The digital revolution and its impact on mental health care

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.

Protecting Mental Health Data Privacy in India: The Case of Data Linkage With Aadhaar

In an underprepared and under-resourced digital mental health system, the linkage of health and personal data with Aadhaar, a biometric system that provides a unique identification number to all Indian residents, poses significant privacy risks to individuals seeking mental health care. We discuss the challenges in protecting mental health data privacy due to these emerging digital health technologies.

An Iterative and Collaborative End-to-End Methodology Applied to Digital Mental Health

Artificial intelligence (AI) algorithms together with advances in data storage have recently made it possible to better characterize, predict, prevent, and treat a range of psychiatric illnesses. Amid the rapidly growing number of biological devices and the exponential accumulation of data in the mental health sector, the upcoming years are facing a need to homogenize research and development processes in academia as well as in the private sector and to centralize data into federalizing platforms. This has become even more important in light of the current global pandemic. Here, we propose an end-to-end methodology that optimizes and homogenizes digital research processes. Each step of the process is elaborated from project conception to knowledge extraction, with a focus on data analysis. The methodology is based on iterative processes, thus allowing an adaptation to the rate at which digital technologies evolve. The methodology also advocates for interdisciplinary (from mathematics to psychology) and intersectoral (from academia to the industry) collaborations to merge the gap between fundamental and applied research. We also pinpoint the ethical challenges and technical and human biases (from data recorded to the end user) associated with digital mental health. In conclusion, our work provides guidelines for upcoming digital mental health studies, which will accompany the translation of fundamental mental health research to digital technologies.

Association between the use of social networking sites and mental health of young generation in Bangladesh: A cross-sectional study

The social networking sites (SNS) are popular among people of all levels. Here we aimed to evaluate the relationship between the use of SNS and the mental health of the young generation in Bangladesh. We conducted this cross-sectional study among 791 subjects aged between 15 and 40 years. Self-reported questionnaires were used to collect demographics and SNS usage patterns of the respondents. We have measured the levels of loneliness, depression, generalized anxiety, and sleep disturbance using the recommended mental health assessment scales. The estimations of loneliness, depression, generalized anxiety, and sleep disturbance among the respondents were 64%, 38%, 63%, and 75%, respectively. Young adults, female sex, unmarried individuals, students, and urban residents reported higher psychological issues regarding the SNS use. Reported mental health issues were associated with time spent in SNS, the number of friends and groups connected with, personal beliefs, and feeling about SNS. A notable association between the use of SNS and the mental health issues of users has been ascertained. The present study findings might have significant implications in the field of clinical psychology and psychotherapy. Therefore, we recommend more comprehensive clinical interventions to find the tangible impact of SNS on the mental health of users.

A Compassion-Focused Ecological Momentary Intervention for Enhancing Resilience in Help-Seeking Youth: Uncontrolled Pilot Study

BACKGROUND

Digital interventions offer new avenues for low-threshold prevention and treatment in young people. Ecological momentary interventions (EMIs) represent a powerful approach that allows for adaptive, real-time, and real-world delivery of intervention components in daily life by real-time processing of ecological momentary assessment (EMA) data. Compassion-focused interventions (CFIs) may be particularly amenable to translation into an EMI to strengthen emotional resilience and modify putative risk mechanisms, such as stress sensitivity, in the daily lives of young help-seeking individuals.

OBJECTIVE

This study aims to investigate the feasibility, safety, and initial therapeutic effects of a novel, accessible, transdiagnostic, ecological momentary CFI for improving emotional resilience to stress (EMIcompass).

METHODS

In this uncontrolled pilot study, help-seeking youth with psychotic, depressive, or anxiety symptoms were offered the EMIcompass intervention in addition to treatment as usual. The EMIcompass intervention consisted of a 3-week EMI (including enhancing, consolidating, and EMA-informed interactive tasks) administered through a mobile health app and three face-to-face sessions with a trained psychologist intended to provide guidance and training on the CFI exercises presented in the app (ie, training session, follow-up booster session, and review session).

RESULTS

In total, 10 individuals (mean age 20.3 years, SD 3.8; range 14-25) were included in the study. Most (8/10, 80%) participants were satisfied and reported a low burden of app usage. No adverse events were observed. In approximately one-third of all EMAs, individuals scored high on stress, negative affect, or threat anticipation during the intervention period, resulting in real-time, interactive delivery of the CFI intervention components in addition to weekly enhancing and daily consolidating tasks. Although the findings should be interpreted with caution because of the small sample size, reduced stress sensitivity, momentary negative affect, and psychotic experiences, along with increased positive affect, were found at postintervention and the 4-week follow-up. Furthermore, reductions in psychotic, anxiety, and depressive symptoms were found (r=0.30-0.65).

CONCLUSIONS

Our findings provide evidence on the feasibility and safety of the EMIcompass intervention for help-seeking youth and lend initial support to beneficial effects on stress sensitivity and mental health outcomes. An exploratory randomized controlled trial is warranted to establish the feasibility and preliminary evidence of its efficacy.

Mobile Attention Bias Modification Training Is a Digital Health Solution for Managing Distress in Multiple Sclerosis: A Pilot Study in Pediatric Onset

Introduction: Emotional health is important dimension of care for patients living with pediatric onset multiple sclerosis (POMS), but few options are available for stress and anxiety reduction. The high burden of interventions requiring regular in person and onsite visits for treatment are less feasible. Attention bias modification training (ABMT) is effective for anxiety reduction in adult and adolescent populations. We tested the feasibility and preliminary efficacy of ABMT delivered through a mobile gamified version as a digital emotional health tool for patients with POMS.

Methods: Participants with POMS were consecutively recruited from the NYU Langone Pediatric MS Care Center and enrolled to complete a 1-month intervention with use of the Personal Zen ABMT app on their mobile personal device. Feasibility was evaluated by use of the 1-month intervention and efficacy was measured by changes in depression, anxiety, and affect.

Results: A total n = 35 patients with POMS were enrolled in the study (M_age = 17.7, SD = 2.2 years, range 14–23). Feasibility criteria were met with 74% completing the full intervention time, and 100% of the sample completing at least 50% of targeted intervention use. Initial efficacy was found for a reduction in negative affect from baseline to intervention end [M = 22.88, SD = 9.95 vs. M = 19.56, SD = 7.37; t₍₃₃₎ = 2.47, p = 0.019]. Anxiety also significantly decreased from pre to post-intervention in adults [M = 11.82, SD = 9.90 vs. M = 7.29, SD = 7.17; t₍₁₆₎ = 3.88, p = 0.001] and youth [M = 51.14, SD = 19.66 vs. M = 40.86, SD = 27.48; t₍₁₃₎ = 3.17, p = 0.007].

Conclusion: Mobile ABMT with the Personal Zen app is a feasible and accessible digital emotional health tool for patients with POMS and may have broader application for managing distress across chronic neurological conditions.

Prescription Habits Related to Chronic Pathologies of Elderly People in Primary Care in the Western Part of Romania: Current Practices, International Recommendations, and Future Perspectives Regarding the Overuse and Misuse of Medicines

The European Commission’s 2019 report regarding the state of health profiles highlighted the fact that Romania is among the countries with the lowest life expectancy in the European Union. Therefore, the objectives of the present study were to assess the current prescription habits of general physicians in Romania related to medicines taken by the elderly population for chronic conditions in both urban and rural setting and to discuss/compare these practices with the current international recommendations for the elderly (American—Beers 2019 criteria and European—STOPP/START v.2, 2015 criteria). A total of 2790 electronic prescriptions for chronic pathologies collected from 18 community pharmacies in the western part of Romania (urban and rural zones) were included. All medicines had been prescribed by general physicians. We identified the following situations of medicine overuse: 15% of the analyzed prescriptions involved the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for >2 weeks, 12% involved the use of a proton-pump inhibitor (PPI) for >8 weeks, theophylline was the bronchodilator used as a monotherapy in 3.17% of chronic obstructive pulmonary disease cases, and zopiclone was the hypnotic drug of choice for 2.31% of cases. Regarding the misuse of medicines, 2.33% of analyzed prescriptions contained an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin II receptor blocker (ARB) for patients with renal failure in addition to vitamin K antagonists (AVKs) and NSAIDs in 0.43% of cases. Prescriptions for COX2 NSAIDs for periods longer than 2 weeks for patients with cardiovascular disorders accounted for 1.33% of prescriptions, and trihexyphenidyl was used as a monotherapy for patients with Parkinson’s disease in 0.18% of cases. From the included medical prescriptions, 32.40% (the major percent of 2383 prescriptions) had two potentially inappropriate medications (PIMs). Rural zones were found to be risk factor for PIMs. Decreasing the chronic prescription of NSAIDs and PPIs, discontinuing the use of hypnotic drugs, and avoiding potentially harmful drug–drug associations will have long term beneficial effects for Romanian elderly patients.

Ensuring patient and public involvement in the transition to AI-assisted mental health care: A systematic scoping review and agenda for design justice

Background

Machine‐learning algorithms and big data analytics, popularly known as ‘artificial intelligence’ (AI), are being developed and taken up globally. Patient and public involvement (PPI) in the transition to AI‐assisted health care is essential for design justice based on diverse patient needs.

Objective

To inform the future development of PPI in AI‐assisted health care by exploring public engagement in the conceptualization, design, development, testing, implementation, use and evaluation of AI technologies for mental health.

Methods

Systematic scoping review drawing on design justice principles, and (i) structured searches of Web of Science (all databases) and Ovid (MEDLINE, PsycINFO, Global Health and Embase); (ii) handsearching (reference and citation tracking); (iii) grey literature; and (iv) inductive thematic analysis, tested at a workshop with health researchers.

Results

The review identified 144 articles that met inclusion criteria. Three main themes reflect the challenges and opportunities associated with PPI in AI‐assisted mental health care: (a) applications of AI technologies in mental health care; (b) ethics of public engagement in AI‐assisted care; and (c) public engagement in the planning, development, implementation, evaluation and diffusion of AI technologies.

Conclusion

The new data‐rich health landscape creates multiple ethical issues and opportunities for the development of PPI in relation to AI technologies. Further research is needed to understand effective modes of public engagement in the context of AI technologies, to examine pressing ethical and safety issues and to develop new methods of PPI at every stage, from concept design to the final review of technology in practice. Principles of design justice can guide this agenda.

Using Digital Health Technologies to Manage the Psychosocial Symptoms of Menopause in the Workplace: A Narrative Literature Review

Many women experience vasomotor, psychosocial, physical and sexual symptoms during their menopausal life-stage. Specifically, the psychosocial symptoms of menopause can include loss of confidence, issues with self-identity and body image, inattention and loss of memory, increased levels of stress, and a higher risk of developing anxiety and depression. In the workplace, such symptoms can impact the woman's capacity to perform to her optimal levels. Even so, many women do not seek help to manage their symptoms due to feelings of embarrassment, the possibility of experiencing adverse reactions from others, or the cultural taboos that are attached to the condition.Digital health technologies, including virtual consultations, therapeutic interventions, and participation in online communities of support, provide an important means by which women can obtain information about menopause. In the field of mental health, digital technologies have an increasing evidence base. This paper considers how mental health practitioners can adapt, utilise or recommend digital health strategies to support older women in occupational settings to manage their psychosocial symptoms of menopause.

A Patient Journey Map to Improve the Home Isolation Experience of Persons With Mild COVID-19: Design Research for Service Touchpoints of Artificial Intelligence in eHealth

BACKGROUND

In the context of the COVID-19 outbreak, 80% of the persons who are infected have mild symptoms and are required to self-recover at home. They have a strong demand for remote health care that, despite the great potential of artificial intelligence (AI), is not met by the current services of eHealth. Understanding the real needs of these persons is lacking.

OBJECTIVE

The aim of this paper is to contribute a fine-grained understanding of the home isolation experience of persons with mild COVID-19 symptoms to enhance AI in eHealth services.

METHODS

A design research method with a qualitative approach was used to map the patient journey. Data on the home isolation experiences of persons with mild COVID-19 symptoms was collected from the top-viewed personal video stories on YouTube and their comment threads. For the analysis, this data was transcribed, coded, and mapped into the patient journey map.

RESULTS

The key findings on the home isolation experience of persons with mild COVID-19 symptoms concerned (1) an awareness period before testing positive, (2) less typical and more personal symptoms, (3) a negative mood experience curve, (5) inadequate home health care service support for patients, and (6) benefits and drawbacks of social media support.

CONCLUSIONS

The design of the patient journey map and underlying insights on the home isolation experience of persons with mild COVID-19 symptoms serves health and information technology professionals in more effectively applying AI technology into eHealth services, for which three main service concepts are proposed: (1) trustworthy public health information to relieve stress, (2) personal COVID-19 health monitoring, and (3) community support.

Digital Mental Health Challenges and the Horizon Ahead for Solutions

The demand outstripping supply of mental health resources during the COVID-19 pandemic presents opportunities for digital technology tools to fill this new gap and, in the process, demonstrate capabilities to increase their effectiveness and efficiency. However, technology-enabled services have faced challenges in being sustainably implemented despite showing promising outcomes in efficacy trials since the early 2000s. The ongoing failure of these implementations has been addressed in reconceptualized models and frameworks, along with various efforts to branch out among disparate developers and clinical researchers to provide them with a key for furthering evaluative research. However, the limitations of traditional research methods in dealing with the complexities of mental health care warrant a diversified approach. The crux of the challenges of digital mental health implementation is the efficacy and evaluation of existing studies. Web-based interventions are increasingly used during the pandemic, allowing for affordable access to psychological therapies. However, a lagging infrastructure and skill base has limited the application of digital solutions in mental health care. Methodologies need to be converged owing to the rapid development of digital technologies that have outpaced the evaluation of rigorous digital mental health interventions and strategies to prevent mental illness. The functions and implications of human-computer interaction require a better understanding to overcome engagement barriers, especially with predictive technologies. Explainable artificial intelligence is being incorporated into digital mental health implementation to obtain positive and responsible outcomes. Investment in digital platforms and associated apps for real-time screening, tracking, and treatment offer the promise of cost-effectiveness in vulnerable populations. Although machine learning has been limited by study conduct and reporting methods, the increasing use of unstructured data has strengthened its potential. Early evidence suggests that the advantages outweigh the disadvantages of incrementing such technology. The limitations of an evidence-based approach require better integration of decision support tools to guide policymakers with digital mental health implementation. There is a complex range of issues with effectiveness, equity, access, and ethics (eg, privacy, confidentiality, fairness, transparency, reproducibility, and accountability), which warrant resolution. Evidence-informed policies, development of eminent digital products and services, and skills to use and maintain these solutions are required. Studies need to focus on developing digital platforms with explainable artificial intelligence-based apps to enhance resilience and guide the treatment decisions of mental health practitioners. Investments in digital mental health should ensure their safety and workability. End users should encourage the use of innovative methods to encourage developers to effectively evaluate their products and services and to render them a worthwhile investment. Technology-enabled services in a hybrid model of care are most likely to be effective (eg, specialists using these services among vulnerable, at-risk populations but not severe cases of mental ill health).

Therapeutic Alliance in COVID-19 Era Remote Psychotherapy Delivered to Physically Ill Patients With Disturbed Body Image

The COVID-19 pandemic outbreak has led to a general reorganization of health services and an increase in outpatient telemedicine in mental healthcare for physically ill people. Current literature highlights facilitators and obstacles concerning the use of new technologies in psychotherapy, an underrated topic of research in the context of supportive expressive psychotherapy. More insight is needed to explore the characteristics of video in therapeutic alliance for treatment of specific mental disorders experienced in psychosomatics, particularly with people suffering from a disturbed body- and self-image. Using two clinical vignettes, it is the authors' intention to enrich the critical debate on current knowledge in psychosomatic remote psychotherapy, with special focus on mentalization deficits and their impact on therapeutic alliance in the consultation-liaison psychiatry setting. In particular, we will question the interpersonal processes at stake related to mirroring and the disruption caused by the use of videoconference applications. We will also reflect upon the relationship between the therapeutic alliance and the medical team, and that between patient and psychotherapist. The aim is to improve psychotherapeutic alliance maintained during the pandemic for specific mental disorders and to inform about possible clinical factors that could be the subject of future empirical studies or professional guidelines.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial

INTRODUCTION

Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial.

METHODS AND ANALYSIS

In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00018803.

Perspectives of Trial Staff on the Barriers to Recruitment in a Digital Intervention for Psychosis and How to Work Around Them: Qualitative Study Within a Trial

BACKGROUND

Recruitment processes for clinical trials of digital interventions for psychosis are seldom described in detail in the literature. Although trial staff have expertise in describing barriers to and facilitators of recruitment, a specific focus on understanding recruitment from the point of view of trial staff is rare, and because trial staff are responsible for meeting recruitment targets, a lack of research on their point of view is a key limitation.

OBJECTIVE

The primary aim of this study was to understand recruitment from the point of view of trial staff and discover what they consider important.

METHODS

We applied pluralistic ethnographic methods, including analysis of trial documents, observation, and focus groups, and explored the recruitment processes of the EMPOWER (Early Signs Monitoring to Prevent Relapse in Psychosis and Promote Well-being, Engagement, and Recovery) feasibility trial, which is a digital app-based intervention for people diagnosed with schizophrenia.

RESULTS

Recruitment barriers were categorized into 2 main themes: service characteristics (lack of time available for mental health staff to support recruitment, staff turnover, patient turnover [within Australia only], management styles of community mental health teams, and physical environment) and clinician expectations (filtering effects and resistance to research participation). Trial staff negotiated these barriers through strategies such as emotional labor (trial staff managing feelings and expressions to successfully recruit participants) and trying to build relationships with clinical staff working within community mental health teams.

CONCLUSIONS

Researchers in clinical trials for digital psychosis interventions face numerous recruitment barriers and do their best to work flexibly and to negotiate these barriers and meet recruitment targets. The recruitment process appeared to be enhanced by trial staff supporting each other throughout the recruitment stage of the trial.

Social Media Use for Health Purposes by Chronic Disease Patients in the United States

Background

Social media can be a cost-effective instant tool for exchanging health information among those with chronic diseases. However, few studies have analyzed the nexus between chronic disease and patients' use of the internet for health-related purposes.

Objective

The objective of this study is to determine if chronic disease patients in the United States use social media platforms to share health information and/or join groups of similar condition.

Materials and Methods

This cross-sectional study conducted a secondary analysis of the Health Information Trends Survey dataset 5 (cycle 1 of 2017 and cycle 2 of 2018) (N = 6650), which is nationally representative of American adults. A series of chi-square tests was carried to examine the association between using social media by chronic disease patients and (a) sharing health information and (b) participating in relevant health groups. Logistic regression analysis was used to determine significant findings.

Results

In terms of sharing health information on social media sites, those who were aged 18-49 years (P < 0.0001) and underweight (P = 0.04) were more likely to share health information on social media, while males were less likely to do so (P < 0.0001). In terms of joining relevant health groups on social media, predictors were being aged 35-49 years (P = 0.008), having a Bachelor's or postbaccalaureate degree (P < 0.02) and having depression or anxiety disorder (P = 0.004); males were less likely to join such groups (P = 0.0004).

Conclusion

Individuals with chronic conditions, except depression or anxiety disorder, were not likely to participate in social media support groups. Future studies should explore how social media can be used to effectively engage those with chronic diseases, which may assist in disease management.

Psychiatric Profiles of eHealth Users Evaluated Using Data Mining Techniques: Cohort Study

BACKGROUND

New technologies are changing access to medical records and the relationship between physicians and patients. Professionals can now use e-mental health tools to provide prompt and personalized responses to patients with mental illness. However, there is a lack of knowledge about the digital phenotypes of patients who use e-mental health apps.

OBJECTIVE

This study aimed to reveal the profiles of users of a mental health app through machine learning techniques.

METHODS

We applied a nonparametric model, the Sparse Poisson Factorization Model, to discover latent features in the response patterns of 2254 psychiatric outpatients to a short self-assessment on general health. The assessment was completed through a mental health app after the first login.

RESULTS

The results showed the following four different profiles of patients: (1) all patients had feelings of worthlessness, aggressiveness, and suicidal ideas; (2) one in four reported low energy and difficulties to cope with problems; (3) less than a quarter described depressive symptoms with extremely high scores in suicidal thoughts and aggressiveness; and (4) a small number, possibly with the most severe conditions, reported a combination of all these features.

CONCLUSIONS

User profiles did not overlap with clinician-made diagnoses. Since each profile seems to be associated with a different level of severity, the profiles could be useful for the prediction of behavioral risks among users of e-mental health apps.

Developing a Theory-Informed Smartphone App for Early Psychosis: Learning Points From a Multidisciplinary Collaboration

Background: Actissist is a smartphone app designed to deliver an intervention grounded in cognitive behavior therapy for early psychosis. Actissist was developed by a multidisciplinary team of academics, clinicians, experts by experience and software engineers. Actissist has been tested in two trials, the first a proof-of-concept trial where Actissist was safe, acceptable and feasible, the second, a powered randomized controlled trial. Objective: This article describes how our multidisciplinary team designed and developed Actissist. This article describes: (i) how Actissist was informed by initial qualitative interviews and focus groups and an expert reference group; (ii) refinements made to the app based on ongoing user feedback; (iii) successes and challenges encountered; and (iv) learning points and recommendations for involving stakeholders in digital health interventions. Methods: Expert reference group meetings informed the development of Actissist and design of subsequent trials, which included individuals with lived experience of psychosis, clinicians, academics, computer scientists and software engineers. Person-centered stakeholder involvement was promoted using focus groups and qualitative interviews prior to the development of the app, which informed version one of Actissist. Interviews were carried out with participants who had used Actissist. Two further versions of Actissist were developed following additional rounds of testing. Results: Multidisciplinary working throughout the Actissist project led to the development, inclusion and improvement of the app design and content. These changes and features included non-directive and compassionate content, co-designed recovery videos, relaxation exercises, psychoeducation material, ability to "favorite" areas of the app that users found helpful, and goal-setting. Challenges to collaborative working included discrepancies between what stakeholders want and what is technically possible to deliver, resource pressures, trying to deliver desired features within the boundaries of fundamental trial design considerations, and power imbalances associated with multidisciplinary working. Conclusions: The involvement of stakeholders in the design and development and delivery of Actissist has been fundamental to our development approach. Through this collaborative process, we have identified different perspectives and ideas that would have not been generated by the research team alone. Clinical Trial Registrations: Proof-of-concept trial: http://www.isrctn.com/ISRCTN34966555 Fully-powered randomized controlled trial: https://www.isrctn.com/ISRCTN76986679.

Digital Clinical Trials for Substance Use Disorders in the Age of Covid-19

: As a result of the coronavirus 2019 (Covid-19) pandemic, clinical research for substance use disorders (SUDs) has been impeded due to widespread stay-at-home mandates limiting the operations of "non-essential" work. Although appropriate to proceed with an abundance of caution to prevent viral spread, there will be detrimental consequences for patients with SUDs if clinical trials research cannot adapt and continue uninterrupted. The field of digital health has strong evidence for its feasibility and effectiveness and offers tools that can facilitate the continuation of SUD clinical trials research remotely in accordance with Covid-19 precautions. Some digital tools have been used as components of SUD research in the past; however, no published clinical trial in SUDs to-date has been entirely virtual. This has important implications for disrupted clinical care, as providers seek guidelines for best digital practices. This paper provides a roadmap for integrating the fields of digital health and SUD clinical trials by proposing methods to complete recruitment, screening, informed consent, other study procedures, and internal lab operations digitally. The immediate future of SUD research depends on the ability to comply with social distancing. Investment in research of digital clinical trials for SUDs provides an opportunity to cultivate benefits for research and clinical care long-term as we can (1) define regulatory requirements for the implementation of digital systems, (2) develop consensus on system-wide standards and protocols in the appropriate use of technology, and (3) gain experience that can translate to the treatment of patients with SUDs through telehealth in the community.

Digital Technology, Health and Well-Being and the Covid-19 Pandemic: It's Time to Call Forward Informal Carers from the Back of the Queue

Objective

To describe the current challenges of family caregivers during and beyond the COVID-19 pandemic, the need for future digital innovations including involvement from professional nursing roles.

Data Sources

Review of recent literature from PubMed and relevant health and care reports.

Conclusion

The COVID-19 pandemic has caused monumental disruption to health care delivery and care. Caregivers face unprecedented levels of uncertainty: both for the people they care for and for their own health and well-being. Given that many carers face poor health and well-being, there is a significant risk that health inequalities will be increased by this pandemic, particularly for high-risk groups. Innovations including those supported and delivered by digital health could make a significant difference but careful planning and implementation is a necessity for widespread implementation.

Implications for Nursing Practice

Carers need to be championed in the years ahead to ensure they do not become left at the “back of the queue” for health and well-being equity. This situation has been exacerbated by the COVID-19 pandemic. Disruptive change to health and social care is now required where digital health solutions hold considerable promise, yet to be fully realized.

Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users

BACKGROUND

Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data.

OBJECTIVE

This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies.

METHODS

Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected.

RESULTS

Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality.

CONCLUSIONS

To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting.

Social Media and Mental Health: Benefits, Risks, and Opportunities for Research and Practice

Social media platforms are popular venues for sharing personal experiences, seeking information, and offering peer-to-peer support among individuals living with mental illness. With significant shortfalls in the availability, quality, and reach of evidence-based mental health services across the United States and globally, social media platforms may afford new opportunities to bridge this gap. However, caution is warranted, as numerous studies highlight risks of social media use for mental health. In this commentary, we consider the role of social media as a potentially viable intervention platform for offering support to persons with mental disorders, promoting engagement and retention in care, and enhancing existing mental health services. Specifically, we summarize current research on the use of social media among mental health service users, and early efforts using social media for the delivery of evidence-based programs. We also review the risks, potential harms, and necessary safety precautions with using social media for mental health. To conclude, we explore opportunities using data science and machine learning, for example by leveraging social media for detecting mental disorders and developing predictive models aimed at characterizing the aetiology and progression of mental disorders. These various efforts using social media, as summarized in this commentary, hold promise for improving the lives of individuals living with mental disorders.

The Asia Pacific Disaster Mental Health Network: Setting a Mental Health Agenda for the Region

Addressing the psychological mechanisms and structural inequalities that underpin mental health issues is critical to recovery following disasters and pandemics. The Asia Pacific Disaster Mental Health Network was established in June 2020 in response to the current disaster climate and to foster advancements in disaster-oriented mental health research, practice and policy across the region. Supported by the World Health Organization (WHO) Thematic Platform for Health Emergency and Disaster Risk Management (Health EDRM), the network brings together leading disaster psychiatry, psychology and public health experts. Our aim is to advance policy, research and targeted translation of the evidence so that communities are better informed in preparation and response to disasters, pandemics and mass trauma. The first meetings of the network resulted in the development of a regional disaster mental health agenda focused on the current context, with five priority areas: (1) Strengthening community engagement and the integration of diverse perspectives in planning, implementing and evaluating mental health and psychosocial response in disasters; (2) Supporting and assessing the capacity of mental health systems to respond to disasters; (3) Optimising emerging technologies in mental healthcare; (4) Understanding and responding appropriately to addressing the mental health impacts of climate change; (5) Prioritising mental health and psychosocial support for high-risk groups. Consideration of these priority areas in future research, practice and policy will support nuanced and effective psychosocial initiatives for disaster-affected populations within the Asia Pacific region.

The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

BACKGROUND

Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.

OBJECTIVE

This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.

METHODS

A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.

RESULTS

Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.

CONCLUSIONS

More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

Text message reminders as an adjunct to a substance use intervention for adolescents and young adults: Pilot feasibility and acceptability findings

OBJECTIVE

Text messaging has been proposed as a method for increasing the reach of interventions for harmful alcohol and other drug use. This paper describes the design of an automated text messaging adjunct to a substance use intervention intended to support adolescents and young adults attempting to change their alcohol and other drug use behavior. Feasibility and acceptability testing was conducted as part of this pilot study.

METHOD

Five focus groups were conducted to refine text message content and finalize pilot intervention design. Automated, daily, substance use-related reminder text messages were sent to pilot intervention participants (n = 39), who were recruited from outpatient treatment.

RESULTS

Of those who were invited, 63% enrolled in the study and 89.7% remained enrolled in the study as measured by completing at least one assessment after baseline. Participants reported a positive experience with the messages, particularly supportive/empowering messages and commitment reminder messages.

CONCLUSIONS

These findings suggest that text messaging is a feasible and acceptable method for delivery of substance use-related reminder content as an adjunct to substance use intervention.

Development of a Lived Experience-Based Digital Resource for a Digitally-Assisted Peer Support Program for Young People Experiencing Psychosis

This paper describes the creation of a web-based digital resource designed for tablet computer use during peer work sessions to structure discussion about recovery in early psychosis. The resource consisted of a series of videos featuring young people who have used early psychosis services discussing how they navigated issues in their own recovery. A participatory process was used to create the resource. Researchers held a series of collaborative development workshops with early psychosis service users, peer workers, other mental health practitioners, and academics. These were used to derive a framework of recovery processes relevant to young people experiencing psychosis, which was considered as useful areas of discussion within a peer work relationship. A semi-structured interview guide based on this framework was then used in video-recorded interviews with young people in recovery from psychosis. Footage was edited into 14 videos and organized into six final themes: My Journey, Self-Care, Connections, My Identity, Life, and Mental Health. The combined expertise of young mental health service users, peer support workers, mental health practitioners, and digital mental health researchers throughout the development process enabled the creation of tailored digital resource for peer work in an early psychosis service.

#Everything Will Be Fine. Duration of Home Confinement and "All-or-Nothing" Cognitive Thinking Style as Predictors of Traumatic Distress in Young University Students on a Digital Platform During the COVID-19 Italian Lockdown

On March 10, 2020, Italy announced its lockdown caused by the novel coronavirus (COVID-19) pandemic, and home confinement exposed individuals to a stressful situation of unknown duration. Our study aimed to analyze the emotional and cognitive experiences and the psychopathological symptoms of young Italian University students seeking help from our University student Counseling and Consultation Service during the COVID-19 lockdown. Also, our study aimed to identify the predictors of traumatic psychological distress, investigating variables that could influence the students' well-being, related to their socio-demographic and clinical condition, to the "exposition" to the social distancing, and related to their cognitive thinking style. One-hundred and three University students were included in our study. The traumatic impact was assessed by the Impact of Event Scale-Revised (IES-R). A digital platform was used in our study, focused on narrative dimensions analyses. Our results showed that 21.4% of our help-seeking students experienced lockdown as a traumatic experience. The main stressful factors reported by students were: adjustment to the new academic activities (23.3 %), lack of autonomy (19.4%), and conflicts with family members (6.8%). The three main areas impaired were: changes in the sleeping pattern (68%), difficulty in concentration (67%), and loss of energy (58.6%). Furthermore, 36% of our student sample reported being suffering from anxiety symptoms, whereas 26% showed depressive symptomatology. Students having previous psychological and psychiatric contacts with mental health services (23%) showed a more severe traumatic and depressive symptomatology. The problematic thinking style "all or nothing" was predominantly associated with psychological distress, anxiety, depression, and posttraumatic symptoms. "Everything Will Be Fine" could be identified by the "optimistic style" (27.2%), inversely correlated with the psychopathological measures and concentration problems. The results of the logistic regression analysis indicated that the length of home confinement (second month) seemed to increase by over 3 times the likelihood of experience posttraumatic symptomatology, and a thinking style "all or nothing" was the final strongest predictor increasing the risk by over 5 times. The implementation of psychological interventions to improve the mental health of vulnerable young subgroups to contain the structuring of psychopathological profiles represent a fundamental challenge.

Are we there yet?!-a literature review of recent digital technology advances for the treatment of early psychosis

Access to psychological interventions during early stages of psychosis is essential for ameliorating outcomes and improving prognosis. However, reaching and engaging individuals at these stages of the illness can be very challenging for early intervention teams. Recent digital technological advances have emerged to overcome some of these challenges and to improve access to psychological interventions. The aim of the present literature review is to summarise main findings of relevant studies published during the last 10 years on the utilization of digital technologies (i.e., virtual reality, smartphone technology and web-based interventions) to enhance psychological treatment outcomes in early psychosis. A literature search from January 2009 to June 2019 was performed to identify relevant papers. Of 1,502 studies identified, nine met inclusion criteria for the review and only five presented results from finalised trials. Overall, these studies showed positive feasibility and acceptability results, along with preliminary evidence of improved therapy outcomes. The present review offers a state-of-the-art summary of the main features of these user-centered digital interventions for early stages of psychosis and a critical discussion about their future implementation in mental health services.

Digital Innovations for Global Mental Health: Opportunities for Data Science, Task Sharing, and Early Intervention

PURPOSE

Globally, individuals living with mental disorders are more likely to have access to a mobile phone than mental health care. In this commentary, we highlight opportunities for expanding access to and use of digital technologies to advance research and intervention in mental health, with emphasis on the potential impact in lower resource settings.

RECENT FINDINGS

Drawing from empirical evidence, largely from higher income settings, we considered three emerging areas where digital technology will potentially play a prominent role: supporting methods in data science to further our understanding of mental health and inform interventions, task sharing for building workforce capacity by training and supervising non-specialist health workers, and facilitating new opportunities for early intervention for young people in lower resource settings. Challenges were identified related to inequities in access, threats of bias in big data analyses, risks to users, and need for user involvement to support engagement and sustained use of digital interventions.

SUMMARY

For digital technology to achieve its potential to transform the ways we detect, treat, and prevent mental disorders, there is a clear need for continued research involving multiple stakeholders, and rigorous studies showing that these technologies can successfully drive measurable improvements in mental health outcomes.

Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach

Fragmentation of processes and interventions plague the psychotherapies (Gilbert & Kirby, ). Part of the problem is that we have not agreed on a framework that could be the basis for integrating knowledge and the scientific enquiry of processes and interventions. This paper outlines an approach that brings together a variety of different disciplines in the service of consilience (Wilson, , Consilience: The unity of knowledge, Vintage, New York, NY; Siegel, ). It presents the importance of an evolutionary framework for understanding the proclivities and dispositions for mental suffering and antisocial behaviour, and how they are choreographed in different sociodevelopmental contexts. Building on earlier models (Gilbert, , Human nature and suffering, Routledge, London, UK; Gilbert, , Clin. Psychol. Psychother., 2, 135; Gilbert, , Br. J. Med. Psychol., 71, 353; Gilbert, , Case formulation in cognitive behaviour therapy: The treatment of challenging cases, Wiley, Chichester, UK, pp. 50-89) the call is for an integrative, evolutionary, contextual, biopsychosocial approach to psychology and psychotherapy. PRACTITIONER POINTS: Evolutionary functional analysis is part of an evolutionary, contextual, biopsychosocial approach to mental health that can serve as a scientific platform for the future developments of psychotherapy. Therapist skills and training will increasing need to focus on the multidimensional textures of mental states especially the context-social-body linkages. Therapies of the future will also focus more on the moral aspects of therapy and address the need to promote prosocial and ethical behaviour to self and others.

"They Are Not Hard-to-Reach Clients. We Have Just Got Hard-to-Reach Services." Staff Views of Digital Health Tools in Specialist Mental Health Services

Background: Digital health products designed to help people with severe mental health problems appear to be feasible, acceptable, and efficacious. The challenge facing the digital mental health field is implementing digital tools in routine service delivery. To date, there has been a paucity of qualitative research exploring staff views of digital health solutions in the context of mental healthcare. Engaging and involving frontline staff in the design and rollout of new technology to improve utilization is imperative for successful uptake and adoption of digital tools. The aim of the current study is to explore frontline staff views regarding the utility and appropriateness of using digital tools in the healthcare pathway for people accessing specialist secondary care mental health services. Method: Qualitative study using framework analysis was used with 48 mental health staff working in early intervention for psychosis services. Six groups comprising 5-10 early intervention service staff members in each group were conducted across the Northwest of England. Robust measures were used to develop a stable framework, including member checking, triangulation, and consensus meetings. Results: Three themes were identified a priori: i) perceived barriers to adopting smartphone apps for early psychosis; ii) acceptability of digital health tools for early psychosis patients; and iii) data security, safety, and risk. Alongside exploring the a priori topics, one theme was generated a posteriori: iv) relationships. Conclusions: Staff working in specialist early intervention for psychosis services found digital tools on the whole acceptable in mental health service provision, but raised a number of concerns that will likely affect implementation of such systems into routine service delivery and practice. Thirteen recommendations are made in this paper as a result of the themes generated in these data. Implementing of digital systems needs to be simple and uncomplicated and improve clinical workflows for staff rather than hinder and increase clinical workflows. Furthermore, organizational support with a clear plan for implementing technological innovations is required for successful adoption of digital systems. Consideration of staff views around digital systems is important if successful adoption and implementation of such systems are to occur. Clinical Trial Registration: http://www.isrctn.com, identifier ISRCTN34966555.