Smartphone Applications Utilizing Biofeedback Can Aid Stress Reduction

Derailment is associated with increased depressed mood at lower levels of stress: An experimental approach

BACKGROUND

As an emergent developmental construct, derailment - an individual difference hallmarked by a temporal discordance of the self - has been positively associated with depressive features, though less is known about the role of stress in this relationship. The aim of the present study was to explore the interaction between derailment and subjective stress on depressed mood.

METHODS

265 adults recruited through Prolific - a crowd sourcing platform were first tasked with completing baseline measures, then were randomly assigned to a low stress or high stress condition. We utilized an adapted version of the Online Trier Stress Test to manipulate stress levels. Next, depressed mood and post-test perceived stress were measured. We analyzed data through STATA using a two-tailed independent samples t-test and multiple linear regression.

RESULTS

Findings suggested the experimental manipulation increased subjective stress within the high stress condition compared to the low stress condition (Mdiff = 36.14, SE = 4.4, t = 8.21, p < .001). Further, we found the interaction between derailment and stress conditions was associated with increased depressed mood (β = -0.11, SE = 0.05, p = .038, R2 = 0.5). Notably, we found significant between-condition differences in depressed mood for those who endorsed either low (d = 0.22, SE = 0.07, p = .003) or moderate levels of derailment (d = 0.11, SE = 0.05, p = .033), but not for those who endorsed high levels of derailment (d = 0.01, SE = 0.07, p = .92).

LIMITATIONS

This study utilized self-report measures, which may be susceptible to biased responses.

CONCLUSIONS

Derailment may play a role in the persistence of depressed mood regardless of varying contexts of stress.

Effect of stress-based interventions on the quality of life of people with an intellectual disability and their caregivers

PURPOSE

People with intellectual disabilities often show challenging behaviour, which can manifest itself in self-harm or aggression towards others. Real-time monitoring of stress in clients with challenging behaviour can help caregivers to promptly deploy interventions to prevent escalations, ultimately to improve the quality of life of client and caregiver. This study aimed to assess the impact of real-time stress monitoring with HUME, and the subsequent interventions deployed by the care team, on stress levels and quality of life.

MATERIALS AND METHODS

Real-time stress monitoring was used in 41 clients with intellectual disabilities in a long-term care setting over a period of six months. Stress levels were determined at the start and during the deployment of the stress monitoring system. The quality of life of the client and caregiver was measured with the Outcome Rating Scale at the start and at three months of use.

RESULTS

The results showed that the HUME-based interventions resulted in a stress reduction. The perceived quality of life was higher after three months for both the clients and caregivers. Furthermore, interventions to provide proximity were found to be most effective in reducing stress and increasing the client's quality of life.

CONCLUSIONS

The study demonstrates that real-time stress monitoring with the HUME and the following interventions were effective. There was less stress in clients with an intellectual disability and an increase in the perceived quality of life. Future larger and randomized controlled studies are needed to confirm these findings.

Use of a Mobile Biofeedback Application to Provide Health Coaching for Stress Self-Management: Findings from a Pilot Quasi-Experiment

BACKGROUND

Mental health is an increasing concern among vulnerable populations, including college students and veterans.

OBJECTIVE

The purpose of this study was to determine if mobile Health (mHealth) technology combined with health coaching can better enable user to self-manage their mental health.

METHODS

This study evaluated a mobile Biofeedback app that provided health coaching on stress self-management for college student veterans' mental health concerns. Twenty-four college student veterans were recruited from a large public university in Texas during the spring 2020 semester, impacted by COVID-19. Ten participants were assigned to the intervention group where they used the mobile Biofeedback app on their smartphones and smartwatches, and 14 were assigned to the control group without the app; assignment was based on mobile phone compatibility. Both groups participated in one initial lab session where they learned a deep breathing exercise technique. The intervention group was then asked to use the mobile Biofeedback app during their daily lives using the Biofeedback app and smartwatch, and the control group was asked to perform the breathing exercises on their own. Both groups filled out Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) self-assessments at two-week intervals. At the end of the semester, both groups were given an exit interview to provide user experience and perceived benefits of health coaching via the mobile Biofeedback app.

RESULTS

Deep breathing exercise in the initial lab session reduced stress in both groups. Over the course of the study, the app recorded 565 coached breathing exercises with a significant decrease (approximately 3 beats per minute) in participants' heart rate during the 6-minute time period immediately after conducting the breathing exercises [Spearman's rank correlation coefficient of -0.61 (P<.001 and S=9,816,176)]. There was no significant difference between the two groups for PHQ-9 and GAD-7 scores over the course of the semester. Exit interview responses indicate that participants perceived that the mobile Biofeedback app improved their health and helped them address stress challenges. All participants reported that the intervention helped them manage their stress better and expressed that health coaching via a mobile device would improve their overall health.

CONCLUSIONS

Participants reported a positive perception of the app for their mental health self-management during a stressful semester. Future work should examine long-term effects of the app with a larger sample size balanced between male and female participants, randomized participant allocation, real-time detection of mental health symptoms, and additional features of the app.

CLINICALTRIAL

Wearable devices for anxiety & depression: A scoping review

Background

The rates of mental health disorders such as anxiety and depression are at an all-time high especially since the onset of COVID-19, and the need for readily available digital health care solutions has never been greater. Wearable devices have increasingly incorporated sensors that were previously reserved for hospital settings. The availability of wearable device features that address anxiety and depression is still in its infancy, but consumers will soon have the potential to self-monitor moods and behaviors using everyday commercially-available devices.

Objective

This study aims to explore the features of wearable devices that can be used for monitoring anxiety and depression.

Methods

Six bibliographic databases, including MEDLINE, EMBASE, PsycINFO, IEEE Xplore, ACM Digital Library, and Google Scholar were used as search engines for this review. Two independent reviewers performed study selection and data extraction, while two other reviewers justified the cross-checking of extracted data. A narrative approach for synthesizing the data was utilized.

Results

From 2408 initial results, 58 studies were assessed and highlighted according to our inclusion criteria. Wrist-worn devices were identified in the bulk of our studies (n = 42 or 71%). For the identification of anxiety and depression, we reported 26 methods for assessing mood, with the State-Trait Anxiety Inventory being the joint most common along with the Diagnostic and Statistical Manual of Mental Disorders (n = 8 or 14%). Finally, n = 26 or 46% of studies highlighted the smartphone as a wearable device host device.

Conclusion

The emergence of affordable, consumer-grade biosensors offers the potential for new approaches to support mental health therapies for illnesses such as anxiety and depression. We believe that purposefully-designed wearable devices that combine the expertise of technologists and clinical experts can play a key role in self-care monitoring and diagnosis.

Correction of Stress-Induced States Using Sensory Stimulation Automatically Modulated by Endogenous Human Rhythms

This article considers the dynamics of the development of a potential approach to correcting stress-induced states in humans, i.e., adaptive neurostimulation. The approach consists of presenting sensory stimulation automatically modulated by intrinsic rhythmic human processes such as the respiratory rhythm, the heartbeat rhythm, and electroencephalograph (EEG) rhythms. Many examples have shown that real-time self-adjustment of the stimulation parameters by these rhythms leads to a high level personalization of therapeutic stimulation and increases in its efficacy in suppressing stress-induced states. The publications reviewed here point to the advantages of this approach for developing innovatory technologies using complex feedback from endogenous human rhythms to correct a wide spectrum of functional disorders.

Evaluation of a tactile breath pacer for sleep problems: A mixed method pilot study

Sleep problems, like insomnia, are a prevalent condition associated with major health risks. Prevention and treatment of sleep problems are thus essential to preserve physical and mental health. Previous work supports the effectiveness of breathing guidance for sleep problems and recommends breathing exercises as an effective intervention for insomnia. While new technologies can support breathing guidance, such novel devices should be assessed for effectiveness and usability to facilitate implementation and continued use. The current pilot study investigates the acceptability and usability of a mobile tactile breathing device and explores its potential impact on subjective sleep quality. In this mixed-method pilot study, 39 participants tested the breathing device for one month in naturalistic circumstances. We collected their experiences, subjective sleep quality, and feedback regarding the usability of the device and the accompanying app through a survey in a pre-post design. The results show that the breathing device is an acceptable solution for sleep problems and participants particularly appreciate the standalone function and design. Nevertheless, important points of attention, such as the size of the device, were also identified. Explorative analyses suggest that subjective sleep quality improved after using the device and accompanying app. The current study supports the usability and acceptability of a tactile breath pacer and provides preliminary evidence supporting a positive impact of the technology on the sleep quality of participants. Recommendations for developers of breathing technologies and eHealth are devised based on the findings.

Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report

Background

Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD.

Objective

The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game—e-Estesia—whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease.

Methods

After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity.

Results

After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased.

Conclusions

The combined intervention—CBT and a serious game—showed positive results in terms of treatment outcomes.

The Effects of a 3-Week Heartbeat Perception Training on Interoceptive Abilities

Recent studies showed promising short-term effects of heartbeat perception training on interoceptive abilities. Research on the effects of heartbeat perception training on interoceptive abilities over time is sparse. Therefore, the aim of this study was to examine the short-term effects and the effects of a 3-week heartbeat perception training over time on interoceptive abilities, namely, cardiac interoceptive accuracy (IAc) and interoceptive sensibility (IS). A total of 40 healthy participants were randomized to the intervention group (n = 20) or the control group (n = 20). The intervention group conducted three cardiac biofeedback sessions (one per week) at the laboratory, whereas the control group watched a documentary instead. Interoceptive abilities were assessed via the heartbeat perception task (IAc) and confidence ratings (IS) at baseline, after each laboratory session, and 1 week after the last session (post-measurement). IAc was significantly increased in the intervention group compared to the control group after the first training session (short-term effect). There were no significant improvements in IS due to the first session, and neither on IAc nor IS over time. Descriptive trends of improved interoceptive abilities over time were found in both groups. Single session of heartbeat perception training seems to be a promising approach to improve IAc. Future research should further investigate the long-term effects of diverse heartbeat perception training varying in frequency and intensity of the training sessions in diverse samples aiming to improve interoceptive abilities.

A Systematic and Comparative Review of Behavior Change Strategies in Stress Management Apps: Opportunities for Improvement

Stress is one of the significant triggers of several physiological and psychological illnesses. Mobile health apps have been used to deliver various stress management interventions and coping strategies over the years. However, little work exists on persuasive strategies employed in stress management apps to promote behavior change. To address this gap, we review 150 stress management apps on both Google Play and Apple's App Store in three stages. First, we deconstruct and compare the persuasive/behavior change strategies operationalized in the apps using the Persuasive Systems Design (PSD) framework and Cialdini's Principles of Persuasion. Our results show that the most frequently employed strategies are personalization, followed by self-monitoring, and trustworthiness, while social support strategies such as competition, cooperation and social comparison are the least employed. Second, we compare our findings within the stress management domain with those from other mental health domains to uncover further insights. Finally, we reflect on our findings and offer eight design recommendations to improve the effectiveness of stress management apps and foster future research.

Efficacy of Using Retro Games in Multimodal Biofeedback System for Mental Relaxation

Video games are used to increase the engagement of biofeedback systems. For cost-effectiveness, the original Nintendo Entertainment System (NES) games can be used. Therefore, a multimodal biofeedback system was developed to leverage the NES games for biofeedback. This study aims to test the efficacy of the developed system, the motivation of participants, and the usability of the system. A within-group design study was conducted with 16 participants followed through four interventions: deep breathing, stress-test, non-biofeedback game (control), and biofeedback game (experiment), where their HRV was recorded. Participants showed significantly different HRV during interventions (F(1.60, 23.93) = 11.94, p &lt; 0.001) and reported higher HRV when using biofeedback game than the non-biofeedback game (t(15) = 9.14, p &lt; 0.0001). The motivation was reported to be the same with biofeedback and non-biofeedback version of the game and the overall system was reported as usable. The results of this study support the efficacy of using original NES games in biofeedback for mental relaxation.

Efficacy of bio- and neurofeedback for depression: a meta-analysis

BACKGROUND

For many years, biofeedback and neurofeedback have been implemented in the treatment of depression. However, the effectiveness of these techniques on depressive symptomatology is still controversial. Hence, we conducted a meta-analysis of studies extracted from PubMed, Scopus, Web of Science and Embase.

METHODS

Two different strings were considered for each of the two objectives of the study: A first group comprising studies patients with major depressive disorder (MDD) and a second group including studies targeting depressive symptomatology reduction in other mental or medical conditions.

RESULTS

In the first group of studies including patients with MDD, the within-group analyses yielded an effect size of Hedges' g = 0.717, while the between-group analysis an effect size of Hedges' g = 1.050. Moderator analyses indicate that treatment efficacy is only significant when accounting for experimental design, in favor of randomized controlled trials (RCTs) in comparison to non RCTs, whereas the type of neurofeedback, trial design, year of publication, number of sessions, age, sex and quality of study did not influence treatment efficacy. In the second group of studies, a small but significant effect between groups was found (Hedges' g = 0.303) in favor of bio- and neurofeedback against control groups. Moderator analyses revealed that treatment efficacy was not moderated by any of the sociodemographic and clinical variables.

CONCLUSIONS

Heart rate variability (HRV) biofeedback and neurofeedback are associated with a reduction in self-reported depression. Despite the fact that the field has still a large room for improvement in terms of research quality, the results presented in this study suggests that both modalities may become relevant complementary strategies for the treatment of MDD and depressive symptomatology in the coming years.

Effects of Virtual Reality-Based Relaxation Techniques on Psychological, Physiological, and Biochemical Stress Indicators

Various relaxation techniques could benefit from merging with virtual reality (VR) technologies, as these technologies are easily applicable, involving, and user-friendly. To date, it is unclear which relaxation technique using biofeedback combined with VR technology is the most effective. The study aimed to compare the effectiveness of brief VR-based biofeedback-assisted relaxation techniques including electroencephalographic biofeedback, mindfulness-based biofeedback, galvanic skin response biofeedback, and respiratory biofeedback. Forty-three healthy volunteers (age 34.7 ± 7.2 years), comprising 28 (65%) women and 15 (35%) men, were enrolled in the study. All the participants were exposed to four distinct relaxation sessions according to a computer-generated random sequence. The efficacy of relaxation methods was evaluated by examining psychological, physiological, and biochemical stress indicators. All VR-based relaxation techniques reduced salivary steroid hormone (i.e., cortisol, cortisone, and total glucocorticoid) levels and increased galvanic skin response values. Similarly, all interventions led to a significantly reduced subjectively perceived psychological strain level. Three out of the four interventions (i.e., electroencephalographic, respiratory, and galvanic skin response-based biofeedback relaxation sessions) resulted in a decreased self-reported fatigue level. We suggest that newly developed VR-based relaxations techniques are potential tools for stress reduction and might be particularly suitable for individuals who are not capable of adhering to a strict and time-consuming stress management intervention schedule.

Features of wearable devices used for Anxiety & Depression: A scoping review (Preprint).. [DOI: 10.2196/preprints.33287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The rates of mental health disorders such as anxiety and depression are at an all time high and the need for readily available digital health care solutions has never been greater. Wearable devices (WD) have seen a steady rise in the usage of sensors previously reserved for hospital settings. The availibity of features that make use of WDs for anxiety and depression is in its infancy, but we are seeing the potential for consumers to self monitor moods and behaviours with everyday commercially available devices and the ability to self-regulate their health needs.

OBJECTIVE

This study aims to explore features of wearable devices (WDs) used for anxiety and depression

METHODS

We have searched the following six bibliographic databases while conducting this review: MEDLINE, EMBASE, PsycINFO, IEEE Xplore, ACM Digital Library, and Google Scholar. Two reviewers independently performed study selection and data extraction; two other individual reviewers justified cross-checking of extracted data. We utilized a narrative approach for synthesizing the data.

RESULTS

From an initial 2,408 studies we assess and report the features in 58 studies that were highlighted according to our inclusion criteria. Wrist worn devices were identified in the bulk of our studies (n=42 or 71%). Depression was assessed in most of the studies (n=27 or 47%), whereas anxiety was assessed in n=15 or 25% of studies. More than a quarter (n=16 or 27%) of the included studies assessed both mental disorders. Finally n=26 or 46% of studies highlighted the wearable device host device as a smartphone.

CONCLUSIONS

The emergence of affordable, consumer-grade biosensors offers the potential for new approaches to support mental health therapies such as anxiety and depression. We see WDs having real potential in aiding with self-care and with purposefully designed WDs that combine the expertise of technologists and clinical experts WDs could play a key role in self-care monitoring and diagnosis.

Combining proactive transcranial stimulation and cardiac biofeedback to substantially manage harmful stress effects

BACKGROUND

Previous studies have identified the dorsolateral prefrontal cortex (dlPFC) as a core region in cognitive emotional regulation. Transcranial direct current stimulations of the dlPFC (tDCS) and heart-rate variability biofeedback (BFB) are known to regulate emotional processes. However, the effect of these interventions applied either alone or concomitantly during an anticipatory stress remains unexplored.

OBJECTIVE

The study investigated the effect of anodal tDCS and BFB, alone or combined, on psychophysiological stress responses and cognitive functioning.

METHODS

Following a stress anticipation induction, 80 participants were randomized into four groups and subjected to a 15-min intervention: neutral video viewing (ctrl), left dlPFC anodal tDCS (tdcs), heart-rate variability biofeedback (bfb), or a combined treatment (bfb + tdcs). Participants were then immediately confronted with the stressor, which was followed by an assessment of executive functions. Psychophysiological stress responses were assessed throughout the experiment (heart rate, heart-rate variability, salivary cortisol).

RESULTS

The tdcs did not modulate stress responses. Compared with both ctrl and tdcs interventions, bfb reduced physiological stress and improved executive functions after the stressor. The main finding revealed that bfb + tdcs was the most effective intervention, yielding greater reduction in psychological and physiological stress responses than bfb.

CONCLUSIONS

Combining preventive tDCS with BFB is a relevant interventional approach to reduce psychophysiological stress responses, hence offering a new and non-invasive treatment of stress-related disorders. Biofeedback may be particularly useful for preparing for an important stressful event when performance is decisive.

A Relaxation App (HeartBot) for Stress and Emotional Well-Being Over a 21-Day Challenge: Randomized Survey Study

BACKGROUND

HeartBot is an app designed to enable people 14 years and older to use relaxation tools offered by Heartfulness Institute to deal with daily stress and anxiety in a healthy, productive manner. These tools have proven effective in stress management and mental wellness when administered in a controlled environment by a certified proctor.

OBJECTIVE

This study aimed to explore the app's effectiveness and evaluate the implementation of the tools.

METHODS

In this study, 88 participants were recruited and randomly sorted into 2 groups, the HeartBot intervention group (n=46) and the waitlist control group (n=42). Pre- and postsurveys measured participants' stress levels using the Perceived Stress Scale (PSS) and their social-emotional well-being using the EPOCH (Engagement, Perseverance, Optimism, Connectedness, and Happiness) Measure of Adolescent Well-Being before and after they used the app for 21 days for 30 minutes every day.

RESULTS

The study received institutional review board approval on August 18, 2019. Participant recruitment lasted from the approval date until September 30, 2019. The 21-day challenge started on October 1, 2019. Of the 135 people who signed up, 88 completed the study. There was a statistically significant difference in the mean PSS scores before and after the intervention (from 18.3 to 7.89; P<.001). The paired Wilcoxon rank sum test on the EPOCH scores indicated a significant difference in the medians of the total scores (W=411.5, P<.001).

CONCLUSIONS

Evidence from this study shows that HeartBot is an effective app that can be used to manage stress and improve positive characteristics of emotional wellness. Future research and widespread usage of the app under this study are encouraged based on this preliminary evidence of its effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04589520; https://clinicaltrials.gov/ct2/show/NCT04589520.

Digital Gaming Interventions in Psychiatry: Evidence, Applications and Challenges

Human evolution has regularly intersected with technology. Digitalization of various services has brought a paradigm shift in consumerism. Treading this path, mental health practice has gradually moved to Digital Mental Health Interventions (DMHI), to improve service access and delivery. Applied games are one such innovation that has gained recent popularity in psychiatry. Based on the principles of gamification, they target psychosocial and cognitive domains, according to the deficits in various psychiatric disorders. They have been used to deliver cognitive behaviour therapy, cognitive training and rehabilitation, behavioural modification, social motivation, attention enhancement, and biofeedback. Research shows their utility in ADHD, autistic spectrum disorders, eating disorders, post-traumatic stress, impulse control disorders, depression, schizophrenia, dementia, and even healthy aging. Virtual reality and artificial intelligence have been used in conjunction with gaming interventions to improvise their scope. Even though these interventions hold promise in engagement, ease of use, reduction of stigma, and bridging the mental-health gap, there are pragmatic challenges, especially in developing countries. These include network quality, infrastructure, feasibility, socio-cultural adaptability, and potential for abuse. Keeping this in the background, this review summarizes the scope, promise, and evidence of digital gaming in psychiatric practice, and highlights the potential caveats in their implementation.

App-Based Delivery of Clinical Emotional Freedom Techniques: Cross-Sectional Study of App User Self-Ratings

BACKGROUND

The burgeoning area of mobile health (mHealth) has experienced rapid growth in mobile apps designed to address mental health issues. Although abundant apps offer strategies for managing symptoms of anxiety and stress, information regarding their efficacy is scarce.

OBJECTIVE

This study aimed to assess the effect of an mHealth app on user self-ratings of psychological distress in a sample of 270,461 app users. The Tapping Solution App guides users through the therapeutic protocols of Clinical Emotional Freedom Techniques (EFT), an evidence-based psychophysiological intervention that combines acupressure with elements of cognitive and exposure therapies.

METHODS

App users provided self-ratings of emotional intensity before and after app sessions (termed "tapping meditations") using an 11-point Subjective Units of Distress scale. App user data for 23 tapping meditations, which addressed psychological symptoms of anxiety and stress, were gathered between October 2018 and October 2019, totaling 380,034 completed app sessions.

RESULTS

Across 12 anxiety-tapping meditations, the difference in emotional intensity ratings from presession (mean 6.66, SD 0.25) to postsession (mean 3.75, SD 0.30) was statistically significant (P<.001; 95% CI -2.92 to -2.91). Across 11 stress-tapping meditations, a statistically significant difference was also found from presession (mean 6.91, SD 0.48) to postsession (mean 3.83, SD 0.54; P<.001; 95% CI -3.08 to -3.07). The results are consistent with the literature on the efficacy of Clinical EFT for anxiety and stress when offered in conventional therapeutic formats.

CONCLUSIONS

The findings provide preliminary support for the effectiveness of the mHealth app in the immediate reduction of self-rated psychological distress. As an adjunct to professional mental health care, the app promises accessible and convenient therapeutic benefits.

Combining Biofeedback with Stress Management Interventions: A Systematic Review of Physiological and Psychological Effects

Current mental healthcare systems experience difficulties meeting the challenges of a growing population with elevated stress symptoms. Outpatient stress management interventions have already proven to be effective in routine care and recent technological advances now allow to expand such interventions, for example by adding a physiological component like biofeedback. Adding biofeedback to stress management interventions appears promising, but there is a lack of insight into the general conceptualization and evaluation of the resulting interventions, both in relation to psychological and physiological stress indicators. A comprehensive literature search was performed to investigate stress management interventions with a biofeedback component. This systematic review provides an overview of these interventions and explores to what extent they can improve both physiological and psychological indicators of stress. Fourteen RCTs were included. A large diversity was observed in intervention design and effectiveness. Nevertheless, there is preliminary evidence that the use of biofeedback can improve both physiological and psychological indicators of stress. Biofeedback could provide an accessible and low-cost addition to stress interventions. Further research into the effectiveness of different components of biofeedback interventions is needed.

Clinical or gimmickal: The use and effectiveness of mobile mental health apps for treating anxiety and depression

OBJECTIVES

The increase in ownership of smartphones and tablet devices has seen a worldwide government push, championed by the World Health Organization, towards digital healthcare services generally. Mental health has been a strong presence in the digitisation of healthcare because of the potential to solve some of the difficulties in accessing face-to-face services. This review summarises the recent history of e-mental health services and illuminates two very different paths. The first is the considerable amount of research that has proven the effectiveness of many online mental health programmes for personal computers and laptops, resulting in widespread acceptance of their ability to make a contribution in an individual's recovery from anxiety and depression. The second is associated with the more recent development of apps for smartphones and tablet devices and the contrasting paucity of research that has accompanied this burgeoning area of e-mental health. This review also outlines the current state of play for research into the effectiveness of mobile mental health apps for anxiety and depression, including issues associated with methodology, and offers sources of practical advice for clinicians wanting more information about these new digital tools.

CONCLUSION

Research into the effectiveness of mental health apps is lacking, and the majority have no evidence of efficacy. Clinicians need to be aware of what apps have such evidence and should exercise caution when recommending apps to patients. Suggestions are offered on the direction of future research, including an appeal to further include clinicians in the development and efficacy testing of mental health apps.

Effect of Brief Biofeedback via a Smartphone App on Stress Recovery: Randomized Experimental Study

Background

Smartphones are often vilified for negatively influencing well-being and contributing to stress. However, these devices may, in fact, be useful in times of stress and, in particular, aid in stress recovery. Mobile apps that deliver evidence-based techniques for stress reduction, such as heart rate variability biofeedback (HRVB) training, hold promise as convenient, accessible, and effective stress-reducing tools. Numerous mobile health apps that may potentially aid in stress recovery are available, but very few have demonstrated that they can influence health-related physiological stress parameters (eg, salivary biomarkers of stress). The ability to recover swiftly from stress and reduce physiological arousal is particularly important for long-term health, and thus, it is imperative that evidence is provided to demonstrate the effectiveness of stress-reducing mobile health apps in this context.

Objective

The purpose of this research was to investigate the physiological and psychological effects of using a smartphone app for HRVB training following a stressful experience. The efficacy of the gamified Breather component of the Happify mobile health app was examined in an experimental setting.

Methods

In this study, participants (N=140) underwent a laboratory stressor and were randomly assigned to recover in one of three ways: with no phone present, with a phone present, with the HRBV game. Those in the no phone condition had no access to their phone. Those in the phone present condition had their phone but did not use it. Those in the HRVB game condition used the serious game Breather on the Happify app. Stress recovery was assessed via repeated measures of salivary alpha amylase, cortisol, and self-reported acute stress (on a 1-100 scale).

Results

Participants in the HRVB game condition had significantly lower levels of salivary alpha amylase during recovery than participants in the other conditions (F_2,133=3.78, P=.03). There were no significant differences among the conditions during recovery for salivary cortisol levels or self-reported stress.

Conclusions

These results show that engaging in a brief HRVB training session on a smartphone reduces levels of salivary alpha amylase following a stressful experience, providing preliminary evidence for the effectiveness of Breather in improving physiological stress recovery. Given the known ties between stress recovery and future well-being, this study provides a possible mechanism by which gamified biofeedback apps may lead to better health.

A Biofeedback App to Instruct Abdominal Breathing (Breathing-Mentor): Pilot Experiment

BACKGROUND

Deep and slow abdominal breathing is an important skill for the management of stress and pain. However, despite multiple proofs on the effectiveness of biofeedback, most breathing apps remain limited to pacing specific breathing patterns, without sensor feedback on the actual breathing behavior.

OBJECTIVE

To fill this gap, an app named Breathing-Mentor was developed. This app combines effective visualization of the instruction with biofeedback on deep abdominal breathing, based on the mobile phone's accelerometers. The aim of this pilot study was to investigate users' feedback and breathing behavior during initial contact with the app.

METHODS

To reveal the possible effects of biofeedback, two versions of the mobile app were developed. Both contained the same visual instruction, but only the full version included additional biofeedback. In total, 40 untrained participants were randomly assigned to one of the two versions of the app. They had to follow the app's instructions as closely as possible for 5 min.

RESULTS

The group with additional biofeedback showed an increased signal-to-noise ratio for instructed breathing frequency (0.1 Hz) compared with those using visual instruction without biofeedback (F1,37=4.18; P<.048). During this initial contact with the full version, self-reported relaxation effectivity was, however, lower than the group using visual instruction without biofeedback (t37=-2.36; P=.02), probably owing to increased cognitive workload to follow the instruction.

CONCLUSIONS

This study supports the feasibility and usefulness of incorporating biofeedback in the Breathing-Mentor app to train abdominal breathing. Immediate effects on relaxation levels should, however, not be expected for untrained users.

Specialized Smartphone Intervention Apps: Review of 2014 to 2018 NIH Funded Grants

Background

The widespread adoption of smartphones provides researchers with expanded opportunities for developing, testing and implementing interventions. National Institutes of Health (NIH) funds competitive, investigator-initiated grant applications. Funded grants represent the state of the science and therefore are expected to anticipate the progression of research in the near future.

Objective

The objective of this paper is to provide an analysis of the kinds of smartphone-based intervention apps funded in NIH research grants during the five-year period between 2014 and 2018.

Methods

We queried NIH Reporter to identify candidate funded grants that addressed mHealth and the use of smartphones. From 1524 potential grants, we identified 397 that met the requisites of including an intervention app. Each grant’s abstract was analyzed to understand the focus of intervention. The year of funding, type of activity (eg, R01, R34, and so on) and funding were noted.

Results

We identified 13 categories of strategies employed in funded smartphone intervention apps. Most grants included either one (35.0%) or two (39.0%) intervention approaches. These included artificial intelligence (57 apps), bionic adaptation (33 apps), cognitive and behavioral therapies (68 apps), contingency management (24 apps), education and information (85 apps), enhanced motivation (50 apps), facilitating, reminding and referring (60 apps), gaming and gamification (52 apps), mindfulness training (18 apps), monitoring and feedback (192 apps), norm setting (7 apps), skills training (85 apps) and social support and social networking (59 apps). The most frequently observed grant types included Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) grants (40.8%) and Research Project Grants (R01s) (26.2%). The number of grants funded increased through the five-year period from 60 in 2014 to 112 in 2018.

Conclusions

Smartphone intervention apps are increasingly competitive for NIH funding. They reflect a wide diversity of approaches that have significant potential for use in applied settings.

New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation

In the last decades, emotion regulation (ER) received increasing attention and became one of the most studied topics within the psychological field. Nevertheless, this construct has not been fully updated with the latest technological advancements. In this perspective, we will show how diverse technologies, such as virtual reality (VR), wearable biosensors, smartphones, or biofeedback techniques, can be applied to the understanding, assessment, and intervention of ER. After providing a brief overview of the currently available technological developments, we will discuss the benefits of incorporating new technologies in ER field, including ecological validity, intervention personalization, and the integration of understudied facets of ER, such as the implicit and interpersonal dimension.

Effects of a cardiorespiratory synchronization training mobile application on heart rate variability and electroencephalography in healthy adults

Cardiorespiratory synchronization training (CRST) uses diaphragmatic breathing to increase balance in the autonomic nervous system and reduce negative emotions. CRST integrated with high-technology mobile applications affords innovative and convenient home-based training. This study examined the effects of a CRST mobile application on heart rate variability (HRV) and electroencephalography (EEG) parameters in healthy adults. Ninety-six participants were randomly assigned to the CRST, relaxation training (RT; active control group), and control (C) groups. The CRST group received paced breathing training using a wearable device connected to a mobile application and received feedback on the HRV indices. The RT group received muscle relaxation training using a wearable device connected to a mobile application and received feedback on heart rate (HR). The training program was conducted for 1 h per week for 4 weeks. The C group did not receive any wearable device, mobile application, or psychological intervention. Psychological questionnaires on depression and anxiety and physiological measurements of the breathing rates, electrocardiography (ECG), and EEG were measured at the pretest and posttest. The CRST group showed significantly higher HRV indices and lower breathing rates at the posttest than the RT and C groups. There were no significant interaction effects on EEG parameters at pretest and posttest among the three groups. Use of a CRST mobile application increased balance in the autonomic nervous system at the resting state. This clinical evidence-based technologically advanced mobile application could be implemented in future clinical practice.

Digital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the efficacy, limitations, and future of e-health treatments for anxiety. Within this, we provide detail on "first-generation" e-health approaches, such as computerized therapies. Additionally, we assess the emergence and early efficacy of newer methods of treatment delivery, including smartphone apps and virtual reality interventions, discussing the potential and pitfalls for each.

RECENT FINDINGS

There is now substantial clinical research demonstrating the efficacy of internet-delivered cognitive behavioral therapy in the treatment of anxiety. However, the ability of these interventions for engaging patients in "real-world" settings is unclear. Recently, smartphone apps for anxiety have presented a more popular and ubiquitous method of intervention delivery, although the evidence base supporting these newer approaches drastically falls behind the extensive marketing and commercialization efforts currently driving their development. Meanwhile, the increasing availability of novel technologies, such as "virtual reality" (VR), introduces further potential of e-health treatments for generalized anxiety and anxiety-related disorders such as phobias and obsessive compulsive disorder, while also creating additional challenges for research. Although still in its infancy, e-health research is already presenting several promising avenues for delivering effective and scalable treatments for anxiety. Nonetheless, several important steps must be taken in order for academic research to keep pace with continued technological advances.

State of the Art on the Use of Portable Digital Devices to Assess Stress in Humans

The aim of this study is to review the current tools for the assessment of stress response in humans, ranging from the use of psychological questionnaires to the latest tools involving portable digital devices. Practical implications in educational context are further discussed.

Mitigation of stress: new treatment alternatives

Complaints of stress are common in modern life. Psychological stress is a major cause of lifestyle-related issues, contributing to poor quality of life. Chronic stress impedes brain function, causing impairment of many executive functions, including working memory, decision making and attentional control. The current study sought to describe newly developed stress mitigation techniques, and their influence on autonomic and endocrine functions. The literature search revealed that the most frequently studied technique for stress mitigation was biofeedback (BFB). However, evidence suggests that neurofeedback (NFB) and noninvasive brain stimulation (NIBS) could potentially provide appropriate approaches. We found that recent studies of BFB methods have typically used measures of heart rate variability, respiration and skin conductance. In contrast, studies of NFB methods have typically utilized neurocomputation techniques employing electroencephalography, functional magnetic resonance imaging and near infrared spectroscopy. NIBS studies have typically utilized transcranial direct current stimulation methods. Mitigation of stress is a challenging but important research target for improving quality of life.

Self-tracking for Mental Wellness: Understanding Expert Perspectives and Student Experiences

Previous research suggests an important role for self-tracking in promoting mental wellness. Recent studies with college student populations have examined the feasibility of collecting everyday mood, activity, and social data. However, these studies do not account for students' experiences and challenges adopting self-tracking technologies to support mental wellness goals. We present two studies conducted to better understand self-tracking for stress management and mental wellness in student populations. First, focus groups and card sorting activities with 14 student health professionals reveal expert perspectives on the usefulness of tracking for three scenarios. Second, an online survey of 297 students examines personal experiences with self-tracking and attitudes toward sharing self-tracked data with others. We draw on findings from these studies to characterize students' motivations, challenges, and preferences in collecting and viewing self-tracked data related to mental wellness, and we compare findings between students with diagnosed mental illnesses and those without. We conclude with a discussion of challenges and opportunities in leveraging self-tracking for mental wellness, highlighting several design considerations.