Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems

Recommendations for the Development of Psychological Smartphone Applications in the Context of Bariatric Surgery: Focus Groups with Professionals and Patients

To explore the experiences and preferences of patients and healthcare professionals regarding the development of an app to provide psychological intervention to improve emotion regulation in the context of bariatric surgery (BS). Sixteen people (6 patients who underwent BS and 10 professionals) participated in two separate focus group sessions. We performed a content analysis of transcribed focus group discussions to extract and organize categories, subcategories and areas. Both sets of stakeholders provided information about how to develop and implement an app. According to participants' comment, content should include information (i.e., nutrition, exercise) and emotional regulation skills. Patients and professionals mentioned that the app should include visual information, continuous emotional assessments and peer contact. It was also mentioned that the app should be used before and after BS and its contents should be developed by a multidisciplinary team (i.e., collaboration of endocrinologist, nutritionists and psychologists). Participants in both focus groups considered technology to be useful in the context of BS, especially as part of blended interventions (combining face-to-face and online sessions). Patients and professionals seem to be receptive towards the use of technology in a BS context. Specific recommendations are identified for designing and implementing app solutions for BS. More efforts should be made in the future to develop and implement evidence-based apps according to patients and professionals' needs.

Current limitations in technology-based cognitive assessment for severe mental illnesses: a focus on feasibility, reliability, and ecological validity

Cognitive impairments are frequently observed in subjects with severe mental illnesses (SMI), leading to a remarkable impact in their real-world functioning. Well-validated and gold standard instruments are available for the assessment of cognitive deficits, but different limitations should be considered, such as the need for specific training, lengthy administration times, practice effects, or reliance on subjective reports. Recent advances in digital technologies, such as ecological momentary assessments (EMA), virtual reality (VR), and passive digital phenotyping (DP), offer promising complementary approaches for capturing real-world cognitive functioning. In the current mini-review, we examine current research gaps that limit the application of these technologies, with a specific focus on feasibility, reliability and ecological validity. EMA may capture real-world functioning by increasing the number of evaluations throughout the day, but its use might be hindered by high participant burden and missing data. Furthermore, to achieve an accurate interpretation of EMA, studies should account for sampling and moment selection biases and the presence of several confounding factors. DP faces significant ethical and logistical challenges, including privacy and informed consent concerns, as well as challenges in data interpretation. VR could serve as a platform for both more ecologically valid cognitive assessments and rehabilitation interventions, but current barriers include technological and psychometric limitations, underdeveloped theoretical frameworks, and ethical considerations. Addressing these issues is crucial for ensuring that these novel technologies can effectively serve as valuable complements to traditional neuropsychological cognitive batteries.

Cost Utility Analysis of Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder: Randomized Controlled Trial

BACKGROUND

Unguided internet-based cognitive behavioral therapy (ICBT) has been proven effective for major depressive disorder (MDD). However, few studies have examined its cost-effectiveness in low-resource countries and under nonspecialist routine care.

OBJECTIVE

This study aimed to evaluate the short- and long-term cost utility of unguided ICBT compared to a waitlist control for persons with MDD from the perspectives of society and the health care system.

METHODS

This analysis was implemented alongside an 8-week 2-arm randomized controlled trial with a 12-month follow-up period conducted in Shenzhen, China. Outcomes including cost and health utility were collected at the pretreatment and posttreatment time points and 3, 6, and 12 months after the intervention. Direct medical costs and indirect costs were prospectively collected using the hospital information system and the Sheehan Disability Scale. Health outcomes were measured using the Chinese version of the Short-Form Six-Dimension health index. The primary outcome was incremental cost utility ratio (ICUR) expressed as the difference in costs between 2 therapies by the difference in quality-adjusted life years (QALYs). The seemingly unrelated regression model and the bootstrap method were performed to estimate adjusted ICURs. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate uncertainty. A series of scenario analyses were conducted to verify the robustness of base-case results.

RESULTS

In total, 244 participants with MDD were randomly allocated to the ICBT (n=122, 50%) or waitlist control (n=122, 50%) groups. At the pretreatment time point, no statistically significant difference was observed in direct medical cost (P=.41), indirect cost (P=.10), or health utility (P=.11) between the 2 groups. In the base-case analysis, the ICBT group reported higher direct medical costs and better quality of life but lower total costs at the posttreatment time point. The adjusted ICURs at the posttreatment time point were CN ¥-194,720.38 (US $-26,551.50; 95% CI CN ¥-198,766.78 to CN ¥-190,673.98 [US $-27,103.20 to US $-25,999.70]) and CN ¥49,700.33 (US $6776.99; 95% CI CN ¥46,626.34-CN ¥52,774.31 [US $6357.83-$7196.15]) per QALY from the societal and health care system perspectives, respectively, with a probability of unguided ICBT being cost-effective of 75.93% and 54.4%, respectively, if the willingness to pay was set at 1 time the per-capita gross domestic product. In the scenario analyses, the probabilities increased to 76.85% and 77.61%, respectively, indicating the potential of ICBT to be cost-effective over the long term.

CONCLUSIONS

Unguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD improve clinically but also generates societal savings. These findings provide health economic evidence for a potential scalable MDD treatment method in low- and middle-income countries.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ChiCTR2100046425; https://tinyurl.com/bdcrj4zv.

Economic Evaluation of Internet-Based Psychological Interventions: A Scoping Review of Methodological Choices

OBJECTIVES

Internet-based psychological interventions hold promise for cost-effectiveness; yet, their evaluation lacks standardization, potentially leading to methodological discrepancies and inconclusive results. This study aims to conduct a scoping review of economic methods used when evaluating these interventions.

METHODS

Articles published between January 2015 and December 2020 were retrieved from PubMed, Embase, Cochrane Library, CINAHL, ECONLIT, and PsychINFO. Two reviewers independently screened titles, abstracts, and full texts of relevant publications and extracted prespecified data. Outcomes related to intervention characteristics, comparators, perspective, time horizon, costs, benefits, economic endpoints, and uncertainty analysis methods were retrieved and synthetized narratively.

RESULTS

We identified 703 references and included 85. Seventy-four of them included a cost-utility analysis and 58 a cost-effectiveness analysis, with 47 carrying out both. The comparator was treatment as usual in 52 studies (61.2%) but varied widely across studies. A societal perspective was adopted in 60 studies, supplemented by a healthcare perspective in half. Time horizon was 1 year or less in 68 articles (80.0%). Intervention costs (71/85 studies) predominantly covered delivery costs (45/71 studies), whereas development and promotional costs were infrequently considered (respectively, 14 and 5/71 studies). Interventions' reach, opportunity costs, user engagement, and equity issues were rarely addressed. Key factors influencing cost-effectiveness included perspective, time horizon, costs included, and methods for handling missing data.

CONCLUSIONS

Assessment of cost-effectiveness in internet-based psychological interventions shows variability, potentially affecting efficiency evidence. Conventional methods are often favored overlooking digital tools' specificities. Tailored guidelines for such evaluations could be helpful for standardized and reliable evidence.

Emotion regulation-based internet-delivered cognitive behavioural therapy for premenstrual dysphoric disorder: study protocol for a randomised controlled trial in Sweden

INTRODUCTION

Premenstrual dysphoric disorder (PMDD) is a cyclic mood disorder affecting around 2%-5% of women of reproductive age. Pharmacological interventions exist, but many patients with PMDD experience residual symptoms, discontinue medications or refrain from them due to side effects. Thus, non-pharmacological treatments are needed as an alternative or additive treatment strategy. Evidence indicates that cognitive behavioural therapy (CBT) is a promising candidate. However, further research is required to establish its efficacy and identify ways to improve the treatment. Specifically, incorporating components targeting emotional and interpersonal dysregulation could theoretically enhance its effects. Furthermore, increasing the generally low accessibility of CBT for PMDD necessitates scalable and cost-effective ways to deliver treatment. The current study aims to evaluate the effects and cost-effectiveness of an internet-delivered CBT (ICBT) intervention for PMDD incorporating skills training in emotion regulation and interpersonal effectiveness.

METHODS AND ANALYSIS

The study is a parallel two-group randomised controlled trial with 1:1 allocation to 8 weeks of therapist-guided ICBT or a waitlist control condition. Following recruitment and inclusion, 164 individuals aged 18-45 years who fulfil the Diagnostic Manual of Mental Disorders-5 criteria for PMDD will be randomly assigned to the two groups. Primary outcomes are pretreatment to post-treatment group differences in premenstrual symptoms and their impact on everyday life, as well as psychological and functional impairment during the premenstrual phase. Secondary outcomes include treatment effects on quality of life and difficulties in emotion regulation. Long-term treatment effects will be assessed 6 and 12 months postintervention. Data will be analysed using latent Gaussian process modelling and linear mixed models. The economic evaluation will analyse individual-level societal costs and outcomes between trial arms. Recruitment is expected to begin in February 2025, with study completion anticipated by February 2028.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority (2023-00655-01). Results will be disseminated via presentations and publications in international journals and national outlets for clinicians and patients with PMDD.

PROTOCOL VERSION

PS2024_v1.

TRIAL REGISTRATION NUMBER

NCT06496139.

What internet- and mobile-based interventions are currently available for adults with overweight or obesity experiencing symptoms of depression? A systematic review

Given the high prevalence of overweight and obesity and high comorbidity of depressive symptoms, there is a need for low-threshold, accessible care approaches for people with overweight/obesity aimed at improving mental health. Internet and mobile-based interventions (IMI) represent an innovative complementary treatment option. This review systematically searches for IMI aimed at improving mental health in people with overweight/obesity. We conducted a systematic literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in the databases MEDLINE, Cochrane Library, PsycINFO, Web of Science and Google Scholar. Randomized controlled trials (RCTs) of IMI for adults with overweight/obesity and comorbid depressive symptoms aiming at improving mental health were screened and extracted. Study quality was assessed with RoB 2 (revised Cochrane Risk of Bias tool in RCTs). After excluding duplicates, n = 790 results were included in title and abstract screening. After full-text-screening of n = 26 studies, n = 3 RCT studies were included. All interventions aimed to reduce both weight and depressive symptoms. In two RCTs, a significant reduction in both depressive symptoms and weight was achieved. One RCT indicated a significant reduction in depressive symptoms, but not in weight. Two intervention had a duration of 6 months and were guided by health carers, the third takes 3 months and can be used without professional guidance. There is evidence that IMI are effective in improving mental health for people with overweight/obesity and comorbid depressive symptoms. However, currently there are few interventions aiming at reducing depressive symptoms, all targeting English-speaking people. As IMI for depressive symptoms can be easily integrated in the somatic therapy of obesity as additional option and has high public health potential, target group-adapted and low-threshold accessible interventions in different languages should be developed and implemented for improving mental health in people with overweight/obesity. Prospero registration number: CRD42023361771.

A Narrative-Gamified Mental Health App (Kuamsha) for Adolescents in Uganda: Mixed Methods Feasibility and Acceptability Study

BACKGROUND

Many adolescents in Uganda are affected by common mental disorders, but only a few affordable treatment options are available. Digital mental health interventions offer promising opportunities to reduce these large treatment gaps, but interventions specifically tailored for Ugandan adolescents are limited.

OBJECTIVE

This study aimed to determine the feasibility and acceptability of the Kuamsha program, an intervention delivered through a gamified app with low-intensity telephonic guidance, as a way to promote mental health among adolescents from the general population in Uganda.

METHODS

A 3-month pre-post single-arm trial was conducted with adolescents aged between 15 and 19 years living in Wakiso District, Central Uganda. The intervention was coproduced with adolescents from the study site to ensure that it was culturally acceptable. The feasibility and acceptability of the intervention were evaluated using an explanatory sequential mixed methods approach. Feasibility was assessed by collecting data on trial retention rates and treatment adherence rates. Acceptability was assessed through a questionnaire and in-depth interviews with participants following the conclusion of the intervention period. As a secondary objective, we explored the changes in participants' mental health before and after the intervention.

RESULTS

A total of 31 adolescents were recruited for the study. Results from the study showed high levels of feasibility and acceptability. Trial retention rates exceeded 90%, and treatment adherence was ≥80%. These results, evaluated against our predefined trial progression criteria, indicate a successful feasibility study, with all criteria exceeding the thresholds necessary to progress to a larger trial. App engagement metrics, such as time spent on the app and modules completed, exceeded existing literature benchmarks, and many adolescents continued to use the app after the intervention. In-depth interviews and questionnaire responses revealed high acceptability levels. Depressive symptoms trended toward reduction (mean difference: 1.41, 95% CI -0.60 to 3.42, Cohen d=0.30), although this was not statistically significant (P=.16). Supporting this trend, we also observed a reduction in the proportion of participants with moderate depressive symptoms from 32% (10/31) to 17% (5/29) after the intervention, but this change was also not significant (P=.10).

CONCLUSIONS

This study presents evidence to support the Kuamsha program as a feasible and acceptable digital mental health program for adolescents in Uganda. A fully powered randomized controlled trial is needed to assess its effectiveness in improving adolescents' mental health.

Digital Health Applications (DiGAs) on a Fast Track: Insights From a Data-Driven Analysis of Prescribable Digital Therapeutics in Germany From 2020 to Mid-2024

BACKGROUND

This study aimed to analyze the rapidly evolving ecosystem of digital health applications (Digitale Gesundheitsanwendung; DiGAs) in Germany, spurred by the 2019 Digital Healthcare Act. With over 73 million people in Germany now having access to DiGAs, these prescribable digital health apps and web-based applications represent a substantial stride in health care modernization, supporting both patients and health care providers with digital solutions for disease management and care improvement.

OBJECTIVE

Through a data-driven approach, this research aimed to unpack the complexities of DiGA market dynamics, economic factors, and clinical evidence, offering insights into their impact over the past years.

METHODS

The analysis draws from a range of public data sources, including the DiGA directory, statutory health insurance reports, app store feedback, and clinical study results.

RESULTS

As of July 1, 2024, there are 56 DiGAs listed by the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte), divided into 35 permanently and 21 preliminarily listed applications. Our findings reveal that a majority of DiGAs extend beyond the intended 1-year period to achieve permanent listing, reflecting the extensive effort required to demonstrate clinical efficacy. Economic analysis uncovered a dynamic pricing landscape, with initial prices ranging from approximately €200 to €700 (€1=US $1.07), averaging at a median of €514 for a 3-month DiGA prescription. Following negotiations or arbitration board decisions, prices typically see a 50% reduction, settling at a median of €221. Prescription data offer valuable insights into DiGA acceptance, with total prescriptions jumping from around 41,000 in the first period to 209,000 in the latest reporting period. The analysis of the top 15 DiGAs, representing 82% of the total prescriptions, shows that these best-performing apps receive from a minimum of 8 to a maximum of 77 daily prescriptions, with native apps and early market entrants achieving higher rates. Clinical evidence from all 35 permanently listed DiGAs indicates a uniform preference for randomized controlled trials to validate primary end points, with no noteworthy use of alternative study designs encouraged in the Digital Healthcare Act and related regulations. Moreover, all evaluated DiGAs focused on medical benefits, with health status improvement as a key end point, suggesting an underuse of patient-relevant structural and procedural improvement in demonstrating health care impact.

CONCLUSIONS

This study highlights the growth and challenges within the DiGA sector, suggesting areas for future research, such as the exploration of new study designs and the potential impact of patient-relevant structural and procedural improvements. For DiGA manufacturers, the strategic advantage of early market entry is emphasized. Overall, this paper underscores the evolving landscape of digital health, advocating for a nuanced understanding of digital health technology integration in Germany and beyond.

Economic evaluation of Be a Mom, a web-based intervention to prevent postpartum depression in high-risk women alongside a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) poses significant challenges, affecting both mothers and children, with substantial societal and economic implications. Internet-based cognitive behavioral therapy interventions (iCBT) offer promise in addressing PPD, but their economic impact remains unexplored. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided iCBT intervention, compared with a waiting-list control among postpartum women at high risk of PPD.

METHODS

This economic evaluation was conducted alongside a 14-month randomized controlled trial adopting a societal perspective. Participants were randomized to Be a Mom (n = 542) or a waitlisted control group (n = 511). Self-report data on healthcare utilization, productivity losses, and quality-adjusted life years (QALYs) were collected at baseline, post-intervention, and 4 and 12 months post-intervention. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness acceptability curves were generated using nonparametric bootstrapping. Sensitivity analyses were conducted to assess result robustness.

RESULTS

Over 14 months, Be a Mom generated a QALY gain of 0.0184 (0.0022, 0.0346), and cost savings of EUR 34.06 (-176.16, 108.04) compared to the control group. At a willingness to pay of EUR 20,000, Be a Mom had a 97.6 % probability of cost-effectiveness.

LIMITATIONS

Results have limitations due to self-selected sample, potential recall bias in self-reporting, missing data, limited follow-up, and the use of a waiting-list control group.

CONCLUSIONS

This study addresses a critical gap by providing evidence on the cost-utility of an iCBT intervention tailored for PPD prevention. Further research is essential to identify scalable and cost-effective interventions for reducing the burden of PPD.

Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

Migrants face many barriers to mental health care, such as different cultural concepts of distress, unfamiliar pathways to care, and language. Digital mental health interventions are effective and scalable in multi-language versions. However, their implementation into routine care is in its infancy. Here, we report on the Arabic- and German-language implementation of two digital interventions in Germany: The iFightDepression® website, providing information about depression to the public, and the iFightDepression® tool, offering guided self-management for depression. Our main goal is to gain empirical knowledge about the success of their implementation and provide evidence-based recommendations for improvement. Data for the current analyses stem from convenience samples, utilizing anonymized user logs of the iFightDepression® website and 15.307 user accounts in the iFightDepression® tool. We found that the acceptability (time on page, usage behavior) of both digital interventions was comparable between the two user groups. The website pervasiveness of the target populations was nine times lower among Arab migrants in Germany than Germans (89 vs. 834 unique page views/ 100,000 inhabitants), but the increase in views was superior and sustained over three years. The adoption of the tool was lower among Arabic than German users (conversion rate from invitation to completed registration: 30.8% vs. 59.0%, p < 0.001) and appropriateness was challenged as Arabic users reported higher depression severities upon first registration (p = 0.027). Our results show that the uptake of digital interventions for migrants requires facilitation and further tailoring to the needs of the target group.

Home-based self-management multimodal cancer interventions & cardiotoxicity: a scoping review

BACKGROUND

Due to advancements in methods of cancer treatment, the population of people living with and beyond cancer is dramatically growing. The number of cancer survivors developing cardiovascular diseases and heart failure is also rising, due in part to the cardiotoxic nature of many cancer treatments. Guidelines are being increasingly released, emphasising the need for interdisciplinary action to address this gap in survivorship care. However, the extent to which interventions exist, incorporating the recommendations of cardio-oncology research, remains undetermined.

OBJECTIVE

The aim of this scoping review is to assess the nature, extent and remit of existing cancer care interventions and their integration of cardio-oncology principles.

METHODS

The review was conducted in accordance with the PRISMA Extension for Scoping Reviews Guidelines. Databases were independently searched for articles from 2010 to 2022, by two members of the research team. Data were charted and synthesised using the following criteria: (a) the focus of the intervention (b) the medium of delivery (c) the duration (d) the modalities included in the interventions (e) the research articles associated with each intervention (f) the type of studies conducted (g) key measures used (h) outcomes reported.

RESULTS

Interventions encompassed six key modalities: Psychological Support, Physical Activity, Nutrition, Patient Education, Lifestyle and Caregiver Support. The focus, medium of delivery and duration of interventions varied significantly. While a considerable number of study protocols and pilot studies exist documenting HSMIs, only 25% appear to have progressed beyond this stage of development. Of those that have, the present review did not identify any 'feasible' interventions that covered each of the six modalities, while being generalisable to all cancer survivors and incorporating the recommendations from cardio-oncology research.

CONCLUSION

Despite the substantial volume of research and evidence from the field of cardio-oncology, the findings of this scoping review suggest that the recommendations from guidelines have yet to be successfully translated from theory to practice. There is an opportunity, if not necessity, for cardiac rehabilitation to expand to meet the needs of those living with and beyond cancer.

Mental health services for German university students: acceptance of intervention targets and preference for delivery modes

Introduction

Most university students with mental disorders remain untreated. Evaluating the acceptance of intervention targets in mental health treatment, promotion, and prevention, as well as mental health service delivery modes is crucial for reducing potential barriers, increasing healthcare utilization, and efficiently allocating resources in healthcare services.

Aim

The study aimed to evaluate the acceptance of various intervention targets and delivery modes of mental health care services in German first-year university students.

Methods

In total, 1,376 first-year students from two German universities from the 2017-2018 multi-center cross-sectional cohort of the StudiCare project, the German arm of the World Mental Health International College Student Survey initiative, completed a web-based survey assessing their mental health. Mental disorder status was based on self-reported data fulfilling the DSM-IV criteria. We report frequencies of accepted delivery modes [categories: group or in-person therapy with on or off campus services, self-help internet- or mobile-based intervention (IMI) with or without coaching, or a combination of a in-person and IMI (blended)]. In a multinomial logistic regression, we estimate correlates of the preference for in-person vs. IMI vs. a combination of both modes (blended) modalities. Additionally, we report frequencies of intervention targets (disorder specific: e.g., social phobia, depressive mood; study-related: test anxiety, procrastination; general well-being: sleep quality, resilience) their association with mental disorders and sex, and optimal combinations of treatment targets for each mental illness.

Results

German university students' acceptance is high for in-person (71%-76%), moderate for internet- and mobile-based (45%-55%), and low for group delivery modes (31%-36%). In-person treatment (72%) was preferred over IMI (19%) and blended modalities (9%). Having a mental disorder [odds ratio (OR): 1.56], believing that digital treatments are effective (OR: 3.2), and showing no intention to use services (OR: 2.8) were associated with a preference for IMI compared to in-person modes. Students with prior treatment experience preferred in-person modes (OR: 0.46). In general, treatment targets acceptance was higher among female students and students with mental disorders. However, this was not true for targets with the highest (i.e., procrastination) and the lowest (i.e., substance-use disorder) acceptance. If only two intervention targets were offered, a combination of study-related targets (i.e., procrastination, stress, time management) would reach 85%-88% of the students.

Conclusion

In-person services are preferred, yet half of the students consider using IMI, preferably aiming for a combination of at least two study-related intervention targets. Student mental health care services should offer a combination of accepted targets in different delivery modes to maximize service utilization.

Tailored internet-delivered cognitive behavioral therapy for individuals experiencing psychological distress associated with climate change: A pilot randomized controlled trial

Even among people who are not directly impacted by the consequences of climate change, perceptions about the ongoing crisis can have a negative effect on mental health and well-being. However, empirical evidence on interventions aiming to provide support is currently scarce. In order to address this issue, a pilot-RCT was carried out to investigate the effects of a novel ICBT treatment program. Sixty participants (23-73 years) were recruited and randomly allocated to eight weeks of therapist-supported ICBT (n = 30) or a wait-list control condition (n = 30). Measures of depressive symptoms, stress, and quality of life were used as primary outcomes, while measures of anxiety, insomnia, climate change-related distress, pro-environmental behaviour, and alcohol use were used as secondary outcomes. The treatment group had moderate to large between-group effects compared to the waitlist group on measures of depression (d = 0.87), stress (d = 0.76), quality of life (d = 0.79) and climate change-related distress (d = 0.79). There were no significant between-group differences on the other outcome measures. The results from this pilot-RCT indicate that individually tailored ICBT can be an effective way to reduce psychological distress associated with climate change without reducing pro-environmental behaviour.

Real-World User Demographics of Three Web-Based Digital Mental Health Interventions Provided by the US Department of Veterans Affairs: Observational Study Using Web Analytics Data

BACKGROUND

Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively.

OBJECTIVE

This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population.

METHODS

Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported.

RESULTS

In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI's age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users.

CONCLUSIONS

Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers.

Investigating the causal effects of smoking, sleep, and BMI on major depressive disorder and bipolar disorder: a univariable and multivariable two-sample Mendelian randomization study

Background

Mental disorders, characterized as products of biopsychosocial interactions, have emerged as a leading contributor to the worldwide rise in overall morbidity and disability rates. Life's essentials can affect nearly every aspect of our lives, from physical to mental health. In this study, we try to identify the associations between life's essentials and mental disorders.

Method

Three assumptions of Mendelian randomization (MR) were applied to obtain the genetic instruments associated with smoking, sleep, and body mass index (BMI) in genome-wide association studies. Then, we conducted univariable MR (UVMR) and multivariable MR (MVMR) two-sample analyses to estimate the causal effects of these life's essentials on two mental disorders namely, major depressive disorder (MDD) and bipolar disorder (BD). Additionally, multiple sensitivity analyses were performed to evaluate the reliability and stability of the study results.

Results

In the MR analysis of the association of smoking, sleep, and BMI with MDD, we obtained 78, 39, and 302 genetic instruments, respectively. Smoking [odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01-1.06; p = 0.004], sleep (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001), and BMI (OR, 1.01; 95% CI, 1.01-1.02; p < 0.001) were all considered as risk factors for MDD and were independent of each other (smoking: OR, 1.03, 95% CI, 1.01-1.06, p = 0.008; sleep: OR, 1.03, 95% CI, 1.01-1.05, p = 0.001; and BMI: OR, 1.01, 95% CI, 1.01-1.02, p < 0.001). Additionally, 78, 38, and 297 genetic instruments were obtained in the MR analysis of smoking, sleep, and BMI with BD, respectively. Causal associations were observed between smoking (OR, 2.46; 95% CI, 1.17-5.15; p = 0.017), sleep (OR, 2.73; 95% CI, 1.52-4.92; p < 0.001), and BD, and smoking (OR, 2.43; 95% CI, 1.69-3.16; p = 0.018) might be a mediator in the causal effects of sleep on BD. Finally, there was no inconsistency between sensitivity and causality analysis, proving that our results are convincing.

Conclusion

The study results provide strong evidence that smoking, sleep, and BMI are causally related to MDD and BD, which need further research to clarify the underlying mechanism.

Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping

BACKGROUND

The adoption of digital health care within health systems is determined by various factors, including pricing and reimbursement. The reimbursement landscape for digital health in Europe remains underresearched. Although various emergency reimbursement decisions were made during the COVID-19 pandemic to enable health care delivery through videoconferencing and asynchronous care (eg, digital apps), research so far has primarily focused on the policy innovations that facilitated this outside of Europe.

OBJECTIVE

This study examines the digital health reimbursement strategies in 8 European countries (Belgium, France, Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom) and Israel.

METHODS

We mapped available digital health reimbursement strategies using a scoping review and policy mapping framework. We reviewed the literature on the MEDLINE, Embase, Global Health, and Web of Science databases. Supplementary records were identified through Google Scholar and country experts.

RESULTS

Our search strategy yielded a total of 1559 records, of which 40 (2.57%) were ultimately included in this study. As of August 2023, digital health solutions are reimbursable to some extent in all studied countries except Poland, although the mechanism of reimbursement differs significantly across countries. At the time of writing, the pricing of digital health solutions was mostly determined through discussions between national or regional committees and the manufacturers of digital health solutions in the absence of value-based assessment mechanisms. Financing digital health solutions outside traditional reimbursement schemes was possible in all studied countries except Poland and typically occurs via health innovation or digital health-specific funding schemes. European countries have value-based pricing frameworks that range from nonexistent to embryonic.

CONCLUSIONS

Studied countries show divergent approaches to the reimbursement of digital health solutions. These differences may complicate the ability of patients to seek cross-country health care in another country, even if a digital health app is available in both countries. Furthermore, the fragmented environment will present challenges for developers of such solutions, as they look to expand their impact across countries and health systems. An increased emphasis on developing a clear conceptualization of digital health, as well as value-based pricing and reimbursement mechanisms, is needed for the sustainable integration of digital health. This study can therein serve as a basis for further, more detailed research as the field of digital health reimbursement evolves.

Effectiveness of internet-based and mobile-based interventions for adults with overweight or obesity experiencing symptoms of depression: a systematic review protocol

INTRODUCTION

Internet-based and mobile-based interventions (IMIs) provide innovative low-threshold and cost-effective prevention and self-management options for mental health problems complementary to standard treatment. The objective of this systematic review is to summarise the effectiveness and to critically evaluate studies on IMIs addressing comorbid depressive symptoms in adults with overweight or obesity.

METHODS AND ANALYSIS

The study authors will systematically search the databases MEDLINE, Cochrane Library, PsycINFO, Web of Science, Embase and Google Scholar (for grey literature) for randomised controlled trials (RCTs) of IMIs for individuals with overweight or obesity and comorbid depressive symptoms without restrictions on publication date (planned inception 1 June 2023 to 1 December 2023). Two reviewers will independently extract and evaluate data from studies eligible for inclusion by assessing quality of evidence and qualitatively synthesising results. Preferred Reporting Items for Systematic reviews Meta-Analyses (PRISMA) standards and the revised Cochrane Risk of Bias tool in RCTs (RoB 2) will be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data will be collected. Study results will be disseminated through publication in a peer-reviewed journal and presentations on conferences.

PROSPERO REGISTRATION NUMBER

CRD42023361771.