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

Development of a Mobile Intervention for Procrastination Augmented With a Semigenerative Chatbot for University Students: Pilot Randomized Controlled Trial

BACKGROUND

Procrastination negatively affects university students' academics and mental health. Traditional time management apps lack therapeutic strategies like cognitive behavioral therapy to address procrastination's psychological aspects. Therefore, we developed and integrated a semigenerative chatbot named Moa into a to-do app.

OBJECTIVE

We intended to determine the benefits of the Moa-integrated to-do app over the app without Moa by verifying behavioral and cognitive changes, analyzing the influence of engagement patterns on the changes, and exploring the user experience.

METHODS

The developed chatbot Moa guided users over 30 days in terms of self-observation, strategy establishment, and reflection. The architecture comprised response-generating and procrastination factor-detection algorithms. A pilot randomized controlled trial was conducted with 85 participants (n=37, 44% female; n=48, 56% male) from a university in South Korea. The control group used a to-do app without Moa, whereas the treatment group used a fully automated Moa-integrated app. The Irrational Procrastination Scale, Pure Procrastination Scale, Time Management Behavior Scale, and the Perceived Stress Scale were examined using linear mixed models with repeated measurements obtained before (T0) and after (T1) 1-month use and after 2-month use (T2) to assess the changes in irrational procrastination, pure procrastination, time management and behavior, academic self-regulation, and stress. Intervention engagement, divided into "high," "middle" and "low" clusters, was quantified using app access and use of the to-do list and grouped using k-means clustering. In addition, changes in the psychological scale scores between the control and treatment groups were analyzed within each cluster. User experience was quantified based on the usability, feasibility, and acceptability of and satisfaction with the app, whereas thematic analysis explored the users' subjective responses to app use.

RESULTS

In total, 75 participants completed the study. The interaction of time × procrastination was significant during the required use period (P=.01). The post hoc test indicated a significant improvement from T0 to T1 in the Time Management Behavior Scale and Perceived Stress Scale scores only in the treatment group (P<.001 and P=.009). The changes in Pure Procrastination Scale score after the required use period were significant in all clusters except for the low cluster of the control group. The high cluster in the treatment group exhibited a significant change in the Irrational Procrastination Scale after Bonferroni correction (P=.046). Usability was determined to be good in the treatment group (mean score 72.8, SD 16.0), and acceptability was higher than in the control group (P=.03). Evaluation of user experience indicated that only the participants in the treatment group achieved self-reflection and experienced an alliance with the app.

CONCLUSIONS

The chatbot-integrated app demonstrated greater efficacy in influencing user behavior providing psychological support. It will serve as a valuable tool for managing procrastination and stress together.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS) KCT0009056; https://tinyurl.com/yc84tedk.

Acceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review

BACKGROUND

Depression and anxiety disorders are common, and treatment often includes psychological interventions. Digital health interventions, delivered through technologies such as web-based programs and mobile apps, are increasingly used in mental health treatment. Acceptability, the extent to which an intervention is viewed positively, has been identified as contributing to patient adherence and engagement with digital health interventions. Acceptability, therefore, impacts the benefit derived from using digital health interventions in treatment. Understanding the acceptability of digital mental health interventions among patients with depression or anxiety disorders is essential to maximize the effectiveness of their treatment.

OBJECTIVE

This review investigated the acceptability of technology-based interventions among patients with depression or anxiety disorders.

METHODS

A systematic review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines. We searched PubMed, Web of Science, and Ovid in May 2022. Studies were included if they evaluated digital interventions for the treatment of depression or anxiety disorders and investigated their acceptability among adult patients. Studies were excluded if they targeted only specific populations (eg, those with specific physical health conditions), investigated acceptability in healthy individuals or patients under the age of 18 years, involved no direct interaction between patients and technologies, used technology only as a platform for traditional care (eg, videoconferencing), had patients using technologies only in clinical or laboratory settings, or involved virtual reality technologies. Acceptability outcome data were narratively synthesized by the direction of acceptability using vote counting. Included studies were evaluated using levels of evidence from the Oxford Centre for Evidence-Based Medicine. The risk of bias was assessed using a tool designed for this review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).

RESULTS

A total of 143 articles met the inclusion criteria, comprising 67 (47%) articles on interventions for depression, 65 (45%) articles on interventions for anxiety disorders, and 11 (8%) articles on interventions for both. Overall, 90 (63%) were randomized controlled trials, 50 (35%) were other quantitative studies, and 3 (2%) were qualitative studies. Interventions used web-based programs, mobile apps, and computer programs. Cognitive behavioral therapy was the basis of 71% (102/143) of the interventions. Digital mental health interventions were generally acceptable among patients with depression or anxiety disorders, with 88% (126/143) indicating positive acceptability, 8% (11/143) mixed results, and 4% (6/143) insufficient information to categorize the direction of acceptability. The available research evidence was of moderate quality.

CONCLUSIONS

Digital mental health interventions seem to be acceptable to patients with depression or anxiety disorders. Consistent use of validated measures for acceptability would enhance the quality of evidence. Careful design of acceptability as an evaluation outcome can further improve the quality of evidence and reduce the risk of bias.

TRIAL REGISTRATION

Open Science Framework Y7MJ4; https://doi.org/10.17605/OSF.IO/SPR8M.

Digital Psychotherapies for Adults Experiencing Depressive Symptoms: Systematic Review and Meta-Analysis

BACKGROUND

Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives.

OBJECTIVE

This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients' and practitioners' perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression.

METHODS

A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients' and therapists' perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups.

RESULTS

Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included "stand-alone" or non-human contact interventions (58/160, 36.2%), "human contact" interventions (11/160, 6.8%), and "blended" including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=-0.61, 95% CI -0.75 to -0.47; Z=-8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=-0.793), while interventions involving human contact (Hedges g=-0.42) or no human contact (Hedges g=-0.40) had slightly smaller effect sizes.

CONCLUSIONS

Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics.

TRIAL REGISTRATION

PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=238462.

User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review

BACKGROUND

There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies.

OBJECTIVE

This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point?

METHODS

Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically.

RESULTS

A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies.

CONCLUSIONS

The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.

Standardising the role of a digital navigator in behavioural health: a systematic review

As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.

Who benefits from guided internet-based interventions? A systematic review of predictors and moderators of treatment outcome

To our knowledge, no systematic review has been conducted on predictors or moderators of treatment outcome across diagnoses in guided internet-based interventions (IBIs) for adults. To identify who benefits from this specific format and therein inform future research on improving patient-treatment fit, we aimed to aggregate results of relevant studies. 2100 articles, identified by searching the databases PsycInfo, Ovid Medline, and Pubmed and through snowballing, were screened in April/May 2021 and October 2022. Risk of bias and intra- and interrater reliability were assessed. Variables were grouped by predictor category, then synthesized using vote counting based on direction of effect. N = 60 articles were included in the review. Grouping resulted in 88 predictors/moderators, of which adherence, baseline symptoms, education, age, and gender were most frequently assessed. Better adherence, treatment credibility, and working alliance emerged as conclusive predictors/moderators for better outcome, whereas higher baseline scores predicted more reliable change but higher post-treatment symptoms. Results of all other predictors/moderators were inconclusive or lacked data. Our review highlights that it is currently difficult to predict, across diagnoses, who will benefit from guided IBIs. Further rigorous research is needed to identify predictors and moderators based on a sufficient number of studies. PROSPERO registration: CRD42021242305.

Personalization strategies in digital mental health interventions: a systematic review and conceptual framework for depressive symptoms

Introduction

Personalization is a much-discussed approach to improve adherence and outcomes for Digital Mental Health interventions (DMHIs). Yet, major questions remain open, such as (1) what personalization is, (2) how prevalent it is in practice, and (3) what benefits it truly has.

Methods

We address this gap by performing a systematic literature review identifying all empirical studies on DMHIs targeting depressive symptoms in adults from 2015 to September 2022. The search in Pubmed, SCOPUS and Psycinfo led to the inclusion of 138 articles, describing 94 distinct DMHIs provided to an overall sample of approximately 24,300 individuals.

Results

Our investigation results in the conceptualization of personalization as purposefully designed variation between individuals in an intervention's therapeutic elements or its structure. We propose to further differentiate personalization by what is personalized (i.e., intervention content, content order, level of guidance or communication) and the underlying mechanism [i.e., user choice, provider choice, decision rules, and machine-learning (ML) based approaches]. Applying this concept, we identified personalization in 66% of the interventions for depressive symptoms, with personalized intervention content (32% of interventions) and communication with the user (30%) being particularly popular. Personalization via decision rules (48%) and user choice (36%) were the most used mechanisms, while the utilization of ML was rare (3%). Two-thirds of personalized interventions only tailored one dimension of the intervention.

Discussion

We conclude that future interventions could provide even more personalized experiences and especially benefit from using ML models. Finally, empirical evidence for personalization was scarce and inconclusive, making further evidence for the benefits of personalization highly needed.

Systematic Review Registration

Identifier: CRD42022357408.

Characterizing observed and effective behavioral engagement with smartphone cognitive behavioral therapy for body dysmorphic disorder: A methods roadmap and use case

Smartphone psychotherapies are growing in popularity, yet little is understood about (1) how people prefer to engage with psychotherapy apps, or (2) which engagement patterns constitute effective engagement. The present study uses secondary data from a 12-week randomized waitlist-controlled trial of smartphone-delivered cognitive behavioral therapy (CBT) for body dysmorphic disorder (BDD) (N = 77) to address these aims. Additionally, using the present study as a use-case, we seek to provide a roadmap for how researchers may improve upon methodological limitations of existing smartphone psychotherapy engagement research. We measured behavioral engagement via 19 objective variables derived from phone analytics data, which we reduced via factor analysis into two factors: 1) use volume and frequency, and 2) session duration. Cluster analysis based on engagement factors yielded three engager types, which mapped onto "deep" users, "samplers," and "light" users. The clusters did not differ significantly in improvement in BDD severity across treatment, although deep users improved more than light users at a marginally significant level. Results suggest that varying patterns of preferred engagement may be efficacious. Moreover, the study's methods provide an example of how researchers can measure and study behavioral engagement comprehensively and objectively. Trial Registration: ClinicalTrials.gov Identifier: NCT04034693.

Effectiveness of Mental Health Apps for Distress During COVID-19 in US Unemployed and Essential Workers: Remote Pragmatic Randomized Clinical Trial

BACKGROUND

During the COVID-19 pandemic, the general public was concerned about the mental health impacts of unemployment due to COVID-19 and the stress essential workers experienced during this time. Several reports indicated that people in distress were turning to digital technology, but there was little evidence about the impact of these tools on mitigating distress.

OBJECTIVE

This study seeks to determine the acceptability, feasibility, usability, and effectiveness of mobile mental health apps for decreasing mental health symptoms in essential workers and unemployed individuals with suicide risk.

METHODS

We recruited participants who indicated that they were unemployed because of COVID-19 or were COVID-19-designated essential workers. Participants were randomized to 1 of 4 free commercial mobile apps for managing distress that were (1) highly rated by PsyberGuide and (2) met the criteria for intervention features these participants indicated were desirable in a previous survey. Participants used the apps for 4 weeks and completed baseline and 4-week self-assessments of depression, anxiety emotional regulation, and suicide risk.

RESULTS

We found no differences between the apps in any outcome but did find significant changes in depression and anxiety over time (Patient Health Questionnaire [PHQ]-9: estimate=-1.5, SE 0.2, 95% CI -1.1 to -1.8, P<.001; Generalized Anxiety Disorder Scale [GAD]-7: estimate=-1.3, SE 0.2, 95% CI -1.0 to -1.6, P<.001). We found no significant changes in suicidal behavior (Suicide Behaviors Questionnaire-Revised [SBQ-R]) or emotional regulation (Difficulties in Emotion Regulation Scale - Short Form [DERS-SF]) for the 4 weeks. We did find a significant dose-response pattern for changes in depression and anxiety. Using the app at least once a week resulted in greater improvements in treatment conditions over time on depression (estimate=-0.6, SE 0.2, 95% CI 1.0-0.2, P=.003) and anxiety (estimate=0.1, SE 0.2, 95% CI 0.4-0.6, P=.78). There was no association between app frequency and changes in suicidal behavior (SBQ-R) or emotional regulation (DERS-SF). We further found a significant difference between the conditions with regard to app usability, with the control app being the most usable (mean_{Beautiful Mood} 72.9, SD 16.7; mean_{COVID Coach} 71.2, SD 15.4; mean_Calm 66.8, SD 17.3; mean_{7 Cups} 65.2, SD 17.7). We found no significant differences for app acceptability or appropriateness.

CONCLUSIONS

Few studies have evaluated prospectively the utility and usability of commercial apps for mood. This study found that free, self-guided commercial mobile mental health apps are seen as usable, but no one app is superior to the other. Although we found that regular use is indicated for effects on depression and anxiety to occur in those who are more symptomatic, regression to the mean cannot be ruled out.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04536935; https://tinyurl.com/mr36zx3s.

Enrollment and Retention of Participants in Remote Digital Health Studies: Scoping Review and Framework Proposal

BACKGROUND

Digital technologies are increasingly used in health research to collect real-world data from wider populations. A new wave of digital health studies relies primarily on digital technologies to conduct research entirely remotely. Remote digital health studies hold promise to significant cost and time advantages over traditional, in-person studies. However, such studies have been reported to typically suffer from participant attrition, the sources for which are still largely understudied.

OBJECTIVE

To contribute to future remote digital health study planning, we present a conceptual framework and hypotheses for study enrollment and completion. The framework introduces 3 participation criteria that impact remote digital health study outcomes: (1) participant motivation profile and incentives or nudges, (2) participant task complexity, and (3) scientific requirements. The goal of this study is to inform the planning and implementation of remote digital health studies from a person-centered perspective.

METHODS

We conducted a scoping review to collect information on participation in remote digital health studies, focusing on methodological aspects that impact participant enrollment and retention. Comprehensive searches were conducted on the PubMed, CINAHL, and Web of Science databases, and additional sources were included in our study from citation searching. We included digital health studies that were fully conducted remotely, included information on at least one of the framework criteria during recruitment, onboarding or retention phases of the studies, and included study enrollment or completion outcomes. Qualitative analyses were performed to synthesize the findings from the included studies.

RESULTS

We report qualitative findings from 37 included studies that reveal high values of achieved median participant enrollment based on target sample size calculations, 128% (IQR 100%-234%), and median study completion, 48% (IQR 35%-76%). Increased median study completion is observed for studies that provided incentives or nudges to extrinsically motivated participants (62%, IQR 43%-78%). Reducing task complexity for participants in the absence of incentives or nudges did not improve median study enrollment (103%, IQR 102%-370%) or completion (43%, IQR 22%-60%) in observational studies, in comparison to interventional studies that provided more incentives or nudges (median study completion rate of 55%, IQR 38%-79%). Furthermore, there were inconsistencies in measures of completion across the assessed remote digital health studies, where only around half of the studies with completion measures (14/27, 52%) were based on participant retention throughout the study period.

CONCLUSIONS

Few studies reported on participatory factors and study outcomes in a consistent manner, which may have limited the evidence base for our study. Our assessment may also have suffered from publication bias or unrepresentative study samples due to an observed preference for participants with digital literacy skills in digital health studies. Nevertheless, we find that future remote digital health study planning can benefit from targeting specific participant profiles, providing incentives and nudges, and reducing study complexity to improve study outcomes.

