An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study

BACKGROUND

Stigma is a barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach people who are not in treatment. SMS text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma.

OBJECTIVE

This paper presents the protocol for a study that aims to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs.

METHODS

We designed a novel automated SMS text message intervention to address the four personal-level constructs of stigma resistance: (1) not believing stigma and catching and challenging stigmatizing thoughts, (2) empowering oneself through learning about substance use and one's recovery, (3) maintaining one's recovery and proving stigma wrong, and (4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot-tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group, within-subjects, community-based pilot trial, we will enroll 30 participants in the Resisting Stigma and Revaluating Your Thoughts (RESTART) intervention. Participants will receive 2 daily SMS text messages for 4 weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via a self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Feasibility and acceptability will be assessed with descriptive statistics; effectiveness outcomes will be assessed with paired 2-tailed t tests, and group differences will be explored using ANOVA. Overall, 12 participants will also be selected to complete acceptability interviews.

RESULTS

This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 by the University of North Carolina-Chapel Hill Institutional Review Board. Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals.

CONCLUSIONS

To the best of our knowledge, this is the first study to address substance use stigma via a self-help SMS text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers who are considering text messaging to address psychosocial needs in hard-to-reach populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06281548; https://clinicaltrials.gov/ct2/show/NCT06281548.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59224.

Randomized Trial of the Effectiveness of Videoconferencing-Based Versus Message-Based Psychotherapy on Depression

OBJECTIVE

The authors compared the engagement, clinical outcomes, and adverse events of text or voice message-based psychotherapy (MBP) versus videoconferencing-based psychotherapy (VCP) among adults with depression.

METHODS

The study used a sequential multiple-assignment randomized trial design with data drawn from phase 1 of a two-phase small business innovation research study. In total, 215 adults (ages ≥18 years) with depression received care from Talkspace, a digital mental health care company. Participants were initially randomly assigned to receive either asynchronous MBP or weekly VCP. All therapists provided evidence-based treatments such as cognitive-behavioral therapy. After 6 weeks of treatment, participants whose condition did not show a response on the Patient Health Questionnaire-9 or was rated as having not improved on the Clinical Global Impressions scale were randomly reassigned to receive either weekly VCP plus MBP or monthly VCP plus MBP. Longitudinal mixed-effects models with piecewise linear time trends applied to multiple imputed data sets were used to address missingness of data.

RESULTS

Participants who were initially assigned to the MBP condition engaged with their therapists over more weeks than did participants in the VCP condition (7.8 weeks for MBP vs. 4.9 weeks for VCP; p<0.001). No meaningful differences were observed between the two groups in rates of change by 6 or 12 weeks for depression, anxiety, disability, or global ratings of improvement. Neither treatment resulted in any adverse events.

CONCLUSIONS

MBP appears to be a viable alternative to VCP for treating adults with depression.

Grief Coach: Feasibility and acceptability of a text message program for bereavement support among grievers in the United Kingdom

To address gaps in bereavement services in the UK, a national charity offered free access to Grief Coach, a 12-month text message-based grief support program. To assess the feasibility and acceptability of the approach, this study examined program reach, retention, and user satisfaction. Over 4000 grievers enrolled in the program over 13.5 months; 6- and 12-month retention rates were 87.8% and 83.2%. Among individuals responding to a satisfaction survey (response rate = 55.9%), 94.8% rated the program as moderately or very helpful and 95.4% said it contributed to their sense of being supported in their grief. Common themes emerging from a qualitative analysis of the written comments were how the program helped with coping with the pain of grief and user appreciation of the program. Grief Coach may be a promising component of high-quality grief support to meet the needs of grieving people in the UK.

An adaptive text message intervention to promote psychological well-being and reduce cardiac risk: The Text4Health controlled clinical pilot trial

OBJECTIVE

In a two-arm pilot trial, we examined the feasibility, acceptability, and preliminary efficacy of a 12-week, adaptive text message intervention (TMI) to promote health behaviors and psychological well-being in 60 individuals with multiple cardiac risk conditions (i.e., hypertension, hyperlipidemia, and/or type 2 diabetes) and suboptimal adherence to exercise or dietary guidance.

METHODS

Participants were allocated to receive the TMI or enhanced usual care (eUC). The TMI included daily adaptive text messages promoting health behaviors, twice-weekly messages to set goals and monitor progress, and monthly phone check-ins. Feasibility (primary outcome) and acceptability were measured by rates of successful text message delivery and daily participant ratings of message utility (0-10 Likert scale). We also assessed impact on health behavior adherence, psychological health, and functional outcomes.

RESULTS

The TMI was feasible (99.3% of messages successfully sent) and well-accepted (mean utility = 7.4/10 [SD 2.6]). At 12 weeks, the TMI led to small-sized greater improvements in moderate to vigorous physical activity (d = 0.37), overall physical activity (d = 0.23), optimism (d = 0.20), anxiety (d = -0.36), self-efficacy (d = 0.22), and physical function (d = 0.20), compared to eUC. It did not impact other outcomes substantially at this time point.

CONCLUSION

This 12-week, adaptive TMI was feasible, well-accepted, and associated with small-sized greater improvements in health behavior and psychological outcomes. Though larger studies are needed, it has the potential to be a scalable, low-intensity program that could be used in clinical practice.

CLINICALTRIALS

govregistration:NCT04382521.

Small Steps over time: A longitudinal usability test of an automated interactive text messaging intervention to support self-management of depression and anxiety symptoms

BACKGROUND

Digital mental health interventions (DMHIs) offer potential solutions for addressing mental health care gaps, but often suffer from low engagement. Text messaging is one promising medium for increasing access and sustaining user engagement with DMHIs. This paper examines the Small Steps SMS program, an 8-week, automated, adaptive text message-based intervention for depression and anxiety.

METHODS

We conducted an 8-week longitudinal usability test of the Small Steps SMS program, recruiting 20 participants who met criteria for major depressive disorder and/or generalized anxiety disorder. Participants used the automated intervention for 8 weeks and completed symptom severity and usability self-report surveys after 4 and 8 weeks of intervention use. Participants also completed individual interviews to provide feedback on the intervention.

RESULTS

Participants responded to automated messages on 70 % of study days and with 85 % of participants sending responses to messages in the 8th week of use. Usability surpassed established cutoffs for software that is considered acceptable. Depression symptom severity decreased significantly over the usability test, but reductions in anxiety symptoms were not significant. Participants noted key areas for improvement including addressing message volume, aligning message scheduling to individuals' availability, and increasing the customizability of content.

LIMITATIONS

This study does not contain a control group.

CONCLUSIONS

An 8-week automated interactive text messaging intervention, Small Steps SMS, demonstrates promise with regard to being a feasible, usable, and engaging method to deliver daily mental health support to individuals with symptoms of anxiety and depression.

Supporting women's health outcomes after breast cancer treatment comparing a text message intervention to usual care: the EMPOWER-SMS randomised clinical trial

PURPOSE

The aim of this study is to evaluate the efficacy, feasibility and acceptability of a co-designed lifestyle-focused text message intervention (EMPOWER-SMS) for breast cancer survivors' self-efficacy, quality of life (QOL), mental (anxiety, depression, stress) and physical (endocrine therapy medication adherence, physical activity, BMI) health.

METHODS

Single-blind randomised controlled trial (1:1) comparing EMPOWER-SMS to usual care at 6-months (intention-to-treat).

SETTING

public Breast Cancer Institute (Sydney, Australia).

ELIGIBILITY CRITERIA

adult (> 18 years) females, < 18-months post-active breast cancer treatment (stage I-III), owned a mobile phone, written informed consent.

PRIMARY OUTCOME

Self-Efficacy for Managing Chronic Disease Scale at 6 months. Process data: message delivery analytics, cost, and post-intervention survey.

RESULTS

Participants (N = 160; mean age ± SD 55.1 ± 11.1 years) were recruited 29th-March-2019 to 7th-May-2020 and randomised (n = 80 EMPOWER-SMS: n = 80 control). Baseline mean self-efficacy was high (I: 7.1 [95%CI 6.6, 7.5], C: 7.4 [7, 7.8]). Six-month follow-up: no significant differences between groups for self-efficacy (I: 7.6 [7.3, 7.9], C: 7.6 [7.3, 7.9], adjusted mean difference 0 (95%CI 0.4, 0.4), QOL, mental health, physical activity, or BMI. Significantly less EMPOWER-SMS participants missed ≥ 1 endocrine therapy medication doses compared to control (I: 3/42[7.1%], C: 8/47[17.0%], Adjusted RR 0.13 [95%CI 0.02, 0.91]). Text messages were delivered successfully (7925/8061, 98.3%), costing $13.62USD/participant. Participants strongly/agreed EMPOWER-SMS was easy-to-understand (64/64; 100%), useful (58/64; 90.6%), motivating for lifestyle change (43/64; 67.2%) and medication adherence (22/46; 47.8%).

CONCLUSION

EMPOWER-SMS was feasible, inexpensive, acceptable for delivering health information to breast cancer survivors between medical appointments, with minor improvements in medication adherence.

IMPLICATIONS FOR CANCER SURVIVORS

Text messages offer a feasible strategy for continuity-of-care between medical appointments.

Cognitive reappraisal in mHealth interventions to foster mental health in adults: a systematic review and meta-analysis

Background

An increasing number of mHealth interventions aim to contribute to mental healthcare of which interventions that foster cognitive reappraisal may be particularly effective.

Objectives

To evaluate the efficacy of mHealth interventions enhancing cognitive reappraisal to improve mental health in adult populations.

Methods

The literature search (four databases) yielded 30 eligible randomized controlled trials (comprising 3,904 participants). We performed a multi-level meta-analysis to examine differences between intervention and comparator conditions at post-intervention assessment. Moderator analyses were conducted for potential moderator variables (e.g., type of comparators).

Results

Most interventions were CBT-based with other training components in addition to cognitive reappraisal. We found preliminary evidence for a small to medium effect favouring mHealth interventions to enhance cognitive reappraisal over comparators, M(SMD) = 0.34, p = .002. When analysing single symptoms, there was evidence for a small to medium effect of mHealth interventions on anxiety and depressive symptoms, but not for psychological distress and well-being. All analyses showed substantial heterogeneity. Moderator analyses revealed evidence for more favourable effects in studies with passive comparators. There was an overall high risk of bias in most of the studies.

Conclusions

We found preliminary evidence for a small to medium effect of mHealth interventions including a cognitive reappraisal component to improve mental health. However, most of the interventions were complex (i.e., reappraisal was provided alongside other components), which prevents us from examining reappraisal-specific effects beyond general mental health promotion in mHealth. Dismantling studies examining the effects of single intervention components are warranted to corroborate these promising results.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=142149, identifier [CRD42019142149].

Text Messages Exchanged Between Individuals With Opioid Use Disorder and Their mHealth e-Coaches: Content Analysis Study

BACKGROUND

Opioid use disorder (OUD) has affected 2.2 million people in the United States. About 7.2 million people reported using illicit drugs in 2019, which contributed to over 70,000 overdose deaths. SMS text messaging interventions have been shown to be effective in OUD recovery. However, the interpersonal communication between individuals in OUD treatment and a support team on digital platforms has not been well examined.

OBJECTIVE

This study aims to understand the communication between participants undergoing OUD recovery and their e-coaches by examining the SMS text messages exchanged from the lens of social support and the issues related to OUD treatment.

METHODS

A content analysis of messages exchanged between individuals recovering from OUD and members of a support team was conducted. Participants were enrolled in a mobile health intervention titled "uMAT-R," a primary feature of which is the ability for patients to instantly connect with a recovery support staff or an "e-coach" via in-app messaging. Our team analyzed dyadic text-based messages of over 12 months. In total, 70 participants' messages and 1196 unique messages were analyzed using a social support framework and OUD recovery topics.

RESULTS

Out of 70 participants, 44 (63%) were between the ages of 31 and 50 years, 47 (67%) were female, 41 (59%) were Caucasian, and 42 (60%) reported living in unstable housing conditions. An average of 17 (SD 16.05) messages were exchanged between each participant and their e-coach. Out of 1196 messages, 64% (n=766) messages were sent by e-coaches and 36% (n=430) by participants. Messages of emotional support occurred the most, with 196 occurrences (n=9, 0.8%) and e-coaches (n=187, 15.6%). Messages of material support had 110 occurrences (participants: n=8, 0.7%; e-coaches: n=102, 8.5%). With OUD recovery topics, opioid use risk factors appeared in most (n=72) occurrences (patient: n=66, 5.5%; e-coach: n=6, 0.5%), followed by a message of avoidance of drug use 3.9% (n=47), which occurred mainly from participants. Depression was correlated with messages of social support (r=0.27; P=.02).

CONCLUSIONS

Individuals with OUD who had mobile health needs tended to engage in instant messaging with the recovery support staff. Participants who are engaged in messaging often engage in conversations around risk factors and avoidance of drug use. Instant messaging services can be instrumental in providing the social and educational support needs of individuals recovering from OUD.

Text4PTSI: A Promising Supportive Text Messaging Program to Mitigate Psychological Symptoms in Public Safety Personnel

BACKGROUND

Public safety personnel experience various mental health conditions due to their work's complex and demanding nature. There are barriers to seeking support and treatment; hence, providing innovative and cost-effective interventions can help improve mental health symptoms in public safety personnel.

OBJECTIVE

The study aimed to evaluate the impact of Text4PTSI on depression, anxiety, trauma, and stress-related symptoms, and the resilience of public safety personnel after six months of providing supportive text message intervention.

METHODS

Public safety personnel subscribed to Text4PTSI and received daily supportive and psychoeducational SMS text messages for six months. Participants were invited to complete standardized self-rated web-based questionnaires to assess depression, anxiety, posttraumatic stress disorder (PTSD), and resilience symptoms measured on the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 scale (GAD-7), Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C), and the Brief Resilience Scale (BRS), respectively. The assessment of mental health conditions was conducted at baseline (enrolment) and six weeks, three months, and six months after enrollment.

