Digital Mental Health for Alcohol and Substance Use Disorders

Development and Evaluation of a Digital App for Patient Self-Management of Opioid Use Disorder: Usability, Acceptability, and Utility Study

BACKGROUND

Self-management of opioid use disorder (OUD) is an important component of treatment. Many patients receiving opioid agonist treatment in methadone maintenance treatment settings benefit from counseling treatments to help them improve their recovery skills but have insufficient access to these treatments between clinic appointments. In addition, many addiction medicine clinicians treating patients with OUD in a general medical clinic setting do not have consistent access to counseling referrals for their patients. This can lead to decreases in both treatment retention and overall progress in the patient's recovery from substance misuse. Digital apps may help to bridge this gap by coaching, supporting, and reinforcing behavioral change that is initiated and directed by their psychosocial and medical providers.

OBJECTIVE

This study aimed to conduct an acceptability, usability, and utility pilot study of the KIOS app to address these clinical needs.

METHODS

We developed a unique, patient-centered computational software system (KIOS; Biomedical Development Corporation) to assist in managing OUD in an outpatient, methadone maintenance clinic setting. KIOS tracks interacting self-reported symptoms (craving, depressed mood, anxiety, irritability, pain, agitation or restlessness, difficulty sleeping, absenteeism, difficulty with usual activities, and conflicts with others) to determine changes in both the trajectory and severity of symptom patterns over time. KIOS then applies a proprietary algorithm to assess the individual's patterns of symptom interaction in accordance with models previously established by OUD experts. After this analysis, KIOS provides specific behavioral advice addressing the individual's changing trajectory of symptoms to help the person self-manage their symptoms. The KIOS software also provides analytics on the self-reported data that can be used by patients, clinicians, and researchers to track outcomes.

RESULTS

In a 4-week acceptability, usability (mean System Usability Scale-Modified score 89.5, SD 9.2, maximum of 10.0), and utility (mean KIOS utility questionnaire score 6.32, SD 0.25, maximum of 7.0) pilot study of 15 methadone-maintained participants with OUD, user experience, usability, and software-generated advice received high and positive assessment scores. The KIOS clinical variables closely correlated with craving self-report measures. Therefore, managing these variables with advice generated by the KIOS software could have an impact on craving and ultimately substance use.

CONCLUSIONS

KIOS tracks key clinical variables and generates advice specifically relevant to the patient's current and changing clinical state. Patients in this pilot study assigned high positive values to the KIOS user experience, ease of use, and the appropriateness, relevance, and usefulness of the specific behavioral guidance they received to match their evolving experiences. KIOS may therefore be useful to augment in-person treatment of opioid agonist patients and help fill treatment gaps that currently exist in the continuum of care. A National Institute on Drug Abuse-funded randomized controlled trial of KIOS to augment in-person treatment of patients with OUD is currently being conducted.

Satisfaction with a digital support tool targeting alcohol consumption: perspectives from participants in a randomized control trial

AIM

Intervention design may be improved through evaluating the feedback from those who have been exposed to such interventions. As such, here the perspectives of the intervention group from a recent randomized control trial investigating the effectiveness of a digital alcohol intervention, in terms of perceived suitability and usefulness of the support tool they engaged with, were investigated.

METHODS

Respondents (N=475; 45% of the intervention group) answered five quantitative questions addressing user experience, completed the 10-item System Useability Scale, and were offered the opportunity to write free-text feedback. Quantitative measures were analysed using ordinal and linear regression with baseline characteristics as predictors, and free-text responses were evaluated using content analysis.

RESULTS

Overall, respondents were positive towards the intervention in terms of it fitting their needs, the usefulness of the tools included, and the usefulness of text message content. The intervention was perceived as more helpful by respondents with lower total weekly alcohol consumption, higher self-reported confidence in their ability to reduce their drinking, and the perceived importance there of, at baseline. The free-text comments revealed the value of reminders as prompts to reflect on one's own drinking behaviour. Nonetheless, criticisms of the intervention were voiced, primarily highlighting the repetitive nature of the reminders and the lack of individuation in advice. Some also feltlike the intervention was impersonal and targeted only a specific drinking pattern.

CONCLUSIONS

Experiences of the intervention group in this trial were generally positive, though there may be demand for more individualised, targeted intervention design.

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022.

Exploratory mixed methods analysis of self-authored content from participants in a digital alcohol intervention trial

BACKGROUND

Digital interventions readily permit data capture of participant engagement with them. If future interventions are intended to be more interactive, tailored, or a useful resource offered to users, it may be valuable to examine such data. One module available in a digital alcohol intervention recently tested in a randomised control trial offered participants the opportunity to self-author prompts that were sent to them by a text message at a time of their choosing. This study thus aimed to evaluate these self-authored prompts to increase knowledge on how individuals negotiate behaviour change and assess whether intervention content can be improved in the future.

METHODS

The self-authored prompts were evaluated qualitatively using a combination of content and thematic analysis. The identified themes and subcategories are exemplified using anonymized quotes, and the frequency that each identified theme was coded for among the prompts was calculated. Associations between baseline characteristics and the odds of authoring a prompt at all, as well as a prompt within each theme, were investigated using logistic regression.

RESULTS

Five themes were identified (Encouragement Style, Level of Awareness, Reminders of reasons to reduce/quit, Strategies to reduce/quit, and Timescale), all with several subcategories. The prompts module was more likely to be used by women and older individuals, as well as those for whom reducing alcohol consumption was perceived as important, or who felt they had the know-how to do so. Participants who had immediate access to the support tool (intervention group) were more than twice as likely to author a prompt (OR = 2.36; probability of association > 99%) compared to those with 4-month delayed access (control group).

CONCLUSIONS

Individuals who engaged with the prompts module showed evidence of using the information provided in the support tool in an active way, with several showing goal setting and making plans to change their drinking behaviour. Individuals also used this opportunity to remind themselves of personal and specific reasons they wanted to change their drinking, as well as to encourage themselves to do so.

Experiences of a mobile phone delivered brief intervention for hazardous drinking: A qualitative study nested in the AMBIT trial from Goa, India

Background

This study explores the experiences of participants receiving a mobile-based brief intervention (BI) for hazardous drinking in India, to determine characteristics that influenced engagement and examine perceived reasons for change in alcohol consumption.

Methods

Semi-structured interviews were conducted with 10 adult hazardous drinkers who received a mobile-based BI in the intervention arm of a pilot randomised control trial. Data were coded through an iterative process and analysed using thematic analysis.

Findings

Study participants reported a positive experience, with factors such as customised intervention delivery and personal motivation facilitating their engagement. Participants reported a reduction in quantity and frequency of alcohol use. This was credited to the intervention, particularly, its provision of health-related information, goal-setting content and strategies to manage drinking. Apart from alcohol reduction, participants reported improvements in diet, lifestyle, wellbeing, and familial relations.

Implication

By providing a context to explain the impact of the intervention, the learnings from this study can be used to strengthen the implementation of mobile-based interventions. This study outlines the scope for further research in digital health, such as Internet-based health interventions, and incorporating digital interventions within the ambit of existing health care programmes.

Recruiting Military Veterans into Alcohol Misuse Research: The Role of Social Media and Facebook Advertising

Background: The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions. Methods: In this work we outline and reflect on the strategies used to recruit help-seeking military veterans into an intervention study, which aimed to evaluate the efficacy of an app (Drinks:Ration) to modify behavior in alcohol misusers. Recruitment strategies included through (1) partner organizations and (2) social media and Facebook advertising (ads). Results: Facebook ads were live for a period of 88 days and were viewed by a total audience of 29,416 people. In total 168 military veterans were recruited across all recruitment strategies, meaning that Drinks:Ration exceeded its recruitment targets. Half of the sample (n = 84) were recruited through social media, including Facebook ads. Conclusions: The current article highlighted that targeted Facebook ads were an efficient strategy to recruit military veterans into a digital intervention trial aiming to reduce alcohol consumption because they reduced the amount of time and resources required to contact a large number of potentially eligible individuals for our study. This article acts as a starting point for other researchers to evaluate their recruitment pathways for recruiting military veterans into alcohol misuse research.

Digital interventions for opioid use disorder treatment: A systematic review of randomized controlled trials

INTRODUCTION

Opioid use disorders are associated with a high burden of disease and treatment gap. Digital interventions can be used to provide psycho-social treatment for opioid use disorders, as an alternative to or together with face-to-face interventions. This review aimed to assess the application and effectiveness of digital interventions to treat opioid use disorder globally.

METHODS

The study team searched four electronic databases (PubMed, Psych INFO, Web of Science and Cochrane Central register of controlled trials). The inclusion criteria were: randomized controlled trials, assessment for opioid use before and at least once following intervention, and use of digital interventions. The primary outcomes were opioid use and/or retention in treatment, with data being summarized in tables and a narrative review presented.

RESULTS

The initial database search yielded 3542 articles, of which this review includes 20. Nineteen were conducted among adults in the United States. The digital interventions used included web-based, computer-based, telephone calls, video conferencing, automated self-management system, mobile applications and text messaging. They were based on therapeutic education systems, community reinforcement approaches, cognitive behavior therapy, relapse prevention, brief interventions, supportive counselling and motivational interviewing. The studies had mixed findings; of the 20 studies, 10 had statistically significant differences between the treatment groups for opioid abstinence, and four had significant differences for treatment retention. Comparisons were difficult due to varying methodologies. Participants rated the interventions as acceptable and reported high rates of satisfaction.

CONCLUSION

The use of digital interventions for opioid use disorder treatment was acceptable, with varying levels of effectiveness for improving outcomes, which is influenced by participant and intervention delivery factors. Further studies in different parts of the world should compare these findings, specifically in low- and middle-income countries.

Telehealth interventions for substance use disorders in low- and- middle income countries: A scoping review

The increasing prevalence and magnitude of harmful effects of substance use disorders (SUDs) in low- and middle-income countries (LMICs) make it imperative to embrace interventions which are acceptable, feasible, and effective in reducing this burden. Globally, the use of telehealth interventions is increasingly being explored as possible effective approaches in the management of SUDs. Using a scoping review of literature, this article summarizes and evaluates evidence for the acceptability, feasibility, and effectiveness of telehealth interventions for SUDs in LMICs. Searches were conducted in five bibliographic databases: PubMed, Psych INFO, Web of Science, Cumulative Index of Nursing and Allied Professionals and the Cochrane database of systematic review. Studies from LMICs which described a telehealth modality, identified at least one psychoactive substance use among participants, and methods that either compared outcomes using pre- and post-intervention data, treatment versus comparison groups, post-intervention data, behavioral or health outcome, and outcome of either acceptability, feasibility, and/or effectiveness were included. Data is presented in a narrative summary using charts, graphs, and tables. The search produced 39 articles across 14 countries which fulfilled our eligibility criteria over a period of 10 years (2010 to 2020). Research on this topic increased remarkably in the latter five years with the highest number of studies in 2019. The identified studies were heterogeneous in their methods and various telecommunication modalities were used to evaluate substance use disorder, with cigarette smoking as the most assessed. Most studies used quantitative methods. The highest number of included studies were from China and Brazil, and only two studies from Africa assessed telehealth interventions for SUDs. There has been an increasingly significant body of literature which evaluates telehealth interventions for SUDs in LMICs. Overall, telehealth interventions showed promising acceptability, feasibility, and effectiveness for SUDs. This article identifies gaps and strengths and suggests directions for future research.

Digital Help for Substance Users (SU): A Systematic Review

The estimated number of Substance Users (SU) globally has currently reached a very high number and is still increasing. This aspect necessitates appropriate interventions for prevention and specific treatments. The literature shows that digital treatments can be useful in the context of health services and substance abuse. This systematic review focuses mainly on research on the effectiveness of digital treatments for SU. Data sources included studies found on PsycINFO, PubMed, SCOPUS, and WebOfScience (WOS) database searches. The following keywords were used: TITLE (digital OR computer OR software OR tablet OR app OR videogame OR seriousgame OR virtualreality) AND ABSTRACT((mental AND health) AND (addiction OR dependence OR substance OR drug)). We focused on peer-reviewed articles published from 2010 through 2021 using PRISMA guidelines. A total of 18 studies met the inclusion criteria (i.e., type of intervention, efficacy in terms of misuse of substances and scored outcomes from questionnaire or toxicology tests, study methodology). The studies included investigations of specific digital treatments for SU of various kinds of drugs. The interventions were administered using personal computers, smartphones, or, in a few cases, tablets. Most of the interventions focused on the cognitive behavior therapy (CBT) model and/or on the use strategies, tips, or feedback. A minority provided information or training programs. The current review shows that digital treatments and interventions are effective in reducing the frequency of use, augmenting abstinence, or reducing the gravity of dependence for most of the studies at post-treatment. However, due to the heterogeneity of the variables (i.e., substance type, digital tool used, and treatment administered), there was a reduced generalizability of the results. This review highlights the need to continue the research in this field, and above all, to create effective digital protocols.

Associations between psychosocial risk factors, and changes in substance dependence and psychosocial functioning, during engagement with digital cognitive behavioral therapy for methamphetamine use: use of 'Breaking Free from Substance Abuse' by incarcerated people during the COVID-19 pandemic

BACKGROUND

Methamphetamine use can be associated with involvement with correctional services and incarceration. Traditionally, treatments for methamphetamine use have been delivered in-person - however, lockdowns initiated during the COVID-19 pandemic significantly reduced access to such in-person support in prisons. Therefore, in May 2020 a digital cognitive-behavioral therapy (CBT) program for substance use disorders - 'Breaking Free from Substance Abuse' - was made available across prisons in Ohio in order to meet this treatment gap. This represents the first time this digital CBT intervention has been made widely available to incarcerated people residing in prisons or jails in the United States (US). This was a within-subjects study using data from 2187 Ohio prison residents who engaged with this digital CBT program to address their methamphetamine use.

RESULTS

Participants reported multiple psychosocial risk factors, including moderate to severe substance dependence, depression and anxiety; interpersonal conflict; aggressive behavior; paranoia; and difficulties with work, education and accommodation. Significant reductions in substance dependence, depression/anxiety and biopsychosocial impairment, and improvements in quality of life, were identified in the sample. Risk factors were associated with less positive outcomes, specifically interpersonal conflict and poor mental health. Completion of specific components of the program were associated with more positive outcomes - a dose response was also identified.

CONCLUSIONS

Digital CBT can be delivered in secure US correctional settings and may help to fill unmet needs for in-person treatment. Specifically, this digital CBT program may support incarcerated individuals to address methamphetamine use, with outcomes being associated with psychosocial risk factors and program engagement.

Mobile phone ownership, digital technology use and acceptability of digital interventions among individuals on opioid use disorder treatment in Kenya

Background

There is limited research on the use of digital interventions among individuals with opioid use disorders (OUD) in low-and-middle income countries. This study aimed to assess mobile phone ownership, digital technology use and acceptability of digital interventions for treatment among individuals on treatment for OUD in Nairobi, Kenya.

Methods

A cross-sectional study was conducted among individuals with OUD. Structured questionnaires were used to collect data on socio-demographic and clinical characteristics, use of mobile phones and other digital technology and acceptability of digital interventions for treatment.

Results

One hundred and eighty participants were enrolled comprising 83.3% males with mean age of 31.5 years (SD 8.6). Mobile phone ownership was reported by 77.2% of participants of which 59.7% used smartphones. One hundred and sixty-six (92.2%) used phones to call, 82.8 and 77.2% used phones to send and receive text messages respectively; 30% used the internet; 57.2% had replaced the phone in past year and 51.1% of participants reported use of at least one social media platform, of these 44.4% had searched social media for information on drug use. Acceptability to receive treatment by phone was 95% and computer 49.4% with majority (88.1%) preferring a text message-based intervention. The preferred approach of delivery of a text message-based intervention were: one text message per day once a week, message to be personalized and individuals allowed to choose time and day to receive the message. Factors associated with acceptability of digital interventions were education level, being single, smartphone ownership and employment.

Conclusion

Majority of individuals on treatment for OUD had access to mobile phones but with high device turnover and limited access to computers and internet. There was high acceptability of digital interventions to provide treatment for OUDs, mostly through phones. These findings highlight factors to consider in the design of a digital intervention for this population.

Online interventions for cannabis use among adolescents and young adults: Systematic review and meta-analysis

BACKGROUND

Young people present high rates of cannabis use, abuse, and dependence. The United Nations estimates that roughly 3.8% of the global population aged 15-64 years used cannabis at least once in 2017. Cannabis use in young people may impair cognitive skills, interfere with learning, impact relationships, and lead to long term behavioural and psychological consequences. Online cannabis interventions (OCI) are increasingly popular, but their dissemination is not often supported by empirical evidence.

AIM

To systematically compile and analyse the effectiveness of OCI for the reduction of cannabis use among adolescents and young adults (AYA).

METHODS

Pooled effect sizes of cannabis use between treatment and control groups were estimated. For each comparison, Hedge's g was calculated using a random effects model.

RESULTS

The search strategy yielded 4531 articles. Of those, a total of 411 articles were retrieved for detailed evaluation resulting in 17 eligible studies (n = 3525). Analyses revealed that online interventions did not significantly reduce cannabis consumption (Hedge's g = -0.061, 95% CI [-0.363] to [-0.242], p = .695) and high heterogeneity was noted (Q = 191.290). More recent studies using structured interventions, daily feedback, AYA centred designs, and peer support, specifically targeting CU seemed to have positive effects to address CU in this population.

CONCLUSIONS

The lack of positive outcomes suggests that more specific and targeted interventions may be necessary to promote cannabis-related behavioural change among young people. These targeted interventions may include structured CU modules, daily feedback, peer support for increased adherence, user-centred design procedures, and input from key stakeholders such as families and service providers.

Data-driven Interpretable Policy Construction for Personalized Mobile Health

To promote healthy behaviors, many mobile health applications provide message-based interventions, such as tips, motivational messages, or suggestions for healthy activities. Ideally, the intervention policies should be carefully designed so that users obtain the benefits without being overwhelmed by overly frequent messages. As part of the HeartSteps physical-activity intervention, users receive messages intended to disrupt sedentary behavior. HeartSteps uses an algorithm to uniformly spread out the daily message budget over time, but does not attempt to maximize treatment effects. This limitation motivates constructing a policy to optimize the message delivery decisions for more effective treatments. Moreover, the learned policy needs to be interpretable to enable behavioral scientists to examine it and to inform future theorizing. We address this problem by learning an effective and interpretable policy that reduces sedentary behavior. We propose Optimal Policy Trees + (OPT+), an innovative batch off-policy learning method, that combines a personalized threshold learning and an extension of Optimal Policy Trees under a budget-constrained setting. We implement and test the method using data collected in HeartSteps V2/V3. Computational results demonstrate a significant reduction in sedentary behavior with a lower delivery budget. OPT+ produces a highly interpretable and stable output decision tree thus enabling theoretical insights to guide future research.

Using community-based participatory methods to design a digital intervention for mothers with substance use disorders: Qualitative results from focus group discussions

PURPOSE

This community-based participatory research project explored the feasibility of delivering parenting and recovery supports through digital technology for mothers recovering from addictive substances.

DESIGN AND METHODS

A community advisory board of key stakeholders (n = 7) served as a focus group of advisors to discuss needed supports. Data were analyzed through qualitative descriptive analysis.

FINDINGS

Results revealed themes about challenges and supports needed, and whether supports delivered through digital technology may improve recovery and parenting.

PRACTICE IMPLICATIONS

Future exploration needs to examine the extent to which the use of community-guided, tailored digital support applications that supplement prescribed treatment can enhance parenting and recovery.

Digital Assessment Tools Using Animation Features to Quantify Alcohol Consumption: Systematic App Store and Literature Review

Background

Accurate and user-friendly assessment tools for quantifying alcohol consumption are a prerequisite for effective interventions to reduce alcohol-related harm. Digital assessment tools (DATs) that allow the description of consumed alcoholic drinks through animation features may facilitate more accurate reporting than conventional approaches.

Objective

This review aims to identify and characterize freely available DATs in English or Russian that use animation features to support the quantitative assessment of alcohol consumption (alcohol DATs) and determine the extent to which such tools have been scientifically evaluated in terms of feasibility, acceptability, and validity.

Methods

Systematic English and Russian searches were conducted in iOS and Android app stores and via the Google search engine. Information on the background and content of eligible DATs was obtained from app store descriptions, websites, and test completions. A systematic literature review was conducted in Embase, MEDLINE, PsycINFO, and Web of Science to identify English-language studies reporting the feasibility, acceptability, and validity of animation-using alcohol DATs. Where possible, the evaluated DATs were accessed and assessed. Owing to the high heterogeneity of study designs, results were synthesized narratively.

Results

We identified 22 eligible alcohol DATs in English, 3 (14%) of which were also available in Russian. More than 95% (21/22) of tools allowed the choice of a beverage type from a visually displayed selection. In addition, 36% (8/22) of tools enabled the choice of a drinking vessel. Only 9% (2/22) of tools allowed the simulated interactive pouring of a drink. For none of the tools published evaluation studies were identified in the literature review. The systematic literature review identified 5 exploratory studies evaluating the feasibility, acceptability, and validity of 4 animation-using alcohol DATs, 1 (25%) of which was available in the searched app stores. The evaluated tools reached moderate to high scores on user rating scales and showed fair to high convergent validity when compared with established assessment methods.

Conclusions

Animation-using alcohol DATs are available in app stores and on the web. However, they often use nondynamic features and lack scientific background information. Explorative study data suggest that such tools might enable the user-friendly and valid assessment of alcohol consumption and could thus serve as a building block in the reduction of alcohol-attributable health burden worldwide.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020172825; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172825

Effects of a minimal-guided on-line intervention for alcohol misuse in Estonia: a randomized controlled trial

BACKGROUND AND AIMS

Estonia has one of the highest alcohol-attributable mortality rates within the European Union. The aim of this study was to estimate the efficacy of an on-line self-help intervention to reduce problem drinking at the population level.

DESIGN

On-line open randomized controlled trial with an 8-week intervention and an active control group (intervention n = 303, control n = 286). Assessments took place at baseline and at 6 months follow-up.

SETTING

On- and offline channels were used for population-based recruitment within a nation-wide prevention campaign in Estonia.

PARTICIPANTS

Inclusion criteria were age ≥ 18 years, heavy drinking [Alcohol Use Disorders Identification (AUDIT) test score ≥ 8], literacy in Estonian and at least weekly access to the internet; n = 589 participants were randomized (50% male, 1% other; mean age 37.86 years; 45% with higher level of education).

INTERVENTION AND COMPARATOR

The intervention consisted of 10 modules based on principles of cognitive-behavioral therapy and motivational interviewing. The active control group received access to a website with a self-test including personalized normative feedback and information for standard alcohol treatment.

MEASUREMENTS

The primary outcome was AUDIT scores at 6 months follow-up adjusted for baseline scores.

FINDINGS

Intention-to-treat analyses were applied. Missing data were addressed by using baseline observation carried forward (BOCF) and multiple imputation by chained equations (MI); 175 completed follow-up in the intervention group and 209 in the control group. AUDIT score at follow-up was significantly smaller in the intervention [BOCF mean = 13.91, standard deviation (SD) = 7.61, MI mean = 11.03, SD = 6.55] than control group (BOCF mean = 15.30, SD = 7.31; MI mean = 14.30, SD = 7.21), with a group difference of -1.38 [95% confidence interval (CI) = -2.58, -0.18], P = 0.02 for BOCF and -3.26 (95% CI = -2.01, -4.51), P < 0.001 for MI.

CONCLUSIONS

A randomized controlled trial has found that an on-line self-help intervention with minimal guidance was effective at reducing problem drinking in Estonia.

Smartphone-based alcohol interventions: A systematic review on the role of notifications in changing behaviors toward alcohol

Background: Smartphone-based interventions are increasingly being used to facilitate positive behavior change, including reducing alcohol consumption. However, less is known about the effects of notifications to support this change, including intervention engagement and adherence. The aim of this review was to assess the role of notifications in smartphone-based interventions designed to support, manage, or reduce alcohol consumption. Methods: Five electronic databases were searched to identify studies meeting inclusion criteria: (1) studies using a smartphone-based alcohol intervention, (2) the intervention used notifications, and (3) published between 1st January 2007 and 30th April 2021 in English. PROSPERO was searched to identify any completed, ongoing, or planned systematic reviews and meta-analyses of relevance. The reference lists of all included studies were searched. Results: Overall, 14 papers were identified, reporting on 10 different interventions. The strength of the evidence regarding the role and utility of notifications in changing behavior toward alcohol of the reviewed interventions was inconclusive. Only one study drew distinct conclusions about the relationships between notifications and app engagement, and notifications and behavior change. Conclusions: Although there are many smartphone-based interventions to support alcohol reduction, this review highlights a lack of evidence to support the use of notifications (such as push notifications, alerts, prompts, and nudges) used within smartphone interventions for alcohol management aiming to promote positive behavior change. Included studies were limited due to small sample sizes and insufficient follow-up. Evidence for the benefits of smartphone-based alcohol interventions remains promising, but the efficacy of using notifications, especially personalized notifications, within these interventions remain unproven.

A randomized controlled trial of a therapeutic relational agent for reducing substance misuse during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted access to treatment for substance use disorders (SUDs), while alcohol and cannabis retail sales increased. During the pandemic, we tested a tailored digital health solution, Woebot-SUDs (W-SUDs), for reducing substance misuse.

METHODS

In a randomized controlled trial, we compared W-SUDs for 8 weeks to a waitlist control. U.S. adults (N = 180) who screened positive for substance misuse (CAGE-AID>1) were enrolled June-August 2020. The primary outcome was the change in past-month substance use occasions from baseline to end-of-treatment (EOT). Study retention was 84%. General linear models tested group differences in baseline-to-EOT change scores, adjusting for baseline differences and attrition.

RESULTS

At baseline, the sample (age M = 40, SD = 12, 65% female, 68% non-Hispanic white) averaged 30.2 (SD = 18.6) substance occasions in the past month. Most (77%) reported alcohol problems, 28% cannabis, and 45% multiple substances; 46% reported moderate-to-severe depressive symptoms. Treatment participants averaged 920 in-app text messages (SD = 892, Median = 701); 96% of completed lessons were rated positively; and 88% would recommend W-SUDs. Relative to waitlist, W-SUDs participants significantly reduced past-month substance use occasions (M = -9.1, SE = 2.0 vs. M = -3.3, SE = 1.8; p = .039). Secondary substance use and mood outcomes did not change significantly by group; however, reductions in substance use occasions correlated significantly with increased confidence and fewer substance use problems, cravings, depression and anxiety symptoms, and pandemic-related mental health effects (p-value<.05).

CONCLUSIONS

W-SUDs was associated with significant reductions in substance use occasions. Reduction in substance use occasions was associated with better outcomes, including improved mental health. W-SUDs satisfaction was high.

Relapse prevention group therapy via video-conferencing for substance use disorder: protocol for a multicentre randomised controlled trial in Indonesia

BACKGROUND

Substance use disorder (SUD) is a leading contributor to the global burden of disease. In Indonesia, the availability of formal treatment for SUD falls short of the targeted coverage. A standardised therapeutic option for SUD with potential for widespread implementation is required, yet evidence-based data in the country are scarce. In this study, we developed a cognitive behavioural therapy (CBT)-based group telemedicine model and will investigate effectiveness and implementability in a multicentre randomised controlled trial.

METHODS

A total of 220 participants will be recruited from the social networks of eight sites in Indonesia: three hospitals, two primary healthcare centres and three rehabilitation centres. The intervention arm will participate in a relapse prevention programme called the Indonesia Drug Addiction Relapse Prevention Programme (Indo-DARPP), a newly developed 12-week module based on CBT and motivational interviewing constructed in the Indonesian context. The programme will be delivered by a healthcare provider and a peer counsellor in a group therapy setting via video-conferencing, as a supplement to participants' usual treatments. The control arm will continue treatment as usual. The primary outcome will be the percentage increase in days of abstinence from the primarily used substance in the past 28 days. Secondary outcomes will include addiction severity, quality of life, motivation to change, psychiatric symptoms, cognitive function, coping, and internalised stigma. Assessments will be performed at baseline (week 0), post-treatment (week 13), and 3 and 12 months post-treatment completion (weeks 24 and 60). Retention, participant satisfaction, and cost-effectiveness will be assessed as the implementation outcomes.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Ethics Committees of Universitas Indonesia and Kyoto University. The results will be disseminated via academic journals and international conferences. Depending on trial outcomes, the treatment programme will be advocated for adoption as a formal healthcare-based approach for SUD.

TRIAL REGISTRATION NUMBER

UMIN000042186.

A Therapeutic Relational Agent for Reducing Problematic Substance Use (Woebot): Development and Usability Study

Background

Misuse of substances is common, can be serious and costly to society, and often goes untreated due to barriers to accessing care. Woebot is a mental health digital solution informed by cognitive behavioral therapy and built upon an artificial intelligence–driven platform to deliver tailored content to users. In a previous 2-week randomized controlled trial, Woebot alleviated depressive symptoms.

Objective

This study aims to adapt Woebot for the treatment of substance use disorders (W-SUDs) and examine its feasibility, acceptability, and preliminary efficacy.

Methods

American adults (aged 18-65 years) who screened positive for substance misuse without major health contraindications were recruited from online sources and flyers and enrolled between March 27 and May 6, 2020. In a single-group pre/postdesign, all participants received W-SUDs for 8 weeks. W-SUDs provided mood, craving, and pain tracking and modules (psychoeducational lessons and psychotherapeutic tools) using elements of dialectical behavior therapy and motivational interviewing. Paired samples t tests and McNemar nonparametric tests were used to examine within-subject changes from pre- to posttreatment on measures of substance use, confidence, cravings, mood, and pain.

Results

The sample (N=101) had a mean age of 36.8 years (SD 10.0), and 75.2% (76/101) of the participants were female, 78.2% (79/101) were non-Hispanic White, and 72.3% (73/101) were employed. Participants’ W-SUDs use averaged 15.7 (SD 14.2) days, 12.1 (SD 8.3) modules, and 600.7 (SD 556.5) sent messages. About 94% (562/598) of all completed psychoeducational lessons were rated positively. From treatment start to end, in-app craving ratings were reduced by half (87/101, 86.1% reporting cravings in the app; odds ratio 0.48, 95% CI 0.32-0.73). Posttreatment assessment completion was 50.5% (51/101), with better retention among those who initially screened higher on substance misuse. From pre- to posttreatment, confidence to resist urges to use substances significantly increased (mean score change +16.9, SD 21.4; P<.001), whereas past month substance use occasions (mean change −9.3, SD 14.1; P<.001) and scores on the Alcohol Use Disorders Identification Test-Concise (mean change −1.3, SD 2.6; P<.001), 10-item Drug Abuse Screening Test (mean change −1.2, SD 2.0; P<.001), Patient Health Questionnaire-8 item (mean change 2.1, SD 5.2; P=.005), Generalized Anxiety Disorder-7 (mean change −2.3, SD 4.7; P=.001), and cravings scale (68.6% vs 47.1% moderate to extreme; P=.01) significantly decreased. Most participants would recommend W-SUDs to a friend (39/51, 76%) and reported receiving the service they desired (41/51, 80%). Fewer felt W-SUDs met most or all of their needs (22/51, 43%).

Conclusions

W-SUDs was feasible to deliver, engaging, and acceptable and was associated with significant improvements in substance use, confidence, cravings, depression, and anxiety. Study attrition was high. Future research will evaluate W-SUDs in a randomized controlled trial with a more diverse sample and with the use of greater study retention strategies.

Trial Registration

ClinicalTrials.gov NCT04096001; http://clinicaltrials.gov/ct2/show/NCT04096001.

Clinician's Guide to Evaluating and Developing eHealth Interventions for Mental Health

Objective

This review aimed to examine key information regarding technology‐delivered interventions for patients with mental health and/or substance use disorders and to provide support for efforts by psychiatrists and other mental health professionals in recommending applications or helping to develop new technology‐delivered interventions.

Methods

The authors reviewed existing information about the appraisal, development, and evaluation of technology‐delivered interventions (eHealth interventions).

Results

High‐level guidance is available for clinicians who want to evaluate eHealth applications for their patients. Clinicians should be familiar with existing models of eHealth intervention development and with traditional as well as unique elements in the evaluation of efficacy for these approaches. However, existing intervention development models have not been empirically validated, and only one includes empirical optimization as an inherent part of its process.

Conclusions

Because of the proliferation of eHealth interventions, mental health professionals should bring to this area the same level of content knowledge, understanding of development and evaluation processes, and rigorous skepticism as they do for pharmacotherapy and therapist‐delivered behavioral interventions.

eHealth interventions are rapidly transforming mental health treatment.

Clinicians should apply the same rigor to evaluating eHealth interventions that they apply to pharmacological treatments or other behavioral therapies.

High‐level guidance and recommendations regarding ideal eHealth intervention development are available to aid in such evaluation, but empirical evidence in support of these guidelines is lacking.

Connected Mental Health: Systematic Mapping Study

BACKGROUND

Although mental health issues constitute an increasing global burden affecting a large number of people, the mental health care industry is still facing several care delivery barriers such as stigma, education, and cost. Connected mental health (CMH), which refers to the use of information and communication technologies in mental health care, can assist in overcoming these barriers.

OBJECTIVE

The aim of this systematic mapping study is to provide an overview and a structured understanding of CMH literature available in the Scopus database.

METHODS

A total of 289 selected publications were analyzed based on 8 classification criteria: publication year, publication source, research type, contribution type, empirical type, mental health issues, targeted cohort groups, and countries where the empirically evaluated studies were conducted.

RESULTS

The results showed that there was an increasing interest in CMH publications; journals were the main publication channels of the selected papers; exploratory research was the dominant research type; advantages and challenges of the use of technology for mental health care were the most investigated subjects; most of the selected studies had not been evaluated empirically; depression and anxiety were the most addressed mental disorders; young people were the most targeted cohort groups in the selected publications; and Australia, followed by the United States, was the country where most empirically evaluated studies were conducted.

CONCLUSIONS

CMH is a promising research field to present novel approaches to assist in the management, treatment, and diagnosis of mental health issues that can help overcome existing mental health care delivery barriers. Future research should be shifted toward providing evidence-based studies to examine the effectiveness of CMH solutions and identify related issues.