Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression

Depression Self-Care Apps' Characteristics and Applicability to Older Adults: Systematic Assessment

BACKGROUND

Depression affects 32% of older adults. Loneliness and social isolation are common risk factors for depression in older adults. Mobile apps can connect users and are also effective in depression management in the general population. However, older adults have specific needs in terms of the content of depression self-care interventions and their accessibility. It remains unknown whether existing apps for depression self-care are applicable to older adults.

OBJECTIVE

The initial aim of this assessment was to systematically identify interactive depression self-care apps specifically designed for older adults. As we did not find any, we assessed the applicability of existing depression self-care apps to the needs of older adult users.

METHODS

Using an established app assessment methodology, we searched for Android and iOS interactive mental health apps providing self-care for depression in English and Chinese in the 42Matters database, Chinese Android app stores, and the first 10 pages of Google and Baidu. We developed an assessment rubric based on extensive revision of the literature. The rubric consisted of the following sections: general characteristics of the apps (eg, developer, platform, and category), app content (eg, epidemiology and risk factors of depression in older adults, techniques to improve mood and well-being), and technical aspects (eg, accessibility, privacy and confidentiality, and engagement).

RESULTS

We identified 23 apps (n=19, 82.6%, English and n=4, 17.4%, Chinese apps), with 5 (21.7%) iOS-only apps, 3 (13%) Android-only apps, and 15 (65.2%) apps on both platforms. None specifically targeted older adults with depression. All apps were designed by commercial companies and were free to download. Most of the apps incorporated cognitive behavior therapy, mood monitoring, or journaling. All but 3 (13%) apps had a privacy and confidentiality policy. In addition, 14 (60.9%) apps covered depression risk factors in older adults, and 3 (13%) apps delivered information about depression epidemiology in older adults via a chatbot. Furthermore, 17 (73.9%) apps mentioned other topics relevant to older adults, such as pain management, grief, loneliness, and social isolation. Around 30% (n=7) of the apps were supported by an online forum. Common accessibility issues included a lack of adaptations for users with visual or hearing impairments and incompatibility with larger font sizes in the phone settings.

CONCLUSIONS

There are no depression apps developed specifically for older adults. Available mobile apps have limited applicability to older adults in terms of their clinical and technical features. Depression self-care apps should aim to incorporate content relevant to older adults, such as grief and loss; include online communities; and improve accessibility to adapt to potential health impairments in older adults.

Smartphone apps for mental health: systematic review of the literature and five recommendations for clinical translation

OBJECTIVES

Providing adequate access to mental health services is a global challenge. Smartphone apps offer a potentially cost-effective, available and accessible solution for monitoring, supporting and treating mental health conditions. This systematic review describes and evaluates the usage of smartphone apps across a wide range of mental health disorders in terms of clinical effectiveness, feasibility and acceptability.

DESIGN

This is a systematic review of studies examining treatment, self-monitoring and multipurpose smartphone apps for mental health disorders.

DATA SOURCES

Studies were identified through a comprehensive search of the Ovid and PubMed databases. Articles published up to 14 January 2024 were included based on predefined criteria.

ELIGIBILITY CRITERIA

We included randomised controlled trials that compared mental health apps (single- or multipurpose) with treatment-as-usual or no treatment for clinical populations with mental health disorders. Studies were excluded if they focused on web-based interventions, combined apps with non-TAU treatments or targeted physical health apps.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and selected studies, with a third reviewer resolving inconsistencies. Extracted data included study details, participant characteristics, app information and outcome measures related to effectiveness, feasibility and acceptability. A risk-of-bias assessment for each study was conducted.

RESULTS

Out of 4153 non-duplicate articles screened, 31 studies met full-text eligibility criteria. These included 6 studies on treatment apps, 4 on self-monitoring apps and 21 on multipurpose apps for a range of mental health disorders. Fifteen were identified as having between some and high concern on the risk-of-bias assessment. While smartphone apps were generally effective and acceptable, their feasibility appeared to decline over time.

CONCLUSIONS

Smartphone apps are promising tools for mental healthcare, demonstrating effectiveness and acceptability. However, challenges such as reduced feasibility over time, potential biases and underrepresented demographics require further research. This review proposes five recommendations for improving clinical translation in future studies.

A Web-Based Resource Informed by Cognitive Behavioral Therapy and Positive Psychology to Address Stress, Negative Affect, and Problematic Alcohol Use: A Usability and Descriptive Study

Background

Research documents that drinking to cope behavior can be disrupted by enhancing emotion regulation and coping skills related to the experience of stress and negative affect. The Alpha Element Self-Coaching Plan incorporates principles of positive psychology and cognitive behavioral therapy to redirect negative thinking and emotions and, therefore, has the potential to benefit individuals who use alcohol to cope with stress.

Objective

This study aimed to evaluate satisfaction and usability of the web-based Alpha Element Self-Coaching Plan in order to inform the development of an expanded digital platform based on the Alpha Element framework.

Methods

Participants enrolled in the web-based program as part of their clinical care were eligible to participate. A total of 20 individuals (14 women and 6 men) between ages 30 and 79 (mean 54.5, SD 14.14) years completed web-based questionnaires to assess product performance in areas such as ease of technology use, quality of videos and handouts, and the value of the activities. Participants also completed the System Usability Scale (SUS) and provided background and demographic information, including alcohol use.

Results

Only 1 participant reported no alcohol use in the past year; 55% (11/20) of participants drank alcohol 2-4 times per month or less and 45% (9/20) reported drinking alcohol 2-3 times per week or more. The average SUS score of 76.38 (SD 17.85) was well above the commonly accepted threshold of 68, indicating high system usability. A majority of the sample (16/19, 84%) agreed or strongly agreed that the activities in the program inspired behavioral changes; and most agreed or strongly agreed that the program was engaging (16/20, 80%), well-organized (18/20, 90%), and easy to follow (17/20, 85%). Only 2 participants endorsed experiencing difficulty using the program on a smartphone. Suggestions for program improvements included expanding the platform, updating the web format, adding user interactivity, and enhancing navigation.

Conclusions

These data suggest that participants were generally satisfied with the web-based Alpha Element Self-Coaching Plan, and rated usability of the program as favorable. Importantly, a significant portion of participants reported that the program inspired behavioral changes. More research is needed with a larger sample to obtain specific data about alcohol consumption and investigate associations between alcohol use and program components, as well as examine gender differences. Data collected from this study will be used to expand the platform and improve user experience.

Feasibility and Acceptability of Digital Behavioral Interventions Among Black and Hispanic Patients With Inflammatory Bowel Disease: A Randomized Pilot Study

The use of digital behavioral interventions was tested among patients with inflammatory bowel disease with a predominately low-income, Black/Hispanic background who had elevated symptoms of anxiety/depression. Both mood-tracking and cognitive behavioral self-management applications were feasible and acceptable to use, with opportunities for improvement identified.

Naturalistic use of a digital mental health intervention for depression and anxiety: A randomized clinical trial

BACKGROUND

Digital mental health interventions (DMHI) may offer scalable treatment for common mental health conditions. However, many commercially available apps have not been subjected to rigorous evaluation of effectiveness, particularly among users experiencing clinically significant symptomatology. We examined depression and anxiety symptom outcomes associated with a top-rated, commercially available self-guided DMHI based on cognitive behavioral therapy ("Sanvello") relative to waitlist control.

METHODS

This preregistered web-based, 2-arm, parallel-group randomized trial enrolled U.S. adults with self-reported elevated symptoms of depression and/or anxiety. Those assigned to the treatment condition were provided 8 weeks of access to Sanvello. Co-primary outcomes of depression (Patient Health Questionnaire [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-item scale [GAD-7]) severity were assessed at baseline and 2, 4, 6, and 8 weeks.

