 1980s (Ghosh et al., 1988), the first versions of digital interventions were little more than a therapeutic manual delivered on a computer via a CD-ROM (Selmi et al., 1990). With the development and widespread adoption of the Internet in the 1990s, interventions have evolved considerably to embrace the latest developments in technology (Andersson, 2016;Andersson et al., 2019), with smartphone-delivered interventions now becoming one of the most popular methods of accessing care (Linardon et al., 2019;Weisel et al., 2019). ...
... 6 into a waitlist until pre-and postmeasures were collected). A more recent review by Linardon et al. (2019) found that smartphonebased interventions significantly outperformed control conditions in improving depressive symptoms when active and inactive control conditions were combined (g = .28), yet no significant difference was found when smartphone apps were compared against active control conditions alone. ...
... The search string was validated using a sample set of articles from previous meta-analyses (see Appendix A in the online supplemental materials). Second, we checked the reference lists of relevant existing systematic reviews and meta-analyses Barak et al., 2008;Baumeister et al., 2014;Carlbring et al., 2018;Cuijpers, Geraedts, et al., 2011;Cuijpers, van Straten, Warmerdam, et al., 2008;Firth, Torous, Nicholas, Carney, Pratap, et al., 2017;Karyotaki et al., 2017;Karyotaki, Ebert, et al., 2018;Königbauer et al., 2017;Linardon et al., 2019;Spek et al., 2007;Weisel et al., 2019). Third and last, we conducted backward searches in all included articles. ...
Article
The high global prevalence of depression, together with the recent acceleration of remote care owing to the COVID-19 pandemic, has prompted increased interest in the efficacy of digital interventions for the treatment of depression. We provide a summary of the latest evidence base for digital interventions in the treatment of depression based on the largest study sample to date. A systematic literature search identified 83 studies (N = 15,530) that randomly allocated participants to a digital intervention for depression versus an active or inactive control condition. Overall heterogeneity was very high (I2 = 84%). Using a random-effects multilevel metaregression model, we found a significant medium overall effect size of digital interventions compared with all control conditions (g = .52). Subgroup analyses revealed significant differences between interventions and different control conditions (WLC: g = .70; attention: g = .36; TAU: g = .31), significantly higher effect sizes in interventions that involved human therapeutic guidance (g = .63) compared with self-help interventions (g = .34), and significantly lower effect sizes for effectiveness trials (g = .30) compared with efficacy trials (g = .59). We found no significant difference in outcomes between smartphone-based apps and computer- and Internet-based interventions and no significant difference between human-guided digital interventions and face-to-face psychotherapy for depression, although the number of studies in both comparisons was low. Findings from the current meta-analysis provide evidence for the efficacy and effectiveness of digital interventions for the treatment of depression for a variety of populations. However, reported effect sizes may be exaggerated because of publication bias, and compliance with digital interventions outside of highly controlled settings remains a significant challenge. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... There is good reason for the enthusiasm over app-based mental health treatments and skills-based approaches such as cognitive behavioral therapy (CBT) in particular that ostensibly lend themselves well to structured, standardized, self-paced platforms [4]. Smartphone-delivered therapies offer clear potential for addressing some of the most critical barriers to accessing mental health care, including prohibitive costs of treatment [5,6], patient-level logistical barriers (eg, need for time off work, transportation, and childcare) [7], and lack of access to providers who offer frontline evidence-based interventions such as CBT [8]. ...
... Coaches may also enhance the potency of app-based CBT, by delivering some of the treatment content, helping to personalize content for individual users, correcting how users implement skills, or answering questions. A meta-analysis of app-based mental health treatment efficacy showed that apps that offered coached guidance had larger effect sizes across several efficacy outcomes [4]. Altogether, both expert opinion [22] and initial, early evidence underscore the potentially critical role that coaches may play in enhancing the value of app-based CBT. ...
... Qualitative data did suggest that users largely appreciate having access to a coach, describing this human element as helpful and even critical to their experience. This aligns with a number of recent reviews and meta-analyses finding that guided app-based treatments-or those with some human support-generally have better completion rates and treatment outcomes than self-guided ones [4,96,97]. However, when we then examined articles that present direct comparisons of guided versus unguided versions of the same app-based treatment or considered level of coaching within a trial, the quantitative data offered a murkier story. ...
Preprint
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. CLINICALTRIAL
... There is good reason for the enthusiasm over app-based mental health treatments and skills-based approaches such as cognitive behavioral therapy (CBT) in particular that ostensibly lend themselves well to structured, standardized, self-paced platforms [4]. Smartphone-delivered therapies offer clear potential for addressing some of the most critical barriers to accessing mental health care, including prohibitive costs of treatment [5,6], patient-level logistical barriers (eg, need for time off work, transportation, and childcare) [7], and lack of access to providers who offer frontline evidence-based interventions such as CBT [8]. ...
... Coaches may also enhance the potency of app-based CBT, by delivering some of the treatment content, helping to personalize content for individual users, correcting how users implement skills, or answering questions. A meta-analysis of app-based mental health treatment efficacy showed that apps that offered coached guidance had larger effect sizes across several efficacy outcomes [4]. Altogether, both expert opinion [22] and initial, early evidence underscore the potentially critical role that coaches may play in enhancing the value of app-based CBT. ...
... Qualitative data did suggest that users largely appreciate having access to a coach, describing this human element as helpful and even critical to their experience. This aligns with a number of recent reviews and meta-analyses finding that guided app-based treatments-or those with some human support-generally have better completion rates and treatment outcomes than self-guided ones [4,96,97]. However, when we then examined articles that present direct comparisons of guided versus unguided versions of the same app-based treatment or considered level of coaching within a trial, the quantitative data offered a murkier story. ...
Article
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.
... Inconsistencies in the literature on mobile health interventions are also reflected in metaanalyses. Examining different portions of the literature have resulted in some meta-analysis of mobile health apps to conclude that self-help apps "cannot be recommended" [20] while others that these apps may "serve as a cost-effective, easily accessible, and low intensity interventions" [21]. Meta-reviews (i.e., systematic reviews of meta-analyses) can be particularly helpful in instances like this [22]. ...
... Studies were eligible if they (1) reported a meta-analytically derived effect size related to mobile phone-based interventions (2) on a mental health outcome (e.g., psychiatric symptoms, stress, quality of life, addictive behaviors that are included in the DSM-5 [33] such as alcohol and tobacco use) (3) based on a minimum of four randomized controlled trials (RCTs) [34] (4) using comparison conditions that could be categorized as inactive, active, non-specific, specific, or adjunct (i.e., added to an active treatment) [21]. We planned a priori to avoid combining across comparison condition types as these estimates are ambiguous to interpret and can lead to misleading results (e.g., interventions tested using more rigorous specific active control conditions appear less effective [35]). ...
... No restrictions were made based on other PICO categories. Interventions could include components beyond mobile phones (e.g., smartphones as adjunct intervention [21]) but must have included a mobile phone component (e.g., telephone-based interventions were not eligible). ...
Article
Full-text available
Mobile phone-based interventions have been proposed as a means for reducing the burden of disease associated with mental illness. While numerous randomized controlled trials and meta-analyses have investigated this possibility, evidence remains unclear. We conducted a systematic meta-review of meta-analyses examining mobile phone-based interventions tested in randomized controlled trials. We synthesized results from 14 meta-analyses representing 145 randomized controlled trials and 47,940 participants. We identified 34 effect sizes representing unique pairings of participants, intervention, comparisons, and outcome (PICO) and graded the strength of the evidence as using umbrella review methodology. We failed to find convincing evidence of efficacy (i.e., n > 1000, p < 10 ⁻⁶ , I ² < 50%, absence of publication bias); publication bias was rarely assessed for the representative effect sizes. Eight effect sizes provided highly suggestive evidence (i.e., n > 1000, p < 10 ⁻⁶ ), including smartphone interventions outperforming inactive controls on measures of psychological symptoms and quality of life ( d s = 0.32 to 0.47) and text message-based interventions outperforming non-specific controls and active controls for smoking cessation ( d s = 0.31 and 0.19, respectively). The magnitude of effects and strength of evidence tended to diminish as comparison conditions became more rigorous (i.e., inactive to active, non-specific to specific). Four effect sizes provided suggestive evidence, 14 effect sizes provided weak evidence, and eight effect sizes were non-significant. Despite substantial heterogeneity, no moderators were identified. Adverse effects were not reported. Taken together, results support the potential of mobile phone-based interventions and highlight key directions to guide providers, policy makers, clinical trialists, and meta-analysts working in this area.
... In recent years, numerous app-based interventions for depression have been evaluated in various populations (Kerst et al., 2020;Linardon et al., 2019). However, there are few studies with non-professional caregivers. ...
... These results are consistent with previous studies on indicated prevention of depression in caregivers (Vázquez et al., 2013(Vázquez et al., , 2014, and reviews and meta-analyses that evaluated the efficacy of apps for depression in various populations (e.g. Kerst et al., 2020;Linardon et al., 2019). The effect sizes were moderate in comparison between the group that received the app without conference calls (CBIA) and the other two groups (d = 0.75 for CBIA vs ACG, and d = 0.77 for CBIA + CC vs CBIA); and large between the app + conference call group (CBIA + CC) and the control group (d = 1.52). ...
... The large effect size for the comparison between CBIA + CC and ACG is congruent with the results of previous studies on indicated prevention of depression in caregivers (Vázquez et al., 2013, Vázquez et al., 2014; but superior than the small effect sizes found in a study that assessed an internet-based intervention for caregivers (Blom et al., 2015) and in reviews and meta-analyses evaluating apps for depression (e.g. Linardon et al., 2019). One factor that may partially explain the greater effectiveness of the CBIA app is that it was adapted from a prevention intervention based on a theoretical model and refined and tested in a clinical context in other formats, consistent with the research development stages by the National Institutes of Health stage model (Onken et al., 2014). ...
Article
Objectives: The main objective of the current study was to evaluate the feasibility and acceptability of a cognitive-behavioral prevention intervention administered through a smartphone app in non-professional caregivers with symptoms of depression. The secondary objective was to make a preliminary evaluation of its effectiveness either alone or supplemented with telephone conference calls. Methods: Eighty-seven participants (Mage = 51.8 years) were randomly assigned to an app-based cognitive-behavioral intervention (CBIA; n = 29), CBIA supplemented with telephone conference calls (CBIA + CC; n = 28), or an attention control group (ACG; n = 30). The participants for both interventions received five cognitive-behavioral modules through the app, and those in CBIA + CC an additional 30-minute phone call in each module. Results: 3.4% of caregivers dropped out. In all groups, the number of modules completed was high. Participants completed a high percentage of the homework and were highly satisfied with both CBIA and CBIA + CC. At post-intervention, there was a lower incidence of depression and depressive symptoms for CBIA + CC compared with CBIA, and for CBIA and CBIA + CC compared with ACG. Conclusion: The results supported the feasibility and acceptability of the cognitive-behavioral intervention, and demonstrated that telephone contact improves its effectiveness.
... Wirksamkeit Die Wirksamkeit von Internetprogrammen und Smartphone-Apps bei Angststörungen ist mittlerweile gut belegt (Domhardt, Gesslein et al. 2019, Linardon, Cuijpers et al. 2019, Lecomte, Potvin et al. 2020. Apps für Angstsymptome scheinen einen klaren Nutzen von kleiner bis mittlerer Effektgrösse zu bringen (Lecomte, Potvin et al. 2020). ...
... Wirksamkeit Apps, welche auf die Reduzierung depressiver Symptome zielen, sind auf Grundlage der bislang vorliegenden Meta-Analysen wirksam und konnten signifikante Effekte kleiner bis mittlerer Grössenordnung im Vergleich zur Warteliste erzielen (Linardon, Cuijpers et al. 2019, Lecomte, Potvin et al. 2020. Verglichen mit aktiven Kontrollgruppen waren die Effekte klein aber dennoch signifikant, bei insgesamt guter Studienqualität (Lecomte, Potvin et al. 2020). ...
