Effect of an internet- and app-based stress intervention compared to online psychoeducation in university students with depressive symptoms: Results of a randomized controlled trial

Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis

Importance

While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary.

Objective

To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness.

Data Sources

A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials.

Study Selection

Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted.

Main Outcomes and Measures

Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs.

Results

The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46).

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.

Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis

BACKGROUND

Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics.

METHODS

Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree.

RESULTS

IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators.

CONCLUSIONS

An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.

The Effect of Digital Mental Health Literacy Interventions on Mental Health: Systematic Review and Meta-Analysis

BACKGROUND

Accelerated by technological advancements and the recent global pandemic, there is burgeoning interest in digital mental health literacy (DMHL) interventions that can positively affect mental health. However, existing work remains inconclusive regarding the effectiveness of DMHL interventions.

OBJECTIVE

This systematic review and meta-analysis investigated the components and modes of DMHL interventions, their moderating factors, and their long-term impacts on mental health literacy and mental health.

METHODS

We used a random-effects model to conduct meta-analyses and meta-regressions on moderating effects of DMHL interventions on mental health.

RESULTS

Using 144 interventions with 206 effect sizes, we found a moderate effect of DMHL interventions in enhancing distal mental health outcomes (standardized mean difference=0.42, 95% CI -0.10 to 0.73; P<.001) and a large effect in increasing proximal mental health literacy outcomes (standardized mean difference=0.65, 95% CI 0.59-0.74; P<.001). Uptake of DMHL interventions was comparable with that of control conditions, and uptake of DMHL interventions did not moderate the effects on both proximal mental health literacy outcomes and distal mental health outcomes. DMHL interventions were as effective as face-to-face interventions and did not differ by platform type or dosage. DMHL plus interventions (DMHL psychoeducation coupled with other active treatment) produced large effects in bolstering mental health, were more effective than DMHL only interventions (self-help DMHL psychoeducation), and were comparable with non-DMHL interventions (treatment as usual). DMHL interventions demonstrated positive effects on mental health that were sustained over follow-up assessments and were most effective in enhancing the mental health of emerging and older adults.

CONCLUSIONS

For theory building, our review and meta-analysis found that DMHL interventions are as effective as face-to-face interventions. DMHL interventions confer optimal effects on mental health when DMHL psychoeducation is combined with informal, nonprofessional active treatment components such as skills training and peer support, which demonstrate comparable effectiveness with that of treatment as usual (client-professional interactions and therapies). These effects, which did not differ by platform type or dosage, were sustained over time. Additionally, most DMHL interventions are found in Western cultural contexts, especially in high-income countries (Global North) such as Australia, the United States, and the United Kingdom, and limited research is conducted in low-income countries in Asia and in South American and African countries. Most of the DMHL studies did not report information on the racial or ethnic makeup of the samples. Future work on DMHL interventions that target racial or ethnic minority groups, particularly the design, adoption, and evaluation of the effects of culturally adaptive DMHL interventions on uptake and mental health functioning, is needed. Such evidence can drive the adoption and implementation of DMHL interventions at scale, which represents a key foundation for practice-changing impact in the provision of mental health resources for individuals and the community.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42023363995; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023363995.

Are web-based stress management interventions effective as an indirect treatment for depression? An individual participant data meta-analysis of six randomised trials

QUESTION

Depression is highly prevalent and associated with numerous adverse consequences for both individuals and society. Due to low uptake of direct treatment, interventions that target related, but less stigmatising problems, such as perceived stress, have emerged as a new research paradigm.This individual participant data (IPD) meta-analysis examines if a web-based stress management intervention can be used as an 'indirect' treatment of depression.

STUDY SELECTION AND ANALYSIS

Bayesian one-stage models were used to estimate pooled effects on depressive symptom severity, minimally important improvement and reliable deterioration. The dose-response relationship was examined using multilevel additive models, and IPD network meta-analysis was employed to estimate the effect of guidance.

FINDINGS

In total, N=1235 patients suffering from clinical-level depression from K=6 randomised trials were included. Moderate-to-large effects were found on depressive symptom severity at 7 weeks post-intervention (d=-0.65; 95% credibility interval (CrI): -0.84 to -0.48) as measured with the Center for Epidemiological Studies' Depression Scale. Effects were sustained at 3-month follow-up (d=-0.74; 95% CrI: -1.01 to -0.48). Post-intervention symptom severity was linearly related to the number of completed sessions. The incremental impact of guidance was estimated at d=-0.25 (95% CrI: -1.30 to 0.82), with a 35% posterior probability that guided and unguided formats produce equivalent effects.

CONCLUSIONS

Our results indicate that web-based stress management can serve as an indirect treatment, yielding effects comparable with direct interventions for depression. Further research is needed to determine if such formats can indeed increase the utilisation of evidence-based treatment, and to corroborate the favourable effects for human guidance.

STUDY REGISTRATION

Open material repository: osf.io/dbjc8, osf.io/3qtbe.

TRIAL REGISTRATION NUMBER

German Clinical Trial Registration (DRKS): DRKS00004749, DRKS00005112, DRKS00005384, DRKS00005687, DRKS00005699, DRKS00005990.

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.

Feasibility, Perceived Impact, and Acceptability of a Socially Assistive Robot to Support Emotion Regulation With Highly Anxious University Students: Mixed Methods Open Trial

BACKGROUND

Mental health difficulties among university students have been rising rapidly over the last decade, and the demand for university mental health services commonly far exceeds available resources. Digital interventions are seen as one potential solution to these challenges. However, as in other mental health contexts, digital programs often face low engagement and uptake, and the field lacks usable, engaging, evidence-supported mental health interventions that may be used flexibly when students need them most.

OBJECTIVE

The aim of this study is to investigate the feasibility and acceptability of a new, in situ intervention tool (Purrble) among university students experiencing anxiety. As an intervention, Purrble was designed to provide in situ support for emotion regulation (ER)-a well-known transdiagnostic construct-directly in the moments when individuals are facing emotionally challenging situations. A secondary aim is to consider the perceived impact of Purrble on youth mental health, as reported by students over a 7-week deployment.

METHODS

A mixed methods open trial was conducted with 78 under- and postgraduate students at Oxford University. Participants were recruited based on moderate to high levels of anxiety measured by Generalized Anxiety Disorder-7 at baseline (mean 16.09, SD 3.03). All participants had access to Purrble for 7 weeks during the spring term with data on their perceived anxiety, emotion dysregulation, ER self-efficacy, and engagement with the intervention collected at baseline (pre), week 4 (mid), and week 8 (postintervention). Qualitative responses were also collected at the mid- and postintervention points.

RESULTS

The findings demonstrated a sustained engagement with Purrble over the 7-week period, with the acceptability further supported by the qualitative data indicating that students accepted Purrble and that Purrble was well-integrated into their daily routines. Exploratory quantitative data analysis indicated that Purrble was associated with reductions in student anxiety (dz=0.96, 95% CI 0.62-1.29) and emotion dysregulation (dz=0.69, 95% CI 0.38-0.99), and with an increase in ER self-efficacy (dz=-0.56, 95% CI -0.86 to -0.26).

CONCLUSIONS

This is the first trial of a simple physical intervention that aims to provide ongoing ER support to university students. Both quantitative and qualitative data suggest that Purrble is an acceptable and feasible intervention among students, the engagement with which can be sustained at a stable level across a 7-week period while retaining a perceived benefit for those who use it (n=32, 61% of our sample). The consistency of use is particularly promising given that there was no clinician engagement or further support provided beyond Purrble being delivered to the students. These results show promise for an innovative intervention model, which could be complementary to the existing interventions.

Systematic review: Effect of mobile applications on college students with depressive symptoms

AIM

To evaluate the effects of mobile applications (apps) on college students with depressive symptoms.

DESIGN

Depression among college students is a school health issue, although little is known regarding effective app-based interventions for managing depressive symptoms. This review follows the concept of (1) theoretical guidance framework on app design, (2) app-based intervention study design and (3) effect of app-based interventions.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text and PubMed were searched in October 2022.

METHODS

English-language reports of app-based interventions for college students with depressive symptoms. Quality appraisal and data extraction of selected articles was conducted by two independent reviewers using the mixed methods appraisal tool. Data synthesis using core outcome and findings of intervention.

