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Shah J, DePietro B, D’Adamo L, Firebaugh ML, Laing O, Fowler LA, Smolar L, Sadeh-Sharvit S, Taylor CB, Wilfley DE, Fitzsimmons-Craft EE. Development and usability testing of a chatbot to promote mental health services use among individuals with eating disorders following screening. Int J Eat Disord 2022; 55:1229-1244. [PMID: 36056648 PMCID: PMC10053367 DOI: 10.1002/eat.23798] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A significant gap exists between those who need and those who receive care for eating disorders (EDs). Novel solutions are needed to encourage service use and address treatment barriers. This study developed and evaluated the usability of a chatbot designed for pairing with online ED screening. The tool aimed to promote mental health service utilization by improving motivation for treatment and self-efficacy among individuals with EDs. METHODS A chatbot prototype, Alex, was designed using decision trees and theoretically-informed components: psychoeducation, motivational interviewing, personalized recommendations, and repeated administration. Usability testing was conducted over four iterative cycles, with user feedback informing refinements to the next iteration. Post-testing, participants (N= 21) completed the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and a semi-structured interview. RESULTS Interview feedback detailed chatbot aspects participants enjoyed and aspects necessitating improvement. Feedback converged on four themes: user experience, chatbot qualities, chatbot content, and ease of use. Following refinements, users described Alex as humanlike, supportive, and encouraging. Content was perceived as novel and personally relevant. USE scores across domains were generally above average (~5 out of 7), and SUS scores indicated "good" to "excellent" usability across cycles, with the final iteration receiving the highest average score. DISCUSSION Overall, participants generally reflected positively on interactions with Alex, including the initial version. Refinements between cycles further improved user experiences. This study provides preliminary evidence of the feasibility and acceptance of a chatbot designed to promote motivation for and use of services among individuals with EDs. PUBLIC SIGNIFICANCE Low rates of service utilization and treatment have been observed among individuals following online eating disorder screening. Tools are needed, including scalable, digital options, that can be easily paired with screening, to improve motivation for addressing eating disorders and promote service utilization.
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Affiliation(s)
- Jillian Shah
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Bianca DePietro
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura D’Adamo
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Olivia Laing
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren A. Fowler
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren Smolar
- National Eating Disorders Association, New York City, NY, USA
| | | | - C. Barr Taylor
- Center for m2Health, Palo Alto University, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Denise E. Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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Topooco N, Fowler LA, Fitzsimmons-Craft EE, DePietro B, Vázquez MM, Firebaugh ML, Ceglarek P, Monterubio G, Newman MG, Eisenberg D, Wilfley DE, Taylor CB. Digital interventions to address mental health needs in colleges: Perspectives of student stakeholders. Internet Interv 2022; 28:100528. [PMID: 35378846 PMCID: PMC8976123 DOI: 10.1016/j.invent.2022.100528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 11/04/2022] Open
Abstract
Objective The need for clinical services in U.S. colleges exceeds the supply. Digital Mental health Interventions (DMHIs) are a potential solution, but successful implementation depends on stakeholder acceptance. This study investigated the relevance of DMHIs from students' perspectives. Methods In 2020-2021, an online cross-sectional survey using mixed methods was conducted with 479 students at 23 colleges and universities. Respondents reported views and use of standard mental health services and DMHIs and rated the priority of various DMHIs to be offered through campus services. Qualitative data included open-ended responses. Findings Among respondents, 91% reported having experienced mental health problems, of which 91% reported barriers to receiving mental health services. Students highlighted therapy and counseling as desired and saw flexible access to services as important. With respect to DMHIs, respondents had the most experience with physical health apps (46%), mental health questionnaires (41%), and mental well-being apps (39%). Most were unaware of or had not used apps or self-help programs for mental health problems. Students were most likely to report the following DMHIs as high priorities: a crisis text line (76%), telehealth (66%), websites for connecting to services (62%), and text/messaging with counselors (62%). They considered a self-help program with coach support to be convenient but some also perceived such services to be possibly less effective than in-person therapy. Conclusions Students welcome DMHIs on campus and indicate preference for mental health services that include human support. The findings, with particular focus on characteristics of the DMHIs prioritized, and students' awareness and perceptions of scalable DMHIs emphasized by policymakers, should inform schools looking to implement DMHIs.
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Affiliation(s)
- Naira Topooco
- Department of Behavioural Sciences and Learning, Linköping University, Sweden
- Center for mHealth, Palo Alto University, Palo Alto, CA, USA
| | - Lauren A. Fowler
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Bianca DePietro
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Melissa M. Vázquez
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Peter Ceglarek
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Grace Monterubio
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michelle G. Newman
- Department of Psychology, Pennsylvania State University, University Park, PA, USA
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Denise E. Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - C. Barr Taylor
- Center for mHealth, Palo Alto University, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Fitzsimmons-Craft EE, Chan WW, Smith AC, Firebaugh ML, Fowler LA, Topooco N, DePietro B, Wilfley DE, Taylor CB, Jacobson NC. Effectiveness of a chatbot for eating disorders prevention: A randomized clinical trial. Int J Eat Disord 2022; 55:343-353. [PMID: 35274362 DOI: 10.1002/eat.23662] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Prevention of eating disorders (EDs) is of high importance. However, digital programs with human moderation are unlikely to be disseminated widely. The aim of this study was to test whether a chatbot (i.e., computer program simulating human conversation) would significantly reduce ED risk factors (i.e., weight/shape concerns, thin-ideal internalization) in women at high risk for an ED, compared to waitlist control, as well as whether it would significantly reduce overall ED psychopathology, depression, and anxiety and prevent ED onset. METHOD Women who screened as high risk for an ED were randomized (N = 700) to (1) chatbot based on the StudentBodies© program; or (2) waitlist control. Participants were followed for 6 months. RESULTS For weight/shape concerns, there was a significantly greater reduction in intervention versus control at 3- (d = -0.20; p = .03) and 6-m-follow-up (d = -0.19; p = .04). There were no differences in change in thin-ideal internalization. The intervention was associated with significantly greater reductions than control in overall ED psychopathology at 3- (d = -0.29; p = .003) but not 6-month follow-up. There were no differences in change in depression or anxiety. The odds of remaining nonclinical for EDs were significantly higher in intervention versus control at both 3- (OR = 2.37, 95% CI [1.37, 4.11]) and 6-month follow-ups (OR = 2.13, 95% CI [1.26, 3.59]). DISCUSSION Findings provide support for the use of a chatbot-based EDs prevention program in reducing weight/shape concerns through 6-month follow-up, as well as in reducing overall ED psychopathology, at least in the shorter-term. Results also suggest the intervention may reduce ED onset. PUBLIC SIGNIFICANCE We found that a chatbot, or a computer program simulating human conversation, based on an established, cognitive-behavioral therapy-based eating disorders prevention program, was successful in reducing women's concerns about weight and shape through 6-month follow-up and that it may actually reduce eating disorder onset. These findings are important because this intervention, which uses a rather simple text-based approach, can easily be disseminated in order to prevent these deadly illnesses. TRIAL REGISTRATION OSF Registries; https://osf.io/7zmbv.
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Affiliation(s)
| | - William W Chan
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
- Center for m2Health, Palo Alto University, Palo Alto, California, USA
| | - Arielle C Smith
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lauren A Fowler
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Naira Topooco
- Center for m2Health, Palo Alto University, Palo Alto, California, USA
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Bianca DePietro
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Denise E Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Barr Taylor
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
- Center for m2Health, Palo Alto University, Palo Alto, California, USA
| | - Nicholas C Jacobson
- Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire, USA
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Chan WW, Fitzsimmons-Craft EE, Smith AC, Firebaugh ML, Fowler LA, DePietro B, Topooco N, Wilfley DE, Taylor CB, Jacobson NC. The Challenges in Designing a Prevention Chatbot for Eating Disorders: Observational Study. JMIR Form Res 2022; 6:e28003. [PMID: 35044314 PMCID: PMC8811687 DOI: 10.2196/28003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/28/2021] [Accepted: 11/30/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Chatbots have the potential to provide cost-effective mental health prevention programs at scale and increase interactivity, ease of use, and accessibility of intervention programs. OBJECTIVE The development of chatbot prevention for eating disorders (EDs) is still in its infancy. Our aim is to present examples of and solutions to challenges in designing and refining a rule-based prevention chatbot program for EDs, targeted at adult women at risk for developing an ED. METHODS Participants were 2409 individuals who at least began to use an EDs prevention chatbot in response to social media advertising. Over 6 months, the research team reviewed up to 52,129 comments from these users to identify inappropriate responses that negatively impacted users' experience and technical glitches. Problems identified by reviewers were then presented to the entire research team, who then generated possible solutions and implemented new responses. RESULTS The most common problem with the chatbot was a general limitation in understanding and responding appropriately to unanticipated user responses. We developed several workarounds to limit these problems while retaining some interactivity. CONCLUSIONS Rule-based chatbots have the potential to reach large populations at low cost but are limited in understanding and responding appropriately to unanticipated user responses. They can be most effective in providing information and simple conversations. Workarounds can reduce conversation errors.
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Affiliation(s)
- William W Chan
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
- Center for m2Health, Palo Alto University, Los Altos, CA, United States
| | | | - Arielle C Smith
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Lauren A Fowler
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Bianca DePietro
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Naira Topooco
- Center for m2Health, Palo Alto University, Los Altos, CA, United States
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Denise E Wilfley
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - C Barr Taylor
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
- Center for m2Health, Palo Alto University, Los Altos, CA, United States
| | - Nicholas C Jacobson
- Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
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Fitzsimmons-Craft EE, Balantekin KN, Graham AK, DePietro B, Laing O, Firebaugh ML, Smolar L, Park D, Mysko C, Funk B, Taylor CB, Wilfley DE. Preliminary data on help-seeking intentions and behaviors of individuals completing a widely available online screen for eating disorders in the United States. Int J Eat Disord 2020; 53:1556-1562. [PMID: 32542896 PMCID: PMC7978480 DOI: 10.1002/eat.23327] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Scaling an online screen that provides referrals may be key in closing the treatment gap for eating disorders (EDs), but we need to understand respondents' help-seeking intentions and behaviors after receiving screen results. This study reported on these constructs among respondents to the National Eating Disorders Association online screen who screened positive or at high risk for an ED. METHOD Respondents completed the screen over 18 months (February 9, 2018-August 28, 2019). Those screening positive or at high risk for an ED (n = 343,072) had the option to provide data on help-seeking intentions (after screen completion) and behaviors (2-month follow-up). RESULTS Of eligible respondents, 4.8% (n = 16,396) provided data on help-seeking intentions, with only 33.7% of those reporting they would seek help. Only 7.6% of eligible respondents opted in to the 2-month follow-up, with 10.6% of those completing it (n = 2,765). Overall, 8.9% of respondents to the follow-up reported being in treatment when they took the screen, 15.5% subsequently initiated treatment, and 75.5% did not initiate/were not already in treatment. DISCUSSION Preliminary results suggest that among the small minority who provided data, only one-third expressed help-seeking intentions and 16% initiated treatment. Online screening should consider ways to increase respondents' motivation for and follow-through with care.
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Affiliation(s)
| | - Katherine N Balantekin
- Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York, USA
| | - Andrea K Graham
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois, USA
| | - Bianca DePietro
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olivia Laing
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lauren Smolar
- National Eating Disorders Association, New York, New York, USA
| | - Dan Park
- National Eating Disorders Association, New York, New York, USA
| | - Claire Mysko
- National Eating Disorders Association, New York, New York, USA
| | - Burkhardt Funk
- Institute of Information Systems, Leuphana University, Lüneburg, Germany
| | - C Barr Taylor
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
- Center for m2Health, Palo Alto University, Palo Alto, California, USA
| | - Denise E Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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