Article
Full-text available
Hintergrund: mHealth Applikationen eröffnen vielfältige Möglichkeiten zur individualisierten Prävention, zur Förderung protektiver Verhaltensweisen und des Selbstmanagements von nichtübertragbaren Krankheiten. Gleichzeitig ist deren Entwicklung und Instandhaltung im Vergleich zu browserbasierten eHealth-Anwendungen deutlich aufwändiger und Nutzenden fällt die Auswahl geeigneter Apps oft schwer. Während es zu allgemeine Qualitätskriterien wie Datenschutz, Design, Usability oder Sicherheit bereits Evaluations-Frameworks gibt wurden die notwendigen Bedingungen zur Erreichung einer Verhaltensänderung durch mHealth-Applikationen bei den Nutzenden bislang nicht systematisch recherchiert und zusammengefasst. Innerhalb von zwei separaten Literaturstudien wurden im Rahmen vorliegender Arbeit (1) Techniken zur Nutzungssteigerung und (2) Verhaltensänderungstechniken untersucht und identifiziert, die bei der Planung und Entwicklung von mHealth Applikationen berücksichtigt werden sollten und auf deren Grundlage auch die Entwicklung eines Kriterienkatalogs zur Bewertung von Gesundheits-Apps für die Nutzenden möglich ist. Fragestellungen: Im Rahmen der ersten Teilstudie wurde untersucht, welche Techniken, die in mHealth Applikationen zu NCDs, psychischer Gesundheit und Sucht eingesetzt werden, die Nutzungsadhärenz beeinflussen. Die zweite Teilstudie untersuchte, welchen Effekt Verhaltensänderungstechniken auf die intendierten Verhaltensänderungen haben. Methodik: In Teilstudie 1 wurde zur Identifikation relevanter Techniken zur Nutzungssteigerung eine systematische Literaturübersicht existierender Primärstudien erstellt. Dabei wurden in einem ersten Schritt Techniken identifiziert, die innerhalb der Primärstudien eine Verbesserung der Nutzungsadhärenz bewirkt haben. In einem zweiten Schritt wurde der Einfluss weiterer Faktoren auf die Nutzungsadhärenz untersucht, wie z.B. die Charakteristika der Zielpopulation oder die Art der Bereitstellung der Applikation. In einem dritten Schritt wurde für jede Primärstudie die Nutzungsadhärenz als Quotient beabsichtigter und tatsächlicher Nutzung berechnet, um einen Referenzwert innerhalb der verschiedenen Gesundheitsbereiche zu erhalten und mHealth Applikationen mit hoher Nutzungsadhärenz zu identifizieren. In Teilstudie 2, zur Identifikation relevanter Verhaltensänderungstechniken, wurde eine systematische Übersicht (englisch: Overview oder Umbrella Review) bereits vorhandener systematischer Reviews erstellt. Relevante wissenschaftliche Artikel für beide Teilstudien wurden durch systematische Recherchen in elektronischen Literaturdatenbanken identifiziert. Die relevante Information aus den Artikeln wurde jeweils extrahiert und analysiert. Ergebnisse: Die Literatursuche zu Teilstudie 1 ergab insgesamt 2862 potentiell relevante Artikel, von denen 99 für vorliegende Übersicht relevant waren und genauer analysiert wurden. Techniken mit positivem Einfluss auf die App-Nutzung wurden für die 7 Gesundheitsbereiche separat dargestellt, wobei folgende drei Techniken als relevant für alle Gesundheitsbereiche identifiziert wurden: (1) Personalierung bzw. die inhaltliche Anpassung der mHealth App an die individuellen Bedürfnisse der Nutzenden, (2) Erinnerungen in Form individualisierter Push-Notifikationen, (3) ein benutzerfreundliches App-Design und technische Stabilität. 5 Die aus den Primärstudien abgeleitete Nutzungsadhärenz lag durchschnittlich bei 56.0% und war am höchsten bei Lifestyle-Interventionen, welche auf die gleichzeitige Veränderung mehrerer Verhaltensweisen abzielen (60.1%) und am niedrigsten bei mHealth Apps zur Reduktion des Substanzkonsums (46.1%). Weiter ergab die quantitative Analyse eine positive Korrelation zwischen Nutzungsadhärenz und dem Grad der persönlichen Betreuung während der Intervention. Für den Bereich NCD-Selbstmanagement ergab sich eine signifikante positive Korrelation zwischen Nutzungsadhärenz und dem Durchschnittsalter der Studienteilnehmenden. Die Literatursuche zu Teilstudie 2 ergab insgesamt 615 potentiell relevante Artikel, von denen 66 für vorliegende Übersicht relevant waren und genauer analysiert wurden. Für den Bereich NCD-Selbstmanagement ist die Wirksamkeit ausschliesslich App-basierter Programme überwiegend gemischt oder noch unklar, mit der Ausnahme von Apps zum Diabetesmanagement. Zentrale Verhaltensänderungstechniken beim NCD-Selbstmanagement sind möglichst individualisierbare Zielsetzungen hinsichtlich der angestrebten Verhaltensweise (z.B. Einnahme von Medikamenten), die Selbstbeobachtung des Verhaltens (z.B. via Tagebuchfunktion in der App) und Rückmeldungen zum Verhalten (z.B. grafische Darstellung hinsichtlich dem Erreichen oder Nichterreichen des Verhaltensziels). Die Begleitung durch eine reale Fachperson scheint eine wichtige Komponente wirksamer digitaler Programme zur Unterstützung des Umgangs mit chronischen Erkrankungen. Auch die Evidenz zur Wirksamkeit App-basierter Programme zur Änderung des Ernährungsverhaltens ist noch gemischt, wobei eine Ernährungsumstellung, z.B. durch die Steigerung des Obst- und Gemüsekonsums häufiger erreicht werden kann als eine Reduktion der aufgenommenen Energiemenge. Die bislang eingesetzten mHealth Applikationen nutzen überwiegend Verhaltensänderungstechniken, die sich auch in traditionellen Einzel- und Gruppenberatungen zur Veränderung des Ernährungsverhaltens bewährt haben: Individuelle Zielsetzungen, Verhaltensbeobachtung und –rückmeldung sowie soziale Unterstützung. Inwieweit andere Techniken, wie z.B. die Veränderung des Selbstbilds oder soziale Vergleiche wirksam sind, lässt sich auf Grundlage der bisherigen Daten nicht beantworten. Die Wirksamkeit von Apps zur Steigerung körperlicher Aktivität ist mittlerweile wissenschaftlich gut fundiert, wobei insbesondere kranke und gefährdete Bevölkerungsgruppen von diesen profitieren. Auch hier spielen die Festlegung individueller Aktivitätsziele, deren Beobachtung und Feedbacks zu deren Erreichung eine zentrale Rolle. Die Einbeziehung einer realen Fachperson scheint bei diesen Programmen nicht notwendig. Dagegen sind Programme effektiver, welche vom System (z.B. via Bewegungssensor) automatisiert erfasste Daten für die Individualisierung verwenden. Bei Apps zur Gewichtsreduktion und zur gleichzeitigen Veränderung mehrerer Verhaltensweisen (sog. Lifestyle-Interventionen), die meist durch Förderung körperlicher Aktivität und gesunder Ernährung auch auf Gewichtsreduktion zielen, ist die Wirksamkeit gemischt. Zentrale Komponenten sind die Verwendung mehrerer und interaktiver Verhaltensänderungstechniken, insbesondere zur Zielsetzung sowie Verhaltensbeobachtung und Feedback. Bei Programmen zur Verbesserung der psychischen Gesundheit haben sich Elemente der kognitiven Verhaltenstherapie bewährt, um via Internet oder App Angst und Depressivität zu reduzieren. Ähnlich den Selbstmanagement-Programmen bei NCDs scheint auch hier die persönliche Begleitung durch eine Fachperson der Wirksamkeit dienlich. Neben der Selbstbeobachtung des Verhaltens stellen die Veränderung kognitiver Prozesse (z.B. Steigerung positiver Gedanken, kognitiver Flexibilität, wahrgenommener Kontrolle) und von Fähigkeiten (z.B. Anwendung von Mindfulness Skills oder kognitiv-behavioraler Techniken) zentrale Wirkmechanismen dar. Die Evidenz zur Wirksamkeit von App-Programmen zur Reduktion des Alkoholkonsums in der Allgemeinbevölkerung ist bislang gemischt, mit einzelnen positiven aber auch vielen Studien ohne signifikante Ergebnisse. Erfolgreiche Programme zeichnen sich insbesondere dadurch aus, dass sie Nutzenden praktische, leicht umsetzbare Hinweise zum Ersetzen des Alkoholkonsums und zur Problemlösung anbieten; diese sollten von einer als glaubwürdig wahrgenommenen Quelle kommen. Auch die Evidenz zur Wirksamkeit von Apps zur Entwöhnung vom Tabakrauchen ist bislang recht heterogen. In Reviews zu primär Internetbasierten Programmen waren verschiedene Techniken mit der Wirksamkeit assoziiert: das Setzen konkreter Verhaltensziele und Handlungsplanung, Hinweise zur Problemlösung und zu gesundheitlichen Folgen des Rauchens, die Abwägung von Vor- und Nachteilen des Rauchstopps aber auch soziale und medikamentöse Unterstützung. Schlussfolgerungen und Empfehlungen: Zentral für eine hohe App-Nutzung und Wirksamkeit sind Technologien zur Personalisierung und Individualisierung der Inhalte. Persönlich relevante Verhaltensziele sollten durch die Nutzenden festgelegt und deren Grad der Realisierung über die Zeit hinweg durch die App beobachtet werden können. Insbesondere geeignet sind dabei interaktive Funktionen, welche neben dem Grad der Zielerreichung auch Charakteristika der Person und des Kontextes berücksichtigen. Regelmässige Erinnerungen durch die App, welche die individuelle Verfügbarkeit und das Bedürfnis nach Interaktion berücksichtigen, stellen eine wesentliche Voraussetzung dar, um diese zentralen Techniken zur Zielsetzung, Verhaltensbeobachtung und –rückmeldung über einen längeren Zeitraum einzusetzen. Neben diesen automatisierten Funktionen bilden Möglichkeiten zur persönlichen Begleitung und sozialen Unterstützung, insbesondere bei Apps die in klinischen Gruppen eingesetzt werden, ein wesentliches Element für deren Nutzung und Wirksamkeit. Für die regelmässige Nutzung sind ausserdem technische Stabilität sowie ein benutzerfreundliches App-Design relevant. Insgesamt ist die Forschung zu erfolgversprechenden Techniken zur Nutzungssteigerung sowie zu Verhaltensänderungstechniken bei mHealth Apps noch wenig fortgeschritten. Die zugrundeliegenden Studien haben häufig Pilotcharakter, die Umsetzung der Techniken und Operationalisierung der Ergebnisse ist sehr uneinheitlich. Da mHealth Apps meist mehrere Techniken zur Nutzungssteigerung und Verhaltensänderung verwenden, sind kausale Aussagen über einzelne Techniken kaum möglich. Dazu sind zukünftig vermehrt kontrollierte und experimentelle Studien notwendig. Die empfohlenen Techniken zur individualisierten Zielsetzung, Verhaltensbeobachtung, Rückmeldung, Erinnerung und sozialen Unterstützung stellen auch Grundelemente aktueller Modelle zum Gesundheitsverhalten und bewährter kognitiv-verhaltenstherapeutischer Interventionen dar. Deren Integration in mHealth Applikationen bildet ein solides Fundament. Für deren Optimierung sollten zukünftig aber gleichzeitig auch neue Techniken erprobt und überprüft werden, deren volles Potential erst durch digitale Technologien ausgeschöpft werden kann.
... Online, self-delivered, interventions are proposed to be both more accessible and cost-effective than in-person approaches, 17 yet there are concerns in non-clinical populations around effectiveness and poor engagement. 18 Regarding mindfulness specifically, concerns are that practice without therapist guidance may result in a greater frequency of adverse events, 19 although this may be mitigated by using guided meditations. ...
... 21 As these forms of intervention are relatively novel, there is a need for wider research to ascertain the best way to implement them in practice. 17 ...
Article
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Background Stress can compromise parental well-being and may contribute to harsh and critical parenting styles, which are in turn associated with children's conduct problems. Coronavirus disease 2019 (COVID-19)-related restrictions are likely to have exacerbated parental stress as, for many, UK-based family life was altered considerably. Mindfulness has been demonstrated to improve stress management and emotion regulation when delivered to parents in person, however, more accessible online interventions are under-researched. Aims To provide preliminary data on family well-being and parent–child relationships as well as the acceptability and usability of the Headspace app – a self-delivered mindfulness-based intervention – for parents in low-risk families during the early days of the COVID-19 pandemic. Method We provided 12 parents with access to Headspace, and collected qualitative data (semi-structured interviews and 5 minute speech samples) immediately following the initial COVID-19 lockdown in the UK. The resulting transcripts were thematically analysed. Results Most parents reported Headspace to be acceptable and useful – improvements in parents’ own sleep were particularly noted – and there was high adherence to the intervention. However, difficulties related to family well-being and parent–child relationships following the lockdown were also reported. Conclusions As a result of the confounding impact of COVID-19 restrictions, and varied access to app content, we were unable to determine any outcomes to be a result of practising mindfulness specifically. However, COVID-19 has had a profound impact on many UK-based families, including those previously at low risk, and our results demonstrate that Headspace may have beneficial effects for parents. There is a need to more rigorously test this tool with a broader range of families.
... Wang et al. (2018) reviewed studies on MH apps from 2013 to 2017 and found that only 11 out of 120 studies actually provided evidence of efficacy. However, a growing number of recent reviews of randomized control trials (RCTs) have supported the efficacy of MH apps, although the effects vary across mental health problems and across reviews, with one meta-analysis (Linardon et al., 2019) citing small but positive effects of MH apps on both depression and anxiety symptoms and another metaanalysis (Weisel et al., 2019) finding positive effects only for depression, not anxiety, apps. ...
