Multicentre, England-wide randomised controlled trial of the 'Foundations' smartphone application in improving mental health and well-being in a healthcare worker population

The evolving field of digital mental health: current evidence and implementation issues for smartphone apps, generative artificial intelligence, and virtual reality

The expanding domain of digital mental health is transitioning beyond traditional telehealth to incorporate smartphone apps, virtual reality, and generative artificial intelligence, including large language models. While industry setbacks and methodological critiques have highlighted gaps in evidence and challenges in scaling these technologies, emerging solutions rooted in co-design, rigorous evaluation, and implementation science offer promising pathways forward. This paper underscores the dual necessity of advancing the scientific foundations of digital mental health and increasing its real-world applicability through five themes. First, we discuss recent technological advances in digital phenotyping, virtual reality, and generative artificial intelligence. Progress in this latter area, specifically designed to create new outputs such as conversations and images, holds unique potential for the mental health field. Given the spread of smartphone apps, we then evaluate the evidence supporting their utility across various mental health contexts, including well-being, depression, anxiety, schizophrenia, eating disorders, and substance use disorders. This broad view of the field highlights the need for a new generation of more rigorous, placebo-controlled, and real-world studies. We subsequently explore engagement challenges that hamper all digital mental health tools, and propose solutions, including human support, digital navigators, just-in-time adaptive interventions, and personalized approaches. We then analyze implementation issues, emphasizing clinician engagement, service integration, and scalable delivery models. We finally consider the need to ensure that innovations work for all people and thus can bridge digital health disparities, reviewing the evidence on tailoring digital tools for historically marginalized populations and low- and middle-income countries. Regarding digital mental health innovations as tools to augment and extend care, we conclude that smartphone apps, virtual reality, and large language models can positively impact mental health care if deployed correctly.

ReNeuWell mental well-being app: protocol for a randomised controlled trial

INTRODUCTION

The field of mental well-being interventions includes numerous studies of smartphone app-based programs, but there is a research-to-retail gap where many studies pertain to apps that are not publicly available, not used as standalone programs, or not tested in the general population, and many publicly available apps (or their proprietary in-app measures) have yet to be submitted to empirical testing. Furthermore, few well-being apps offer multicomponent interventions, despite such interventions having demonstrated efficacy outside the smartphone context. In response to these openings in the literature and marketplace, we have developed ReNeuWell, an iPhone app designed to measure the user's mental well-being (via the validated Composure, Own-worth, Mastery, Positivity, Achievement and Satisfaction for Well-being (COMPAS-W) scale) and improve their well-being via a personalised, multicomponent program of activities informed by the peer-reviewed evidence base. This article describes the protocol for the preregistered randomised controlled trial (RCT) of ReNeuWell, to test the app in adult participants from the general population of Apple App Store users. It is hypothesised that ReNeuWell users will experience significant increases in mental well-being and decreases in mental distress over the 6-12-week trial period, relative to users of an active control version of the app.

METHODS AND ANALYSIS

The RCT will recruit participants from Apple Store users who choose to download ReNeuWell in the normal course of browsing the marketplace. Following consent, the app will randomly allocate participants to receive either the full version of the app or the active control version. The full version assesses the user's well-being via the validated COMPAS-W scale, provides feedback on their well-being across six dimensions and creates a personalised schedule of daily positive psychology activities designed to enhance well-being along each dimension. Participants will be instructed to use the app for at least 10 min (at least one activity) per day for the first 6 weeks, and as they wish for the following 6 weeks. Trial outcomes will be measured via in-app surveys administered in weeks 1, 6 and 12. Data collection will begin when the app is officially launched on the Apple Store. Data will be analysed using linear mixed models to estimate condition-by-time interaction effects on the primary and secondary outcomes, and to assess whether any such effects are themselves moderated by other key variables.

ETHICS AND DISSEMINATION

This protocol has been approved by the Human Research Ethics Committee of the University of New South Wales (reference number: HC210302). Trial outcomes will be published in accordance with the preregistered protocol described here, both in the peer-reviewed literature and on the registry website.

TRIAL REGISTRATION NUMBER

This protocol was preregistered with the Australian New Zealand Clinical Trials Registry (registration approved on 4 August 2021; trial ID number: ACTRN12621001014842p).

Testing the Effectiveness of a Mobile Smartphone App Designed to Improve the Mental Health of Junior Physicians: Protocol for a Randomized Controlled Trial

BACKGROUND

Shift (Black Dog Institute) is the first mobile health smartphone app created to support the mental health of junior physicians. Junior physicians experience demanding work conditions, leading to high levels of psychological distress and burnout. However, they are often concerned about the potential career impacts of seeking mental health support. The confidentiality and ease of access of digital interventions may be particularly suited to address these concerns. The Shift app provides therapeutic and psychoeducational content and strategies contextualized for the specific needs of physicians in training. App content includes information on mental health, help seeking, mindfulness, and common workplace-related concerns of junior physicians.

OBJECTIVE

This study aims to test, at scale, the effectiveness of Shift among junior physicians working in Australia using a randomized controlled trial design. The primary aim is to examine whether junior physicians using Shift experience a reduction in depressive symptoms compared with a waitlist control group. The secondary aim is to examine whether the app intervention group experiences improvements in anxiety, work and social functioning, help seeking, quality of life, and burnout compared with the control group.

METHODS

A total of 778 junior physicians were recruited over the internet through government and nongovernment medical organizations across Australia, as well as through paid social media advertisements. They were randomly allocated to one of 2 groups: (1) the intervention group, who were asked to use the Shift app for a period of 30 days, or (2) the waitlist control group, who were placed on a waitlist and were asked to use the app after 3 months. Participants completed psychometric measures for self-assessing mental health and wellbeing outcomes, with assessments occurring at baseline, 1 month after completing the baseline period, and 3 months after completing the baseline period. Participants in the waitlist control group were asked to complete an additional web-based questionnaire 1 month after receiving access to the app or 4 months after completing the baseline survey. Participants took part in the study on the internet; the study was completely automated.

RESULTS

The study was funded from November 2022 to December 2024 by the New South Wales Ministry of Health. Data collection for the study occurred between January and August 2024, with 780 participants enrolling in the study during this time. Data analysis is underway; the effectiveness of the intervention will be estimated on an intention-to-treat basis using a mixed-model, repeated measures analysis. Results are expected to be submitted for publication in 2025.

CONCLUSIONS

To the best of our knowledge, this is the first randomized controlled trial to examine the effectiveness of a mobile health smartphone app specifically designed to support the mental health of junior physicians.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12623000664640; https://tinyurl.com/7xt24dhk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58288.

Mapping the needs of healthcare workers caring for COVID-19 patients using the socio-ecological framework: a rapid scoping review

Undoubtedly, the mental health of healthcare workers (HCWs) was negatively affected because of caring for patients during the COVID-19 pandemic. However, literature is limited on mapping the challenges and needs of HCWs during COVID-19 pandemic. A widely used framework in public health for mapping evidence includes the socio-ecological models, suggesting behavior can be influenced by individual, interpersonal, organizational, and community factors. The aim of this rapid scoping review was to use the socio-ecological model to map and compile lessons learnt from the literature regarding primarily the challenges and needs and secondly available psychological interventions for HCWs caring for COVID-19 patients. PubMed, CINAHL and Scopus databases were searched, with 21 studies finally included examining challenges and needs of HCWs and 18 studies presenting psychological interventions. Organizational-level challenges and needs such as inadequate staff preparation and supplies of protective equipment, flexible work policies and paid rest periods were the most reported. Individual-level challenges and needs included COVID-19-related fears and reduced mental health, whereas interpersonal-related needs included support provision. Community-level challenges included societal stigma. Certain psychological interventions were found to be promising for HCWs, but these were utilized to address only individual-level challenges and needs. Given that well-being entails an interaction of factors, multi-level interventions addressing multiple socio-ecological levels (interpersonal, organizational, community) and that place HCWs in their social context should be administrated to increase and maintain intervention' effects long-term and possibly aid in better coping with future pandemics.

Potential strategies for supporting mental health and mitigating the risk of burnout among healthcare professionals: insights from the COVID-19 pandemic

Healthcare professionals (HCPs) experienced prolonged stressful conditions during the coronavirus disease 2019 pandemic, and the global situation (particularly in the United Kingdom) meant that they continue to sustain mental stress related to the subsequent cost-of-living and healthcare budgeting crises. The psychological toll on HCPs may lead to increased staff attrition, adversely impacting the quality of patient care and work security. To help mitigate this psychological impact, the current evidence is strongly supportive of healthcare providers consistently adopting programmes fostering improvement in coping and resilience, facilitating healthy lifestyle, and allocating some resources for therapeutic strategies (e.g. cognitive behavioural therapy-based strategies and other strategies specified to trauma-related issues) which can be delivered by trained professionals. We stress that some approaches are not a one-size-fits-all strategy, and we also highlight the need to encourage treatment-seeking among those who need it. These strategies are highly relevant to healthcare employers and policymakers to support all HCPs in settings marked by prolonged periods of stress. The investment in these strategies are expected not only to reduce staff attrition in the long-term, but are likely to add to the cost-effectiveness of overall healthcare budgetary allocation.

Advantages and disadvantages of mobile applications for workplace health promotion: A scoping review

Different interventions and methods are used for workplace health promotion (WHP) programmes, including mobile applications (apps), which have proven effective among different health outcomes if properly communicated and developed. However, knowledge is lacking on the potential advantages and disadvantages of using this technology for WHP compared with nontechnical WHP programmes to support employers in their decision making and effective development of such an intervention. To obtain an overview of factors that decision-makers should consider when deciding whether to implement an WHP app, we conducted a scoping review of studies that have evaluated WHP apps. Potential advantages and disadvantages of using mobile apps for WHP were summarised using a strengths, weaknesses, opportunities and threats (SWOT) analysis. Articles were included if they focussed on a WHP app, were published between 2007 and 2022 in German or English, and evaluated an app for the general employee population. Altogether, 38 studies were included in the review, demonstrating WHP apps' effectiveness among various use cases in terms of content, e.g., mindfulness or sleep, and target groups, e.g., office workers, nurses or pilots. Strengths were found in the context of adoption, convenience for users, the targeted employee group's reach and cost-effectiveness. However, the review also identified some disadvantages in apps, including technical difficulties and usage barriers, as well as challenges, e.g., privacy issues and maintenance costs. Generally, our review found that different factors need to be considered when deciding whether to implement a WHP app based on the individual company situation, e.g., shift work, content to be communicated, and expectations for health parameter screening, among many others. By summarising recent literature on WHP apps, this review uses scientific knowledge to give employers an overview of potential factors to consider in their decision making.

Protective and risk factors associated with substance use coping among healthcare workers during the COVID-19 pandemic

Background

Healthcare workers (HCWs) experienced high levels of stress and mental health consequences associated with the COVID-19 pandemic, which may have contributed to unhealthy coping behaviors, such as substance use coping (SUC). This study aimed to understand the extent of and predictors of SUC.

Methods

The sample consisted of 263 HCWs in North Central Florida. Univariable and multivariable logistic regression analyses investigated whether moral injury and other work risk factors, protective factors, and clinically relevant symptoms (i.e., work exhaustion, interpersonal disengagement, depression, anxiety, and/or PTSD) were associated with likelihood of SUC.

Results

Clinically relevant levels of interpersonal disengagement and anxiety increased the likelihood of SUC. Mediational analyses found that interpersonal disengagement and anxiety explained 54.3% of the relationship between Self Moral Injury and SUC and explained 80.4% of the relationship between professional fulfillment and SUC.

Conclusion

Healthcare supervisors should be aware that providers who are experiencing moral injury and less professional fulfillment may be experiencing significant interpersonal disengagement and anxiety, which could lead to SUC. Future studies should examine the effects of implementing targeted prevention and treatment interventions, along with longitudinal outcomes related to SUC behaviors.

Psychological interventions for healthcare professionals during the COVID-19 pandemic: A systematic review

Healthcare professionals were especially vulnerable to pandemic, both to become infected and to develop a psychological problem. The aim of this systematic review is to analyze the effectiveness of psychological interventions for healthcare professionals in reducing the experienced psychological impact. From the 405 identified studies, 10 were included in this review. Four databases were searched and the risk of bias of included studies was assessed. The studies considered were randomized controlled trials. The screening and selection process was conducted by two independent reviewers. All studies presented results related with depression, anxiety, and stress during pandemic. Six were delivered using new technologies. The most effective were two psychological interventions with frequent contact and feedback provided by a mental health professional. The psychological interventions compared with non-intervention groups presented more significant results than those compared with another intervention. The highlights of this systematic review were the urgency of designing effectiveness psychological interventions for healthcare professionals to reduce the emotional burden associate with this job. These interventions should be maintained over the time, supported by a professional and provided from the workplace. These proposals presented promising results but were more psychological resources than psychological interventions.

What are effective strategies to respond to the psychological impacts of working on the frontlines of a public health emergency?

Background

The COVID-19 pandemic has disrupted the healthcare and public health sectors. The impact of working on the frontlines as a healthcare or public health professional has been well documented. Healthcare organizations must support the psychological and mental health of those responding to future public health emergencies.

Objective

This systematic review aims to identify effective interventions to support healthcare workers' mental health and wellbeing during and following a public health emergency.

Methods

Eight scientific databases were searched from inception to 1 November 2022. Studies that described strategies to address the psychological impacts experienced by those responding to a public health emergency (i.e., a pandemic, epidemic, natural disaster, or mass casualty event) were eligible for inclusion. No limitations were placed based on study design, language, publication status, or publication date. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute critical appraisal tools. Discrepancies were resolved through discussion and a third reviewer when needed. Results were synthesized narratively due to the heterogeneity of populations and interventions. Outcomes were displayed graphically using harvest plots.

Results

A total of 20,018 records were screened, with 36 unique studies included in the review, 15 randomized controlled trials, and 21 quasi-experimental studies. Results indicate that psychotherapy, psychoeducation, and mind-body interventions may reduce symptoms of anxiety, burnout, depression, and Post Traumatic Stress Disorder, with the lowest risk of bias found among psychotherapy interventions. Psychoeducation appears most promising to increase resilience, with mind-body interventions having the most substantial evidence for increases in quality of life. Few organizational interventions were identified, with highly heterogeneous components.

Conclusion

Promoting healthcare workers' mental health is essential at an individual and health system level. This review identifies several promising practices that could be used to support healthcare workers at risk of adverse mental health outcomes as they respond to future public health emergencies.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=203810, identifier #CRD42020203810 (PROSPERO).

Presenteeism and mental health of workers during the COVID-19 pandemic: a systematic review

Background

A large number of workers attend work despite being ill. Attending work during sickness can have a number of consequences for the worker (e.g., worsening of physical and mental condition), for co-workers, and for the company, and for service users.

Objectives

The aim of this study was to assess the factors influencing presenteeism and mental health of workers during the COVID-19 pandemic.

Methods

A systematic review following the PRISMA format was conducted in the PubMed, Scopus, Web of Science (WoS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and ScienceDirect electronic databases in January 2023, using the following key words: Presenteeism, Mental Health, and COVID-19. The eligibility criteria applied were original articles published in English, Spanish, French, German, and Portuguese, workers during the COVID-19 pandemic (data collection date: January 01, 2020 - January 01, 2023), and articles assessing at least one measure of presenteeism and mental health status. Methodological quality was assessed using the critical appraisal tools of the Joanna Briggs Institute. The followed protocol is listed in the International Prospective Register of Systematic Reviews (PROSPERO) with code CRD42023391409.

Results

A total of 25 studies were included in this review recruiting a total of 164,274 participants. A number of factors influencing mental health and sickness presenteeism were identified: (1) mental health-related factors (burnout [in 4 studies], stress [in 9 studies], depression [in 1 study], fear of COVID-19 [in 1 study], no well-being [in 2 studies], etc.); (2) individual factors (health status [in 1 study], being young [in 1 study], workers who experienced interrupted medical care [in 2 studies], having a chronic disease [in 1 study], etc.); (3) factors related to the situation caused by COVID-19 (confinement, symptoms, loss of contract, risk of bankruptcy, etc. [in 1 study each one]); and (4) factors derived from working conditions (organisational support [in 1 study], patient care [in 1 study], work functioning or task performance impairment [in 4 studies], work fatigue [in 2 studies], safety climate [in 1 study], workload [in 1 study], etc.).

Conclusion

Identifying the key determinants of presenteeism and understanding the phenomena and origins of sickness presenteeism will help to create a safe working environment and optimal organisational systems to protect vulnerable workers in a pandemic context.

Systematic review registration

The unique identifier is CRD42023391409.

Reducing intrusive memories after trauma via an imagery-competing task intervention in COVID-19 intensive care staff: a randomised controlled trial

Intrusive memories (IMs) after traumatic events can be distressing and disrupt mental health and functioning. We evaluated the impact of a brief remotely-delivered digital imagery-competing task intervention on the number of IMs for intensive care unit (ICU) staff who faced repeated trauma exposure during the COVID-19 pandemic using a two-arm, parallel-group, single-blind randomised controlled trial, with the comparator arm receiving delayed access to active treatment (crossover). Eligible participants worked clinically in a UK NHS ICU during the pandemic and had at least 3 IMs of work-related traumatic events in the week before recruitment. Participants were randomly assigned (1:1) to immediate (weeks 1-4) or delayed (weeks 5-8) intervention access. Sequential Bayesian analyses to optimise the intervention and increase trial efficiency are reported elsewhere [1]. The primary endpoint for the pre-specified frequentist analysis of the final study population compared the number of IMs experienced in week 4 between the immediate and delayed access arms. Secondary outcomes included clinical symptoms, work functioning and wellbeing. Safety was assessed throughout the trial by scheduled questions and free report. All analyses were undertaken on an intention-to-treat basis (86 randomised participants). There were significantly fewer intrusive memories during week 4 in the immediate (median = 1, IQR = 0-3, n = 43), compared to the comparator delayed arm (median = 10, IQR = 6-17, n = 43), IRR 0.31, 95% CI: 0.20-0.48, p < 0.001. After crossover, the delayed arm also showed a significant reduction in IMs at week 8 compared to week 4. There were convergent findings for symptoms of PTSD, insomnia and anxiety, work engagement and burnout, general functioning and quality of life. The intervention was found safe and acceptable to participants. All adverse events were unrelated to the study. Our study provides the first evidence of a benefit on reducing IMs, improving other clinical symptoms, work functioning and wellbeing, as well as safety of a brief remotely-delivered digital imagery-competing task intervention. An efficacy trial with an active control and longer follow-up is warranted. The trial is registered at ClinicalTrials.gov (NCT04992390).

Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial

BACKGROUND

Evidence-based mental health interventions to support healthcare workers (HCWs) in crisis settings are scarce.

OBJECTIVE

To evaluate the capacity of a mental health intervention in reducing anxiety and depression symptoms in HCWs, relative to enhanced care as usual (eCAU), amidst the COVID-19 pandemic.

METHODS

We conducted an analyst-blind, parallel, multicentre, randomised controlled trial. We recruited HCWs with psychological distress from Madrid and Catalonia (Spain). The intervention arm received a stepped-care programme consisting of two WHO-developed interventions adapted for HCWs: Doing What Matters in Times of Stress (DWM) and Problem Management Plus (PM+). Each intervention lasted 5 weeks and was delivered remotely by non-specialist mental health providers. HCWs reporting psychological distress after DWM completion were invited to continue to PM+. The primary endpoint was self-reported anxiety/depression symptoms (Patient Health Questionnaire-Anxiety and Depression Scale) at week 21.

FINDINGS

Between 3 November 2021 and 31 March 2022, 115 participants were randomised to stepped care and 117 to eCAU (86% women, mean age 37.5). The intervention showed a greater decrease in anxiety/depression symptoms compared with eCAU at the primary endpoint (baseline-adjusted difference 4.4, 95% CI 2.1 to 6.7; standardised effect size 0.8, 95% CI 0.4 to 1.2). No serious adverse events occurred.

CONCLUSIONS

Brief stepped-care psychological interventions reduce anxiety and depression during a period of stress among HCWs.

CLINICAL IMPLICATIONS

Our results can inform policies and actions to protect the mental health of HCWs during major health crises and are potentially rapidly replicable in other settings where workers are affected by global emergencies.

TRIAL REGISTRATION NUMBER

NCT04980326.