It Is Time to REACT: Opportunities for Digital Mental Health Apps to Reduce Mental Health Disparities in Racially and Ethnically Minoritized Groups

Equity in Digital Mental Health Interventions in the United States: Where to Next?

Health care technologies have the ability to bridge or hinder equitable care. Advocates of digital mental health interventions (DMHIs) report that such technologies are poised to reduce the documented gross health care inequities that have plagued generations of people seeking care in the United States. This is due to a multitude of factors such as their potential to revolutionize access; mitigate logistical barriers to in-person mental health care; and leverage patient inputs to formulate tailored, responsive, and personalized experiences. Although we agree with the potential of DMHIs to advance health equity, we articulate several steps essential to mobilize and sustain meaningful forward progression in this endeavor, reflecting on decades of research and learnings drawn from multiple fields of expertise and real-world experience. First, DMHI manufacturers must build diversity, equity, inclusion, and belonging (DEIB) processes into the full spectrum of product evolution itself (eg, product design, evidence generation) as well as into the fabric of internal company practices (eg, talent recruitment, communication principles, and advisory boards). Second, awareness of the DEIB efforts-or lack thereof-in DMHI research trials is needed to refine and optimize future study design for inclusivity as well as proactively address potential barriers to doing so. Trials should incorporate thoughtful, inclusive, and creative approaches to recruitment, enrollment, and measurement of social determinants of health and self-identity, as well as a prioritization of planned and exploratory analyses examining outcomes across various groups of people. Third, mental health care advocacy, research funding policies, and local and federal legislation can advance these pursuits, with directives from the US Preventive Services Taskforce, National Institutes of Health, and Food and Drug Administration applied as poignant examples. For products with artificial intelligence/machine learning, maintaining a "human in the loop" as well as prespecified and adaptive analytic frameworks to monitor and remediate potential algorithmic bias can reduce the risk of increasing inequity. Last, but certainly not least, is a call for partnership and transparency within and across ecosystems (academic, industry, payer, provider, regulatory agencies, and value-based care organizations) to reliably build health equity into real-world DMHI product deployments and evidence-generation strategies. All these considerations should also extend into the context of an equity-informed commercial strategy for DMHI manufacturers and health care organizations alike. The potential to advance health equity in innovation with DMHI is apparent. We advocate the field's thoughtful and evergreen advancement in inclusivity, thereby redefining the mental health care experience for this generation and those to come.

Pre-implementation determinants for digital mental health integration in Chicago pediatric primary care

OBJECTIVE

Pediatric primary care (PPC) is a common treatment site for pediatric mental health, but it is currently unable to meet the needs of all teen patients, particularly those with minoritized identities and/or marginalized experiences. Digital mental health (DMH) low-intensity treatments (LITs) can increase mental health screening and care capacity in PPC, but how this is done successfully without burdening providers, patients, or families is unclear. This paper presents a pre-implementation study aimed at understanding the implementation context (PPCs in Chicago, IL) for a specific DMH LIT.

METHOD

Using a mixed-methods design, quantitative data from an online survey of providers assessed current DMH practices in PPC, and qualitative interviews with Pediatricians and Pediatric Psychologists examined implementation determinants for a specific DMH LIT. Quantitative data were analyzed using descriptive statistics, and interviews were analyzed using rapid qualitative assessment.

RESULTS

Survey reports (n = 105) and interviews (n = 6) indicated low current use of DMH. Providers in PPC clinics voiced multiple reasons for low usage and low perceived feasibility, including: Consolidated Framework for Implementation Research (CFIR) Inner Setting Domain (PPC clinic workflow, responsibility and ethical considerations, patient privacy and confidentiality), CFIR Outer Setting Domain (hospital and healthcare system factors), CFIR Innovation Domain (DMH design), and a cross-cutting theme of safety.

CONCLUSIONS

Provider-reported low feasibility for integrating DMH in PPC is a call to action to partner with interdisciplinary colleagues and identify how such settings can ethically and seamlessly deliver digital evidence-based and accessible screening and care prior to implementation.

The Acceptability, Engagement, and Feasibility of Mental Health Apps for Marginalized and Underserved Young People: Systematic Review and Qualitative Study

BACKGROUND

Smartphone apps may provide an opportunity to deliver mental health resources and interventions in a scalable and cost-effective manner. However, young people from marginalized and underserved groups face numerous and unique challenges to accessing, engaging with, and benefiting from these apps.

OBJECTIVE

This study aims to better understand the acceptability (ie, perceived usefulness and satisfaction with an app) and feasibility (ie, the extent to which an app was successfully used) of mental health apps for underserved young people. A secondary aim was to establish whether adaptations can be made to increase the accessibility and inclusivity of apps for these groups.

METHODS

We conducted 2 sequential studies, consisting of a systematic literature review of mental health apps for underserved populations followed by a qualitative study with underserved young male participants (n=20; age: mean 19). Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, an electronic search of 5 databases was conducted in 2021. The search yielded 18,687 results, of which 14 articles met the eligibility criteria.

RESULTS

The included studies comprised a range of groups, including those affected by homelessness, having physical health conditions, living in low- and middle-income countries, and those with sexual and gender minority identities. Establishing and maintaining user engagement was a pervasive challenge across mental health apps and populations, and dropout was a reported problem among nearly all the included studies. Positive subjective reports of usability, satisfaction, and acceptability were insufficient to determine users' objective engagement.

CONCLUSIONS

Despite the significant amount of funding directed to the development of mental health apps, juxtaposed with only limited empirical evidence to support their effectiveness, few apps have been deliberately developed or adapted to meet the heterogeneous needs of marginalized and underserved young people. Before mental health apps are scaled up, a greater understanding is needed of the types of services that more at-risk young people and those in limited-resource settings prefer (eg, standard vs digital) followed by more rigorous and consistent demonstrations of acceptability, effectiveness, and cost-effectiveness. Adopting an iterative participatory approach by involving young people in the development and evaluation process is an essential step in enhancing the adoption of any intervention, including apps, in "real-world" settings and will support future implementation and sustainability efforts to ensure that marginalized and underserved groups are reached.

TRIAL REGISTRATION

PROSPERO CRD42021254241; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254241.

Advancing equitable access to digital mental health in the Asia-Pacific region in the context of the COVID-19 pandemic and beyond: A modified Delphi consensus study

The COVID-19 pandemic had an unprecedented impact on global mental health and well-being, including across the Asia-Pacific. Efforts to mitigate virus spread led to far-reaching disruption in the delivery of health and social services. In response, there was a rapid shift to the use of digital mental health (DMH) approaches. Though these technologies helped to improve access to care for many, there was also substantial risk of access barriers leading to increased inequities in access to mental health care, particularly among at-risk and equity-deserving populations. The objective of this study was to conduct a needs assessment and identify priorities related to equitable DMH access among at-risk and equity-deserving populations in the Asia Pacific region during the first year of the COVID-19 pandemic. The study consisted of a modified Delphi consensus methodology including two rounds of online surveys and online consultations with stakeholders from across the region. Study participants included policy makers, clinicians and service providers, and people with lived experience of mental health conditions. Results demonstrate that vulnerabilities to negative mental health impacts and access barriers were compounded during the pandemic. Access barriers included a lack of linguistically and culturally appropriate DMH options, low mental health literacy and poor access to technological infrastructure and devices, low levels of awareness and trust of DMH options, and lack of policies and guidelines to support effective and equitable delivery of DMH. Recommendations to improve equitable access include ensuring that diverse people with lived experience are engaged in research, co-design and policy development, the development and implementation of evidence-based and equity-informed guidelines and frameworks, clear communication about DMH evidence and availability, and the integration of DMH into broader health systems. Study results can inform the development and implementation of equitable DMH as its use becomes more widespread across health systems.