RESULTS

Intention-to-treat analyses included 280 participants (mean age 32.47 ± 9.32 years; 86.1 % women). Generalized linear mixed models showed a significant improvement in depression (F(4,779) = 6.51, p < .001) and anxiety (F(4,907) = 3.28, p = .01) associated with the DMHI over time. The intervention was also associated with a greater proportion of participants exhibiting depression response (25 [45.5 %] vs 26 [16.9 %]) and remission (10 [18.2 %] vs 7 [4.5 %]) on the PHQ-9, and anxiety response (31 [44.9 %] vs 39 [22.8 %]) and remission (20 [29.0 %] vs 27 [15.8 %]) on the GAD-7, relative to waitlist.

LIMITATIONS

Findings may not represent people with serious mental illness, suicidality, or the broader population of DMHI users.

CONCLUSIONS

A commercially available, self-guided DMHI was effective at improving symptoms in individuals experiencing depression or anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov [NCT05373329].

Systematic review and meta-analysis of adverse events in clinical trials of mental health apps

Mental health apps are efficacious, yet they may pose risks in some. This review (CRD42024506486) examined adverse events (AEs) from mental health apps. We searched (May 2024) the Medline, PsycINFO, Web of Science, and ProQuest databases to identify clinical trials of mental health apps. The risk of bias was assessed using the Cochrane Risk of Bias tool. Only 55 of 171 identified clinical trials reported AEs. AEs were more likely to be reported in trials sampling schizophrenia and delivering apps with symptom monitoring technology. The meta-analytic deterioration rate from 13 app conditions was 6.7% (95% CI = 4.3, 10.1, I2 = 75%). Deterioration rates did not differ between app and control groups (OR = 0.79, 95% CI = 0.62-1.01, I2 = 0%). Reporting of AEs was heterogeneous, in terms of assessments used, events recorded, and detail provided. Overall, few clinical trials of mental health apps report AEs. Those that do often provide insufficient information to properly judge risks related to app use.

Efficacy of mental health smartphone apps on stress levels: a meta-analysis of randomised controlled trials

The management of stress has evolved in recent years due to widespread availability of mobile-device applications (apps) and their capacity to deliver psychological interventions. We evaluated the efficacy of mental health apps on stress and sought to identify characteristics associated with effect size estimates. Sixty-nine randomised controlled trials (RCTs) were included. Random effects meta-analyses were performed and putative moderators were examined at univariate and multivariate (combinations and interactions) levels. From 78 comparisons, we observed a small but significant pooled effect of apps over control conditions on perceived stress levels (g = 0.27; 95% CI = 0.20, 0.34; I2 = 68%). This effect weakened after taking into account small-study bias according to the trim-and-fill procedure (g = 0.10; 95% CI = 0.02, 0.19; I2 = 78%). Delivery of apps with stress monitoring features produced smaller efficacy estimates, although this association interacted with other trial features (small sample size and inactive control group) in multivariate analyses, suggesting that this effect may have been explained by features characteristic of low-quality trials. Mental health apps appear to have small, acute effects on reducing perceived stress. Future research should shift focus towards identifying change mechanisms, longitudinal outcomes, features that facilitate sustained app usage, and tangible pathways to integrating apps into real-world clinical settings.

Examining efficacy and potential mechanisms of mindfulness-based cognitive therapy for anxiety and stress reduction among college students in a cluster-randomized controlled trial

The pervasiveness of anxiety and stress among college students necessitates the investigation of potential alternative and accessible interventions which can be implemented into existing curricular and student-support programming to improve students' mental health. Mindfulness based cognitive therapy (MBCT) smartphone applications have shown promising outcomes in alleviating anxiety and stress. However, it is essential to gain insight into the feasibility and efficacy of such an interventional approach in a collegiate population, as well as explore potential underlying mechanisms, which could be better targeted to enhance the efficacy of future interventions for promoting mental health and well-being. The aims for this study were (1) to assess the efficacy of a 4-week MBCT intervention using the Sanvello smartphone application in reducing trait-level anxiety and chronic stress in college-aged young adults (n = 150) compared to a positive control group (n = 139), and (2) to examine potential mediators of this effect. Participants completed assessments of trait anxiety, chronic stress, cognitive reappraisal, cognitive refocusing, distractive refocusing, and negative automatic thoughts at pretest and following 4 weeks of the interventions. Analysis of primary outcomes revealed greater reductions in trait anxiety and chronic stress for the MBCT group, relative to the positive control group with small to moderate effect sizes. The anxiolytic and stress-reducing effects of the MBCT intervention were observed to be mediated by changes in negative automatic thoughts but not by changes in cognitive reappraisal, constructive refocusing, or distractive refocusing. Given the efficacy of the Sanvello smartphone application and the overwhelmingly strong assessments of the appropriateness and feasibility of it use; student support initiatives may be well served by adopting such a platform within the context of first-line treatment and prevention of high anxiety and chronic stress within first year college students. Registered at ClinicalTrials.gov [number NCT06019299].

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Opportunities and challenges in leveraging digital technology for mental health system strengthening: a systematic review to inform interventions in the United Arab Emirates

Digital technology offers scalable, real-time interventions for mental health promotion and treatment. This systematic review explores the opportunities and challenges associated with the use of digital technology in mental health, with a focus on informing mental health system strengthening interventions in the United Arab Emirates (UAE). Following PRISMA guidelines, a systematic search of databases was conducted up to August 2023 and identified a total of 8479 citations of which 114 studies were included in the qualitative analysis. The included studies encompass diverse digital interventions, platforms, and modalities used across various mental health conditions. The review identifies feasible, acceptable, and efficacious interventions, ranging from telehealth and mobile apps to virtual reality and machine learning models. Opportunities for improving access to care, reducing patients' transfers, and utilizing real-world interaction data for symptom monitoring are highlighted. However, challenges such as digital exclusion, privacy concerns, and potential service replacement caution policymakers. This study serves as a valuable evidence base for policymakers and mental health stakeholders in the UAE to navigate the integration of digital technology in mental health services effectively.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Effects of comprehensive nursing with cognitive behavioral therapy in orthodontic osteodilated arch treatment

BACKGROUND

This work explored the effects of cognitive behavior therapy (CBT)-based comprehensive nursing intervention (CNI) mode in arch expansion to treat patients with orthodontic osteodilated arch (OOA).

AIM

To explore the application effect of CBT-based CNI model in orthodontic expansion arch treatment.

METHODS

Using convenient sampling method, 81 patients with OOA were selected and rolled into a control group (Ctrl group, 40 cases) and an observation group (Obs group, 41 cases). During the treatment, patients in the Ctrl group received routine nursing intervention mode, and the those in the Obs group received CBT mode on the basis of this. Before and after intervention, the incidence of oral mucositis, the mastery rate of correct arch expansion method, self-rating anxiety scale score, soft scale index, and plaque index were compared for patients in different groups. In addition, satisfaction and complications were comparatively analyzed.

RESULTS

Incidence of oral mucositis in the Obs group was lower (14.6% vs 38.5%), and the mastery rate of correct arch expansion method was obviously higher (90.2% vs 55.0%) was obviously higher (all P < 0.05). Meanwhile, the soft scale index and plaque index in the Obs group were much lower (P < 0.05). The compliance (90.24%) and satisfaction (95.12%) in the Obs group were greatly higher (P < 0.05).

CONCLUSION

The CBT-based CNI mode greatly improved the mastery rate of correct arch expansion method during arch expansion in treating patients with OOA and enhanced the therapeutic effect of arch expansion and the oral health of patients, improving the patient compliance.

Guided self-help mindfulness-based intervention for increasing psychological resilience and reducing job burnout in psychiatric nurses: A randomized controlled trial

AIMS

The present study aimed to explore the effects of a guided self-help mindfulness intervention on psychological resilience and job burnout among psychiatric nurses.

BACKGROUND

Psychiatric nurses work in challenging and potentially high stress settings. Mindfulness interventions can improve psychological resilience and reduce job burnout of nurses. However, face-to-face delivery of mindfulness interventions may be inconvenient for individuals. Guided self-help interventions may be more accessible.

METHODS

This randomized controlled trial was conducted from January to August 2022. One hundred and eighteen psychiatric nurses were randomized into the intervention and control groups. The individuals in the intervention group received an 8-week guided self-help mindfulness intervention, while the individuals in the control group received a psycho-educational brochure. The Five Facet Mindfulness Questionnaire, the Connor-Davidson Resilience Scale and the Maslach Burnout Inventory-Human Services Survey were used to evaluate the levels of mindfulness, psychological resilience and job burnout, respectively.

RESULTS

After an 8-week intervention, compared with the control group, the levels of mindfulness and psychological resilience were higher, while the level of job burnout was lower in the intervention group.

CONCLUSIONS

The guided self-help mindfulness intervention can improve psychological resilience and reduce job burnout among psychiatric nurses.

Feasibility and Acceptability of a Mobile App-Based TEAM-CBT (Testing Empathy Assessment Methods-Cognitive Behavioral Therapy) Intervention (Feeling Good) for Depression: Secondary Data Analysis

BACKGROUND

The Feeling Good App is an automated stand-alone digital mobile mental health tool currently undergoing beta testing with the goal of providing evidence-informed self-help lessons and exercises to help individuals reduce depressive symptoms without guidance from a mental health provider. Users work through intensive basic training (IBT) and ongoing training models that provide education regarding cognitive behavioral therapy principles from a smartphone.

OBJECTIVE

The key objective of this study was to perform a nonsponsored third-party academic assessment of an industry-generated data set; this data set focused on the safety, feasibility, and accessibility of a commercial automated digital mobile mental health app that was developed to reduce feelings associated with depression.

METHODS

The Feeling Good App development team created a waitlist cohort crossover design and measured symptoms of depression and anxiety using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and an app-specific measure of negative feelings called the 7 Dimension Emotion Slider (7-DES). The waitlist cohort crossover design divided the participants into 2 groups, where 48.6% (141/290) of the participants were given immediate access to the apps, while 51.4% (149/290) were placed on a 2-week waitlist before being given access to the app. Data collected by the Feeling Good App development team were deidentified and provided to the authors of this paper for analysis through a nonsponsored university data use agreement. All quantitative data were analyzed using SPSS Statistics (version 28.0; IBM Corp). Descriptive statistics were calculated for demographic variables. Feasibility and acceptability were descriptively assessed. All participants included in the quantitative data were given access to the Feeling Good App; this study did not include a control group.

RESULTS

In terms of safety, there was no statistically significant change in suicidality from preintervention to postintervention time points (t288=0.0; P>.99), and there was a statistically significant decrease in hopelessness from preintervention to postintervention time points (F289=30.16; P<.01). In terms of acceptability, 72.2% (166/230) of the users who started the initial 2-day IBT went on to complete it, while 34.8% (80/230) of the users who started IBT completed the entirety of the apps' 4-week protocol (150/230, 65.22% dropout rate over 4 weeks).

CONCLUSIONS

This study is the first reported proof-of-concept evaluation of the Feeling Good App in terms of safety, feasibility, and statistical trends within the data set. It demonstrates a feasible and novel approach to industry and academic collaboration in the process of developing a digital mental health technology translated from an existing evidence-informed treatment. The results support the prototype app as safe for a select nonclinical population. The app had acceptable levels of engagement and dropouts throughout the intervention. Those who stay engaged showed reductions in symptom severity of depression warranting further investigation of the app's efficacy.

The clinical effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: results from a multicenter, pragmatic randomized controlled trial

BACKGROUND

Persistent depressive disorder (PDD) is prevalent and debilitating. For patients with PDD, psychiatric rehabilitation using self-management interventions is advised as the next therapeutic step after multiple unsuccessful treatment attempts. The "Patient and Partner Education Program for All Chronic Diseases" (PPEP4All) is a brief, structured self-management program that focuses on functional recovery for patients and their partners/caregivers. In chronic somatic disorder populations, PPEP4All has already been shown to be clinically effective. We examined whether PPEP4All adapted for PDD (PPEP4All-PDD, nine weekly group or individual sessions) is also clinically effective for adults/elderly with PDD and their partners/caregivers compared to care-as-usual (CAU) in specialized mental healthcare.

METHODS

In this mixed-method multicenter pragmatic randomized controlled trial, 70 patients with PDD and 14 partners/caregivers were allocated to either PPEP4All-PDD (patients, n = 37; partners/caregivers, n = 14) or CAU (patients, n = 33; partners/caregivers, not included) and completed questionnaires at 0, 3, 6, and 12 months regarding depressive symptoms, psychopathology, psychosocial burden, mental resilience, and happiness/well-being. Qualitative data were collected regarding treatment satisfaction. Data were analyzed using mixed model analyses and an intention-to-treat (ITT) approach.

RESULTS

There was no statistically significant difference in any outcome regarding clinical effectiveness between PPEP4All-PDD and CAU. Subgroup analysis for depressive symptoms did not show any interaction effect for any subgroup. Although 78% of participants recommended PPEP4All-PDD, there was no difference in treatment satisfaction between PPEP4All-PDD (score = 6.6; SD = 1.7) and CAU (score = 7.6; SD = 1.2), p = 0.06.

CONCLUSION

Although depressive symptoms did not improve relative to CAU, this only confirmed that treatment for patients with treatment-resistant PDD should move from symptom reduction to functional recovery. Also, functional recovery may be reflected in other outcomes than psychosocial burden, such as self-empowerment, in patients with treatment-resistant PDD. Future research on PPEP4All-PDD could focus on a longer-term program and/or online program that may also be offered earlier in the treatment process as an empowerment intervention.  TRIAL REGISTRATION: Netherlands Trial Register Identifier NL5818. Registered on 20 July 2016 https://clinicaltrialregister.nl/nl/trial/20302.

Longitudinal assessment of psychological distress and its determinants in a sample of firefighters based in Montreal, Canada

Introduction

Firefighters face elevated risks of common mental health issues, with distress rates estimated at around 30%, surpassing those of many other occupational groups. While exposure to potentially traumatic events (PTEs) is a well-recognized risk factor, existing research acknowledges the need for a broader perspective encompassing multidimensional factors within the realm of occupational stress. Furthermore, this body of evidence heavily relies on cross-sectional studies. This study adopts an intensive longitudinal approach to assess psychological distress and its determinants among firefighters.

Methods

Participants were recruited from 67 fire stations in Montreal, Canada, meeting specific criteria: full-time employment, smartphone ownership, and recent exposure to at least one PTE, or first responder status. Subjects underwent a telephone interview and were directed to use an app to report depressive, post-traumatic, and generalized anxiety symptoms every 2 weeks, along with work-related stressors, social support, and coping styles. Analyses involved 274 participants, distinguishing between those exceeding clinical thresholds in at least one distress measure (the "distressed" subgroup) and those deemed "resilient." The duration and onset of distress were computed for the distressed group, and linear mixed models were employed to evaluate determinants for each psychological distress variable.

Results

Clinical psychological distress was observed in 20.7% of participants, marked by depressive, post-traumatic, and anxiety symptoms, often within the first 4-week reference period. Contextual factors (operational climate, social support, solitude) and individual factors (coping style, solitude and lifetime traumatic events in private life) exhibited more significant impacts on psychological distress than professional pressures within the firefighters' work environment.

Discussion

This study reports lower rates of psychological distress than previous research, possibly attributable to sample differences. It highlights that reported symptoms often represent a combined and transient layer of distress rather than diagnosable mental disorders. Additionally, determinants analysis underscores the importance of interpersonal relationships and coping mechanisms for mental health prevention interventions within this worker group. The findings carry implications for the development of prevention and support programs for firefighters and similar emergency workers.

The efficacy of mindfulness apps on symptoms of depression and anxiety: An updated meta-analysis of randomized controlled trials

Mindfulness apps have become popular tools for addressing symptoms of depression and anxiety. Since the publication of earlier meta-analyses evaluating the efficacy of mindfulness apps for depression and anxiety symptoms, over 20 randomized controlled trials (RCTs) have been conducted. There is a need for an updated meta-analysis that quantifies the effects of mindfulness apps on these symptoms and tests for potential moderators.. Random effects meta-analyses were conducted on 45 RCTs. Small, significant effect sizes were found for symptoms of depression (Ncomp = 46, N = 5852, g = 0.24, 95% CI = 0.17, 0.31, NNT = 13.57) and anxiety (Ncomp = 48, N = 6082, g = 0.28, 95% CI = 0.21, 0.35, NNT = 11.47) in favour of mindfulness apps over control groups. This effect was not explained by symptom deterioration in participants allocated to control groups. Effects remained stable when restricting analyses to lower risk of bias and larger sample trials. No significant moderators were observed, except trials that offered monetary compensation produced larger effects on depression. Non-significant effects were observed when comparing mindfulness apps to active therapeutic comparisons (g = -0.15 depression, g = 0.10 anxiety), though the number of studies was low. Growing evidence indicates that mindfulness apps can acutely reduce symptoms of depression and anxiety, although higher quality studies with longer follow-ups are needed.

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].

Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis

OBJECTIVE

To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies.

METHODS

A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558.

RESULTS

From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT.

LIMITATIONS

Uneven quality of literature, simple network, and subjective judgment.

CONCLUSION

Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

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.

Efficacy of stand-alone digital mental health applications for anxiety and depression: A meta-analysis of randomized controlled trials

BACKGROUND

Anxiety and depressive disorders affect 20% of the population, cause functional impairment, and represent a leading cause of disability. Although evidence-based treatments exist, the shortage of trained clinicians and high demand for mental health services have resulted in limited access to evidence-based care. Digital mental health applications (DMHA) present innovative, scalable, and sustainable solutions to address disparities in mental health care.

METHODS

The present study used meta-analytic techniques to evaluate the therapeutic effect of DMHAs in randomized controlled trials (RCTs) for individuals experiencing anxiety and/or depressive symptoms. Search terms were selected based on concepts related to digital mental health applications, mental health/wellness, intervention type, trial design, and anxiety and/or depression symptoms/diagnosis outcomes to capture all potentially eligible results. Potential demographic, DMHA, and trial design characteristics were examined as moderators of therapeutic effects.

RESULTS

Random effects meta-analyses found that stand-alone DMHAs produced a modest reduction in anxiety (g = 0.31) and depressive (g = 0.35) symptom severity. Several moderators influenced the therapeutic effects of DMHAs for anxiety and/or depressive symptoms including treatment duration, participant inclusion criteria, and outcome measures.

LIMITATIONS

Minimal information was available on DMHA usability and participant engagement with DMHAs within RCTs.

CONCLUSIONS

While DMHAs have the potential to be scalable and sustainable solutions to improve access and availability of evidence-based mental healthcare, moderator analyses highlight the considerations for implementation of DMHAs in practice. Further research is needed to understand factors that influence therapeutic effects of DMHAs and investigate strategies to optimize its implementation and overcome the extant research-to-practice gap.

Designing High-Fidelity Mobile Health for Depression in Indonesian Adolescents Using Design Science Research: Mixed Method Approaches

BACKGROUND

COVID-19 mitigation protocols, enacted to control the pandemic, have also been shown to have a negative impact on mental health, including the mental health of adolescents. The threat of being infected by SARS-CoV-2 and substantial changes in lifestyle, including limited social interaction due to stay-at-home orders, led to loneliness as well as depressive symptoms. However, offline psychological assistance is restricted, as psychologists are bounded by mitigation protocols. Further, not all adolescents' guardians are open to their children attending or have the means to pay for psychological service; thus, adolescents remain untreated. Having a mobile health (mHealth) app for mental health that uses monitoring, provides social networks, and delivers psychoeducation may provide a solution, especially in countries that have limited health facilities and mental health workers.

OBJECTIVE

This study aimed to design an mHealth app to help prevent and monitor depression in adolescents. The design of this mHealth app was carried out as a high-fidelity prototype.

METHODS

We used a design science research (DSR) methodology with 3 iterations and 8 golden rule guidelines. The first iteration used interviews, and the second and third iterations used mixed method approaches. The DSR stages include the following: (1) identify the problem; (2) define the solution; (3) define the solution objective; (4) develop, demonstrate, and evaluate the solution; and (5) communicate the solution. This study involved students and medical experts.

RESULTS

The first iteration resulted in a wireframe and prototype for the next iteration. The second iteration resulted in a System Usability Scale score of 67.27, indicating a good fit. In the third iteration, the system usefulness, information quality, interface quality, and overall values were 2.416, 2.341, 2.597, and 2.261, respectively, indicating a good design. Key features of this mHealth app include a mood tracker, community, activity target, and meditation, and supporting features that complement the design include education articles and early detection features.

CONCLUSIONS

Our findings provide guidance for health facilities and to design and implement future mHealth apps to help treat adolescent depression.

Persuasive features for patient engagement through mHealth applications in managing chronic conditions: A systematic literature review and meta-analysis

Patient engagement is currently considered the cornerstone of a revolution in healthcare for its positive impact on health outcomes, health behaviors and healthcare costs. Patient engagement is focused on personalized care to consumers through providing knowledge, skills and confidence. Mobile health (mHealth) applications are an innovative means to facilitate patient engagement. Nevertheless, the extent to which the current mHealth applications are designed to engage patients in managing their chronic diseases is unclear. This paper aims to identify the Persuasive System Design (PSD) features present in current mHealth applications that increased the engagement of patients with chronic diseases. This review also aims to identify patient engagement-related outcomes of these features. This paper conducted a systematic literature review and meta-analysis to find relevant studies published from all years up to 2020 through six databases: PubMed, Scopus, Web of Science, Cinahl plus with full text, MEDLINE with full text, and Cochrane Library (Central register of controlled trials). The database search returned 4939 articles; after applying the inclusion and exclusion criteria, the number of included articles for the final review was 13. A qualitative content analysis was performed to identify PSD model features and their patient engagement-related outcomes. The quality assessment has been done through the Cochrane Risk of Bias tool for RCTs. The systematic literature review and meta-analysis identified eleven PSD features that can increase patient engagement through using mHealth applications. The identified PSD features have been shown to have various patient engagement-related outcomes. Behavior Change Techniques (BCTs) were combined with the identified PSD features. This paper identified persuasive features of mHealth application design that influence the engagement of patients with chronic diseases toward changing their behavior. The impact of these features is also analyzed in this review. The results show that an mHealth technology-mediated patient engagement model is needed.

Sensa Mobile App for Managing Stress, Anxiety, and Depression Symptoms: Pilot Cohort Study

BACKGROUND

An increase in depression, anxiety, and stress symptoms worldwide, attributed to the COVID-19 pandemic, has been reported. If not treated, it may negatively affect a person's everyday life by altering physical and social well-being and productivity and increasing expenditure on health care. Cognitive behavioral therapy (CBT)-based interventions are gaining popularity as a means to reduce stress and alleviate anxiety and depression symptoms. Moreover, CBT delivered through a mobile app has the same elements as traditional CBT training (eg, guided discovery). However, unlike conventional training, users of mobile apps are allowed to tailor their own experience at their own speed and schedule.

OBJECTIVE

This study aims to analyze Sensa users' retrospective data and explore the dose-duration effect to find the optimal usage time when the user showed results.

METHODS

The study cohort comprised 381 consecutive community-based nonclinical users who started using Sensa between October 2021 and March 2022. All users included in the study took the Depression Anxiety Stress Scale-21 (DASS-21) assessment at least 2 times. Other parameters from the database containing all self-reported data were gender, number of active days, total time of use, and age. The primary outcome of the study was a change in the DASS-21 score. Statistical analyses were performed using GraphPad Prism (version 9, GraphPad Software). In addition, a logistic regression model was created to predict how the obtained independent parameters influenced the DASS-21 score.

RESULTS

The main finding of our study was that the majority of participants who started using Sensa were experiencing depression, anxiety, and stress symptoms (92.13%, 80.05%, and 87.93%, respectively). There was a statistically significant decrease of the DASS-21 subdomain scores after the use of the application (anxiety: mean 7.25, SD 4.03 vs mean 6.12, SD 4.00; P=.001; depression: mean 11.05, SD 4.26 vs mean 9.01, SD 4.77; P=.001; stress: mean 11.42, SD 3.44 vs mean 9.96, SD 3.65; P<.001). Finally, the logistic regression model showed that users who were using the app for more than 24 days and had at least 12 active days during that time had 3.463 (95% CI 1.142-11.93) and 2.644 (95% CI 1.024-7.127) times higher chances to reduce their DASS-21 subdomain scores of depression and anxiety, respectively.

CONCLUSIONS

Using the Sensa mobile app was related to decreased depression, anxiety, and stress symptoms.

CBT-informed psychological interventions for adult patients with anxiety and depression symptoms: A narrative review of digital treatment options

BACKGROUND

Across a range of age, educational and clinical characteristics, adults experiencing depression and anxiety already use digital technology to manage their symptoms. Although several reviews and meta-analyses indicated feasibility and efficacy for adults with depression and anxiety, digital treatments are poorly accessed and disseminated. This review illustrates potentials and limitations of interventions that specifically leveraged unique features of digital technology and were grounded in the principles of Cognitive Behavioral Therapy (CBT).

METHODS

This systematic review followed the PRISMA guidelines. An electronic database search was conducted in October 2021. Peer-reviewed, English-language studies were included if i) they reported data from RCTs for adults aged 18+ who engaged with CBT-informed digital interventions targeting primarily depression and anxiety; ii) they used at least PHQ-9 or GAD-7 as standardized and validated assessment self-report measures for depression and anxiety.

RESULTS

Findings from 35 RCTs examining 33 interventions (25 internet-based, 6 mobile-based, a2 mobile/web) are discussed. The quality of the evidence differed widely as many small-scale RCTs reported only short-term feasibility and preliminary efficacy. Effects of CBT-informed digital interventions were substantially larger when compared to waitlist than active control conditions. Greater therapeutic benefits were observed for interventions that offered clinical assistance or were used in combination with other treatments.

CONCLUSIONS

CBT-informed digital interventions have accumulated enough scientific evidence to be positioned today as: i) a low-intensity tool for those with subclinical levels of symptoms; ii) a first step in a stepped-care approach to service delivery iii) a low-cost, easily accessible option for targeted preventive programs.

Mental health mobile application self-help for adolescents exhibiting psychological distress: A single case experimental design

OBJECTIVES

The present demand for child and adolescent mental health services exceeds the capacity for service provision. Greater research is required to understand the utility of accessible self-help interventions, such as mobile apps. This study sought to investigate whether use of a mental health app, underpinned by CBT, led to changes in psychological distress amongst adolescents. Mechanisms of change were examined, specifically whether changes are attributable to cognitive strategies.

DESIGN

This study utilised a multiple-baseline single-case experimental design, tracking variables across baseline and intervention phases. Surveys assessing participant experience were also administered.

METHODS

Five participants with moderate-to-severe levels of psychological distress engaged with a CBT-based app over five weeks. Participants were recruited from both a well-being service and the general population. Supplementary weekly calls to participants offered clarification of app content.

RESULTS

A small overall effect of the intervention of psychological distress was evident; however, outcomes were dependent on the analysis conducted. The intervention appeared to promote an increase in use of adaptive cognitive strategies but not negative thinking styles. The CBT app did not promote changes in participant well-being. Participant feedback highlighted practical challenges of utilising the app.

CONCLUSIONS

The clinical benefits of app-based CBT were small, and a range of barriers to engagement were recognised. While further research is required, caution should be exercised in the interpretation of studies reporting on app effectiveness.

The Effects of APP-Based Intervention for Depression Among Community-Dwelling Individuals With Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

To assess the effect of a self-management intervention delivered by mobile application (APP) for depression among community-dwelling individuals with spinal cord injury (SCI).

DESIGN

Randomized controlled trial.

SETTINGS

General communities in China.

PARTICIPANTS

Community-dwelling individuals with SCI who were diagnosed within 2 years were recruited in this study (N=98). It was a convenience sample with an average age of 41.71, 82.7% participants were men.

INTERVENTIONS

Participants in the intervention group (n=49) received 5 sessions on self-management training provided by nurse-led multidisciplinary team via APP at the second, fourth, sixth, eighth, and 12th weeks, respectively, after they discharge from hospitals. Participants in the control group (n=49) received routine telephone counselling provided by follow-up nurses at the 12th week after they discharge.

OUTCOME MEASURE

The outcome of this study is depression, which is not the primary outcomes in the registration of this program. Depression was measured by version 2 of Beck Depression Inventory at discharge (T₀), the 12th week after discharge from hospitals (T₁), and the 24th week after discharge from hospitals (T₂).

RESULTS

There were 98 participants (49 in the intervention group and 49 in the control group) completing the intervention and data collection. Compared with the control group, the intervention group had lower level of depression at T2 (B=-5.76; 95% CI=-9.97, -1.54; P=.007). Small to moderate effect sizes on depression favoring the intervention were demonstrated at T₁ (Cohen's d=-.178) and T₂ (Cohen's d=-.535).

CONCLUSIONS

APP-based self-management support can be a potential intervention to reduce depression among community-dwelling individuals with SCI.

Investigating Popular Mental Health Mobile Application Downloads and Activity During the COVID-19 Pandemic

OBJECTIVE

This article analyzes the changes in downloads and activity of users of select popular mental health mobile applications (mHealth apps) during coronavirus disease 2019 (COVID-19).

BACKGROUND

The outbreak of the COVID-19 crisis has shown a negative impact on public mental health. Mobile health has the potential to help address the psychological needs of existing and new patients during the pandemic and beyond.

METHOD

Downloads data of 16 widely used apps were analyzed. The quality of apps was reviewed using the Mobile Application Rating Scale (MARS) framework. Correlation analysis was conducted to investigate the relationship between app quality and app popularity.

RESULTS

Among the 16 apps, 10 were meditational in nature, 13 showed increased downloads, with 11 apps showing above 10% increase in the downloads after the pandemic started. The popular apps were satisfactory in terms of functionality and esthetics but lacked clinical grounding and evidence base. There exists a gap between app quality and app popularity.

CONCLUSION

This study provided evidence for increased downloads of mental mHealth apps (primarily meditation apps) during the COVID-19 pandemic but revealed several gaps and opportunities to address deficiencies in evidence-based design, usability and effective assessment, and integration into current workflows.

APPLICATION

The COVID-19 pandemic is a potential turning point for mHealth applications for mental health care. Whereas the evidence suggests a need for alternative delivery of care, human factors and ergonomics methods should be utilized to ensure these tools are user-centered, easy to use, evidence-based, well-integrated with professional care, and used sustainably.

Examining young adults daily perspectives on usage of anxiety apps: A user study

The growing number of mental health smartphone applications has led to increased interest in how these tools might support users in different models of care. However, research on the use of these interventions in real-world settings has been scarce. It is important to understand how apps are used in a deployment setting, especially among populations where such tools might add value to current models of care. The objective of this study is to explore the daily use of commercially-available mobile apps for anxiety that integrate CBT, with a focus on understanding reasons for and barriers for app use and engagement. This study recruited 17 young adults (age M = 24.17 years) while on a waiting list to receive therapy in a Student Counselling Service. Participants were asked to select up to two of a list of three selected apps (Wysa, Woebot, and Sanvello) and instructed to use the apps for two weeks. Apps were selected because they used techniques from cognitive behavioral therapy, and offer diverse functionality for anxiety management. Qualitative and quantitative data were gathered through daily questionnaires to capture participants' experiences with the mobile apps. In addition, eleven semi-structured interviews were conducted at the end of the study. We used descriptive statistics to analyze participants' interaction with different app features and used a general inductive approach to analyze the collected qualitative data. The results highlight that users form opinions about the apps during the first days of app use. A number of barriers to sustained use are identified including cost-related issues, inadequate content to support long-term use, and a lack of customization options for different app functions. The app features used differ among participants with self-monitoring and treatment elements being the most used features.

A randomized controlled trial of a 14-day mindfulness ecological momentary intervention (MEMI) for generalized anxiety disorder

BACKGROUND

Little is known about whether brief mindfulness ecological momentary interventions (MEMIs) yield clinically beneficial effects. This gap exists despite the rapid growth of smartphone mindfulness applications. Specifically, no prior brief MEMI has targeted generalized anxiety disorder (GAD). Moreover, although theories propose that MEMIs can boost executive functioning (EF), they have largely gone untested. Thus, this randomized controlled trial (RCT) aimed to address these gaps by assessing the efficacy of a 14-day smartphone MEMI (versus self-monitoring placebo [SMP]).

METHOD

Participants with GAD were randomly assigned to either condition (68 MEMI and 42 SMP). MEMI participants exercised multiple core mindfulness strategies and were instructed to practice mindfulness continually. Comparatively, SMP participants were prompted to practice self-monitoring and were not taught any mindfulness strategies. All prompts occurred five times a day for 14 consecutive days. Participants completed self-reports and neuropsychological assessments at baseline, posttreatment, and 1-month follow-up (1MFU). Piecewise hierarchical linear modeling analyses were conducted.

RESULTS

MEMI (versus SMP) produced greater pre-1MFU reductions in GAD severity and perseverative cognitions (between-group d = 0.393-0.394) and stronger improvements in trait mindfulness and performance-based inhibition (d = 0.280-0.303). Further, MEMI (versus SMP) led to more considerable pre- to posttreatment reduction in state-level depression and anxiety and more mindfulness gains (d = 0.50-1.13). Overall, between-treatment effects were stronger at pre-1MFU than pre- to posttreatment for trait-level than state-level treatment outcome measures.

CONCLUSIONS

Preliminary findings suggest that the beneficial effect of an unguided brief MEMI to target pathological worry, trait mindfulness, and EF is modest yet potentially meaningful. Other theoretical and clinical implications were discussed.

Innovative approaches to service integration addressing the unmet needs of irritable bowel syndrome patients and new approaches for the needs of IBS patients

Background

Irritable bowel syndrome (IBS) is a common multifactorial condition that affects the large intestine and is characterized by chronic and relapsing abdominal pain and altered bowel habit. IBS is due to a combination of genetic, environmental and dietary factors. It's usually a lifelong problem very frustrating to live with and can have a big impact on quality of life, as single-agent therapy ra.

Objective

To analyze the approaches and solutions that address the social and health unmet needs of patients with IBS.

Design

A quantitative-qualitative approach was adopted in the current study to identify and specify key digital solution and high impact user scenarios applied to IBS patients, through an adaptation of the “Blueprint on Digital Transformation in Health and Care in an Ageing Society” persona methodology.

Settings

Digital health solutions bring the potential of supporting health interventions through mobile apps, wearable devices, telemedicine.

Patients

A Survey was administered to a group of patients in an anonymous form, and no need for Medical Ethical Committee approval was identified.

Interventions

The theoretical elaboration IBS personas was developed through an interdisciplinary Focus Group, which also mapped the pathway for the patient's management.

Main outcome

Three main needs were identified to be met to improve IBS patient's lifestyle: access to psychological support, mHealth solutions supporting diet and adapted physical activity, and home-based digital health support. mHealth intervention has been identified for diet adherence, physical exercise and psychological well-being. The process has been mapped and adapted to integrate the new solutions into the care pathway.

Limitation

Further research is needed to evaluate how mHealth services enable IBS patients to manage their conditions and improve their quality of life.

Conclusion

The person-centered approach was implemented through a multidisciplinary Focus group that enabled the identification of the need for a mHealth intervention.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Digital Mental Health Interventions for Depression: Scoping Review of User Engagement

BACKGROUND

While many digital mental health interventions (DMHIs) have been found to be efficacious, patient engagement with DMHIs has increasingly emerged as a concern for implementation in real-world clinical settings. To address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare with other treatments.

OBJECTIVE

This scoping review aims to examine the state of reporting on intervention engagement in RCTs of mobile app-based interventions intended to treat symptoms of depression. We sought to identify what engagement metrics are and are not routinely reported as well as what the metrics that are reported reflect about standard engagement levels.

METHODS

We conducted a systematic search of 7 databases to identify studies meeting our eligibility criteria, namely, RCTs that evaluated use of a mobile app-based intervention in adults, for which depressive symptoms were a primary outcome of interest. We then extracted 2 kinds of information from each article: intervention details and indices of DMHI engagement. A 5-element framework of minimum necessary DMHI engagement reporting was derived by our team and guided our data extraction. This framework included (1) recommended app use as communicated to participants at enrollment and, when reported, app adherence criteria; (2) rate of intervention uptake among those assigned to the intervention; (3) level of app use metrics reported, specifically number of uses and time spent using the app; (4) duration of app use metrics (ie, weekly use patterns); and (5) number of intervention completers.

RESULTS

Database searching yielded 2083 unique records. Of these, 22 studies were eligible for inclusion. Only 64% (14/22) of studies included in this review specified rate of intervention uptake. Level of use metrics was only reported in 59% (13/22) of the studies reviewed. Approximately one-quarter of the studies (5/22, 23%) reported duration of use metrics. Only half (11/22, 50%) of the studies reported the number of participants who completed the app-based components of the intervention as intended or other metrics related to completion. Findings in those studies reporting metrics related to intervention completion indicated that between 14.4% and 93.0% of participants randomized to a DMHI condition completed the intervention as intended or according to a specified adherence criteria.

CONCLUSIONS

Findings suggest that engagement was underreported and widely varied. It was not uncommon to see completion rates at or below 50% (11/22) of those participants randomized to a treatment condition or to simply see completion rates not reported at all. This variability in reporting suggests a failure to establish sufficient reporting standards and limits the conclusions that can be drawn about level of engagement with DMHIs. Based on these findings, the 5-element framework applied in this review may be useful as a minimum necessary standard for DMHI engagement reporting.

Effectiveness and Minimum Effective Dose of App-Based Mobile Health Interventions for Anxiety and Depression Symptom Reduction: Systematic Review and Meta-Analysis

BACKGROUND

Mobile health (mHealth) apps offer new opportunities to deliver psychological treatments for mental illness in an accessible, private format. The results of several previous systematic reviews support the use of app-based mHealth interventions for anxiety and depression symptom management. However, it remains unclear how much or how long the minimum treatment "dose" is for an mHealth intervention to be effective. Just-in-time adaptive intervention (JITAI) has been introduced in the mHealth domain to facilitate behavior changes and is positioned to guide the design of mHealth interventions with enhanced adherence and effectiveness.

OBJECTIVE

Inspired by the JITAI framework, we conducted a systematic review and meta-analysis to evaluate the dose effectiveness of app-based mHealth interventions for anxiety and depression symptom reduction.

METHODS

We conducted a literature search on 7 databases (ie, Ovid MEDLINE, Embase, PsycInfo, Scopus, Cochrane Library (eg, CENTRAL), ScienceDirect, and ClinicalTrials, for publications from January 2012 to April 2020. We included randomized controlled trials (RCTs) evaluating app-based mHealth interventions for anxiety and depression. The study selection and data extraction process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We estimated the pooled effect size using Hedge g and appraised study quality using the revised Cochrane risk-of-bias tool for RCTs.

RESULTS

We included 15 studies involving 2627 participants for 18 app-based mHealth interventions. Participants in the intervention groups showed a significant effect on anxiety (Hedge g=-.10, 95% CI -0.14 to -0.06, I2=0%) but not on depression (Hedge g=-.08, 95% CI -0.23 to 0.07, I2=4%). Interventions of at least 7 weeks' duration had larger effect sizes on anxiety symptom reduction.

CONCLUSIONS

There is inconclusive evidence for clinical use of app-based mHealth interventions for anxiety and depression at the current stage due to the small to nonsignificant effects of the interventions and study quality concerns. The recommended dose of mHealth interventions and the sustainability of intervention effectiveness remain unclear and require further investigation.

Understanding users’ perspectives on mobile apps for anxiety management

Anxiety disorders are the most common type of mental health problem. The potential of apps to improve mental health has led to an increase in the number of anxiety apps available. Even though anxiety apps hold the potential to enhance mental health care for individuals, there is relatively little knowledge concerning users’ perspectives. This mixed-methods study aims to understand the nature of user burden and engagement with mental health apps (MHapps) targeting anxiety management, in order to identify ways to improve the design of these apps. Users’ perspectives on these apps were gathered by analyzing 600 reviews from 5 apps on the app stores (Study 1), and conducting 15 interviews with app users (Study 2). The results shed light on several barriers to adoption and sustained use. Users appreciate apps that offer content variation, customizability, and good interface design, and often requested an enhanced, personalized experience to improve engagement. We propose addressing the specific app quality issues identified through human-centered design, more personalized content delivery, and by improving features for social and therapeutic support.

Appropriate Use and Operationalization of Adherence to Digital Cognitive Behavioral Therapy for Depression and Anxiety in Youth: Systematic Review

BACKGROUND

Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment.

OBJECTIVE

This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes.

METHODS

A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs.

RESULTS

There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this.

CONCLUSIONS

Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence.

TRIAL REGISTRATION

PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram.

Recruitment and retention in mobile application-based intervention studies: a critical synopsis of challenges and opportunities

Use of mobile health applications (mHealth apps) is becoming increasingly popular for the management of chronic illnesses, but mHealth-based intervention studies often have limitations associated with subject recruitment and retention. In this synopsis, we focus on targeted aspects of mHealth-based intervention studies, specifically: (i) subject recruitment, (ii) cohort sizes, and (iii) retention rates. We used the Google Scholar (meta-search) and Galileo search engines to identify sample articles focusing on mHealth apps and interventions published between 2010 and 2020 and selected 21 papers for detailed review. Most studies recruited relatively small cohorts (minimum: 20, maximum: 510). Retention rates had high variance with only five studies managing >80% subject retention throughout the study duration, 10.4% being the lowest. Eighty-five percent of the studies expressed concerns regarding study duration, app usage, and lack of proper implementation. The use of mHealth interventions generally yielded positive outcomes, but most studies discussed facing challenges associated with recruitment and retention. There is a clear need to identify strategies for recruiting larger cohorts and improving retention rates, and ultimately increasing the reliability of mHealth app-based intervention studies. We advise that potential underutilized opportunities lie at the intersection of mHealth and social media to address the limitations identified in the synopsis.

Implementation of Cognitive Behavioral Therapy in e-Mental Health Apps: Literature Review

Background

To address the matter of limited resources for treating individuals with mental disorders, e–mental health has gained interest in recent years. More specifically, mobile health (mHealth) apps have been suggested as electronic mental health interventions accompanied by cognitive behavioral therapy (CBT).

Objective

This study aims to identify the therapeutic aspects of CBT that have been implemented in existing mHealth apps and the technologies used. From these, we aim to derive research gaps that should be addressed in the future.

Methods

Three databases were screened for studies on mHealth apps in the context of mental disorders that implement techniques of CBT: PubMed, IEEE Xplore, and ACM Digital Library. The studies were independently selected by 2 reviewers, who then extracted data from the included studies. Data on CBT techniques and their technical implementation in mHealth apps were synthesized narratively.

Results

Of the 530 retrieved citations, 34 (6.4%) studies were included in this review. mHealth apps for CBT exploit two groups of technologies: technologies that implement CBT techniques for cognitive restructuring, behavioral activation, and problem solving (exposure is not yet realized in mHealth apps) and technologies that aim to increase user experience, adherence, and engagement. The synergy of these technologies enables patients to self-manage and self-monitor their mental state and access relevant information on their mental illness, which helps them cope with mental health problems and allows self-treatment.

Conclusions

There are CBT techniques that can be implemented in mHealth apps. Additional research is needed on the efficacy of the mHealth interventions and their side effects, including inequalities because of the digital divide, addictive internet behavior, lack of trust in mHealth, anonymity issues, risks and biases for user groups and social contexts, and ethical implications. Further research is also required to integrate and test psychological theories to improve the impact of mHealth and adherence to the e–mental health interventions.

Healthy Dwelling: Design of Biophilic Interior Environments Fostering Self-Care Practices for People Living with Migraines, Chronic Pain, and Depression

The benefits of biophilic interior design have been recognized by healthcare facilities, but residential environments receive relatively less attention with respect to improving the health of people living with chronic diseases. Recent “stay-at-home” restrictions due to the COVID-19 pandemic further emphasized the importance of creating interior spaces that directly and indirectly support physical and mental health. In this viewpoint article, we discuss opportunities for combining biophilic interventions with interior design, fostering disease-specific self-care. We provide examples of designing residential spaces integrating biophilic interventions, light therapy, relaxation opportunities, mindfulness meditation, listening to music, physical activities, aromatherapy, and quality sleep. These modalities can provide the clinical benefits of reducing migraine headaches and chronic pain, as well as improving depressive symptoms. The disease-specific interior environment can be incorporated into residential homes, workplaces, assisted-living residences, hospitals and hospital at home programs. This work aims to promote a cross-disciplinary dialogue towards combining biophilic design and advances in lifestyle medicine to create therapeutic interior environments and to improve healthcare outcomes.

Characteristics of Mobile Health Platforms for Depression and Anxiety: Content Analysis Through a Systematic Review of the Literature and Systematic Search of Two App Stores

Background

Mobile health (mHealth) platforms show promise in the management of mental health conditions such as anxiety and depression. This has resulted in an abundance of mHealth platforms available for research or commercial use.

Objective

The objective of this review is to characterize the current state of mHealth platforms designed for anxiety or depression that are available for research, commercial use, or both.

Methods

A systematic review was conducted using a two-pronged approach: searching relevant literature with prespecified search terms to identify platforms in published research and simultaneously searching 2 major app stores—Google Play Store and Apple App Store—to identify commercially available platforms. Key characteristics of the mHealth platforms were synthesized, such as platform name, targeted condition, targeted group, purpose, technology type, intervention type, commercial availability, and regulatory information.

Results

The literature and app store searches yielded 169 and 179 mHealth platforms, respectively. Most platforms developed for research purposes were designed for depression (116/169, 68.6%), whereas the app store search reported a higher number of platforms developed for anxiety (Android: 58/179, 32.4%; iOS: 27/179, 15.1%). The most common purpose of platforms in both searches was treatment (literature search: 122/169, 72.2%; app store search: 129/179, 72.1%). With regard to the types of intervention, cognitive behavioral therapy and referral to care or counseling emerged as the most popular options offered by the platforms identified in the literature and app store searches, respectively. Most platforms from both searches did not have a specific target age group. In addition, most platforms found in app stores lacked clinical and real-world evidence, and a small number of platforms found in the published research were available commercially.

Conclusions

A considerable number of mHealth platforms designed for anxiety or depression are available for research, commercial use, or both. The characteristics of these mHealth platforms greatly vary. Future efforts should focus on assessing the quality—utility, safety, and effectiveness—of the existing platforms and providing developers, from both commercial and research sectors, a reporting guideline for their platform description and a regulatory framework to facilitate the development, validation, and deployment of effective mHealth platforms.

Impact of Smartphone App-Based Psychological Interventions for Reducing Depressive Symptoms in People With Depression: Systematic Literature Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility.

OBJECTIVE

We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression.

METHODS

We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success.

RESULTS

After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] -0.51, 95% CI -0.69 to -0.33; 2018/2859, 70.58% of the participants; I2=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD -0.67, 95% CI -0.79 to -0.55), compared with trials with participants exhibiting mild to moderate depression (SMD -0.15, 95% CI -0.43 to -0.12).

CONCLUSIONS

App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention.

TRIAL REGISTRATION

PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689.

Engagement Strategies to Improve Adherence and Retention in Web-Based Mindfulness Programs: Systematic Review

Background

Web-based mindfulness programs may be beneficial in improving the well-being outcomes of those living with chronic illnesses. Adherence to programs is a key indicator in improving outcomes; however, with the digitization of programs, it is necessary to enhance engagement and encourage people to return to digital health platforms. More information is needed on how engagement strategies have been used in web-based mindfulness programs to encourage adherence.

Objective

The aim of this study is to develop a list of engagement strategies for web-based mindfulness programs and evaluate the impact of engagement strategies on adherence.

Methods

A narrative systematic review was conducted across the MEDLINE Complete, CINAHL Complete, APA PsycINFO, and Embase databases and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Articles were screened using the population, intervention, comparator, and outcome framework. Adults aged >18 years with chronic health conditions were included in the study. Mindfulness interventions, including those in combination with mindfulness-based cognitive therapy, delivered on the web through the internet or smartphone technology were included. Interventions lasted at least 2 weeks. Studies with a randomized controlled trial design or a pilot randomized controlled trial design were included. Engagement strategies, including web-based program features and facilitator-led strategies, adherence, and retention, were included.

Results

A total of 1265 articles were screened, of which 19 were relevant and were included in the review. On average, 70.98% (2258/3181) of the study participants were women with a mean age of 46 (SD 13) years. Most commonly, mindfulness programs were delivered to people living with mental health conditions (8/19, 42%). Of the 19 studies, 8 (42%) used only program features to encourage adherence, 5 (26%) used facilitator-led strategies, and 6 (32%) used a combination of the two. Encouraging program adherence was the most common engagement strategy used, which was used in 77% (10/13) of the facilitator-led studies and 57% (8/14) of the program feature studies. Nearly two-thirds (63%) of the studies provided a definition of adherence, which varied between 50% and 100% completion across studies. The overall mean participant compliance to the mindfulness programs was 56% (SD 15%). Most studies (10/19, 53%) had a long-term follow-up, with the most common follow-up period being 12 weeks after intervention (3/10, 30%). After the intervention, the mean retention was 78% (SD 15%).

Conclusions

Engagement strategies in web-based mindfulness programs comprise reminders to use the program. Other features may be suitable for encouraging adherence to interventions, and a facilitator-led component may result in higher retention. There is variance in the way adherence is measured, and intervention lengths and follow-up periods are inconsistent. More thorough reporting and a standardized framework for measuring adherence are needed to more accurately assess adherence and engagement strategies.

Clinical wisdom in the age of computer apps: a systematic review of four functions that may complement clinical treatment

Mental health clinicians perform complex tasks with patients that potentially could be improved by the massive computing power available through mobile apps. This study aimed to analyse commercially available mobile and computer applications (apps) focused on treating psychiatric disorders. Apps were analysed by two independent raters for whether they took advantage of computer power to process data in a fashion that augments four main elements of clinical treatment including (1) assessment/diagnosis, (2) treatment planning, (3) treatment fidelity monitoring, and (4) outcome tracking. The evidence base for each of these apps was also explored via PsychINFO, Research Gate and Google Scholar. Searches of the Google Play Store, the Apple App Store, and the One Mind PsyberGuide found 722 apps labelled for mental health use, of which 163 apps were judged relevant to clinical work with patients with psychiatric disorders. Fifty-nine of these were determined to contain a computer-driven function for at least one of the four main elements of clinical treatment. The most common element was assessment/diagnosis (55/59 apps), followed by outcome tracking (34/59 apps). Six apps updated treatment plans using user input. Only one app tracked treatment fidelity. None of the apps contained computer-driven functions for all four elements. Twelve apps were supported in randomized clinical trials to show greater efficacy compared with either wait-list or other active treatments. Results showed that these four clinical elements can be meaningfully augmented, but the full potential of computer processing appears unreached in mental health-related apps.

Key learning aims

(1)

Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis

BACKGROUND

Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification.

OBJECTIVE

The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements.

METHODS

A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis.

RESULTS

A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40).

CONCLUSIONS

The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.

Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p < 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.

Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Challenges in Participant Engagement and Retention using Mobile Health Apps: A Literature Review (Preprint)

Background

Mobile health (mHealth) apps are revolutionizing the way clinicians and researchers monitor and manage the health of their participants. However, many studies using mHealth apps are hampered by substantial participant dropout or attrition, which may impact the representativeness of the sample and the effectiveness of the study. Therefore, it is imperative for researchers to understand what makes participants stay with mHealth apps or studies using mHealth apps.

Objective

This study aimed to review the current peer-reviewed research literature to identify the notable factors and strategies used in adult participant engagement and retention.

Methods

We conducted a systematic search of PubMed, MEDLINE, and PsycINFO databases for mHealth studies that evaluated and assessed issues or strategies to improve the engagement and retention of adults from 2015 to 2020. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Notable themes were identified and narratively compared among different studies. A binomial regression model was generated to examine the factors affecting retention.

Results

Of the 389 identified studies, 62 (15.9%) were included in this review. Overall, most studies were partially successful in maintaining participant engagement. Factors related to particular elements of the app (eg, feedback, appropriate reminders, and in-app support from peers or coaches) and research strategies (eg, compensation and niche samples) that promote retention were identified. Factors that obstructed retention were also identified (eg, lack of support features, technical difficulties, and usefulness of the app). The regression model results showed that a participant is more likely to drop out than to be retained.

Conclusions

Retaining participants is an omnipresent challenge in mHealth studies. The insights from this review can help inform future studies about the factors and strategies to improve participant retention.

A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE

Background

People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority.

Objective

The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains.

Methods

Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods.

Results

Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F_1,313=13.38; P<.001), GAD-7 (F_1,313=5.87; P=.01), RAS (F_1,313=23.42; P<.001), RSES (F_1,313=19.28; P<.001), and SDS (F_1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3.

Conclusions

We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond.

Trial Registration

ClinicalTrials.gov NCT04068467; https://clinicaltrials.gov/ct2/show/NCT04068467

Mobile Apps That Promote Emotion Regulation, Positive Mental Health, and Well-being in the General Population: Systematic Review and Meta-analysis

BACKGROUND

Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being.

OBJECTIVE

We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness.

METHODS

A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims.

RESULTS

In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality.

CONCLUSIONS

The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs.