Assessing the Efficacy of Mobile Health Apps Using the Basic Principles of Cognitive Behavioral Therapy: Systematic Review

Mobile Health for Perinatal Depression and Anxiety: Scoping Review

Background

The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers.

Objective

This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work.

Methods

Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded.

Results

A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies.

Conclusions

Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth.

PROTOCOL: A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents

This is the protocol for a Campbell review. The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regards to intervention completion/attrition (used as a proxy for intervention acceptability). The review will provide relative effect estimates and ranking probabilities for each outcome based on intervention delivery.

Apps for Depression: Are They Ready to Work?

PURPOSE OF REVIEW

To summarize the latest evidence about mobile phone applications for the management of depression.

RECENT FINDINGS

Depression apps are very heterogeneous, given the absence of standards for their development, description, and evaluation. Randomized clinical trials show the effectiveness of some of these applications in reducing depressive symptoms. Attrition is an important issue whose evaluation is limited by the frequent use of incentives in the studies. The number of mobile applications for depression far exceeds the number of studies evaluating their efficacy and feasibility. Despite the limitations of the digital market, there are a small number of apps that have demonstrated sufficient effectiveness and tolerability to think of short-term clinical use. However, there are still barriers at different levels that may delay the implementation of these interventions in daily clinical practice.

Engagement and Usability of a Cognitive Behavioral Therapy Mobile App Compared With Web-Based Cognitive Behavioral Therapy Among College Students: Randomized Heuristic Trial

Background

Recent evidence in mobile health has demonstrated that, in some cases, apps are an effective way to improve health care delivery. Health care interventions delivered via mobile technology have demonstrated both practicality and affordability. Lately, cognitive behavioral therapy (CBT) interventions delivered over the internet have also shown a meaningful impact on patients with anxiety and depression.

Objective

Given the growing proliferation of smartphones and the trust in apps to support improved health behaviors and outcomes, we were interested in comparing a mobile app with Web-based methods for the delivery of CBT. This study aimed to compare the usability of a CBT mobile app called MoodTrainer with an evidence-based website called MoodGYM.

Methods

We used convenience sampling to recruit 30 students from a large Midwestern university and randomly assigned them to either the MoodGYM or MoodTrainer user group. The trial period ran for 2 weeks, after which the students completed a self-assessment survey based on Nielsen heuristics. Statistical analysis was performed to compare the survey results from the 2 groups. We also compared the number of modules attempted or completed and the time spent on CBT strategies.

Results

The results indicate that the MoodTrainer app received a higher usability score when compared with MoodGYM. Overall, 87% (13/15) of the participants felt that it was easy to navigate through the MoodTrainer app compared with 80% (12/15) of the MoodGYM participants. All MoodTrainer participants agreed that the app was easy to use and did not require any external assistance, whereas only 67% (10/15) had the same opinion for MoodGYM. Furthermore, 67% (10/15) of the MoodTrainer participants found that the navigation controls were easy to locate compared with 80% (12/15) of the MoodGYM participants. MoodTrainer users, on average, completed 2.5 modules compared with 1 module completed by MoodGYM users.

Conclusions

As among the first studies to directly compare the usability of a mobile app–based CBT with smartphone-specific features against a Web-based CBT, there is an opportunity for app-based CBT as, at least in our limited trial, it was more usable and engaging. The study was limited to evaluate usability only and not the clinical effectiveness of the app.

Automated assessment of psychiatric disorders using speech: A systematic review

OBJECTIVE

There are many barriers to accessing mental health assessments including cost and stigma. Even when individuals receive professional care, assessments are intermittent and may be limited partly due to the episodic nature of psychiatric symptoms. Therefore, machine-learning technology using speech samples obtained in the clinic or remotely could one day be a biomarker to improve diagnosis and treatment. To date, reviews have only focused on using acoustic features from speech to detect depression and schizophrenia. Here, we present the first systematic review of studies using speech for automated assessments across a broader range of psychiatric disorders.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We included studies from the last 10 years using speech to identify the presence or severity of disorders within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For each study, we describe sample size, clinical evaluation method, speech-eliciting tasks, machine learning methodology, performance, and other relevant findings.