Feasibility, Acceptability, and Preliminary Outcomes of a Cognitive Behavioral Therapy–Based Mobile Mental Well-being Program (Noom Mood): Single-Arm Prospective Cohort Study

Background

The prevalence of anxiety, depression, and general distress has risen in recent years. Mobile mental health programs have been found to provide support to nonclinical populations and may overcome some of the barriers associated with traditional in-person treatment; however, researchers have voiced concerns that many publicly available mobile mental health programs lack evidence-based theoretical foundations, peer-reviewed research, and sufficient engagement from the public.

Objective

This study aimed to evaluate the feasibility, acceptability, and preliminary outcomes of Noom Mood, a commercial mobile cognitive behavioral therapy– and mindfulness-based program.

Methods

In this single-arm prospective cohort study, individuals who joined Noom Mood between August and October 2021 completed surveys at baseline and 4-week follow-up. Per-protocol analyses included those who completed both surveys (n=113), and intention-to-treat analyses included all participants (N=185).

Results

A majority of the sample reported that the program is easy to use, they felt confident recommending the program to a friend, and they perceived the program to be effective at improving stress and anxiety. There were significant improvements in anxiety symptoms, perceived stress, depressive feelings, emotion regulation, and optimism in both the per-protocol and intention-to-treat analyses (all P<.001). Participants reported benefiting most from learning skills (eg, breathing and cognitive reframing techniques), interacting with the program features, and gaining awareness of their emotions and thought patterns. Participants also made a number of suggestions to improve product functionality and usability.

Conclusions

Results suggest that Noom Mood is feasible and acceptable to participants, with promising preliminary outcomes. Future studies should build on these results to evaluate the effects of Noom Mood using more rigorous designs.

Effectiveness of mobile applications for patients with severe mental illness: A meta-analysis of randomized controlled trials

BACKGROUND

A systematic review and meta-analysis was conducted to evaluate the effectiveness of mobile applications used by patients diagnosed with mental disorders.

METHODS

An electronic literature search in five databases including PubMed, Embase, the Cochrane Library, CINAHL, and PsychInfo was conducted. The keywords used were "mental disorder," "mental illness," "mobile phone," "smartphone," "mHealth," "application," and "app". The search was restricted to randomized controlled trials (RCTs) written in English and Korean.

RESULTS

Fourteen RCTs, involving 1307 patients diagnosed with depression, schizophrenia, and bipolar disorder were included in the analysis. The included studies were published between 2012 and 2020 and used mobile applications. The risk of bias tool was used to assess methodological quality and the overall risk of bias of the included studies was moderate. The pooled data favored mobile application interventions in reducing the disease-related symptoms of depression (standardized mean difference [SMD] = -0.255, 95% CI: -0.370 to -0.141), mania symptoms (SMD = -0.279, 95% CI: -0.456 to -0.102), and positive (SMD = -0.205, 95% CI: -0.388 to -0.022) and negative psychotic symptoms (SMD = -0.406, 95% CI: -0.791 to -0.020). In subgroup analysis, the incorporation of feedback, notification, and data tracking features in the mobile application intervention produced better outcomes.

CONCLUSION

This review provided evidence that mobile applications could well-assist patients diagnosed with mental disorders. Greater benefits could be achieved by well-designed interventions incorporating strategies with thoughtful consideration of the disease characteristics. Mobile applications present the potential to be effective supplements to clinical treatment.

Engagement with mobile health interventions for depression: A systematic review

BACKGROUND

Depressive disorders are a major public health problem, and many people face barriers to accessing evidence-based mental health treatment. Mobile health (mHealth) interventions may circumvent logistical barriers to in-person care (e.g., cost, transportation), however the symptoms of depression (low motivation, concentration difficulties) may make it difficult for people with the disorder to engage with mHealth.

OBJECTIVE

The aim of this systematic review is to examine assessment and reporting of engagement in clinical trials of mHealth interventions for depression, including objective engagement (e.g., number of times program is used), subjective engagement (e.g., qualitative data on users' experiences), and associations between engagement and other clinically important variables (e.g., symptom improvement, participant characteristics).

METHODS

Three electronic databases (PsycINFO, Web of Science, PubMed) were searched in February 2020 using search terms for mHealth and depression. Studies were included in the review if they tested a mHealth intervention designed for people with depressive disorders or elevated depression symptoms.

RESULTS

Thirty studies met inclusion criteria and were reviewed. Most studies reported objective engagement (N = 23, 76.7%), approximately half reported subjective engagement (N = 16, 53.3%), and relatively few examined associations between engagement and clinical improvement, participant characteristics, or other clinically relevant variables (N = 13, 43.3%).

CONCLUSIONS

Although most studies in this small but rapidly growing literature report at least one measure of engagement, there is substantial heterogeneity. Intentional, theory-driven, and consistent measurement of engagement with mHealth interventions for depression may advance the field's understanding of effective engagement to facilitate clinical improvement, identify dose-response relationships, and maximize generalizability for underserved populations.

Technological prescription: evaluation of the effectiveness of mobile applications to improve depression and anxiety. Systematic review

Several studies have shown that, due to their features, mobile applications have a great potential to address mental health in depression and anxiety. We carried out a systematic review of publications from the last 10 years: from 1 January 2010 until 31 March 2020. Systematic reviews and meta-analyses related to the research question were also selected to identify other potentially eligible studies. The literature search in selected databases returned a total of 3,011 records from which a total of 22 articles were finally selected. The main conclusion of the study is that most of the scientific evidence found supports the hypothesis that mobile applications significantly improve the symptoms associated with depression and anxiety. Therefore, their effectiveness as a digital tool in the treatment of such health problems is proven. However, further studies and further evaluations of mobile applications are required (also in other languages) to incorporate this resource into the healthcare context. In addition, since mobile applications allow reinforcing concepts such as patient empowerment, shared decision-making and health literacy, their use would be highly positive for depression and anxiety, where there is a strong element of self-managing the disease.

Integration of a smartwatch within an internet-delivered intervention for depression: Protocol for a feasibility randomized controlled trial on acceptance

BACKGROUND

Mood tracking is commonly employed within a range of mental health interventions. Physical activity and sleep are also important for contextualizing mood data but can be difficult to track manually and rely on retrospective recall. Smartwatches could enhance self-monitoring by addressing difficulties in recall of sleep and physical activity and reducing the burden on patients in terms of remembering to track and the effort of tracking. This feasibility study will explore the acceptance of a smartwatch app for self-monitoring of mood, sleep, and physical activity, in an internet-based cognitive-behavioral therapy (iCBT) for depression offered in a routine care setting.

METHODS

Seventy participants will be randomly allocated to (i) iCBT intervention plus smartwatch app or (ii) iCBT intervention alone. Patient acceptance will be measured longitudinally using a theory-based acceptance questionnaire to understand and compare the evolution of acceptance of the technology-delivered self-report in the two groups. A post-treatment interview will explore participants subjective experience of using the smartwatch. Engagement with the intervention, including self-report, and clinical outcomes, will be measured across both groups to assess for any differences.

IMPLICATIONS

This is the first study investigating the evolution of patient acceptance of smartwatch self-report in an iCBT delivered intervention in a clinical sample. Through an engaging and convenient means of capturing ecologically valid mood data, the study has the potential to show that smartwatches are an acceptable means for patient self-monitoring within iCBT interventions for depression and support potential use-cases for smartwatches in the context of mental health interventions in general. Prospectively registered at ClinicalTrials.gov (NCT04568317).

Investigator Experiences Using Mobile Technologies in Clinical Research: Qualitative Descriptive Study

Background

The successful adoption of mobile technology for use in clinical trials relies on positive reception from key stakeholders, including clinical investigators; however, little information is known about the perspectives of investigators using mobile technologies in clinical trials.

Objective

The aim of this study was to seek investigators’ insights on the advantages and challenges of mobile clinical trials (MCTs); site-level budgetary, training, and other support needs necessary to adequately prepare for and implement MCTs; and the advantages and disadvantages for trial participants using mobile technologies in clinical trials.

Methods

Using a qualitative descriptive study design, we conducted in-depth interviews with investigators involved in the conduct of MCTs. Data were analyzed using applied thematic analysis.

Results

We interviewed 12 investigators who represented a wide variety of clinical specialties and reported using a wide range of mobile technologies. Investigators most commonly cited 3 advantages of MCTs over traditional clinical trials: more streamlined study operations, remote data capture, and improvement in the quality of studies and data collected. Investigators also reported that MCTs can be designed around the convenience of trial participants, and individuals may be more willing to participate in MCTs because they can take part from their homes. In addition, investigators recognized that MCTs can also involve additional burden for participants and described that operational challenges, technology adoption barriers, uncertainties about data quality, and time burden made MCTs more challenging than traditional clinical trials. Investigators stressed that additional training and dedicated staff effort may be needed to select a particular technology for use in a trial, helping trial participants learn and use the technology, and for staff troubleshooting the technology. Investigators also expressed that sharing data collected in real time with investigators and trial participants is an important aspect of MCTs that warrants consideration and potentially additional training and education.

Conclusions

Investigator perspectives can inform the use of mobile technologies in future clinical trials by proactively identifying and addressing potential challenges.

Usability, Acceptability, and Adherence Rates of Mobile Application Interventions for Prevention or Treatment of Depression: A Systematic Review

Mobile health applications (apps) have been growing as a new frontier in mental health care delivery. The objective of the current systematic review was to summarize the evidence regarding usability, acceptability, and adherence rates of mobile app interventions for prevention or treatment of depression. A literature search was conducted in relevant databases, including PubMed, PsycINFO, and Embase, for articles published between January 1, 2009, and August 1, 2019. Key terms used for searching included depression AND smartphone OR mobile AND application AND acceptability OR feasibility. Based on a full-text examination, seven studies were included for review. All studies were conducted in developed countries and five studies were developing a mobile app for depression treatment. The current study highlights the need for developers of mobile apps for individuals with mental health care needs to consider user acceptability and adherence rates. Innovation in designing a mobile app for individuals with depression is needed to improve the adherence rates of users. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 41-47.].

Standalone Smartphone Cognitive Behavioral Therapy-Based Ecological Momentary Interventions to Increase Mental Health: Narrative Review

BACKGROUND

A growing number of psychological interventions are delivered via smartphones with the aim of increasing the efficacy and effectiveness of these treatments and providing scalable access to interventions for improving mental health. Most of the scientifically tested apps are based on cognitive behavioral therapy (CBT) principles, which are considered the gold standard for the treatment of most mental health problems.

OBJECTIVE

This review investigates standalone smartphone-based ecological momentary interventions (EMIs) built on principles derived from CBT that aim to improve mental health.

METHODS

We searched the MEDLINE, PsycINFO, EMBASE, and PubMed databases for peer-reviewed studies published between January 1, 2007, and January 15, 2020. We included studies focusing on standalone app-based approaches to improve mental health and their feasibility, efficacy, or effectiveness. Both within- and between-group designs and studies with both healthy and clinical samples were included. Blended interventions, for example, app-based treatments in combination with psychotherapy, were not included. Selected studies were evaluated in terms of their design, that is, choice of the control condition, sample characteristics, EMI content, EMI delivery characteristics, feasibility, efficacy, and effectiveness. The latter was defined in terms of improvement in the primary outcomes used in the studies.

RESULTS

A total of 26 studies were selected. The results show that EMIs based on CBT principles can be successfully delivered, significantly increase well-being among users, and reduce mental health symptoms. Standalone EMIs were rated as helpful (mean 70.8%, SD 15.3; n=4 studies) and satisfying for users (mean 72.6%, SD 17.2; n=7 studies).

CONCLUSIONS

Study quality was heterogeneous, and feasibility was often not reported in the reviewed studies, thus limiting the conclusions that can be drawn from the existing data. Together, the studies show that EMIs may help increase mental health and thus support individuals in their daily lives. Such EMIs provide readily available, scalable, and evidence-based mental health support. These characteristics appear crucial in the context of a global crisis such as the COVID-19 pandemic but may also help reduce personal and economic costs of mental health impairment beyond this situation or in the context of potential future pandemics.

Psych-APP-Therapie: Smartphonebasierte Interventionen in der Psychotherapie – Eine systematische Übersichtsarbeit

<b><i>Hintergrund:</i></b> Technologiebasierte Interventionen haben in der Psychotherapie an Bedeutung gewonnen. Ein versorgungsrelevanter Ansatz sind Mental Health Apps. Ziel dieser systematischen Übersichtsarbeit ist es (1) international eva­luierte Apps zu den Störungsbildern Depressionen, Angststörungen und Essstörungen zu identifizieren, (2) deren Verfügbarkeit in deutschen App-Stores sowie (3) in deutscher Sprache zu prüfen und (4) ihre Effektivitätsergebnisse aus randomisiert-kontrollierten (Pilot-)Studien (RCTs) darzustellen. <b><i>Methode:</i></b> Die Übersichtsarbeit wurde in Anlehnung an das PRISMA Statement durchgeführt und ausgewertet. Eine systematische Recherche (2007–2018) der Datenbanken PubMed, PsychINFO sowie PSYNDEX wurde durchgeführt. Zudem fand eine Beurteilung der methodischen Qualität sowie der Effektivitätsergebnisse der (Pilot-)RCTs statt. <b><i>Ergebnisse:</i></b> Es wurden 2’571 Abstracts identifiziert und 47 Publikationen eingeschlossen (<i>N</i> = 32 unterschiedliche Apps; <i>N</i> = 24 [Pilot-]RCTs). Die Qualität der (Pilot-)RCTs ist überwiegend als gut bis moderat einzustufen. Die Ergebnisse waren heterogen (keine bis große Effekte [Cohens <i>d</i>] zwischen den Gruppen: –0,01; KI [–0,36; 0,34] bis 1,49; KI [1,00; 1,99]). Vier Apps mit einer Evaluation durch (Pilot-)RCTs sind in den deutschen App-Stores verfügbar – eine in deutscher Sprache. <b><i>Schlussfolgerungen:</i></b> Es liegt international eine Vielzahl von ersten App-Evaluationen zu den Störungsbildern vor, die Verfügbarkeit ausreichend evalu­ierter deutschsprachiger Apps in den deutschen App-Stores ist aber extrem limitiert. Englischsprachige, bereits evalu­ierte Apps könnten in das Deutsche übersetzt und – genauso wie schon verfügbare, aber nicht evaluierte deutschsprachige Apps – in RCTs inkl. Katamnesedaten evaluiert werden. So könnten smartphonebasierte Interventionen im Rahmen des “Digitalen-Versorgungs-Gesetzes” als ergänzendes Element in der Psychotherapie an Bedeutung gewinnen.

Jamaican adolescents' receptiveness to digital mental health services: A cross-sectional survey from rural and urban communities

BACKGROUND

Improving access to mental health resources for young people is an urgent healthcare challenge. As the majority of youth live in low and middle-income countries (LMICs) mental ill health can exert substantial adverse impacts on societies that can least afford it. Digital mental health technologies might help close the treatment gap but we need to understand barriers to implementing these strategies, especially in resource constrained contexts such as LMICs.

METHODS

We surveyed adolescents (N = 107; aged 10-19 years) from Jamaican communities using questionnaires adopted from previous studies conducted in LMICs. The questions addressed mental health help-seeking preferences, expectations of help-seeking effectiveness, and practical and attitudinal barriers to using mobile-phone-based mental health resources. We present descriptive data alongside exploratory analyses of differences in attitudes and preferences expressed by subgroups of respondents.

RESULTS

Adolescents reported very few practical or infrastructure barriers to accessing digital mental health resources. >90% of the sample had access to a smartphone, 78% expected that digital solutions could benefit adolescents with symptoms of mental distress, and 56% were interested in using mental health apps to monitor their own mental health. Stigma, shame, and embarrassment were major barriers to help-seeking and formal professional help was only preferred for more severe conditions such as psychosis and substance abuse.

CONCLUSIONS

Practical barriers are unlikely to impede the uptake of digital mental health resources by Jamaican adolescents. Our data suggest that mental health literacy, stigma, and embarrassment pose more serious blocks to help-seeking.

Technology Acceptance in Mobile Health: Scoping Review of Definitions, Models, and Measurement

BACKGROUND

Designing technologies that users will be interested in, start using, and keep using has long been a challenge. In the health domain, the question of technology acceptance is even more important, as the possible intrusiveness of technologies could lead to patients refusing to even try them. Developers and researchers must address this question not only in the design and evaluation of new health care technologies but also across the different stages of the user's journey. Although a range of definitions for these stages exists, many researchers conflate related terms, and the field would benefit from a coherent set of definitions and associated measurement approaches.

OBJECTIVE

This review aims to explore how technology acceptance is interpreted and measured in mobile health (mHealth) literature. We seek to compare the treatment of acceptance in mHealth research with existing definitions and models, identify potential gaps, and contribute to the clarification of the process of technology acceptance.

METHODS

We searched the PubMed database for publications indexed under the Medical Subject Headings terms "Patient Acceptance of Health Care" and "Mobile Applications." We included publications that (1) contained at least one of the terms "acceptability," "acceptance," "adoption," "accept," or "adopt"; and (2) defined the term. The final corpus included 68 relevant studies.

RESULTS

Several interpretations are associated with technology acceptance, few consistent with existing definitions. Although the literature has influenced the interpretation of the concept, usage is not homogeneous, and models are not adapted to populations with particular needs. The prevalence of measurement by custom surveys suggests a lack of standardized measurement tools.

CONCLUSIONS

Definitions from the literature were published separately, which may contribute to inconsistent usage. A definition framework would bring coherence to the reporting of results, facilitating the replication and comparison of studies. We propose the Technology Acceptance Lifecycle, consolidating existing definitions, articulating the different stages of technology acceptance, and providing an explicit terminology. Our findings illustrate the need for a common definition and measurement framework and the importance of viewing technology acceptance as a staged process, with adapted measurement methods for each stage.

A Review of Smartphone Applications for Persons With Traumatic Brain Injury: What Is Available and What Is the Evidence?

OBJECTIVES

To map the number and type of smartphone applications available for persons with traumatic brain injury (TBI), evaluate validity of app content, and investigate evidence for any claims made.

METHODS

We searched iTunes and Google Play and also completed a web search. The purpose of each app and any claims were extracted, and a search for best available evidence was performed.

RESULTS

Seventy apps met our inclusion criteria (35 related to assessment, 11 to education, 9 to treatment/management, 8 to impact sensors, and 7 to symptom tracking). To the best of our knowledge, no empirical research has been published to demonstrate that the use of any particular TBI-related app leads to clinically meaningful benefits compared with not using the app. Other problems include potential biases in self-report leading to possible app misuse, lack of references for app content, and inappropriate marketing to laypersons not trained to interpret the findings of tools validated for use by healthcare professionals.

CONCLUSIONS

The current evidence for benefit from using TBI-related apps is minimal. More collaborative research is needed among clinicians, scientists, and app developers to determine whether, and how, apps may be helpful to individuals at risk for or following TBI.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

BACKGROUND

Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective.

OBJECTIVE

This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features.

RESULTS

We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods.

CONCLUSIONS

There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders.

Review and Implementation of Self-Help and Automated Tools in Mental Health Care

Self-help and automated technologies can be useful for behavioral and mental health education and interventions. These technologies include interactive media, online courses, artificial intelligence-powered chatbots, voice assistants, and video games. Self-help media can include books, videos, audible media like podcasts, blog and print articles, and self-contained Internet sites. Social media, online courses, and mass-market mobile apps also can include such media. These technologies serve to decrease geospatial, temporal, and financial barriers. This article describes different self-help and automated technologies, how to implement such technologies in existing clinical services, and how to implement according to patient needs.

Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study

Background

Depression is one of the most common mental health disorders and severely impacts one’s physical, psychological, and social functioning. To address access barriers to care, we developed Ascend—a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. A previous feasibility study with 102 adults with elevated depression reported that Ascend is associated with a postintervention reduction in depression symptoms.

Objective

We aimed to examine whether Ascend is associated with a reduction in symptoms of anxiety, and importantly, whether reductions in symptoms of depression and anxiety are maintained up to 12-months postintervention.

Methods

We assessed whether the previously reported, end-of-treatment improvements seen in the 102 adults with elevated symptoms of depression extended up to 12 months posttreatment for depression symptoms (measured by the Patient Health Questionnaire-9 [PHQ-9]) and up to 6 months posttreatment for anxiety symptoms (added to the intervention later and measured using the Generalized Anxiety Disorder-7 [GAD-7] scale). We used linear mixed effects models with Tukey contrasts to compare time points and reported intention-to-treat statistics with a sensitivity analysis.

Results

The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67-point reduction in PHQ-9 score, 95% CI 5.59-7.75; P<.001; Hedges g=1.14, 95% CI 0.78-1.49). A total of 60% of the participants with PHQ-9 scores above the cutoff for major depression at baseline (PHQ≥10) reported clinically significant improvement at the 12-month follow-up (at least 50% reduction in PHQ-9 score and postprogram score <10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26-point reduction in GAD-7 score, 95% CI 3.14-5.38; P<.001; Hedges g=0.91, 95% CI 0.54-1.28).

Conclusions

There is limited evidence on whether outcomes associated with smartphone-based interventions for common mental health problems are maintained posttreatment. Participants who enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to 1 year and 6 months after the intervention, respectively. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and anxiety.

User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity

OBJECTIVE

Despite the potential benefits of mobile mental health apps, real-world results indicate engagement issues because of low uptake and sustained use. This review examined how studies have measured and reported on user engagement indicators (UEIs) for mental health apps.

METHODS

A systematic review of multiple databases was performed in July 2018 for studies of mental health apps for depression, bipolar disorder, schizophrenia, and anxiety that reported on UEIs, namely usability, user satisfaction, acceptability, and feasibility. The subjective and objective criteria used to assess UEIs, among other data, were extracted from each study.

RESULTS

Of 925 results, 40 studies were eligible. Every study reported positive results for the usability, satisfaction, acceptability, or feasibility of the app. Of the 40 studies, 36 (90%) employed 371 indistinct subjective criteria that were assessed with surveys, interviews, or both, and 23 studies used custom subjective scales, rather than preexisting standardized assessment tools. A total of 25 studies (63%) used objective criteria-with 71 indistinct measures. No two studies used the same combination of subjective or objective criteria to assess UEIs of the app.

CONCLUSIONS

The high heterogeneity and use of custom criteria to assess mental health apps in terms of usability, user satisfaction, acceptability, or feasibility present a challenge for understanding real-world low uptake of these apps. Every study reviewed claimed that UEIs for the app were rated highly, which suggests a need for the field to focus on engagement by creating reporting standards and more carefully considering claims.

Verbal learning deficits associated with increased anticholinergic burden are attenuated with targeted cognitive training in treatment refractory schizophrenia patients

Targeted cognitive training (TCT) has been reported to improve verbal learning deficits in patients with schizophrenia (SZ). Despite positive findings, it is not clear whether demographic factors and clinical characteristics contribute to the success of TCT on an individual basis. Medication-associated anticholinergic burden has been shown to impact TCT-associated verbal learning gains in SZ outpatients, but the role of anticholinergic medication burden on TCT gains in treatment refractory SZ patients has not been described. In this study, SZ patients mandated to a locked residential rehabilitation center were randomized to treatment as usual (TAU; n=22) or a course of TAU augmented with TCT (n=24). Anticholinergic medication burden was calculated from medication data at baseline and follow-up using the Anticholinergic Cognitive Burden (ACB) Scale. MATRICS Consensus Cognitive Battery Verbal Learning domain scores were used as the primary outcome variable. The TAU and TCT groups were matched in ACB at baseline and follow-up. While baseline ACB was not associated with verbal learning in either group, increases in ACB over the course of the study were significantly associated with deterioration of verbal learning in the TAU group (r=-0.51, p=0.02). This was not seen in subjects randomized to TCT (r=-0.13, p=0.62). Our results suggest that TCT may blunt anticholinergic medication burden associated reduction in verbal learning in severely disabled SZ inpatients.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial

INTRODUCTION

As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described.

METHODS AND ANALYSIS

30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months.

ETHICS AND DISSEMINATION

Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15.

TRIAL REGISTRATION NUMBER

German clinical trials register, reference number DRKS00008946.

Collaborative Care and Related Interventions in Patients With Heart Disease: An Update and New Directions

BACKGROUND

Psychiatric disorders, such as depression, are very common in cardiac patients and are independently linked to adverse cardiac outcomes, including mortality. Collaborative care and other integrated care models have been used successfully to manage psychiatric conditions in patients with heart disease, with beneficial effects on function and other outcomes. Novel programs using remote delivery of mental health interventions and promotion of psychological well-being may play an increasingly large role in supporting cardiovascular health.

METHODS

We review prior studies of standard and expanded integrated care programs among patients with cardiac disease, examine contemporary intervention delivery methods (e.g., Internet or mobile phone) that could be adapted for these programs, and outline mental health-related interventions to promote healthy behaviors and overall recovery across all cardiac patients.

RESULTS

Standard integrated care models for mental health disorders are effective at improving mood, anxiety, and function in patients with heart disease. Novel, "blended" collaborative care models may have even greater promise in improving cardiac outcomes, and interfacing with cardiac patients via mobile applications, text messages, and video visits may provide additional benefit. A variety of newer interventions using stress management, mindfulness, or positive psychology have shown promising effects on mental health, health behaviors, and overall cardiac outcomes.

CONCLUSIONS

Further study of novel applications of collaborative care and related interventions is warranted given the potential of these programs to increase the reach and effect of mental health interventions in patients with heart disease.