A pilot study of a smartphone application supporting recovery from drug addiction

Describing the evolution of three features of China's drug policy: Regulation, crime and punishment, and rehabilitation

In view of evolving problematic drug use patterns and shifts in social governance, China's drug control efforts have undergone significant changes over the past few decades. The aim of this paper is to describe the evolution of three features of China's drug policy. First, although still operating within a reactive framework, the legislative basis for drug control is progressively improving and exhibits shifts towards greater precision and responsiveness, especially with reference to New Psychoactive Substances. Second, the scope of drug crimes under criminal law has broadened, accompanied by a trend toward harsher sentencing. This trend signifies the punitive and deterrent objectives in addressing drug crimes. Third, despite notable improvements, the current rehabilitation system remains focused on containment and control, with punitive undertones. These features exhibit a high degree of overlap and are shaped by shared underlying logics. While these transformations have been influenced by historical, political and international circumstances and environments, the principle of prohibition remains deeply rooted in the policy.

Evolving role of the internet in China as a medium for promoting psychological well-being and mental health: a scoping review

The rapid development of China's 5G 'Internet Plus' industry has led to increasing use of the Internet to provide healthcare services. Internet-based services in China are already widely used to prevent, identify, monitor, and manage mental disorders, but few of these services have been formally evaluated. To provide a clear baseline of this rapidly evolving field, we searched articles published before December 31, 2022, about internet-based interventions and surveys for mental health-related conditions in China in five international databases (Web of Science, PubMed, PsycINFO, Embase, and Cochrane Library) and four Chinese databases (CNKI, SinoMed, VIP, and WanFang). The 143 identified studies-54 in Chinese and 89 in English-described internet-based interventions and surveys in individuals with mental disorders, community residents, college students, older adults, pregnant women, and health professionals. The number of identified studies, which were mainly conducted in economically developed regions of the country, quadrupled after the 2019 onset of the COVID-19 pandemic. Available studies suggest-but do not prove-that internet-based interventions can reduce the severity of psychiatric symptoms, decrease healthcare costs, and improve the quality of life for individuals with mental disorders. Innovative smartphone applications could potentially improve the quality and expand the scope of internet-based interventions, making them a key component in ongoing efforts to prevent and monitor mental illness, enhance the self-management of mental disorders, and alleviate psychological distress among adolescents and other at-risk populations. However, achieving this long-term goal will require establishing standardised methods of administering internet-based interventions, training mental health professionals to implement and monitor the interventions, identifying methods of maintaining the confidentiality of collected information, and rigorously assessing the effectiveness of the interventions based on periodic assessment of uniform outcome measures. Clinical and policy research about expanding internet-based mental health interventions should focus on confidentiality, efficacy, and cost-effectiveness.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Use of Mobile Applications in Smoking, Alcohol and Substance Use Disorders

Currently, technology and mobile health applications are developing and being applied in different fields every day. Especially the use of mobile technology in many health fields offers various opportunities for the use of mobile applications in smoking, alcohol and substance use disorders, which is an important public mental health problem. The aim of this review study was to examine 16 mobile applications designed for the treatment and monitoring of smoking, alcohol and substance use. It was concluded that self-monitoring, notification and warning systems, location services, peer and expert support services were frequently used in the analyzed mobile applications. As a result of the studies, the use of mobile applications as a preventive intervention in the prevention of addiction and as an additional treatment option in addiction treatment is promising. However, this situation brings along various harms, risks and obstacles. This review of the relevant literature provides a critical update of mobile applications used in smoking, alcohol and substance use disorders. This review is expected to be an important guide for mental health professionals and mobile application designers working on addiction.

The Craving-Manager smartphone app designed to diagnose substance use/addictive disorders, and manage craving and individual predictors of relapse: a study protocol for a multicenter randomized controlled trial

Background

The rate of individuals with addiction who are currently treated are low, and this can be explained by barriers such as stigma, desire to cope alone, and difficulty to access treatment. These barriers could be overcome by mobile technologies. EMI (Ecological Momentary Intervention) is a treatment procedure characterized by the delivery of interventions (messages on smartphones) to people in their daily lives. EMI presents opportunities for treatments to be available to people during times and in situations when they are most needed. Craving is a strong predictor of relapse and a key target for addiction treatment. Studies using Ecological Momentary Assessment (EMA) method have revealed that, in daily life, person-specific cues could precipitate craving, that in turn, is associated with a higher probability to report substance use and relapse in the following hours. Assessment and management of these specific situations in daily life could help to decrease addictive use and avoid relapse. The Craving-Manager smartphone app has been designed to diagnose addictive disorders, and assess and manage craving as well as individual predictors of use/relapse. It delivers specific and individualized interventions (counseling messages) composed of evidence-based addiction treatments approaches (cognitive behavioral therapy and mindfulness). The Craving-Manager app can be used for any addiction (substance or behavior). The objective of this protocol is to evaluate the efficacy of the Craving-Manager app in decreasing use (of primary substance(s)/addictive behavior(s)) over 4 weeks, among individuals on a waiting list for outpatient addiction treatment.

Methods/design

This multicenter double-blind randomized controlled trial (RCT) will compare two parallel groups: experimental group (full interventional version of the app, 4 weeks, EMA + EMI), versus control group (restricted version of the app, 4 weeks, only EMA). Two hundred and seventy-four participants will be recruited in 6 addiction treatment centers in France.

Discussion

This RCT will provide indication on how the Craving-Manager app will reduce addictive use (e.g., better craving management, better stimulus control) in both substance and behavioral addictions. If its efficacy is confirmed, the app could offer the possibility of an easy to use and personalized intervention accessible to the greatest number of individuals with addiction.

Clinical Trial Registration

ClinicalTrials.gov: NCT04732676.

Effects of Text4Hope-Addiction Support Program on Cravings and Mental Health Symptoms: Results of a Longitudinal Cross-sectional Study

BACKGROUND

Drug misuse is complex, and various treatment modalities are emerging. Providing supportive text messages to individuals with substance use disorder offers the prospect of managing and improving symptoms of drug misuse and associated comorbidities.

OBJECTIVE

This study evaluated the impact of the daily supportive text message program (Text4Hope-Addiction Support) in mitigating cravings and mental health symptoms in subscribers and quantify user satisfaction with the Text4Hope-Addiction Support program.

METHODS

Subscribers to the Text4Hope-Addiction Support program received daily supportive text messages for 3 months; the messages were crafted based on addiction counseling and cognitive behavioral therapy principles. Participants completed an anonymous web-based questionnaire to assess cravings, anxiety, and depressive symptoms using the Brief Substance Craving Scale (BSCS), Generalized Anxiety Disorder-7 (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9) scale at enrollment (baseline), after 6 weeks, and after 3 months. Likert scale satisfaction responses were used to assess various aspects of the Text4Hope-Addiction program.

RESULTS

In total, 408 people subscribed to the program, and 110 of 408 (26.9%) subscribers completed the surveys at least at one time point. There were significant differences between the mean baseline and 3-month BSCS scores P=.01 (-2.17, 95% CI -0.62 to 3.72), PHQ-9 scores, P=.004 (-5.08, 95% CI -1.65 to -8.51), and GAD-7 scores, P=.02 (-3.02, 95% CI -0.48 to -5.56). Participants who received the supportive text messages reported a reduced desire to use drugs and a longer time interval between substance use, which are reflected in 41.1% and 32.5% decrease, respectively, from baseline score. Approximately 89% (23/26) of the participants agreed that Text4Hope-Addiction program helped them cope with addiction-related stress, and 81% (21/25) of the participants reported that the messages assisted them in dealing with anxiety. Overall, 69% (18/26) of the participants agreed that it helped them cope with depression related to addiction; 85% (22/26) of the participants felt connected to a support system; 77% (20/26) of the participants were hopeful of their ability to manage addiction issues; and 73% (19/26) of the participants felt that their overall mental well-being was improved. Most of the participants agreed that the interventions were always positive and affirmative (19/26, 73%), and succinct (17/26, 65%). Furthermore, 88% (21/24) of the participants always read the messages; 83% (20/24) of the participants took positive or beneficial actions after reading; and no participant took a negative action after reading the messages. In addition, most participants agreed to recommend other diverse technology-based services as an adjunctive treatment for their mental and physical health disorders.

CONCLUSIONS

Subscribers of Text4Hope-Addiction Support program experienced improved mental health and addiction symptoms. Addiction care practitioners and policy makers can implement supportive text-based strategies to complement conventional treatments for addiction, given that mobile devices are widely used.

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.

Six-month outcomes of the HOPE smartphone application designed to support treatment with medications for opioid use disorder and piloted during an early statewide COVID-19 lockdown

Background

Morbidity and mortality related to opioid use disorder (OUD) in the U.S. is at an all-time high. Innovative approaches are needed to address gaps in retention in treatment with medications for opioid use disorder (MOUD). Mobile health (mHealth) approaches have shown improvement in engagement in care and associated clinical outcomes for a variety of chronic diseases, but mHealth tools designed specifically to support patients treated with MOUD are limited.

Methods

Following user-centered development and testing phases, a multi-feature smartphone application called HOPE (Heal. Overcome. Persist. Endure) was piloted in a small cohort of patients receiving MOUD and at high risk of disengagement in care at an office-based opioid treatment (OBOT) clinic in Central Virginia. Outcomes were tracked over a six-month period following patient enrollment. They included retention in care at the OBOT clinic, usage of various features of the application, and self-rated measures of mental health, substance use, treatment and recovery.

Results

Of the 25 participants in the HOPE pilot study, a majority were retained in care at 6 months (56%). Uptake of bi-directional features including messaging with providers and daily check-ins of mood, stress and medication adherence peaked at one month, and usage persisted through the sixth month. Patients who reported that distance to clinic was a problem at baseline had higher loss to follow up compared to those without distance as a reported barrier (67% vs 23%, p = 0.03). Patients lost to in-person clinic follow up continued to engage with one or more app features, indicating that mHealth approaches may bridge barriers to clinic visit attendance. Participants surveyed at baseline and 6 months (N = 16) scored higher on scales related to overall self-control and self-efficacy related to drug abstinence.

Conclusions

A pilot study of a novel multi-feature smartphone application to support OUD treatment showed acceptable retention in care and patient usage at 6 months. Further study within a larger population is needed to characterize ‘real world’ uptake and association with outcomes related to retention in care, relapse prevention, and opioid-associated mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00296-4.

Mapping network connectivity between internet addiction and residual depressive symptoms in patients with depression

BACKGROUND AND AIMS

Depression often triggers addictive behaviors such as Internet addiction. In this network analysis study, we assessed the association between Internet addiction and residual depressive symptoms in patients suffering from clinically stable recurrent depressive disorder (depression hereafter).

MATERIALS AND METHODS

In total, 1,267 depressed patients were included. Internet addiction and residual depressive symptoms were measured using the Internet Addiction Test (IAT) and the two-item Patient Health Questionnaire (PHQ-2), respectively. Central symptoms and bridge symptoms were identified via centrality indices. Network stability was examined using the case-dropping procedure.

RESULTS

The prevalence of IA within this sample was 27.2% (95% CI: 24.7-29.6%) based on the IAT cutoff of 50. IAT15 ("Preoccupation with the Internet"), IAT13 ("Snap or act annoyed if bothered without being online") and IAT2 ("Neglect chores to spend more time online") were the most central nodes in the network model. Additionally, bridge symptoms included the node PHQ1 ("Anhedonia"), followed by PHQ2 ("Sad mood") and IAT3 ("Prefer the excitement online to the time with others"). There was no gender difference in the network structure.

CONCLUSION

Both key central and bridge symptoms found in the network analysis could be potentially targeted in prevention and treatment for depressed patients with comorbid Internet addiction and residual depressive symptoms.

Digital mental health in China: a systematic review

Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.

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 Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Feasibility and Preliminary Efficacy of a Community-Based Addiction Rehabilitation Electronic System in Substance Use Disorder: Pilot Randomized Controlled Trial

BACKGROUND

Drug use disorder has high potential for relapse and imposes an enormous burden on public health in China. Since the promulgation of the Anti-drug law in 2008, community-based rehabilitation has become the primary approach to treat drug addiction. However, multiple problems occurred in the implementation process, leading to a low detoxification rate in the community. Mobile health (mHealth) serves as a promising tool to improve the effectiveness and efficiency of community-based rehabilitation. Community-based addiction rehabilitation electronic system (CAREs) is an interactive system for drug users and their assigned social workers.

OBJECTIVE

The study aimed to examine the feasibility and preliminary efficacy of CAREs in community-based rehabilitation from the perspective of drug users and social workers in Shanghai, China.

METHODS

In this pilot randomized controlled trial, 40 participants were recruited from the community in Shanghai from January to May 2019. Participants randomized to the intervention group (n=20) received CAREs + community-based rehabilitation, while participants in the control group (n=20) received community-based rehabilitation only for 6 months. CAREs provided education, assessment, and SOS (support) functions for drug users. The assigned social workers provided service and monitored drug use behavior as usual except that the social workers in the intervention group could access the webpage end to obtain drug users' information and fit their routine workflow into CAREs. The primary outcome was the feasibility of CAREs, reflected in the overall proportion and frequency of CAREs features used in both app and webpage end. The secondary outcomes were the effectiveness of CAREs, including the percentage of drug-positive samples, longest period of abstinence, contact times with social workers, and the change of Addiction Severity Index (ASI) from baseline to the 6-month follow-up.

RESULTS

The number of participants logged in to the app ranged from 7 to 20 per week, and CAREs had relatively high levels of continued patient use. Drug users preferred assessment and education features in the app end while their social workers showed high levels of use in urine results record and viewing assessment results on the webpage end. After the 6-month intervention, 3.3% (17/520) of samples in the intervention group and 7.5% (39/520) in the control group were drug-positive (F=4.358, P=.04). No significant differences were noted between the control and intervention groups in terms of longest duration of abstinence, number of contact times and ASI composite scores.

CONCLUSIONS

The study preliminarily demonstrated that with relatively good feasibility and acceptability, CAREs may improve the effectiveness and efficiency of the community-based rehabilitation, which provided instruction for further improvement of the system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03451344; https://clinicaltrials.gov/ct2/show/NCT03451344.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3389/fpsyt.2018.00556.

Substance Use Disorder Status Moderates the Association between Personality Traits and Problematic Mobile Phone/Internet Use

BACKGROUND

Associations between personality traits and problematic smartphone use (PSU) among individuals with substance use disorder (SUD) have not been widely investigated. The current study aims to assess whether SUD status moderates the association between personality traits and PSU.

METHODS

The study group included 151 individuals with SUD and a normative sample (NS) comprised of 554 non-SUD students. The following self-report questionnaires were used: the Mobile Phone Problem Use Scale (MPPUS-10) to assess problematic smartphone use (PSU), the Internet Addiction Test (IAT) to assess intensity of internet use, and the NEO Five-Factor Inventory (NEO-FFI) to assess Personality traits.

RESULTS

SUD status moderated the association between neuroticism and openness to new experiences on PSU. That is, greater neuroticism and openness were significantly associated with more excessive PSU among the NS. In the SUD group, greater openness was a significant protective factor against PSU. Moderation results were similar when using the IAT (which was significantly correlated with MPPUS) as an outcome.

CONCLUSIONS

The presence of SUD may influence how personality traits are associated with problematic mobile phone/internet use. Given that this is among one of the first studies examining this topic, findings should be replicated with additional studies.

The emergence of digital mental health in low-income and middle-income countries: A review of recent advances and implications for the treatment and prevention of mental disorders

In low-income and middle-income countries (LMICs), emerging digital mental health interventions should be accompanied by regular and comprehensive assessment of available scientific evidence. This review aims to support efforts to monitor progress in digital mental health research, ensuring new evidence can guide researchers, clinicians, policymakers and program managers positioned to adopt and implement these digitally-enabled treatments. In accordance with PRISMA guidelines, an electronic database search from 2016 to 2020 yielded 37 digital intervention studies for detection, diagnosis, prevention, treatment, and/or management of a broad range of mental disorders in 13 LMICs. This date range was selected to update previous reviews. Most studies involved online interventions and many reported feasibility and acceptability, reflected by participant satisfaction or program adherence. About half the studies (N = 23) reported clinical benefits based on changes in mental health. For depression and mood disorders, some digital interventions showed improvements in depressive symptoms, quality of life, treatment adherence, and recovery. However, sample sizes were small and studies focused primarily on adults. Further limiting generalizability was the lack of consistency in clinical assessment and measurement tools between studies. No studies reported worsening symptoms, negative acceptability or dissatisfaction with digital interventions, suggesting possible publication bias. While digital interventions show promise, it remains difficult to conclude that digital interventions are effective from these studies, as it is prudent to exercise caution before drawing conclusions about clinical effectiveness. This review reflects continued growth in digital mental health research in LMICs and further highlights the need for rigorous evaluation of effectiveness and cost-effectiveness.

Inventory and Analysis of Controlled Trials of Mobile Phone Applications Targeting Substance Use Disorders: A Systematic Review

Background: Less than 20% of people with addictions have access to adequate treatment. Mobile health could improve access to care. No systematic review evaluates effectiveness of mobile health applications for addiction. Objectives: First aim was to describe controlled trials evaluating the effectiveness of smartphone applications targeting substance use disorders and addictive behaviors. Secondly, we aimed to understand how the application produced changes in behavior and craving management. Method: A systematic review based on PRISMA recommendations was conducted on MEDLINE, CENTRAL, and PsycINFO. Studies had to be controlled trials concerning addictive disorders (substance/behavior), mobile application-based interventions, assessing effectiveness or impact of those applications upon use, published after 2008. Relevant information was systematically screened for synthesis. Quality and risk of bias were evaluated with JADAD score. Results: Search strategy retrieved 22 articles (2014-2019) corresponding to 22 applications targeting tobacco, alcohol, other substances and binge eating disorder. Control groups had access to usual treatments or a placebo-application or no treatment. Eight applications showed reduced use. Most of the applications informed about risks of use and suggestions for monitoring use. Twelve applications managed craving. Discussion: Heterogeneity limited study comparisons. Duration of studies was too short to predict sustainable results. A reduction of craving seemed related to a reduction in use. Conclusion: There is a lack of robust and comparable studies on mHealth applications for addiction treatment. Such applications could become significant contributors in clinical practice in the future so longer-termed double-blind studies are needed. Targeting craving to prevent relapse should be systematic.

Mobile Apps to Reduce Tobacco, Alcohol, and Illicit Drug Use: Systematic Review of the First Decade

Background

Mobile apps for problematic substance use have the potential to bypass common barriers to treatment seeking. Ten years following the release of the first app targeting problematic tobacco, alcohol, and illicit drug use, their effectiveness, use, and acceptability remains unclear.

Objective

This study aims to conduct a systematic literature review of trials evaluating mobile app interventions for problematic tobacco, alcohol, and illicit drug use.

Methods

The review was conducted according to recommended guidelines. Relevant databases were searched, and articles were included if the mobile app study was a controlled intervention trial and reported alcohol, tobacco, or illicit drug consumption as outcomes.

Results

A total of 20 studies met eligibility criteria across a range of substances: alcohol (n=11), tobacco (n=6), alcohol and tobacco (n=1), illicit drugs (n=1), and illicit drugs and alcohol (n=1). Samples included the general community, university students, and clinical patients. The analyzed intervention sample sizes ranged from 22 to 14,228, and content was considerably diverse, from simple stand-alone apps delivering self-monitoring or psychoeducation to multicomponent apps with interactive features and audio content, or used as adjuncts alongside face-to-face treatment. Intervention duration ranged from 1 to 35 weeks, with notifications ranging from none to multiple times per day. A total of 6 of the 20 app interventions reported significant reductions in substance use at post or follow-up compared with a comparison condition, with small to moderate effect sizes. Furthermore, two other app interventions reported significant reductions during the intervention but not at post treatment, and a third reported a significant interaction of two app intervention components.

Conclusions

Although most app interventions were associated with reductions in problematic substance use, less than one-third were significantly better than the comparison conditions at post treatment. A total of 5 out of the 6 apps that reported intervention effects targeted alcohol (of those, one targeted alcohol and illicit drugs and another alcohol and tobacco) and 1 targeted tobacco. Moreover, 3 out of 6 apps included feedback (eg, personalized) and 2 had high risk of bias, 1 some risk, and 3 low risk. All 6 apps included interventions of 6 weeks or longer. Common study limitations were small sample sizes; risk of bias; lack of relevant details; and, in some cases, poorly balanced comparison conditions. Appropriately powered trials are required to understand which app interventions are most effective, length of engagement required, and subgroups most likely to benefit. In sum, evidence to date for the effectiveness of apps targeting problematic substance use is not compelling, although the heterogeneous comparison conditions and trial designs across studies limit the ability to compare efficacy between apps. We discuss potential approaches that can help ascertain whether the promise of mobile app interventions for problematic substance use can be fulfilled.

Effectiveness of digital psychological interventions for mental health problems in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

The effectiveness of digital psychological interventions in low-income and middle-income countries (LMICs) remains unclear. We aimed to systematically investigate the available evidence for digital psychological interventions in reducing mental health problems in LMICs.

METHODS

In this systematic review and meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane databases for articles published in English from database inception to March 9, 2020. We included randomised controlled trials investigating digital psychological interventions in individuals with mental health problems in LMICs. We extracted data on demographics, inclusion and exclusion criteria, details of the intervention, including the setting, digital delivery method, control group conditions, number of sessions, therapeutic orientation (eg, cognitive therapy or behaviour therapy), presence or absence of guidance, and length of follow-up, and statistical information to calculate effect sizes. If a study reported insufficient data to calculate effect sizes, the corresponding authors were contacted to provide data that could be aggregated. We did random-effects meta-analyses, and calculated the standardised mean difference in scores of digital psychological interventions versus control conditions (Hedges'g). Quality of evidence was assessed by use of the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was post-intervention mental health problems, as measured by self-reporting instruments or clinical interviews. This study is registered with PROSPERO, CRD42019137755.

FINDINGS

We identified 22 eligible studies that were included in the meta-analysis. The included studies involved a total of 4104 participants (2351 who received a digital psychological intervention and 1753 who were in the control group), and mainly focused on young adults (mean age of the study population was 20-35 years) with depression or substance misuse. The results showed that digital psychological interventions are moderately effective when compared with control interventions (Hedges'g 0·60 [95% CI 0·45-0·75]; Hedges'g with treatment as usual subgroup for comparison 0·54 [0·35-0·73]). Heterogeneity between studies was substantial (I²=74% [95% CI 60-83]). There was no evidence of publication bias, and the quality of evidence according to the GRADE criteria was generally high.

INTERPRETATION

Digital psychological interventions, which have been mostly studied in individuals with depression and substance misuse, are superior to control conditions, including usual care, and are moderately effective in LMICs. However, the considerable heterogeneity observed in our analysis highlights the need for more studies to be done, with standardised implementation of digital psychological intervention programmes to improve their reproducibility and efficiency. Digital psychological interventions should be considered for regions where usual care for mental health problems is minimal or absent.

FUNDING

None.

TRANSLATIONS

For the Persian, Chinese, Hindi, Portuguese, Bahasa, Turkish, Romanian, Spanish and Thai translations of the abstract see Supplementary Materials section.

Ethische Aspekte internet- und mobilgestützter Interventionen (IMIs) bei Suchtstörungen

Ziel der Studie Internet- und mobilgestützte Interventionen (IMIs) werden häufig bei Suchtstörungen eingesetzt. Für die Wirksamkeit von IMIs liegt eine umfangreiche Evidenz vor. Hinsichtlich der spezifischen ethischen Aspekte, die sich aus dem Einsatz von IMIs bei Suchtstörungen ergeben, fehlt es bislang an Forschung. Mit unserem Beitrag leisten wir die erste eingehende ethische Analyse von IMIs in der Suchttherapie. Dabei orientieren wir uns an normativen Aspekten, die spezifisch für die Behandlung von Suchtstörungen sind. Dazu gehören die besondere Stigmatisierung von Suchtkranken, die Zuschreibung von Schuld und Eigenverantwortung, die mangelnde Akzeptanz des Krankheitskonzepts Sucht sowie die daraus resultierende Ablehnung und Abwertung von Betroffenen.

Methode Als methodisches Instrument verwenden wir den 3 ACES-Ansatz von Thornicroft und Tansella. Dieses Instrument erlaubt eine umfassende ethische Analyse des Einsatzes von IMIs im konkreten Einzelfall sowie der Implementierung von IMIs im Versorgungssystem.

Ergebnisse Unsere Analyse zeigt, dass IMIs in der Suchttherapie das Potential haben, ein Empowerment von PatientInnen zu leisten, die Stigmatisierung zu umgehen und einen niedrigschwelligen Zugang zu Versorgungsleistungen zu ermöglichen. Kritisch zu sehen sind Aspekte der Passung von Anwendungen auf die Bedürfnisse einzelner Patientengruppen und individueller PatientInnen, der therapeutischen Verantwortung, des Datenschutzes, der Datensicherheit und Privatheit sowie der Vernetzung unterschiedlicher Anbieter von Versorgungsleistungen.

Schlussfolgerung Eine weitere Implementierung von IMIs in der Suchttherapie ist nur dann wünschenswert, wenn verbindliche Qualitätsstandards geschaffen und die patientenzentrierte Anwendung unter Berücksichtigung individueller Patientencharakteristika sichergestellt wird.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

BACKGROUND

Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective.

OBJECTIVE

This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features.

RESULTS

We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods.

CONCLUSIONS

There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders.

Common themes and emerging trends for the use of technology to support mental health and psychosocial well-being in limited resource settings: A review of the literature

There are significant disparities in access to mental health care. With the burgeoning of technologies for health, digital tools have been leveraged within mental health and psychosocial support programming (eMental health). A review of the literature was conducted to understand and identify how eMental health has been used in resource-limited settings in general. PubMed, Ovid Medline and Web of Science were searched. Six-hundred and thirty full-text articles were identified and assessed for eligibility; of those, 67 articles met the inclusion criteria and were analyzed. The most common mental health use cases were for depression (n = 25) and general mental health and well-being (n = 21). Roughly one-third used a website or Internet-enabled intervention (n = 23) and nearly one-third used an SMS intervention (n = 22). Technology was applied to enhance service delivery (n = 32), behavior change communication (n = 26) and data collection (n = 8), and specifically dealt with adherence (n = 7), ecological momentary assessments (n = 7), well-being promotion (n = 5), education (n = 8), telemedicine (n = 28), machine learning (n = 5) and games (n = 2). Emerging trends identified wearables, predictive analytics, robots and virtual reality as promising areas. eMental health interventions that leverage low-tech tools can introduce, strengthen and expand mental health and psychosocial support services and can be a starting point for future, advanced tools.

Methodological Challenges in Randomized Controlled Trials on Smartphone-Based Treatment in Psychiatry: Systematic Review

BACKGROUND

Smartphone-based technology is developing at high speed, and many apps offer potential new ways of monitoring and treating a range of psychiatric disorders and symptoms. However, the effects of most available apps have not been scientifically investigated. Within medicine, randomized controlled trials (RCTs) are the standard method for providing the evidence of effects. However, their rigidity and long time frame may contrast with the field of information technology research. Therefore, a systematic review of methodological challenges in designing and conducting RCTs within mobile health is needed.

OBJECTIVE

This systematic review aimed to (1) identify and describe RCTs investigating the effect of smartphone-based treatment in adult patients with a psychiatric diagnosis, (2) discuss methodological challenges in designing and conducting individual trials, and (3) suggest recommendations for future trials.

METHODS

A systematic search in English was conducted in PubMed, PsycINFO, and EMBASE up to August 12, 2019. The search terms were (1) psychiatric disorders in broad term and for specific disorders AND (2) smartphone or app AND (3) RCT. The Consolidated Standards of Reporting Trials electronic health guidelines were used as a template for data extraction. The focus was on trial design, method, and reporting. Only trials having sufficient information on diagnosis and acceptable diagnostic procedures, having a smartphone as a central part of treatment, and using an RCT design were included.

RESULTS

A total of 27 trials comprising 3312 patients within a range of psychiatric diagnoses were included. Among them, 2 trials were concerning drug or alcohol abuse, 3 psychosis, 10 affective disorders, 9 anxiety and posttraumatic stress disorder, 1 eating disorder, and 1 attention-deficit/hyperactivity disorder. In addition, 1 trial used a cross-diagnostic design, 7 trials included patients with a clinical diagnosis that was subsequently assessed and validated by the researchers, and 11 trials had a sample size above 100. Generally, large between-trial heterogeneity and multiple approaches to patient recruitment, diagnostic procedures, trial design, comparator, outcome measures, and analyses were identified. Only 5 trials published a trial protocol. Furthermore, 1 trial provided information regarding technological updates, and only 18 trials reported on the conflicts of interest. No trial addressed the ethical aspects of using smartphones in treatment.

CONCLUSIONS

This first systematic review of the methodological challenges in designing and conducting RCTs investigating smartphone-based treatment in psychiatric patients suggests an increasing number of trials but with a lower quality compared with classic medical RCTs. Heterogeneity and methodological issues in individual trials limit the evidence. Methodological recommendations are presented.

A systematic review of mobile health interventions in China: Identifying gaps in care

INTRODUCTION

Mobile health has a promising future in the healthcare system in most developed countries. China's rapidly developing mobile technology infrastructure offers an unprecedented opportunity for wide adoption of mobile health interventions in the delivery of effective and timely healthcare services. However, there is little data on the current extent of the mobile health landscape in China. The aim of this study was to systematically review the existing mobile health initiatives in China, characterise the technology used, disease categories targeted, location of the end user (urban versus rural), and examine the potential effects of mobile health on health system strengthening in China. Furthermore, we identified gaps in development and evaluation of the effectiveness of mobile health interventions.

METHODS

A systematic review of the literature published from 18 December 2015 - 3 April 2019 was conducted and yielded 2863 articles from English and Chinese retrieval database and trial registries, including PubMed, EMBASE, China National Knowledge of Infrastructure and World Health Organization International Clinical Trials Registry Platform. Studies were included if they used mobile health to support patient healthcare outcomes.

RESULTS

A total of 1129 full-text articles were assessed and 338 were included in this study. The review found that most studies targeted client education and behaviour change via applications (apps) (65.4%), including WeChat, and text messaging (short text messages) (19.8%) to improve patient medical treatment outcomes such as compliance and appointment reminders. The most common disease-specific mobile health interventions focused primarily on chronic disease management and behaviour change in cardiology (13.3%), endocrinology/diabetes (12.1%), behavioural health (11.8%), oncology (11.2%) and neurology (6.8%). The mobile health interventions related to nutrition (0.6%) and chronic respiratory diseases (1.6%) are underrepresented in mobile health in comparison to the burden of disease in China. The majority (90.0%) of the mobile health interventions were conducted exclusively in urban areas, with few opportunities reaching rural populations.

CONCLUSIONS

Overall, mobile health has a promising future in China, with recent rapid growth in initiatives. The majority are focused on education and behaviour change in the realm of chronic diseases and target patients in urban areas. The imbalance in mobile health between the urban and rural areas, as well as between population disease spectrum and health service delivery, pose substantial dilemmas. However, mobile health may be redirected to correct this imbalance, possibly improving access to healthcare services, and filling the gaps in order to improve health equity for the underserved populations in China.

Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

Background

Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.

Methods

Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.

Results

Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.

Conclusions

Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.

Implementations of a text-message intervention to increase linkage from the emergency department to outpatient treatment for substance use disorders

AIM

To determine acceptability and explore potential usefulness of a text messaging (SMS) program aimed at increasing attendance at outpatient treatment for substance use disorders (SUD) after emergency department (ED) referral.

METHOD

A retrospective analysis of 377 adult patients from 2 urban EDs seeking treatment for SUD (opioids (n = 168), alcohol (n = 188), benzodiazepines (n = 21)) referred to outpatient treatment and offered an SMS program which included daily (1) motivational messages focused on positive thinking, (2) ecological momentary assessments (EMA) related to craving with tailored behavioral strategy messages, (3) EMA of drug use with tailored feedback to reduce abstinence violation effects, and (4) reminders about treatment location and phone number. We assessed acceptability by examining opt-in rates, EMA completion rates over the first week and end-of-program qualitative feedback. We assessed how individuals who opt in differ in outcomes from those who opt out by examining rates of outpatient SUD treatment attendance recorded from the medical record.

RESULTS

167 patients (44%) opted in to the SMS program. Over 7 days, around 33% of EMA were completed. Median helpfulness score was 8 (IQR 6 to 10) out of 10 and 84% would recommend the SMS program to someone else. Individuals who opted in to the SMS program had higher rates of SUD treatment initiation than individuals who did not opt-in (70.7% vs. 40.9%).

CONCLUSIONS

We found evidence supporting acceptability and potential usefulness of an automated text message program to assist treatment attendance for some individuals with SUDs discharged from the ED. A controlled trial is needed to examine whether SMS program exposure is associated with improved treatment attendance compared to standard care.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of the breadth of research studies published from April 2017 to April 2018 on mobile-based interventions for mental health, with a special emphasis on smartphone-based interventions.

RECENT FINDINGS

Several studies during the review period have described the process of applying user-centred design in the development of mental health apps and novel approaches to enhance user-engagement. Studies on consumer perspectives indicate largely positive findings about open-ness to utilize mental health apps. There is a scarcity of similar studies on health providers. Efficacy studies have provided evidence for apps for a variety of psychiatric disorders. There are fewer studies on preventive and promotive interventions. Although a plethora of mental health apps is available for public, most have not undergone scientific evaluation. Many well researched apps are not accessible to public. The potential of smartphone technology in enhancing healthcare service delivery in low-resource settings has also been examined in a few studies.

SUMMARY

Evidence for acceptability, feasibility and efficacy of mobile-based mental health interventions for facilitating recovery is on the rise. More research is needed on implementation and integration of these interventions in diverse real-world clinical and community contexts.

Portable System for Real-Time Detection of Stress Level

Currently, mental stress is a major problem in our society. It is related to a wide variety of diseases and is mainly caused by daily-life factors. The use of mobile technology for healthcare purposes has dramatically increased during the last few years. In particular, for out-of-lab stress detection, a considerable number of biosignal-based methods and systems have been proposed. However, these approaches have not matured yet into applications that are reliable and useful enough to significantly improve people’s quality of life. Further research is needed. In this paper, we propose a portable system for real-time detection of stress based on multiple biosignals such as electroencephalography, electrocardiography, electromyography, and galvanic skin response. In order to validate our system, we conducted a study using a previously published and well-established methodology. In our study, ten subjects were stressed and then relaxed while their biosignals were simultaneously recorded with the portable system. The results show that our system can classify three levels of stress (stress, relax, and neutral) with a resolution of a few seconds and 86% accuracy. This suggests that the proposed system could have a relevant impact on people’s lives. It can be used to prevent stress episodes in many situations of everyday life such as work, school, and home.