RESULTS

1395 studies were screened of which 127 studies met the inclusion criteria. The majority of studies were on depression, schizophrenia, and bipolar disorder, and the remaining on post-traumatic stress disorder, anxiety disorders, and eating disorders. 63% of studies built machine learning predictive models, and the remaining 37% performed null-hypothesis testing only. We provide an online database with our search results and synthesize how acoustic features appear in each disorder.

CONCLUSION

Speech processing technology could aid mental health assessments, but there are many obstacles to overcome, especially the need for comprehensive transdiagnostic and longitudinal studies. Given the diverse types of data sets, feature extraction, computational methodologies, and evaluation criteria, we provide guidelines for both acquiring data and building machine learning models with a focus on testing hypotheses, open science, reproducibility, and generalizability.

LEVEL OF EVIDENCE

3a.

What is the clinical value of mHealth for patients?

Despite growing interest from both patients and healthcare providers, there is little clinical guidance on how mobile apps should be utilized to add value to patient care. We categorize apps according to their functionality (e.g. preventative behavior change, digital self-management of a specific condition, diagnostic) and discuss evidence for effectiveness from published systematic reviews and meta-analyses and the relevance to patient care. We discuss the limitations of the current literature describing clinical outcomes from mHealth apps, what FDA clearance means now (510(k)/de novo FDA clearance) and in the future. We discuss data security and privacy as a major concern for patients when using mHealth apps. Patients are often not involved in the development of mobile health guidelines, and professionals' views regarding high-quality health apps may not reflect patients' views. We discuss efforts to develop guidelines for the development of safe and effective mHealth apps in the US and elsewhere and the role of independent app reviews sites in identifying mHealth apps for patient care. There are only a small number of clinical scenarios where published evidence suggests that mHealth apps may improve patient outcomes.

Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study

BACKGROUND

The use of mobile health (mHealth) interventions has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management.

AIM

The aim of this study was to explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD. It could inform the development and successful implementation of mHealth interventions for COPD management.

METHODS

This was a qualitative study. We conducted semi-structured individual interviews with HCPs, including nurses, pharmacists and physicians who work directly with patients with COPD. Interviews were also conducted with a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management.

RESULTS

A total of 40 people, including nurses, physicians and pharmacists, participated. The main recommendations for the proposed mHealth intervention were categorised into two categories: patient interface and HCP interface. The prevalent features suggested for the patient interface include educating patients, collecting baseline data, collecting subjective data, collecting objective data via compatible medical devices, providing a digital action plan, allowing patients to track their progress, enabling family members to access the mHealth intervention, tailoring the features based on the patient's unique needs, reminding patients about critical management tasks and rewarding patients for their positive behaviours. The most common features of the HCP interface include allowing HCPs to track their patients' progress, allowing HCPs to communicate with their patients, educating HCPs and rewarding HCPs.

CONCLUSION

This study identifies important potential features so that the most effective, efficient and feasible mHealth intervention can be developed to improve the management of COPD.The reviews of this paper are available via the supplemental material section.

Trust Me, I'm a Chatbot: How Artificial Intelligence in Health Care Fails the Turing Test

Over the next decade, one issue which will dominate sociotechnical studies in health informatics is the extent to which the promise of artificial intelligence in health care will be realized, along with the social and ethical issues which accompany it. A useful thought experiment is the application of the Turing test to user-facing artificial intelligence systems in health care (such as chatbots or conversational agents). In this paper I argue that many medical decisions require value judgements and the doctor-patient relationship requires empathy and understanding to arrive at a shared decision, often handling large areas of uncertainty and balancing competing risks. Arguably, medicine requires wisdom more than intelligence, artificial or otherwise. Artificial intelligence therefore needs to supplement rather than replace medical professionals, and identifying the complementary positioning of artificial intelligence in medical consultation is a key challenge for the future. In health care, artificial intelligence needs to pass the implementation game, not the imitation game.

Usability, Acceptability, Feasibility, and Effectiveness of a Gamified Mobile Health Intervention (Triumf) for Pediatric Patients: Qualitative Study

Background

Mental disorders are notably prevalent in children with chronic illnesses, whereas a lack of access to psychological support might lead to potential mental health problems or disruptions in treatment. Digitally delivered psychological interventions have shown promising results as a supportive treatment measure for improving health outcomes during chronic illness.