Race and Socioeconomic Status as Predictors of Willingness to Use Digital Mental Health Interventions or One-On-One Psychotherapy: National Survey Study

BACKGROUND

There is an ongoing debate about whether digital mental health interventions (DMHIs) can reduce racial and socioeconomic inequities in access to mental health care. A key factor in this debate involves the extent to which racial and ethnic minoritized individuals and socioeconomically disadvantaged individuals are willing to use, and pay for, DMHIs.

OBJECTIVE

This study examined racial and ethnic as well as socioeconomic differences in participants' willingness to pay for DMHIs versus one-on-one therapy (1:1 therapy).

METHODS

We conducted a national survey of people in the United States (N=423; women: n=204; mean age 45.15, SD 16.19 years; non-Hispanic White: n=293) through Prolific. After reading descriptions of DMHIs and 1:1 therapy, participants rated their willingness to use each treatment (1) for free, (2) for a small fee, (3) as a maximum dollar amount, and (4) as a percentage of their total monthly income. At the end of the study, there was a decision task to potentially receive more information about DMHIs and 1:1 therapy.

RESULTS

Race and ethnicity was associated with willingness to pay more of one's income, as a percent or in dollar amounts, and was also associated with information-seeking for DMHIs in the behavioral task. For most outcomes, race and ethnicity was not associated with willingness to try 1:1 therapy. Greater educational attainment was associated to willingness to try DMHIs for free, the decision to learn more about DMHIs, and willingness to pay for 1:1 therapy. Income was inconsistently associated to willingness to try DMHIs or 1:1 therapy.

CONCLUSIONS

If they are available for free or at very low costs, DMHIs may reduce inequities by expanding access to mental health care for racial and ethnic minoritized individuals and economically disadvantaged groups.

Designing a Novel Digitally Delivered Antiracism Intervention for Mental Health Clinicians: Exploratory Analysis of Acceptability

BACKGROUND

There is a great need for evidence-based antiracism interventions targeting mental health clinicians to help mitigate mental health disparities in racially and ethnically minoritized groups.

OBJECTIVE

This study provides an exploratory analysis of mental health clinicians' perspectives on the acceptability of a web-based antiracism intervention.

METHODS

Mental health clinicians were recruited from a single academic medical center through outreach emails. Data were collected through individual 30-minute semistructured remote video interviews with participants, then recorded, transcribed, and analyzed using content analysis.

RESULTS

A total of 12 mental health clinicians completed the study; 10 out of 12 (83%) were female candidates. Over half (7/12, 58%) of the respondents desired more robust antiracism training in mental health care. Regarding the web-based antiracism intervention, (8/12, 67%) enjoyed the digitally delivered demo module, (7/12, 58%) of respondents suggested web-based content would be further enhanced with the addition of in-person or online group components.

CONCLUSIONS

Our results suggest a strong need for additional antiracist training for mental health clinicians. Overall, participants responded favorably to novel web-based delivery methods for an antiracism intervention. These findings provide important support for future development and pilot testing of a large-scale digitally enhanced antiracist curriculum targeting mental health clinicians.

Common practices for sociodemographic data reporting in digital mental health intervention research: a scoping review

BACKGROUND

The ability of digital mental health interventions (DMHIs) to reduce mental health disparities relies on the recruitment of research participants with diverse sociodemographic and self-identity characteristics. Despite its importance, sociodemographic reporting in research is often limited, and the state of reporting practices in DMHI research in particular has not been comprehensively reviewed.

OBJECTIVES

To characterise the state of sociodemographic data reported in randomised controlled trials (RCTs) of app-based DMHIs published globally from 2007 to 2022.

METHODS

A scoping review of RCTs of app-based DMHIs examined reporting frequency for 16 sociodemographic domains (eg, gender) and common category options within each domain (eg, woman). The search queried five electronic databases. 5079 records were screened and 299 articles were included.

RESULTS

On average, studies reported 4.64 (SD=1.79; range 0-9) of 16 sociodemographic domains. The most common were age (97%) and education (67%). The least common were housing situation (6%), residency/location (5%), veteran status (4%), number of children (3%), sexual orientation (2%), disability status (2%) and food security (<1%). Gender or sex was reported in 98% of studies: gender only (51%), sex only (28%), both (<1%) and gender/sex reported but unspecified (18%). Race or ethnicity was reported in 48% of studies: race only (14%), ethnicity only (14%), both (10%) and race/ethnicity reported but unspecified (10%).

CONCLUSIONS

This review describes the widespread underreporting of sociodemographic information in RCTs of app-based DMHIs published from 2007 to 2022. Reporting was often incomplete (eg, % female only), unclear (eg, the conflation of gender/sex) and limited (eg, only options representing majority groups were reported). Trends suggest reporting has somewhat improved in recent years. Diverse participant populations must be welcomed and described in DMHI research to broaden learning and the generalisability of results, a prerequisite of DMHI's potential to reduce disparities in mental healthcare.

Lessons Learned About Trauma Related to Racial Discrimination During COVID-19 in the United States

Race scholars have discussed how the pandemic has disproportionately burdened marginalized communities and exacerbated pre-existing inequities, particularly for Black Indigenous People of Color (BIPOC) in the United States (U.S.). One glaring social determinant during the time of the COVID-19 is racial discrimination. This chapter will discuss lessons learned regarding the negative impact of discrimination on BIPOC, especially as it pertains to their experiences of trauma. Some of these lessons include (1) the need for clinical psychologist to improve access to treatment through increased research on culturally adaptive interventions, (2) increased research on the effects of race-based trauma on mental health symptomatology, (3) policy and institutional changes that reduce disparities in access to care, and (4) increased education for psychologists around billing procedures for individuals with race-based stress.

Exploring Generation Z and Young Millennials' Perspectives of a Spiritual Self-Care App and Their Spiritual Identity (Skylight): Qualitative Semistructured Interview Study

BACKGROUND

Generation Z and young millennials (ages 18-35 years), collectively referred to as GenZennials, are connected to technology and the internet like no other generation before them. This has mental health implications, such as increased rates of anxiety and stress. Recent research has shown that app-based mental health interventions can be useful to address such mental health concerns. However, spirituality is an untapped resource, especially since GenZennials largely identify as spiritual and already integrate spiritual practices into their self-care.

OBJECTIVE

There were four objectives to this study: (1) comprehensively explore reasons why GenZennials use a spiritual self-care app (ie, Skylight; Radiant Foundation), (2) understand how GenZennials identify spiritually, (3) understand the app's relevance to GenZennials, and (4) gather feedback and suggestions to improve the app.

METHODS

Semistructured interviews were conducted with 23 GenZennials (ages 18-35 years; mean 28.7, SD 5.0 years; n=20, 87% female) who used the Skylight app. Interviews were 30 to 60 minutes and conducted on Zoom. Thematic analysis was used to analyze interviews.

RESULTS

Five major categories emerged from the analysis, each encompassing one to several themes: (1) reasons for using the Skylight app, (2) content favorites, (3) defining spiritual identity, (4) relevance to GenZennials, and (5) overall improvement recommendations. Participants used the app for various reasons including to relax, escape, or ground themselves; improve mood; and enhance overall health and wellness. Participants also cited the app's variety of content offerings and its free accessibility as their primary reasons for using it. Most participants identified themselves as solely spiritual (8/23/35%) among the options provided (ie, spiritual or religious or both), and they appreciated the app's inclusive content. Participants felt that the app was relevant to their generation as it offered modern content (eg, spiritual self-care activities and short content). Participants recommended adding more personalization capabilities, content, and representation to the app.

CONCLUSIONS

This is the first study to qualitatively explore GenZennials' perspectives and the use of a spiritual self-care app. Our findings should inform the future creation and improvement of spiritual self-care apps aimed at cultivating GenZennials' spiritual and mental well-being. Future research is warranted to examine the effects of using a spiritual self-care app on GenZennial mental health.

Stakeholders' views and opinions on existing guidelines on "How to Choose Mental Health Apps"

Background

Mental health Applications (Mhealth Apps) can change how healthcare is delivered. However, very little is known about the efficacy of Mhealth Apps. Currently, only minimum guidance is available in Assessment and Evaluation Tools (AETs). Therefore, this project aims to understand AET developers' perspectives and end users' experiences and opinions on "how to choose a Mhealth App".

Objective

The primary objectives were: (1) obtaining stakeholder's opinions and experiences of development and use of AETs for Mhealth Apps, their weaknesses and strengths, and barriers in their implementation of Mhealth Apps; (2) the experiences of App users, their analyzation and, obstacles in the use of apps; and (3) to quantify themes related to choosing a Mhealth App.

Methods

This qualitative study, used a sampling method to recruit six stakeholders (one App developer, two AET developers, an individual with lived experience of mental health illness, and two physicians) who were interviewed using a topic guide. These were examined by researchers (CT, WK, & FN) using thematic content analysis. Additionally, an anonymous online survey of 107 individuals was conducted.

Findings

Our analyses revealed six main themes: (a) needs and opportunities; (b) views on Mhealth apps; (c) views & opinions on AETs; (d) implementation barriers; (e) system of evaluation and; (f) future directions. The first key concept was, all stakeholders agreed that Apps could significantly impact mental health and that end-users were unaware of mental health AETs and Apps. Secondly, due to commercial interests, end-users reliability of App evaluations requires clear conflict-free guidelines. Thirdly, AETs should be evaluated and developed through a rigorous methodology. Finally, stakeholders shared insights into future developments for AETs and Mhealth Apps. Additionally, online survey respondents chose a "health professional" as their preferred source of guidance in selecting a Mhealth app (84%) and best suited to develop guidelines (70%).

Conclusion

The interviews and survey highlight the need for Mhealth Apps to be regulated and the importance of health professionals' engagement in the implementation process. Similarly, without well-defined roles for App evaluations within the health care system, it is unlikely that AETs will have wider spread use and impact without risk.

Real-World Adoption of Mental Health Support Among Adolescents: Cross-Sectional Analysis of the California Health Interview Survey

OBJECTIVE

We aim to examine: (a) the extent to which patterns of adoption of counseling services and digital mental health interventions (DMHIs) shifted in recent years (2019-2021); (b) the impact of distress on adoption of mental health support; and (c) reasons related to adolescents' low adoption of DMHIs when experiencing distress.

METHODS

Data were from three cohorts of adolescents aged 12-17 years (n = 847 in 2019; n = 1,365 in 2020; n = 1,169 in 2021) recruited as part of the California Health Interview Survey. We estimated logistic regression models to examine the likelihood of using mental health support as a function of psychological distress, sociodemographic characteristics, and cohorts. We also analyzed adolescents' self-reported reasons for not trying DMHIs as a function of distress.

RESULTS

The proportion of adolescents reporting elevated psychological distress (∼50%) was higher than those adopting counseling services (<20%) or DMHIs (<10%). A higher level of distress was associated with a greater likelihood of receiving counseling (OR = 1.15), and using DMHIs to connect with a professional (Odds ratio (OR) = 1.11) and for self-help (OR = 1.17). Among those experiencing high distress, adolescents' top reason for not adopting an online tool was a lack of perceived need (19.2%).

CONCLUSION

Adolescents' main barriers to DMHI adoption included a lack of perceived need, which may be explained by a lack of mental health literacy. Thoughtful marketing and dissemination efforts are needed to increase mental health awareness and normalize adoption of counseling services and DMHIs.

The Experience of ADHD as Reported by Racially and Ethnically Minoritized Adolescents: a Survey-Based Phenomenological Investigation

The variety of possible suboptimal long-term outcomes associated with attention-deficit/hyperactivity disorder (ADHD) when left unsupported highlights the importance of timely and accurate identification followed by intervention. Though considerations of race and ethnicity are essential to service delivery, disparities in ADHD identification and intervention persist for racially and ethnically minoritized (REM) youth. This is exacerbated by a lack of research focusing on REM populations. The current study is a phenomenological investigation of REM adolescents' (N = 35) experiences with ADHD. Participant responses to an online phenomenological survey yielded four themes and eleven subthemes related to ADHD symptom experiences, navigating social relationships and school, stigma, and finding positivity in ADHD. Participant experiences corroborate and expand on extant research regarding ADHD symptoms, social isolation, school discipline referrals, and stigma. These findings highlight the importance of including REM participants in research and increased efforts to decrease stigma.

Digital intervention in improving the outcomes of mental health among LGBTQ+ youth: a systematic review

LGBTQ+ youth experience mental health disparities and higher rates of mental disorders due to barriers to accessing care, including insufficient services and the anticipated stigma of revealing their identities. This systematic review incorporated 15 empirical studies on digital interventions' impact on LGBTQ+ youth mental health, examining their potential to address these inequities. This study innovatively categorized existing digital interventions into four streams: Structured Formal (telehealth, online programs), Structured Informal (serious games), Unstructured Formal (mobile applications), and Unstructured Informal (social media). We found that S&F and U&F effectively reduced symptoms. U&F showed potential but required enhancement, while U&I fostered resilience but posed risks. Further integration of emerging technologies like virtual reality may strengthen these interventions. This review identifies the characteristics of effective digital health interventions and evaluates the overall potential of digital technologies in improving LGBTQ+ youth mental health, uniquely contributing insights on digital solutions advancing LGBTQ+ youth mental healthcare.

Working towards a ready to implement digital literacy program

Background

As healthcare continues to expand online and digital care offerings multiply, the importance of digital inclusion and equity is now better recognized. Yet despite impressive regional grassroots efforts, today there remain few readily deployable programs designed to support patient digital literacy.

Methods

Digital Outreach for Obtaining Resources and Skills (DOORs) is one such digital literacy program that has evolved over the last 5 years to meet the rising demand. Through community partnerships, the DOORs curriculum and delivery has been updated to make the program more accessible and applicable as Coronavirus Disease 2019 (COVID-19) changes healthcare. Participants' experience in the most updated iteration of DOORS was assessed through surveys and semi-structured interviews.