... Another six full-text articles were eliminated after assessing eligibility by reading the full-text articles. Finally, 10 articles met all inclusion criteria and were included in the review (Akgün et al., 2019;Firth, Torous, Nicholas, Carney, Pratap, et al., 2017;Rathbone et al., 2017;Goreis et al., 2020;Linardon et al., 2019;Menon et al., 2017;Stratton et al., 2017;Weisel et al., 2019;Wang et al., 2018). Figure 1 displays the flowchart of record screening. ...
... Emerging evidence has indicated that smartphone-based interventions are effective in reducing depressive symptoms (g = 0.26-0.41) (Kerst et al., 2020;Linardon et al., 2019;Weisel et al., 2019). However, high dropout rates remain a major challenge in their implementation (Himle et al., 2021;Torous et al., 2020;Webelhorst et al., 2020). ...
... The effect of Lifestyle Hub on depressive symptoms at immediate post-intervention in our study (d = 0.66) was superior to the effects of other smartphone-based interventions for depressive symptoms reported in recent meta-analyses (d = 0.26-0.41) (Firth et al., 2017;Linardon et al., 2019;Weisel et al., 2019) as well as multicomponent LM interventions for depressive symptoms reported in another meta-analysis (d = 0.22) (Wong et al., 2021). The difference in This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
Article
Objective: To evaluate the efficacy and credibility of a smartphone-delivered multicomponent lifestyle medicine (LM) intervention, Lifestyle Hub, as a primary modality for managing depressive symptoms in an adult Chinese population. Method: Participants with at least a moderate level of depressive symptoms (n = 79), as indicated by a Patient Health Questionnaire-9 score of ≥10, were randomly assigned to an LM intervention group (LMG; n = 39; eight weekly sessions) or a waitlist control group (WLG; n = 40). Results: The intention-to-treat analysis revealed significant improvements in depressive symptoms (d = 0.66), generalized anxiety symptoms (d = 0.93), insomnia symptoms (d = 0.20), functional impairment (d = 0.22), and health-related quality of life (HRQoL; d = 0.11) from Week 0 (baseline) to Week 9 (immediate post-intervention assessment) in the LMG relative to the WLG. Moreover, significantly more health-promoting behaviors (overall health behaviors, health responsibility, physical activity level, nutrition, spiritual growth, and stress management) (d = 0.40-0.89) and higher levels of total activity (d = 0.55) and walking activity (d = 0.55) were found at Week 9 in the LMG relative to the WLG. However, no significant differences were observed in interpersonal relationships, vigorous and moderate exercise levels, sedentary behavior levels, or food frequency questionnaire measures at Week 9 between the LMG and the WLG. From Week 9 to Week 13 (1-month follow-up assessment), a significant within-group reduction in HRQoL (d = 0.50) and an increase in alcohol intake (d = 0.41) were observed in the LMG. Conclusions: The smartphone-delivered multicomponent LM intervention Lifestyle Hub may serve as a primary modality for managing depressive symptoms. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Therefore, considering the growing interest in the delivery of therapeutic techniques outside the classical therapeutic setting (51), helping the client to immerse themselves in memory seems to be important in the memory rehearsal and in satisfying the unmet emotional needs. This is in line with the study showing larger effects when app-based interventions are combined with therapist support (52). ...
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Imagery Rescripting (ImR) has proved to be effective in the treatment of different mental disorders as an integral part of broader clinical protocols or as a standalone technique. ImR has also been successfully incorporated as part of group Schema Therapy treatment; however, to the best of our knowledge, it has never been assessed as a standalone technique in a group setting. In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants’ affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique. A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering. The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3–100%). Overall, memory realism values (level of vividness, ability to immerse, and participants’ distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session. A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient’s basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.
... In addition to their feasibility, there is a growing body of evidence supporting the efficacy of app-based mental health interventions [44,45]. Although somewhat limited, existing data with POC samples are promising [40]. ...
Article
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Background: People of color (POC) who experience race-related stress are at risk of developing mental health problems, including high levels of stress, anxiety, and depression. Mindfulness meditation may be especially well suited to help POC cope, given its emphasis on gaining awareness and acceptance of emotions associated with discriminatory treatment. However, mindfulness meditation rarely reaches POC, and digital approaches could reduce this treatment gap by addressing traditional barriers to care. Objective: This study will test the effectiveness of a self-directed app-based mindfulness meditation program among POC who experience elevated levels of race-related stress. Implementation outcomes such as treatment acceptability, adherence, and satisfaction will be examined. Methods: Participants (n=80) will be recruited online by posting recruitment materials on social media and sending emails to relevant groups. In-person recruitment will consist of posting flyers in communities with significant POC representation. Eligible participants will be block randomized to either the intervention group (n=40) that will complete a self-directed 4-week mindfulness meditation program or a wait-list control condition (n=40) that will receive access to the app after study completion. All participants will complete measures at baseline, midtreatment, and posttreatment. Primary outcomes include changes in stress, anxiety, and depression, and secondary outcomes constitute changes in mindfulness, self-compassion, rumination, emotion suppression, and experiential avoidance. Exploratory analyses will examine whether changes in the secondary outcomes mediate changes in primary outcomes. Finally, treatment acceptability, adherence, and satisfaction will be examined descriptively. Results: Recruitment began in October 2021. Data will be analyzed using multilevel modeling, a statistical methodology that accounts for the dependence among repeated observations. Considering attrition issues in self-directed digital interventions and their potential effects on statistical significance and treatment effect sizes, we will examine data using both intention-to-treat and per-protocol analyses. Conclusions: To our knowledge, this will be the first study to provide data on the effectiveness of a self-directed app-based mindfulness meditation program for POC recruited based on elevated race-related stress, a high-risk population. Similarly, meaningful clinical targets for POC affected by stressors related to race will be examined. Findings will provide important information regarding whether this type of intervention is an acceptable treatment among these marginalized groups. Trial Registration: ClinicalTrials.gov NCT05027113; https://clinicaltrials.gov/ct2/show/NCT05027113 International Registered Report Identifier (IRRID): DERR1-10.2196/35196
... During the program, three scheduled weekly study-related notifications will be sent to participants in the intervention group through the BEAM app. Sending engagement reminders to participants has been found to contribute to greater mental health benefits from e-health interventions [46] and increase the effectiveness of online parenting programs [47]. Participants will receive detailed schedules with weekly videos and activities to be completed as part of their BEAM program welcome package. ...
Preprint
Background: The prevalence of maternal depression and anxiety has increased during the COVID-19 pandemic and pregnant individuals are experiencing concerningly elevated levels of mental health symptoms worldwide. Many individuals may now be at heightened risk of postpartum mental health disorders. Recent evidence suggests that the cognitive development of children born during the pandemic has been impacted. There are significant concerns that a cohort of children may be at-risk for impaired self-regulation and mental illness due to elevated exposure to perinatal maternal mental illness. The intergenerational effects of maternal mental illness are most pronounced when depression persists. With both an increased prevalence of depression and limited availability of services due to the pandemic, there is an urgent need for accessible eHealth interventions for mothers of young children. The aims of this trial are to evaluate the efficacy of the Building Emotion Awareness and Mental Health (BEAM) app-based program for reducing maternal depression symptoms (primary outcome) as well as for improving anxiety symptoms, family relationships, parenting, mother and child functioning (secondary outcomes) compared to treatment as usual (TAU). Methods: A two-arm randomized controlled trial (RCT) with repeated measures will be used to evalute the efficacy of the BEAM intervention compared to TAU among a sample of 140 mothers with children aged 18 to 36 months, who self-report moderate-to-severe symptoms of depression and/or anxiety. Individuals will be recruited online and those randomized to the treatment group will participate in 10 weeks of modules on mental health and parenting, an online social support forum, and weekly group teletherapy sessions. Assessment of depression (primary outcome), family relationship quality, anxiety, parenting, and mother and child functioning will occur at 18-36 months postpartum (pre-test, T1), immediately after the last week of the BEAM intervention (post-test, T2), and at 3 months after the intervention (follow-up, T3). Primary outcomes will also be assessed weekly throughout the 10 week intervention. Discussion: eHealth interventions have the potential to address elevated maternal mental health symptoms, parenting stress, and child funtioning concerns during and after the COVID-19 pandemic and provide accessible programming to mothers who are in need of support. This RCT will build on an open pilot trial of the BEAM program and provide further evaluation of this evidence-based intervention for mothers experiencing depression. Findings will increase understanding of depression and parenting stress in mothers with young children and reveal the potential for long-term improvements in maternal and child health and family well-being.
... However, the subset of applications tested empirically has been shown to be effective. Meta-analyses of DMHIs show small to medium effects on depression and anxiety symptoms [27][28][29][30], with larger effects when programs include more engagement features [31], though other meta-analyses found significant pooled effects for depression but not for other psychological outcomes, including anxiety [32]. Similarly, a review of DMHIs among college students found that most programs (81%) were at least partially effective in improving depressive symptoms, anxiety, psychological distress, or wellbeing [33]. ...
Article
Full-text available
Introduction Increasing demand for mental health services and the expanding capabilities of artificial intelligence (AI) in recent years has driven the development of digital mental health interventions (DMHIs). To date, AI-based chatbots have been integrated into DMHIs to support diagnostics and screening, symptom management and behavior change, and content delivery. Areas covered We summarize the current landscape of DMHIs, with a focus on AI-based chatbots. Happify Health’s AI chatbot, Anna, serves as a case study for discussion of potential challenges and how these might be addressed, and demonstrates the promise of chatbots as effective, usable, and adoptable within DMHIs. Finally, we discuss ways in which future research can advance the field, addressing topics including perceptions of AI, the impact of individual differences, and implications for privacy and ethics. Expert opinion Our discussion concludes with a speculative viewpoint on the future of AI in DMHIs, including the use of chatbots, the evolution of AI, dynamic mental health systems, hyper-personalization, and human-like intervention delivery.
... It is of note that in previous studies, the amount of human support was limited -with studies using stand-alone interventions or only minimal human support. This appears to be problematic as it has been shown that the efficacy of app-based interventions increases when professional human guidance is provided (Linardon et al., 2019). Therefore, a promising way of improving the efficacy of app-based interventions against AUD is to include a significant amount of guidance. ...
Article
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Background Alcohol use disorder, a prevalent and disabling mental health problem, is often characterized by a chronic disease course. While effective inpatient and aftercare treatment options exist, the transferal of treatment success into everyday life is challenging and many patients remain without further assistance. App-based interventions with human guidance have great potential to support individuals after inpatient treatment, yet evidence on their efficacy remains scarce. Objectives To develop an app-based intervention with human guidance and evaluate its usability, efficacy, and cost-effectiveness. Methods Individuals with alcohol use disorder (DSM-5), aged 18 or higher, without history of schizophrenia, undergoing inpatient alcohol use disorder treatment (N = 356) were recruited in eight medical centres in Bavaria, Germany, between December 2019 and August 2021. Participants were randomized in a 1:1 ratio to either receive access to treatment as usual plus an app-based intervention with human guidance (intervention group) or access to treatment as usual plus app-based intervention after the active study phase (waitlist control/TAU group). Telephone-based assessments are conducted by diagnostic interviewers three and six weeks as well as three and six months after randomization. The primary outcome is the relapse risk during the six months after randomization assessed via the Timeline Follow-Back Interview. Secondary outcomes include intervention usage, uptake of aftercare treatments, AUD-related psychopathology, general psychopathology, and quality of life. Discussion This study will provide further insights into the use of app-based interventions with human guidance as maintenance treatment in individuals with AUD. If shown to be efficacious, the intervention may improve AUD treatment by assisting individuals in maintaining inpatient treatment success after returning into their home setting. Due to the ubiquitous use of smartphones, the intervention has the potential to become part of routine AUD care in Germany and countries with similar healthcare systems.
... Moreover, digital interventions may also enable researchers to access geographically distant and busy parents [19], while addressing participants' anonymity concerns. Although the efficacy of smartphone-delivered interventions is emerging, high rates of attrition and low adherence were reported, both of which threaten the validity of randomized controlled trial findings [20]. ...
