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Alimohammadi A, Roshanpajouh M, Hosseini R, Ekrami K, Aghdaee M, Rajab Boloukat R, Mohagheghi M. A Comparative Study of the Effectiveness of Text-Based Crisis Intervention and Phone-Based Crisis Intervention in Reducing Emotional Distress Among Texters and Callers. Suicide Life Threat Behav 2025; 55:e70002. [PMID: 39825632 DOI: 10.1111/sltb.70002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 06/20/2024] [Accepted: 01/08/2025] [Indexed: 01/20/2025]
Abstract
INTRODUCTION Today, dying by suicide is one of the most important mental health challenges in the world, and proper planning and using various preventive methods play an important role in this field. The present research aimed to study comparatively the effectiveness of text-based intervention in reducing emotional distress of people involved in psychosocial crises, comparing it with phone-based intervention. METHODS In this study, the Distress Thermometer, assessing emotional distress, was used at the start and end of both text and phone-based interventions to explore their effectiveness in crisis de-escalation and management. This study comprises two samples within an overarching study, with 700 clients receiving text-based intervention and 737 clients receiving phone-based intervention. RESULTS The research findings indicate the effectiveness of both methods in reducing emotional distress among individuals in crisis. The mean emotional distress significantly differed between pre-and post-tests. Importantly, prior to controlling for baseline distress levels, text-based intervention demonstrated particularly strong efficacy in reducing emotional distress, showing a statistically significant difference. CONCLUSION Recognizing the effectiveness of both intervention methods and particularly the favorable response of young people with immediate suicide risk to text-based intervention, prioritizing the implementation of text-based systems is recommended in the national suicide prevention programs of developing countries.
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Affiliation(s)
- Amirali Alimohammadi
- Department of Clinical Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Roshanpajouh
- Addiction Researches Department, School of Behavioral Sciences and Mental Health, Tehran Psychiatry Institute, Iran University of Medical Science, Tehran, Iran
| | | | - Kourosh Ekrami
- Department of Psychology, Hekmat Razavi Institute of Higher Education, Mashhad, Iran
| | | | | | - Maryam Mohagheghi
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
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Li Y, Legler A, Bourgeois J, Podlogar M, Lauver M, Adams RS, Strombotne K, Garrido MM. Contact resolution among Veterans Crisis Line phone and text contacts regarding Veterans Health Administration enrollees. Suicide Life Threat Behav 2025; 55:e13129. [PMID: 39344791 DOI: 10.1111/sltb.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 09/05/2024] [Accepted: 09/18/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION To expand access to suicide prevention and support services, the Veteran Crisis Line (VCL) added text capabilities in 2011. It is unknown whether the likelihood of a contact being terminated by the user varies by contact type. We aimed to assess whether contact resolution varies by contact type after accounting for Veterans' sociodemographic and clinical characteristics, contact risk, and reasons for contact. METHOD A retrospective cohort study of VCL phone and text contacts regarding identified VHA enrollees between 2016 and 2021 was performed. To examine differences in contact resolution between contact types, inverse probability of treatment weights were used to balance characteristics of text and phone contacts. RESULTS Relative to phone contacts, text contacts were associated with 3.39 percentage point (PP) (95% CI, 3.27-3.50; p < 0.001) lower likelihood of receiving an emergency dispatch/welfare check, 2.65 PP (95% CI, 2.55-2.76; p < 0.001) lower likelihood of requiring arrangement for same-day care, and 9.47 (95% CI, 9.34-9.59; p < 0.001) PP higher likelihood of being terminated by the user. CONCLUSIONS VCL text contact was associated with an increased likelihood of being terminated by the user. Further investigation is needed to understand the reasons for terminating contact for those who texted VCL.
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Affiliation(s)
- Yufei Li
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
| | - Aaron Legler
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
| | - Jolie Bourgeois
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Matthew Podlogar
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - MaryGrace Lauver
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Rachel Sayko Adams
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
| | - Kiersten Strombotne
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
| | - Melissa M Garrido
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
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Pisani AR, Gallo C, Gould MS, Kanuri N, Marcotte JE, Pascal B, Rousseau D, Ranney ML, Filbin B, Turner S. Authors' Reply: Commentary on "Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line". J Med Internet Res 2025; 27:e59734. [PMID: 39842004 PMCID: PMC11799806 DOI: 10.2196/59734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/06/2024] [Accepted: 07/05/2024] [Indexed: 01/24/2025] Open
Abstract
We appreciate Reierson's thoughtful commentary on our 2019 paper, which described our experiences, ethical process, judgment calls, and lessons from a 2016-2017 data-sharing pilot between Crisis Text Line and academic researchers. The commentary raises important questions about the ethical conduct of health research in the digital age, particularly regarding informed consent, potential conflicts of interest, and the protection of vulnerable populations. Our article focused specifically on the noncommercial use of Crisis Text Line data for research purposes, so we restrict our reply to points relevant to such usage. While we acknowledge the limitations of Crisis Text Line's Terms of Service as a means of informing users about data sharing for research, we maintain that our guidelines were ethically sound and aligned with well-established practices for institutional review board (IRB) review and researcher training. We emphasize the critical role of IRBs in ensuring that research involving vulnerable populations, including minors, is conducted ethically and with appropriate safeguards. Regarding potential conflicts of interest, we argue that unpaid, nonfiduciary advisory board service for a nonprofit organization does not constitute a conflict requiring disclosure. The transparent nature of our collaboration with Crisis Text Line, as evidenced by the authorship and acknowledgments in our paper, further underscores our commitment to ethical research practices. We recognize the complexity and evolving nature of the challenges surrounding data-sharing partnerships in digital health research. As the field progresses, we remain committed to ongoing, transparent engagement and to refining best practices in collaboration with colleagues, stakeholders, and the public. Our response aims to provide clarity and context for the concerns raised in the commentary while reaffirming the integrity and value of our original work. Ultimately, we maintain that our paper contributed meaningfully to the ongoing discourse on ethical data sharing and laid the groundwork for future improvements in this critical area of digital health research.
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Affiliation(s)
- Anthony R Pisani
- Department of Psychiatry, Center for the Study and Prevention of Suicide, University of Rochester Medical Center, University of Rochester, Rochester, NY, United States
- Department of Pediatrics, University of Rochester Medical Center, University of Rochester, Rochester, NY, United States
| | - Carlos Gallo
- Northwestern University, Evanston, IL, United States
| | - Madelyn S Gould
- Department of Psychiatry, Columbia University, New York, NY, United States
- Department of Epidemiology, Columbia University, New York, NY, United States
| | | | | | - Brian Pascal
- Stanford University, Palo Alto, CA, United States
| | - David Rousseau
- Henry J Kaiser Family Foundation, Menlo Park, CA, United States
| | - Megan L Ranney
- Yale School of Public Health, New Haven, CT, United States
| | - Bob Filbin
- Meta (United States), Menlo Park, CA, United States
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Reierson TD. Commentary on "Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line". J Med Internet Res 2024; 26:e42144. [PMID: 39753221 PMCID: PMC11730236 DOI: 10.2196/42144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/28/2024] [Indexed: 01/18/2025] Open
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Gordon-Achebe K, Legha RK, Durham MP, Hamilton AT, Praylow T, Fortuna LR. Reimagining the CARE in Systems to Combat the Pediatric Mental Health Crisis in America: A Healing-Centered Approach. Child Adolesc Psychiatr Clin N Am 2024; 33:511-525. [PMID: 39277309 DOI: 10.1016/j.chc.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
The US child mental health care system requires a revival and reimagination. We need to shift toward healing-centered models of care and prioritize access to high-quality mental health care through policy changes and resource allocation. Funding community-based programs that provide culturally responsive, antiracist, and equitable (CARE) systems is essential. Policies must be implemented to reduce barriers to accessing mental health services for underresourced communities. By prioritizing (CARE) over control, we can build a just workforce that is equipped to address the needs of a growing diverse population and ensure that all children and families can heal and thrive.
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Affiliation(s)
- Kimberly Gordon-Achebe
- BHETC, LLC (Bringing Health Equity Training and Consulting to Communities of Color), 8407 Main Street, Ellicott City, MD 21043, USA; Department of Psychiatry & Behavioral Science, Tulane University, School of Medicine, 1440 Canal Street, New Orleans, LA 70112, USA; Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, 701 West Pratt Street, 4th Floor, Baltimore, MD 21201, USA.
| | | | - Michelle P Durham
- University of Houston Tilman J. Fertitta Family College of Medicine, 5600 Fishers Lane, Rockville, MD 20857, USA
| | - Anika T Hamilton
- UMSOM Office of Student Affairs, 685 West Baltimore Street, Suite 150, Baltimore, MD 21201, USA
| | - Tiona Praylow
- Three Rivers Midlands, 200 Ermine Road, West Columbia, SC 29170, USA; Resiliency Empowerment Strategies, 5 Pocosin Court, Elgin, SC 29045, USA
| | - Lisa R Fortuna
- Department of Psychiatry and Neuroscience, 900 University Avenue, Riverside, CA 92521, USA
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Salmi S, Mérelle S, Gilissen R, van der Mei R, Bhulai S. The Most Effective Interventions for Classification Model Development to Predict Chat Outcomes Based on the Conversation Content in Online Suicide Prevention Chats: Machine Learning Approach. JMIR Ment Health 2024; 11:e57362. [PMID: 39326039 PMCID: PMC11467604 DOI: 10.2196/57362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/25/2024] [Accepted: 08/11/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND For the provision of optimal care in a suicide prevention helpline, it is important to know what contributes to positive or negative effects on help seekers. Helplines can often be contacted through text-based chat services, which produce large amounts of text data for use in large-scale analysis. OBJECTIVE We trained a machine learning classification model to predict chat outcomes based on the content of the chat conversations in suicide helplines and identified the counsellor utterances that had the most impact on its outputs. METHODS From August 2021 until January 2023, help seekers (N=6903) scored themselves on factors known to be associated with suicidality (eg, hopelessness, feeling entrapped, will to live) before and after a chat conversation with the suicide prevention helpline in the Netherlands (113 Suicide Prevention). Machine learning text analysis was used to predict help seeker scores on these factors. Using 2 approaches for interpreting machine learning models, we identified text messages from helpers in a chat that contributed the most to the prediction of the model. RESULTS According to the machine learning model, helpers' positive affirmations and expressing involvement contributed to improved scores of the help seekers. Use of macros and ending the chat prematurely due to the help seeker being in an unsafe situation had negative effects on help seekers. CONCLUSIONS This study reveals insights for improving helpline chats, emphasizing the value of an evocative style with questions, positive affirmations, and practical advice. It also underscores the potential of machine learning in helpline chat analysis.
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Affiliation(s)
- Salim Salmi
- Research Department, 113 Suicide Prevention, Amsterdam, Netherlands
| | - Saskia Mérelle
- Research Department, 113 Suicide Prevention, Amsterdam, Netherlands
| | - Renske Gilissen
- Research Department, 113 Suicide Prevention, Amsterdam, Netherlands
| | - Rob van der Mei
- Department of Stochastics, Centrum Wiskunde & Informatica, Amsterdam, Netherlands
| | - Sandjai Bhulai
- Department of Mathematics, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Foster AA, Zabel M, Schober M. Youth Crisis: The Current State and Future Directions. Psychiatr Clin North Am 2024; 47:595-611. [PMID: 39122348 DOI: 10.1016/j.psc.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
The number of children and youth experiencing behavioral health crisis in the United States is substantially increasing. Currently, there are shortages to home-based and community-based services as well as psychiatric outpatient and inpatient pediatric care, leading to high emergency department utilization. This article introduces a proposed crisis continuum of care, highlights existing evidence, and provides opportunities for further research and advocacy.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco, 550 16th Street, Box 0649, San Francisco, CA 94143, USA.
| | - Michelle Zabel
- Innovations Institute, University of Connecticut School of Social Work, 38 Prospect Street, Hartford, CT 06103, USA
| | - Melissa Schober
- Innovations Institute, University of Connecticut School of Social Work, 38 Prospect Street, Hartford, CT 06103, USA
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Williamson T, Sugg MM, Singh D, Green S, Runkle JD. Crisis response in Texas youth impacted by Hurricane Harvey: A difference-in-differences analysis. J Affect Disord 2024; 359:215-223. [PMID: 38768821 PMCID: PMC11284573 DOI: 10.1016/j.jad.2024.05.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Hurricane Harvey was the second costliest storm to impact the U.S. More research is needed to understand the mental health consequences of these extreme events in children and adolescents extending beyond the acute recovery period. METHODS Daily anonymized Crisis Text Line (CTL) conversations were used to understand patterns in crisis responses for youth one year before and after Harvey's landfall. A quasi-experimental difference-in-differences analysis compared changes in texts for stress/anxiety, depression, thoughts of suicide, and self-harm following Harvey between exposed and unexposed youth in Texas. RESULTS CTL users with Texas-based area codes (N = 23,016) were compriesd largely of youth who self-identified as female (78.1 %), 14-17 year old (50.4 %), white (38.9 %), and LGBTQ+ (51.2 %). We observed parallel increases in crisis texts for depression and thoughts of suicide in most months following Harvey among exposed and unexposed youth. However, non-impacted youth had significantly larger increases in texts for depression up to three months post-Harvey and thoughts of suicide one year after Harvey compared to directly impacted communities. LIMITATIONS Sample size was restricted to texters who completed the post-conversation demographics survey, who may fundamentally differ from those who declined to respond. Harvey exposure was determined using texter area code and county-level disaster declarations, limiting our ability to guarantee individual-level exposure. CONCLUSIONS Texas youth traditionally considered unexposed experienced nearly identical increases in concerns of depression and thoughts of suicide to those directly exposed. Findings suggest spillover effects (e.g., economic concerns, media exposure) may contribute to statewide impacts on youth mental health after natural disasters.
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Affiliation(s)
- Trey Williamson
- North Carolina Institute for Climate Studies, North Carolina State University, 151 Patton Avenue, Asheville, NC 28801, USA
| | - Margaret M Sugg
- Department of Geography and Planning, Appalachian State University, Boone, NC 28607, USA
| | - Devyani Singh
- Research & Impact Team, Crisis Text Line, New York, NY, USA
| | | | - Jennifer D Runkle
- North Carolina Institute for Climate Studies, North Carolina State University, 151 Patton Avenue, Asheville, NC 28801, USA.
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Xu Y, Chan CS, Chan E, Chen J, Cheung F, Xu Z, Liu J, Yip PSF. Tracking and Profiling Repeated Users Over Time in Text-Based Counseling: Longitudinal Observational Study With Hierarchical Clustering. J Med Internet Res 2024; 26:e50976. [PMID: 38815258 PMCID: PMC11176871 DOI: 10.2196/50976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/14/2023] [Accepted: 04/12/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Due to their accessibility and anonymity, web-based counseling services are expanding at an unprecedented rate. One of the most prominent challenges such services face is repeated users, who represent a small fraction of total users but consume significant resources by continually returning to the system and reiterating the same narrative and issues. A deeper understanding of repeated users and tailoring interventions may help improve service efficiency and effectiveness. Previous studies on repeated users were mainly on telephone counseling, and the classification of repeated users tended to be arbitrary and failed to capture the heterogeneity in this group of users. OBJECTIVE In this study, we aimed to develop a systematic method to profile repeated users and to understand what drives their use of the service. By doing so, we aimed to provide insight and practical implications that can inform the provision of service catering to different types of users and improve service effectiveness. METHODS We extracted session data from 29,400 users from a free 24/7 web-based counseling service from 2018 to 2021. To systematically investigate the heterogeneity of repeated users, hierarchical clustering was used to classify the users based on 3 indicators of service use behaviors, including the duration of their user journey, use frequency, and intensity. We then compared the psychological profile of the identified subgroups including their suicide risks and primary concerns to gain insights into the factors driving their patterns of service use. RESULTS Three clusters of repeated users with clear psychological profiles were detected: episodic, intermittent, and persistent-intensive users. Generally, compared with one-time users, repeated users showed higher suicide risks and more complicated backgrounds, including more severe presenting issues such as suicide or self-harm, bullying, and addictive behaviors. Higher frequency and intensity of service use were also associated with elevated suicide risk levels and a higher proportion of users citing mental disorders as their primary concerns. CONCLUSIONS This study presents a systematic method of identifying and classifying repeated users in web-based counseling services. The proposed bottom-up clustering method identified 3 subgroups of repeated users with distinct service behaviors and psychological profiles. The findings can facilitate frontline personnel in delivering more efficient interventions and the proposed method can also be meaningful to a wider range of services in improving service provision, resource allocation, and service effectiveness.
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Affiliation(s)
- Yucan Xu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (Hong Kong)
| | | | - Evangeline Chan
- Department of Social and Behavioural Sciences, City University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Junyou Chen
- The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Florence Cheung
- The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Zhongzhi Xu
- School of Public Health, Sun Yat-sen University, Guang Zhou, China
| | - Joyce Liu
- The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Paul Siu Fai Yip
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China (Hong Kong)
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Ryan SC, Sugg MM, Runkle JD, Wertis L, Singh D, Green S. Short-term changes in mental health help-seeking behaviors following exposure to multiple social stressors and a natural disaster. Soc Sci Med 2024; 348:116843. [PMID: 38603916 PMCID: PMC11134597 DOI: 10.1016/j.socscimed.2024.116843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/23/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
In 2020, unprecedented circumstances led to significant mental health consequences. Individuals faced mental health stressors that extended beyond the devastating impact of the COVID-19 pandemic, including widespread social unrest following the murder of George Floyd, an intense hurricane season in the Atlantic, and the politically divisive 2020 election. The objective of this analysis was to consider changes in help-seeking behavior following exposure to multiple social stressors and a natural disaster. Data from Crisis Text Line (CTL), a national text-based mental health crisis counseling service, was used to determine how help-seeking behavior changed in the wake of each event. Wilcoxon rank sum tests assessed changes in help-seeking behavior for each event in 2020 as compared to the same period in 2019. AutoRegressive Integrated Moving Average (ARIMA) models examined if changes in crisis conversation volumes following each event differed. Higher median conversation volumes noted for the COVID-19 pandemic (+1 to +5 conversations), Hurricane Laura (+1 to +7 conversations) and the 2020 Election (+1 to +26 conversations). ARIMA models show substantial increases in help-seeking behavior following the declaration of a national emergency for the COVID-19 pandemic (+4.3 to +38.2%) and following the 2020 election (+3 to +24.44%). Our analysis found that the mental health response following social stressors may be distinct from natural events, especially when natural disasters occur in the context of multiple social stressors. This analysis adds to the growing body of literature considering the mental health impact of exposure to multiple co-occurring societal stressors, like police violence and a global pandemic.
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Affiliation(s)
- Sophia C Ryan
- Department of Geography and Planning, Appalachian State University, Boone NC, 28607, USA.
| | - Margaret M Sugg
- Department of Geography and Planning, Appalachian State University, Boone NC, 28607, USA
| | - Jennifer D Runkle
- North Carolina Institute for Climate Studies, North Carolina State University, Raleigh NC, 27695, USA
| | - Luke Wertis
- Department of Geography and Planning, Appalachian State University, Boone NC, 28607, USA
| | - Devyani Singh
- Data Team, Crisis Text Line, New York City, New York, USA
| | - Shannon Green
- Data Team, Crisis Text Line, New York City, New York, USA
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Côté LP, Lane J. Evaluation of the Effectiveness of Suicide.ca, Quebec's Digital Suicide Prevention Strategy Platform: Cross-Sectional Descriptive Study. JMIR Form Res 2024; 8:e46195. [PMID: 38446536 PMCID: PMC10955392 DOI: 10.2196/46195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/07/2023] [Accepted: 12/04/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND In 2017, the Quebec government assigned the Association québécoise de prévention du suicide (AQPS) to develop a digital suicide prevention strategy (DSPS). The AQPS responded by creating a centralized website that provides information on suicide and mental health, identifies at-risk individuals on the internet, and offers direct crisis intervention support via chat and text. OBJECTIVE This study aims to evaluate the effectiveness of suicide.ca, Quebec's DSPS platform. METHODS This study used a cross-sectional descriptive design. The study population comprised internet users from Quebec, Canada, who visited the suicide.ca platform between October 2020 and October 2021. Various data sources, such as Google Analytics, Firebase Console, and Customer Relation Management data, were analyzed to document the use of the platform. To understand the profile of suicide.ca users, frequency analyses were conducted using data from the self-assessment module questionnaires, the intervention service's triage questionnaire, and the counselors' intervention reports. The effectiveness of the platform's promotional activities on social media was assessed by examining traffic peaks. Google Analytics was used to evaluate the effectiveness of AQPS' strategy for identifying at-risk internet users. The impact of the intervention service was evaluated through an analysis of counselors' intervention reports and postintervention survey results. RESULTS The platform received traffic from a diverse range of sources, with promotional efforts on social media directly contributing to the increased traffic. The requirement of a user account posed a barrier to the use of the mobile app, and a triage question that involved personal information led to a substantial number of dropouts during the intervention service triage. AdWords campaigns and fact sheets addressing suicide risk factors played a crucial role in driving traffic to the platform. With regard to the profile of suicide.ca users, the findings revealed that the platform engaged individuals with diverse levels of suicidal risk. Notably, users of the chat service displayed a higher suicide risk than those who used the self-assessment module. Crisis chat counselors reported a positive impact on approximately half of the contacts, and overall, intervention service users expressed satisfaction with the support they received. CONCLUSIONS A centralized digital platform can be used to implement a DSPS, effectively reaching the general population, individuals with risk factors for suicide, and those facing suicidal issues.
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Affiliation(s)
- Louis-Philippe Côté
- Centre for Research and Intervention on Suicide, Ethical Issues and End-of-life practices, Université du Québec à Montréal, Montreal, QC, Canada
| | - Julie Lane
- Centre RBC d'expertise universitaire en santé mentale, Université de Sherbrooke, Sherbrooke, QC, Canada
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Obuobi-Donkor G, Shalaby R, Agyapong B, Dias RDL, Agyapong VIO. Mitigating Psychological Problems Associated with the 2023 Wildfires in Alberta and Nova Scotia: Six-Week Outcomes from the Text4Hope Program. J Clin Med 2024; 13:865. [PMID: 38337558 PMCID: PMC10856019 DOI: 10.3390/jcm13030865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Background: In 2023, wildfires led to widespread destruction of property and displacement of residents in Alberta and Nova Scotia, Canada. Previous research suggests that wildfires increase the psychological burden of impacted communities, necessitating population-level interventions. Cognitive Behavioural Therapy (CBT)-based text message interventions, Text4HopeAB and Text4HopeNS, were launched in Alberta and Nova Scotia, respectively, during the 2023 wildfire season to support the mental health of impacted individuals. Objectives: The study examines the effectiveness of Text4HopeNS and Text4HopeAB in alleviating psychological symptoms and improving wellbeing among subscribers. Methods: The study involved longitudinal and naturalistic controlled trial designs. The longitudinal study comprised subscribers who completed program surveys at baseline and six weeks post-enrolment, while the naturalistic controlled study compared psychological symptoms in subscribers who had received daily supportive text messages for six weeks (intervention group) and new subscribers who had enrolled in the program during the same period but had not yet received any text messages (control group). The severity of low resilience, poor mental wellbeing, likely Major Depressive Disorder (MDD), likely Generalized Anxiety Disorder (GAD), likely Post-Traumatic Stress Disorder (PTSD), and suicidal ideation were measured on the Brief Resilience Scale (BRS), the World Health Organization-5 Wellbeing Index (WHO-5), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) scale, PTSD Checklist-Civilian Version (PCL-C), and the ninth question on the PHQ-9, respectively. The paired and independent sample t-tests were employed in data analysis. Results: The results from the longitudinal study indicated a significant reduction in the mean scores on the PHQ-9 (-12.3%), GAD-7 (-14.8%), and the PCL-C (-5.8%), and an increase in the mean score on the WHO-5, but not on the BRS, from baseline to six weeks. In the naturalistic controlled study, the intervention group had a significantly lower mean score on the PHQ-9 (-30.1%), GAD-7 (-29.4%), PCL-C (-17.5%), and the ninth question on the PHQ-9 (-60.0%) which measures the intensity of suicidal ideation, and an increase in the mean score on the WHO-5 (+24.7%), but not on the BRS, from baseline to six weeks compared to the control group. Conclusions: The results of this study suggests that the Text4Hope program is an effective intervention for mitigating psychological symptoms in subscribers during wildfires. This CBT-based text messaging program can be adapted to provide effective support for individuals' mental health, especially in the context of traumatic events and adverse experiences such as those induced by climate change. Policymakers and mental health professionals should consider these findings when shaping strategies for future disaster response efforts, emphasizing the value of scalable and culturally sensitive mental health interventions.
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Affiliation(s)
- Gloria Obuobi-Donkor
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada; (G.O.-D.); (R.d.L.D.)
| | - Reham Shalaby
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (R.S.); (B.A.)
| | - Belinda Agyapong
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (R.S.); (B.A.)
| | - Raquel da Luz Dias
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada; (G.O.-D.); (R.d.L.D.)
| | - Vincent Israel Opoku Agyapong
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada; (G.O.-D.); (R.d.L.D.)
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (R.S.); (B.A.)
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Chiauzzi E, Williams A, Mariano TY, Pajarito S, Robinson A, Kirvin-Quamme A, Forman-Hoffman V. Demographic and clinical characteristics associated with anxiety and depressive symptom outcomes in users of a digital mental health intervention incorporating a relational agent. BMC Psychiatry 2024; 24:79. [PMID: 38291369 PMCID: PMC10826101 DOI: 10.1186/s12888-024-05532-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Digital mental health interventions (DMHIs) may reduce treatment access issues for those experiencing depressive and/or anxiety symptoms. DMHIs that incorporate relational agents may offer unique ways to engage and respond to users and to potentially help reduce provider burden. This study tested Woebot for Mood & Anxiety (W-MA-02), a DMHI that employs Woebot, a relational agent that incorporates elements of several evidence-based psychotherapies, among those with baseline clinical levels of depressive or anxiety symptoms. Changes in self-reported depressive and anxiety symptoms over 8 weeks were measured, along with the association between each of these outcomes and demographic and clinical characteristics. METHODS This exploratory, single-arm, 8-week study of 256 adults yielded non-mutually exclusive subsamples with either clinical levels of depressive or anxiety symptoms at baseline. Week 8 Patient Health Questionnaire-8 (PHQ-8) changes were measured in the depressive subsample (PHQ-8 ≥ 10). Week 8 Generalized Anxiety Disorder-7 (GAD-7) changes were measured in the anxiety subsample (GAD-7 ≥ 10). Demographic and clinical characteristics were examined in association with symptom changes via bivariate and multiple regression models adjusted for W-MA-02 utilization. Characteristics included age, sex at birth, race/ethnicity, marital status, education, sexual orientation, employment status, health insurance, baseline levels of depressive and anxiety symptoms, and concurrent psychotherapeutic or psychotropic medication treatments during the study. RESULTS Both the depressive and anxiety subsamples were predominantly female, educated, non-Hispanic white, and averaged 38 and 37 years of age, respectively. The depressive subsample had significant reductions in depressive symptoms at Week 8 (mean change =-7.28, SD = 5.91, Cohen's d = -1.23, p < 0.01); the anxiety subsample had significant reductions in anxiety symptoms at Week 8 (mean change = -7.45, SD = 5.99, Cohen's d = -1.24, p < 0.01). No significant associations were found between sex at birth, age, employment status, educational background and Week 8 symptom changes. Significant associations between depressive and anxiety symptom outcomes and sexual orientation, marital status, concurrent mental health treatment, and baseline symptom severity were found. CONCLUSIONS The present study suggests early promise for W-MA-02 as an intervention for depression and/or anxiety symptoms. Although exploratory in nature, this study revealed potential user characteristics associated with outcomes that can be investigated in future studies. TRIAL REGISTRATION This study was retrospectively registered on ClinicalTrials.gov (#NCT05672745) on January 5th, 2023.
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Affiliation(s)
- Emil Chiauzzi
- Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, USA
| | - Andre Williams
- Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, USA
| | - Timothy Y Mariano
- Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, USA
- RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sarah Pajarito
- Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, USA
| | - Athena Robinson
- Woebot Health, 535 Mission Street, 14th Floor, San Francisco, CA, 94105, USA
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Miller AB, Oppenheimer CW, Chew RF, Weitzel KJ, D'Arcangelo B, Barnes A, Lowe A, Yaros AC. Exploring whether mental health crisis text conversations that include discussion of firearms differ from those without firearms. Prev Med 2023; 177:107783. [PMID: 37980956 PMCID: PMC10783174 DOI: 10.1016/j.ypmed.2023.107783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Firearm violence represents a public health crisis in the United States. Yet, there is limited knowledge about how firearms are discussed in the context of mental health emergencies representing a major gap in the current research literature. This study addresses this gap by examining whether the content of mental health crisis text conversations that mention firearms differ from those that do not mention firearms in a large, unique dataset from a national crisis text line. METHODS We examined data from over 3.2 million conversations between texters to Crisis Text Line and volunteer crisis counselors between September 2018 and July 2022. We used a study developed text classification machine learning algorithm that builds on natural language processing to identify and label whether crisis conversations mentioned firearms. We compared the frequency of psychosocial factors between conversations that mention firearms with those that did not. RESULTS Results from a generalized linear mixed-effects model demonstrated that. conversations mentioning firearms more frequently were associated with suicide, racism, physical, sexual, emotional, and unspecified abuse, grief, concerns about a third party, substance use, bullying, gender and sexual identity, relationships, depression, and loneliness. Further, conversations mentioning firearms were less likely to be related to self-harm and eating/body image. CONCLUSIONS These results offer an initial glimpse of how firearms are mentioned in the context of acute mental health emergencies, which has been completely absent in prior literature. Our results are preliminary and help sharpen our understanding of contextual factors surrounding mental health emergencies where a firearm is mentioned.
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Affiliation(s)
| | | | | | | | | | | | - Ashley Lowe
- RTI International, Research Triangle Park, NC, USA
| | - Anna C Yaros
- RTI International, Research Triangle Park, NC, USA
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Dias RDL, Shalaby R, Agyapong B, Vuong W, Gusnowski A, Surood S, Greenshaw AJ, Agyapong VIO. The effectiveness of CBT-based daily supportive text messages in improving female mental health during COVID-19 pandemic: results from the Text4Hope program. Front Glob Womens Health 2023; 4:1182267. [PMID: 38025982 PMCID: PMC10667914 DOI: 10.3389/fgwh.2023.1182267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The COVID-19 pandemic has significantly exacerbated gender disparities in mental health, particularly impacting women. To address this, Alberta, Canada, launched Text4Hope, a Cognitive Behaviour Therapy-based text messaging intervention, to provide support and resources for psychological challenges during the pandemic. This study aimed to assess the effectiveness of Text4Hope in reducing stress, anxiety, depression, sleeping disturbances, and suicidal ideation among female subscribers during the COVID-19 pandemic. Methods The study employed both an uncontrolled longitudinal design and a controlled cohort design. The uncontrolled longitudinal study analyzed a one-year dataset (n = 9,545) of clinical outcomes, comparing mean differences in mental health symptoms from baseline to 6 weeks after subscription. The controlled cohort design compared two groups, with (n = 1,763) and without (n = 567) intervention exposure during the same period. Data were collected through self-administered online surveys completed at baseline and six weeks after subscription. Sociodemographic information and validated scales (e.g., 10-item Perceived Stress Scale (PSS-10), Generalized Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9)) were used to assess mental health outcomes. Results The results from the longitudinal study indicated a significant reduction in anxiety prevalence and anxiety symptoms, with a 19.63% decrease in GAD-7 mean score and a 32.02% decrease in likely anxiety from baseline to six weeks. Depressive symptoms and perceived stress also showed a significant reduction (p < 0.001), albeit to a lesser extent. In the controlled cohort study, the intervention group had significantly (p < 0.001) lower PHQ-9 [19.5 (SD 7.05)], GAD-7 [7.5 (SD 5.27)], and CMH [35.53 (SD 18.45)] scores. Additionally, the study found substantial differences (p < 0.001) in suicidal ideation (26.1 vs. 15.7) between groups but no significant differences in sleep disruption. Discussion These findings suggest that Text4Hope could be an effective intervention for reducing stress, depression, suicidal ideation, and particularly anxiety symptoms among women during public emergencies. The study provides valuable insights into the potential benefits of text messaging interventions in supporting mental health during crisis situations.
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Affiliation(s)
- Raquel da Luz Dias
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Reham Shalaby
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Belinda Agyapong
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Wesley Vuong
- Addiction and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - April Gusnowski
- Addiction and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Shireen Surood
- Addiction and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Andrew James Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vincent I. O. Agyapong
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Nova Scotia Health Authority, Halifax, NS, Canada
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Baldofski S, Kohls E, Efe Z, Eckert M, Saee S, Thomas J, Wundrack R, Rummel-Kluge C. The Impact of a Messenger-Based Psychosocial Chat Counseling Service on Further Help-Seeking Among Children and Young Adults: Longitudinal Study. JMIR Ment Health 2023; 10:e43780. [PMID: 37195747 DOI: 10.2196/43780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/21/2022] [Accepted: 03/22/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Mental crises have high prevalences in adolescence. Early interventions appear to be highly important to diminish the risk of the deterioration, recurrence, or chronification of symptoms. In recent years, various providers have started offering live chat support in psychological crises. The messenger-based psychological counseling service krisenchat aims to support young people in crises and, if necessary, provide a recommendation for a referral to the health care system or to seek further help from a trusted adult person. OBJECTIVE This study aimed to investigate the impact of using the counseling service of krisenchat on the further help-seeking behavior of young people, and to identify associated factors of further help-seeking. METHODS This longitudinal study analyzed anonymous data from 247 individuals who used krisenchat between October 2021 and March 2022, and received a recommendation for further help-seeking. An online survey directly after the chat assessed the perceived helpfulness of the chat and well-being after the chat. After 4 weeks, further help-seeking, facilitators and barriers to help-seeking, and self-efficacy were assessed in an online follow-up survey. RESULTS The most frequently recommended services or persons to seek further help from included a psychotherapist or social psychiatric service (75/225, 33.3%), a school psychologist or school social worker (52/225, 23.1%), and the user's parents (45/225, 20.0%). Of the 247 users, 120 (48.6%) indicated that they contacted the recommended service or person, and of these, 87 (72.5%) stated that they already had an appointment (or talk) with the respective service or person or that an appointment (or talk) was scheduled. The most frequently reported facilitators for further help-seeking were mental health literacy (54/120, 45.0%), improvement of self-efficacy (55/120, 45.8%), and symptom recognition (40/120, 33.3%). In users not displaying further help-seeking behavior, the most frequent barriers included stigmatization (60/127, 47.2%), lack of mental health literacy (59/127, 46.5%), need for self-reliance and autonomy (53/127, 41.7%), and negative family beliefs regarding help services (53/127, 41.7%). Subgroup comparisons indicated significantly higher levels of self-efficacy in users displaying further help-seeking behavior than in those not displaying further help-seeking behavior. Both subgroups did not differ in gender, age, recommended service or person, chat topics, perceived helpfulness, and well-being. CONCLUSIONS The findings of this study indicate that children and young adults receiving counseling on krisenchat benefit in terms of seeking further help. Further help-seeking seems to be associated with higher levels of self-efficacy. TRIAL REGISTRATION Deutsches Register Klinischer Studien DRKS00026671; https://tinyurl.com/4fm5xe68.
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Affiliation(s)
- Sabrina Baldofski
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Elisabeth Kohls
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
- Department of Psychiatry and Psychotherapy, University Leipzig Medical Center, Leipzig, Germany
| | - Zeki Efe
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
| | | | | | | | | | - Christine Rummel-Kluge
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
- Department of Psychiatry and Psychotherapy, University Leipzig Medical Center, Leipzig, Germany
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Mavragani A, Chew RF, Miller AB, Oppenheimer CW, Lowe A, Yaros A. The Use of Crisis Services Following the Mass School Shooting in Uvalde, Texas: Quasi-Experimental Event Study. JMIR Public Health Surveill 2023; 9:e42811. [PMID: 36753321 PMCID: PMC9947763 DOI: 10.2196/42811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Mass shootings result in widespread psychological trauma for survivors and members of the affected community. However, less is known about the broader effects of indirect exposure (eg, media) to mass shootings. Crisis lines offer a unique opportunity to examine real-time data on the widespread psychological effects of mass shootings. OBJECTIVE Crisis Text Line is a not-for-profit company that provides 24/7 confidential SMS text message-based mental health support and crisis intervention service. This study examines changes in the volume and composition of firearm-related conversations at Crisis Text Line before and after the mass school shooting at Robb Elementary School on May 24, 2022, in Uvalde, Texas. METHODS A quasi-experimental event study design was used to compare the actual volume of firearm-related conversations received by Crisis Text Line post shooting to forecasted firearm conversation volume under the counterfactual scenario that a shooting had not occurred. Conversations related to firearms were identified among all conversations using keyword searches. Firearm conversation volume was predicted using a seasonal autoregressive integrated moving average model trained on the 3 months of data leading up to the shooting. Additionally, proportions of issue tags (topics coded post conversation by volunteer crisis counselors at Crisis Text Line after the exchange) were compared in the 4 days before (n=251) and after (n=417) the shooting to assess changes in conversation characteristics. The 4-day window was chosen to reflect the number of days conversation volume remained above forecasted levels. RESULTS There was a significant increase in the number of conversations mentioning firearms following the shooting, with the largest spike (compared to forecasted numbers) occurring the day after the shooting (n=159) on May 25, 2022. By May 28, the volume reverted to within the 95% CI of the forecasted volume (n=77). Within firearm conversations, "grief" issue tags showed a significant increase in proportion in the week following the shooting, while "isolation/loneliness," "relationships," and "suicide" issue tags showed a significant decrease in proportions the week following the shooting. CONCLUSIONS The results suggest that the Uvalde school shooting may have contributed to an increase in demand for crisis services, above what would be expected given historical trends. Additionally, we found that these firearm-related crises conversations immediately post event are more likely to be related to grief and less likely to be related to suicide, loneliness, and relationships. Our findings provide some of the first data showing the real-time repercussions for the broader population exposed to school shooting events. This work adds to a growing evidence base documenting and measuring the rippling effects of mass shootings outside of those directly impacted.
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Affiliation(s)
| | - Robert F Chew
- Center for Data Science and AI, RTI International, Research Triangle Park, NC, United States
| | - Adam Bryant Miller
- Center on Social Determinants, Risk Behaviors & Prevention Science, RTI International, Research Triangle Park, NC, United States.,Department of Psychology & Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caroline W Oppenheimer
- Center on Social Determinants, Risk Behaviors & Prevention Science, RTI International, Research Triangle Park, NC, United States
| | - Ashley Lowe
- Transformative Research Unit for Equity, RTI International, Research Triangle Park, NC, United States
| | - Anna Yaros
- Center on Social Determinants, Risk Behaviors & Prevention Science, RTI International, Research Triangle Park, NC, United States
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