Objective

This study aimed to evaluate the usability, acceptability, and feasibility of providing psychological and treatment support in a clinical setting via a mobile game environment. In addition, the study aimed to evaluate the preliminary effectiveness of the mobile health game.

Methods

Patients aged 7 to 14 years with less than a year from their diagnosis were eligible to participate in the study. In total, 15 patients were invited to participate by their doctor. A total of 9 patients (age range: 7-12 years; mean age 9.1 years) completed the 60-day-long study in which the Triumf mobile health game was delivered as a digital intervention. In an engaging game environment, patients were offered psychological and treatment support, cognitive challenges, and disease-specific information. The fully digital intervention was followed by a qualitative interview conducted by a trained psychologist. The results of the interview were analyzed in conjunction with patient specific in-game qualitative data. Ethical approval was obtained to conduct the study.

Results

Patients positively perceived the game, resulting in high usability and acceptability evaluations. Participants unanimously described the game as easy to use and engaging in terms of gamified activities, while also providing beneficial and trustworthy information. Furthermore, the overall positive evaluation was emphasized by an observed tendency to carry on gaming post study culmination (67%, 10/15). Psychological support and mini games were the most often used components of the game, simultaneously the participants also highlighted the education module as one of the most preferred. On average, the patients sought and received psychological support or education on 66.6 occasions during the 60-day intervention. Participants spent the most time collecting items from the city environment (on average 15.6 days, SD 8.1), indicative of exploratory behavior, based on the quantitative in-game collected data. During the intervention period, we observed a statistically significant decrease in general health problems (P=.003) and saw a trend toward a decrease in depression and anxiety symptoms.

Conclusions

This study demonstrated that a game environment could be a promising medium for delivering comprehensive supportive care to pediatric patients with cancer alongside standard treatment, with potential application across a variety of chronic conditions. Importantly, the results indicate that the study protocol was feasible with modifications to randomized controlled trials, and the game could be considered applicable in a clinical context. By giving an empirical evaluation of delivering psychological support via the game environment, our work stands to inform future mobile health interventions.

New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation

In the last decades, emotion regulation (ER) received increasing attention and became one of the most studied topics within the psychological field. Nevertheless, this construct has not been fully updated with the latest technological advancements. In this perspective, we will show how diverse technologies, such as virtual reality (VR), wearable biosensors, smartphones, or biofeedback techniques, can be applied to the understanding, assessment, and intervention of ER. After providing a brief overview of the currently available technological developments, we will discuss the benefits of incorporating new technologies in ER field, including ecological validity, intervention personalization, and the integration of understudied facets of ER, such as the implicit and interpersonal dimension.

"I Feel Like A Neurotic Mother at Times"-a mixed methods study exploring online health information seeking behaviour in new parents

BACKGROUND

In contemporary society, due to the exponential growth of technology and the online platform, data acquisition has never been so effortless. Subsequent accessibility to health information has been reported as having many positive and negative effects. Health anxiety is the apprehension of experiencing or developing an ailment due to symptomology misinterpretation. One such lifetime occurrence which causes increased anxiety is becoming a new parent. New parents often use the online platform to seek information which will educate them on how best to care for their child and to keep their child's health at the optimum level.

METHODS

The online Pregnancy Questionnaire used within this study was inclusive of the Short HAI Health Anxiety Inventory (HAI) and was tailored for both pregnant women and new parents. This study focuses specifically on the results provided by the new parents. The research was disseminated and advertised on social media platforms such as Facebook, Twitter and a purpose-built website named "A Healthy Search" which provided all information relevant to the study and participation. Quantitative data were analysed using a regression and qualitative data were thematically analysed.

RESULTS

Results shows that medical complications in pregnancy did not significantly predict health anxiety however medical care within the past year did. It can also be seen that frequency of searching online for self, did not significantly predict health anxiety, yet searching online for child did significantly predict health anxiety. Anxiety specific to pregnancy ceases when gravidity comes to an end and feelings of health anxiety then tend to be transferred from the mother (parent) to the child when one becomes a new parent. New parents strive to expand their own knowledge base, in regards to typical and atypical symptomology, so that they are better equipped to monitor development, care for, and make decisions on behalf of their child. The online platform was used as opposed to offline provisos due to inexperience, judgement and anonymity. Online health information seeking behaviour also has the probability of both increasing and decreasing levels of anxiety in new parents.

CONCLUSIONS

This research recognised and reinforced positive and negative aspects of online health information seeking behaviour. It is recommended that further research be carried out into relevant, efficacious interventional techniques that may relieve health anxiety within new parents as contemporary technology has become a pivotal aspect of life.

Effects, Adherence, and Therapists' Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study

BACKGROUND

Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients' adherence to and therapists' perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings.

OBJECTIVE

This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format.

METHODS

A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey.

RESULTS

Primary symptom reduction was high (d=1.31 to 1.51) and remained stable for the follow-up period. Therapists identified advantages (eg, patient engagement, treatment intensification, and improved therapeutic relation) and disadvantages (eg, increased workload, data issues, and undesired effects) of bGT. The required online guidance time was 10.3 min per patient and week, including guidance on exercises (67% or 6.9 min) and intimate communication (33% or 3.4 min). Concerning patients' adherence to bGT, tracked completion of all Web-based and mobile tasks was high and comparable with group attendance.

CONCLUSIONS

Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions.

Brain-Gut Therapies for Pediatric Functional Gastrointestinal Disorders and Inflammatory Bowel Disease

PURPOSE OF REVIEW

The purpose of this review is to discuss current knowledge of brain-gut therapies (BGT) in pediatric functional gastrointestinal disorders (FGID) and inflammatory bowel disease (IBD), including their evidence base, the common psychopathology that they address, and the integration of this knowledge into medical settings.

RECENT FINDINGS

Cognitive behavioral therapy (CBT), hypnotherapy (HT), mindfulness-based therapy (MBT), and exposure-based therapy (EBT) have the most data supporting their use in children, particularly in FGID, more so than in IBD. This difference is most likely because of the increased role of psychological factors in FGID, though these same factors can be seen comorbidly in IBD. Integrative BGT treatment strategies with the collaboration of clinicians across disciplines may provide the most benefit to patients. This review details our current understanding of the evidence for BGT in pediatric FGID and IBD and how they may best be used in treatment strategies.

Automated Mobile Phone Messaging Utilizing a Cognitive Behavioral Intervention: A Pilot Investigation

BACKGROUND

In the setting of outpatient orthopaedic surgery, this pilot study utilized automated mobile messaging to assess (1) the feasibility of and interaction rates with a software delivered cognitive behavior therapy (CBT) intervention for postoperative opioid utilization, (2) the reliability of patient reported opioid utilization through our platform, (3) daily patient reported pain and opioid utilization within the first two postoperative weeks, and (4) the effect of software delivered CBT intervention on patient reported opioid utilization.

METHODS

Musculoskeletal tumor patients scheduled for outpatient surgery were randomized into two study groups. Control patients received standard postoperative communication limited to a two-week postoperative follow-up visit. The intervention group received automated daily text-messages regarding pain, opioid utilization, and a daily CBT intervention. Interventional group patients also completed a patient satisfaction questionnaire at their two-week follow-up. Completion rates of all software delivered questions were determined in the interventional group. Median values of opioid utilization and interquartile range (IQR) were determined to compare utilization between groups. Spearman correlation coefficients were used to determine reliability of patient reported opioid utilization in the interventional group.

RESULTS

Fourteen patients completed the pilot study (seven controls, seven intervention). Patients in the intervention arm completed 90% of pain and opioid questions. Intervention group patients utilized less of their daily prescribed opioid medication (20%, IQR:10%-27%) compared to controls (50%, IQR:4%-68%). Correlation between in-office pill counts and patient reported opioid medication utilization via our software messaging system was high (r=0.90, p=0.037).

CONCLUSION

Automated mobile phone messaging in outpatient tumor surgery yielded high interaction rates. Patient reported opioid utilization obtained through our platform demonstrated a high correlation with in-office pill counts. CBT delivered via automated mobile phone messaging demonstrated decreased opioid utilization in this pilot investigation.Level of evidence: II.

