Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial

Mothers and Babies Virtual Group (MBVG) for perinatal Latina women: study protocol for a hybrid type-1 effectiveness-implementation randomized controlled trial

BACKGROUND

Immigrant Latinas (who are foreign-born but now reside in the USA) are at greater risk for developing postpartum depression than the general perinatal population, but many face barriers to treatment. To address these barriers, we adapted the Mothers and Babies Course-an evidence-based intervention for postpartum depression prevention-to a virtual group format. Additional adaptations are inclusion of tailored supplemental child health content and nutrition benefit assistance. We are partnering with Early Learning Centers (ELC) across the state of Maryland to deliver and test the adapted intervention.

METHODS

The design is a Hybrid Type I Effectiveness-Implementation Trial. A total of 300 participants will be individually randomized to immediate (N = 150) versus delayed (N = 150) receipt of the intervention, Mothers and Babies Virtual Group (MB-VG). The intervention will be delivered by trained Early Learning Center staff. The primary outcomes are depressive symptoms (measured via the Center for Epidemiologic Studies-Depression Scale), parenting self-efficacy (measured via the Parental Cognition and Conduct Towards the Infant Scale (PACOTIS) Parenting Self-Efficacy subscale), and parenting responsiveness (measured via the Maternal Infant Responsiveness Instrument) at 1-week, 3-month, and 6-month post-intervention. Depressive episodes (Structured Clinical Interview for DSM-V- Disorders Research Version) at 3-month and 6-month post-intervention will also be assessed. Secondary outcomes include social support, mood management, anxiety symptoms, perceived stress, food insecurity, and mental health stigma at 1-week, 3-month, and 6-month post-intervention. Exploratory child outcomes are dysregulation and school readiness at 6-month post-intervention. Intervention fidelity, feasibility, acceptability, and appropriateness will also be assessed guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

DISCUSSION

This study will be one of the first to test the efficacy of a group-based virtual perinatal depression intervention with Latina immigrants, for whom stark disparities exist in access to health services. The hybrid effectiveness-implementation design will allow rigorous examination of barriers and facilitators to delivery of the intervention package (including supplemental components) which will provide important information on factors influencing intervention effectiveness and the scalability of intervention components in Early Learning Centers and other child-serving settings.

REGISTRATION

ClinicalTrials.gov NCT05873569.

Deceptively Simple yet Profoundly Impactful: Text Messaging Interventions to Support Health

This paper examines the use of text message (SMS) interventions for health-related behavioral support. It first outlines the historical progress in SMS intervention research publications and the variety of funds from US government agencies. A narrative review follows, highlighting the effectiveness of SMS interventions in key health areas, such as physical activity, diet and weight loss, mental health, and substance use, based on published meta-analyses. It then outlines advantages of text messaging compared to other digital modalities, including the real-time capability to collect information and deliver microdoses of intervention support. Crucial design elements are proposed to optimize effectiveness and longitudinal engagement across communication strategies, psychological foundations, and behavior change tactics. We then discuss advanced functionalities, such as the potential for generative artificial intelligence to improve user interaction. Finally, major challenges to implementation are highlighted, including the absence of a dedicated commercial platform, privacy and security concerns with SMS technology, difficulties integrating SMS interventions with medical informatics systems, and concerns about user engagement. Proposed solutions aim to facilitate the broader application and effectiveness of SMS interventions. Our hope is that these insights can assist researchers and practitioners in using SMS interventions to improve health outcomes and reducing disparities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis

BACKGROUND

As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance.

OBJECTIVE

This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement.

METHODS

Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II).

RESULTS

Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β=-0.029, 95% CI -0.11 to 0.048) and in each of the 3 categories: appreciating alliance (β=-0.096, 95% CI -0.80 to 0.61), alliance building disclosures (β=-0.098, 95% CI -0.28 to 0.084), and agreement confirmation (β=-0.076, 95% CI -0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement.

CONCLUSIONS

The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication.

TRIAL REGISTRATION

Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052.

Machine-Learning-Based Prediction of Client Distress From Session Recordings

Natural language processing (NLP) is a subfield of machine learning that may facilitate the evaluation of therapist-client interactions and provide feedback to therapists on client outcomes on a large scale. However, there have been limited studies applying NLP models to client outcome prediction that have (a) used transcripts of therapist-client interactions as direct predictors of client symptom improvement, (b) accounted for contextual linguistic complexities, and (c) used best practices in classical training and test splits in model development. Using 2,630 session recordings from 795 clients and 56 therapists, we developed NLP models that directly predicted client symptoms of a given session based on session recordings of the previous session (Spearman's rho =0.32, p<.001). Our results highlight the potential for NLP models to be implemented in outcome monitoring systems to improve quality of care. We discuss implications for future research and applications.

HealthySMS Text Messaging System Adjunct to Adolescent Group Cognitive Behavioral Therapy in the Context of COVID-19 (Let's Text!): Pilot Feasibility and Acceptability Study

BACKGROUND

The widespread occurrence and devastating impact of adolescent depression warrant health service research focused on feasible and acceptable digital health tools to supplement evidence-based intervention (EBI) efforts, particularly in the context of shelter-in-place guidelines disrupting youth socialization and service use in the wake of the COVID-19 pandemic. Given the promise of SMS text message interventions to enhance EBI engagement, our team developed the HealthySMS system as an adjunct to one of the most empirically supported interventions for adolescent depression: cognitive behavioral therapy (CBT) group services. The system sends daily SMS text messages requesting responses assessing mood, thoughts, and activities; weekly attendance reminder messages; daily tips about adherence (eg, a prompt for activity completion); and personalized responses based on participants' texts.

OBJECTIVE

This study aims to evaluate the feasibility and acceptability of HealthySMS in a real-world setting and explore potential mechanisms of change in EBI engagement, before evaluating the system's impact on adolescents' group CBT engagement and, ultimately, depression outcomes.

METHODS

Over the course of 2020, we invited all 20 adolescents receiving CBT group services for depression at an outpatient psychiatry clinic to enroll in our HealthySMS study; ultimately, 17 (85%) adolescents agreed to participate. We tracked participant initiation and engagement with the HealthySMS system as well as the content of SMS text message responses to HealthySMS. We also invited each participant to engage in a semistructured interview to gather additional qualitative inputs on the system.

RESULTS

All (n=17, 100%) research participants invited agreed to receive HealthySMS messages, and 94% (16/17) of the participants maintained use during the first month without opting out. We uncovered meaningful qualitative themes regarding the feasibility and acceptability of HealthySMS, as well as its potential impact on EBI engagement.

CONCLUSIONS

Taken together, the results of this pilot study suggest that HealthySMS adjunct to adolescent CBT group depression services is feasible and acceptable, as evidenced by high rates of HealthySMS initiation and low rates of dropout, as well as meaningful themes uncovered from participants' qualitative feedback. In addition, the findings provide evidence regarding iterative improvements to the HealthySMS system and research protocol, as well as potential mechanisms of change for enhanced EBI engagement and, ultimately, adolescent depression outcomes, which can be used in future effectiveness research.

Language adaptations of mental health interventions: User interaction comparisons with an AI-enabled conversational agent (Wysa) in English and Spanish

Background

In recent times, digital mental health interventions (DMHIs) have been proven to be efficacious; however, most are available only for English speakers, leaving limited options for non-English languages like Spanish. Research shows that mental health services in one's dominant language show better outcomes. Conversational agents (CAs) offer promise in supporting mental health in non-English populations. This study compared a culturally adapted version of an artificial intelligence (AI)-led mental health app, called Wysa, in Spanish and English.

Objectives

To compare user engagement patterns on Wysa-Spanish and Wysa-English and to understand expressions of distress and preferred language in both versions of Wysa.

Methods

We adopted a cross-sectional retrospective exploratory design with mixed methods, analyzing users from 10 Spanish-speaking countries between 1 February and 1 August 2022. A quantitative sample A (n = 2767) was used for descriptive statistics, including user engagement metrics with a Wilcoxon test. A subset qualitative sample B (n = 338) was examined for word count differences based on valence, and a content analysis was conducted to examine idioms of distress.

Results

Compared to Wysa-English, Wysa-Spanish had more sessions (P < .001, d = 0.18) and a greater volume of disclosure of distress. In Wysa-Spanish, the average length of a conversation was significantly longer than in Wysa-English (P < .001, d = 0.44). Users preferred interventions with free text responses ("Thought recording") in Spanish (P < .01, d = 0.41), and Spanish messages were significantly longer (P < .01, d = 0.24). Wysa-Spanish saw more frequent expressions of negative emotions and feelings of self-harm and suicide.

Conclusion

Given the high engagement within the Spanish version of Wysa, the findings demonstrate the need for culturally adapted DMHIs among non-English populations, emphasizing the importance of considering linguistic and cultural differences in the development of DMHIs to improve accessibility for diverse populations.

Cultural Responsivity in Technology-Enabled Services: Integrating Culture Into Technology and Service Components

Technology-enabled services (TESs) are clinical interventions that combine technological and human components to provide health services. TESs for mental health are efficacious in the treatment of anxiety and depression and are currently being offered as frontline treatments around the world. It is hoped that these interventions will be able to reach diverse populations across a range of identities and ultimately decrease disparities in mental health treatment. However, this hope is largely unrealized. TESs include both technology and human service components, and we argue that cultural responsivity must be considered in each of these components to help address existing treatment disparities. To date, there is limited guidance on how to consider cultural responsivity within these interventions, including specific targets for the development, tailoring, or design of the technologies and services within TESs. In response, we propose a framework that provides specific recommendations for targets based on existing models, both at the technological component level (informed by the Behavioral Intervention Technology Model) and the human support level (informed by the Efficiency Model of Support). We hope that integrating culturally responsive considerations into these existing models will facilitate increased attention to cultural responsivity within TESs to ensure they are ethical and responsive for everyone.

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

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

Virtual reality exposure therapy for reducing social anxiety in stuttering: A randomized controlled pilot trial

We report on findings from the first randomized controlled pilot trial of virtual reality exposure therapy (VRET) developed specifically for reducing social anxiety associated with stuttering. People who stutter with heightened social anxiety were recruited from online adverts and randomly allocated to receive VRET (n = 13) or be put on a waitlist (n = 12). Treatment was delivered remotely using a smartphone-based VR headset. It consisted of three weekly sessions, each comprising both performative and interactive exposure exercises, and was guided by a virtual therapist. Multilevel model analyses failed to demonstrate the effectiveness of VRET at reducing social anxiety between pre- and post-treatment. We found similar results for fear of negative evaluation, negative thoughts associated with stuttering, and stuttering characteristics. However, VRET was associated with reduced social anxiety between post-treatment and one-month follow-up. These pilot findings suggest that our current VRET protocol may not be effective at reducing social anxiety amongst people who stutter, though might be capable of supporting longer-term change. Future VRET protocols targeting stuttering-related social anxiety should be explored with larger samples. The results from this pilot trial provide a solid basis for further design improvements and for future research to explore appropriate techniques for widening access to social anxiety treatments in stuttering.

Use of Telehealth to Address Depression and Anxiety in Low-income US Populations: A Narrative Review

Symptoms of anxiety and depressive disorders have been increasing substantially among adults in the United States (US) during the COVID-19 pandemic, particularly for low-income populations. Under-resourced communities have difficulties accessing optimal treatment for anxiety and depression due to costs as well as the result of limited access to health care providers. Telehealth has been growing as a digital strategy to treat anxiety and depression across the country but it is unclear how best to implement telehealth interventions to serve low-income populations. A narrative review was conducted to evaluate the role of telehealth in addressing anxiety and depression in low-income groups in the US. A PubMed database search identified a total of 14 studies published from 2012 to 2022 on telehealth interventions that focused on strengthening access to therapy, coordination of care, and medication and treatment adherence. Our findings suggest that telehealth increases patient engagement through virtual therapy and the use of primarily telephone communication to treat and monitor anxiety and depression. Telehealth seems to be a promising approach to improving anxiety and depressive symptoms but socioeconomic and technological barriers to accessing mental health services are substantial for low-income US populations.

Text Messages for Depression, Anxiety and Alcohol Abuse Therapy-Are Construction Guidelines Needed?

Despite the effectiveness of text messaging therapy in improving mental health conditions, limited attention has been paid to how the text messages are constructed. Thus, this study questions whether there is a need to develop a model of text message construction for mental health therapy. In this backdrop, this study reviews how a text message for mental health therapy is constructed, specifically focused on the process and guidelines. This study also aims to identify the research gap regarding the guideline of text message construction for mental health therapy and to identify mental health professionals' practices in text messaging therapy. In addition, the opinions of mental health professionals on the need to develop a text message construction guideline were also gathered. The findings from the literature review confirmed that there are still limited guidelines explaining the process of constructing text messages for mental health therapy. Meanwhile, results from the online survey found that mental health professionals expressed a high need to explore and develop a model of text message construction for mental health therapy. With this research gap addressed, this study proposes further research into the development of a text message construction model for mental health therapy.

Blending Internet-based and tele group treatment: Acceptability, effects, and mechanisms of change of cognitive behavioral treatment for depression

The current COV-19 pandemic increases the need for remote treatment. Among several provision strategies, tele groups have been tested as an efficient option. Still, the number of studies is comparably low, with a clear lack of studies investigating supposed treatment mechanisms. Sixty-one mildly to moderately depressed participants from Salzburg, Bavaria, and Upper Austria were randomized to the intervention or a waiting list control group (RCT). The seven-week treatment comprised preparatory online modules, followed by personalized feedback and a subsequent tele group session. Large treatment effects were observed for depression (CES-D: d = 0.99, p < .001; PHQ-9: d = 0.87, p = .002), together with large effects for cognitive behavioral skills (cognitive style, and behavioral activation, d = 0.88-0.97). Changes in skills mediated treatment outcomes for CES-D and PHQ-9, suggesting comparable mechanisms as in face-to-face therapy. Two typical moderators, therapeutic alliance, and group cohesion, however, failed to predict outcome (p = .289), or only exhibited statistical tendencies (p = .049 to .071). Client satisfaction, system usability, and treatment adherence were high. Blending Internet-based and tele group interventions offers additional options for low-threshold care that is less dependent on population density, commuting distances, or constraints due to the current COV-19 crisis. Results indicate that the blended intervention is clinically effective by fostering core CBT skills. While findings suggest the notion that working alliance and group cohesion can be established online, their relevancy for outcomes of blended treatment needs to be further investigated.

Blended Therapies and Mobile Phones for Improving the Health of Female Victims of Gender Violence

We carried out a case study with a group of female victims of gender violence (n = 39) with the objective of evaluating a blended psychotherapeutic intervention. The results show that blended therapies with mobile text messages combined with face-to-face group therapies significantly improved the health of these women. Mood states and the symptoms of depression were measured with a PHQ-9 personal health questionnaire and evolved positively. In the group of women (n = 39) the scores improved from an initial 13.5 (SD = 7.2, range 3-34) to 6.0 at the end of the period of messages (SD = 5.2, range 0-18), which was a significant difference (t (39) = 2.02; p = 0.000). Most of the women stated that the messages had helped them improve their mood (91.6%) and their general health (83.3%), which made them feel more connected to their social environment (80.6%). We observed that adherence to medication for each woman improved. With mixed therapies and mobile phones, social service professionals can incorporate technology into daily practices and offer personalized attention and daily counseling to victims of gender-based violence.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Mindfulness and Mobile Health for Quitting Smoking: A Qualitative Study Among Predominantly African American Adults with Low Socioeconomic Status

Low-income and African American adults experience severe tobacco-related health disparities. Mindfulness-based interventions show promise for promoting smoking cessation, but most mindfulness research has focused on higher income, Caucasian samples. "iQuit Mindfully" is a personalized, interactive text messaging program that teaches mindfulness for smoking cessation. This qualitative study sought feedback from predominantly low-income African American smokers, to improve the intervention for this priority population. After receiving 8 weekly group sessions of Mindfulness-Based Addiction Treatment for smoking cessation and between-session iQuit Mindfully text messages, participants (N=32) completed semi-structured interviews. Participants were adult cigarette smokers (90.6% African American, 62.6% annual income <$30,000, mean age 45.1 [±12.9]). Interviews inquired about participants' experiences with and suggestions for improving iQuit Mindfully, including message content, number, and timing. Interviews were audio-recorded, transcribed verbatim, and coded by a team of 5 coders in NVivo. The coding manual was developed based on response categories from the interview guide and themes emerging from the data. Themes were organized into a conceptual model of factors related to engagement with the mHealth program. Response categories included helpful aspects (e.g., themes of social support, mindfulness, personalization); unhelpful/disliked aspects (e.g., too many/repetitive messages); links between in-person sessions and texts; and suggestions (e.g., changes to number/timing and more personalization). Findings provide insight into participants' day-to-day experiences with iQuit Mindfully and suggest ways to improve mHealth programs among low-income and African American adults.

App-Based Mindfulness Meditation for People of Color Who Experience Race-Related Stress: Protocol for a Randomized Controlled Trial (Preprint)

Background

People of color (POC) who experience race-related stress are at risk of developing mental health problems, including high levels of stress, anxiety, and depression. Mindfulness meditation may be especially well suited to help POC cope, given its emphasis on gaining awareness and acceptance of emotions associated with discriminatory treatment. However, mindfulness meditation rarely reaches POC, and digital approaches could reduce this treatment gap by addressing traditional barriers to care.

Objective

This study will test the effectiveness of a self-directed app-based mindfulness meditation program among POC who experience elevated levels of race-related stress. Implementation outcomes such as treatment acceptability, adherence, and satisfaction will be examined.

Methods

Participants (n=80) will be recruited online by posting recruitment materials on social media and sending emails to relevant groups. In-person recruitment will consist of posting flyers in communities with significant POC representation. Eligible participants will be block randomized to either the intervention group (n=40) that will complete a self-directed 4-week mindfulness meditation program or a wait-list control condition (n=40) that will receive access to the app after study completion. All participants will complete measures at baseline, midtreatment, and posttreatment. Primary outcomes include changes in stress, anxiety, and depression, and secondary outcomes constitute changes in mindfulness, self-compassion, rumination, emotion suppression, and experiential avoidance. Exploratory analyses will examine whether changes in the secondary outcomes mediate changes in primary outcomes. Finally, treatment acceptability, adherence, and satisfaction will be examined descriptively.

Results

Recruitment began in October 2021. Data will be analyzed using multilevel modeling, a statistical methodology that accounts for the dependence among repeated observations. Considering attrition issues in self-directed digital interventions and their potential effects on statistical significance and treatment effect sizes, we will examine data using both intention-to-treat and per-protocol analyses.

Conclusions

To our knowledge, this will be the first study to provide data on the effectiveness of a self-directed app-based mindfulness meditation program for POC recruited based on elevated race-related stress, a high-risk population. Similarly, meaningful clinical targets for POC affected by stressors related to race will be examined. Findings will provide important information regarding whether this type of intervention is an acceptable treatment among these marginalized groups.

Trial Registration

ClinicalTrials.gov NCT05027113; https://clinicaltrials.gov/ct2/show/NCT05027113

International Registered Report Identifier (IRRID)

DERR1-10.2196/35196

Integrating SMS Text Messages Into a Preventive Intervention for Postpartum Depression Delivered via In-Home Visitation Programs: Feasibility and Acceptability Study

BACKGROUND

The Mothers and Babies (MB) Course is recognized by the US Preventive Services Task Force as an evidence-based preventive intervention for postpartum depression (PPD) that should be recommended to pregnant women at risk for PPD.

OBJECTIVE

This report examines the feasibility and acceptability of enhancing the MB 1-on-1 intervention by adding 36 SMS text messages that target 3 areas: reinforcement of skills, between-session homework reminders, and responding to self-monitoring texts (ie, MB Plus Text Messaging [MB-TXT]).

METHODS

In partnership with 9 home visiting programs, 28 ethnically and racially diverse pregnant women (mean 25.6, SD 9.0 weeks) received MB-TXT. Feasibility was defined by home visitors' adherence to logging into the HealthySMS platform to enter session data and trigger SMS text messages within 7 days of the in-person session. The acceptability of MB-TXT was measured by participants' usefulness and understanding ratings of the SMS text messages and responses to the self-monitoring SMS text messages.

RESULTS

On average, home visitors followed the study protocol and entered session-specific data between 5.50 and 61.17 days following the MB 1-on-1 sessions. A high proportion of participants responded to self-monitoring texts (25/28, 89%) and rated the text message content as very useful and understandable.

CONCLUSIONS

This report contributes to a growing body of research focusing on digital adaptations of the MB course. SMS is a low-cost, accessible digital tool that can be integrated into existing interventions. With appropriate resources to support staff, it can be implemented in community-based organizations and health care systems that serve women at risk for PPD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03420755; https://clinicaltrials.gov/ct2/show/NCT03420755.

Protocol for a sequential, multiple assignment, randomised trial to test the effectiveness of message-based psychotherapy for depression compared with telepsychotherapy

INTRODUCTION

Digital mental health tools have become popular alternatives to traditional psychotherapy. One emerging form of digital mental health is message-based care, the use of text messages or asynchronous voice or video messaging to provide psychotherapy. There has been no research into whether this is an effective method of psychotherapy as a stand-alone treatment or in combination with traditional psychotherapy.

METHODS AND ANALYSIS

This is a sequential, multiple assignment randomised trial to compare message-based care, videoconference-psychotherapy and a combination of the two treatments in 1000 depressed adults. Participants will be recruited through Talkspace, a digital mental health company, and randomised to receive 6 weeks of either message-based care only or videoconference-psychotherapy only. At 6 weeks, participants will be evaluated for their response to treatment. Those with a 50% or more response to treatment will continue with their assigned condition. Those who do not respond will be randomised to either monthly videoconference-psychotherapy or weekly videoconference-psychotherapy plus message-based care. Primary outcomes will be depression and social functioning. We will also explore moderators of treatment outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from the University of Washington Institutional Review Board. Results of this study will be presented in peer-reviewed journals and at professional conferences.

TRIAL REGISTRATION NUMBER

NCT04513080; Pre-results.

A Text Messaging Intervention (StayWell at Home) to Counteract Depression and Anxiety During COVID-19 Social Distancing: Pre-Post Study

BACKGROUND

Social distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19-related depression and anxiety symptoms among people who speak English and Spanish in the United States.

OBJECTIVE

This paper describes the changes in StayWell participants' anxiety and depression levels after 60 days of exposure to skills-based SMS text messages.

METHODS

We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Questionnaire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used 2-tailed paired t tests to detect changes in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later.

RESULTS

The analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of -1.72 (95% CI -2.35 to -1.09) in PHQ-8 scores and -0.48 (95% CI -0.71 to -0.25) in GAD-2 scores. These improvements translated to an 18.5% and 17.2% reduction in mean PHQ-8 and GAD-2 scores, respectively.

CONCLUSIONS

StayWell is an accessible, low-intensity population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/23592.

Addressing anhedonia to increase depression treatment engagement

Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.

The Development and Pilot of a Technology-Based Intervention in the United States for Father's Mental Health in the Perinatal Period

Paternal mental health is increasingly recognized as an important public health issue, with about 10% of men experiencing depression perinatally. Paternal depression is associated with less responsive parenting, greater parenting stress, and suboptimal child development. In response to a lack of existing interventions that directly focus on fathers’ mental health in the United States, we developed and pilot tested the Fathers and Babies (FAB) intervention for use with partners of women enrolled in home visiting (HV) programs.

After a review of the extant literature, FAB was developed with input from HV stakeholders and infant mental health consultants. FAB was subsequently pilot tested with 30 father-mother dyads, with mixed-method data collected from a subset of intervention participants to assess intervention feasibility and acceptability and guide intervention refinement.

Five themes related to FAB content and delivery considerations emerged from the initial focus groups that were used to guide FAB development. Mixed-method data collected during the pilot study established that fathers receiving FAB reported its content appropriate and thought it was feasible to receive the intervention. Several recommendations for FAB revisions were also provided.

FAB is an innovative intervention developed for fathers from contemporary family structures that was well-received during its pilot testing. Feasibility and acceptability data suggest that fathers have favorable opinions about intervention content and delivery, while also highlighting areas for future revisions of FAB.

Examining the Effectiveness of the Fathers and Babies Intervention: A Pilot Study

There is increasing recognition of the importance of addressing the mental health of fathers, including during the perinatal period. Fathers exhibiting mental health concerns during the perinatal period are at heightened risk for future negative mental health outcomes and are less likely to engage in nurturing relationships with their children, leading to a sequalae of negative child outcomes during infancy and into adolescence. Although interventions have been developed for perinatal fathers, they typically do not focus directly on addressing paternal mental health. To fill this gap, we developed the Fathers and Babies intervention to be delivered to perinatal fathers whose partners (mothers) were enrolled in home visiting programs. A pre-post longitudinal study was conducted in which 30 father-mother dyads were recruited from home visiting programs. Fathers received the 12-session Fathers and Babies intervention while the mother concurrently received the Mothers and Babies intervention delivered to her by a home visitor. Baseline, 3- and 6-month self-report surveys were conducted with both fathers and mothers. Fathers and mothers had statistically significant decreases in perceived stress between baseline and both follow-up time points, with moderate effect sizes generated for both sexes. No statistically significant differences were found for depressive symptoms, anxiety symptoms, or perceived partner support, although we found small effects for reductions in depressive symptoms among fathers, as well as increases in the percentage of fathers and mothers who reported high levels of emotional and instrumental support post-intervention. While preliminary, these findings suggest the potential for Fathers and Babies to positively impact the mental health of fathers in the perinatal period, and also signal the viability of home visiting as a setting for delivering this intervention. Future research should employ a comparison group to generate stronger evidence of intervention effectiveness and include measurement of dyadic relationships and paternal parenting practices.

Promoting Culturally Tailored mHealth: A Scoping Review of Mobile Health Interventions in Latinx Communities

This scoping review of mHealth research focuses on intervention studies that utilize mobile technologies to promote behavior change and improve health outcomes in U.S. Latinx communities. 342 mHealth articles were reviewed using PRIMSA protocols; most did not include a majority Latinx study population or did not report on an intervention. The final sample resulted in 23 articles published between 2012 and 2020. Reviewed interventions focused on conditions such as: diabetes, depression, substance abuse, obesity, hypertension, maternal health, and farmworker safety. About one-third of mHealth interventions included mobile applications, the rest were limited to texting programs. Text message reminders can help improve medication adherence and care access, especially when coupled with support from community health workers. Bi-directional text message interventions with feedback loops and personalized treatment options can build user agency. Additionally, multi-modal applications that combine texting with self-guided interactive content show promise for culturally tailored mHealth.

Conducting Internet-Based Visits for Onboarding Populations With Limited Digital Literacy to an mHealth Intervention: Development of a Patient-Centered Approach

Background

The COVID-19 pandemic has propelled patient-facing research to shift to digital and telehealth strategies. If these strategies are not adapted for minority patients of lower socioeconomic status, health inequality will further increase. Patient-centered models of care can successfully improve access and experience for minority patients.

Objective

This study aims to present the development process and preliminary acceptability of altering in-person onboarding procedures into internet-based, remote procedures for a mobile health (mHealth) intervention in a population with limited digital literacy.

Methods

We actively recruited safety-net patients (English- and Spanish-speaking adults with diabetes and depression who were receiving care at a public health care delivery system in San Francisco, United States) into a randomized controlled trial of text messaging support for physical activity. Because of the COVID-19 pandemic, we modified the in-person recruitment and onboarding procedures to internet-based, remote processes with human support. We conducted a preliminary evaluation of how the composition of the recruited cohort might have changed from the pre–COVID-19 period to the COVID-19 enrollment period. First, we analyzed the digital profiles of patients (n=32) who had participated in previous in-person onboarding sessions prior to the COVID-19 pandemic. Next, we documented all changes made to our onboarding processes to account for remote recruitment, especially those needed to support patients who were not very familiar with downloading apps onto their mobile phones on their own. Finally, we used the new study procedures to recruit patients (n=11) during the COVID-19 social distancing period. These patients were also asked about their experience enrolling into a fully digitized mHealth intervention.

Results

Recruitment across both pre–COVID-19 and COVID-19 periods (N=43) demonstrated relatively high rates of smartphone ownership but lower self-reported digital literacy, with 32.6% (14/43) of all patients reporting they needed help with using their smartphone and installing apps. Significant changes were made to the onboarding procedures, including facilitating app download via Zoom video call and/or a standard phone call and implementing brief, one-on-one staff-patient interactions to provide technical assistance personalized to each patient’s digital literacy skills. Comparing recruitment during pre–COVID-19 and COVID-19 periods, the proportion of patients with digital literacy barriers reduced from 34.4% (11/32) in the pre–COVID-19 cohort to 27.3% (3/11) in the COVID-19 cohort. Differences in digital literacy scores between both cohorts were not significant (P=.49).

Conclusions

Patients of lower socioeconomic status have high interest in using digital platforms to manage their health, but they may require additional upfront human support to gain access. One-on-one staff-patient partnerships allowed us to provide unique technical assistance personalized to each patient’s digital literacy skills, with simple strategies to troubleshoot patient barriers upfront. These additional remote onboarding strategies can mitigate but not eliminate digital barriers for patients without extensive technology experience.

Trial Registration

Clinicaltrials.gov NCT0349025, https://clinicaltrials.gov/ct2/show/NCT03490253

Digital Health Interventions in Prevention, Relapse, and Therapy of Mild and Moderate Depression: Scoping Review

BACKGROUND

Depression is a major cause for disability worldwide, and digital health interventions are expected to be an augmentative and effective treatment. According to the fast-growing field of information and communication technologies and its dissemination, there is a need for mapping the technological landscape and its benefits for users.

OBJECTIVE

The purpose of this scoping review was to give an overview of the digital health interventions used for depression. The main goal of this review was to provide a comprehensive review of the system landscape and its technological state and functions, as well as its evidence and benefits for users.

METHODS

A scoping review was conducted to provide a comprehensive overview of the field of digital health interventions for the treatment of depression. PubMed, PSYNDEX, and the Cochrane Library were searched by two independent researchers in October 2020 to identify relevant publications of the last 10 years, which were examined using the inclusion and exclusion criteria. To conduct the review, we used Rayyan, a freely available web tool.

RESULTS

In total, 65 studies were included in the qualitative synthesis. After categorizing the studies into the areas of prevention, early detection, therapy, and relapse prevention, we found dominant numbers of studies in the area of therapy (n=52). There was only one study for prevention, 5 studies for early detection, and 7 studies for relapse prevention. The most dominant therapy approaches were cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy. Most of the studies revealed significant effects of digital health interventions when cognitive behavioral therapy was applied. Cognitive behavioral therapy as the most dominant form was often provided through web-based systems. Combined interventions consisting of web-based and smartphone-based approaches are increasingly found.

CONCLUSIONS

Digital health interventions for treating depression are quite comprehensive. There are different interventions focusing on different fields of care. While most interventions can be beneficial to achieve a better depression treatment, it can be difficult to determine which approaches are suitable. Cognitive behavioral therapy through digital health interventions has shown good effects in the treatment of depression, but treatment for depression still stays very individualistic.

Transforming Population-Based Depression Care: a Quality Improvement Initiative Using Remote, Centralized Care Management

INTRODUCTION

With the growing prevalence of value-based contracts, health systems are incentivized to consider population approaches to service delivery, particularly for chronic conditions like depression. To this end, UW Medicine implemented the Depression-Population Approach to Health (PATH) program in primary care (PC) as part of a system-wide Center for Medicare and Medicaid Innovation (CMMI) quality improvement (QI) initiative.

AIM

To examine the feasibility of a pilot PATH program and its impact on clinical and process-of-care outcomes.

SETTING

A large, diverse, geographically disparate academic health system in Western Washington State including 28 PC clinics across five networks.

PROGRAM DESCRIPTION

The PATH program was a population-level, centralized, measurement-based care intervention that utilized a clinician to provide remote monitoring of treatment progress via chart review and facilitate patient engagement when appropriate. The primary goals of the program were to improve care engagement and increase follow-up PHQ-9 assessments for patients with depression and elevated initial PHQ-9 scores.

PROGRAM EVALUATION

We employed a prospective, observational study design, including commercially insured adult patients with new depression diagnoses and elevated initial PHQ-9 scores. The pilot intervention group, consisting of accountable care network (ACN) self-enrollees (N = 262), was compared with a similar commercially insured cohort (N = 2527) using difference-in-differences analyses adjusted for patient comorbidities, initial PHQ-9 score, and time trends. The PATH program was associated with three times the odds of PHQ-9 follow-up (OR 3.28, 95% CI 1.79-5.99), twice the odds of a follow-up PC clinic visit (OR 1.74, 95% CI 0.99-3.08), and twice the odds of treatment response, defined as reduction in PHQ-9 score by ≥ 50% (OR 2.02, 95% CI 0.97-4.21).

DISCUSSION

Our results demonstrate that a centralized, remote care management initiative is both feasible and effective for large academic health systems aiming to improve depression outcome ascertainment, treatment engagement, and clinical care.

A Text Messaging Intervention for Coping With Social Distancing During COVID-19 (StayWell at Home): Protocol for a Randomized Controlled Trial

BACKGROUND

Social distancing is a crucial intervention to slow down person-to-person transmission of COVID-19. However, social distancing has negative consequences, including increases in depression and anxiety. Digital interventions, such as text messaging, can provide accessible support on a population-wide scale. We developed text messages in English and Spanish to help individuals manage their depressive mood and anxiety during the COVID-19 pandemic.

OBJECTIVE

In a two-arm randomized controlled trial, we aim to examine the effect of our 60-day text messaging intervention. Additionally, we aim to assess whether the use of machine learning to adapt the messaging frequency and content improves the effectiveness of the intervention. Finally, we will examine the differences in daily mood ratings between the message categories and time windows.

METHODS

The messages were designed within two different categories: behavioral activation and coping skills. Participants will be randomized into (1) a random messaging arm, where message category and timing will be chosen with equal probabilities, and (2) a reinforcement learning arm, with a learned decision mechanism for choosing the messages. Participants in both arms will receive one message per day within three different time windows and will be asked to provide their mood rating 3 hours later. We will compare self-reported daily mood ratings; self-reported depression, using the 8-item Patient Health Questionnaire; and self-reported anxiety, using the 7-item Generalized Anxiety Disorder scale at baseline and at intervention completion.

RESULTS

The Committee for the Protection of Human Subjects at the University of California Berkeley approved this study in April 2020 (No. 2020-04-13162). Data collection began in April 2020 and will run to April 2021. As of August 24, 2020, we have enrolled 229 participants. We plan to submit manuscripts describing the main results of the trial and results from the microrandomized trial for publication in peer-reviewed journals and for presentations at national and international scientific meetings.

CONCLUSIONS

Results will contribute to our knowledge of effective psychological tools to alleviate the negative effects of social distancing and the benefit of using machine learning to personalize digital mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23592.

Digital privacy in mental healthcare: current issues and recommendations for technology use

Mental healthcare providers increasingly use technology for psychotherapy services. This progress enables professionals to communicate, store information, and rely on digital software and hardware. Emails, text messaging, telepsychology/telemental health therapy, electronic medical records, cloud-based storage, apps/applications, and assessments are now available within the provision of services. Of those mentioned, some are directly utilized for psychotherapy while others indirectly aid providers. Whereas professionals previously wrote notes locally, technology has empowered providers to work more efficiently with third-party services and solutions. However, the implementation of these advancements in mental healthcare involves consequences to digital privacy and might increase clients' risk of unintended breaches of confidentiality. This manuscript reviews common technologies, considers the vulnerabilities therein, and proposes suggestions to strengthen privacy.

Feasibility, Acceptability, and Influence of mHealth-Supported N-of-1 Trials for Enhanced Cognitive and Emotional Well-Being in US Volunteers

Although group-level evidence supports the use of behavioral interventions to enhance cognitive and emotional well-being, different interventions may be more acceptable or effective for different people. N-of-1 trials are single-patient crossover trials designed to estimate treatment effectiveness in a single patient. We designed a mobile health (mHealth) supported N-of-1 trial platform permitting US adult volunteers to conduct their own 30-day self-experiments testing a behavioral intervention of their choice (deep breathing/meditation, gratitude journaling, physical activity, or helpful acts) on daily measurements of stress, focus, and happiness. We assessed uptake of the study, perceived usability of the N-of-1 trial system, and influence of results (both reported and perceived) on enthusiasm for the chosen intervention (defined as perceived helpfulness of the chosen intervention and intent to continue performing the intervention in the future). Following a social media and public radio campaign, 447 adults enrolled in the study and 259 completed the post-study survey. Most were highly educated. Perceived system usability was high (mean scale score 4.35/5.0, SD 0.57). Enthusiasm for the chosen intervention was greater among those with higher pre-study expectations that the activity would be beneficial for them (p < 0.001), those who obtained more positive N-of-1 results (as directly reported to participants) (p < 0.001), and those who interpreted their N-of-1 study results more positively (p < 0.001). However, reported results did not significantly influence enthusiasm after controlling for participants' interpretations. The interaction between pre-study expectation of benefit and N-of-1 results interpretation was significant (p < 0.001), such that those with the lowest starting pre-study expectations reported greater intervention enthusiasm when provided with results they interpreted as positive. We conclude that N-of-1 behavioral trials can be appealing to a broad albeit highly educated and mostly female audience, that usability was acceptable, and that N-of-1 behavioral trials may have the greatest utility among those most skeptical of the intervention to begin with.

Developing a Text Messaging Intervention to Reduce Deliberate Self-Harm in Chinese Adolescents: Qualitative Study

Background

Deliberate self-harm is common during adolescence and can have detrimental consequences for the well-being of adolescents. Although it is sometimes difficult to engage adolescents in traditional psychotherapies for deliberate self-harm, SMS text messaging has been shown to be promising for cost-effective and low-intensity interventions.

Objective

This study aimed to investigate the views of Chinese adolescents with deliberate self-harm about SMS text messaging interventions in order to develop an acceptable and culturally competent intervention for adolescents with deliberate self-harm.

Methods

Semistructured interviews were conducted with 23 adolescents who had experience with deliberate self-harm. The transcripts of the interviews were analyzed using thematic analysis.

Results

Four themes were identified: beneficial perception of receiving messages, short frequency and duration of messages, caring content in messages, and specific times for sending messages. Most of the participants perceived SMS text messaging interventions to be beneficial. The key factors that emerged for the content of the intervention included encouragement and company, feeling like a virtual friend, providing coping strategies, and individualized messages. In addition, the preferred frequency and duration of the SMS text messaging intervention were identified.

Conclusions

Our study will help in the development of a culturally appropriate SMS text messaging intervention for adolescents with deliberate self-harm. It has the potential to decrease deliberate self-harm instances by providing acceptable support for adolescents with deliberate self-harm who may be reluctant to seek face-to-face psychotherapies.

How Are Information and Communication Technologies Supporting Routine Outcome Monitoring and Measurement-Based Care in Psychotherapy? A Systematic Review

Psychotherapy has proven to be effective for a wide range of mental health problems. However, not all patients respond to the treatment as expected (not-on-track patients). Routine outcome monitoring (ROM) and measurement-based care (MBC), which consist of monitoring patients between appointments and using this data to guide the intervention, have been shown to be particularly useful for these not-on-track patients. Traditionally, though, ROM and MBC have been challenging, due to the difficulties associated with repeated monitoring of patients and providing real-time feedback to therapists. The use of information and communication technologies (ICTs) might help reduce these challenges. Therefore, we systematically reviewed evidence regarding the use of ICTs for ROM and MBC in face-to-face psychological interventions for mental health problems. The search included published and unpublished studies indexed in the electronic databases PubMed, PsycINFO, and SCOPUS. Main search terms were variations of the terms “psychological treatment”, “progress monitoring or measurement-based care”, and “technology”. Eighteen studies met eligibility criteria. In these, ICTs were frequently handheld technologies, such as smartphone apps, tablets, or laptops, which were involved in the whole process (assessment and feedback). Overall, the use of technology for ROM and MBC during psychological interventions was feasible and acceptable. In addition, the use of ICTs was found to be effective, particularly for not-on-track patients, which is consistent with similar non-ICT research. Given the heterogeneity of reviewed studies, more research and replication is needed to obtain robust findings with different technological solutions and to facilitate the generalization of findings to different mental health populations.

Effectiveness of a Psychosocial Therapy with SMS in Immigrant Women with Different Degrees of Depression

Immigrant women who are forced to adapt to a new cultural context often live in low income situations, have informal jobs, and experience social inclusion difficulties; these women frequently have mental health and social relationship problems. We conducted an experimental investigation with a group of vulnerable immigrant women who were receiving support from public social services. Our goal was to analyze the effectiveness of a bio-psychosocial therapy system with text messages to personal mobile phones. We grouped women by different degrees of depression. We studied psychosocial characteristics from personalized interviews and developed message banks to advise healthy habits and accompany moods. We programmed a remote delivery system, and for 26 days, each woman (n = 44) received four of our messages. We analyzed changes in mood and depression at the beginning and at the end of therapy and observed positive changes. The analysis of the initial and final (Personal Health Questionnaire) PHQ−9 quartile intervals shows that text messages significantly improve the mood and depression symptoms of immigrant women when the initial PHQ−9 value is greater than 5 (moderate depression).

Who Benefits Most from Adding Technology to Depression Treatment and How? An Analysis of Engagement with a Texting Adjunct for Psychotherapy

Introduction: Cognitive behavioral therapy (CBT) is an established treatment for depression, but its success is often impeded by low attendance. Supportive text messages assessing participants' mood in between sessions might increase attendance to in-clinic CBT, although it is not fully understood who benefits most from these interventions and how. This study examined (1) user groups showing different profiles of study engagement and (2) associations between increased response rates to mood texts and psychotherapy attendance. Methods: We included 73 participants who attended Group CBT (GCBT) in a primary care clinic and participated in a supportive automated text-messaging intervention. Using unsupervised machine learning, we identified and characterized subgroups with similar combinations of total texting responsiveness and total GCBT attendance. We used mixed-effects models to explore the association between increased previous week response rate and subsequent week in-clinic GCBT attendance and, conversely, response rate following attendance. Results: Participants could be divided into four clusters of overall study engagement, showing distinct profiles in age and prior texting knowledge. The response rate to texts in the week before GCBT was not associated with GCBT attendance, although the relationship was moderated by age; there was a positive relationship for younger, but not older, participants. Attending GCBT was, however, associated with higher response rate the week after an attended session. Conclusion: User groups of study engagement differ in texting knowledge and age. Younger participants might benefit more from supportive texting interventions when their purpose is to increase psychotherapy attendance. Our results have implications for tailoring digital interventions to user groups and for understanding therapeutic effects of these interventions.

Text message reminders as an adjunct to a substance use intervention for adolescents and young adults: Pilot feasibility and acceptability findings

OBJECTIVE

Text messaging has been proposed as a method for increasing the reach of interventions for harmful alcohol and other drug use. This paper describes the design of an automated text messaging adjunct to a substance use intervention intended to support adolescents and young adults attempting to change their alcohol and other drug use behavior. Feasibility and acceptability testing was conducted as part of this pilot study.

METHOD

Five focus groups were conducted to refine text message content and finalize pilot intervention design. Automated, daily, substance use-related reminder text messages were sent to pilot intervention participants (n = 39), who were recruited from outpatient treatment.

RESULTS

Of those who were invited, 63% enrolled in the study and 89.7% remained enrolled in the study as measured by completing at least one assessment after baseline. Participants reported a positive experience with the messages, particularly supportive/empowering messages and commitment reminder messages.

CONCLUSIONS

These findings suggest that text messaging is a feasible and acceptable method for delivery of substance use-related reminder content as an adjunct to substance use intervention.

Engaging users in the design of an mHealth, text message-based intervention to increase physical activity at a safety-net health care system

OBJECTIVES

Text-messaging interventions are a promising approach to increasing physical activity in vulnerable populations. To better inform the development of a text-messaging intervention, we sought to identify barriers and facilitators to using text messaging and engaging in physical activity among patients with diabetes and comorbid depression.

MATERIALS AND METHODS

We conducted interviews with primary care patients at a safety-net health care system (N = 26). Data were collected at 3 stages, including a focus group (stage 1), and individual interviews (stage 2 and 3). Patients in stage 1 and 2 previously participated in a text-messaging intervention as part of depression treatment. Discussions focused on participant experience of previously using a text-messaging intervention, influences and perceptions of physical activity, and mobile phone use. We analyzed all transcripts for emerging themes.

RESULTS

Participants were 56.2 years (±9.7); 69.2% were female, 65.4% identified as Hispanic/Latino(a), and 46.2% reported having less than a high school education. All had depression and 61.5% had diabetes. Specific barriers that emerged included low literacy and only basic use of mobile phones in everyday life, in combination with a high prevalence of comorbid health conditions and limited mobility. These were each addressed with a specific content or intervention delivery change in the overall intervention design.

CONCLUSIONS

Conducting a focus group and individual interviews with end users of an mHealth intervention under development has implications for tailoring and modifying components of the content and format to ensure that the final intervention will engage end users most effectively.

Usefulness and utilization of treatment elements from the Transdiagnostic Sleep and Circadian Intervention for adolescents with an evening circadian preference

OBJECTIVE

Existing research has demonstrated that patient ratings of usefulness and ratings of utilization of treatment elements are associated with treatment outcome. Few studies have examined this relationship among adolescents and with an extended follow-up. This study examined the extent to which elements of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) were rated by youth as useful and utilized 6-months and 12-months after treatment.

METHOD

Participants were 64 adolescents with an evening circadian preference who were given TranS-C as a part of their participation in a NICHD-funded study. At 6-month and 12-month follow-up, they completed the Usefulness Scale, the Utilization Scale, a 7-day sleep diary assessing total sleep time (TST) and bedtime, and the Children's Morningness-Eveningness Preference Scale (CMEP).

RESULTS

On average, adolescents rated treatment elements as moderately useful and they utilized the treatment elements occasionally. Ratings of usefulness were associated with TST at 6-month follow-up, but not with bedtime or CMEP. Ratings of utilization were associated with a change in bedtime from 6-month to 12-month follow-up, but not with TST or CMEP. Ratings of usefulness and utilization were associated with selected treatment outcome measures at both follow-ups.

CONCLUSIONS

These findings have implications for understanding mechanisms of change following treatment.

Feasibility of an Interactive Patient Portal for Monitoring Physical Activity, Remote Symptom Reporting, and Patient Education in Oncology: Qualitative Study

Background

Digital health interventions, such as the use of patient portals, have been shown to offer benefits to a range of patients including those with a diagnosis of cancer.

Objective

This study aimed to explore the participant experience and perception of using an interactive Web-based portal for monitoring physical activity, remote symptom reporting, and delivering educational components.

Methods

Participants who were currently under treatment or had recently completed intensive treatment for cancer were recruited to three cohorts and invited to join a Web-based portal to enhance their physical activity. Cohort 1 received Web portal access and an activity monitor; cohort 2 had additional summative messaging; and cohort 3 had additional personalized health coaching messaging. Following the 10-week intervention, participants were invited to participate in a semistructured interview. Interview recordings were transcribed and evaluated using qualitative thematic analysis.

Results

A total of 17 semistructured interviews were carried out. Participants indicated that using the Web portal was feasible. Personalized messaging improved participant perceptions of the value of the intervention. There was a contrast between cohorts and levels of engagement with increasing health professional contact leading to an increase in engagement. Educational material needs to be tailored to the participants’ cancer treatment status, health literacy, and background.

Conclusions

Participants reported an overall positive experience using the Web portal and that personalized messaging positively impacted on their health behaviors. Future studies should focus more on design of interventions, ensuring appropriate tailoring of information and personalization of behavioral support messaging.

International Registered Report Identifier (IRRID)

RR2-10.2196/9586

A preliminary study on the acceptability of a brief SMS program for perinatal women

This study examined the acceptability of the BabyText program, a Spanish and English textmessaging program adapted from a prevention of postpartum depression group intervention. Ten ethnically and racially diverse pregnant and postpartum women (mean age = 31.3, standard deviation = 5.25) recruited from a metropolitan, urban area of the United States received the BabyText program over a 69-day period (between October 2015 and April 2016). Each tip was assessed for the helpfulness of the content, and all women were invited to provide qualitative feedback about the program. Eighteen of the tips received a positive endorsement of helpfulness from 75 to 100 percent of the women, 12 tips received a positive endorsement of helpfulness from 50 percent of the women, and one tip was rated negatively by those who responded. Qualitative feedback described the need to personalize the tips to reflect the characteristics of women such as planned/unplanned pregnancy status, available economic resources, and current psychological distress. Women in this study favored tips that described stress management skills and emphasized caring for the self (vs only the baby). Data from this study are preliminary but add to the growing sentiment that digital tools should continue to be developed and tested, and personalization of intervention content is important to users.

Assessing Mobile Phone Digital Literacy and Engagement in User-Centered Design in a Diverse, Safety-Net Population: Mixed Methods Study

Background

Health care systems are rapidly deploying digital tools for disease management; however, few studies have evaluated their usability by vulnerable populations. To understand the barriers to app usage among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app.

Objective

The study aimed to describe variations in patients’ engagement in the app design process, focusing on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL).

Methods

We conducted 20 in-depth semistructured interviews with primary care patients at a public health care system, used open-ended discussions and card sorting tasks to seek input about mobile phones and text messaging, and used open coding to categorize the patterns of mobile phone usage and to evaluate engagement in the card sorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content and calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy.

Results

The average age of the 20 participants was 59 (SD 8) years; 13 (65%) were female, 18 (90%) were nonwhite, 16 (80%) had LHL, and 13 (65%) had LEP. All had depression, and 14 (70%) had diabetes. Most participants had smartphones (18/20, 90%) and regularly used text messaging (15/20, 75%), but 14 (70%) of them reported having difficulty texting because of inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP, and all 10 had LHL. Half of the participants required a modification of the card sorting activity owing to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (4/13, 30% vs 5/7, 71%), limited versus adequate health literacy (7/16, 44% vs 3/4, 75%), and limited versus adequate digital literacy (4/10, 40% vs 6/10, 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (8/16, 50% vs 4/4, 100%); there were no statistical differences by any subgroup.

Conclusions

Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the card sorting activity varied among participants and appeared to be lower among those with LHL, LEP, and LDL. Researchers employing traditional UCD methods should routinely measure these communication domains among their end-user samples. Future work is needed to replicate our findings in larger samples, but augmentation of card sorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.

Using Participatory Design Methodologies to Co-Design and Culturally Adapt the Spanish Version of the Mental Health eClinic: Qualitative Study

Background

The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students.

Objective

We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype.

Methods

A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype.

Results

We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P<.001) and content (kappa=.92; P<.001) and substantial agreement for the user interface (kappa=.785; P<.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking.

Conclusions

Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries.

Exploratory Study of Psychosocial Therapies with Text Messages to Mobile Phones in Groups of Vulnerable Immigrant Women

Various experimental studies on psychosocial therapy have been carried out through text messages with groups of people suffering from depression, anxiety, alcoholism, addictions, etc., but without distinguishing between men and women or highly vulnerable groups such as immigrants. We present an exploratory study of a mobile communication system which intends to improve the mental, physical and social health of a group of vulnerable immigrant women in Spain (n = 71), distinguishing between an intervention group and a non-equivalent control group. We sent automatic text messages (SMS) to the mobile phones of an intervention group formed by immigrant women who used the social services (n = 44). During a 26-day intervention period, the women received 4 daily automatic text messages on their phones, at a predetermined time. We measured mood and depression symptoms at the beginning and end of the intervention, and analysed the qualitative data to determine the acceptance level of a remote message program. The mood and depression symptoms were measured with the personal health questionnaire-9 (PHQ-9) and were significantly better in the intervention group; they evolved from an initial 9.4 (DS = 6.4, range 1-25) to a 5.0 score at the end of the message period (DS = 4.8); with a significant difference (t (44) = 2.01, p = 7.80). Most women stated that the messages had improved their mood (86.3%), which made them feel more connected to their social environment (65.9%) and that they would like to continue receiving more messages (86.6%).

Effect of Mobile Health on In-person Service Use Among People With Serious Mental Illness

OBJECTIVE

This study examined whether mobile health (mHealth) affects the use of in-person services among people with serious mental illness.

METHODS

This randomized comparative effectiveness trial evaluated minutes of service use among 163 participants for 3 months before, during, and after exposure to mHealth or clinic-based care.

RESULTS

mHealth and clinic-based care participants used fewer services during the intervention (9% and 14%, respectively) and follow-up (2% and 12%) periods than during the preintervention phase. During treatment, mHealth treatment responders (participants who experienced recovery gains and maintained them at follow-up) reduced service use more than nonresponders (12% vs. 10%). Postintervention, service use by mHealth treatment responders continued to drop (an additional 11%), whereas service use by mHealth nonresponders increased by 8%.

CONCLUSIONS

mHealth and clinic-based illness management interventions may reduce the need for other in-person services among people with serious mental illness, particularly among mHealth users who experience sustained recovery.

Effects, Adherence, and Therapists' Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study

Background

Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients’ adherence to and therapists’ perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings.

Objective

This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format.

Methods

A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey.

Results

Primary symptom reduction was high (d=1.31 to 1.51) and remained stable for the follow-up period. Therapists identified advantages (eg, patient engagement, treatment intensification, and improved therapeutic relation) and disadvantages (eg, increased workload, data issues, and undesired effects) of bGT. The required online guidance time was 10.3 min per patient and week, including guidance on exercises (67% or 6.9 min) and intimate communication (33% or 3.4 min). Concerning patients’ adherence to bGT, tracked completion of all Web-based and mobile tasks was high and comparable with group attendance.

Conclusions

Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions.