Coached Mobile App Platform for the Treatment of Depression and Anxiety Among Primary Care Patients: A Randomized Clinical Trial

Uptake and effectiveness of a self-guided mobile app platform for college student mental health

BACKGROUND

College students endorse high rates of mental health problems. While many colleges offer on-campus services, many students who could benefit from mental health services do not receive care. Indeed, nearly half of students who screen positive for depression, for example, do not receive treatment. Digital mental health programs, such as those delivered via mobile apps, may help expand access to mental health care and resources. This mixed-methods study aims to examine the uptake and effectiveness of an implementation of IntelliCare for College Students, a self-guided app-based mental health platform, on two university campuses.

METHODS

Data on counseling center utilization was collected prior to the implementation of the app (pre-implementation phase) and while the app was available on campus (implementation phase). Data on app usage was collected throughout the implementation phase. A subset of participants (n = 20), along with counseling center staff members (n = 10), completed feedback interviews.

RESULTS

Overall, uptake of the app platform was low. A total of 117 participants downloaded the app and registered their study ID during the implementation phase. Approximately 24% (28/117) of participants used the app only once. The number of days between the first and last day of app use ranged from 0 to 299, with a mean of 35.01 days and a median of 14 days. A relatively small portion of the sample (26.5%; 31/117) downloaded one or more of the IntelliCare interactive apps. In examining counseling center utilization, there were no significant changes in intake appointments, individual therapy sessions, or crisis appointments observed from the pre-implementation phase to the implementation phase of the study. Feedback interviews highlighted the significant level of disruption caused by the COVID-19 pandemic and shift to remote learning, including challenges disseminating information to students and a preference to spend less time with digital devices outside of class time.

CONCLUSIONS

Findings from this study indicate that there is an ongoing need to identify ways to reach college students and support student mental health and wellness for the remainder of the COVID-19 pandemic and beyond.

Interactive System for Similarity-Based Inspection and Assessment of the Well-Being of mHealth Users

Recent digitization technologies empower mHealth users to conveniently record their Ecological Momentary Assessments (EMA) through web applications, smartphones, and wearable devices. These recordings can help clinicians understand how the users’ condition changes, but appropriate learning and visualization mechanisms are required for this purpose. We propose a web-based visual analytics tool, which processes clinical data as well as EMAs that were recorded through a mHealth application. The goals we pursue are (1) to predict the condition of the user in the near and the far future, while also identifying the clinical data that mostly contribute to EMA predictions, (2) to identify users with outlier EMA, and (3) to show to what extent the EMAs of a user are in line with or diverge from those users similar to him/her. We report our findings based on a pilot study on patient empowerment, involving tinnitus patients who recorded EMAs with the mHealth app TinnitusTips. To validate our method, we also derived synthetic data from the same pilot study. Based on this setting, results for different use cases are reported.

Initial findings from a prospective, large scale patient reported outcomes program in patients with gynecologic malignancy

INTRODUCTION

Patient reported outcome measures (PROMs) are associated with improved overall survival in patients with metastatic malignancy; however, routine collection of PROMs is nascent. Little is known about PROs in women with gynecologic malignancy outside of a trial setting, limiting our understanding of how routine populations experience treatment, disease and morbidity. The goal of this study was to prospectively collect and describe disease-specific PROs in a non-trial population of women with gynecologic malignancy.

METHODS

PROMs were assigned electronically to all patients presenting for care in our gynecologic oncology clinic. Patients received a general oncology questionnaire (EORTC QLQ C30) a disease specific questionnaire (FACT V, EORTC EN24, EORTC OV28, EORTC Cx 24), and questionnaires assessing support at home. Responses were mapped to relevant clinical variables. Descriptive statistics were performed, and comparisons made with parametric and nonparametric analyses. The association between support at home and perioperative complications was assessed via logistic regression.

RESULTS

In the study period, 3239 unique patients were evaluated at new patient visits, post-operative visits, chemotherapy visits and surveillance visits with a PROMs completion rate of 78.1% (n = 2530 women with 4402 completions). There was no difference in completion rates based on age or self-identified race. The EORTC QLQ C-30 questionnaire was able to adequately discern differences between disease sites. Overall, scores were lower than those obtained in trial populations. PROMs responses were not associated with perioperative complications.

CONCLUSION

Systematic collection of PROMs is feasible and tech-enabled workflows result in high collection rates. Quality of life scores in our clinic population were lower than published data, indicating caution should be used when extrapolating quality of life data from clinical trials to counseling and decision making around routine patient populations.

Strengthening the Impact of Digital Cognitive Behavioral Interventions through a Dual Intervention: Proficient Motivational Interviewing-based Health Coaching Plus In-Application Techniques (Preprint)

Background

The COVID-19 pandemic has accelerated the adoption of digital tools to support individuals struggling with their mental health. The use of a digital intervention plus human coaching (“dual” intervention) is gaining momentum in increasing overall engagement in digital cognitive behavioral interventions (dCBIs). However, there is limited insight into the methodologies and coaching models used by those deploying dual interventions. To achieve a deeper understanding, we need to identify and promote effective engagement that leads to clinical outcomes versus simply monitoring engagement metrics. Motivational interviewing (MI) is a collaborative, goal-oriented communication approach that pays particular attention to the language of change and is an effective engagement approach to help people manage mental health issues. However, this approach has been traditionally used for in-person or telephonic interventions, and less is known about the application of MI to digital interventions.

Objective

We sought to provide a dual intervention approach and address multiple factors across two levels of engagement to operationalize a dCBI that combined cognitive behavioral therapy–based techniques and MI-based interactions between the digital health coach (DHC) and user.

Methods

We reviewed hundreds of digital exchanges between DHCs and users to identify and improve training and quality assurance activities for digital interventions.

Results

We tested five hypotheses and found that: (1) users of a dual digital behavioral health intervention had greater engagement levels than users of a noncoached intervention (P<.001); (2) DHCs with a demonstrated competency in applying MI to digital messages had more engaged users, as measured by the DHC-to-user message exchange ratio (P<.001); (3) the DHC-to-user message exchange ratio was correlated with more engagement in app activities (r=0.28, 95% CI 0.23-0.33); (4) DHCs with demonstrated MI proficiency elicited a greater amount of “change talk” from users than did DHCs without MI proficiency (H=25.12, P<.001); and (5) users who were engaged by DHCs with MI proficiency had better clinical outcomes compared to users engaged by DHCs without MI proficiency (P=.02).

Conclusions

To our knowledge, this pilot was the first of its kind to test the application of MI to digital coaching protocols, and it demonstrated the value of MI proficiency in digital health coaching for enhanced engagement and health improvement. Further research is needed to establish coaching models in dCBIs that incorporate MI to promote effective engagement and optimize positive behavioral outcomes.

The effect of depression and anxiety symptom severity on clinical outcomes and app use in digital mental health treatments: Meta-regression of three trials

A large number of trials have consistently shown that guided digital mental health treatments (DMHTs) are effective for depression and anxiety. As DMHTs are adopted by healthcare organizations, payers, and employers, they are often considered most appropriate for people with mild-to-moderate levels of symptom severity. Thus, the aim of this study was to examine the effects of symptom severity on depression and anxiety outcomes and app use across three trials of a guided DMHT, IntelliCare. Participants were categorized into mild, moderate, moderately severe, and severe symptom severity groups on depression and anxiety. All symptom severity groups showed significant reductions in depression and anxiety in a clear ordinal pattern, with the mild symptom severity group showing the smallest changes and the severe symptom group showing the largest improvements. Those with the lowest levels of educational attainment showed the largest symptom improvement. Baseline symptom severity was not significantly related to app use. App use was significantly related to depression and anxiety outcomes. These findings suggest that depression and anxiety symptom severity is not useful in determining who should be referred to a guided DMHT.

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

As the COVID-19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies - such as smartphone apps, vir-tual reality, chatbots, and social media - have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for "digital phenotyping" and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self-management of psychological well-being and early intervention, along with more nascent research supporting their use in clinical management of long-term psychiatric conditions - including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders - as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real-world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.

Targeting subjective engagement in experimental therapeutics for digital mental health interventions

Engagement is a multifaceted construct and a likely mechanism by which digital interventions achieve clinical improvements. To date, clinical research on digital mental health interventions (DMHIs) has overwhelmingly defined engagement and assessed its association with clinical outcomes through the objective/behavioral metrics of use of or interactions with a DMHI, such as number of log-ins or time spent using the technology. However, engagement also entails users' subjective experience. Research is largely lacking that tests the relationship between subjective metrics of engagement and clinical outcomes. The purpose of this study is to present a proof-of-concept exploratory evaluation of the association between subjective engagement measures of a mobile DMHI with changes in depression and anxiety. Adult primary care patients (N = 146) who screened positive for depression or anxiety were randomized to receive a DMHI, IntelliCare, immediately or following an 8-week waitlist. Subjective engagement was measured via the Usefulness, Satisfaction, and Ease of Use (USE) Questionnaire. Across both conditions, results showed that individuals who perceived a mobile intervention as more useful, easy to use and learn, and satisfying had greater improvements in depression and anxiety over eight weeks. Findings support our proposed experimental therapeutics framework that hypothesizes objective/behavioral and subjective engagement metrics as mechanisms that lead to changes in clinical outcomes, as well as support directing intervention design efforts for DMHIs to target the user experience.

Integration of Digital Tools Into Community Mental Health Care Settings That Serve Young People: Focus Group Study

BACKGROUND

Digital mental health tools have substantial potential to be easily integrated into people's lives and fundamentally impact public health. Such tools can extend the reach and maximize the impact of mental health interventions. Before implementing digital tools in new settings, it is critical to understand what is important to organizations and individuals who will implement and use these tools. Given that young people are highly familiar with technology and many mental health concerns emerge in childhood and adolescence, it is especially crucial to understand how digital tools can be integrated into settings that serve young people.

OBJECTIVE

This study aims to learn about considerations and perspectives of community behavioral health care providers on incorporating digital tools into their clinical care for children and adolescents.

METHODS

Data were analyzed from 5 focus groups conducted with clinicians (n=37) who work with young people at a large community service organization in the United States. This organization provides care to more than 27,000 people annually, most of whom are of low socioeconomic status. The transcripts were coded using thematic analysis.

RESULTS

Clinicians first provided insight into the digital tools they were currently using in their treatment sessions with young people, such as web-based videos and mood-tracking apps. They explained that their main goals in using these tools were to help young people build skills, facilitate learning, and monitor symptoms. Benefits were expressed, such as engagement of adolescents in treatment, along with potential challenges (eg, accessibility and limited content) and developmental considerations (eg, digital devices getting taken away as punishment). Clinicians discussed their desire for a centralized digital platform that securely connects the clinician, young person, and caregivers. Finally, they offered several considerations for integrating digital tools into mental health care, such as setting up expectations with clients and the importance of human support.

CONCLUSIONS

Young people have unique considerations related to complex accessibility patterns and technology expectations that may not be observed when adults are the intended users of mental health technologies. Therefore, these findings provide critical insights to inform the development of future tools, specifically regarding connectivity, conditional restraints (eg, devices taken away as punishment and school restrictions), expectations of users from different generations, and the blended nature in which digital tools can support young people.

Emerging Needs and Viability of Telepsychiatry During and Post COVID-19 Era: A Literature Review

The coronavirus disease 2019 (COVID-19) pandemic has resulted in nationwide stay-at-home orders in an effort to slow the spread severely impacting the healthcare sector. Telepsychiatry provides a platform bridging the gap through advanced technologies connecting mental health providers and patients who need their services, overcoming previous barriers of great distances, lack of transportation, and even time constraints. The most obvious benefit is increased accessibility to mental healthcare, especially in underserved and remote areas where there is no easy access for in-person care. It is important to note that benefits are not limited to patients, but also allow clinicians greater flexibility in scheduling and reduced practice overhead costs, both of which aid with physician burnout and burden. Telepsychiatry during COVID-19 provides its own unique advantages over in-person visits. The risk of exposure to healthcare workers and patients receiving care is reduced, allowing immunocompromised patients to receive much-needed psychiatric care. Without the need to meet in person, self-isolating psychiatrists can still provide care, decreasing strain on their co-workers. Although telepsychiatry is relatively new, it has already exhibited considerable success in its effectiveness at treating psychiatric conditions and widespread corollary benefits. Telepsychiatric consults may be carried out synchronously and asynchronously, each having benefits and setbacks. Different mobile application interventions have been explored, which are available for the purpose of both monitoring/assessing patients and/or providing treatment. The scope of conditions these applications address is broad, from anxiety disorders to schizophrenia to depression. As promising and beneficial telepsychiatry may seem, it is necessary to recognize that building the program can be challenging. It involves adapting to new methods in medicine. We highlighted barriers to general telepsychiatry, the most prominent being technological literacy of both physician and patient, and possible negative effects of eliminating the in-person patient-doctor interaction.

Self-guided Cognitive Behavioral Therapy Apps for Depression: Systematic Assessment of Features, Functionality, and Congruence With Evidence

Background

Mental health disorders affect 1 in 10 people globally, of whom approximately 300 million are affected by depression. At least half of the people affected by depression remain untreated. Although cognitive behavioral therapy (CBT) is an effective treatment, access to mental health specialists, habitually challenging, has worsened because of the COVID-19 pandemic. Internet-based CBT is an effective and feasible strategy to increase access to treatment for people with depression. Mental health apps may further assist in facilitating self-management for people affected by depression; however, accessing the correct app may be cumbersome given the large number and wide variety of apps offered by public app marketplaces.

Objective

This study aims to systematically assess the features, functionality, data security, and congruence with evidence of self-guided CBT-based apps targeting users affected by depression that are available in major app stores.

Methods

We conducted a systematic assessment of self-guided CBT-based apps available in Google Play and the Apple App Store. Apps launched or updated since August 2018 were identified through a systematic search in the 42matters database using CBT-related terms. Apps meeting the inclusion criteria were downloaded and assessed using a Samsung Galaxy J7 Pro (Android 9) and iPhone 7 (iOS 13.3.1). Apps were appraised using a 182-question checklist developed by the research team, assessing their general characteristics, technical aspects and quality assurance, and CBT-related features, including 6 evidence-based CBT techniques (ie, psychoeducation, behavioral activation, cognitive restructuring, problem solving, relaxation, and exposure for comorbid anxiety) as informed by a CBT manual, CBT competence framework, and a literature review of internet-based CBT clinical trial protocols. The results were reported as a narrative review using descriptive statistics.

Results

The initial search yielded 3006 apps, of which 98 met the inclusion criteria and were systematically assessed. There were 20 well-being apps; 65 mental health apps, targeting two or more common mental health disorders, including depression; and 13 depression apps. A total of 28 apps offered at least four evidence-based CBT techniques, particularly depression apps. Cognitive restructuring was the most common technique, offered by 79% (77/98) of the apps. Only one-third of the apps offered suicide risk management resources, whereas 17% (17/98) of the apps offered COVID-19–related information. Although most apps included a privacy policy, only a third of the apps presented it before account creation. In total, 82% (74/90) of privacy policies stated sharing data with third-party service providers. Half of the app development teams included academic institutions or health care providers.

Conclusions

Only a few self-guided CBT-based apps offer comprehensive CBT programs or suicide risk management resources. Sharing of users’ data is widespread, highlighting shortcomings in health app market governance. To fulfill their potential, self-guided CBT-based apps should follow evidence-based clinical guidelines, be patient centered, and enhance users’ data security.

Evaluating mobile health technologies: does the traditional randomized controlled trial serve our needs?

Mobile health technologies are increasingly used by cardiovascular nurses and allied health clinicians to support behaviour change and self-care in patients. Randomized controlled trials provide rigorous methodology for evaluation but progress slowly, so the technology is often outdated by completion. A helpful modification to the trial design includes identification of the behaviour intervention principles involved and concurrently track in-app usage data, allowing updates to be made. These data collected alongside user experiences enables analysis of effects on outcomes and determination of the relative influence of component parts. Cardiovascular and mental health mHealth strategies are used to exemplify these recommendations.

Digital Disparities: Lessons learned from a Patient Reported Outcomes Program During the COVID-19 Pandemic

The collection of patient reported outcomes (PROs) allows us to incorporate the patient's voice within their care in a quantifiable, validated manner. Large scale collection of PROs is facilitated by the electronic health record (EHR) and its portal, though historically patients have eschewed the portal and completed patient reported outcome measures (PROMS) in clinic via tablet. Furthermore, access to and use of the portal is associated with known racial inequities. Our institution oversees the largest clinical PRO program in the world, and has a long history of racially equitable PRO completion rates via tablet. However, when the COVID-19 pandemic forced us to remove tablets from clinics and rely exclusively on portal use for PRO completion, profound racial disparities resulted immediately. Our experience quantifiably demonstrates the magnitude of inequity that the portal, in its current configuration, generates and serves as a cautionary tale to other health care systems and EHRs.

Approaches for Implementing App-Based Digital Treatments for Drug Use Disorders Into Primary Care: A Qualitative, User-Centered Design Study of Patient Perspectives

Background

Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them.

Objective

This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care.

Methods

The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data.

Results

Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel).

Conclusions

A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients’ needs for structure, support in and outside of visits, and desire for convenience.

The Economic Burden of Adults with Major Depressive Disorder in the United States (2010 and 2018)

BACKGROUND

The incremental economic burden of US adults with major depressive disorder (MDD) was estimated at $US210.5 billion in 2010 (year 2012 values).

OBJECTIVE

Following a similar methodology, this study updates the previous findings with more recent data to report the economic burden of adults with MDD in 2018.

METHOD

This study used a framework for evaluating the incremental economic burden of adults with MDD in the USA that combined original and literature-based estimates, focusing on key changes between 2010 and 2018. The prevalence rates of MDD by sex, age, employment, and treatment status over time were estimated based on the National Survey on Drug Use and Health (NSDUH). The incremental direct and workplace costs per individual with MDD were primarily derived from administrative claims data and NSDUH data using comparative analyses of individuals with and without MDD. Societal direct and workplace costs were extrapolated by multiplying NSDUH estimates of the number of people with MDD by the direct and workplace cost estimates per patient. The suicide-related costs were estimated using a human capital method.

RESULTS

The number of US adults with MDD increased by 12.9%, from 15.5 to 17.5 million, between 2010 and 2018, whereas the proportion of adults with MDD aged 18-34 years increased from 34.6 to 47.5%. Over this period, the incremental economic burden of adults with MDD increased by 37.9% from $US236.6 billion to 326.2 billion (year 2020 values). All components of the incremental economic burden increased (i.e., direct costs, suicide-related costs, and workplace costs), with the largest growth observed in workplace costs, at 73.2%. Consequently, the composition of 2018 costs changed meaningfully, with 35% attributable to direct costs (47% in 2010), 4% to suicide-related costs (5% in 2010), and 61% to workplace costs (48% in 2010). This increase in the workplace cost share was consistent with more favorable employment conditions for those with MDD. Finally, the proportion of total costs attributable to MDD itself as opposed to comorbid conditions remained stable at 37% (38% in 2010).

CONCLUSION

Workplace costs accounted for the largest portion of the growing economic burden of MDD as this population trended younger and was increasingly likely to be employed. Although the total number of adults with MDD increased from 2010 to 2018, the incremental direct cost per individual declined. At the same time, the proportion of adults with MDD who received treatment remained stable over the past decade, suggesting that substantial unmet treatment needs remain in this population. Further research is warranted into the availability, composition, and quality of MDD treatment services.

Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment

A major obstacle to mental health treatment for many Americans is accessibility: the United States faces a shortage of mental health providers, resulting in federally designated shortage areas. Although digital mental health treatments (DMHTs) are effective interventions for common mental disorders, they have not been widely adopted by the U.S. health care system. National and international expert stakeholders representing health care organizations, insurance companies and payers, employers, patients, researchers, policy makers, health economists, and DMHT companies and the investment community attended two Banbury Forum meetings. The Banbury Forum reviewed the evidence for DMHTs, identified the challenges to successful and sustainable implementation, investigated the factors that contributed to more successful implementation internationally, and developed the following recommendations: guided DMHTs should be offered to all patients experiencing common mental disorders, DMHT products and services should be reimbursable to support integration into the U.S. health care landscape, and an evidence standards framework should be developed to support decision makers in evaluating DMHTs.

Case studies from the digital clinic: integrating digital phenotyping and clinical practice into today's world

The following case series provides several examples from the Digital Clinic, an outpatient mental health program which uses smartphone technology to augment traditional mental health care. The themes highlighted in this piece, expanding emotional-awareness, symptom tracking, and medication management, provide real-clinical examples of how the Digital Clinic offered remote mental health care to a diverse group of people. Furthermore, the following piece demonstrates to practicing clinicians how digital technologies, like smartphone apps, can diversify methods of clinical engagement, assist with collecting health metrics in a safe and ethical manner, and promote person centred care. With the COVID-19 pandemic forcing re-evaluation of how mental health services are provided, it is critical to ensure that digitally infused systems of care, like the Digital Clinic, are effective, accessible, and scalable.

A therapist-guided smartphone app for major depression in young adults: A randomized clinical trial

BACKGROUND

Meru Health Program (MHP) is a therapist-guided, 8-week intervention for depression delivered via smartphone. The aim was to test its efficacy in patients with clinical depression in a Finnish university student health service.

METHODS

Patients (n=124, women 72.6%, mean age 25y) were stratified based on antidepressant status, and randomized into intervention group receiving MHP plus treatment as usual (TAU), and control group receiving TAU only. Depression, measured by the Patient Health Questionnaire-9 (PHQ-9) scale, was the primary outcome. After baseline (T0), follow-ups were at mid-intervention (T4), immediately post-intervention (T8); 3 months (T20), and 6 months (T32) post-intervention.

RESULTS

The intervention group and control group did not have significant differences in depression outcomes throughout end of treatment and follow-up. Among secondary outcomes, increase in resilience (d=0.32, p=0.03) and mindfulness (d=0.57, p=0.002), and reduction in perceived stress (d=-0.52, p=0.008) were greater in MHP+TAU versus TAU at T32; no differences were found in anxiety, sleep disturbances, and quality of life between groups. Post-hoc comparisons of patients on antidepressants showed significantly greater reduction in depression at T32 for MHP+TAU versus TAU (d=-0.73, p=0.01); patients not on antidepressants showed no between-group differences.

LIMITATIONS

Limitations include unknown characteristics of TAU, potential bias from patients and providers not being blinded to treatment group, and failure to specify examination of differences by antidepressant status in the protocol.

CONCLUSIONS

Most outcomes, including depression, did not significantly differ between MHP+TAU and TAU. Exploratory analysis revealed intervention effect at the end of the 6-month follow-up among patients on antidepressant medication.

Coronavirus Awareness and Mental Health: Clinical Symptoms and Attitudes Toward Seeking Professional Psychological Help

The current study analyzed the relationship between Coronavirus (COVID-19) Awareness, mental health, and willingness to seek professional psychological help. This was made through a quantitative approach, using online questionnaires to collect data from 855 subjects. The questionnaires included the Brief Symptom Inventory (BSI-53) to measure mental health indicators, the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form, and the Coronavirus Awareness Scale-10 (CAS-10). An Exploratory Factor Analysis suggests that three factors underlie the CAS-10: Coronavirus Concern, Exaggerated Perception, and Immunity Perception. Results indicate a significant positive correlation between Coronavirus Concern and both general anxiety and phobic anxiety symptoms. Immunity Perception is positively related to paranoid ideation and psychotic symptoms. A Mediation Analysis determined that Coronavirus Concern has a significant positive direct effect on Openness to Seeking Psychological Treatment (OSPT), while Exaggerated Perception and Immunity Perception scores have significant direct negative effects on the Value and Need in Seeking Treatment (VNST) scores. Indirectly, the relationship between Coronavirus Concern and OPST is significantly mediated by anxiety symptoms. Similar results were found for the VNST subscale. There is a negative significant effect of Immunity Perception over OSPT mediated by Paranoid Ideation. However, the overall model only achieved small r 2 coefficients for the OSPT (0.060) and VNST (0.095) scores. Comparisons in Coronavirus Awareness between sex, age, and the presence of children and older adults at home were also made. These results are discussed regarding their practical implications for mental health providers and policymakers.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

Background

Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.

Objective

This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.

Methods

A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.

Results

A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.

Conclusions

Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

Development of a cognitive bias modification intervention for anxiety disorders in primary care

OBJECTIVES

There is a great need for low-intensity, scalable treatments in primary care, where most anxious patients first present for treatment. We describe Stage IA treatment development and a Stage IB feasibility trial of cognitive bias modification (CBM) for transdiagnostic anxiety in primary care.

METHODS

The online intervention, Mental Habits, comprised eight sessions of a personalized CBM targeting attention and interpretation biases. Coaches assisted patients in using the website, monitored progress via a dashboard, and shared information with primary care providers. We evaluated Mental Habits in an open trial (N = 14) and a randomized controlled trial (RCT) (N = 40) in primary care patients with anxiety disorders.

RESULTS

We compared results to a priori benchmarks of clinically meaningful outcomes. In the open trial, Mental Habits met feasibility, acceptability, and efficacy benchmarks. In the pilot RCT, there was greater dropout at one study site which ultimately closed. In the intent-to-treat analyses, Mental Habits met the benchmark for self-report, but not the interview measure of anxiety. Symptom Tracking did not meet the benchmark for self-report or interview measures of anxiety. In per-protocol analyses, Mental Habits exceeded the benchmark for both self-report and interview measures, whereas Symptom Tracking met the benchmark for self-report. Interpretation bias improved in the Mental Habits group, but not in Symptom Tracking. No effects were observed for attention bias.

CONCLUSION

The online CBM intervention demonstrated good acceptability and, when delivered at a stable primary care clinic, preliminary effectiveness in primary care. A larger RCT is warranted to test effectiveness.

PRACTITIONER POINTS

A personalized, transdiagnostic Cognitive Bias Modification (CBM) intervention for anxiety in primary care is acceptable to primary care patients with social anxiety disorder, generalized anxiety disorder, and/or panic disorder /agoraphobia. With training and supervision from licensed mental health clinicians, bachelor's-level coaches can assist primary care patients to self-administer CBM. Offering a low-intensity, self-directed anxiety intervention in primary care can greatly expand the reach of anxiety treatment, with minimal need for additional resources. Interpretation bias may be an important clinical target for primary care patients with anxiety.

Examining an App-Based Mental Health Self-Care Program, IntelliCare for College Students: Single-Arm Pilot Study

BACKGROUND

In recent years, there has been an increase in symptoms of depression, anxiety, and other mental illnesses in college student populations alongside a steady rise in the demand for counseling services. Digital mental health programs, such as those delivered through mobile apps, can add to the array of available services but must be tested for usability and acceptability before implementation.

OBJECTIVE

This study aims to examine how students used IntelliCare for College Students over an 8-week period to examine the preliminary associations between app use and psychosocial targets and to gather user feedback about usability issues that need to be remedied before a larger implementation study.

METHODS

IntelliCare for College Students is an app-based platform that provides symptom assessments with personalized feedback, information about campus resources, lessons on mental health and wellness topics, and access to the suite of interactive skill-focused IntelliCare apps. A total of 20 students were recruited to participate in an 8-week study. To test for a broad range of potential users, we recruited a mixed sample of students with elevated symptoms of depression or anxiety and students without elevated symptoms. Participants completed psychosocial questionnaires at baseline, week 4, and week 8. Participants also completed user feedback interviews at weeks 4 and 8 in which they provided feedback on their experience using the app and suggestions for changes they would like to be made to the app.

RESULTS

Of the 20 students who downloaded the app, 19 completed the study, indicating a high rate of retention. Over the study period, participants completed an average of 5.85 (SD 2.1; range 1-8) symptom assessments. Significant improvements were observed in the Anxiety Literacy Questionnaire scores (Z=-2.006; P=.045) and in the frequency with which participants used both cognitive (Z=-2.091; P=.04) and behavioral (Z=-2.249; P=.03) coping skills. In the feedback interviews, we identified a high degree of usability with minor bugs in the app software, which were quickly fixed. Furthermore, in feedback interviews, we identified that users found the app to be convenient and appreciated the ability to use the program in short bursts of time.

CONCLUSIONS

The findings indicate that the IntelliCare for College Students program was perceived as largely usable and engaging. Although the program demonstrated usability and preliminary benefits to students, further testing is needed to determine its clinical utility among college students.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04035577; https://clinicaltrials.gov/ct2/show/NCT04035577.

Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies

BACKGROUND

Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use.

OBJECTIVE

The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period.

METHODS

The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention.

RESULTS

The 3 participants' unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves.

CONCLUSIONS

These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages.