A Systematic Review of Cognitive Behavioral Therapy and Behavioral Activation Apps for Depression

Depressive symptoms and web user experience

BACKGROUND

Depression, as one of the most prevalent mental disorders, is expected to become a leading cause of disability. While evidence-based treatments are not always easily accessible, Internet-based information and self-help appears as a promising approach to improve the strained supply situation by avoiding barriers of traditional offline treatment. User experience in the domain of mental problems therefore emerges as an important research topic. The aim of our study is to investigate the impact of depressive symptoms on subjective and objective measures of web user experience.

METHOD

In this two-part online study (Ntotal = 721) we investigate the relationship between depressive symptoms of web users and basic website characteristics (i.e., content, subjective and objective usability, aesthetics). Participants completed search and memory tasks on different fully-functional websites. In addition, they were asked to evaluate the given websites with standardized measures and were screened for symptoms of depression using the PHQ-9. We used structural equation modeling (SEM) to determine whether depression severity affects users' perception of and performance in using information websites.

RESULTS

We found significant associations between depressive symptoms and subjective user experience, specifically of website content, usability, and aesthetics, as well as an effect of content perception on the overall appraisal of a website in terms of the intention to visit it again. Small yet significant negative effects of depression severity on all named subjective website evaluations were revealed, leading to an indirect negative effect on the intention to revisit a website via impaired content perceptions. However, objective task performance was not influenced by depressiveness of users.

DISCUSSION

Depression emerges as capable of altering the subjective perception of a website to some extend with respect to the main features content, usability, and aesthetics. The user experience of a website is crucial, especially as it facilitates revisiting a website and thus might be relevant in avoiding drop-out in online interventions. Thus, the biased impression of persons affected by symptoms of depression and resulting needs of those users should be considered when designing and evaluating E-(Mental)-Health-platforms. The high prevalence of some mental disorders such as depression in the general population stresses the need for further investigations of the found effects.

Engagement in mobile phone app for self-monitoring of emotional wellbeing predicts changes in mental health: MoodPrism

BACKGROUND

Mobile apps are being used increasingly for mental health purposes, but evidence of their efficacy remains limited. The mechanisms underlying any effects of such apps are also unclear. This study examined the effectiveness of a self-monitoring mobile phone app by investigating the relationships between app engagement and mental health outcomes.

METHOD

Participants downloaded the MoodPrism app from the iOS and Android app stores, completing in-app assessments at start of use and again 30days later. The app prompted participants daily to complete a short mood questionnaire and formulated their responses into a mood diary. Data from 234 assessment completers (73% female; M age = 34.8 years) were analysed via hierarchical and mediation regressions.

RESULTS

In this community sample, app engagement ratings predicted decreases in depression and anxiety, and increases in mental well-being. These effects were mediated by increases in emotional self-awareness, but only for participants who were clinically depressed or anxious at the time of the baseline assessment. Mental health literacy and coping self-efficacy did not play mediating roles.

LIMITATIONS

Findings suggest that other influential mediators may have not been measured, and future studies could verify the findings by using alternative methodologies, such as comparison with a control group.

CONCLUSIONS

Engaging with an emotional wellbeing self-monitoring app may reduce depressive and anxious symptoms, and increase mental well-being. Increases in emotional self-awareness may mediate these changes in clinical populations, and further research is needed to reveal other mechanisms that mental health apps can utilize.

Novel technology as platform for interventions for caregivers and individuals with severe mental health illnesses: A systematic review

BACKGROUND

Severe mental illnesses (SMIs) have been found to be associated with both increases in morbidity-mortality, need for treatment care in patients themselves, and burden for relatives as caregivers. A growing number of web-based and mobile software applications have appeared that aim to address various barriers with respect to access to care. Our objective was to review and summarize recent advancements in such interventions for caregivers of individuals with a SMI.

METHODS

We conducted a systematic search for papers evaluating interactive mobile or web-based software (using no or only minimal support from a professional) specifically aimed at supporting informal caregivers. We also searched for those supporting patients with SMI so as to not to miss any which might include relatives.

RESULTS

Out of a total of 1673 initial hits, we identified 11 articles reporting on 9 different mobile or web-based software programs. The main result is that none of those studies focused on caregivers, and the ones we identified using mobile or web-based applications were just for patients and not their relatives.

LIMITATIONS

Differentiating between online and offline available software might not always have been totally reliable, and we might have therefore missed some studies.

CONCLUSIONS

In summary, the studies provided evidence that remotely accessible interventions for patients with SMI are feasible and acceptable to patients. No such empirically evaluated program was available for informal caregivers such as relatives. Keeping in mind the influential role of those informal caregivers in the process of treatment and self-management, this is highly relevant for public health. Supporting informal caregivers can improve well-being of both caregivers and patients.

Systematic Review and Meta-analysis of the Effects of Caffeine in Fatigued Shift Workers: Implications for Emergency Medical Services Personnel

BACKGROUND

Emergency Medical Services (EMS) workers may experience fatigue as a consequence of shift work. We reviewed the literature to determine the impact of caffeine as a countermeasure to fatigue in EMS personnel and related shift workers.

METHODS

We employed the GRADE methodology to perform a systematic literature review and search multiple databases for research that examined the impact of caffeine on outcomes of interest, such as patient and EMS personnel safety. For selected outcomes, we performed a meta-analysis of pooled data and reported the pooled effect in the form of a Standardized Mean Difference (SMD) with corresponding 95% confidence intervals.

RESULTS

There are no studies that investigate caffeine use and its effects on EMS workers or on patient safety. Four of 8 studies in shift workers showed that caffeine improved psychomotor vigilance, which is important for performance. Caffeine decreased the number of lapses on a standardized test of performance [SMD = 0.75 (95% CI: 0.30 to 1.19), p = 0.001], and lessened the slowing of reaction time at the end of shifts [SMD = 0.52 (95% CI: 0.19 to 0.85); p = 0.002]. Finally, 2 studies reported that caffeine reduced sleep quality and sleep duration.

CONCLUSIONS

Although the quality of evidence was judged to be low to moderate, when taken together, these studies demonstrate that caffeine can improve psychomotor performance and vigilance. However, caffeine negatively affects sleep quality and sleep duration. More systematic, randomized studies need to be conducted in EMS workers in order to address the critical outcomes of health and safety of EMS personnel and patients. The risk/benefit ratio of chronic caffeine use in shift workers is currently unknown.

Reiterated Concerns and Further Challenges for Mindfulness and Meditation Research: A Reply to Davidson and Dahl

In response to our article, Davidson and Dahl offer commentary and advice regarding additional topics crucial to a comprehensive prescriptive agenda for future research on mindfulness and meditation. Their commentary raises further challenges and provides an important complement to our article. More consideration of these issues is especially welcome because limited space precluded us from addressing all relevant topics. While we agree with many of Davidson and Dahl's suggestions, the present reply (a) highlights reasons why the concerns we expressed are still especially germane to mindfulness and meditation research (even though those concerns may not be entirely unique) and (b) gives more context to other issues posed by them. We discuss special characteristics of individuals who participate in mindfulness and meditation research and focus on the vulnerability of this field inherent in its relative youthfulness compared to other more mature scientific disciplines. Moreover, our reply highlights the serious consequences of adverse experiences suffered by a significant subset of individuals during mindfulness and other contemplative practices. We also scrutinize common contemporary applications of mindfulness and meditation to illness, and some caveats are introduced regarding mobile technologies for guidance of contemplative practices.

eHealth in Treatment of Offenders in Forensic Mental Health: A Review of the Current State

BACKGROUND

Treatment of offenders in forensic mental health is complex. Often, these in- or outpatients have low treatment motivation, suffer from multiple disorders, and have poor literacy skills. eHealth may be able to improve treatment outcomes because of its potential to increase motivation and engagement, and it can overcome the predominant one-size-fits-all approach by being tailored to individual patients.

OBJECTIVE

To examine its potential, this systematic review studies the way that eHealth has been used and studied in forensic mental health and identifies accompanying advantages and disadvantages for both patients and treatment, including effectiveness.

METHODS

A systematic search in Scopus, PsycINFO, and Web of Science was performed up until December 2017. Studies were included if they focused on technological interventions to improve the treatment of forensic psychiatric patients.

RESULTS

The search resulted in 50 studies in which eHealth was used for treatment purposes. Multiple types of studies and technologies were identified, such as virtual reality, web-based interventions, and videoconferencing. The results confirmed the benefits of technology, for example, the acquisition of unique information about offenders, effectiveness, and tailoring to specific characteristics, but indicated that these are not fully taken advantage of.

DISCUSSION

To overcome the barriers and obtain the benefits, eHealth has to have a good fit with patients and the forensic psychiatric context. It has to be seamlessly integrated in existing care and should not be added as an isolated element. To bridge the gap between the current situation and eHealth's potential, further research on development, implementation, and evaluation should be conducted.

Mental health apps in a college setting: openness, usage, and attitudes

BACKGROUND

The ubiquity of smartphones and the development of mental health apps (MHAs) calls for evaluation of consumers' attitudes towards and usage of MHAs. Due to the increasing demand for mental health services on college campuses, research is especially needed to evaluate MHAs as a potentially viable treatment modality in that setting.

METHODS

The study team developed survey questions related to MHAs, added these to the Healthy Minds Study, and used Qualtrics as the platform. The participants were 741 students, age 18 and older, from a large Midwest public university. Students could answer a varying number of multiple choice questions based on embedded display logic, and the survey required 20-25 minutes for most participants to complete. Based on embedded display logic in the survey and how questions were answered, students could receive anywhere from 1-20 questions. Questions were primarily categorical (e.g., "Yes", "Maybe", "No"), with the remaining questions in free response format. The survey was fielded in April, 2016.

RESULTS

26.1% of respondents were open to using an MHA yet only 7.3% had used an MHA. 9.0% of respondents preferred to use an MHA versus seeing a mental health professional. 13.2% of respondents felt that MHAs do have an evidence base. 23.8% of users felt that MHAs helped with their mental health. Those who reported receiving mental health services within the past 12 months were significantly more open to using MHAs than those who had not received services. Convenience, immediate availability, and confidentiality were common reasons for interest in MHAs.

CONCLUSIONS

There is interest in, but limited usage, of MHAs among university students, providing evidence of MHAs as a potentially untapped treatment modality for this population. Further research could help assess how best to integrate this technology into the university and college mental health system.

Role of mHealth in overcoming the occurrence of post-stroke depression

Depression associated with stroke affects roughly one-third of stroke survivors. Post-stroke depression (PSD) is thought to adversely influence functional outcome by limiting participation in rehabilitation, decreasing physical, social, and cognitive function, and affecting neuroplasticity thereby placing stroke survivors at high risk for future vascular events. PSD has also been associated with higher mortality rates after stroke. In Peru, a country where there is no national stroke program and mental health disorders are largely underdiagnosed and untreated, people with PSD are likely to be further challenged by dependency and impoverished conditions that will limit their use of ambulatory services, leading to inadequate clinical follow-up. In this scenario, mobile health (mHealth) technology offers a promising approach to extend access to high-quality and culturally tailored evidence-based psychological care to address PSD given that cell phone use, Internet connectivity, and digital health technology have met a rapid growth in the last years and thus contribute to the attainment of broader Sustainable Development Goals (SDGs). The limited evidence of the effectiveness of mHealth for PSD calls for researchers to fill a knowledge gap where Peru poses as an ideal setting because rapid expansion of digital technology and current mental healthcare reform could be leveraged to enhance post-stroke outcomes. This article proposes the rationale for a suitable evidence-driven, mHealth-based, PSD self-management intervention called iMOODS-Investigating the role of mHealth in overcoming occurrence of depression after stroke-that could be tested among recent stroke patients with PSD in resource constrained settings.

Methods for Evaluating the Content, Usability, and Efficacy of Commercial Mobile Health Apps

Commercial mobile apps for health behavior change are flourishing in the marketplace, but little evidence exists to support their use. This paper summarizes methods for evaluating the content, usability, and efficacy of commercially available health apps. Content analyses can be used to compare app features with clinical guidelines, evidence-based protocols, and behavior change techniques. Usability testing can establish how well an app functions and serves its intended purpose for a target population. Observational studies can explore the association between use and clinical and behavioral outcomes. Finally, efficacy testing can establish whether a commercial app impacts an outcome of interest via a variety of study designs, including randomized trials, multiphase optimization studies, and N-of-1 studies. Evidence in all these forms would increase adoption of commercial apps in clinical practice, inform the development of the next generation of apps, and ultimately increase the impact of commercial apps.

Digital health technology for use in patients with serious mental illness: a systematic review of the literature

BACKGROUND

As the capabilities and reach of technology have expanded, there is an accompanying proliferation of digital technologies developed for use in the care of patients with mental illness. The objective of this review was to systematically search published literature to identify currently available health technologies and their intended uses for patients with serious mental illness.

MATERIALS AND METHODS

The Medline, Embase, and BIOSIS Previews electronic databases were searched to identify peer-reviewed English language articles that reported the use of digital, mobile, and other advanced technology in patients with schizophrenia/schizoaffective disorder, bipolar disorder, and major depressive disorder. Eligible studies were systematically reviewed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Eighteen studies that met the inclusion criteria were identified. Digital health technologies (DHTs) assessed in the selected studies included mobile applications (apps), digital medicine, digital personal health records, and an electronic pill container. Smartphone apps accounted for the largest share of DHTs. The intended uses of DHTs could be broadly classified as monitoring to gain a better understanding of illness, clinical assessment, and intervention. Overall, studies indicated high usability/feasibility and efficacy/effectiveness, with several reporting validity against established clinical scales. Users were generally engaged with the DHT, and mobile assessments were deemed helpful in monitoring disease symptoms.

CONCLUSION

Rapidly proliferating digital technologies seem to be feasible for short-term use in patients with serious mental illness; nevertheless, long-term effectiveness data from naturalistic studies will help demonstrate their usefulness and facilitate their adoption and integration into the mental health-care system.

Unguided Mental Health Self-help Apps: Reflections on Challenges through a Clinician's Lens

The past one decade has witnessed a boom in the availability of Internet-based self-help apps in the field of mental health. Several apps have emerged that aim to provide information and strategies to empower individuals with self-help approaches to deal with issues and concerns related to mental health. A large number of these apps in developing countries are likely to be those which depend entirely on the users to go over the self-help program on their own (unguided internet-based self-help). Only a few apps add a component of periodic professional contact/technical support through phone/email or other means to supplement the self-help strategies suggested in the app that the user is expected to utilize. This scenario poses several challenges in use of unguided self-help apps for mental health. This paper enumerates some of these challenges for potential users of the apps from the perspective of clinicians. These range from difficulties in choosing the right app, limited scope for contextualization, and motivation management to awareness about when to step up to a higher intensity intervention. Despite these challenges, unguided self-help apps can serve important purposes, and hence we propose a few recommendations to address such challenges.

Advances in mobile mental health: opportunities and implications for the spectrum of e-mental health services

Mobile health (mHealth), telemedicine and other technology-based services facilitate mental health service delivery and may be considered part of an e-mental health (eMH) spectrum of care. Web- and Internet-based resources provide a great opportunity for the public, patients, healthcare providers and others to improve wellness, practice prevention and reduce suffering from illnesses. Mobile apps offer portability for access anytime/anywhere, are inexpensive versus traditional desktop computers, and have additional features (e.g., context-aware interventions and sensors with real-time feedback. This paper discusses mobile mental health (mMH) options, as part of a broader framework of eMH options. The evidence-based literature shows that many people have an openness to technology as a way to help themselves, change behaviors and engage additional clinical services. Studies show that traditional video-based synchronous telepsychiatry (TP) is as good as in-person service, but mHealth outcomes have been rarely, directly compared to in-person and other eMH care options. Similarly, technology options added to in-person care or combined with others have not been evaluated nor linked with specific goals and desired outcomes. Skills and competencies for clinicians are needed for mHealth, social media and other new technologies in the eMH spectrum, in addition to research by randomized trials and study of health service delivery models with an emphasis on effectiveness.

Free mobile apps on depression for Indian users: A brief overview and critique

The present study aimed at identifying the nature of mobile apps available to Indian android phone users who might search for free apps to help them deal with depression. The specific objectives were to examine the available interactive self-care apps in terms of guidance provided to users to make decisions regarding use of app, inclusion of elements that encourage professional help-seeking, guidance regarding managing psychological crisis and the range of therapeutic strategies incorporated. Using the search term 'depression', 278 apps were identified in the first step and these spanned a wide range of categories. Information on coping with depression and stand alone screening tools formed the two largest types of free apps. Features of interactive self-care apps (N = 33) were reviewed further and this exercise showed that less than 10% of the apps incorporated explicit delineation of their scope or initial screening for suitability. Guidance regarding managing suicidal crisis were incorporated in only about 12% of the interactive apps. Slightly more than one third of these apps included content aimed at encouraging professional help seeking when needed or an explicit mention of their theoretical or empirical basis. Monitoring moods, thoughts and behaviors were the commonest therapeutic strategies incorporated in these apps, in addition, to a wide range of other strategies such as behavioral activation, identifying and correcting cognitive errors, mindfulness exercises, cultivation of gratitude, and medication management. The challenges for a potential user of these apps are discussed and ways to address the same are highlighted.

Health App Use Among Individuals With Symptoms of Depression and Anxiety: A Survey Study With Thematic Coding

BACKGROUND

Researchers have largely turned to commercial app stores, randomized trials, and systematic reviews to make sense of the mHealth landscape. Few studies have approached understanding by collecting information from target end users. The end user perspective is critical as end user interest in and use of mHealth technologies will ultimately drive the efficacy of these tools.

OBJECTIVE

The purpose of this study was to obtain information from end users of mHealth technologies to better understand the physical and mental health apps people use and for what purposes.

METHODS

People with depressive or anxious symptoms (N=176) seeking entry into a trial of mental health and well-being apps for Android devices completed online questionnaires assessing depression and anxiety (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), past and current mental health treatment-seeking behavior, overall mobile device use, and use of mobile health apps. Participants reported the physical health and mental health apps on their devices and their reasons for using them. Data were extracted from the participant self-reports and apps and app purposes were coded in order to categorize them.

RESULTS

Participants were largely white, middle-aged females from the Midwest region of the United States recruited via a health care organization and Web-based advertising (135 female, 41 male, mean age 38.64 years, age range 19-75 years.) Over three-quarters (137/176, 77.8%) of participants indicated having a health app on their device. The top 3 kinds of apps were exercise, fitness, and pedometers or heart rate monitoring apps (93/176, 52.8%); diet, food, or calorie counting apps (65/177, 36.9%); and mental health/wellness apps (46/177, 26.1%). The mean number of mobile physical and mental health apps on a participant's phone was 2.15 (SD 3.195). Of 176 participants, 107 (60.8%) specifically reported the top 5 health apps that they used and their purposes. Across the 107 participants, a total of 285 apps were reported, with 139 being unique apps. The majority of these apps were free (129/139, 92.8%). Almost two-thirds of participants (67/107, 62.6%) reported using health apps at least on a daily basis.

CONCLUSIONS

Among those seeking support for their well-being via physical and mental health apps, people are using a variety of health apps. These people use health apps on a daily basis, especially free apps. The most common reason for using a health app is to track some health-related data; for mental health apps specifically, training or habit building was the most popular reason. Understanding the end user perspective is important because it allows us to build on the foundation of previously established mHealth research and may help guide future work in mHealth.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02176226; https://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation.org/6rGc1MGyM).

Implementation of eMental Health care: viewpoints from key informants from organizations and agencies with eHealth mandates

Background

The use of technology such as computers, tablets, and smartphones to improve access to and the delivery of mental health care (eMental Health care) is growing worldwide. However, despite the rapidly expanding evidence base demonstrating the efficacy of eMental Health care, its implementation in clinical practice and health care systems remains fragmented. To date, no peer-reviewed, key-informant studies have reported on the perspectives of decision-makers concerned with whether and how to implement eMental Health care.

Methods

From September to November 2015, we conducted 31 interviews with key informants responsible for leadership, policy, research, and/ or information technology in organizations influential in the adoption of technology for eMental Health care. Deductive and inductive thematic analyses of transcripts were conducted using the Behavior Change Wheel as an organizing framework. Frequency and intensity effect sizes were calculated for emerging themes to further explore patterns within the data.

Results

Key informant responses (n = 31) representing 6 developed countries and multiple organizations showed consensus on common factors impacting implementation: individual and organizational capacities (e.g., computer literacy skills [patients and providers], knowledge gaps about cyber security, limited knowledge of available services); motivational drivers of technology-based care (e.g., extending care, data analytics); and opportunities for health systems to advance eMental Health care implementation (e.g., intersectoral research, rapid testing cycles, sustainable funding). Frequency effect sizes showed strong associations between implementation and credibility, knowledge, workflow, patient empowerment, electronic medical record (EMR) integration, sustained funding and intersectoral networks. Intensity effect sizes showed the highest concentration of statements (>10% of all comments) related to funding, credibility, knowledge gaps, and patient empowerment.

Conclusion

This study provides previously unavailable information about key informant perspectives on eMental Health care implementation. The themes that emerged, namely the need to intensify intersectoral research, measure/monitor readiness to implement, define cost-utility benchmarks, raise awareness about available technologies, and test assumptions that ‘proven’ technologies will be easily integrated can inform the design and evaluation of eMental Health care implementation models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0474-9) contains supplementary material, which is available to authorized users.

Digital technology and clinical decision making in depression treatment: Current findings and future opportunities

Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains.

There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence-based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as "multipurpose" apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable.

The feasibility, acceptability, and outcomes of PRIME-D: A novel mobile intervention treatment for depression

BACKGROUND

Despite decades of research and development, depression has risen from the fifth to the leading cause of disability in the United States. Barriers to progress in the field are (1) poor access to high-quality care; (2) limited mental health workforce; and (3) few providers trained in the delivery of evidence-based treatments (EBTs). Although mobile platforms are being developed to give consumers greater access to high-quality care, too often these tools do not have empirical support for their effectiveness. In this study, we evaluated PRIME-D, a mobile app intervention that uses social networking, goal setting, and a mental health coach to deliver text-based, EBT's to treat mood symptoms and functioning in adults with depression.

METHODS

Thirty-six adults with depression remotely participated in PRIME-D over an 8-week period with a 4-week follow-up, with 83% retained over the 12-week course of thestudy.

RESULTS

On average, participants logged into the app 5 days/week. Depression scores (PHQ-9) significantly improved over time (over 50% reduction), with coach interactions enhancing these effects. Mood-related disability (Sheehan Disability Scale (SDS)) also significantly decreased over time with participants no longer being impaired by their mood symptoms. Overall use of PRIME-D predicted greater gains in functioning. Improvements in mood and functioning were sustained over the 4-week follow-up.

CONCLUSIONS

Results suggest that PRIME-D is a feasible, acceptable, and effective intervention for adults with depression and that a mobile service delivery model may address the serious public health problem of poor access to high-quality mental health care.

Smartphone apps for the self-management of low back pain: A systematic review

Guidelines for low back pain (LBP) often recommend the use of self-management such as unsupervised exercise, booklets, and online education. Another potentially useful way for patients to self-manage LBP is by using smartphone applications (apps). However, to date, there has been no rigorous evaluation of LBP apps and no guidance for consumers on how to select high-quality, evidence-based apps. This chapter reviews smartphone apps for the self-management of LBP and evaluates their content quality and whether they recommend evidence-based interventions. This chapter shows that generally app developers are selecting interventions that are endorsed by guidelines, although their quality is low. There are many apps available for the self-management of LBP, but their effectiveness in improving patient outcomes has not been rigorously assessed. App developers need to work closely with healthcare professionals, researchers, and patients to ensure app content is accurate, evidence based, and engaging.

Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review

Background

There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear.

Objective

This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years.

Methods

The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years.

Results

A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate.

Conclusions

Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed.

Annual Research Review: Digital health interventions for children and young people with mental health problems - a systematic and meta-review

BACKGROUND

Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation.

METHODS

We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years.

RESULTS

Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs.

CONCLUSIONS

Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP.

Technology-enhanced human interaction in psychotherapy

Psychotherapy is on the verge of a technology-inspired revolution. The concurrent maturation of communication, signal processing, and machine learning technologies begs an earnest look at how these technologies may be used to improve the quality of psychotherapy. Here, we discuss 3 research domains where technology is likely to have a significant impact: (1) mechanism and process, (2) training and feedback, and (3) technology-mediated treatment modalities. For each domain, we describe current and forthcoming examples of how new technologies may change established applications. Moreover, for each domain we present research questions that touch on theoretical, systemic, and implementation issues. Ultimately, psychotherapy is a decidedly human endeavor, and thus the application of modern technology to therapy must capitalize on-and enhance-our human capacities as counselors, students, and supervisors. (PsycINFO Database Record

Creating state of the art, next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions

Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic "Big Data" that promises to inform learning theory and behavioral therapy in general.

Moodivate: A self-help behavioral activation mobile app for utilization in primary care-Development and clinical considerations

Depressive symptoms are highly prevalent and are associated with considerable functional impairment, significant public health costs, and heightened mortality risk. Individuals experiencing impairment due to depressive symptomatology are most likely to report their symptoms to a primary care provider. As such, national guidelines highlight the need to assess and effectively treat depression via primary care. Despite these guidelines, the dissemination of evidence-based psychotherapy via primary care is limited, likely due to both provider- and patient-level treatment barriers. Mobile health (mHealth) technologies are promising for addressing these barriers and for promoting uptake of evidence-based depression treatment. Among evidence-based psychotherapies for depression, brief Behavioral Activation Treatment for Depression (BATD) has shown great promise and is particularly amenable to mHealth delivery. Herein, we discuss the development of a BATD mobile application, Moodivate, that was developed in order to disseminate BATD via primary care. This paper focuses on description of (1) rationale for Moodivate treatment development, (2) Moodivate treatment components, (3) ongoing clinical trial evaluation of Moodivate, and (4) clinical considerations for incorporating Moodivate into clinical practice.

Ethical perspectives on recommending digital technology for patients with mental illness

The digital revolution in medicine not only offers exciting new directions for the treatment of mental illness, but also presents challenges to patient privacy and security. Changes in medicine are part of the complex digital economy based on creating value from analysis of behavioral data acquired by the tracking of daily digital activities. Without an understanding of the digital economy, recommending the use of technology to patients with mental illness can inadvertently lead to harm. Behavioral data are sold in the secondary data market, combined with other data from many sources, and used in algorithms that automatically classify people. These classifications are used in commerce and government, may be discriminatory, and result in non-medical harm to patients with mental illness. There is also potential for medical harm related to poor quality online information, self-diagnosis and self-treatment, passive monitoring, and the use of unvalidated smartphone apps. The goal of this paper is to increase awareness and foster discussion of the new ethical issues. To maximize the potential of technology to help patients with mental illness, physicians need education about the digital economy, and patients need help understanding the appropriate use and limitations of online websites and smartphone apps.

IntelliCare: An Eclectic, Skills-Based App Suite for the Treatment of Depression and Anxiety

Background

Digital mental health tools have tended to use psychoeducational strategies based on treatment orientations developed and validated outside of digital health. These features do not map well to the brief but frequent ways that people use mobile phones and mobile phone apps today. To address these challenges, we developed a suite of apps for depression and anxiety called IntelliCare, each developed with a focused goal and interactional style. IntelliCare apps prioritize interactive skills training over education and are designed for frequent but short interactions.

Objective

The overall objective of this study was to pilot a coach-assisted version of IntelliCare and evaluate its use and efficacy at reducing symptoms of depression and anxiety.

Methods

Participants, recruited through a health care system, Web-based and community advertising, and clinical research registries, were included in this single-arm trial if they had elevated symptoms of depression or anxiety. Participants had access to the 14 IntelliCare apps from Google Play and received 8 weeks of coaching on the use of IntelliCare. Coaching included an initial phone call plus 2 or more texts per week over the 8 weeks, with some participants receiving an additional brief phone call. Primary outcomes included the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety. Participants were compensated up to US $90 for completing all assessments; compensation was not for app use or treatment engagement.

Results

Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P<.001). Participants used the apps an average of 195.4 (SD 141) times over the 8 weeks. The average length of use was 1.1 (SD 2.1) minutes, and 95% of participants downloaded 5 or more of the IntelliCare apps.

Conclusions

This study supports the IntelliCare framework of providing a suite of skills-focused apps that can be used frequently and briefly to reduce symptoms of depression and anxiety. The IntelliCare system is elemental, allowing individual apps to be used or not used based on their effectiveness and utility, and it is eclectic, viewing treatment strategies as elements that can be applied as needed rather than adhering to a singular, overarching, theoretical model.

Trial Registration

Clinicaltrials.gov NCT02176226; http://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation/6mQZuBGk1)

Mobile Health Interventions for Psychiatric Conditions in Children: A Scoping Review

A scoping review was performed to determine what evidence exists to support the clinical use of mobile health (mHealth) interventions to address child psychiatric disorders. The review focused on children less than 18 years old who were diagnosed with a mental disorder, used an mHealth intervention, and included novel outcome data. Each study assessed feasibility of the intervention and concluded that the interventions were accepted and/or liked by patients. Of the 2 studies that examined effectiveness using a randomized controlled trial design, there were no statistically significant differences in clinical outcomes, but results were limited by small sample size.

The Use and Effectiveness of Mobile Apps for Depression: Results From a Fully Remote Clinical Trial

Background

Mobile apps for mental health have the potential to overcome access barriers to mental health care, but there is little information on whether patients use the interventions as intended and the impact they have on mental health outcomes.

Objective

The objective of our study was to document and compare use patterns and clinical outcomes across the United States between 3 different self-guided mobile apps for depression.

Methods

Participants were recruited through Web-based advertisements and social media and were randomly assigned to 1 of 3 mood apps. Treatment and assessment were conducted remotely on each participant’s smartphone or tablet with minimal contact with study staff. We enrolled 626 English-speaking adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5, or if their score on item 10 was ≥2. The apps were (1) Project: EVO, a cognitive training app theorized to mitigate depressive symptoms by improving cognitive control, (2) iPST, an app based on an evidence-based psychotherapy for depression, and (3) Health Tips, a treatment control. Outcomes were scores on the PHQ-9 and the Sheehan Disability Scale. Adherence to treatment was measured as number of times participants opened and used the apps as instructed.

Results

We randomly assigned 211 participants to iPST, 209 to Project: EVO, and 206 to Health Tips. Among the participants, 77.0% (482/626) had a PHQ-9 score >10 (moderately depressed). Among the participants using the 2 active apps, 57.9% (243/420) did not download their assigned intervention app but did not differ demographically from those who did. Differential treatment effects were present in participants with baseline PHQ-9 score >10, with the cognitive training and problem-solving apps resulting in greater effects on mood than the information control app (χ22=6.46, P=.04).

Conclusions

Mobile apps for depression appear to have their greatest impact on people with more moderate levels of depression. In particular, an app that is designed to engage cognitive correlates of depression had the strongest effect on depressed mood in this sample. This study suggests that mobile apps reach many people and are useful for more moderate levels of depression.

ClinicalTrial

Clinicaltrials.gov NCT00540865; https://www.clinicaltrials.gov/ct2/show/NCT00540865 (Archived by WebCite at http://www.webcitation.org/6mj8IPqQr)

Quality of Smartphone Apps Related to Alcohol Use Disorder

BACKGROUND

Apps for smartphones are opening an important range of opportunities for improving the care of people with alcohol use disorders (AUDs).

AIMS

This study aimed to evaluate the quality of English language apps for AUDs and to compare paid and free apps. The keywords 'alcohol', 'alcohol addiction', 'alcohol help' and 'stop drinking' were entered into the iTunes Store search engine. Apps were evaluated using a standardized assessment designed to rate the quality of apps in terms of accountability, interactivity, self-help score and evidence-based content. The Brief DISCERN score and the criteria of the 'Health on the Net' label were also used as content quality indicators.

RESULTS AND CONCLUSIONS

Of the 137 unique apps identified, 52 met the inclusion criteria. Overall, the content quality and self-help scores of these AUD apps were poor. The main quality indicators were not linked to payment status. Multiple linear regressions showed that the Brief DISCERN score significantly predicted content quality. Poor content quality and self-help scores of AUD smartphone apps underline the gap between their potential promises and the overall quality of available products in stores. The quality indicators used in the present study may be used for further app developments.