Internet-based psychological interventions for bipolar disorder: Review of the present and insights into the future

BI-REAL: A 12-session DBT skills group intervention adapted for bipolar disorder - A feasibility randomised pilot trial

International guidelines endorse psychological treatment for Bipolar Disorder (BD); however, the absence of a recognised gold-standard intervention requires further research. A Dialectical Behaviour Therapy (DBT) skills group intervention with 12 sessions was developed. This pilot randomised controlled trial (RCT) aims to evaluate the feasibility, acceptability, and outcomes variance of Bi-REAL - Respond Effectively, Assertively, and Live mindfully, tailored for individuals with BD, in preparation for a future RCT.

METHODS

52 participants (female = 62.7 %; mean age = 43.2 ± 11.1) with BD were randomised by blocks to either the experimental group (EG; n = 26; Bi-REAL + Treatment as Usual, TAU) receiving 12 weekly 90-minutes sessions, or the control group (CG; n = 26, TAU). Feasibility and acceptability were assessed with a multimethod approach (qualitative interviews, semi-structured clinical interviews and a battery of self-report questionnaires - candidate main outcomes Bipolar Recovery Questionnaire (BRQ) and brief Quality of Life for Bipolar Disorder (QoL.BD)). All participants were evaluated at baseline (T0), post-intervention (T1) and 3-month follow-up (T2).

RESULTS

Acceptability was supported by participants' positive feedback and ratings of the sessions and programme overall, as well as the treatment attendance (86.25 % of sessions attended). The trial overall retention rate was 74.5 %, with CG having a higher dropout rate across the 3-timepoints (42.31 %). A significant Time × Group interaction effect was found for BRQ and QoL.BD favouring the intervention group (p < .05).

LIMITATIONS

The assessors were not blind at T1 (only at T2). Recruitment plan was impacted due to COVID-19 restrictions and replication is questionable. High attrition rates in the CG.

CONCLUSIONS

The acceptability of Bi-REAL was sustained, and subsequent feasibility testing will be necessary to establish whether the retention rates of the overall trial improve and if feasibility is confirmed, before progressing to a definitive trial.

The effectiveness of e-mental health interventions on stress, anxiety, and depression among healthcare professionals: a systematic review and meta-analysis

BACKGROUND

Many healthcare professionals are experiencing psychological distress. Electronic mental health (e-mental health) interventions are convenient and multifunctional. This review aimed to examine the effectiveness of e-mental health interventions in enhancing the well-being of healthcare professionals and to identify moderating factors.

METHODS

A comprehensive and systematic retrieval of randomized controlled trial (RCT) studies was conducted across eight databases. Population, intervention, comparison, and outcome (PICO) were used to define eligibility criteria. Stress, anxiety, and depression were included as the main outcomes. The overall effect was calculated based on the random effect model, and the effect size was presented using the standardized mean difference. The characteristics of the research design, intervention object, and intervention design were further selected as potential moderating factors for subgroup analysis. Meta-regression analyses were finally performed, incorporating intervention duration and sample size as independent variables.

RESULTS

A total of 20 studies were included in the systematic review, and 17 were included in the meta-analysis. A large effect on relieving stress and anxiety and a small-to-medium effect on reducing depression were observed. Subgroup analyses showed that features including mindfulness approaches, online courses, computer use, group interventions, and professional guidance were more favorable in the design of services. Meta-regression revealed that intervention duration only affected anxiety symptoms. Caution should be exercised, as some subgroups had fewer studies and higher heterogeneity. For the secondary outcomes, a large effect on emotional exhaustion and a small-to-medium effect on well-being were observed.

CONCLUSION

In general, e-mental health interventions significantly improve the psychological health of healthcare staff. Future high-quality, large-scale studies targeting healthcare professionals and specific intervention scenarios are warranted.

Examining the role of AI technology in online mental healthcare: opportunities, challenges, and implications, a mixed-methods review

Introduction

Online mental healthcare has gained significant attention due to its effectiveness, accessibility, and scalability in the management of mental health symptoms. Despite these advantages over traditional in-person formats, including higher availability and accessibility, issues with low treatment adherence and high dropout rates persist. Artificial intelligence (AI) technologies could help address these issues, through powerful predictive models, language analysis, and intelligent dialogue with users, however the study of these applications remains underexplored. The following mixed methods review aimed to supplement this gap by synthesizing the available evidence on the applications of AI in online mental healthcare.

Method

We searched the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE, and Cochrane. This review included peer-reviewed randomized controlled trials, observational studies, non-randomized experimental studies, and case studies that were selected using the PRISMA guidelines. Data regarding pre and post-intervention outcomes and AI applications were extracted and analyzed. A mixed-methods approach encompassing meta-analysis and network meta-analysis was used to analyze pre and post-intervention outcomes, including main effects, depression, anxiety, and study dropouts. We applied the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the quality of the evidence.

Results

Twenty-nine studies were included revealing a variety of AI applications including triage, psychotherapy delivery, treatment monitoring, therapy engagement support, identification of effective therapy features, and prediction of treatment response, dropout, and adherence. AI-delivered self-guided interventions demonstrated medium to large effects on managing mental health symptoms, with dropout rates comparable to non-AI interventions. The quality of the data was low to very low.

Discussion

The review supported the use of AI in enhancing treatment response, adherence, and improvements in online mental healthcare. Nevertheless, given the low quality of the available evidence, this study highlighted the need for additional robust and high-powered studies in this emerging field.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=443575, identifier CRD42023443575.

Online cognitive behavioral therapy (eCBT) for the management of depression symptoms in unipolar and bipolar spectrum disorders, a systematic review and network meta-analysis

BACKGROUND

Face-to-face cognitive behavioral therapy (CBT) is effective in the management of depression symptoms in unipolar and bipolar spectrum disorders. Though, compared to electronic adaptations of CBT (eCBT), it carries several accessibility limitations. Furthermore, unlike eCBT for depression symptoms (eCBTg), eCBT specific for bipolar depression (eCBT-Bipol) remains largely understudied. Thus, supplementing this gap, this systematic review and network meta-analysis (NMA) synthesized the available literature on eCBT for the treatment of unipolar and bipolar depression symptoms.

METHOD

MEDLINE, CINAHL, PsycINFO, EMBASE, and Cochrane were searched for relevant randomized controlled trials (RCTs) on eCBTg and eCBT-Bipol The review followed PRISMA guidelines and used the Cochrane risk of bias tool and GRADE criteria for quality assessment. Effect sizes were summarized using standardized mean differences (SMDs) and risk ratios (RRs).

RESULTS

eCBT-Bipol was comparable to eCBTg (SMD: 0.05, 95 % CI: -0.18; 0.28) and other psychotherapeutic interventions (SMD: 0.14, 95 % CI: -0.07; 0.35) for the management of mild to moderate depression symptoms. eCBT-Bipol was significantly more effective than attention controls (SMD: 0.35, 95 % CI: 0.11; 0.59), treatment as usual (SMD: 0.55, 95 % CI: 0.21; 0.90) and no intervention controls (SMD: 0.66, 95 % CI: 0.40; 0.93) in mitigating symptoms.

LIMITATIONS

The scarcity of eCBT-Bipol studies impacted the quality of the evidence in terms of risk of bias and imprecision.

