Efficacy and Moderation of Mobile App-Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on Mental Health: Randomized Controlled Noninferiority Trial

Mindfulness in treatment-seeking adults with comorbid obsessive-compulsive and major depressive disorders: Mediating effects of obsessive beliefs and mental well-being

Background

Mindfulness-based interventions have shown promise in alleviating symptoms associated with obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). However, the specific mechanisms that drive these effects, mainly through obsessive beliefs and mental well-being, are seldom examined.

Aim

To explore the mechanisms by which mindfulness influences symptom severity in adults with comorbid OCD and MDD, focusing on the mediating roles of obsessive beliefs and mental well-being.

Methods

Primary data from 60 treatment-seeking adults with comorbid OCD and MDD were analyzed. Ordinary least-squares path analysis was employed to examine the mediating roles of obsessive beliefs and mental well-being in the relationship between mindfulness and the severity of OCD and MDD symptoms.

Results

Mindfulness was significantly associated with reduced symptom severity for both OCD (β = - 0.40, P < 0.001) and MDD (β = - 0.49, P < 0.001). For MDD, obsessive beliefs (β = - 0.20, P < 0.001) and mental well-being (β = - 0.33, P < 0.001) significantly mediated the relationship. In contrast, no significant indirect effects were observed for OCD symptoms through obsessive beliefs (β = - 0.10, P = 0.16) or mental well-being (β = - 0.08, P = 0.20).

Conclusion

These findings highlight the distinct mechanisms of mindfulness in comorbid OCD and MDD, underscoring the importance of customized interventions based on specific pathways.

A meta-analysis of persuasive design, engagement, and efficacy in 92 RCTs of mental health apps

This systematic review and meta-analysis examined the efficacy of digital mental health apps and the impact of persuasive design principles on intervention engagement and outcomes. Ninety-two RCTs and 16,728 participants were included in the meta-analyses. Findings indicate that apps significantly improved clinical outcomes compared to controls (g = 0.43). Persuasive design principles ranged from 1 to 12 per app (mode = 5). Engagement data were reported in 76% of studies, with 25 distinct engagement metrics identified, the most common being the percentage of users who completed the intervention and the average percentage of modules completed. No significant association was found between persuasive principles and either efficacy or engagement. With 25 distinct engagement metrics and 24% of studies not reporting engagement data, establishing overall engagement with mental health apps remains unfeasible. Standardising the definition of engagement and implementing a structured framework for reporting engagement metrics and persuasive design elements are essential steps toward advancing effective, engaging interventions in real-world settings.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

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

Psychosocial Interventions to Improve Wellbeing in Teenage and Young Adult Post-Treatment Survivors of Childhood Cancer: A Systematic Review

OBJECTIVE

This systematic review explores psychosocial interventions aimed at improving the well-being of teenage and young adult (TYA) survivors of childhood cancer. It focuses on post-treatment survivors aged 13-39 years, examining the types of interventions trialled, their efficacy in enhancing different facets of mental well-being, and any potential negative impacts. The review was prospectively registered on PROSPERO and utilised randomised controlled trials (RCTs) to assess psychosocial interventions such as cognitive-behavioural therapy, psychoeducation, peer support, and physical activity programmes.

METHODS

Fifteen studies involving 1109 participants were included, covering interventions across multiple modes of delivery; online, in-person, and app-based.

RESULTS

Interventions demonstrated varied effects on outcomes like quality of life, depression, anxiety, stress, mood, behaviour, coping skills, and social support. While some interventions, such as psychoeducation and physical activity programs, showed promising improvements in well-being, others demonstrated limited or mixed results. No significant adverse effects were reported.

CONCLUSIONS

The heterogeneity of interventions and outcome measures pose challenges for definitive conclusions, emphasising the need for future research with standardised measures, consistent sample sizes, and long-term follow-up to better assess the sustainability of intervention effects. Overall, the findings highlight the importance of tailored psychosocial support to address the unique needs of TYA cancer survivors during their survivorship journey.

A Chatbot-Delivered Stress Management Coaching for Students (MISHA App): Pilot Randomized Controlled Trial

BACKGROUND

Globally, students face increasing mental health challenges, including elevated stress levels and declining well-being, leading to academic performance issues and mental health disorders. However, due to stigma and symptom underestimation, students rarely seek effective stress management solutions. Conversational agents in the health sector have shown promise in reducing stress, depression, and anxiety. Nevertheless, research on their effectiveness for students with stress remains limited.

OBJECTIVE

This study aims to develop a conversational agent-delivered stress management coaching intervention for students called MISHA and to evaluate its effectiveness, engagement, and acceptance.

METHODS

In an unblinded randomized controlled trial, Swiss students experiencing stress were recruited on the web. Using a 1:1 randomization ratio, participants (N=140) were allocated to either the intervention or waitlist control group. Treatment effectiveness on changes in the primary outcome, that is, perceived stress, and secondary outcomes, including depression, anxiety, psychosomatic symptoms, and active coping, were self-assessed and evaluated using ANOVA for repeated measure and general estimating equations.

RESULTS

The per-protocol analysis revealed evidence for improvement of stress, depression, and somatic symptoms with medium effect sizes (Cohen d=-0.36 to Cohen d=-0.60), while anxiety and active coping did not change (Cohen d=-0.29 and Cohen d=0.13). In the intention-to-treat analysis, similar results were found, indicating reduced stress (β estimate=-0.13, 95% CI -0.20 to -0.05; P<.001), depressive symptoms (β estimate=-0.23, 95% CI -0.38 to -0.08; P=.003), and psychosomatic symptoms (β estimate=-0.16, 95% CI -0.27 to -0.06; P=.003), while anxiety and active coping did not change. Overall, 60% (42/70) of the participants in the intervention group completed the coaching by completing the postintervention survey. They particularly appreciated the quality, quantity, credibility, and visual representation of information. While individual customization was rated the lowest, the target group fitting was perceived as high.

CONCLUSIONS

Findings indicate that MISHA is feasible, acceptable, and effective in reducing perceived stress among students in Switzerland. Future research is needed with different populations, for example, in students with high stress levels or compared to active controls.

TRIAL REGISTRATION

German Clinical Trials Register DRKS 00030004; https://drks.de/search/en/trial/DRKS00030004.

Efficacy of Internet-based rumination-focused cognitive behavioral therapy and mindfulness-based intervention with guided support in reducing risks of depression and anxiety: A randomized controlled trial

Rumination and worry are common risk factors of depression and anxiety. Internet-based transdiagnostic interventions targeting individuals with these specific risks may be an effective way to prevent depression and anxiety. This three-arm randomized controlled trial compared the efficacy of Internet-based rumination-focused cognitive behavioral therapy (RFCBT), mindfulness-based intervention (MBI), and psychoeducation (EDU) control among 256 at-risk individuals. Participants' levels of rumination, worry, depressive, and anxiety symptoms were assessed at post-intervention (6 weeks), 3-month, and 9-month follow-ups. Linear mixed model analysis results showed similar levels of improvement in all outcomes across the three conditions. Changes in rumination differed comparing RFCBT and MBI, where a significant reduction in rumination was noted at a 3-month follow-up among participants in RFCBT, and no significant long-term effect among participants in MBI was noted at a 9-month follow-up. All three conditions showed similar reductions in risks and symptoms, implying that the two active interventions were not superior to EDU control. The high attrition at follow-ups suggested a need to exercise caution when interpreting the findings. Future studies should tease apart placebo effect and identify ways to improve adherence.

Acceptability and experience of a smartphone symptom monitoring app for people with psychosis in China (YouXin): a qualitative study

BACKGROUND

Access to high-quality mental healthcare remains challenging for people with psychosis globally, including China. Smartphone-based symptom monitoring has the potential to support scalable mental healthcare. However, no such tool, until now, has been developed and evaluated for people with psychosis in China. This study investigated the acceptability and the experience of using a symptom self-monitoring smartphone app (YouXin) specifically developed for people with psychosis in China.

METHODS

Semi-structured interviews were conducted with 10 participants with psychosis to explore the acceptability of YouXin. Participants were recruited from the non-randomised feasibility study that tested the validity, feasibility, acceptability and safety of the YouXin app. Data analysis was guided by the theoretical framework of acceptability.

RESULTS

Most participants felt the app was acceptable and easy to use, and no unbearable burdens or opportunity costs were reported. Participants found completing the self-monitoring app rewarding and experienced a sense of achievement. Privacy and data security were not major concerns for participants, largely due to trust in their treating hospital around data protection. Participants found the app easy to use and attributed this to the training provided at the beginning of the study. A few participants said they had built some form of relationship with the app and would miss the app when the study finished.

CONCLUSIONS

The YouXin app is acceptable for symptom self-monitoring in people with experience of psychosis in China. Participants gained greater insights about their symptoms by using the YouXin app. As we only collected retrospective acceptability in this study, future studies are warranted to assess hypothetical acceptability before the commencement of study to provide a more comprehensive understanding of implementation.

The Effect of Digital Mental Health Literacy Interventions on Mental Health: Systematic Review and Meta-Analysis

BACKGROUND

Accelerated by technological advancements and the recent global pandemic, there is burgeoning interest in digital mental health literacy (DMHL) interventions that can positively affect mental health. However, existing work remains inconclusive regarding the effectiveness of DMHL interventions.

OBJECTIVE

This systematic review and meta-analysis investigated the components and modes of DMHL interventions, their moderating factors, and their long-term impacts on mental health literacy and mental health.

METHODS

We used a random-effects model to conduct meta-analyses and meta-regressions on moderating effects of DMHL interventions on mental health.

RESULTS

Using 144 interventions with 206 effect sizes, we found a moderate effect of DMHL interventions in enhancing distal mental health outcomes (standardized mean difference=0.42, 95% CI -0.10 to 0.73; P<.001) and a large effect in increasing proximal mental health literacy outcomes (standardized mean difference=0.65, 95% CI 0.59-0.74; P<.001). Uptake of DMHL interventions was comparable with that of control conditions, and uptake of DMHL interventions did not moderate the effects on both proximal mental health literacy outcomes and distal mental health outcomes. DMHL interventions were as effective as face-to-face interventions and did not differ by platform type or dosage. DMHL plus interventions (DMHL psychoeducation coupled with other active treatment) produced large effects in bolstering mental health, were more effective than DMHL only interventions (self-help DMHL psychoeducation), and were comparable with non-DMHL interventions (treatment as usual). DMHL interventions demonstrated positive effects on mental health that were sustained over follow-up assessments and were most effective in enhancing the mental health of emerging and older adults.

CONCLUSIONS

For theory building, our review and meta-analysis found that DMHL interventions are as effective as face-to-face interventions. DMHL interventions confer optimal effects on mental health when DMHL psychoeducation is combined with informal, nonprofessional active treatment components such as skills training and peer support, which demonstrate comparable effectiveness with that of treatment as usual (client-professional interactions and therapies). These effects, which did not differ by platform type or dosage, were sustained over time. Additionally, most DMHL interventions are found in Western cultural contexts, especially in high-income countries (Global North) such as Australia, the United States, and the United Kingdom, and limited research is conducted in low-income countries in Asia and in South American and African countries. Most of the DMHL studies did not report information on the racial or ethnic makeup of the samples. Future work on DMHL interventions that target racial or ethnic minority groups, particularly the design, adoption, and evaluation of the effects of culturally adaptive DMHL interventions on uptake and mental health functioning, is needed. Such evidence can drive the adoption and implementation of DMHL interventions at scale, which represents a key foundation for practice-changing impact in the provision of mental health resources for individuals and the community.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42023363995; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023363995.

Effectiveness and experiences of integrating Mindfulness into Peer-assisted Learning (PAL) in clinical education for nursing students: A mixed method study

INTRODUCTION

Nursing students can find clinical learning to be challenging, unpredictable and stressful. To address this problem, this study integrated Mindfulness into Peer-assisted Learning (PAL) for nursing clinical education and investigated the feasibility and effectiveness on improving student participants' emotional reactions, and explored the perception and experience towards the programme.

METHOD

This quasi-experimental, repeated-measure, mixed methods study was conducted in a convenience sample of 126 Year 2 and Year 3 university nursing students. The participants engaged in an online mindfulness peer-assisted learning (PAL) programme that consisted of mindfulness practice, senior students sharing their experiences, and peer-assisted group learning. Emotional status (in terms of depression, anxiety and stress), burnout and self-efficacy were measured at baseline, 8 weeks after programme commencement and immediately after programme completion. Linear mixed-effects models and an intention-to-treat analysis were used to investigate changes in the dependent variables over time. Thirty-nine participants were also invited to engage in semi-structured interviews to explore their learning experiences in the programme.

RESULTS

The programme significantly improved the participants' self-reported self-efficacy (β = 1.44, 95 % confidence interval (CI): 0.58 to 2.30, p = 0.001) and decreased their level of burnout (β = -2.31, 95 % CI: -3.24 to -1.38, p < 0. 001) but did not significantly alleviate their depression, anxiety or stress across time (p > 0.05). Three themes emerged from the qualitative data, namely 1) nurturing self-care capacity through mindfulness; (2) empowering essential skills for clinical placement; (3) maintaining momentum alongside various challenges and enablers.

CONCLUSION

The mindfulness PAL programme may facilitate nursing students' clinical preparedness. Further trials are recommended to investigate its applicability and use in clinical nursing education.

Escaping through virtual gaming-what is the association with emotional, social, and mental health? A systematic review

Background

The realm of virtual games, video games, and e-sports has witnessed remarkable and substantial growth, captivating a diverse and global audience. However, some studies indicate that this surge is often linked to a desire to escape from real life, a phenomenon known as escapism. Much like substance abuse, escapism has been identified as a significant motivator, leading to adverse outcomes, including addiction. Therefore, it is crucial to comprehend the existing research on the connection between escapism and engagement in virtual gaming. This understanding can shed light on the reasons behind such practices and their potential impact on mental and public health.

Purpose

The objective of this systematic review is investigate the findings pertaining to association between escapism and the practice of virtual games, such as video-games and e-sport.

Methods

PUBMED and SCOPUS database were systematically searched. Six independent researchers screened articles for relevance. We extracted data regarding escapism-related measures, emotional/mental health-related measures and demographic information relevant to the review purpose.

Results

The search yielded 357 articles, 36 were included. Results showed that: (i) Escapist motivation (EM) is one of the main motives for playing virtual games; (ii) EM is related to negative clinical traits; (iii) EM predicts negative psychological/emotional/mental health outcomes; (iv) EM is associated with impaired/negative perception of the real-world life; (v) EM predicts non-adaptive real social life; and (vi) EM is associated with dysfunctional gaming practices in some cases. However, EM can have beneficial effects, fostering confidence, determination, a sense of belonging in virtual communities, and representation through avatars. Furthermore, the reviewed findings suggest that EM was positively linked to mitigating loneliness in anxious individuals and promoting social activities that preserved mental health among typical individuals during the pandemic.

Conclusion

Our review reinforces the evidence linking EM in the context of virtual games to poor mental health and non-adaptive social behavior. The ensuing discussion explores the intricate connection between escapism and mental health, alongside examining the broad implications of virtual gaming practices on underlying motivations for escapism in the realms of social cognition, health promotion, and public health.

A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation

RATIONALE

Alternatives to center-based pulmonary rehabilitation are needed to improve patient access to this important therapy. A critical challenge to overcome is how to maximize safety of unsupervised exercise for at-risk patients. We investigated if a novel remote monitoring-enabled mobile health (mHealth) program is safe, feasible, and effective for patients who experience exercise-induced hemoglobin desaturation.

METHODS

An interstitial lung disease (ILD) commonly associated with pronounced exercise desaturation was investigated - the rare, female-predominant ILD lymphangioleiomyomatosis (LAM). Over a 12-week program, hemoglobin saturation (SpO2) was continuously recorded during all home exercise sessions. Intervention effects were assessed with 6-min walk test (6MWT), maximal cardiopulmonary exercise test (CPET), lower extremity computerized dynamometry, pulmonary function tests, and health-related quality of life (QoL) surveys. Safety was assessed by blood biomarkers of systemic inflammation and cardiac wall stress, and incidence of adverse events.

RESULTS

Fifteen LAM patients enrolled and 14 completed the intervention, with high adherence to aerobic (87 ± 15%) and strength (87 ± 12%) training components. An innovative characterization of exercise training SpO2 revealed that while mild-to-moderate desaturation was common during home workouts, participants were able to self-adjust exercise intensity and supplemental oxygen levels to maintain recommended exercise parameters. Significant improvements included 6MWT distance (+36 ± 34 m, p = 0.003), CPET time (p = 0.04), muscular endurance (p = 0.008), QoL (p = 0.009 to 0.03), and fatigue (p = 0.001 to 0.03). Patient acceptability and satisfaction indicators were high, blood biomarkers remained stable (p > 0.05), and no study-related adverse events occurred.

CONCLUSION

A remote monitoring-enabled home exercise program is a safe, feasible, and effective approach even for patients who experience exercise desaturation.

The Effectiveness of Fully Automated Digital Interventions in Promoting Mental Well-Being in the General Population: Systematic Review and Meta-Analysis

BACKGROUND

Recent years have highlighted an increasing need to promote mental well-being in the general population. This has led to a rapidly growing market for fully automated digital mental well-being tools. Although many individuals have started using these tools in their daily lives, evidence on the overall effectiveness of digital mental well-being tools is currently lacking.

OBJECTIVE

This study aims to review the evidence on the effectiveness of fully automated digital interventions in promoting mental well-being in the general population.

METHODS

Following the preregistration of the systematic review protocol on PROSPERO, searches were carried out in MEDLINE, Web of Science, Cochrane, PsycINFO, PsycEXTRA, Scopus, and ACM Digital (initial searches in February 2022; updated in October 2022). Studies were included if they contained a general population sample and a fully automated digital intervention that exclusively used psychological mental well-being promotion activities. Two reviewers, blinded to each other's decisions, conducted data selection, extraction, and quality assessment of the included studies. Narrative synthesis and a random-effects model of per-protocol data were adopted.

RESULTS

We included 19 studies that involved 7243 participants. These studies included 24 fully automated digital mental well-being interventions, of which 15 (63%) were included in the meta-analysis. Compared with no intervention, there was a significant small effect of fully automated digital mental well-being interventions on mental well-being in the general population (standardized mean difference 0.19, 95% CI 0.04-0.33; P=.02). Specifically, mindfulness-, acceptance-, commitment-, and compassion-based interventions significantly promoted mental well-being in the general population (P=.006); insufficient evidence was available for positive psychology and cognitive behavioral therapy-based interventions; and contraindications were found for integrative approaches. Overall, there was substantial heterogeneity, which could be partially explained by the intervention duration, comparator, and study outcomes. The risk of bias was high, and confidence in the quality of the evidence was very low (Grading of Recommendations, Assessment, Development, and Evaluations), primarily because of the high rates of study dropout (average 37%; range 0%-85%) and suboptimal intervention adherence (average 40%).

CONCLUSIONS

This study provides a novel contribution to knowledge regarding the effectiveness, strengths, and weaknesses of fully automated digital mental well-being interventions in the general population. Future research and practice should consider these findings when developing fully automated digital mental well-being tools. In addition, research should aim to investigate positive psychology and cognitive behavioral therapy-based tools as well as develop further strategies to improve adherence and reduce dropout in fully automated digital mental well-being interventions. Finally, it should aim to understand when and for whom these interventions are particularly beneficial.

TRIAL REGISTRATION

PROSPERO CRD42022310702; https://tinyurl.com/yc7tcwy7.

An mHealth Text Messaging Program Providing Symptom Detection Training and Psychoeducation to Improve Hypoglycemia Self-Management: Intervention Development Study

BACKGROUND

Hypoglycemia remains a challenge for roughly 25% of people with type 1 diabetes (T1D) despite using advanced technologies such as continuous glucose monitors (CGMs) or automated insulin delivery systems. Factors impacting hypoglycemia self-management behaviors (including reduced ability to detect hypoglycemia symptoms and unhelpful hypoglycemia beliefs) can lead to hypoglycemia development in people with T1D who use advanced diabetes technology.

OBJECTIVE

This study aims to develop a scalable, personalized mobile health (mHealth) behavioral intervention program to improve hypoglycemia self-management and ultimately reduce hypoglycemia in people with T1D who use advanced diabetes technology.

METHODS

We (a multidisciplinary team, including clinical and health psychologists, diabetes care and education specialists, endocrinologists, mHealth interventionists and computer engineers, qualitative researchers, and patient partners) jointly developed an mHealth text messaging hypoglycemia behavioral intervention program based on user-centered design principles. The following five iterative steps were taken: (1) conceptualization of hypoglycemia self-management processes and relevant interventions; (2) identification of text message themes and message content development; (3) message revision; (4) patient partner assessments for message readability, language acceptability, and trustworthiness; and (5) message finalization and integration with a CGM data-connected mHealth SMS text message delivery platform. An mHealth web-based SMS text message delivery platform that communicates with a CGM glucose information-sharing platform was also developed.

RESULTS

The mHealth SMS text messaging hypoglycemia behavioral intervention program HypoPals, directed by patients' own CGM data, delivers personalized intervention messages to (1) improve hypoglycemia symptom detection and (2) elicit self-reflection, provide fact-based education, and suggest practical health behaviors to address unhelpful hypoglycemia beliefs and promote hypoglycemia self-management. The program is designed to message patients up to 4 times per day over a 10-week period.

CONCLUSIONS

A rigorous conceptual framework, a multidisciplinary team (including patient partners), and behavior change techniques were incorporated to create a scalable, personalized mHealth SMS text messaging behavioral intervention. This program was systematically developed to improve hypoglycemia self-management in advanced diabetes technology users with T1D. A clinical trial is needed to evaluate the program's efficacy for future clinical implementation.

Sequential multiple assignment randomised controlled trial protocol for developing an adaptive intervention to improve depressive symptoms among family caregivers of people with dementia

OBJECTIVES

Family caregivers of people with dementia (FC-of-PWD) suffer from a high level of stress and depressive symptoms, which usually require different interventions at different stages. Although some standalone interventions such as behavioural activation (BA) and mindfulness practice (MP) have been shown to be potentially effective at reducing depressive symptoms, the best sequence and combination of these interventions for caregivers are unknown. This study aims to develop and identify a two-stage adaptive intervention with prespecified rules guiding whether, how or when to offer different interventions initially/over time to reduce depressive symptoms in FG-of-PWD.

METHODS

A sequential multiple assignment randomised trial design will be adopted. 272 FG-of-PWD with mild to moderate depressive symptoms will be recruited from the community. Four two-stage, embedded adaptive interventions involving BA and MP of different sequences and dosages (eg, 8 weeks of BA followed by booster sessions for responders and 8 weeks of MP for non-responders) will be assigned to the participants following a set of decision rules. The primary outcomes will be depressive symptoms (measured using the Patient Health Questionnaire-9), assessed after the second stage of the intervention. Other outcomes, such as positive aspects of caregiving (measured using the Positive Aspects of Caregiving Scale), sleep quality (measured using the Pittsburgh Sleep Quality Index) and time points will also be assessed. The analyses will follow the intention-to-treat principle. Several process indicators (eg, engagement in meaningful activities and level of mindfulness) will also be assessed. The findings will have strong implications for the further development of psychosocial adaptive interventions to reduce depressive symptoms among FC-of-PWD.

ETHICS AND DISSEMINATION

This study has received ethical approval from the Human Research Ethics Committee at The Hong Kong Polytechnic University (HSEARS20211223001). The findings will be presented at academic conferences and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

NCT05634317.

Mindfulness-Based Mobile Apps and Their Impact on Well-Being in Nonclinical Populations: Systematic Review of Randomized Controlled Trials

BACKGROUND

Mindfulness-based mobile apps have become popular tools for enhancing well-being in today's fast-paced world. Their ability to reduce geographical, financial, and social barriers makes them a promising alternative to traditional interventions.

OBJECTIVE

As most available apps lack a theoretical framework, this review aimed to evaluate their effectiveness and assess their quality. We expected to find small sample sizes, high dropout rates, and small effect sizes in the included studies.

METHODS

A systematic literature search was conducted using PsycInfo, PsycNet, PubMed, an institutional search engine (u:search), and Google Scholar. Randomized controlled trials assessing the impact of mobile mindfulness apps on well-being in nonclinical samples were included. Study selection, risk of bias (using the version 2 of the Cochrane risk-of-bias tool for randomized trials), and reporting quality (using selected CONSORT [Consolidated Standards of Reporting Trials] statement criteria) assessments were performed by 2 authors independently and discussed until a consensus was reached.

RESULTS

The 28 included randomized controlled trials differed in well-being measures, apps, and intervention duration (7 to 56 days; median duration 28 days). A wide range of sample sizes (12 to 2282; median 161) and attrition rates (0% to 84.7%; median rate 23.4%) were observed. Most studies (19/28, 68%) reported positive effects on at least one aspect of well-being. The effects were presented using different metrics but were primarily small or small to medium in size. Overall risk of bias was mostly high.

CONCLUSIONS

The wide range of sample sizes, attrition rates, and intervention periods and the variation in well-being measures and mobile apps contributed to the limited comparability of the studies. Although most studies (16/28, 57%) reported small or small to medium effects for at least one well-being outcome, this review demonstrates that the generalizability of the results is limited. Further research is needed to obtain more consistent conclusions regarding the impact of mindfulness-based mobile apps on well-being in nonclinical populations.

Effects and mechanisms of an online short-term audio-based mindfulness program on positive affect: A randomized controlled trial including exploratory moderator analyses

This study investigated the effects and mechanisms of an online short-term audio-based mindfulness (SAM) intervention program on positive affect and explored how well-being and negative affect influenced these effects and mechanisms. Participants (N = 100) were randomized into an intervention group (n = 50) and a control group (n = 50). Those in the mindfulness group underwent 3 weeks of an online SAM program and completed the online measures four times, while those in the control group completed the measures twice. Participants completed measures including the World Health Organization Well-Being Index, the Freiburg Mindfulness Inventory, and the Positive and Negative Affect Schedule. The effects of measures in both groups were compared. Parallel process latent growth curve modeling analysis was used to explore the longitudinal moderated mediation effects. The results showed that SAM was effective at improving positive affect, mindfulness, well-being, and reducing negative affect. Mindfulness growth speed during the intervention period mediated the relationship between SAM and positive affect improvement speed. The moderation effects of baseline well-being and negative effect on mediation effects were found to be significant. The SAM program was effective for the general public and was more beneficial for those with medium/high well-being and low/medium negative affect.

Effects of Self-Compassion Interventions on Reducing Depressive Symptoms, Anxiety, and Stress: A Meta-Analysis

Objectives

A growing body of evidence shows self-compassion can play a key role in alleviating depressive symptoms, anxiety, and stress in various populations. Interventions fostering self-compassion have recently received increased attention. This meta-analysis aimed to identify studies that measured effects of self-compassion focused interventions on reducing depressive symptoms, anxiety, and stress.

Methods

A comprehensive search was conducted within four databases to identify relevant randomized controlled trials (RCTs). The quality of the included RCTs was assessed using the Cochrane Collaboration risk-of-bias tool. Either a random-effects model or fixed-effects model was used. Subgroup analyses were conducted according to types of control groups, intervention delivery modes, and the involvement of directly targeted populations with psychological distress symptoms.

Results

Fifty-six RCTs met the eligibility criteria. Meta-analyses showed self-compassion focused interventions had small to medium effects on reducing depressive symptoms, anxiety, and stress at the immediate posttest and small effects on reducing depressive symptoms and stress at follow-up compared to control conditions. The overall risk of bias across included RCTs was high.

Conclusions

Fewer studies were conducted to compare effects of self-compassion interventions to active control conditions. Also, fewer studies involved online self-compassion interventions than in-person interventions and directly targeted people with distress symptoms. Further high-quality studies are needed to verify effects of self-compassion interventions on depressive symptoms, anxiety, and stress. As more studies are implemented, future meta-analyses of self-compassion interventions may consider conducting subgroup analyses according to intervention doses, specific self-compassion intervention techniques involved, and specific comparison or control groups.

Preregistration

This study is not preregistered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-023-02148-x.

A Web-Based Stratified Stepped Care Platform for Mental Well-being (TourHeart+): User-Centered Research and Design

BACKGROUND

Internet-based mental health interventions have been demonstrated to be effective in alleviating psychological distress and promoting mental well-being. However, real-world uptake and engagement of such interventions have been low. Rather than being stand-alone interventions, situating internet-based interventions under a stratified stepped care system can support users to continue with mental health practice and monitor their mental health status for timely services that are commensurate with their needs. A user-centered approach should be used in the development of such web-based platforms to understand the facilitators and barriers in user engagement to enhance platform uptake, usability, and adherence so it can support the users' continued adoption and practice of self-care for their mental health.

OBJECTIVE

The aim of this study was to describe the design process taken to develop a web-based stratified stepped care mental health platform, TourHeart+, using a user-centered approach that gathers target users' perceptions on mental self-care and feedback on the platform design and incorporates them into the design.

METHODS

The process involved a design workshop with the interdisciplinary development team, user interviews, and 2 usability testing sessions on the flow of registration and mental health assessment and the web-based self-help interventions of the platform. The data collected were summarized as descriptive statistics if appropriate and insights are extracted inductively. Qualitative data were extracted using a thematic coding approach.

RESULTS

In the design workshop, the team generated empathy maps and point-of-view statements related to the possible mental health needs of target users. Four user personas and related processes in the mental health self-care journey were developed based on user interviews. Design considerations were derived based on the insights drawn from the personas and mental health self-care journey. Survey results from 104 users during usability testing showed that the overall experience during registration and mental health assessment was friendly, and they felt cared for, although no statistically significant differences on preference ratings were found between using a web-based questionnaire tool and through an interactive chatbot, except that chatbot format was deemed more interesting. Facilitators of and barriers to registering the platform and completing the mental health assessment were identified through user feedback during simulation with mock-ups. In the usability testing for guided self-help interventions, users expressed pain points in course adherence, and corresponding amendments were made in the flow and design of the web-based courses.

CONCLUSIONS

The design process and findings presented in the study are important in developing a user-centric platform to optimize users' acceptance and usability of a web-based stratified stepped care platform with guided self-help interventions for mental well-being. Accounting for users' perceptions and needs toward mental health self-care and their experiences in the design process can enhance the usability of an evidence-based mental health platform on the web.

The impact of Emotion-focused training for emotion couching delivered as mobile app on self-compassion and self-criticism

Introduction

Being self-compassionate is considered a beneficial emotion regulation strategy. Therefore, the acquisition of emotional skills can raise self-compassion levels and consequently reduce self-criticism.

Methods

Hence, the goal of the current study was to develop a mobile app based on the empirically proven group version of Emotion-Focused Training for Emotional Coaching (EFT-EC) and test its effectiveness in reducing self-criticism and raising self-compassion and self-protection. The sample consisted of 85 participants, of whom 22.4% were men and 77.6% were women. The mean age was 32.53 (SD = 14.51), ranging from 18 to 74 years. The participants filled out the following scales immediately before and after using the fourteen-day mobile app: The Forms of Self-Criticizing/Attacking & Self-Reassuring Scale (FSCRS), The Sussex-Oxford Compassion for the Self Scale (SOCS-S), and The Short-form Version of The Scale for interpersonal behaviour (s-SIB).

Results

Use of the 14-day EFT-EC mobile app significantly improved self-compassion and self-reassurance and significantly reduced self-criticism compared to pre- and post-measurements.

Discussion

The results are promising as self-criticism is a transdiagnostic phenomenon observed in various kinds of psychopathology and reducing it may prevent the emergence of psychopathologies. Moreover, the mobile app intervention can easily be accessed by a wide range of users, without requiring the services of a mental health professional, and thereby reduces the potential risk of shame or stigmatization.

Preliminary effectiveness of an evidence-based mobile application to promote resilience among working adults in Singapore and Hong Kong: Intensive longitudinal study

Evidence-based mobile health (mHealth) applications on smartphones are a cost-effective way for employees to take proactive steps to improve well-being and performance. However, little is known about what sustains engagement on these applications and whether they could dynamically improve occupational outcomes such as resilience and mood. Using real-world data, this intensive longitudinal study examines (a) which employees would continually engage with a cognitive behavioural therapy-informed mHealth application ('Intellect'); and (b) if daily engagement of 'Intellect' would relate to better occupational outcomes on the following day. A total of 515 working adults in Singapore and Hong Kong (Mage = 32.4, SDage = 8.17) completed daily in-app items on mood and resilience components (i.e. sleep hours, sleep quality, physical activity, and stress levels). Our results revealed that employees with lower baseline resilience (β = -0.048, odds ratio (OR) = 0.953, p < 0.01), specifically poorer sleep quality (β = -0.212, OR = 0.809, p = 0.001) and/or higher stress levels (β = -0.255, OR = 0.775, p = 0.05), were more likely to resume engagement on the application. Among the 150 active users (i.e. ≥3 consecutive days of engagement) (Mage = 32.2, SDage = 8.17), daily engagement predicted higher resilience (β = 0.122; 95% confidence interval (CI) 0.039-0.206), specifically lower stress levels (β = 0.018; 95% CI 0.004-0.032), higher physical activity (β = 0.079; 95% CI 0.032-0.126), and mood levels (β = 0.020; 95% CI 0.012-0.029) on the following day even after controlling for same-day outcomes. Our preliminary findings suggest that engaging with a mHealth application was associated with higher dynamic resilience and emotional well-being in employees.

Self-Compassion Focused Writing Practices: A Systematic Review

In the current systematic review study, it is focused on examining the interventions of 'self-compassion-focused writing', which is a method that combines the concept of self-compassion, which has gained attention in the psychology literature in recent years, and the Written Emotional Disclosure Paradigm which is based on expressing emotions by writing. For this purpose, ScienceDirect, PsycINFO, Web of Science, PubMed, EbscoHost and DergiPark databases were searched through various keywords. Considering the inclusion and exclusion criteria of the study, 31 studies determined to be fit for purpose were examined in terms of sample characteristics, methodology and results. It was observed that the studies were generally conducted with college students and predominantly female, the results were compared with the active intervention groups, random assignment was made to the groups, and repeated measurements were taken. Generally, it has been determined that self-compassion-focused writing provides positive changes on psychological (depression, positive/negative affect), body-related (body satisfaction, body image) and physical (pain) variables. In the reviewed studies, it was concluded that self-compassion-focused writing generally tended to produce stronger positive results compared to active control groups (traditional writing, self-esteem-based writing). Besides, it was observed that the positive changes obtained in studies that carried out follow-up evaluations tended to continue partially. The results show that self-compassion-focused writing is a promising method.

Efficacy of the Mental Health App Intellect to Reduce Stress: Randomized Controlled Trial With a 1-Month Follow-up

BACKGROUND

Excessive stress is a major global health concern, particularly in young adults. Short skills-focused self-guided interventions (SGIs) on smartphones are a scalable way to improve stress-coping skills at the population level.

OBJECTIVE

In this randomized controlled trial, we aimed to examine the possible efficacy of a recently developed stress-coping SGI (Intellect) in improving psychological distress, relative to an active control group and 2 potential moderators of this predicted relationship (ie, psychological mindedness [PM] and coping self-efficacy [CSE]).

METHODS

University students (N=321) were randomly assigned to either an 8-day SGI on stress-coping or an active control group. Self-reported measures were obtained at baseline, after the intervention, and at the 1-month follow-up. The primary outcome was psychological stress (Psychological Stress Measure-9). Secondary outcomes were anxiety (Generalized Anxiety Disorder-7) and depressive symptoms (Patient Health Questionnaire-9). PM and CSE were assessed as potential moderators at baseline.

RESULTS

The final sample (n=264) included 188 (71.2%) female, 66 (25%) male, 7 (2.7%) nonbinary, and 3 (1.1%) others participants with a mean age of 22.5 (SD 5.41) years. The intervention group reported significantly lower perceived stress (partial eta-squared [ηp²]=0.018; P=.03) and anxiety (ηp²=0.019; P=.03) levels after intervention relative to the active control group. The effects on perceived stress levels remained statistically significant at the 1-month follow-up (ηp²=0.015; P=.05). Students with the lowest CSE and highest PM experienced the fastest decline in perceived stress levels (β=6.37, 95% Cl 2.98-9.75). Improvements in anxiety levels were not observed at 1-month follow-up. Similarly, no intervention effects were found for depression levels at postintervention and follow-up periods.

CONCLUSIONS

This study provides evidence that the Intellect stress-coping SGI is effective in reducing perceived stress and anxiety levels among university students. Mobile health apps are brief, scalable, and can make important contributions to public mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04978896; https://www.clinicaltrials.gov/ct2/show/NCT04978896.

Effectiveness of an online short-term audio-based mindfulness program on negative emotions during the COVID-19 pandemic: Latent growth curve analyses of anxiety and moderated mediation effects of anxiety between mindfulness and negative affect

This pilot study aims to explore the effects and mechanisms of a mindfulness-based intervention on negative emotions in community settings during the COVID-19 pandemic. Participants (N = 100) were randomized into an intervention group (n = 50) and a waitlist control group (n = 50). Participants in the mindfulness group underwent 3 weeks (21 sessions) of an online audio-based mindfulness-based intervention program and completed the online measures four times whereas those in the waitlist control group needed to complete the measures twice. Participants completed measures of the Hospital Anxiety and Depression Scale and Positive and Negative Affect Schedule. The results of the measures of the two groups were compared. Moderated mediation analysis was used to analyze intervention outcomes on negative affect through anxiety. Unconditional quadratic latent growth analysis was used to test the growth trajectories of anxiety. The results showed that this intervention program was effective at improving positive affect and at reducing depression, anxiety, and negative affect. The baseline anxiety moderator was found to be significant, and indirect effects of anxiety post-intervention were found between the mindfulness-based intervention and negative affect. Anxiety levels of participants were not at the same starting point and had similar but non-quadratic growth trajectories. The mindfulness-based intervention program was effective at promoting mental wellbeing and reducing mental problems in community settings in China. Mindfulness practices were beneficial to people with different anxiety levels but had more obvious benefits on anxiety and a negative affect for participants with low anxiety levels. Clinical trial registration: ISRCTN16205138 on 26/02/2021.

The effectiveness of digital health technologies for patients with diabetes mellitus: A systematic review

Introduction

Diabetes mellitus (DM) is a leading cause of morbidity and mortality worldwide. At the same time, digital health technologies (DHTs), which include mobile health apps (mHealth) have been rapidly gaining popularity in the self-management of chronic diseases, particularly following the COVID-19 pandemic. However, while a great variety of DM-specific mHealth apps exist on the market, the evidence supporting their clinical effectiveness is still limited.

Methods

A systematic review was performed. A systematic search was conducted in a major electronic database to identify randomized controlled trials (RCTs) of mHealth interventions in DM published between June 2010 and June 2020. The studies were categorized by the type of DM and impact of DM-specific mHealth apps on the management of glycated haemoglobin (HbA1c) was analysed.

Results

In total, 25 studies comprising 3,360 patients were included. The methodological quality of included trials was mixed. Overall, participants diagnosed with T1DM, T2DM and Prediabetes all demonstrated greater improvements in HbA1c as a result of using a DHT compared with those who experienced usual care. The analysis revealed an overall improvement in HbA1c compared with usual care, with a mean difference of -0.56% for T1DM, -0.90% for T2DM and -0.26% for Prediabetes.

Conclusion

DM-specific mHealth apps may reduce HbA1c levels in patients with T1DM, T2DM and Prediabetes. The review highlights a need for further research on the wider clinical effectiveness of diabetes-specific mHealth specifically within T1DM and Prediabetes. These should include measures which go beyond HbA1c, capturing outcomes including short-term glycemic variability or hypoglycemic events.

Emotion-Focused Mobile App for Promoting Self-Compassion, Self-Protection, and Self-Criticism

The COVID-19 pandemic has changed our daily lives and restricted access to traditional psychological interventions. Hence there is an immediate and growing demand for accessible and scalable mental health solutions. Emotion-focused training for self-compassion and self-protection was developed and distributed using mobile phone technologies, and its effectiveness was tested. The available research sample consisted of 97 participants with a mean age of 26.06 years and a standard deviation of 10.53. Participants using the mobile app underwent a 14-day program aimed at reducing self-criticism while increasing self-compassion and self-protection. Pre- and post-measurements were collected. The results showed a statistically significant medium effect on self-compassion, self-criticism, and self-protection performance and a significant small effect on self-protection distress. The finding that a 14-day mobile app was able to foster well-being in the form of self-compassion, self-protection, and self-criticism is promising. It indicates the potential for individuals to obtain help through the use of remote tools such as MHapps for a fraction of the usual cost, at their own pace, and without other restrictions.

Meditation Using a Mobile App Improves Surgery Trainee Performance: a simulation-based randomized controlled trial

PURPOSE

To primarily investigate: (1) whether a 10 min instant meditation practice using mobile app could enhance arthroscopy performance and (2) whether a 10-day app-based meditation could reduce short-term arthroscopic skills deterioration.

METHODS

Orthopedic residents with no previous experience in arthroscopy and meditation were randomly assigned to Groups A, B, and C. After initial standard competency-based arthroscopy training on the simulator on Day 1, a pretest was performed via simulator by all participants to assess their initial level of performance, then Groups A and B were required to practice app-based mindfulness meditation 10 min/day for 10 consecutive days, while Group C did nothing. On Day 11, all participants came back to perform a posttest. Prior to the posttest, the participants in Group A practiced app-based meditation (10 min) , whereas Groups B and C had no intervention.

RESULTS

43 participants were included and reached similar level of performance after initial training phase in Day1. In Day11, participants in Group A had statistically better instant arthroscopy performance than Group B, with higher total score (Mean Difference, 3.57; P<.001), less completion time (MD, -42.89s; P=.001), shorter camera (MD, -23.38cm; P<.001) and grasper (MD, -15.23cm; P=.002) path length and less cartilage injury (MD, -1.07%; P=.012). Participants in Group B had less skills deterioration than Group C, with better total score (MD, -5.42; P<.001), less completion time (MD, 51.96s; P=.002), camera path length (MD, 28.41cm; P=.007) and cartilage injury (MD, 1.19%; P=.038).

CONCLUSION

Meditation training using mobile app enhanced instant simulation-based arthroscopy performance and reduced short-term skills deterioration of orthopedic residents with no arthroscopy hands-on experience.

CLINICAL RELEVANCE

Meditation using mobile app for clinicians and educators should be incorporated into simulation-based arthroscopy curriculums and perhaps clinical settings to improve arthroscopy performance and mental health of orthopedic residents without any prior arthroscopy experience.

A WeChat-based self-compassion training to improve the treatment adherence of patients with schizophrenia in China: Protocol for a randomized controlled trial

Background

At present, adherence to antipsychotic treatment is often poor, leading to the recurrence of symptoms. This increases the likelihood of the patient experiencing disability and thus increases the disease burden for the patient, their family, and society as a whole. However, to date, there is no clear evidence regarding the effect of medication adherence interventions on outcomes for patients with schizophrenia. Moreover, the traditional intervention methods are limited by manpower and resources in low- and middle-income countries. Recent studies have demonstrated that increasing a patient’s level of self-compassion may improve their treatment adherence. Online mental health care interventions have advantages in terms of feasibility and acceptability for patients with schizophrenia. In this regard, a WeChat-based self-compassion training protocol to improve patient treatment adherence was designed in this study and will be evaluated in the future to determine its impact on patients with schizophrenia.

Methods

The protocol for the randomized controlled trial (RCT) is based on the SPIRIT 2013 statement. This parallel RCT will aim to recruit 392 patients with schizophrenia who will be randomized at a 1:1 ratio into a 3-week intervention or control group. Both groups will receive routine care. The intervention group will also receive WeChat-based self-compassion training, which requires participants to complete three tasks every day, including a reading task, a meditation task, and a self-compassion journal task. The control group will receive WeChat-based psychological health education, which will only require participants to read positive articles about psychological health every day. Medication adherence, self-compassion, stigma, and social support will be measured at baseline (T0), immediately after the intervention (T1), and 3 weeks after the intervention (T2). Program feasibility will be evaluated throughout the course of the study, and acceptability will be measured immediately after the intervention (T1).

Expected results:

The intervention described here will address the barriers to accessing mental health care for people with schizophrenia, including patients’ desire for independent management, difficulty accessing providers, and concerns about privacy and stigma. The current study provides guidance for clinical nurses to carry out psychological intervention, with the ultimate aim of addressing the problems associated with a shortage of psychological professionals in low- and middle-income countries.

Efficacy of a transdiagnostic cognitive-behavioral intervention for eating disorder psychopathology delivered through a smartphone app: a randomized controlled trial

BACKGROUND

Although effective treatments exist for diagnostic and subthreshold-level eating disorders (EDs), a significant proportion of affected individuals do not receive help. Interventions translated for delivery through smartphone apps may be one solution towards reducing this treatment gap. However, evidence for the efficacy of smartphones apps for EDs is lacking. We developed a smartphone app based on the principles and techniques of transdiagnostic cognitive-behavioral therapy for EDs and evaluated it through a pre-registered randomized controlled trial.

METHODS

Symptomatic individuals (those who reported the presence of binge eating) were randomly assigned to the app (n = 197) or waiting list (n = 195). Of the total sample, 42 and 31% exhibited diagnostic-level bulimia nervosa and binge-eating disorder symptoms, respectively. Assessments took place at baseline, 4 weeks, and 8 weeks post-randomization. Analyses were intention-to-treat. The primary outcome was global levels of ED psychopathology. Secondary outcomes were other ED symptoms, impairment, and distress.

RESULTS

Intervention participants reported greater reductions in global ED psychopathology than the control group at post-test (d = -0.80). Significant effects were also observed for secondary outcomes (d's = -0.30 to -0.74), except compensatory behavior frequency. Symptom levels remained stable at follow-up. Participants were largely satisfied with the app, although the overall post-test attrition rate was 35%.

CONCLUSION

Findings highlight the potential for this app to serve as a cost-effective and easily accessible intervention for those who cannot receive standard treatment. The capacity for apps to be flexibly integrated within current models of mental health care delivery may prove vital for addressing the unmet needs of people with EDs.

Psychoeducational interventions to promote adolescents' mental health literacy in schools: Identifying theory for the development of a complex intervention

TOPIC

The concept of mental health literacy (MHL) was defined as the knowledge and beliefs about mental disorders that help in their recognition, management, or prevention. The complexity of interventions to promote adolescents' MHL requires that they be investigated through a process of development, feasibility/piloting, evaluation, and implementation, according to Medical Research Council (MRC) Framework.

PURPOSE

This article aimed to identify the theory that supports the development of a psychoeducational intervention to promote adolescents' MHL in schools, possibly to be developed by mental health and psychiatric nurses.

SOURCES USED

Journal articles, books, reports, and regulations.

CONCLUSIONS

This theory allows us to design a psychoeducational intervention to promote adolescents' MHL in schools and supports the subsequent phases of the MRC Framework.

A Mobile App for Stress Management in Middle-Aged Men and Women (Calm): Feasibility Randomized Controlled Trial

BACKGROUND

Middle-aged adults (40-65 years) report higher stress levels than most other age groups. There is a need to determine the feasibility of using a meditation app to reduce stress and improve stress-related outcomes in middle-aged adults with a focus on men, as previous meditation app-based studies have reported a low proportion of or even no male participants.

OBJECTIVE

This study aims to (1) determine the feasibility (ie, acceptability and demand with a focus on men) of a consumer-based meditation app (Calm), to reduce stress among middle-aged adults reporting elevated stress levels, and (2) explore the preliminary effects of Calm on perceived stress, psychological outcomes (anxiety, depressive symptoms, mindfulness, and general coping), health behaviors (physical activity and eating habits), and COVID-19 perceptions.

METHODS

This feasibility randomized controlled trial evaluated an app-based meditation intervention in middle-aged adults (N=83) with elevated stress levels (ie, Perceived Stress Scale score ≥15) and limited or no previous experience with meditation. Participants were randomized to the intervention group (Calm app) or a control (educational podcasts; POD) group. Participants completed self-report assessments at baseline and postintervention (week 4). Feasibility was measured as acceptability and demand using Bowen framework. Feasibility and COVID-19 perceptions data were examined using descriptive statistics, and preliminary effects were evaluated using repeated measures analysis of variance.

RESULTS

Participants were satisfied with Calm (27/28, 96%) and found it appropriate or useful (26/28, 93%). Most reported they would likely continue using the Calm app (18/28, 64%). More Calm users reported satisfaction, appropriateness or usefulness, and intent to continue app use than POD users. Calm users (n=33) completed a mean of 20 (SD 31.1) minutes of meditation on the days they meditated and 103 (SD 109.1) minutes of meditation per week. The average adherence rate to the prescribed meditation was 71% among Calm app users, compared to 62% among POD users. Recruitment rate of men was 35% (29/83). Of those randomized to Calm, 55% (15/29) were men, and retention among them was higher (14/15, 93%) than that among women (12/20, 60%). No significant within or between group differences were observed.

CONCLUSIONS

A 4-week, app-based mindfulness meditation intervention (Calm) may be feasible for middle-aged adults and a useful stress-management tool. Calm users expressed satisfaction with the app and felt it was appropriate and useful. Significant improvements in perceived stress and psychological outcomes or stress-related health behaviors were not observed. Even though men spent less time in meditation than women did and completed fewer weekly sessions, they were more likely to adhere to the prescription. Further research is needed for improving stress and stress-related outcomes among middle-aged adults with emphasis on the effects of mindfulness meditation apps for men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04272138; https://clinicaltrials.gov/ct2/show/NCT04272138.

Emergency Department Nurses' Experiences of a Mindfulness Training Intervention: A Phenomenological Exploration

Purpose: The purpose of this study was to explore emergency care nurses' experiences of an intervention to increase compassion and empathy and reduce stress through individual mindfulness training delivered via workshops and a smartphone application. We also explored how the nurses felt about the practical and technical aspects of the intervention. Design: Qualitative interview study. Method: Individual interviews were conducted with eight of the 56 participants in the intervention study and used phenomenological analysis to illuminate how they made sense of their lived experiences of mindfulness training. Findings: Three themes illuminated the nurses' experiences: becoming aware, changing through mindfulness, and gaining the tools for mindfulness through workshops and the mobile application. The first two themes expressed personal experiences, whereas the third expressed experiences of the practical and technical aspects of the intervention. Most nurses found the mobile application easy to use and effective. Conclusions: Emergency care nurses can feel that the awareness and changes that come with mindfulness training benefit them, their colleagues, and the patients for whom they care. The findings also provide insights into the challenges of practicing mindfulness in a busy emergency care setting and into the practical aspects of using a smartphone application to train mindfulness.

Feasibility, Acceptability, and Preliminary Outcomes of a Cognitive Behavioral Therapy–Based Mobile Mental Well-being Program (Noom Mood): Single-Arm Prospective Cohort Study

Background

The prevalence of anxiety, depression, and general distress has risen in recent years. Mobile mental health programs have been found to provide support to nonclinical populations and may overcome some of the barriers associated with traditional in-person treatment; however, researchers have voiced concerns that many publicly available mobile mental health programs lack evidence-based theoretical foundations, peer-reviewed research, and sufficient engagement from the public.

Objective

This study aimed to evaluate the feasibility, acceptability, and preliminary outcomes of Noom Mood, a commercial mobile cognitive behavioral therapy– and mindfulness-based program.

Methods

In this single-arm prospective cohort study, individuals who joined Noom Mood between August and October 2021 completed surveys at baseline and 4-week follow-up. Per-protocol analyses included those who completed both surveys (n=113), and intention-to-treat analyses included all participants (N=185).

Results

A majority of the sample reported that the program is easy to use, they felt confident recommending the program to a friend, and they perceived the program to be effective at improving stress and anxiety. There were significant improvements in anxiety symptoms, perceived stress, depressive feelings, emotion regulation, and optimism in both the per-protocol and intention-to-treat analyses (all P<.001). Participants reported benefiting most from learning skills (eg, breathing and cognitive reframing techniques), interacting with the program features, and gaining awareness of their emotions and thought patterns. Participants also made a number of suggestions to improve product functionality and usability.

Conclusions

Results suggest that Noom Mood is feasible and acceptable to participants, with promising preliminary outcomes. Future studies should build on these results to evaluate the effects of Noom Mood using more rigorous designs.

Individual differences in meditation interventions: A meta-analytic study

Objectives

Meditation interventions typically show small to moderate effects on health and well‐being, but we know little about how these effects vary across individuals. This meta‐analytic study investigates the relationship between baseline participant characteristics and the outcomes of meditation.

Methods

A systematic search yielded 51 eligible studies with 7782 participants. A combination of subgroup analyses and meta‐regression based on the random‐effects model were used.

Results

We found that a higher baseline level of psychopathology or depression was associated with deterioration in mental health after a meditation intervention. On the other hand, participants with higher scores on interpersonal variables, motivation, medical conditions, and mindfulness showed higher levels of positive meditation outcomes. Higher well‐being and stress were simultaneously associated with moderate increases in negative and positive meditation outcomes. Participant demographics, psychological traits, self‐concept, and length of meditation practice did not significantly influence the response to meditation.

Conclusions

Overall, we found that meditation interventions affect participants differently, and identified some of the individual characteristics that should be considered when using meditation interventions.

An mHealth App-Based Self-management Intervention for Family Members of Pediatric Transplant Recipients (myFAMI): Framework Design and Development Study

BACKGROUND

Solid-organ transplantation is the treatment of choice for children with end-stage organ failure. Ongoing recovery and medical management at home after transplant are important for recovery and transition to daily life. Smartphones are widely used and hold the potential for aiding in the establishment of mobile health (mHealth) protocols. Health care providers, nurses, and computer scientists collaboratively designed and developed mHealth family self-management intervention (myFAMI), a smartphone-based intervention app to promote a family self-management intervention for pediatric transplant patients' families.

OBJECTIVE

This paper presents outcomes of the design stages and development actions of the myFAMI app framework, along with key challenges, limitations, and strengths.

METHODS

The myFAMI app framework is built upon a theory-based intervention for pediatric transplant patients, with aid from the action research (AR) methodology. Based on initially defined design motivation, the team of researchers collaboratively explored 4 research stages (research discussions, feedback and motivations, alpha testing, and deployment and release improvements) and developed features required for successful inauguration of the app in the real-world setting.

RESULTS

Deriving from app users and their functionalities, the myFAMI app framework is built with 2 primary components: the web app (for nurses' and superadmin usage) and the smartphone app (for participant/family member usage). The web app stores survey responses and triggers alerts to nurses, when required, based on the family members' response. The smartphone app presents the notifications sent from the server to the participants and captures survey responses. Both the web app and the smartphone app were built upon industry-standard software development frameworks and demonstrate great performance when deployed and used by study participants.

CONCLUSIONS

The paper summarizes a successful and efficient mHealth app-building process using a theory-based intervention in nursing and the AR methodology in computer science. Focusing on factors to improve efficiency enabled easy navigation of the app and collection of data. This work lays the foundation for researchers to carefully integrate necessary information (from the literature or experienced clinicians) to provide a robust and efficient solution and evaluate the acceptability, utility, and usability for similar studies in the future.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1002/nur.22010.

A Counseling Application as an Alternative Tool in Increasing Coping Self-Efficacy Among University Students With Academic Distress During Coronavirus Disease 2019 Pandemic in Indonesia: A Study Protocol for a Randomized Controlled Non-Inferiority Trial

The coronavirus disease 2019 (COVID-19) pandemic increased education-related distress among University students globally, including in Indonesia. Psychological factors, such as academic demands, limited opportunity to meet their peers, problematic use of technology, and domestic problems, influenced the well-being of the students, leading to poor academic performance. A mobile-based counseling application was developed to address the distress among University students. The application was meant to reach students living remotely to enable them to access psychological assistance. Therefore, the purpose of this study was to describe a protocol aimed to evaluate the equivalence of the application when compared to the Treatment-As-Usual (TAU) in increasing the coping self-efficacy (CSE) and resilience of students as well as in decreasing their level of depression. A two-armed parallel randomized control non-inferiority trial will be conducted among approximately 430 students with selected academic problems. The participants will be randomly allocated into the TAU and the intervention groups. The primary and secondary outcomes will be measured by the Indonesian versions of the Coping Self-Efficacy (CSE) Scale, the Resilience Scale (RS-14), and the Patient Health Questionnaire (PHQ-9). The data will be collected at baseline, at the end of each session, and after 3 months. The outcomes will be analyzed using repeated-measures ANOVAs, intention-to-treat, and per-protocol analysis. If proven, the application will be used as an alternative media in helping the students.

Clinical Trial Registration: Thailand Clinical Trials Registry (TCTR20200530001); Date of registration: May 28, 2020.

Mobile Apps That Promote Emotion Regulation, Positive Mental Health, and Well-being in the General Population: Systematic Review and Meta-analysis

BACKGROUND

Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being.

OBJECTIVE

We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness.

METHODS

A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims.

RESULTS

In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality.

CONCLUSIONS

The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs.

Can a little bit of mindfulness do you good? A systematic review and meta-analyses of unguided mindfulness-based self-help interventions

Over the last decade there has been an explosion of interest in mindfulness-based self-help (MBSH) interventions. While widely available and extensively promoted, there is little consensus on their impact in public health or healthcare contexts. We present a systematic review and meta-analyses of 83 randomized controlled trials, comparing unguided MBSH to control conditions on outcomes of depression, mindfulness, anxiety, stress and/or wellbeing/ quality of life. A random effects model was used to compute post-intervention, between-groups effect sizes for each outcome. MBSH demonstrated small, statistically significant effects at post-interventions for outcomes of depression (g = -0.23), mindfulness (g = 0.37) anxiety (g = -0.25), stress (g = -0.41) and wellbeing/ quality of life (g = 0.34). Significant effects were retained at follow-up for mindfulness, stress and wellbeing/ quality of life but not for depression or anxiety. Planned moderator analyses demonstrated significantly larger effects of MBSH when compared to inactive, versus active-control conditions on all outcomes except wellbeing/ quality of life, and non-digital MBSH interventions demonstrated significantly greater effects on depression, mindfulness and wellbeing/ quality of life outcomes than digitally-delivered MBSH. When studies that utilised samples selected for mental and physical health-related difficulties were respectively compared to studies that utilised unselected samples, no significant moderation effects were observed. In sum, these findings provide evidence for the effectiveness of unguided MBSH in public health settings and the practical, access-related implications of this are discussed.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing.

OBJECTIVE

This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects.

METHODS

We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model.

RESULTS

The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs.

CONCLUSIONS

Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

A Self-Compassion and Mindfulness-Based Cognitive Mobile Intervention (Serene) for Depression, Anxiety, and Stress: Promoting Adaptive Emotional Regulation and Wisdom

Introduction: Many individuals and families are currently experiencing a high level of COVID-19-related stress and are struggling to find helpful coping mechanisms. Mindfulness-based interventions are becoming an increasingly popular treatment for individuals experiencing depression and chronic levels of stress. The app (Serene) draws from scholarly evidence on the efficacy of mindfulness meditations and builds on the pre-existing apps by incorporating techniques that are used in some therapies such as cognitive behavioral therapy and mindfulness-based cognitive therapy. Methods: Participants were randomly assigned to a 4-week mindfulness and self-compassion-based cognitive smartphone intervention (Serene) or a wait-list control group. They were instructed to engage in self-compassion and mindfulness practices and a cognitive restructuring task. They also completed measures that evaluated their levels of depression, stress, anxiety, self-compassion, wisdom, psychological well-being, and subjective well-being. The intervention group was also instructed to track their weekly engagement with the app. Standardized effect sizes for between-group differences were calculated using Cohen's d for complete case analyses. Results: Complete case analyses from baseline to the end of this randomized controlled trial demonstrated significant moderate between-group differences for depressive symptoms (d = -0.43) and decisiveness (d = 0.34). Moderate between-group differences were also found for self-compassion (d = 0.6) such that significant improvements in self-kindness, common humanity, mindfulness and decreases in self-judgement, isolation, and overidentification were observed. A small between-group difference was found for emotional regulation (d = 0.28). Moreover, a significant moderate within-group decrease in stress (d = -0.52) and anxiety symptoms (d = -0.47) was also observed in the intervention group. Conclusions: Serene is an effective intervention that promotes increased levels of self-compassion and emotional regulation. Engaging with Serene may help reduce depressive symptoms through mindfulness, self-compassion, and cognitive restructuring which help reduce overidentification with one's negative emotions. As individuals rebalance their thinking through cognitive restructuring, they can identify the varying stressors in their life, develop action plans and engage in adaptive coping strategies to address them. Serene may promote greater self-understanding which may provide one with a more balanced perspective on their current upsetting situations to positively transform their challenges during the pandemic.

Meta-analytic review on the differential effects of self-compassion components on well-being and psychological distress: The moderating role of dialecticism on self-compassion

Although self-compassion has been extensively studied in the recent decades, the representation of self-compassion as a unitary measure or the presence of self-warmth (i.e., presence of the positive components: self-kindness, common humanity, and mindfulness) and self-coldness (i.e., presence of the negative components: self-judgment, isolation, and mindfulness) remains controversial. Moreover, the differential effects of the six components of self-compassion on mental well-being and psychological distress have not been systematically investigated. To synthesize the differential effects of the six components of self-compassion and to examine how people in different cultures may associate the positive and negative components of self-compassion differentially, the present meta-analysis synthesized 183 effect sizes across 27 cultures. Results showed that the negative components of self-compassion (rs = 0.44 to 0.45) showed greater effect sizes with psychological distress than the positive counterparts (rs = -0.17 to -0.29) whereas the positive components of SCS (rs = 0.29 to.39) showed greater effect sizes with mental well-being than the negative counterparts (rs = -0.29 to -0.36), with the exception of common humanity and isolation (r = 0.29 and - 0.36). Cultural orientation of dialecticism moderated the association between the positive and the negative components of self-compassion, with dialectical cultures showing lower associations between the two opposing components. Findings have implications on the design and implementation of self-compassion interventions cross-culturally.

Factors Associated With Dropout of Participants in an App-Based Child Injury Prevention Study: Secondary Data Analysis of a Cluster Randomized Controlled Trial

Background

Mobile health (mHealth) interventions offer great potential to reach large populations and improve public health. However, high attrition rates threaten evaluation and implementation of mHealth intervention studies.

Objective

We explored factors associated with attrition of study participants in an mHealth randomized controlled trial (RCT) evaluating an intervention to reduce unintentional child injury risk in China.

Methods

The cluster RCT compared two groups of an app-based intervention for caregivers of 3-6–year-old children (Bao Hu San). The intervention group received unintentional child injury and parenting education, whereas only parenting education was implemented in the control group. The trial included 2920 study participants in Changsha, China, and lasted 6 months. Data on participant engagement (using the app) were collected electronically throughout the 6-month period. Associations between participant attrition and demographic characteristics, and between attrition and intervention engagement were tested and quantified separately for the intervention and control groups using the adjusted odds ratio (aOR) based on generalized linear mixed models.

Results

In total, 2920 caregivers from 20 eligible preschools participated, with 1510 in the intervention group and 1410 in the control group. The 6-month attrition rate differed significantly between the two groups (P<.001), at 28.9% (437/1510) in the intervention group and 35.7% (503/1410) in the control group. For the intervention group, the only significant predictor of attrition risk was participants who learned fewer knowledge segments (aOR 2.69, 95% CI 1.19-6.09). For the control group, significant predictors of attrition risk were lower monthly login frequency (aOR 1.48, 95% CI 1.00-2.18), learning fewer knowledge segments (aOR 1.70, 95% CI 1.02-2.81), and shorter learning durations during app engagement (aOR 2.39, 95% CI 1.11-5.15). Demographic characteristics were unrelated to attrition.

Conclusions

Engagement in the app intervention was associated with participant attrition. Researchers and practitioners should consider how to best engage participants in app-based interventions to reduce attrition.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IOR-17010438; http://www.chictr.org.cn/showproj.aspx?proj=17376

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-018-5790-1

The efficacy of mindfulness meditation apps in enhancing users' well-being and mental health related outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Mindfulness applications are popular tools for improving well-being, but their effectiveness is unclear. We conducted a meta-analysis of randomized controlled trials (RCTs) that employed a mindfulness meditation app as the main intervention to improve users' well-being and mental-health related outcomes.

METHODS

A systematic search was conducted in PsycINFO, PubMed, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Library, Open Grey and ResearchGate through June, 2020. Effects were calculated as standardized mean difference (Hedges' g) between app-delivered mindfulness interventions and control conditions at post-test and pooled with a random-effects model.

RESULTS

From 2637 records, we selected 34 trials (N = 7566). Significant effect sizes were found at post-test for perceived stress (n = 15; g = 0.46, 95% CI [0.24, .68], I2= 68%), anxiety (n = 15; g = 0.28, 95% CI [0.16, .40], I2= 35%), depression (n = 15; g = 0.33, 95% CI [0.24, .43], I2= 0%), and psychological well-being (n = 5; g = 0.29, 95% CI [0.14, .45], I2= 0%). No significant effects were found for distress at post-test (n = 6; g = 0.10, 95% CI [-0.02, .22], I2= 11%) and general well-being (n = 5; g = 0.14, 95% CI [-0.02, 0.29], I2 = 14%).

CONCLUSION AND LIMITATIONS

Mindfulness apps seem promising in improving well-being and mental-health, though results should be interpreted carefully due to the small number of included studies, overall uncertain risk of bias and heterogeneity.

Evaluation of the E-Mental Health Mindfulness-Based and Skills-Based "CoPE It" Intervention to Reduce Psychological Distress in Times of COVID-19: Results of a Bicentre Longitudinal Study

Background: The SARS-CoV-2 pandemic poses immense challenges for health care systems and population-wide mental health. The e-mental health intervention "CoPE It" has been developed to offer standardized and manualized support to overcome psychological distress caused by the pandemic. The aim of this study was to assess the effectiveness of "CoPE It" in terms of reducing distress (primary outcome), depression and anxiety symptoms, and improving self-efficacy, and mindfulness (secondary outcomes). Furthermore, the intervention's usability, feasibility, and participants' satisfaction with "CoPE It" was evaluated (tertiary outcome). The study protocol has been published previously. Methods: A bicentre longitudinal study was conducted from April 27th 2020 to May 3rd 2021. N = 110 participants were included in the analyses. The intervention consisted of four modules featuring different media promoting evidence-based methods of cognitive behavioral therapy and mindfulness-based stress reduction. Difference in psychological distress between baseline (T0) and post-intervention (T1) were analyzed by repeated measure analysis of covariance. Mixed linear models were applied to assess moderating effects. Depressive symptoms, generalized anxiety symptoms, self-efficacy, and mindfulness were compared between baseline (T0) and post-intervention (T1) via t-tests. Usability of the "CoPE It" intervention and participants' satisfaction was evaluated by calculation means and frequencies. Results: Primary outcome: A significant effect of time on psychological distress at post-intervention (T1) after controlling for age, gender, education, mental illness and attitudes toward online interventions was found. Depressive and anxiety symptoms, and mindfulness were a significant moderators of the relationship between time and psychological distress for consistent wording. Secondary outcomes: There was a significant decrease in depressive symptoms and generalized anxiety, and a significant increase in self-efficacy and mindfulness between baseline (T0) and post-intervention (T1). Tertiary outcomes: 95.83% of the participants thought the "CoPE It" intervention was easy to use and 87.50% were satisfied with the "CoPE It" intervention in an overall, general sense. Conclusion: The e-mental health "CoPE It" intervention seems to be an effective approach in reducing psychological distress, anxiety and depressive symptoms, and in enhancing self-efficacy and mindfulness during the COVID-19 pandemic. Participants' satisfaction and the program's feasibility, and usability were proven to be high. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: DRKS00021301.

College student veterans' experience with a mindfulness- and acceptance-based mobile app intervention for PTSD: A qualitative study

This study aimed to explore college student military veterans' experience with a mindfulness- and acceptance-based smartphone app intervention. Upon the 4-week participation in the intervention, 23 student veterans took part in semi-structured interviews. In the thematic analysis of the interview transcripts, three main themes emerged: (1) generating momentum of app use; (2) optimizing the functions and benefits of the app; and (3) resolving to deepen the practice of mindfulness and acceptance. Considering the low engagement rates of several previous app-based studies, our results provide a useful framework for incorporating human feedback and support in enhancing users' engagement with the app.

Testing the Efficacy of a Multicomponent, Self-Guided, Smartphone-Based Meditation App: Three-Armed Randomized Controlled Trial

BACKGROUND

A growing number of randomized controlled trials (RCTs) suggest psychological benefits associated with meditation training delivered via mobile health. However, research in this area has primarily focused on mindfulness, only one of many meditative techniques.

OBJECTIVE

This study aims to evaluate the efficacy of 2 versions of a self-guided, smartphone-based meditation app-the Healthy Minds Program (HMP)-which includes training in mindfulness (Awareness), along with practices designed to cultivate positive relationships (Connection) or insight into the nature of the self (Insight).

METHODS

A three-arm, fully remote RCT compared 8 weeks of one of 2 HMP conditions (Awareness+Connection and Awareness+Insight) with a waitlist control. Adults (≥18 years) without extensive previous meditation experience were eligible. The primary outcome was psychological distress (depression, anxiety, and stress). Secondary outcomes were social connection, empathy, compassion, self-reflection, insight, rumination, defusion, and mindfulness. Measures were completed at pretest, midtreatment, and posttest between October 2019 and April 2020. Longitudinal data were analyzed using intention-to-treat principles with maximum likelihood.

RESULTS

A total of 343 participants were randomized and 186 (54.2%) completed at least one posttest assessment. The majority (166/228, 72.8%) of those assigned to HMP conditions downloaded the app. The 2 HMP conditions did not differ from one another in terms of changes in any outcome. Relative to the waitlist control, the HMP conditions showed larger improvements in distress, social connectedness, mindfulness, and measures theoretically linked to insight training (d=-0.28 to 0.41; Ps≤.02), despite modest exposure to connection- and insight-related practice. The results were robust to some assumptions about nonrandom patterns of missing data. Improvements in distress were associated with days of use. Candidate mediators (social connection, insight, rumination, defusion, and mindfulness) and moderators (baseline rumination, defusion, and empathy) of changes in distress were identified.

CONCLUSIONS

This study provides initial evidence of efficacy for the HMP app in reducing distress and improving outcomes related to well-being, including social connectedness. Future studies should attempt to increase study retention and user engagement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04139005; https://clinicaltrials.gov/ct2/show/NCT04139005.

Rates of Attrition and Dropout in App-Based Interventions for Chronic Disease: Systematic Review and Meta-Analysis

Background

Chronic disease represents a large and growing burden to the health care system worldwide. One method of managing this burden is the use of app-based interventions; however attrition, defined as lack of patient use of the intervention, is an issue for these interventions. While many apps have been developed, there is some evidence that they have significant issues with sustained use, with up to 98% of people only using the app for a short time before dropping out and/or dropping use down to the point where the app is no longer effective at helping to manage disease.

Objective

Our objectives are to systematically appraise and perform a meta-analysis on dropout rates in apps for chronic disease and to qualitatively synthesize possible reasons for these dropout rates that could be addressed in future interventions.

Methods

MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, Cochrane CENTRAL (Central Register of Controlled Trials), and Embase were searched from 2003 to the present to look at mobile health (mHealth) and attrition or dropout. Studies, either randomized controlled trials (RCTs) or observational trials, looking at chronic disease with measures of dropout were included. Meta-analysis of attrition rates was conducted in Stata, version 15.1 (StataCorp LLC). Included studies were also qualitatively synthesized to examine reasons for dropout and avenues for future research.

Results

Of 833 studies identified in the literature search, 17 were included in the review and meta-analysis. Out of 17 studies, 9 (53%) were RCTs and 8 (47%) were observational trials, with both types covering a range of chronic diseases. The pooled dropout rate was 43% (95% CI 29-57), with observational studies having a higher dropout rate (49%, 95% CI 27-70) than RCTs in more controlled scenarios, which only had a 40% dropout rate (95% CI 16-63). The studies were extremely varied, which is represented statistically in the high degree of heterogeneity (I²>99%). Qualitative synthesis revealed a range of reasons relating to attrition from app-based interventions, including social, demographic, and behavioral factors that could be addressed.

Conclusions

Dropout rates in mHealth interventions are high, but possible areas to minimize attrition exist. Reducing dropout rates will make these apps more effective for disease management in the long term.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) CRD42019128737; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128737

Short-term effect of a smartphone application on the mental health of university students: A pilot study using a user-centered design self-monitoring application for mental health

BACKGROUND

Despite the widespread recognition of the importance of mental health in young people, only a small proportion of young people with a mental disorder, including university students, receive mental health care.

OBJECTIVE

We developed a smartphone application (Mental App) for the university students and examined the effects of the app on their mental health.

METHODS

The app was designed according to a questionnaire survey conducted before this study. The Mental App was installed on the students' smartphone and the psychological tests (the Link Stigma Scale, the Center for Epidemiologic Studies Depression Scale, and the 12-item General Health Questionnaire) were performed on the same day. After using the App for two weeks, the students completed a questionnaire survey and underwent the same psychological tests. We compared the results between the app user and non-user group.

RESULTS

A total of 68 students participated, of which 57 students completed the study (app user group, n = 28; control group, n = 29). The mean number of days spent using the app was 5.66 ± 3.16 (mean ± SD). The mean total screen time of the app was 9:03 ± 06:41(min:sec). The mean number of total actions (screen taps or swipes) was 161.91 ± 107.34. There were no significant between-group differences in the ΔLink Stigma Scale score (-0.11 ± 4.28 vs. -0.59 ± 3.30, p = 0.496) or the ΔCenter for Epidemiologic Studies Depression Scale score (-4.39 ± 7.13 vs. -2.07 ± 8.78, p = 0.143). There was a significant between-group difference in the ΔGeneral Health Questionnaire score (-2.21± 2.23 vs. -0.17 ± 2.69, p = 0.007).

CONCLUSIONS

This non-randomized controlled pilot study indicates that the app we developed, may provide effective mental health care for university students, even in the short-term. Trial registration: UMIN000040332.

Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis

BACKGROUND

Digital interventions targeting common mental disorders (CMDs) or symptoms of CMDs are growing rapidly and gaining popularity, probably in response to the increased prevalence of CMDs and better awareness of early help-seeking and self-care. However, no previous systematic reviews that focus on these novel interventions were found.

OBJECTIVE

This systematic review aims to scope entirely web-based interventions that provided screening and signposting for treatment, including self-management strategies, for people with CMDs or subthreshold symptoms. In addition, a meta-analysis was conducted to evaluate the effectiveness of these interventions for mental well-being and mental health outcomes.

METHODS

Ten electronic databases including MEDLINE, PsycINFO, and EMBASE were searched from January 1, 1999, to early April 2020. We included randomized controlled trials (RCTs) that evaluated a digital intervention (1) targeting adults with symptoms of CMDs, (2) providing both screening and signposting to other resources including self-care, and (3) delivered entirely through the internet. Intervention characteristics including target population, platform used, key design features, and outcome measure results were extracted and compared. Trial outcome results were included in a meta-analysis on the effectiveness of users' well-being and mental health outcomes. We also rated the meta-analysis results with the Grading of Recommendations, Assessment, Development, and Evaluations approach to establish the quality of the evidence.

RESULTS

The electronic searches yielded 21 papers describing 16 discrete digital interventions. These interventions were investigated in 19 unique trials including 1 (5%) health economic study. Most studies were conducted in Australia and North America. The targeted populations varied from the general population to allied health professionals. All interventions offered algorithm-driven screening with measures to assess symptom levels and to assign treatment options including automatic web-based psychoeducation, self-care strategies, and signposting to existing services. A meta-analysis of usable trial data showed that digital interventions improved well-being (3 randomized controlled trials [RCTs]; n=1307; standardized mean difference [SMD] 0.40; 95% CI 0.29 to 0.51; I2=28%; fixed effect), symptoms of mental illness (6 RCTs; n=992; SMD -0.29; 95% CI -0.49 to -0.09; I2=51%; random effects), and work and social functioning (3 RCTs; n=795; SMD -0.16; 95% CI -0.30 to -0.02; I2=0%; fixed effect) compared with waitlist or attention control. However, some follow-up data failed to show any sustained effects beyond the post intervention time point. Data on mechanisms of change and cost-effectiveness were also lacking, precluding further analysis.

CONCLUSIONS

Digital mental health interventions to assess and signpost people experiencing symptoms of CMDs appear to be acceptable to a sufficient number of people and appear to have enough evidence for effectiveness to warrant further study. We recommend that future studies incorporate economic analysis and process evaluation to assess the mechanisms of action and cost-effectiveness to aid scaling of the implementation.