RESULTS

Five studies have shown that depressive symptoms significantly decreased after app use, specifically indicating the effects that occur in 4 weeks. Although four studies have applied the theoretical framework to the app design, the findings showed the low implementation of the intervention activities as originally designed and at the specified dosage and difficulty in understanding the processes through which the intervention resolves the depressive symptoms.

CONCLUSION

App-based intervention can decrease depressive symptoms; furthermore, 4 weeks was the time point at which the changes were expected to occur. However, the theory-based app design for the depression population was rarely related, and studies clearly explaining the intervention measures, intervention dosage and duration required to achieve effectiveness are needed.

IMPACT

This study provides the synthesis of evidence-based app interventions to manage depressive symptoms to zoom in on different views and we suggest using the applications for at least 4 weeks before changes are expected to occur.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this study.

Digital Therapy: Alleviating Anxiety and Depression in Adolescent Students During COVID-19 Online Learning - A Scoping Review

The learning method has changed from offline to online since Coronavirus Disease 2019 pandemic cause mental health problems in students such as stress, anxiety, and even depression. Interventions to reduce mental health problems in adolescents need to be carried out digitally to reduce the transmission of Coronavirus Disease 2019. The purpose of this study is to explore methods of digital therapy to reduce symptoms of anxiety and depression among students during the Coronavirus Disease 2019. A scoping review study design was used in this study. Database the study from CINAHL, PubMed, and Scopus databases. This study used PRISMA Extension for Scoping Reviews (PRISMA-ScR) and for quality appraisal used JBI Quality Appraisal. The inclusion criteria for articles in this study are full text, randomized control trial or quasi-experiment research design, English language, students sample, and the publication period during COVID-19 pandemic (2019-2022). There were found 13 articles discussing digital therapy and it was found that the digital therapy model to reduce anxiety and depression includes directions through digital modules, directions via video, and asynchronous discussions via online meeting. The sample range in this study is 37-1986 students. Most of the articles come from developed countries. Delivery services of digital therapy consist of three phases, namely psycho-education, problem-solving, and implementation of problem-solving strategies. The authors found that there are four digital therapy methods, namely Improving psychological abilities, Bias-modification intervention, Self-help intervention, and Mindfulness intervention. The implementation of digital therapy must still pay attention to various aspects that affect students, so that therapists need to pay attention to physical, psychological, spiritual, and cultural aspects. Here we highlight, digital therapy interventions are proven for improving mental health by reducing depression and anxiety levels among students during the COVID-19 pandemic by paying attention to all aspects that affect students.

Mindfulness Intervention for Improving Psychological Wellbeing Among Students During COVID-19 Pandemic: A Scoping Review

The COVID-19 pandemic can cause mental health problems such as stress, social anxiety, depression, and decrease social life on students. Mental health problems need to be taken seriously to develop the stage of development and improve the psychological well-being of students on learning in the school. The aim of this study was to explore mindfulness interventions to improve psychological well-being among students. This study used the Scoping Review method. Literature from CINAHL, PubMed, and Scopus databases. The keywords used in English are psychological wellbeing, students, and mindfulness. The inclusion criteria were full text, study design randomized control trial or quasi-experimental, English language, population and sample were students, and the publication period is the last 10 years (2013-2022). From 2194 articles based on initial research, we found 10 articles were analyzed related to mindfulness interventions consisting of several methods, namely internet-based mindfulness, mindfulness-based intervention, and mindfulness-based stress reduction. Most of samples the study from the United States with the range samples were 20-166 students. Mindfulness interventions can be carried out improve the psychological well-being of students. Mindfulness therapy is done by fully concentrating the mind in meditation so that it can improve psychological health. Providing mindfulness therapy involves health workers such as nurses and psychologists to provide comprehensive therapy covering both physical and psychological aspects.

The Effectiveness of Digital-Based Psychotherapy in Overcoming Psychological Problems in College Students During the COVID-19 Pandemic: A Scoping Review

Purpose: This review aims to determine the effectiveness of the application of digital-based psychotherapy in overcoming the psychological problems of college students during the COVID-19 pandemic. Methods: Several databases consisting of EBSCO-Host CINAHL, PubMed, Scopus, Sage Journal, and Taylor and Francis were used in the search process and resulted in experimental studies focusing on the effectiveness of the application of digital-based psychotherapy during the COVID-19 pandemic timeline (2019-2022). Descriptive and exploratory analyses were performed based on the data set from the study. Results: A total of 12 articles were included in the review. The digital psychotherapy interventions found are diverse including websites, smartphone applications, and video conferencing with the types of therapies provided in the form of, Cognitive Therapy, Cognitive-Behavioral Therapy, Psychodynamic Therapy, and Mindfulness Therapy. Each intervention has a diverse duration and frequency adjusting to the type of therapy given. Digital psychotherapeutic interventions are effective in reducing mental health problems among college students during the COVID-19 pandemic. Conclusions: The use of digital psychotherapy can be used as a prevention and support service for students who experience psychological problems during the COVID-19 pandemic. The combination of the use of digital media with video conferencing can be considered to increase the effectiveness of this service. Nurses need to understand how the procedure for implementing digital-based psychotherapy is to improve the quality of mental care services as an effort to prevent and support students. More research is needed to find out the effectiveness of the use of digital psychotherapy services and how they impact the psychological well-being of students holistically.

Effect of psychotherapy for adult depression on self-esteem: A systematic review and meta-analysis

BACKGROUND

There is emerging evidence to suggest that Cognitive Behavioral Therapy for depression may have a secondary effect on self-esteem, but less is known about non-CBT based interventions. To examine this, we had two main aims; (1) to meta-analyze psychotherapy effects on (i) depression and (ii) self-esteem, and (2) to investigate the relationship between reductions in depression symptoms and improvements in self-esteem.

DESIGN

A systematic review and meta-analysis.

METHODS

Following the PRISMA guidelines, we conducted a meta-analysis of randomized control trials of psychotherapy for adult depression, which included a self-esteem outcome at post-treatment. Nineteen studies with a total of 3423 participants met the inclusion criteria. For each comparison between psychotherapy and a control condition, we calculated Hedges' g both for depression and self-esteem and pooled them in two separate meta-analyses. Furthermore, meta-regression was used to explore the association between the effect of psychotherapy for depression and its effect on self-esteem.

RESULTS

The effects on depression were large and significant (Hedges' g = -0.95; [95 % CI: -1.27, -0.63]). We found evidence of smaller, albeit still moderate, effects on self-esteem (Hedges'g = 0.63; [95 % CI:0.32, 0.93]), with sustained effects at 6-12 months (Hedges'g = 0.70; [95 % CI: -0.03, 1.43]). We also found a strong inverse association between the effects of psychotherapy for depression and self-esteem (β = -0.60, p < 0.001).

LIMITATIONS

Heterogeneity was very high (I² = 97 %), and out of 19 trials, only 6 trials were rated as having a low risk of bias.

CONCLUSIONS

The results suggest that psychotherapy for depression may improve self-esteem to a moderate degree.

Preventive Effects of Group Cognitive Behavioral Therapy in First-Year University Students at Risk for Depression: A Non-Randomized Controlled Trial

High scores on Harm Avoidance (HA) on Cloniger's Temperament and Character Inventory (TCI) have been identified as a risk factor for depression. Group cognitive-behavioral therapy (GCBT) has been found effective in preventing depression and improving depressive symptoms among university students. However, no randomized controlled trials of GCBT have been conducted with university students with high HA. Although we initiated a randomized controlled trial in this study, some participants submitted incomplete questionnaires at baseline interfering with assured randomization; therefore, we report this study as a non-randomized controlled trial. We evaluated whether a GCBT intervention would be effective at reducing HA and, thereby, preventing depression in university students with high HA. We performed final analysis of data on 59 participants in the intervention group and 60 in a control group. We used scores on the Beck Depression Inventory-II (BDI-II) as the primary outcome measure and analysis of covariance to assess group differences on mean BDI-II change scores before the intervention and at six months and one year after the intervention. The intervention group had lower BDI-II scores than the control group at six months after the intervention. GCBT may have facilitated cognitive modification in individuals with high HA, or GCBT may have fostered mutual modeling by group participants. Thus, GCBT may contribute to reducing depressive symptoms in university students with high HA, and associated risk for developing depression.

Analysis of Mobile App-Based Mental Health Solutions for College Students: A Rapid Review

BACKGROUND

College students are one of the most susceptible age groups to mental health problems. With the growing popularity of mobile health (mHealth), there is an increasing need to investigate its implications for mental health solutions. This review evaluates mHealth interventions for addressing mental health problems among college students.

METHODS

An online database search was conducted. Articles were required to focus on the impact of mHealth intervention on student mental health. Fifteen of the 487 articles, initially pulled from the search query, were included in the review.

RESULTS

The review identified three primary aspects of mental health: depression, anxiety, and stress. Research that found statistically significant improvements following mHealth intervention involved study durations between four and eight weeks, daily app use, guided lessons using cognitive behavioral therapy, acceptance and commitment therapy, and meditation. The review's findings show that future work must address the concern of digital divide, gender and sex differences, and have larger sample sizes.

CONCLUSIONS

There is potential to improve depressive symptoms and other similar mental health problems among college students via mobile app interventions. However, actions must be taken to improve barriers to communication and better reach the younger generations.

Introducing mobile apps to promote the well-being of German and Italian university students. A cross-national application of the Technology Acceptance Model

Stress represents a significant risk factor for several psychophysical diseases among college students, such as depression and anxiety, which may undermine their academic functioning, resulting in high drop rates from college. Nevertheless, university services for mental health promotion are typically underutilized. As a result, professionals and authorities strive to find new ways to address students' mental health needs. In this view, mobile apps seem appropriate for well-being promotion interventions. Drawing on the Technology Acceptance Model (TAM), which is the most widely used theory on users' intention to use technologies, we assumed that perceived usefulness (PU) and perceived ease of use (PEOU) would be positively related to intention to use (INT), and PEOU would be positively related to PU among both Italian and German university students. To test our hypotheses, we replicated the same cross-sectional study in Italy (n = 255) and Germany (n = 228) with university students. Although we found partial scalar invariance of the TAM dimensions across the two nations, our predictions were only partially confirmed: PEOU was positively related to PU in the Italian sample only. Overall, this study is one of the first empirical attempts to compare TAM cross-nationally within the European context and it contributes to the small but increasing body of research investigating students' acceptance of smartphone-based interventions for stress management and well-being promotion. Understanding mobile health acceptance could help universities increase students' chances of adopting the proposed services, considering the factors influencing this choice.

A Web-Based Stress Management Intervention for University Students in Indonesia (Rileks): Feasibility Study Using a Pretest-Posttest Design

Background

University students are susceptible to excessive stress. A web-based stress management intervention holds promise to improve stress but is still at a novel stage in Indonesia.

Objective

The aim of this paper was to report the feasibility of the intervention we developed—Rileks—among university students in Indonesia in terms of acceptability and usability, and to propose recommendations for future improvements.

Methods

A single-group pretest and posttest design was used. Participants with scores of 15 or higher on the stress subscale of the 42-item Depression Anxiety Stress Scales were given access to the intervention (N=68). The main outcome measures were the 8-item Client Satisfaction Questionnaire (CSQ-8) score, the System Usability Scale (SUS) score, and intervention uptake. Participants’ experience in each session was evaluated using closed- and open-ended questions for future improvements. Descriptive statistics were used to examine primary outcome and qualitative session evaluations. Participants’ responses to each topic of the open questions were summarized.

Results

The intervention was evaluated as being satisfactory (CSQ-8 mean score 21.89, SD 8.72; range 8-32). However, the intervention’s usability was still below expectation (SUS mean score 62.8, SD 14.74; range 0-100). The core modules were completed by 10 out of 68 participants (15%), and the study dropout rate was 63% (43/68) at postassessment. In general, the module content was rated positively, with some notes for improvement covering content and technical aspects.

Conclusions

This study indicates that Rileks is potentially feasible for Indonesian university students. In order to be optimally applied in such a context and before scaling up web-based interventions in Indonesia, in general, further development and refinement are needed.

International Registered Report Identifier (IRRID)

RR2-10.2196/11493

Akzeptanz und Nutzung von E-Mental-Health-Angeboten unter Studierenden

Zielsetzung

Trotz der Effektivität verschiedener E‑Mental-Health-Interventionen wurden bislang verhältnismäßig geringe Nutzungsraten, selbst unter Digital Natives wie Studierenden, identifiziert. Ziel dieser Studie ist daher, das Verhältnis der generellen Akzeptanz, dem konkreten Interesse und der tatsächlichen Registrierung für ausgewählte, zielgruppenspezifische E‑Mental-Health-Programme zu untersuchen.