RESULTS

One hundred and thirty-one subscribers participated in the Text4PTSI program, and eighteen completed both the baseline and any follow-up survey. A total of 31 participants completed the baseline survey and 107 total surveys were recorded at all follow-up time points. The baseline prevalence of psychological problems among public safety personnel were as follows: likely major depressive disorder (MDD) was 47.1%, likely generalized anxiety disorder (GAD) was 37.5%, low resilience was 22.2%, and likely PTSD was 13.3%. At six months post-intervention, the prevalence of likely MDD, likely GAD, and likely PTSD among respondents reduced; however, a statistically significant reduction was reported only for likely MDD (-35.3%, X² (1) = 2.55, p = 0.03). There was no significant change in the prevalence of low resilience between baseline and post-intervention. There was a decrease in the mean scores on the PHQ-9, GAD-7, PCL-C, and the BRS from baseline to post-intervention by 25.8%, 24.7%, 9.5%, and 0.3%, respectively. However, the decrease was only statistically significant for the mean change in GAD-7 scores with a low effect size (t (15) = 2.73, p = 0.02).

CONCLUSIONS

The results of this study suggest a significant reduction in the prevalence of likely MDD as well as the severity of anxiety symptoms from baseline to post-intervention for subscribers of the Text4PTSI program. Text4PTSI is a cost-effective, convenient, and easily scalable program that can augment other services for managing the mental health burdens of public safety personnel.

Prospective associations of text-message-based sentiment with symptoms of depression, generalized anxiety, and social anxiety

OBJECTIVE

Language patterns may elucidate mechanisms of mental health conditions. To inform underlying theory and risk models, we evaluated prospective associations between in vivo text messaging language and differential symptoms of depression, generalized anxiety, and social anxiety.

METHODS

Over 16 weeks, we collected outgoing text messages from 335 adults. Using Linguistic Inquiry and Word Count (LIWC), NRC Emotion Lexicon, and previously established depression and stress dictionaries, we evaluated the degree to which language features predict symptoms of depression, generalized anxiety, or social anxiety the following week using hierarchical linear models. To isolate the specificity of language effects, we also controlled for the effects of the two other symptom types.

RESULTS

We found significant relationships of language features, including personal pronouns, negative emotion, cognitive and biological processes, and informal language, with common mental health conditions, including depression, generalized anxiety, and social anxiety (ps < .05). There was substantial overlap between language features and the three mental health outcomes. However, after controlling for other symptoms in the models, depressive symptoms were uniquely negatively associated with language about anticipation, trust, social processes, and affiliation (βs: -.10 to -.09, ps < .05), whereas generalized anxiety symptoms were positively linked with these same language features (βs: .12-.13, ps < .001). Social anxiety symptoms were uniquely associated with anger, sexual language, and swearing (βs: .12-.13, ps < .05).

CONCLUSION

Language that confers both common (e.g., personal pronouns and negative emotion) and specific (e.g., affiliation, anticipation, trust, and anger) risk for affective disorders is perceptible in prior week text messages, holding promise for understanding cognitive-behavioral mechanisms and tailoring digital interventions.

Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial

Background

The incidence of mental health disorders in Canada is increasing with costs of CAD $51 billion (US $40 billion) per year. Depression is the most prevalent cause of disability while cognitive behavioral therapy (CBT) is the best validated behavioral depression treatment. CBT, when combined with mindfulness meditation (CBT-M), has strong evidence for increased efficacy. While randomized controlled trials (RCTs) have demonstrated online CBT-M efficacy, comparisons with in-office delivery are lacking.

Objective

The aim of this research is to assess whether online group CBT-M (with standard psychiatric care) is non-inferior in efficacy and more cost-effective than office-based, on-site group CBT-M at post-intervention and 6-months follow-up in major depressive disorder. The study will also assess whether digitally recorded data (ie, online workbooks completed, Fitbit step count, and online text messages) predict depression symptom reduction in online participants.

Methods

This single-center, two-arm, noninferiority RCT employs assessor-blinded and self-report outcomes and economic evaluation. The research site is the Centre for Addiction and Mental Health (Toronto), a research-based psychiatry institution where participants will be identified from service wait lists and through contacts with other Toronto clinics. Inclusion criteria are as follows: (1) aged 18-60 years, any ethnicity; (2) Beck Depression Inventory-II (BDI-II) of mild severity (score ≥14) with no upper severity limit; (3) Mini-International Neuropsychiatric Interview-confirmed, psychiatric major depressive disorder diagnosis; (4) fluent in English. All patients are diagnosed by staff psychiatrists. Exclusion criteria are as follows: (1) receipt of weekly structured psychotherapy; (2) observation of Diagnostic and Statistical Manual of Mental Disorders (5th Edition) criteria for severe alcohol or substance use disorder (in past 3 months), borderline personality disorder, schizophrenia (or other primary psychotic disorder), bipolar disorder, or obsessive-compulsive disorder; (3) clinically significant suicidal ideation (imminent intent or attempted suicide in the past 6 months); and (4) treatment-resistant depression. All participants receive standard psychiatric care, experimental participants receive online group CBT-M, and controls receive standard care in-office group CBT-M. The online group program (in collaboration with NexJ Health, Inc) combines smartphone and computer-accessed workbooks with mental health phone counselling (16 hours in 16 weeks) that coordinates software interactions (eg, secure text messaging and Fitbit-tracked walking). The primary outcome is BDI-II, and secondary outcomes are anxiety (Beck Anxiety Inventory), depression (ie, Quick Inventory of Depressive Symptomatology and 17-item Hamilton Depression Rating Scale), mindfulness (Five-Facet Mindfulness Questionnaire), quality of life (European Quality of Life Five Dimension), and pain (Brief Pain Inventory).

Results

Based on prior studies with the BDI-II and 80% power to reject an inferiority hypothesis with a 1-sided type I error rate of 5%, a sample of 78 per group is adequate to detect small-to-medium–effect sizes.

Conclusions

This study assesses online CBT-M efficacy and noninferiority in relation to in-person CBT, and the cost-effectiveness of both interventions.

Trial Registration

ClinicalTrials.gov NCT04825535; https://www.clinicaltrials.gov/ct2/show/NCT04825535

International Registered Report Identifier (IRRID)

DERR1-10.2196/29726

Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews

BACKGROUND

The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation.

OBJECTIVE

The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.

METHODS

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach.

RESULTS

A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.

CONCLUSIONS

We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.12688/f1000research.27150.2.

Mobile phone-based interventions for mental health: A systematic meta-review of 14 meta-analyses of randomized controlled trials

Mobile phone-based interventions have been proposed as a means for reducing the burden of disease associated with mental illness. While numerous randomized controlled trials and meta-analyses have investigated this possibility, evidence remains unclear. We conducted a systematic meta-review of meta-analyses examining mobile phone-based interventions tested in randomized controlled trials. We synthesized results from 14 meta-analyses representing 145 randomized controlled trials and 47,940 participants. We identified 34 effect sizes representing unique pairings of participants, intervention, comparisons, and outcome (PICO) and graded the strength of the evidence as using umbrella review methodology. We failed to find convincing evidence of efficacy (i.e., n > 1000, p < 10^-6, I ² < 50%, absence of publication bias); publication bias was rarely assessed for the representative effect sizes. Eight effect sizes provided highly suggestive evidence (i.e., n > 1000, p < 10^-6), including smartphone interventions outperforming inactive controls on measures of psychological symptoms and quality of life (ds = 0.32 to 0.47) and text message-based interventions outperforming non-specific controls and active controls for smoking cessation (ds = 0.31 and 0.19, respectively). The magnitude of effects and strength of evidence tended to diminish as comparison conditions became more rigorous (i.e., inactive to active, non-specific to specific). Four effect sizes provided suggestive evidence, 14 effect sizes provided weak evidence, and eight effect sizes were non-significant. Despite substantial heterogeneity, no moderators were identified. Adverse effects were not reported. Taken together, results support the potential of mobile phone-based interventions and highlight key directions to guide providers, policy makers, clinical trialists, and meta-analysts working in this area.

Technological and Digital Interventions for Mental Health and Wellbeing: An Overview of Systematic Reviews

Background: Research increasingly shows how selective and targeted use of technology within care and welfare can have several advantages including improved quality of care and active user involvement.

Purpose: The current overview of reviews aims to summarize the research on the effectiveness of technology for mental health and wellbeing. The goal is to highlight and structure the diverse combinations of technologies and interventions used so far, rather than to summarize the effectiveness of singular approaches.

Methods: The current overview includes reviews published in the past five years with a focus on effectiveness of digital and technological interventions targeting mental health and wellbeing.

Results: A total of 246 reviews could be included. All reviews examined the effectiveness of digital and technological interventions in the context of care and welfare. A combination of two taxonomies was created through qualitative analysis, based on the retrieved interventions and technologies in the reviews. Review classification shows a predominance of reviews on psychotherapeutic interventions using computers and smartphones. It is furthermore shown that when smartphone applications as stand-alone technology are researched, the primary focus is on self-help, and that extended reality is the most researched emerging technology to date.

Conclusion: This overview of reviews shows that a wide range of interventions and technologies, with varying focus and target populations, have been studied in the field of care and wellbeing. The current overview of reviews is a first step to add structure to this rapidly changing field and may guide both researchers and clinicians in further exploring the evidence-base of particular approaches.

Text Messages in the Field of Mental Health: Rapid Review of the Reviews

BACKGROUND

While mental health problems constitute a worldwide concern contributing to the global rates of morbidity and mortality, conventional mental healthcare services do not meet the current needs. Text messages (TM) represent a live model that incorporates technology into health services, spanning a large number of health conditions and playing different roles that may support the current healthcare system.

OBJECTIVE

To examine the TM services in the field of mental health, regarding their effectiveness, feasibility, acceptability, and economic evaluation in different contexts of mental health diagnoses and during critical times, when provided to individuals with mental health symptoms/disorders.

METHODS

This rapid review was conducted through an online search in PubMed, Embase, PsycINFO, and Medline databases. The review targeted the review studies which examined online or mobile addiction and mental health services, utilizing TM services. The search was run from the inception up to September 30, 2021.

RESULTS

Sixty review articles met the inclusion criteria and were included in this review. All reviews were published over the last decade. The results showed that people of a young age were fairly represented, and most reviews were run over substance use disorders (SUD), including Alcohol. Most reviews examined the effectiveness outcomes of the texting service, while to a lesser extent the acceptability and feasibility, among others. Texting services were reported as effective in psychotic disorders and SUD. However, the results related to depression and anxiety were mixed. Most reviews reported a considerably high risk of bias among their included studies. High satisfaction and acceptability of the texting services were reported for patients with various mental health conditions, including those with severe mental illness.

CONCLUSIONS

This rapid review highlighted the applications, usability, benefits, and satisfaction with the TM in the field of mental health. For a higher quality of evidence, future studies should consider TM interventions in the contexts with mixed results or a dearth of literature, and during critical times, such as the COVID-19 pandemic. Policy- and decision-makers, therefore, need to further support text-based services with guided investments in interventions that were evidenced to be accepted, economic and feasible.

Methamphetamine use and technology-mediated psychosocial interventions: A mini-review

Engagement with face-to-face psychosocial interventions is often compromised in people using methamphetamine (MA), in the context of high rates of polysubstance use, mental health disorders, cognitive impairment and geographic isolation. Technology-mediated interventions offer flexible ways of engaging with treatment and are readily accessible. This mini-review evaluates evidence from eight studies for the effectiveness of telephone, mHealth (text-messaging and apps) and computer-based interventions for MA use. Two papers from one telephone counselling study showed a small improvement in MA-related outcomes, particularly for individuals in active use. However, a directive counselling style was associated with a higher likelihood of MA use during recovery for those higher in resistance to authority. Text-messaging interventions generally showed small but significant reductions in MA use in non-treatment seekers. When compared, there was no significant difference in level of MA use reduction between interactive, automated and self-monitoring text messages. Studies in other modalities (smartphone app, one trial; computer-based interventions, two trials) did not confer statistically significant reductions in MA use, though were likely impacted by app design and participant characteristics. Preliminary findings hint at the potential effectiveness of telephone counselling in aftercare and the capacity for text-messaging to reach those who are not in treatment. Given the small amount of existing literature, this review discusses the potential value of emerging interventions, the importance of adapting interventions to the characteristics of people who use MA and suggests specific directions for research in each technology modality.

Efficacité des applications mobiles et des messages textes comme intervention en cybersanté mentale pour les 3 blessures de stress opérationnel les plus fréquentes chez le personnel de la sécurité publique : une recension-cadre

Contexte La fréquence de diagnostic probable de trouble de santé mentale est beaucoup plus haute chez le personnel de la sécurité publique (PSP) que dans la population générale, ce qui s’explique entre autres par l’exercice des fonctions opérationnelles. Les blessures de stress opérationnelles (BSO) les plus fréquentes chez les PSP au Canada sont la dépression, le trouble de stress posttraumatique et le trouble d’anxiété généralisée. Par leur caractère confidentiel et accessible, les interventions en cybersanté mentale délivrées par des téléphones intelligents (interventions mobiles) offrent un fort potentiel chez les PSP. La Commission de la santé mentale du Canada a proposé des critères évaluatifs afin de faire un examen complet des interventions mobiles, qui dépasse l’examen scientifique de l’efficacité de l’outil.

Objectifs Cette recension-cadre vise d’abord à recenser les résultats des recensions systématiques et des méta-analyses qui portent sur l’évaluation des interventions mobiles visant à diminuer les symptômes reliés à au moins une BSO chez les PSP. Ensuite, nous évaluerons les interventions mobiles ayant été étudiées auprès de PSP à l’aide des critères évaluatifs proposés par la Commission de la santé mentale du Canada, afin d’établir si leur usage peut être recommandé.

Méthode Des termes en lien avec les BSO, les technologies mobiles et les interventions ont été utilisées dans les bases de données PubMed, PsycInfo et Embase. Les articles évaluant l’efficacité des interventions mobiles en lien avec au moins une BSO et desquels il était possible d’extraire les informations nécessaires à cette recension ont été retenus. Un examen des articles inclus dans les recensions retenues a été fait afin de repérer les études réalisées auprès d’un échantillon de PSP.

Résultats La recherche de la littérature n’a relevé aucune recension qui s’intéressait particulièrement aux PSP, ce pour quoi nous avons dû élargir notre recherche à la population générale. Neuf articles correspondent aux critères d’inclusion, lesquels ont été publiés entre 2016 et 2019. De manière générale, les interventions mobiles semblent réduire de manière significative les symptômes d’anxiété, de dépression et de stress posttraumatique. Deux interventions mobiles étudiées auprès de PSP ont été identifiées, et ces dernières remplissent la majorité des critères évaluatifs.

Conclusion Les interventions mobiles recensées dans la littérature offrent un fort potentiel auprès de la population générale et auprès des PSP. Toutefois, les méta-analyses et les recensions systématiques rapportent certaines limites importantes telles qu’une hétérogénéité entre les études et un taux d’abandon élevé. Les recherches futures sur les interventions mobiles destinées aux PSP gagneraient à investiguer davantage les aspects liés à l’ergonomie, la désirabilité pour l’utilisateur et la sécurité des renseignements personnels. Les échantillons devraient également inclure une plus grande variété de professions liées à la sécurité publique.

A mixed-method systematic review of text-based telehealth interventions in eating disorder management

Purpose

Eating disorders (EDs) is a major health condition affecting 9% of the global population and 10% of those with EDs lost their lives as a result. Text-based telehealth interventions (TTIs) seem to provide a low-cost and convenient treatment option; however, the evidence is scarce. This study aimed to synthesize evidence relating to the use of TTIs for the management of EDs.

Design/methodology/approach

Five databases were searched published between January 2020 and May 2019. The authors used keywords relating to telehealth and EDs. The authors used Joanna Briggs Institute's (JBI's) critical appraisal instrument to assess the methodology quality of included studies.

Findings

Fifteen studies were included in this mix-method systematic review and assessed for methodology quality. Email, web-based texting, text-messaging and online chat room were used as mode for deliver healthcare for patients with EDs. In the treatment phase, all studies (nine studies; n = 860 participants) showed effectiveness (for RCTs) and usefulness (for non-RCT studies). In the aftercare phase (six studies; n = 364 participants), the results regarding the effectiveness of TTIs were mixed. Two studies showed effectiveness whilst four studies did not find statistically significant change of ED outcomes.

Research limitations/implications

The qualities of these studies varied; firstly, 66% (n = 10) of the studies were non-randomized studies (e.g. single-arm trial, case report) with small samples. Moreover, one-fourth (n = 4) of the studies did not use validated instruments or indicate the instrument. Also, half (n = 7) of the studies used TTIs as adjunct to face-to-face treatment or bigger online treatment, it is hard to make conclusion that the changes were due to TTIs' effect. In addition, follow-up rate is not satisfactory, thus results should be interpreted cautiously.

Practical implications

TTIs seem to be promising for management of EDs, particularly in the treatment phase. This provides an important treatment option for health practitioners and people with EDs as an alternative or in adjunct with face-to-face services.

Originality/value

This is the first review to synthesis the use of TTIs for ED management.

Effectiveness of clinical decision support systems and telemedicine on outcomes of depression: a cluster randomized trial in general practice

BACKGROUND

Computerized Clinical Decision Support Systems (CCDSS) are information technology tools, designed to improve clinical decision-making. Telemedicine is a health care service delivery using videoconferencing, telephone or messaging technologies.

OBJECTIVES

Our project aimed at testing the effectiveness of a composite CCDSS and telemedicine approach designed to treat depression in primary care.

METHODS

This cluster randomized trial involved four GP clinics located in Northern Italy. Two clinics were assigned to the experimental protocol, and two served as controls. The study compared the telemedicine group (TG), in which GPs had access to a CCDSS platform, with the control group (CG) in which GPs provided treatment as usual (TAU). Patients scoring ≥11 on Patient Heath Questionnaire and ≥26 on the Inventory of Depressive Symptomatology-Self-Report were eligible for participation. Patients were also administered the World Health Organization Quality of Life-BREF to assess quality of life and Medical Interview Satisfaction Scale 21 to assess satisfaction with the medical interview.

RESULTS

Overall, 2810 patients were screened and 66 in the experimental group and 32 in the CG passed the screening stages and met inclusion criteria. The percentage of remitters at 6 months was significantly higher in the TG than in the CG group (24.1% versus 3.1%, χ 2 = 6.6, P = 0.01). This difference remained significant after adjusting for baseline confounders. Physical and psychological quality of life improved significantly from baseline in both groups. Patients reported, on average, good satisfaction with the medical interview.

CONCLUSIONS

Our study showed that a combined CCDSS and telemedicine approach may be more effective than the TAU offered by GPs to patients with depression.

TRIAL REGISTRATION

The trial was registered on https://clinicaltrials.gov/ on 5 October 2012 with identifier: NCT01701791. The first participant was enrolled on 5 May 2014 and the study was completed on May 2016.

Development of a framework for the implementation of synchronous e-mental health: a protocol for a realist synthesis of systematic reviews

Background: During the COVID-19 pandemic, it has been necessary to deliver mental health care using technologies (e-mental health). But there have been difficulties in its application. Quantitative systematic reviews such as meta-analysis doesn't allow us to fully identify and properly describe this subject. Thus, our study has two main objectives: a) "to determine what evidence is available for synchronous e-mental health implementation"; and b) "to develop a framework informed by a realist analysis for the implementation of synchronous e-mental health". Methods: We will search MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020, with no language restriction. A systematic review with a narrative description and a realist synthesis will be conducted. Primary studies relating to adults with common mental health problems using any type of mobile mental health intervention that includes a synchronic component and communication with a mental health professional will be included. For the analysis, we will make a realist synthesis of the systematic reviews, using a grounded theory approach with an emergent approach to synthesize the information, prioritizing the systematic reviews with a lower risk of bias in the AMSTAR-2 tool. The realist synthesis will be based on the interpretation, integration, and inference of the evaluated elements and the generation of hypotheses to better understand the implementation process of synchronous e-mental health. Finally, we will present the overall assessment in a Summary of Qualitative Findings table. Conclusion: Our results will allow a better understanding of the facilitator and limitations in implementing e-mental health.

Development of a framework for the implementation of electronic interventions in mental health: a protocol for a meta-synthesis of systematic reviews

Background: During the COVID-19 pandemic, it has been necessary to incorporate technologies in the care of mental health problems. But there have been difficulties in the application of technology-based interventions in mental health. Some quantitative systematic reviews don't allow us to fully identify and properly describe this subject. In order to answer the question "how do electronic interventions apply in mental health and what makes the application of any of these interventions work", this study will carry out an overview of systematic reviews, which will make it possible to develop a theoretical framework on the implementation of electronic care in mental health problems. Methods: We will search MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020, with no language restriction. We will follow a qualitative method approach and include systematic reviews that assess primary studies relating to adults with common mental health problems using any type of mobile mental health intervention that includes a synchronic component and communication with a mental health professional. For the analysis, we will make a meta-synthesis of the systematic reviews, using an emergent grounded theory approach to synthesize the information, prioritizing the systematic reviews with the lowest risk of bias in the AMSTAR-2 tool. The meta-synthesis will be based on interpreting, integrating, and inferring the evaluation elements to understand better the e-health implementation process for patients with mental health problems. Finally, we will present the overall assessment in a Summary of Qualitative Findings table. Conclusion: Our results will allow a better understanding of the facilitator and limitations in implementing e-health interventions for mental health problems.

A Literature Review Comparing Clinicians' Approaches and Skills to In-Person, Synchronous, and Asynchronous Care: Moving Toward Competencies to Ensure Quality Care

Introduction: Research is increasing on asynchronous technologies used by specialist clinicians and primary care, including e-mail, text, e-consultation, and store-and-forward (asynchronous) options. Studies typically describe interventions and care outcomes rather than development of clinical skills for using technology. Methods: This article attempts to compare clinicians' approaches to, and skills for, asynchronous technologies versus in-person and synchronous (i.e., video) care. Literature from technology, health care, pedagogy, and business were searched from 2000 to 2019 for title words, including synchronous (e.g., video, telemental or behavioral health, telepsychiatry), asynchronous (e.g., app, e-consultation, e-mail, text, sensor in a wearable device), education, clinical, and consultation. Results: From a total of 4,812 potential references, two authors (D.M.H., J.T.) found 4,622 eligible for full text review and found 381 articles directly relevant to the concept areas in combination for full text review. However, exclusion criteria subtracted 305, leaving a total of 76 articles. While in-person and synchronous care are similar in many ways, the clinical approach to asynchronous care has many differences. As asynchronous technologies and models of care are feasible and effective, often for consultation, an outline of patient, primary care provider, and specialist clinician goals and skills are presented. Few studies specifically discuss skills or competencies for asynchronous care, but components from published clinical informatics, video, social media, and mobile health competencies were organized into Accreditation Council of Graduate Medical Education domains. Conclusions: Further implementation of science research is needed for asynchronous technology interventions, as well as clinician competencies using asynchronous technologies, to ensure optimal outcomes for patients in health care.