Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses

Is digital alliance associated with engagement & outcomes in guided digital interventions? An analysis of data from two studies

BACKGROUND

Digital interventions have the potential to increase access to care. Despite their demonstrated efficacy in clinical trials, however, they often suffer from low sustained engagement in real-world contexts. Digital alliance (i.e., therapeutic alliance between user and app) may enhance engagement and outcomes, but its role in guided digital interventions (i.e., those with human support) is little understood.

OBJECTIVE

Using data from two studies involving the mental health app mindLAMP, we examined digital alliance and its association with engagement and outcomes.

METHODS

In Study 1, mindLAMP was offered as a standalone app with several brief check-ins by a digital navigator (aka coach). In Study 2, mindLAMP was integrated into a brief teletherapy program supported by a clinician and a digital navigator. Digital alliance was assessed near study midpoint with a validated measure.

RESULTS

Digital alliance was associated with engagement in both studies. In Study 1, digital alliance predicted subsequent app engagement, b = 0.18, p < .01, adjusting for prior engagement, which remained significant, b = 0.62, p < .001. Similarly, in Study 2, digital alliance predicted subsequent engagement, b = 0.21, p < .01, adjusting for prior engagement, b = 0.22, p < .05. Digital alliance also predicted co-morbid anxiety and depressive symptoms at post-intervention, after adjusting for baseline symptoms, in Study 1, b = -0.27, p < .001, but not in Study 2.

LIMITATIONS

Participant demographics were not representative of the general population.

CONCLUSION

Findings underscore the potential of digital alliance in enhancing engagement and outcomes in digital interventions.

Digital interventions in mental health: An overview and future perspectives

As e-health offerings rapidly expand, they are transforming and challenging traditional mental health care systems globally, presenting both promising opportunities and significant risks. This article critically examines the potential and pitfalls of integrating digital technologies into mental health care, particularly in the realms of diagnosis, prevention, and treatment. It explores current advancements and evidence-based practices, and provides a vision for how future technologies can evolve responsibly to meet mental health needs. The article concludes with the TEQUILA framework, addressing essential elements and challenges for fostering a beneficial and ethical future. A responsible future for digital mental health requires building Trust by ensuring data privacy, security, and transparency in AI-driven decisions, along with Evidence-based and robust regulatory oversight to maintain Quality. Usability, design, usability tailored to diverse needs, and ethical alignment with users' Interests will all be essential, while Liability and Accreditation standards will safeguard accountability in this evolving landscape.

Designing smartphone-based cognitive assessments for schizophrenia: Perspectives from a multisite study

Introduction

Cognitive deficits represent a core symptom of schizophrenia and a principal contributor to illness disability, yet evaluating cognition in routine clinical settings is often not feasible as cognitive assessments take longer than a standard doctor's visit. Using smartphones to assess cognition in schizophrenia offers the advantages of convenience in that patients can complete assessments outside of the clinic, temporality in that longitudinal trends can be identified, and contextuality in that cognitive scores can be interpreted with other measures captured by the phone (e.g. sleep). The current study aims to design a battery of cognitive assessments corresponding to the MATRICs Consensus Battery of Cognition (MCCB), in partnership with people living with schizophrenia.

Methodology

Focus group discussions (FGDs) and interviews were conducted with people diagnosed with schizophrenia across three sites (Boston, Bhopal, and Bangalore) to help design, refine, and assess the proposed smartphone battery of cognitive tests on the mindLAMP app. Interviews were conducted between December 2023 and March 2024. Inductive thematic analysis was used to analyze data.

Results

Participants found the app and its proposed cognitive assessments to be acceptable, helpful, and easy to use. They particularly found the gamified nature of the cognitive tests to be appealing and engaging. However, they also proposed ways to further increase engagement by including more information about each cognitive test, more visual instructions, and more information about scoring. Across all sites, there were many similarities in themes.

Discussion & conclusion

People living with schizophrenia, from different sites in the US and India, appear interested in using smartphone apps to track their cognition. Thematic analysis reinforces the importance of feedback and data sharing, although this presents a challenge, given the novel nature of smartphone-based cognitive measures that have not yet been standardized or validated.

Burnout, Compassion Fatigue, and Compassion Satisfaction Interventions via Mobile Applications: A Systematic Review and a Meta-Analysis

BACKGROUND

The increasing prevalence of burnout, compassion fatigue, and reduced compassion satisfaction among healthcare professionals has highlighted the need for effective interventions. Mobile applications offer a promising solution due to their accessibility and low cost.

METHODS

This systematic review and meta-analysis evaluates the effectiveness of mobile interventions in addressing burnout, compassion fatigue, and compassion satisfaction among healthcare professionals, while analyzing subcomponents of burnout to account for the frequently overlapping definitions and symptoms shared by these conditions. We included randomized controlled trials (RCTs) and quasi-experimental studies published between 2010 and 2024. Data were synthesized using a random effects model, with effect sizes estimated in Hedge's g.

RESULTS

Fourteen studies met the inclusion criteria, comprising 11 RCTs and 3 quasi-experimental studies, with participant numbers ranging from 20 to 2182. Most intervention content focused on mindfulness and meditation (n = 7) and resilience-based programs (n = 3). The systematic review indicated mixed results for mindfulness and resilience apps, while most studies that used meditation showed improvements in burnout. Although interventions directly targeting compassion fatigue and compassion satisfaction showed no significant effects, the meta-analysis revealed improvements in burnout domains, including a significant effect on personal accomplishment (Hedge's g = 0.51) and mixed findings for emotional exhaustion. While these interventions do not directly reduce compassion fatigue or raise compassion satisfaction, they may contribute to job satisfaction and a sense of professional efficacy. A sensitivity analysis improved homogeneity, leading to significant effects on emotional exhaustion and the generalizability of our findings.

LINKING EVIDENCE TO ACTION

Interventions focused on mindfulness, resilience training, and other strategies via mobile applications enhance personal accomplishment among healthcare professionals and show promising results in reducing emotional exhaustion. Their effectiveness in reducing compassion fatigue, depersonalization, and increasing compassion satisfaction remains inconsistent. Current research predominantly focuses on healthcare professionals, despite evidence suggesting that a broader range of healthcare professionals also suffer from compassion fatigue and burnout. The limited data on compassion fatigue and satisfaction highlights a gap in the current literature, showing the need for further high-quality studies in the form of RCTs.

A Mobile Ecological Momentary Intervention for Reducing Experiential Avoidance in the Context of Rumination: Protocol for a Randomized Controlled Trial

BACKGROUND

Rumination is a transdiagnostic process present in several psychological disorders, involving repetitive negative thinking that individuals may perceive as difficult to control. While the roles of numerous mechanisms underlying rumination have been supported, experiential avoidance (EA) still lacks empirical backing, despite a strong theoretical foundation, partly due to difficulties in examining EA in an ecologically valid context. One promising approach to addressing this challenge is through reducing EA using mobile health (mHealth) and ecological momentary intervention (EMI), and assessing any subsequent decrease in rumination's deleterious outcomes.

OBJECTIVE

This paper outlines the protocol for a randomized controlled trial using a novel mHealth EMI to address EA in the context of rumination. The app was developed by a multidisciplinary team, incorporating feedback from potential end users.

METHODS

Consenting individuals (target N=60) who meet the inclusion criteria (self-reporting problems with repetitive negative thinking) will be randomly assigned to 1 of 4 conditions: (1) intervention with therapist support and daily sampling, (2) intervention without support and with daily sampling, (3) partial intervention (emotion validation EMI only) with daily sampling, or (4) control (daily sampling only). The intervention consists of a series of modules delivered over 4 weeks, with assessments conducted before and after intervention, and again at 1-month follow-up (plus an additional 3-month follow-up for intervention participants). Data will be collected both through online self-report assessments and via the app itself. The potential of the EMI to modify the maladaptive feature of repetitive negative thinking will be assessed using mixed-design ANOVA, while the links between avoidance-mood and rumination-mood, in terms of the moderating effect of trial condition, will be evaluated using multilevel models. These will be assessed as primary outcomes. Secondary outcomes are the effects of a supporting therapist on postintervention outcomes in the intervention groups, and time spent using the app as a measure of engagement (analyzed using the mixed-design analysis of covariance). Compliance will be defined as completing both of the first 2 weeks of intervention content in full, and 5 out of the 6 exercises from weeks 3 and 4. Additionally, the study will control for both the amount of time spent in the app and the length of responses to open-ended questions.

RESULTS

Recruitment and enrollment for the trial are expected to begin in May 2025 and be completed by July 2025. Data collection will conclude once the target sample size for each of the 4 conditions has been reached. The main results of the trial are expected to be submitted for publication in October 2025.

CONCLUSIONS

The outcomes of this research trial will not only provide insights into the clinical capabilities of the app, including its usability and acceptability in real-world contexts (and its potential future viability as a scalable product), but will also offer valuable theoretical insights into the role of EA in maladaptive rumination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06570694; https://clinicaltrials.gov/ct2/show/NCT06570694.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/66067.

When Attempts to Help Backfire: Psychosocial Interventions that May Inadvertently Prolong Anxiety Among Youth

Anxiety disorders are among the most common and impairing mental health conditions in children and adolescents. Although exposure-focused cognitive behavioral therapy (CBT) is a well-established treatment for this population based on decades of psychological science, many available psychosocial interventions are not based on this strong empirical foundation. In some cases, interventions for youth with anxiety disorders have the potential to maintain anxiety in the long run. Grounded in a well-developed cognitive-behavioral theoretical frame, this commentary aimed to discuss popular and emerging psychosocial interventions for anxious youth that may inadvertently prolong anxiety. We argue that (1) although the availability of gold-standard CBT (with an adequate focus on exposure therapy) appears to be increasing, it continues to be difficult to access for many youth, (2) several available interventions prescribe avoidance-based strategies that do not enable a child to experience self-efficacy building and corrective learning experiences related to their fears or anxieties, thereby potentially maintaining anxiety in the long-run, and (3) several available interventions are not based in any clear, empirically-supported theoretical frame or evidence base, and thus have unclear benefits for anxiety. In a time when there is increasing alarm about anxiety disorders among youth, building systems that can support tried-and-true interventions based on strong science is of utmost importance. Future research, intervention deployment, and policy efforts should pay more attention to the harms that could arise from psychosocial interventions.

A systematic review and Bayesian network meta-analysis on the efficacy and potential of mobile interventions for stress management

The increasing prevalence of stress underscores the demand for effective, self-administered mobile mental health interventions, yet their efficacy and accessibility are still unclear. Here, this systematic review and meta-analysis aimed to classify self-administered mobile stress management interventions, compare their efficacy and examine their moderators. We searched PsycINFO, PubMed, Web of Science, MEDLINE, Embase, CINAHL, Scopus and PsycARTICLES from database inception to 20 November 2023. Eligible studies were randomized controlled trials on peer-reviewed, Internet-based, self-administered psychological interventions for stress reduction in healthy or subhealthy adults. A total of 63 studies with 20,454 participants were included (68.18% female; mean age 39.14 years). Integrated expert insights with large language models to develop a three-dimensional framework encompassing theoretical foundation, human support and mobile technology. Intervention labels were independently coded by the authors and ChatGPT. The included studies' quality was assessed using the Cochrane Risk of Bias 2.0 tool. Bayesian network meta-analysis and Bayesian meta-regression were used to explore comparative efficacy and potential moderators. The framework classified and compared 19 mobile stress interventions, identifying key moderating factors for optimization. Stress management programmes, problem-solving therapy and mindfulness meditation ranked the top. There was no conclusive evidence that human support or mobile technology significantly enhanced intervention outcomes. The evidence is subject to sex imbalance and quality risk, while the limited statistical power of meta-regression warrants caution in interpreting moderator effects. Our findings provide insights for designing more effective and scalable stress interventions and offer promising strategies to reduce health service disparities and advance the Sustainable Development Goals.

FRAILSURVEY-an mHealth App for Self-Assessment of Frailty Based on the Portuguese Version of the Groningen Frailty Indicator: Validation and Reliability Study

BACKGROUND

Portugal is facing the challenge of population ageing, with a notable increase in the proportion of older individuals. This has positioned the country among those in Europe with a high prevalence of frailty. Frailty, a geriatric syndrome characterized by diminished physiological reserve and heightened vulnerability to stressors, imposes a substantial burden on public health.

OBJECTIVE

This study seeks to address two primary objectives: (1) translation and psychometric evaluation of the European Portuguese version of the Groningen Frailty Indicator (GFI); and (2) development and evaluation of the FRAILSURVEY app, a novel assessment tool for frailty based on the GFI. By achieving these objectives, the study aims to enhance the accuracy and reliability of frailty assessment in the Portuguese context, ultimately contributing to improved health care outcomes for older individuals in the region.

METHODS

To accomplish the objectives of the study, a comprehensive research methodology was used. The study comprised 2 major phases: the initial translation and validation of the GFI into European Portuguese and the development of the FRAILSURVEY app. Following this, an extensive examination of the app's validity and reliability was conducted compared with the conventional paper version of the GFI. A randomized repeated crossover design was used to ensure rigorous evaluation of both assessment methods, using both the paper form of the GFI and the smartphone-based app FRAILSURVEY.

RESULTS

The findings of the study revealed promising outcomes in line with the research objectives. The meticulous translation process yielded a final version of the GFI with robust psychometric properties, ensuring clarity and comprehensibility for participants. The study included 522 participants, predominantly women (367/522, 70.3%), with a mean age of 73.7 (SD 6.7) years. Psychometric evaluation of the European Portuguese GFI in paper form demonstrates good reliability (internal consistency: Cronbach a value of 0.759; temporal stability: intraclass correlation coefficient=0.974) and construct validity (revealing a 4D structure explaining 56% of variance). Evaluation of the app-based European Portuguese GFI indicates good reliability (interinstrument reliability: Cohen k=0.790; temporal stability: intraclass correlation coefficient=0.800) and concurrent validity (r=0.694; P<.001).

CONCLUSIONS

Both the smartphone-based app and the paper version of the GFI were feasible and acceptable for use. The findings supported that FRAILSURVEY exhibited comparable validity and reliability to its paper counterpart. FRAILSURVEY uses a standardized and validated assessment tool, offering objective and consistent measurements while eliminating subjective biases, enhancing accuracy, and ensuring reliability. This app holds promising potential for aiding health care professionals in identifying frailty in older individuals, enabling early intervention, and improving the management of adverse health outcomes associated with this syndrome. Its integration with electronic health records and other data may lead to personalized interventions, improving frailty management and health outcomes for at-risk individuals.

Effects of Web-Based Psychotherapeutic Interventions on Depression in Mood Disorders: A Meta-Analysis Study

PURPOSE

To investigate the effects of web-based psychotherapeutic interventions on depression among individuals with mood disorders.

METHOD

For this meta-analysis study, data were obtained from October to December 2023 by searching PubMed, Web of Science, EBSCOhost, Google Scholar, and YÖK Thesis Center for articles published in the past 5 years. In the first stage of the search, 12,056 records were obtained. After removing duplicate studies, 4,910 records were considered for title and abstract review. After this evaluation, 139 studies were identified for full-text review. After the review, six studies reporting results on the effectiveness of web-based psychotherapeutic interventions on depression among individuals with mood disorders were ultimately included.

RESULTS

Web-based interventions had significant positive effects and provided decreases in depression levels (standardized mean difference = -0.168, 95% confidence interval [-0.315, -0.021]; Z = -2.243; p < 0.05).

CONCLUSION

Web-based interventions for mood disorders may play an effective role in reducing the burden of chronic mental illness and improving patient outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 63(3), 36-41.].

Evaluation of the Clear Fear Smartphone App for Young People Experiencing Anxiety: Uncontrolled Pre- and Post-Follow-Up Study

BACKGROUND

Mobile health apps are proving to be an important tool for increasing access to psychological therapies early on, particularly with rising rates of anxiety and depression in young people.

OBJECTIVE

We aimed to assess the usability, acceptability, safety, and effectiveness of a new app, Clear Fear, developed to help young people manage symptoms of anxiety using the principles of cognitive behavioral therapy.

METHODS

The Clear Fear app was developed to provide cognitive behavioral strategies to suit anxiety disorders. An uncontrolled pre- and post-follow-up design over a 9-week period was used to assess the app and its effects. This study comprised 3 phases: baseline (stage 1), post-app familiarization phase (stage 2), and follow-up (stage 3). Eligible participants were aged between 16 and 25 years with mild to moderate anxiety but not currently receiving treatment or in contact with specialist mental health services or using other interventions or apps to help monitor or manage their mental health. A community sample was recruited via advertisements, relevant websites, and social media networks. Eligible participants completed standardized self-report tools and questionnaires at each study stage. These measured probable symptoms of anxiety (7-item Generalized Anxiety Disorder scale) and depression (Mood and Feelings Questionnaire); emotional and behavioral difficulties (Strengths and Difficulties Questionnaire); and feedback on the usability, accessibility, and safety of the app. Mean scores at baseline and follow-up were compared using paired 2-tailed t tests or Wilcoxon signed rank tests. Qualitative data derived from open-ended questions were coded and entered into NVivo (version 10) for analysis.

RESULTS

A total of 48 young people entered the study at baseline, with 37 (77%) completing all outcome measures at follow-up. The sample was mostly female (37/48, 77%). The mean age was 20.1 (SD 2.1) years. In total, 48% (23/48) of the participants reached the threshold for probable anxiety disorder, 56% (27/48) had positive scores for probable depression, and 75% (36/48) obtained a total score of "very high" on the Strengths and Difficulties Questionnaire for emotional and behavioral difficulties. The app was well received, offering reassurance, practical and immediate help to manage symptoms, and encouragement to seek help, and was generally found easy to use. A small minority (3/48, 6%) found the app difficult to navigate. The Clear Fear app resulted in statistically significant reductions in probable symptoms of anxiety (t36=2.6, 95% CI 0.41-3.53; P=.01) and depression (z=2.3; P=.02) and behavioral and emotional difficulties (t47=4.5, 95% CI 3.67-9.65; P<.001), representing mostly medium to large standardized effect sizes.

CONCLUSIONS

The Clear Fear app was found to be usable, acceptable, safe, and effective in helping manage symptoms of anxiety and depression and emotional and behavioral difficulties.

Starting well, staying well: randomised controlled trial of "Whitu - seven ways in seven days," a well-being app for university students

OBJECTIVES

Digitally native university students face challenges to their well-being and up to a third develop mental health problems. "Whitu: seven ways in seven days" is an app based on positive psychology, cognitive behaviour therapy (CBT) and psychoeducation principles.

METHODS

Ninety-first year university students (45 per arm) participated in a randomised controlled trial of Whitu against a university self-help website ("Be Well"). Primary outcomes were changes in well-being on the World Health Organisation 5-item well-being index (WHO-5) and the short Warwick-Edinburgh mental well-being scale (SWEMWBS). Secondary outcomes were changes in depression, anxiety, self-compassion, stress, sleep and self-reported acceptability of the app.

RESULTS

At 4 weeks (primary endpoint), participants in the intervention group experienced significantly higher mental well-being (mean difference: 2.53 (95%CI: 0.53, 4.52); p = 0.013) and significantly lower depression (-4.23 (-8.32, -0.15); p = 0.042), compared to controls. Emotional well-being was greater in the intervention group at 3 months (12.23 (3.93, 20.54; p = 0.004). Other outcomes were similar between groups. User feedback was positive, with 88% saying they would recommend the app to a friend.

CONCLUSIONS

Whitu is an acceptable, effective, scalable and multi-modal means of improving some aspects of well-being and mental health among university students.

TRIAL REGISTRATION

This study was registered with the Australian New Zealand Clinical Trials Network Registry: ACTRN12622000053729.

Web-enhanced return-to-work coordination for employees with common mental disorders: reduction of sick leave duration and relapse

BACKGROUND

Common mental disorders (CMDs) are highly prevalent in workplace settings, and have become a significant public health challenge. This study aims to assess the effectiveness of PRATICAdr, a web application facilitated by a Return-to-Work Coordinator (RTW-C), with a focus on reducing sick leave duration and preventing relapse in individuals with CMDs.

METHODS

PRATICAdr, designed to enhance collaboration among Return-to-Work (RTW) stakeholders and provide systematic support throughout the RTW process, was evaluated in a quasi-experimental study. Survival analyses were used to compare sick leave durations and relapses between the experimental group (PRATICAdr with RTW-C), and control groups (RTW-C only). Both conditions had equal distribution of 50% from large public health organizations (n = 35) and 50% from a large private financial organization (n = 35). Mixed linear models were used to observe changes in clinical symptoms over time, especially for the experimental group.

RESULTS

The experimental group demonstrated significantly shorter sick leave durations and fewer relapses compared to the control group. Notably, the average absence duration was close to 3 months shorter in the experimental group. This difference was found when the RTW-C intervention (rehabilitation care) began 2 months after the onset of sick leave. Relapses occurred only in the control group (13.2%). The absence of relapses in the experimental group is noteworthy, along with the significant decrease in depressive and anxious symptoms over time.

CONCLUSIONS

The findings suggest that incorporating PRATICAdr into RTW-C intervention can lead to substantial cost savings by facilitating coordination among stakeholders and guiding the RTW process with validated tools. Initiation of RTW-C intervention alongside PRATICAdr within the first month of absence is recommended for optimal health and work outcomes.

Technology in the Trenches: The Impact of evolving technologies on Combat Mental Health

PURPOSE OF REVIEW

Medicine and specifically mental health have been affected by emerging technologies advancing mental health treatment while at the same time bringing new challenges and stressors to the battlefield, military systems, and the warfighter.

RECENT FINDINGS

This article reviews the evolving positive and negative impacts of technology on combat mental health and treatment. A history of technology and military mental health concerns and services is followed by an overview of present benefits and risks. The conflict in Ukraine, the Russo-Ukraine War, is used to illustrate the current state-of-affairs with examples of the use, deployment, and consequence of technology on battlefield mental health. Models need to be developed that assess specific battlefield environments and then selected and appropriately paired with available resources, technology, infrastructure, and workforce for mental health services at the individual and systems level, while understanding the impact of the changing battlefield ton mental health.

The effectiveness of telemedicine applications in mental health services: a meta-analysis study

AIM

This study was conducted to reveal the effectiveness of telemedicine applications in mental health services.

MATERIAL METHOD

For this meta-analysis study, data were obtained by searching PubMed, Web of Science, EBSCOhost, Google Scholar, and YÖK Thesis Center databases for the last 5 years in September-December 2023. After the review, 24 studies were included.

FINDINGS

In this meta-analysis, it was found that telemedicine interventions in mental health services decreased the depression level of individuals (SMD - 0.168, 95% CI - 0.315 to - 0.021; Z =  - 2.243; p < .05). In addition, it was determined that the duration of the intervention played a role in the effectiveness of telemedicine interventions applied to individuals. In addition, it was determined that the type of intervention, the country where the research was conducted, and the patient group did not play a role in the effectiveness of telemedicine interventions applied to individuals.

CONCLUSION

Telemedicine applications in mental health services can play an effective role in reducing the burden of chronic mental illness and improving patient outcomes.

RegulEm, a smartphone app based on the unified protocol for the transdiagnostic treatment of emotional disorders: description of its application in blended format in a clinical case

Objective

The Spanish national health system (SNHS) faces significant barriers to psychological care, such as long waiting lists and a lack of human resources. In addition, with emotional disorders being the most prevalent disorders worldwide, and less than half of those affected receiving proper treatment, there is an urgent need for new treatment alternatives for this group of disorders. The Unified Protocol (UP) is presented as a possible solution that has amply demonstrated its efficacy in different formats and contexts. Another promising alternative involves the use of blended formats, combining face-to-face UP sessions with a UP-based application. This manuscript focuses on the description of RegulEm, a UP-based application developed following a participatory design approach. In addition, a case example of receiving UP in a blended format in a specialized mental health unit of the SNHS is presented.

Methods

The following components of RegulEm are described: content and exercises of the modules; aesthetics and multimedia-based content; intervention delivery; testimonials section; emotional and motivation assessment; exposure hierarchy for guided in vivo and imaginal exposure; emergency button and Gamification. A case example of a 26-year-old male patient with anxiety and depressive symptoms receiving UP in a blended format in a specialized mental health unit of the SNHS is presented.

Results

The user showed improvements in emotional regulation skills, anxiety, and depressive symptoms over time, though stressors remained. RegulEm allowed independent progress between face-to-face UP sessions, but low internalization of some content emphasized the importance of therapist guidance in face-to-face sessions. User feedback highlighted satisfaction with the intervention but improvement proposals for RegulEm were identified, such as simplifying emotional exposure exercises.

Conclusion

This manuscript describes in detail the first UP-based smartphone application's components and illustrates important implications, such as enabling users to progress at their own pace between sessions and advancing more quickly in the intervention.

mHealth for Women with Pregnancies with Fetal Anomalies: A Scoping Review

PURPOSE

The purpose of this review is to investigate the current landscape of evidence-based mHealth resources designed to support pregnant patients with fetal anomalies, with a focus on enhancing maternal wellbeing, disseminating relevant information, and facilitating communication with nurses, physicians, and other health care professionals.

STUDY DESIGN

Using the JBI (formerly known as the Joanna Briggs Institute) scoping review protocol and the PRISMA-ScR framework, we conducted a comprehensive search across databases including CINAHL, Medline, Web of Science, and Google Scholar.

METHODS

A keyword search was conducted, resulting in 227 unique records. Articles discussing mobile apps for pregnancies with a fetal diagnosis or fetal risk for anomaly were included, including hospital-affiliated or telehealth apps that were adapted for use with this specific population.

RESULTS

Ten articles were selected for inclusion. Our analysis identified several predominant themes. The surge of mHealth, influenced in part by the COVID-19 pandemic, has provided critical access to care for pregnant patients with fetal anomalies through mobile platforms. Comprehensive resource tools integrating informational components via mHealth are needed to offer flexibility to patients as well as nurses, physicians, and other health care professionals. Adopting a patient-driven approach in developing mHealth resources is important in meeting the needs of patients, their families, and their health care team.

CLINICAL IMPLICATIONS

A framework for the development and implementation of high-fidelity mHealth resources tailored to this vulnerable population is needed. Emphasizing a patient-centered approach in the creation of mHealth resources is paramount to ensuring their effectiveness and usefulness for pregnant women experiencing fetal anomalies, their families, and the perinatal health care team.

Efficacy of the mHealth App Intellect in Improving Subclinical Obsessive-Compulsive Disorder in University Students: Randomized Controlled Trial With a 4-Week Follow-Up

BACKGROUND

Obsessive-compulsive disorder (OCD) is the third most prevalent mental health disorder in Singapore, with a high degree of burden and large treatment gaps. Self-guided programs on mobile apps are accessible and affordable interventions, with the potential to address subclinical OCD before symptoms escalate.

OBJECTIVE

This randomized controlled trial aimed to examine the efficacy of a self-guided OCD program on the mobile health (mHealth) app Intellect in improving subclinical OCD and maladaptive perfectionism (MP) as a potential moderator of this predicted relationship.

METHODS

University students (N=225) were randomly assigned to an 8-day, self-guided app program on OCD (intervention group) or cooperation (active control). Self-reported measures were obtained at baseline, after the program, and at a 4-week follow-up. The primary outcome measure was OCD symptom severity (Obsessive Compulsive Inventory-Revised [OCI-R]). Baseline MP was assessed as a potential moderator. Depression, anxiety, and stress (Depression Anxiety and Stress Scales-21) were controlled for during statistical analyses.

RESULTS

The final sample included 192 participants. The intervention group reported significantly lower OCI-R scores compared with the active control group after the intervention (partial eta-squared [ηp2]=0.031; P=.02) and at 4-week follow-up (ηp2=0.021; P=.044). A significant, weak positive correlation was found between MP and OCI-R levels at baseline (r=0.28; P<.001). MP was not found to moderate the relationship between condition and OCI-R scores at postintervention (P=.70) and at 4-week follow-up (P=.88).

CONCLUSIONS

This study provides evidence that the self-guided OCD program on the Intellect app is effective in reducing subclinical OCD among university students in Singapore. Future studies should include longer follow-up durations and study MP as a moderator in a broader spectrum of OCD symptom severity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06202677; https://clinicaltrials.gov/study/NCT06202677.

Trends and associated factors of mental health diagnoses in Catalan Primary Care (2010-2019)

BACKGROUND

The prevalence of mental health disorders has significantly increased in recent years, posing substantial challenges to healthcare systems worldwide, particularly primary care (PC) settings. This study examines trends in mental health diagnoses in PC settings in Catalonia from 2010 to 2019 and identifies associated sociodemographic, clinical characteristics, psychopharmacological treatments, and resource utilization patterns.

METHODS

Data from 947,698 individuals without prior severe mental illness, derived from the Data Analytics Program for Health Research and Innovation (PADRIS), were analyzed for this study. Sociodemographic data, diagnoses, and resource utilization were extracted from electronic health records. Descriptive statistics, chi-square tests, Mann-Whitney tests, and a multivariate binary logistic regression were employed to analyze the data.

RESULTS

Over the study period, 172,112 individuals (18.2%) received at least one mental health diagnosis in PC, with unspecified anxiety disorder (40.5%), insomnia (15.7%) and unspecified depressive disorder (10.2%) being the most prevalent. The prevalence of these diagnoses increased steadily until 2015 and stabilized thereafter. Significant associations were found between mental health diagnoses, female sex, lower socioeconomic status, higher BMI, and smoking status in a multivariate binary logistic regression.

CONCLUSIONS

This study highlights a growing burden of stress-related mental health diagnoses in PC in Catalonia, driven by demographic and socioeconomic factors. These findings may be indicative of broader trends across Europe and globally. Addressing this rising prevalence requires innovative approaches and collaborative strategies that extend beyond traditional healthcare resources. Engaging stakeholders is essential for implementing effective, sustainable solutions that promote mental health in Catalonia and potentially inform similar initiatives worldwide.

Acceptability, User Satisfaction, and Feasibility of an App-Based Support Service During the COVID-19 Pandemic in a Psychiatric Outpatient Setting: Prospective Longitudinal Observational Study

BACKGROUND

Patients with mental disorders often have difficulties maintaining a daily routine, which can lead to exacerbated symptoms. It is known that apps can help manage mental health in a low-threshold way and can be used in therapeutic settings to complement existing therapies.

OBJECTIVE

The aim of this study was to evaluate the acceptability, usability, and feasibility of an app-based support service specifically developed for outpatients with severe mental disorders in addition to regular face-to-face therapy during the COVID-19 pandemic.

METHODS

Patients in a psychiatric outpatient department at a German university hospital were invited to use an app-based support service designed transdiagnostically for mental disorders for 4 weeks. The app included 7 relaxation modules, consisting of video, audio, and psychoeducational text; ecological momentary assessment-like questionnaires on daily mood answered via a visual smiley-face scale; and an activity button to record and encourage daily activities. Standardized questionnaires at baseline (T0; preintervention time point) and after 4 weeks (T2; postintervention time point) were analyzed. Feedback via the smiley-face scale was provided after using the app components (T1; during the intervention). Measures included depressive symptoms, quality of life, treatment credibility and expectancy, and satisfaction. Furthermore, participation rates, use of app modules and the activity button, and daily mood and the provided feedback were analyzed (T2).

RESULTS

In total, 57 patients participated in the study, and the data of 38 (67%) were analyzed; 17 (30%) dropped out. Satisfaction with the app was high, with 53% (30/57) of the participants stating being rather satisfied or satisfied. Furthermore, 79% (30/38) of completers stated they would be more likely or were definitely likely to use an app-based support service again and recommend it. Feasibility and acceptability were high, with nearly half (18/38, 47%) of the completers trying relaxation modules and 71% (27/38) regularly responding to the ecological momentary assessment-like questionnaire between 15 and 28 times (mean 19.91, SD 7.57 times). The activity button was used on average 12 (SD 15.72) times per completer, and 58% (22/38) felt "definitely" or "rather" encouraged to perform the corresponding activities. Depressive symptomatology improved significantly at the postintervention time point (P=.02). Quality of life showed a nonsignificant increase in the physical, psychological, and social domains (P=.59, P=.06, and P=.42, respectively) and a significant improvement in the environment domain (P=.004). Treatment credibility and expectancy scores were moderate and significantly decreased at T2 (P=.02 and P<.001, respectively). Posttreatment expectancy scores were negatively associated with posttreatment depressive symptomatology (r=-0.36; P=.03).

CONCLUSIONS

App-based programs seem to be an accessible tool for stabilizing patients with severe mental disorders, supporting them in maintaining a daily routine, complementing existing face-to-face treatments, and overall helping respond to challenging situations such as the COVID-19 pandemic.

The effectiveness of Parentbot - a digital healthcare assistant - on parenting outcomes: A randomized controlled trial

BACKGROUND

Transitioning to parenthood is a stressful period that makes parents more prone to depression and anxiety. Mobile application-based interventions and chatbots could improve parents' well-being across the perinatal period. Hence, the Parentbot - a Digital healthcare Assistant was developed to support parents across the perinatal period.

OBJECTIVE

To evaluate the effectiveness of the Parentbot - a Digital healthcare Assistant in improving parenting self-efficacy (primary outcome), stress, depression, anxiety, social support, parent-child bonding, and parenting satisfaction (secondary outcomes) among parents across the perinatal period.

METHODS

A two-group pre-test and repeated post-test randomized controlled trial was used where 118 heterosexual couples (118 mothers and 118 fathers) were recruited from a public tertiary hospital in Singapore. Couples were randomly assigned to the intervention group receiving the Parentbot - a Digital healthcare Assistant and standardized care (59 couples) and a control group receiving the standard care only (59 couples). Data collection occurred at baseline (>24 weeks of gestation - age of viability in Singapore) and at one month (post-test 1) and three months (post-test 2) postpartum. Linear mixed models were used to compare parental outcomes between groups and a linear mixed model with repeated measures was used to analyze within-group differences. General linear models were used to conduct subgroup analyses of mothers and fathers between groups.

RESULTS

After adjusting for baseline values and sociodemographic covariates, parents in the intervention group had higher parenting self-efficacy compared to the control group at one-month postpartum (mean difference = 1.22, 95 % CI: 0.06 to 2.39, p = 0.04; Cohen standardized effect size = 0.14), and mothers had lower state-anxiety compared to the control group at three-months postpartum (mean difference = -2.21, 95 % CI: -4.18 to -0.24, p = 0.03; Cohen standardized effect size = -0.22). Non-statistically significant differences between groups were reported for the other parental outcomes.

CONCLUSIONS

This study showed that the Parentbot - a Digital healthcare Assistant is feasible and promising in supporting parents especially enhancing their self-efficacy across the perinatal period. The lack of statistical significance in most outcomes showed that further evaluation of the intervention is required among varied populations of parents across different cultural and geographical contexts. The intervention could be enhanced to support more diverse groups of parents including single parents, parents with high-risk pregnancies and infants with medical complications, and parents with limited English language skills. Future trials could explore the cost-effectiveness of such interventions and investigate infant outcomes for a more comprehensive assessment of mobile application-based perinatal interventions.

TRIAL REGISTRATION

Clinicaltrails.gov (NCT05463926).

Afraid of the dentist? There's an app for that: Development and usability testing of a cognitive behavior therapy-based mobile app

OBJECTIVES

Although several brief cognitive behavior therapy (CBT)-based treatments for dental fear have proven efficacious, these interventions remain largely unavailable outside of the specialty clinics in which they were developed. Leveraging technology, we sought to increase access to treatment for individuals with dental fear through the development of a mobile application (Dental FearLess).

MATERIALS AND METHODS

To assess the resonance of our app as an avenue for dental fear treatment, we conducted a study assessing the usability, feasibility, and acceptability of the beta app. Participants with moderate to severe dental fear (N = 80) completed the app and reported on the perceived usability of the mobile interface (Systems Usability Scale, SUS; α = .82) and credibility of the intervention (Credibility and Expectancy Questionnaire, CEQ; α = .88). A sub-sample of participants naïve to the app (n = 10) completed the app during a think-aloud procedure, sharing their candid thoughts and reactions while using the app, prior to reporting on usability and credibility metrics.

RESULTS

Overall usability (M = 78.5, SD = 17.7) and credibility (M = 21.7, SD = 5.5) of the beta version of the app were good. The think-aloud data further corroborated the app's acceptability, while highlighting several areas for user improvement (i.e., aesthetics, navigation, engagement).

CONCLUSIONS

Usability and acceptability results are promising for the viability of an accessible, feasible, self-administered intervention for dental fear. Refinements made based on user feedback have produced a clinical-trial-ready mobile application. App refinement decisions, informed by user feedback, are representative of the larger literature-that is, of the ubiquitous negotiations m-health developers must make across treatment fidelity, usability, and engagement. Implications for future research are discussed.

Cost-effectiveness of adding a smartphone app (BlueIce) to the mental health care of adolescents who repeatedly self-harm

Digital interventions can offer crises support although their cost-effectiveness is unknown. We undertook an economic evaluation alongside a two-arm, single blind, randomised controlled trial. 170 adolescents aged 12-17, receiving child and adolescent mental health care who had self-harmed ≥2 in the past 12 months were randomised to usual care with or without an app (BlueIce). The Risk-Taking and Self-Harm Inventory for Adolescents (RTSHIA), and Child Health Utility 9-Dimensions (CHU-9D) were completed at baseline, 12-weeks, and 6-months. Mental healthcare use was extracted from clinical records. CHU-9D responses were converted to preference-based utility values to estimate quality-adjusted life-years (QALYs). Generalised linear models examined the effect of BlueIce from the NHS and Personal Social Services perspective on costs and QALYs. The cost of BlueIce was £32.26 with the mean cost of mental healthcare over 6 months ranging between £1750 - £2472 per participant. The 6-month difference in mean costs [-£722.09 (95 % CI:1998.84, 334.65)] and the utility score [0.009 (95 %CI:0.033, 0.052)] both favoured BlueIce. Youth derived QALYs showed an incremental net monetary benefit (NMB) at 6-months of £782.09 with an almost 70 % probability of being cost-effective. Given the low intervention cost, the addition of an app could be considered a good investment.

Technological Advances in Treating Anxiety Disorders

There has been tremendous interest in utilizing digital interventions to assist in the treatment of anxiety disorders. Anxiety disorders are widely prevalent and often characterized by avoidance, intolerance of uncertainty, interpersonal concerns, and worry. Digital mental health interventions, given their flexibility, may be particularly suited to this population. The authors review the literature on the use of videoconference, virtual reality, website self-help, and mobile applications in the treatment of anxiety disorders. Empirical evidence, advantages, and disadvantages of each format are considered. Additionally, we identify clinical and social challenges unique to the use of these technologies for intervention purposes.

Mental Health Monitoring for Young People Through Mood Apps: Protocol for a Scoping Review and Systematic Search in App Stores

BACKGROUND

The researchers have used mobile phones to assist in monitoring, analyzing, and managing moods to acquire insight into mood patterns. There is a lack of evidence in their use as clinical tools and interventions, which necessitates a comprehensive review and quality assessment to understand barriers and facilitators for app implementation as an impactful clinical intervention.

OBJECTIVE

This review aims to (1) provide an overview of the recent evidence on mobile mood-monitoring apps that are intended for facilitating self-management and support of mental health in children, adolescents, and young people; and (2) investigate the quality of publicly available apps.

METHODS

The study will first involve a scoping review of the literature on mood-monitoring apps for children, adolescents, and young people followed by an evaluation of features of the apps available in the marketplace. The scoping review will follow the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines and search 6 databases- Embase, CINAHL, PubMed, ACM Digital Library, Scopus, and Springer LNCS-for relevant studies and reviews published in the last 3 years. The author will then screen the references, extract data from the included studies, and analyze them to synthesize the evidence on mood apps. Next, the Apple App Store and Google Play Store will be searched for mood apps. A total of 2 independent reviewers will screen the apps based on eligibility criteria, and disagreements will be resolved through consensus. The features of the selected apps will then be evaluated using the Mobile Health Index and Navigation framework, and descriptive analysis will be used to synthesize the findings.

RESULTS

Literature search and screening began soon after submission of the protocol and is expected to be completed by September 2024. The app evaluation will be completed by October 2024.

CONCLUSIONS

Combined, the scoping literature review and app evaluation will provide an in-depth overview of the most recent scientific evidence related to mood apps and the quality of apps actually available for use.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56400.

Characteristic of mental health app usage: a cross-sectional survey in the general population

BACKGROUND

Mental health apps (MHA) have gained popularity in recent years. Most freely available apps are of low quality and lack evidence for effectiveness. Yet, download rates indicate high usage. MHA are potentially beneficial for individuals with no/low symptom severity as prevention, or as an option to reach underserviced populations. However, currently very little is known about the characteristics of MHA users in the general population, about the kind of MHA used, or the motivation behind MHA usage.

METHODS

We collected survey-data from N = 1,247 individuals from the general population to investigate MHA usage.

RESULTS

Descriptive statistics revealed that 41% had used MHA in the past 12 months; prescription app-use however was low (1.5% of MHA users). Mindfulness, moodtracking, and relaxation were the most popular categories of MHA. Perceived helpfulness, fun, and availability were the top reasons for MHA usage. Non-users reported distrust, lack of perceived need, and data security concerns as usage barriers. MHA users and non-users did not differ regarding sociodemographic variables. Multiple regression analyses revealed that sub-threshold symptoms of psychological disorders as well as higher levels of anxiety and stress were linked to higher probability of MHA usage. Higher levels of depression were associated with lower likelihood of MHA usage in general, but increased likelihood of usage of self-help apps specifically for depression.

CONCLUSIONS

It follows that MHA use is common in the general population independent of sociodemographic characteristics. MHA can reach people who might benefit, but more awareness and better structure of the market is needed to reduce distrust, increase usage of high-quality MHA, and improve the fit between app and user.

Gender differences in preferences for mental health apps in the general population - a choice-based conjoint analysis from Germany

BACKGROUND

Men and women differ in the mental health issues they typically face. This study aims to describe gender differences in preferences for mental health treatment options and specifically tries to identify participants who prefer AI-based therapy over traditional face-to-face therapy.

METHOD

A nationally representative sample of 2,108 participants (53% female) aged 18 to 74 years completed a choice-based conjoint analysis (CBCA). Within the CBCA, participants evaluated twenty choice sets, each describing three treatment variants in terms of provider, content, costs, and waiting time.

RESULTS

Costs (relative importance [RI] = 55%) emerged as the most critical factor when choosing between treatment options, followed by provider (RI = 31%), content (RI = 10%), and waiting time (RI = 4%). Small yet statistically significant differences were observed between women and men. Women placed greater importance on the provider, while men placed greater importance on cost and waiting time. Age and previous experience with psychotherapy and with mental health apps were systematically related to individual preferences but did not alter gender effects. Only a minority (approximately 8%) of participants preferred AI-based treatment to traditional therapy.

CONCLUSIONS

Overall, affordable mental health treatments performed by human therapists are consistently favored by both men and women. AI-driven mental health apps should align with user preferences to address psychologist shortages. However, it is uncertain whether they alone can meet the rising demand, highlighting the need for alternative solutions.

Brief Peer-Supported Web-Based Skills Training in Affective and Interpersonal Regulation (BPS webSTAIR) for Trauma-Exposed Veterans in the Community: Randomized Controlled Trial

BACKGROUND

Peer-supported mobile health (mHealth) programs hold the promise of providing a low-burden approach to increasing access to care and improving mental health. While peer support has been shown to improve engagement in care, there is limited investigation into the impact of peers on symptom outcomes. Trauma-exposed populations frequently endure co-occurring posttraumatic stress and depressive symptoms as well as difficulties in day-to-day functioning. This study evaluated the potential benefits of a peer-supported, transdiagnostic mHealth program on symptom outcomes and functioning.

OBJECTIVE

This randomized controlled trial tested the effectiveness of Brief Peer-Supported (BPS) web-based Skills Training in Affective and Interpersonal Regulation (webSTAIR), a 6-module transdiagnostic digital program derived from Skills Training in Affective and Interpersonal Regulation and compared to waitlist control in a community sample of veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression.

METHODS

A total of 178 veterans were enrolled in this study using a 2:1 randomization scheme with 117 assigned to BPS webSTAIR and 61 assigned to waitlist control. PTSD and depressive symptoms as well as emotion regulation and psychosocial functioning were assessed at pretreatment, posttreatment, and 8-week follow-up time points. Mixed-effects models were used to assess change in outcome measures across time points. Exploratory analyses were conducted to determine whether the type and number of peer interactions influenced outcomes.

RESULTS

Significant interaction effects were observed for all outcomes such that participants randomized to BPS webSTAIR reported significantly greater improvement at the posttreatment time point compared to waitlist control with moderate effect sizes for PTSD (d=0.48), depression (d=0.64), emotion regulation (d=0.61), and functional impairment (d=0.61); gains were maintained at 8-week follow-up. An initial cohort of participants who were required to engage with a peer coach to progress through the modules interacted more frequently with peers but completed fewer modules compared to a later cohort for whom peer engagement was optional. Overall, those who completed more modules reported greater improvement in all outcomes.

CONCLUSIONS

BPS webSTAIR was effective in improving PTSD and depression symptoms, emotion regulation, and psychosocial functioning in community veterans. Peer-supported, transdiagnostic mHealth programs may be a particularly efficient, effective, and low-burden approach to improving mental health among trauma-exposed populations. Investigation of peer-supported programs among other populations is necessary to evaluate the generalizability of the findings. Analyses comparing peer support that was required versus optional indicated that some veterans may not need or want peer support. Future research should evaluate how best to deliver peer support and for whom it is most beneficial. If successful, peer-supported tech programs may increase the Veteran Affairs workforce as well as improve veteran mental health services and outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04286165; https://clinicaltrials.gov/study/NCT04286165.

Acceptability and Scalability of a Meditation App Among Adolescents With Type 1 Diabetes Mellitus

Background Adolescents with type 1 diabetes mellitus (T1DM) experience stress from general life stressors and diabetes-specific stressors. This stress manifests in a range of ways, such as mood swings, heightened frustration, strained familial relationships, and difficulties in T1DM self-management, which then leads to worse health outcomes. There is small to moderate evidence that frequent use of mental health applications (MHapps) improves mental and physical health outcomes. Meditation apps may help reduce some of the stress associated with living with T1DM. This study explores the acceptability and scalability of a self-guided, smartphone-based meditation app, the Healthy Minds Program (HMP) app, among adolescents with T1DM using the Unified Theory of Acceptance and Use of Technology. Methods Eight adolescents ages 15-19 were recruited from a pediatric clinic in a Midwestern state and introduced to the HMP app. After using the HMP app for one week, they were invited to participate in three successive focus group meetings. During the meetings, they shared their perspectives on the content, navigation, and acceptability of the HMP app and strategies to introduce and scale app utilization among adolescents with T1DM. Researchers conducted conventional content analysis using a hybrid coding approach. Data was managed and analyzed using NVivo 10 (Lumivero, Denver, Colorado, USA). Findings Participants believed that the HMP app has the potential to enhance their stress management, mood, and coping abilities when dealing with the challenges of T1DM management. They found the app enjoyable and easy to use but expressed concerns about time constraints as a potential barrier. To address this, they shared recommendations for facilitating app uptake and usage. Conclusions This study's results provide an in-depth understanding of how positively this subset of adolescents with T1DM viewed the HMP app. The participants also offered valuable suggestions that can promote the adoption and sustained use of MHapps by adolescents living with T1DM.

RegulEm, an unified protocol based-app for the treatment of emotional disorders: a parallel mixed methods usability and quality study

BACKGROUND

Interest in mental health smartphone applications has grown in recent years. Despite their effectiveness and advantages, special attention needs to be paid to two aspects to ensure app engagement: to include patients and professionals in their design and to guarantee their usability. The aim of this study was to analyse the perceived usability and quality of the preliminary version of RegulEm, an app based in the Unified Protocol, as part of the second stage of the app development.

METHODS

A parallel mixed methods study was used with 7 professionals and 4 users who were previously involved in the first stage of the development of the app. MARS, uMARS and SUS scales were used, and two focus groups were conducted. Descriptive statistical analysis and a thematic content analysis were performed in order to gather as much information as possible on RegulEm's usability and quality as well as suggestions for improvement.

RESULTS

RegulEm's usability was perceived through the SUS scale scores as good by users (75 points) and excellent by professionals (84.64 points), while its quality was perceived through the uMARS and MARS scales as good by both groups, with 4 and 4.14 points out of 5. Different areas regarding RegulEm's usability and suggestions for improvement were identified in both focus groups and 20% of the suggestions proposed were implemented in the refined version of RegulEm.

CONCLUSION

RegulEm's usability and quality were perceived as good by users and professionals and different identified areas have contributed to its refinement. This study provides a more complete picture of RegulEm's usability and quality prior analysing its effectiveness, implementation and cost-effectiveness in Spanish public mental health units.

Emotion Regulation Self-Efficacy as a Mechanism of Alliance and Outcomes in a Brief, Transdiagnostic Digital Mental Health Intervention: L'auto-efficacité de la régulation des émotions en tant que mécanisme d'alliance et de résultats dans une brève intervention transdiagnostique numérique en santé mentale

OBJECTIVES

Digital mental health interventions have shown promise for alleviating various forms of psychopathology, including depression and anxiety. However, the mechanisms of such interventions remain largely unexplored. The purpose of this study was to investigate a potential mechanistic process through which one hybrid digital mental health intervention (i.e., the Digital Clinic) might operate. We hypothesized that emotion regulation (ER) self-efficacy at the treatment midpoint may mediate the relationship between alliance (i.e., therapeutic alliance and digital alliance) and outcome (i.e., co-morbid symptoms of depression and anxiety) at the treatment endpoint.

METHODS

Data used in this study came from the Digital Clinic, a brief transdiagnostic telehealth treatment program augmented by a dual-purpose digital phenotyping and intervention smartphone app. Recruited primarily from primary care, participants were 82 adults (73% White, 64% cisgender women, mean age 41) receiving outpatient treatment in the northeastern United States. All constructs were measured with validated scales, including The Working Alliance Inventory-Short Revised (WAI-SR) for therapeutic alliance, the Digital Working Alliance Inventory (DWAI) for digital alliance, the PROMIS Self-Efficacy for Managing Emotions Short Form scale for ER self-efficacy, and the Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS) for co-morbid symptoms of depression and anxiety.

RESULTS

Significant reductions in co-morbid symptoms of depression and anxiety and significant increases in ER self-efficacy were found from baseline to treatment endpoint. Therapeutic and digital alliance at the midpoint each predicted reductions in co-morbid symptoms of depression and anxiety at the endpoint through ER self-efficacy, controlling for baseline scores.

CONCLUSIONS

Findings suggest that ER self-efficacy may be a proximal predictor of clinical improvement that may be enhanced by therapeutic and digital alliance. Future controlled research is essential to improve knowledge of the mechanisms of digital mental health interventions and to enhance their effectiveness.

Engagement, Acceptability, and Effectiveness of the Self-Care and Coach-Supported Versions of the Vira Digital Behavior Change Platform Among Young Adults at Risk for Depression and Obesity: Pilot Randomized Controlled Trial

BACKGROUND

Adolescence and early adulthood are pivotal stages for the onset of mental health disorders and the development of health behaviors. Digital behavioral activation interventions, with or without coaching support, hold promise for addressing risk factors for both mental and physical health problems by offering scalable approaches to expand access to evidence-based mental health support.

OBJECTIVE

This 2-arm pilot randomized controlled trial evaluated 2 versions of a digital behavioral health product, Vira (Ksana Health Inc), for their feasibility, acceptability, and preliminary effectiveness in improving mental health in young adults with depressive symptoms and obesity risk factors.

METHODS

A total of 73 participants recruited throughout the United States were randomly assigned to use Vira either as a self-guided product (Vira Self-Care) or with support from a health coach (Vira+Coaching) for 12 weeks. The Vira smartphone app used passive sensing of behavioral data related to mental health and obesity risk factors (ie, activity, sleep, mobility, and language patterns) and offered users personalized insights into patterns of behavior associated with their daily mood. Participants completed self-reported outcome measures at baseline and follow-up (12 weeks). All study procedures were completed via digital communications.

RESULTS

Both versions of Vira showed strong user engagement, acceptability, and evidence of effectiveness in improving mental health and stress. However, users receiving coaching exhibited more sustained engagement with the platform and reported greater reductions in depression (Cohen d=0.45, 95% CI 0.10-0.82) and anxiety (Cohen d=0.50, 95% CI 0.13-0.86) compared to self-care users. Both interventions also resulted in reduced stress (Vira+Coaching: Cohen d=-1.05, 95% CI -1.57 to --0.50; Vira Self-Care: Cohen d=-0.78, 95% CI -1.33 to -0.23) and were perceived as useful and easy to use. Coached users also reported reductions in sleep-related impairment (Cohen d=-0.51, 95% CI -1.00 to -0.01). Moreover, participants increased their motivation for and confidence in making behavioral changes, with greater improvements in confidence among coached users.

CONCLUSIONS

An app-based intervention using passive mobile sensing to track behavior and deliver personalized insights into behavior-mood associations demonstrated feasibility, acceptability, and preliminary effectiveness for reducing depressive symptoms and other mental health problems in young adults. Future directions include (1) optimizing the interventions, (2) conducting a fully powered trial that includes an active control condition, and (3) testing mediators and moderators of outcome effects.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05638516; https://clinicaltrials.gov/study/NCT05638516.

The SoCAP (Social Communication, Affiliation, and Presence) Taxonomy of Social Features: Scoping Review of Commercially Available eHealth Apps

BACKGROUND

eHealth interventions have proven to be valuable resources for users with diverse mental and behavioral health concerns. As these technologies continue to proliferate, both academic researchers and commercial app creators are leveraging the use of features that foster a sense of social connection on these digital platforms. Yet, the literature often insufficiently represents the functionality of these key social features, resulting in a lack of understanding of how they are being implemented.

OBJECTIVE

This study aimed to conduct a methodical review of commercially available eHealth apps to establish the SoCAP (social communication, affiliation, and presence) taxonomy of social features in eHealth apps. Our goal was to examine what types of social features are being used in eHealth apps and how they are implemented.

METHODS

A scoping review of commercially available eHealth apps was conducted to develop a taxonomy of social features. First, a shortlist of the 20 highest-rated eHealth apps was derived from One Mind PsyberGuide, a nonprofit organization with trained researchers who rate apps based on their (1) credibility, (2) user experience, and (3) transparency. Next, both mobile- and web-based versions of each app were double-coded by 2 trained raters to derive a list of social features. Subsequently, the social features were organized by category and tested on other apps to ensure their completeness.

RESULTS

Four main categories of social features emerged: (1) communication features (videoconferencing, discussion boards, etc), (2) social presence features (chatbots, reminders, etc), (3) affiliation and identity features (avatars, profiles, etc), and (4) other social integrations (social network and other app integrations). Our review shows that eHealth apps frequently use resource-intensive interactions (eg, videoconferencing with a clinician and phone calls from a facilitator), which may be helpful for participants with high support needs. Furthermore, among commercially available eHealth apps, there is a strong reliance on automated features (eg, avatars, personalized multimedia, and tailored content) that enhance a sense of social presence without requiring a high level of input from a clinician or staff member.

CONCLUSIONS

The SoCAP taxonomy includes a comprehensive list of social features and brief descriptions of how these features work. This classification system will provide academic and commercial eHealth app creators with an understanding of the various social features that are commonly implemented, which will allow them to apply these features to enhance their own apps. Future research may include comparing the synergistic effects of various combinations of these social features.

Clinical effectiveness and safety of adding a self-harm prevention app (BlueIce) to specialist mental health care for adolescents who repeatedly self-harm: A single blind randomised controlled trial (the BASH study)

No randomised controlled trials have evaluated whether the addition of a smartphone app to usual child and adolescent mental health care (CAMHS) can reduce self-harm in adolescents (<18 years) with repeated self-harm. We enrolled 170 participants aged 12-17, receiving CAMHS treatment who had self-harmed ≥2 in the past 12 months. Participants were randomised via an independent web-based system (1:1, minimised for gender, age, self-harm frequency, and depression severity) to treatment as usual (TAU) or treatment as usual plus BlueIce (TAU+BI). BlueIce is a self-harm prevention app that includes techniques from CBT and DBT that was co-designed with adolescents who self-harm. The primary outcome was change from baseline to 12-weeks on the self-harm scale of the Risk Taking and Self-Harm Inventory for Adolescents (RTSHIA), analysed by intention to treat (ITT). Emergency department attendances or admissions for self-harm were assessed over 6-months via a review of clinical records. Both groups improved but there were no statistically significant between group differences at 12 weeks or 6 months on the self-harm scale of the RTSHIA. There were fewer emergency department attendances and admissions in those who received the app, a finding that approached statistical significance. BlueIce can be helpful in some important aspects by contributing to fewer emergency department admissions and attendances. TRIAL REGISTRATION: Trial registration number ISRCTN10541045.

Mental health apps within the healthcare system: associations with stigma and mental health literacy

BACKGROUND

Mental health apps (MHA) as a new form of self-help have gained popularity over the last years. Tentative evidence has suggested that MHA might also present a first step into the help-seeking process, because their anonymity circumvents stigma. Using MHA might also increase mental health literacy and reduce stigma through psychoeducation, which could encourage formal help-seeking. To date, it remains unclear how MHA usage relates to stigma, mental health literacy, and utilization of professional help within the public healthcare system.

METHODS

We conducted a cross-sectional survey with N = 1,263 individuals from the general population (mean age 32.56 ± 11.51, 58.2% female) and employed structural equation modeling to investigate associations between stigma (against individuals with psychological disorders and against help-seeking), mental health literacy, MHA usage, and service utilization within the public healthcare system for mental health problems.

RESULTS

MHA usage is high within the general population (40.5% of participants). Results indicate that higher stigma against help-seeking is associated with and increased likelihood of MHA usage, which in turn is positively associated with increased likelihood of service utilization. Symptoms of psychological disorder were associated with higher likelihood of service utilization, but not MHA usage.

CONCLUSIONS

It can be concluded that MHA appeal especially to individuals with higher stigma against help-seeking and therefore might provide an opportunity to reach underserviced individuals. At the current time, MHA usage appears to take place mostly in a preventative manner or as a supplement to treatment. Better integration into the public healthcare system might help to exploit both preventative and interventional benefits of MHA.

Feasibility and acceptability of measuring prenatal stress in daily life using smartphone-based ecological momentary assessment and wearable physiological monitors

High levels of stress during pregnancy can have lasting effects on maternal and offspring health, which disproportionately impacts families facing financial strain, systemic racism, and other forms of social oppression. Developing ways to monitor daily life stress during pregnancy is important for reducing stress-related health disparities. We evaluated the feasibility and acceptability of using mobile health (mHealth) technology (i.e., wearable biosensors, smartphone-based ecological momentary assessment) to measure prenatal stress in daily life. Fifty pregnant women (67% receiving public assistance; 70% Black, 6% Multiracial, 24% White) completed 10 days of ambulatory assessment, in which they answered smartphone-based surveys six times a day and wore a chest-band device (movisens EcgMove4) to monitor their heart rate, heart rate variability, and activity level. Feasibility and acceptability were evaluated using behavioral meta-data and participant feedback. Findings supported the feasibility and acceptability of mHealth methods: Participants answered approximately 75% of the surveys per day and wore the device for approximately 10 hours per day. Perceived burden was low. Notably, participants with higher reported stressors and financial strain reported lower burden associated with the protocol than participants with fewer life stressors, highlighting the feasibility of mHealth technology for monitoring prenatal stress among pregnant populations living with higher levels of contextual stressors. Findings support the use of mHealth technology to measure prenatal stress in real-world, daily life settings, which shows promise for informing scalable, technology-assisted interventions that may help to reduce health disparities by enabling more accessible and comprehensive care during pregnancy.

Applying Digital Technology to Understand Human Experiences of Climate Change Impacts on Food Security and Mental Health: Scoping Review

BACKGROUND

The global impact of climate change ranges from intense heatwaves to extreme weather events that endanger entire ecosystems and people's way of life. Adverse climate change events place undue stress on food and health systems, with consequences for human food security and mental health status. Ubiquitous digital devices, such as smartphones, have the potential to manage existing and emerging climate-related crises, given their ability to enable rapid response, instant communication, and knowledge sharing.

OBJECTIVE

This scoping review aimed to identify digital apps being used to capture or address climate change impacts on food security and mental health to inform the development of a digital citizen science initiative.

METHODS

A scoping review was conducted using 3 peer-reviewed databases (PubMed, IEEE Xplore, and Web of Science) and manual gray literature searches of relevant organizational (ie, governmental and nonprofit) websites to identify articles and reports published between January 2012 and July 2023. Three separate searches were conducted in each database to identify digital apps focused on climate change and (1) food security, (2) mental health, and (3) food security and mental health. Two reviewers conducted initial screening, with a third reviewer resolving any discrepancies. Articles focused on climate change impacts on wildlife or agriculture (ie, not human food security) were excluded. Full-text screening was conducted for shortlisted articles, and a final data abstraction table was generated, summarizing key app features, contextual factors, and participant involvement.

RESULTS

From the 656 records screened, 14 digital apps met the inclusion criteria. The food security apps (n=7, 50%) aimed to capture traditional knowledge to preserve food systems, conduct food security assessments, and aid users in decreasing food insecurity risk. The mental health apps (n=7, 50%) assessed climate change-related stress and provided users with coping strategies following adverse weather events. No digital apps examined the intersection of climate change, food security, and mental health. Key app features included user-to-user communication (n=5, 36%), knowledge databases (n=5, 36%), data collection and analysis (n=3, 21%), gamification (n=1, 7%), and educational resources (n=2, 14%) to address climate change impacts on food security or mental health. In total, 3 approaches to participant involvement were used across studies, including contributory (n=1, 7%), collaborative (n=1, 7%), and cocreative (n=1, 7%) approaches, to ensure the relevance and use of digital apps.

CONCLUSIONS

Most digital apps identified provided a service to citizens to either prevent adverse climate change-related health impacts or manage these effects following an acute event or a natural disaster. The capacity of ubiquitous digital tools to enable near real-time communication, the involvement of various stakeholder groups, and their ability to share relevant educational resources in a timely manner are important for developing tailored climate change adaptation and mitigation strategies across jurisdictions.

Comparative Effectiveness of Three Digital Interventions for Adults Seeking Psychiatric Services: A Randomized Clinical Trial

Importance

There is a substantial gap between demand for and availability of mental health services. Digital mental health interventions (DMHIs) are promising tools for bridging this gap, yet little is known about their comparative effectiveness.

Objective

To assess whether patients randomized to a cognitive behavioral therapy (CBT)-based or mindfulness-based DMHI had greater improvements in mental health symptoms than patients randomized to the enhanced personalized feedback (EPF)-only DMHI.

DESIGN,

SETTING, AND PARTICIPANTS This randomized clinical trial was conducted between May 13, 2020, and December 12, 2022, with follow-up at 6 weeks. Adult patients of outpatient psychiatry services across various clinics within the University of Michigan Health System with a scheduled or recent outpatient psychiatry appointment were recruited. Eligible patients were randomized to an intervention arm. All analyses followed the intent-to-treat principle.

Interventions

Participants were randomized to 1 of 5 intervention arms: (1) EPF only; (2) Silvercloud only, a mobile application designed to deliver CBT strategies; (3) Silvercloud plus EPF; (4) Headspace only, a mobile application designed to train users in mindfulness practices; and (5) Headspace plus EPF.

Main Outcomes and Measures

The primary outcome was change in depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9; score range: 0-27, with higher scores indicating greater depression symptoms). Secondary outcomes included changes in anxiety, suicidality, and substance use symptoms.

Results

A total of 2079 participants (mean [SD] age, 36.8 [14.3] years; 1423 self-identified as women [68.4%]) completed the baseline survey. The baseline mean (SD) PHQ-9 score was 12.7 (6.4) and significantly decreased for all 5 intervention arms at 6 weeks (from -2.1 [95% CI, -2.6 to -1.7] to -2.9 [95% CI, -3.4 to -2.4]; n = 1885). The magnitude of change was not significantly different across the 5 arms (F4,1879 = 1.19; P = .31). Additionally, the groups did not differ in decrease in anxiety or substance use symptoms. However, the Headspace arms reported significantly greater improvements on a suicidality measure subscale compared with the Silvercloud arms (mean difference in mean change = 0.63; 95% CI, 0.20-1.06; P = .004).

Conclusions and Relevance

This randomized clinical trial found decreases in depression and anxiety symptoms across all DMHIs and minimal evidence that specific applications were better than others. The findings suggest that DMHIs may provide support for patients during waiting list-related delays in care.

Trial Registration

ClinicalTrials.gov Identifier: NCT04342494.

Perspectives on the Implementation of Mental Health Apps on Clinical Interventions in Mental Health

N/a.

Awake bruxism report in a population of dental students with and without ecological momentary assessment monitorization-A randomised trial

OBJECTIVE

The Ecological Momentary Assessment (EMA) concept was the basis for developing a smartphone application for the real-time report of awake bruxism (AB) activities. The aim of this study was to assess the effects of the EMA with a randomised controlled trial designed to compare the frequency of AB reported in two separate single observation points between a group of students monitored over time with an EMA smartphone application and a non-EMA monitored group.

METHODS

Sixty-four (N = 64) dental students (22.3 YO [±2.6]; 52F; 12 M) answered the Oral Behaviour Checklist (OBC-1) and were randomised into an EMA-group (EG) and control group (CG). EG were monitored with a smartphone application for AB report during seven consecutive days and completed three EMA monitoring periods (EMA-1, 2 and 3) at one-month intervals. After the third period (EMA-3), both EG and CG answered again the OBC (OBC-2). Descriptive statistics were performed to characterise the sample. Pearson's chi-squared test, Fixer Exact test and post hoc Z test with Bonferroni correction were performed. The study hypothesis was that EMA could influence the AB reported by the participants because it implies an increase in the awareness, self-recognition, and self-control of bruxism behaviours. The level of significance was set at p < .05.

RESULT

The percentage of participants who changed the report of the activity of clenching their teeth while awake between OBC-1 and OBC-2 was significantly higher among participants in EG, when compared to CG (p = .027). For all other behaviours reported the within- and between-group differences from OBC-1 to OBC-2 were not significant. Clenching and bracing were the most frequently reported, whilst grinding was the less frequent behaviour.

CONCLUSION

A smartphone-based EMA approach demonstrated be useful to monitor AB over time, increasing individual's awareness, particularly to bracing and clenching behaviours.

Long-Term Efficacy of a Mobile Mental Wellness Program: Prospective Single-Arm Study

BACKGROUND

Rising rates of psychological distress (symptoms of depression, anxiety, and stress) among adults in the United States necessitate effective mental wellness interventions. Despite the prevalence of smartphone app-based programs, research on their efficacy is limited, with only 14% showing clinically validated evidence. Our study evaluates Noom Mood, a commercially available smartphone-based app that uses cognitive behavioral therapy and mindfulness-based programming. In this study, we address gaps in the existing literature by examining postintervention outcomes and the broader impact on mental wellness.

OBJECTIVE

Noom Mood is a smartphone-based mental wellness program designed to be used by the general population. This prospective study evaluates the efficacy and postintervention outcomes of Noom Mood. We aim to address the rising psychological distress among adults in the United States.

METHODS

A 1-arm study design was used, with participants having access to the Noom Mood program for 16 weeks (N=273). Surveys were conducted at baseline, week 4, week 8, week 12, week 16, and week 32 (16 weeks' postprogram follow-up). This study assessed a range of mental health outcomes, including anxiety symptoms, depressive symptoms, perceived stress, well-being, quality of life, coping, emotion regulation, sleep, and workplace productivity (absenteeism or presenteeism).

RESULTS

The mean age of participants was 40.5 (SD 11.7) years. Statistically significant improvements in anxiety symptoms, depressive symptoms, and perceived stress were observed by week 4 and maintained through the 16-week intervention and the 32-week follow-up. The largest changes were observed in the first 4 weeks (29% lower, 25% lower, and 15% lower for anxiety symptoms, depressive symptoms, and perceived stress, respectively), and only small improvements were observed afterward. Reductions in clinically relevant anxiety (7-item generalized anxiety disorder scale) and depression (8-item Patient Health Questionnaire depression scale) criteria were also maintained from program initiation through the 16-week intervention and the 32-week follow-up. Work productivity also showed statistically significant results, with participants gaining 2.57 productive work days from baseline at 16 weeks, and remaining relatively stable (2.23 productive work days gained) at follow-up (32 weeks). Additionally, effects across all coping, sleep disturbance (23% lower at 32 weeks), and emotion dysregulation variables exhibited positive and significant trends at all time points (15% higher, 23% lower, and 25% higher respectively at 32 weeks).

CONCLUSIONS

This study contributes insights into the promising positive impact of Noom Mood on mental health and well-being outcomes, extending beyond the intervention phase. Though more rigorous studies are necessary to understand the mechanism of action at play, this exploratory study addresses critical gaps in the literature, highlighting the potential of smartphone-based mental wellness programs to lessen barriers to mental health support and improve diverse dimensions of well-being. Future research should explore the scalability, feasibility, and long-term adherence of such interventions across diverse populations.

Working mechanisms of the use and acceptability of ecological momentary interventions: a realist evaluation of a guided self-help ecological momentary intervention targeting self-esteem

BACKGROUND

Technology improves accessibility of psychological interventions for youth. An ecological momentary intervention (EMI) is a digital intervention geared toward intervening in daily life to enhance the generalizability and ecological validity, and to be able to intervene in moments most needed. Identifying working mechanisms of the use of ecological momentary interventions might generate insights to improve interventions.

METHODS

The present study investigates the working mechanisms of the use and acceptability of an ecological momentary intervention, named SELFIE, targeting self-esteem in youth exposed to childhood trauma, and evaluates under what circumstances these mechanisms of use and acceptability do or do not come into play. A realist evaluation approach was used for developing initial program theories (data: expert interviews and a stakeholders focus group), and subsequently testing (data: 15 interviews with participants, a focus group with therapists, debriefing questionnaire), and refining them.

RESULTS

The SELFIE intervention is offered through a smartphone application enabling constant availability of the intervention and thereby increasing accessibility and feasibility. When the intervention was offered on their personal smartphone, this enhanced a sense of privacy and less hesitance in engaging with the app, leading to increased disclosure and active participation. Further, the smartphone application facilitates the practice of skills in daily life, supporting the repeated practice of exercises in different situations leading to the generalizability of the effect. Buffering against technical malfunction seemed important to decrease its possible negative effects.

CONCLUSIONS

This study enhanced our understanding of possible working mechanisms in EMIs, such as the constant availability supporting increased accessibility and feasibility, for which the use of the personal smartphone was experienced as a facilitating context. Hereby, the current study contributes to relatively limited research in this field. For the field to move forward, mechanisms of use, and acceptability of EMIs need to be understood. It is strongly recommended that alongside efficacy trials of an EMI on specific target mechanisms, a process evaluation is conducted investigating the working mechanisms of use.

TRIAL REGISTRATION

The current paper reports on a realist evaluation within the SELFIE trial (Netherlands Trial Register NL7129 (NTR7475)).

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

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

Mobile apps to reduce depressive symptoms and alcohol use in youth: A systematic review and meta-analysis: A systematic review

Background

Among youth, symptoms of depression, anxiety, and alcohol use are associated with considerable illness and disability. Youth face many personal and health system barriers in accessing mental health care. Mobile applications (apps) offer youth potentially accessible, scalable, and anonymous therapy and other support. Recent systematic reviews on apps to reduce mental health symptoms among youth have reported uncertain effectiveness, but analyses based on the type of app-delivered therapy are limited.

Objectives

We conducted this systematic review with youth co-researchers to ensure that this review addressed the questions that were most important to them. The objective of this review is to synthesize the best available evidence on the effectiveness of mobile apps for the reduction of depressive symptoms (depression, generalized anxiety, psychological distress) and alcohol use among youth.

Search Methods

We conducted electronic searches of the following bibliographic databases for studies published between January 1, 2008, and July 1, 2022: MEDLINE (via Ovid), Embase (via Ovid), PsycINFO (via Ovid), CINAHL (via EBSCOHost), and CENTRAL (via the Cochrane Library). The search used a combination of indexed terms, free text words, and MeSH headings. We manually screened the references of relevant systematic reviews and included randomized controlled trials (RCTs) for additional eligible studies, and contacted authors for full reports of identified trial registries or protocols.

Selection Criteria

We included RCTs conducted among youth aged 15-24 years from any setting. We did not exclude populations on the basis of gender, socioeconomic status, geographic location or other personal characteristics. We included studies which assessed the effectiveness of app-delivered mental health support or therapy interventions that targeted the management of depressive disorders and/or alcohol use disorders. We excluded apps that targeted general wellness, apps which focused on prevention of psychological disorders and apps that targeted bipolar disorder, psychosis, post-traumatic stress disorder, attention-deficit hyperactivity disorder, substance use disorders (aside from alcohol), and sleep disorders. Eligible comparisons included usual care, no intervention, wait-list control, alternative or controlled mobile applications. We included studies which reported outcomes on depressive symptoms, anxiety symptoms, alcohol use and psychological distress over any follow-up period.

Data Collection and Analysis

We standardized the PICO definitions (population, intervention, comparison, and outcome) of each included study and grouped studies by the type of therapy or support offered by the app. Whenever app design and clinical homogeneity allowed, we meta-analyzed outcomes using a random-effects model. Outcome data measured using categorical scales were synthesized using odds ratios. Outcome data measured using continuous scales were synthesized as the standardized mean difference. We assessed the methodological quality of each included study using the Cochrane Risk of Bias 2.0 tool and we assessed certainty of the evidence using the GRADE approach.

Main Results

From 5280 unique citations, we included 36 RCTs published in 37 reports and conducted in 15 different countries (7984 participants). Among the 36 included trials, we assessed two with an overall low risk of bias, 8 trials with some concern regarding risk of bias, and 26 trials with a high risk of bias. Interventions varied in the type of therapy or supports offered. The most common intervention designs employed mindfulness training, cognitive behavioral therapy (CBT), or a combination of the two (mindfulness + CBT). However, other interventions also included self-monitoring, medication reminders, cognitive bias modification or positive stimulation, dialectical behavioral therapy, gamified health promotion, or social skill building. Mindfulness apps led to short term improvements in depressive symptoms when compared to a withheld control (SMD = -0.36; 95% CI [-0.63, -0.10]; p = 0.007, n = 3 RCTs, GRADE: very low certainty) and when compared to an active control (SMD = -0.27; 95% CI [-0.53, -0.01]; p = 0.04, n = 2 RCTs, GRADE: very low). Apps delivering this type of support also significantly improved symptoms of anxiety when compared to a withheld control (SMD = -0.35; 95% CI [-0.60, -0.09]; p = 0.008, n = 3 RCTs, GRADE: very low) but not when compared to an active control (SMD = -0.24; 95% CI [-0.50, 0.02]; p = 0.07, n = 2 RCTs, GRADE: very low). Mindfulness apps showed improvements in psychological stress that approached statistical significance among participants receiving the mindfulness mobile apps compared to those in the withheld control (SMD = -0.27; 95% CI [-0.56, 0.03]; p = .07, n = 4 RCTs, GRADE: very low). CBT apps also led to short-term improvements in depressive symptoms when compared to a withheld control (SMD = -0.40; 95% CI [-0.80, 0.01]; p = 0.05, n = 2 RCTs, GRADE: very low) and when compared to an active control (SMD = -0.59; 95% CI [-0.98, -0.19]; p = 0.003, n = 2 RCTs, GRADE: very low). CBT-based apps also improved symptoms of anxiety compared to a withheld control (SMD = -0.51; 95% CI [-0.94, -0.09]; p = 0.02, n = 3 RCTs, GRADE: very low) but not when compared to an active control (SMD = -0.26; 95% CI [-1.11, 0.59]; p = 0.55, n = 3 RCTs, GRADE: very low). Apps which combined mindfulness and CBT did not significantly improve symptoms of depression (SMD = -0.20; 95% CI [-0.42, 0.02]; p = 0.07, n = 2 RCTs, GRADE: very low) or anxiety (SMD = -0.21; 95% CI [-0.49, 0.07]; p = 0.14, n = 2 RCTs, GRADE: very low). However, these apps did improve psychological distress (SMD = -0.43; 95% CI [-0.74, -0.12]; p = 0.006, n = 2 RCTs, GRADE: very low). The results of trials on apps to reduce alcohol use were inconsistent. We did not identify any harms associated with the use of apps to manage mental health concerns. All effectiveness results had a very low certainty of evidence rating using the GRADE approach, meaning that apps which deliver therapy or other mental health support may reduce symptoms of depression, anxiety and psychological distress but the evidence is very uncertain.

Authors' Conclusions

We reviewed evidence from 36 trials conducted among youth. According to our meta-analyses, the evidence is very uncertain about the effect of apps on depression, anxiety, psychological distress, and alcohol use. Very few effects were interpreted to be of clinical importance. Most of the RCTs were small studies focusing on efficacy for youth at risk for depressive symptoms. Larger trials are needed to evaluate effectiveness and allow for further analysis of subgroup differences. Longer trials are also needed to better estimate the clinical importance of these apps over the long term.

A mixed methods analysis of existing assessment and evaluation tools (AETs) for mental health applications

Introduction

Mental health Applications (MH Apps) can potentially improve access to high-quality mental health care. However, the recent rapid expansion of MH Apps has created growing concern regarding their safety and effectiveness, leading to the development of AETs (Assessment and Evaluation Tools) to help guide users. This article provides a critical, mixed methods analysis of existing AETs for MH Apps by reviewing the criteria used to evaluate MH Apps and assessing their effectiveness as evaluation tools.

Methods

To identify relevant AETs, gray and scholarly literature were located through stakeholder consultation, Internet searching via Google and a literature search of bibliographic databases Medline, APA PsycInfo, and LISTA. Materials in English that provided a tool or method to evaluate MH Apps and were published from January 1, 2000, to January 26, 2021 were considered for inclusion.

Results

Thirteen relevant AETs targeted for MH Apps met the inclusion criteria. The qualitative analysis of AETs and their evaluation criteria revealed that despite purporting to focus on MH Apps, the included AETs did not contain criteria that made them more specific to MH Apps than general health applications. There appeared to be very little agreed-upon terminology in this field, and the focus of selection criteria in AETs is often IT-related, with a lesser focus on clinical issues, equity, and scientific evidence. The quality of AETs was quantitatively assessed using the AGREE II, a standardized tool for evaluating assessment guidelines. Three out of 13 AETs were deemed 'recommended' using the AGREE II.

Discussion

There is a need for further improvements to existing AETs. To realize the full potential of MH Apps and reduce stakeholders' concerns, AETs must be developed within the current laws and governmental health policies, be specific to mental health, be feasible to implement and be supported by rigorous research methodology, medical education, and public awareness.

Smartphone-based serious games for mental health: a scoping review

The use of smartphone-based Serious Games in mental health care is an emerging and promising research field. Combining the intrinsic characteristics of games (e.g., interactiveness, immersiveness, playfulness, user-tailoring and engaging nature) with the capabilities of smartphones (e.g., versatility, ubiquitous connectivity, built-in sensors and anywhere-anytime nature) yields great potential to deliver innovative psychological treatments, which are engaging, effective, fun and always available. This article presents a scoping review, based on the PRISMA (scoping review extension) guidelines, of the field of smartphone-based serious games for mental health care. The review combines an analysis of the technical characteristics, including game design, smartphone and game-specific features, with psychological dimensions, including type and purpose of use, underlying psychological frameworks and strategies. It also explores the integration of psychological features into Serious Games and summarizes the findings of evaluations performed. A systematic search identified 40 smartphone-based Serious Games for mental health care. The majority consist of standalone and self-administrable interventions, applying a myriad of psychological strategies to address a wide range of psychological symptoms and disorders. The findings explore the potential of Serious Games as treatments and for enhancing patient engagement; we conclude by proposing several avenues for future research in order to identify best practices and success factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11042-024-18971-w.

Can an app increase health literacy and reduce the stigma associated with obsessive-compulsive disorder? A crossover randomized controlled trial

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling condition with a high delay in seeking treatment. esTOCma is an app developed to increase mental health literacy (MHL) about OCD, reduce stigma, and increase the intention to seek professional treatment. It is a serious game and participants are asked to fight against the "OCD stigma monster" by accomplishing 10 missions. The aim of this study is to evaluate the effectiveness of this app in a community sample.

METHODS

A randomized controlled trial with a crossover design was carried out. Participants were randomized to two groups: immediate use (iApp, n = 102) and delayed use (dApp, n = 106) of esTOCma. The iApp group started using the app at baseline until the game was over. The dApp group initiated at 10-days until the game finished. Participants were requested to complete a set of questionnaires at baseline and 10-day, 20-day and 3-month follow-ups.

RESULTS

The Time×Group interaction effect was significant for the primary outcome measures: there was an increase in MHL and intention to seek help, and a decrease in stigma and OC symptoms, with large effect sizes, only after using the app. Changes were maintained (or increased) at follow-up.

LIMITATIONS

The study did not include an active control group and some of the scales showed low internal consistency or a ceiling effect.

CONCLUSIONS

This study provides first evidence for the effectiveness of esTOCma as a promising intervention to fight stigma and reduce the treatment gap in OCD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04777292. Registered February 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04777292.

The use of mHealth apps to improve hospital nurses' mental health and well-being: A systematic review

BACKGROUND

Nursing well-being has become a heightened focus since the COVID-19 pandemic. Nurses are leaving the profession early in their careers or retiring sooner than expected. Those who remain in the workforce report higher levels of burnout, anxiety, depression, and exhaustion. There is concern that there may be a shortage of at least half a million nurses by 2030.

AIMS

This systematic review aimed to investigate the evidence of using a mental health promotion mHealth app to improve the mental health of hospital nurses.

METHODS

A systematic search was conducted in CINAHL Plus with Full Text, MEDLINE with Full Text, Professional Development Collection, Psychology and Behavioral Sciences Collection, Sociological Collection, PsycInfo, Embase, and PubMed with search dates of January 2012-November 15, 2022. The mHealth intervention needed to be asynchronously delivered through a smartphone with hospital nurse participants to be included in this review.

RESULTS

Of the 157 articles screened for this review, six were included. Primary outcome variables were anxiety, burnout, coping, depression, self-efficacy, stress, well-being, and work engagement. Intervention types included mindfulness-based interventions (MBIs), cognitive behavioral therapy (CBT), stress inoculation therapy (SIT), psychoeducation, and stress management. Anxiety, depression, well-being, and burnout improved with MBIs; depression improved with CBT; and anxiety and active coping improved with SIT.

LINKING EVIDENCE TO ACTION

This review demonstrated promising findings in using mHealth apps to improve the mental health of hospital nurses. However, more randomized controlled trials with larger sample sizes may reveal which type of mHealth app and how much exposure to the intervention is more effective in improving specific mental health symptoms. Longitudinal follow-up is also recommended to study sustainability of the mental health improvements.

The Effectiveness of a Cell Phone eHealth App in Changing Knowledge, Stigmatizing Attitudes, and Intention to Seek Help Associated With Obsessive-Compulsive Disorder: Pilot Questionnaire Study

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling disorder associated with high interference in people's lives. However, patients with OCD either do not seek help or delay seeking help. Research suggests that this could be explained by poor mental health literacy about the disorder and the associated stigma.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a mental health mobile app, esTOCma, developed to improve knowledge about OCD and its treatment, increase help-seeking intention, and reduce stigmatizing attitudes and social distance associated with OCD.

METHODS

We used preintervention, postintervention, and 3-month follow-up assessments in this single-arm pilot intervention. Overall, 90 participants were recruited from the community using the snowball sampling method. We used esTOCma to defeat the "stigma monster" over the course of 10 missions. The participants completed the sociodemographic information and Obsessive-Compulsive Inventory-Revised at preassessment and an acceptability questionnaire at postassessment. All other measures were completed at the preassessment, postassessment, and 3-month follow-up (ie, the Spanish Mental Illness Stigma Attribution Questionnaire-27, the General Help-Seeking Questionnaire, the Social Distance Scale, and the Mental Health Literacy Questionnaire).

RESULTS

Of the 90 participants from the community that were assessed for eligibility, 86% (n=78) were allocated to intervention. Of these 78 participants, 79% (n=62) completed the game and answered the postintervention assessment (completer group). Overall, 69% (43/62) of the participants also completed the 3-month follow-up assessment. The participants completing the study were older (P=.003) and had a higher baseline knowledge of OCD (P=.05). The participants took an average of 13.64 (SD 10.50) days to complete the intervention, including the pre- and postassessments. The participants spent an average of 4.56 (SD 3.33) days completing the 10 missions included in the app. Each mission took a mean of between 2 (SD 3.01) and 9.35 (SD 3.06) minutes. The app was rated as useful or very useful by the vast majority of participants 90% (56/62). Moreover, 90% (56/62) of the participants reported that they had learned or learned a lot, and 98% (61/62) of the participants reported that they would recommend the app to a friend. Repeated measures ANOVA (43/62, 69%) showed that after the intervention participants showed an increased knowledge of mental health and intention to seek help as well as fewer stigmatizing attitudes and less social distance.

CONCLUSIONS

Preliminary data show that esTOCma is a feasible and acceptable app, and after completing its 10 missions, there is an increase in the understanding of OCD and help-seeking intention along with a decrease in the social stigma and social distance associated with OCD that lasts for at least 3 months. The results support the potential of technology-based interventions to increase the intention to seek help and reduce the stigma associated with OCD. A larger, community-controlled study is also recommended.

Association of Digital Engagement With Relaxation Tools and Stress Level Reduction: Retrospective Cohort Study

BACKGROUND

Stress is an emotional response caused by external triggers and is a high-prevalence global problem affecting mental and physical health. Several different digital therapeutic solutions are effective for stress management. However, there is limited understanding of the association between relaxation components and stress levels when using a digital app.

OBJECTIVE

This study investigated the contribution of relaxation tools to stress levels over time. We hypothesized that participation in breathing exercises and cognitive behavioral therapy-based video sessions would be associated with a reduction in stress levels. We also hypothesized a significant reduction specifically in participants' perceived sense of burden and lack of productivity when engaged with breathing exercises and video sessions.

METHODS

Stress levels were evaluated in a real-world data cohort using a behavioral health app for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform-based treatment followed users (N=490) who started with moderate and above levels of stress and completed at least 2 stress assessments. The levels of stress were tracked throughout the first 10 weeks. A piecewise mixed effects model was applied to model the trajectories of weekly stress mean scores in 2 time segments (1-6 weeks and 6-10 weeks). Next, a simple slope analysis was used for interpreting interactions probing the moderators: breathing exercises and video sessions. Piecewise mixed-effects models were also used to model the trajectories of specific perceived stress item rates in the stress questionnaire in the 2 segments (1-6 weeks and 6-10 weeks) and whether they are moderated by the relaxation engagements. Simple slope analysis was also used here for the interpretation of the interactions.

RESULTS

Analysis revealed a significant decrease in stress symptoms (β=-.25; 95% CI -0.32 to -0.17; P<.001) during the period of 1-6 weeks of app use that was maintained during the period of 6-10 weeks. Breathing exercises significantly moderated the reduction in stress symptoms during the period of 1-6 weeks (β=-.07; 95% CI -0.13 to -0.01; P=.03), while engagement in digital video sessions did not moderate stress scores. Engagement in digital video sessions, as well as breathing exercises, significantly moderated the reduction in perceived sense of burden and lack of productivity during weeks 1-6 and remained stable during weeks 6-10 on both items.

CONCLUSIONS

This study sheds light on the association between stress level reduction and specific components of engagement in a digital health app, breathing exercises, and cognitive behavioral therapy-based video sessions. Our findings provide a basis for further investigation of current and moderating factors that contribute to the personalization of digital intervention. In addition, results may aid in developing a more comprehensive understanding of how digital intervention tools work for mental health and for whom they are most effective.

Digital psychiatry in low-and-middle-income countries: New developments and the way forward

Low- and middle-income countries (LMICs) bear the greater share of the global mental health burden but are ill-equipped to deal with it because of severe resource constraints leading to a large treatment gap. The remote provision of mental health services by digital means can effectively augment conventional services in LMICs to reduce the treatment gap. Digital psychiatry in LMICs has always lagged behind high-income countries, but there have been encouraging developments in the last decade. There is increasing research on the efficacy of digital psychiatric interventions. However, the evidence is not adequate to conclude that digital psychiatric interventions are invariably effective in LMICs. A striking development has been the rise in mobile and smartphone ownership in LMICs, which has driven the increasing use of mobile technologies to deliver mental health services. An innovative use of mobile technologies has been to optimize task-shifting, which involves delivering mental healthcare services in community settings using non-specialist health professionals. Emerging evidence from LMICs shows that it is possible to use digital tools to train non-specialist workers effectively and ensure that the psychosocial interventions they deliver are efficacious. Despite these promising developments, many barriers such as service costs, underdeveloped infrastructure, lack of trained professionals, and significant disparities in access to digital services impede the progress of digital psychiatry in LMICs. To overcome these barriers, digital psychiatric services in LMICs should address contextual factors influencing the delivery of digital services, ensure collaboration between different stakeholders, and focus on reducing the digital divide.