A feasibility study of a mental health mobile app in the Dominican Republic: The untold story

Dominican Adolescents' Preferences for Content, Design, and Functionality of a Mobile Application for Type 1 Diabetes Mellitus Self-management

OBJECTIVE

The purpose of this interdisciplinary study was to determine Dominican adolescents' preferences for the content, functionality (i.e. food's glycemic index list, and amount of insulin based on foods' carbohydrate count), and design of a culturally and linguistically relevant mobile application (app) for type 1 diabetes mellitus (T1DM) self-management. The app would facilitate T1DM self-management education and support by addressing providers' challenges in monitoring patients' disease progression and promoting patient adherence to recommended lifestyle changes. Findings inform an app development process that considers the linguistic and cultural values, norms, and structures of people with T1DM and their providers in the Dominican Republic.

METHODS

Phone interviews were conducted with 23 adolescents (14 to 18 years of age), using a semistructured questionnaire. The research team conducted the data analysis using NVivo through a deductive and inductive approach.

RESULTS

The findings suggest that, regardless of the context, adolescents with T1DM desire similar features and functionalities in a self-management app. Overall, participants preferred an app with a graphic format that has accessible information, a straightforward design, and instructional videos. Participants also desired that an app provide information and reminders about proper eating and insulin administration timing and be a vehicle to access a social network to foster mutual support and encouragement.

CONCLUSIONS

Our study highlights adolescents' perspectives on components for inclusion in an app for T1DM self-management. Participants' recommendations for the app's potential usability, contents, and design features will be used to guide the development of a new app to promote engagement and foster better health outcomes.

Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review

BACKGROUND

New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness.

OBJECTIVE

This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy.

METHODS

We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study.

RESULTS

This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability.

CONCLUSIONS

Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.

User perceptions of mobile digital apps for mental health: Acceptability and usability - An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Mobile mental health apps are increasingly being used by both mental health nurses to promote individual self-managemental of mental health conditions and by consumers. Perceptions about specific apps are known, but the overarching acceptability and usability of mental health apps in general less understood. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper identified consumer perceptions of mobile mental health apps. Six key areas were identified that future mobile app developers should consider to maximize consumer engagement with mental health apps. Consumers also highlighted that apps do not replace traditional mental health nursing-rather these supplement existing care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review found that mental health apps are generally viewed positively by consumers; however, factors such as ease of use, usefulness of content and privacy need to be considered to maximise and sustain app engagement. ABSTRACT: Introduction There is increasing interest in the use of mobile mental health applications (apps) to manage mental health conditions. Understanding user perceptions is key to maximise app engagement and inform how apps can be used to support mental health nursing care. Aim This integrative review explores consumers' perceptions of mobile mental health apps to gain insight into user preferences and acceptability. Methods This integrative review was based on searching four databases: CINAHL, EMBASE, Medline, PsycInfo. Inclusion criteria were: (i) articles published after 2000; (ii) focused on apps for mental health disorders; (iii) explored consumers' perception of using a mental health app. Abstracts were screened and eligible papers reviewed. Data on user perceptions were extracted and analysed thematically. Results Seventeen articles were identified. Overall, consumers did not feel that app use replaced traditional health care. Six themes were identified: "Helpfulness," "Improvements/enhancements," "Technical issues," "Easy to use," "Satisfaction with the app" and "Perceived issues." Consumers indicated a preference for personalization for the app to meet individual needs. Discussion and Implications for Practice Mental health apps are generally viewed positively by consumers; however, factors such as ease of use, usefulness of content and privacy need to be considered to maximise and sustain app engagement.

Engagement with mobile health interventions for depression: A systematic review

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological helpline in response to the COVID-19 pandemic in the Dominican Republic

The global health emergency due to COVID‐19 is a disruptive event that has had various effects on mental health. Given this emergency, the Dominican Republic intervened to mitigate the negative impact of the pandemic, considering the physical isolation decreed in the country. In this context, the Autonomous University of Santo Domingo and the School of Psychology designed the UASD COVID‐19 Psychological Helpline. The objective of this article is to describe the development, implementation and evaluation of a programme of psychological first aid. The programme aimed to attenuate the impact of morbidity and mortality due to mental health issues associated with the COVID‐19 pandemic through mobile technology. There were 62 psychologists involved and trained to provide care, and a protocol was developed, implemented, monitored and evaluated. Over the course of four months, the programme assisted 497 people. The average age of the participants was 32 years, and 73% were women. The reasons for contacting the helpline included anxiety, stress, depression, domestic violence, suicidal behaviours and other behavioural problems. Following the intervention, most users reported feeling satisfied and having improved emotions. The first psychological aid in the country developed through telephone and chat messaging was an optimal resource since face‐to‐face interaction was not possible. It also reached more people and reduced the attention gap.

Telemedicine solutions for patients with mental disorders: a Delphi study and review of mobile applications in virtual stores

Mental disorders are a critical public health challenge since they profoundly affected people lifestyle. Mental healthcare treatments aim to promote a higher quality of life of the patients. These procedures include interventions for prolonged mental illness which can be supported by telemedicine technologies. This paper presents a comprehensive analysis of mobile applications selected to address the most critical needs of people with mental problems. Needs include areas of the patient's life, such as basic activities, behavioral changes, and daily life tasks. This work has two main objectives; (1) identify critical needs for patients with mental disorders and (2) identify and analyze apps that can meet the identified critical needs. A Delphi methodology survey was carried with a group of thirteen volunteers, including nurses, assistants, and psychiatrists who are working in Zamora and Valladolid, Spain. This survey has recommended different needs for patients with mental disorders and address objective 1. Google Play and Apple Store have been assessed to select the most relevant mobile applications that were recommended in the Delphi study to address the essential needs of these patients according to objective 2. The results of the Delphi survey show 24 different needs for patients with mental disorders. This study has analyzed 62 mobile applications which address the essential needs recommended in the Delphi study. The selected mobile applications represent 31 applications with feedback (50%); 15 informative applications (24%), and 16 independent applications (26%). On the one hand, applications with feedback request can address 13 recommended needs (54%). On the other hand, informative applications can address 7 needs (29%). Finally, the independent applications are only able to respond to 4 of the 24 recommend needs (17%). Mobile health applications present effective technologies to support the needs of patients with mental disorders. However, this study suggests a critical limitation of mobile applications for mental health since the majority of the applications require user activity. Therefore, future research initiatives on the design and development of mobile apps for people who have mental disorders should focus on independent applications.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

Background

Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.

Objective

This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.

Methods

A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.

Results

A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.

Conclusions

Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

Smartphone apps for depression and anxiety: a systematic review and meta-analysis of techniques to increase engagement

Meta-analyses have shown that digital mental health apps can be efficacious in reducing symptoms of depression and anxiety. However, real-world usage of apps is typically not sustained over time, and no studies systematically examine which features increase sustained engagement with apps or the relationship between engagement features and clinical efficacy. We conducted a systematic search of the literature to identify empirical studies that (1) investigate standalone apps for depression and/or anxiety in symptomatic participants and (2) report at least one measure of engagement. Features intended to increase engagement were categorized using the persuasive system design (PSD) framework and principles of behavioral economics. Twenty-five studies with 4159 participants were included in the analysis. PSD features were commonly used, whereas behavioral economics techniques were not. Smartphone apps were efficacious in treating symptoms of anxiety and depression in randomized controlled trials, with overall small-to-medium effects (g = 0.2888, SE = 0.0999, z(15) = 2.89, p = 0.0119, Q(df = 14) = 41.93, p < 0.0001, I2 = 66.6%), and apps that employed a greater number of engagement features as compared to the control condition had larger effect sizes (β = 0.0450, SE = 0.0164, t(15) = 2.7344, p = 0.0161). We observed an unexpected negative association between PSD features and engagement, as measured by completion rate (β = -0.0293, SE = 0.0121, t(17) = 02.4142, p = 0.0281). Overall, PSD features show promise for augmenting app efficacy, though engagement, as reflected in study completion, may not be the primary factor driving this association. The results suggest that expanding the use of PSD features in mental health apps may increase clinical benefits and that other techniques, such as those informed by behavioral economics, are employed infrequently.

Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK: the feasibility of a randomised controlled trial of a guided online intervention

BACKGROUND

The evidence for the effectiveness of e-mental health interventions among ethnic minorities is still preliminary. This mixed methods study investigates the feasibility of a culturally adapted, guided online intervention with the intention to understand how it works and for whom to inform refinement. It also examines its likely effectiveness in reducing suicidal ideation when compared with the treatment as usual.

METHODS

Turkish migrants with mild to moderate suicidal thoughts were recruited from the general population using social media and newspaper advertisements. The intervention group obtained direct access to a 6-week guided online intervention while participants in the waiting list condition had to wait for 6 weeks. The intervention is based on an existing online intervention and was culturally adapted. Participants in both conditions completed baseline, post-test, and follow-up questionnaires on suicidal ideation (primary outcome), depression, worrying, hopelessness, suicide attempt and self-harm, acculturation, quality of life, and usability. In addition, participants were interviewed to examine the feasibility and mechanisms of action in more depth. The responses were analysed by inductive thematic analysis.

RESULTS

Eighty-five people signed up via the study website, and we included 18 (10 intervention, 8 waitlist control). While the therapeutic benefits were emphasised (e.g. feeling connected with the intervention), the feasibility was judged to be low. The main reasons given were not having severe suicidal thoughts and not being represented by the culturally adapted intervention. No suicide attempts were recorded during the study. The suicidal ideation, depression, and hopelessness scores were improved in both groups.

CONCLUSION

Although intended to be a definitive trial, the current study became a feasibility study with process evaluation to understand the components and how they operate. The online intervention was not superior to the control condition. Future studies need to attend the implementation issues raised including measures of stigma, acculturation, and careful cultural adaptations alongside more attention to coaching and relational support. They should also consider how to improve engagement alongside selection of those who are motivated to use online interventions and offer alternatives for those who are not.

TRIAL REGISTRATION

Netherlands Trial Register, NTR5028 . Registered on 1 March 2015.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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