An Empathy-Driven, Conversational Artificial Intelligence Agent (Wysa) for Digital Mental Well-Being: Real-World Data Evaluation Mixed-Methods Study

BACKGROUND

A World Health Organization 2017 report stated that major depression affects almost 5% of the human population. Major depression is associated with impaired psychosocial functioning and reduced quality of life. Challenges such as shortage of mental health personnel, long waiting times, perceived stigma, and lower government spends pose barriers to the alleviation of mental health problems. Face-to-face psychotherapy alone provides only point-in-time support and cannot scale quickly enough to address this growing global public health challenge. Artificial intelligence (AI)-enabled, empathetic, and evidence-driven conversational mobile app technologies could play an active role in filling this gap by increasing adoption and enabling reach. Although such a technology can help manage these barriers, they should never replace time with a health care professional for more severe mental health problems. However, app technologies could act as a supplementary or intermediate support system. Mobile mental well-being apps need to uphold privacy and foster both short- and long-term positive outcomes.

OBJECTIVE

This study aimed to present a preliminary real-world data evaluation of the effectiveness and engagement levels of an AI-enabled, empathetic, text-based conversational mobile mental well-being app, Wysa, on users with self-reported symptoms of depression.

METHODS

In the study, a group of anonymous global users were observed who voluntarily installed the Wysa app, engaged in text-based messaging, and self-reported symptoms of depression using the Patient Health Questionnaire-9. On the basis of the extent of app usage on and between 2 consecutive screening time points, 2 distinct groups of users (high users and low users) emerged. The study used mixed-methods approach to evaluate the impact and engagement levels among these users. The quantitative analysis measured the app impact by comparing the average improvement in symptoms of depression between high and low users. The qualitative analysis measured the app engagement and experience by analyzing in-app user feedback and evaluated the performance of a machine learning classifier to detect user objections during conversations.

RESULTS

The average mood improvement (ie, difference in pre- and post-self-reported depression scores) between the groups (ie, high vs low users; n=108 and n=21, respectively) revealed that the high users group had significantly higher average improvement (mean 5.84 [SD 6.66]) compared with the low users group (mean 3.52 [SD 6.15]); Mann-Whitney P=.03 and with a moderate effect size of 0.63. Moreover, 67.7% of user-provided feedback responses found the app experience helpful and encouraging.

CONCLUSIONS

The real-world data evaluation findings on the effectiveness and engagement levels of Wysa app on users with self-reported symptoms of depression show promise. However, further work is required to validate these initial findings in much larger samples and across longer periods.

Introduction to the Special Issue: Integration of Technological Advances in Cognitive-Behavior Therapy

A wide range of technological approaches has been adopted in assessment and intervention using cognitive-behavior therapy (CBT). The articles that comprise this special issue cover a diversity of areas, including motion-tracking devices, ecological momentary assessment, facial recognition software to provide rapid feedback, audio and tablet-based CBT-administered procedures, web-based acceptance program for stress reduction, and videoconferencing for delivery of anxiety treatment in youth. It is expected that technological advances will continue to lead to additional advances in CBT delivery.

Feasibility and Acceptability of Mobile Phone-Based Auto-Personalized Physical Activity Recommendations for Chronic Pain Self-Management: Pilot Study on Adults

BACKGROUND

Chronic pain is a globally prevalent condition. It is closely linked with psychological well-being, and it is often concomitant with anxiety, negative affect, and in some cases even depressive disorders. In the case of musculoskeletal chronic pain, frequent physical activity is beneficial. However, reluctance to engage in physical activity is common due to negative psychological associations (eg, fear) between movement and pain. It is known that encouragement, self-efficacy, and positive beliefs are effective to bolster physical activity. However, given that the majority of time is spent away from personnel who can give such encouragement, there is a great need for an automated ubiquitous solution.

OBJECTIVE

MyBehaviorCBP is a mobile phone app that uses machine learning on sensor-based and self-reported physical activity data to find routine behaviors and automatically generate physical activity recommendations that are similar to existing behaviors. Since the recommendations are based on routine behavior, they are likely to be perceived as familiar and therefore likely to be actualized even in the presence of negative beliefs. In this paper, we report the preliminary efficacy of MyBehaviorCBP based on a pilot trial on individuals with chronic back pain.

METHODS

A 5-week pilot study was conducted on people with chronic back pain (N=10). After a week long baseline period with no recommendations, participants received generic recommendations from an expert for 2 weeks, which served as the control condition. Then, in the next 2 weeks, MyBehaviorCBP recommendations were issued. An exit survey was conducted to compare acceptance toward the different forms of recommendations and map out future improvement opportunities.

RESULTS

In all, 90% (9/10) of participants felt positive about trying the MyBehaviorCBP recommendations, and no participant found the recommendations unhelpful. Several significant differences were observed in other outcome measures. Participants found MyBehaviorCBP recommendations easier to adopt compared to the control (βint=0.42, P<.001) on a 5-point Likert scale. The MyBehaviorCBP recommendations were actualized more (βint=0.46, P<.001) with an increase in approximately 5 minutes of further walking per day (βint=4.9 minutes, P=.02) compared to the control. For future improvement opportunities, participants wanted push notifications and adaptation for weather, pain level, or weekend/weekday.

CONCLUSIONS

In the pilot study, MyBehaviorCBP's automated approach was found to have positive effects. Specifically, the recommendations were actualized more, and perceived to be easier to follow. To the best of our knowledge, this is the first time an automated approach has achieved preliminary success to promote physical activity in a chronic pain context. Further studies are needed to examine MyBehaviorCBP's efficacy on a larger cohort and over a longer period of time.

Efficacy and Moderation of Mobile App-Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on Mental Health: Randomized Controlled Noninferiority Trial

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).

Pokémon GO Within the Context of Family Health: Retrospective Study

BACKGROUND

Pokémon GO illuminated the potential for mobile phone gaming apps to engage users and promote health. However, much work is needed to fully understand the mechanisms through which digitally supported behavior change interventions operate, particularly for children and families.

OBJECTIVE

The aims of this study were (1) to explore the Pokémon GO user experience from a family perspective and (2) to investigate Pokémon GO within the context of family health.

METHODS

Between January and February 2017, congruent with one of the largest anticipated Pokémon GO updates Gen 2, participants were recruited from parks, word of mouth, and social media to complete a Web-based survey. Participants were surveyed about family characteristics, interest, and experiences playing Pokémon GO and healthy lifestyle beliefs. Using a revised Godin Leisure-Time Exercise Questionnaire, a retrospective pre-post design assessed changes in parent physical activity (PA) before and after playing Pokémon GO.

RESULTS

Self-reported data from 160 parents and 31 children were included in the final analyses (representing 129 parents and 31 parent-child dyads). Gameplay most often occurred between sons aged 10 years or younger and mothers. "Spending time together" was the most cited reason for gameplay by both parents (122/160, 76.3%) and children (24/31, 77%), followed by "it helped me go outdoors" for parents (113/160, 70.1%) and "I am a Pokémon fan" by children (21/31, 68%). Interestingly, open-ended responses indicated that gameplay could trigger both positive and negative emotional parent response. The most cited reason for app disengagement was boredom; conversely, the most cited reason for app re-engagement was in-app events. For parents, there were significant increases in minutes spent in mild (mean 23.36 [SD 66.02]; t₉₇=3.50, P<.001) and moderate (mean 21.76 [SD 53.04]; t₁₃₀=4.70, P<.001) PA per week after playing Pokémon GO. However, child perceptions of parental influence on PA most significantly associated with parents who reported weekly strenuous PA both before (r_s=.514, P=.003) and after (r_s=.536, P=.003) Pokémon GO uptake.

CONCLUSIONS

Pokémon GO transcended traditional understanding of digital health and uniquely reached across generations to engage users. Findings from this study highlight that, for a period of time, Pokémon GO fostered social and physical well-being for children and families through a multifaceted approach.

An Exploratory Correlational Study in the Use of Mobile Technology Among Adult Kidney Transplant Recipients

INTRODUCTION

Rapidly growing use of mobile technology provides a platform for self-management of care support for those with chronic conditions. Few studies have explored the characteristics or access patterns of kidney transplant recipients who use mHealth applications (apps) for self-management of care.

RESEARCH QUESTIONS

The primary aim of this study was to describe demographics, use, barriers, and perceptions of mobile apps for self-management of care among adult kidney transplants recipients. The secondary aim was to compare blood urea nitrogen, glomerular filtration rate, and number of hospitalizations among mHealth app users, other app users, and non-app users.

METHODS

A cross-sectional design was used to administer the Mobile Application Use among Kidney Transplant Recipients Questionnaire. Descriptive statistics, χ² statistics, and analysis of variance were used for the primary aim and linear regression was used for the secondary aim.

RESULTS

The sample included mostly African American males (n = 123, 75.5%) with a mean age of 50 (13.2) years. Knowledge was the greatest barrier reported by the non-app users (mHealth app users 9%, other app users 12%, non-app users, 49%, P < .001). Significantly fewer hospitalizations were found in the mHealth app users compared to other app users (regression coefficient b = -1.2, standard error [SE] = 0.5) and non-app users ( b = -0.9, SE = 0.6), adjusting for patient demographic and clinical characteristics.

DISCUSSION

Findings suggest a relationship may exist between mHealth app use and a decrease in the number of hospitalizations following kidney transplantation.

Mobile App Tools for Identifying and Managing Mental Health Disorders in Primary Care

PURPOSE OF REVIEW

Mental health apps are intriguing yet challenging tools for addressing barriers to treatment in primary care. In the current review, we seek to assist primary care professionals with evaluating and integrating mental health apps into practice. We briefly summarize two leading frameworks for evaluating mental health apps and conduct a systematic review of mental health apps across a variety of areas commonly encountered in primary care.

RECENT FINDINGS

Existing frameworks can guide professionals and patients through the process of identifying apps and evaluating dimensions such as privacy and security, credibility, and user experience. For specific apps, several problem areas appear to have relatively more scientific evaluation in the current app landscape, including PTSD, smoking, and alcohol use. Other areas such as eating disorders not only lack evaluation, but contain a significant subset of apps providing potentially harmful advice.

SUMMARY

Overall, individuals seeking mental health apps will likely encounter strengths such as symptom tracking and psychoeducational components, while encountering common weaknesses such as insufficient privacy settings and little integration of empirically-supported techniques. While mental health apps may have more promise than ever, significant barriers to finding functional, usable, effective apps remain for health professionals and patients alike.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of the breadth of research studies published from April 2017 to April 2018 on mobile-based interventions for mental health, with a special emphasis on smartphone-based interventions.

RECENT FINDINGS

Several studies during the review period have described the process of applying user-centred design in the development of mental health apps and novel approaches to enhance user-engagement. Studies on consumer perspectives indicate largely positive findings about open-ness to utilize mental health apps. There is a scarcity of similar studies on health providers. Efficacy studies have provided evidence for apps for a variety of psychiatric disorders. There are fewer studies on preventive and promotive interventions. Although a plethora of mental health apps is available for public, most have not undergone scientific evaluation. Many well researched apps are not accessible to public. The potential of smartphone technology in enhancing healthcare service delivery in low-resource settings has also been examined in a few studies.

SUMMARY

Evidence for acceptability, feasibility and efficacy of mobile-based mental health interventions for facilitating recovery is on the rise. More research is needed on implementation and integration of these interventions in diverse real-world clinical and community contexts.

Connecting With Your Dentist on Facebook: Patients' and Dentists' Attitudes Towards Social Media Usage in Dentistry

BACKGROUND

Social media has begun to proliferate across medical areas and transformed how medical professionals serve and interact with their patients. It offers a new communication avenue that has the potential to engage patients and, hence, may be used to create value for both medical professionals and patients. In dentistry, even though patients and dentists frequently use social media in their personal lives, little is known about their attitudes and expectations toward using social media for professional interactions.

OBJECTIVE

In this paper, we focus on the role of social media in dentistry. Specifically, we explore patients' and dentists' attitudes toward social media usage and their current online behaviors in this context. Furthermore, we examine potential challenges and opportunities regarding dentists' adoption of social media practices.

METHODS

This research employed a large-scale online survey of 588 patients and 532 dental professionals. We assessed the attitudes, expectations, and social media behaviors from both patients' and dentists' perspectives.

RESULTS

We found that more than 55% (290/532) of dentists in our sample have accounts for their dental practice on various social media platforms. Interestingly, while 73% (374/511) of patients did not expect their dental practice to have a social media presence, and 44% (207/468) thought that establishing a friendship with their dentists is not appropriate, the findings show that 36% (164/460) of patients had searched for their dentists, and 44% (207/470) of them were happy to establish contacts with dentists on social media. Furthermore, the findings highlight that patients were interested in exploring additional information such as online reviews and the qualifications of their dentists on Facebook pages. For dentists, more than half (375/432, 83%) of them in our sample thought that social media marketing is more efficient compared to traditional marketing.

