Theme issue on e-mental health: a growing field in internet research

A Chatbot (Juno) Prototype to Deploy a Behavioral Activation Intervention to Pregnant Women: Qualitative Evaluation Using a Multiple Case Study

BACKGROUND

Despite the increasing focus on perinatal care, preventive digital interventions are still scarce. Furthermore, the literature suggests that the design and development of these interventions are mainly conducted through a top-down approach that limitedly accounts for direct end user perspectives.

OBJECTIVE

Building from a previous co-design study, this study aimed to qualitatively evaluate pregnant women's experiences with a chatbot (Juno) prototype designed to deploy a preventive behavioral activation intervention.

METHODS

Using a multiple-case study design, the research aims to uncover similarities and differences in participants' perceptions of the chatbot while also exploring women's desires for improvement and technological advancements in chatbot-based interventions in perinatal mental health. Five pregnant women interacted weekly with the chatbot, operationalized in Telegram, following a 6-week intervention. Self-report questionnaires were administered at baseline and postintervention time points. About 10-14 days after concluding interactions with Juno, women participated in a semistructured interview focused on (1) their personal experience with Juno, (2) user experience and user engagement, and (3) their opinions on future technological advancements. Interview transcripts, comprising 15 questions, were qualitatively evaluated and compared. Finally, a text-mining analysis of transcripts was performed.

RESULTS

Similarities and differences have emerged regarding women's experiences with Juno, appreciating its esthetic but highlighting technical issues and desiring clearer guidance. They found the content useful and pertinent to pregnancy but differed on when they deemed it most helpful. Women expressed interest in receiving increasingly personalized responses and in future integration with existing health care systems for better support. Accordingly, they generally viewed Juno as an effective momentary support but emphasized the need for human interaction in mental health care, particularly if increasingly personalized. Further concerns included overreliance on chatbots when seeking psychological support and the importance of clearly educating users on the chatbot's limitations.

CONCLUSIONS

Overall, the results highlighted both the positive aspects and the shortcomings of the chatbot-based intervention, providing insight into its refinement and future developments. However, women stressed the need to balance technological support with human interactions, particularly when the intervention involves beyond preventive mental health context, to favor a greater and more reliable monitoring.

Transitioning Virtual-Only Group Therapy for Substance Use Disorder Patients to a Hybrid Model

Purpose

Telehealth is associated with a myriad of benefits; however, little is known regarding substance use disorder (SUD) treatment outcomes when participants join group therapy sessions in a combination in-person and virtual setting (hybrid model). We sought to determine if treatment completion rates differed.

Patients and Methods

Policy changes caused by the COVID-19 pandemic created a naturalistic, observational cohort study at seven intensive outpatient (IOP) programs in rural Minnesota. Virtual-only delivery occurred 6/1/2020-6/30/2021, while hybrid groups occurred 7/1/2021-7/31/2022. Data was evaluated retrospectively for participants who initiated and discharged treatment during the study period. Participants were IOP group members 18 years and older who had a SUD diagnosis that both entered and discharged treatment during the 26-month period. A consecutive sample of 1502 participants (181-255 per site) was available, with 644 removed: 576 discharged after the study conclusion, 49 were missing either enrollment or discharge data, 14 transferred sites during treatment, and 5 initiated treatment before the study initiation. Helmert contrasts evaluated the impact of hybrid group exposure.

Results

A total of 858 individuals were included. Data was not from the medical chart and was deidentified preventing specific demographics; however, the overall IOP sample for 2020-2022, from which the sample was derived, was 29.8% female, and 64.1% were 18-40 years of age. For completed treatment, hybrid group exposure relative to virtual-only had a univariate odds ratio of 1.88 (95% CI: 1.50-2.41, p < 0.001). No significant difference was seen across IOP sites.

Conclusion

These results describe a novel hybrid group approach to virtual care for SUDs with outcome data not previously documented in the literature. While virtual treatment delivery can increase access, these results suggest a benefit is derived from including an in-person option. Further research is needed to identify how an in-person component may change dynamics and if it can be replicated in virtual-only models.

Assessing the Influence of Patient Empowerment Gained Through Mental Health Apps on Patient Trust in the Health Care Provider and Patient Compliance With the Recommended Treatment: Cross-sectional Study

BACKGROUND

In chronic mental illness, noncompliance with treatment significantly worsens the illness course and outcomes for patients. Considering that nearly 1 billion people worldwide experience mental health issues, including 1 of 5 Canadians in any given year, finding tools to lower noncompliance in these populations is critical for health care systems. A promising avenue is apps that make mental health services more accessible to patients. However, little is known regarding the impact of the empowerment gained from mental health apps on patient compliance with recommended treatment.

OBJECTIVE

This study aimed to investigate the impact of patient empowerment gained through mental health apps on patient trust in the health care provider and patient compliance with the recommended treatment.

METHODS

A cross-sectional web-based survey was conducted in Canada. Eligible participants were Canadian adults diagnosed with chronic mental health disorders who were using at least one of the following apps: Dialogue, MindBeacon, Deprexis, Ginger, Talkspace, BetterHelp, MindStrong, Mindshift, Bloom, Headspace, and Calm. A total of 347 valid questionnaires were collected and analyzed using partial least-squares structural equation modeling. Trust in the health care provider and patient compliance were measured with multiple-item scales adapted from existing scales. Patient empowerment was conceived and measured as a higher-order construct encompassing the following 2 dimensions: patient process and patient outcome. All the items contributing to the constructs in the model were measured with 7-point Likert scales. The reliability and validity of the measurement model were assessed, and the path coefficients of the structural model were estimated.

RESULTS

The results clearly show that patient empowerment gained through mental health apps positively influenced patient trust in the health care provider (β=.306; P<.001). Patient trust in the health care provider had a positive effect on patient compliance (β=.725; P<.001). The direct relationship between patient empowerment and patient compliance was not significant (β=.061, P=.23). Interestingly, the data highlight that the effect of patient empowerment on patient compliance was fully mediated by trust in the health care provider (β=.222; P<.001). The results show that patient empowerment gained through the mental health app involves 2 dimensions: a process and an outcome.

CONCLUSIONS

This study shows that for individuals living with mental health disorders, empowerment gained through mental health apps enhances trust in the health care provider. It reveals that patient empowerment impacts patient compliance but only through the full mediating effect of patient trust in the health care provider, indicating that patient trust is a critical variable to enhance patient compliance. Hence, our results confirm that health care systems could encourage the use of mental health apps to favor a climate that facilitates patients' trust in health care provider recommendations, possibly leading to better compliance with the recommended treatment.

Promoting Sexual Health in Colorectal Cancer Patients and Survivors: Results from a Systematic Review

BACKGROUND

Colorectal cancer diagnosis and treatment negatively impact sexual health. However, there is still a lack of interventions targeting the sexual healthcare needs of colorectal cancer patients and survivors. This systematic review aimed to identify and summarize the efficacy of available psychological interventions aimed at improving colorectal cancer patients' and survivors' sexual health.

METHODS

This review followed PRISMA guidelines for systematic reviews. A database search was conducted for studies published until July 2023 on EBSCO Host, Web of Science, PubMed, and the Cochrane Library. Manuscripts were screened according to inclusion and exclusion criteria. The risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies.

RESULTS

From the 1499 records screened, four studies describing psychological interventions to improve the sexual health of the target population were identified. All studies reported on e-health programs and showed evidence of their efficacy in the improvement of participants' sexual function. The studies presented low scores on the Quality Assessment Tool for Quantitative Studies.

CONCLUSIONS

Despite the evidence that tele/e-health psychological interventions have the potential to effectively promote sexual health in colorectal cancer patients and survivors, more robust research is needed to allow for generalization. Future research should further assess the efficacy of e-health interventions (eMental Health) in promoting sexual health in patients with colorectal cancer.

Comparison of Resilience, Personal Recovery, and Quality of Life Measures Pre- and Post-Discharge from Inpatient Mental Health Units in Alberta: Analysis of Control Group Data from a Randomized Trial

Background: The transition from hospital to community settings for most mental health service users is often hindered by challenges that affect community adjustment and continuity of care. The first few weeks and days after discharge from mental health inpatient units represent a critical phase for many service users. This paper aims to evaluate the changes in the resilience, personal recovery, and quality of life status of individuals with mental health challenges recently discharged from acute mental health care into the community. Methods: Data for this study were collected as part of a pragmatic stepped-wedge cluster-randomized, longitudinal approach in Alberta. A paired sample t-test and Chi-squared/Fisher test were deployed to assess changes from baseline to six weeks in the recovery assessment scale (RAS), brief resilience scale (BRS), and EuroQol-5d (EQ-5D), using an online questionnaire. Results: A total of 306 service users were recruited and 88 completed both baseline and six weeks, giving a response rate of 28.8%. There was no statistically significant change in the level of resilience, recovery and quality of life as measured with the brief resilience scale, recovery assessment scale and EQ-5D from baseline to six weeks (p > 0.05). Conclusions: The study showed that there was neither an improvement nor deterioration in resilience, recovery, or quality of life status of service users six weeks post-discharge from inpatient mental health care. The lack of further progress calls into question whether the support available in the community when patient's leave inpatient care is adequate to promote full recovery. The results justify investigations into the effectiveness of innovative and cost-effective programs such as peer and text-based supportive interventions for service users discharged from inpatient psychiatric care.