Results

Improvements to DOORs include an updated DOORs curriculum, updated facilitator manual, an online platform with a learning management system, standardized training, patient-facing educational handouts, consolidation of all DOORs materials into a single package that is ready to be shared with other groups, implementation of a single-session intervention model, and Spanish translation. Participants reported improved confidence on 72% of the digital skills assessed. Thematic analysis resulted in three themes: awareness of divide, patient-centered design, and expanded skills and confidence.

Conclusions

Combined, these changes and participant outcomes better position DOORS to meet the rising need for digital literacy and offers a scalable model for teams across the world.

Perspective of Artificial Intelligence in Disease Diagnosis: A Review of Current and Future Endeavours in the Medical Field

Artificial intelligence (AI) has demonstrated significant promise for the present and future diagnosis of diseases. At the moment, AI-powered diagnostic technologies can help physicians decipher medical pictures like X-rays, magnetic resonance imaging, and computed tomography scans, resulting in quicker and more precise diagnoses. In order to make a prospective diagnosis, AI algorithms may also examine patient information, symptoms, and medical background. The application of AI in disease diagnosis is anticipated to grow as the field develops. In the future, AI may be used to find patterns in enormous volumes of medical data, aiding in disease prediction and prevention before symptoms appear. Additionally, by combining genetic data, lifestyle data, and environmental variables, AI may help in the diagnosis of complicated diseases. It is crucial to remember that while AI can be a powerful tool, it cannot take the place of qualified medical personnel. Instead, AI ought to support and improve diagnostic procedures, enhancing patient care and healthcare results. Future research and the use of AI for disease diagnosis must take ethical issues, data protection, and ongoing model validation into account.

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.

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

BACKGROUND

Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap.

OBJECTIVE

We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department.

METHODS

Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time.

RESULTS

The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023.

CONCLUSIONS

SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45666.

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.

"The library is so much more than books": considerations for the design and implementation of teen digital mental health services in public libraries

Background

Adolescence is a vulnerable developmental period, characterized by high rates of mental health concerns, yet few adolescents receive treatment. Public libraries support adolescents by providing them with access to teen programming, technological resources, and have recently been providing mental health services. Digital mental health (DMH) services may help libraries provide scalable mental health solutions for their adolescent patrons and could be well positioned to address the mental health needs of historically underrepresented racial and ethnic (HURE) adolescents; however, little research has been conducted on the compatibility of DMH services with adolescent patron mental health needs or resource needs of library workers supporting them.

Methods

The research team formed a partnership with a public library, which serves a large HURE adolescent population. We conducted needs assessment and implementation readiness interviews with 17 library workers, including leadership, librarians, and workers with specialized areas of practice. Interview questions focused on library infrastructure, as well as library needs and preferences around the design and implementation of DMH services for adolescents. We used the Consolidated Framework for Implementation Research as guiding implementation determinant framework to code and analyze the interview transcripts.

Results

Our findings revealed library workers play an important role in guiding patrons to desired resources and share a goal of implementing adolescent DMH resources into the library and elevating marginalized adolescents' voices. Existing library resources, such as the library's role as a safe space for adolescents in the community, close relationships with external and community organizations, and availability of no-cost technological resources, could help facilitate the implementation of DMH services. Barriers related to community buy-in, mental health stigma, and library worker confidence in supporting adolescent mental health could affect service implementation.

Conclusions

Our findings suggest public libraries are highly promising settings to deploy DMH services for adolescents. We identified important determinants that may impact the implementation of DMH services in public library settings. Special considerations are needed to design services to meet the mental health needs of HURE adolescent populations and those adolescents' most experiencing health inequities.

Increasing digital mental health reach and uptake via youth partnerships

Youth in the United States are facing an unprecedented mental health crisis. Yet, brick-and-mortar mental healthcare, such as face-to-face therapy, is overwhelmingly inaccessible to youth despite research advances in youth mental health. Digital Mental Health tools (DMH), the use of technologies to deliver mental health assessments and interventions, may help to increase mental healthcare accessibility. However, for a variety of reasons, evidence-based DMH have not been successful in reaching youth in real-world settings, particularly those who are most encumbered with access barriers to mental healthcare. This Comment therefore focuses on increasing DMH reach and uptake by young people, particularly among minoritized youth, by engaging in community-based youth partnerships. This idea recognizes and grows from decades' worth of community-based participatory research and youth partnerships successfully conducted by other disciplines (e.g., social work, public health, urban planning, education). Increasing uptake and engagement is an issue that is unlikely to be solved by adult-driven theory and design. As such, we emphasize the necessity of reframing youth input into DMH design and deployment from one-time participants to integral community-based partners. Indeed, recognizing and valuing their expertise to equitably address DMH implementation challenges, youth should help to pose the very questions that they will help to answer throughout the design and implementation planning for DMH moving forward.

Effectiveness and implementation of a text messaging intervention to reduce depression and anxiety symptoms among Latinx and Non-Latinx white users during the COVID-19 pandemic

Text messaging interventions are increasingly used to help people manage depression and anxiety. However, little is known about the effectiveness and implementation of these interventions among U.S. Latinxs, who often face barriers to using mental health tools. The StayWell at Home (StayWell) intervention, a 60-day text messaging program based on cognitive behavioral therapy (CBT), was developed to help adults cope with depressive and anxiety symptoms during the COVID-19 pandemic. StayWell users (n = 398) received daily mood inquiries and automated skills-based text messages delivering CBT-informed coping strategies from an investigator-generated message bank. We conduct a Hybrid Type 1 mixed-methods study to compare the effectiveness and implementation of StayWell for Latinx and Non-Latinx White (NLW) adults using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Effectiveness was measured using the PHQ-8 depression and GAD-7 anxiety scales, assessed before starting and after completing StayWell. Guided by RE-AIM, we conducted a thematic text analysis of responses to an open-ended question about user experiences to help contextualize quantitative findings. Approximately 65.8% (n = 262) of StayWell users completed pre-and-post surveys. On average, depressive (-1.48, p = 0.001) and anxiety (-1.38, p = 0.001) symptoms decreased from pre-to-post StayWell. Compared to NLW users (n = 192), Latinx users (n = 70) reported an additional -1.45 point (p < 0.05) decline in depressive symptoms, adjusting for demographics. Although Latinxs reported StayWell as relatively less useable (76.8 vs. 83.9, p = 0.001) than NLWs, they were more interested in continuing the program (7.5 vs. 6.2 out of 10, p = 0.001) and recommending it to a family member/friend (7.8 vs. 7.0 out of 10, p = 0.01). Based on the thematic analysis, both Latinx and NLW users enjoyed responding to mood inquiries and sought bi-directional, personalized text messages and texts with links to more information to resources. Only NLW users stated that StayWell provided no new information than they already knew from therapy or other sources. In contrast, Latinx users suggested that engagement with a behavioral provider through text or support groups would be beneficial, highlighting this group's unmet need for behavioral health care. mHealth interventions like StayWell are well-positioned to address population-level disparities by serving those with the greatest unmet needs if they are culturally adapted and actively disseminated to marginalized groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04473599.

Facilitators of and Barriers to Integrating Digital Mental Health Into County Mental Health Services: Qualitative Interview Analyses

BACKGROUND

Digital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts.

OBJECTIVE

This paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors.

METHODS

This study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework.

RESULTS

On the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate.

CONCLUSIONS

The successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field

Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.

Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial

Objective

The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD.

Methods

Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires.

Results

Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group.

Conclusion

The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group.

Clinical Trial Registration

ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.

The facilitators and barriers of mHealth adoption and use among people with a low socio-economic position: A scoping review

Background

Despite the fact that 95% of the global population has a mobile phone, the adoption of mHealth lags among people with a low socio-economic position (SEP). As they face health risks and many barriers in the traditional offline healthcare system, mHealth has an important role. Therefore, it is important to understand the factors that promote and impede mHealth adoption among people with a lower SEP.

Objective

The current study aims to provide an overview of what is known about the facilitators and barriers to the adoption and use of autonomous mHealth applications among people with low SEP.

Methods

A PRISMA scoping review in which the scientific databases PubMed, Web of Science, PsychInfo and SocINDEX were searched in the period of March 2017 to March 2022.

Results

Of the 1827 indexed papers, 13 papers were included in the review. In these papers, 30 factors have been identified as promoting or hindering the adoption of autonomous mHealth applications among low SEP people.

Conclusions

Thirty factors were found to facilitate or impede mHealth adoption among people with a low SEP, categorised into intrapersonal, interpersonal, community, ecological and app specific levels. Factors are assumed to be interrelated. The relationship between traditional (offline) care and digital care appeared to be of particular interest as the current study revealed that face-to-face contact is a prerequisite of mHealth adoption among people with low SEP. Therefore, a well-structured cosmopolitan system of stakeholders has been recommended.

Trial registration

This study was registered in OSF (https://doi.org/10.17605/OSF.IO/ATU9D).

Are remote psychotherapy/remediation efforts accessible and feasible in patients with schizophrenia? A narrative review

Background

Cognitive remediation (CR) therapy provides an effective way to improve cognitive impairments in schizophrenia. With the advent of telehealth services, especially during COVID 19 pandemic, a suitable alternative can be found in computer and cell phone-based mental health interventions. Previous studies have proven that remote mental health interventions have by and large been successful. Remote psychotherapy/CR services can now be accessed through smartphone apps, iPads, laptops and wearable devices. This has the advantage of reaching a wider population in resource-limited settings. The lack of access to technology, difficulty in using these online interventions and lack of privacy provide impediments to the delivery of care through these online platforms. Further, as some previous studies have shown, there may be a high rate of dropout in people using remote mental health resources. We aim to look at the factors, which influence the accessibility of remote mental health interventions in schizophrenia. Additionally, we test the feasibility of these interventions and look at how they compare and the potential they hold for implementation in future clinical settings.

Results

We found remote cognitive remediation to be both accessible and feasible. Concerning features, however, are the high attrition rates and the concentration of the studies in Western populations.

Conclusions

Remote interventions are a viable alternative to in-person psychotherapy when in-person resources may not always be present. They are efficacious in improving health outcomes among patients with schizophrenia. Further research into the widespread implementation of remote CR will be beneficial in informing clinical decision-making.

A Hybrid Ecological Momentary Compassion–Focused Intervention for Enhancing Resilience in Help-Seeking Young People: Prospective Study of Baseline Characteristics in the EMIcompass Trial

Background

Young people are a target population for mental health–related early intervention and prevention. Although evidence for early intervention is promising, availability of and access to youth mental health services remain limited. Therefore, the development of an evidence-based hybrid intervention is urgently needed.

Objective

This study aimed to present a manual for a hybrid intervention, combining an ecological momentary intervention and face-to-face sessions aimed for enhancing resilience in help-seeking young people based on compassion-focused interventions, and explore whether participants’ baseline characteristics are associated with putative mechanisms and outcomes of the EMIcompass intervention. Specifically, we aimed to explore initial signals as to whether participants’ sociodemographic, clinical, and functional characteristics at baseline are associated with putative mechanisms (ie, change in self-compassion, change in emotion regulation, working alliance, training frequency); and whether participants’ sociodemographic, clinical, and functional characteristics, self-compassion, and emotion regulation at baseline are associated with clinical outcomes (ie, psychological distress and general psychopathology at postintervention and 4-week follow-ups) in the experimental condition and obtain first parameter estimates.

Methods

We recruited young people aged 14 to 25 years, with psychological distress, Clinical High At-Risk Mental State, or first episodes of severe mental disorder for an exploratory randomized controlled trial with assessments at baseline and postintervention and 4-week follow-ups. A structured manual was developed and optimized based on a pilot study’s manual, a scoping review of existing literature and manuals, exchange with experts, the team’s clinical experience of working with compassion-focused interventions, and the principles of ecological momentary interventions. This analysis focuses on the experimental condition receiving the EMIcompass intervention.

Results

A total of 46 young individuals were randomized to the experimental condition. There was evidence for initial signals of effects of age (B=0.11, 95% CI 0.00-0.22), general psychopathology (B=0.08, 95% CI −0.01 to 0.16), and clinical stage (B=1.50, 95% CI 0.06-2.93) on change in momentary self-compassion and change in emotion regulation from baseline to postintervention assessments. There was no evidence for associations of other baseline characteristics (eg, gender, minority status, and level of functioning) and putative mechanisms (eg, overall self-compassion, working alliance, and training frequency). In addition, except for an initial signal for an association of momentary self-compassion at baseline and psychological distress (B=−2.83, 95% CI −5.66 to 0.00), we found no evidence that baseline characteristics related to clinical outcomes.

Conclusions

The findings indicated the reach of participants by the intervention largely independent of sociodemographic, clinical, and functional baseline characteristics. The findings need to be confirmed in a definitive trial.

Trial Registration

German Clinical Trials Register NDRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265

International Registered Report Identifier (IRRID)

RR2-10.2196/27462

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Digital headache self-management interventions for patients with a primary headache disorder: A systematic review of randomized controlled trials

OBJECTIVE

This article systematically reviews the empirical literature examining the efficacy of digital headache management interventions for patients with a primary headache disorder.

BACKGROUND

Digital headache management interventions provide opportunities to improve access to behavioral headache interventions to underserved groups.

METHODS

A systematic search of PubMed, Scopus, and EBSCO (PsycInfo, Education Research Complete, ERIC, Health Source: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection) and reference review was conducted. Included studies had to recruit a sample with a primary headache diagnosis, be a randomized controlled trial including a digital component, assess a headache outcome (i.e., frequency, duration, severity, intensity, disability) or quality of life, and be published in English. Two authors independently extracted data for included studies. The methodological quality of studies was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

Thirteen studies with unique interventions met inclusion criteria. More than half of the studies were pilots; however, nearly 70% (9/13) demonstrated significant between-group or within-group improvements on one or more headache-related outcomes. All interventions included some form of relaxation training and the majority were delivered via interactive website. While fewer than half the studies report participant race and/or ethnicity, of those that do, 83% (5/6) reported a predominately White/Caucasian sample.

CONCLUSIONS

Efficacy testing of digital headache interventions is in its infancy with the majority of these studies relying on pilot studies with small samples comprised of homogenous patient populations. Interactive websites were the most common digital medium to deliver digital headache management interventions and have demonstrated promising results. Further testing using large-scale randomized controlled trials and exploration of other digital tools is warranted. Future studies with more diverse samples are needed to inform health equity of digital headache interventions.

System design of a text messaging program to support the mental health needs of non-treatment seeking young adults

Young adults (ages 18-25) experience the highest levels of mental health problems of any adult age group, but have the lowest mental health treatment rates. Text messages are the most used feature on the mobile phone and provide an opportunity to reach non-treatment engaged users throughout the day in a conversational manner. We present the design of an automated text message-based intervention for symptom self-management. The intervention comprises: (1) psychological strategies (i.e., types of evidence-based techniques leveraged to achieve symptom reduction) and (2) interaction types or the form that intervention content takes as it is delivered to and elicited from users.

A Framework for the Implementation of Digital Mental Health Interventions: The Importance of Feasibility and Acceptability Research

Digital mental health interventions (DMHIs) have the potential to serve a significantly wider portion of the population in need of mental health services. The coronavirus disease 2019 (COVID-19) pandemic has especially highlighted the exacerbation of mental health disparities among minoritized populations. Innovations and research on DMHIs continue to expand, reinforcing the need for a more systemic process of DMHI implementation. In practice, DMHI implementation often skips the fundamental steps of conducting acceptability and feasibility studies. We propose a DMHI implementation framework that identifies an acceptability and feasibility study as an essential first step, simultaneously centering equitable processes that address populations disproportionately affected by mental illness.

Insights Into Needs and Preferences for Mental Health Support on Social Media and Through Mobile Apps Among Black Male University Students: Exploratory Qualitative Study

BACKGROUND

Black college-aged men are less likely than their peers to use formal, therapeutic in-person services for mental health concerns. As the use of mobile technologies and social media platforms is steadily increasing, it is important to conduct work that examines the future utility of digital tools and technologies to improve access to and uptake of mental health services for Black men and Black men in college.

OBJECTIVE

The aim of this study was to identify and understand college-attending Black men's needs and preferences for using digital health technologies and social media for stress and mental health symptom management.

METHODS

Interviews were conducted with Black male students (N=11) from 2 racially diverse universities in the Midwestern United States. Participants were asked questions related to their current mental health needs and interest in using social media platforms and mobile-based apps for their mental health concerns. A thematic analysis was conducted.

RESULTS

Four themes emerged from the data: current stress relief strategies, technology-based support needs and preferences (subthemes: mobile-based support and social media-based support), resource information dissemination considerations (subthemes: information-learning expectations and preferences and information-sharing preferences and behaviors), and technology-based mental health support design considerations (subtheme: relatability and representation). Participants were interested in using social media and digital technologies for their mental health concerns and needs, for example, phone notifications and visual-based mental health advertisements that promote awareness. Relatability in the context of representation was emphasized as a key factor for participants interested in using digital mental health tools. Examples of methods for increasing relatability included having tools disseminated by minority-serving organizations and including components explicitly portraying Black men engaging in mental health support strategies. The men also discussed wanting to receive recommendations for stress relief that have been proven successful, particularly for Black men.

CONCLUSIONS

The findings from this study provide insights into design and dissemination considerations for future work geared toward developing mental health messaging and digital interventions for young Black men.

Developing the Workforce of the Digital Future: Leveraging Technology to Train Community-Based Mobile Mental Health Specialists

Challenges in training, dissemination, and implementation have impeded the ability of providers to integrate promising digital health tools in real-world services. There is a need for generalizable strategies to rapidly train real-world providers at scale to support the adoption of digital health. This study describes the development of principles guiding rapid training of community-based clinicians in the support of digital health. This training approach was developed in the context of an ongoing trial examining implementation strategies for FOCUS, a mobile mental health intervention designed for people with serious mental illness. The SAIL (Simple, Accessible, Inverted, Live) model introduces how digital tools can be leveraged to facilitate rapid training of community agency-based personnel to serve as digital mental health champions, promoters, and providers. This model emphasizes simple and flexible principles of intervention delivery, accessible materials in a virtual learning environment, inverted or "flipped" live training structure, and live consultation calls for ongoing support. These initial insights lay the groundwork for future work to test and replicate generalizable training strategies focused on real-world delivery of digital mental health services. These strategies have the potential to remove key obstacles to the implementation and dissemination of digital health interventions for mental health.

Single-Session Interventions Embedded Within Tumblr: Acceptability, Feasibility, and Utility Study

Background

Existing mental health treatments are insufficient for addressing mental health needs at scale, particularly for teenagers, who now seek mental health information and support on the web. Single-session interventions (SSIs) may be particularly well suited for dissemination as embedded web-based support options that are easily accessible on popular social platforms.

Objective

We aimed to evaluate the acceptability and effectiveness of three SSIs, each with a duration of 5 to 8 minutes (Project Action Brings Change, Project Stop Adolescent Violence Everywhere, and REFRAME)—embedded as Koko minicourses on Tumblr—to improve three key mental health outcomes: hopelessness, self-hate, and the desire to stop self-harm behavior.

Methods

We used quantitative data (ie, star ratings and SSI completion rates) to evaluate acceptability and short-term utility of all 3 SSIs. Paired 2-tailed t tests were used to assess changes in hopelessness, self-hate, and the desire to stop future self-harm from before to after the SSI. Where demographic information was available, the analyses were restricted to teenagers (13-19 years). Examples of positive and negative qualitative user feedback (ie, written text responses) were provided for each program.

Results

The SSIs were completed 6179 times between March 2021 and February 2022. All 3 SSIs generated high star ratings (>4 out of 5 stars), with high completion rates (approximately 25%-57%) relative to real-world completion rates among other digital self-help interventions. Paired 2-tailed t tests detected significant pre-post reductions in hopelessness for those who completed Project Action Brings Change (P<.001, Cohen d_z=−0.81, 95% CI −0.85 to −0.77) and REFRAME (P<.001, Cohen d_z=−0.88, 95% CI −0.96 to −0.80). Self-hate significantly decreased (P<.001, Cohen d_z=−0.67, 95% CI −0.74 to −0.60), and the desire to stop self-harm significantly increased (P<.001, Cohen d_z=0.40, 95% CI 0.33 to 0.47]) from before to after the completion of Project Stop Adolescent Violence Everywhere. The results remained consistent across sensitivity analyses and after correcting for multiple tests. Examples of positive and negative qualitative user feedback point toward future directions for SSI research.

Conclusions

Very brief SSIs, when embedded within popular social platforms, are one promising and acceptable method for providing free, scalable, and potentially helpful mental health support on the web. Considering the unique barriers to mental health treatment access that many teenagers face, this approach may be especially useful for teenagers without access to other mental health supports.

Assessment of Smartphone Apps for Common Neurologic Conditions (Headache, Insomnia, and Pain): Cross-sectional Study

BACKGROUND

There are thousands of apps for individuals struggling with headache, insomnia, and pain, but it is difficult to establish which of these apps are best suited for patients' specific needs. If clinicians were to have access to a platform that would allow them to make an informed decision on the efficacy and feasibility of smartphone apps for patient care, they would feel confident in prescribing specific apps.

OBJECTIVE

We sought to evaluate the quality of apps for some of the top common, disabling neurologic conditions (headache, insomnia, and pain) based on principles derived from the American Psychiatric Association's (APA) app evaluation model.

METHODS

We used the Mobile Health Index and Navigation database and expanded upon the database's current supported conditions by adding 177 new app entries. Each app was rated for consistency with the APA's app evaluation model, which includes 105 objective questions based on the following 5 major classes of consideration: (1) accessibility, (2) privacy and security, (3) clinical foundation, (4) engagement style, and (5) interoperability. These characteristics were evaluated to gain a broader understanding of the significant features of each app category in comparison against a control group.

RESULTS

Approximately 90% (187/201) of all apps evaluated were free to download, but only 50% (63/201) of headache- and pain-related apps were truly free. Most (87/106, 81%) sleep apps were not truly free to use. The apps had similar limitations with limited privacy, accessibility, and crisis management resources. For example, only 17% (35/201) of the apps were available in Spanish. The apps offered mostly self-help tools with little tailoring; symptom tracking was the most common feature in headache- (32/48, 67%) and pain-related apps (21/47, 45%), whereas mindfulness was the most common feature in sleep-related apps (73/106, 69%).

CONCLUSIONS

Although there are many apps for headache, pain, and insomnia, all 3 types of apps have room for improvement around accessibility and privacy. Pain and headache apps share many common features, whereas insomnia apps offer mostly mindfulness-based resources. Given the many available apps to pick from, clinicians and patients should seek apps that offer the highest-quality features, such as complete privacy, remedial features, and the ability to download the app at no cost. These results suggest that there are many opportunities for the improvement of apps centered on headache, insomnia, and pain.

Emerging Artificial Intelligence–Empowered mHealth: Scoping Review

Background

Artificial intelligence (AI) has revolutionized health care delivery in recent years. There is an increase in research for advanced AI techniques, such as deep learning, to build predictive models for the early detection of diseases. Such predictive models leverage mobile health (mHealth) data from wearable sensors and smartphones to discover novel ways for detecting and managing chronic diseases and mental health conditions.

Objective

Currently, little is known about the use of AI-powered mHealth (AIM) settings. Therefore, this scoping review aims to map current research on the emerging use of AIM for managing diseases and promoting health. Our objective is to synthesize research in AIM models that have increasingly been used for health care delivery in the last 2 years.

Methods

Using Arksey and O’Malley’s 5-point framework for conducting scoping reviews, we reviewed AIM literature from the past 2 years in the fields of biomedical technology, AI, and information systems. We searched 3 databases, PubsOnline at INFORMS, e-journal archive at MIS Quarterly, and Association for Computing Machinery (ACM) Digital Library using keywords such as “mobile healthcare,” “wearable medical sensors,” “smartphones”, and “AI.” We included AIM articles and excluded technical articles focused only on AI models. We also used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) technique for identifying articles that represent a comprehensive view of current research in the AIM domain.

Results

We screened 108 articles focusing on developing AIM models for ensuring better health care delivery, detecting diseases early, and diagnosing chronic health conditions, and 37 articles were eligible for inclusion, with 31 of the 37 articles being published last year (76%). Of the included articles, 9 studied AI models to detect serious mental health issues, such as depression and suicidal tendencies, and chronic health conditions, such as sleep apnea and diabetes. Several articles discussed the application of AIM models for remote patient monitoring and disease management. The considered primary health concerns belonged to 3 categories: mental health, physical health, and health promotion and wellness. Moreover, 14 of the 37 articles used AIM applications to research physical health, representing 38% of the total studies. Finally, 28 out of the 37 (76%) studies used proprietary data sets rather than public data sets. We found a lack of research in addressing chronic mental health issues and a lack of publicly available data sets for AIM research.

Conclusions

The application of AIM models for disease detection and management is a growing research domain. These models provide accurate predictions for enabling preventive care on a broader scale in the health care domain. Given the ever-increasing need for remote disease management during the pandemic, recent AI techniques, such as federated learning and explainable AI, can act as a catalyst for increasing the adoption of AIM and enabling secure data sharing across the health care industry.

Transportation and other social needs as markers of mental health conditions

Objective

The study sought to determine whether reporting a history of depression, anxiety, PTSD, bipolar disorder, drug or alcohol use disorder, ADHD, schizophrenia, or current depressive symptoms was associated with requesting help for any of 12 social needs.

Methods

A community-based sample of 1,944 low-income adult smokers in Missouri who had called a telephone helpline for social needs were recruited between June 1, 2017 and November 15, 2020. Helpline data on callers' requests for assistance with utilities, housing, food, household goods, healthcare, transportation, adult care, financial assistance, employment, legal assistance, personal safety and childcare were merged with self-reported mental health data collected in a subsequent phone survey with the same callers. Using binary logistic regression, we examined which mental health conditions were associated with each social need.

Results

Reporting mental health conditions were associated with greater odds of requests for assistance with transportation, food, healthcare and personal safety. Of these, the strongest and most consistent associations were with transportation needs. In post-hoc analyses, most associations between transportation needs and mental health remained significant after adjusting for possible confounders.

Conclusions

Compared to participants who did not report histories of mental health conditions, those who reported mental health conditions were more likely to call 2-1-1 seeking transportation assistance. Community-based agencies providing transportation or mental health services could partner to provide linkages between services and increase capacity to address transportation and mental health needs.

Older Veterans' Treatment Preferences: Psychotherapy and Self-Management Treatment Modalities

OBJECTIVES

Self-management may help older Veterans with mental health challenges and can overcome barriers to traditional psychotherapy. However, the reasons underlying older Veterans' treatment preferences remain unknown. The current study investigated older Veterans' perspectives on psychotherapy and self-management.

METHODS

Seventy-four Veterans ≥ 60 years old were included in this mixed methods study. Participants provided rationale(s) after ranking their preferences for psychotherapy and four self-management modalities. Logistic regressions examined whether depressive and anxiety symptom severity contributes to preferences. Qualitative analyses were conducted to investigate reasoning for preferences.

RESULTS

Most participants preferred psychotherapy (64.9%) over self-management (35.1%). Logistic regressions showed that depressive and anxiety symptom severity was not significantly associated with preferences. Qualitative analyses revealed that past experience and access-related barriers were underlying the preferences. Themes unique to psychotherapy included the availability of emotional support and the process of information sharing. In contrast, ease of access was associated with self-management.

CONCLUSIONS

Older Veterans preferred psychotherapy to receive support and to develop trust in meeting their goals.

CLINICAL IMPLICATIONS

Older Veterans' needs point to the importance of providers' consideration of a person-centered approach and treatment collaboration. Notably, Veterans' preference for psychotherapy highlights the importance and need for human support in addition to self-management tools.

An overview of and recommendations for more accessible digital mental health services

Mental health concerns are common, and various evidence-based interventions for mental health conditions have been developed. However, many people have difficulty accessing appropriate mental health care and this has been exacerbated by the COVID-19 pandemic. Digital mental health services, such as those delivered by mobile phone or web-based platforms, offer the possibility of expanding the reach and accessibility of mental health care. To achieve this goal, digital mental health interventions and plans for their implementation must be designed with the end users in mind. In this Review, we describe the evidence base for digital mental health interventions across various diagnoses and treatment targets. Then, we explain the different formats for digital mental health intervention delivery, and offer considerations for their use across key age groups. We discuss the role that the COVID-19 pandemic has played in emphasizing the value of these interventions, and offer considerations for ensuring equity in access to digital mental health interventions among diverse populations. As healthcare providers continue to embrace the role that technology can play in broadening access to care, the design and implementation of digital mental healthcare solutions must be carefully considered to maximize their effectiveness and accessibility.

Canadian perspectives of digital mental health supports: Findings from a national survey conducted during the COVID-19 pandemic

Objectives

The impact of the COVID-19 pandemic on population mental health has highlighted the potential for digital mental health to support the needs of those requiring care. This study sought to understand the digital mental health experiences and priorities of Canadians affected by mental health conditions (i.e. seekers, patients, and care partners).

Methods

A national cross-sectional electronic survey of Canadians was administered through a market research firm's survey panel. Seekers, patients, and care partners were asked about their digital mental health experiences (e.g. uptake, barriers to access) and priorities. Survey responses were summarized using descriptive statistics.

Results

Overall, 1003 participants completed the survey. 70.2% of participants routinely use digital mental health supports to support themselves or those they care for; however, only 28.6% of participants are satisfied with the available digital mental health supports. Most participants (73.3%) have encountered some barriers when accessing digital mental health supports. Awareness of digital mental health supports was a top barrier identified by participants. The top digital mental health priorities consisted of digital mental health curation, navigation, and a digital mental health passport.

Conclusions

Most participants use digital mental health supports for themselves or others, however, many are unaware of digital mental health supports available. Efforts to improve navigating access to digital and in-person mental health services are seen as a top priority, highlighting the need to enable seekers, patients, and care partners to find the appropriate support and make decisions on how to best improve their mental health.

Mindfulness Training Intervention With the Persian Version of the Mindfulness Training Mobile App for Premenstrual Syndrome: A Randomized Controlled Trial

Premenstrual syndrome (PMS) is a common problem for women of reproductive age, affecting various aspects of their lives. While various in-person psychotherapeutic interventions, including Mindfulness therapy, have yielded promising results in reducing PMS symptoms, due to the COVID-19 Pandemic, psychotherapists are providing their services via online methods. Therefore, the present study is the first one worldwide to examine whether smartphone-based Mindfulness training can reduce symptoms of PMS and improve the quality of life in women with PMS. We recruited 80 Iranian women (aged 25-45) with PMS through online advertising who were randomly allocated into two groups of 40. The intervention group underwent two online introductory group sessions followed by 8 weeks of Mindfulness practice, while the control group received no intervention. Before and after the intervention, participants completed the 12-Item Short-Form Health Survey and the Premenstrual Symptoms Screening (PSST) questionnaires. Data were analyzed using the Analysis of Covariance (ANCOVA). Following the intervention, the mean scores of PMS symptoms were significantly lower in the intervention group than in the control group (p < 0.001; η² = 0.18). Likewise, the quality of life score was significantly higher in the intervention group (p < 0.001; η² = 0.14). Our results indicated that the smartphone-based Mindfulness training intervention could be an effective treatment modality for women with PMS symptoms, especially during the COVID-19 Pandemic, which has posed limitations for in-person therapies.

CLINICAL TRIAL REGISTRATION

https://fa.irct.ir/trial/59924, identifier: IRCT20180607040000N2.

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19

The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.

Considerations of diversity, equity, and inclusion in mental health apps: A scoping review of evaluation frameworks

Mental health applications or apps are a promising approach to reduce the pervasive unmet mental health need observed among marginalized groups. However, these groups face unique challenges to engage in and benefit from these interventions, and apps that consider issues of diversity, equity, and inclusion (DEI) may be better positioned to reach them. App evaluation frameworks emerge as crucial tools for researchers, clinicians, and users to select evidence-based apps. Nevertheless, it is unclear the extent to which existing assessment tools capture DEI factors. The present scoping review identified 68 studies that employed one or more assessment tools to evaluate a mental health app, leading to 44 unique app evaluation frameworks. Results showed that most frameworks were developed after 2015, and only 58% of them considered at least one DEI criterion. Frameworks that performed exceptionally well were those that combined multiple standardized and validated measures. This lack of consideration for DEI variables may limit the ability of app-based interventions to serve marginalized communities, or even worse, create new disparities. Therefore, we provide recommendations to improve current app evaluation frameworks' cultural robustness and clinical utility, maximizing their effectiveness when working with individuals from marginalized communities.

Exploring Social Media Recruitment Strategies and Preliminary Acceptability of an mHealth Tool for Teens with Eating Disorders

(1) Background: The current study leveraged social media to connect with teens with EDs to identify population specific characteristics and to gather feedback on an mHealth intervention. (2) Methods: We recruited teens with EDs from social media in two phases: (1) Discovery Group, (2) Testing Group. The Discovery Group (n = 14) participants were recruited from Facebook/Instagram and were asked to review the app for up to one week and provide qualitative feedback. After incorporating feedback from the Discovery Group, we refined our social media outreach methods to connect with 30 teens with EDs to pilot this mobile app. Recruitment from a variety of platforms on social media was successful, with the majority of enrolled participants in the Testing Group coming from Snapchat (60%) and a large percentage of participants belonging to gender and sexual minority groups (63%). (3) Results: Participants from both groups experienced extremely high rates of depression (100% Discovery, 90% Testing) and/or anxiety symptoms (100% Discovery, 93% Testing) in addition to ED symptoms, and noted this as a possible barrier to app engagement. (4) Conclusion: Use of social media for recruitment of teens with EDs is feasible and may connect with groups who may be more difficult to reach using traditional recruitment methods. Among the Discovery Group there was high acceptability of and interest in an app to support ED recovery, and characteristics of both groups demonstrated need for support in other mental health domains. Future studies should evaluate the preliminary efficacy of such tools among teens to determine the effects of such interventions on ED symptoms and other mental health outcomes.

Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review

BACKGROUND

The COVID-19 health crisis has disproportionately impacted populations who have been historically marginalized in health care and public health, including low-income and racial and ethnic minority groups. Members of marginalized communities experience undue barriers to accessing health care through virtual care technologies, which have become the primary mode of ambulatory health care delivery during the COVID-19 pandemic. Insights generated during the COVID-19 pandemic can inform strategies to promote health equity in virtual care now and in the future.

OBJECTIVE

The aim of this study is to generate insights arising from literature that was published in direct response to the widespread use of virtual care during the COVID-19 pandemic, and had a primary focus on providing recommendations for promoting health equity in the delivery of virtual care.

METHODS

We conducted a narrative review of literature on health equity and virtual care during the COVID-19 pandemic published in 2020, describing strategies that have been proposed in the literature at three levels: (1) policy and government, (2) organizations and health systems, and (3) communities and patients.

RESULTS

We highlight three strategies for promoting health equity through virtual care that have been underaddressed in this literature: (1) simplifying complex interfaces and workflows, (2) using supportive intermediaries, and (3) creating mechanisms through which marginalized community members can provide immediate input into the planning and delivery of virtual care.

CONCLUSIONS

We conclude by outlining three areas of work that are required to ensure that virtual care is employed in ways that are equity enhancing in a post-COVID-19 reality.