Interdisciplinary perspectives on digital technologies for global mental health

Digital Mental Health Technologies (DMHTs) have the potential to close treatment gaps in settings where mental healthcare is scarce or even inaccessible. For this, DMHTs need to be affordable, evidence-based, justice-oriented, user-friendly, and embedded in a functioning digital infrastructure. This viewpoint discusses areas crucial for future developments of DMHTs. Drawing back on interdisciplinary scholarship, questions of health equity, consumer-, patient- and developer-oriented legislation, and requirements for successful implementation of technologies across the globe are discussed. Economic considerations and policy implications complement these aspects. We discuss the need for cultural adaptation specific to the context of use and point to several benefits as well as pitfalls of DMHTs for research and healthcare provision. Nonetheless, to circumvent technology-driven solutionism, the development and implementation of DMHTs require a holistic, multi-sectoral, and participatory approach.

Mediators of digital depression prevention in patients with chronic back pain: Findings from a multicenter randomized clinical trial

OBJECTIVE

The mechanisms of change in digital interventions for the prevention of depression are largely unknown. Here, we explored whether five theoretically derived intervening variables (i.e., pain intensity, pain-related disability, pain self-efficacy, quality of life [QoL], and work capacity) were mediating the effectiveness of a digital intervention specifically designed to prevent depression in patients with chronic back pain (CBP).

METHOD

This study is a secondary analysis of a pragmatic, observer-masked randomized clinical trial conducted at 82 orthopedic clinics in Germany. A total of 295 adults with a diagnosis of CBP and subclinical depressive symptoms were randomized to either the intervention group (n = 149) or treatment-as-usual (n = 146). Longitudinal mediation analyses were conducted with structural equation modeling and depression symptom severity as primary outcome (Patient Health Questionnaire-9 [PHQ-9]; 6 months after randomization) on an intention-to-treat basis.

RESULTS

Beside the effectiveness of the digital intervention in preventing depression, we found a significant causal mediation effect for QoL as measured with the complete scale of Assessment of Quality of Life (AQoL-6D; axb: -0.234), as well as for the QoL subscales mental health (axb: -0.282) and coping (axb: -0.249). All other potential intervening variables were not significant.

CONCLUSION

Our findings suggest a relevant role of QoL, including active coping, as change mechanism in the prevention of depression. Yet, more research is needed to extend and specify our knowledge on empirically supported processes in digital depression prevention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Culturally adapting internet- and mobile-based health promotion interventions might not be worth the effort: a systematic review and meta-analysis

Health promotion interventions offer great potential in advocating a healthy lifestyle and the prevention of diseases. Some barriers to communicating health promotion to people of certain cultural groups might be overcome via the internet- and mobile-based interventions (IMI). This systematic review and meta-analysis aims to explore the effectiveness of culturally adapted IMI for health promotion interventions among culturally diverse populations. We systematically searched on Cochrane Central Register of Controlled Trials (CENTRAL), EbscoHost/MEDLINE, Ovid/Embase, EbscoHost/PsychINFO, and Web of Science databases in October 2020. Out of 9438 records, 13 randomized controlled trials (RCT) investigating culturally adapted health promotion IMI addressing healthy eating, physical activity, alcohol consumption, sexual health behavior, and smoking cessation included. From the included studies 10,747 participants were eligible. Culturally adapted IMI proved to be non-superior over active control conditions in short- (g = 0.10, [95% CI −0.19 to 0.40]) and long-term (g = 0.20, [95% CI −0.11 to 0.51]) in promoting health behavior. However, culturally adapted IMI for physical activity (k = 3, N = 296) compared to active controls yielded a beneficial effect in long-term (g = 0.48, [95%CI 0.25 to 0.71]). Adapting health promotion IMI to the cultural context of different cultural populations seems not yet to be recommendable given the substantial adaption efforts necessary and the mostly non-significant findings. However, these findings need to be seen as preliminary given the limited number of included trials with varying methodological rigor and the partly substantial between-trial heterogeneity pointing in the direction of potentially useful culturally adapted IMI which now need to be disentangled from the less promising approaches.

PROSPERO registration number: 42020152939

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

Effectiveness of an internet-based intervention to improve sleep difficulties in a culturally diverse sample of international students: A randomised controlled pilot study

Sleep difficulties are widespread among international students. Internet-based interventions are suggested as a low-threshold treatment option but may require cultural adaptation among culturally diverse populations. The present pilot study investigated the effectiveness and acceptance of an internet-based intervention to improve sleep difficulties in international students. A total of 81 international students of 36 nationalities were randomly assigned to the intervention (n = 41) or waitlist control group (n = 40). The intervention group received immediate access to a culturally non-adapted unguided internet-based sleep intervention consisting of three modules based on sleep hygiene and cognitive techniques to reduce rumination. At baseline, 4 and 12 weeks after randomisation, insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, depression, anxiety, perceived stress, well-being, presenteeism, mental health literacy) were assessed. Data were analysed using linear multi-level analyses. Additionally, satisfaction and perceived cultural appropriateness of the intervention were evaluated by international students after 4 weeks, and compared with ratings of German students, who represent the original target group. Insomnia severity improved over time in the intervention group compared to the control group, revealing a significant estimated mean difference of -5.60 (Hedges' g = 0.84, p < 0.001) after 12 weeks. Satisfaction and perceived cultural appropriateness was high and comparable to that of German students. The present study shows that a culturally non-adapted internet-based sleep intervention can be a low-threshold treatment option to help meet the high demand for mental healthcare among international students. It thus indicates that cultural adaptation might not represent a precondition for providing effective internet-based sleep interventions to this target group.

Cultural adaptation of internet- and mobile-based interventions for mental disorders: a systematic review

Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation.PROSPERO registration number: CRD42019142320.

Protocol for a systematic review and meta-analysis of culturally adapted internet- and mobile-based health promotion interventions

INTRODUCTION

High rates of immigration pose challenges for the healthcare systems of many countries to offer high-quality care to diverse populations. Advancing health interventions with incorporating the cultural background of diverse populations can be helpful to overcome this challenge. First studies suggest that culturally diverse populations might benefit from culturally adapted internet-based and mobile-based interventions (IMI) to promote health behaviours. However, the effectiveness of culturally adapted IMIs for health promotion interventions has not been evaluated systematically. Therefore, the aim of this review is to assess the effectiveness of culturally adapted IMIs regarding health promotion. Additionally, the cultural adaptation features of these interventions will be outlined.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) investigating the effectiveness of culturally adapted IMIs to promote health behaviours in the field of healthy eating, smoking cessation, alcohol consumption, physical activity and sexual health behaviour will be identified via a systematic search of the databases MEDLINE, Embase, PsycINFO, CENTRAL. The preliminary search has been conducted on the 26 August 2019 and will be updated in the process. Data will be pooled meta-analytically in case of at least three included studies reporting on the same outcome. Moreover, a narrative synthesis of the included studies will be conducted. The risk of bias will be assessed using the Cochrane Collaboration's tool for the Quality Assessment of RCTs V. 2.0. Publication bias will be assessed using funnel plots.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The results of this study will be published in a peer-reviewed international journal.

PROSPERO REGISTRATION NUMBER

PROSPERO; CRD42020152939.

Effectiveness of a Guided Web-Based Self-help Intervention to Prevent Depression in Patients With Persistent Back Pain: The PROD-BP Randomized Clinical Trial

IMPORTANCE

Depression is a frequent comorbid condition in patients with persistent back pain and is associated with substantial adverse consequences, including the risk of developing opioid use disorders. Shifting the focus from depression treatment to preventing depression might be a viable way to reduce the disease burden.

OBJECTIVE

To evaluate the effectiveness of a web-based self-help intervention to reduce the incidence of major depressive episode (MDE) in patients with persistent back pain.

DESIGN, SETTING, AND PARTICIPANTS

Prevention of Depression in Back Pain Patients (PROD-BP) was a pragmatic, observer-blinded randomized clinical trial with a parallel design conducted in Germany. Eligible adults with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited either on-site or after discharge from 82 orthopedic clinics between October 1, 2015, and July 31, 2017. All analyses were conducted according to the intention-to-treat principle from October 31, 2018, to April 30, 2019.

INTERVENTIONS

The intervention group received an e-coach-guided, web-based self-help intervention that was based on cognitive behavioral therapy and tailored to the needs of patients with persistent back pain. The intervention included 6 obligatory modules and 3 optional modules to be completed by participants as well as feedback from e-coaches. Both the intervention and control groups had unrestricted access to treatment as usual.

MAIN OUTCOMES AND MEASURES

Primary outcome was time to onset of an MDE over a 12-month period as assessed by blinded diagnostic raters using the Structured Clinical Interview for DSM-5. Secondary outcomes included depression severity, quality of life, pain intensity, pain-related disability, pain self-efficacy, work capacity, and user satisfaction assessed with a variety of instruments.

RESULTS

A total of 295 participants (mean [SD] age, 52.8 [7.7] years; 184 women [62.4%]) were recruited and randomized to either the intervention group (n = 149) or control group (n = 146). The intervention reduced the risk of MDE onset by 52% (hazard ratio, 0.48; 95% CI, 0.28-0.81; P < .001). Twenty-one participants (14.1%) in the intervention group and 41 participants (28.1%) in the control group experienced an MDE over the 12-month period. The number needed to treat to prevent 1 new case of MDE was 2.84 (95% CI, 1.79-9.44).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that among patients with persistent back pain, depression can be prevented by a guided web-based self-help intervention in addition to treatment as usual. This finding suggests that using a scalable digital approach to integrate psychological treatment into routine pain management is feasible.

TRIAL REGISTRATION

German Clinical Trials Register Identifier: DRKS00007960.

Cultural adaptation of Internet- and mobile-based interventions for mental disorders: a systematic review protocol

BACKGROUND

Internet- and mobile-based interventions (IMI) are an effective and scalable low-threshold solution to reach people who are undersupplied by current healthcare. Adapting interventions to the cultural and ethnic background of the target group enhances their acceptance and effectiveness. However, no systematic approach to cultural adaptation of IMI has been established so far. Therefore, this review aims to summarise components and procedures commonly used in the cultural adaptation of IMI for mental disorders, as well as the current evidence base on whether such a cultural adaptation leads to an increased acceptance, adherence, and effectiveness of IMI for mental disorders.

METHODS

A systematic literature search will be performed using the following databases: MEDLINE, Embase, PsycINFO, CENTRAL, and WoS. The search term will include keywords related to cultural adaptation, IMI, and mental disorders/disturbances. Two independent reviewers will evaluate studies against inclusion and exclusion criteria and extract study and intervention characteristics, details on the cultural adaptation approach, and outcome data. Quality of evidence will be assessed using the Quality Assessment Tool for Reviewing Studies with Diverse Designs, and results will be synthesised qualitatively.

DISCUSSION

Providing adequate mental healthcare regardless of cultural backgrounds is a major global health challenge. The planned systematic review will lay the foundation for the further development of the cultural adaptation of IMI for mental disorders by summarising the current state and providing recommendations for future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019142320.

Flashbulb memory recall in healthy adults - a functional magnetic resonance imaging study

The present study investigated neural activations related to flashbulb memory (FM) recall and examined whether the amygdala and hippocampus are involved in FM recall. 20 healthy adults completed a block design with an FM-condition, where the reception events for a number of potential FM events had to be recalled, and a control condition (FMC) comprising reception events lacking FM characteristics. A definition naming task was used as an implicit baseline. The individual emotional reaction to the FM events (EMO) and self-rated retrieval success were included in the SPM model as modulating parameters. The main contrast of interest were FM > FMC and activations associated with EMO. ROI-analyses on mesiotemporal regions were performed. FM > FMC yielded activations in line with the autobiographical memory network, with mostly left sided-activations. EMO was associated with a more bilateral activation pattern. ROI-analysis revealed activations for EMO in the right amygdala and HATA. FM > FMC was associated with right hippocampal activations. The present findings are compatible with previous research into autobiographical memory, but also show activations for FM recall different from ordinary, not highly emotional autobiographical memories, as EMO is associated with a more bilateral network. Moreover, the amygdala seems to be involved in FM recall.

'Help for trauma from the app stores?' A systematic review and standardised rating of apps for Post-Traumatic Stress Disorder (PTSD)

Background: Mobile health applications (apps) are considered to complement traditional psychological treatments for Post-Traumatic Stress Disorder (PTSD). However, the use for clinical practice and quality of available apps is unknown. Objective: To assess the general characteristics, therapeutic background, content, and quality of apps for PTSD and to examine their concordance with established PTSD treatment and self-help methods. Method: A web crawler systematically searched for apps targeting PTSD in the British Google Play and Apple iTunes stores. Two independent researchers rated the apps using the Mobile App Rating Scale (MARS). The content of high-quality apps was checked for concordance with psychological treatment and self-help methods extracted from current literature on PTSD treatment. Results: Out of 555 identified apps, 69 met the inclusion criteria. The overall app quality based on the MARS was medium (M = 3.36, SD = 0.65). Most apps (50.7%) were based on cognitive behavioural therapy and offered a wide range of content, including established psychological PTSD treatment methods such as processing of trauma-related emotions and beliefs, relaxation exercises, and psychoeducation. Notably, data protection and privacy standards were poor in most apps and only one app (1.4%) was scientifically evaluated in a randomized controlled trial. Conclusions: High-quality apps based on established psychological treatment techniques for PTSD are available in commercial app stores. However, users are confronted with great difficulties in identifying useful high-quality apps and most apps lack an evidence-base. Commercial distribution channels do not exploit the potential of apps to complement the psychological treatment of PTSD.

Cultural adaptation of internet interventions for refugees: Results from a user experience study in Germany

BACKGROUND

The estimated number of refugees worldwide resulting from persecution, conflict, violence, or human rights violations reached 25.4 million in 2017. An increased prevalence of mental disorders combined with language and socio-cultural barriers pose a challenge for healthcare systems. Internet-based interventions can help to meet this challenge. For the effective use of such interventions in refugees, cultural adaptations are necessary. The variety of their cultural backgrounds thereby is particularly challenging.

METHODS

We conducted this explorative qualitative study in order to identify elements of Internet-based interventions that need cultural adaptation to be suitable for refugees. Six refugees from Syria, Iran, Eritrea, Algeria, and Iraq, and six healthcare providers (two social workers, two psychologists, one physiotherapist, one physician) working with refugees went through an intervention for individuals with sleeping problems (eSano Sleep-e). Possible threats to user experience were identified using the Think Aloud method and semi-structured interviews. Statements were analysed based on the grounded theory method.

RESULTS

Results indicate the necessity to adapt the intervention to the specifics of refugees including aspects related to the flight (i.e., past and current stressors) and non-western characteristics (i.e., habits, disease and treatment concepts). Elements of adaptation should include pictures, role models, language, psychoeducational elements, structure of modules, and format of presentation.

CONCLUSIONS

Cultural adaptation can be used to facilitate the identification with an intervention, which seems crucial to increase the acceptance among refugees. In spite of their diverse cultural backgrounds, it appears feasible to create interventions that allow identification by refugees from different home countries.

Flashbulb memories: Is the amygdala central? An investigation of patients with amygdalar damage

Flashbulb memories (FM) are a subgroup of autobiographical memories referring to the circumstances in which a person first heard of a surprising, emotionally arousing event. Patients with temporal lobe epilepsy (TLE) have been reported to be impaired in FM recall. As emotional arousal is central to FM, various authors have suggested a crucial role of the amygdala. However, to date, no studies have directly addressed this hypothesis. In this study, 33 TLE patients and 20 healthy controls (HC) were tested on an FM task twice with a minimum interval of two months. FM recall quality was measured as consistency of the answers. Patients were grouped according to the presence as well as the lateralisation of amygdalar damage, using information of brain imaging and intracranial electroencephalography-recordings. Analyses revealed that, relative to HC, patients with amygdalar damage had significantly diminished FM recall quality, whereas patients with intact amygdalae did not. Particularly patients with amygdalar damage in the non-language-dominant hemisphere performed significantly worse than HC. Findings suggest a negative influence of amygdalar damage, possibly especially in the non-dominant hemisphere, on FM retrieval quality. Given the shocking character of events evoking FM, a rapid emotion detection system involving the right (i.e. non-dominant) amygdala could be influential to FM formation. Thus, the present findings support previous, not yet examined, hypotheses concerning a crucial role of the amygdala in FM.