Article
Full-text available
Background This study assessed the feasibility and effect of two mobile modes (WhatsApp vs. a specially designed app) in their delivery of updates and assignments to parents. Methods Two three-armed, randomized, controlled feasibility studies were conducted. In each trial, four schools with a total of 418 students in grade 5th, mean age 10.1 years, were randomly allocated to the control arm, youth-only arm, or youth & parental component arm. Only the data of those that completed all three assessments (pre, post and 3 months post program) were analyzed: 133 in the first trial and 137 in the second. In the youth-only arm, students participated in an interactive age-tailored prevention program delivered in 10 weekly, 90-min sessions on self-care behaviors, media literacy, self-esteem, and positive body image. The control groups in both studies received three health- and nutrition-related sessions. In the parental arm, in addition to the ‘Favoring-Myself–Young’s ten sessions program, parents received updates and were requested to complete shared assignments with their children. In the first year, the assignments were sent via WhatsApp, and in the following year via “Favoring Myself” smartphone application. Facilitators were third year undergraduate students. They used a detailed semi-structured guide and received 4-weekly hours of didactic and group dynamic supervision. Mixed-methods assessments were performed using semi-structured interviews with ten parents and five school staff members each year, as well as a computerized self-report questionnaire. Results Feasibility of parent-adolescent shared assignments in both digital modes was lower than expected. The use of WhatsApp had higher feasibility and uptake than the use of the special application. The addition of the concurrent parental component via WhatsApp was associated with superior improvement in self-esteem and identification of advertisement strategies, compared with the youth-only program. However, adolescents in the youth-only program delivered via the smartphone application demonstrated superior improvement compared to those in the youth and parental component arm. Conclusions Although the addition of the concurrent parenting component was praised by the actively participating parents, overall, under the chosen structure and population, it did not prove to add statistically significant value to the youth-only arm. Trial registrations NCT03216018 (12.7.2017) and NCT03540277 (26.4.2018).
... Regarding efficacy, the meta-analysis by Linardon et al. (2019) suggested that apps can be low-intensity, cost-effective, and easily accessible interventions for people who are unable to receive standard psychological treatment. Recently, Miralles et al. (2020) reported that most of the research conducted so far with apps has focused mainly on the most prevalent mental disorders, with less attention paid to the less prevalent or more severe disorders. ...
Article
The prevalence of mental disorders continues to increase, especially with the advent of the COVID-19 pandemic. Although we have evidence-based psychological treatments to address these conditions, most people encounter some barriers to receiving this help (e.g., stigma, geographical or time limitations). Digital mental health interventions (e.g., Internet-based interventions, smartphone apps, mixed realities -virtual and augmented reality) provide an opportunity to improve accessibility to these treatments. This article summarizes the main contributions of the different types of digital mental health solutions. It analyzes their limitations (e.g., drop-out rates, lack of engagement, lack of personalization, lack of cultural adaptations) and showcases the latest sophisticated and innovative technological advances under the umbrella of precision medicine (e.g., digital phenotyping, chatbots, or conversational agents). Finally, future challenges related to the need for real world implementation of these interventions, the use of predictive methodology, and hybrid models of care in clinical practice, among others, are discussed.
... The ability of unguided interventions to function without human support also makes them cheaper to deliver compared with guided interventions. Unguided interventions have demonstrated efficacy relative to control conditions (including wait-list and active controls) for common mental health problems, such as depression and generalized anxiety disorder, but the effects are smaller than for guided interventions that include human support 80 . However, this difference between guided and unguided interventions may be moderated by symptom severity; in a large network meta-analysis of patient data from individuals with depression, the effects of guided interventions relative to unguided interventions were more pronounced for those with higher symptom severity (that is, individuals with moderate to severe depression benefit more from guided interventions) 68 . ...
Article
Mental health concerns are common, and various evidence-based interventions for mental health conditions have been developed. However, many people have difficulty accessing appropriate mental health care and this has been exacerbated by the COVID-19 pandemic. Digital mental health services, such as those delivered by mobile phone or web-based platforms, offer the possibility of expanding the reach and accessibility of mental health care. To achieve this goal, digital mental health interventions and plans for their implementation must be designed with the end users in mind. In this Review, we describe the evidence base for digital mental health interventions across various diagnoses and treatment targets. Then, we explain the different formats for digital mental health intervention delivery, and offer considerations for their use across key age groups. We discuss the role that the COVID-19 pandemic has played in emphasizing the value of these interventions, and offer considerations for ensuring equity in access to digital mental health interventions among diverse populations. As healthcare providers continue to embrace the role that technology can play in broadening access to care, the design and implementation of digital mental healthcare solutions must be carefully considered to maximize their effectiveness and accessibility. Mental health concerns are common, but many people have difficulty accessing appropriate mental health care. In this Review, Lattie et al. present an overview of digital mental health services and provide recommendations for increasing their accessibility.
... Digital mental health interventions address the accessibility-, cost-, convenience-, and stigma-related barriers to traditional in-person mental health treatment [16]. Furthermore, a growing body of evidence supports the effectiveness of digital mental health interventions in improving depression and anxiety symptoms, sometimes to a degree equivalent to that obtained from in-person treatment [17][18][19]. With the widespread, everyday use of smartphones, these emerging digital tools could function as efficient, widely available mental health resources for orthopedic clinicians to offer their patients [16,[20][21][22]. ...
Article
Background: Symptoms of depression and anxiety commonly coexist with chronic musculoskeletal pain, and when this occurs, standard orthopedic treatment is less effective. Nevertheless, addressing mental health is not yet a routine part of standard orthopedic treatment, in part due to access related barriers. Digital mental health intervention offers the potential to be a scalable resource that could feasibly be incorporated into orthopedic care. Objective: The primary purpose of this study was to assess the feasibility of introducing a digital mental health intervention (Wysa) within an outpatient orthopedic setting to patients who endorse coexisting symptoms of depression and/or anxiety. The secondary purpose was to perform a preliminary effectiveness analysis of the intervention. Methods: In this single-arm, prospective cohort study, participants included adult patients (18 years and older) who presented to a non-surgical orthopedic specialist at a single tertiary care academic center for evaluation of a musculoskeletal condition and who self-reported symptoms of depression and/or anxiety (Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and/or Anxiety score ≥ 55). Enrollment was performed face-to-face by a research coordinator immediately after the participant's encounter with an orthopedic clinician. Participants were provided two months of access to a mobile app called Wysa, which is an established, multi-component digital mental health intervention that uses chatbot technology and text-based access to human counselors to deliver cognitive behavioral therapy, mindfulness training, and sleep tools, among other features. For this study, Wysa access also included novel, behavioral activation based features specifically developed for users with chronic pain. Primary feasibility outcomes included the study recruitment rate, retention rate, and engagement rate with Wysa (defined as engaging with a therapeutic Wysa tool at least once during the study period). Secondary effectiveness outcomes were between-group differences in mean longitudinal PROMIS mental and physical health score changes at two-month follow-up between high Wysa users and low Wysa users, defined by a median split. Results: The recruitment rate was 61/208 (29%), retention rate was 51/61 (84%), and engagement rate was 44/61 (72%). Compared to low users, high Wysa users achieved greater improvement in PROMIS Anxiety (between-group difference -4.2 points [95% CI -8.1 to -0.2], P=.044) at two-month follow-up. Between-group differences in PROMIS Depression (-3.2 points [-7.5 to 1.2], P=.15) and Pain Interference (-2.3 points [-6.3 to 1.7], P=.26) favored high users but did not meet statistical significance. Improvements in PROMIS Physical Function were comparable between groups. Conclusions: Delivery of a digital mental health intervention within the context of orthopedic care is feasible and demonstrates potential to improve mental health and pain-related impairment to a clinically meaningful degree. Participants' engagement rates exceeded industry standards, and additional opportunities to improve recruitment and retention were identified. Further pilot study followed by a definitive, randomized controlled trial is warranted. Clinicaltrial: ClinicalTrials.gov NCT202005219.
... There is often an assumption that clinical intervention requires highly trained professionals to optimize outcomes, despite research suggesting that the presence of human support alone increases adherence to digital mental health interventions, thereby yielding improved efficacy and outcomes [47]. In line with our findings, the presence of a guide-clinician or nonclinician-is beneficial for evoking positive changes. ...
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Full-text available
BACKGROUND Digital mental health interventions are increasingly prevalent in the current context of rapidly evolving technology, and research indicates that they yield effectiveness outcomes comparable to in-person treatment. Integrating professionals (i.e. psychologists, physicians) into digital mental health interventions has been common, and the inclusion of guidance within programs can increase adherence to interventions. However, employing professionals to enhance mental health programs may undermine the scalability of digital interventions. Therefore, delegating guidance tasks to paraprofessionals (peer supporters, technicians, lay counsellors, or other non-clinicians) can help reduce costs and increase accessibility. OBJECTIVE This systematic review and meta-analysis evaluates the effectiveness, adherence, and other process outcomes of non-clinician guided digital mental health interventions. METHODS Four databases (MEDLINE, EMBASE, CINAHL, and PSYCInfo) were searched for randomized controlled trials published between 2010 and 2020 examining digital mental health interventions. Three journals focused on digital intervention were also hand searched and grey literature was searched using ProQuest and the Cochrane Central Register of Control Trials (CENTRAL). Two researchers independently assessed risk of bias using the Cochrane Risk of Bias Tool 2. Data were collected on effectiveness, adherence, and other process outcomes, and meta-analyses were conducted for effectiveness and adherence outcomes. Non-clinician guided interventions were compared with treatment as usual, clinician-guided interventions, and unguided interventions. RESULTS Thirteen studies qualified for inclusion. Results indicate that non-clinician guided interventions yielded higher post-treatment effectiveness outcomes when compared to conditions involving control programs (e.g. online psychoeducation, monitored attention control) or waitlist controls (k=7, Hedges g=-0.73 (95% CI -1.08 to -0.38)). There are significant differences between non-clinician guided interventions and unguided interventions as well (k=6, Hedges g=-0.17 (95% CI -0.23 to -0.11)). In addition, non-clinician guided interventions did not differ in effectiveness from clinician-guided interventions (k=3, Hedges g=0.08 (95% CI -0.01 to 0.17)). These results suggest that guided digital mental health interventions are helpful to improve mental health outcomes regardless of the qualification, and that the presence of a non-clinician guide improves effectiveness outcomes more than no guidance. Non-clinician guided interventions did not yield significantly different effects on adherence outcomes when compared with unguided interventions (k=3, OR 1.58 (95% CI 0.51 to 4.92)), although a general trend of improved adherence was observed within non-clinician guided interventions. CONCLUSIONS Integrating paraprofessionals and non-clinicians appear to improve outcomes of digital mental health interventions, and may also enhance adherence outcomes (though the trend was nonsignificant). Further research should focus on the specific types of tasks these paraprofessionals can successfully provide (i.e. psychosocial support, therapeutic alliance, technical augmentation) and their associated outcomes. CLINICALTRIAL The protocol is preregistered on PROSPERO (CRD42020191226).
... A recent systematic review highlighted that only 2% of publicly available psychosocial wellness and stress management mobile apps have published peer-reviewed evidence of feasibility or efficacy [18]. Mental health apps vary by different factors, such as the mental health conditions they target [59,60] and the BCTs used [17]. For example, providing instructions on how to perform a behavior and allowing or encouraging practice or rehearsal in addition to daily activities are the two most popular BCTs used in apps that aim to improve mental well-being [17]. ...
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Background Although mental ill-health is more prevalent among people from lower socioeconomic groups, digital mental well-being innovations are often developed for people from higher socioeconomic groups, who already have resources to maintain good mental and physical health. To decrease health inequalities and ensure that available solutions are appealing and accessible to people with fewer resources, new approaches should be explored. We developed the app Wakey!, which focused on creating engaging mental health content that is accessible, particularly among lower socioeconomic groups in the United Kingdom. Objective The aim of this study is to assess engagement with the app, investigate initial effectiveness data for 6 well-being outcomes, and explore participants’ subjective experiences of using Wakey! Methods The app Wakey! was publicly launched on January 20, 2020, and was free to download from Apple Store and Google Play. The app provided its users with entertaining and educational content related to mental well-being. Concurrently, a single-arm mixed methods feasibility trial was carried out from January to April 2020 among people who had downloaded the app and created an account. The primary outcome was engagement, which was collected passively from data logs. Secondary outcome measures were 6 well-being outcomes collected from self-report questionnaires. Individual interviews with 19 app users were carried out in April 2020. Results In total, 5413 people fit the inclusion criteria and were included in the final sample—65.62% (3520/5364) women, 61.07% (3286/5381) aged between 25 and 44 years, 61.61% (2902/4710) in employment, 8.92% (420/4710) belonging to the lower socioeconomic group, and 8.09% (438/5413) were engaged users. There was no evidence of a difference in engagement regarding sociodemographic and socioeconomic characteristics. There was evidence that users with a higher average daily sleep score, who joined the study more recently, who had higher baseline self-report of sleep quality, and who found episodes more entertaining were more likely to be engaged users. Among 230 users who provided follow-up data, there was evidence of improvements on four of the six well-being outcomes: life satisfaction (P<.001), feeling that life is worthwhile (P=.01), ease of getting up in the morning (P<.001), and self-efficacy (P=.04). The app and its content were well received by those who were interviewed, and several people perceived a positive change in their mental well-being. Conclusions This study shows that the app Wakey! could potentially be engaging across different socioeconomic groups, and there is an indication that it could positively impact the mental well-being of those engaged with the app. However, this study was a pragmatic trial with a limited sample, and the selection bias was present in the qualitative and quantitative study. Further work is needed to make any generalizable conclusions. Trial Registration ClinicalTrials.gov NCT04287296; https://clinicaltrials.gov/ct2/show/NCT04287296
... Other tools included under ICT systems are mobile phone and smartphone apps. The large increase in mobile phones and smartphones over the years [54] offers additional and largely unexplored advantages for implementing psychological treatments for different mental disorders with the support of these technologies [55,56]. Hawker, Markouris, Youssef & Dowling [57] conducted a single-arm study that supports the acceptability, feasibility and preliminary efficacy of an app-delivered EMI for craving management in people with gambling problems. ...
