Efficacy and Moderation of Mobile App-Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on Mental Health: Randomized Controlled Noninferiority Trial

E-mental health mindfulness-based and skills-based 'CoPE It' intervention to reduce psychological distress in times of COVID-19: study protocol for a bicentre longitudinal study

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic poses immense challenges for national and international healthcare systems. Especially in times of social isolation and governmental restrictions, mental health should not be neglected. Innovative approaches are required to support psychologically burdened people. The e-mental health intervention 'CoPE It' has been developed to offer manualised and evidence-based psychotherapeutic support adapted to COVID-19-related issues in order to overcome psychological distress. In our study, we aim to assess the efficacy of the e-mental health intervention 'CoPE It' in terms of reducing distress (primary outcome), depression and anxiety symptoms as well as improving self-efficacy, quality of life and mindfulness (secondary outcomes). Furthermore, we want to evaluate the programme's usability, feasibility and participants' satisfaction with 'CoPE It' (tertiary outcome).

METHODS AND ANALYSIS

The e-mental health intervention 'CoPE It' consists of four 30 min modules, conducted every other day, involving psychotherapeutic techniques of mindfulness-based stress reduction and cognitive-behavioural therapy. The widely applied and previously established content has been adapted to the context of the COVID-19 pandemic by experts in psychosomatic medicine and stress prevention. In our longitudinal study, adult participants-with adequate German language and computer skills, and who have provided informed consent-will be recruited via emergency support hotlines in Germany. Flyers will be distributed, and online channels will be used. Participants will complete a baseline assessment (T0), a postintervention assessment (T1) and assessments 1 and 3 months later (T2 and T3, respectively). We will perform repeated measures analysis of covariance, mixed linear models, standard analyses of variance and regression, and correlation coefficients. In case of binary outcome variables, either mixed logistic regression or χ² tests will be used.

ETHICS AND DISSEMINATION

The Ethics Committees of the University of Duisburg-Essen (20-9243-BO) and University of Tübingen (469/2020BO) approved the study. Results will be published in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

DRKS00021301.

Mobile Mental Health Apps in China: Systematic App Store Search

Background

Smartphones have become ubiquitous in China, offering a promising way to deliver mental health interventions; however, little is known about the current use and characteristics of smartphone apps for mental health.

Objective

The purpose of this study was to gain insight into mobile mental health apps available in China as of December 2018.

Methods

A systematic search was conducted to identify and evaluate the most downloaded apps from iOS and Android platforms. Apps were categorized according to their main purpose and downloaded to evaluate their content. Each app’s affiliation, cost, target users, information security, and evidence-based nature were evaluated.

Results

Of the 172 unique apps that were identified, there were 37 apps (21.5%) for psychological counseling, 50 apps (29.1%) for assessment, 12 apps (7.0%) to relieve stress, 24 apps (14.0%) for psychoeducation, and 49 (28.4%) multipurpose apps (ie, a combination of counseling and assessment). Most apps were developed for adults in the general population (166/172, 96.5%), rather than for psychiatric patients. App-based counseling was mostly provided by psychologists, and of the assessed apps, only 40% (70/172) used evidence-based scales to assess mental health problems such as anxiety or depressed mood. Guided meditation was used as the main technique in stress-relieving apps.

Conclusions

Many apps contained useful and evidence-based elements, such as good quality information, validated measurements, and useful meditation methods; however, for mobile apps to contribute significantly to mental health care in China, considerable challenges remain, including the need for more patient-focused apps that can actually take on the role of a health care provider. In addition, efficacy studies are needed.

Can Acceptance, Mindfulness, and Self-Compassion Be Learned by Smartphone Apps? A Systematic and Meta-Analytic Review of Randomized Controlled Trials

The potential health benefits of acceptance, mindfulness, and self-compassion are well-documented. However, interventions that teach these principles typically rely on face-to-face delivery, which can limit their dissemination. Delivering these interventions through smartphone apps could help overcome this. This meta-analysis examined whether principles of acceptance, mindfulness, and self-compassion can be learned through smartphone apps. Twenty-seven randomized controlled trials were included. Smartphone apps that included acceptance and/or mindfulness components resulted in significantly higher levels of acceptance/mindfulness than comparison conditions (k = 33; g = 0.29; 95% CI = 0.17, 0.41). These effects were moderated by the type of comparison and whether reminders to engage were offered. Smartphone apps also resulted in significantly lower levels of psychological distress than comparisons (k = 22; g = -0.32; 95% CI = -0.48, -0.16). Meta-regression revealed a negative relationship between the effect sizes for mindfulness/acceptance and the effect sizes for distress. Smartphone apps produced significantly greater increases in self-compassion than comparisons (k = 9; g = 0.31; 95% CI = 0.07, 0.56), although the quality of RCTs in this analysis was poor. Findings suggest that principles of acceptance, mindfulness, and self-compassion may be learned through cheap, easily accessible, and low-intensity interventions delivered via smartphone apps. However, the quality of available evidence is poor, as low risk of bias was noted in few trials (18%) and the observed effects were likely explained by a digital placebo.

Delivery of Compassionate Mental Health Care in a Digital Technology-Driven Age: Scoping Review

BACKGROUND

Compassion is a vital component to the achievement of positive health outcomes, particularly in mental health care. The rise of digital technologies may influence the delivery of compassionate care, and thus this relationship between compassion and digital health care needs to be better understood.

OBJECTIVE

This scoping review aimed to identify existing digital technologies being used by patients and health professionals in the delivery of mental health care, understand how digital technologies are being used in the delivery of compassionate mental health care, and determine the facilitators of and barriers to digital technology use among patients and health professionals in the delivery of compassionate mental health care.

METHODS

We conducted this scoping review through a search of Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process and EPub Ahead of Print, PsycINFO, and Web of Science for articles published from 1990 to 2019.

RESULTS

Of the 4472 articles screened, 37 articles were included for data extraction. Telemedicine was the most widely used technology by mental health professionals. Digital technologies were described as facilitating compassionate care and were classified using a conceptual model to identify each digital intersection with compassionate care. Facilitators of and barriers to providing compassionate care through digital technology were identified, including increased safety for providers, health care professional perceptions and abilities, and the use of picture-in-picture feedback to evaluate social cues.

CONCLUSIONS

Implementing digital technology into mental health care can improve the current delivery of compassionate care and create novel ways to provide compassion. However, as this is a new area of study, mental health professionals and organizations alike should be mindful that compassionate human-centered care is maintained in the delivery of digital health care. Future research could develop tools to facilitate and evaluate the enactment of compassion within digital health care.

Online self-compassion training to improve the wellbeing of youth with chronic medical conditions: protocol for a randomised control trial

BACKGROUND

Chronic medical conditions (CMCs) affect up to 35% of children and adolescents. Youth with chronic medical conditions are at an increased risk of psychological distress and reduced health-related quality of life, and report rates of mental illness up to double that of their physically healthy peers. Accessible, evidence-based interventions for young people with chronic illness are urgently required to improve their mental health and daily functioning. Self-compassion involves taking a mindful, accepting approach to difficult experiences, being aware that one is not alone in one's suffering, and being kind and understanding with oneself during challenging times. Self-compassion shares strong associations with mental health outcomes among young people and preliminary work indicates that interventions that build self-compassion have the potential to substantially improve youth mental health. Self-compassion is also associated with better physical and mental health outcomes among individuals living with CMCs. While face-to-face self-compassion training is available, there are several barriers to access for youth with CMCs. Online self-compassion training potentially offers an accessible alternative for this high-risk group.

METHODS

Self-Compassion Online (SCO) is a self-compassion program that has been tested with a non-clinical adult group. For the proposed trial, a reference group of youth (16-25 years) with chronic illness reviewed the program and proposed adaptations to improve its suitability for youth with chronic illness. In alignment with the SPIRIT Checklist, this paper outlines the protocol for a CONSORT-compliant, single-blind randomised controlled trial to test the efficacy of the adapted program, relative to a waitlist control, for improving self-compassion, wellbeing, distress, emotion regulation, coping and quality of life among young Australians with CMCs. Mechanisms of action and feasibility of SCO will be analysed using quantitative data and participant interviews, respectively. Finally, cost-utility will be analysed using health-related quality of life data.

DISCUSSION

The SCO program could provide a scalable solution for improving psychological outcomes and quality of life among youth with chronic illness. The proposed trial will be the first to determine its efficacy for improving these outcomes, relative to waitlist control.

TRIAL REGISTRATION

The trial was registered on the Australian New Zealand Clinical Trials Registry on the 11th April 2019, ACTRN12619000572167. Protocol version: Version 2, 21 December 2019.

A New Mental Health Mobile App for Well-Being and Stress Reduction in Working Women: Randomized Controlled Trial

BACKGROUND

Although the availability and use of mobile mental health apps has grown exponentially in recent years, little data are available regarding their efficacy.

OBJECTIVE

This study aimed to evaluate the effectiveness of an app developed to promote stress management and well-being among working women compared with a control app.

METHODS

Female employees at a private hospital were invited to participate in the study via mailing lists and intranet ads. A total of 653 individuals self-enrolled through the website. Eligible participants were randomized between control (n=240) and intervention (n=250) groups. The well-being mobile app provides an 8-week program with 4 classes per week (including a brief theoretical portion and a 15-min guided practice). The active control app also provided 4 assessments per week that encouraged participants to self-observe how they were feeling for 20 min. We also used the app to conduct Web-based questionnaires (10-item Perceived Stress Scale and 5-item World Health Organization Well-Being Index) and ask specific questions to assess subjective levels of stress and well-being at baseline (t₁), midintervention (t₄=4 weeks after t₁) and postintervention (t₈=8 weeks after t₁). Both apps were fully automated without any human involvement. Outcomes from the control and intervention conditions at the 3 time points were analyzed using a repeated measures analysis of variance.

RESULTS

Among the randomized participants (n=490), 185 participants were excluded at the 4-week follow-up and another 79 at the 8-week follow-up because of noncompliance with the experimental protocol. Participants who did not complete t₄ and t₈ assessments were equally distributed between groups (t₄: control group=34.6% [83/240] and intervention group=40.8% [102/250]; P=.16; t₈: control group=29.9% [47/157] and intervention group=21.6% [32/148]; P=.10). Both groups showed a significant increase in general well-being as a function of time (F_2,426=5.27; P=.006), but only the intervention group presented a significant increase in work-related well-being (F_2,426=8.92; P<.001), as well as a significant reduction in work-related and overall stress (F_2,426=5.50; P=.004 and F_2,426=8.59; P<.001, respectively).

CONCLUSIONS

The well-being mobile app was effective in reducing employee stress and improving well-being.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02637414; https://clinicaltrials.gov/ct2/show/NCT02637414.

For Whom Does Cognitively Based Compassion Training (CBCT) Work? An Analysis of Predictors and Moderators among African American Suicide Attempters

OBJECTIVES

Both Cognitively-Based Compassion Training (CBCT) and support-based group intervention have been found to be effective for African American suicide attempters in reducing suicidal ideation and depression, as well as enhancing self-compassion. This study aims to further our understanding of effective interventions by exploring participants' responses to both interventions.

METHODS

Exploratory analyses were conducted in a sample of low-income African Americans who had attempted suicide (n=82) to determine how baseline demographic and psychological characteristics would (1) predict outcomes (i.e., suicidal ideation, depression, and self-compassion) regardless of intervention conditions, and (2) moderate outcomes in interaction with intervention condition.

RESULTS

Non-reactivity, a mindfulness facet, was identified as an intervention moderator for suicidal ideation and depressive symptoms, suggesting that CBCT outperformed the support group for African American suicide attempters who had low baseline non-reactivity (or high reactivity). Individuals who had high non-reactivity at baseline appeared to benefit more from both conditions in self-compassion as an outcome. There was a pattern that homeless individuals benefited less in terms of their levels of depressive symptoms and self-compassion as outcomes regardless of the assigned condition. When applying Bonferroni corrections, only non-reactivity as an intervention moderator for depressive symptoms was significant.

CONCLUSIONS

Findings reveal the relevance of mindfulness and to a lesser extent socioeconomic status in informing compassion-based intervention outcomes with this underserved population and the importance of intervention matching and tailoring to maximize treatment effects. Future large trials are needed to replicate findings and directions indicated from the current pilot study.

The efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials

Although impressive progress has been made toward developing empirically-supported psychological treatments, the reality remains that a significant proportion of people with mental health problems do not receive these treatments. Finding ways to reduce this treatment gap is crucial. Since app-supported smartphone interventions are touted as a possible solution, access to up-to-date guidance around the evidence base and clinical utility of these interventions is needed. We conducted a meta-analysis of 66 randomized controlled trials of app-supported smartphone interventions for mental health problems. Smartphone interventions significantly outperformed control conditions in improving depressive (g=0.28, n=54) and generalized anxiety (g=0.30, n=39) symptoms, stress levels (g=0.35, n=27), quality of life (g=0.35, n=43), general psychiatric distress (g=0.40, n=12), social anxiety symptoms (g=0.58, n=6), and positive affect (g=0.44, n=6), with most effects being robust even after adjusting for various possible biasing factors (type of control condition, risk of bias rating). Smartphone interventions conferred no significant benefit over control conditions on panic symptoms (g=-0.05, n=3), post-traumatic stress symptoms (g=0.18, n=4), and negative affect (g=-0.08, n=5). Studies that delivered a cognitive behavior therapy (CBT)-based app and offered professional guidance and reminders to engage produced larger effects on multiple outcomes. Smartphone interventions did not differ significantly from active interventions (face-to-face, computerized treatment), although the number of studies was low (n≤13). The efficacy of app-supported smartphone interventions for common mental health problems was thus confirmed. Although mental health apps are not intended to replace professional clinical services, the present findings highlight the potential of apps to serve as a cost-effective, easily accessible, and low intensity intervention for those who cannot receive standard psychological treatment.