Methodik

Wir führten eine Sekundäranalyse einer in ein Online-Experiment eingebetteten Befragungsstudie mit n = 451 Studierenden (89 % Fernstudierende) zu Informationseffekten auf die Akzeptanz von E‑Mental-Health-Angeboten mit Untersuchung der Nutzungsabsicht sowie des Interesses im Verhältnis zu objektiven Daten, d. h. Registrierungen für ausgewählte E‑Mental-Health-Angebote zur Stressprävention und Gesundheitsförderung, durch.

Ergebnisse

Eine hierarchische Regressionsanalyse ergab das Stresslevel, wahrgenommene Ähnlichkeit mit Informationsquellen und Einstellungen als Determinanten der Nutzungsabsicht (R2 = 0,49). Aktuelles Interesse an der Teilnahme an einem bestimmten E‑Mental-Health-Angebot berichtete weniger als ein Drittel der Stichprobe (31 %). Überdies war die Intentions-Verhaltens-Lücke bei der Follow-up-Messung (n/N in %) beim Programm für Berufstätige geringer (85 % registriert) als für das Programm für Studierende (69 % registriert; insgesamt: 77 %).

Schlussfolgerung

Über drei Viertel der interessierten Studierenden haben sich für ein Programm registriert, was für die Bereitstellung einfacher, direkter Zugangsoptionen spricht. Zukünftige Studien sollten die Determinanten der Nutzung sowie Adhärenz bei E‑Mental-Health-Angeboten in Abhängigkeit von der Akzeptanz für verschiedene Subgruppen von Studierenden zur Entwicklung passgenauer Akzeptanzförderungsmaßnahmen genauer untersuchen.

The development and usability of a video game to attenuate pandemic-related stress using an equity lens

Background

The emergence of the novel coronavirus (COVID-19) has introduced additional pressures on an already fragile mental health care system due to a significant rise in depression, anxiety, and stress among Canadians. Although cognitive behavioral therapy (CBT) is known to be an efficacious treatment to reduce such mental health issues, few people have access to CBT in an engaging and sustainable manner. To address this gap, a collaboration between the Centre for Addiction and Mental Health (CAMH) and the National Research Council of Canada (NRC) developed CBT-based self-led, online, clinician-tested modules in the form of a video game, named Legend of Evelys, and evaluated its usability in the attenuation of a COVID-19–related increase in stress.

Objective

We here present the conceptualization and design of new self-care modules in the form of a video game, its implementation in a technological infrastructure, and inclusivity and privacy considerations that informed the development. A usability study of the modules was performed to assess the video game’s usability, user engagement, and user perceptions.

Methods

The development of the video game involved establishment of a technology infrastructure for secure implementation of the software for the modules and a clinician-led assessment of the clinical utility of these modules through two “whiteboard” sessions. The usability study was informed by a mixed methods sequential explanatory design to evaluate the intervention of the mobile app through two distinct phases: quantitative data collection using in-app analytics data and two surveys, followed by qualitative data collection by semistructured interviews.

Results

A total of 32 participants trialed the app for 2 weeks. They used the video game an average of six times and rated the game as “good” based on the Systems Usability Scale score. In terms of stress reduction, the study demonstrated a significant difference in the participants’ Perceived Stress Scale score at baseline (mean 22.14, SD 6.187) compared with that at the 2-week follow-up (mean 18.04, SD 6.083; t₂₇=3.628, P=.001). Qualitative interviews helped participants identify numerous functionality issues and provided specific recommendations, most of which were successfully integrated into the video game for future release.

Conclusions

Through this collaboration, we have established that it is possible to incorporate CBT exercises into a video game and have these exercises adopted to address stress. While video games are a promising strategy to help people with their stress and anxiety, there is a further need to examine the real-world effectiveness of the Legend of Evelys in reducing anxiety.

Boredom Intervention Training Phase I: Increasing Boredom Knowledge through a Psychoeducational Video

Boredom is a salient emotion experienced in postsecondary settings, and evidence reveals that it can negatively impact academic achievement and motivation. Drawing from the control-value theory (CVT) of achievement emotions (Pekrun, 2006) and the component process model of emotions (CPM; Scherer, 1984), our study examines the first phase of a multi-sequenced online boredom intervention training (BIT) program. The goal of Phase I of BIT was to increase university students' (N = 85) knowledge about boredom as a scholarly construct. Students completed four components of the Phase I BIT session, including: (a) a baseline survey and knowledge quiz, (b) a psychoeducational video, (c) a consolidation exercise, and (d) a follow-up knowledge quiz. We employed a repeated measures analysis to measure changes in knowledge after students watched the psychoeducational boredom video. Our findings reveal that students became more knowledgeable about boredom, learned something novel, and were interested in the intervention. The results are discussed in terms of the implications for research, theory, and practice.

Investigating the Persuasive Effects of Testimonials on the Acceptance of Digital Stress Management Trainings Among University Students and Underlying Mechanisms: A Randomized Controlled Trial

Objective: This experiment aims to investigate the influence of narrative information varying in the degree of perceived similarity and source credibility in supplemented testimonials on the acceptance of digital mental health services (digi-MHSs).

Methods: In fall 2020, n=231 university students were randomly assigned to an active control group (aCG, n=55, “information only”) or one of three intervention groups (IGs) receiving information plus different testimonials being presented either by nonacademic staff (IG1, n=60), university students (IG2, n=58) or experts (IG3, n=58). We assessed mediation effects of similarity and credibility on acceptance in terms of attitudes and usage intentions.

Results: Exposure to testimonials was associated with higher usage intentions (d=0.50) and more positive attitudes toward digi-MHSs (d=0.32) compared to mere information (aCG). Regarding source-related effects, one-way ANOVA showed group differences in intentions (ηp2=0.13) that were significantly higher after exposure to testimonials targeted at students than in the other groups after adjusting for baseline intentions (ηp2=0.24). Concerning underlying mechanisms, there were full mediation effects of similarity (IG1 versus IG2) on attitudes [95%CI (0.030, 0.441)] and intentions to use digi-MHSs [95%CI (0.100, 0.528)] and of credibility on attitudes [IG2 versus IG3; 95%CI (−0.217, −0.004)], all favoring students’ testimonials.

Conclusion: Overall, this study indicates that the acceptance of digi-MHSs can be substantially increased by providing a simple, context-sensitive information intervention, including testimonials by university students. Since we identified mediating effects of credibility on cognitive attitudes and similarity on affect-driven intentions, a future trial could vary these features using narrative versus statistic information on digi-MHSs.

Exploring the influence of testimonial source on attitudes towards e-mental health interventions among university students: Four-group randomized controlled trial

Electronic mental health services (eMHSs) offer additional options for the dissemination of psychological interventions for university students. Still, many university students are reluctant to use eMHSs. Narrative messages may help increase the awareness and acceptance of quality-approved programs. However, little is known about the usefulness of narrative messages to improve attitudes towards eMHSs. In this experiment, we thus aimed to explore in how far different ways of targeting information to students affect their attitudes towards eMHSs for stress prevention and therapy, and to identify potential determinants of attitude change. N = 451 students (Mean = 32.6 years, SD = 10.2, 75% female, 7% with eMHS experience) were randomly assigned to one of four study arms involving information designed to induce different levels of perceived similarity. While the active control condition only received general information (arm 1, “information only”, n = 116), the other experimental arms were additionally exposed to testimonials on specific eMHSs either addressing an unspecified audience (arm 2, n = 112), employees (arm 3, n = 115) or working university students (arm 4, n = 108). Two-way ANOVA revealed no impact of information on the alteration of attitudes towards eMHSs for stress coping (d = 0.20). Only a small effect of target-group specific testimonials on attitudes towards online therapies was identified at post-intervention (d = 0.29). Regression analyses demonstrated significant influences of source credibility and perceived similarity on attitudes for preventative eMHSs (p_s<0.01), as well as a partial mediation effect of perceived similarity in favor of testimonials targeted to students (95% CI [0.22, 0.50]). Overall, this study indicated no meaningful impact of information on attitudes and limited evidence for benefits of tailored narrative messages. Since attitudes were already positive at baseline, further research with a representative student sample mimicking real-world decision scenarios is needed to gain an in-depth understanding of acceptance-facilitating message features that may contribute to promote the adoption of evidence-based eMHSs.