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... Additionally, although each participant noted that the use of technology to deliver the intervention, including phone, videoconferencing, and apps might be suitable, they consistently stated that some element of human interaction would be essential to the intervention. This is consistent with the larger literature indicating that smartphone apps delivering an intervention Behavioral Activation After Orthopedic Trauma 23 independent of human interaction tended to be less effective and engaging than those supported by a human provider (Linardon et al., 2019). ...
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... This need is compounded by the limitations of existing app-rating platforms, such as contradictory app ratings and lack of focus on consumer preferences. 42 Applying this criterion in an evaluation tool may be problematic due to the fact that not all mental health apps have been thoroughly tested for effectiveness 43 ; however, it may be approximated by determining whether the app was developed based on a credible treatment or practice. It is worth noting that the apps themselves can be tested as interventions, they can include evidence-based interventions, or both. ...
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Objective The popularity of smartphone technology provides a unique opportunity to make mental health support widely accessible, especially among young people. Despite the promising results of some mobile mental health support applications, the overwhelming number of available applications (apps) on the market makes it difficult to make a choice that will be safe and effective. Currently, widely available tools are either developed by experts, without end user input or are solely based on usability rankings. Thus, it remains unclear what aspects of mental health apps are important for young people. The purpose of this study was to determine what criteria young adults use when they select mental health applications and what is the relative importance of these criteria to inform the development of a user-driven app-rating platform. Methods We conducted 4 group sessions with 47 youth and young adults aged 15–25 in British Columbia, Canada using a modified nominal group technique. This method allows for establishing the relative importance of criteria in a structured group discussion. We recorded, transcribed and analysed the resulting data using qualitative content analysis and quantitative methods. Results Criteria that are the most important to young adults when selecting mental health apps include accessibility, security and grounding in scientific evidence. We identified specific aspects of the discussed criteria which were ranked in the order of importance. Conclusion Consulting end users about their priorities when evaluating mental health apps ensures that their values and priorities are incorporated into future app-rating platforms, alongside expert opinions. The present study also outlines the common contexts in which apps are used as well as their desirable features to inform mental health app development.
... [6][7][8] Rapid growth in the area of eHealth represents a new frontier for delivering tailored interventions to men. 9,10 Research has reported that young men in particular have a strong preference for web-based health information and interventions. 11,12 Various eHealth programs tailored to men have been developed to address prostate cancer, smoking cessation, prenatal health education, weight loss, sexual health, fathering, and health behaviours. ...
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Background: Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs. Methods: MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies. Results: 24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim. Conclusions: Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.
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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.
Article
Background: Nascent evidence indicates that the mental health of parents and children has markedly declined during the COVID-19 pandemic. Considering disruptions to traditional face-to-face mental health services resultant from stay-at-home orders, the potential value of digital mental health interventions has become extremely apparent. Despite this, uptake of digital interventions remains poor, indicating that a better understanding is needed of factors that determine a willingness to use digital platforms. Method: The present multi-wave, longitudinal study of 2365 Australian parents explored between-person and within-person predictors of intentions to use digital interventions during the pandemic. Results: More than one-third of parents reported likely use of a self-guided and therapist-guided digital intervention, with the most endorsed reason for use being to support their child's mental health. Between-person baseline predictors of higher intention ratings were parent's prior mental illness, not living with a partner and recent environmental stressors. Within-person predictors of higher intention ratings were endorsement of mindful parenting strategies, child access to the Internet, better perceived management of child's education, lower social support and financial hardship. Conclusion: Findings demonstrate that willingness to engage in digital interventions fluctuates in response to changing circumstances. Identifying novel ways to increase acceptance and uptake of digital interventions based on modifiable predictors established here is needed to realize the full potential of these modes of care in times of need.
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Background: Chinese young adults experience barriers to mental health treatment, including the lack of treatment providers and stigma around treatment seeking. Evidence-based digital mental health interventions are promising and scalable alternatives to face-to-face treatment for this population, but lack rigorous evidence to support scale-up in China. Aim: The study was a feasibility study for a large-scale RCT of Step-by-Step, a behavioral activation-based, mental health intervention to address depression and anxiety symptoms in Chinese young adults. It sought to assess feasibility of recruitment and of delivery of Step-by-Step in a University setting, to assess acceptability of the intervention, and to examine potential effectiveness. Method: An uncontrolled, feasibility trial was conducted to assess the feasibility and acceptability of Chinese Step-by-Step for Chinese University students with elevated depressive symptoms (PHQ-9 scores at or above 10) in Macao, China. Data was collected at two different time points (i.e., baseline and 8-weeks after baseline), administered via questionnaires embedded in an interventional mobile application. Participation rate and dropout rate were measured. Depressive and anxiety symptom severity, well-being, and self-defined stress were assessed. Satisfaction with the program was assessed using qualitative interviews. Results: A total of 173 students were screened, 22.0% ( n = 38) were eligible, and 63.2% of them ( n = 24) started the intervention. The dropout rate by post-test was 45.8%. Results from completers showed that Step-by-Step was potentially effective in reducing depressive and anxiety symptom severity, and self-defined stress. Students were generally satisfied with the program, but also offered suggestions for continued improvement. Qualitative feedback was reported within the RE-AIM framework, covering recruitment, effectiveness, adoption, implementation, and maintenance. Amendments to the program were made according to the feedback (e.g., adding notification for new session, modify the time zone). Conclusion: A minimally guided Step-by-Step protocol and the study procedure were successfully pilot tested for use for Chinese University students. The intervention was acceptable and no adverse events were reported. The results support the potential effectiveness and feasibility of a large-scale evaluation of the program.
Article
Background Nonsuicidal self-injury (NSSI) is a widespread behavior among adolescents and young adults. Although many individuals who self-injure do not seek treatment, there is evidence for web-based help-seeking through web-based communities and mobile peer support networks. However, few studies have rigorously tested the efficacy of such platforms on outcomes relevant for NSSI recovery. Objective The aim of this small-scale preregistered randomized controlled trial is to provide preliminary insight into the shorter- and longer-term efficacy of the use of a peer support app, TalkLife, in reducing NSSI frequency and urges and increasing readiness to change. In addition, we explore contact with informal support, interest in therapy, and attitudes toward professional help–seeking. Methods Individuals aged 16-25 years with current (within 3 months) and chronic (>6 episodes in the past year) NSSI history were eligible to participate in this study. After baseline assessments, the intervention group was instructed to use the app actively (eg, post or comment at least three times per week) and the control group received weekly psychoeducational materials through email, for 8 weeks. Follow-up was assessed at 1 month and 2 months. Linear mixed modeling was used to evaluate condition and time point effects for the primary outcomes of NSSI frequency and urges, readiness to change, contact with informal support, interest in therapy, and attitudes toward professional help–seeking. Results A total of 131 participants were included in the analysis. We evidenced a significant effect of condition on NSSI frequency such that the participants using the peer support app self-injured less over the course of the study (mean 1.30, SE 0.18) than those in the control condition (mean 1.62, SE 0.18; P=.02; η2=0.02). We also evidenced a significant condition effect of readiness to change such that the treatment participants reported greater confidence in their ability to change their NSSI behavior (mean 6.28, SE 0.41) than the control participants (mean 5.67, SE 0.41; P=.04; η2=0.02). No significant differences were observed for contact with informal support, interest in therapy, or attitudes toward professional help–seeking. Conclusions Use of the peer support app was related to reduced NSSI frequency and greater confidence in one’s ability to change NSSI behavior over the course of the study period, but no effects on NSSI urges, contact with informal support, interest in therapy, or attitudes toward professional help–seeking were observed. The findings provide preliminary support for considering the use of mobile peer support apps as a supplement to NSSI intervention and point to the need for larger-scale trials. Trial Registration Open Science Foundation; https://osf.io/3uay9
Article
Objective: We aimed to evaluate the feasibility, acceptability, and potential impact of a tele-guided digital-based intervention based on the addictive appetite model of recurrent binge eating. Method: Female college students with bulimia nervosa (BN) or binge-eating disorder (BED) (n = 22) received a 6-week guided intervention targeting addictive processes and emotion regulation. The feasibility of the intervention was evaluated, and the outcomes were assessed at baseline, the end of the intervention, and 1-month follow-up. Results: Of the participants, 86.4% (n = 19) completed the intervention. The self-help materials were viewed 6.03 ± 3.06 times per week, and the duration of using the self-help materials was 113.16 ± 160.19 min/week. The intervention group experienced a significant reduction with a moderate effect on binge eating at the end of the intervention (Hedges' g = 0.58), and the effects lasted through follow-up (Hedges' g = 0.82). Discussion: The results suggest that the digital intervention targeting a maintenance mechanism of recurrent binge eating was feasible and acceptable for patients with BN and BED, proving the potential for symptom improvement. Public significance: The addictive appetite model provides the framework for new interventions to improve treatments for BN and BED. This study found that the digital intervention based on the model was feasible and acceptable for patients with BN and BED.
Article
Background: The use of mobile health (mHealth) apps is increasing rapidly worldwide. More and more institutions and organizations develop regulations and guidelines to enable an evidence-based and safe use. In Germany, mHealth apps fulfilling predefined criteria (Digitale Gesundheitsanwendungen [DiGA]) can be prescribed and are reimbursable by the German statutory health insurance scheme. Due to the increasing distribution of DiGA, problems and barriers should receive special attention. Objective: This study aims to identify the relevant problems and barriers related to the use of mHealth apps fulfilling the criteria of DiGA. Methods: This scoping review will follow published methodological frameworks and the PRISMA-Scr (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews) criteria. Electronic databases (MEDLINE, EMBASE, PsycINFO, and JMIR), reference lists of relevant articles, and grey literature sources will be searched. Two reviewers will assess the eligibility of the articles by a two-stage (title and abstract as well as full text) screening process. Only problems and barriers related to mHealth apps fulfilling the criteria of DiGA are included for this research. The identified studies will be categorized and analyzed with MAXQDA. Results: This scoping review gives an overview of the available evidence and identifies research gaps regarding problems and barriers related to DiGA. The results are planned to be submitted to an indexed, peer-reviewed journal in the first quarter of 2022. Conclusions: This is the first review to identify the problems and barriers related to the use of mHealth apps fulfilling the German definition of DiGA. Nevertheless, the findings can be applied to other contexts and health care systems as well. International registered report identifier (irrid): DERR1-10.2196/32702.
Article
Background: Transcranial electrical stimulation (tES) is considered effective and safe for depression, albeit modestly, and prone to logistical burdens when performed in external facilities. Investigation of portable tES (ptES), and potentiation of ptES with remote psychological interventions have shown positive, but preliminary, results. Research design: We report the rationale and design of an ongoing multi-arm, randomized, double-blind, sham-controlled clinical trial with digital features, using ptES and internet-based behavioral therapy (iBT) for major depressive disorder (MDD) (NCT04889976). Methods: We will evaluate the efficacy, safety, tolerability and usability of (1) active ptES + active iBT ("double-active"), (2) active ptES + sham iBT ("ptES-only"), and (3) sham ptES + sham iBT ("double-sham"), in adults with MDD, with a Hamilton Depression Rating Scale - 17 item version (HDRS-17) score ≥ 17 at baseline, during 6 weeks. Antidepressants are allowed in stable doses during the trial. Results: We primarily co-hypothesize changes in HDRS-17 will be greater in (1) "double-active" compared to "ptES-only", (2) "double-active" compared to "double-sham", and (3) "ptES-only" compared to "double-sham". We aim to enroll 210 patients (70 per arm). Conclusions: Our results should offer new insights regarding the efficacy and scalability of combined ptES and iBT for MDD, in digital mental health. Clinical trial registration: NCT04889976.
Article
Depression is a challenging condition that requires individuals to manage their moods and emotions over time. Within CSCW, there has been an interest in understanding how individuals seek and share support on social media and in online communities. However, less attention has been paid to how collaboration as an aspect of self-management of depression unfolds in people's daily lives. In this paper, we explore the collaborative self-management work of 28 individuals managing depression who live in the United States. Data collection included remote semi-structured interviews with an associated cognitive mapping exercise. Our findings describe who participants turn to for day-to-day collaborative support, how collaborative activities are enacted (across both mood-focused and preventative support practices), and where these often technology-mediated interactions occur across text, phone, video, and picture-based channels. We discuss collaborative self-management in the depression support context, including key characteristics: agency, reciprocity, time, and interaction. We also present a four-step model of how the process occurs over time (awareness, planning, interaction, and reflection). We conclude by discussing how technology ecosystems support individuals' collaborative self-management.
Thesis
Depressive Störungen stellen die häufigsten psychischen Erkrankungen weltweit dar. Depressive Störungen sind eine der Hauptursachen für Invalidität und stehen als Ursachen für Krankheitslast auf Platz drei in Europa. Jedoch ist die psychotherapeutische Versorgungslage für depressive Störungen auch in Deutschland unzureichend, weswegen die Notwendigkeit einer Verbesserung der Versorgung dringlich ist. Dies wird durch das häufige Vorhandensein von weiteren psychischen sowie somatischen Erkrankungen potenziert. Es gibt jedoch nur wenige spezifische Behandlungsangebote für das gleichzeitige Auftreten einer Depression mit komorbiden psychischen oder somatischen Erkrankungen, obwohl depressive Störungen einen starken Einfluss auf die Bewältigungskompetenzen von Betroffenen in Bezug auf weitere Komorbiditäten haben. Eine Kombinationsbehandlung von Depressionen und bestehenden Komorbiditäten ist daher sinnvoll und notwendig, um sowohl die Krankheitslast für Betroffene als auch die Belastung für die Gesellschaft durch die entstehenden Kosten zu mindern. Der stetig wachsende Zugang zum Internet und zu mobilen Anwendungen (Apps) bietet umfangreiche Möglichkeiten zur Bereitstellung von kombinierten Behandlungsangeboten. Eine Vielzahl an Studien konnte bereits die Effektivität von Internet- und mobilbasierten Interventionen (IMIs) für die Behandlung von depressiven Störungen nachweisen. Dennoch bleiben zwei zentrale Herausforderungen für diese spezifische Depressionstherapie bestehen. Zum einen gibt es nur wenig Wissen über die Effektivität von IMIs zur Behandlung von depressiven Störungen bei gleichzeitiger Komorbidität. Zum anderen bleibt - trotz der in der Fachliteratur vorhandenen zahlreichen Belege für die Effektivität von transdiagnostischen Faktoren - die Frage offen, weshalb Emotionsregulation als transdiagnostischer Faktor bisher nur wenig in IMIs integriert wurde und welche Rolle Emotionsregulation bei der Behandlung von depressiven Störungen mit vorhandenen Komorbiditäten spielt. Diese Dissertation setzt sich mit diesen zentralen Herausforderungen auseinander. Publikation 1 beschreibt eine dreiarmige, randomisiert-kontrollierte Studie, die das Ziel verfolgte, die Wirksamkeit eines SMS-basierten Nachsorgeprogramms zur Förderung der adaptiven Emotionsregulation zu untersuchen. Teilnehmende (N = 226) wurden im Anschluss an eine stationäre, akut-psychosomatische, verhaltenstherapeutische Behandlung für Depression und psychische Komorbiditäten einer von drei Studienbedingungen (1.) standardisierte SMS zur Förderung der adaptiven Emotionsregulation, 2.) individualisierte SMS, 3.) Wartekontrollgruppe) zugewiesen. Multilevel-Analysen zeigten, dass Teilnehmende, die standardisierte SMS erhielten, eine geringere Zunahme von depressiven Symptomen berichteten als Teilnehmende der anderen beiden Studienbedingungen. Das Ergebnis unterstreicht die Wichtigkeit der Förderung der adaptiven Emotionsregulation als Behandlungsfaktor für depressive und komorbid bestehende psychische Störungen und zeigt darüber hinaus die Relevanz von Nachsorgeinterventionen für den langfristigen Therapieerfolg. In Publikation 2 wird eine multizentrische, randomisiert-kontrollierte Studie beschrieben, in der ein Internet- und mobilbasiertes Nachsorgeprogramm für Betroffene von depressiven Störungen und chronischen Rückenschmerzen im Anschluss an eine stationäre, orthopädische Rehabilitation entwickelt wurde. Publikation 3 stellt die Ergebnisse der in Publikation 2 beschriebenen Studie dar (N = 210). Mittels Regressionsanalysen wurde gezeigt, dass die von Klinikern beurteilte Depressionsschwere in der Interventionsgruppe zwar geringer war als in der Kontrollgruppe, der Unterschied jedoch nicht signifikant ausfiel. Bei der von den Teilnehmenden beurteilten Depressionsschwere zeigte sich eine signifikant geringere Depressionsschwere in der Interventionsgruppe im Vergleich zur Kontrollgruppe. Die Ergebnisse deuten darauf hin, dass diese Intervention in der Routineversorgung nur begrenzten Einfluss auf die Depressionssymptomatik hat, jedoch positive Effekte in Bezug auf sekundäre Outcomes wie die subjektiv wahrgenommene Depressionsschwere, die Lebensqualität und die wahrgenommene Schmerzstärke zeigt. In Publikation 4 wurde eine randomisiert-kontrollierte Machbarkeitsstudie (N = 76) zur Untersuchung der Effektivität und Nutzungszufriedenheit einer IMI für depressiv Erkrankte mit chronischen Rückenschmerzen und Arbeitsunfähigkeit durchgeführt. Kovarianzanalysen zeigten eine kleine, statistisch signifikante Reduktion der Depressionsschwere in der Interventionsgruppe im Vergleich zur Wartekontrollgruppe. In Publikation 5 wurden die differenziellen Behandlungseffekte einer IMI für depressiv Erkrankte mit Diabetes mellitus untersucht (N = 253). Teilnehmende in der Interventionsgruppe erlebten eine signifikante Reduktion der Depressionssymptomatik. Dies war auch in einer Subgruppe von schwer depressiven Teilnehmenden der Fall war. Die Effekte wurden nicht durch den Schweregrad der Symptome moderiert, sondern ließen sich bei leichter bis schwerer Ausprägung der Depressionssymptomatik finden. Daraus kann abgeleitet werden, dass schwer Depressive von IMIs profitieren können. Zwei zentrale Schlüsse lassen sich aus dieser Dissertation ziehen: 1.) Die Förderung der adaptiven Emotionsregulation ist sehr wichtig und sollte in der Versorgung von psychischen Störungen, insbesondere bei depressiven Störungen, stärker fokussiert werden. 2.) Die Effektivität von IMIs konnte insbesondere für hochbelastete Betroffene mit Depression und bestehenden psychischen sowie somatischen Komorbiditäten gezeigt werden. Zusammenfassend lässt sich sagen, dass Internet- und mobilbasierte Interventionen dazu beitragen können, die psychotherapeutische Versorgung für depressiv Erkrankte mit psychischen sowie somatischen Komorbiditäten zu verbessern.
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Introduction Infertility and its treatment bring a considerable emotional burden. Increasing evidence demonstrates the effectiveness of smartphone-delivered mindfulness apps for reducing symptoms of emotional distress in both clinical and non-clinical populations. Evidence on this topic in women, men and couples experiencing infertility is currently under-represented. The aim of the MoMiFer study is, therefore, to investigate the efficacy of a stand-alone mobile mindfulness app on symptoms of emotional distress and fertility-related quality of life in people experiencing infertility. Methods and analysis This study is an exploratory randomised controlled trial (RCT) with open enrollment. The primary outcomes are symptoms of emotional distress and fertility-related quality of life. Secondary outcomes are mindfulness skills, repetitive negative thinking, self-compassion, user-rated quality of the stand-alone mobile mindfulness app and use of the app. Experience sampling method and standardised self-report questionnaires are combined within a repeated measures design to measure the effects of the stand-alone mobile mindfulness app on the primary and secondary outcomes, apart from the use of the app. The latter will be evaluated through app tracking. People, including women, men and couples, experiencing infertility (n=60) will be randomised to an intervention group receiving the stand-alone mobile mindfulness app for 3 months or a wait-list control group. The app follows the format and content of Mindfulness-Based Stress Reduction. Data will be collected at baseline, at 1.5 months and 3 months after randomisation. Analysis will be according to intention to treat and based on general linear modelling and multilevel mixed-effects modelling. Ethics and dissemination This study received approval from the Medical Ethical Committee of the Leuven University Hospital (Belgium). The findings of this exploratory RCT will be disseminated through presentations at public lectures, scientific institutions and meetings, and through peer-reviewed scientific articles. Trial registration number NCT04143828 .
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Purpose: A rapid increase in global smartphone ownership and digital health technologies offers the potential for mobile phone applications to deliver mental health interventions. The purpose of this umbrella review was to bring together evidence reporting on mental health mobile applications to gain an understanding of the quality of current evidence, the positive and adverse effects of applications, and the mechanisms underlying such effects. Design/methodology/approach: A systematic search was carried out across six databases, for any systematic reviews or meta-analyses conducted up to 2020. Review quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2). Findings: Across a total of 24 articles, a variety of clinical outcomes were assessed. Most compelling support was shown for applications targeting anxiety symptoms; some evidence favoured the use of applications for depression symptoms. Less evidence was available for the remaining clinical symptoms such as bipolar disorder, schizophrenia, post-traumatic stress disorder, sleep disorders, and substance use. Overall, there was limited evidence pertaining to adverse effects and change mechanisms, and a lack of quality reporting across a large proportion of included reviews. The included reviews demonstrate the need for further robust research before applications are recommended clinically. Originality: This umbrella review makes a valuable contribution to the current status of research and reviews investigating mental health mobile apps. Recommendations are made for improved adherence to review guidelines, to ensure risk of bias is minimised.
Article
Background The COVID-19 pandemic has been suggested to constitute a broad base stressor with severe mental health consequences. mHealth applications are accessible self-help tools that can be used to reduce psychological distress during the pandemic. This randomized controlled trial evaluated the effects of mobile-based cognitive training exercises on COVID-19 related distress and maladaptive cognitions. Methods Following initial screening (n = 924), participants scoring 1 standard deviations above the mean of the COVID-19 Distress Scale were randomized into two groups. Participants in the immediate-app group (iApp; n = 25) started using the application at baseline (T0) for 12 days (from T0 to T1). Participants in the delayed-app group (dApp; n = 22) started using the mobile application at T1 (crossover) and used it for the following 12 days (T1 to T2). Results Intention to treat analyses indicated that the iApp group exhibited lower COVID-19 distress, lower depression, fewer intolerance of uncertainty and obsessive beliefs than the dApp group at T1. In addition, using the app for 12 consecutive days was associated with large effect-size reductions (Cohen's d ranging from 0.81 to 2.35) in COVID-19 distress and related maladaptive cognitions in the iApp group (from T0 to T1) and the dApp group (from T1 to T2). Moreover, these reductions were maintained at the follow-up. Limitations This study was a crossover trial with a relatively limited sample size and mainly female participants. Conclusion Our findings underscore the usefulness of brief, low-intensity, portable interventions in alleviating the negative effects of the pandemic on mental health.
Article
Background: Most people with mental disorders in communities exposed to adversity in low-income and middle-income countries (LMICs) do not receive effective care. Digital mental health interventions are scalable when digital access is adequate, and can be safely delivered during the COVID-19 pandemic. Objective: To examine the effects of a new WHO-guided digital mental health intervention, Step-by-Step, supported by a non-specialist helper in Lebanon, in the context of concurring economic, humanitarian and political crises, a large industrial disaster and the COVID-19 pandemic. Methods: We conducted a single-blind, two-arm pragmatic randomised trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among people suffering from depression and impaired functioning. Primary outcomes were depression (Patient Health Questionnaire 9 (PHQ-9)) and impaired functioning (WHO Disability Assessment Schedule-12 (WHODAS)) at post-treatment. Findings: 680 people with depression (PHQ-9>10) and impaired functioning (WHODAS>16) were randomised to Step-by-Step or ECAU. Intention-to-treat analyses showed effects on depression (standardised mean differences, SMD: 0.71; 95% CI: 0.45 to 0.97), impaired functioning (SMD: 0.43; 95% CI: 0.21 to 0.65), post-traumatic stress (SMD: 0.53; 95% CI: 0.27 to 0.79), anxiety (SMD: 0.74; 95% CI: 0.49 to 0.99), subjective well-being (SMD: 0.37; 95% CI: 0.12 to 0.62) and self-identified personal problems (SMD: 0.56; 95% CI 0.29 to 0.83). Significant effects on all outcomes were retained at 3-month follow-up. Conclusions: Guided digital mental health interventions can be effective in the treatment of depression in communities exposed to adversities in LMICs, although some uncertainty remains because of high attrition. Clinical implications: Guided digital mental health interventions should be considered for implementation in LMICs. Trial registration number: ClinicalTrials.gov NCT03720769.
Article
Beading is a cultural art form that holds great significance for Indigenous communities. Across history, the practice of beading has been widely recognized by Indigenous peoples as a means of recording and translating cultural knowledge, and of promoting wellness across various contexts. While beading existed long before Settler-European contact, its survival amidst Canada’s colonial history is profound. With the rise of social media platforms, Indigenous communities have taken up digital spaces such as Twitter to support cultural resurgence and healing. Our study is interested in the everyday ways in which digital environments like Twitter may be therapeutic. Conceptually situated within the interdisciplinary nexus of Indigenous studies, psychotherapeutic studies, and contextualist qualitative research, we draw on an analysis of tweets and interviews from Indigenous beaders within Canada. Using a thematic approach (Clark & Braun, 2006), our analysis yielded 12 themes that speak to the relationship between, and possibilities and challenges related to, beading, Indigenous healing processes, and digital space. A discussion is provided on the benefits of the digital space for therapeutic healing, its limitations, tensions, and the colonial legacies that become re-enacted in digital spaces. Strengths and limitations of the study are also discussed.
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Background Depression and anxiety frequently coexist with chronic musculoskeletal pain and can negatively impact patients’ responses to standard orthopedic treatments. Nevertheless, mental health is not routinely addressed in the orthopedic care setting. If effective, a digital mental health intervention may be a feasible and scalable method of addressing mental health in an orthopedic setting. Objective We aimed to compare 2-month changes in mental and physical health between orthopedic patients who received a digital mental health intervention in addition to usual orthopedic care, those who received usual orthopedic care only (without a specific mental health intervention), and those who received in-person care with a psychologist as part of their orthopedic treatment plan. Methods In this single-center retrospective cohort study involving ancillary analysis of a pilot feasibility study, 2-month self-reported health changes were compared between a cohort of orthopedic patients who received access to a digital mental health intervention (Wysa) and 2 convenience sample comparison cohorts (patients who received usual orthopedic care without a specific mental health intervention and patients who received in-person care with a psychologist as part of their orthopedic treatment plan). All patients were 18 years or older and reported elevated symptoms of depression or anxiety at an orthopedic clinic visit (Patient-Reported Outcomes Measurement Information System [PROMIS] Depression or Anxiety score ≥55). The digital intervention was a multi-component mobile app that used chatbot technology and text-based access to human counselors to provide cognitive behavioral therapy, mindfulness training, and sleep tools, among other features, with an emphasis on behavioral activation and pain acceptance. Outcomes of interest were between-cohort differences in the 2-month longitudinal changes in PROMIS Depression and Anxiety scores (primary outcomes) and PROMIS Pain Interference and Physical Function scores (secondary outcomes). Results Among 153 patients (mean age 55, SD 15 years; 128 [83.7%] female; 51 patients per cohort), patients who received the digital mental health intervention showed clinically meaningful improvements at the 2-month follow-up for all PROMIS measures (mean longitudinal improvement 2.8-3.7 points; P≤.02). After controlling for age and BMI, the improvements in PROMIS Depression, Pain Interference, and Physical Function were meaningfully greater than longitudinal changes shown by patients who received usual orthopedic care (mean between-group difference 2.6-4.8 points; P≤.04). Improvements in PROMIS Physical Function were also meaningfully greater than longitudinal changes shown by patients who received in-person psychological counseling (mean between-group difference 2.4 points; P=.04). Conclusions Patients who received a digital mental health intervention as part of orthopedic care reported greater 2-month mean improvements in depression, pain interference, and physical function than patients who received usual orthopedic care. They also reported a greater mean improvement in physical function and comparable improvements in depression, anxiety, and pain interference compared with orthopedic patients who received in-person psychological counseling.
Article
Background: Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle 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 usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), 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 (CA). 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 taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be 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 WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage 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 (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with 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 with a human therapist in loop. 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. Clinicaltrial:
Article
Background Most displaced people with mental disorders in low- and middle-income countries do not receive effective care, and their access to care has deteriorated during the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health interventions are scalable when digital access is adequate, and they can be safely delivered during the COVID-19 pandemic. We examined whether a new WHO-guided digital mental health intervention, Step-by-Step, in which participants were supported by a nonspecialist helper, was effective in reducing depression among displaced people in Lebanon. Methods and findings We conducted a single-blind, 2-arm pragmatic randomized clinical trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among displaced Syrians suffering from depression and impaired functioning in Lebanon. Primary outcomes were depression (Patient Health Questionnaire, PHQ-9) and impaired functioning (WHO Disability Assessment Schedule-12, WHODAS) at posttreatment. Secondary outcomes included subjective well-being, anxiety, post-traumatic stress, and self-described problems. A total of 569 displaced people from Syria with depression (PHQ-9 ≥ 10) and impaired functioning (WHODAS > 16) were randomized to Step-by-Step ( N = 283; lost to follow-up: N = 167) or ECAU ( N = 286; lost to follow-up: 133). Participants were considered to be lost to follow-up when they did not fill in the outcome measures at posttest or follow-up. Recruitment started on December 9, 2019 and was completed on July 9, 2020. The last follow-up assessments were collected in December 2020. The study team had access to the online platform, where they could see treatment arm assignment for each participant. All questionnaires were completed by participants online. Intention-to-treat (ITT) analyses showed intervention effects on depression (standardized mean differences [SMDs]: 0.48; 95% CI: 0.26; 0.70; p < 0.001), impaired functioning (SMD: 0.35; 95% CI: 0.14; 0.56; p < 0.001), post-traumatic stress (SMD: 0.36; 95% CI: 0.16; 0.56; p < 0.001), anxiety (SMD: 0.46; 95% CI: 0.24; 0.68; p < 0.001), subjective well-being (SMD: 0.47; 95% CI: 0.26; 0.68; p < 0.001), and self-identified personal problems (SMD: 0.49; 95% CI 0.28; 0.70; p < 0.001). Significant effects on all outcomes were maintained at 3 months follow-up. During the trial, one serious adverse event occurred, unrelated to the intervention. The main limitation of the current trial is the high dropout rate. Conclusions In this study, we found that a guided, digital intervention was effective in reducing depression in displaced people in Lebanon. The guided WHO Step-by-Step intervention we examined should be made available to communities of displaced people that have digital access. Trial registration ClinicalTrials.gov NCT03720769 .
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We present the results of a pre-registered randomised controlled trial (RCT) that tested whether two smartphone-based mindfulness meditation applications (apps) lead to improvements in mental health. University students (n = 208, aged 18 to 49) were randomly assigned to use one of the three apps: Headspace, Smiling Mind, or Evernote (control group). Participants were instructed to use their assigned app for 10 min each day for 10 days, after which they received an extended 30 days’ access to continue practicing at their discretion. Participants completed measures of depressive symptoms, anxiety, stress, college adjustment, flourishing, resilience, and mindfulness at baseline, after the 10-day intervention, and after the 30-day continued access period. App usage was measured by self-report. Mindfulness app usage was high during the 10-day period (used on 8 of 10 days), but low during the 30-day extended use period (less than 20% used the app 2+ times per week). Mindfulness app users showed significant improvements in depressive symptoms, college adjustment, resilience (Smiling Mind only), and mindfulness (Headspace only) from baseline to the end of 10 days relative to control participants. Participants who continued to use the app frequently were more likely to maintain improvements in mental health, e.g. in depressive symptoms and resilience (Headspace only), until the end of the 30-day period. Thus, brief mobile mindfulness meditation practice can improve some aspects of negative mental health in the short term and may strengthen positive mental health when used regularly. Further research is required to examine the long-term effects of these apps.
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Background: Mindfulness-based interventions, self-compassion training, and cognitive behavioral therapy have garnered much evidence in its salutary effects on mental health. With increasing application of smartphone and mobile technology on health promotion, this study investigated the efficacy and possible moderators of mindfulness, self-compassion, and cognitive behavioral psychoeducation training mobile apps in the improvement of mental health. Objective: The aim of this study was to examine the efficacy of 3 mobile app-based programs: mindfulness-based program, self-compassion program, and cognitive behavioral psychoeducation program in improving mental well-being and reducing psychological distress. Changes in mindful awareness and self-compassion were also assessed. To further delineate the suitability of each program for different types of individuals, individual difference variables (ie, discomfort with emotions and tolerance for ambiguity) were explored for potential moderation. Methods: This study was a 3-arm, randomized, controlled, noninferiority trial examining the efficacy of mindfulness-based program, self-compassion program, and cognitive behavioral psychoeducation. Participants were randomized into either 1 of the 3 conditions. Throughout the 4-week, 28-session program, participants spent 10-15 min daily reviewing the course content and practicing various related exercises. At preprogram, postprogram, and 3-month follow-up, participants also completed Web-based measures of mental well-being, psychological distress, mindful-awareness, and self-compassion as well as the proposed moderators. Results: Among the 2161 study participants, 508 and 349 completed the post- and 3-month follow-up assessment, respectively. All 3 conditions (mindfulness-based program: N=703; cognitive behavioral psychoeducation: N=753; self-compassion program: N=705) were found to be efficacious in improving mental well-being and reducing psychological distress. All conditions enhanced mindful awareness at postprogram. Significant interaction effect was found on self-compassion; cognitive behavioral psychoeducation and self-compassion program, but not mindfulness-based program, significantly enhanced self-compassion at postprogram. No significant differences regarding usage and users' satisfaction were found among the 3 conditions. None of the proposed moderators were found to be significant. Conclusions: Mindfulness-based, self-compassion, and cognitive behavioral psychoeducation mobile apps were efficacious in improving mental well-being and reducing psychological distress among adults at postprogram and 3-month follow-up. Future app-based psychological training programs should consider gamification and personalization of content or feedback to enhance engagement and mitigate the high attrition rates that are common in app-based health promotion programs. Trial registration: Chinese Clinical Trial Registry (ChiCTR) ChiCTR-TRC-13003468; http://www.chictr.org.cn/hvshowproject.aspx?id=6220 (Archived by WebCite at http://www.webcitation.org/734PlOz50).
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Background Psychotherapy can alleviate mental distress and improve quality of life, but little is known about its potential negative effects and how to determine their frequency. Aims To present a commentary on the current understanding and future research directions of negative effects in psychotherapy. Method An anonymous survey was distributed to a select group of researchers, using an analytical framework known as strengths, weaknesses, opportunities and threats. Results The researchers perceive an increased awareness of negative effects in psychotherapy in recent years, but also discuss some of the unresolved issues in relation to their definition, assessment and reporting. Qualitative methods and naturalistic designs are regarded as important to pursue, although a number of obstacles to using such methods are identified. Conclusion Negative effects of psychotherapy are multifaceted, warranting careful considerations in order for them to be monitored and reported in research settings and routine care. Declaration of interest None.
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There are ongoing questions regarding the similarities and differences in the clinical impact and processes of change for cognitive restructuring and cognitive defusion. This clinical component test compared 87 adults high in self-criticism randomized to a cognitive defusion mobile app, restructuring app, or waitlist condition for 2 weeks. Equivalent improvements were found from the defusion and restructuring apps relative to the waitlist on self-criticism and distress as well as decentering, self-compassion, and dysfunctional attitudes. However, the defusion condition had a more consistent pattern of improvements relative to waitlist. Improvements in cognitive decentering, self-compassion, and dysfunctional attitudes mediated effects for cognitive defusion relative to waitlist. These mediators were inconsistent for cognitive restructuring. Improvements in self-compassion and cognitive decentering correlated with improvements in outcomes in the defusion condition, but not the restructuring condition. Overall, these results suggest mobile apps providing cognitive defusion and cognitive restructuring strategies are equally effective, but work through distinct processes of change. © 2018 Springer Science+Business Media, LLC, part of Springer Nature
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Background: Most people living with HIV (PLWH) reside in middle- and low-income countries with limited access to health services. Thus, cost-effective interventions that can reach a large number of PLWH are urgently needed. Objective: The objective of our study was to assess the feasibility and acceptability of an mHealth intervention among PLWH in China. Methods: Based on previous formative research, we designed an mHealth intervention program that included sending weekly reminders to participants via text messages (short message service, SMS) and articles on HIV self-management three times a week via a popular social media app WeChat. A total of 62 PLWH recruited from an HIV outpatient clinic were randomly assigned to intervention or control group. The intervention lasted for 3 months, and all participants were assessed for their medication adherence, presence of depression, quality of life (QoL), and CD4 (cluster of differentiation 4) counts. Upon completing the intervention, we interviewed 31 participants to further assess the feasibility and acceptability of the study. Results: At baseline, the intervention and control groups did not differ in terms of demographic characteristics or any of the major outcome measures. About 85% (53/62) of the participants completed the intervention, and they provided valuable feedback on the design and content of the intervention. Participants preferred WeChat as the platform for receiving information and interactive communication for ease of access. Furthermore, they made specific recommendations about building trust, interactive features, and personalized feedback. In the follow-up assessment, the intervention and control groups did not differ in terms of major outcome measures. Conclusions: This pilot study represents one of the first efforts to develop a text messaging (SMS)- and WeChat-based intervention that focused on improving the medication adherence and QoL of PLWH in China. Our data indicates that an mHealth intervention is feasible and acceptable to this population. The data collected through this pilot study will inform the future designs and implementations of mHealth interventions in this vulnerable population. We recommend more innovative mHealth interventions with rigorous designs for the PLWH in middle- and low-income countries. Trial registration: Chinese Clinical Trial Registry ChiCTR1800017987; http://www.chictr.org.cn/showprojen.aspx?proj=30448 (Archived by WebCite at http://www.webcitation.org/71zC7Pdzs). Registered report ientifier: RR1-10.2196/.
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We investigated whether a mindfulness meditation program delivered via a smartphone application could improve psychological well-being, reduce job strain, and reduce ambulatory blood pressure during the workday. Participants were 238 healthy employees from two large United Kingdom companies that were randomized to a mindfulness meditation practice app or a wait-list control condition. The app offered 45 prerecorded 10- to 20-min guided audio meditations. Participants were asked to complete one meditation per day. Psychosocial measures and blood pressure throughout one working day were measured at baseline and eight weeks later; a follow-up survey was also emailed to participants 16 weeks after the intervention start. Usage data showed that during the 8-week intervention period, participants randomized to the intervention completed an average of 17 meditation sessions (range 0–45 sessions). The intervention group reported significant improvement in well-being, distress, job strain, and perceptions of workplace social support compared to the control group. In addition, the intervention group had a marginally significant decrease in self-measured workday systolic blood pressure from pre- to post-intervention. Sustained positive effects in the intervention group were found for well-being and job strain at the 16-week follow-up assessment. This trial suggests that short guided mindfulness meditations delivered via smartphone and practiced multiple times per week can improve outcomes related to work stress and well-being, with potentially lasting effects.
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Background: Mental health problems are highly prevalent among college students. Most students with poor mental health, however, do not receive professional help. Internet-based self-help formats may increase the utilization of treatment. Objective: The aim of this randomized controlled trial was to evaluate the efficacy of an internet-based, app-supported stress management intervention for college students. Methods: College students (n=150) with elevated levels of stress (Perceived Stress Scale 4-item version, PSS-4 ≥8) were randomly assigned to either an internet- and mobile-based stress intervention group with feedback on demand or a waitlist control group. Self-report data were assessed at baseline, posttreatment (7 weeks), and 3-month follow-up. The primary outcome was perceived stress posttreatment (PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinically relevant symptoms of depression (Center for Epidemiological Studies’ Depression Scale >17). Results: A total of 106 participants (76.8%) indicated that they were first-time help-seekers, and 77.3% (intervention group: 58/75; waitlist control group: 58/75) showed clinically relevant depressive symptoms at baseline. Findings indicated significant effects of the intervention compared with the waitlist control group for stress (d=0.69; 95% CI 0.36-1.02), anxiety (d=0.76; 95% CI 0.43-1.09), depression (d=0.63; 95% CI 0.30-0.96), college-related productivity (d=0.33; 95% CI 0.01-0.65), academic work impairment (d=0.34; 95% CI 0.01-0.66), and other outcomes after 7 weeks (posttreatment). Response rates for stress symptoms were significantly higher for the intervention group (69%, 52/75) compared with the waitlist control group (35%, 26/75, P<.001; number needed to treat=2.89, 95% CI 2.01-5.08) at posttest (7 weeks). Effects were sustained at 3-month follow-up, and similar findings emerged in students with symptoms of depression. Conclusions: Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress and might potentially attract students with clinically relevant depression who would not otherwise seek help.
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Objective: Perseverative cognition (e.g. worry) and unconscious stress are suggested to be important mediators in the relation between stressors and physiological health. We examined whether a smartphone-based worry-reduction training improved a physiological marker of stress (i.e. increased heart rate variability [HRV]) and unconscious stress. Design: Randomised-controlled trial was conducted with individuals reporting work stress (n = 136). Participants were randomised to the experimental, control or waitlist condition (resp. EC, CC, WL). The EC and CC registered emotions five times daily for four weeks. The EC additionally received a worry-reduction training with mindfulness exercises. Main Outcome Measures: Primary outcome was 24-h assessments of HRV measured at pre-, mid- and post-intervention. Secondary outcomes were implicit affect and stress. Effects on heart rate and other psychological outcomes were explored. Results: A total of 118 participants completed the study. No change from pre- to post-intervention was observed for the primary or secondary outcomes. The change over time was not different between conditions. Conclusion: Findings suggest that the training was ineffective for improving HRV or psychological stress. Future studies may focus on alternative smartphone-based stress interventions, as stress levels are high in society. There is need for easy interventions and smartphones offer possibilities for this.
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Objective: Internet-based cognitive-behavioral treatments (ICBT) have shown promise for various mental disorders, including social anxiety disorder (SAD). Most of these treatments have been delivered on desktop computers. However, the use of smartphones is becoming ubiquitous and could extend the reach of ICBT into users' everyday life. Only a few studies have empirically examined the efficacy of ICBT delivered through a smartphone app and there is no published study on mobile app delivered ICBT for SAD. This three-arm randomized-controlled trial (RCT) is the first to compare the efficacy of guided ICBT for smartphones (app) and conventional computers (PC) with a wait list control group (WL). Method: A total of 150 individuals meeting the diagnostic criteria for SAD were randomly assigned to one of the three conditions. Primary endpoints were self-report measures and diagnostic status of SAD. Results: After 12 weeks of treatment, both active conditions showed superior outcome on the composite of all SAD measures (PC vs. WL: d = 0.74; App vs. WL: d = 0.89) and promising diagnostic response rates (NNTPC = 3.33; NNTApp = 6.00) compared to the WL. No significant between-groups effects were found between the two active conditions on the composite score (Cohen's d = 0.07). Treatment gains were maintained at 3-month follow-up. Program use was more evenly spread throughout the day in the mobile condition, indicating an integration of the program into daily routines. Conclusions: ICBT can be delivered effectively using smartphones. (PsycINFO Database Record
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Objective: The aim of this study was to assess whether an in-person mindfulness-based resilience training (MBRT) program or a smartphone-delivered resiliency-based intervention improved stress, well-being, and burnout in employees at a major tertiary health care institution. Methods: Sixty participants were randomized to a 6-week MBRT, a resiliency-based smartphone intervention, or an active control group. Stress, well-being, and burnout were assessed at baseline, at program completion, and 3 months postintervention. Results: Both the MBRT and the smartphone groups showed improvements in well-being, whereas only the MBRT group showed improvements in stress and emotional burnout over time. The control group did not demonstrate sustained improvement on any outcome. Conclusion: Findings suggest that brief, targeted interventions improve psychological outcomes and point to the need for larger scale studies comparing the individual and combined treatments that can inform development of tailored, effective, and low-cost programs for health care workers.
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Background: One in five Canadians experience mental health issues with those in the age range of 15 to 24 years being most at risk of a mood disorder. University students have shown significantly higher rates of mental health problems than the general public. Current university support services are limited by factors such as available staff and finances, and social stigma has frequently been identified as an additional barrier that prevents students from accessing these resources. Mobile health (mHealth) apps are one form of alternative health support that is discrete and accessible to students, and although they are recognized as a promising alternative, there is limited research demonstrating their efficacy. Objective: The aim of this study was to evaluate a mindfulness-based app's ("DeStressify") efficacy on stress, anxiety, depressive symptomology, sleep behavior, work or class absenteeism, work or school productivity, and quality of life (QoL) among university students. Methods: Full-time undergraduate students at a Canadian university with smartphones and Internet access were recruited through in-class announcements and on-campus posters. Participants randomized into an experimental condition were given and instructed to use the DeStressify app 5 days a week for 4 weeks. Control condition participants were wait-listed. All participants completed pre- and postintervention Web-based surveys to self-assess stress, anxiety, depressive symptomatology, sleep quality, and health-related QoL. Results: A total of 206 responses were collected at baseline, with 163 participants completing the study (86 control, 77 experimental). Using DeStressify was shown to reduce trait anxiety (P=.01) and improve general health (P=.001), energy (P=.01), and emotional well-being (P=.01) in university students, and more participants in the experimental condition believed their productivity improved between baseline and postintervention measurements than the number of participants expected to believe so randomly by chance (P=.01). The app did not significantly improve stress, state anxiety, physical and social functioning, and role limitations because of physical or emotional health problems or pain (P>.05). Conclusions: Mindfulness-based apps may provide an effective alternative support for university students' mental health. Universities and other institutions may benefit from promoting the use of DeStressify or other mindfulness-based mHealth apps among students who are interested in methods of anxiety management or mindfulness-based self-driven health support. Future steps include examining DeStressify and similar mHealth apps over a longer period and in university staff and faculty.
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Mobile apps may be useful in teaching psychological skills in a high-frequency, low-intensity intervention. The acceptance and commitment therapy (ACT) matrix is a visual tool to help develop psychological flexibility by categorizing moment-to-moment experience and is well suited to a mobile app. This pilot study tested the effects of a simple and complex version of a novel app using the ACT matrix in two distinct samples: help-seeking individuals ( n = 35) and students receiving SONA credit ( n = 63). Findings indicated no differences between app conditions and a waitlist condition in the SONA credit sample. However, in the help-seeking sample, improvements were found on well-being and valued action in participants who used the app, with greater improvements and app adoption for those using a complex version with additional skills. A mobile app based on the ACT matrix has benefits for help-seeking individuals, but supplementary features may be necessary to support consistent use and benefits.
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During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, -.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.
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Background This study is one of the first randomized controlled trials investigating cognitive behavioral therapy for insomnia (CBT-I) delivered by a fully automated mobile phone app. Such an app can potentially increase the accessibility of insomnia treatment for the 10% of people who have insomnia. Objective The objective of our study was to investigate the efficacy of CBT-I delivered via the Sleepcare mobile phone app, compared with a waitlist control group, in a randomized controlled trial. Methods We recruited participants in the Netherlands with relatively mild insomnia disorder. After answering an online pretest questionnaire, they were randomly assigned to the app (n=74) or the waitlist condition (n=77). The app packaged a sleep diary, a relaxation exercise, sleep restriction exercise, and sleep hygiene and education. The app was fully automated and adjusted itself to a participant’s progress. Program duration was 6 to 7 weeks, after which participants received posttest measurements and a 3-month follow-up. The participants in the waitlist condition received the app after they completed the posttest questionnaire. The measurements consisted of questionnaires and 7-day online diaries. The questionnaires measured insomnia severity, dysfunctional beliefs about sleep, and anxiety and depression symptoms. The diary measured sleep variables such as sleep efficiency. We performed multilevel analyses to study the interaction effects between time and condition. Results The results showed significant interaction effects (P<.01) favoring the app condition on the primary outcome measures of insomnia severity (d=–0.66) and sleep efficiency (d=0.71). Overall, these improvements were also retained in a 3-month follow-up. Conclusions This study demonstrated the efficacy of a fully automated mobile phone app in the treatment of relatively mild insomnia. The effects were in the range of what is found for Web-based treatment in general. This supports the applicability of such technical tools in the treatment of insomnia. Future work should examine the generalizability to a more diverse population. Furthermore, the separate components of such an app should be investigated. It remains to be seen how this app can best be integrated into the current health regimens. Trial Registration Netherlands Trial Register: NTR5560; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5560 (Archived by WebCite at http://www.webcitation.org/6noLaUdJ4)
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Objectives Rates of youth suicide in Australian Indigenous communities are 4 times the national youth average and demand innovative interventions. Historical and persistent disadvantage is coupled with multiple barriers to help seeking. Mobile phone applications offer the opportunity to deliver therapeutic interventions directly to individuals in remote communities. The pilot study aimed to evaluate the effectiveness of a self-help mobile app (ibobbly) targeting suicidal ideation, depression, psychological distress and impulsivity among Indigenous youth in remote Australia. Setting Remote and very remote communities in the Kimberley region of North Western Australia. Participants Indigenous Australians aged 18–35 years. Interventions 61 participants were recruited and randomised to receive either an app (ibobbly) which delivered acceptance-based therapy over 6 weeks or were waitlisted for 6 weeks and then received the app for the following 6 weeks. Primary and secondary outcome measures The primary outcome was the Depressive Symptom Inventory—Suicidality Subscale (DSI-SS) to identify the frequency and intensity of suicidal ideation in the previous weeks. Secondary outcomes were the Patient Health Questionnaire 9 (PHQ-9), The Kessler Psychological Distress Scale (K10) and the Barratt Impulsivity Scale (BIS-11). Results Although preintervention and postintervention changes on the (DSI-SS) were significant in the ibobbly arm (t=2.40; df=58.1; p=0.0195), these differences were not significant compared with the waitlist arm (t=1.05; df=57.8; p=0.2962). However, participants in the ibobbly group showed substantial and statistically significant reductions in PHQ-9 and K10 scores compared with waitlist. No differences were observed in impulsivity. Waitlist participants improved after 6 weeks of app use. Conclusions Apps for suicide prevention reduce distress and depression but do not show significant reductions on suicide ideation or impulsivity. A feasible and acceptable means of lowering symptoms for mental health disorders in remote communities is via appropriately designed self-help apps. Trial registration number ACTRN12613000104752.
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The psychological treatment of mental health problems is beginning to undergo a sea-change driven by the widespread availability of digital technology. In this paper we provide an overview of the developments to date and those in the pipeline. We describe the various uses of digital interventions and consider their likely impact on clinical practice, clinical services and the global dissemination of psychological treatments. We note the importance of online clinics, blended treatment, digital assessment and digital training.
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Background Mobile apps for mental health have the potential to overcome access barriers to mental health care, but there is little information on whether patients use the interventions as intended and the impact the