CONCLUSIONS

The findings of this systematic review suggest that eCBT-Bipol has comparable effectiveness to eCBTg in managing depressive symptoms of unipolar and bipolar spectrum disorder. Though, they also highlighted the need for more studies on eCBT-Bipol.

Service Design of a Loss Prevention Device for Older Adults with Dementia

This aim of this research was to explore the appraisal of the use of smart alert bracelets by older adults diagnosed with dementia. Convenience sampling was adopted to recruit older adults with dementia in Yunlin County, Taiwan. A manual questionnaire survey was conducted, and SPSS 26.0 statistical software was used for analysis. The results of this study showed noticeable positive correlation results in the post-test for the modes "wearing device", "degree of dementia", and "field configuration". Based on the experimental results, the following suggestions are provided: (1) in terms of statistical calculation, the statistical results were affected by changes in some participants; (2) as for the design of equipment, to be more suitable for adult use, the size and color of bracelets need to be optimized; (3) as for the problem of battery charging of the device, because the charging location of the device is not easy to find, it is better to extend device standby time; (4) regarding the selection of equipment, older adults with early-stage dementia could be concerned about the function of the wearable device, so it is recommended to provide a device designed with clear functions, such as a watch, so that older adults are more willing to wear it. Patients diagnosed with moderate and severe dementia should be advised to use concealed non-sensory devices, such as charms and cards, to better facilitate assistance from caregivers in wearing them; and (5) as for the device, in case of a loss event, in addition to mobile phone notifications, other light and sound device notifications can be added, allowing caregivers to pay more attention to information in real time. In summary, the feedback from caregivers and older adults suggests that if the device is to be used without charging, the overall design should be light and small, which is more suitable for service designs.

Effects of a Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder on Relapse, Symptom Burden, and Quality of Life: A Randomized Clinical Trial

Importance

Bipolar disorder-specific psychotherapy combined with pharmacotherapy improves relapse risk, symptom burden, and quality of life, but psychotherapy is not easily accessible.

Objective

To determine if a smartphone-based self-management intervention (LiveWell) can assist individuals with bipolar disorder to maintain wellness.

Design, Setting, and Participants

An assessor-blind randomized clinical trial enrolled participants from March 20, 2017, to April 25, 2019, with 48-week follow-up ending on April 10, 2020. Participants were randomly assigned to usual care or usual care plus the smartphone intervention stratified by relapse risk based on initial clinical status (low risk: asymptomatic recovery; high risk: continued symptomatic, prodromal, recovering, symptomatic recovery). Participants with bipolar disorder I were recruited from clinics in the Chicago and Minneapolis-Saint Paul areas. Data were analyzed from June 19, 2020, to May 25, 2022.

Interventions

The smartphone-based self-management intervention consisted of an application (app), coach, and website. Over 16 weeks, participants had a coach visit followed by 6 phone calls, and they completed daily and weekly app check-ins. The app provided adaptive feedback and information for developing a personalized wellness plan, the coach provided support, and the website provided summary data and alerts.

Main Outcomes and Measures

The primary outcome was time to relapse. Secondary outcomes were percentage-time symptomatic, symptom severity, and quality of life.

Results

Of the 205 randomized participants (mean [SD] age, 42 [12] years; 125 female individuals [61%]; 5 Asian [2%], 21 Black [10%], 13 Hispanic or Latino [6%], 7 multiracial [3%], 170 White [83%], 2 unknown race [1%]), 81 (40%) were randomly assigned to usual care, and 124 (60%) were randomly assigned to usual care plus the smartphone intervention. This clinical trial did not detect a reduction in relapse risk for the smartphone intervention (hazard ratio [HR], 0.65; 95% CI, 0.39-1.09; log-rank P = .08). However, decreased relapse was observed for low-risk individuals (HR, 0.32; 95% CI, 0.12-0.88; log-rank P = .02) but not high-risk individuals (HR, 0.86; 95% CI, 0.47-1.57; log-rank P = .62). Reduced manic symptom severity was observed for low-risk individuals (mean [SE] difference, -1.4 [0.4]; P = .001) but not for high-risk individuals (mean [SE] difference, 0 [0.3]; P = .95). The smartphone-based self-management intervention decreased depressive symptom severity (mean [SE] difference, -0.80 [0.34]; P = .02) and improved relational quality of life (mean [SE] difference, 1.03 [0.45]; P = .02) but did not decrease percentage-time symptomatic (mean [SE] difference, -5.6 [4.3]; P = .20).

Conclusions and Relevance

This randomized clinical trial of a smartphone-based self-management intervention did not detect a significant improvement in the primary outcome of time to relapse. However, a significant decrease in relapse risk was observed for individuals in asymptomatic recovery. In addition, the intervention decreased depressive symptom severity and improved relational quality of life. These findings warrant further work to optimize the smartphone intervention and confirm that the intervention decreases relapse risk for individuals in asymptomatic recovery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03088462.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Process and Outcome Evaluations of Smartphone Apps for Bipolar Disorder: Scoping Review

Background

Mental health apps (MHAs) provide opportunities for accessible, immediate, and innovative approaches to better understand and support the treatment of mental health disorders, especially those with a high burden, such as bipolar disorder (BD). Many MHAs have been developed, but few have had their effectiveness evaluated.

Objective

This systematic scoping review explores current process and outcome measures of MHAs for BD with the aim to provide a comprehensive overview of current research. This will identify the best practice for evaluating MHAs for BD and inform future studies.

Methods

A systematic literature search of the health science databases PsycINFO, MEDLINE, Embase, EBSCO, Scopus, and Web of Science was undertaken up to January 2021 (with no start date) to narratively assess how studies had evaluated MHAs for BD.

Results

Of 4051 original search results, 12 articles were included. These 12 studies included 435 participants, and of these, 343 had BD type I or II. Moreover, 11 of the 12 studies provided the ages (mean 37 years) of the participants. One study did not report age data. The male to female ratio of the 343 participants was 137:206. The most widely employed validated outcome measure was the Young Mania Rating Scale, being used 8 times. The Hamilton Depression Rating Scale-17/Hamilton Depression Rating Scale was used thrice; the Altman Self-Rating Mania Scale, Quick Inventory of Depressive Symptomatology, and Functional Assessment Staging Test were used twice; and the Coping Inventory for Stressful Situations, EuroQoL 5-Dimension Health Questionnaire, Generalized Anxiety Disorder Scale-7, Inventory of Depressive Symptomatology, Mindfulness Attention Awareness Scale, Major Depression Index, Morisky-Green 8-item, Perceived Stress Scale, and World Health Organization Quality of Life-BREF were used once. Self-report measures were captured in 9 different studies, 6 of which used MONARCA. Mood and energy levels were the most commonly used self-report measures, being used 4 times each. Furthermore, 11 of the 12 studies discussed the various confounding factors and barriers to the use of MHAs for BD.

Conclusions

Reported low adherence rates, usability challenges, and privacy concerns act as barriers to the use of MHAs for BD. Moreover, as MHA evaluation is itself developing, guidance for clinicians in how to aid patient choices in mobile health needs to develop. These obstacles could be ameliorated by incorporating co-production and co-design using participatory patient approaches during the development and evaluation stages of MHAs for BD. Further, including qualitative aspects in trials that examine patient experience of both mental ill health and the MHA itself could result in a more patient-friendly fit-for-purpose MHA for BD.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT

BACKGROUND

Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

OBJECTIVE

The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT).

DESIGN AND SETTING

This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

PARTICIPANTS

A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

INTERVENTION

REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

MAIN OUTCOME MEASURE

The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items.

RESULTS

Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

LIMITATIONS

The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

CONCLUSIONS

An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only.

FUTURE WORK

Further research in improving the effectiveness of online carer support interventions is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72019945.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

Development of Coaching Support for LiveWell: A Smartphone-Based Self-Management Intervention for Bipolar Disorder

Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to recurrence of episodes, long episode durations, and persistence of interepisode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates, with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, timing of delivery, and the training and supervision for coaching support of the LiveWell technology. This support includes clearly defined and structured roles that aim to encourage the use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention.

An online supported self-management toolkit for relatives of people with psychosis or bipolar experiences: the IMPART multiple case study

Background

Digital health interventions have the potential to improve the delivery of psychoeducation to people with mental health problems and their relatives. Despite substantial investment in the development of digital health interventions, successful implementation into routine clinical practice is rare.

Objectives

Use the implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and develop an implementation plan to support the delivery of REACT.

Design

This was an implementation study using a mixed-methods, theory-driven, multiple case study approach. A study-specific implementation theory for REACT based on normalisation process theory was developed and tested, and iterations of an implementation plan to address the key factors affecting implementation were developed.

Setting

Early-intervention teams in six NHS mental health trusts in England (three in the north and three in the south).

Participants

In total, 281 staff accounts and 159 relatives’ accounts were created, 129 staff and 23 relatives took part in qualitative interviews about their experiences, and 132 relatives provided demographic data, 56 provided baseline data, 21 provided data at 12 weeks’ follow-up and 20 provided data at 24 weeks’ follow-up.

Interventions

REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum, and a confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address identified barriers. Adaptations included modifications to the toolkit and how it was delivered by teams.

Main outcome measures

The main outcome was factors affecting implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invitations), use of REACT (relatives’ logins and time spent on the website) and the impact of REACT [relatives’ distress (General Health Questionnaire-28), and carer well-being and support (Carer Well-being and Support Scale questionnaire)].

Results

Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties with prioritising supporting relatives; technical difficulties of using REACT; poor interoperability with trust information technology systems and care pathways; lack of access to mobile technology and information technology training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invitations. In total, 355 relatives’ invitations were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (standard deviation 4.43), but with wide variation from 0 to 31 (median 2, interquartile range 1–8). The mean total time spent on the website was 40.6 minutes (standard deviation 54.54 minutes), with a range of 0–298 minutes (median 20.1 minutes, interquartile range 4.9–57.5 minutes). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety and insomnia, and increases in relatives’ well-being and eHealth literacy, but no changes were statistically significant.

Conclusions

Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long-term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure that they have adequate training, risk protocols and resources to deliver the technology. Cost-effectiveness and impact on workload and inequalities in accessing health care need further testing, along with the generalisability of our findings to other digital health interventions.

Limitations

REACT was offered by the same team running the IMPlementation of A Relatives’ Toolkit (IMPART) study, and was perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited.

Trial registration

Current Controlled Trials ISRCTN16267685.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 37. See the NIHR Journals Library website for further project information.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Distant mood monitoring for depressive and bipolar disorders: a systematic review

BACKGROUND

Broadening our knowledge of the longitudinal course of mood symptoms is cardinal to providing effective long-term treatments. Research indicates that patients with mental illness are willing to engage in the use of telemonitoring and mobile technology to assess and monitor their mood states. However, without the provision of distant support, adverse outcomes and events may be difficult to prevent and manage through self-monitoring. Understanding patient perspectives is important to achieving the best balance of self-monitoring, patient empowerment, and distant supporter involvement.

METHODS

This systematic review synthesises quantitative and qualitative evidence of the effectiveness and feasibility of daily/weekly/monthly remote mood monitoring that includes distant support in participants with mood disorders. Inclusion criteria comprised mood monitoring of mood disorder patients as main intervention, study design, method of monitoring, and presence of psychotherapy and psychoeducation. Effectiveness was defined by the change in depression and/or mania scores. Feasibility was determined on participant feedback and completion/attrition rates. Studies were assessed for quality using the Mixed Methods Appraisal Tool version 2018.

RESULTS

Nine studies of acceptable quality met the inclusion criteria. Distant mood monitoring was effective in improving depression scores but not mania scores. Feasibility, as measured through compliance and completion rates and participant feedback, varied.

CONCLUSION

Distant mood monitoring with support may be a useful, acceptable, and feasible intervention for diverse groups of patients in terms of age and ethnicity. Further, it may be effective in improving symptoms of depression, increasing treatment adherence, and facilitating the prevention and management of adverse outcomes. As a task-shifting intervention, distant mood monitoring may help to alleviate the burden on mental health providers in developing countries.

Development of an Emotion-Sensitive mHealth Approach for Mood-State Recognition in Bipolar Disorder

Internet- and mobile-based approaches have become increasingly significant to psychological research in the field of bipolar disorders. While research suggests that emotional aspects of bipolar disorders are substantially related to the social and global functioning or the suicidality of patients, these aspects have so far not sufficiently been considered within the context of mobile-based disease management approaches. As a multiprofessional research team, we have developed a new and emotion-sensitive assistance system, which we have adapted to the needs of patients with bipolar disorder. Next to the analysis of self-assessments, third-party assessments, and sensor data, the new assistance system analyzes audio and video data of these patients regarding their emotional content or the presence of emotional cues. In this viewpoint, we describe the theoretical and technological basis of our emotion-sensitive approach and do not present empirical data or a proof of concept. To our knowledge, the new assistance system incorporates the first mobile-based approach to analyze emotional expressions of patients with bipolar disorder. As a next step, the validity and feasibility of our emotion-sensitive approach must be evaluated. In the future, it might benefit diagnostic, prognostic, or even therapeutic purposes and complement existing systems with the help of new and intuitive interaction models.

An internet-delivered self-management programme for bipolar disorder in mental health services in Ireland: Results and learnings from a feasibility trial

Bipolar disorder (BD) is a chronic condition that requires continued care. Psychological interventions are recommended by clinical guidelines but there are treatment barriers that prevent patients to access these services. Internet-delivered self-management interventions are promising alternatives to improve treatment accessibility in patients with BD. Several studies indicate that these interventions are acceptable and beneficial for patients with BD, but no studies have been conducted in routine care settings. This trial aimed to examine the feasibility, acceptability, and preliminary efficacy of implementing an internet-delivered, clinician-supported intervention for BD as an adjunct to treatment as usual at two secondary-care services in Ireland. This study used an uncontrolled design with mixed-methods evaluation. Feasibility and acceptability were assessed in terms of recruitment, use of the intervention, and satisfaction from both clinicians and patients' perspectives. Personal recovery, quality of life, and severity of symptoms were measured at baseline and post-intervention. Fifteen patients signed consent and used the programme for 10 weeks. Usage of the intervention was adequate with high frequency of tool usage. There was a significant improvement in patients' sense of personal recovery (z = 2.38, p = .017). The intervention was found acceptable and easy-to-use; however, implementation barriers will need to be overcome for scaling the intervention. This is the first study testing the feasibility of a digital intervention for patients with BD in public mental health services in Ireland. More research is needed in order to increase the understanding of how to promote the integration and the uptake of digital interventions for individuals with BD.

mHealth in affective disorders: hype or hope? A focused narrative review

The constant growth and widespread availability of mobile technologies (i.e. smartphones and wearables) over the last decades have been a subject of intense interest and research in the affective disorders (AD) field. The potential of mHealth for collecting a new kind of passive and active information while providing cost-effective and tailored interventions have raised many hopes. However, until now, despite some encouraging results, research in the field has not been translated to reach real-world clinical settings or to develop additional evidence-based mHealth tools for people suffering from AD. Meanwhile, commercial untested apps and wearables are already being increasingly used and adopted by patients for the self-management of their illnesses. Hence, there is a latent need and demand from service users to integrate mHealth in their care, which the field cannot yet fulfil. In this article, through a focused narrative review, we discuss the evidence available for the use, validity and efficacy of mHealth tools in AD. Challenges in the academic field hampering the advancement of these technologies and its implementation into clinical practice are discussed. Lastly, we propose a framework to overcome these issues, which may facilitate mHealth solutions reaching service users.

Feasibility, Acceptability, and Preliminary Impacts of Web-Based Patient Education on Patients With Schizophrenia Spectrum Disorder: Quasi-Experimental Cluster Study

BACKGROUND

Web-based interventions are promising tools for increasing the understanding of illness and treatment among patients with serious mental disorders.

OBJECTIVE

This study aimed to test the feasibility and acceptability of a Web-based patient education intervention using a quasi-experimental cluster design to report feedback on patient education sessions and the website used and to report preliminary evidence of the intervention's impact on patients with schizophrenia spectrum disorder.

METHODS

A single-blind, parallel, quasi-experimental cluster study over a 6-month period comparing Web-based education (n=33) with a nonequivalent control group (treatment as usual, n=24) for people with schizophrenia spectrum disorder was conducted. Participants (N=57) were recruited from one psychiatric hospital (6 wards). Feasibility was assessed by participants' commitment (refusal rate, dropout rate) to the study. Acceptability was assessed as participants' commitment to the intervention. Patient education sessions and website feedback were assessed by the patients and health care professionals. The preliminary impact of the sessions on patients' self-efficacy, self-esteem, illness cognition, and knowledge level was measured at baseline and follow-ups (8 weeks, 6 months) with self-rated questionnaires.

RESULTS

The refusal rate among patients was high with no statistically significant difference (69% [74/107] in the intervention group, 76% [76/100] in the control group; P=.21). The same result was found for the dropout rates (48% [16/33] vs 58% [14/24]; P=.46). The acceptability of the intervention was good; 31 participants out of 33 (94%) completed all five sessions. Feedback on the intervention was mainly positive; three out of four subscales of session were rated above the midpoint of 4.0. Feedback on the website was also positive, with a grade of good for content (69%, 20/29 patients; 75%, 21/28 professionals), layout (62%, 18/29 patients; 61%, 17/28 professionals), and usability (62%, 18/29 patients; and 68%, 19/28 professionals). The patients using the intervention had significantly higher scores 6 months after the sessions in self-efficacy (baseline mean 26.12, SD 5.64 vs 6-month mean 29.24, SD 6.05; P=.003) and regarding knowledge level about schizophrenia (mean 11.39, SD 4.65 vs 6-month mean 15.06, SD 5.26; P=.002), and lower scores in the subscale of helplessness in illness cognition (mean 2.26, SD 0.96 vs 6-month mean 1.85, SD 0.59; P=.03). Differences from the control group were not significant. No differences were found in patients' self-esteem or other subscales in illness cognition.

CONCLUSIONS

The patients were reluctant to participate in the study and tended to drop out before the follow-ups. Once they had participated, their acceptance of the intervention was high. A more effective recruitment strategy and monitoring method will be needed in future studies. To assess the impact of the intervention, a more rigorous study design with an adequately powered sample size will be used in cooperation with outpatient mental health services.

The Impact of a Web-Based Course Concerning Patient Education for Mental Health Care Professionals: Quasi-Experimental Study

BACKGROUND

Continuing education has an important role in supporting the competence of health care professionals. Although Web-based education is a growing business in various health sectors, few studies have been conducted in psychiatric settings to show its suitability in demanding work environments.

OBJECTIVE

We aimed to describe the impact of a Web-based educational course to increase self-efficacy, self-esteem, and team climate of health care professionals. Possible advantages and disadvantages of the Web-based course are also described.

METHODS

The study used nonrandomized, pre-post intervention design in 1 psychiatric hospital (3 wards). Health care professionals (n=33) were recruited. Self-efficacy, self-esteem, and team climate were measured at 3 assessment points (baseline, 8 weeks, and 6 months). Possible advantages and disadvantages were gathered with open-ended questions at the end of the course.

RESULTS

Our results of this nonrandomized, pre-post intervention study showed that health care professionals (n=33) had higher self-efficacy after the course, and the difference was statistically significant (mean 30.16, SD 3.31 vs mean 31.77, SD 3.35; P=.02). On the other hand, no differences were found in the self-esteem or team climate of the health care professionals before and after the course. Health care professionals found the Web-based course useful in supporting their work and relationships with patients. The tight schedule of the Web-based course and challenges in recruiting patients to use the patient education program with health care professionals were found to be the disadvantages.

CONCLUSIONS

Web-based education might be a useful tool to improve the self-efficacy of health care professionals even in demanding work environments such as psychiatric hospitals. However, more studies with robust and sufficiently powered data are still needed.

A randomized controlled trial of MoodSwings 2.0: An internet-based self-management program for bipolar disorder

OBJECTIVES

MoodSwings 2.0 is an online self-guided intervention for bipolar disorder that includes educational modules, interactive tools, and discussion forums. The primary aim of the study was to determine if participation in MoodSwings 2.0 would result in decreased symptoms of depression and mania compared to the control condition. Secondary aims were to identify improvements in core depression symptoms, quality of life, medication adherence, functioning, and time to relapse.

METHODS

This was a three-arm randomized controlled trial that compared two intervention arms against a peer support control group (forum). A total of 304 adults aged 21 to 65 years with a diagnosis of bipolar disorder were assigned to a forum-only control group (Group 1; n = 102), a forum plus modules treatment group (Group 2; n = 102), or a forum, modules, and tools treatment group (Group 3; n = 100), in addition to usual care.

RESULTS

There was a significant intervention impact showing improvement on the primary outcome of depression for Group 2 compared to Group 1 (P = .05) with effect sizes (Cohen's d) ranging from 0.17 to 0.43. There was also a significant intervention impact showing improvement on the secondary outcome of core depression for Group 2 (P = .02) and Group 3 (P = .05), but worse physical functioning for Group 3 (P = .01), compared to Group 1.

CONCLUSIONS

This study provides evidence of the efficacy of internet-based psychoeducation interventions for bipolar disorder in reducing depressive symptoms. Further investigation is needed to assess effectiveness in a public program.

