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

Mental health consumers and primary care providers co-designing improvements and innovations: a scoping review

Co-design and co-production are increasingly used to improve and innovate healthcare practices and services to better address people's healthcare needs. Mental health consumers, especially people diagnosed with serious mental illness, experience considerable health disparities and barriers to primary care, while primary care providers experience barriers to addressing the healthcare needs of people diagnosed with serious mental illness. Both mental health consumers and primary care providers bring knowledge and expertise to improving mental health consumers' health care. This scoping review of the peer-reviewed and grey literature was undertaken to determine the extent and scope of co-design and co-production involving mental health consumers and primary care providers to address mental health consumers' healthcare needs. The review also sought to determine factors that enable or limit co-design and co-production involving mental health consumers and primary care providers. Twelve studies and reports of co-design and co-production involving mental health consumers and primary care providers were identified by the review. These studies showed that co-design and co-production were feasible and beneficial, and that there was significant scope for collaboration at the intersection of mental health and primary care services. Lessons learned from projects that have led the way include the need for (1) co-design/co-production practices that sustain equitable participation and address inevitable power imbalances when service users and service providers work together, (2) sufficient reporting on methods to ascertain claims of co-design/co-production and allow replication of these methods in similar healthcare improvement projects, and (3) co-design/co-production projects to be supported by other systems change strategies.

Digitally transforming community mental healthcare: Real-world lessons from algorithmic workforce integration

Community-based high intensity services for people living with severe and enduring mental illnesses face critical workforce shortages and workflow efficiency challenges. The expectation to monitor complex, dynamic patient data from ever-expanding electronic health records leads to information overload, a significant factor contributing to worker burnout and attrition. An algorithmic workforce, defined as a suite of algorithm-driven processes, can work alongside health professionals assisting with oversight tasks and augmenting human expertise. This selective review summarises lessons learned from our five-year experience (2018-22) of algorithmic workforce implementation research in two community mental health services in Australia covering both rural and urban populations. We retrace our implementation journey to illustrate four foundational processes: (i) algorithm design (ii) proof-of-concept validation (iii) workflow integration and (iv) optimization. By examining our previous studies, we discuss insights gained regarding intended human-centricity of services, potential algorithm-human misalignments, and unintended workload and accountability consequences for clinicians and organizations.

Organizational factors impacting the implementation of a digital mental health tool in Alberta's mental health care of youth and young adults

With mental health concerns on the rise among youth and young adults (age 12-24), increased mental health options include virtual care, apps and online tools, self-management and tracking tools, and digitally-enabled coordination of care. These tools may function as alternatives or adjuncts to face-to-face models of care. Innovative solutions in the form of digital mental health (dMH) services not only provide support, resources and care, but also decrease wait times and waitlists, increase access, and empower youth. However, organizational factors may impact the extent of dMH interventions are that accepted, used, and sustained in clinical settings. This qualitative study explores organizational barriers and facilitators surrounding the implementation of a digital platform (Innowell), which uses measurement-based care (MBC) to track youth progress and outcomes. Data was collected from 154 mental health care providers participating in 23 focus groups across Alberta, drawing on school and community settings, specialized mental health services, and primary care networks. A thematic analysis revealed the following: barriers included incompatibility with current systems and workflows, lack of inter-organizational collaboration, time commitment, perceived sustainability and lack of digital literacy. Facilitators included positive attitudes towards using dMH to optimize clinical practices by empowering youth and improving continuity of care, transitions in care, and quality of care, as well as workplace culture and leadership. The study highlights a critical need for decision makers and clinical leaders to address organizational factors by integrating training and support, establishing interoperability between digitized and in-person healthcare systems, and leveraging support for MBC and youth-centred care.

An international expert survey on the worldwide digitalization in psychiatry: Global findings from the WPA survey

BACKGROUND

The World Psychiatric Association (WPA) Working Group on Digital Psychiatry aims to digitally supplement, support and improve mental health and care literacy, acceptance and accessibility across WPA member countries and National Psychiatric Associations (NPAs). To help with this goal, the present study was set to explore first the global status of digital mental health and care across NPAs METHODS: An international expert survey on the digitalization level across all 145 WPA NPAs was electronically distributed through Qualtrics. Descriptive statistics were carried out on the global dataset.

RESULTS

Across all 145 responses, 57 were included for analysis (39.3 % response rate). Most NPAs reported lacking an official section on digital mental health (73.7 %), missing national (59.6 %) or regional policies (82.5 %), clinical guidelines (>60 % depending on the digital tool/program), and education/training in both medicine (77.2 %) either and psychiatry training programs (71.9 %). Telemedicine seemed to be the most regulated digital tool in more than half of all included NPAs. Telemedicine (45.6 %) and telemental healthcare (38.6 %) were generally reimbursed. The reported highest priority areas for future actions across WPA Regions were education and training, and the development of guidelines.

CONCLUSION

This study represents a benchmark in the work of the WG on Digital Psychiatry. It presents clear priority areas that will guide the delivery of targeted actions aimed to promote digital mental health and care, and ultimately, equitable mental health outcomes around the world. Overall, the highest priorities to be globally implemented are represented by education/training and evidence-based clinical practice guidelines.

Exploring VR in municipal mental health services: A pilot study

Introduction: The study reports the results from piloting an 8-step program for social skills training using VR technology in a municipal mental health service. Method: 14 mental health service users were recruited to test the 8-step programme. Eight mental health professionals delivered the programme and registered information about the participants and their experiences. Results: All participants lived socially isolated lives before they started, and various social and personal problems contributed to the complexity of their situation. Seven participants completed the programme, while seven did not. Two participants did not complete because they stopped isolating themselves before completing and these two, and the seven that completed the programme, experienced a positive effect on their social skills. Two of those who did not complete were able to attend group therapy sessions instead, and two were too ill to complete. The last one just stopped showing up to the appointments. Conclusion: The pilot study shows promising results and efforts should now be made to develop relevant, flexible, and high-quality VR scenarios, as this technology has the potential to help socially isolated persons become more socially active and thus increase their quality of life.

Providing digital mental health support and guidance across Colombia: An observational study

Objective

Colombia's mental health system is plagued by significant shortages in services and health professionals. Digital health technologies enable access to information and care, overcoming barriers related to systemic limitations, geographic location, cost and stigma. This paper aims to characterise the sample of Colombians who sought telecounselling and support through Mentes Colectivas, a web-based mental health counselling platform.

Methods

Participants provided basic demographics and completed the Kessler 6 to track psychological distress. Counsellors collected information about participants' level of functional impairment, presenting problems, mental health warning signs and session attendance. Descriptive statistics were used to characterise the sample. A range of inferential statistics were used to analyse group differences based on age and session, explore associations within clinical presentations, examine predictors of session attendance and analyse clinical differences between episodes of care.

Results

A total of 6442 participants (mean age = 33.6 years; 78.5% female) attended an initial session, with 35.7% returning for at least one follow-up session. Participants on average reported moderate levels of psychological distress, with young people reporting significantly higher distress relative to adults and older adults. Symptoms of anxiety and depression and sleep disturbances were most common.

Conclusions

This research confirms the feasibility of Mentes Colectivas to promote help-seeking and support self-management of mental health across the lifespan in Colombia. Digital health technologies have the potential to play a vital role in increasing equity of access to care for the Colombian population, improving mental health and functioning as well as potentially strengthening the health of families and communities.

A Digital Approach for Addressing Suicidal Ideation and Behaviors in Youth Mental Health Services: Observational Study

BACKGROUND

Long wait times for mental health treatments may cause delays in early detection and management of suicidal ideation and behaviors, which are crucial for effective mental health care and suicide prevention. The use of digital technology is a potential solution for prompt identification of youth with high suicidality.

OBJECTIVE

The primary aim of this study was to evaluate the use of a digital suicidality notification system designed to detect and respond to suicidal needs in youth mental health services. Second, the study aimed to characterize young people at different levels of suicidal ideation and behaviors.

METHODS

Young people aged between 16 and 25 years completed multidimensional assessments using a digital platform, collecting demographic, clinical, social, functional, and suicidality information. When the suicidality score exceeded a predetermined threshold, established based on clinical expertise and service policies, a rule-based algorithm configured within the platform immediately generated an alert for treating clinicians. Subsequent clinical actions and response times were analyzed.

RESULTS

A total of 2021 individuals participated, of whom 266 (11%) triggered one or more high suicidal ideation and behaviors notification. Of the 292 notifications generated, 76% (222/292) were resolved, with a median response time of 1.9 (range 0-50.8) days. Clinical actions initiated to address suicidality included creating safety plans (60%, 134/222), conducting safety checks (18%, 39/222), psychological therapy (8%, 17/222), transfer to another service (3%, 8/222), and scheduling of new appointments (2%, 4/222). Young people with high levels of suicidality were more likely to present with more severe and comorbid symptoms, including low engagement in work or education, heterogenous psychopathology, substance misuse, and recurrent illness.

CONCLUSIONS

The digital suicidality notification system facilitated prompt clinical actions by alerting clinicians to high levels of suicidal ideation and behaviors detected among youth. Further, the multidimensional assessment revealed complex and comorbid symptoms exhibited in youth with high suicidality. By expediting and personalizing care for those displaying elevated suicidality, the digital notification system can play a pivotal role in preventing rapid symptom progression and its detrimental impacts on young people's mental health.

Incorporating Complexity and System Dynamics into Economic Modelling for Mental Health Policy and Planning

Care as usual has failed to stem the tide of mental health challenges in children and young people. Transformed models of care and prevention are required, including targeting the social determinants of mental health. Robust economic evidence is crucial to guide investment towards prioritised interventions that are effective and cost-effective to optimise health outcomes and ensure value for money. Mental healthcare and prevention exhibit the characteristics of complex dynamic systems, yet dynamic simulation modelling has to date only rarely been used to conduct economic evaluation in this area. This article proposes an integrated decision-making and planning framework for mental health that includes system dynamics modelling, cost-effectiveness analysis, and participatory model-building methods, in a circular process that is constantly reviewed and updated in a 'living model' ecosystem. We describe a case study of this approach for mental health system policy and planning that synergises the unique attributes of a system dynamics approach within the context of economic evaluation. This kind of approach can help decision makers make the most of precious, limited resources in healthcare. The application of modelling to organise and enable better responses to the youth mental health crisis offers positive benefits for individuals and their families, as well as for taxpayers.

Building Mutually Beneficial Collaborations Between Digital Navigators, Mental Health Professionals, and Clients: Naturalistic Observational Case Study

Unlabelled

Despite the efficacy of digital mental health technologies (DMHTs) in clinical trials, low uptake and poor engagement are common in real-world settings. Accordingly, digital technology experts or "digital navigators" are increasingly being used to enhance engagement and shared decision-making between health professionals and clients. However, this area is relatively underexplored and there is a lack of data from naturalistic settings. In this paper, we report observational findings from the implementation of a digital navigator in a multidisciplinary mental health clinic in Sydney, Australia. The digital navigator supported clients and health professionals to use a measurement-based DMHT (the Innowell platform) for improved multidimensional outcome assessment and to guide personalized decision-making. Observational data are reported from implementation logs, platform usage statistics, and response rates to digital navigator emails and phone calls. Ultimately, support from the digital navigator led to improved data collection and clearer communications about goals for using the DMHT to track client outcomes; however, this required strong partnerships between health professionals, the digital navigator, and clients. The digital navigator helped to facilitate the integration of DMHT into care, rather than providing a stand-alone service. Thus, collaborations between health professionals and digital navigators are mutually beneficial and empower clients to be more engaged in their own care.

Youth Perspectives on 'Highly Personalised and Measurement-Based Care': Qualitative Co-Design of Education Materials

OBJECTIVES

Despite high levels of mental ill-health amongst young people (aged 15-30), this group demonstrates low help-seeking and high drop-out from mental health services (MHS). Whilst shared decision-making can assist people in receiving appropriate and effective health care, young people frequently report that they do not feel involved in treatment decisions. The current study focused on co-design of a clinical education and participant information programme for the Brain and Mind Centre Youth Model of Care. This model, which articulates a youth-focused form of highly personalised and measurement-based care, is designed to promote shared decision-making between young people and clinical service providers.

METHODS

We conducted workshops with 24 young people (16-31; MAge = 21.5) who had accessed mental health services. Participants were asked what advice they would give to young people entering services, before giving advice on existing materials. Workshops were conducted and transcripts were coded using thematic analysis by two lived experience researchers and a clinical researcher.

RESULTS

Young people found it empowering to be educated on transdiagnostic models of mental illness, namely clinical staging, which gives them a better understanding of why certain treatments may be inappropriate and ineffective, and thus reduce self-blame. Similarly, young people had limited knowledge of links between mental health and other life domains and found it helpful to be educated on multidisciplinary treatment options. Measurement-based care was seen as an important method of improving shared decision-making between young people and health professionals; however, to facilitate shared decision-making, young people also wanted better information on their rights in care and more support to share their expertise in their own needs, values and treatment preferences.

CONCLUSIONS

These findings will inform the delivery of the further development and implementation of a youth-specific clinical education and participant information programme for the BMC Youth Model.

PATIENT OR PUBLIC CONTRIBUTION

Workshops were facilitated by researchers with lived expertise in mental ill-health (A.H. and/or C.G.) and a clinical researcher (who has expertise as an academic and a clinical psychologist). A.H. and C.G. were also involved in conceptualisation, analysis, interpretation, review and editing of this paper.

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

N/a.

Digital Lifestyle Interventions for Young People With Mental Illness: A Qualitative Study Among Mental Health Care Professionals

BACKGROUND

Given the physical health disparities associated with mental illness, targeted lifestyle interventions are required to reduce the risk of cardiometabolic disease. Integrating physical health early in mental health treatment among young people is essential for preventing physical comorbidities, reducing health disparities, managing medication side effects, and improving overall health outcomes. Digital technology is increasingly used to promote fitness, lifestyle, and physical health among the general population. However, using these interventions to promote physical health within mental health care requires a nuanced understanding of the factors that affect their adoption and implementation.

OBJECTIVE

Using a qualitative design, we explored the attitudes of mental health care professionals (MHCPs) toward digital technologies for physical health with the goal of illuminating the opportunities, development, and implementation of the effective use of digital tools for promoting healthier lifestyles in mental health care.

METHODS

Semistructured interviews were conducted with MHCPs (N=13) using reflexive thematic analysis to explore their experiences and perspectives on using digital health to promote physical health in youth mental health care settings.

RESULTS

Three overarching themes from the qualitative analysis are reported: (1) motivation will affect implementation, (2) patients' readiness and capability, and (3) reallocation of staff roles and responsibilities. The subthemes within, and supporting quotes, are described.

CONCLUSIONS

The use of digital means presents many opportunities for improving the provision of physical health interventions in mental health care settings. However, given the limited experience of many MHCPs with these technologies, formal training and additional support may improve the likelihood of implementation. Factors such as patient symptomatology, safety, and access to technology, as well as the readiness, acceptability, and capability of both MHCPs and patients to engage with digital tools, must also be considered. In addition, the potential benefits of data integration must be carefully weighed against the associated risks.

Digital Adoption by an Organization Supporting Informal Caregivers During COVID-19 Pandemic Showing Impact on Service Use, Organizational Performance, and Carers' Well-Being: Retrospective Population-Based Database Study With Embedded User Survey

BACKGROUND

The COVID-19 pandemic has catalyzed a move from face-to-face to digital delivery of services by hospitals and primary care. However, little is known about the impact of digital transformation on organizations supporting unpaid caregivers. Since the start of the COVID-19 pandemic, the value of care provided by such informal caregivers is estimated to be £111 billion (US$ 152.7 billion) in England.

OBJECTIVE

This study aims to analyze service uptake patterns (including digital service options) over the pandemic period in an English caregivers' support organization covering a population of 0.98 million; measure changes in organizational performance, service efficiency, and quality; and identify the views of caregivers on service provision and future digital delivery.

METHODS

This was a retrospective analysis of the use of digital versus nondigital support services (January 2019 to June 2021) by caregivers in city and rural geographic areas. We compared organizational performance and service quality indicators for 2 financial years (2019-2020 and 2020-2021). A survey was conducted to identify barriers and facilitators to digital service uptake, the computer proficiency of caregivers (the Computer Proficiency Questionnaire, 12-item version), and preferences for future digital service provision. Quantitative data were analyzed using Stata 13 (StataCorp LLC). Thematic analysis was used for open-text survey responses.

RESULTS

The number of caregivers registered with the organization rose from 14,817 in 2019 to 20,237 in 2021. Monthly contacts rose from 1929 to 6741, with remote contacts increasing from 48.89% (943/1929) to 86.68% (5843/6741); distinctive patterns were observed for city versus rural caregivers. There was an increase in one-to-one contacts (88.8%) and caregiver assessments (20.9%), with no expansion in staffing. Service quality indicators showed an improvement in 5 of 8 variables (all P<.05). The 152 carers completing the survey had similar demographics to all registered caregivers. The Computer Proficiency Questionnaire, 12-item version, mean score of 25.61 (SD 4.40) indicated relatively high computer proficiency. The analysis of open-text responses identified a preference for the organization to continue to offer face-to-face services as well as web-based options. The digital services that were the most highly rated were carers' well-being assessments, support needs checks, and peer support groups.

CONCLUSIONS

Our findings show that staff in the caregiver support organization were agile in adapting their services to digital delivery while dealing with increased numbers of registered clients and higher monthly contacts, all without obvious detriment to service quality. Caregivers indicated a preference for blended services, even while recording high computer proficiency. Considering the economic importance of unpaid caregivers, more attention should be given to organizations funded to provide support for them and to the potential for technology to enhance caregivers' access to, and engagement with, such services.

Therapies go digital. What drives physicians' acceptance?

National healthcare systems face multiple challenges, including the increasing demand for care and decreasing availability of healthcare professionals. Digital health technologies represent opportunities that offer improved efficiency, accessibility, and patient care. In this scenario, Digital Therapeutics are technological advancements to treat or alleviate a disease and deliver a medical intervention with evidence-based therapeutic impacts and regulatory approval. Digital Therapeutics are a paradigm shift for physicians, who exercise caution in terms of trust and wide usage. Digital Therapeutics represents an opportunity and a challenge in healthcare system integration. The research investigates the factors explaining physicians' acceptance of Digital Therapeutics. A research model that combines organizational mechanisms derived from Institutional Theory and rational factors derived from the Technology Acceptance model was developed. The model was tested through 107 responses from a survey distributed to the members of the leading Italian scientific society in Diabetology. Literature-based hypotheses were empirically tested through Structural Equation Modelling. The analysis confirmed the influence of Perceived Ease of Use on Perceived Usefulness and Perceived Usefulness on the Intention To Use Digital Therapeutics. Rules and norms impact Perceived Usefulness when considering the influence of the scientific society. Culture and mindset towards innovation within the hospital positively affect Perceived Ease of Use. The readiness of hospital facilities enhances the extent to which physicians perceive the ease of employing Digital Therapeutics in their daily practice. Instead, esteemed colleagues' opinions and guidelines from the scientific society reveal to physicians the value of Digital Therapeutics in patients' care pathways. Institutions should prioritize cultural, normative, and regulative aspects to accelerate physicians' endorsement of Digital Therapeutics. Findings advance the theoretical knowledge around clinicians' adoption of innovative digital health technologies, unveiling the interaction between rational and institutional factors. The results highlight practical implications for healthcare institutions and Digital Therapeutics manufacturers willing to promote their adoption.

Unpeeling the onion: Digital triage and monitoring of general practice, private psychiatry, and psychology

OBJECTIVE

The Australian federal government is considering a 'digital front door' to mental healthcare. The Brain and Mind Centre at the University of Sydney has published a discussion paper advocating that the government should adopt a comprehensive model of digital triage and monitoring (DTM) based on a government-funded initiative Project Synergy ($30 million). We critically examine the final report on Project Synergy, which is now available under a Freedom of Information request.

CONCLUSION

The DTM model is disruptive. Non-government organisations would replace general practitioners as care coordinators. Patients, private psychiatrists, and psychologists would be subjected to additional layers of administration, assessment, and digital compliance, which may decrease efficiency, and lengthen the duration of untreated illness. Only one patient was deemed eligible for DTM, however, during the 8-month regional trial of Project Synergy (recruitment rate = 1/500,000 across the region). Instead of an unproven DTM model, the proposed 'digital front door' to Australian mental healthcare should emphasise technology-enabled shared care (general practitioners and mental health professionals) for the treatment of moderate-to-severe illness.

Implementation of an Electronic Mental Health Platform for Youth and Young Adults in a School Context Across Alberta, Canada: Thematic Analysis of the Perspectives of Stakeholders

BACKGROUND

Youth, aged 15 to 24 years, are more likely to experience mental health (MH) or substance use issues than other age groups. This is a critical period for intervention because MH disorders, if left unattended, may become chronic and serious and negatively affect many aspects of a young person's life. Even among those who are treated, poor outcomes will still occur for a percentage of youth. Electronic MH (eMH) tools have been implemented in traditional MH settings to reach youth requiring assistance with MH and substance use issues. However, the utility of eMH tools in school settings has yet to be investigated.

OBJECTIVE

The objective of this study was to gain an understanding of the perspectives of key school staff stakeholders regarding barriers and facilitators to the implementation of the Innowell eMH platform in secondary schools across the province of Alberta, Canada.

METHODS

Guided by a qualitative descriptive approach, focus groups were conducted to elicit stakeholder perspectives on the perceived implementation challenges and opportunities of embedding the Innowell eMH platform in secondary school MH services. In total, 8 focus groups were conducted with 52 key school staff stakeholders.

RESULTS

Themes related to barriers and facilitators to youth and school MH care professional (MHCP) capacity in implementing and using eMH tools were identified. With respect to youth capacity barriers, the following themes were inductively generated: (1) concerns about some students not being suitable for eMH services, (2) minors requiring consent from parents or caregivers to use eMH services as well as confidentiality and privacy concerns, and (3) limited access to technology and internet service among youth. A second theme related to school MHCP barriers to implementation, which included (1) feeling stretched with high caseloads and change fatigue, (2) concerns with risk and liability, and (3) unmasking MH issues in the face of limited resources. In contrast to the barriers to youth and MHCP capacity, many facilitators to implementation were discussed. Youth capacity facilitators included (1) the potential for youth to be empowered using eMH tools, (2) the platform fostering therapeutic relationships with school personnel, and (3) enhancing access to needed services and resources. MHCP capacity facilitators to implementation were (1) system transformation through flexibility and problem-solving, (2) opportunities for collaboration with youth and MHCPs and across different systems, and (3) an opportunity for the continuity of services.

CONCLUSIONS

Our findings highlight nuanced school MHCP perspectives that demonstrate critical youth and MHCP capacity concerns, with consideration for organizational factors that may impede or enhance the implementation processes for embedding eMH in a school context. The barriers and facilitators to implementation provide future researchers and decision makers with challenges and opportunities that could be addressed in the preimplementation phase.

Mental health provider and youth service users' perspectives regarding implementation of a digital mental health platform for youth: A survey study

Background

For youth and young adults (YYAs) with mental health concerns, digital mental health (dMH) can improve access to care and support collaboration with providers. Measurement-based care using a dMH platform may further optimize YYA outcomes by individualizing treatment approaches. Engaging service providers and YYA provides an opportunity to better understand how to mitigate implementation challenges.

Aim

Explore the experiences of mental health care providers and YYAs regarding the implementation of a dMH platform for YYAs accessing mental health care in multiple care settings.

Methods

Mental health care providers and YYA service users completed an electronic survey exploring their experiences and perceptions of implementing a dMH platform. Survey design, data analysis, and reporting were informed by the Consolidated Framework for Implementation Research (CFIR).

Results

A total of 195 individuals (100 providers, 95 YYAs) responded. Of those, 48 providers and 79 YYAs reported using the platform at least once. Both groups identified several important factors supporting implementation including collaborative relationships between providers and YYAs, the ability to monitor mental health outcomes, and increased YYA engagement in care. The need for increased provider training and automatic reminders for YYAs to use the platform were common barriers. Each group perceived the other to be uninterested in using the platform, highlighting the importance of using all stakeholder views to inform implementation planning.

Conclusions

Successful implementation of dMH for care of YYA requires ongoing, user-informed training, integration into existing workflows, and alignment with YYA priorities for care. Future work exploring provider and youth perceptions of the others' "buy-in" is needed to inform future implementation strategies.

What have been the clinical outcomes of the Project Synergy/InnoWell digital health platform?

Project Synergy is a digital mental health tool for assessment, referral and follow-up of people with mental health problems. The Australian federal government Department of Health entered an AUD33 million formal funding arrangement with InnoWell, a proprietary company vehicle (primarily the consultancy firm PwC and University of Sydney) to continue development of Project Synergy. This followed an initial federal National Health and Medical Research Council grant of AUD5.5 million over the previous 3 years. However, based on the assessment of peer-reviewed research data, the Project Synergy/InnoWell platform does not seem to have demonstrated clinical outcomes of healthcare value to date.

Facilitating In-House Mobile App Development Within Psychiatric Outpatient Services for Patients Diagnosed With Borderline Personality Disorder: Rapid Application Development Approach

BACKGROUND

Mobile app development within mental health is often time- and resource-consuming, challenging the development of mobile apps for psychiatry. There is a continuum of software development methods ranging from linear (waterfall model) to continuous adaption (Scrum). Rapid application development (RAD) is a model that so far has not been applied to psychiatric settings and may have some advantages over other models.

OBJECTIVE

This study aims to explore the utility of the RAD model in developing a mobile app for patients with borderline personality disorder (BPD) in a psychiatric outpatient setting.

METHODS

The 4 phases of the RAD model: (1) requirements planning, (2) user design, (3) construction, and (4) cutover, were applied to develop a mobile app within psychiatric outpatient services for patients diagnosed with BPD.

RESULTS

For the requirements planning phase, a short time frame was selected to minimize the time between product conceptualization and access within a clinical setting. Evidenced-based interactive content already developed was provided by current staff to enhance usability and trustworthiness. For the user design phase, activity with video themes and a discrete number of functions were used to improve the app functionality and graphical user interface. For the construction phase, close collaboration between clinicians, researchers, and software developers yielded a fully functional, in-house-developed app ready to be tested in clinical practice. For the cutover phase, the mobile app was tested successfully with a small number (n=5) of patients with a BPD.

CONCLUSIONS

The RAD model could be meaningfully applied in a psychiatric setting to develop an app for BPD within a relatively short time period from conceptualization to implementation in the clinic. Short time frames and identifying a limited number of stakeholders with relevant skills in-house facilitated the use of this model. Despite some limitations, RAD could be a useful model in the development of apps for clinical populations to enable development and access to evidence-based technology.

Developing a Theory of Change for a Digital Youth Mental Health Service (Moderated Online Social Therapy): Mixed Methods Knowledge Synthesis Study

BACKGROUND

Common challenges in the youth mental health system include low access, poor uptake, poor adherence, and limited overall effectiveness. Digital technologies offer promise, yet challenges in real-world integration and uptake persist. Moderated Online Social Therapy (MOST) aims to overcome these problems by integrating a comprehensive digital platform into existing youth mental health services. Theory of change (ToC) frameworks can help articulate how and why complex interventions work and what conditions are required for success.

OBJECTIVE

The objective of this study is to create a ToC for MOST to explain how it works, why it works, who benefits and how, and what conditions are required for its success.

METHODS

We used a multimethod approach to construct a ToC for MOST. The synthesis aimed to assess the real-world impact of MOST, a digital platform designed to enhance face-to-face youth mental health services, and to guide its iterative refinement. Data were gathered from 2 completed and 4 ongoing randomized controlled trials, 11 pilot studies, and over 1000 co-design sessions using MOST. Additionally, published qualitative findings from diverse clinical contexts and a review of related digital mental health literature were included. The study culminated in an updated ToC framework informed by expert feedback. The final ToC was produced in both narrative and table form and captured components common in program logic and ToC frameworks.

RESULTS

The MOST ToC captured several assumptions about digital mental health adoption, including factors such as the readiness of young people and service providers to embrace digital platforms. External considerations included high service demand and a potential lack of infrastructure to support integration. Young people and service providers face several challenges and pain points MOST seeks to address, such as limited accessibility, high demand, poor engagement, and a lack of personalized support. Self-determination theory, transdiagnostic psychological treatment approaches, and evidence-based implementation theories and their associated mechanisms are drawn upon to frame the intervention components that make up the platform. Platform usage data are captured and linked to short-, medium-, and long-term intended outcomes, such as reductions in mental health symptoms, improvements in functioning and quality of life, reductions in hospital visits, and reduced overall mental health care costs.

CONCLUSIONS

The MOST ToC serves as a strategic framework for refining MOST over time. The creation of the ToC helped guide the development of therapeutic content personalization, user engagement enhancement, and clinician adoption through specialized implementation frameworks. While powerful, the ToC approach has its limitations, such as a lack of standardized methodology and the amount of resourcing required for its development. Nonetheless, it provides an invaluable roadmap for iterative development, evaluation, and scaling of MOST and offers a replicable model for other digital health interventions aiming for targeted, evidence-based impact.

EMPOWERED trial: protocol for a randomised control trial of digitally supported, highly personalised and measurement-based care to improve functional outcomes in young people with mood disorders

OBJECTIVES

Many adolescents and young adults with emerging mood disorders do not achieve substantial improvements in education, employment, or social function after receiving standard youth mental health care. We have developed a new model of care referred to as 'highly personalised and measurement-based care' (HP&MBC). HP&MBC involves repeated assessment of multidimensional domains of morbidity to enable continuous and personalised clinical decision-making. Although measurement-based care is common in medical disease management, it is not a standard practice in mental health. This clinical effectiveness trial tests whether HP&MBC, supported by continuous digital feedback, delivers better functional improvements than standard care and digital support.

METHOD AND ANALYSIS

This controlled implementation trial is a PROBE study (Prospective, Randomised, Open, Blinded End-point) that comprises a multisite 24-month, assessor-blinded, follow-up study of 1500 individuals aged 15-25 years who present for mental health treatment. Eligible participants will be individually randomised (1:1) to 12 months of HP&MBC or standardised clinical care. The primary outcome measure is social and occupational functioning 12 months after trial entry, assessed by the Social and Occupational Functioning Assessment Scale. Clinical and social outcomes for all participants will be monitored for a further 12 months after cessation of active care.

ETHICS AND DISSEMINATION

This clinical trial has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (HREC Approval Number: X22-0042 & 2022/ETH00725, Protocol ID: BMC-YMH-003-2018, protocol version: V.3, 03/08/2022). Research findings will be disseminated through peer-reviewed journals, presentations at scientific conferences, and to user and advocacy groups. Participant data will be deidentified.

TRIAL REGISTRATION NUMBER

ACTRN12622000882729.

Developing Culturally Appropriate Content for a Child-Rearing App to Support Young Children's Socioemotional and Cognitive Development in Afghanistan: Co-Design Study

BACKGROUND

Optimal child-rearing practices can help mitigate the consequences of detrimental social determinants of health in early childhood. Given the ubiquity of personal digital technologies worldwide, the direct delivery of evidence-based information about early childhood development holds great promise. However, to make the content of these novel systems effective, it is crucial to incorporate place-based cultural beliefs, traditions, circumstances, and value systems of end users.

OBJECTIVE

This paper describes the iterative approach used to develop the Thrive by Five child-rearing app in collaboration with Afghan parents, caregivers (eg, grandparents, aunts, and nannies), and subject matter experts (SMEs). We outline how co-design methodologies informed the development and cultural contextualization of content to meet the specific needs of Afghan parents and the content was tested and refined in collaboration with key Afghan stakeholders.

METHODS

The preliminary content was developed based on a comprehensive literature review of the historical and sociocultural contexts in Afghanistan, including factors that influence child-rearing practices and early childhood development. After an initial review and refinement based on feedback from SMEs, this content was populated into a beta app for testing. Overall, 8 co-design workshops were conducted in July and August 2021 and February 2022 with 39 Afghan parents and caregivers and 6 SMEs to collect their feedback on the app and its content. The workshops were audio recorded and transcribed; detailed field notes were taken by 2 scribes. A theoretical thematic analysis using semantic codes was conducted to inform the refinement of existing content and development of new content to fulfill the needs identified by participants.

RESULTS

The following 4 primary themes were identified: child-rearing in the Afghan sociocultural context, safety concerns, emotion and behavior management, and physical health and nutrition. Overall, participants agreed that the app had the potential to deliver valuable information to Afghan parents; however, owing to the volatility in the country, participants recommended including more activities that could be safely done indoors, as mothers and children are required to spend most of their time at home. Additionally, restrictions on public engagement in music required the removal of activities referencing singing that might be performed outside the home. Further, activities to help parents reduce their children's screen time, promote empathy, manage emotions, regulate behavior, and improve physical health and nutrition were requested.

CONCLUSIONS

Direct engagement with Afghan parents, caregivers, and SMEs through co-design workshops enabled the development and refinement of evidence-based, localized, and contextually relevant child-rearing activities promoting healthy social, emotional, and cognitive development during the first 5 years of children's lives. Importantly, the content was adapted for the ongoing conflict in Afghanistan with the aim of empowering Afghan parents and caregivers to support their children's developmental potential despite the security concerns and situational stressors.

The Polarization of Clinician and Service Staff Perspectives After the Use of Health Information Technology in Youth Mental Health Services: Implementation and Evaluation Study

BACKGROUND

Highly personalized care is substantially improved by technology platforms that assess and track patient outcomes. However, evidence regarding how to successfully implement technology in real-world mental health settings is limited.

OBJECTIVE

This study aimed to naturalistically monitor how a health information technology (HIT) platform was used within 2 real-world mental health service settings to gain practical insights into how HIT can be implemented and sustained to improve mental health service delivery.

METHODS

An HIT (The Innowell Platform) was naturally implemented in 2 youth mental health services in Sydney, Australia. Web-based surveys (n=19) and implementation logs were used to investigate staff attitudes toward technology before and after implementation. Descriptive statistics were used to track staff attitudes over time, whereas qualitative thematic analysis was used to explore implementation log data to gain practical insights into useful implementation strategies in real-world settings.

RESULTS

After the implementation, the staff were nearly 3 times more likely to agree that the HIT would improve care for their clients (3/12, 25% agreed before the implementation compared with 7/10, 70% after the implementation). Despite this, there was also an increase in the number of staff who disagreed that the HIT would improve care (from 1/12, 8% to 2/10, 20%). There was also decreased uncertainty (from 6/12, 50% to 3/10, 30%) about the willingness of the service to implement the technology for its intended purpose, with similar increases in the number of staff who agreed and disagreed with this statement. Staff were more likely to be uncertain about whether colleagues in my service are receptive to changes in clinical processes (not sure rose from 5/12, 42% to 7/10, 70%). They were also more likely to report that their service already provides the best mental health care (agreement rose from 7/12, 58% to 8/10, 80%). After the implementation, a greater proportion of participants reported that the HIT enabled shared or collaborative decision-making with young people (2/10, 20%, compared with 1/12, 8%), enabled clients to proactively work on their mental health care through digital technologies (3/10, 30%, compared with 2/12, 16%), and improved their response to suicidal risk (4/10, 40% compared with 3/12, 25%).

CONCLUSIONS

This study raises important questions about why clinicians, who have the same training and support in using technology, develop more polarized opinions on its usefulness after implementation. It seems that the uptake of HIT is heavily influenced by a clinician's underlying beliefs and attitudes toward clinical practice in general as well as the role of technology, rather than their knowledge or the ease of use of the HIT in question.

Canadian pediatric eating disorder programs and virtual care during the COVID-19 pandemic: a mixed-methods approach to understanding clinicians' perspectives

BACKGROUND

As a result of the public health measures put in place during the COVID-19 pandemic in Canada, many health services, including those for the treatment of eating disorders, were provided at a distance. This study aims to describe the adaptations made in specialized pediatric eating disorder programs in Canada and the impact of these adaptations on health professionals' experience of providing care.

METHODS

A mixed-methods design was used to survey healthcare professionals working in specialized pediatric eating disorder programs about adaptations to treatment made during the pandemic and the impact of these adaptations on their experience of providing care. Data were collected between October 2021 and March 2022 using a cross-sectional survey comprising 25 questions and via semi-structured interviews. Quantitative data were summarized using descriptive statistics and qualitative data were interpreted using qualitative content analysis.

RESULTS

Eighteen healthcare professionals in Canada completed the online survey, of whom six also participated in the semi-structured interviews. The cross-sectional survey confirmed that, unlike in pre-pandemic times, the majority of participants provided medical care (15/18) and mental health care (17/18) at a distance during the pandemic, with most participants using telephone (17/18) and videoconferencing (17/18). Most (16/18) health professionals indicated that virtual care would continue to be used as a tool in pediatric ED treatment after the pandemic. Participants used a combination of virtual and in-person care, with most reporting weighing patients both in clinic (16/18) and virtually (15/18). Qualitative content analysis generated five themes: (1) responding to increased demand with insufficient resources; (2) adapting to changes in care due to the COVID-19 pandemic; (3) dealing with uncertainty and apprehension; (4) virtual care as an acceptable and useful clinical tool, and (5) optimal conditions and future expectations. Most interview participants (5/6) had globally positive views of virtual care.

CONCLUSIONS

Providing virtual multidisciplinary treatment for children and adolescents with eating disorders seemed feasible and acceptable to professionals during the pandemic. Moving forward, focusing on health professionals' perspectives and providing appropriate training in virtual interventions is essential given their central role in successful implementation and continued use of virtual and hybrid care models.

Evaluation of the Use of Digital Mental Health Platforms and Interventions: Scoping Review

BACKGROUND

The increasing use of digital mental health (DMH) platforms and digital mental health interventions (DMHIs) is hindered by uncertainty over effectiveness, quality and usability. There is a need to identify the types of available evidence in this domain.

AIM

This study is a scoping review identifying evaluation of the (1) DMH platform/s used; and (2) DMHI/s applied on the DMH platform/s.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guided the review process. Empirical studies that focused on evaluation of the use and application of DMH platforms were included from journal articles (published 2012-2022). A literature search was conducted using four electronic databases (Scopus, ScienceDirect, Sage and ACM Digital Library) and two search engines (PubMed and Google Scholar).

RESULTS

A total of 6874 nonduplicate records were identified, of which 144 were analyzed and 22 met the inclusion criteria. The review included general/unspecified mental health and/or suicidality indications (n = 9, 40.9%), followed by depression (n = 5, 22.7%), psychosis (n = 3, 13.6%), anxiety and depression (n = 2, 9.1%), as well as anxiety, depression and suicidality (n = 1, 4.5%), loneliness (n = 1, 4.5%), and addiction (n = 1, 4.5%). There were 11 qualitative studies (50%), 8 quantitative studies (36.4%), and 3 mixed-methods studies (n = 3, 13.6%). The results contained 11 studies that evaluated the DMH platform/s and 11 studies that evaluated the DMHI/s. The studies focused on feasibility, usability, engagement, acceptability and effectiveness. There was a small amount of significant evidence (1 in each 11), notably the (cost-)effectiveness of a DMHI with significant long-term impact on anxiety and depression in adults.

CONCLUSION

The empirical research demonstrates the feasibility of DMH platforms and DMHIs. To date, there is mostly heterogeneous, preliminary evidence for their effectiveness, quality and usability. However, a scalable DMHI reported effectiveness in treating adults' anxiety and depression. The scope of effectiveness may be widened through targeted strategies, for example by engaging independent young people.

Adapting and Implementing Apps for Mental Healthcare

PURPOSE OF REVIEW

To describe examples of adapting apps for use in mental healthcare and to formulate recommendations for successful adaptation in mental healthcare settings.

RECENT FINDINGS

International examples are given to explore implementation procedures to address this multitude of challenges. There are only few published examples of adapting apps for use in mental healthcare. From these examples and from results of studies in implementation science in general clinical settings, it can be concluded that the process of adapting apps for mental healthcare needs to address clinician training and information needs, user needs which include cultural adaptation and go beyond mere translation, and organizational needs for blending app use into everyday clinical mental healthcare workflows.