Conceptualizing the digital therapeutic alliance in the context of fully automated mental health apps: A thematic analysis

The Safety of Digital Mental Health Interventions: Findings and Recommendations From a Qualitative Study Exploring Users' Experiences, Concerns, and Suggestions

BACKGROUND

The literature around the safety of digital mental health interventions (DMHIs) is growing. However, the user/patient perspective is still absent from it. Understanding the user/patient perspective can ensure that professionals address issues that are significant to users/patients and help direct future research in the field.

OBJECTIVE

This qualitative study aims to explore DMHI users' experiences, views, concerns, and suggestions regarding the safety of DMHIs.

METHODS

We included individuals aged 18 years old or older, having experience in using a DMHI, and can speak and understand English without the need for a translator. Fifteen individual interviews were conducted. Deductive thematic analysis was used to analyze the data.

RESULTS

The analysis of the interview transcripts yielded 3 main themes: Nonresponse: A Concern, a Risk, and How Users Mitigate It, Symptom Deterioration and Its Management, and Concerns Around Data Privacy and How to Mitigate Them.

CONCLUSIONS

The results of this study led to 7 recommendations on how the safety of DMHIs can be improved: provide "easy access" versions of key information, use "approved by..." badges, anticipate and support deterioration, provide real-time feedback, acknowledge the lack of personalization, responsibly manage access, and provide genuine crisis support. These recommendations arose from users' experiences and suggestions. If implemented, these recommendations can improve the safety of DMHIs and enhance users' experience.

Developing an Evidence- and Theory-Informed Mother-Daughter mHealth Intervention Prototype Targeting Physical Activity in Preteen Girls of Low Socioeconomic Position: Multiphase Co-Design Study

BACKGROUND

Preteen girls of lower socioeconomic position are at increased risk of physical inactivity. Parental support, particularly from mothers, is positively correlated with girls' physical activity levels. Consequently, family-based interventions are recognized as a promising approach to improve young people's physical activity. However, the effects of these interventions on girls' physical activity are often inconsistent, with calls for more rigorous, theory-informed, and co-designed family-based interventions to promote physical activity in this cohort.

OBJECTIVE

This study aimed to use co-design methods to develop an evidence- and theory-informed mother-daughter mobile health intervention prototype targeting physical activity in preteen girls.

METHODS

The intervention prototype was developed in accordance with the United Kingdom Medical Research Council framework, the Behaviour Change Wheel, the Theoretical Domains Framework, and the Behaviour Change Techniques Ontology. The Behaviour Change Intervention Ontology was also used to annotate the intervention characteristics. The co-design process incorporated three phases: (1) behavioral analysis, (2) the selection of intervention components, and (3) refinement of the intervention prototype. Throughout these phases, workshops were conducted with preteen girls (n=10), mothers of preteen girls (n=9), and primary school teachers (n=6), with additional input from an academic advisory panel.

RESULTS

This 3-phase co-design process resulted in the development of a theory-informed intervention that targeted two behaviors: (1) mothers' engagement in a range of supportive behaviors for their daughters' physical activity and (2) daughters' physical activity behavior. Formative research identified 11 theoretical domains to be targeted as part of the intervention (eg, knowledge, skills, and beliefs about capabilities). These were to be targeted by 6 intervention functions (eg, education, persuasion, and modeling) and 27 behavior change techniques (eg, goal setting and self-monitoring). The co-design process resulted in a mobile app being chosen as the mode of delivery for the intervention.

CONCLUSIONS

This paper offers a comprehensive description and analysis of using co-design methods to develop a mother-daughter mobile health intervention prototype that is ready for feasibility and acceptability testing. The Behaviour Change Wheel, Theoretical Domains Framework, and Behaviour Change Techniques Ontology provided a systematic and transparent theoretical foundation for developing the prototype by enabling the identification of potential pathways for behavior change. Annotating the Behaviour Change Intervention Ontology entities represents the intervention characteristics in a detailed and structured way that supports improved communication, replication, and implementation of interventions.

Retracted: Reliability and validity of the Chinese version of the mobile Agnew Relationship Measure (mARM-C)

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief and the authors. The authors requested post acceptance two new names to be added to the authorship of the article. However, the authors were not able to provide a satisfactory explanation for the requested authorship change and demanded the retraction of the article. Consequently, the Editor no longer has confidence in this article and decided to retract it.

Efficacy of digital mental health interventions for PTSD symptoms: A systematic review of meta-analyses

BACKGROUND

The present systematic review aimed to synthesize the results of meta-analyses which examine the effects of digital mental health interventions (DMHIs) on post-traumatic stress disorder (PTSD) symptoms, and investigate whether intervention characteristics (i.e., technique, timeframe, and therapeutic guidance) and methodological characteristics including outcome measures and sample inclusion criteria (age, gender, socioeconomic status, country, comorbidity) moderate the efficacy of digital interventions.

METHODS

A systematic search of various sources (ECSCOhost PsycInfo, PubMed, Web of Science, Scopus, EBSCOhost ERIC, Google Scholar, ProQuest Dissertations & Theses) including five peer-reviewed journals was conducted to identify relevant meta-analyses up to December 2023, and 11 meta-analyses were included in the final review.

RESULTS

Overall, our review elucidates that DMHIs are appropriate for alleviating PTSD symptoms in adults, with more consistent evidence supporting the efficacy of cognitive behavioral therapy (CBT)-based, compared to non-CBT-based, interventions when compared to control conditions. However, we found inconclusive evidence that the efficacy of DMHIs varied according to intervention timeframe, therapeutic guidance, or sample characteristics.

LIMITATIONS

A relatively limited number of different populations was sampled across meta-analyses. Further, while our review focused on PTSD symptoms to indicate the efficacy of digital interventions, other indices of effectiveness were not examined.

CONCLUSION

Our findings indicate the clinical utility of DMHIs for managing PTSD symptoms particularly when CBT-based intervention techniques are employed.

Acceptability and experience of a smartphone symptom monitoring app for people with psychosis in China (YouXin): a qualitative study

BACKGROUND

Access to high-quality mental healthcare remains challenging for people with psychosis globally, including China. Smartphone-based symptom monitoring has the potential to support scalable mental healthcare. However, no such tool, until now, has been developed and evaluated for people with psychosis in China. This study investigated the acceptability and the experience of using a symptom self-monitoring smartphone app (YouXin) specifically developed for people with psychosis in China.

METHODS

Semi-structured interviews were conducted with 10 participants with psychosis to explore the acceptability of YouXin. Participants were recruited from the non-randomised feasibility study that tested the validity, feasibility, acceptability and safety of the YouXin app. Data analysis was guided by the theoretical framework of acceptability.

RESULTS

Most participants felt the app was acceptable and easy to use, and no unbearable burdens or opportunity costs were reported. Participants found completing the self-monitoring app rewarding and experienced a sense of achievement. Privacy and data security were not major concerns for participants, largely due to trust in their treating hospital around data protection. Participants found the app easy to use and attributed this to the training provided at the beginning of the study. A few participants said they had built some form of relationship with the app and would miss the app when the study finished.

CONCLUSIONS

The YouXin app is acceptable for symptom self-monitoring in people with experience of psychosis in China. Participants gained greater insights about their symptoms by using the YouXin app. As we only collected retrospective acceptability in this study, future studies are warranted to assess hypothetical acceptability before the commencement of study to provide a more comprehensive understanding of implementation.

A qualitative study exploring the digital therapeutic alliance with fully automated smartphone apps

Background

Digital mental health interventions are increasingly used to scale up access to mental health support, yet very few mental health apps are empirically supported, with high attrition rates. The therapeutic alliance between therapists and clients is a key factor in predicting psychological therapy retention and outcomes. Understanding how this concept translates to the digital context, the so-called digital therapeutic alliance (DTA), may help enhance retention and outcomes in digital mental health.

Objectives

To explore and conceptualise the DTA with mental health interventions delivered by standalone apps. Specifically: (1) whether people with mental health difficulties form an alliance with mental health apps; (2) what constitutes the DTA; and (3) the similarities and differences across the traditional therapeutic alliance and DTA.

Methods

Qualitative semi-structured interviews were conducted with 17 individuals utilising mental health apps. Interview topic examples included rationale for app support, goals around app use and perceived connection. Interviews were analysed using thematic analysis.

Results

Five core themes were identified: (1) connection with 'an other'; (2) accessibility; (3) choice and empowerment; (4) goals and expectations: having lower expectations than in-person support; and (5) safe place: non-judgemental, loyalty, trust.

Conclusions

The study strengthens support for the concept of the DTA but adds to existing knowledge by suggesting that the DTA needs to be conceived differently to the traditional therapeutic alliance. App developers can enhance alliance by paying particular attention to the use of human voice features, validating statements, personalised interfaces, and multiple options for activities and strategies.