A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems

BACKGROUND

The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions.

METHODS

Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically.

RESULTS

Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management.

CONCLUSIONS

Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

The user experiences and clinical outcomes of an online personal health record to support self-management of bipolar disorder: A pretest-posttest pilot study

BACKGROUND

Self-management comprises knowledge, behavior, activities and resources providing people with bipolar disorder (BD) control over fluctuating mood and activity-patterns. The 'Self-management and Dialogue in Bipolar Disorder' project entailed the tailoring of an online personal health record (PHR) originally designed for the chronically ill to monitor condition and share information with their clinician to people with BD (PHR-BD). The aim of this study was to evaluate the feasibility, utility and user-experiences of participants with BD, relatives, and healthcare professionals who worked with the PHR-BD.

METHODS

Post-test online closed- and open ended questionnaires were used to collect information on utility, and user-experiences with PHR-BD. A pre-posttest design to evaluate clinical effects on quality of life, empowerment, symptom reduction, changes in mood and activity, and illness burden and severity at baseline and at 12-months follow-up.

RESULTS

Sixty-six participants with BD logged in at baseline. At study endpoint thirty-nine participants with BD, eleven professionals and one family caregiver filled out the evaluations. No significant differences in the clinical outcomes from baseline were found. Qualitative evaluations showed a frequent utility of the mood chart modules, improved communication between clinician and participant with BD and, increased insight in influencing factors of mood fluctuations.

LIMITATIONS

Small convenience sample, no controls.

CONCLUSIONS

The option to alternate the interface from a prospective to a retrospective mood chart , and integration with the personal crisis plan was considered to be of added value in self-managing BD. The findings of this study will guide the future implementation of the PHR-BD.

Internet use by older adults with bipolar disorder: international survey results

Background

The world population is aging and the number of older adults with bipolar disorder is increasing. Digital technologies are viewed as a framework to improve care of older adults with bipolar disorder. This analysis quantifies Internet use by older adults with bipolar disorder as part of a larger survey project about information seeking.

Methods

A paper-based survey about information seeking by patients with bipolar disorder was developed and translated into 12 languages. The survey was anonymous and completed between March 2014 and January 2016 by 1222 patients in 17 countries. All patients were diagnosed by a psychiatrist. General estimating equations were used to account for correlated data.

Results

Overall, 47% of older adults (age 60 years or older) used the Internet versus 87% of younger adults (less than 60 years). More education and having symptoms that interfered with regular activities increased the odds of using the Internet, while being age 60 years or older decreased the odds. Data from 187 older adults and 1021 younger adults were included in the analysis excluding missing values.

Conclusions

Older adults with bipolar disorder use the Internet much less frequently than younger adults. Many older adults do not use the Internet, and technology tools are suitable for some but not all older adults. As more health services are only available online, and more digital tools are developed, there is concern about growing health disparities based on age. Mental health experts should participate in determining the appropriate role for digital tools for older adults with bipolar disorder.

Users' experiences of an online intervention for bipolar disorder: important lessons for design and evaluation

Background

The evidence base for digital interventions for physical and mental health, including severe and enduring mental health difficulties, is increasing. In a feasibility trial, web-based Enhanced Relapse Prevention (ERPonline) for bipolar disorder demonstrated high recruitment and retention rates. Relative to participants in the waitlist control group, those who received ERPonline showed increased monitoring for early warning signs of relapse and had developed more positive illness models.

Objective

To understand users’ motivations and barriers for taking part in an online/telephone-based trial, and for engagement with ERPonline.

Methods

Participants from the trial who had been allocated to receive ERPonline were purposively sampled to participate in telephone-based, in-depth qualitative interviews about their experiences. Interviews (n=19) were analysed using framework analysis to identify themes relevant to study aims.

Findings

Participants took part due to the convenient, flexible and rewarding aspects of the trial design, as well as a desire to improve the mental health of themselves and others. Barriers included extensive assessments, practical difficulties and mood. ERPonline was was generally considered to be accessible, relevant and straightforward, but there were individual preferences regarding design, content and who it was for. Several participants reported positive changes, but there was a sense that digital interventions should not replace routine care.

Conclusions

There are a number of barriers and facilitators to consider when evaluating and implementing digital interventions. Individual preferences and human contact were key factors for both trial design and engagement with an online intervention.

Clinical implications

Digital interventions should be co-produced, personalised, interactive and embedded as one component in a broader package of care.

Trial registration number

ISRCTN56908625; Post-results.

Behavioural biomarkers and mobile mental health: a new paradigm

Over recent decades, the field of psychiatry has allocated a vast amount of resources and efforts to make available more accurate and objective methods to diagnose, assess and monitor treatment outcomes in psychiatric disorders. Despite the optimism and some significant progress in biological markers, it has become increasingly evident that they are failing to meet initial expectations due to their lack of specificity, inconsistent reliability and limited availability. On the other hand, there is an increasingly emerging evidence of mobile technologies' feasibility to measure mental illness activity. Moreover, taking into account its widespread use, availability and potential to capture behavioural markers, mobile-connected technologies could be strong candidates to fill and complement-at least at some degree-the gaps that biological markers couldn't. This represents an especially interesting opportunity to reform our current diagnostic system using a bottom-up research methodology based on digital and biological markers data instead of the classical traditional top-down approach. Therefore, the field might benefit of further exploring this promising -and increasingly evidence-based- pathway as well as other auspicious alternatives in order to attain a more holistic and integrative approach in research, which could ultimately impact real-world clinical practice.

Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health

Abstract. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clinicians could potentially be overcome by providing Internet- and mobile-based psychological interventions (IMIs). This paper is a report of the Taskforce E-Health of the European Federation of Psychologists’ Association and will provide an introduction to the subject, discusses areas of application, and reviews the current evidence regarding the efficacy of IMIs for the prevention and treatment of mental disorders. Meta-analyses based on randomized trials clearly indicate that therapist-guided stand-alone IMIs can result in meaningful benefits for a range of indications including, for example, depression, anxiety, insomnia, or posttraumatic stress disorders. The clinical significance of results of purely self-guided interventions is for many disorders less clear, especially with regard to effects under routine care conditions. Studies on the prevention of mental health disorders (MHD) are promising. Blended concepts, combining traditional face-to-face approaches with Internet- and mobile-based elements might have the potential of increasing the effects of psychological interventions on the one hand or to reduce costs of mental health treatments on the other hand. We also discuss mechanisms of change and the role of the therapist in such approaches, contraindications, potential limitations, and risk involved with IMIs, briefly review the status of the implementation into routine health care across Europe, and discuss confidentiality as well as ethical aspects that need to be taken into account, when implementing IMIs. Internet- and mobile-based psychological interventions have high potential for improving mental health and should be implemented more widely in routine care.

Disease management apps and technical assistance systems for bipolar disorder: Investigating the patients´ point of view

BACKGROUND

Smartphone-based disease management has become increasingly interesting for research in the field of bipolar disorders. This article investigates the attitudes of persons affected by this disorder towards the appropriation of mobile apps or assistance systems for the management of their disease.

METHODS

We conducted two separate studies. Study 1 was an online survey with 88 participants. In study 2 we consulted 15 participants during a semi-structured interview. All the participants had formerly been diagnosed with bipolar disorder.

RESULTS

More than half of the participants of study 1 and most participants of study 2 agreed with the use of an app or assistance system for self-ratings, third party ratings and an objective symptom monitoring. Potential interventions that were popular in both groups included a regular feedback, the visualization of monitored data and advice in crises.

LIMITATIONS

With study 1 we were not able to ensure correct diagnoses or to interact in a flexible way. In Study 2 those issues were resolved, but the small number of participants raises the question of a possible generalisability of the results. Furthermore, for both studies a selection bias could not be excluded.

CONCLUSIONS

Our results indicate positive attitudes of bipolar patients towards disease management apps and assistance systems. Even new and innovative features such as partner apps or the analysis of facial expressions in video data were appreciated and daily interactions were favoured. However, the variety of answers calls for flexible systems which allow activating or deactivating certain features.

Bipolar disorders

Bipolar disorders are chronic and recurrent disorders that affect >1% of the global population. Bipolar disorders are leading causes of disability in young people as they can lead to cognitive and functional impairment and increased mortality, particularly from suicide and cardiovascular disease. Psychiatric and nonpsychiatric medical comorbidities are common in patients and might also contribute to increased mortality. Bipolar disorders are some of the most heritable psychiatric disorders, although a model with gene-environment interactions is believed to best explain the aetiology. Early and accurate diagnosis is difficult in clinical practice as the onset of bipolar disorder is commonly characterized by nonspecific symptoms, mood lability or a depressive episode, which can be similar in presentation to unipolar depression. Moreover, patients and their families do not always understand the significance of their symptoms, especially with hypomanic or manic symptoms. As specific biomarkers for bipolar disorders are not yet available, careful clinical assessment remains the cornerstone of diagnosis. The detection of hypomanic symptoms and longtudinal clinical assessment are crucial to differentiate a bipolar disorder from other conditions. Optimal early treatment of patients with evidence-based medication (typically mood stabilizers and antipsychotics) and psychosocial strategies is necessary.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

An update on adjunctive treatment options for bipolar disorder

OBJECTIVES

Bipolar disorder is a complex illness often requiring combinations of therapies to successfully treat symptoms. In recent years, there have been significant advancements in a number of therapies for bipolar disorder. It is therefore timely to provide an overview of current adjunctive therapeutic options to help treating clinicians to inform their patients and work towards optimal outcomes.

METHODS

Publications were identified from PubMed searches on bipolar disorder and pharmacotherapy, nutraceuticals, hormone therapy, psychoeducation, interpersonal and social rhythm therapy, cognitive remediation, mindfulness, e-Health and brain stimulation techniques. Relevant articles in these areas were selected for further review. This paper provides a narrative review of adjunctive treatment options and is not a systematic review of the literature.

RESULTS

A number of pharmacotherapeutic, psychological and neuromodulation treatment options are available. These have varying efficacy but all have shown benefit to people with bipolar disorder. Due to the complex nature of treating the disorder, combination treatments are often required. Adjunctive treatments to traditional pharmacological and psychological therapies are proving useful in closing the gap between initial symptom remission and full functional recovery.

CONCLUSIONS

Given that response to monotherapy is often inadequate, combination regimens for bipolar disorder are typical. Correspondingly, psychiatric research is working towards a better understanding of the disorder's underlying biology. Therefore, treatment options are changing and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes. Towards this end, this paper provides an overview of novel treatments that may improve clinical outcomes for people with bipolar disorder.

Smartphone-based objective monitoring in bipolar disorder: status and considerations

In 2001, the WHO stated that: "The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe". Within mental health, interventions and monitoring systems for depression, anxiety, substance abuse, eating disorder, schizophrenia and bipolar disorder have been developed and used. The present paper presents the status and findings from studies using automatically generated objective smartphone data in the monitoring of bipolar disorder, and addresses considerations on the current literature and methodological as well as clinical aspects to consider in the future studies.

IMPlementation of A Relatives' Toolkit (IMPART study): an iterative case study to identify key factors impacting on the implementation of a web-based supported self-management intervention for relatives of people with psychosis or bipolar experiences in a National Health Service: a study protocol

BACKGROUND

Web-based interventions to support people to manage long-term health conditions are available and effective but rarely used in clinical services. The aim of this study is to identify critical factors impacting on the implementation of an online supported self-management intervention for relatives of people with recent onset psychosis or bipolar disorder into routine clinical care and to use this information to inform an implementation plan to facilitate widespread use and inform wider implementation of digital health interventions.

METHODS

A multiple case study design within six early intervention in psychosis (EIP) services in England, will be used to test and refine theory-driven hypotheses about factors impacting on implementation of the Relatives' Education And Coping Toolkit (REACT). Qualitative data including behavioural observation, document analysis, and in-depth interviews collected in the first two EIP services (wave 1) and analysed using framework analysis, combined with quantitative data describing levels of use by staff and relatives and impact on relatives' distress and wellbeing, will be used to identify factors impacting on implementation. Consultation via stakeholder workshops with staff and relatives and co-facilitated by relatives in the research team will inform development of an implementation plan to address these factors, which will be evaluated and refined in the four subsequent EIP services in waves 2 and 3. Transferability of the implementation plan to non-participating services will be explored.

DISCUSSION

Observation of implementation in a real world clinical setting, across carefully sampled services, in real time provides a unique opportunity to understand factors impacting on implementation likely to be generalizable to other web-based interventions, as well as informing further development of implementation theories. However, there are inherent challenges in investigating implementation without influencing the process under observation. We outline our strategies to ensure our design is transparent, flexible, and responsive to the timescales and activities happening within each service whilst also meeting the aims of the project.

TRIAL REGISTRATION

ISCTRN 16267685 (09/03/2016).

Is a SIMPLe smartphone application capable of improving biological rhythms in bipolar disorder?

BACKGROUND

Biological rhythms (BR) disturbance has been suggested as a potential mediator of mood episodes in Bipolar Disorder (BD). The Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN) was designed as an assessment tool to evaluate BR domains comprehensively. In the context of a trial evaluating a smartphone application delivering personalized psychoeducational contents for BD (SIMPLe 1.0), the main aim of this study is to evaluate the potential impact of SIMPLe 1.0 in BR regulation using the BRIAN scale.

METHODS

51 remitted BD patients were asked to use the application for 3 months. Paired t-test analyses were employed to compare baseline and follow-up BRIAN´s total and domains scores. The sample was divided into completers and non-completers of the study to evaluate differences between groups regarding BRIAN scores using ANCOVA analyses.

RESULTS

The BRIAN's mean total score of the whole sample significantly decreased from baseline to post-intervention (35.89 (SD 6.64) vs. 31.18 (SD 6.33), t = 4.29, p = 0.001). At post-intervention, there was a significant difference between groups regarding the total BRIAN mean score (29.47 (SD 6.21) completers vs. 35.92 (SD 3.90) non-completers, t = 2.50, p = 0.02). This difference was maintained after conducting a one-way ANCOVA controlling for pre-intervention BRIAN scores, F (1, 46) = 10.545, p=0.002.

LIMITATIONS

A limited sample, pre-post measures, and a short study timeframe could have affected the results. Additional factors affecting BR, such as medication, could not be ruled out.

CONCLUSION

Our results suggest that there are potential positive effects of a psychoeducational smartphone application as an adjunctive to treatment as usual on BD patients' BR.

[Internet- and mobile-based approaches : Psycho-social diagnostics and treatment in medical rehabilitation]

Technology-based approaches for psychosocial diagnostics and interventions provide an attractive opportunity to optimize medical rehabilitation. Based on an Internet- and mobile-based assessment of existing functional health impairments, appropriate planning, implementation of corresponding courses of action as well as outcome assessment can take place. This can be implemented in the form of Internet- and mobile-based interventions (IMI).The present article provides an overview of the basic knowledge of IMI and their evidence base both in general and in particular for their use in medical rehabilitation. Important aspects of internet and mobile-based psycho-social diagnostics are discussed subsequently. Finally, an outlook for the use of Internet- and mobile-based diagnostics and interventions in medical rehabilitation is given.

Online ethics: where will the interface of mental health and the internet lead us?

While e-health initiatives are poised to revolutionize delivery and access to mental health care, conducting clinical research online involves specific contextual and ethical considerations. Face-to-face psychosocial interventions can at times entail risk and have adverse psychoactive effects, something true for online mental health programs too. Risks associated with and specific to internet psychosocial interventions include potential breaches of confidentiality related to online communications (such as unencrypted email), data privacy and security, risks of self-selection and self-diagnosis as well as the shortcomings of receiving psychoeducation and treatment at distance from an impersonal website. Such ethical issues need to be recognized and proactively managed in website and study design as well as treatment implementation. In order for online interventions to succeed, risks and expectations of all involved need to be carefully considered with a focus on ethical integrity.

Smartphone-Based Monitoring of Objective and Subjective Data in Affective Disorders: Where Are We and Where Are We Going? Systematic Review

Background

Electronic mental health interventions for mood disorders have increased rapidly over the past decade, most recently in the form of various systems and apps that are delivered via smartphones.

Objective

We aim to provide an overview of studies on smartphone-based systems that combine subjective ratings with objectively measured data for longitudinal monitoring of patients with affective disorders. Specifically, we aim to examine current knowledge on: (1) the feasibility of, and adherence to, such systems; (2) the association of monitored data with mood status; and (3) the effects of monitoring on clinical outcomes.

Methods

We systematically searched PubMed, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials for relevant articles published in the last ten years (2007-2017) by applying Boolean search operators with an iterative combination of search terms, which was conducted in February 2017. Additional articles were identified via pearling, author correspondence, selected reference lists, and trial protocols.

Results

A total of 3463 unique records were identified. Twenty-nine studies met the inclusion criteria and were included in the review. The majority of articles represented feasibility studies (n=27); two articles reported results from one randomized controlled trial (RCT). In total, six different self-monitoring systems for affective disorders that used subjective mood ratings and objective measurements were included. These objective parameters included physiological data (heart rate variability), behavioral data (phone usage, physical activity, voice features), and context/environmental information (light exposure and location). The included articles contained results regarding feasibility of such systems in affective disorders, showed reasonable accuracy in predicting mood status and mood fluctuations based on the objectively monitored data, and reported observations about the impact of monitoring on clinical state and adherence of patients to the system usage.

Conclusions

The included observational studies and RCT substantiate the value of smartphone-based approaches for gathering long-term objective data (aside from self-ratings to monitor clinical symptoms) to predict changes in clinical states, and to investigate causal inferences about state changes in patients with affective disorders. Although promising, a much larger evidence-base is necessary to fully assess the potential and the risks of these approaches. Methodological limitations of the available studies (eg, small sample sizes, variations in the number of observations or monitoring duration, lack of RCT, and heterogeneity of methods) restrict the interpretability of the results. However, a number of study protocols stated ambitions to expand and intensify research in this emerging and promising field.

Protocol for an online randomised controlled trial to evaluate the clinical and cost-effectiveness of a peer-supported self-management intervention for relatives of people with psychosis or bipolar disorder: Relatives Education And Coping Toolkit (REACT)

INTRODUCTION

Despite clinical guidelines recommendations, many relatives of people with psychosis or bipolar disorder do not currently receive the support they need. Online information and support may offer a solution.

METHODS AND ANALYSIS

This single-blind, parallel, online randomised controlled trial will determine clinical and cost-effectiveness of the Relatives Education And Coping Toolkit (REACT) (including an online resource directory (RD)), compared with RD only, for relatives of people with psychosis or bipolar disorder. Both groups continue to receive treatment as usual. Independent, web-based variable, block, individual randomisation will be used across 666 relatives. Primary outcome is distress at 24 weeks (measured by General Health Questionnaire; GHQ-28) compared between groups using analysis of covariance, adjusting for baseline score. Secondary clinical outcomes are carer well-being and support. Cost-effectiveness analysis will determine cost of a significant unit change (three-point reduction) in the GHQ-28. Costs include offering and supporting the intervention in the REACT arm, relevant healthcare care costs including health professional contacts, medications prescribed and time off (or ability to) work for the relative. Cost utility analysis will be calculated as the marginal cost of changes in quality-adjusted life years, based on EuroQol. We will explore relatives' beliefs, perceived coping and amount of REACT toolkit use as possible outcome mediators. We have embedded two methodological substudies in the protocol to determine the relative effectiveness of a low-value (£10) versus higher value (£20) incentive, and an unconditional versus conditional incentive, on improving follow-up rates.

ETHICS AND DISSEMINATION

The trial has ethical approval from Lancaster National Research Ethics Service (NRES)Committee (15/NW/0732) and is overseen by an independent Data Monitoring and Ethics Committee and Trial Steering Committee. Protocol version 1.5 was approved on 9 January 2017. All updates to protocols are uploaded to the National Institute for Health Research (NIHR) Journals Library. A full statistical analysis plan is available at https://figshare.com/account/home#/projects/19975. Publications will be in peer-reviewed journals (open access wherever possible). Requests for access to the data at the end of the study will be reviewed and granted where appropriate by the Trial Management Group.

TRIAL REGISTRATION NUMBER

ISRCTN72019945, pre-results.

Online psycho-education to the treatment of bipolar disorder: protocol of a randomized controlled trial

BACKGROUND

Bipolar disorder patients frequently present recurrent episodes and often experience subsyndromal symptoms, cognitive impairment and difficulties in functioning, with a low quality of life, illness relapses and recurrent hospitalization. Early diagnosis and appropriate intervention may play a role in preventing neuroprogression in this disorder. New technologies represent an opportunity to develop standardized psychological treatments using internet-based tools that overcome some of the limitations of face-to-face treatments, in that they are readily accessible and the timing of therapy can be tailored to user needs and availability. However, although many psychological programs are offered through the web and mobile devices for bipolar disorder, there is a lack of high quality evidence concerning their efficacy and effectiveness due to the great variability in measures and methodology used.

METHODS

This clinical trial is a simple-blind randomized trial within a European project to compare an internet-based intervention with treatment as usual. Bipolar disorder patients are to be included and randomly assigned to one of two groups: 1) the experimental group (tele-care support) and 2) the control group. Participants in both groups will be evaluated at baseline (pre-treatment) and post-treatment.

DISCUSSION

This study describes the design of a clinical trial based on psychoeducation intervention that may have a significant impact on both prognosis and treatment in bipolar disorder. Specifically, bringing different services together (service aggregation), it is hoped that the approach proposed will significantly increase the impact of information and communication technologies on access and adherence to treatment, quality of the service, patient safety, patient and professional satisfaction, and quality of life of patients.

TRIAL REGISTRATION

NCT02924415 . Retrospectively registered 27 September 2016.

A review of design characteristics of cognitive behavioral therapy-informed behavioral intervention technologies for youth with depression and anxiety

Objective

Cognitive behavioral therapy (CBT) has the strongest evidence base for the prevention and treatment of depression and anxiety in youth. Behavioral intervention technologies (BITs) provide an opportunity to overcome access barriers to traditional delivery of CBT. The present review evaluates the design characteristics of CBT-informed BITs for depression and anxiety designed for and tested with youth.

Methods

A state-of-the-art review of three library databases (PubMed, Scopus, and Web of Science) was conducted to identify papers that evaluated the use of CBT-informed BITs for the prevention and/or treatment of depression and anxiety among youth. Narrative results of design characteristics were organized using the BIT model, which provides a framework for design and evaluation.

Results

219 unique results were retrieved through the search. After review, 14 papers (4 prevention and 10 treatment) met the selection criteria. A broad diversity occurred in reporting the design and methodology of CBT delivered to youth through BITs. Psychoeducation was overwhelmingly utilized as the primary change strategy throughout the interventions, with a heavy use of content delivery elements and linear workflows. The reporting of sample characteristics was minimal and varied.

Conclusions

Providing psychoeducation via content delivery was the most utilized BIT change strategy in the interventions, likely limiting the use of multiple BIT elements or flexible workflows. While characterizations could be inferred from the current reports, the high level of variability in reporting is problematic. Generalizability becomes increasingly more difficult to carry out effectively without clear descriptions of the design for evaluated BITs.

Internet use by patients with bipolar disorder: Results from an international multisite survey

There is considerable international interest in online education of patients with bipolar disorder, yet little understanding of how patients use the Internet and other sources to seek information. 1171 patients with a diagnosis of bipolar disorder in 17 countries completed a paper-based, anonymous survey. 81% of the patients used the Internet, a percentage similar to the general public. Older age, less education, and challenges in country telecommunications infrastructure and demographics decreased the odds of using the Internet. About 78% of the Internet users looked online for information on bipolar disorder or 63% of the total sample. More years of education in relation to the country mean, and feeling very confident about managing life decreased the odds of seeking information on bipolar disorder online, while having attended support groups increased the odds. Patients who looked online for information on bipolar disorder consulted medical professionals plus a mean of 2.3 other information sources such as books, physician handouts, and others with bipolar disorder. Patients not using the Internet consulted medical professionals plus a mean of 1.6 other information sources. The percentage of patients with bipolar disorder who use the Internet is about the same as the general public. Other information sources remain important.

Online information seeking by patients with bipolar disorder: results from an international multisite survey

Background

Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information.

Methods

A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data.

Results

976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor.

Conclusion

Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.

Electronic supplementary material

The online version of this article (doi:10.1186/s40345-016-0058-0) contains supplementary material, which is available to authorized users.

Psychoeducation in bipolar disorder with a SIMPLe smartphone application: Feasibility, acceptability and satisfaction

BACKGROUND

During the last fifteen years, the possibility of delivering psychoeducation programs through Internet-based platforms have been explored. Studies evaluating those programs have shown good to acceptable retention rates. In this context, we developed a smartphone application (SIMPLe) collecting information about mood symptoms and offering personalized psychoeducation messages. The main aims of this study were to evaluate the feasibility, acceptability and satisfaction of the smartphone application.

METHODS

The study was conducted from March to August 2015. Participation in the study was proposed to a consecutive sample of adult patients attending an outpatient mental health clinic. Sociodemographic data, clinical and functional assessments alongside smartphone ownership and uses were collected at baseline and at 3 months' follow-up. A 5 item Likert-scale satisfaction questionnaire was also employed.

RESULTS

51 participants were initially enrolled in the study, 36 (74%) remained actively using the application after 3 months. The whole sample interacted with the application a mean of 77 days (SD=26.2). During these days they completed 88% of the daily tests. Over 86% of the participants agreed that the experience using the application was satisfactory.

LIMITATIONS

The diversity of smartphones operating systems led to a moderate, although representative, sample number. Additionally, the subjective data reporting, narrow time frame of use and stability of the patients could have affected the results.

CONCLUSIONS

The results confirm that this particular intervention is feasible and represent a satisfactory and acceptable instrument for the self-management of bipolar disorder as an add-on to the usual treatment but future clinical trials must still probe its efficacy.

Acceptability of Interventions Delivered Online and Through Mobile Phones for People Who Experience Severe Mental Health Problems: A Systematic Review

Background

Psychological interventions are recommended for people with severe mental health problems (SMI). However, barriers exist in the provision of these services and access is limited. Therefore, researchers are beginning to develop and deliver interventions online and via mobile phones. Previous research has indicated that interventions delivered in this format are acceptable for people with SMI. However, a comprehensive systematic review is needed to investigate the acceptability of online and mobile phone-delivered interventions for SMI in depth.

Objective

This systematic review aimed to 1) identify the hypothetical acceptability (acceptability prior to or without the delivery of an intervention) and actual acceptability (acceptability where an intervention was delivered) of online and mobile phone-delivered interventions for SMI, 2) investigate the impact of factors such as demographic and clinical characteristics on acceptability, and 3) identify common participant views in qualitative studies that pinpoint factors influencing acceptability.

Methods

We conducted a systematic search of the databases PubMed, Embase, PsycINFO, CINAHL, and Web of Science in April 2015, which yielded a total of 8017 search results, with 49 studies meeting the full inclusion criteria. Studies were included if they measured acceptability through participant views, module completion rates, or intervention use. Studies delivering interventions were included if the delivery method was online or via mobile phones.

Results

The hypothetical acceptability of online and mobile phone-delivered interventions for SMI was relatively low, while actual acceptability tended to be high. Hypothetical acceptability was higher for interventions delivered via text messages than by emails. The majority of studies that assessed the impact of demographic characteristics on acceptability reported no significant relationships between the two. Additionally, actual acceptability was higher when participants were provided remote online support. Common qualitative factors relating to acceptability were safety and privacy concerns, the importance of an engaging and appealing delivery format, the inclusion of peer support, computer and mobile phone literacy, technical issues, and concerns about the impact of psychological state on intervention use.

Conclusions

This systematic review provides an in-depth focus on the acceptability of online and mobile phone-delivered interventions for SMI and identified the need for further research in this area. Based on the results from this review, we recommend that researchers measure both hypothetical and actual acceptability to identify whether initial perceptions of online and mobile phone-delivered interventions change after access. In addition, more focus is needed on the potential impact of demographic and clinical characteristics on acceptability. The review also identified issues with module completion rates and intervention use as measures of acceptability. We therefore advise researchers to obtain qualitative reports of acceptability throughout each phase of intervention development and testing. Further implications and opportunities for future research are discussed.