CONCLUSIONS

Our findings revealed some key challenges and opportunities to utilize social media in dentistry. For both patients and dentists, the role of social media in dental services remains vague, and both parties still share concerns about connecting with each other on social media platforms. However, there also exists a sizeable number of patients who are already comfortable to connect with their dentists on social media sites such as Facebook. The current findings show that there is an opportunity for dental practices to trade upon a more active social media presence for enhanced patient interaction and engagement.

Effective Behavioral Changes through a Digital mHealth App: Exploring the Impact of Hedonic Well-Being, Psychological Empowerment and Inspiration

Background

New mobile health (mHealth) software apps are emerging and are providing the foundation to radically transform the practice and reach of medical research and care. For this study we collaborated with Quit Genius, a cognitive behavioral therapy (CBT) based mHealth app that helps users quit smoking, to explore the effective design of a digital mHealth app; one that delivers important benefits to its users and helps them change their behaviors for a healthier lifestyle.

Objective

The specific aims of this study were to (1) explore the key role of CBT program progress, (2) examine the gamification design app elements that deliver significant benefits (ie, empowerment, well-being, inspiration) to users, (3) explore the effectiveness of these app elements to help users quit smoking or reduce the number of cigarettes smoked, and (4) identify and describe any potential drivers and hindrances arising from the app design elements.

Methods

We developed an online survey and sent an email invitation to 4144 individuals, who had previously or were at the time using the Quit Genius mHealth app, to encourage participation in the study. We matched the online survey data with objective app usage data of the study participants.

Results

A dataset of 190 completed responses was used. At the time of the survey, respondents had completed an average of 60% of the CBT program in the Quit Genius mHealth app. Of the respondents, 36.3% (69/190) noted to have quit smoking successfully after using the Quit Genius app. As for those who remained smokers after using the app (N=121), the number of cigarettes smoked per day was significantly reduced by 59.6%. The ability of the app to enhance users’ hedonic well-being and psychologically empower them in their daily lives was identified as being key in helping users quit smoking. Specifically, the results show that users whose well-being was enhanced through the app were 1.72 times more likely to quit smoking successfully. Moreover, a one-unit increase on a 7-point Likert scale in the app’s ability to empower smokers in their daily lives led to a reduction of cigarettes smoked per day of 53%. The app’s inspiration to users, however, was negatively associated with quitting success and the reduction in cigarette smoked per day.

Conclusions

The findings offer important insights for the effective design of digital mHealth apps. Specifically, we find that perceived psychological empowerment and enhanced hedonic well-being from the mobile solution may be a more impactful way to support the effectiveness of mobile cognitive behavioral therapy for smoking cessation than eliciting strong inspiration.

Development and Pilot Testing of an Internet-Based Self-Help Intervention for Depression for Indian Users

There is a dearth of published research on uptake and utility of mental health apps in India, despite a rising global trend in the application of technology in the field of mental health. We describe the development and pilot testing of a self-help intervention for depression, PUSH-D (Practice and Use Self-Help for Depression) for urban Indians. This guided self-help app, with essential and optional zone sections, was developed to provide a comprehensive coverage of therapeutic strategies drawn from cognitive behavior therapy, interpersonal therapy, supportive psychotherapy, and positive psychology. Pilot testing was carried out using a single group pre-, post- and follow-up design in 78 eligible participants. Participants were typically young adults with major depression or dysthymia and significant impairment in functioning. Almost two-thirds of the participants had never sought professional mental health help. Significant reductions in depression and improvement in the functioning and well-being were notedon standardized measures in participants completing all 10 essential zone sections. These gains were maintained at follow-up. The results were similar for partial completers, who completed fiveout of the 10 essential sections. PUSH-D is one of the first indigenously developed self-help apps for depression and it shows promise in reducing the treatment gap for depression in India.

Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal Study

Background

Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety.

Objective

The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety.

Methods

This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status.

Results

Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001).

Conclusions

This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.