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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... 6 However, despite the development of more than 10 000 mental health apps, only a small proportion are based on robust science and established treatment principles or have been rigorously tested in well-powered, randomised controlled trials. [6][7][8] Although there is emerging evidence for apps as treatments for anxiety and depression, 6-8 the average sample size is fewer than 100 participants per trial group, and few trials evaluate outcomes after 6-12 weeks 8 or whether apps can prevent poor mental health in young people. 8 To our knowledge, Emotional Competence for Wellbeing in the Young (ECoWeB) is the first, fully powered, definitive trial of apps for preventing depression in young people across multiple countries and languages. ...
... [6][7][8] Although there is emerging evidence for apps as treatments for anxiety and depression, 6-8 the average sample size is fewer than 100 participants per trial group, and few trials evaluate outcomes after 6-12 weeks 8 or whether apps can prevent poor mental health in young people. 8 To our knowledge, Emotional Competence for Wellbeing in the Young (ECoWeB) is the first, fully powered, definitive trial of apps for preventing depression in young people across multiple countries and languages. ...
... The CBT app was based on generic, well established CBT principles and strategies including behavioural activation, problem solving, and spotting and challenging negative thoughts, which have been shown to reduce symptoms of depression and anxiety in young adults via online delivery. 4,5,8 The CBT app was designed to include important elements of CBT, unlike most mental health apps that lack core CBT elements, such as cognitive restructuring and problem-solving. 23 The CBT app had identical architecture and features and an identical menu to the emotional competence app to match the interventions for delivery, structure, and format, but with different specific CBT content in animated videos, challenges, and tools. ...
... With the surge in mobile technology, mobile apps emerged, transforming the delivery format of various services in life. The many advantages of mobile apps, such as easy access, budget-friendly, and anonymity (Edge et al., 2023;Linardon et al., 2019), make them a seemingly viable alternative to traditional in-person mental health treatment. While an estimated 10,000-20,000 mental health apps (MHAs) are available to the public (Clay, 2021;Lecomte et al., 2020), only limited empirical evidence was presented for their effectiveness in alleviating mental illness symptoms (Lecomte et al., 2020). ...
... Depression is a prevalent mental health condition that has affected millions of people globally (World Health Organization [WHO], 2023) and is one of the most important risk factors for suicides (Bachmann, 2018). Recent meta-analyses assessed comparative studies (e.g., randomized controlled trials [RCTs]) and found MHAs effective in improving depressive conditions with small-to-moderate effects (Firth et al., 2017;Linardon et al., 2019;Qin et al., 2022). However, studies utilized smaller sample sizes, and within-group research designs remain unexamined. ...
... However, studies utilized smaller sample sizes, and within-group research designs remain unexamined. Efforts to identify factors related to these effects yielded preliminary findings (Firth et al., 2017;Linardon et al., 2019;Qin et al., 2022;Six et al., 2021), accentuating the need for further investigations. Given these research gaps, we conducted a comprehensive meta-analysis to evaluate the effectiveness of MHAs in alleviating depression symptoms through scrutinizing quantitative outcome studies. ...
Article
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The rapid growth of mobile technology and the increasing prevalence of mental health issues highlight the need to investigate the potential of mobile apps for promoting mental health. In this study, we conducted a comprehensive meta‐analysis to systematically review and synthesize research studies published between 2002 and 2021. The search yielded 46 eligible studies (26 comparative studies and 20 within‐group studies) evaluating the effectiveness of mental health apps (MHAs) in treating depression, with outcome data from 4207 participants. Overall, analyses showed small (for comparative studies) and medium (for within‐group studies) effect sizes favoring MHAs reducing depression symptoms. In within‐group studies, participants had significantly more treatment gain with MHA interventions lasting over 4 weeks, with over 8‐week intervals associated with the greatest reductions in depression symptoms. Gender, ethnicity, intervention type, and app type are not significant moderators.
... Implementation of evidence based digital mental health interventions into real-world care is therefore lacking, resulting in the need to prioritise research exploring workflow considerations (Torous et al., 2021). Linardon et al. (2019) found that studies that took a blended approach improved engagement (a blended approach includes human support supplementing a digital intervention). There is also a lack of gold standard evidence and best practices to determine which interventions are effective for specific industry sectors or workforce populations alongside identifying those which may potentially cause harm (Stratton et al. 2017). ...
... Previous studies have shown the positive impact of guidance or human support supplementing a digital intervention (Linardon et al. 2019), where Philips et al.'s (2019 review of in particular stress reduction interventions found the treatment effect was significantly increased by guidance. However, in contrast Carolan et al.'s (2017) review found no significant difference between interventions that had guidance, and those that did not. ...
Preprint
BACKGROUND There is potential for digital mental health interventions to provide affordable, efficient, and scalable support to individuals. Digital interventions, including CBT, stress-management, and mindfulness programs, have shown promise when applied in workplace settings. OBJECTIVE The aim of this study is to conduct an umbrella review of systematic reviews in order to critically evaluate, synthesise, and summarise evidence of various digital mental health interventions available within a workplace setting. METHODS A systematic search was conducted to identify systematic reviews relating to digital interventions for the workplace, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The review protocol was registered in the Open Science Framework (OSF) https://doi.org/10.17605/OSF.IO/RC6DS The following databases were searched: Pubmed, Web of Science, Medline, and Cochrane Library. Data was extracted using a pre-defined extraction table. To assess the methodological quality of a study, the AMSTAR-2 tool was used to critically appraise systematic reviews of healthcare interventions. RESULTS The literature search resulted in 4,122 records, which was reduced to 13 full-text systematic literature reviews with the use of Covidence to remove duplicates and screen titles and abstracts. The 13 included reviews were published between 2014 and 2023, comprising of eight systematic reviews and five systematic reviews and meta-analysis. AMSTAR-2 was used to complete a quality assessment of the reviews, the results were critically low (n = 7), and low (n = 6). The most common types of digital intervention studied were cognitive behavioural therapy (CBT), mindfulness/meditation, stress-management followed by other self-help interventions. Effectiveness of digital interventions was found for many mental health symptoms and conditions in employee populations, such as stress, anxiety, depression, burnout and psychological wellbeing. Factors such as type of technology, guidance, recruitment, tailoring, and demographics were found to impact on effectiveness. CONCLUSIONS This umbrella review aimed to critically evaluate, synthesise and summarise evidence of various digital mental health interventions available within a workplace setting. Despite the low quality of the reviews, best practice guidelines can be derived from factors that impact the effectiveness of digital interventions in the workplace.
... Mental health apps have been accessible on smartphones for over a decade, with growing evidence for their ability to reduce depression, anxiety, and other psychiatric symptoms [9][10][11][12]. Bene ts of smartphone apps include convenience, scalability, anonymity, personalisation, and real time monitoring of patients. ...
... These ndings extend the available literature on the credibility and acceptability of mindfulness apps as a method of low-intensity treatment for mental health symptoms [10][11][12]18]. Attrition was roughly 30% during the acute 4-week intervention period and varied during later timepoints but generally stayed below the expected average reported in a review of mindfulness app RCTs (i.e., upwards of 39%) in studies where larger samples, like ours (n > 100), and more general population targets are recruited. ...
Preprint
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Background While mindfulness apps have received growing clinical attention, their integration within health systems has received limited empirical investigation. In this study, we evaluated a mindfulness app as a low-intensity treatment option for adults waiting for psychological services. A non-randomized clinical trial was conducted with a 4-week acute intervention period with an 8-week follow-up. Adults (N = 193) with moderate depression and anxiety symptoms, completed a baseline session and received access to AmDTx, a mobile mindfulness training app. Additional assessments were completed at 2, 4, 8, and 12 weeks. Descriptive statistics of attrition, adoption, acceptability, and engagement were computed. Linear mixed models estimated treatment outcomes for functional disability (primary endpoint), depression, anxiety, stress, rumination, and mindful awareness/acceptance. We also evaluated the dose-response association between app use and functional disability. Results Using intent-to-treat analyses, there was a 75% adoption of the app and a 30% attrition rate in the first 4 weeks. In addition, 1.09 hours of meditation time and 9.16 exercises were recorded on average within the first 4 weeks. Participants reported positive credibility, acceptability, and usability ratings on established measures. Treatment effects were observed in the expected direction for all outcomes but one (mindful awareness). Dose-response relationships indicated that increases in app engagement correlated with decreases in functional disability. Conclusions The findings reinforce the potential for AmDTx, and mindfulness apps more broadly, to serve as low-intensity tools to alleviate unmet service needs and impart clinically meaningful benefit for a significant subset of those waiting for psychological services. Clinical Trial Registration: Clinicaltrials.gov, NCT05211960, Registered 2022-01-26.
... 27 Moreover, as mHealth apps have greater flexibility, they become a more accessible, low-cost, and userfriendly alternative to traditional interventions. 8,28 For instance, mobile DTx platform Clickotine, helps smokers quit using a customized plan and scientifically based strategies to overcome cravings as well as social support and direct access to quit aids. 26,29 Moreover, app-based DTx interventions are effective for several common mental health problems such as improving depressive symptoms, anxiety symptoms, stress levels, general psychiatric distress, and quality of life. ...
... There is also huge potential for real-world data generation since apps allow continuous real-time data collection on the patient's phone, leading to the personalization of the care process and to the reduction of bias in healthcare databases and algorithms. 28 Artificial intelligence: AI could play a significant role in driving personalization and increasing engagement of DTx interventions. AI-enabled DTx promise to provide more personalized support to better address a patient's specific issues and to anticipate needs and challenges based on the individual's behavior throughout their treatment journey. ...
Article
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Digital therapeutics (DTx), a burgeoning subset of digital health solutions, has garnered considerable attention in recent times. These cutting-edge therapeutic interventions employ diverse technologies, powered by software algorithms, to treat, manage, and prevent a wide array of diseases and disorders. Although DTx shows significant promise as an integral component of medical care, its widespread integration is still in the preliminary stages. This limited adoption can be largely attributed to the scarcity of comprehensive research that delves into DTx's scope, including its technological underpinnings, potential application areas, and challenges—namely, regulatory hurdles and modest physician uptake. This review aims to bridge this knowledge gap by offering an in-depth overview of DTx products’ value to both patients and clinicians. It evaluates the current state of maturity of DTx applications driven by digital technologies and investigates the obstacles that developers and regulators encounter in the market introduction phase.
... Depression is among the most common mental disorders worldwide (Kessler & Bromet, 2013;Lim et al., 2018) and constitutes a substantial global disease burden (GBD 2019 Diseases andInjuries Collaborators, 2022) that necessitates effective and broadly available treatment. Several meta-analyses indicate that digital interventions are effective in the treatment of depression (Karyotaki et al., 2018;Karyotaki et al., 2021;Königbauer et al., 2017;Linardon et al., 2019;Moshe et al., 2021;Reins et al., 2021), particularly when implemented with some type of human guidance (Baumeister et al., 2014;Karyotaki et al., 2021;Moshe et al., 2021). Digital interventions possess the potential to extend mental healthcare and overcome some of the treatment barriers of on-site psychotherapy (Andrade et al., 2014;Ebert et al., 2017), due to their remote delivery format and by promoting greater flexibility and anonymity, as well as potentially increased costeffectiveness and accessibility on a population scale (Andersson et al., 2019;Ebert et al., 2018;Linardon et al., 2019;Paganini et al., 2018;Torous et al., 2021). ...
... Several meta-analyses indicate that digital interventions are effective in the treatment of depression (Karyotaki et al., 2018;Karyotaki et al., 2021;Königbauer et al., 2017;Linardon et al., 2019;Moshe et al., 2021;Reins et al., 2021), particularly when implemented with some type of human guidance (Baumeister et al., 2014;Karyotaki et al., 2021;Moshe et al., 2021). Digital interventions possess the potential to extend mental healthcare and overcome some of the treatment barriers of on-site psychotherapy (Andrade et al., 2014;Ebert et al., 2017), due to their remote delivery format and by promoting greater flexibility and anonymity, as well as potentially increased costeffectiveness and accessibility on a population scale (Andersson et al., 2019;Ebert et al., 2018;Linardon et al., 2019;Paganini et al., 2018;Torous et al., 2021). ...
Article
Background: While the efficacy of digital interventions for the treatment of depression is well established, comprehensive knowledge on how therapeutic changes come about is still limited. This systematic review aimed to provide an overview of research on change mechanisms in digital interventions for depression and meta-analytically evaluate indirect effects of potential mediators. Methods: The databases CENTRAL, Embase, MEDLINE, and PsycINFO were systematically searched for randomized controlled trials investigating mediators of digital interventions for adults with depression. Two reviewers independently screened studies for inclusion, assessed study quality and categorized potential mediators. Indirect effects were synthesized with a two-stage structural equation modeling approach (TSSEM). Results: Overall, 25 trials (8110 participants) investigating 84 potential mediators were identified, of which attentional (8 %), self-related (6 %), biophysiological (6 %), affective (5 %), socio-cultural (2 %) and motivational (1 %) variables were the scope of this study. TSSEM revealed significant mediation effects for combined self-related variables (ab = −0.098; 95 %-CI: [−0.150, −0.051]), combined biophysiological variables (ab = −0.073; 95 %-CI: [−0.119, −0.025]) and mindfulness (ab = −0.042; 95 %-CI: [−0.080, −0.015]). Meta-analytical evaluations of the other three domains were not feasible. Limitations: Methodological shortcomings of the included studies, the considerable heterogeneity and the small number of investigated variables within domains limit the generalizability of the results. Conclusion: The findings further the understanding of potential change mechanisms in digital interventions for depression and highlight recommendations for future process research, such as the consideration of temporal precedence and experimental manipulation of potential mediators, as well as the application of network approaches.
... The advent of mental health apps is another digital innovation that has equipped individuals with tools for monitoring and management. 39 Lastly, artificial intelligence (AI) can augment mental health care by improving the precision of psychological diagnostic and treatment approaches. 40 AI-powered algorithms and machine learning techniques, trained on vast datasets of clinical information, can be used to generate individualized recommendations for mental health assessment and treatment. ...
... 105 These app-supported interventions have demonstrated significant efficacy in improving various mental health outcomes, including depressive symptoms, generalized anxiety, stress levels, quality of life, social anxiety, and positive affect. 39 Additionally, these apps offer specific skill-building resources, such as mindfulness practices, 106 mood tracking, 107 emotional well-being 108 and resilience, 109 further enhancing their utility for users. However, it is crucial to note that while many mobile health (mHealth) apps exist, a substantial portion lack clinically validated evidence of efficacy. ...
Article
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In recent years, the integration of digital technology into mental health care has become increasingly prevalent. However, digitalization serves as a dual-force catalyst in the domain of psychological sciences, presenting a spectrum of unparalleled opportunities and significant challenges. The technological growth required for providing mental health interventions transcending geographical and temporal constraints also contributes massively to the emergence of psychological phenomena that can detrimentally impact mental health. This overview explores the intricate relationship shared between digitalization and mental health, investigating the challenges posed by the digital landscape on psychological well-being while highlighting the potential of digital platforms to address mental health concerns and enhance overall well-being
... Most research on the alliance-outcome association has been focused on interventions delivered in person (Flückiger et al., 2018). Recently, there has been exponential growth in public use of mental-health apps (Wasil et al., 2020) and an increasingly number of randomized controlled trials (RCTs) testing such approaches (Goldberg, Lam, et al., 2022;Linardon et al., 2019). The successful application of mobile-health (mHealth) interventions has enormous potential to lower the cost of care, increase access by reducing barriers related to geography and provider availability, protect patient privacy, and ultimately, improve mental health at the population level (Steinhubl et al., 2013;Wehmann et al., 2020). ...
... The successful application of mobile-health (mHealth) interventions has enormous potential to lower the cost of care, increase access by reducing barriers related to geography and provider availability, protect patient privacy, and ultimately, improve mental health at the population level (Steinhubl et al., 2013;Wehmann et al., 2020). There is some evidence supporting the efficacy of mHealth interventions; meta-analyses of RCTs have shown positive effects on common mental-health symptoms (e.g., depression, anxiety; Goldberg, Lam, et al., 2022;Linardon et al., 2019;Weisel et al., 2019). There is also clear evidence that mHealth interventions, especially unguided smartphone apps, have high and rapid rates of disengagement (Baumel et al., 2019;Linardon & Fuller-Tyszkiewicz, 2020), and effect sizes are generally smaller than in-person interventions (Goldberg, Lam, et al., 2022). ...
Article
Bidirectional associations between changes in symptoms and alliance are established for in-person psychotherapy. Alliance may play an important role in promoting engagement and effectiveness within unguided mobile-health (mHealth) interventions. Using models disaggregating alliance and psychological distress into within- and between-persons components (random intercept cross-lagged panel model), we report bidirectional associations between alliance and distress over the course of a 4-week smartphone-based meditation intervention ( n = 302, 80.0% elevated depression/anxiety). Associations were stable across time, and effect sizes were similar to those observed for psychotherapy (distress to alliance: βs = −0.13 to −0.14; alliance to distress: βs = −0.09 to −0.10). Alliance may be worth measuring to improve the acceptability and effectiveness of mHealth tools. Further empirical and theoretical work characterizing the role and meaning of alliance in unguided mHealth is warranted.
... Several controlled trials of DHIDs conducted over the past twenty years have shown moderate to large effects for the prevention and treatment of depression [10,[17][18][19][20]. However, there is considerable variation in their effectiveness [15,18,[21][22][23], which might be explained due to DHIDs differing greatly in terms of their features, mode of delivery, and therapeutic approach. For example, some DHIDs are blended (i.e., websites and/or mobile applications which include access to a clinician or a coach as part of the treatment package), while other DHIDs only feature self-guided components, without the need for a coach or clinician [24,25]. ...
... Smartphone technologies also create novel platforms to deliver user-friendly psychological interventions based on the internet 32 . One meta-analysis showed the efficacy of using smartphone-delivered to reduce both depression and anxiety 33 . However, to what extent these effects are due to the therapy itself rather than using the smartphones and individuals' connection with their smartphones has to be determined 34 . ...
Article
Full-text available
As the internet is becoming more and more accessible and prevalent, there has been growing interest in determining the effect of internet use on human cognition, particularly memory. However, much less is known about how internet use frequency is related to episodic memory, which refers to the memory of past events as opposed to facts (i.e., semantic memory). Episodic memory is very relevant to the internet because of the notion that the internet is a form of transactive memory, which requires people to retrieve how information was accessed (i.e., episodic memory) rather than the information itself (i.e., semantic memory). By analyzing data from 36, 542 participants with 44.06% females and a mean age of 46.63 years old from the Understanding Society using multivariate and univariate analysis of variances (ANOVA), the current study found that the frequency of internet use is positively related to episodic memory (assessed using the immediate recall and delayed word recall tasks). These results provide support to the notion that the internet is a form of transactive memory and the “use it, or lose it” theory.
... While evidence is emerging on the efficacy of these apps for the improvement of EDs [1,12], it is still inconclusive [13]. In this regard, a systematic review and metaanalysis does not recommend to use apps as standalone psychological interventions but to combine them with face-to-face therapy ("blended care"; BC) [14]. ...
Article
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Background Interest in mental health smartphone applications has grown in recent years. Despite their effectiveness and advantages, special attention needs to be paid to two aspects to ensure app engagement: to include patients and professionals in their design and to guarantee their usability. The aim of this study was to analyse the perceived usability and quality of the preliminary version of RegulEm, an app based in the Unified Protocol, as part of the second stage of the app development. Methods A parallel mixed methods study was used with 7 professionals and 4 users who were previously involved in the first stage of the development of the app. MARS, uMARS and SUS scales were used, and two focus groups were conducted. Descriptive statistical analysis and a thematic content analysis were performed in order to gather as much information as possible on RegulEm’s usability and quality as well as suggestions for improvement. Results RegulEm’s usability was perceived through the SUS scale scores as good by users (75 points) and excellent by professionals (84.64 points), while its quality was perceived through the uMARS and MARS scales as good by both groups, with 4 and 4.14 points out of 5. Different areas regarding RegulEm’s usability and suggestions for improvement were identified in both focus groups and 20% of the suggestions proposed were implemented in the refined version of RegulEm. Conclusion RegulEm’s usability and quality were perceived as good by users and professionals and different identified areas have contributed to its refinement. This study provides a more complete picture of RegulEm’s usability and quality prior analysing its effectiveness, implementation and cost-effectiveness in Spanish public mental health units.
... Mobile apps can increase access to and engagement in mental health-related interventions [15]. Many apps exist, with meta-analyses and systematic reviews suggesting mental health-focused apps improve mental healthrelated outcomes such as depression, anxiety, stress, and quality of life, with small to large effects [16][17][18]. Findings also generally suggest that post-secondary students are open to using apps to address their mental health concerns [19]. While promising in their impact, mobile mental health apps are heterogenous in terms of their specific interventions (e.g., mindfulness techniques, stress reduction), and there are many apps that have not been adequately evaluated [20]. ...
Article
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Background Technology use may be one strategy to promote mental health and wellbeing among young adults in post-secondary education settings experiencing increasing distress and mental health difficulties. The JoyPop™ app is mobile mental health tool with a growing evidence base. The objectives of this research are to (1) evaluate the effectiveness of the JoyPop™ app in improving emotion regulation skills (primary outcome), as well as mental health, wellbeing, and resilience (secondary outcomes); (2) evaluate sustained app use once users are no longer reminded and determine whether sustained use is associated with maintained improvements in primary and secondary outcomes; (3) determine whether those in the intervention condition have lower mental health service usage and associated costs compared to those in the control condition; and (4) assess users’ perspectives on the quality of the JoyPop™ app. Methods A pragmatic, parallel arm randomized controlled trial will be used. Participants will be randomly allocated using stratified block randomization in a 1:1 ratio to the intervention (JoyPop™) or control (no intervention) condition. Participants allocated to the intervention condition will be asked to use the JoyPop™ app at least twice daily for 4 weeks. Participants will complete outcome measures at four assessment time-points (first [baseline], second [after 2 weeks], third [after 4 weeks], fourth [after 8 weeks; follow-up]). Participants in the control condition will be offered access to the app after the fourth assessment time-point. Discussion Results will determine the effectiveness of the JoyPop™ app for promoting mental health and wellbeing among post-secondary students. If effective, this may encourage more widespread adoption of the JoyPop™ app by post-secondary institutions as part of their response to student mental health needs. Trial registration ClinicalTrials.gov NCT06154369. Registered on November 23, 2023.
... In this context, engagement refers to the degree to which users are involved, interact, and emotionally and cognitively invest in the intervention (Peters et al., 2018). This aspect of user experience is crucial, influencing treatment adherence, participant satisfaction, and ultimately, the effectiveness of the intervention (Linardon et al., 2019). User engagement is fundamental, serving as a bridge between the intervention and its outcomes. ...
Preprint
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Objective: Mental health concerns are rising, particularly among post-secondary students, who may lack access to traditional therapeutic resources due to barriers like long wait times and high costs. To help address these challenges, we explored the potential of large language model-based chatbots for supporting mental health and wellbeing in student populations. Methods: We conducted two studies, lasting one week and four weeks, to examine the effectiveness of chatbot interventions over different durations. Both studies compared two chatbot interventions—one mindfulness-focused and one value-focused—against an active check-in-only control condition. The primary outcome measure was the improvement in wellbeing through the mindfulness-to-meaning (MM) pathway, a process in which enhanced decentering, the ability to see one’s experience from a wider perspective, leads to improved positive reappraisal, the ability to find constructive and empowered interpretations of experience. Results: All conditions showed evidence of stress reduction. However, compared to the active control group, both intervention styles at both durations resulted in improved wellbeing via the MM pathway. This effect was primarily driven by significant improvements in decentering. For the longer duration only, we also observed enhanced reappraisal. Conclusions: These results emphasize the potential of chatbot-based interventions to support the development of regulatory skills by leveraging the MM pathway to enhance mental health. Educational institutions and mental health providers might consider integrating such tools into scalable and accessible student support systems, addressing a broader and more diverse audience while promoting sustained wellbeing through skills development.
... Mobile apps for mental health are also broadly feasible, acceptable, and of interest among veterans (Erbes et al., 2014). However, not all self-guided mobile apps have yielded benefits for PTSD symptoms (Goreis et al., 2020;Linardon et al., 2019), with one potential reason being variations in-app quality (Sander et al., 2020). Importantly, no research has yet examined whether a publicly available self-guided app tailored to the needs of military veterans and trauma survivors can extend the benefits of mindfulness training to addressing PTSD symptoms. ...
Article
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Objective: Mindfulness training can relieve posttraumatic stress disorder (PTSD) symptoms in military veterans and others but is inconsistently accessible. Self-guided mobile apps could improve access but their acceptability, feasibility, and benefits for veterans with PTSD have not been established. We conducted a pilot randomized trial of Mindfulness Coach (MC), a free, publicly available, trauma-informed mobile app tailored to veterans. Method: U.S. veterans with PTSD (n = 173) were randomized to self-guided use of MC or waitlist control (WLC) with 8-week follow-up. Clinical outcomes were PTSD symptoms (PTSD Symptom Checklist–5), depression symptoms (Patient Health Questionnaire, nine item), and psychosocial functioning (Brief Inventory of Psychosocial Functioning). Primary analyses were intent-to-treat using linear mixed models with maximum likelihood estimation. App uptake, objective usage, and usability ratings measured acceptance and feasibility. Results: Participants varied in age, gender, and ethnoracial identity; most reported recent mental health care utilization. Although study attrition was high (68.4% overall) due to participant dropout (treatment: 43.0%; control: 43.7%) and technical study issues (23% overall), diagnostic tests showed no evidence of bias due to missingness. Study completers (MC: n = 19; WLC: n = 37) showed medium effects on PTSD symptoms (b = −9.31, d = −0.69) and depression (b = −3.10, d = −0.52). Higher-intensity users showed greater benefits. App engagement trended lower for women and minoritized subpopulations. No changes were observed in psychosocial functioning. Usability and helpfulness ratings were favorable. Conclusions: Transdiagnostic clinical benefits indicate promise for MC as a public health resource for veterans with PTSD. Further study is warranted to confirm these benefits and ensure consistent engagement across subpopulations.
... At the same time, heart coherence exercises (HCEs) are often integrated into health apps on smartphones for direct use in stressful situations, though relaxation effects without prolonged training should be investigated more closely. Overall, evidence-based validation studies on the functions and effectiveness of health apps are lacking (Linardon et al., 2019;Wang et al., 2018). Only a few studies have investigated the use of short app-guided breathing exercises after acute stress, with initial study results indicating higher HRV and lower alpha-amylase levels during recovery but no differences in cortisol or self-reported stress (e.g., Chelidoni et al., 2020;Hunter et al., 2019;Plans et al., 2019). ...
... In addition to traditional evidence-based treatment modalities, mindfulness-based interventions have gained research interest, showing enhanced well-being in various settings [32][33][34], particularly for coping with chronic conditions, such as chronic pain [35][36][37]. Studies have demonstrated that mindfulness interventions benefit individuals with headaches by improving psychological functioning [38][39][40]. ...
... While the present study focused on the overarching intervention effects of the mTDI on depression, psychological distress, and positive wellbeing, future research should consider the role of human support (e.g., coaching, peer supportive accountability, orientation/training to use the app) in boosting app engagement and adherence, and the dose-response relationship between human support and potential improvements in user outcomes (Bernstein et al., 2022). Previous work indicates that this is a promising direction for improving app adherence and use (Fortuna et al., 2019;Linardon et al., 2019;Välimäki et al., 2017), and future research in this area is critical to harness the full potential of evidence-based mTDIs to improve mental health and wellbeing at scalable levels. Additionally, future research may also aim to study an active control condition in addition to a waitlist control group in order to better isolate active intervention mechanisms that may be related directly to the role of human support and as such, may have intervention effects on key outcome variables that extend beyond the intent to boost engagement and adherence. ...
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Objectives The rate of depression among college students has increased significantly, reducing vitality and ability to flourish. Mindfulness interventions delivered via technological platforms offer great promise for reducing depression symptoms and supporting positive wellbeing outcomes for college students. The present study aimed to understand the broader positive wellbeing outcomes that accompany a reduction in psychological distress following use of a technology-delivered mindfulness intervention. Methods Using a randomized controlled treatment design, this study evaluated the benefits of a mindfulness-based mobile application (app), Headspace, on various aspects of wellbeing in depressed college students. Students (n = 145) were randomly assigned to 2 months of app-based intervention or to a waitlist control. Participants completed self-report surveys assessing mental health and wellbeing at pre-intervention, midpoint (1 month), post-intervention (2 months), and follow-up (3 months). Results Using intent-to-treat analysis, those randomized to use the app, compared to those on the waitlist, demonstrated a reduction in depression symptoms, and in other indicators of psychological distress (e.g., anxiety, stress, negative affect), over time. Self-reported positive wellbeing outcomes included an increase in positive affect and happiness, enhanced capacity to savor the moment, enhanced compassion, self-regulation, and trait mindfulness. These statistically significant benefits were medium to large in size and lasted into the 1-month follow-up period. Further, students’ patterns of app use point to the critical gap that evidence-based technology-delivered interventions can fill. Conclusions Building on previous research, the present study illustrated that a technology-delivered mindfulness intervention comprehensively improved aspects of psychological distress and positive wellbeing in a sustained manner in college students. Preregistration This study was registered at OSF, https://osf.io/3trzk.
... Recent meta-analyses and reviews suggest that self-guided interventions effectively reduce symptoms and distress and increase positive attitudes toward help-seeking (Evans-Lacko et al., 2022). While therapistsupported digital interventions appear associated with greater benefits (Linardon et al., 2019), a large and growing body of evidence supports the efficacy of self-guided interventions as well for a variety of concerns including depression (Moshe et al., 2021), anxiety (Pauley et al., 2023), and suicidal ideation (Büscher et al., 2022). ...
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This study aimed to characterize the needs and preferences for digital health of individuals waitlisted for services. One hundred thirty-five people who sought mental health services in the past year and who were not receiving the service they sought completed questionnaires assessing their experiences during this period as well as their preferences related to digital interventions. Participants had sought services on average nearly 8 months prior to completing the survey (M = 7.74 months, SD = 8.51), most commonly for anxiety (N = 118, 87.4%) and depression (N = 101, 74.8%). Relative to the date they first sought services, participants reported reduced interest (d = −0.45) and motivation to engage (d = −0.43) in treatment, as well as reduced conviction in the belief that they would get better (d = −0.23) or that treatment would help (d = −0.30), although they also reported reduced symptom distress (d = −0.39). Very few (8%) reported satisfaction with the materials they were given by providers when seeking services. Participants reported high interest in a digital tool providing information about therapies (94.7% reporting moderate or greater interest), mental illnesses (87.4%), and places to find treatment (91.1%), as well as one that would provide interactive cognitive practices (85.2%) and strategies to improve sleep (85.8%). Over half of all participants reported that a mobile app would be their first choice for mode of delivery. This study highlights the need for and potential of digital tools optimized for waitlisted individuals, particularly interactive and informational resources provided through mobile devices.
... While there is some evidence that DHA might be effective in reducing symptoms of panic disorder and agoraphobia, the relevance of additional therapeutic contact is still object of debate. While some studies have indicated that guided DHA were significantly more effective in reducing symptom severity (Domhardt et al., 2019) and led to higher adherence rates (Linardon et al., 2019) than self-management interventions, Pauley et al. (2023) and Ivanova et al. (2016) found no significant difference between guided and unguided digital interventions for anxiety. With regard to the limited resources in health care, evidencebased interventions working without any therapist guidance might further help to improve health care for individuals suffering from PD/A who cannot be treated otherwise. ...
Article
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Background Cognitive behavioral therapy has proven to be effective in the treatment of panic disorder and/or agoraphobia (PD/A). However, psychotherapy is often not available in a timely manner. Hence, there is a need for alternative and easily accessible interventions. The current study, thus, aimed to evaluate a smartphone-based self-management-tool for panic disorder and/or agoraphobia. Method 107 participants were randomly assigned to either an intervention group (app “Mindable”) or a waitlist control group. Primary outcome was panic and agoraphobic symptom severity, further outcomes included perceived quality of life, anxiety control beliefs, and functional impairment. Linear mixed models were used to analyze the data in intent-to-treat- and completer-data sets. Results After the eight-week observation period, participants in the intervention group reported significantly stronger reductions in panic and agoraphobic symptoms (R² = 0.20) and a higher increase in anxiety-related control beliefs (R² = 0.125) than participants in the control condition. Despite this symptom reduction, only 4.3% of participants in the app group and none in the control group were considered as remitted. Quality of life and functional impairment improved in all participants over time, but no significant group x time interactions were found. Discussion A smartphone-based self-management tool is an easily accessible intervention to reduce panic and agoraphobic symptoms and enhance anxiety control in people with PD/A. As no symptom remission could be achieved, this approach may be suitable as part of a stepped care approach for anxiety disorders. Trial Registration Registration number: DRKS00029090, registered on 10.06.2022.
... Smartphone-based mental health applications have garnered considerable attention due to their ubiquity and seamless integration into everyday life [31,52]. These consumer-oriented apps offer a diverse array of services, ranging from self-guided meditation platforms such as Headspace a and Calm b , to peer-support networks like Talklife c , and online counseling services, for example, Talkspace d . ...
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Sustaining long-term user engagement with mobile health (mHealth) interventions while preserving their high efficacy remains an ongoing challenge in real-world well-being applications. To address this issue, we introduce a new algorithm, the Personalized, Context-Aware Recommender (PCAR), for intervention selection and evaluate its performance in a field experiment. In a four-week, in-the-wild experiment involving 29 parents of young children, we delivered personalized stress-reducing micro-interventions through a mobile chatbot. We assessed their impact on stress reduction using momentary stress level ecological momentary assessments (EMAs) before and after each intervention. Our findings demonstrate the superiority of PCAR intervention selection in enhancing the engagement and efficacy of mHealth micro-interventions to stress coping compared to random intervention selection and a control group that did not receive any intervention. Furthermore, we show that even brief, one-minute interventions can significantly reduce perceived stress levels (p=0.001). We observe that individuals are most receptive to one-minute interventions during transitional periods between activities, such as transitioning from afternoon activities to bedtime routines. Our study contributes to the literature by introducing a personalized context-aware intervention selection algorithm that improves engagement and efficacy of mHealth interventions, identifying key timing for stress interventions, and offering insights into mechanisms to improve stress coping.
... Furthermore, online interventions with self-management tools can address barriers like the need for self-reliance and autonomy. Especially for youths, prevention and intervention in an online sphere could therefore be attractive [45,46]. ...
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Background Mental health problems, such as depression, have a high prevalence in young people. However, the majority of youths suffering from depression do not seek professional help. This study aimed to compare help-seeking behavior, intentions and perceived barriers between youthswith different levels of depressive symptoms. Methods This cross-sectional study is part of a large-scale, multi-center project. Participants were n = 9509 youths who were recruited in German schools and completed a baseline screening questionnaire. Based on their depressive symptoms, youths were allocated to the following three subgroups: (a) without depressive symptoms, (b) with subclinical symptoms, (c) with clinical symptoms (measured by PHQ-A). Quantitative analyses compared previous help-seeking behavior, help-seeking intentions and perceived barriers (Barriers questionnaire) between these subgroups. An additional exploratory qualitative content analysis examined text answers on other perceived barriers to help-seeking. Results Participants were mostly female (n = 5575, 58.6%) and 12 to 24 years old (M = 15.09, SD 2.37). Participants with different levels of depressive symptoms differed significantly in help-seeking behavior, intentions and perceived barriers. Specifically, participants with clinical depressive symptoms reported more previous help-seeking, but lower intentions to seek help compared to participants without symptoms (all p < 0.05). Participants with subclinical depressive symptoms reported a similar frequency of previous help-seeking, but higher intentions to seek help compared to participants without symptoms (all p < 0.05). Perception of barriers was different across subgroups: participants with clinical and subclinical depressive symptoms perceived the majority of barriers such as stigma, difficulties in accessibility, and family-related barriers as more relevant than participants without depressive symptoms. Across all subgroups, participants frequently mentioned intrapersonal reasons, a high need for autonomy, and a lack of mental health literacy as barriers to help-seeking. Conclusions Youths with higher levels of depressive symptoms are more reluctant to seek professional help and perceive higher barriers. This underlines the need for effective and low-threshold interventions to tackle barriers, increase help-seeking, and lower depressive symptoms in adolescents and young adults differing in depression severity. Trial registration DRKS00014685.
... In recent years, technology-based mental health interventions, such as mobile applications, social robots, and VIPAs have been developed to help manage mental health symptoms [1,5,70,73,83] by delivering CBT through psychoeducation, mood and symptom tracking, and skills development [50]. Among these tools, the low-cost VIPAs, such as Apple Siri, Google Home, and Amazon Echo, show promising potential to help deliver mental health services longitudinally in home at a large scale due to their natural voice-based mode of interaction [43,45,63] , which can mitigate some common challenges older adults experience when using other tools (e.g., difficulty with texting on small mobile interfaces) [8,31,33,101]. ...
Conference Paper
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The number of older adults who are homebound with depressive symptoms is increasing. Due to their homebound status, they have limited access to trained mental healthcare support, which leaves this support often to untrained family caregivers. To increase access, a growing interest is placed on using technology-mediated solutions, such as voice-assisted intelligent personal assistants (VIPAs), to deliver mental health services to older adults. To better understand how older adults and family caregivers intend to interact with a VIPA for mental health interventions, we conducted a participatory design study during which 6 older adults and 7 caregivers designed VIPA-human dialogues for various scenarios. Using conversation style preferences as a starting point, we present aspects of human-likeness older adults and family caregivers perceived as helpful or uncanny, specifically in the context of the delivery of mental health interventions, which helps inform potential roles VIPAs can play in mental healthcare for older adults.
... A small to medium time by group interaction effect size (Cohen f=0. 15) for the primary outcome perceived stress due to prior results [87] was expected. The G*Power (Heinrich-Heine-Universität Düsseldorf) analysis [88] revealed that a sample size of 90 participants would be sufficient with a power of 0.80 and a correlation of r=0.5 between measurements. ...
Article
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Background: Globally, students face increasing mental health challenges, including elevated stress levels and declining well-being, leading to academic performance issues and mental health disorders. However, due to stigma and symptom underestimation, students rarely seek effective stress management solutions. Conversational agents in the health sector have shown promise in reducing stress, depression, and anxiety. Nevertheless, research on their effectiveness for students with stress remains limited. Objective: This study aims to develop a conversational agent–delivered stress management coaching intervention for students called MISHA and to evaluate its effectiveness, engagement, and acceptance. Methods: In an unblinded randomized controlled trial, Swiss students experiencing stress were recruited on the web. Using a 1:1 randomization ratio, participants (N=140) were allocated to either the intervention or waitlist control group. Treatment effectiveness on changes in the primary outcome, that is, perceived stress, and secondary outcomes, including depression, anxiety, psychosomatic symptoms, and active coping, were self-assessed and evaluated using ANOVA for repeated measure and general estimating equations. Results: The per-protocol analysis revealed evidence for improvement of stress, depression, and somatic symptoms with medium effect sizes (Cohen d=−0.36 to Cohen d=−0.60), while anxiety and active coping did not change (Cohen d=−0.29 and Cohen d=0.13). In the intention-to-treat analysis, similar results were found, indicating reduced stress (β estimate=−0.13, 95% CI −0.20 to −0.05; P<.001), depressive symptoms (β estimate=−0.23, 95% CI −0.38 to −0.08; P=.003), and psychosomatic symptoms (β estimate=−0.16, 95% CI −0.27 to −0.06; P=.003), while anxiety and active coping did not change. Overall, 60% (42/70) of the participants in the intervention group completed the coaching by completing the postintervention survey. They particularly appreciated the quality, quantity, credibility, and visual representation of information. While individual customization was rated the lowest, the target group fitting was perceived as high. Conclusions: Findings indicate that MISHA is feasible, acceptable, and effective in reducing perceived stress among students in Switzerland. Future research is needed with different populations, for example, in students with high stress levels or compared to active controls. Trial Registration: German Clinical Trials Register DRKS 00030004; https://drks.de/search/en/trial/DRKS00030004
... Turning off notification or sound and experiencing decreased motivation and subsequently less active participation human guidance within an app-based intervention to be positively associated with engagement, completion rates, and treatment outcomes [10,[57][58][59], and offering smartphone apps as standalone psychological interventions is not advisable due to the low level of current evidence on this [35]. These findings corroborate the results of the previous realist evaluation within the SELFIE trial, researching the element of guided self-help [50]. ...
Article
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Background Technology improves accessibility of psychological interventions for youth. An ecological momentary intervention (EMI) is a digital intervention geared toward intervening in daily life to enhance the generalizability and ecological validity, and to be able to intervene in moments most needed. Identifying working mechanisms of the use of ecological momentary interventions might generate insights to improve interventions. Methods The present study investigates the working mechanisms of the use and acceptability of an ecological momentary intervention, named SELFIE, targeting self-esteem in youth exposed to childhood trauma, and evaluates under what circumstances these mechanisms of use and acceptability do or do not come into play. A realist evaluation approach was used for developing initial program theories (data: expert interviews and a stakeholders focus group), and subsequently testing (data: 15 interviews with participants, a focus group with therapists, debriefing questionnaire), and refining them. Results The SELFIE intervention is offered through a smartphone application enabling constant availability of the intervention and thereby increasing accessibility and feasibility. When the intervention was offered on their personal smartphone, this enhanced a sense of privacy and less hesitance in engaging with the app, leading to increased disclosure and active participation. Further, the smartphone application facilitates the practice of skills in daily life, supporting the repeated practice of exercises in different situations leading to the generalizability of the effect. Buffering against technical malfunction seemed important to decrease its possible negative effects. Conclusions This study enhanced our understanding of possible working mechanisms in EMIs, such as the constant availability supporting increased accessibility and feasibility, for which the use of the personal smartphone was experienced as a facilitating context. Hereby, the current study contributes to relatively limited research in this field. For the field to move forward, mechanisms of use, and acceptability of EMIs need to be understood. It is strongly recommended that alongside efficacy trials of an EMI on specific target mechanisms, a process evaluation is conducted investigating the working mechanisms of use. Trial registration The current paper reports on a realist evaluation within the SELFIE trial (Netherlands Trial Register NL7129 (NTR7475)).
... Cognitive behavioral therapy (CBT) is frequently applied in treating major depressive disorder (MDD), with decades of research demonstrating efficacy [1][2][3]. Recent research has focused on whether technological innovations, particularly internet and phone delivery, can amplify treatment effects, improve adherence, and overcome travel and cost barriers [4][5][6][7]. Structured and goal-directed CBT modules are particularly suited to internet-based delivery, and multiple randomized control trials (RCTs) support the efficacy of internet-based CBT (ICBT) in symptom reduction and remission [7][8][9][10]. Several RCTs have demonstrated that guided ICBT depression interventions achieve symptom reductions equivalent to in-person CBT [3,11]. ...
Article
Background As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance. Objective This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement. Methods Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II). Results Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β=–0.029, 95% CI –0.11 to 0.048) and in each of the 3 categories: appreciating alliance (β=–0.096, 95% CI –0.80 to 0.61), alliance building disclosures (β=–0.098, 95% CI –0.28 to 0.084), and agreement confirmation (β=–0.076, 95% CI –0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement. Conclusions The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication. Trial Registration Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052
... The effectiveness of web-based health approaches is well established across settings, populations (e.g., non-clinical, clinical, adolescents, adults), and a range of mental health outcomes, such as improvement of clinical symptoms, mindfulness, and quality of life/ well-being [22][23][24][25]. Studies directly comparing the efficacy of face-to-face and web-based approaches show no significant differences between the two approaches [26][27][28]. Yet, web-based approaches can vary substantially in their delivery format ranging from unguided self-help services to guided services (human support mostly through tailored, written feedback) to real-time, direct human support through, for example, videoconferencing or telephone services. With regard to specific delivery format, the efficacy of web-based approaches increases with the extent of support: Web-based approaches including human support come with larger effects and greater adherence compared to unguided self-help and tend to be as effective as face-to-face intervention formats [29][30][31][32]. ...
Article
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Background Adolescents and young adults in residential care and correctional institutions face various challenges, leading to negative life outcomes. Implementation barriers within these institutions, such as limited financial and spatial resources, pose significant hurdles to providing necessary support. Web-based approaches address these challenges by offering cost-effective, accessible solutions. This study aims to assess the efficacy of a newly developed web-based version of the existing evidence-based START NOW skills training in fostering emotion regulation and resilience among institutionalized adolescents and young adults. We present the study protocol (Version 5, August 2023) of the trial titled “Implementation of an e-version of the skills training START NOW for promoting emotion regulation and resilience in residential youth care and correctional institutions”. Methods The study is a monocentric, prospective, confirmatory randomized controlled trial with 150 institutionalized adolescents and young adults with a need to improve resilience (predefined cut-offs). Participating institutions will be randomized to one of three conditions: (i) 9-week web-based group training guided by a facilitator, (ii) 9-week web-based self-help training, (iii) and treatment as usual. The primary endpoint is the change in psychological flexibility, assessed by the Avoidance and Fusion Questionnaire for Youth score, from baseline to follow-up 12 weeks post skills training. Secondary objectives encompass assessing pre-post changes in psychological flexibility and other psychological health-related outcome measures in participating adolescents, young adults, and caretakers from baseline, to post training, and to 12- and 24-week follow-ups. Discussion This study evaluates the efficacy of START NOW as web-based training for institutionalized adolescents and young adults, providing valuable insights into web-based interventions and aiming to optimize support levels. Trial registration {2a and 2b} ClinicalTrials.gov NCT05313581. Registered on 6 April 2022.
... Although not a strategy utilized in services reported in this study, waiting time barriers could also be alleviated through potential delivery of low-intensity interventions such as basic self-directed stress reduction interventions or skill-based training delivered by trained community facilitators (Gibson et al., 2021;Linardon et al., 2019). Using this kind of stepped model of care, like those used in medical settings (Gagliardi et al., 2021), patients could be engaged with these interventions to assist them while they wait for more intense interventions to be delivered by mental health providers in formal treatment settings. ...
Article
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Police experience mental health conditions at higher rates than the general population. To improve mental health and enhance quality of care, services and treatment practices can be better tailored to their needs and preferences. This study examined the experiences of Australian police members who received mental health treatment to understand how services and practice can be improved. Semistructured qualitative interviews were conducted with 13 current or retired Victorian police members. Interviews were transcribed verbatim, and interpretative phenomenological analysis was performed. Three aspects of treatment were discussed: accessing treatment, delivery of treatment by mental health providers, and efficacy of treatments delivered. Findings highlight the importance of improving access by increasing awareness of treatment options, offering specialist mental health services, encouraging access through trusted sources, and reducing barriers. Findings indicate that treatment can be improved by supporting providers to develop cultural competence and expertise in treating trauma-related symptoms. Finally, treatments can be improved by delivering evidence-based trauma-focused therapies and utilizing measurement-based care approaches. This study provides insights into how mental health services can be improved based on real-world, first-person experiences which health professionals and treatment services may use to refine and tailor practices according to the needs and preferences of this population.
...  Even the applications with the strongest evidence of efficacy are not more or as superior to the quality of a session with a mental health professional.  The option of access to some form of interaction or support from a real person through the application is currently responsible for the overall perceived benefit of DHTs [26].  At present, these applications are not good standalone replacements or substitutes for the real-life versions of the treatment modalities replicated by them. ...
Chapter
Book series on Medical Science gives the opportunity to students and doctors from all over the world to publish their research work in a set of Preclinical sciences, Internal medicine, Surgery and Public Health. This book series aim to inspire innovation and promote academic quality through outstanding publications of scientists and doctors. It also provides a premier interdisciplinary platform for researchers, practitioners, and educators to publish the most recent innovations, trends, and concerns as well as practical challenges encountered and solutions adopted in the fields of Medical Science. The content of the book is as follows
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The influence of digital technology on mental well-being is nuanced, affecting individuals in various ways, both advantageous and detrimental. On one hand, digital technology has revolutionized accessibility to mental health resources, providing avenues for support and intervention. On the other hand, excessive screen time, social media pressures, and digital addiction contribute to heightened stress levels and mental health challenges. In this chapter, the authors delve into the intricate dynamics of how digital technology shapes mental well-being, the positive aspects, such as increased access to mental health resources, alongside the negative implications, including the potential for digital-related stressors. Addressing current limitations, the objective is to offer an in-depth grasp of the current terrain. Furthermore, the authors consider the future avenues for research in this field and wrap up by consolidating essential insights into the complex interplay between digital technology and mental well-being.
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Health care technologies have the ability to bridge or hinder equitable care. Advocates of digital mental health interventions (DMHIs) report that such technologies are poised to reduce the documented gross health care inequities that have plagued generations of people seeking care in the United States. This is due to a multitude of factors such as their potential to revolutionize access; mitigate logistical barriers to in-person mental health care; and leverage patient inputs to formulate tailored, responsive, and personalized experiences. Although we agree with the potential of DMHIs to advance health equity, we articulate several steps essential to mobilize and sustain meaningful forward progression in this endeavor, reflecting on decades of research and learnings drawn from multiple fields of expertise and real-world experience. First, DMHI manufacturers must build diversity, equity, inclusion, and belonging (DEIB) processes into the full spectrum of product evolution itself (eg, product design, evidence generation) as well as into the fabric of internal company practices (eg, talent recruitment, communication principles, and advisory boards). Second, awareness of the DEIB efforts—or lack thereof—in DMHI research trials is needed to refine and optimize future study design for inclusivity as well as proactively address potential barriers to doing so. Trials should incorporate thoughtful, inclusive, and creative approaches to recruitment, enrollment, and measurement of social determinants of health and self-identity, as well as a prioritization of planned and exploratory analyses examining outcomes across various groups of people. Third, mental health care advocacy, research funding policies, and local and federal legislation can advance these pursuits, with directives from the US Preventive Services Taskforce, National Institutes of Health, and Food and Drug Administration applied as poignant examples. For products with artificial intelligence/machine learning, maintaining a “human in the loop” as well as prespecified and adaptive analytic frameworks to monitor and remediate potential algorithmic bias can reduce the risk of increasing inequity. Last, but certainly not least, is a call for partnership and transparency within and across ecosystems (academic, industry, payer, provider, regulatory agencies, and value-based care organizations) to reliably build health equity into real-world DMHI product deployments and evidence-generation strategies. All these considerations should also extend into the context of an equity-informed commercial strategy for DMHI manufacturers and health care organizations alike. The potential to advance health equity in innovation with DMHI is apparent. We advocate the field’s thoughtful and evergreen advancement in inclusivity, thereby redefining the mental health care experience for this generation and those to come.
Article
Background Generalized anxiety disorder (GAD) is a prevalent anxiety disorder characterized by uncontrollable worry, trouble sleeping, muscle tension, and irritability. Cognitive behavioural therapy (CBT) is one of the first-line treatments that has demonstrated high efficacy in reducing symptoms of anxiety. Electronically delivered CBT (e-CBT) has been a promising adaptation of in-person treatment, showing comparable efficacy with increased accessibility and scalability. Finding further scalable interventions that can offer benefits to patients requiring less intensive interventions can allow for better resource allocation. Some studies have indicated that weekly check-ins can also lead to improvements in GAD symptoms. However, there is a lack of research exploring the potential benefits of online check-ins for patients with GAD. Objective This study aims to investigate the effects of weekly online asynchronous check-ins on patients diagnosed with GAD and compare it with a group receiving e-CBT. Methods Participants ( n e-CBT = 45; n check-in = 51) with GAD were randomized into either an e-CBT or a mental health check-in program for 12 weeks. Participants in the e-CBT program completed pre-designed modules and homework assignments through a secure online delivery platform where they received personalized feedback from a trained care provider. Participants in the mental health check-in condition had weekly asynchronous messaging communication with a care provider where they were asked structured questions with a different weekly theme to encourage conversation. Results Both treatments demonstrated statistically significant reductions in GAD—7-item questionnaire (GAD-7) scores over time, but when comparing the groups there was no significant difference between the treatments. The number of participants who dropped out and baseline scores on all questionnaires were comparable for both groups. Conclusions The findings support the effectiveness of e-CBT and mental health check-ins for the treatment of GAD.
Article
Background Major depressive disorder (MDD) is common worldwide and can be highly disabling. People with MDD face many barriers to treatment and may not experience full symptom relief even when treated. Therefore, new treatment modalities are needed for MDD. Digital therapeutics (DTx) may provide people with MDD an additional treatment option. Objective This study aimed to describe a phase 3 remote, multicenter, randomized, masked, sham-controlled trial evaluating the efficacy of a smartphone app–based DTx (CT-152) in adult participants diagnosed with MDD, used as an adjunct to antidepressant therapy (ADT). Methods Participants aged 22-64 years with a current primary diagnosis of MDD and an inadequate response to ADT were included. Participants were randomized 1:1 to CT-152 or a sham DTx. CT-152 is a smartphone app–based DTx that delivers a cognitive-emotional and behavioral therapeutic intervention. The core components of CT-152 are the Emotional Faces Memory Task exercises, brief lessons to learn and apply key therapeutic skills, and SMS text messaging to reinforce lessons and encourage engagement with the app. The sham DTx is a digital working memory exercise with emotionally neutral stimuli designed to match CT-152 for time and attention. Participants took part in the trial for up to 13 weeks. The trial included a screening period of up to 3 weeks, a treatment period of 6 weeks, and an extension period of 4 weeks to assess the durability of the effect. Sites and participants had the option of an in-person or remote screening visit; the remaining trial visits were remote. Efficacy was evaluated using the Montgomery-Åsberg Depression Rating Scale, the Generalized Anxiety Disorder-7, Clinical Global Impression–Severity scale, the Patient Health Questionnaire-9, and the World Health Organization Disability Assessment Schedule 2.0. The durability of the effect was evaluated with the Montgomery-Åsberg Depression Rating Scale and Generalized Anxiety Disorder-7 scale. Adverse events were also assessed. Satisfaction, measured by the Participant and Healthcare Professional Satisfaction Scales, and health status, measured by the EQ-5D-5L, were summarized using descriptive statistics. Results This study was initiated in February 2021 and had a primary completion date in October 2022. Conclusions This represents the methodological design for the first evaluation of CT-152 as an adjunct to ADT. This study protocol is methodologically robust and incorporates many aspects of conventional pivotal pharmaceutical phase 3 trial design, such as randomization and safety end points. Novel considerations included the use of a sham comparator, masking considerations for visible app content, and outcome measures relevant to DTx. The rigor of this methodology will provide a more comprehensive understanding of the effectiveness of CT-152. Trial Registration ClinicalTrials.gov NCT04770285; https://clinicaltrials.gov/study/NCT04770285 International Registered Report Identifier (IRRID) RR1-10.2196/56960
Article
Background Adolescence and early adulthood are pivotal stages for the onset of mental health disorders and the development of health behaviors. Digital behavioral activation interventions, with or without coaching support, hold promise for addressing risk factors for both mental and physical health problems by offering scalable approaches to expand access to evidence-based mental health support. Objective This 2-arm pilot randomized controlled trial evaluated 2 versions of a digital behavioral health product, Vira (Ksana Health Inc), for their feasibility, acceptability, and preliminary effectiveness in improving mental health in young adults with depressive symptoms and obesity risk factors. Methods A total of 73 participants recruited throughout the United States were randomly assigned to use Vira either as a self-guided product (Vira Self-Care) or with support from a health coach (Vira+Coaching) for 12 weeks. The Vira smartphone app used passive sensing of behavioral data related to mental health and obesity risk factors (ie, activity, sleep, mobility, and language patterns) and offered users personalized insights into patterns of behavior associated with their daily mood. Participants completed self-reported outcome measures at baseline and follow-up (12 weeks). All study procedures were completed via digital communications. Results Both versions of Vira showed strong user engagement, acceptability, and evidence of effectiveness in improving mental health and stress. However, users receiving coaching exhibited more sustained engagement with the platform and reported greater reductions in depression (Cohen d=0.45, 95% CI 0.10-0.82) and anxiety (Cohen d=0.50, 95% CI 0.13-0.86) compared to self-care users. Both interventions also resulted in reduced stress (Vira+Coaching: Cohen d=–1.05, 95% CI –1.57 to –-0.50; Vira Self-Care: Cohen d=–0.78, 95% CI –1.33 to –0.23) and were perceived as useful and easy to use. Coached users also reported reductions in sleep-related impairment (Cohen d=–0.51, 95% CI –1.00 to –0.01). Moreover, participants increased their motivation for and confidence in making behavioral changes, with greater improvements in confidence among coached users. Conclusions An app-based intervention using passive mobile sensing to track behavior and deliver personalized insights into behavior-mood associations demonstrated feasibility, acceptability, and preliminary effectiveness for reducing depressive symptoms and other mental health problems in young adults. Future directions include (1) optimizing the interventions, (2) conducting a fully powered trial that includes an active control condition, and (3) testing mediators and moderators of outcome effects. Trial Registration ClinicalTrials.gov NCT05638516; https://clinicaltrials.gov/study/NCT05638516
Article
Background Rising rates of psychological distress (symptoms of depression, anxiety, and stress) among adults in the United States necessitate effective mental wellness interventions. Despite the prevalence of smartphone app–based programs, research on their efficacy is limited, with only 14% showing clinically validated evidence. Our study evaluates Noom Mood, a commercially available smartphone-based app that uses cognitive behavioral therapy and mindfulness-based programming. In this study, we address gaps in the existing literature by examining postintervention outcomes and the broader impact on mental wellness. Objective Noom Mood is a smartphone-based mental wellness program designed to be used by the general population. This prospective study evaluates the efficacy and postintervention outcomes of Noom Mood. We aim to address the rising psychological distress among adults in the United States. Methods A 1-arm study design was used, with participants having access to the Noom Mood program for 16 weeks (N=273). Surveys were conducted at baseline, week 4, week 8, week 12, week 16, and week 32 (16 weeks’ postprogram follow-up). This study assessed a range of mental health outcomes, including anxiety symptoms, depressive symptoms, perceived stress, well-being, quality of life, coping, emotion regulation, sleep, and workplace productivity (absenteeism or presenteeism). Results The mean age of participants was 40.5 (SD 11.7) years. Statistically significant improvements in anxiety symptoms, depressive symptoms, and perceived stress were observed by week 4 and maintained through the 16-week intervention and the 32-week follow-up. The largest changes were observed in the first 4 weeks (29% lower, 25% lower, and 15% lower for anxiety symptoms, depressive symptoms, and perceived stress, respectively), and only small improvements were observed afterward. Reductions in clinically relevant anxiety (7-item generalized anxiety disorder scale) and depression (8-item Patient Health Questionnaire depression scale) criteria were also maintained from program initiation through the 16-week intervention and the 32-week follow-up. Work productivity also showed statistically significant results, with participants gaining 2.57 productive work days from baseline at 16 weeks, and remaining relatively stable (2.23 productive work days gained) at follow-up (32 weeks). Additionally, effects across all coping, sleep disturbance (23% lower at 32 weeks), and emotion dysregulation variables exhibited positive and significant trends at all time points (15% higher, 23% lower, and 25% higher respectively at 32 weeks). Conclusions This study contributes insights into the promising positive impact of Noom Mood on mental health and well-being outcomes, extending beyond the intervention phase. Though more rigorous studies are necessary to understand the mechanism of action at play, this exploratory study addresses critical gaps in the literature, highlighting the potential of smartphone-based mental wellness programs to lessen barriers to mental health support and improve diverse dimensions of well-being. Future research should explore the scalability, feasibility, and long-term adherence of such interventions across diverse populations.
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近年,メンタルヘルスアプリが多く利用され,その有効性も実証されている。その中で,メンタルヘルスアプリの利用者の大半がマインドフルネスに関するコンテンツを利用していることが明らかとなった。本研究の目的は,日本で利用可能なマインドフルネスに関するスマートフォンアプリを,標準化された評価尺度を用いて体系的に評価することであった。加えて,アプリ内コンテンツの科学的根拠の有無やプライバシーポリシーについての評価も行われた。2022年12月にアプリストアから1638個のアプリが特定され,「マインドフルネスに関するコンテンツを十分に提供している」「日本語で利用可能である」の適格基準に基づいて,最終的に21個のアプリが評価対象となった。アプリの品質評価にはMobile App Rating Scaleが用いられ,評価の平均値は3.380と中程度の水準にあったが,機能性においては先行研究よりも低い評価となった。また,科学的根拠の有無については7個のアプリが学術論文で取り上げられており,プライバシーポリシーに関しては17個のアプリが公開していた。これらの割合は先行研究と比較して高いことが示された。以上より,本研究において,日本におけるマインドフルネスアプリは,プライバシーなどを配慮した質の良いアプリである傾向が示唆された。
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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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Currently, in the United States and worldwide, the vast majority of children and adolescents in need of mental health services receive no treatment. Although there are many barriers, a key barrier is the dominant model of delivering psychosocial interventions. That model includes one‐to‐one, in‐person treatment, with a trained mental health professional, provided in clinical setting (e.g., clinic, private practice office, health‐care facility). That model greatly limits the scale and reach of psychosocial interventions. The article discusses many novel models of delivering interventions that permit scaling treatment to encompass children and adolescents who are not likely to receive services. Special attention is accorded the use of social media, socially assistive robots, and social networks that not only convey the ability to scale interventions but also encompass interventions that depart from the usual forms of intervention that currently dominate psychosocial treatment research.
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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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The rapid advances and adoption of smartphone technology presents a novel opportunity for delivering mental health interventions on a population scale. Despite multi-sector investment along with wide-scale advertising and availability to the general population, the evidence supporting the use of smartphone apps in the treatment of depression has not been empirically evaluated. Thus, we conducted the first meta-analysis of smartphone apps for depressive symptoms. An electronic database search in May 2017 identified 18 eligible randomized controlled trials of 22 smartphone apps, with outcome data from 3,414 participants. Depressive symptoms were reduced significantly more from smartphone apps than control conditions (g=0.38, 95% CI: 0.24-0.52, p<0.001), with no evidence of publication bias. Smartphone interventions had a moderate positive effect in comparison to inactive controls (g=0.56, 95% CI: 0.38-0.74), but only a small effect in comparison to active control conditions (g=0.22, 95% CI: 0.10-0.33). Effects from smartphone-only interventions were greater than from interventions which incorporated other human/computerized aspects along the smartphone component, although the difference was not statistically significant. The studies of cognitive training apps had a significantly smaller effect size on depression outcomes (p=0.004) than those of apps focusing on mental health. The use of mood monitoring softwares, or interventions based on cognitive behavioral therapy, or apps incorporating aspects of mindfulness training, did not affect significantly study effect sizes. Overall, these results indicate that smartphone devices are a promising self-management tool for depression. Future research should aim to distil which aspects of these technologies produce beneficial effects, and for which populations.
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Objective: As a common experience in the general population, dissatisfaction with one’s body is associated with a variety of psychological problems and unhealthy behaviors, including the development of eating disorders. Therefore, the purpose of the present study was to develop and evaluate an app-based intervention to reduce body dissatisfaction. Method: Participants reporting elevated levels of body dissatisfaction were randomly allocated to an app-based intervention (n = 26) or to a wait list group (n = 27). The app-based intervention included a brief counseling session and 14 days of training with the Mindtastic Body Dissatisfaction app (MT-BD). The MT-BD app uses gamification strategies to systematically foster approach of functional and avoidance of dysfunctional stimuli. The primary outcome was body dissatisfaction as assessed with the Body Dissatisfaction scale of the Eating Disorder Inventory-2 (Garner, 1991). Secondary outcome measures included severity of eating disorder symptoms and depressive symptoms. Results: Participants in the intervention group showed significantly greater reductions in body dissatisfaction compared to the wait list group (d = −0.62). The intervention group also showed greater reductions in eating disorder symptoms compared to the wait list group (d = −0.46). Reductions in body dissatisfaction and eating disorder symptoms were sustained at a 1-month follow-up. Conclusion: We found preliminary evidence that an app-based intervention may significantly reduce body dissatisfaction. Further research using larger samples and targeting clinical populations is necessary to evaluate the potential of interventions such as MT-BD.
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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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Background Depression in the workplace creates a significant burden on employees and employers in terms of lost productivity and related costs. myStrength provides a robust, holistic Web- and mobile-based solution empowering users to learn, practice, and implement a range of evidence-based psychological interventions. Objective The main aim of this study was to demonstrate improvement in depressive symptoms among employees at risk of depression through myStrength use. Methods A 26-week, parallel-arm, pilot, randomized controlled trial was designed to assess the effectiveness of myStrength compared to a series of informational “Depression Tip/Fact of the Week” emails as the active control arm. Study participants (n=146) were commercially insured employees of a mid-sized financial software solutions firm. The primary outcome was self-reported change in depression score as best fit by a linear random effects model accounting for individual baseline symptoms. Results The final sample consisted of 78 participants in the experimental arm, myStrength, and 68 participants in the active control arm. myStrength users demonstrated significantly steeper and more rapid reduction in depressive symptoms over time compared to the active control (P<.001), suggesting that the intervention generated improvement in behavioral health symptoms, even in a nonclinical sample. Conclusions This pilot study builds foundational support for the scalable deployment of myStrength as a complementary behavioral health offering to promote overall mental health and well-being in the workplace.
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Objective: Posttraumatic stress disorder (PTSD) is highly prevalent in the population, but relatively few affected individuals receive treatment for it. Smartphone applications (apps) could help address this unmet need by offering sound psychoeducational information and evidence-based cognitive behavioral coping tools. We conducted a randomized controlled trial to assess the efficacy of a free, publicly available smartphone app (PTSD Coach) for self-management of PTSD symptoms. Method: One hundred 20 participants who were an average of 39 years old, mostly women (69.2%) and White (66.7%), recruited primarily through online advertisements, were randomized to either a PTSD Coach (n = 62) or a waitlist condition (n = 58) for 3 months. Web-administered self-report measures of PTSD, PTSD symptom coping self-efficacy, depression, and psychosocial functioning were conducted at baseline, posttreatment, and 3 months following treatment. Results: Following the intent-to-treat principle, repeated-measures analyses of variance (ANOVAs) revealed that at posttreatment, PTSD Coach participants had significantly greater improvements in PTSD symptoms (p = .035), depression symptoms (p = .005), and psychosocial functioning (p = .007) than did waitlist participants; however, at posttreatment, there were no significant mean differences in outcomes between conditions. A greater proportion of PTSD Coach participants achieved clinically significant PTSD symptom improvement (p = .018) than waitlist participants. Conclusion: PTSD Coach use resulted in significantly greater improvements in PTSD symptoms and other outcomes relative to a waitlist condition. Given the ubiquity of smartphones, PTSD Coach may provide a wide-reaching, convenient public health intervention for individuals with PTSD symptoms who are not receiving care. (PsycINFO Database Record
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Background: Stress has been identified as one of the major public health issues in this century. New technologies offer opportunities to provide effective psychological interventions on a large scale. Objective: The aim of this study is to investigate the efficacy of Web- and computer-based stress-management interventions in adults relative to a control group. Methods: A meta-analysis was performed, including 26 comparisons (n=4226). Cohen d was calculated for the primary outcome level of stress to determine the difference between the intervention and control groups at posttest. Analyses of the effect on depression, anxiety, and stress in the following subgroups were also conducted: risk of bias, theoretical basis, guidance, and length of the intervention. Available follow-up data (1-3 months, 4-6 months) were assessed for the primary outcome stress. Results: The overall mean effect size for stress at posttest was Cohen d=0.43 (95% CI 0.31-0.54). Significant, small effects were found for depression (Cohen d=0.34, 95% CI 0.21-0.48) and anxiety (Cohen d=0.32, 95% CI 0.17-0.47). Subgroup analyses revealed that guided interventions (Cohen d=0.64, 95% CI 0.50-0.79) were more effective than unguided interventions (Cohen d=0.33, 95% CI 0.20-0.46; P=.002). With regard to the length of the intervention, short interventions (≤4 weeks) showed a small effect size (Cohen d=0.33, 95% CI 0.22-0.44) and medium-long interventions (5-8 weeks) were moderately effective (Cohen d=0.59; 95% CI 0.45-0.74), whereas long interventions (≥9 weeks) produced a nonsignificant effect (Cohen d=0.21, 95% CI –0.05 to 0.47; P=.006). In terms of treatment type, interventions based on cognitive behavioral therapy (CBT) and third-wave CBT (TWC) showed small-to-moderate effect sizes (CBT: Cohen d=0.40, 95% CI 0.19-0.61; TWC: Cohen d=0.53, 95% CI 0.35-0.71), and alternative interventions produced a small effect size (Cohen d=0.24, 95% CI 0.12-0.36; P=.03). Early evidence on follow-up data indicates that Web- and computer-based stress-management interventions can sustain their effects in terms of stress reduction in a small-to-moderate range up to 6 months. Conclusions: These results provide evidence that Web- and computer-based stress-management interventions can be effective and have the potential to reduce stress-related mental health problems on a large scale.
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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 they have on mental health outcomes. Objective The objective of our study was to document and compare use patterns and clinical outcomes across the United States between 3 different self-guided mobile apps for depression. Methods Participants were recruited through Web-based advertisements and social media and were randomly assigned to 1 of 3 mood apps. Treatment and assessment were conducted remotely on each participant’s smartphone or tablet with minimal contact with study staff. We enrolled 626 English-speaking adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5, or if their score on item 10 was ≥2. The apps were (1) Project: EVO, a cognitive training app theorized to mitigate depressive symptoms by improving cognitive control, (2) iPST, an app based on an evidence-based psychotherapy for depression, and (3) Health Tips, a treatment control. Outcomes were scores on the PHQ-9 and the Sheehan Disability Scale. Adherence to treatment was measured as number of times participants opened and used the apps as instructed. Results We randomly assigned 211 participants to iPST, 209 to Project: EVO, and 206 to Health Tips. Among the participants, 77.0% (482/626) had a PHQ-9 score >10 (moderately depressed). Among the participants using the 2 active apps, 57.9% (243/420) did not download their assigned intervention app but did not differ demographically from those who did. Differential treatment effects were present in participants with baseline PHQ-9 score >10, with the cognitive training and problem-solving apps resulting in greater effects on mood than the information control app (χ22=6.46, P=.04). Conclusions Mobile apps for depression appear to have their greatest impact on people with more moderate levels of depression. In particular, an app that is designed to engage cognitive correlates of depression had the strongest effect on depressed mood in this sample. This study suggests that mobile apps reach many people and are useful for more moderate levels of depression. ClinicalTrial Clinicaltrials.gov NCT00540865; https://www.clinicaltrials.gov/ct2/show/NCT00540865 (Archived by WebCite at http://www.webcitation.org/6mj8IPqQr)
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Objective: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive-behavioral therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. Method: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2,866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation. Results: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, odds ratios (ORs) = 3.10, 95% confidence interval (CI) [2.21, 4.34]. Clinical severity at pretreatment was related to lower odds, OR = 0.62, 95% CI [0.50, 0.77], and OR = 0.51, 95% CI [0.51, 0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, OR = 0.58, 95% CI [0.35, 0.95], having at least a university degree, OR = 0.54, 95% CI [0.33, 0.88], and being older, OR = 0.78, 95% CI, [0.62, 0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition. Conclusion: Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers to reverse and prevent a negative treatment trend. (PsycINFO Database Record
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Background: Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being. Objective: The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment. Methods: We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks. Results: During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage. Conclusions: Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners. Trial registration: Clinicaltrials.gov NCT01680419; https://clinicaltrials.gov/ct2/show/NCT01680419 (Archived by WebCite at http://www.webcitation.org/6jJuadfzj).
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Objective: This randomized controlled trial (RCT) aimed at evaluating the efficacy of an Internet-based stress management intervention (iSMI) in employees compared to a 6-month waitlist-control group (WLC) with full access to treatment as usual. Method: A sample of 264 employees with elevated symptoms of perceived stress (Perceived Stress Scale, PSS-10 ≥ 22) was assigned to either the iSMI or to the WLC group. The iSMI consisted of 7 sessions and 1 booster session including problem-solving and emotion regulation techniques. Participants received guidance from an e-coach which focused on improving the adherence to the intervention. Self-report data were assessed at baseline, at seven weeks, and six months following randomization. The primary outcome was perceived stress (PSS-10). The secondary outcomes included other relevant mental and work-related health outcomes. Results: The iSMI participants showed a significantly higher reduction in perceived stress from baseline to seven weeks (d=0.79, 95%-CI:0.54-1.04) and to the 6-month follow up (d=0.85, 95%-CI:0.59 – 1.10) compared to controls. Significant moderate to large effect sizes were also found for depression, anxiety, emotional exhaustion, sleeping problems, worrying, quality of life (mental health), psychological detachment and emotion regulation skills. Work engagement, quality of life (physical health), absenteeism and presenteeism were not found to significantly differ between the iSMI and WLC groups. Changes in emotion regulation regarding general distress mediated changes in perceived stress. Conclusion: The iSMI investigated in this study was found to be effective in reducing typical symptoms of stress. However, several important work-related health symptoms were not significantly affected by the intervention. Internet-based guided self-help interventions could be an acceptable, effective approach to reduce a range of negative consequences associated with work-related stress. Future studies should investigate the comparative (cost-) effectiveness of guided and unguided stress management interventions.
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Background: The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available. Objective: To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps. Methods: A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design. Results: Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp. Conclusions: Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems.