Implementation strategies for digital mental health interventions in health care settings

Online photography intervention reduces internet addiction during COVID-19: A randomised controlled trial

The COVID-19 pandemic has escalated concerns regarding internet addiction. This study investigated the impact of an online photograph intervention on internet addiction and identified its effectiveness mechanisms. Individuals diagnosed with internet addiction (internet addiction test score > 36, Mage = 22.85, 78.6% women) were randomly allocated to either the intervention (n = 64) or control (n = 81) groups. For 10 days, the intervention group was tasked with photographing "things that make you feel a sense of control in life" and writing 100-word descriptions explaining the reason for the sense of control elicited by the image. Meanwhile, the control group participated only in the assessments. Assessments were conducted before the intervention, immediately afterward and 7 days later. A significant interaction between group and time was observed, with the intervention group showing a notable reduction in internet addiction and an increase in sense of control. The sense of control at post-test significantly mediated the intervention's effect on reducing internet addiction at follow-up, but only among individuals with high perceived social support. The findings indicate that online photography interventions can effectively diminish internet addiction, with a sense of control acting as a potent mechanism for intervention, particularly in individuals with substantial perceived social support.

Effectiveness of a Web-Based Cognitive Behavioral Self-Help Intervention for Binge Eating Disorder: A Randomized Clinical Trial

Importance

Binge eating disorder (BED) is one of the most frequent eating pathologies and imposes substantial emotional and physical distress, yet insufficient health care resources limit access to specialized treatment. Web-based self-help interventions emerge as a promising solution, offering more accessible care.

Objective

To examine the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with BED.

Design, Setting, and Participants

This 2-arm, parallel-group randomized clinical trial conducted from January 15, 2021, to August 3, 2022, in Germany and other German-speaking countries enrolled patients aged 18 to 65 years who met the diagnostic criteria for BED (according to the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]). Data analysis occurred between January 27 and September 4, 2023, following our statistical analysis plan.

Interventions

Participants were randomized to a web-based self-help intervention or a waiting-list control condition.

Main Outcomes and Measures

The primary outcome was a change in objective binge eating episodes from baseline to after treatment. Secondary outcomes included global eating pathology, clinical impairment, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation.

Results

A total of 1602 patients were screened, of whom 154 (mean [SD] age, 35.93 [10.59] years; 148 female [96.10%]) fulfilled the criteria for BED and were randomized (77 each to the intervention and control groups). The web-based intervention led to significant improvements in binge eating episodes (Cohen d, -0.79 [95% CI, -1.17 to -0.42]; P < .001), global eating psychopathology (Cohen d, -0.71 [95% CI, -1.07 to -0.35]; P < .001), weekly binge eating (Cohen d, -0.49 [95% CI, -0.74 to -0.24]; P < .001), clinical impairment (Cohen d, -0.75 [95% CI, -1.13 to -0.37]; P < .001), well-being (Cohen d, 0.38 [95% CI, 0.01 to 0.75]; P = .047), depression (Cohen d, -0.49 [95% CI, -0.86 to -0.12]; P = .01), anxiety (Cohen d, -0.37 [95% CI, -0.67 to -0.07]; P = .02), self-esteem (Cohen d, 0.36 [95% CI, 0.13 to 0.59]; P = .003), and emotion regulation (difficulties: Cohen d, -0.36 [95% CI, -0.65 to -0.07]; P = .01 and repertoire: Cohen d, 0.52 [95% CI, 0.19 to 0.84]; P = .003).

Conclusion and Relevance

In this randomized clinical trial of a web-based self-help intervention for patients with BED, the findings confirmed its effectiveness in reducing binge eating episodes and improving various mental health outcomes, highlighting a scalable solution to bridge the treatment gap for this condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT04876183.

AI-Led Mental Health Support (Wysa) for Health Care Workers During COVID-19: Service Evaluation

BACKGROUND

The impact that the COVID-19 pandemic has had on health care workers' mental health, in particular, cannot be ignored. Not only did the pandemic exacerbate mental health challenges through elevated stress, anxiety, risk of infection, and social isolation, but regulations to minimize infection additionally hindered the conduct of traditional in-person mental health care.

OBJECTIVE

This study explores the feasibility of using Wysa, an artificial intelligence-led mental health app, among health care workers.

METHODS

A national tertiary health care cluster in Singapore piloted the use of Wysa among its own health care workers to support the management of their mental well-being during the pandemic (July 2020-June 2022). The adoption of this digital mental health intervention circumvented the limitations of in-person contact and enabled large-scale access to evidence-based care. Rates and patterns of user engagement were evaluated.

RESULTS

Overall, the opportunity to use Wysa was well-received. Out of the 527 staff who were onboarded in the app, 80.1% (422/527) completed a minimum of 2 sessions. On average, users completed 10.9 sessions over 3.80 weeks. The interventions most used were for sleep and anxiety, with a strong repeat-use rate. In this sample, 46.2% (73/158) of health care workers reported symptoms of anxiety (Generalized Anxiety Disorder Assessment-7 [GAD-7]), and 15.2% (24/158) were likely to have symptoms of depression (Patient Health Questionnaire-2 [PHQ-2]).

CONCLUSIONS

Based on the present findings, Wysa appears to strongly engage those with none to moderate symptoms of anxiety. This evaluation demonstrates the viability of implementing Wysa as a standard practice among this sample of health care workers, which may support the use of similar digital interventions across other communities.

Application of 'Readiness for Change' concept within implementation of evidence-based mental health interventions globally: protocol for a scoping review

Background

Concerning the growing burden of mental illnesses globally, there has been an increased investment into the implementation of evidence-based mental health interventions (EBmhIs) in routine care settings. However, the uptake and implementation of these EBmhIs has faced challenges in the real-world context. Among the many barriers and facilitators of implementation of EBmhIs identified by implementation science frameworks, evidence on the role of readiness for change (RFC) remains sparse. RFC constitutes the willingness and perceived capacity of stakeholders across an organization to implement a new practice. Theoretically, RFC has been defined at organizational, group, and individual levels, however, its conceptualization and operationalization across all these levels have differed in studies on the implementation of EBmhIs. By conducting a scoping review, we aim to examine the literature on RFC within the implementation of EBmhIs.

Methods

This scoping review will be conducted following the PRISMA-ScR guidelines. Iterative review stages will include a systematic and comprehensive search through four electronic databases (PubMed, Web of Science, Embase, and PsycINFO), selecting studies, charting data, and synthesizing the results. English-language studies meeting the inclusion criteria will be screened independently by two reviewers.

Discussion

This review will synthesize knowledge on the conceptualization of RFC across organizational, group, and individual levels within the implementation of EBmhIs. In addition, it will identify how RFC has been measured in these studies and summarize the reported evidence on its impact on the implementation of EBmhIs.

Conclusions

This review will assist mental health researchers, implementation scientists, and mental health care providers to gain a better understanding of the state of research on RFC within the implementation of EBmhIs.

Registration

The final protocol was registered with the Open Science Framework on October 21, 2022 ( https://osf.io/rs5n7).

Factors influencing the successful implementation of a novel digital health application to streamline multidisciplinary communication across multiple organisations for emergency care

RATIONALE

Delivering optimal patient health care requires interdisciplinary clinician communication. A single communication tool across multiple pre-hospital and hospital settings, and between hospital departments is a novel solution to current systems. Fit-for-purpose, secure smartphone applications allow clinical information to be shared quickly between health providers. Little is known as to what underpins their successful implementation in an emergency care context.

AIMS

To identify (a) whether implementing a single, digital health communication application across multiple health care organisations and hospital departments is feasible; (b) the barriers and facilitators to implementation; and (c) which factors are associated with clinicians' intentions to use the technology.

METHODS

We used a multimethod design, evaluating the implementation of a secure, digital communication application (Pulsara™). The technology was trialled in two Australian regional hospitals and 25 Ambulance Victoria branches (AV). Post-training, clinicians involved in treating patients with suspected stroke or cardiac events were administered surveys measuring perceived organisational readiness (Organisational Readiness for Implementing Change), clinicians' intentions (Unified Theory of Acceptance and Use of Technology) and internal motivations (Self-Determination Theory) to use Pulsara™, and the perceived benefits and barriers of use. Quantitative data were descriptively summarised with multivariable associations between factors and intentions to use Pulsara™ examined with linear regression. Qualitative data responses were subjected to directed content analysis (two coders).

RESULTS

Participants were paramedics (n = 82, median 44 years) or hospital-based clinicians (n = 90, median 37 years), with organisations perceived to be similarly ready. Regression results (F(11, 136) = 21.28, p = <0.001, Adj R2  = 0.60) indicated Habit, Effort Expectancy, Perceived Organisational Readiness, Performance Expectancy and Organisation membership (AV) as predictors of intending to use Pulsara™. Themes relating to benefits (95% coder agreement) included improved communication, procedural efficiencies and faster patient care. Barriers (92% coder agreement) included network accessibility and remembering passwords. PulsaraTM was initiated 562 times.

CONCLUSION

Implementing multiorganisational, digital health communication applications is feasible, and facilitated when organisations are change-ready for an easy-to-use, effective solution. Developing habitual use is key, supported through implementation strategies (e.g., hands-on training). Benefits should be emphasised (e.g., during education sessions), including streamlining communication and patient flow, and barriers addressed (e.g., identify champions and local technical support) at project commencement.

Effect of digital based nursing intervention on knowledge of self-care behaviors and self-efficacy of adult clients with diabetes

BACKGROUND

In recent years, there has been growing interest in the use of Digital Based Nursing Intervention to support diabetes management. This study aimed to evaluate the effect of digital based nursing intervention on knowledge of self-care behaviors and self-efficacy of clients with diabetes.

METHODS

Employing a quasi-experimental design, a sample of 120 adult participants diagnosed with type 2 diabetes, aged more than 18 years with focus on older adults was drawn from outpatient clinics at Cairo University Hospital. The intervention was approved and registered by the ethical committee of the faculty of nursing with IRB number: RHDIRB2019041701. The intervention group (n = 60) received a digital-based nursing intervention, while the control group (n = 60) received standard care. Data were collected using adopted standardized tools including the Diabetes Knowledge Test, the Diabetes Self-Efficacy Scale, and the Summary of Diabetes Self-Care Activities. Demographic characteristics were analyzed, and pre- and post-intervention scores were compared using paired t-tests were statistical methods.

RESULTS

The digital-based nursing intervention resulted in significant enhancements in participants with diabetes knowledge and self-efficacy levels. Moreover, the intervention group demonstrated marked improvements in various self-care behaviors encompassing diet, exercise, medication adherence, blood glucose testing, and foot care. While the control group also exhibited some progress, the effects were less pronounced. Regression analyses highlighted age as a consistent factor associated with knowledge, self-efficacy, and specific self-care behaviors.

CONCLUSION

This study underscores the potential of tailored digital nursing interventions to complement traditional care approaches, empowering patients with type 2 diabetes to actively engage in self-management. The findings suggest that digital-based nursing interventions hold promise for enhancing patient knowledge, confidence, and proactive health behaviors. Nevertheless, limitations, including the relatively short intervention duration and a sample from a single clinic, warrant consideration. Future research should address these limitations to bolster the validity and applicability of the study's conclusions.

Development, piloting and evaluation of an app-supported psychosocial prevention intervention to strengthen participation in working life: a study protocol of a mixed-methods approach

INTRODUCTION

Rates of incapacity to work due to mental disorders have increased in many European countries. The consequences of persistent stress can impact individuals' physical and psychological well-being and gradually develop into chronic stress. Mental disorders or symptoms of burn-out syndrome can have severe consequences. Mental disorders leading to work incapacity significantly burden the health system. Prevention interventions can protect against burn-out, depression, anxiety and other mental health disorders. Digital health is a promising approach to increase the utilisation of effective prevention interventions. This mixed-methods study evaluates a newly developed app-supported psychosocial prevention intervention called 'RV Fit Mental Health' to strengthen participation in working life.

METHODS AND ANALYSIS

The study uses a three-stage parallel mixed-methods design. This study accompanies the development (stage 1), piloting (stage 2) and evaluation (stage 3) of the new intervention. Within the stages, there is a quantitative as well as a qualitative research strand. Employed persons with an incipient mental disorder will be included. Additionally, experts within the project or connected areas will be included. Quantitative data will be analysed using multifactorial variance analyses in a pre-post design. Qualitative data will be analysed using qualitative content analysis. The study is a comprehensive research approach to investigate the development, piloting and evaluation of an app-supported psychosocial app-based prevention intervention. The rigour of the study will be achieved through data triangulation.

ETHICS AND DISSEMINATION

All participants will receive detailed study information and give written informed consent before data collection. Ethical approval was obtained from the Technical University of Munich Ethics Committee. All data collection will follow all legislative rules regarding data protection, also following the Declaration of Helsinki. The study results will be disseminated in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBERS

DRKS00030818 and DRKS00033080.

Effectiveness-implementation hybrid trial of Spanish language, digital cognitive-behavioral therapy (dCBT) intervention for depression and anxiety - protocol for the SUPERA (SUpport from PEeRs to expand Access) study

BACKGROUND

Limited English Proficiency (LEP) Latinxs experience a longer duration of untreated depression and anxiety. LEP Latinxs have difficulty accessing mental healthcare due to insufficient Spanish-speaking behavioral/mental health clinicians to meet demand. These under-resourced healthcare systems are less likely to be the site for the implementation of innovations. Digital interventions can provide an effective option for overcoming these barriers; yet, when digital evidence-based treatments are available, uptake and engagement is often low. This manuscript presents the protocol for the SUPERA (SUpport from PEeRs to expand Access) study which will evaluate the implementation of an evidence-based, Spanish language, digital cognitive-behavioral therapy (dCBT) intervention (i.e., SilverCloud) in safety-net primary care clinics for LEP Latinx patients with depression or anxiety.

METHODS

We will conduct an effectiveness-implementation hybrid trial (Type 2) design comparing engagement and clinical outcomes in two modalities of dCBT delivery (peer-supported vs. unsupported). We will also compare provider-level outreach (using a clinic patient registry) versus inreach (traditional provider referral) to compare rates of initiation, completion, and cost. Participants will be 426 LEP Latinx adults ≥18 years of age, PHQ-9 ≥ 10 or GAD-7 ≥ 8, with access to the internet via smartphone, and not currently receiving individual psychotherapy. We will collect baseline, post-intervention (8 weeks), and follow up (3 months) data.

CONCLUSION

The long-term goal of this research is to aid in the implementation of digital mental health interventions that can be sustainably implemented in low-resourced settings, while reducing the reliance on professionals, overcoming workforce deficits, and increasing relevance for diverse populations.

Ethical considerations in using sensors to remotely assess pediatric health behaviors

Sensors, including accelerometer-based and electronic adherence monitoring devices, have transformed health data collection. Sensors allow for unobtrusive, real-time sampling of health behaviors that relate to psychological health, including sleep, physical activity, and medication-taking. These technical strengths have captured scholarly attention, with far less discussion about the level of human touch involved in implementing sensors. Researchers face several subjective decision points when collecting health data via sensors, with these decisions posing ethical concerns for users and the public at large. Using examples from pediatric sleep, physical activity, and medication adherence research, we pose critical ethical questions, practical dilemmas, and guidance for implementing health-based sensors. We focus on youth given that they are often deemed the ideal population for digital health approaches but have unique technology-related vulnerabilities and preferences. Ethical considerations are organized according to Belmont principles of respect for persons (e.g., when sensor-based data are valued above the subjective lived experiences of youth and their families), beneficence (e.g., with sensor data management and sharing), and justice (e.g., with sensor access and acceptability among minoritized pediatric populations). Recommendations include the need to increase transparency about the extent of subjective decision making with sensor data management. Without greater attention to the human factors involved in sensor research, ethical risks could outweigh the scientific promise of sensors, thereby negating their potential role in improving child health and care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Digital Mental Health Interventions: Differences in Diet Culture Intervention Framing

Diet culture is a societal norm that ranks thin bodies as superior to other body types and has been associated with negative outcomes, such as eating disorders. Wellness has evolved into a term that is often used to promote diet culture messages. One possible way to combat diet culture is through single-session, digital mental health interventions (DMHIs), which allow for increased access to brief public health treatments. The framing of DMHIs is critical to ensure that the target population is reached. Participants (N = 397) were enrolled in a single-session DMHI, which was framed as either a Diet Culture Intervention (n = 201) or a Wellness Resource (n = 196). Baseline group differences in eating disorder pathology, body image, weight stigma concerns, fat acceptance, and demographic characteristics were analyzed. Across groups, participants reported moderately high eating disorder pathology, low-to-moderate levels of body dissatisfaction, moderate levels of fat acceptance, and either very low or very high weight stigma concerns. Participants in the Diet Culture Intervention group reported higher levels of fat acceptance than those in the Wellness Resource group (p < 0.001). No other framing group differences were identified, though post hoc analyses revealed differences based on recruitment source (i.e., social media versus undergraduate research portal). This study found that framing a DMHI as targeting diet culture or as a Wellness Resource can result in the successful recruitment of individuals at risk of disordered eating. Framing a DMHI as a Wellness Resource may increase recruitment of individuals with low levels of fat acceptance, which may be particularly important for dismantling diet culture, disordered eating, and weight stigma concerns. Future research should assess DMHI framing in other populations, such as men and adolescents.

Exploring the psychosocial needs of persons with lower extremity amputation and feasibility of internet cognitive behavioural therapy: a qualitative study

PURPOSE

Following major lower extremity amputation (LEA), patients experience significant emotional distress and are at risk for anxiety and depression. There is a lack of mental health supports for this population, and internet-based cognitive behavioural therapy (iCBT) may be a useful resource to meet this need. The purpose of this study was to use a qualitative approach to explore the mental health needs of LEA patients and to gauge their attitudes of the use of iCBT to help them cope with their amputation.

METHODS

Semi-structured qualitative interviews were conducted with inpatients and outpatients with LEA recruited from a major urban rehabilitation hospital. Data were analysed using inductive codebook thematic analysis (TA).

RESULTS

Ten interviews were completed with individuals with LEA. The main themes identified were: (1) Fixating on the past; (2) Worry about the future; (3) Unmet mental health needs; (4) Barriers to Mental Health Support; (5) Importance of peer support; and (6) Tailoring iCBT.

CONCLUSIONS

Our findings highlight that patients with LEA are open to learning more about iCBT to meet their mental health needs. Key iCBT implementation considerations include taking into account issues of stigma associated with mental health, timing of delivery, levels of digital literacy, online security, and interactive content.IMPLICATIONS FOR REHABILITATIONFollowing lower extremity amputation (LEA), people experience significant emotional distress and are at risk for the development of anxiety and/or depression.Patients with LEA are receptive to an online mental health resource (i.e., internet-based cognitive behavioural therapy [iCBT]) but it needs to be tailored to meet the various mental health needs and digital literacy of the LEA population.The use of an implementation science approach can help identify factors related to the development and potential uptake of an iCBT for patients with LEA.

The Longitudinal Implementation Strategy Tracking System (LISTS): feasibility, usability, and pilot testing of a novel method

BACKGROUND

Systematic approaches are needed to accurately characterize the dynamic use of implementation strategies and how they change over time. We describe the development and preliminary evaluation of the Longitudinal Implementation Strategy Tracking System (LISTS), a novel methodology to document and characterize implementation strategies use over time.

METHODS

The development and initial evaluation of the LISTS method was conducted within the Improving the Management of SymPtoms during And following Cancer Treatment (IMPACT) Research Consortium (supported by funding provided through the NCI Cancer MoonshotSM). The IMPACT Consortium includes a coordinating center and three hybrid effectiveness-implementation studies testing routine symptom surveillance and integration of symptom management interventions in ambulatory oncology care settings. LISTS was created to increase the precision and reliability of dynamic changes in implementation strategy use over time. It includes three components: (1) a strategy assessment, (2) a data capture platform, and (3) a User's Guide. An iterative process between implementation researchers and practitioners was used to develop, pilot test, and refine the LISTS method prior to evaluating its use in three stepped-wedge trials within the IMPACT Consortium. The LISTS method was used with research and practice teams for approximately 12 months and subsequently we evaluated its feasibility, acceptability, and usability using established instruments and novel questions developed specifically for this study.

RESULTS

Initial evaluation of LISTS indicates that it is a feasible and acceptable method, with content validity, for characterizing and tracking the use of implementation strategies over time. Users of LISTS highlighted several opportunities for improving the method for use in future and more diverse implementation studies.

CONCLUSIONS

The LISTS method was developed collaboratively between researchers and practitioners to fill a research gap in systematically tracking implementation strategy use and modifications in research studies and other implementation efforts. Preliminary feedback from LISTS users indicate it is feasible and usable. Potential future developments include additional features, fewer data elements, and interoperability with alternative data entry platforms. LISTS offers a systematic method that encourages the use of common data elements to support data analysis across sites and synthesis across studies. Future research is needed to further adapt, refine, and evaluate the LISTS method in studies with employ diverse study designs and address varying delivery settings, health conditions, and intervention types.

Real-World Adoption of Mental Health Support Among Adolescents: Cross-Sectional Analysis of the California Health Interview Survey

OBJECTIVE

We aim to examine: (a) the extent to which patterns of adoption of counseling services and digital mental health interventions (DMHIs) shifted in recent years (2019-2021); (b) the impact of distress on adoption of mental health support; and (c) reasons related to adolescents' low adoption of DMHIs when experiencing distress.

METHODS

Data were from three cohorts of adolescents aged 12-17 years (n = 847 in 2019; n = 1,365 in 2020; n = 1,169 in 2021) recruited as part of the California Health Interview Survey. We estimated logistic regression models to examine the likelihood of using mental health support as a function of psychological distress, sociodemographic characteristics, and cohorts. We also analyzed adolescents' self-reported reasons for not trying DMHIs as a function of distress.

RESULTS

The proportion of adolescents reporting elevated psychological distress (∼50%) was higher than those adopting counseling services (<20%) or DMHIs (<10%). A higher level of distress was associated with a greater likelihood of receiving counseling (OR = 1.15), and using DMHIs to connect with a professional (Odds ratio (OR) = 1.11) and for self-help (OR = 1.17). Among those experiencing high distress, adolescents' top reason for not adopting an online tool was a lack of perceived need (19.2%).

CONCLUSION

Adolescents' main barriers to DMHI adoption included a lack of perceived need, which may be explained by a lack of mental health literacy. Thoughtful marketing and dissemination efforts are needed to increase mental health awareness and normalize adoption of counseling services and DMHIs.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals

BACKGROUND

Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability.

OBJECTIVE

This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration.

METHODS

We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems.

RESULTS

Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration.

CONCLUSIONS

Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

Comparing the Acceptability and Quality of Intervention Modalities for Suicidality in the Emergency Department: Randomized Feasibility Trial

BACKGROUND

Emergency departments (EDs) manage many patients with suicide risk, but effective interventions for suicidality are challenging to implement in this setting. ReachCare is a technology-facilitated version of an evidence-based intervention for suicidal ED patients. Here, we present findings on the acceptability and quality of ReachCare in the ED, as well as a comparison of these measures across 3 potential delivery modalities.

OBJECTIVE

Our aim was to test the feasibility of the ReachCare intervention in its entirety through conducting a pilot study with patients presenting with suicidality to the ED. We tested three different ways of receiving the ED-based components of ReachCare: (1) self-administered on the tablet app using a chatbot interface, (2) administered by an in-person clinician, or (3) administered by a telehealth clinician.

METHODS

In total, 47 ED patients who screened positive for suicide risk were randomly allocated to receive one of three delivery modalities of ReachCare in the ED: (1) self-administered on the patient-facing tablet app with a chatbot interface, (2) delivered by an in-person clinician, or (3) delivered by a telehealth clinician, with the latter two using a clinician-facing web app. We measured demographic and clinical characteristics, acceptability and appropriateness of the intervention, and quality and completeness of the resulting safety plans.

RESULTS

Patients assigned high ratings for the acceptability (median 4.00/5, IQR 4.00-4.50) and appropriateness (median 4.00/5, IQR 4.00-4.25) of ReachCare's ED components, and there were no substantial differences across the 3 delivery modalities [H(acceptability)=3.90, P=.14; H(appropriateness)=1.05, P=.59]. The self-administered modality took significantly less time than the 2 clinician modalities (H=27.91, P<.001), and the usability of the self-administered version was in the "very high" range (median 93.75/100, IQR 80.00-97.50). The safety plans created across all 3 modalities were high-quality (H=0.60, P=.74).

CONCLUSIONS

Patients rated ReachCare in the ED as highly acceptable and appropriate regardless of modality. Self-administration may be a feasible way to ensure patients with suicide risk receive an intervention in resource constrained EDs. Limitations include small sample size and demographic differences between those enrolled versus not enrolled. Further research will examine the clinical outcomes of patients receiving both the in-ED and post-ED components of ReachCare.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04720911; https://clinicaltrials.gov/ct2/show/NCT04720911.

Biofeedback-Based Videogames: Fostering Emotion Regulation at a Diverse Community Summer Camp

Implementing nonstigmatized mental health interventions and tools within community programs serving diverse populations may reduce inequities in access to mental health care and preventative emotional learning. One potentially impactful tool is Mightier, a heart rate biofeedback-based videogame that aims to foster emotion regulation skills and practice through game play. In a randomized controlled trial, the present study evaluated the efficacy of Mightier when utilized in a community setting. Seventy-two children (ages 7-12) from a low-cost community summer camp were randomly assigned to play Mightier for 6 weeks or continue camp activities as usual. All campers participated in biweekly social and emotional learning groups. Participants exhibited significantly greater levels of adaptive emotion regulation and lower levels of emotional dysregulation, internalizing symptoms, and externalizing behaviors after the intervention. Caregivers of participants in the intervention group also reported significantly less parenting-related stress after the intervention. When incorporated into community programs, biofeedback-based videogames can foster emotional intelligence competencies in children without access to traditional mental health services.

"Our Job is to be so Temporary": Designing Digital Tools that Meet the Needs of Care Managers and their Patients with Mental Health Concerns

Digital tools have potential to support collaborative management of mental health conditions, but we need to better understand how to integrate them in routine healthcare, particularly for patients with both physical and mental health needs. We therefore conducted interviews and design workshops with 1) a group of care managers who support patients with complex health needs, and 2) their patients whose health needs include mental health concerns. We investigate both groups' views of potential applications of digital tools within care management. Findings suggest that care managers felt underprepared to play an ongoing role in addressing mental health issues and had concerns about the burden and ambiguity of providing support through new digital channels. In contrast, patients envisioned benefiting from ongoing mental health support from care managers, including support in using digital tools. Patients' and care managers' needs may diverge such that meeting both through the same tools presents a significant challenge. We discuss how successful design and integration of digital tools into care management would require reconceptualizing these professionals' roles in mental health support.

The Development of Game-Based Digital Mental Health Interventions: Bridging the Paradigms of Health Care and Entertainment

Game elements are increasingly used to improve user engagement in digital mental health interventions, and specific game mechanics may yield therapeutic effects per se and thereby contribute to digital mental health intervention efficacy. However, only a few commercial game-based interventions are available. We suggest that the key challenge in their development reflects the tension between the 2 underlying paradigms, health care and entertainment, which have disparate goals and processes in digital development. We describe 3 approaches currently used to negotiate the 2 paradigms: the gamification of health care software, designing serious games, and purpose shifting existing entertainment games. We advanced an integrative framework to focus attention on 4 key themes in intervention development: target audience, engagement, mechanisms of action, and health-related effectiveness. On each theme, we show how the 2 paradigms contrast and can complement each other. Finally, we consider the 4 interdependent themes through the new product development phases from concept to production. Our viewpoint provides an integrative synthesis that facilitates the research, design, and development of game-based digital mental health interventions.

The engagement problem: A review of engagement with digital mental health interventions and recommendations for a path forward

Purpose of the review

Digital mental health interventions (DMHIs) are an effective and accessible means of addressing the unprecedented levels of mental illness worldwide. Currently, however, patient engagement with DMHIs in real-world settings is often insufficient to see clinical benefit. In order to realize the potential of DMHIs, there is a need to better understand what drives patient engagement.

Recent findings

We discuss takeaways from the existing literature related to patient engagement with DMHIs and highlight gaps to be addressed through further research. Findings suggest that engagement is influenced by patient-, intervention- and systems-level factors. At the patient-level, variables such as sex, education, personality traits, race, ethnicity, age and symptom severity appear to be associated with engagement. At the intervention-level, integrating human support, gamification, financial incentives and persuasive technology features may improve engagement. Finally, although systems-level factors have not been widely explored, the existing evidence suggests that achieving engagement will require addressing organizational and social barriers and drawing on the field of implementation science.

Summary

Future research clarifying the patient-, intervention- and systems-level factors that drive engagement will be essential. Additionally, to facilitate improved understanding of DMHI engagement, we propose the following: (a) widespread adoption of a minimum necessary 5-element engagement reporting framework; (b) broader application of alternative clinical trial designs; and (c) directed efforts to build upon an initial parsimonious conceptual model of DMHI engagement.

Scaling and sustaining COVID-19 vaccination through meaningful community engagement and care coordination for underserved communities: hybrid type 3 effectiveness-implementation sequential multiple assignment randomized trial

BACKGROUND

COVID-19 inequities are abundant in low-income communities of color. Addressing COVID-19 vaccine hesitancy to promote equitable and sustained vaccination for underserved communities requires a multi-level, scalable, and sustainable approach. It is also essential that efforts acknowledge the broader healthcare needs of these communities including engagement in preventive services.

METHODS

This is a hybrid type 3 effectiveness-implementation study that will include a multi-level, longitudinal, mixed-methods data collection approach designed to assess the sustained impact of a co-created multicomponent strategy relying on bidirectional learning, shared decision-making, and expertise by all team members. The study capitalizes on a combination of implementation strategies including mHealth outreach with culturally appropriate messaging, care coordination to increase engagement in high priority preventive services, and the co-design of these strategies using community advisory boards led by Community Weavers. Community Weavers are individuals with lived experience as members of an underserved community serving as cultural brokers between communities, public health systems, and researchers to co-create community-driven, culturally sensitive public health solutions. The study will use an adaptive implementation approach operationalized in a sequential multiple assignment randomized trial design of 300 participants from three sites in a Federally Qualified Health Center in Southern California. This design will allow examining the impact of various implementation strategy components and deliver more intensive support to those who benefit from it most. The primary effectiveness outcomes are COVID-19 vaccine completion, engagement in preventive services, and vaccine confidence. The primary implementation outcomes are reach, adoption, implementation, and maintenance of the multicomponent strategy over a 12-month follow-up period. Mixed-effects logistic regression models will be used to examine program impacts and will be triangulated with qualitative data from participants and implementers.

DISCUSSION

This study capitalizes on community engagement, implementation science, health equity and communication, infectious disease, and public health perspectives to co-create a multicomponent strategy to promote the uptake of COVID-19 vaccination and preventive services for underserved communities in San Diego. The study design emphasizes broad engagement of our community and clinic partners leading to culturally sensitive and acceptable strategies to produce lasting and sustainable increases in vaccine equity and preventive services engagement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05841810 May 3, 2023.

Provision of Digital Health Technologies for Opioid Use Disorder Treatment by US Health Care Organizations

Importance

Digital health technologies may expand organizational capacity to treat opioid use disorder (OUD). However, it remains unclear whether these technologies serve as substitutes for or complements to traditional substance use disorder (SUD) treatment resources in health care organizations.

Objective

To characterize the use of patient-facing digital health technologies for OUD by US organizations with accountable care organization (ACO) contracts.

Design, Setting, and Participants

This cross-sectional study analyzed responses to the 2022 National Survey of Accountable Care Organizations (NSACO), collected between October 1, 2021, and June 30, 2022, from US organizations with Medicare and Medicaid ACO contracts. Data analysis was performed between December 15, 2022, and January 6, 2023.

Exposures

Treatment resources for SUD (eg, an addiction medicine specialist, sufficient staff to treat SUD, medications for OUD, a specialty SUD treatment facility, a registry to identify patients with OUD, or a registry to track mental health for patients with OUD) and organizational characteristics (eg, organization type, Medicaid ACO contract).

Main Outcomes and Measures

The main outcomes included survey-reported use of 3 categories of digital health technologies for OUD: remote mental health therapy and tracking, virtual peer recovery support programs, and digital recovery support for adjuvant cognitive behavior therapy (CBT). Statistical analysis was conducted using descriptive statistics and multivariable logistic regression models.

Results

Overall, 276 of 505 organizations responded to the NSACO (54.7% response rate), with a total of 304 respondents. Of these, 161 (53.1%) were from a hospital or health system, 74 (24.2%) were from a physician- or medical group-led organization, and 23 (7.8%) were from a safety-net organization. One-third of respondents (101 [33.5%]) reported that their organization used at least 1 of the 3 digital health technology categories, including remote mental health therapy and tracking (80 [26.5%]), virtual peer recovery support programs (46 [15.1%]), and digital recovery support for adjuvant CBT (27 [9.0%]). In an adjusted analysis, organizations with an addiction medicine specialist (average marginal effect [SE], 32.3 [4.7] percentage points; P < .001) or a registry to track mental health (average marginal effect [SE], 27.2 [3.8] percentage points; P < .001) were more likely to use at least 1 category of technology compared with otherwise similar organizations lacking these capabilities.

Conclusions and Relevance

In this cross-sectional study of 276 organizations with ACO contracts, organizations used patient-facing digital health technologies for OUD as complements to available SUD treatment capabilities rather than as substitutes for unavailable resources. Future studies should examine implementation facilitators to realize the potential of emerging technologies to support organizations facing health care practitioner shortages and other barriers to OUD treatment delivery.

Minimal Effect of Messaging on Engagement in a Digital Anxiety Intervention

This study evaluated the effectiveness of different recruitment messages for encouraging enrollment in a digital mental health intervention (DMHI) for anxiety among 1,600 anxious patients in a large healthcare system. Patients were randomly assigned to receive a standard message, or one of five messages designed to encourage enrollment: Three messages offered varying financial incentives, one message offered coaching, and one message provided consumer testimonials. Patients could then click a link in the message to visit the DMHI website, enroll, and start the first session. We examined the effects of message features and message length (short vs. long) on rates of site clicks, enrollment, and starting the first session. We also tested whether demographic and clinical factors derived from patients' electronic health records were associated with rates of enrollment and starting the first session to understand the characteristics of patients most likely to use DMHIs in this setting. Across messages, 19.4% of patients clicked a link to visit the DMHI website, but none of the messages were significantly associated with rates of site clicks, enrollment, or starting the first session. Females (vs. males) had a greater probability of enrollment. No other demographic or clinical variables were significantly associated with enrollment or starting the first session. Findings provide guidance for resource allocation decisions in larger scale DMHI implementations in healthcare settings.

Facilitators of and Barriers to Integrating Digital Mental Health Into County Mental Health Services: Qualitative Interview Analyses

BACKGROUND

Digital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts.

OBJECTIVE

This paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors.

METHODS

This study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework.

RESULTS

On the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate.

CONCLUSIONS

The successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Implementation and workflow strategies for integrating digital therapeutics for alcohol use disorders into primary care: a qualitative study

BACKGROUND

Alcohol use disorders (AUD) are prevalent and often go untreated. Patients are commonly screened for AUD in primary care, but existing treatment programs are failing to meet demand. Digital therapeutics include novel mobile app-based treatment approaches which may be cost-effective treatment options to help fill treatment gaps. The goal of this study was to identify implementation needs and workflow design considerations for integrating digital therapeutics for AUD into primary care.

METHODS

We conducted qualitative interviews with clinicians, care delivery leaders, and implementation staff (n = 16) in an integrated healthcare delivery system in the United States. All participants had experience implementing digital therapeutics for depression or substance use disorders in primary care. Interviews were designed to gain insights into adaptations needed to optimize existing clinical processes, workflows, and implementation strategies for use with alcohol-focused digital therapeutics. Interviews were recorded and transcribed and then analyzed using a rapid analysis process and affinity diagramming.

RESULTS

Qualitative themes were well represented across health system staff roles. Participants were enthusiastic about digital therapeutics for AUD, anticipated high patient demand for such a resource, and made suggestions for successful implementation. Key insights regarding the implementation of digital therapeutics for AUD and unhealthy alcohol use from our data include: (1) implementation strategy selection must be driven by digital therapeutic design and target population characteristics, (2) implementation strategies should seek to minimize burden on clinicians given the large numbers of patients with AUD who are likely to be interested in and eligible for digital therapeutics, and (3) digital therapeutics should be offered alongside many other treatment options to accommodate individual patients' AUD severity and treatment goals. Participants also expressed confidence that previous implementation strategies used with other digital therapeutics such as clinician training, electronic health record supports, health coaching, and practice facilitation would be effective for the implementation of digital therapeutics for AUD.

CONCLUSIONS

The implementation of digital therapeutics for AUD would benefit from careful consideration of the target population. Optimal integration requires tailoring workflows to meet anticipated patient volume and designing workflow and implementation strategies to meet the unique needs of patients with varying AUD severity.

Integrating digital interventions with clinical practice in youth mental health services

OBJECTIVE

Integrating digital technologies with clinical practice promises to improve access and enhance care in the context of high service demand and constrained capacity.

METHOD

We outline the emerging research in the integration of digital tools in clinical care, known as blended care, and provide case examples of mental health technology platforms currently in use, summarise findings regarding novel technologies such as virtual reality, and outline real-world implementation challenges and potential solutions.

RESULTS

Recent evidence shows that blended care approaches are clinically effective and improve service efficiency. Youth-specific technologies such as moderated online social therapy (MOST) are achieving a range of positive clinical and functional outcomes, while emerging technologies like virtual reality have strong evidence in anxiety disorder, and accumulating evidence in psychotic conditions. Implementation science frameworks show promise in helping overcome the common challenges faced in real-world adoption and ongoing use.

CONCLUSION

The integrated, blended use of digital mental health technologies with face-to-face clinical care has the potential to improve care quality for young people while helping overcome the growing challenges faced by youth mental health service providers.

Effectiveness and implementation of an electronic health record-integrated digital health intervention for managing depressive symptoms in ambulatory oncology: The My Well-Being Guide study rationale and protocol

BACKGROUND

Rates of clinically elevated depressive symptoms among ambulatory oncology patients are higher than in the general population and are associated with poorer health-related quality of life. Furthermore, a reduction in depressive symptoms may be associated with improved cancer survival. Several interventions have demonstrated efficacy in reducing oncologic depressive symptoms, including cognitive-behavioral stress management (CBSM). However, more work is needed to understand how to best implement CBSM into practice, such as through stepped-care approaches and digital health interventions linked to electronic health records (EHR). This manuscript presents the protocol of the My Well-Being Guide study, a pragmatic type 1 effectiveness-implementation hybrid study. This trial will test the effectiveness of My Well-Being Guide, a seven-week structured, CBSM-based digital health intervention designed to reduce depressive symptoms. This trial will also evaluate My Well-Being Guide's implementation across two health systems.

METHODS

The final sample (N = 4561) will be oncology patients at Northwestern Medicine or University of Miami Health System who are ≥18 years of age; have a cancer diagnosis; elevated depressive symptoms on the Patient-Reported Outcomes Measurement Information System Depression; and primary language is English or Spanish. Data collection will occur at baseline, and 2-, 6-, and 12-months post baseline. Outcome domains include depressive symptoms and implementation evaluation.

DISCUSSION

This study may provide valuable data on the effectiveness of our depressive symptom management digital health intervention linked to the EHR and the scalability of digital health interventions in general.

eHealth Use on Acute Inpatient Mental Health Units: Implementation Processes, Common Practices, and Barriers to Use

Information technology to promote health (eHealth) is an important and growing area of mental healthcare, yet little is known about the use of patient-facing eHealth in psychiatric inpatient settings. This quality improvement project examined the current practices, barriers, implementation processes, and contextual factors affecting eHealth use across multiple Veteran Health Administration (VHA) acute mental health inpatient units. Staff from units serving both voluntary and involuntary patients (n = 49 from 37 unique sites) completed surveys regarding current, desired, and barriers to use of Veteran-facing eHealth technologies. Two subsets of respondents were then interviewed (high success sites in eHealth use, n = 6; low success sites, n = 4) to better understand the context of their eHealth use. Survey responses indicated that 20% or less of Veterans were using any type of eHealth technology while inpatient. Tablets and video chat were the most desired overall and most successfully used eHealth technologies. However, many sites noted difficulty implementing these technologies (e.g., limited Wi-Fi access). Qualitative analysis of interviews revealed differences in risk/benefit analysis and implementation support between high and low success eHealth sites. Despite desired use, patient-facing eHealth technology is not regularly implemented on inpatient units due to multiple barriers (e.g., limited staffing, infrastructure needs). Successful implementation of patient-facing eHealth may require an internal champion, guidance from external supports with experience in successful eHealth use, workload balance for staff, and an overall perspective shift in the benefits to eHealth technology versus the risks.

Efficacy of a Therapist-Assisted Self-Help Internet-Based Intervention Targeting PTSD, Depression, and Insomnia Symptoms After a Disaster: A Randomized Controlled Trial

This study aimed at evaluating the efficacy of an online CBT intervention with limited therapist contact targeting a range of posttraumatic symptoms among evacuees from the 2016 Fort McMurray wildfires. One hundred and thirty-six residents of Fort McMurray who reported either moderate PTSD symptoms (PCL-5 ≥ 23) or mild PTSD symptoms (PCL-5 ≥ 10) with moderate depression (PHQ-9 ≥ 10) or subthreshold insomnia symptoms (ISI ≥ 8) were randomized either to a treatment (n = 69) or a waitlist condition (n = 67). Participants were on average 45 years old, and mostly identified as White (82%) and as women (76%). Primary outcomes were PTSD, depression, and insomnia symptoms. Secondary outcomes were anxiety symptoms and disability. Significant Assessment Time × Treatment Condition interactions were observed on all outcomes, indicating that access to the treatment led to a decrease in posttraumatic stress (F[1,117.04] = 12.128, p = .001; d = .519, 95% CI = .142-.895), depression (F[1,118.29] = 9.978, p = .002; d = .519, 95% CI = .141-.898) insomnia (F[1,117.60] = 4.574, p = .035; d = .512, 95% CI = .132-.892), and anxiety (F[1,119.64] = 5.465, p = .021; d = .421, 95% CI = .044-.797) symptom severity and disability (F[1,111.55] = 7.015, p = .009; d = .582, 95% CI = .200-.963). Larger effect sizes (d = 0.823-1.075) were observed in participants who completed at least half of the treatment. The RESILIENT online treatment platform was successful to provide access to specialized evidence-based mental health care after a disaster.

"Decoding MH"-A de-stigmatization campaign in the Hong Kong Police Force

Police officers are under high level of stress given the intense and emergent work nature. If left untreated, their mental wellbeing would be at risk and work performance compromised. However, mental health stigma is common among police officers and is perpetuated by factors like police cultures emphasizing toughness and self-reliance. In view of this, since 2016, the Hong Kong Police Force had launched a holistic campaign for Force members which was the first among law enforcement organizations in Hong Kong, aiming to reduce stigma, by enhancing mental health knowledge and decreasing negative attitudes and behaviors towards mental health issues. The programme incorporated standardised trainings of the Mental Health First Aid course with examples modified to the local police context, and psychoeducation via the use of digital medium and sharing by public figures. Positive feedback was received. It was foreseen that the campaign effects would increase Force members' awareness of their mental health, encourage help-seeking and facilitate officers' decision making when encountering crises in the community.

Preparing a Workforce of Care Coordinators to Address Patient Mental Health Needs in the Digital Age: Training and Needs Identification

Introduction

Care coordinators (CCs) are specialized healthcare providers and often the primary point of contact for patients with multiple medical and mental health comorbidities in integrated healthcare settings. Prior work shows CCs have lower comfort addressing mental health than physical health concerns. Digital mental health interventions can support CCs' management of patient mental health needs, but training gaps must be addressed prior to a digital mental health intervention's implementation.

Methods

As part of a quality improvement initiative, a 1-hour training focused on the assessment and management of depression and suicide-related thoughts and behaviors was delivered to CCs within a large midwestern healthcare system's Division of Ambulatory Care Coordination. CCs completed online surveys prior to and following the training.

Conclusion

Training resulted in increased comfort working with clinical populations, including patients who experience suicide-related thoughts and behaviors. Gains around screening for suicide risk were modest. Brief trainings for CCs can address training gaps, however, ongoing training and case consultation may also be indicated.

Digital mental health interventions for chronic serious mental illness: Findings from a qualitative study on usability and scale-up of the Life Goals app for bipolar disorder

The Life Goals (LG) application is an evidence-based self-management tool intended to help individuals with bipolar disorder (BD) by aligning symptom coping strategies with personal goals. The program has traditionally been offered in-person or via the web, but has recently been translated into an individualized, customizable mobile intervention to improve access to care and reduce provider burden. The LG app previously showed acceptability with ease of use and satisfaction with user interface, but less success in encouraging self-management. To better understand patient needs, our team conducted semi-structured interviews with 18 individuals with BD who used the LG app for 6 months. These interviews also investigated participant interest in sharing LG app data with their provider through an online dashboard. Using affinity mapping, a collaborative, qualitative data analysis technique, our team identified emerging common themes in the interviews. Through this process, team members identified 494 pieces of salient information from interviews that were mapped and translated into three main findings: (1) many participants found Mood Monitoring and LG modules helpful/interesting and stated the app overall had positive impacts on their mental health, (2) some components of the app were too rudimentary or impersonal to be beneficial, and (3) feedback was mixed regarding future implementation of an LG provider dashboard, with some participants seeing potential positive impacts and others hesitating due to perceived efficacy and privacy concerns. These findings can help researchers improve app-based interventions for individuals with BD by increasing app usage and improving care overall.

Do the Expert Recommendations for Implementing Change (ERIC) strategies adequately address sustainment?

Background

Sustainability science is an emerging area within implementation science. There is limited evidence regarding strategies to best support the continued delivery and sustained impact of evidence-based interventions (EBIs). To build such evidence, clear definitions, and ways to operationalize strategies specific and/or relevant to sustainment are required. Taxonomies and compilations such as the Expert Recommendations for Implementing Change (ERIC) were developed to describe and organize implementation strategies. This study aimed to adapt, refine, and extend the ERIC compilation to incorporate an explicit focus on sustainment. We also sought to classify the specific phase(s) of implementation when the ERIC strategies could be considered and applied.

Methods

We used a two-phase iterative approach to adapt the ERIC. This involved: (1) adapting through consensus (ERIC strategies were mapped against barriers to sustainment as identified via the literature to identify if existing implementation strategies were sufficient to address sustainment, needed wording changes, or if new strategies were required) and; (2) preliminary application of this sustainment-explicit ERIC glossary (strategies described in published sustainment interventions were coded against the glossary to identify if any further amendments were needed). All team members independently reviewed changes and provided feedback for subsequent iterations until consensus was reached. Following this, and utilizing the same consensus process, the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework was applied to identify when each strategy may be best employed across phases.

Results

Surface level changes were made to the definitions of 41 of the 73 ERIC strategies to explicitly address sustainment. Four additional strategies received deeper changes in their definitions. One new strategy was identified: Communicate with stakeholders the continued impact of the evidence-based practice. Application of the EPIS identified that at least three-quarters of strategies should be considered during preparation and implementation phases as they are likely to impact sustainment.

Conclusion

A sustainment-explicit ERIC glossary is provided to help researchers and practitioners develop, test, or apply strategies to improve the sustainment of EBIs in real-world settings. Whilst most ERIC strategies only needed minor changes, their impact on sustainment needs to be tested empirically which may require significant refinement or additions in the future.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

Engagement in digital interventions

The notion of "engagement," which plays an important role in various domains of psychology, is gaining increased currency as a concept that is critical to the success of digital interventions. However, engagement remains an ill-defined construct, with different fields generating their own domain-specific definitions. Moreover, given that digital interactions in real-world settings are characterized by multiple demands and choice alternatives competing for an individual's effort and attention, they involve fast and often impulsive decision-making. Prior research seeking to uncover the mechanisms underlying engagement has nonetheless focused mainly on psychological factors and social influences and neglected to account for the role of neural mechanisms that shape individual choices. This article aims to integrate theories and empirical evidence across multiple domains to define engagement and discuss opportunities and challenges to promote effective engagement in digital interventions. We also propose the affect-integration-motivation and attention-context-translation (AIM-ACT) framework, which is based on a neurophysiological account of engagement, to shed new light on how in-the-moment engagement unfolds in response to a digital stimulus. Building on this framework, we provide recommendations for designing strategies to promote engagement in digital interventions and highlight directions for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using Implementation Science to Inform Workforce and Service Development in Youth Mental Health: An Australian Case Study

Globally, mental illness and substance use disorders are the leading cause of disability and disease burden for young people. Orygen is an Australian youth mental health organisation with a mission to reduce the impact of mental ill health on young people, families and society, through research, clinical services, advocacy, and the design and delivery of youth mental health workforce and service development initiatives. Orygen is one of only a few known research and clinical centres with a dedicated knowledge translation division, which concentrates on growing the capacity of the systems, services, and professionals who support young people experiencing mental ill health. This paper provides a case study of the workforce development team within the Orygen knowledge translation, outlining how implementation science informs their work and how the division has adapted its model in the face of COVID-19. Since 2017, the team has delivered training to more than 4000 youth mental health workers across Australia, on the topics of trauma, psychosis, mood and anxiety disorders, brief interventions, cognition and other areas of youth mental health. The COVID-19 pandemic generated abrupt and dramatic changes to the delivery of workforce and service development initiatives in Australia due to significant restrictions to travel and in-person events. It also placed major delivery demands on youth mental health services. This paper outlines how the team at Orygen adapted their approach to youth mental health workforce development in response to COVID-19, offering reflections and future directions for implementation science that can support flexible models of support in a changing system.

Examining the complementarity between the ERIC compilation of implementation strategies and the behaviour change technique taxonomy: a qualitative analysis

BACKGROUND

Efforts to generate evidence for implementation strategies are frustrated by insufficient description. The Expert Recommendations for Implementing Change (ERIC) compilation names and defines implementation strategies; however, further work is needed to describe the actions involved. One potentially complementary taxonomy is the behaviour change techniques (BCT) taxonomy. We aimed to examine the extent and nature of the overlap between these taxonomies.

METHODS

Definitions and descriptions of 73 strategies in the ERIC compilation were analysed. First, each description was deductively coded using the BCT taxonomy. Second, a typology was developed to categorise the extent of overlap between ERIC strategies and BCTs. Third, three implementation scientists independently rated their level of agreement with the categorisation and BCT coding. Finally, discrepancies were settled through online consensus discussions. Additional patterns of complementarity between ERIC strategies and BCTs were labelled thematically. Descriptive statistics summarise the frequency of coded BCTs and the number of strategies mapped to each of the categories of the typology.

RESULTS

Across the 73 strategies, 41/93 BCTs (44%) were coded, with 'restructuring the social environment' as the most frequently coded (n=18 strategies, 25%). There was direct overlap between one strategy (change physical structure and equipment) and one BCT ('restructuring physical environment'). Most strategy descriptions (n=64) had BCTs that were clearly indicated (n=18), and others where BCTs were probable but not explicitly described (n=31) or indicated multiple types of overlap (n=15). For some strategies, the presence of additional BCTs was dependent on the form of delivery. Some strategies served as examples of broad BCTs operationalised for implementation. For eight strategies, there were no BCTs indicated, or they did not appear to focus on changing behaviour. These strategies reflected preparatory stages and targeted collective cognition at the system level rather than behaviour change at the service delivery level.

CONCLUSIONS

This study demonstrates how the ERIC compilation and BCT taxonomy can be integrated to specify active ingredients, providing an opportunity to better understand mechanisms of action. Our results highlight complementarity rather than redundancy. More efforts to integrate these or other taxonomies will aid strategy developers and build links between existing silos in implementation science.

Implementing a text-messaging intervention for unhealthy alcohol use in emergency departments: protocol for implementation strategy development and a pilot cluster randomized implementation trial

BACKGROUND

Unhealthy alcohol use (UAU) is a leading cause of premature mortality among adults in the USA. Emergency departments (EDs) are key intervention settings for UAU but often have limited time and resources. One low-burden, scalable approach to address UAU is text-messaging interventions. Despite strong research support and promise for scalability, there is little research on how to implement such interventions in healthcare settings. The process of providers making them available to patients in an efficient way within already busy and overburdened ED workflows and patients adopting them remains a new area of research. The purpose of this three-phase study is to develop and test an implementation strategy for UAU text-messaging interventions in EDs.

METHOD

Our first aim is to examine barriers and facilitators to staff offering and patients accepting a text-messaging intervention in the ED using an explanatory, sequential mixed methods approach. We will examine alcohol screening data in the electronic health records of 17 EDs within a large integrated health system in the Northeast and conduct surveys among chairpersons in each. This data will be used to purposively sample 4 EDs for semi-structured interviews among 20 clinical staff, 20 patients, and 4 chairpersons. Our second aim is to conduct a stakeholder-engaged intervention mapping process to develop a multi-component implementation strategy for EDs. Our third aim is to conduct a mixed method 2-arm cluster randomized pilot study in 4 EDs that serve ~11,000 UAU patients per year to assess the feasibility, acceptability, and preliminary effectiveness of the implementation strategy. The Integrated Promoting Action on Research Implementation in Health Services framework will guide study activities.

DISCUSSION

Low-burden technology, like text messaging, along with targeted implementation support and strategies driven by identified barriers and facilitators could sustain large-scale ED-based alcohol screening programs and provide much needed support to patients who screen positive while reducing burden on EDs. The proposed study would be the first to develop and test this targeted implementation strategy and will prepare for a larger, fully powered hybrid effectiveness-implementation trial. Findings may also be broadly applicable to implementation of patient-facing mobile health technologies.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05350878) on 4/28/2022.

Efficacy of digital health interventions on depression and anxiety in patients with cardiac disease: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022;3:445-454. [PMID: 36712158 PMCID: PMC9707908 DOI: 10.1093/ehjdh/ztac037]

Aims

Depression and anxiety have a detrimental effect on the health outcomes of patients with heart disease. Digital health interventions (DHIs) could offer a solution to treat depression and anxiety in patients with heart disease, but evidence of its efficacy remains scarce. This review summarizes the latest data about the impact of DHIs on depression/anxiety in patients with cardiac disease.

Methods and results

Articles from 2000 to 2021 in English were searched through electronic databases (PubMed, Cochrane Library, and Embase). Articles were included if they incorporated a randomized controlled trial design for patients with cardiac disease and used DHIs in which depression or anxiety was set as outcomes. A systematic review and meta-analysis were performed. A total of 1675 articles were included and the screening identified a total of 17 articles. Results indicated that telemonitoring systems have a beneficial effect on depression [standardized mean difference for depression questionnaire score -0.78 (P = 0.07), -0.55 (P < 0.001), for with and without involving a psychological intervention, respectively]. Results on PC or cell phone-based psychosocial education and training have also a beneficial influence on depression [standardized mean difference for depression questionnaire score -0.49 (P = 0.009)].

Conclusion

Telemonitoring systems for heart failure and PC/cell phone-based psychosocial education and training for patients with heart failure or coronary heart disease had a beneficial effect especially on depression. Regarding telemonitoring for heart failure, this effect was reached even without incorporating a specific psychological intervention. These results illustrate the future potential of DHIs for mental health in cardiology.

Usability Issues in Evidence-Based Psychosocial Interventions and Implementation Strategies: Cross-project Analysis

BACKGROUND

People often prefer evidence-based psychosocial interventions (EBPIs) for mental health care; however, these interventions frequently remain unavailable to people in nonspecialty or integrated settings, such as primary care and schools. Previous research has suggested that usability, a concept from human-centered design, could support an understanding of the barriers to and facilitators of the successful adoption of EBPIs and support the redesign of EBPIs and implementation strategies.

OBJECTIVE

This study aimed to identify and categorize usability issues in EBPIs and their implementation strategies.

METHODS

We adapted a usability issue analysis and reporting format from a human-centered design. A total of 13 projects supported by the National Institute of Mental Health-funded Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness Center at the University of Washington used this format to describe usability issues for EBPIs and implementation strategies with which they were working. Center researchers used iterative affinity diagramming and coding processes to identify usability issue categories. On the basis of these categories and the underlying issues, we propose heuristics for the design or redesign of EBPIs and implementation strategies.

RESULTS

The 13 projects reported a total of 90 usability issues, which we categorized into 12 categories, including complex and/or cognitively overwhelming, required time exceeding available time, incompatibility with interventionist preference or practice, incompatibility with existing workflow, insufficient customization to clients/recipients, intervention buy-in (value), interventionist buy-in (trust), overreliance on technology, requires unavailable infrastructure, inadequate scaffolding for client/recipient, inadequate training and scaffolding for interventionists, and lack of support for necessary communication. These issues range from minor inconveniences that affect a few interventionists or recipients to severe issues that prevent all interventionists or recipients in a setting from completing part or all of the intervention. We propose 12 corresponding heuristics to guide EBPIs and implementation strategy designers in preventing and addressing these usability issues.

CONCLUSIONS

Usability issues were prevalent in the studied EBPIs and implementation strategies. We recommend using the lens of usability evaluation to understand and address barriers to the effective use and reach of EBPIs and implementation strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14990.

Strategies for Implementing Occupational eMental Health Interventions: Scoping Review

BACKGROUND

The implementation of eMental health interventions, especially in the workplace, is a complex process. Therefore, learning from existing implementation strategies is imperative to ensure improvements in the adoption, development, and scalability of occupational eMental health (OeMH) interventions. However, the implementation strategies used for these interventions are often undocumented or inadequately reported and have not been systematically gathered across implementations in a way that can serve as a much-needed guide for researchers.

OBJECTIVE

The objective of this scoping review was to identify implementation strategies relevant to the uptake of OeMH interventions that target employees and detail the associated barriers and facilitation measures.

METHODS

A scoping review was conducted. The descriptive synthesis was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and the Consolidated Framework for Implementation Research.

RESULTS

A total of 31 of 32,916 (0.09%) publications reporting the use of the web-, smartphone-, telephone-, and email-based OeMH interventions were included. In all, 98 implementation strategies, 114 barriers, and 131 facilitators were identified. The synthesis of barriers and facilitators produced 19 facilitation measures that provide initial recommendations for improving the implementation of OeMH interventions.

CONCLUSIONS

This scoping review represents one of the first steps in a research agenda aimed at improving the implementation of OeMH interventions by systematically selecting, shaping, evaluating, and reporting implementation strategies. There is a dire need for improved reporting of implementation strategies and combining common implementation frameworks with more technology-centric implementation frameworks to fully capture the complexities of eHealth implementation. Future research should investigate a wider range of common implementation outcomes for OeMH interventions that also focus on a wider set of common mental health problems in the workplace. This scoping review's findings can be critically leveraged by discerning decision-makers to improve the reach, effectiveness, adoption, implementation, and maintenance of OeMH interventions.

Machine learning model to predict mental health crises from electronic health records

The timely identification of patients who are at risk of a mental health crisis can lead to improved outcomes and to the mitigation of burdens and costs. However, the high prevalence of mental health problems means that the manual review of complex patient records to make proactive care decisions is not feasible in practice. Therefore, we developed a machine learning model that uses electronic health records to continuously monitor patients for risk of a mental health crisis over a period of 28 days. The model achieves an area under the receiver operating characteristic curve of 0.797 and an area under the precision-recall curve of 0.159, predicting crises with a sensitivity of 58% at a specificity of 85%. A follow-up 6-month prospective study evaluated our algorithm’s use in clinical practice and observed predictions to be clinically valuable in terms of either managing caseloads or mitigating the risk of crisis in 64% of cases. To our knowledge, this study is the first to continuously predict the risk of a wide range of mental health crises and to explore the added value of such predictions in clinical practice.

Machine learning applied on electronic health records can predict mental health crises 28 days in advance and become a clinically valuable tool for managing caseloads and mitigating the risk of crisis.

Understanding and Addressing Occupational Stressors in Internet-Delivered Therapy for Public Safety Personnel: A Qualitative Analysis

Internet-delivered cognitive behavioral therapy (ICBT) is effective when tailored to meet the needs of public safety personnel (PSP). Nevertheless, there is limited research on the nature of the occupational stressors faced by PSP who seek ICBT and how PSP use ICBT to address occupational stressors. We provided tailored ICBT to PSP (N = 126; 54% women) and conducted a qualitative content analysis on clinicians’ eligibility screening notes, clients’ emails, and clients’ survey responses to understand the occupational stressors faced by PSP and their use of ICBT to address such stressors. Clients described several occupational stressors, including operational stressors (e.g., potentially psychologically traumatic events and sleep/shiftwork issues) and organizational stressors (e.g., issues with leadership, resources, and workload). More clients shared occupational concerns during the screening process (97%) than during treatment (58%). The most frequently cited occupational stressor was exposure to potentially psychologically traumatic events. Clients reported using course skills (e.g., controlled breathing and graduated exposure) to manage occupational stressors (e.g., responding to calls, workplace conflict, and work–family conflict). Thought challenging was the most frequently reported strategy used to manage occupational stressors. The current results provide insights into the occupational stressors PSP experience and endeavor to manage using ICBT, which can inform further efforts to tailor ICBT for PSP (e.g., adapting course materials and examples to take into account these operational and occupational stressors).

Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews

BACKGROUND

The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation.

OBJECTIVE

The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.

METHODS

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach.

RESULTS

A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.

CONCLUSIONS

We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.12688/f1000research.27150.2.

Informing the Future of Integrated Digital and Clinical Mental Health Care: Synthesis of the Outcomes From Project Synergy

BACKGROUND

Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users' needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care.

OBJECTIVE

Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms.

METHODS

Participating health care organizations included the following: Open Arms-Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation's National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention.

RESULTS

Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted.

CONCLUSIONS

Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care.

What is the Current and Future Status of Digital Mental Health Interventions?

The prevalence of mental disorders continues to increase, especially with the advent of the COVID-19 pandemic. Although we have evidence-based psychological treatments to address these conditions, most people encounter some barriers to receiving this help (e.g., stigma, geographical or time limitations). Digital mental health interventions (e.g., Internet-based interventions, smartphone apps, mixed realities -virtual and augmented reality) provide an opportunity to improve accessibility to these treatments. This article summarizes the main contributions of the different types of digital mental health solutions. It analyzes their limitations (e.g., drop-out rates, lack of engagement, lack of personalization, lack of cultural adaptations) and showcases the latest sophisticated and innovative technological advances under the umbrella of precision medicine (e.g., digital phenotyping, chatbots, or conversational agents). Finally, future challenges related to the need for real world implementation of these interventions, the use of predictive methodology, and hybrid models of care in clinical practice, among others, are discussed.

A Comparison of Self-Referral and Referral via Primary Care Providers, through Two Similar Digital Mental Health Services in Western Australia

Digital mental health services (DMHSs) deliver mental health information, assessment, and treatment, via the internet, telephone, or other digital channels. The current study compares two DMHSs operating in Western Australia (WA)-The Practitioner Online Referral System (PORTS) and MindSpot. Both provide telephone and online psychological services at no cost to patients or referrers. However, PORTS is accessed by patients via referral from health practitioners, and is designed to reach those who are financially, geographically, or otherwise disadvantaged. In contrast, MindSpot services are available to all Australian residents and patients can self-refer. This observational study compares characteristics and treatment outcomes for patients of PORTS and MindSpot in WA. Eligible patients were people who resided in WA and registered with either clinic from January 2019 to December 2020. Results showed that PORTS patients were more likely to be older, male, and unemployed. They were less likely to report a tertiary education and were more likely to live in areas with higher levels of socioeconomic disadvantage. Despite these differences, treatment outcomes were excellent for patients from both clinics. Results provide further evidence for the accessibility, acceptability, and effectiveness of DMHSs regardless of referral pathway or patient characteristics.

Learnings from user feedback of a novel digital mental health assessment

Digital mental health interventions (DMHI) have the potential to address barriers to face-to-face mental healthcare. In particular, digital mental health assessments offer the opportunity to increase access, reduce strain on services, and improve identification. Despite the potential of DMHIs there remains a high drop-out rate. Therefore, investigating user feedback may elucidate how to best design and deliver an engaging digital mental health assessment. The current study aimed to understand 1304 user perspectives of (1) a newly developed digital mental health assessment to determine which features users consider to be positive or negative and (2) the Composite International Diagnostic Interview (CIDI) employed in a previous large-scale pilot study. A thematic analysis method was employed to identify themes in feedback to three question prompts related to: (1) the questions included in the digital assessment, (2) the homepage design and reminders, and (3) the assessment results report. The largest proportion of the positive and negative feedback received regarding the questions included in the assessment (n = 706), focused on the quality of the assessment (n = 183, 25.92% and n = 284, 40.23%, respectively). Feedback for the homepage and reminders (n = 671) was overwhelmingly positive, with the largest two themes identified being positive usability (i.e., ease of use; n = 500, 74.52%) and functionality (i.e., reminders; n = 278, 41.43%). The most frequently identified negative theme in results report feedback (n = 794) was related to the report content (n = 309, 38.92%), with users stating it was lacking in-depth information. Nevertheless, the most frequent positive theme regarding the results report feedback was related to wellbeing outcomes (n = 145, 18.26%), with users stating the results report, albeit brief, encouraged them to seek professional support. Interestingly, despite some negative feedback, most users reported that completing the digital mental health assessment has been worthwhile (n = 1,017, 77.99%). Based on these findings, we offer recommendations to address potential barriers to user engagement with a digital mental health assessment. In summary, we recommend undertaking extensive co-design activities during the development of digital assessment tools, flexibility in answering modalities within digital assessment, customizable additional features such as reminders, transparency of diagnostic decision making, and an actionable results report with personalized mental health resources.

Approaches for implementing digital interventions for alcohol use disorders in primary care: A qualitative, user-centered design study

Background

Digital interventions, such as smartphone apps, can be effective in treating alcohol use disorders (AUD). However, efforts to integrate digital interventions into primary care have been challenging. To inform successful implementation, we sought to understand how patients and clinicians preferred to use apps in routine primary care.

Methods

This study combined user-centered design and qualitative research methods, interviewing 18 primary care patients with AUD and nine primary care clinicians on topics such as prior experiences with digital tools, and design preferences regarding approaches for offering apps for AUD in primary care. Interviews were recorded and transcribed for template analysis whereby a priori codes were based on interview topics and refined through iterative coding. New codes and cross-cutting themes emerged from the data.

Results

Patient participants with AUD indicated they would be more likely to engage in treatment if primary care team members were involved in their use of apps. They also preferred to see clinicians “invested” and recommended that clinicians ask about app use and progress during follow-up appointments or check-ins. Clinician participants valued the opportunity to offer apps to their patients but noted that workflows would need to be tailored to individual patient needs. Time pressures, implementation complexity, and lack of appropriate staffing were cited as barriers. Clinicians proposed concrete solutions (e.g., education, tools, and staffing models) that could improve their ability to use apps within the constraints of primary care and suggested that some patients could potentially use apps without clinician support.

Conclusions

A user-centered approach to engaging patients in digital alcohol interventions in primary care may require personalized support for both initiation and follow-up. Meeting patients’ needs likely require increased staffing and efficient workflows in primary care. Health systems should consider offering multiple pathways for enrolling patients in apps to accommodate individual preferences and contextual barriers.

Plain Language Summary

Healthcare systems have begun using app-based treatments to help patients manage their health conditions, including alcohol use disorders. Some apps have been tested in research studies and appear to be effective. However, it is difficult for healthcare teams to offer apps to patients. Clinicians must engage in new activities that they have not done before, such as “teaching” patients to use apps and checking in on their use of the apps. Identifying how to use apps in routine healthcare is critical to their successful implementation. This study interviewed 27 people, including healthcare providers and patients in primary care, to uncover the most optimal ways to offer apps to patients with alcohol use disorders. The interviews combined the use of qualitative research methods and user-centered design. Results suggest that to use to address alcohol use disorders, primary care teams should be prepared to offer personalized support to patients. Both patient and clinician interviewees said that the steps required to use apps must be intuitive and simple. Patients could gain more benefits if clinicians introduced the apps and guided patients to use them, as opposed to making apps available for patients to download and use on their own. However, the exact approach to offering apps would depend on a given patient’s preferences and the extent that staffing was available in the clinic to support patients. Health systems should be prepared to offer and support patients in their use of apps, which should accommodate patient preferences and the constraints of the clinic.

The Implementation and Effectiveness of Digital Cognitive Behavioral Therapy for Insomnia in Primary Care: A Pilot Study

Background

Digital interventions delivering Cognitive Behavioral Therapy for insomnia (Digital CBTi) may increase utilization of effective care for a common and serious condition. A low-intensity implementation strategy may facilitate digital CBTi use in healthcare settings. This pilot study assessed the feasibility of implementing a digital CBTi in Veterans Health Administration (VA) primary care through iterative modifications to a low-intensity implementation strategy, while evaluating clinical outcomes of a specific digital CBTi program.

Methods

A self-directed digital CBTi was implemented in the primary care clinics of a single VA facility using a cohort trial design that iteratively modified an implementation strategy over three 8-month phases. The phase 1 implementation strategy included (1) provider education; (2) point-of-care information via pamphlets; and (3) provider referral to digital CBTi through phone calls or messages. Phases 2 and 3 maintained these activities, while (1) adding a clinic-based coach who performed initial patient education and follow-up support contacts, (2) providing additional recruitment pathways, and (3) integrating the referral mechanism into provider workflow. Implementation outcomes included provider adoption, patient adoption, and acceptability. Clinical outcomes (insomnia severity, depression severity, and sedative hypnotic use) were compared among enrollees at baseline and 10 weeks.

Results

Across all phases 66 providers (48.9%) made 153 referrals, representing 0.38% of unique clinic patients. Of referrals, 77 (50.3%) enrolled in the study, 45 (29.4%) engaged in the program, and 24 (15.7%) completed it. Provider and patient adoption did not differ meaningfully across phases. Among enrollees, digital CBTi was acceptable and the Insomnia Severity Index decreased by 4.3 points (t = 6.41, p < 0.001) and 13 (18.6%) reached remission. The mean number of weakly sedative-hypnotic doses decreased by 2.2 (35.5%) (t = 2.39, p < 0.02).

Conclusions

Digital CBTi implementation in VA primary care is feasible using low-intensity implementation strategy, resulting in improved clinical outcomes for users. However, iterative implementation strategy modifications did not improve adoption. The trial was registered at clinicaltrials.gov (NCT03151083).

Insights into internet-delivered cognitive behavioural therapy for public safety personnel: Exploration of client experiences during and after treatment

Canadian public safety personnel (PSP) experience high rates of mental health problems and barriers to receiving care. Internet-delivered cognitive behavioural therapy (ICBT) may help reduce barriers to care; however, there is no literature involving qualitative analyses of client feedback to describe PSP experiences with ICBT. Identifying these experiences is important because it can inform future use of ICBT with this group that has unique needs. The current study was designed to explore how clients (N = 82) experienced ICBT that had been tailored to meet their needs; specifically, the study assessed their perceptions of program impacts, what clients found helpful, and client suggestions for improvements. The ICBT course included five core lessons, client stories, and nine initial additional resources, as well as flexible frequencies (optional, once weekly, or twice weekly) and durations (8 to 16 weeks) of therapist support. A qualitative reliability thematic analysis was used to analyze client communications and feedback. Responses to a Treatment Satisfaction Questionnaire administered at eight weeks post-enrollment were available for 57 clients. Client emails with therapists were also examined among all clients, including an additional 25 clients who did not complete the Treatment Satisfaction Questionnaire. Themes identified in the qualitative analyses were related to: reported impacts and hindering events, helpful and challenging course skills and content, helpful aspects of the course, and areas for improvement. Clients who completed the Treatment Satisfaction Questionnaire and those who did not reported beneficial impacts from the program, with the most commonly endorsed themes being skill development and normalizing mental health issues. Hindering events were experienced by both groups and included timeline challenges, technology challenges, and negative effects. Comments from both groups suggested that clients had more success than challenges when practicing the skills. Thought challenging was the skill most frequently identified as helpful. Clients described many aspects of the program as helpful with the most frequently endorsed themes being the course format and content, the flexible nature of the course, access to additional materials and case stories, and therapist assistance. Clients also provided suggestions for improving the course (e.g., case stories, additional resources, timelines audio and videos). Overall, client communications suggest that ICBT is accepted and perceived as beneficial among PSP. These results informed rapid improvements to the ICBT program tailored for PSP and may inform others seeking to provide digital mental health services to PSP.