An Implementation Pilot of Web-Based Self-Training Programs on Sexual Dysfunctions in the Dutch Public Sexual Health Setting: Mixed Methods Study

BACKGROUND

Web-based sexual health interventions may be more acceptable to people compared with face-to-face support, given the stigma and embarrassment often associated with sexual problems. The Dutch public sexual health clinics (SHCs) conducted an implementation pilot with 4 web-based self-training programs on sexual dysfunctions (WSTPs) for young people. In addition to a basic sexuality program, the WSTPs focused on the following complaints: pain during intercourse, premature ejaculation, and no sex drive.

OBJECTIVE

This study aims to gain insight into the potential reach of the freely offered WSTPs; use, acceptance, evaluation, and perceived impact of the WSTPs by young people; and evaluation and acceptance of the WSTPs by nurses of the SHCs.

METHODS

A quantitative baseline measurement (BM) and a follow-up measurement (FM) were conducted among the users. In addition, qualitative data were gathered through video interviews with a sample of respondents of the FM and nurses of the SHCs to gain more in-depth insights into their assessment of the WSTPs. Participants were recruited via social media, posters, and referrals by nurses of the SHCs. Quantitative data were analyzed using descriptive statistics. Independent 2-tailed t tests and one-way independent ANOVAs were used to compare the scores between subgroups based on background characteristics. Dependent 2-tailed t tests were used to assess the possible changes between BM and FM. The interviews were analyzed using a thematic analysis.

RESULTS

A total of 1028 young people (aged 16-24 y) completed the BM, 666 started with 1 of the WSTPs, and 104 participants completed the FM. In addition, 8 users and 8 nurses were interviewed. Of the participants who completed the BM, 87.74% (902/1028) experienced moderate (411/1028, 39.98%) to high (491/1028, 47.76%) severity of complaints, of which 20.43% (210/1028) had had them for >1 year and 27.82% (286/1028) even for ≥2 years, and 38.91% (400/1028) were dissatisfied with their sex lives. Only 8.75% (90/1028) had sought professional help in the past 2 years. At FM, users rated satisfaction with their sex life more positively than they did at BM, and they experienced less discomfort from their complaints. The overall rating was positive, with a mean report grade of 7.3 (SD 1.45; on a 10-point scale). Anonymity, clear information and explanation, and practical exercises are indicated as strengths of the WSTPs, leading to more understanding and normalization. Nurses appreciate the high quality of information and accessibility of the WSTPs. They consider them as a valuable addition to the consultation hours.

CONCLUSIONS

WSTPs can reach a large number of young people with sexual problems who are less likely to seek professional help. This can result in an improved understanding of their issues, a decrease in complaints, and reduced barriers to communicating with a partner or professional.

Effect of online interventions on reducing anxiety and depression for women with breast cancer: a systematic review and network meta-analysis protocol

INTRODUCTION

Breast cancer has becoming the most common malignancy in women globally. Various online interventions have been conducted to help women with breast cancer to manage their psychological symptoms. However, there has been not yet a network meta-analysis that has synthesised scientific evidence about online intervention on reducing anxiety and depression for women with breast cancer. To fill the literature gap, this protocol aims to generate a systematic review and network meta-analysis to assess the effectiveness of online interventions on reducing anxiety and depression for these women with breast cancer. The study results may inform the recommendations for clinical guidelines and facilitate the decision-making process to improve psychological health of women with breast cancer.

METHODS AND ANALYSIS

The protocol is in compliance with the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols and for Systematic Reviews and Network Meta-Analysis. The electronic databases of Pubmed, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Central Registry of Controlled Trials and OpenGrey will be used for searching of related randomised controlled trials from their inception. No restrictions on publication date and language will be applied. The primary outcomes are the symptoms of anxiety and depression, and the secondary outcome is the satisfaction with the received healthcare. Two reviewers independently evaluate the risk of bias using the Cochrane Collaboration's Risk of Bias tool. The assessment of heterogeneity, inconsistency, subgroup analysis, sensitivity analysis and publication bias will be conducted. The netmeta package of R software will be used to perform the network meta-analysis.

ETHICS AND DISSEMINATION

This study will be based on previous research findings, so that ethics approval is not required. Data searching commences in July 2023 and expects to complete in January, 2024. The findings will be disseminated through peer-reviewed journals and academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42022318530.

E-mental health in Germany - what is the current use and what are experiences of different types of health care providers for patients with mental illnesses?

BACKGROUND

As a new and effective support option, e-mental health interventions can be useful in complementing treatment in mental health care. To date, little is known about how health care providers use these programs to treat patients with mental illnesses in Germany. The present study aims to examine the use of and experiences with e-mental health interventions from the point of view of different types of health care providers for patients with mental illnesses.

METHODS

Data from a cross-sectional survey of routine care health care providers in Germany in 2021 were analysed. In this survey, data were collected from n = 107 general practitioners (GPs), n = 114 specialist doctors, n = 102 psychotherapists, and n = 102 inpatient clinicians. Assessments included professional use of digital media, as well as knowledge, use and experiences regarding e-mental health interventions in care of people with mental illness.

RESULTS

In the total sample of n = 425, 65.6% (n = 279) were female. The study participants had an average age of 47.7 years (SD = 11.0) and their average work experience was 20.0 years (SD = 11.1). Overall, the majority (83.8%, n = 353) had heard of e-mental health interventions, but few felt well informed. Only 28.5% (n = 121) had already used e-mental health interventions for treatment support. The most commonly recommended e-mental health interventions in the sample were deprexis (39.7%, n = 48), moodgym (24.8%, n = 30), and iFightDepression (22.3%, n = 27). The use was predominantly considered to be helpful and satisfactory. Insufficient knowledge about e-mental health interventions and lack of informational materials for patients were reported as relevant barriers to the use of e-mental health interventions.

CONCLUSIONS

E-mental health interventions can be a useful support option, but they are rarely used in the treatment of patients with mental illnesses. There is a need to disseminate information specific to the various types of health care providers. Tailored implementation strategies need to be developed in order to capitalize on the potential of effective e-mental health interventions and to improve health care for patients with mental illnesses.

Breast Cancer Survivors' Attitudes toward eMental Health: A Cross-Sectional Study

BACKGROUND

Breast cancer survivors' (BCS) attitudes toward eMental Health (eMH) are largely unknown, and adoption predictors and their interrelationships remain unclear. This study aimed to explore BCS' attitudes toward eMH and investigate associated variables.

METHODS

A cross-sectional study involving 336 Portuguese BCS was conducted. Attitudes toward eMH, depression and anxiety symptoms, health-related quality of life, and sociodemographic, clinical, and internet-related variables were assessed using validated questionnaires. Spearman-ranked correlations, χ2, and multiple regression analyses were computed to explore associations between attitudes and collected variables.

RESULTS

BCS held a neutral stance toward eMH. In models adjusted for age and education, positive attitudes were statistically significantly associated with increased depressive symptoms and worse emotional, cognitive, and body image functioning. Social network use, online health information and mental healthcare seeking, higher self-reported knowledge of eMH, and previous use of remote healthcare were positively associated with better attitudes toward eMH.

CONCLUSIONS

eMH programs targeting BCS seem to be a promising strategy for providing supportive psychosocial care to BCS. However, increasing awareness about eMH efficacy and security may be necessary to improve its acceptance and use among BCS. Additional research is necessary to understand how BCS' unmet care needs, and specifically their psychological distress severity, may impact BCS' acceptance and use of eMH.

Exploring the usability of an internet-based intervention and its providing eHealth platform in an eye-tracking study

The proliferation of online eHealth has made it much easier for users to access healthcare services and interventions from the comfort of their own homes. This study looks at how well one such platform-eSano-performs in terms of user experience when delivering mindfulness interventions. In order to assess usability and user experience, several tools such as eye-tracking technology, think-aloud sessions, a system usability scale questionnaire, an application questionnaire, and post-experiment interviews were employed. Participants were evaluated while they accessed the first module of the mindfulness intervention provided by eSano to measure their interaction with the app, and their level of engagement, and to obtain feedback on both the intervention and its overall usability. The results revealed that although users generally rated their experience with the app positively in terms of overall satisfaction, according to data collected through the system usability scale questionnaire, participants rated the first module of the mindfulness intervention as below average. Additionally, eye-tracking data showed that some users skipped long text blocks in favor of answering questions quickly while others spent more than half their time reading them. Henceforth, recommendations were put forward to improve both the usability and persuasiveness of the app-such as incorporating shorter text blocks and more engaging interactive elements-in order to raise adherence rates. Overall findings from this study provide valuable insights into how users interact with the eSano's participant app which can be used as guidelines for the future development of more effective and user-friendly platforms. Moreover, considering these potential improvements will help foster more positive experiences that promote regular engagement with these types of apps; taking into account emotional states and needs that vary across different age groups and abilities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12652-023-04635-4.

To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers

Post-traumatic stress disorder (PTSD) can become a chronic and severely disabling condition resulting in a reduced quality of life and increased economic burden. The disorder is directly related to exposure to a traumatic event, e.g., a real or threatened injury, death, or sexual assault. Extensive research has been done on the neurobiological alterations underlying the disorder and its related phenotypes, revealing brain circuit disruption, neurotransmitter dysregulation, and hypothalamic–pituitary–adrenal (HPA) axis dysfunction. Psychotherapy remains the first-line treatment option for PTSD given its good efficacy, although pharmacotherapy can also be used as a stand-alone or in combination with psychotherapy. In order to reduce the prevalence and burden of the disorder, multilevel models of prevention have been developed to detect the disorder as early as possible and to reduce morbidity in those with established diseases. Despite the clinical grounds of diagnosis, attention is increasing to the discovery of reliable biomarkers that can predict susceptibility, aid diagnosis, or monitor treatment. Several potential biomarkers have been linked with pathophysiological changes related to PTSD, encouraging further research to identify actionable targets. This review highlights the current literature regarding the pathophysiology, disease development models, treatment modalities, and preventive models from a public health perspective, and discusses the current state of biomarker research.

Technologies Applied to the Mental Health Care of Pregnant Women: A Systematic Literature Review

OBJECTIVE

 This article aims to review the literature regarding the use of technologies to promote mental health for pregnant women. We seek to: understand the strategies that pregnant women use for mental health care. Also, we investigate the existence of scientific evidence that validates such practices.

METHODS

 This study follows the PRISMA guidelines for systematic reviews. We analyze 27 studies published between 2012 and 2019. We include publications in Portuguese, English, and Spanish.

RESULTS

 The results revealed several different possibilities to use technology, including the use of text messages and mobile applications on smartphones. Mobile applications are the most commonly used approaches (22.5%). Regarding the strategies used, cognitive-behavioral approaches, including mood checks, relaxation exercises, and psychoeducation comprised 44.12% of the content.

CONCLUSION

 There is a need for further investigation and research and development efforts in this field to better understand the possibilities of intervention in mental health in the digital age.

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary.

OBJECTIVE

This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia.

METHODS

A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit.

RESULTS

In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it.

CONCLUSIONS

The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04686-4.

Measuring working alliance and technical alliance from the perspective of healthcare professionals working with people with mild intellectual disabilities: adaptation, factor structure and reliability

BACKGROUND

The establishment of a valuable and meaningful working alliance between people with mild intellectual disabilities (IDs) and healthcare professionals is critically important for improving both the quality of life and impact of therapy for people with mild IDs. Measuring the working alliance as a treatment or support component is therefore of utmost relevance. In light of the increased use of eHealth tools, it is also essential to measure the alliance using these tools, which is referred to as technical alliance. There was a lack of validation of these two measurements for healthcare professionals working with people with mild IDs, which this study sought to address.

METHOD

Both the validated Working Alliance Inventory - Short Form - MID (WAI-SF-MID) and Technical Alliance Inventory - Short Form - MID (TAI-SF-MID) for general patient populations were adapted for healthcare professionals working with people with mild IDs. A two-step approach was conducted to systematically adapt both measurements with an expert group of healthcare professionals. Confirmatory factor analysis was conducted to test a three-factor structure for both the WAI-SF-MID (N = 199) and the TAI-SF-MID (N = 139), and internal consistency was determined for both scales.

RESULTS

An acceptable-to-good model fit was found for both the WAI-SF-MID and the TAI-SF-MID; confirmatory factor analysis confirmed a three-factor model for both measurements. Cronbach's alpha and McDonald's omega were excellent for both total scales (≥0.90) and acceptable to good for sub-scales of both versions.

CONCLUSION

Both the WAI-SF-MID and the TAI-SF-MID are promising measurements for determining healthcare professionals' perspective on the (digital) working alliance with people with mild IDs.

Investigating information needs and preferences regarding digital mental health services among medical and psychology students in Germany: A qualitative study

Background

Since 2020, physicians and psychotherapists in Germany can prescribe digital mental health services (dMHSs). However, even future healthcare professionals (HCPs), such as medical and psychology students, remain reluctant to use dMHSs, although they are a risk group for mental health issues themselves. Reasons include scepticism and lacking awareness of dMHSs, which can be addressed by acceptance-facilitating interventions (AFIs) such as information strategies. To date, though, little is known about their information needs.

Methods

Semi-structured interviews with n = 21 students were conducted between August and September 2021. Students of legal age studying psychology or medicine at a German university could participate. Interview recordings were transcribed verbatim and content-analyzed according to Mayring, using deductive and inductive coding.

Results

Most students reported having little experience with dMHSs. Digital health has barely been raised in their study, even though it was perceived as crucial for personal needs as well as in preparation for their work as HCPs. Students favoured receiving information on and recommendations for dMHSs from their university via, e.g. social media or seminars. Among others, information about data safety, scientific evidence base and application scope were preferred. Additionally, information on costs as well as user reviews seemed to be essential components of information strategies because students were concerned that high costs or low usability would hinder uptake.

Conclusions

The results give first insights on how future HCPs would like to be informed on dMHSs. Future research should focus on systematic variations of AFIs' components mimicking real-world decision scenarios to increase the adoption of dMHSs.

Implementation of e-Mental Health Interventions for Informal Caregivers of Adults With Chronic Diseases: Mixed Methods Systematic Review With a Qualitative Comparative Analysis and Thematic Synthesis

BACKGROUND

Informal caregivers commonly experience mental health difficulties related to their caregiving role. e-Mental health interventions provide mental health support in a format that may be more accessible to informal caregivers. However, e-mental health interventions are seldom implemented in real-world practice.

OBJECTIVE

This mixed methods systematic review aimed to examine factors associated with the effectiveness and implementation of e-mental health interventions for informal caregivers of adults with chronic diseases. To achieve this aim, two approaches were adopted: combinations of implementation and intervention characteristics sufficient for intervention effectiveness were explored using qualitative comparative analysis, and barriers to and facilitators of implementation of e-mental health interventions for informal caregivers were explored using thematic synthesis.

METHODS

We identified relevant studies published from January 1, 2007, to July 6, 2022, by systematically searching 6 electronic databases and various secondary search strategies. Included studies reported on the effectiveness or implementation of e-mental health interventions for informal caregivers of adults with cancer, chronic obstructive pulmonary disease, dementia, diabetes, heart disease, or stroke. Randomized controlled trials reporting on caregivers' mental health outcomes were included in a crisp-set qualitative comparative analysis. We assessed randomized controlled trials for bias using the Risk of Bias 2.0 tool, and we assessed how pragmatic or explanatory their trial design was using the Pragmatic Explanatory Continuum Indicator Summary 2 tool. Studies of any design reporting on implementation were included in a thematic synthesis using the Consolidated Framework for Implementation Research to identify barriers to and facilitators of implementation.

RESULTS

Overall, 53 reports, representing 29 interventions, were included in the review. Most interventions (27/29, 93%) focused on informal cancer or dementia caregivers. In total, 14 reports were included in the qualitative comparative analysis, exploring conditions including the presence of peer or professional support and key persuasive design features. Low consistency and coverage prevented the determination of condition sets sufficient for intervention effectiveness. Overall, 44 reports were included in the thematic synthesis, and 152 barriers and facilitators were identified, with the majority related to the intervention and individual characteristic domains of the Consolidated Framework for Implementation Research. Implementation barriers and facilitators in the inner setting (eg, organizational culture) and outer setting (eg, external policies and resources) domains were largely unexplored.

CONCLUSIONS

e-Mental health interventions for informal caregivers tend to be well-designed, with several barriers to and facilitators of implementation identified related to the intervention and individual user characteristics. Future work should focus on exploring the views of stakeholders involved in implementation to determine barriers to and facilitators of implementing e-mental health interventions for informal caregivers, focusing on inner and outer setting barriers and facilitators.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020155727; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020155727.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035406.

Feasibility of Digital Cognitive Behavioral Therapy for Depressed Older Adults With the Moodbuster Platform: Protocol for 2 Pilot Feasibility Studies

Background

Internet-based interventions can be effective in the treatment of depression. However, internet-based interventions for older adults with depression are scarce, and little is known about their feasibility and effectiveness.

Objective

To present the design of 2 studies aiming to assess the feasibility of internet-based cognitive behavioral treatment for older adults with depression. We will assess the feasibility of an online, guided version of the Moodbuster platform among depressed older adults from the general population as well as the feasibility of a blended format (combining integrated face-to-face sessions and internet-based modules) in a specialized mental health care outpatient clinic.

Methods

A single-group, pretest-posttest design will be applied in both settings. The primary outcome of the studies will be feasibility in terms of (1) acceptance and satisfaction (measured with the Client Satisfaction Questionnaire-8), (2) usability (measured with the System Usability Scale), and (3) engagement (measured with the Twente Engagement with eHealth Technologies Scale). Secondary outcomes include (1) the severity of depressive symptoms (measured with the 8-item Patient Health Questionnaire depression scale), (2) participant and therapist experience with the digital technology (measured with qualitative interviews), (3) the working alliance between patients and practitioners (from both perspectives; measured with the Working Alliance Inventory–Short Revised questionnaire), (4) the technical alliance between patients and the platform (measured with the Working Alliance Inventory for Online Interventions–Short Form questionnaire), and (5) uptake, in terms of attempted and completed modules. A total of 30 older adults with mild to moderate depressive symptoms (Geriatric Depression Scale 15 score between 5 and 11) will be recruited from the general population. A total of 15 older adults with moderate to severe depressive symptoms (Geriatric Depression Scale 15 score between 8 and 15) will be recruited from a specialized mental health care outpatient clinic. A mixed methods approach combining quantitative and qualitative analyses will be adopted. Both the primary and secondary outcomes will be further explored with individual semistructured interviews and synthesized descriptively. Descriptive statistics (reported as means and SDs) will be used to examine the primary and secondary outcome measures. Within-group depression severity will be analyzed using a 2-tailed, paired-sample t test to investigate differences between time points. The interviews will be recorded and analyzed using thematic analysis.

Results

The studies were funded in October 2019. Recruitment started in September 2022.

Conclusions

The results of these pilot studies will show whether this platform is feasible for use by the older adult population in a blended, guided format in the 2 settings and will represent the first exploration of the size of the effect of Moodbuster in terms of decreased depressive symptoms.

International Registered Report Identifier (IRRID)

PRR1-10.2196/41445

Using Remotely Supervised At-Home TES for Enhancing Mental Resilience

We are in the midst of a mental health crisis with major depressive disorder being the most prevalent among mental health disorders and up to 30% of patients not responding to first-line treatments. Noninvasive Brain Stimulation (NIBS) techniques have proven to be effective in treating depression. However, there is a fundamental problem of scale. Currently, any type of NIBS treatment requires patients to repeatedly visit a clinic to receive brain stimulation by trained personnel. This is an often-insurmountable barrier to both patients and healthcare providers in terms of time and cost. In this perspective, we assess to what extent Transcranial Electrical Stimulation (TES) might be administered with remote supervision in order to address this scaling problem and enable neuroenhancement of mental resilience at home. Social, ethical, and technical challenges relating to hardware- and software-based solutions are discussed alongside the risks of stimulation under- or over-use. Solutions to provide users with a safe and transparent ongoing assessment of aptitude, tolerability, compliance, and/or misuse are proposed, including standardized training, eligibility screening, as well as compliance and side effects monitoring. Looking into the future, such neuroenhancement could be linked to prevention systems which combine home-use TES with digital sensor and mental monitoring technology to index decline in mental wellbeing and avoid relapse. Despite the described social, ethical legal, and technical challenges, the combination of remotely supervised, at-home TES setups with dedicated artificial intelligence systems could be a powerful weapon to combat the mental health crisis by bringing personalized medicine into people’s homes.

Strategies for Implementing Occupational eMental Health Interventions: Scoping Review

BACKGROUND

The implementation of eMental health interventions, especially in the workplace, is a complex process. Therefore, learning from existing implementation strategies is imperative to ensure improvements in the adoption, development, and scalability of occupational eMental health (OeMH) interventions. However, the implementation strategies used for these interventions are often undocumented or inadequately reported and have not been systematically gathered across implementations in a way that can serve as a much-needed guide for researchers.

OBJECTIVE

The objective of this scoping review was to identify implementation strategies relevant to the uptake of OeMH interventions that target employees and detail the associated barriers and facilitation measures.

METHODS

A scoping review was conducted. The descriptive synthesis was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and the Consolidated Framework for Implementation Research.

RESULTS

A total of 31 of 32,916 (0.09%) publications reporting the use of the web-, smartphone-, telephone-, and email-based OeMH interventions were included. In all, 98 implementation strategies, 114 barriers, and 131 facilitators were identified. The synthesis of barriers and facilitators produced 19 facilitation measures that provide initial recommendations for improving the implementation of OeMH interventions.

CONCLUSIONS

This scoping review represents one of the first steps in a research agenda aimed at improving the implementation of OeMH interventions by systematically selecting, shaping, evaluating, and reporting implementation strategies. There is a dire need for improved reporting of implementation strategies and combining common implementation frameworks with more technology-centric implementation frameworks to fully capture the complexities of eHealth implementation. Future research should investigate a wider range of common implementation outcomes for OeMH interventions that also focus on a wider set of common mental health problems in the workplace. This scoping review's findings can be critically leveraged by discerning decision-makers to improve the reach, effectiveness, adoption, implementation, and maintenance of OeMH interventions.

Understanding Mental Health Professionals' Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study

BACKGROUND

Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices.

OBJECTIVE

This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices.

METHODS

A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed.

RESULTS

Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals.

CONCLUSIONS

The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals.

Acceptance of E-Mental Health Services for Different Application Purposes Among Psychotherapists in Clinical Training in Germany and Switzerland: Secondary Analysis of a Cross-Sectional Survey

Background

Despite solid evidence supporting the efficacy of electronic mental health (EMH) services, their acceptance among psychotherapists is limited and uptake rates remain low. However, the acceptance of different EMH services has yet barely been examined in future generations of psychotherapists in a differentiated manner. The aims of this study were (1) to elaborate the intention to use various EMH services for different application purposes and (2) to determine predictors of EMH service acceptance among psychotherapists in clinical training (PiT).

Materials and Methods

Our paper is based on a secondary data analysis of a cross-sectional survey. Respondents were recruited via recognized educational institutions for psychotherapy within Germany and the German-speaking part of Switzerland between June and July of 2020. The survey contained items on the intention to use different EMH services (i.e., guided and unguided programs, virtual reality, psychotherapy by telephone and videoconference) for various application purposes (i.e., prevention, treatment addition, treatment substitute, aftercare). Potential predictors of EMH service acceptance (e.g., barriers and advantages) were examined based on an extension of the Unified Theory of Acceptance and Use of Technology (UTAUT).

Results

Most of the n = 216 respondents were female (88.4%) and located in Germany (72.2%). General acceptance of EMH was moderate (M = 3.4, SD = 1.12, range 1-5), while acceptance of psychotherapy via videoconference was highest (M = 3.7, SD = 1.15) and acceptance of unguided programs was lowest (M = 2.55, SD = 1.14). There was an interaction effect of EMH service and application purpose (η2 = 0.21). Barriers and advantages both had a uniform influence on EMH service acceptance (Pr > 0.999), while impersonality, legal concerns, concerns about therapeutic alliance, simplified information provision, simplified contact maintenance, time flexibility, and geographic flexibility were significant predictors (all p < 0.05). Results showed that the extended UTAUT model was the best fitting model to predict EMH service acceptance (Pr > 0.999).

Conclusions

The intention to use different EMH services varied between application purposes among PiT. To increase acceptance of EMH services and reduce misconceptions, we identified predictors that should be addressed in future acceptance-facilitating interventions when educating PiT.

Analysis of E-mental health research: mapping the relationship between information technology and mental healthcare

BACKGROUND

E-mental healthcare is the convergence of digital technologies with mental health services. It has been developed to fill a gap in healthcare for people who need mental wellbeing support that may not otherwise receive psychological treatment. With an increasing number of e-mental healthcare and research, this study aimed to investigate the trends of an e-mental health research field that integrates interdisciplinary fields and to examine the information technologies is being used in mental healthcare. To achieve the research objectives, bibliometric analysis, information extraction, and network analysis were applied to analyze e-mental health research data.

METHODS

E-mental health research data were obtained from 3663 bibliographic records from the Web of Science (WoS) and 3172 full-text articles from PubMed Central (PMC). The text mining techniques used for this study included bibliometric analysis, information extraction, and visualization.

RESULTS

The e-mental health research topic trends primarily involved e-health care services and medical informatics research. The clusters of research comprised 16 clusters, which refer to mental sickness, e-health, diseases, information technology (IT), and self-management. The information extraction analysis revealed a triple relation with IT and biomedical domains. Betweenness centrality was used as a measure of network graph centrality, based on the shortest path to rank the important entities and triple relation; nodes with higher betweenness centrality had greater control over the network because more information passes through that node. The IT entity-relations of "mobile" had the highest score at 0.043466. The top pairs were related to depression, mobile health, and text message.

CONCLUSIONS

E-mental related publications were associated with various research fields, such as nursing, psychology, medical informatics, computer science, telecommunication, and healthcare innovation. We found that trends in e-mental health research are continually rising. These trends were related to the internet of things (IoT) and mobile applications (Apps), which were applied for mental healthcare services. Moreover, producing AI and machine learning for e-mental healthcare were being studied. This work supports the appropriate approaches and methods of e-mental health research that can help the researcher to identify important themes and choose the best fit with their own survey work.

Technological Interventions for the Treatment of Substance Use Disorders

Substance use disorders (SUDs) pose a major public health concern. In recent years, technological (i.e., e-health) interventions have emerged and are increasingly offered in a variety of settings, including substance use treatment. E-health interventions encompass a wide variety of advantages depending on the chosen delivery format. This chapter discusses existing interventions and the effectiveness of delivering them as an e-health intervention, with a focus on randomized controlled trials, for the treatment of alcohol, cannabis, opioid, psychostimulant, or poly-substance use, as well as in transdiagnostic interventions. Based on the literature, suggestions for future research and clinical implications are discussed.

Integrating technology in mental healthcare practice: A repeated cross-sectional survey study on professionals' adoption of Digital Mental Health before and during COVID-19

As a consequence of the outbreak of the COVID-19 global pandemic in the spring of 2020, large-scale social distancing measures were implemented, resulting in the forced adoption of online or digital forms of psychological treatment. This sudden transition to digital care offered a unique opportunity to investigate if and how this experience impacted mental healthcare professionals' perceptions and use of Digital Mental Health tools. The current paper presents findings of a repeated cross-sectional study consisting of three iterations of a national online survey in the Netherlands. This survey contained open and closed questions on professionals' adoption readiness, frequency of use, perceived competency, and perceived value of Digital Mental Health collected in 2019 (before the pandemic), in 2020 (after the first wave), and in 2021 (after the second wave). The inclusion of data gathered prior to the COVID-19 pandemic offers a unique window to assess how professionals' adoption has developed through this transition from voluntary to mandatory use of Digital Mental Health tools. Our study also re-assesses the drivers, barriers, and needs of mental healthcare professionals after having gained experience with Digital Mental Health. In total, 1,039 practitioners completed the surveys (Survey 1: n = 432, Survey 2: n = 363, and Survey 3: n = 244). Results indicate that compared to the period before the pandemic, there was a particularly large increase in use, competency, and perceived value regarding videoconferencing. Small differences were also found for some other basic tools that were crucial to ensure the continuation of care, such as e-mail, text messaging, and online screening, but not for more innovative technologies, such as virtual reality and biofeedback. Many practitioners reported to have gained skills regarding Digital Mental Health and experienced several benefits of it. They expressed the intention to continue with a blended approach, using Digital Mental Health tools in combination with face-to-face care, focused on situations in which they found it to have specific added value, such as when clients are unable to travel. Others were less satisfied with the technology-mediated interactions and remained more reluctant to future use of DMH. Implications for broader implementation of Digital Mental Health and future research are discussed.

Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up

BACKGROUND

Anxiety disorders are highly prevalent and cause substantial economic burden. Blended cognitive-behavioural therapy (bCBT), which integrates Internet-based CBT and face-to-face CBT (ftfCBT), is an attractive and potentially cost-saving treatment alternative to conventional CBT for patients with anxiety disorders in specialised mental health care. However, little is known about the effectiveness of bCBT in routine care. We examined the acceptability, effectiveness and cost-effectiveness of bCBT versus ftfCBT in outpatient specialised care to patients with panic disorder, social anxiety disorder and generalised anxiety disorder.

METHODS AND FINDINGS

Patients with anxiety disorders were randomised to bCBT (n = 52) or ftfCBT (n = 62). Acceptability of bCBT and ftfCBT were evaluated by assessing treatment preference, adherence, satisfaction and therapeutic alliance. Costs and effects were assessed at post-treatment and one-year follow-up. Primary outcome measure was the Beck Anxiety Inventory (BAI). Secondary outcomes were depressive symptoms, general psychopathology, work and social adjustment, quality of life and mastery. Incremental cost-effectiveness ratios (ICERs) were computed from societal and healthcare perspectives by calculating the incremental costs per incremental quality-adjusted life year (QALY). No significant differences between bCBT and ftfCBT were found on acceptability or effectiveness measures at post-treatment (Cohen's d between-group effect size on BAI = 0.15, 95% CI -0.30 to 0.60) or at one-year follow-up (d = -0.38, 95% CI -0.84 to 0.09). The modelled point estimates of societal costs (bCBT €10945, ftfCBT €10937) were higher and modelled point estimates of direct medical costs (bCBT €3748, ftfCBT €3841) were lower in bCBT. The acceptability curves showed that bCBT was expected to be a cost-effective intervention. Results should be carefully interpreted due to the small sample size.

CONCLUSIONS

bCBT appears an acceptable, clinically effective and potentially cost-saving alternative option for treating patients with anxiety disorders. Trials with larger samples are needed to further investigate cost-effectiveness.

TRIAL REGISTRATION

Netherlands Trial Register: NTR4912.

Psychological Science Into Practice During the COVID-19 Pandemic

Abstract. The public health outbreak of the COVID-19 virus has hit all aspects of life as we know it. We found ourselves trying to solve several concurrent crises that have afflicted us. The European Federation of Psychologists’ Associations (EFPA) launched the Psychologists’ Support Hub to share resources among its members and beyond and promote the continuing adoption of psychological science to battle the pandemic. In the greater context of evidence-based practice (EBP), the best available evidence is what we turn to for help in our decision-making on how best to address different challenges. However, there are challenges in implementing EBP when the science is limited, and we are still expected to be effective and efficient as professionals. The article outlines the need for EBP during the pandemic. Three vignettes display how that can be done while identifying obstacles and recommending ways forward in the future. The first one relates to the development of e-mental health services in Belgium following the March 2020 lockdown. The second describes addressing the needs of older adults in Croatia when it was hit by two crises simultaneously – the March 2020 lockdown and a destructive earthquake. The third looks at how targeted community-based interventions in Norway directed at social change can positively impact times of crisis. Overall, the pandemic presents a unique opportunity for professional growth for researchers, trainers, practitioners, and policymakers alike. EFPA can play a pivotal role in EBP adoption.

Integrating eHealth within a Transforming Mental Healthcare Setting: A Qualitative Study into Values, Challenges, and Prerequisites

Mental health care is shifting towards more person-centered and community-based health care. Although integrating eHealth within a transforming healthcare setting may help accomplishing the shift, research studying this is lacking. This study aims to improve our understanding of the value of eHealth within a transforming mental healthcare setting and to define the challenges and prerequisites for implementing eHealth in particular within this transforming context. In this article, we present the results of 29 interviews with clients, social network members, and professionals of an ambulatory team in transition within a Dutch mental health care institute. The main finding is that eHealth can support a transforming practice shifting towards more recovery-oriented, person-centered, and community-based service in which shared-decision making is self-evident. The main challenge revealed is how to deal with clients' voices, when professionals see the value of eHealth but clients do not want to start using eHealth. The shift towards client-centered and network-oriented care models and towards blended care models are both high-impact changes in themselves. Acknowledging the complexity of combining these high-impact changes might be the first step towards creating blended client-centered and network-oriented care. Future research should examine whether and how these substantial shifts could be mutually supportive.

Assessing Professionals' Adoption Readiness for eMental Health: Development and Validation of the eMental Health Adoption Readiness Scale

BACKGROUND

The last few decades have witnessed significant advances in the development of digital tools and applications for mental health care. Despite growing evidence for their effectiveness, acceptance and use of these tools in clinical practice remain low. Hence, a validated and easy-to-use instrument for assessing professionals' readiness to adopt eMental health (EMH) is necessary to gain further insights into the process of EMH adoption and facilitate future research on this topic.

OBJECTIVE

The aim of this study is to develop and validate an instrument for assessing mental health care professionals' readiness to adopt EMH.

METHODS

Item generation was guided by literature and inputs from mental health care professionals and experts in survey development. Exploratory factor analyses were conducted on an initial set of 29 items completed by a sample of mental health care professionals (N=432); thereafter, the scale was reduced to 15 items in an iterative process. The factor structure thus obtained was subsequently tested using a confirmatory factor analysis with a second sample of mental health care professionals (N=363). The internal consistency, convergent validity, and predictive validity of the eMental Health Adoption Readiness (eMHAR) Scale were assessed.

RESULTS

Exploratory factor analysis resulted in a 3-factor solution with 15 items. The factors were analyzed and labeled as perceived benefits and applicability of EMH, EMH proactive innovation, and EMH self-efficacy. These factors were confirmed through a confirmatory factor analysis. The total scale and subscales showed a good internal consistency (Cronbach α=.73-.88) along with acceptable convergent and predictive relationships with related constructs.

CONCLUSIONS

The constructed eMHAR Scale showed a conceptually interpretable 3-factor structure having satisfactory characteristics and relationships with relevant concepts. Its ease of use allows for quick acquisition of data that can contribute to understanding and facilitating the process of adoption of EMH by clinical professionals.

Upscaling e-mental health in Europe: a six-country qualitative analysis and policy recommendations from the eMEN project

E-mental health (eMH) encompasses the use of digital technologies to deliver, support, or enhance mental health services. Despite the growing evidence for the effectiveness of eMH interventions, the process of implementation of eMH solutions in healthcare remains slow throughout Europe. To address this issue, the e-Mental Health Innovation and Transnational Implementation Platform North-West Europe (eMEN) project was initiated to increase the dissemination and quality of eMH services in Europe. In this project, status analyses regarding eMH in the six participating countries (i.e., Belgium, France, Germany, Ireland, The Netherlands, and the UK) were conducted and eight recommendations for eMH were developed. Expert teams from the six participating countries conducted status analyses regarding the uptake of eMH based on a narrative literature review and stakeholder interviews. Based on these status analyses, the eMEN consortium developed eight policy recommendations to further support the implementation of eMH in Europe. The status analyses showed that the participating countries are in different stages of implementing eMH into mental healthcare. Some barriers to implementing eMH were common among countries (e.g., a limited legal and regulatory framework), while others were country-specific (e.g., fragmented, federal policies). The policy recommendations included fostering awareness, creating strong political commitment, and setting reliable standards related to ethics and data security. The eMEN project has provided the initial recommendations to guide political and regulatory processes regarding eMH. Further research is needed to establish well-tailored implementation strategies and to assess the generalizability of the recommendations beyond the countries involved in the eMEN project.

Technology and psychotherapeutic interventions: Bibliometric analysis of the past four decades

BACKGROUND

Rapid growth of the integration of technology and psychotherapeutic interventions has been noted, but no clear quantification of this growth has been done.

AIMS

This bibliometric analysis seeks to quantify the growth, trends, and applications of technology in psychotherapeutic interventions over the last 40 years.

METHODS

Searches were conducted in the Web of Science (WOS) database for all existing technology-psychotherapy-related publications from 1981 to October 2020. Search terms were refined using a systematic screening strategy, based upon Cochrane protocol, generating 52 technology terms. Analyses across 40 years and by decade from 1981 to 2020 were conducted.

RESULTS

A total of 13,934 peer-reviewed articles were identified. Yearly publication rate has increased from one in 1981 to 1902 by October 2020. The growth rate of publications across decades consistently tripled in size (762.50% from the 1980s to 1990s, 539.71% from the 1990s to 2000s, and 337.24% from the 2000s to 2010s). The author, country, journal, and institution with the most publications were Andersson, G., USA, Journal of Medical Internet Research, and Karolinska Institute, respectively. The most frequent technology search term across all four decades was "internet*." The trends in percentages of peer-reviewed publications within each decade showed: 1) a declining trend for the term "computer," 2) an upward trend for the combined terms, "internet," "online," and "web," 3) and a steady but smaller proportion of publications for other terms ("cell phone," "phone/telephone," "technology," "video," "virtual reality or VR," "apps," "digital," "machine learning," "electronic," "robo," and "telehealth").

DISCUSSION

The rapid growth and trends identified in technology and psychotherapy publications can inform related policies addressing the role of technology in mental health. Moreover, pattern analyses may provide direction for a standard nomenclature to address terminology usage inconsistencies across the field.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing.

OBJECTIVE

This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects.

METHODS

We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model.

RESULTS

The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs.

CONCLUSIONS

Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

Primary care professionals' attitudes towards digital health interventions for common mental disorders: study protocol for a mixed methods systematic review

INTRODUCTION

Mental disorders such as depression are common, and an estimated 264 million people are affected by them throughout the world. In recent years, studies on digital health interventions to treat mental disorders have shown evidence of their efficacy, and interest in using them has increased as a result. In the primary care setting, depression and anxiety are the two most frequently diagnosed and treated mental disorders. When they do not refer them to specialists, primary care professionals such as general practitioners treat patients with mental disorders themselves but have insufficient time to treat them adequately. Furthermore, there is a shortage of psychotherapists and those that exist have long waiting lists for an appointment. The purpose of this mixed methods systematic review is to explore the attitudes of primary care professionals towards the use of digital health interventions in the treatment of patients with mental disorders. Their attitudes will provide an indication whether digital mental health interventions can effectively complement standard care in the primary care setting.

METHODS AND ANALYSIS

We searched for qualitative, quantitative and mixed methods studies published in English, German, Spanish, Russian, French and Dutch after January 2010 for inclusion in the review. The included studies must involve digital mental health interventions conducted via computer and/or mobile devices in the primary care setting. The search was conducted in July 2020 in the following electronic bibliographic databases: MEDLINE, Embase, CINAHL, PsycINFO and Web of Science Core Collection. Two reviewers will independently screen titles, abstracts and full texts and extract data. We will use the 'Integrated methodology' framework to combine both quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval is not required. We will disseminate the results of the mixed methods systematic review in a peer-reviewed journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020188879.

[Awareness and Use of Digital Health Services in Germany: A Cross-sectional Study Representative of the Population]

OBJECTIVES

In light of the current efforts of health policy to implement eHealth, the question arises which sections of the population already use online self-help in order to tailor them to users' needs. The present study aims to determine the differences in the use of health information and psychological online counseling based on socio-demographic variables, health status and previous illnesses.

METHODS

The basis for the cross-sectional data analyses using logistic regression analysis was the innovation sample of the German socio-economic panel. Data were collected from September 2016 to February 2017, with 4802 participants aged between 17-95 years.

RESULTS

Fifty-five percent of the sample searched for health information on the Internet, while 1.1% had experience with online counseling. Logistic regression analyses showed that online search for information was significantly determined by age (Odds Ratio (OR)=0.96; 95-%-CI=0.96-0.97), gender (OR=1.20; 95-%-CI=1.05-1.36), awareness of Internet therapy (OR=2.57; 95-%-CI=2.20-3.00), experience with psychotherapy (OR=1.40; 95-%-CI=1.16-1.69) and the diagnosis of asthma (OR=1.14; 95-%-CI=1.01-1.29) or stroke (OR=0.66; 95-%-CI=0.52-0.84). Regarding the use of online counseling, awareness of Internet therapy and experience with face-to-face psychotherapy proved to be significant determinants.

CONCLUSION

For the first time, a reliable picture has become available of the determinants of the awareness of internet therapy and online self-help utilization among the German public that should enable target-group-specific strategies to improve the care situation.

Help-seeking behaviour and attitudes towards internet-administered psychological support among adolescent and young adults previously treated for cancer during childhood: protocol for a survey and embedded qualitative interview study in Sweden

INTRODUCTION

A subgroup of adolescent and young adult childhood cancer survivors (AYACCS) are at increased risk of psychological distress. Despite this, AYACCS experience difficulties accessing psychological support. E-mental health (e-MH) may offer a solution to reduce this treatment gap. However, research examining e-MH for AYACCS has experienced difficulties with recruitment, retention and adherence. Such difficulties may relate to: (1) help-seeking behaviour and/or (2) e-MH acceptability. The overall study aims are to: (1) examine potential associations between health service use factors, informed by Andersen's behavioural model of health services use, and help-seeking behaviour; (2) examine attitudes towards e-MH interventions; and (3) explore perceived need for mental health support; past experience of receiving mental health support; preferences for support; and barriers and facilitators to help-seeking.

METHODS AND ANALYSIS

An online and paper-based cross-sectional self-report survey (98 items) and embedded qualitative interview study across Sweden, with a target sample size of n=365. Participants are aged 16-39 years, diagnosed with cancer when 0-18 years and have completed successful cancer treatment. The survey examines sociodemographic and clinical characteristics, actual help-seeking behaviour, attitudes towards e-MH, stigma of mental illness, mental health literacy, social support and current symptoms of depression, anxiety, and stress. Survey respondents with past and/or current experience of mental health difficulties are invited into the qualitative interview study to explore: (1) perceived need for mental health support; (2) past experience of receiving mental health support; (3) preferences for support; and (4) barriers and facilitators to help-seeking. Potential associations between health service use factors and help-seeking behaviour are examined using univariable and multivariable logistic regressions. Qualitative interviews are analysed using content analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Swedish Ethical Review Authority (Dnr: 2020-06271). Results will be disseminated in scientific publications and academic conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN70570236.

Dropping the E: The potential for integrating e-mental health in psychotherapy

E-mental health, or the use of technology in mental healthcare, has been the focus of research for over two decades. Over that period, the evidence base for the potential of technology to improve psychotherapeutic practice has grown steadily. This sharply contrasts with the actual use of e-mental health by psychotherapists, which has remained limited. In this article, we aim to illustrate how and when different technological tools and applications can play a role in psychotherapy. At the same time, we also highlight current limitations and discuss challenges for future research. A specific, yet hypothetical case, is used to guide this narrative review and make proposed applications tangible and concrete.

A Blended Cognitive-Behavioral Intervention for the Treatment of Postpartum Depression: Study Protocol for a Randomized Controlled Trial

Despite the existence of effective treatment for postpartum depression, few women seek professional help, indicating the need for a new and innovative format of treatment that can overcome help-seeking barriers. This article presents the study protocol for a blended cognitive–behavioral intervention for the treatment of postpartum depression, by integrating face-to-face sessions with a web-based program (Be a Mom) into one treatment protocol. This study will be a two-arm, noninferiority randomized controlled trial comparing blended intervention to usual treatment for postpartum depression provided in healthcare centers. Portuguese postpartum adult women diagnosed with postpartum depression (according to the DSM-5 diagnostic criteria for major depressive disorder) will be recruited during routine care appointments in local healthcare centers and will be eligible to participate. Measures will be completed at baseline, postintervention, and at three- and six-month follow-ups. The primary outcome will be depressive symptoms. Secondary outcomes will include anxiety symptoms, fatigue, quality of life, marital satisfaction, maternal self-efficacy, and mother–child bonding. Cost-effectiveness analysis and mediator and moderator analysis will be conducted. This study will provide insight into the efficacy and cost-effectiveness of a blended psychological intervention in the Portuguese context and increase the empirically validated treatment options for postpartum depression.

Mitigating COVID-19 Impact on the Portuguese Population Mental Health: The Opportunity That Lies in Digital Mental Health

COVID-19 mitigation measures present unprecedented challenges in mental healthcare delivery, posing high risk to the mental health of at-risk populations, namely patients diagnosed with COVID-19, frontline healthcare providers, and those submitted to quarantine or isolation measures, as well as the general population. Ensuring safe and equitable access to mental healthcare by these groups entails resorting to innovative psychosocial intervention strategies, such as digital mental health. In this perspective piece, we describe the impact of COVID-19 on the Portuguese population's mental health, present an overview on initiatives developed to address the challenges currently faced by the Portuguese mental healthcare system, and discuss how the timely implementation of a comprehensive digital mental health strategy, coupling research, education, implementation, and quality assessment initiatives, might buffer COVID-19's impact on the Portuguese society.

Improving adherence to an online intervention for low mood with a virtual coach: study protocol of a pilot randomized controlled trial

Background

Internet-based cognitive-behavioral therapy (iCBT) is more effective when it is guided by human support than when it is unguided. This may be attributable to higher adherence rates that result from a positive effect of the accompanying support on motivation and on engagement with the intervention. This protocol presents the design of a pilot randomized controlled trial that aims to start bridging the gap between guided and unguided interventions. It will test an intervention that includes automated support delivered by an embodied conversational agent (ECA) in the form of a virtual coach.

Methods/design

The study will employ a pilot two-armed randomized controlled trial design. The primary outcomes of the trial will be (1) the effectiveness of iCBT, as supported by a virtual coach, in terms of improved intervention adherence in comparison with unguided iCBT, and (2) the feasibility of a future, larger-scale trial in terms of recruitment, acceptability, and sample size calculation. Secondary aims will be to assess the virtual coach’s effect on motivation, users’ perceptions of the virtual coach, and general feasibility of the intervention as supported by a virtual coach. We will recruit N = 70 participants from the general population who wish to learn how they can improve their mood by using Moodbuster Lite, a 4-week cognitive-behavioral therapy course. Candidates with symptoms of moderate to severe depression will be excluded from study participation. Included participants will be randomized in a 1:1 ratio to either (1) Moodbuster Lite with automated support delivered by a virtual coach or (2) Moodbuster Lite without automated support. Assessments will be taken at baseline and post-study 4 weeks later.

Discussion

The study will assess the preliminary effectiveness of a virtual coach in improving adherence and will determine the feasibility of a larger-scale RCT. It could represent a significant step in bridging the gap between guided and unguided iCBT interventions.

Trial registration

Netherlands Trial Register (NTR) NL8110. Registered on 23 October 2019.

E-health applications in the field of traumatic stress

E-health offers great potential in the field of traumatic stress to deliver training, assessment, prevention, and treatment of adverse outcomes after trauma worldwide. In order to encourage research on E-health applications in the field of traumatic stress, this current special issue of the European Journal of Psychotraumatology presents a series of papers divided into three emergent topics: I) development of digital interventions, II) the use of digital interventions to foster self-management and deliver therapy, and III) digital methods to improve prediction, assessment, and monitoring of post-trauma outcomes. These studies show acceptance of the tools by various end-user groups and improvements of current research and clinical practices, but also areas for improvement regarding the development process and making even better use of technological capabilities of E-Health. We propose three general themes to accelerate the quality of e-Health interventions and studies in this area in the coming years: optimizing user engagement and adherence, conducting more (innovative) research, and increasing implementation and dissemination activities. This issue appears in the midst of the COVID-19 pandemic. It is exactly at times like these that we need effective online interventions and we see an enormous increase in the use of e-Health. We hope this issue will contribute to help those affected and to serve the community worldwide.

Views of Implementers and Nonimplementers of Internet-Administered Cognitive Behavioral Therapy for Depression and Anxiety: Survey of Primary Care Decision Makers in Sweden

BACKGROUND

Internet-administered cognitive behavioral therapy (ICBT) has been demonstrated to be an effective intervention for adults with depression and/or anxiety and is recommended in national guidelines for provision within Swedish primary care. However, the number and type of organizations that have implemented ICBT within primary care in Sweden is currently unclear. Further, there is a lack of knowledge concerning barriers and facilitators to ICBT implementation.

OBJECTIVE

The two primary objectives were to identify and describe primary care organizations providing ICBT in Sweden and compare decision makers' (ie, directors of primary care organizations) views on barriers and facilitators to implementation of ICBT among ICBT implementers (ie, organizations that offered ICBT) and nonimplementers (ie, organizations that did not offer ICBT).

METHODS

An online survey based on a checklist for identifying barriers and facilitators to implementation was developed and made accessible to decision makers from all primary care organizations in Sweden. The survey consisted of background questions (eg, provision of ICBT and number of persons working with ICBT) and barriers and facilitators relating to the following categories: users, therapists, ICBT programs, organizations, and wider society.

RESULTS

The participation rate was 35.75% (404/1130). The majority (250/404, 61.8%) of participants were health care center directors and had backgrounds in nursing. Altogether, 89.8% (363/404) of the participating organizations provided CBT. A minority (83/404, 20.5%) of organizations offered ICBT. Most professionals delivering ICBT were psychologists (67/83, 80%) and social workers (31/83, 37%). The majority (61/83, 73%) of organizations had 1 to 2 persons delivering ICBT interventions. The number of patients treated with ICBT during the last 12 months was 1 to 10 in 65% (54/83) of the organizations, ranging between 1 and 400 treated patients across the whole sample. There were 9 significant (P<.05) differences out of 37 possible between implementers and nonimplementers. For example, more implementers (48/51, 94%) than nonimplementers (107/139, 76.9%) perceived few technical problems (P<.001), and more implementers (53/77, 68%) than nonimplementers (103/215, 47.9%) considered that their organization has resources to offer ICBT programs (P<.001).

CONCLUSIONS

Despite research demonstrating the effectiveness of ICBT for depression and anxiety and national guidelines recommending its use, ICBT is implemented in few primary care organizations in Sweden. Several interesting differences between implementers and nonimplementers were identified, which may help inform interventions focusing on facilitating the implementation of ICBT.

Evaluation of a three-phase implementation program in enhancing e-mental health adoption within Indigenous primary healthcare organisations

Background

A three-phase implementation program was carried out to support Indigenous primary healthcare organisations in Australia to integrate e-mental health approaches into the day-to-day practice. The present study aimed to evaluate the process and the effectiveness of the program.

Methods

A concurrent triangulation design was employed to collect and compare quantitative and qualitative data from organisations that participated in the implementation program (case studies) to those that participated in training only (non-case studies). Quantitative methods, i.e., t-tests and descriptive statistics, were used to measure outcomes relating to the frequency of e-mental health usage and levels of organisational readiness. Qualitative data were analysed separately, using theoretical thematic analysis, to gain an in depth understanding of the implementation process. The findings were integrated and interpreted within the implementation science literature.

Results

The case studies evidenced greater use of e-mental health approaches than the non-case studies. They also demonstrated increased organisational readiness over the course of the implementation program. The program helped organisations to work and improve on essential aspects within the organisation so that they better supported e-mental health adoption. The key areas addressed were Information Technology resources and infrastructure, leadership and support, policy and protocols around e-mental health utilisation and its integration into practice.

Conclusions

By addressing and improving essential aspects relating to e-mental health implementation, the program helped organisations to increase organisational readiness and enhance uptake of e-mental health approaches.

Implementation of e-mental health interventions for informal caregivers of adults with chronic diseases: a protocol for a mixed-methods systematic review with a qualitative comparative analysis

INTRODUCTION

Informal caregivers provide the majority of care to individuals with chronic health conditions, benefiting the care recipient and reducing use of formal care services. However, providing informal care negatively impacts the mental health of many caregivers. E-mental health interventions have emerged as a way to provide accessible mental healthcare to caregivers. Much attention has been given to reviewing the effectiveness and efficacy of such interventions, however, factors related to implementation have received less consideration. Therefore, this mixed-methods systematic review will aim to examine factors associated with the effectiveness and implementation of e-mental health interventions for caregivers.

METHODS AND ANALYSIS

Eligible studies published since 1 January 2007 will be searched for in several electronic databases (CINAHL Plus with Full Text, the Cochrane Library, EMBASE, PsycINFO, PubMed and Web of Science), clinical trial registries and OpenGrey, with all screening steps conducted by two independent reviewers. Studies will be included if they focus on the implementation or effectiveness of e-mental health interventions designed for informal adult caregivers of adults with cancer, heart disease, stroke, diabetes, dementia or chronic obstructive pulmonary disease. Pragmatic randomised controlled trials quantitatively reporting on caregiver anxiety, depression, psychological distress or stress will be used for a qualitative comparative analysis to identify combinations of conditions that result in effective interventions. Qualitative and quantitative data on implementation of e-mental health interventions for caregivers will be integrated in a thematic synthesis to identify barriers and facilitators to implementation. These results will inform future development and implementation planning of e-mental health interventions for caregivers.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as no primary data will be collected. Results will be disseminated in the form of a scientific publication and presentations at academic conferences and plain language summaries for various stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020155727.

Evaluation of Electronic Mental Health Implementation in Northern Territory Services Using the Integrated "Promoting Action on Research Implementation in Health Services" Framework: Qualitative Study

BACKGROUND

Electronic mental health is a promising strategy to bridge the treatment gap in mental health care. Training workshops have been delivered to service providers working with Aboriginal and Torres Strait Islander people at a primary health care level to raise awareness and knowledge of electronic mental health approaches.

OBJECTIVE

This study aimed to understand service providers' perspectives and experiences of electronic mental health adoption. More specifically, it aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to further identify and understand how different factors facilitate or impede electronic mental health uptake within primary health care settings providing services to Aboriginal and Torres Strait Islander people.

METHODS

Qualitative interviews were conducted with 57 service providers working with Aboriginal and Torres Strait Islander people, who had undergone electronic mental health training workshops.

RESULTS

Several factors related to innovation (electronic mental health approach), recipients (service providers as an individual and as a team), and context (local, organizational, and external contexts) were found to influence electronic mental health uptake. Particularly, organizational readiness, in terms of information technology resources and infrastructure, policies, workforce and culture, and processes to mandate electronic mental health use, were found to be significant impediments to electronic mental health utilization. These findings led to the development of a three-phase implementation strategy that aims to enhance electronic mental health adoption by addressing organizational readiness before and post electronic mental health training.

CONCLUSIONS

The i-PARIHS provides a useful determinant framework that deepens our understanding of how different factors impede or facilitate electronic mental health adoption in this setting. This insight was used to develop a practical and comprehensive implementation strategy to enhance the utilization of electronic mental health approaches within primary health care settings, involving three phases: pretraining consultations, training workshops, and post-training follow-up support.

Smartphone and Internet Access and Utilization by People With Schizophrenia in South Australia: Quantitative Survey Study

BACKGROUND

Web-based information and interventions for mental illness are increasingly being provided. There is an expectation that citizens have access to the internet and are competent in using technology. People with schizophrenia are often excluded from social engagement, have cognitive impairment, and have very limited income, all of which may reduce their use of technology.

OBJECTIVE

This study aimed to investigate technology access, use of digital technology, and confidence in using technology among people with schizophrenia living in the community.

METHODS

Face-to-face structured interviews with 50 people with schizophrenia (aged 18-65 years) living in the northern suburbs of Adelaide, South Australia, were conducted using an instrument designed to assess technology access and utilization.

RESULTS

Most participants (42/50, 84%) owned a mobile phone, but only 58% (29/50) owned a smartphone. Two-thirds of participants (33/50, 66%) had access to the internet at home, using a smartphone or computer. Moreover, 40% (20/50) of participants used the internet at least daily, but 30% (15/50) of participants had never accessed the internet from any device. Approximately half of the participants (24/50, 48%) had never used Facebook. Participants rarely used community facilities (eg, libraries and cafes) to access the internet. There were no significant differences (P values ranged from .14 to .70) between younger participants (aged 18-34 years) and older participants (aged 35-64 years) in internet or smartphone access or confidence in using technology.

CONCLUSIONS

Although the sample size of this study is small, it shows limited technology access, use of digital technology, and confidence in using technology among the participants. This could be a barrier to the online delivery of information and interventions for people with schizophrenia. To better understand the impacts of such technological disadvantage and potential disparities in access and use of online resources, prospective studies should recruit a larger sample size and include control subjects matched for socioeconomic disadvantage.

Accuracy of a Chatbot (Ada) in the Diagnosis of Mental Disorders: Comparative Case Study With Lay and Expert Users

Background

Health apps for the screening and diagnosis of mental disorders have emerged in recent years on various levels (eg, patients, practitioners, and public health system). However, the diagnostic quality of these apps has not been (sufficiently) tested so far.

Objective

The objective of this pilot study was to investigate the diagnostic quality of a health app for a broad spectrum of mental disorders and its dependency on expert knowledge.

Methods

Two psychotherapists, two psychology students, and two laypersons each read 20 case vignettes with a broad spectrum of mental disorders. They used a health app (Ada—Your Health Guide) to get a diagnosis by entering the symptoms. Interrater reliabilities were computed between the diagnoses of the case vignettes and the results of the app for each user group.

Results

Overall, there was a moderate diagnostic agreement (kappa=0.64) between the results of the app and the case vignettes for mental disorders in adulthood and a low diagnostic agreement (kappa=0.40) for mental disorders in childhood and adolescence. When psychotherapists applied the app, there was a good diagnostic agreement (kappa=0.78) regarding mental disorders in adulthood. The diagnostic agreement was moderate (kappa=0.55/0.60) for students and laypersons. For mental disorders in childhood and adolescence, a moderate diagnostic quality was found when psychotherapists (kappa=0.53) and students (kappa=0.41) used the app, whereas the quality was low for laypersons (kappa=0.29). On average, the app required 34 questions to be answered and 7 min to complete.

Conclusions

The health app investigated here can represent an efficient diagnostic screening or help function for mental disorders in adulthood and has the potential to support especially diagnosticians in their work in various ways. The results of this pilot study provide a first indication that the diagnostic accuracy is user dependent and improvements in the app are needed especially for mental disorders in childhood and adolescence.

Usability evaluation of an eHealth intervention for family carers of individuals affected by psychosis: A mixed-method study

Background

Existing research suggests that eHealth interventions targeting family carers of individuals with long-term illness offer a promising approach to care delivery. In particular, digital psychoeducational interventions with interactive psychosocial support are well-received with high rates of satisfaction and acceptability. However, development of such interventions for psychosis carers is lacking. We developed a multi-component eHealth intervention specifically for carers of individuals affected by psychosis, called COPe-support (Carers fOr People with Psychosis e-support).

Objective

Using mixed methods to evaluate usability, system heuristics and perceived acceptability, we conducted a usability study to establish the suitability of the intervention prototype for the target user group.

Methods

Twenty-three carers were recruited to the study and participated in a think-aloud test or a remote online trial of the intervention. Qualitative feedback, post-use System Usability Scale (SUS) scores, and real-world usage data collected from the tests were analysed. These were also supplemented with heuristic evaluation data provided by an independent eLearning technology expert.

Results

Participants evaluated the intervention content as useful and helpful, and indicated that the system had satisfactory usability with a mean SUS score of 73%, above the usability quality benchmark threshold. Study results identified some minor usability issues, which were corroborated with the eLearning expert’s heuristic evaluation findings. We used these results to refine the COPe-support intervention.

Conclusions

The usability study with end-users and service providers identified real-life usage and usability issues. The study results helped us refine COPe-support and its delivery strategy before its launch as part of a large-scale clinical trial.

A Multicomponent eHealth Intervention for Family Carers for People Affected by Psychosis: A Coproduced Design and Build Study

Background

Psychosis, including schizophrenia, is the most common severe mental illness affecting 1% of the population worldwide. A large number of people provide long-term support and care for a relative with psychosis. Although psychoeducational interventions, especially those delivered through a face-to-face group format, have an established evidence base for improving the caregiving experience, well-being, and health outcomes, large-scale implementation and access remain limited. There is a demand for such provision to be made through the internet for greater flexibility and wider access.

Objective

This study aimed to integrate participatory research methodologies by the public, patients, and carers into the eHealth (electronic health) intervention design and build process to improve the product’s usability and acceptability.

Methods

We adapted a structured eHealth intervention build method to include participatory research activities involving key stakeholders and end users to co-design and coproduce our intervention. An expert advisory group (EAG) comprising public involvement members led the formative design and build work using an agile build process. Carers independent from the study were consulted on the evolving drafts of the intervention prototype through focus group meetings. These results were fed back into the intervention build work continuously to ensure end users’ input inform every stage of the process.

Results

An EAG comprising individuals with lived experience of psychosis, carers, health care professionals, researchers, voluntary organization workers, and eLearning experts (n=14) was established. A total of 4 coproduction workshops were held over 1 year during which the alpha and beta prototypes were designed and built through the participatory research work. Alongside this, 2 rounds of focus group study with carers (n=24, in 4 groups) were conducted to seek consultation on end users’ views and ideas to optimize the intervention design and usability. Finally, the EAG carried out a Web-based walk-through exercise on the intervention prototype and further refined it to make it ready for an online usability test. The final product contains multiple sections providing information on psychosis and related caregiving topics and interactive discussion forums with experts and peers for psychosocial support. It provides psychoeducation and psychosocial support for carers through the internet, promoting flexible access and individualized choices of information and support.

Conclusions

The participatory research work led to the coproduction of a eHealth intervention called COPe-support (Carers fOr People with Psychosis e-support). We believe the study methodology, results, and output have optimized the intervention design and usability, fitting the end users’ needs and usage pattern. COPe-support is currently being tested for its effectiveness in promoting carers’ health outcome through an online randomized controlled trial.

Trial Registration

ISRCTN Registry ISRCTN89563420; http://www.isrctn.com/ISRCTN89563420

A multi-faceted approach to characterizing user behavior and experience in a digital mental health intervention

Digital interventions offer great promise for supporting health-related behavior change. However, there is much that we have yet to learn about how people respond to them. In this study, we present a novel mixed-methods approach to analysis of the complex and rich data that digital interventions collect. We perform secondary analysis of IntelliCare, an intervention in which participants are able to try 14 different mental health apps over the course of eight weeks. The goal of our analysis is to characterize users' app use behavior and experiences, and is rooted in theoretical conceptualizations of engagement as both usage and user experience. In the first aim, we employ cluster analysis to identify subgroups of participants that share similarities in terms of the frequency of their usage of particular apps, and then employ other engagement measures to compare the clusters. We identified four clusters with different app usage patterns: Low Usage, High Usage, Daily Feats Users, and Day to Day users. Each cluster was distinguished by its overall frequency of app use, or the main app that participants used. In the second aim, we developed a computer-assisted text analysis and visualization method - message highlighting - to facilitate comparison of the clusters. Last, we performed a qualitative analysis using participant messages to better understand the mechanisms of change and usability of salient apps from the cluster analysis. Our novel approach, integrating text and visual analytics with more traditional qualitative analysis techniques, can be used to generate insights concerning the behavior and experience of users in digital health contexts, for subsequent personalization and to identify areas for improvement of intervention technologies.

Technology Delivered Interventions for Depression and Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis

Depression and anxiety are common during adolescence. Whilst effective interventions are available treatment services are limited resulting in many adolescents being unable to access effective help. Delivering mental health interventions via technology, such as computers or the internet, offers one potential way to increase access to psychological treatment. The aim of this systematic review and meta-analysis was to update previous work and investigate the current evidence for the effect of technology delivered interventions for children and adolescents (aged up to 18 years) with depression and anxiety. A systematic search of eight electronic databases identified 34 randomized controlled trials involving 3113 children and young people aged 6-18. The trials evaluated computerized and internet cognitive behavior therapy programs (CBT: n = 17), computer-delivered attention bias modification programs (ABM: n = 8) cognitive bias modification programs (CBM: n = 3) and other interventions (n = 6). Our results demonstrated a small effect in favor of technology delivered interventions compared to a waiting list control group: g = 0.45 [95% CI 0.29, 0.60] p < 0.001. CBT interventions yielded a medium effect size (n = 17, g = 0.66 [95% CI 0.42-0.90] p < 0.001). ABM interventions yielded a small effect size (n = 8, g = 0.41 [95%CI 0.08-0.73] p < 0.01). CBM and 'other' interventions failed to demonstrate a significant benefit over control groups. Type of control condition, problem severity, therapeutic support, parental support, and continuation of other ongoing treatment significantly influenced effect sizes. Our findings suggest there is a benefit in using CBT based technology delivered interventions where access to traditional psychotherapies is limited or delayed.